UC SOUTHERN REGIONAL LIBRARY FACILITY 
 
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 THE LIBRARY 
 
 OF 
 
 THE UNIVERSITY 
 
 OF CALIFORNIA 
 
 LOS ANGELES 
 
 GIFT OF 
 
 SAN FRANCISCO 
 COUNTY MEDICAL SOCIETY
 
 DIAGNOiSIS AND TREATMENT 
 
 DISEASES OF THE CHEST.
 
 ^
 
 S^ '^ ■■ . -v^y; 
 
 /f'f,^c/y/H4./m^ay>ty oC "iptf" au^<Jo--f-uJt^-
 
 A TREATISE 
 
 ON THE 
 
 DIAGNOSIS AND TREATMENT 
 
 OF 
 
 DISEASES OF THE CHEST. 
 
 PART L 
 
 DISEASES OF THE LUNG AND WINDPIPE. 
 
 BY 
 
 WILLIAM ^ STOKES, M.D., P.R.I.A., D.C.L. Oxon, F.R.S., 
 
 REGIUS PROFESSOR^ OF PHYSIC IN THE UNIVERSITY OP DUBLIN, PHYSICIAN 
 TO THE QUEEN IN IRELAND, ETC., ETC., ETC. 
 
 WITH 
 
 MEMOIR BY DR. ACLAND, F.R.S. 
 
 EDITED POE THE NEW SYDENHAM SOCIETY 
 
 BY 
 
 ALFRED HUDSON, M.D., M.R.I.A., 
 
 REGIUS PROFESSOR OF PHYSIC IN THE UNIVERSITY OF DUBLIN. 
 
 THE NEW SYDENHAM SOCIETY. 
 
 MDCCCLXXXII.
 
 500
 
 INTEODUCTION BY DE. ACLAND. 
 
 The volume which is now again given to the world, with some 
 important additions, has been for many years out of print. Dr. 
 Stokes was unwilling in advanced life to republish this work of his 
 prime without alterations which would have involved, in fact, re- 
 writing. The treatise was at its time as complete as it was 
 masterly. 
 
 On his death, and in compliance with his request, Dr. Hudson, 
 the valued friend of many years, undertook to prepare, as an 
 ^ historical landmark in medicine, a reprint with additions which 
 ^ Dr. Stokes had himself prepared and put in Dr. Hudson's hands. 
 ^ Dr. Hudson made me promise that if he edited the book, I would 
 -J write a brief memoir of our common friend as a prefix to the 
 work. Death has now removed Dr. Hudson also, and what I 
 o write cannot, alas ! be revised bv him. Had I foreseen this, I 
 
 ^ probably should not have undertaken the difl&cult duty. As it is, 
 
 X 
 
 ^ the few pages that follow are poor offerings placed on tho grave 
 
 J of a beloved teacher, at the dying request of his comrade, who fell 
 
 9 while erecting a monument to his friend. For the love of both 
 
 would that my offering were more worthy. I pray the members 
 
 of the New Sydenham Society to accept the tribute, such as it is, 
 
 not for the deed but for the will. 
 
 59S17S
 
 VI INTEODUCTION. 
 
 The Readers should take note that the aim of the Memoir is 
 to represent Stokes as a man rather than to describe in detail 
 his work as Physician and Author. The reprint of his work 
 tells its own tale. What like man was he who wrote it ? 
 
 Henry W. Acland. 
 OxFOED, January 6, 1882.
 
 M E M I K. 
 
 The Author of the work to which this Memoir is prefixed,VDr. 
 William Stokes, was born in July of the year 1804, in the City 
 of Dublin. His father, Whitley Stokes, was Regius Professor 
 of Medicine in the University and Senior Fellow of Trinity 
 College. He was a man of lofty aims and untiring energy, 
 and employed these not only in the work of his profession, but 
 in promoting by various methods the welfare of his country. 
 He was a successful teacher of medicine in the University of 
 Dublin and in the Meath Hospital. By his exertions the 
 Botanical Gardens and Museum of Trinity College were estab- 
 lished. He was the first University Lecturer on Natural History, 
 at a time when the conditions of society in Ireland were un- 
 favourable to intellectual progress. Indeed, he sought to develop 
 the resources of Ireland in many ways, and to further the education 
 and religious instruction of the people through their native 
 language. 
 
 The early life of William Stokes was much influenced by his 
 father. The boy was his assistant in his laboratory ; the com- 
 panion of his botanical and geological walks among the Dublin 
 hills. This companionship was of the more value because 
 the tone of Irish society, notwithstanding the brilliant talent and 
 energy of the people, had not recovered the misfortunes, excite- 
 ment, and depression consequent on the revolutionary movement 
 which closed the 18th century. Trinity College had no adequate 
 museum, lecture-rooms, or laboratories, such as were to be found 
 in Edinburgh, Paris, Vienna, Leyden, or Berhn. No journal of 
 medical science existed in Ireland before 1800. It was no doubt 
 fi-om these causes that Whitley Stokes, the father, sought his 
 degree in Edinburgh in 1793, as did William Stokes in 1825 ;
 
 VIH MEMOIR. 
 
 hence it was that Eobert Graves spent several years workhig in the 
 continental schools. Whitley Stokes, after his Edinburgh degree, 
 obtained a fellowship at Trinity College, which, however, religious 
 scruples led him to resign. He decided, probably in consequence 
 of these scruples, that his sons should go neither to school nor 
 college. William received, however, a thorough classical education 
 from John Walker, also an ex-Fellow of Trinity College, and a 
 learned scholar and mathematician. It was a source of regret 
 to William Stokes in after life that he had not been allowed 
 to enter College, but this circumstance was compensated in his 
 case to some extent by the intimate personal relations into which 
 he was led thereby with his father. This early intercourse 
 with so able and active a man led him, no doubt, to appreciate 
 the great opportunities which he had on arriving in Edinburgh, 
 at that time the most active scientific University in the king- 
 dom. He left his home at the age of nineteen for Glasgow, 
 where he remained some months, passing on to Edinburgh in 
 the spring of 1823. There the circumstance occurred which 
 exercised the deepest influence on his future life. He became 
 the pupil of William Alison, the Professor of Medicine, whose 
 name no pupil or friend can write without feelings of the deepest 
 admiration, affection, and gratitude. Later in life. Dr. Stokes 
 wrote of this remarkable man : " Alison was the best man I ever 
 knew. I wonder how it has happened that men should forget 
 what reverence is due to his memory — whether we look on him 
 personally as a man of science and a teacher, or at his life as that 
 of an exemplar of a soldier of Christ. It Avas my good fortune 
 to be very closely connected with him during my student days in 
 Edinburgh, and to attend him by day, and more often far into 
 the night, in his visits of mercy to the sick poor of that city, to 
 whom he was for many a year physician, counsel, and support." 
 William Stokes had, indeed, just the nature to be led captive by 
 that noble man. He followed him by day and by night in his 
 wanderings through the wretched wynds and the then miserable 
 haunts of Edinburgh ; he saw the acute observer investigating
 
 MEMOIR. IX 
 
 every form of the severest disease, whether in the homes of the 
 poor or in the wards of the great Infirmary ; and he watched the 
 workings of the tender spirit whose goodness sm-passed even its 
 great scientific knowledge, and drew in the lessons to he derived 
 from one, in whom the pursuit of intellectual truth in things 
 material or physiological was a passion, hut who yet never 
 seemed to forget that the moral elevation of his fellow-men 
 was a worthier ohject than the promotion of their material 
 interests and comforts. 
 
 Of his life as a student I am unable to find details, but what 
 has just been said, added to one other fact, is sufficient. Before 
 he left Edinburgh, at the end of two years residence, he had 
 prepared for publication and published a volume on the use of 
 the stethoscope — for which little work he received the large sum 
 of £70. No better evidence than this can be adduced of the 
 effect that the influence of Alison and others had upon the 
 young Irish student. Yet I cannot forbear relating a story 
 of how this influence began, as I have heard it, not from 
 himself, but from his family. He was walking one wet 
 night down the old Cowgate ; he observed a crowd at the 
 entrance of a dark passage ; he stopped to see what it could 
 mean ; he entered a low room filled with sick poor and Professor 
 Alison seated among them ; he watched the scene ; a young man 
 evidently suffering from advanced fever stepped forward, Alison 
 said, " My poor man " (I can now hear him say it), " go to your 
 bed, and when I have done here I will come to you." Young- 
 Stokes then stepped forward and said, " Sir, I will take the poor 
 man to his home." " Who are you ? " asked Alison. " One of 
 your pupils ; my name is Stokes." "I never saw you before," 
 said Alison. " Perhaps not, but I have seen you, for I go to 
 your lectures. Let me take the poor man home, and I will come 
 and tell you how he goes on." " Very well," said Alison, " yon 
 may go." From that time they were companions and friends. 
 With this seed, scientific and human, I would almost say Christ- 
 like or divine, thus sown, Stokes returned to Dublin, to face in
 
 X MEMOIR. 
 
 Lis native metropolis the realities of professional life in similar 
 scenes. He left Scotland in 1825. Before he left he had formed 
 an attachment to a lady, who in 1828 became his wife. 
 
 Thus prepared, Mr., now Doctor, Stokes, of the University of 
 Edinburgh, settled in Dublin to enter on his professional life. 
 He brought with him the reputation of having already, while 
 still a student, published an important treatise on Diseases of 
 the Chest, fully abreast with the most advanced knowledge of 
 the day, and a subject the development of which has marked one 
 of the greatest epochs in the history of medicine. He was at once 
 elected Physician to the great Meath Hospital, in the place of 
 his father, who had resigned. He became the colleague of Dr. 
 Kobert Graves, one of the most remarkable men that L-eland 
 has produced in the profession of medicine ; nay more, one of 
 the truest geniuses which that profession has seen in any 
 country. The two henceforward were friends ; and being friends, 
 were comrades in what they both felt, and properly felt, to be a 
 hard fight with actual evils, physical and moral. Hence- 
 forward Stokes is to be thought of as above all else the 
 Physician of the poor, working in a great and famous Hospital, 
 surrounded by pupils hanging on his lips, and who himself 
 remained through life the most devoted student and keenest 
 observer of his whole class. Whatever he acquired of duty, 
 honour, or place in after life, was engrafted on this fundamental 
 office and character. He began at once to lecture. About this 
 time, August, 1826, when he was 22 years of age, he writes : 
 " I rise early, write until breakfast, then go to dispensary, 
 where I sit in judgment on disease for an hour; then to the 
 hospital, where I go round the wards attended by a crowd of 
 pupils ; from the hospital I return home, write again till two, 
 and then go round and visit my patients through difl'erent parts 
 of the town attended by a pupil. My patients have all one great 
 defect, viz., that instead of giving money, they too often, 
 unfortunate beings, have to solicit it from their medical atten- 
 dant ; and who, with the heart of a man, would refuse to relieve
 
 MEMOIR. XI 
 
 their su£ferings when he has a shilling in his pocket ? A poor 
 woman whom I attended for long, and who ultimately recovered, 
 said, ' Oh, Doctor, j^ou have given me a good stomach, hut I have 
 nothing to put into it.' " 
 
 In the autumn and winter of this same year, 1826, fever was 
 raging in Duhlin in consequence of the great distress caused hy 
 the failure of the potato crop in summer. He writes, September 
 17th, "Were you in Dublin just now you would be shocked at 
 the distress, aggravated by disease, under which the lower classes 
 are labouring. They are literally lying in the streets under fever, 
 turned by force out of their wretched lodgings, their bed the cold 
 ground, and the sky their only roof. We have now 240 cases in 
 the Meath Hospital of fever,* and yet we are daily obliged to 
 refuse admittance to crowds of miserable objects labouring under 
 the severest form of the disease. God help the poor ! I often 
 wonder why any of them who can afford it should remain in this 
 land of poverty and misrule. Government has now opened in 
 different parts of the town hospitals with accommodation for 
 1,100 patients, and yet this is not half enough. I walked out 
 the other night, and on passing by a lane my attention was 
 arrested by a crowd of persons gathered in a circle round a group 
 which occupied the steps of a hall door. This was a family, con- 
 sisting of a father, mother, and three wretched children, who had 
 been just expelled from their lodgings as having fever. The 
 father was in high delirium, and as I approached him started 
 off and ran down the street ; the mother was lying at the foot of 
 the door perfectly insensible, with an infant screaming on the 
 breast, where it had sought milk in vain, and the other two filled 
 the air with their lamentations. It was a shocking sight in- 
 deed. No one would go near them to bring them even a drop 
 of cold water. In a short time, however, I succeeded in having 
 them all carried to the hospital, where they have since recovered." 
 
 Thus, by hospital practice, by attendance on the poor in their 
 own homes, and by constant teaching in both, he acquired, and 
 
 * Shortly afterwards this hospital accommodated 300 fever patients.
 
 Xn MEMOIE. 
 
 continued to acquire, the material which through a long life 
 was freely distributed by writing, by lectures, and by personal 
 intercourse. The printed systematic works which he published 
 during the next forty-five years were not as numerous as those 
 of many other great practitioners, but as naturally the case with 
 one who had gone through such a course of training, every 
 utterance of his was weighty and full. The circumstances of 
 the time had specially directed his attention to the works of 
 Laennec, and, as we have already seen, to the use of the stetho- 
 scope. Accordingly, although he lectured on medical practice 
 generally, he was specially storing his mind with every fact and 
 inference bearing on pulmonary disease. This knowledge cul- 
 minated in the work reprinted in this volume. It was published 
 in 1837, twelve years after his return from Edinburgh. But 
 prior to that, in 1828, he printed two lectures, dedicated to the 
 class of the Meath Hospital, on the application of the stethoscope 
 to the diagnosis and the treatment of thoracic disease. That 
 which appears now so obvious as to be of the nature of truism 
 then required argument. In his own words,* " a new source 
 of knowledge has been lately added to medicine ; the sense of 
 hearing has been called to our assistance, and has, I will affirm, 
 added more to the facility, certainty, and utility of diagnosis 
 than anything which has been done for centuries. By the 
 stethoscope we substitute the ear for the eye ; penetrate into the 
 mysteries of hidden disease, and throw light on a class of 
 affections perhaps more important than most of those to which 
 the human frame is liable." And it is worth noticing by the 
 way that in these technical lectures he takes the opportunity of 
 reminding the surgical students of that day to avoid the error of 
 neglecting what were termed medical diseases. The line of 
 distinction in the study of the two professions of medicine and 
 surgery is now looked upon by the liberal and enlightened to 
 serve neither and to injure both, and he tells all the students in 
 his faithful and graphic way that "the stethoscope is an instru- 
 
 * Two lectures on the Application of the Stethoscope. Dublin, 1828, p. 12.
 
 MEMOIR. xm 
 
 ment, not, as some represent it, the bagatelle of a day, the brain- 
 born fancy of some speculative enthusiast, the use of which, like 
 the universal medicine of the animal magnetism, will be soon 
 forgotten, or remembered only to be ridiculed. It is one of 
 those rich and splendid gifts which Science now and then 
 bestows upon her most favoured votaries, which, while they 
 extend our views and open to us wide and fruitful fields of 
 inquiry, confer in the meantime the richest benefits and blessings 
 on mankind. This instrument was first introduced by one whose 
 works will ever remain as an example of patient investigation, 
 philosophical research, and brilliant discovery, and its use is now 
 supported by the liberal and enlightened and the scientific 
 portion of the medical world." I cannot but remember now 
 that more than ten years after this passage was written, I 
 myself being a clerk in a great hospital, had to withstand the 
 ridicule of an able teacher for devoting myself to the mastery of 
 the instrument. 
 
 Nine years elapsed before he published the present volume. 
 As the volume is in the hands of the reader it is hardly desirable 
 to ofier an analysis of its contents, or to give any judgment upon 
 them. It is perhaps sufficient to say that it at once placed him, 
 in the opinion of the whole medical profession, in the front rank 
 of observers and thinkers. 
 
 The terseness of his language and clearness of his statements 
 produced a profound impression on vigorous and active young 
 minds at the time. The precise summaries at the end of the 
 various chapters, notably that of the physical signs of diseases 
 of the pleura, seemed almost a revelation both in statement of 
 fact and drawing of inference. 
 
 Such was the book which raised Stokes to the high position 
 which he ever after maintained. It is worthy of note in 
 the present day that one of his settled beliefs was that true 
 progress in any art is gradual and cautious, and that the wisest 
 worker carefully and thankfully uses all good material left by 
 predecessors. " If you would advance a knowledge," he would
 
 XIV MEMOIR. 
 
 say, " be content to take up the thread where the last investigator 
 laid it down, and set yourself to carry on his work." In this 
 temper he lived ; in this he worked. He looked on himself as 
 promoting the objects of his predecessors and his fellow-workers, 
 ever using, ever adding, never detracting. 
 
 In a very few years from this period the degree of M.D. was 
 conferred upon him, honoris causa, by the University of Dublin ; 
 he was elected a Fellow of the King's and Queen's College of 
 Physicians of Ireland ; honorary member of the Imperial College 
 of Vienna ; of the Royal Medical Societies of Berlin, Leipsic, 
 Edinburgh, and Ghent ; of the Medical Societies of the Grand 
 Duchy of Baden, the National Institute of Philadelphia, and 
 many others. In 1842 he became Regius Professor of Physic 
 in the University of Dublin, succeeding his father, who had 
 occupied the chair for many years. Dr. Stokes published no 
 great work from this time for eighteen years, when another volume, 
 of a very different character, but of equal merit, that on Diseases 
 of the Heart, confirmed the general impression of all physicians 
 of the great powers of the now veteran teacher. This work was 
 translated into German. The translator, Dr. Lindwurm, makes 
 this pregnant remark in his introduction, " Our more modern 
 German works are, to a greater or less extent, only treatises on the 
 physical diagnosis of organic affections of the heart ; Stokes, on 
 the contrary, resists this one-sided tendency, which bases the 
 diagnosis solely on physical signs and disregards the all-important 
 vital phenomena ; he lays less weight on the differential diagnosis 
 of lesions of the several valves, and on the situation of a sound, 
 than on the condition of the heart in general, and especially on 
 the question as to whether a murmur is organic or inorganic, 
 and whether the disease itself is organic or functional ; and he 
 devotes especial attention to functional disturbances of the heart, 
 such as occur in typhus, in anemia, and in nervous conditions 
 of that organ." The book is illustrative of one of the most re- 
 markable features of Stokes' character. In talking over a case 
 with him, it was hard to say which was the more striking, his
 
 MEMOIK. XV 
 
 power of observation and sagacity, or his modesty; and in no 
 cases was this more remarkable than in that class of diseases in 
 which he was confessedly a supreme master. The reason of this 
 is found in a passage of the volume on the heart : " The diagnosis 
 of the combinations of diseases, even in so small an organ as 
 the heart, is still to be worked out ; and until this be done the 
 rules of physical diagnosis founded on the presumed isolation of 
 disease must be used with great caution. I cannot, even at the 
 risk of being charged with understating the position of physical 
 investigation at the present day, avoid expressing my opinion 
 that a too great positiveness marks some of the statements in 
 our standard works, and that the difficulties of special diagnosis 
 are still infinitely greater than many might be led to suppose. 
 I desire to enter a protest against the tendency, still too prevalent 
 in many schools, which would base the diagnosis of disease in 
 great part, if not entirely, on the consideration of purely physical 
 signs, to the exclusion of that important class of phenomena 
 which, for want of a better name, we are obliged still to call 
 Vital. For there is nothing more calculated than this to cause 
 the neglect of that first and greatest lesson in medicine, which, 
 while inculcating modesty and caution in diagnosis, makes us 
 bring every possible light to bear on the case before us. As the 
 student fresh from the schools, and proud of his supposed 
 superiority in the refinements of diagnosis, advances into the 
 stern realities of practice, he will be taught greater modesty, and 
 a more wholesome caution. He will find, especially in chronic 
 disease, that important changes may exist without corresponding 
 physical signs — that as disease advances its original special 
 evidences may disappear — that the signs of a recent and trivial 
 affection at one portion of the heart may altogether obscure, or 
 prevent, those of a disease longer in standing and much more 
 important — that functional alteration may not only cause the 
 signs of organic lesion to vary infinitely, but even to wholly dis- 
 appear — that the signs on which he has formed his opinion to- 
 day may be wanting to-morrow — and, lastly, that to settle the
 
 XVI MEMOIK. 
 
 simple question between the existence of functional and that of 
 organic disease, will occasionally baffle the powers of even the 
 most enlightened and experienced physicians." 
 
 This volume on the Diseases of the Heart was at once accepted, 
 and since has been received, as one of the most acute, graphic, 
 and complete accounts of the clinical aspects of the organ 
 under discussion. It exemplifies, in a very remarkable way, the 
 several characteristics of Dr. Stokes' mind, at once so purely 
 scientific and so eminently practical. No practitioner can open 
 the volume without feeling it to be a store-house of knowledge 
 obtained at the bed-side. It is sufficient to refer to the table of 
 cases at the close of the volume, and to the several summaries 
 at the end of the discussion of the various forms of heart- 
 disease, to satisfy oneself of the truth of this observation ; but 
 two illustrations of his acuteness and care may be here given. 
 
 " We read that a murmur with the first sound, under certain 
 circumstances, indicates lesion of the mitral valves. And again, 
 that a murmur with the second sound has this or that value. 
 All this may be very true, but is it always easy to determine 
 which of the sounds is the first, and which the second ? Every 
 candid observer must answer this question in the negative. In 
 certain cases of weakened hearts acting rapidly and irregularly, 
 it is often scarcely possible to determine the point. Again even 
 where the pulsations of the heart are not much increased in 
 rapidity, it sometimes, when a loud murmur exists, becomes 
 difficult to say with which sound the murmur is associated. The 
 murmur may mask not only the sound with which it is properly 
 synchronous, but also that with which it has no connexion, so 
 that in some cases even of regularly acting hearts, with a distinct 
 systolic impulse, and the back stroke with the second sound, 
 nothing is to be heard but one loud murmur. 
 
 " So great is the difficulty in some cases, that we cannot resist 
 altering our opinions from day to day as to which is the first and 
 which the second sound.
 
 MEMOIR. XVll 
 
 * * To the inexperienced the detailed descriptions of such phenomena 
 as the intensification of the sounds of the pulmonary valves ; of 
 constrictive murmurs as distinguished from non-constrictive ; of 
 associations of different murmurs at the opposite sides of the 
 heart ; of presystolic and post-systolic, prediastolic and post- 
 diastolic murmurs, act injuriously — first, by conveying the idea 
 that the separate existence of these phenomena is certain, and 
 that their diagnostic value is established — and secondly, by 
 diverting attention from the great object, which — it cannot be 
 too often repeated — is to ascertain if the murmur proceeds from 
 an organic cause ; and again, to determine the vital and physical 
 state of the cavities of the heart. 
 
 "If the question as to the practicability of the negative diagnosis, 
 with reference to either orifice, be raised, it appears probable 
 that where a mitral murmur is manifest, it will be easier to 
 determine the absence of disease of the aortic valves than to 
 declare the integrity of the mitral valves in a case of aortic 
 patency. The experience of each succeeding day devoted to the 
 study of diseases of the heart will make us less and less confident 
 in pronouncing as to the absence of disease in any one orifice, 
 although no physical sign of such a lesion exist, if there be 
 manifest disease in another, or again, if there be symptoms of 
 an organic affection of the heart." 
 
 About this time, 1854, he published the lectures on Fever in 
 the Medical Times and Gazette. These were afterwards col- 
 lected, but not before the year 1874, into a single volume with 
 additions. In this volume he did not pretend to give even a 
 sketch of all that is known or believed to be known respecting 
 fever. " Nothing will be found in them relating to histological 
 research, the chemico-vital states, of the fluids^ or organs, or 
 the analysis of the laws of crisis." He does not even attempt 
 to weigh the evidence concerning the separate identity of fevers, 
 and in these respects surprised some who leant on his judgment 
 in the most absolute manner. But, as was his wont, he confined 
 
 b
 
 XVIU MEMOIR. 
 
 himself to that which he seemed to himself to know, and he 
 would not allow himself to go beyond his convictions. In one of 
 his early lectures he speaks of the difficulty of changing ideas in 
 which one has been educated. " There is nothing more difficult," 
 he says, "than for a man who has been educated in a particular 
 doctrine to free himself from it, even though he has found it to 
 be wrong. There is something in the human mind which 
 renders the reception of a doctrine, if it be a bad one, a most 
 dangerous circumstance ; it is like the imbibition of a particular 
 poison or miasma. We find that some men who have once been 
 exposed to the miasmatic influences which cause intermittent 
 fever will for nearly the whole course of their lives be incapable 
 of getting rid of that influence which has been once received ; 
 and thus it is not only with physical but with moral or intel- 
 lectual impressions." Whether he had in mind when he wrote 
 these words his own unwillingness to accept in full the modern 
 distinctions between fevers cannot be positively said, but he dis- 
 cusses the subject in his sixth lecture with great care, and he 
 seems quite unwilling to admit the modern accepted distinctions. 
 " I have said," he writes in the seventh lecture, " that I hold the 
 study of the marks or points of agreement amongst these diseases 
 to be of more value than that of their differences, and for this 
 reason, that the former bears on the question of treatment much 
 more than does that of their distinctions." He had seen, 
 studied, and treated fever on a great scale for fifty years, and 
 like his great master, Alison, was familiar with it in all its forms 
 and under all the conditions which appear to cause it. He 
 seemed never to have satisfied himself that there were generic 
 differences in these forms, but was inclined to consider them 
 varieties. This I learn on the authority of Sir William Gull to 
 have been the belief of Dr. Alison to the last. Again and 
 a<^ain this impression seems to be ineffaceable from Stokes' 
 mind. He reasoned on the data he had in Ireland, as did 
 Alison in Scotland, or Jenner in London. "I have told you," 
 he says, " that no two epidemics are exactly alike, either as
 
 MEMOIE. six 
 
 regards their essential symptoms or local complications. . . . 
 I have said that this is not the place to go into the history of 
 every observed form of fever and into various controversial 
 questions that have arisen regarding them. Study the excellent 
 works of Dr. Murchison, Dr. Hudson, Sir Wm. Jenner, and 
 Dr. Stewart, and use your own judgment as to how far your 
 experience bears on the great questions therein discussed ; in 
 the meantime let us continue to study the local complication^, 
 after which we shall be in a position to deal with the question 
 of the treatment, if not the prevention of the disease." The 
 volume will always be worthy of careful attention in historical 
 relation to the writings of Alison and Graves, Murchison and 
 Jenner, as the observations, for preventive and therapeutical 
 purposes, of a most acute physician. Many passages ring in it 
 as if they had been written by Sydenham or by Hunter in their 
 best moods. 
 
 In the year 1863 Dr. Stokes edited a volume containing studies 
 in physiology and medicine by Dr. Kobert Graves, who had 
 become Professor of the Institutes of Medicine and the School 
 of Physics in Ireland. Of the influence which these two men, 
 Graves and Stokes, exercised on one another for good it would 
 not be possible to speak too strongly. Those who remember the 
 effect which Graves' Clinical Lectures produced when they 
 appeared will readily understand this. Stokes, in writing of 
 him after his death, calls him "the most remarkable man, from 
 his erudition, the variety of his mental powers, his industry, 
 and from the multitudinous additions which he made to practical 
 medicine, of which the profession in this country can boast." 
 He ■\vas a man who in a marked degree combined the scientific 
 mind of the physiologist with the intensely practical quickness of 
 the clinical observer. Stokes used to tell with delight a saying 
 of Graves'. He was going round the hospital, when on entering 
 the convalescent ward he began to expatiate on the healthy 
 appearance of some who had recovered from severe typhus. 
 "This is all the effect of our good feeding," he exclaimed; 
 
 62
 
 XX MEMOIR. 
 
 " and lest when I am gone you may be at a loss for an 
 epitaph for me, let me give you one in three words, ' He fed 
 Fevers.' " 
 
 "He was a man," he also said, "besides with a warm and 
 sensitive heart ; loving truth for its own sake, he held in uncon- 
 cealed abhorrence all attempts to sully or distort it, and he never 
 withheld or withdrew his friendship from any, even those below 
 him in education and social rank, if he found in them the quali- 
 ties which he loved, and which he never omitted to honour." 
 
 And again : " The world never spoiled him, so that he pre- 
 served most of the youthful, and all the kindly and better 
 qualities of his mind up to the hour of his death." 
 
 His volumes of clinical medicine, and his remarkable powers 
 as a clinical teacher will never be forgotten in the history of 
 Ireland. His Physiological Essays, edited by Dr. Stokes, derive 
 their chief present interest from the personal characters of the 
 author and editor. 
 
 During the three epochs of Dr. Stokes' life marked out by the 
 intervals between the publication of his principal works, — viz., 
 his volume on the Stethoscope in 1825 at Edinburgh ; that on 
 Diseases of the Chest in 1837 ; on the Heart in 1854 ; and on 
 Fever in 1874, — each of them evidencing in dififerent ways the 
 mixed scientific and practical nature of his professional life, — a 
 tide of other medical writing was flowing in full force from his 
 pen. These writings were very various. A series of Lectures 
 on the Practice of Physic, written between 1832 and 1835, and 
 delivered in the Meath Hospital and the Park Street School, 
 appeared in the London Medical and Surgical Journal (vols. 
 3, 4, 5, 6). They were reprinted in America; and the volume 
 was edited afterwards, with additional matter, by Dr. Bell, and 
 became one of the standard medical treatises of the United 
 States. He was at this time only twenty-eight years of age. 
 He wrote seven articles for the Cyclopaedia of Medicine between 
 1832 and 1835. The subjects were. Derivatives, Dysphagia, 
 Enteritis, Gastritis, Gastroenteritis, Inflammation of the Liver ;
 
 MEMOIE. xxi 
 
 and in conjunction with Dr. Mac Adam, Peritonitis. Under what 
 circumstances this particular class of subjects was assigned to 
 Dr. Stokes I have no evidence. In the Dublin Medical Journal 
 there are various important papers. One in the volume for 
 1832 is on the use of large doses of opium in certain cases 
 of disease, a paper of great practical value. It will interest 
 pupils of his revered teacher Alison, with whom this subject 
 was one of cardinal importance. This was followed by two of 
 not less moment from the point of view of practice and treat- 
 ment. One in 1833 is on the Diagnosis of Pericarditis. The 
 other paper in 1839 is on the " State of the Heart, and the Use 
 of Wine in Typhoid Fever." His words at the outset of this 
 treatise, written more than forty years ago, are so graphic that 
 they may be quoted here for" the sake of younger readers who do 
 not know the story of the past. 
 
 "If we compare the inexperienced man with him who has 
 had a long-continued practice in fever, we may often observe that 
 the former employs a too vigorous antiphlogistic treatment in 
 the commencement of the disease, and delays the exhibition of 
 stimulants until the powers of life are sunk too long, while the 
 latter is much more cautious in husbanding the strength of his 
 patient, and shews much less fear of resorting to wine and other 
 stimulants. It is in determining on the use of wine in fever 
 that the junior or inexperienced man feels the greatest difficulty ; 
 it is in its exhibition that he betrays the greatest uncertainty 
 and fear. This is to be explained by referring to the general 
 character of the doctrines which have prevailed within the last 
 quarter of a century, and which are only now beginning to yield 
 to a more rational pathology. The doctrine of an exclusive or 
 almost exclusive solidism which referred all diseases to visible 
 changes of organs, which taught that inflammation was the first 
 and principal morbid phenomenon, and that fevers were always 
 the result of, or accompanied with, some local inflammation, was, 
 however disguised under various denominations, the doctrine 
 taught to the majority of our students. Their ideas were thus
 
 XXll MEMOIK. 
 
 exclusively anatomical ; inflammation formed the basis of their 
 limited pathology, and thus instructed, they entered on the wide 
 field of practice, most of them having never even attended a 
 fever hospital ; utterly ignorant of the nature of essential fevers, 
 they applied, in the diseases of debility, the treatment of acute 
 local inflammation, and delayed stimulation until nature could 
 not be stimulated. Let it not be suj^posed that in this picture 
 I seek to make a favourable contrast between the education 
 which I myself received, and that given to others — far from it, 
 I confess that it was not until several years after I commenced 
 practice that I became fully aware of the erroneousness of what 
 is termed the anatomical theory of disease ; and I feel certain, 
 humiliating though the confession may be, that the fear of 
 stimulants in fever with which I was imbued, was the means of 
 my losing many patients whose lives would have been saved, had 
 I trusted less to the doctrine of inflammation, and more to the 
 lessons of experience, given to us by men who observed and 
 wrote before the times of Bichat or of Hunter. 
 
 " The hospital physician will be frequently asked by students to 
 state the principle on which he administers wine in fever. I 
 conceive the question may be thus answered. Typhus fever is 
 a disease which has a tendency to a spontaneous and favourable 
 termination, but one in the course of which the powers of life 
 are attacked by a most malignant influence. By wine, food, and 
 other stimulants we support nature, until the struggle is past, so 
 that, to use the words of an ancient author, which embody a 
 more profound principle than appears at first sight, we ' cure 
 the patient by preventing him from dying ' ; that is to say, we 
 prolong his existence until the natural and favourable termination 
 of the disease arrives. We do not allow our patients to die of 
 exhaustion, and bearing in mind the depressing influence they 
 have to struggle with, we give stimulants at the proper time and 
 with a bold hand. We give our patients an artificial life till the 
 period arrives when nature and health resume their sway." 
 
 Between these papers was one on the Pathology of Aneurism
 
 KEMOIB. XXlll 
 
 (1834), and one on Emphysema (1836), besides others on pomts 
 of Thoracic Pathology, shewing the clear purpose for which his 
 mind was being stored with the knowledge that was to bear fruit 
 in his mature life.* He was now only thirty-three years of age. 
 His great work on the Diseases of the Chest was published. He 
 became overwhelmed with private practice. At the Meath 
 Hospital he worked, thought, and taught. Henceforward, 
 wherever he spoke or wrote, men felt that there was one who 
 spoke and wrote only when there was something which should 
 not be withheld. Of such utterances there is a remarkable illus- 
 tration in a paper by himself and Dr. Cusack on the mortality of 
 medical men in Ireland. They only who know Ireland can fully 
 estimate either the sufferings of the people, or the devotion 
 of such active and able men as, loving their country, live for it ; 
 and who, living there, work with discretion and steadiness. The 
 occasion of this document was the deep sense he entertained of 
 the hardships and dangers to which the medical men in Ireland 
 are exposed in attending on Fever Hospitals and Dispensaries. 
 Many old pupils had fallen victims ; they had perished while 
 li\ing on the poorest pittance from the Government, and their 
 widows were unprovided for. Ireland, from whatever cause, is 
 most productive of fever. In ten years prior to June, 1841, a 
 period not characterized by any remarkable epidemic, nearly one- 
 tenth of all deaths in the province of Leinster was from fever. In 
 Ireland, he said, few medical men escape fever, and they 
 generally have it with great malignity. It was rarely absent 
 from the rural districts, in which, owing to the nature of the 
 dwellings and the condition of the peasantry, and the distances 
 to be travelled, the dispensary surgeon has to meet, in cold and 
 wet, fatigue and hunger, the most concentrated contagion. A 
 cholera epidemic is far less dangerous than the ordinary tj^phus. 
 Of 1,220 medical men in charge of 406 Medical Institutions, 568 
 had fever between 1818 and 1843. These facts, among which he 
 lived, and which he collected with care, became the subject 
 * For a list of his minor papers see Note, p. xlii.
 
 XXIV MEMOm. 
 
 of Parliamentary inquiry. Though so recent, they seem now as 
 the ghastly tale of some dark bygone age. 
 
 The keen interest which Dr. Stokes had in all that concerned 
 the condition and happiness of the medical profession is illus- 
 trated by the paper just discussed. One of the methods in which 
 through life this strong feeling was displayed, is seen in the 
 efforts which he made to advance the culture of the profession. 
 His opinion on this subject, in the year 1861, should be told in 
 his own words : "The chief, the long existing, and, I gi-ieve to 
 say it, the still prominent evils among us are the neglect of 
 general education, the confounding of instruction with education, 
 and the giving a greater importance to the special training than 
 to the general culture of the student." And the reason of this 
 he gives in these words : " Let us now ask, TSTiat is medicine ? 
 Is it an isolated science ; an exception to all other branches of 
 human knowledge ; a study having no use for the great weapons 
 of the human mind, observation, and the reasoning power ? Are 
 the studies of letters, the influence of history, ethics, and the laws 
 of physical science nothing to it ? I will not dwell on such 
 questions, from my respect for your understandings. But what 
 it is not, it may be wholesome to declare. It is not the result of 
 a poor seed, sown on a raw and sterile soil. It is not a handi- 
 craft, governed by a fixed rule, or any set of rules, that you may 
 learn by rote ; it is not a study of fixed, but of varying con- 
 ditions. It is no solitary science, but rather a complex system 
 of knowledge of many kinds, derived from many sources — from 
 the observations of bygone years, and the multiplied discoveries 
 of the present day. It is related to, and inseparable from, all 
 other branches of human knowledge, from which it largely 
 borrows, and to which it pays back vrith. interest." . . . . " The 
 old Universities of England and Ireland have ever kept up the 
 dignity and the reality of their medical degrees. They have not 
 sought to create revenue for their schools, and increase the mem- 
 bers attending in their medical classes, by lowering the degree 
 in Medicine below that in Divinity or in Law. . . . They have
 
 MEMOIR. XXV 
 
 taken a riglit view of the first objects of their foundation, 
 which are the general mental culture and moral training of all 
 over whom their powers may extend. With them the general 
 culture has been the leading object, and has been fostered and 
 valued, first, for its own sake, and next, as giving the only safe 
 ground for such special instruction as may be requisite for this 
 or that calling." ..." The Medical Council have marked their 
 sense of the predominating importance of general culture in this 
 wise — that their Eeport on Medical Education deals almost 
 wholly with the subject of general or extra-professional training. 
 It hardly touches on special education except so far as relates 
 to the mode of conducting examinations. The Council have 
 obviously felt that the greater question claimed their first care." 
 And, speaking of the modern system of cramming for examina- 
 tions, he says: " It is a system the evils of which have increased, 
 in place of diminishing. The overloading of special instruction 
 will not help but really retard the production of the higher class 
 of men. ... It was not in this fashion that the fathers of 
 British Medicine were moulded ; nor our great Jurists, or our 
 learned and pious Theologians were trained. Will not its result 
 be, at the best, to produce a crowd of mediocrities, with no 
 chance, or but a little one, of the development of the larger man ? " 
 And then he ends this address, delivered at the Meath Hospital, 
 from which these passages have been quoted, thus : " Let us 
 labour to place the teaching of medicine in its true position. 
 Let us emancipate the student, and give him time and oppor- 
 tunity for the cultivation of his mind, so that in his pupilage he 
 shall not be a puppet in the hands 'of others, but rather a self- 
 relying and reflecting being. Let us ever foster the general 
 education in preference to the special training, not ignoring the 
 latter, but seeing that it be not thrust upon a mind uncultivated 
 or degraded. Let us strive to encourage every means of large 
 and liberal education in the true sense of the term, and so help to 
 place and sustain our noble profession in the position which it 
 ought to occupy."
 
 XXVI MEMOIR. 
 
 I must repeat once more that nothing impresses me more 
 on looking through his various utterances in relation to the con- 
 dition of medicine in this country than the intensity with which 
 he feels the importance not only of training the faculties of 
 reason and ohservation, but also at promoting the general culture 
 of the mind. He breaks out from time to time, aj)parently 
 with horror, of the opposite \iews. In one address concerning 
 the effect of small professional corporations he says : " The 
 student was taught not only in private, but in public lectures, 
 that he should make his special training the great object. He 
 was taught to neglect the larger culture of his mind, and the 
 lower aim was ever kept before him. No wonder that in course 
 of time the claims of medicine to be considered as one of the 
 leading professions were lowered. It is plain that unless a\i 
 this be changed, unless this cancer be eradicated, the time 
 will come when we shall be shamed by seeing the more difficult 
 problems of medicine attempted and solved by men outside the 
 profession ; men of large and liberal education, who will succeed 
 in doing that which its proper members were unable to perform. 
 Among the many errors which we must try to get rid of in 
 dealing with this matter, this is one of such magnitude that to 
 its existence may be traced most of the enls that beset the 
 student of medicine." 
 
 I am bound to record, in connexion with this subject, the 
 deep interest which he took in the progress of opportunities for 
 scientific education in Oxford, whether in its bearing on the 
 general Education of the Country, or the Education of the 
 Medical Profession. He shewed in his writings and speeches 
 how he desired chiefly for his profession that its youth should 
 have access to the same culture, should enjoy the same thorough 
 education of their higher faculties, and should be placed in the 
 same circumstances for the elevation of their personal character, 
 as our Statesmen, our Clergy, or the members of the Bar. He 
 looked, therefore, with much interest at the modern exertions 
 which were made by the ancient Universities to give that kind
 
 MEMOIR. XXYH 
 
 of fundamental scientific training which should be useful to the 
 members of his own profession, prior to their introduction to 
 the great schools for studying pathological phenomena and 
 pursuing therapeutical observation, which are supplied by our 
 great metropolitan Hospitals. 
 
 His conversation and his addresses were full of observations 
 bearing so forcibly on medical education that a few of them must 
 here be quoted. For instance, "It is with societies of men, as 
 well as with individuals, that which commands scientific respect 
 does not so much depend on the successful teaching of what has 
 already been discovered, as upon the production of original work 
 by the society or individuals." 
 
 2. " It is with the living that medicine has to do. The living 
 man must be studied in health as in disease ; to the phj^sician or 
 surgeon the sick or wounded man is as the mineral to the 
 geologist, as the star to the astronomer." 
 
 3. " Other schools have earned a reputation in physiology and 
 comparative anatomy, and those branches of medicine which are 
 termed theoretic ; but the enduring fame of the Dublin contribu- 
 tions to science arises from their essential practicality and truth- 
 fulness. They are records of unbiassed observation made by 
 men originally well educated and brought up in a practical school." 
 
 4. " There can be no greater error than to compel a medical 
 officer to attend to a number of patients beyond that which his 
 mental or physical powers can reach. I speak from experience 
 when I say that no physician or surgeon ought to be called on to 
 attend more than fifty hospital patients daily ; to treat more than 
 this proportion causes exhaustion both of body and mind, and he 
 is rendered unfit to perform duties which of all others require a 
 quiet mind and a vigorous frame." 
 
 5. " Additional encouragement must be given to the students 
 to obtain that education which can alone fit them to preserve 
 the social position and rank of their profession, to use the 
 words of a great surgeon, to keep it from degenerating into a 
 trade, and the worst of trades. To me the real patriot is he who,
 
 XXVIU MEMOIE. 
 
 in a life of labour and of trial, with integrity, practical wisdom, 
 and far-seeing intelligence, labours onward to no other end but 
 that his country shall rise, and with the honourable and justifiable 
 ambition that, loving her, he may rise with her also." 
 
 6. '* In the wards of the hospital the student learns that which 
 cannot be taught in the dissecting room or in the theatre ; he 
 learns to teach himself to act and to discover ; and he 
 does much more ; the kindlier feelings of his heart are stirred, 
 and he becomes so trained to works of charity and mercy that 
 their practice is at last a second nature ; he acquires that moral 
 courage by which at the call of duty, or of mercy, which is duty, 
 he learns to despise danger, and to meet death whether it comes 
 by pestilence or by the sword." 
 
 7. " Medicine cannot be taught in a purely medical hospital, 
 any more than surgery in a purely surgical one." 
 
 8. " Medicine is essentially a progressive science, and avails 
 itself of almost every branch of knowledge in its progress. 
 Medicine is an inexact science, but this is no reproach. By this 
 very character it enters into fellowship with the most noble of 
 human inquiries, with those which have for their objects the 
 relations of the created to the Creator, the future state of man, 
 his moral and his intellectual nature." 
 
 9. " We have to do with something which cannot be measured 
 or weighed ; something too in which experiment can only be used 
 within narrow bounds ; an element whose nature is yet unknown, 
 fleeting in its action, and every day producing new combinations, 
 not merely new because they were never observed before, but 
 really new as appearing for the first time." 
 
 10. "Every connexion that can be established between the 
 mathematical and physical sciences and medicine will impart to 
 it more or less of certainty." 
 
 11. " Medicine, in its great quality as a practical art, advances 
 in many directions ; of which two may be indicated as the most 
 important. One is the discovery of new facts, whether relating 
 to physiology, pathology, or therapeutics, each of which, even
 
 MEMOIR. XXIX 
 
 although its practical bearing be not apparent, enlarges the 
 boundaries of the field of certainty. The second is the applica- 
 tion of those new facts, on the one hand, to testing the value 
 of methods long in use ; and, on the other, as a guide in 
 the wilderness of the unknown which stretches around us, 
 which we are seeking to explore, and which we hope in time to 
 reclaim." 
 
 12. "Do not be misled by the opinion that a University 
 education will do nothing more than give you a certain pro- 
 ficiency in classical literature, in the study of Logic and Ethics, 
 or in Mathematical or Physical Science. If it does these things 
 for you, you will be great gainers, for there is no one branch of 
 professional life in which these studies will not prove the most 
 signal helps to you. But it has other, and equally important 
 results ; it enforces respect for the ordinances of religion ; it 
 habituates the mind to the humility of prayer ; it enlarges it by 
 communion with contemporaries who are preparing for their 
 varied walks in life ; and it excites the best ambition, by 
 presenting so many examples of successful exertion." 
 
 Thus far Dr. Stokes has been spoken of partly as an eager 
 student of medical science, partly as a physician. We must now 
 look upon him from a somewhat diff"erent point of view. In one 
 of his addresses he puts as the first " great object of our labours" 
 the prevention of disease. This proposition, now that " sanitary 
 science " has become a fashion, seems but an obvious sentiment. 
 With him, long before it became popular, it was a veritable 
 passion. " Preventive medicine, as distinguished from curative 
 medicine, touches every hearth and home in the country ; every 
 man, woman, or child, from the highest to the lowest; every 
 institution in the State ; its power, its defences, its education, its 
 manufactures ; every trade, every occupation, domestic purity, 
 domestic happiness, national prosperit}'', national health, lon- 
 gevity, and morals ; the duties of property ; the exercise of charity, 
 the blossoming and fruit of our common Christianity. Its end is 
 to improve and to preserve man's body in the best condition, and
 
 XXX MEMOIK. 
 
 through it his immortal paTt." And throughout his various dis- 
 courses and teaching on this subject he takes the widest view of 
 its nature and relations. He presses home his idea with all the 
 force of his ardent nature. " The list of causes," he says, 
 "independent of epidemic disease, which damage the general 
 health of the community is a long one. The parent of many 
 others is destitution with its consequences. But to prevent 
 destitution in masses of men, and to promote their prosperity, 
 is the province of the social rather than the sanitary reformer, 
 who has to deal rather with the effects than with the causes 
 of destitution, though it is certain that disease and destitution 
 may be and often are reciprocally cause and effect." And 
 speaking of many of the Poor Law surgeons in their relation 
 to this great work, he quotes this passage from a memorandum 
 of the Sanitary Commission: "'They have had a scientific 
 education, and are essentially benevolent and practically humane. 
 Their life is spent in striving to alleviate the greatest calamities 
 of the most suffering, that is, of those who, being willing to 
 work, are disabled by enfeebled health or actual disease. Pene- 
 trating every corner of the filthiest districts at the ghastliest 
 moments, succouring the vicious when they are disposed (if 
 ever) to repent, and tending the innocent who are ruined in 
 body by the sins of those who begat them ; hundreds of these 
 men do their duty, their hearts beating with sympathy, sighing 
 for power to remove causes the effects of which they are incom- 
 petent to check. And, lastly, being themselves far from rich, 
 they are thrifty, and as little disposed to increase unnecessary 
 taxation as the most indifiereut or the most incredulous opponent 
 of sanitary reform.' " 
 
 And he ends another address thus : "A time may come when 
 the conqueror of disease will be more honoured than the victor 
 in a hundred fights." 
 
 In the year 1870, when he was sixty-six years of age, and had 
 been forty-four years a clinical teacher, he urged his hospital to 
 erect a laboratory for the purpose of physical investigation in
 
 MEMOIR. XXxi 
 
 connexion with the clinical wards. This great practical teacher, 
 who had laid so much stress upon the qualities of ohservation 
 and sagacity shewn hy the older physicians, now late in life sees 
 how the modern appliances of physical science must he used for 
 the scientific study of disease. He refers to the progress in this 
 direction in London, in Edinburgh, and on the Continent, 
 and says, "We must henceforward provide instruction in all 
 methods hy which physical science is brought to bear on 
 the advance of medicine " ; that " every hospital in Dublin 
 should have a physical laboratory furnished with such apparatus 
 and appliances as the science of the present day requires for the 
 investigation of disease." And with that mixture of simplicity 
 and sagacity which was so striking in him, he says : " It is not 
 to be expected that the senior physicians and surgeons of a hos- 
 pital could be so conversant with the modern modes of physical 
 inquiry as to be able to train the students in that direction " ; 
 but adds that a specially trained officer must be appointed for 
 the purpose. And finding the authorities deficient in the alacrity 
 which, even at his age, he desired, he says : "We have not been 
 reading the signs of the times, and it is plain at all events that 
 these matters should be seriously considered by us all." It 
 must not be, however, supposed that this was the first occasion 
 on which he had urged the giving great facilities to the student 
 for acquiring precise physical knowledge and experimental dex- 
 terity ; for nearly ten years before he had, in an elaborate discourse, 
 pointed out the different ways in which such persons as 
 Virchow, Helmholtz, Liebreich, Beale, Jellett, Hoppe-Seyler, 
 G. G. Stokes, Haughton, Bonders, and others had in several 
 directions placed within the reach of the younger generation of 
 medical men knowledge and power wholly unknown to our fathers, 
 and such as it is impossible for the present race of men to ignore. 
 And it must be borne in mind that this was the conviction of a 
 pre-eminent clinical observer and practitioner. 
 
 It would thus far seem that Dr. Stokes was engrossed by the 
 study of disease, love of his profession, and his conception of the
 
 XXxii MEMOIR. 
 
 dignity of medicine, as the averter, alleviator, and healer of 
 bodily and mental disorder. 
 
 But did nothing else lie hidden in the nature of this large- 
 hearted man ? Yes ; and chiefly two things. First, a Love of 
 Art. What did Art convey to him? What its attractions, 
 and what its link with his nature ? This "is not hard to see nor 
 to show. The study of Man was with him an instinct, both on 
 the material and on the intellectual side. On the material side ; 
 for he was a physiognomist ; a great judge of character ; and 
 had a keen perception of all physical characteristics ; qualities 
 which he obtained by intense observation of men in disease ; of 
 men in health ; and of persons in every class of society and 
 every kind of occupation. On the intellectual side ; for the 
 phenomena of man's external nature were to him only expressions 
 of the mind working within ; mind the result of inheritance ; 
 mind formed by itself; mind the result of circumstance. The 
 second thing to be remarked was his intense interest in every 
 form of human character, in persons of every age, occupation, 
 and condition. He had that which many accomplished persons 
 have not, the keenest sense of humour, which sparkled up in a 
 way quite indescribable. He combined with real delight in all 
 intellectual development the most tender human interest. 
 Some of the stories of sorrow and of characteristic life among 
 the Irish poor were told by him with a pathos of voice and 
 utterance impossible to be imagined : it must have been 
 heard. When pressed he would relate some story such as 
 this : " An aged priest, Dean of Westport, told me a story 
 illustrating the deep religious feeling of the Irish peasantry. 
 * I had the largest parish,' he said, 'in the diocese, and had no 
 less than four curates — God help them. They were scattered 
 here and there through the mountains. It was a Sunday 
 morning early, and you never saw such heavy rain as was 
 falling, when a boy on a horse rode up to my house with word 
 that Father Sheehy was taken very bad and would not be able 
 to celebrate mass. All the curates had their hands full ; I was
 
 MEMOIK. XXXIU 
 
 going to breakfast, but I had to go off without it, and the rain 
 was so thick and heavy that in five minutes I felt the water 
 running down my back as it poured in through the roof and 
 sides of the covered car in which I travelled. Well, I went 
 on ; the blast and the storm only seemed to increase as I got 
 higher and higher among the mountains, for the best part 
 of twelve miles, when the boy pulled up. " What are you 
 stopping for?" said I. "For your reverence to say mass," 
 said he. "Where?" said I. "There!" he said, pointing 
 with his whip to the ditch, where I saw a large flat stone. 
 "That's the altar!" he said. So I got out and put on my 
 wet vestments, and after a while one poor creature came out of 
 the mist and then another, and then a woman and a man carry- 
 ing the child, and then more and more till a great crowd gathered 
 round the stone, so great you couldn't see the end of it in the 
 fog and the mist ; and they were all wet to the skin after walking 
 over the mountains in the storm. They were all do^vn on their 
 bended knees when I came to the elevation of the Host, and with 
 one consent there arose a great cry from them, " Cead mille 
 failthe ! Christo mo Slanach ! " A hundred thousand welcomes ! 
 Christ my Saviour ! ' " 
 
 Though often saddened through his boundless sympathy, 
 he was never so depressed by the gravity of things but 
 that there might come, often most unexpectedly, rays 
 of his tender humour, like sunbeams on a showery day. 
 This close study of man was perhaps natural for a great physi- 
 cian practising largely among the poorer men and women of 
 Ireland, the raciest specimens of the raciest people. He was, 
 moreover, passionately fond of the external aspects of Nature, 
 either in themselves, or as expressed by landscape painters. 
 He was a lover of country life ; of country objects of the sim- 
 plest description ; of country scenes. He would even take notes 
 of effects of skies, or compositions of landscapes, which had 
 struck him as he went along, and would cautiously and care- 
 fully write what he had seen and wondered at, whether in an 
 
 c
 
 XXXIV MEMOIR. 
 
 ordinary continental tour, or on the splendid Atlantic coasts 
 of Ireland. 
 
 J . The following passage, describing a sunset seen from Sybil 
 Head in the County of Kerry, may be given as an instance of 
 this close study of effects in Nature.* 
 
 " Over the surface of the great Atlantic, and at least a thousand 
 feet beneath where we stood, lay a boundless extent of mist or 
 vapour, which, before it became tinged by the sun's rays, had 
 assumed the appearance of an open champaign country, divided, 
 as it were, into large fields, spacious highways, broad pastoral 
 plains, and extensive meadows. Gradually, however, this scene 
 changed, and as the sun began to sink in the far distance, his 
 sloping beams caught the upper portions of this beautiful vapour, 
 and coloured them with an exquisite variety of the richest hues, 
 each portion assuming a different tinge, in consequence of its 
 position with regard to the sun. The effect of these higher 
 parts, thus lit up into glowing and varied splendour, as contrasted 
 with the calm, broad reaches of wonderful country which lay 
 under them, was inconceivably fine. Thus elevated, they looked 
 like towers of gold and precious stones, shining under the evening 
 sun, in some enchanted land. 
 
 " A more wonderful effect was still to come. 
 
 " As the sun went down into the sea the whole expanse by 
 degrees kindled into one great flood of prismatic light, glowing 
 in the richest and most gorgeous colours, all of which now blazed 
 with the deep effulgence of what seemed his last glow. 
 
 " Then a third change came on the scene. 
 
 "All at once the sun's disc dipped into the ocean, where it had 
 nearly disappeared, leaving on this cloud scenery a golden haze, 
 rich, warm, and transparent. But this was illusion ; for the sun, 
 which had only set in a deceptive horizon, reappeared in a few 
 moments, thus literally seeming to rise again. He now shone 
 for a brief period in mild and cloudless effulgence. 
 
 ♦ Given by ■William Stokes to Carleton, who printed it in Dublin University Magazine, 
 April, 1847, vol. xxix. p. 438.
 
 MEMOIR. XXXV 
 
 " The cliff from which we contemplated this scene was covered 
 with lichens and mosses of various colours. It stood out mighty 
 and stupendous facing the crimson sun, whose deep empurpled 
 light touched the whole magnificent mass with colour. Then 
 the sun finally sank, and two eagles shot out far below us from 
 the side of the cliflf, and rose circling and wheeling round till 
 they disappeared in the darkness. The rich colour faded away — 
 the deep-toned fires grew fainter and fainter — the ideal world 
 vanished — darkness succeeded — the winds as it were leaped into 
 motion^the mighty waters began to heave, and there remained 
 before us nothing but the desert bosom of the dark Atlantic." 
 
 There were other reasons also why this close observation of 
 nature was constantly alive in him. He was essentially an 
 Irishman. In the study of the history of Ireland he thought 
 that nothing in its antiquity was too trifling to be noticed, or 
 too unimportant to be loved. And it is quite true that Ireland 
 so considered is, in every part of its interior and its coast line, 
 full of objects till lately too much neglected, and full of interest 
 for the antiquary, the historian, and the Christian philosopher. 
 Not that it would be true that he was blind to faults, or deaf to 
 tales of misgovernment and misconduct. He deplored them, he 
 wept over them, he yearned for the freedom of her people — 
 freedom from license, from folly, from superstition, from law- 
 lessness, from misguiding leaders. 
 
 It happened that he had from early life an intimacy with two 
 remarkable men : one, Mr. Burton, now Director of the National 
 Gallery ; and the other, Mr. Petrie, artist, antiquary, musician. 
 Of Mr. Burton, so highly esteemed, so well known, so scholarly, 
 it is not, perhaps, becoming to say more now in his lifetime. 
 Petrie was a man of exquisite refinement, great vivacity and 
 tenderness, a romantic admirer of the people, and a collector 
 of national music. This remarkable person wandered through 
 the wildest districts, pencil and violin in hand, making at once 
 sketches of the loveliest scenes, and treasuring up and commit- 
 ting to paper melodies which, in the remoter parts, or even in 
 
 c2
 
 XXX Yl MEMOIR. 
 
 the crowded alleys of Dublin, he found to be traditional among 
 the people. None who had heard that genial man once play 
 those Irish airs would ever forget either the scene or the sound. 
 The influence of these two persons on him during a great part 
 of his life, his sympathy in his hours of leisure with what was 
 the reality of their professional work, need not be enlarged upon. 
 Nor must it be overlooked that he had a keen appreciation of 
 the drama, as embodying, both in writing and in action, the 
 highest artistic expressions of human nature ; and this led him 
 at one time, partly through the acquaintance of Miss Helen 
 Faucit, now the wife of Sir Theodore Martin, to study the con- 
 ditions under which the actor should learn and represent human 
 action in disease; and he formed the 'distinct opinion that the 
 study of mental or physical disease in as3'lum or in hospital was 
 not desirable for the artist. He drew a clear line of distinction 
 between imaginative and realistic processes in art, and he held 
 that the dramatic artist should trust to native instinct and to 
 such knowledge of human life and suffering as are lo be found 
 in his own heart and drawn from his own experience. 
 
 In 1842 Dr. Stokes wrote a review of Kugler's Hand-book of 
 Painting, passages from which may be quoted as shewing the love 
 he had even then formed for the early religious i)ainters. " Why 
 is it," he asks, "that before their works all faults of painting are 
 forgotten and criticism is silent ? In works, the early offspring 
 of the cloister and the cell, and of minds imbued with religious 
 love, we may perceive the hardness of the outline, the bad per- 
 spective, the unpleasing backgrounds and landscape, and the 
 manifold and glaring anachronisms ; but yet there is something 
 which elevates the work and harmonises it with those high and 
 mysterious objects which it presents to the outward and inward 
 eye." And he adds, speaking of the later Italian schools, " Yet 
 the change effected in them was not to be commended, if the 
 highest object of art is the effect on the devotional feeling. In 
 music, architecture, in sculpture, painting, oratory, or writing, 
 the grand object is to produce the best effect ; and there are
 
 MEMOTK. XXXVll 
 
 compositions and combinations by human genius which, analyti- 
 cally considered, are defective, but which produce the most 
 ennobling results upon the mind ; and the merit is not so much 
 in the execution of the individual parts as in their combination 
 for a particular end. And with reference to the devotional 
 feeling, who will deny that the ancient liturgies, the old music, 
 the early architecture, all declare that the nearer we approach 
 the times of a more undoubting faith, a more intense devotion, 
 the more completely do we find that these holy influences stamped 
 a character on the creations of the day ?" In another passage he 
 adds, " It has been said that the real end and object of art is to 
 deliver in its varied language the light-imparting message of 
 God to man, and for this purpose to avail itself of every human 
 feeling, sympathy, and perception, physical as well as moral. 
 And it is plain that whosoever establishes a single new means to 
 so great an end, and adds it to the bright apparatus of the poet, 
 the painter, the sculptor, the architect, actor, and musician, 
 must claim a high place in the world's esteem." 
 
 In 1874 Dr. Stokes was elected President of the Royal Irish 
 Academy, and as such he received the testimony of the most 
 cultivated men in Ireland of his fitness to preside over a body 
 which represents the highest development of literature, science, 
 a]Q^'"^^^h8eology in Dublin. His inaugural address was one, 
 w-Mch, for its breadth of view and the genial interest shewn in 
 every department of knowledge, including some, as mathematics, 
 in which he was not a proficient, fully justified his election. On 
 reading this address it is hard to say whether the character of 
 the man, or the professional enthusiasm of the scientific physi- 
 cian, finds the more complete utterance. This, and the second 
 address in the following year, were the last public utterances of 
 his laborious life. The ability and earnestness which, at a time 
 of much difficulty, he brought to bear on the aff'airs of the 
 Academy will long be remembered. 
 
 This brief description of Dr. Stokes must now be brought to a 
 close. It would be wholly incomplete without some attempt to
 
 XXXVIU MEMOIK. 
 
 portray the personal character and mode of life of the man. 
 There is a passage in his Memoir of Petrie, in which he de- 
 scribes Petrie's house as the place "where were assembled men 
 of letters, artists, poets, archaeologists, all lovers of Ireland, and 
 true workers for her, whose hearts were kindled and purified by 
 the perfect strains of simple music." This in truth equally 
 represented the conditions of his own home. There was a 
 charm about him which attracted persons of intelligence and 
 accomplishment of every kind, and his genial and humorous 
 disposition made gatherings of friends fascinating to every one 
 admitted to them. He would preside at the games of children. 
 He exercised the most gentle influence over refractory students. 
 He never tormented them with elaborate exhortations. His 
 hard working days, constantly ending in these little gatherings, 
 often had begun between four and five, when he rose to write 
 lectures or other literary work until eight, and after a rapid 
 breakfast proceed to his hospital. He once said, "My father 
 left me but one legacy, the blessed gift of rising early." It might 
 be supposed from this picture that his life was one of those rare 
 ones in which all seems sunshine, lighting a smooth and flowery 
 way. It was far otherwise. This is not the place to lift the 
 veil from family care. Probably no professional man had more 
 genuine education through sufl'ering and necessary toi}\^^fi 
 had he. His marriage was in every way a blessing to him. 
 He was comforted by many and happy children ; some greatly 
 distinguished. Law, Scholarship, Surgery, Archaeology, all bear 
 record to their valued work. But large family circles usually 
 mean as multiform pleasures, so also abundant sorrow. One of 
 the circumstances which to all who knew him well, either by 
 personal experience or by hearsay, was the most notable, was 
 the manner in which he spent such periods of change and rest as 
 from time to time he was able to obtain. The splendid work by 
 Lord Dunraven, completed and edited by his daughter, was in 
 great measure prepared during excursions which he made. And 
 indeed in many parts of Ireland there are scenes so lovely, and
 
 MEMOIR. XXXIX 
 
 antiquities so singular, as to have necessarily exercised a great 
 charm over this imaginative nature. Witness the Fort of Dun 
 Angus, hanging over the western cHffs of lonely Arran, dashed by 
 the heavy splash of the long unbroken Atlantic swell, and 
 surrounded by the huts of a people so primitive, so picturesque, 
 so beautiful ; or the dark and mystic vaults of New Grange, on 
 the banks of the Boyne, with the strange and uninterpreted 
 hieroglyphics on great subterranean stones ; or- the huge 
 sculptured crosses, the chapels, the burial grounds, the towers 
 of Kells or Clonmacnois; or the wild monastery majestically 
 perched on the storm-stricken Skelligs. All these were 
 calculated to evolve just that admixture of historical, 
 archaeological; and artistic delight which were combined 
 in him. An account is given in a manuscript to which I 
 have had access of one of these scenes ; it was not indeed in 
 Ireland, but in a place as romantic and as interesting as the 
 most romantic and the most interesting of the island, at once 
 a cradle and centre of Christianity, indissolubly connected with 
 the religious history of all the British Isles. He describes a 
 scene in lona too graphically to be here omitted : " We had 
 gone to Port-na-Curraich to explore the landing-place of St. 
 Columba, and having seen the mound where it is said his boat 
 lies buried, we climbed the heights over the bay. The summit 
 of the hill forms a low wide basin, carpeted with soft green- 
 sward, whose rim rises around like the side of an amphitheatre 
 or circus. Presently we saw the form of a girl with a milk-pail 
 on her head, standing clear against the crimson evening sky on 
 the verge of the opposite hill, then another appeared, and then 
 another, till all the circle round was crowded by these maidens 
 with their milk-cans. Presently the cattle grazing in the fields 
 around came moving slowly forward in long processions and entered 
 the circle. Then the girls began to call each cow by its name, and 
 the patient animal answered to the call, and each moved quietly 
 up and stood by her mistress's side to be milked. When this 
 was finished an extraordinary scene ensued. A flight of calves
 
 NOTE TO PAGE XXIII. 
 
 ARTICLES IN " DUBLIN JOURNAL OF MEDICAL SCIENCE," 
 BY DR. STOKES. 
 
 May, 1832— Januaey, 1872, 
 
 Clinical Observations on the Exhibition of Opium in Large Doses, in certain cases of 
 
 Disease, i. 125. 
 Contributions to Thoracic Pathology, ii. 51. 
 
 Ditto ditto ditto iii. 50. 
 
 Researches on the Diagnosis of Pericarditis, iv. 29. 
 Researches on the Diagnosis and Pathology of Aneurism, v. 400. 
 Researches on Laennec's Vesicular Emphysema, with Observations on Paralysis of 
 
 the Intercostal Muscles and Diaphragm, considered as new source of Diagnosis, 
 
 ix. 27. 
 Researches on the State of the Heart, and the Use of Wine in Typhous Fever, xv. 1. 
 Researches on the Pathology and Diagnosis of Cancers of the Lung and Mediastinum, 
 
 xxi. 206. 
 Observations on the Case of the late Abraham Colles, M.D., i. 303. 
 Observations on some Cases of Permanently Slow Pulse, ii. 73. 
 On the Mortality of Medical Practitioners from Fever in Ireland (and J. W. Cuaack, 
 
 M.D.), iv. J 34. 
 On the Mortality of Medical Practitioners in Ireland, 2nd Article (and J. W. Cusack, 
 
 M.D.), V. 111. 
 Clinical Researches on the Gangrene of the Limg, ix. 1. 
 On the Prevention of Pitting of the Face in Confluent Small-pox, xxix. 111. 
 On some Requirements in Clinical Teaching in Dublin, Ii. 38. 
 Some Notes on the Treatment of SmaU-pox, liii. 9. 
 
 PAPERS READ TO SOCIETIES BY DR. STOKES, REPORTED 
 IN " DUBLIN JOURNAL OF MEDICAL SCIENCE." 
 
 August, 1835 — Pebeuaet, 1874. 
 
 On the Diagnosis of some Diseases of the Thorax, viii. 196. 
 
 Softening of the Heart with Thinning of its Parietes, xxi. 133. 
 
 Bright's Disease of the Kidney, xxi. 144. 
 
 Acute Induration of the Lung, xxi. 151. 
 
 Cirrhosis of the Lung, xxi. 293. 
 
 Gangrene of the Lung, xxi. 317. 
 
 Aneurism of the Abdominal Aorta, opening into the Parenchyma of the Lungs, 
 
 xxiii. 166. 
 Vegetation on the Semilunar Valves, causing Patency, xxiv. 279. 
 Atrophy of the Heart in Phthisis, xxiv. 283. 
 
 Granular Kidney — Diabetes — Pneumonia— Hydrothorax, xxiv. 295. 
 Observations on Dr. Bigger's Commiudcation at the last Meeting (Contraction of Left 
 
 Auriculo-ventricular Opening), xxv. 5'2P.
 
 NOTE TO PAGE XXIII. xliii 
 
 Fatty Degeneration of the Heart, i. 491. 
 
 Hypertrophy with Dilatation of the Left Ventricle, in an Anaemic Subject, i. 493. 
 
 Aneurism of the Arch of the Aorta, Compressing the Oesophagus, and perforating its 
 
 Parietes, i. 498. 
 Jaundice — Fungous Growth round the Orifice of the Ductus Choledochus ; Dilatation 
 
 of the Hepatic Ducts in the Liver, ii. 505. 
 Aneurism of the Abdominal Aorta, involving the Coeliac Axis, bursting by a large 
 
 rent into the Peritoneum ; gradual Separation of the Serous Coat from the Liver 
 
 and Stomach by Aneurism ; absence of Caries of VertebrEe, ii. 519. 
 Hydrocephalus, ii. 52G. 
 
 Encephaloid Tumours in the Abdomen, x. 202. 
 Psoas Abscess bursting into the Cavity of the Peritoneum, x. 471. 
 Endocarditis : Disease of the Mitral Valve, xi. 198. 
 Aneurism of the Thoracic Aorta, xi. 201. 
 
 Partial Displacement of the Sternal End of each Clavicle, xiii. 459, 
 Aneurism of the Abdominal Aorta, xv. 480. 
 Diphtheria, xxxv. 175. 
 Cancer of the Liver, xxxviii. 201. 
 Pelvic Abscess, xxxviii. 440. 
 Stricture of the Pylorus, xxxviii. 448. 
 Cancer of the Gall Bladder, xxxix. 218. 
 Report on Three Cases which occurred in Meath Hospital under the care of Drs. 
 
 Stokes and Hudson, xliv. 193. 
 Disease of the Aortic Valves, xliv. 423. 
 Cancer of the Liver, xliv. 428. 
 
 Chronic Ulcer of Stomach, opening the Coronary Artery, xlv. 201. 
 Cancer of the Thyroid Gland and adjoining Lymphatics, xlvi. 220/ 
 Pulmonary Phthisis, with Emphysema, xlvii. 216. 
 Ulcer of the Stomach, xlvii. 220. 
 Heart in Typhoid Fever, 1. 197. 
 
 Phlebitis of the Cerebral Sinuses — Disease of the Tympanum, 1. 212. 
 Cancer of the Stomach and Mesentery, 1, 220. 
 Varicose Aneurism, lii. 249. 
 
 Cancerous Tumours of the Abdomen and Thorax, liv. 67. 
 Chronic Inflammation of the Spinal Chord and its Membranes. Dis of the Spleen, 
 
 Ivi. 62. 
 Enteric Fever, Ivii. 483. 
 Enteric Fever j Intestinal Haemorrhage, Iviii. 97. 
 
 SHORT REPORT ON A CASE BY DR. STOKES IN "DUBLIN JOURNAL 
 
 OF MEDICAL SCIENCE." 
 Observations on the Existence of a Proper Fibrous Tunic of the Lung, vi. 471,
 
 EDITOE'S PEEFACE. (Dr. HUDSON.) 
 
 The objects and scope of this work are fully set forth in the 
 Author's preface; and in the preparation of this edition I have 
 kept within the same lines, and have not attempted to mo- 
 dernize it by the introduction of new pathological doctrines or 
 researches. 
 
 The plan I have adopted is to give the original text— carefully 
 revised — with a very few omissions or corrections, and with no 
 interpolation, save in those instances in which Dr. Stokes had 
 either rewritten portions of the work Avith a view to a future 
 re-issue, or had embodied his riper experience in published 
 essays. 
 
 In the first instance the chapters on Pneumonia and Pleuritis 
 have been enlarged by passages from his own note books; in the 
 second, the chapters on Cancer and on Gangi-ene of the Lung have 
 been enlarged by the addition of portions of two essays on these 
 subjects, published in the first and second series of the Duhlin 
 Medical Journal. 
 
 In dealing thus with the text, and in adding a few notes of a 
 practical nature, chiefly drawn from contemporary contributions 
 to the Pathological Society of Dublin, I have endeavoured to 
 realize the views expressed by a distinguished member of the 
 Council of the New Sydenham Society,* that "by editing this 
 work with reference to the original papers of Stokes himself, 
 and perhaps of his contemporaries who were working along with 
 him in the Dublin hospitals and journals, it might be made a 
 representative book as regards a most important period in the 
 history of auscultation." 
 
 ALFRED HUDSON. 
 
 * (Dr. W. T. Gairdner, in a letter to the Editor.)
 
 PREFACE. 
 
 It is now more than two years since this work was commenced, 
 and more than a year since the three first sections were printed. 
 This delay was unavoidable, and proceeded from causes which 
 need not be specified here; and I mention it in order to explain 
 many imperfections, and seemingly wilful omissions. 
 
 In the composition of the work, I have kept two great objects 
 steadily in view. Of these, the first is the close connexion of 
 the study of physical signs with that of symptoms, so as to 
 illustrate their mutual bearing on diagnosis, and remove that un- 
 just opprobrium thrown on the advocates of auscultation, that 
 they neglect the study of symptoms. In the next place, I have 
 endeavoured to simplify the subject as much as possible. A 
 sufficient experience has convinced me, that any man of ordinary 
 education may acquire the power of distinguishing thoracic 
 diseases in a degree sufficient for all practical purposes, without 
 troubling himself with those excessive refinements in the diagnosis 
 from acoustic signs, on which some have improperly prided 
 themselves. I have endeavoured to adapt this work to the wants 
 of the practical man, always assuming that he is familiar with the 
 groundworks of the subject, with the characters and causes of 
 physical signs, as originally taught by Laennec, and more 
 recently investigated in the works of Forbes, Williams, and Clark. 
 Hence, I have not entered at any length into the characters of 
 physical signs, but rather into the art of reasoning justly upon 
 them ; for it is in this that most observers fail. It cannot be 
 too often repeated, that physical signs only reveal mechanical 
 conditions, which may proceed from the most difi'erent causes ; 
 and that the latter are to be determined by a process of reasoning
 
 PREFACE. Xlvii 
 
 on their connexion and succession, on their relation to time, 
 and their association with symptoms : it is in this that the 
 medical mind is seen. Without this power, I have no hesitation 
 in saying, that it would be safer to wholly neglect the physical 
 signs, and to trust in practice to symptoms alone. 
 
 When thus considered, every addition to our knowledge of 
 physical signs must be gladly received. I trust I may, without 
 vanity, allude to the subjects of dilatation of the air cells ; the 
 early stages of pneumonia, and phthisis ; cancer of the lung ; 
 and the signs of the accumulative diseases — in evidence, that I 
 have felt the value of physical diagnosis^ and that in this still 
 wide and open field, the labours of many years have not been 
 unrewarded. 
 
 I have only spoken of pathological anatomy so far as was 
 necessary to illustrate diagnosis ; for on this latter subject there 
 is now such a mass of facts, that were I to have attempted full 
 pathological descriptions, the work would have been swelled far 
 beyond a convenient size. 
 
 The purely haemorrhagic and spasmodic diseases of the lung 
 are not described in this work. I could add nothing to what is 
 already known with respect to pulmonary apoplexy, asthma, and 
 hooping-cough, and have determined, for the present, to omit 
 their consideration. These are diseases which still require 
 much original investigation. 
 
 In discussing treatment, I have endeavoured more to point 
 out principles, than enter at any length into the details of 
 practice. It would be impossible to anticipate all the 
 combinations of symptoms which may arise. If we can get a 
 general principle, we must trust to our tact and experience, to 
 modify its application according to circumstances. As far as 
 was possible, I have shewn the utility of physical signs in 
 practice ; for it is in the curable diseases that their great value 
 is seen. Indeed, in a large proportion of such cases, the first 
 effect of treatment is to render disease latent, and to cause an 
 absolute necessity for the study of physical signs.
 
 xlviii PKEFACE. 
 
 I have not entered into any description of the different 
 modifications of the stethoscope which have been from time to 
 time proposed. All that is necessary for a good instrument, is 
 that it shall consist of but one piece, be constructed of cedar or 
 some light wood, have its bell small, and with rounded edges, 
 and the ear-piece sufficiently concave. On the subject of 
 mediate percussion, I can only say, that the finger, with its back 
 turned to the chest, seems the best pleximeter ; and that I have 
 not found the instrument of M. Piorry, or his mode of 
 investigation, to possess the advantages which he has described. 
 I am far, however, from undervaluing M. Piorry's labours in the 
 field of diagnosis. 
 
 Finally, in availing myself of the labours of others, I have 
 always endeavoured to acknowledge the sources of my information. 
 If in any instance this has not been done, the authors may rest 
 assured that the omission was unintentional, and that I shall 
 thankfully receive the notification of the error, and take the 
 first opportunity of correcting it. 
 
 W. S. 
 
 Dublin, April 4, 1837.
 
 CONTENTS. 
 
 PAGE 
 
 Introduction by Br, Acland v 
 
 Memoir of Dr. Stokes by Dk. Acland vii 
 
 Editor's Preface. Dr. Hudson xlv 
 
 Preface. Dr. Stokes xlvi 
 
 SECTION I. 
 
 GENERAL PRINCIPLES OF THE DIAGNOSIS OF THORACIC 
 
 DISEASE 1 
 
 Connexion of Symptoms and Physical Signs 1 
 
 Physical and Vital Conditions of the Thorax 3 
 
 Similarity of Symptoms 11 
 
 Mutual Dependence of Signs and Symptoms 12 
 
 Sources of Physical Diagnosis 12 
 
 Insufficiency of Signs alone 13 
 
 Division of the Acoustic Signs into the Active and Passive. . . 17 
 
 Principle of Percussion 17 
 
 Active Auscultatory Signs 20 
 
 Elucidation of the great principle of comparison 21 
 
 Combination of Signs 27 
 
 Signs considered with relation to Time 28 
 
 Successive Changes 30 
 
 Relation to Symptoms 32 
 
 Combination of Diseases 36 
 
 SECTION II. 
 
 DISEASES OF THE MUCOUS MEMBRANE ... 41 
 
 Bronchitis ... 41 
 
 Importance of the Disease 41 
 
 InfantUe Bronchitis 42 
 
 Acute Primary Bronchitis 48 
 
 Symptoms of ^^ 
 
 Successive Changes ^^ 
 
 d
 
 CONTENTS. 
 
 PAGE 
 
 Chronic Primary Bronchitis. ^ 51 
 
 Expectoration in 51 
 
 Plastic Bronchitis 56 
 
 Researches of Eeynaud 57 
 
 Physical Signs 60 
 
 Results of Percussion 60 
 
 Signs from Touch 63 
 
 Active Auscultatory Signs 64 
 
 Passive Signs 65 
 
 Acute Secondary Bronchitis 72 
 
 Bronchitis of Typhus 72 
 
 Physical Signs 74 
 
 Bronchitis in the Exanthemata 76 
 
 Chronic Secondary Bronchitis 79 
 
 Gouty Bronchitis 80 
 
 Syphilitic do 81 
 
 Sympathetic Cough 85 
 
 Diagnosis of 88 
 
 Bronchitis from Worms 89 
 
 Treatment op Bronchitis 93 
 
 Treatment of the Disease in the Infant 93 
 
 Do. in the Adult 95 
 
 Bloodletting 96 
 
 Antimonial Treatment 98 
 
 Treatment of the Second Stage 100 
 
 Do. of Apyrexial Bronchitis 107 
 
 Stimulants and Emetics 109 
 
 Treatment of Secondary Bronchitis 112 
 
 Emetics in the Suffocative Catarrh 114 
 
 Organic Changes in the Tubes and Air Cells considered in re- 
 lation to Bronchitis 117 
 
 Structure of the Lung 117 
 
 Narrowing and Obliteration of the Tubes 119 
 
 Researches of Reynaud 119 
 
 Obliteration by Adhesion and Deposition 121 
 
 Cases Illustrative ... 124 
 
 Dilatation op the Tubes 129 
 
 Varieties of ... . 129 
 
 Cases of Dilatation 130 
 
 Effect of Paralysis of the Circular Fibres 131 
 
 Researches of Purkinje, Valentin, and Sharpey 132 
 
 Complications and Diagnosis 136 
 
 Physical Signs 142 
 
 Recapitulation 147 
 
 Ulceration op the Bronchial Tubes 149 
 
 Varieties of Bronchial Fistulffi ......... 150
 
 CONTENTS. li 
 
 PAGE 
 
 Dilatation of the Air-Cells. Emphysema or Laennkc . . .150 
 
 Causes and Symptoms 151 
 
 Physical Signs 155 
 
 EflEect of the Yielding of the Chest 160 
 
 State of the Intercostals and Diaphragm 161 
 
 Mediastinal Displacement 164 
 
 Signs from Bronchitis 166 
 
 Treatment of Dilatation of the Cells 169 
 
 Recapitulation 173 
 
 Atrophy of the Lung 175 
 
 Connexion with Impermeability 176 
 
 SECTION III. 
 
 DISEASES OF THE LARYNX AND TRACHEA . . 180 
 
 Acute Diseases 180 
 
 Primary and Secondary Croup 181 
 
 Physical Signs of Croup 187 
 
 Treatment 189 
 
 Tracheotomy 192 
 
 Laryngitis in the Adult 196 
 
 Secondary Croup 196 
 
 OEdematous Laryngitis • 198 
 
 Other Forms of Laryngitis 200 
 
 Diagnosis of Laryngitis 201 
 
 Treatment of Acute Laryngitis in the Adult 203 
 
 Chronic Diseases op the Larynx and Trachea .... 205 
 
 Enumeration and Observations on 206 
 
 Physical Signs of Chronic Laryngitis 214 
 
 Theory of M. Beau 217 
 
 Examination of the Lung in Chronic Laryngitis 218 
 
 Treatment of Chronic Laryngitis 222 
 
 Diseases of the Uvula 223 
 
 Specific Irritations of the La^rynx 225 
 
 Spasmodic Affection 225 
 
 In the Child 226 
 
 In the Adult 227 
 
 Foreign Bodies in the Larynx, Trachea, and Bronchial Tubes . 230 
 
 Entrance of the Foreign Body 231 
 
 Lodgment in the Bronchus 231 
 
 Effect of Complete or Imperfect Obstruction 235 
 
 Diagnosis, Principles of 236 
 
 Cases of the production of Pulmonary Disease 244 
 
 Stethoscopic Diagnosis 245 
 
 Recapitulation 2o2 
 
 cZ2
 
 lii CONTENTS. 
 
 PAGE 
 
 TaMOURS External to and Compressing the Windpipe , . 256 
 
 Enumeration and Classification 256 
 
 Symptoms and Diagnosis 259 
 
 Dislocation of the Clavicle 259 
 
 Diseased Bronchial Glands 26 1 
 
 Enlargement of the Thymus 262 
 
 SECTION IV. 
 
 PNEUMONIA 267 
 
 Acute Primary Pneumonia 268 
 
 Division of the Disease into Five Stages 270 
 
 Pneumonic Abscess 271 
 
 Seat and resolution 276 . 
 
 General History 278 
 
 Physical Signs 282 
 
 Pulsation of the Lung 292 
 
 Pneumo-thorax 293 
 
 Atrophy of the Lung 295 
 
 Kecapitulation 301 
 
 Typhoid Pneumonia 303 
 
 Varieties of 303 
 
 Treatment of Pneumonia 320 
 
 Bloodletting 321 
 
 Antimony in Large Doses 323 
 
 Mercurial Treatment 323 
 
 Treatment of Typhoid Pneumonia H'Zd 
 
 Chronic Pneumonia 332 
 
 Different forms of 332 
 
 SECTION V. 
 
 GANGRENE OF THE LUNG 349 
 
 Causes of 349 
 
 Cases Illustrative of 349 
 
 SECTION VI. 
 
 PERFORATING ABSCESS OF THE LUNG ... 378 
 
 Different Causes of 378 
 
 Principles of Diagnosis and Illustrative Cases 379 
 
 Perforation of the Diaphragm and Lung 379
 
 CONTENTS. liii 
 
 SECTION VII. 
 
 PAGE 
 
 CANCER OF THE LUNG . . . . 385 
 
 Division according to the Mechanical Conditions of the Cancerous Matter 385 
 
 Difficulty of Diagnosis 386 
 
 Formation of a Compressing Tumour 390 
 
 Pulsation of Cancerous Tumours 391 
 
 Rarity of Signs of Ulceration 394 
 
 Recapitulation 396 
 
 SECTION VIII. 
 
 TUBERCLE OF THE LUNG . . . . .422 
 
 Combination and Enumeration of Signs 423 
 
 Signs of Bronchial Irritation 423 
 
 Parenchymatous Irritation 425 
 
 Irritation of the Serous Membrane 429 
 
 Solidification 430 
 
 Ulceration 434 
 
 Atrophy 440 
 
 from Measurement in the earlier Stages 440 
 
 from the State of the Circulating System .... 441 
 
 Varieties of Phthisis 443 
 
 Acute Non-Suppurative Tubercle 443 
 
 Principles of Diagnosis 444 
 
 Acute Suppurative Phthisis 445 
 
 Principles of Diagnosis 446 
 
 Chronic Progressive Tubercle 447 
 
 Symptoms and Signs 447 
 
 Chronic Ulceration succeeding to Pneumonia 451 
 
 Principles of Diagnosis 451 
 
 Tubercle consequent on Chronic Bronchitis 452 
 
 Principles of Diagnosis 452 
 
 Tubercle consequent on the Cure of an Empyema. . . . 453 
 
 Principles of Diagnosis 453 
 
 Complication with Pneumothorax and Fistula .... 455 
 
 Complication with Laryngeal Disease 455 
 
 Principles of Diagnosis 455 
 
 Chronic Latent Forms 456 
 
 Examination of a Phthisical Patient 457 
 
 Recapitulation 459
 
 :iiv CONTENTS. 
 
 PAGE 
 
 Treatment of Phthisis 462 
 
 Connexion of Tubercle with Irritation 463 
 
 Circumstances favourable to cure 4C5 
 
 Treatment of the Bronchitic form 466 
 
 of the Tracheal variety 468 
 
 of the Haemoptysical variety 468 
 
 Use of Mercury in Incipient Phthisis 470 
 
 Treatment after Excavation . . .■ 474 
 
 Palliative Treatment 475 
 
 Appendix • 477 
 
 SECTION IX. 
 
 DISEASES OF THE PLEURA .... 479 
 
 The Pleura a Fibro-serous Membrane 479 
 
 Extensibility of the Mediastinum 481 
 
 Diseases of Accumulation 481 
 
 Paralysis of the Intercostals and Diaphragm 484 
 
 Dry Pleuritis 486 
 
 Principles of Diagnosis 486 
 
 Causes of the Friction Sounds 420 
 
 Pleuritis with Liquid Effusion •. . 490 
 
 Acute Inflammation 491 
 
 Diaphragmatic Pleurisy 494 
 
 Complications 495 
 
 Chronic Pleurisy with Effusion 496 
 
 SjTnptoms of Empyema 497 
 
 Physical Signs 500 
 
 Loss of Sonoriety 501 
 
 Signs of Respiration . ' 503 
 
 Phenomena of Voice 505 
 
 Signs of Excentric Displacement 506 
 
 Displacement of the Heart 507 
 
 of the Mediastinum 509 
 
 of the Intercostals 509 
 
 of the Diaphragm 512 
 
 Phenomena of Absorption 531 
 
 Influence on the Heart 514 
 
 New form of Dexiocardia . . . 516 
 
 Contraction of the Chest 518 
 
 Differential Diagnosis 546 
 
 Phthisis 547 
 
 Hepatization 548 
 
 Enlargement of Liver 548 
 
 Typho(T) Pleuritis 549 
 
 Analogy to Typhoid Pneumonia 549
 
 CONTENTS. Iv 
 
 PAGE 
 
 Treatment of Pleuritis 550 
 
 Bloodletting 551 
 
 Mercury 552 
 
 Diuretics 558 
 
 Iodine 554 
 
 Operation for Empyema 555 
 
 Mode of Performing 657 
 
 Passive Effusions 558 
 
 Ulcerations of the Pleura 559 
 
 Division of Cases 559 
 
 Empyema and Pneumothorax 560 
 
 Perforation in Phthisis 577 
 
 in Gangrene of the Lung 581 
 
 Pneumothorax by External Fistula 583 
 
 Recapitulation 591
 
 THE 
 
 DIAGNOSIS AJN^D TEEATMENT 
 
 OF 
 
 DISEASES OF THE CHEST. 
 
 SECTION I. 
 
 GENEEAL PRINCIPLES OF THE DIAGNOSIS OF THORACIC DISEASE. 
 
 It cannot be doubted, that the labours of modern pathologists 
 in the localization of disease, overrated though they, perhaps, 
 have been by the disciples of certain schools of medicine, have 
 yet done much to remove that great reproach of the art — its 
 uncertainty. The discoveries of the different and numerous 
 seats of morbid action, led, directly, to the study of the symp- 
 toms of these lesions, and of those physical phenomena, which 
 resulted from, or accompanied them ; and thus has the science 
 of diagnosis been placed on a sure basis, that time with its 
 mutations of opinion can never shake. 
 
 In the recognition of the seat and nature of disease, it is 
 obvious that a gi-eat number of circumstances must be taken into 
 consideration besides the actual signs and symptoms of the 
 affection. Age, sex, habit, exciting cause, and duration of 
 symptoms, all form links in the chain of evidence on which 
 we ground our opinion : but, it would appear, that it is in the 
 study of what are termed the signs and symptoms of disease that 
 ■we have made the greatest advances in modern times. 
 
 By morbid signs we mean phenomena, recognizable to the 
 senses, but particularly to those of sight, touch, and hearing, 
 which are evidences of physical alterations in the conditions and 
 
 B
 
 2 GENERAL PRINCIPLES OF THE 
 
 relations of parts. These alterations may be enumerated, as 
 changes in colour, shape, and volume, changes in resistance, 
 peculiarities of feel, and lastly, the production of particular 
 sounds under certain circumstances, perceptible either with or 
 without the assistance of mediate auscultation, and either wholly 
 new or characteristically altered. To the diagnosis founded on 
 the observation of these phenomena we give the name of physical 
 diagnosis, inasmuch as by it, that is to say, by the observation of 
 physical signs, we recognize certain physical alterations of parts, 
 Avhich may be studied without reference to those functional 
 lesions which have preceded, accompany, or follow them. Thus, 
 the feeling of fluctuation reveals the existence of a fluid, but tells 
 us nothing of its cause. The sound of fluctuation shows the 
 co-existence of fluid and air, which may arise from diflereut 
 diseases. The signs of gurgling and cavernous respiration in the 
 lung point out a cavity communicating with the bronchial tubes 
 and containing some fluid, but the cavities which produce these 
 phenomena may be of various kinds — gangrenous, phthisical, 
 pneumonic, &c. Duluess of sound of the chest points out an 
 obliteration or displacement of the air cells, and the substitution 
 of a solid or liquid for air, a condition which may arise from 
 various causes. The sensation of friction only points out a 
 roughened condition of serous membranes, but reveals nothing as 
 to its cause. The deviations of shape and volume of the great 
 cavities indicate some anormal state, but when we seek for 
 their causes we must have reference to other sources of 
 information. These illustrations of physical signs might be 
 extended, but enough has been said to explain the true significa- 
 tion of the term. 
 
 We may consider symptoms as difterent from signs in this, 
 that while the signs belonging to sight, touch, and hearing 
 are founded on physical conditions of the organs themselves, 
 symptoms result from changes in the functions of the sufi'ering 
 organs, and in the modifications produced by disease in their vital 
 relations with other parts. And hence we consider symptoms in 
 a threefold manner : 
 
 1st. Changes in the functions of the part itself. 
 
 •2nd. Changes in the phenomena of organic life in various 
 parts of the system. 
 
 3rd. Changes in the phenomena of animal life.
 
 DIAGNOSIS OF THORACIC DISEASE. 3 
 
 Thus, in examining the symptoms of a disease of a particular 
 organ, we investigate the state of its own functions. We then 
 examine the changes caused hy disease in all the phenomena of 
 organic life, such as digestion, respiration, circulation, absorption, 
 nutrition, exhalation, secretion, and animal heat. From these 
 we advance to the phenomena of the life of relation, and 
 examine the changes produced in the muscular power or func- 
 tion, the organs of sense, the moral affections, and intellectual 
 manifestations. 
 
 In a case of acute inflammation of the lung, we observe, in 
 the first place, lesions of its own function, painful and hurried 
 respiration, imperfect arterialization of blood, cough, and expec- 
 toration ; these are what may be called local symptoms, but we 
 may have others referrible to the disturbance of organic life in 
 parts distinct from the lung ; thus we observe excitement of the 
 heart, fever, and various derangements of the digestive and 
 urinary systems : further, in certain cases there may be signs 
 of a lesion of the phenomena of the life of relation, as for instance, 
 prostration of strength, and other signs of derangement of the 
 cerebro- spinal system. 
 
 It must be obvious, that in the detection of the nature and 
 seat of any disease, the more we can combine the observation of 
 physical signs with functional symptoms the greater Avill be the 
 accuracy of our diagnosis. Now, if we compare together the 
 diseases of the three great splanchnic cavities, we find that those 
 in which this desirable combination is most attainable are, first, 
 those of the chest ; next, the abdomen ; and lastly, the afiections 
 of the brain and spinal marrow. Accordingly, if we compare the 
 diseases of these cavities or systems with respect to the perfection 
 of diagnosis, we find the order to be, first, the respiratory ; next, 
 the abdominal ; and last, the cerebro-spinal, or that in which 
 this combination is least applicable. 
 
 As the principal object of this work is to elucidate the diag- 
 nosis of the diseases of the thoracic viscera, we shall enter on 
 this subject by remarking, that the contents of the chest in the 
 healthy and diseased state are most favourably circumstanced for 
 the multiplication and distinctness of physical signs. And it is 
 obvious, that the great improvement by which the present time is 
 distinguished in the diagnosis, and consequently the treatment, 
 of thoracic disease, is traceable to this circumstance. 
 
 b2
 
 4 GENERAL PRINCIPLES OF THE 
 
 In confirmation of the former proposition, let us consider, 
 
 First. — That of the different cavities of the body, the chest is 
 that in which the existence of air in quantity is a natural con- 
 dition. It is wanting in the cranium, and when occurring in the 
 abdominal cavity may be generally considered as a morbid pro- 
 duction or an excretion. But the chest is the receptacle of air 
 for the body. Now it is easy to show, that other things being 
 equal, the sound on percussion is directly as the quantity of air 
 within the chest : and the applicability of this to diagnosis is at 
 once seen, when we consider that the effect of every organic 
 change of the lung is to diminish or to increase the whole quantity 
 of air within the thorax, and, of course, to cause a corresponding 
 increase or diminution of the natural sound. 
 
 Secondly. — We must recollect the remarkable separation of 
 the viscera on either side of the chest. In fact, of all the organs, 
 which in the life of the embryo, and by the law of excentric 
 development, are formed primitively double on the mesian line, 
 there is none that preserves its duplicity more completely than 
 the lung. The brain, it is true, is separated into hemispheres, 
 and the liver into a right and left lobe ; but the union of opposite 
 portions of either organ is much more complete than what is 
 found to exist in the lung, and the latter also, Avith the exception 
 of the testicle, is the only organ of the body whose original 
 symmetrical halves are covered by separate serous membranes. 
 The importance of all this to physical diagnosis is immense, 
 for it is on this circumstance of separation that its true principle, 
 comparison, mainly depends. 
 
 If this great separation of the lungs did not exist — if in 
 place of their being merely connected by their vessels and air 
 tubes at the root, they were fused by continuity of their pa- 
 renchyma, and covered by the one serous membrane, as the 
 liver or brain, then the diagnosis of the exact seat of disease, 
 which we will see is of the greatest practical importance, could 
 not be attained : and it would be indeed difficult to discover an 
 emp3'ema, a partial pneumonia, or an incipient phthisis. Fur- 
 ther, the division of the lung into lobes, although these portions 
 be not wholly separated, is yet advantageous in the same point 
 of view, as these divisions act more or less in circumscribing 
 diseased action, and of course increase the applicability of the 
 principle of comparison.
 
 DIAGNOSIS OF THORACIC DISEASE. 6 
 
 Thirdly. — The thoracic viscera differ widely from those of 
 the cranium or abdomen in the constant, uniform, and extensive 
 motions which their functions require. These, whether of the 
 lungs or heart, whether active or automatic, are perceptible by 
 physical signs, and thus we have a standard by which many de- 
 partures from the healthy condition may be easily estimated. It 
 may be said indeed, that this circumstance of motion is not pecu- 
 liar to the lung or heart. But while we admit the existence of 
 the motions of the brain, we must remember that they are slight, 
 and in the adult totally concealed by the bony cranium, while 
 those originating in the viscera of the abdomen are irregular 
 and often imperceptible. Now, on the existence of these mo- 
 tions depends much of the physical diagnosis. If we look to 
 the lungs merely, we find that the act of respiration causes phe- 
 nomena appreciable by the ear, eye, and touch. The murmur 
 produced during inspiration and expiration, and the alternate 
 contractions and expansions of the chest, evident both to 
 sight and feeling, all furnish most important physical signs in 
 cases of disease. Thus, in Laennec's emphysema, when the 
 disease has been carried to a high degree, we find that on ac- 
 count of the great volume of the lung the murmur produced is 
 feeble, and the expansion and contraction of the chest trifling, 
 as compared with the efi'ort of the respiratory muscles. These 
 circumstances may often suffice for the recognition of the disease. 
 Again, in certain cases of empyema, we can easily recognize 
 the absence of motion on one side and the corresponding in- 
 crease of expansion on the other. Many more examples might 
 be given. 
 
 Further, the regular motions of the heart, productive as they 
 are of peculiar impulses and sounds, are not only directly avail- 
 able for the detection of cardiac and aortic diseases, but also for 
 those of the lung, as will be abundantly shown in the progress 
 of this work. 
 
 Fourthly. — The thoracic cavity is the only one in the dis- 
 eases of which the phenomena of the voice can be made 
 available for diagnosis. It is true, that of the various phy- 
 sical signs these are perhaps of the lowest value and most 
 liable to mislead, but when combined with other circum- 
 stances, they become of important assistance in the detection 
 of pulmonary disease. There is one case of disease of the cir-
 
 b GENERAL PRINCIPLES OF THE 
 
 dilating system in which we may avail ourselves of the signs 
 drawn from this source.* 
 
 Fifthly. — Great assistance is derived in the detection of 
 pulmonary and cardiac disease, from the peculiar modifications 
 of shape which the chest undergoes from a number of causes. 
 If we look to the affections of the head and spinal cavity, we 
 find, that with the exception of some few cases of congenital 
 dropsy, arrest of development, or chronic effusion, the more 
 frequent diseases of this class clo not produce any perceptible 
 alteration or change of shape in the bony cases of the cerebro- 
 spinal mass. In the abdomen, on the other hand, from the 
 very yielding nature of its parietes, changes of volume and 
 shape are common ; but it will be found, that these seldom are 
 available for the detection of the nature of their cause, a cir- 
 cumstance as well attributable to the great yielding of the 
 parietes, as to the fact of the viscera being contained in a 
 single cavity. The chest, however, presents bony, elastic, and 
 fleshy parietes, and its principal viscera occupy three distinct 
 cavities. 
 
 Although it cannot be maintained, that the alterations of 
 shape and volume of the chest will always suffice to point out 
 the nature of their causes, yet we must admit, that with respect 
 to the diseases of its interior, the modifications of its exterior 
 are more numerous and of greater diagnostic value in the chest 
 than in either of the other two cavities. Let us consider the 
 extraordinary convexity of the whole chest, the arching of the 
 sternum, and the appearance of the shoulders in a case of dila- 
 tation of the air cells ; the loss of symmetry in the sides, and 
 the peculiar smooth appearance produced by the pressure of 
 the fluid on the intercostal spaces, in the case of empyema ; the 
 contraction of the side and the depression of the shoulder while 
 the spine remains unbent, in the same case, where absorption of 
 the fluid has taken place ; and the sunken and flattened appear- 
 ance of the antero-superior regions in advanced phthisis. All 
 these are instances of peculiar modifications of shape of the ex- 
 terior walls of the cavity, coinciding with physical changes in 
 the subjacent viscera. It is true, that taken alone they could 
 not lead to a positive diagnosis, but when combined with other 
 signs and symptoms their value is highly important, and this, 
 
 * See Aneurism of the Aorta.
 
 DIAGNOSIS OF THORACIC DISEASE. 7 
 
 with their number, should make us admit, that as a means of 
 diagnosis, the modifications of external form produced by dis- 
 ease are more valuable and much more frequently applicable in 
 thoracic than in the cerebro-spinal or abdominal affections. 
 
 SixtJily. — The thoracic viscera, at least as far as the lungs 
 are concerned, differ most remarkably from the cranial and 
 the abdominal, in the facilities furnished by their structure and 
 function, for the detection of disease, by the direct recognition 
 of the products of that disease. The conditions on which these 
 facilities are found to depend are various, but the principal are 
 separation, mobility, elasticitj', and their direct and universal 
 permeability to air by means of the bronchial ramifications. Of 
 these the last is the most important. 
 
 Thus, if we look to the brain with respect to the discovery 
 of eff'usion in a case of arachnitis, we find that there is no direct 
 physical sign of such a lesion, and its presence can only be 
 guessed at by the existence of certain symptoms, which modern 
 researches have shown to be extremely fallacious.* We have 
 no physical means of ascertaining its presence or absence. But 
 how different is the case with the lung, in which, by the assist- 
 ance of percussion, by the observation of changes of position, by 
 the characters of respiration and of the voice, and by the obser- 
 vation of the displacements of the lung itself, the heart, and the 
 abdominal viscera, the detection of a fluid in the serous cavity 
 becomes as easy as it is certain. Again, let us compare the 
 facility of diagnosis of an abscess of the cerebral with that of the 
 pulmonary substance ; here also, the existence of the first lesion 
 can only be determined by the study of functional alterations ; 
 there is no physical sign, and we must farther admit, that even 
 after the researches of a Lallemand, a Serres, a Foville, or an 
 Abercrombie, that he who would make the positive diagnosis of 
 such a lesion, must have a confidence not justified by the present 
 state of the science. 
 
 But if in a case of pneumonia, after the recognition of the 
 ordinary symptoms and signs of the disease, we discover the 
 phenomena of cavernous respiration, gurgling, and pectorilo- 
 quism in the affected portion of the lung, we know that there 
 must be a cavity of some kind, and of its nature our previous 
 observations leave scarcely a doubt. Here, the facility of 
 * See Andral, Clinique Medicale, Maladies de I'Encephale.
 
 8 . GENERAL PRINCIPLES OF THE 
 
 diagnosis would not exist, if, like the brain, the lung had been 
 a closed organ ; but its permeability to air, and the regular and 
 forcible entrance and expulsion of this fluid into and from its 
 cavities, are the conditions which, by enabling us to discover 
 new secretions, and organic changes, easily reveal the lesion. 
 
 The same train of reasoning applies to the diseases of the 
 parenchymatous organs of the abdomen : the liver, spleen, 
 kidneys, pancreas, and mesenteric glands. Here, for the same 
 reasons, neither auscultation nor percussion can apply, unless in 
 a case of mere enlargement, when the latter mode of investiga- 
 tion can be sometimes employed. Abscess of any of these organs 
 cannot be accompanied by signs similar to those of abscess of 
 the lung, nor are there any physical means which assist in detect- 
 ing the earlier stages of inflammation. Nothing is so easy as to 
 detect the suppuration of pulmonary tubercles ; but in the case 
 of the abdominal organs, even supposing that tubercles were 
 recognized, who could pronounce upon their actual state ? 
 
 Further, in comparing the diseases of the gastro-intestinal 
 with those of the pulmonary mucous membrane, with respect to 
 the facility of diagnosis, we are at once struck with the diff"erence 
 in favour of the latter. There is no physical sign proper to a 
 gastro-enteritis, and its detection must depend altogether upon 
 vital phenomena ; but in the case of bronchitis we have, in 
 addition to the functional lesion, a group of signs resulting from 
 the physical changes of the part, which often enable us to detect 
 the slightest shade of mucous irritation, and to pronounce on the 
 exact locality, extent, and stage of the disease. 
 
 LastUj. — If we consider the chest as to the mechanical nature 
 of its walls, and the mobility of its contained viscera, we see, 
 that in its diseases, a fruitful source of physical signs is contained 
 in the various and remarkable displacements, not only of these 
 viscera, but of those contained in the cavity of the abdomen, a 
 source of diagnosis not applicable to the diseases of the brain, 
 and scarcely to those of the digestive system. 
 
 Thus, a moderate eftusion into the pleura will displace the 
 lung from below upwards, acting but little on the side, on 
 account of its greater resistance. When more extensive it 
 presses the lung against the mediastinum, and in consequence 
 of this septum yielding more than the bony wall, it is pushed 
 beyond the mesian line, of course carrying with it the heart
 
 DIAGNOSIS OF THORACIC DISEASE. \) 
 
 either to the right or left side, as the case may be. Now all 
 these displacements of the lung, mediastinum, and heart, are 
 easily appreciable by physical signs. 
 
 But we observe displacements of the abdominal viscera conse- 
 quent on thoracic disease, a circumstance explicable by consider- 
 ing the nature of the floor of the thorax ; that it is not, as the 
 rest of its parietes, bony or cartilaginous, but formed principally 
 by muscle and some tendinous expansion. Under circumstances 
 of great accumulation of fluid, or of hypertrophy of the lung, 
 this muscular wall yields to pressure, its convex surface becomes 
 flattened or even concave, the viscera of the abdomen, on the 
 side corresponding to the affected lung, are pushed down before 
 it, and from their displacement a new and most important 
 source of diagnosis is obtained. It is true that the reverse 
 may happen, and the thoracic viscera shall be displaced by 
 abdominal disease ; thus, an enlarged liver or spleen, an abdo- 
 minal aneurism, or an accumulation of air or fluid in the belly, 
 by pressing on the concave side of the diaphragm, may displace 
 the lung or heart, but it is obvious, that when we consider the 
 difterence between the abdominal and thoracic walls, and the 
 yielding nature of the latter, such can only occur in very exten- 
 sive disease. It is plain, too, that the natural action of the 
 diaphragm will tend to diminish these effects, while in the 
 former case it could have no such influence ; and it will be 
 proved in the following pages, that an amount of pressure on the 
 concave side of the diaphragm, carried even so far as to displace 
 the superjacent viscera, does not deprive it of its contractile power. 
 
 If we take a general view of the cranial, thoracic, and abdo- 
 minal cavities, it would appear that in none of them is the 
 diagnosis of disease, from symptoms alone, so difficult as in the 
 chest. But further investigation will prove to us, that there is 
 no cavity in the diseases of which, when we combine the study 
 of symptoms, properly so called, with that of physical signs, 
 the determination of the nature, extent, and modifications of 
 disease is so easy and certain. In fact, the diagnosis of thoracic 
 diseases is founded on the combination of signs and symptoms, 
 and we shall find, that of all the cavities the chest is that in 
 which the physical signs are most numerous and of most exten- 
 sive application. 
 
 The nature of thoracic disease may be occasionally determined
 
 10 GENERAL PEINCIPLES OF THE 
 
 by the consideration of signs or the observation of symptoms ; 
 but it is obvious that the more we combine the two the more 
 exact will our diagnosis be. In diseases of the thoracic viscera 
 there is a greater necessity for mechanical diagnosis than in 
 those of the brain or abdomen, for the general resemblance of 
 the symptoms of the different thoracic diseases is much more 
 striking than that of the cranial or abdominal affections. 
 
 In the case of the brain we can often distinguish between 
 arachnitis and deep-seated local inflammation. In that of the 
 abdomen it is not difficult to distinguish between a mucous and 
 a serous inflammation, nay, we are even able to distinguish 
 between the disease of the different portions of the mucous 
 expansion, as between gastritis, duodenitis, ileitis, and inflam- 
 mation of the large intestine. But in the case of the thorax, 
 this accuracy from symptoms alone is too often inaccessible. 
 Pain, dyspnoea, acceleration of breathing, cough, and expectora- 
 tion, are the prominent characteristics of a great number of 
 essentially different diseases. 
 
 It has been asserted, that by studying the varieties in the 
 nature, mode of occurrence, succession, and modification of these 
 symptoms, we can, independently of the information derivable 
 from physical signs, arrive at an accurate diagnosis of thoracic 
 disease. This is the common assertion of those few who are 
 still opposed to the use of mechanical diagnosis. It is not to be 
 denied, that in many instances the physician without the aid of 
 the stethoscope or percussion may arrive at a sufficiently accurate 
 diagnosis, and, that before these modes of ascertaining chest 
 disease were introduced, the nature of many cases was cor- 
 rectly determined ; but I feel no hesitation in saying, that for 
 the attainment of such accuracy, the combination of careful 
 observation, uncommon tact, and long experience, is absolutely 
 necessary. In other words, that there must be qualifications 
 which it is next to impossible any young practitioner can pos- 
 sess. And, after all, however painfully and slowly this power 
 of diagnosis has been acquired, it is still imperfect, an assertion 
 well borne out by the comparison of the state of our know- 
 ledge previous and subsequent to the discoveries of Laennec. 
 The prominent symptoms of chest affections which have been 
 enumerated, may occur in the same order and the same manner 
 in many essentially different diseases ; in bronchitis, pneumonia,
 
 DIAGNOSIS OF THORACIC DISEASE. 11 
 
 tuberculization of the lung, and pleuritis. Every one who has 
 studied chest affections must have seen examples of all these 
 cases, accompanied by symptoms exhibiting a resemblance which 
 would puzzle the most profound and accurate symptomatologist. 
 Now, supposing that the character and succession of the symptoms 
 were the same, and the diseases of equal frequency, and that we 
 were to fix upon any one disease as the cause of these symptoms, 
 there would be three chances to one against our coming to an 
 accurate conclusion. 
 
 I am quite aware that many persons will object to this, and 
 maintain, that although these symptoms occur in the above- 
 mentioned diseases, and even in the same order, yet that their 
 nature is different. In the characters of expectoration, for 
 instance, sufficient data for ascertaining the nature of its cause 
 may exist ; thus, in advanced phthisis it is purulent ; in bron- 
 chitis, mucous ; in pneumonia, bloody, and so on. All this, 
 though true to a certain degree, is yet, when generally applied, 
 far behind the actual state of medicine, which has proved, that 
 we may have in each of these principal diseases every variety of 
 expectoration, or no expectoration at all ; and we may extend the 
 same kind of observation to the cough, dyspnoea, acceleration of 
 breathing, and pain. 
 
 It may be said, that besides those mentioned there are other 
 symptoms capable of assisting in diagnosis ; as, for instance, 
 the mode of decubitus, or the occurrence or non-occurrence of 
 hectic. But both of these are equally fallacious. A patient 
 with the most enormous empyema shall lie on the healthy side, 
 and hectic is often absent, though the lung be full of suppurating 
 cavities, or well marked without a tubercle in the lung. And, 
 with respect to the occurrence of fever in general, it is notorious 
 that every disease of the lung may be apyrexial, or occur with 
 all varieties of fever. 
 
 Lastly, the advocates of physical examination may well appeal 
 to the frequency of the latent affections of the lung, as showing 
 the necessity of this mode of investigation. The lung may be 
 hepatized without cough, dyspnoea, acceleration of breathing, 
 pain, expectoration, or fever. But this change cannot occur 
 Avithout the existence of physical signs sufficient for its detection, 
 and nearly the same remark is applicable to many other in- 
 stances of pulmonary lesion.
 
 12 GENEEAL PRINCIPLES OF THE 
 
 It is plain that the study of symptoms alone cannot lead to 
 accurate distinction of chest disease ; the same remark is appli- 
 cable to that of physical signs unconnected with symptoms. 
 Symptoms are insufficient without signs, and signs insufficient 
 without a careful comparison of these with the symptoms. 
 There is no such thing as a perfectly pathognomonic symptom 
 or sign of any thoracic disease. We must combine the lights 
 drawn from the careful study of symptoms, both past and pre- 
 sent, with the observation of physical signs, for by this mode 
 alone, can we hope to arrive at an accurate result. Great injury 
 has been done to the cause of physical diagnosis by some in- 
 experienced men, who, departing from the principles of its 
 illustrious founder, have neglected too much the study of symp- 
 toms. To this subject I shall hereafter recur. 
 
 Let us now enumerate the sources of physical diagnosis. 
 1st. Sig7is purely acoustic, including the results of percussion 
 and of auscultation, mediate and immediate. It may be observed 
 here, that of all the signs these are of the most universal appli- 
 cation, there being no disease of the lung or heart in which they 
 do not occur. 
 
 2nd. Signs derived from the alterations of shape and volume 
 of the thorax. This source of diagnosis is capable of application 
 to many, though by no means to all the diseases of the lungs, 
 heart, and great vessels. Changes of shape and volume imply 
 either the existence of acute diseases, in which the products of 
 the disease have rapidly accumulated, or, which is the more 
 frequent case, of diseases which have a great degree of chronicity. 
 Under the first head we may reckon rapid liquid effusions into 
 the pleura or pericardium, the result of inflammation ; and recent 
 pneumothorax from fistula. Under the second, we have chronic 
 liquid and aeriform effusions ; hypertrophy and atrophy of the 
 lung, both the result of chronic disease ; and aneurismal or other 
 organic tumours. 
 
 3rd. Signs referrible to the sense of touch : these we find to 
 occur in a considerable number of thoracic diseases, as, for 
 instance, in bronchitis with eftusiou, in dry pleurisy and peri- 
 carditis, in various diseases of the heart and great vessels, in 
 abscesses of the lung communicating with the bronchial tubes, 
 and in certain cases of liquid effusions into the serous cavities, 
 and in hepatization of the lung.
 
 DIAGNOSIS OF THORACIC DISEASE 13 
 
 4th. Signs derived from the inspection of the motions of the 
 thorax during respiration : these occur in cases of local or 
 general impermeability of one lung, and in cases where the 
 motions of respiration are otherwise impeded or altered. 
 
 5th. Signs derived from the inspection of the thorax with 
 reference to the action of the heart and great vessels. 
 
 6th. Signs derived from the existence of an external collateral 
 circulation, as indicative of the existence of obstruction of the 
 great internal venous trunks, such as the cava and innominata. 
 
 7th. Signs derived from the observation of the displacement 
 of the thoracic or abdominal viscera; of these, some may be 
 appreciable by the senses of sight and touch merely, while others 
 must be ascertained principally by that of hearing. The dis- 
 placement of the heart (perceptible to the eye and touch) and 
 the protrusion of the liver into the abdominal cavity are ex- 
 amples of the first division ; while the displacements and com- 
 pression of the lung from liquid or aeriform effusions into the 
 serous sacs furnish examples of the second. 
 
 Now it is never to be forgotten, that although in these various 
 classes we have a vast number of well-marked and essentially 
 differing physical phenomena, there is not one of them which, 
 taken singly, can he considered as a pathognomonic sign. Nay, 
 ive might go farther and declare, that no possible combination of 
 them can be considered absolutely pathognomonic. By some of 
 them, taken singly, or by various possible combinations, we 
 may, indeed, ascertain the existence of certain mechanical con- 
 ditions of the intra-thoracic viscera, as, for instance, permeability 
 or impermeability, increase or diminution of the quantity of 
 air, the existence of cavities of various sizes and with various 
 communications, the roughened state of a serous membrane, or 
 the displacement of particular organs ; but if we seek to deter- 
 mine by physical signs alone the cause of all or any of these 
 phenomena, we shall find it to be difficult or impossible. It is 
 only, as we have said before, by the connexion of the accurately 
 ascertained physical signs with the previous history and actual 
 symptoms of the case that a correct diagnosis can be ever 
 arrived at. 
 
 In order to establish the proposition that no physical sign, 
 taken singly, can be considered as pathognomic, let us take a 
 brief review of these different signs, commencing with those least
 
 14 GENERAL PRINCIPLES OF THE 
 
 frequently applicable, and proceeding to those of most common 
 occurrence. 
 
 1st. Existence of an external collateral venous circulation. 
 
 This appearance, which has been described by Reynaud, is 
 indicative of a great amount of obstruction to the internal venous 
 circvilation. But of the nature of that obstruction it alone can 
 tell nothing. It may proceed from the pressure of a tumour, 
 aneurismal or otherwise, or from disease on the internal surface 
 of the venous trunk itself. This was observed to occur in the 
 vena portse and inferior cava in a patient whose case is described 
 by the same author, and in whom the superficial veins of the 
 abdomen took on a supplementary action. 
 
 In obstructions at the right side of the heart, the dilatations 
 of the jugular veins, so long noticed, seems to be the commence- 
 ment of the same morbid appearance, and Dr. Graves has shown 
 that a varicose state of the superficial thoracic veins may occur 
 from cancerous degeneration of the lung itself. 
 
 If, for the sake of argument, we assume that these diflerent 
 causes for the appearance in question were of equal frequency, 
 and that from it alone we determined on the existence of any 
 one of them, there would be four chances to one against our 
 making a correct diagnosis. 
 
 2nd. Signs derived from the displacement of the thoracic or 
 abdominal viscera. 
 
 Of these, those that are most frequently recognized are the 
 displacements of the heart and liver ; the first is commonly 
 observed in cases of empyema, the displacement to the right of 
 the mesian line occurring in empyema of the left side, while that 
 in the opposite direction indicates accumulation in the right 
 pleura. Now, although displacement of the heart to the right 
 side of the sternum constitutes one of the best indications of 
 empyema of the left pleura, yet taken alone it is anything but 
 unequivocal. A tumour or an hypertrophy of the left lung may 
 produce a pulsation to the right of the sternum ; the same 
 may be caused by an hypertrophy and dilatation of the right 
 cavities of the heart. And Dr. Graves and I have shown that 
 an aneurism of the aorta may push the heart to the right side.
 
 DIAGNOSIS OF THORACIC DISEASE. 15 
 
 I have also published the particulars of an extraordinary case of 
 dislocation of the heart from external violence, in which the 
 oi'gan was driven far to the right of the mesiau line, and in 
 which no sign of empyema of the left pleura had ever occurred. 
 When I come to treat of the affections of the heart I shall give 
 the particulars of this case. Lastly, well attested examples of 
 congenital displacement of the viscera have been recorded, in 
 which the heart was placed at the right of the mesian line. On 
 the other hand, displacement of the heart towards the left 
 axillary region is a circumstance which, from its nature, is 
 commonly overlooked, and which may occur from other causes. 
 I may also remark, that the previous contraction of either side 
 from a former attack of pleurisy should be added to the possible 
 uncertainties of this source of diagnosis, for in such cases the 
 heart seldom resumes its normal situation with respect to the 
 healthy side. 
 
 As the displacement of the heart, considered alone, and with- 
 out reference to any acoustic observation, is reducible, as a sign, 
 to the mere feeling or seeing its pulsations in an anormal situa- 
 tion ; so, the displacement of the liver is reducible to the ob- 
 servation of a tumour in the right hypochondrium. Now, even 
 supposing that the case was one of displacement of the liver, it 
 will be shewn that this might arise from other causes than 
 empyema, to which it is commonly attributed : intra-thoracic 
 tumours may produce it. I have observed it from Laennec's 
 emphysema ; it may occur from aneurism of the abdominal aorta, 
 or from that of the hepatic artery ; and I need scarcely remark, that 
 we may have hepatic tumours, independent of any disease of the 
 pleura, and conversely, pleural effusion without this sign. These 
 observations are sufficient to shew, that displacements of the 
 heart or liver cannot alone be looked upon as certain diagnostics 
 of the lesion Avhich has produced them. 
 
 3rd. Signs derived from the inspection of the motions of the 
 thorax during respiration. 
 
 I shall not occupy the time of my readers with any com- 
 mentary upon this class of signs. The respiratory movements 
 are so infinitely various in the different diseases of the chest, 
 that we are not warranted in founding an}- certain diagnosis 
 upon the obserA'ation of them alone.
 
 16 GENEKAL PRINCIPLES OF THE 
 
 4th. Signs referrible to the sense of touch. 
 
 This class presents to us several signs, which, as far as they 
 go, lead to a greater degree of certainty than those in the pre- 
 ceding one. Yet, like the other physical signs, they only reveal 
 to us, and that not constantly, mechanical conditions, without 
 leading to the diagnosis of the nature of disease, or the patholo- 
 gical state of the viscera. Thus, the bronchial vibration maj' 
 occur from any liquid eifusion into the tubes, and with various 
 states of the lungs. The feeling of gurgling may proceed from 
 a tuberculous, pneumonic, or gangrenous abscess, or from a 
 dilated tube containing muco-puriform matter. The cause of 
 the sensation of friction has not been sufficiently investigated, 
 but we know that the rubbing feel may arise in various states of 
 the serous membranes ; while that of non-expansion of parts of 
 the lung, will obviously be produced by many different causes. 
 The cases in which the sense of touch leads us to most certainty 
 in diagnosis are those of the diseases of the heart and great 
 vessels ; yet every practical man knows, that the most violent 
 impulses occur without organic disease of the circulating system, 
 while, on the other hand, extensive hypertrophy of the heart 
 may exist with a natural impulse, and an aneurism of the aorta 
 give no morbid pulsation. 
 
 5th. Signs derived from alteration in the shape and volume of 
 
 tlie thorax. 
 
 In this class of signs we meet with some of considerable value ; 
 thus, the convexity of the chest in Laennec's emphysema, when 
 carried to a great degree, is an appearance almost peculiar to the 
 disease ; and which, combined with the elevated shoulders and 
 the hypertrophied state of the muscles in the neck, will scarcely 
 mislead. But of the various partial dilatations and contractions, 
 there is no one at all pathognomonic : many of them may be 
 congenital, or the result of former, and of various diseases. 
 Thus, dilatation of either side may arise from emphysema, 
 pneumothorax, pleural effusions of various kinds, effusions into 
 the pericardium, enlargements of the liver, or aneurisms of the 
 aorta. An apparent dilatation too, may exist, in consequence 
 of the contraction of the opposite side : and contraction itself 
 may arise from a variety of morbid causes, or be a congenital 
 conformation.
 
 DIAGNOSIS OF THORACIC DISEASE. 17 
 
 6th. Sig)is referrihle to acoustics. 
 
 These have been hitherto divided into those obtained by 
 percussion, and by mediate or immediate auscultation ; a divi- 
 sion which seems to be unnecessary, as both classes of signs 
 being appreciable by the ear alone, should be ranged under the 
 general head of auscultatorif j)^^^^^om£na. Under this head, 
 therefore, we shall treat of Percussion, and Auscultation, whe- 
 ther Mediate or Immediate. Previous, however, to our entering 
 on an investigation of their value as diagnostic means, we shall 
 briefly describe the principles of these modes of diagnosis. 
 It is plain, that we have acoustic phenomena referrihle to a 
 passive and an active state of the lung ; in other words, to 
 conditions, on the one hand independent of motion or life, 
 and on the other, inseparable from them. The passive phe- 
 nomena, or those of percussion, which relate merely to the 
 quantity of air Avithin the thorax, may be as well observed in 
 the dead as in the living body ; while the active, or those of 
 respiration, the voice, or the phenomena of the heart and 
 arteries, imply motion and life. Hence, we may divide the 
 phenomena of auscultation into those of the passive and active 
 conditions. 
 
 PASSIVE AUSCULTATORY PHENOMENA. 
 
 The great object of percussion is to determine the diminution 
 or increase of the quantity of air within the thorax, or in certain 
 portions of that cavity. It has been already observed that of the 
 different cavities in the body, the chest is that in which the 
 existence of air in quantity is a natural condition ; and it need 
 scarcely be repeated, that in the normal state of the cerebro- 
 spinal cavities, air, in a free state, is always wanting. We 
 know, also, that when it occurs in any part of the abdomen, it is 
 either the product of disease, of the fermentation of the ingesta, 
 or of a secretion from the mucous surface, by no means constant 
 in its occurrence or quantity; but the chest is the great re- 
 ceptacle for air, and from the first moments of extra-uterine life, 
 contains a vast quantity of it. Upon this peculiarity does the 
 employment of percussion depend, because, ceteris paribus, the 
 
 c
 
 18 GENERAL PRINCIPLES OF THE 
 
 sound on percussion is directly as the quantity of air contained 
 within the thorax. 
 
 Now, the result of almost every organic disease of the lung or 
 heart is to diminish or increase the capacity of the thorax for 
 air, and consequently to diminish or increase the sound on per- 
 cussion ; hearing this in mind, we find that the greater number 
 of thoracic afiections tend to diminish the quantity of contained 
 air, and consequently are accompanied by a proportional decrease 
 of sound, while the smaller (very few in number) have the 
 opposite effect and results. If we consider that the general 
 result of most of the organic diseases is to cause impermeability 
 of the lung, produced either by deposition within, or pressure 
 without the organ, we shall see that the principle above stated 
 holds good : thus, in pneumonia, congestion, oedema, pulmonary 
 apoplexy, tubercle, cancer, and hydatid of the lung, portions of 
 the lung, more or less extensive, which had previously contained 
 air, are now filled by a fluid or solid substance. Even in 
 bronchitis, we can have no doubt, that the sound on percussion 
 is diminished in proportion to the turgescence of the mucous 
 membrane, a fact observed by Avenbrugger in the exanthematous 
 diseases. It is true, that the diminution of sound is generally 
 so slight as to escape detection ; yet that it exists even in the 
 first stages cannot be doubted ; and when secretion takes place 
 to any degree into the bronchial tubes, the diminution of the 
 quantity of air can be generally detected by percussion. 
 
 The same result is observed in all those cases of disease of 
 the pleura or pericardium, in which a liquid effusion occurs. 
 In these cases, as in the former, we see a similar effect, though 
 from a different cause : namely, the obliteration of air cells, the 
 diminution of the quantity of air, and the occupation of its 
 situation with reference to the thorax, by a medium giving a 
 dull sound on percussion. The same remarks are applicable to 
 enlargements of the heart, aneurisms of the aorta, and organic 
 tumours exterior to the lunef. 
 
 Of those diseases, in which an increase of the quantity of air, 
 and consequently an increase of the sound on percussion, are 
 results, we have but two : namely, dilatation of the air cells, and 
 pneumothorax. It seems possible also, that an extremely 
 anaemic state of the body, by diminishing the amount of the 
 circulating fluid, may produce a morbidly clear sound on percus-
 
 DIAGNOSIS OF THORACIC DISEASE. 19 
 
 sion, and that in this way, we may explain the extraordinary 
 clearness observed in many phthisical patients, even though the 
 lung contains considerable quantities of scattered tubercle. 
 
 I shall now briefly recapitulate the principal thoracic aflfections, 
 with reference to the result of percussion. 
 
 First. — Diseases causing a diminution i)i the sound on 
 percussion. 
 
 The different forms and stages of pneumonia, serous and san- 
 guineous congestions, pulmonary apoplexy. 
 
 Tubercle, cancer, melanosis, hydatids. 
 
 Bronchitis in its first and second stages. 
 
 All liquid effusions into the pleura and pericardium. 
 
 Active and passive enlargements of the heart. 
 
 Aneurisms of the aorta or innominata. 
 
 Organic tumours of the mediastinum, pleurae, pericardium, or 
 heart. 
 
 Secondly. — Diseases causing an increase of the sound on 
 percussion, either partial or general. 
 
 Dilatation of the air cells. 
 
 Hypertrophy of the lung. 
 
 Pneumothorax, Avith or without fistula. 
 
 Pneumopericardium. 
 
 Now, the great point, as connected with the applicability of 
 percussion to diagnosis is, that these diminutions or augmenta- 
 tions of the quantity of air being almost always partial, give 
 consequently, partial phenomena. A circumstance admitting of 
 the application of comparison, Avhich, as we have said before, is 
 so important in physical diagnosis. 
 
 For example, in the case of solidification of one lung, although, 
 for the sake of argument, we may suppose that the quantity of 
 air wdthin the thorax is diminished by one-half ; yet, it does not 
 follow, that the sound on percussion of the whole thorax is pro- 
 portionally lessened. For the healthy side retains its natural 
 sound, or at all events gives a sound so little diminished, as by 
 no means to interfere Avith the comparison of the healthy Avith 
 the diseased lung. Again, in a case of incipient phthisis, the 
 upper lobe of the lung is tubercular ; yet, this diminution of the 
 
 c2
 
 20 GENEKAL PRINCIPLES OF THE 
 
 quantity of air does not affect the sound of the lower portions : 
 and hence, a comparison between them can be estabHshed, and 
 the disease be thus detected. Further, in a case of pneumo- 
 thorax, or of partial dilatation of the air cells, the increase of 
 sound is only partially observed, the healthy portions giving less 
 resonance on percussion ; so that here also, comparison can be 
 established. I am aware, that, reasoning upon strictly physical 
 principles, we should expect some diminution or increase of sound 
 in the healthy portions ; yet, if this does occur, the alteration is 
 so slight as not to interfere with the focility of diagnosis, unless 
 in extreme cases of disease. It is plain, that if such alteration 
 occur, it will interfere more with the comparison of the parts of 
 the aftected lung among one another, than to that of the diseased 
 with the healthy lung. 
 
 ACTIVE AUSCULTATORY PHENOMENA. 
 
 The principle of diagnosis, founded on these signs, is ex- 
 tremely simple. I may give the following explanation of this 
 principle. 
 
 The manner in which the stethoscope assists us in detecting 
 the state of the thoracic viscera can be explained in a very few 
 words. The air, as it passes through the lungs in the acts of 
 inspiration and expiration ; the sound of the voice in different 
 parts of the chest ; and the impulse and sound of the heart at 
 each pulsation, have all certain characters in the state of health. 
 The}'^ present phenomena, which are to be considered as standards 
 of comparison. Now, every disease of the lungs and heart alters 
 or modifies these characters, according as the case may be ; and 
 it is by the knowledge of the morbid i^lic}io))iena or deviations 
 from the natural state, that we may judge of the state of the 
 thoracic viscera. 
 
 I need scarcelj' remark, that I do not maintain, that health 
 implies an identity of phenomena in every individual ; the signs 
 in a child differ from those in the adult, those of the female 
 from those of the male ; and there are other cases of natural 
 modification, but still, taking these circumstances into con- 
 sideration, the active auscultatory phenomena of health have a 
 sufficiently constant character to deserve the name of standards 
 of comparison, and to be used as such.
 
 DIAGNOSIS OF THORACIC DISEASE. 21 
 
 The active auscultatory plienomena may be classed as follows : 
 I. Sounds of respiration : — 
 Tracheal. 
 Vesicular. 
 II. Sounds of cough. 
 
 III. Sounds of voice. 
 
 IV. Sounds of the heart and great vessels. 
 
 Now, the effect of disease is two-fold : it modifies these 
 plienomena, and it gives rise to new and non-analogous signs ; 
 so that we have active auscultatory phenomena of health, — 
 next, modifications of these, produced by disease ; and, lastly, 
 entirely new active auscultatory signs, whose existence is solely 
 the result of a diseased state : as for instance, the different 
 rales ; the metallic phenomena ; the rubbing sounds of the 
 serous membranes ; and the various murmurs of the heart and 
 great vessels, &c. 
 
 Having now given a short sketch of the sources of physical 
 diagnosis, I shall announce the great principles that govern their 
 application to the detection of disease ; these may be stated as 
 follows : — 
 
 First. — That the value of most of the preceding signs, or 
 of their combinations, in the determination of the seat, nature, 
 or extent of disease, is to be estimated more by comparison with 
 the phenomena of other portions of the chest, than by their mere 
 existence in a particular situation. 
 
 Second, — -That the greater the number of physical signs which 
 can be combined in any particular case, the more accurate will 
 our conclusions be. But of these combinations, the most im- 
 portant and indispensable is that of the passive and active aus- 
 cultatory phenomena. 
 
 Third. — That the existing physical signs are to be considered 
 in relation to the period of duration of the disease, and the 
 rapidity or slowness of their own changes. 
 
 Fourth. — That in all cases, the value of physical signs must 
 be tested by the existing symptoms and previous history ; while 
 on the other hand, the observation of these physical signs, enables 
 us to correct the conclusions to which we would be led by the 
 unaided study of symptoms. 
 
 I shall first proceed to the elucidation of the principle of 
 Comparison. This principle, which may be said to be the basis
 
 22 GENEEAL PRINCIPLES OF THE 
 
 of physical diagnosis, has not heen sufficiently insisted on, either 
 in the work of Laennec, or of any of the succeeding writers on 
 auscultation. Indeed, Dr. Williams is the only author who 
 alludes to the subject.* But even this author does not suffi- 
 ciently insist on its paramount importance, and refers to i-t 
 principally as connected with the use of percussion. "A person 
 commencing the practice of percussion, will be guided more 
 safely by the comparative than by the absolute sounds of different 
 pai-ts of the chest ; and although he should lose no opportunity 
 of acquainting himself with the sounds, both of percussion and 
 auscultation, in healthy subjects, he should in case of disease, 
 more particularly at first, direct his attention to irregularities or 
 want of correspondence of the two sides in the same subject. 
 In instituting this comparison, he should be careful, likewise, to 
 practise percussion on corresponding parts of the two sides, and 
 with such an attention to the manner in which his fingers fall, 
 and, if he uses the digital pleximeter, the manner in which this 
 is placed, that any difference of sound may not arise from these 
 fortuitous circumstances." 
 
 But the principle of comparison must be applied to all tlie 
 means of physical diagnosis, and must never be lost sight of, 
 either by the tyro or the most practised investigator of disease ; 
 for, as will be shewn, it is the only mode of avoiding error. 
 
 We have already seen how beautifully the anatomical structure 
 of the thorax favours the application of this principle ; the organs 
 in this cavity being more remarkably and completely separated 
 than those of the cranium or abdomen. From this circumstance 
 two impoi-tant consequences are derived : first, the facility of 
 comparison of the different portions, and next, the circumscription 
 of disease. 
 
 Let us now take some examples of the value of comparison. 
 Feebleness of respiration occurs in many diseases of the lung. 
 Now, suppose we are called to examine a patient with symptoms 
 of incipient phthisis, we may find the vesicular murmur under 
 the clavicle exceedingly feeble, a character of common occurrence 
 in cases of tubercular disease ; yet, if from this alone we were to 
 conclude, that the case was really phthisis, we might be altogether 
 TNTong, for many persons have a naturallj' feeble respiration ovei' 
 
 * Rational Exposition of the Physical Signs of the Diseases of the Lungs and 
 Pleura.
 
 DIAGNOSIS OF THORACIC DISEASE. 23 
 
 the whole chest. In such a case, the sign of feebleness of 
 res2?iration under the clavicle might be of no value, for it would 
 be only the natural character of the respiratory murmur. But 
 suppose that, in another case, we found the same feebleness of 
 respiration in the same place, and not content with this super- 
 ficial examination, we explored the opposite side, and found the 
 respiration there unusually loud, then, indeed, the feebleness 
 of respiration would become a sign of positive value ; because, 
 under such circumstances, experience tells us, that in most 
 cases, it is actually produced by tubercular development. 
 Thus, in this instance, the sign derives its whole value from 
 comparison. 
 
 Let us now take the opposite case : there is a character of 
 respiration, termed puerile, from its resemblance to that of 
 children, and which commonly occurs in cases where some 
 other portion of the lung has been disorganized. But the mere 
 circumstance of hearing puerile respiration in one portion of the 
 lung, is by no means a conclusive proof of the existence of 
 disease in some other part, for, in certain cases, the respiration 
 is universally puerile, independent of any disease ; it is only the 
 co-existence of puerility in one portion and feebleness in another, 
 that gives any value to the sign ; in other words, it is by the test 
 of comparison that its value must be estimated. 
 
 The same observations apply to the phenomena of the voice. 
 An increased resonance of the voice is a common sign of solidity 
 of the lung, but one of no value, except by comparison, for many 
 persons present a natural bronchophony over a large portion of 
 both lungs. But, where the resonance is loud and distinct in 
 one lung, and either wanting or much less intense in the corres- 
 ponding portion of the opposite one ; it then becomes a sign 
 of decided value. I might also extend this to the sign of 
 pectoriloquism, about which, such a quantity of error is extant. 
 Some persons are naturally pectoriloquous in the upper 
 portions of the lungs ; and it is plain that, in such cases, the 
 discovery of the phenomenon under the clavicle, or over the 
 shoulder of one side, might lead to great error unless tested by 
 comparison. 
 
 The following is an important and common illustration of the 
 value of comparison. A patient presents the symptoms of cough, 
 muco-purulent expectoration, accelerated breathing and pulse.
 
 24 GENERAL PRINCIPLES OF THE 
 
 emaciation, and hectic. Under these circumstances, we detect a 
 mucous rattle in the subclavicular region ; a sign which, when 
 properly estimated and corrected, may lead to an almost positive 
 diagnosis of phthisis, with softening of the tubercles. Now if, 
 in a patient labouring under the above symptoms, we were to 
 conclude from the mere existence of this sign in this situation, 
 that the case was really phthisis, we might fall into error, for a 
 comparative examination of the different portions of the chest 
 might shew, that the rale was universal ; a discovery, which 
 would greatly diminish its value as a sign of phthisis, and leave 
 a probability that the case Avas one of bronchitis, with copious 
 effusion into the smaller tubes. In such a case, the value of 
 comparison is obvious. 
 
 On the other hand, the existence of rale, either under one or 
 both clavicles, while the inferior portions remained free, would, 
 when occurring with the symptoms described, be a most important 
 diagnostic sign of phthisis. 
 
 Comparison must be used in determining the value of the 
 modifications of the original active phenomena, as well as of that 
 of the new or non-analogous signs. A good example of this is 
 seen in the detection of foreign bodies in the bronchial tubes, for 
 it is i^rincipally b}^ the comparison of the respiratory sounds in 
 both lungs, that the diagnosis of a foreign body can be arrived 
 at : to this subject I shall return hereafter. I may also 
 observe, that in certain cases of aneurism of the aorta or in- 
 nominata, it is by a comparison of the respiratory murmur in 
 either lung, that the existence of the tumour at an early period 
 can be detected. 
 
 We get a good idea of the value of comparison, by reflecting 
 that the cases in which diagnosis is most difficult, are those in 
 which the phenomena are the same over the entire chest. There 
 are two cases of phthisis in which physical diagnosis is extremely 
 difficult; the one an acute, the other, a chronic case ; yet, in botli 
 of which, the tubercle is equally and universally developed in 
 both lungs, and consequently, similar phenomena being given by 
 all parts of the chest, the diagnosis by comparison founded on 
 the localization of disease, becomes inapplicable. The same 
 remarks apply to the case of double empyema, in which we lose 
 the advantages that the comparison of the differences betAveen 
 the physical phenomena of either side gives us in single pleurisy;
 
 DIAGNOSIS OF THORACIC DISEASE. 25 
 
 and also to that of double and equal dilatation of the aiv cells, 
 the detection of which must depend on the direct signs, and 
 history of the case. 
 
 One of the most striking instances of the difficulties which 
 arise when the application of comparison is fallacious, is that of 
 the development of tubercle in a patient, Avhose chest has been 
 deformed from previous disease. Patients who have recovered 
 from empyema with a contracted side, are liable to tubercular 
 development, and the stethoscopist may be called to determine 
 the question, as to whether tubercle exist or not. I have been 
 more than once in this situation, and believe that a more difficult 
 case for diagnosis can hardly be met with. The symptoms will 
 seldom afford any assistance, as they may proceed either from 
 incipient phthisis, or be those commonly present during the 
 convalescence from empyema. And in consequence of the previous 
 disease of one pleura, and the contraction of the chest, we are 
 deprived of the advantages of comparison of the phenomena of 
 both lungs, by the stethoscope and percussion. Thus, if we find 
 the side originally affected to be duller than the other on per- 
 cussion, this may be explained either by the diminished volume 
 of the lung, or by the development of tubercles. The same 
 difficulty exists in the observation of respiration, and the phe- 
 nomena of the voice. But if the opposite lung be the seat of 
 tuberculous disease, we may detect the affection in its early 
 periods ; yet, in a remarkable case that I lately saw, and in 
 which, after a comparatively rapid recovery from empyema of the 
 left side, tuberculous disease set in ; all the stethoscopic signs 
 indicated disease in the left lung, and not in the right ; and yet, 
 on dissection, the right lung was found full of miliary and 
 granular tubercles, while the left contained scarcely anj^ Of 
 this, the preceding considerations afford an easy explanation. 
 The left lung was dull on percussion, from its diminished volume; 
 for the same reason, its vesicular murmur Avas feeble, while in 
 the right, the disease had not become sufficiently extensive to 
 cause a greater dulness, or even an equality of sound. It is plain, 
 that under these circumstances, a greater amount of disease in 
 the right lung would be required to lead to its detection, than in 
 a case where the opposite lung had not been previously affected 
 by empyema. 
 
 Independent of the importance of the principle of compa-
 
 26 GENERAL PRINCIPLES OF THE 
 
 rison, its practice in all cases is of the greatest utility, by lead- 
 ing to the discovery of lesions which would otherwise escape us. 
 I remember being called to see a patient, who had received an 
 injury of the side, and who Avas labouring under fever, cough, 
 expectoration, and dyspnoea. His attendants had examined him 
 repeatedly with the stethoscope, and discovered nothing but 
 bronchitis. I had him stripped, and found the phenomena of 
 empyema and pneumothorax in the lower part of the right 
 lung ; his attendants had examined the upper part of the chest 
 carefully, but had neglected the lower, and thus the true nature 
 of the disease had escaped them. 
 
 With respect to the heart, it is evident, that the diagnosis 
 by comparison of signs with one another, is not so applicable as 
 in the lungs. We are forced, in many cases, to depend upon the 
 characters of isolated phenomena ; and hence, the difficulty which 
 attends the detection of diseases of the heart may be in part ex- 
 plained. If we consider the heart as a single organ, it is plain, 
 that we have no standard for comparison, and the same obser- 
 vation applies, if we take it as a double organ ; for the arterial 
 and pulmonary hearts have original differences, whether ana- 
 tomically or physiologically considered. 
 
 Yet, comparison is not wholly inapplicable in cases of dis- 
 eases of the heart. By it, we may often determine the seat of 
 disease, if not its nature ; we also find it applicable in the 
 diagnosis of certain cases of aneurism of the gi-eat vessels. 
 
 In the progress of this work, I shall shew many other ex- 
 amples of the importance of comparison. We now proceed to 
 consider the next principle of physical diagnosis ; namely, the 
 combination of signs, and in particular, those drawn from per- 
 cussion and the stethoscope. 
 
 For example : a patient is affected with stridulous breath- 
 ing, and by percussion \ye discover that one clavicle is decidedly 
 dull. This proves, that there is in that situation a diminution 
 of the normal quantity of air ; a condition generally produced 
 by either pulmonary solidity, or by displacement of the lung 
 from an aneurismal tumour. Here, to determine the important 
 question, as to whether the case be disease of the lung or 
 aneurism, the employment of the stethoscope becomes abso- 
 lutely necessary. We must correct the passive by the active 
 signs.
 
 DIAGNOSIS OF THORACIC DISEASE. 27 
 
 Again, suppose that we detect feeble respiration in any 
 portion of the lung, we have a character which may be produced 
 by essentially opposite states of the pulmonary tissue, in other 
 words, by an increased or a diminished quantity of air. Percus- 
 sion must be used to correct the stethoscopic observation. The 
 active signs are to be corrected by the passive. 
 
 A patient has presented, for some time, decided dulness of 
 the upper portion of one lung, and we find, subsequently, that 
 this portion regains its sound. Now, this circumstance may be 
 produced either by the formation of a cavity, or by the return of 
 the lung to its healthy state. Here the observation of the active 
 signs is necessary to determine the value of the passive. 
 
 A patient has presented the sign of friction, or the rub- 
 bing sound produced by the inflamed state of the serous mem- 
 brane ; and after a time, this active phenomenon is observed to 
 disappear, which may result either from the cure of the disease, 
 or the separation of the layers of the pleura or pericardium, 
 by a liquid efi'usion. To determine the point, we must have 
 recourse to the observation of the passive phenomena. If it 
 be the former case, percussion will give a clear, if the latter, a 
 dull sound. 
 
 In the case of a foreign body in the trachea, or the pressure of 
 an aneurismal tumour on one bronchus, we may observe either 
 complete absence or great diminution of the respiratory murmur 
 in either lung. This modification of the active auscultatory 
 phenomena, for its value in the diagnosis of aneurism, depends 
 entirely on the result of percussion, as we shall see hereafter. 
 
 It is only by the combination of these two classes of signs, that 
 we are able to arrive at the diagnosis of a rare, but most impor- 
 tant disease, namely, acute general development of tubercle, 
 with bronchial irritation. In many of these cases, stethoscopic 
 observation can only detect intense bronchitis ; and, without the 
 aid of percussion, no other diagnosis could be arrived at. Now, 
 acute bronchitis may exist with apparent clearness of sound ; but 
 if, in such a case, we observe an increasing and decided dulness 
 of the chest, the diagnosis of a general development of tubercle 
 may be often safely arrived at. 
 
 Many more instances, illustrative of the necessity of this and 
 other combinations, will be given in the course of the work. I 
 may, however, add one more common example. A patient has
 
 28 GENERAL PRINCIPLES OF THE 
 
 been attacked with symptoms of inflammation of the lung, and 
 at an advanced period we find the affected side completely dull 
 on i^ercussion. This may arise either from a pleural effusion or 
 a solidification of the lung, and the observation of the active 
 phenomena will be necessary to determine the question. 
 
 Thus, the passive and active auscultatory signs mutually 
 correct each other ; yet, even their combination with all other 
 classes of signs will be insufficient, if the history and symptoms 
 of the case be not accurately considered and compared with 
 them. In other words, it is not enough to compare one set of 
 signs with another, but all the signs, whether acoustic or not, 
 with the history and symptoms. 
 
 Let us next consider the physical signs in reference to the 
 duration of the disease, and the rapidity or slowness of their 
 own changes.* 
 
 A patient, previously healthy, is attacked with inflammatory 
 symptoms and pain in the side. Now, if in the course of twenty- 
 four hours we find the affected side dull on percussion, a strong 
 probability exists that the case is one of effusion into the pleura, 
 rather than of hepatization of the lung. Let us, on the other 
 hand, suppose that the symptoms have continued for a Aveek or 
 ten days, and that at the end of that time we find the sound 
 clear on percussion, then, at all events, we may conclude, that 
 the case is not pleurisy with effusion, or hepatization of the lung. 
 It may be dry plcuritis, pleurodyne, or bronchitis. 
 
 We discover the signs of a cavity in any portion of the chest. 
 Now, the determination of the nature of tha-t cavity will depend 
 much on the history of the patient. If he has been in good 
 health, and free from pulmonary symptoms up to within a week 
 or fortnight of the time when we have first examined him, the 
 great probal)ility is, that the cavity is not tuberculous. It may 
 
 * The consideration of time in reference to the existence of morbid phenomena is a 
 subject of the greatest importance. We cannot in local, as in some of the essential 
 diseases, shew any rule as to the duration of phenomena, or their period of develop- 
 ment, considered with reference to certain stages of the disease; in pleurisy, for 
 example, we cannot say when the effusion will appear, when the secreting process 
 will stop, and when the absorption will commence ; while in variola the progress of 
 the disease is generally so certain, and the relation of its different stages to regular 
 periods of time so generally constant, that the rule is easily applicable. And even 
 though we had such a rule in the acute diseases, we could never hope for it in the 
 chronic affections. Yet the study of time iu relation to morbid phenomena gives 
 approximative results of great value in Diagnosis. — MS, Note Book.
 
 DIAGNOSIS OF THORACIC DISEASE. 29 
 
 be a pneumonic or a gangrenous abscess. On the other hand, 
 if the case has been chronic, in the ordinarj' acceptation of the 
 word, the chances are, that the cavity is tuberculous. 
 
 Let us suppose that we discover an extensive gurgling over 
 the upper portion of one side, and that the question arises as 
 to whether this is caused by an anfractuous phthisical cavity, or 
 by dilated tubes. Here, along with other sources, the period of 
 the continuance of the symptoms is a most important element 
 in settling the question. If the patient has had similar symp- 
 toms for five, ten, or fifteen years, the chances are that the 
 case is one of dilated tubes, but if his symptoms have continued 
 only for three or six months, then it would be almost certain 
 that the signs proceeded from a multilocular phthisical abscess. 
 
 It would be easy to shew that many other diagnoses are 
 founded on the connexion of the actually existing physical signs 
 with reference to the period of continuance of symptoms. I may 
 enumerate a few of these. 
 
 Foreign bodies in the trachea. 
 
 Acute general development of tubercle. 
 
 Laennec's emphysema of the lung. 
 
 Certain cases of empyema and pneumothorax. 
 
 Hydro thorax. 
 
 Nervous palpitation of the heart, as distinguished from organic 
 disease. 
 
 Pericarditis with eftusion. 
 
 Rupture of an hepatic abscess into the lung. 
 
 Sympathetic cough. This example, perhaps, requires some 
 explanation. We may find in a case, where violent cough has 
 existed, either that there is no physical sign of disease, active or 
 passive, or that if there be, the signs are insufficient to account 
 for the symptoms. Now, these circumstances may arise either 
 from incipient organic disease, or from mere functional lesion. 
 If the symptoms have continued for a considerable length of 
 time, the great probabilities are that the case is one of original 
 or symptomatic neurosis of the lung. 
 
 The above instances are sufficient to shew the application of 
 the principle of combination of the history of the case, quoad the 
 period of duration of symptoms, with the actually existing 
 physical signs. " But we must go farther, and consider these 
 signs with reference to the rapidity and slowness of their own
 
 30 GENERAL PRINCIPLES OF THE 
 
 changes. Perhaps the most interesting source of physical diag- 
 nosis is drawn from considering the signs, with reference to 
 their permanence for certain periods, and the mode and order of 
 their successive manifestations. One of the best examples of 
 this is seen in the case of dilated tubes. It may be often 
 difficult to pronounce whether the signs of an excavation proceed 
 from a phthisical cavity or from dilated tubes. Now, as a 
 general rule, it may be stated, that the extension of the cavity is 
 much more rapid in the former than in the latter case ; and 
 from this we derive the following rule : that if, in any instance, 
 we can recognize a rapid extension of a cavity, the case is not 
 one of dilated tubes. If, in the course of a fortnight, or a 
 month, the stethoscope indicates a decided increase in the size 
 of the excavation, we recognize an ulcerative extension, rather 
 than that almost imperceptibly slow process by which the 
 bronchial tubes become dilated, so as to simulate abscess of the 
 lung. 
 
 Again, we may experience difficulty in determining whether 
 a patient labours under enlargement and valvular disease of the 
 heart, or an aneurism of the ascending aorta. I have seen 
 several of such cases, in which I at first suspected an aneurism ; 
 as much, if not more, from the history and symptoms as from 
 the signs ; but in which my suspicions were converted into cer- 
 tainty from observing that the extension of the signs of dulness, 
 pulsation, and the accompanying murmurs occurred much too 
 rapidly to permit the supposition, that they proceeded from a 
 further enlargement of the heart itself. 
 
 In the case of a foreign body lodging in the right bronchus, 
 we have another excellent example of this source of diagnosis : 
 the sudden suspensions and re-appearances of the respiratory 
 murmur in the affected lung, while the sound on percussion 
 remains clear, point out sudden alternations of the conditions of 
 permeability and impermeability in the corresponding bronchus. 
 And it is scarcely necessary to observe that these are circum- 
 stances only explicable on the supposition of a moveable foreign 
 body existing in the tube. Indeed, in the mode of succession 
 of the various signs in the different thoracic diseases, we have a 
 source of diagnosis of such importance, that it seems not im- 
 possible but that future investigation will show that it is in 
 this department we are to seek for the perfection of physical
 
 DIAGNOSIS OF THORACIC DISEASE. 81 
 
 diagnosis. For in many instances we find that in different 
 diseases the characters of the signs are identical, but their modes 
 of succession are constantly and characteristically different. 
 
 For example, oedema of the lung presents a crepitating rale, 
 often undistinguishable from that of pneumonia, as far as its 
 physical characters are concerned ; but successive observations 
 may determine the point. In oedema the dropsy of the lung 
 causes no further organic change, and the crepitus consequently 
 persists, with little or no change, for a length of time, the 
 sound on percussion remaining the same. On the other hand, 
 there exists in pneumonia a cause which produces successive 
 and important modifications in the structure of the lung ; and 
 accordingly, we find corresponding changes in the physical 
 signs. The crepitating rale by degrees masks the vesicular 
 murmur, and as the congestion advances gradually disappears, 
 until impermeability of the cells and finer tubes is produced. 
 We have then dulness of sound and bronchial respiration. But 
 the changes do not stop here, for the lung may pass into 
 suppuration, or return to health ; in either of which cases 
 important changes in physical signs take place. 
 
 In these successive changes, then, is founded the physical 
 diagnosis between pneumonia and oedema. I may here remark, 
 as illustrative of the importance of studying the mode of suc- 
 cession of signs, that although there is no single sign in pneu- 
 monia which is pathognomonic, the possibility existing of every 
 one of them arising from other causes ; yet we know of no other 
 disease which presents, in its progress or resolution, the same 
 mode of succession of phenomena. I have already stated that 
 no possible combination of signs can be considered as absolutely 
 pathognomonic. The observations just now made are by no 
 means contradictory of this, as they apply not to any existing 
 combination, but to the successive developments of physical 
 phenomena. 
 
 I might adduce many other instances of this mode of inves- 
 tigation, but enough has been stated to explain the principle. 
 The preceding observations strongly illustrate one of the most 
 important principles connected with the science of thoracic 
 disease, namely, that it is not enough to be able to recognize, 
 nicely distinguish and remember signs, but that we must know 
 how to reason upon them. Here we see the fusion of the
 
 32 GENERAL PRINCIPLES OF THE 
 
 mechauical and the pathological parts of the science, learn their 
 mutual dependence, and find why it is that the mere auscultator, 
 or the mere symptomatologist, can never excel in the diagnosis 
 of diseases of the chest. 
 
 I shall now, in conclusion, briefly allude to the absolute 
 necessity of studying the symptoms in relation to the physical 
 signs. 
 
 It is true that the mere observation of certain physical signs 
 may, under particular circumstances, lead us to conclusions 
 probably correct, but the object of medicine is certainty. The 
 existence of gurgling and cavernous respiration under the clavicle, 
 tells of a cavity communicating with the bronchial tubes, and 
 containing air and liquid ; in other words, of an anormal 
 physical change ; so far we have certainty. From the relative 
 frequency of its causes, we might say, that the cavity was pro- 
 bably phthisical, but the possibility would exist of its being a 
 dilated tube, a pneumonic or a gangrenous abscess. 
 
 Again, the occurrence of metallic tinkling and amphoric 
 resonance points out the presence of a vast cavity communicating 
 with the bronchial tubes, and containing air and liquid ; and in 
 like manner, from the comparative frequency of its cause, Ave 
 might conclude that the case was probably an example of 
 empyema, pneumothorax and fistula ; but on the other hand, 
 these phenomena may occur from an essentially difierent patho- 
 logical condition of the lung; nay, further, we shall find that 
 some of the metallic phenomena may arise from sources alto- 
 gether external to the thorax. 
 
 Let us take a few more examples, illustrative of the insuffi- 
 ciency of mere physical diagnosis. It is commonly held by 
 those who are but partially acquainted with auscultation, that 
 the crepitating rale is a sign of pneumonia ; that it is so is true, 
 but in some of its forms, it may occur in other affections. Let 
 us suppose that we are called to a patient whom we have never 
 before seen, and with the history of whose case, or his jjresent 
 symptoms, we are ignorant, and that on applying the stethoscope 
 to the postcro- inferior portion of the right lung, we discover a 
 crepitating rale, we have then a phenomenon which may be pro- 
 duced by many essentially diflerent causes ; and were we to 
 make the diagnosis of pneumonia, our opinion would rank 
 nothing better than a mere guess. Among its various causes.
 
 DIAGNOSIS OF THORACIC DISEASE. 33 
 
 the phenomenon might be produced by the following : acute 
 pneumonia in the first, the suppurative, or the resolutive stage ; 
 chronic pneumonia, congestion, oedema, mucous catarrh, tuber- 
 cle, hepatic abscess opening into the lung, pulmonary apo- 
 plexy. Now, supposing that these were all the possible causes 
 of the phenomenon, and that their occurrence was of equal 
 frequency, and that without an accurate investigation into the 
 history and symptoms of the case, we concluded that its cause 
 was an acute pneumonia in the first stage, there would be nine 
 chances to one against our guessing right. But if this crepi- 
 tating rale was observed in a patient, who had been but twenty- 
 four or forty-eight hours ill, and had previously no symptoms 
 of pulmonary disease ; if he had inflammatory fever, pain of the 
 side, cough, acceleration of breathing, and viscid expectoration, 
 we might safely conclude that its cause was an acute pneumonia 
 in the early stage. Again, if it occurred in a patient who 
 had been attacked some days before with the constitutional 
 symptoms of pneumonia, which had subsided after judicious 
 treatment, and in whom there had been pain of the side which 
 had disappeared ; bloody and viscid expectoration, which had 
 been succeeded by a clear or concocted mucus ; dulness of sound 
 and bronchial respiration, which had subsided or was diminish- 
 ing ; we might safely conclude, that the rale was an example 
 of Laennec's crepitus of resolution. Lastly, if it occurred in a 
 patient in the advanced stages of pneumonia, in whom the 
 powers of life were sinking, who had the prune juice sputa, 
 or was expectorating a yellow purulent matter, and in whom 
 the afi"ected portion of the chest sounded absolutely dull and 
 with distinct bronchial respiration, we might safely declare that 
 the lung was in the third or suppurative stage. It is true, that 
 difterences in the character of the sign in these different stages 
 may exist, and be appreciable, but my experience leads me to 
 the firm belief, that in testing the value of any sign, we are to 
 look more to the history of the case, and the accompanying 
 physical and vital phenomena than to its absolute character. 
 Here, I am anxious not to be understood as depreciating the 
 importance of studying the actual characters of physical signs. 
 On the contrary, I am convinced, that the more the ear is accus- 
 tomed to appreciate minute differences of sound, the greater 
 will be our accuracy in detecting the nature of disease. But 
 
 D
 
 64 GENERAL PRINCIPLES OF THE 
 
 while I do not deny the possibilit}' of training the sense of 
 heai-ing to such a pitch of accuracy, as that from the character 
 of sounds we may, in certain cases, infer the vital cause of 
 phenomena, I yet feel, that this perfection is not easily attainable, 
 and at best, can be enjoyed only by the few. And it must never 
 be forgotten, that disease occurs under infinitely numerous modi- 
 fications, so that the result being the same, the physical pheno- 
 mena may not be absolutely similar. 
 
 Again, we meet, under the same circumstances, a patient 
 with feebleness of respiration, and dull sound on percussion in 
 the same situation ; this may depend on inflammatory, tuber- 
 cular, or cancerous solidification of the lung, pulmonary apo- 
 plexy, empyema, hydrothorax, contraction of the chest from 
 a former attack of pleuritis, enlargement of the liver, pushing 
 up the diaphragm, ascites, and aneurism of the aorta. Here 
 the same observations, as in the former case, evidently apply. 
 
 The same train of argument is applicable to most of the other 
 classes of physical signs, as Avill be abundantly shewn when 
 I come to speak of the diseases in particular. 
 
 It has been objected to the advocates for the stethoscope, that 
 they discard the consideration of symptoms, and that throwing 
 overboard all the knowledge we possessed previously to the 
 introduction of auscultation, they pretend to ascertain the exist- 
 ence of all diseases of the chest by the sole observation of phy- 
 sical signs. There is onlj- one answer to be made to this 
 objection, namely, that it is wholly groundless ; indeed, those 
 who make it only betray their ignorance of the subject. Laennec 
 never taught that auscultation could supersede the mode of 
 examination by symptoms : on the contrary, he devotes a con- 
 siderable portion of his work to their history and analysis, 
 and in many places, especially insists on the necessity of their 
 careful study. He gives instances where the physical signs 
 having been accurately observed, the history and symptoms of 
 the case were alone to determine the nature of the disease : 
 thus in describing a case of dilatation of the bronchial tubes, 
 he states that the physical signs allowed of two suppositions ; 
 cither that of an extensive dilatation of the bronchial tubes, or 
 of a multilocular phthisical excavation ; — " I determined how- 
 ever on the first diagnosis," says Laennec, "from the general 
 state of the patient and the history of the disease." Andral,
 
 DIAGNOSIS OF THORACIC DISEASE. 35 
 
 who is the second writer on auscultation, devotes a large portion 
 of his work to the examination of symptoms ; so do Louis, 
 Bertin, Forbes, Duncan, Elliotson, Hope, Williams, and all 
 other writers of any authority on the subject. 
 
 It is true that combinations of physical phenomena may 
 sometimes arise, which would lead to a great degree of proba- 
 bility, indeed, almost a certainty in diagnosis. A patient with 
 a dilated side, giving morbid clearness on percussion, with the 
 sound of fluctuation on succussion, and in whom also the stetho- 
 scope detected the metallic tinkling, &c., might be said, with 
 almost positive certainty, to labour under empyema, pneumotho- 
 rax, and pulmonary fistula : but such cases, or those analogous to 
 them, are comparatively rare ; and even in the case in question, 
 the cause of the fistula would be undetermined. In the cases 
 we are every day called to treat, the value of 'physical signs 
 must be tested by the history and symptoms, and these in their 
 turn must be corrected by the physical signs. Whoever neglects 
 either source of information will fall into the most fatal errors. 
 We must have recourse to the assistance of each and every one of 
 these means ; and even still, with all this combined knowledge, 
 we shall meet with cases, the real nature of which is involved 
 in the greatest obscurity. Indeed, when we reflect on the 
 infinite complications of disease, modified b}^ circumstances 
 infinitely numerous, it would be strange if such did not arise, 
 and there can be no doubt, that if our means of diagnosis were 
 extended one hundred fold beyond their present state, the 
 same circumstances would still occur. Physical signs form an 
 addition, constitute an assistance to diagnosis, but nothing more ; 
 yet of their value every impartial mind must be convinced, who 
 compares the state of our knowledge previous and subsequent 
 to their discovery. It is on the discovery, explanation, and 
 connexion of these signs with organic changes, and with the 
 symptoms and history of the case, that Laennec's imperishable 
 fame is founded. Time has shown that his principles of diag- 
 nosis were not the bagatelle of a day, or the brain-born fancy 
 of an enthusiast, the use of which, like the universal medicine, 
 was to be soon forgotten, or remembered only to be ridiculed. 
 It has shown that the introduction of auscultation, and its sub- 
 sidiary physical signs, has been one of the greatest boons ever 
 conferred by the genius of man on the world. A new era in 
 
 d2
 
 36 GENERAL PRINCIPLES OF THE 
 
 medicine has been marked by a new science, depending on the 
 immutable laws of phj^sical phenomena, and, like other dis- 
 coveries, founded on such a basis, simple in its application and 
 easily understood. A gift of science to a favoured sou : not as 
 was formerly supposed, a means of merely forming a useless 
 diagnosis in incurable disease, but one by which the ear is con- 
 verted into the eye ; the hidden recesses of visceral disease 
 opened to the view ; a new guide in the treatment, and a new 
 help in the early detection, prevention, and cure, of the most 
 widely spread diseases which afflict mankind. 
 
 In conclusion, I would refer to one of the most essential 
 points as bearing on the diagnosis of chest disease, namely, the 
 co-existence of morbid action in the different tissues or struc- 
 tures of the lung. In a practical point of view the lung may be 
 considered as consisting of three different parts or tissues. We 
 have in the first place an extensive mucous expansion, forming 
 the internal or lining membrane of the lung, and which may be 
 described as commencing at the rima glottidis and terminating 
 in the air cells. We have next, these air cells, and their con- 
 necting cellular tissue, forming, with their blood vessels, what is 
 called the parenchyma of the lung ; and lastly, we have its 
 external serous covering, the pleura. 
 
 From this division authors have arranged pulmonary affec- 
 tions into those of the mucous membrane, those which involve 
 the air cells and intervesicular cellular tissue, and lastly, those 
 affecting the serous covering. Under the first they class the 
 different varieties of laryngeal, tracheal, and bronchial disease ; 
 under the second, such affections as pneumonia, tubercle, pul- 
 monary apoplexy, &c., &c., and under the third, we have the 
 different forms of pleuritic inflammations, and the various 
 effusions into the cavity of the pleura. 
 
 This division, though convenient in the writing of systems, 
 and to a certain degree applicable in the practice of medicine, 
 is found to fail when we accurately consider the symj^toms 
 and pathology of thoracic disease. In many cases, indeed, do 
 we find it impossible to draw the line of distinction between the 
 affections of these different elements, for not unfrequently the 
 diseased action extends more or less to them all. We have 
 bronchitis combined with pneumonia, pneumonia complicated 
 with pleuritis, and very frequently the three lesions co-exist ;
 
 DIAGNOSIS OF THORACIC DISEASE. 37 
 
 an observation which applies both to the acute and the chronic 
 diseases of the lung. In the treatment of pulmonary affections 
 it is of the utmost importance to bear this principle always in 
 view. 
 
 For example, in almost every instance of acute pneumonia 
 there is bronchitis also, a circumstance never to be forgotten in 
 the treatment and progress of the case. For in many instances, 
 after the relief of the pneumonia, properly so called, we have to 
 contend with an extensive and severe bronchial inflammation, 
 which if unrelieved, may cause the death of the patient. And 
 the imj^ortance of this is further shewn, if we recollect that the 
 mode of treatment of the two cases is not the same, and 
 the source of danger and the effects on the economy totally 
 different. 
 
 But the complication with bronchitis is not the only one to 
 which such a case is subject, for disease of the pleura is per- 
 haps as frequent, from whence the term pleuro-pneumonia, one 
 applicable to the great majority of cases. It is true that the 
 pleuritic inflammation is generally of the dry kind, and hence of 
 less importance ; but the reverse may occur, and a purulent 
 effusion, or a serous collection, form in the cavities of the 
 pleura ; so that in certain cases the practitioner, ignorant of 
 these facts, might suppose that he was contending with hepa- 
 tization of the lung, when in truth his patient was labouring 
 under empyema or hydrothorax. 
 
 Again, let us consider the ordinary case of tubercular con- 
 sumption. Were we to confine our ideas of this affection to the 
 mere growth and suppuration of tubercles, we would have indeed 
 a most limited and erroneous view of the disease. For in this 
 affection we have not only tubercle in every stage and form, but 
 also the extension of disease to all the tissues of the lung. 
 Many varieties of pneumonia may occur, and the disease in the 
 abstract is a common complication, producing the most im- 
 portant modifications in the symptoms and progress of the case. 
 If we consider the mucous membrane we shall find the same 
 remarks to apply ; many cases ajjpear to commence by bronchitis, 
 and in their progress the state of the mucous membrane comes 
 to be of the utmost importance. Every form of disease may, 
 and commonly does occur, and bronchial secretion is frequently 
 the chief source of the wasting expectoration.
 
 38 GENERAL PRINCIPLES OF THE 
 
 If we now examine the serous membrane we find eyidence of 
 extensive disease. In tlie great majority of cases, adhesions — 
 sometimes so complete as to obliterate the whole sac — thicken- 
 ings, effusions, or even ulceration with a fistulous communication 
 passing inwards, are common occurrences. This frequent com- 
 plication of pleuritis in consumption, as we shall find hereafter, 
 may be considered as a great good ; for in many cases it may be 
 looked on as one of the processes of nature towards bringing 
 about a cure. 
 
 It may be laid down as a general principle, that in many 
 acute, and in almost all chronic aftections of the lung, we find 
 these three tissues more or less engaged. In one case the 
 disease predominates in the bronchial mucous membrane, in 
 another, in the parenchyma, in a third, in the pleura ; yet still 
 the principle will be found very generally true, and its j)ractical 
 application is sufficiently obvious. But as in the present state 
 of our pathological knowledge, we must admit that cases are to 
 be met with, in which disease seems to be confined to a single 
 tissue, and further, that even in the complicated cases, disease 
 may be traced as commencing in one tissue and then extending 
 to another, it becomes convenient to study the affections sepa- 
 rately ; and experience shews that the principles of treatment 
 should vary according to the isolation or predominance of irrita- 
 tion in any of these three essential elements. 
 
 Now the knowledge of these facts is of the utmost im- 
 portance to the student of physical diagnosis, and will remove 
 many difficulties which must otherwise occur in the course of his 
 investigations. Thus, in a case of bronchitis, he will be pre- 
 pared to meet with dulness of sound on percussion, resulting 
 from an accompanying congestion of the vesicular structure, or 
 the sound of frottement from the deposition of lymph on the 
 pleura, or even oegophony from a slight liquid effusion. Nor 
 will he be surprised or puzzled, if, in a similar case, the signs of 
 a pneumonia or a hydrothorax should supervene. In a case of 
 partial pneumonia, the existence of a sonorous or sonoro-mucous 
 rattle in the other portions of the lung will not embarrass him. 
 He gives to the first case the denomination of bronchitis, because 
 he finds that irritation predominates in the mucous membrane, 
 and although there may be signs of sanguineous congestion, or 
 even of pleurisy, yet these seem of comparatively little im-
 
 DIAGNOSIS OF THORACIC DISEASE. 89 
 
 portance, and tlieir treatment may often Le merged in that of 
 the prominent inflammation. On the other hand these may 
 become sources of danger, and for this he is prepared. So also 
 in the case of pneumonia, the extent and character of its proper 
 signs enable him to recognize the disease, even although more 
 or less of bronchitis or pleurisy may co-exist. The same 
 observations will apply to the diseases of empyema and phthisis ; 
 in the first of which the signs of bronchitis so commonly occur, 
 and in the second, where there is scarcel}^ a physical sign of 
 pulmonary disease that may not arise. 
 
 (Dr. Stokes' account of the passive acoustic phenomena is open 
 to the criticism of Dr. Walshe, who says, " English writers as 
 a body have hitherto employed only two terms to indicate the 
 varying characters of the thoracic percussion sounds : namely, 
 dulness and clearness." 
 
 This writer and Skoda have each arranged these sounds under 
 four heads, tlieir nomenclature differing : thus — Skoda's division 
 is into 
 
 1. Full or empty. 
 
 2. Clear or dull. 
 
 3. Tyrapanitic or nou-tympanitic. 
 
 4. High or low. 
 
 Dr. Walshe's into 
 
 Moditied in cases of disease. 
 
 1. Amount of intensit}' of _f Diminished. 
 
 resonance { Increased. 
 
 2. Pitch j Lowered. 
 
 I Raised. 
 
 {Hardened or otherwise inoditied. 
 Softened. 
 Annulled 
 {Increased. 
 Lessened, 
 or not sensibly changed. 
 
 The alteration of sound in morbid states he arranges under 
 four types: namely. Type 1. Tonelessness, or dulness. Type 2. 
 Extra resonance. Type 3. Hardness. Type 4. Muffled tone.
 
 40 DIAGNOSIS OF THORACIC DISEASE. 
 
 Dr. Stokes makes no mention of the important sign of varia- 
 tion in pitch of the percussion sound which Dr. AValshe justly 
 places "in the first rank clinically considered," nor of the feeling 
 of resistance communicated to the finger in degree difi"ering in 
 different diseased conditions. Of its value as a sign Dr. Walshe 
 remarks, ' ' that doubt often exists as to the relative resonance on 
 the two sides is unquestionable ; and in these cases the condition 
 of the subjacent parts may frequently be settled by taking into 
 consideration the amount of resistance. To those persons whose 
 sense of touch is more delicate than that of hearing, this source 
 of diagnosis is of especial value." 
 
 Skoda asserts that " this resistance is greatest when the walls 
 of the chest are rendered tense, and its intercostal spaces dis- 
 tended by pleuritic effusions." It is even more remarkable in 
 tubercular consolidation with thickened pleura of the apex, and 
 most of all in medullary cancer of the lung and pleura.*) 
 
 * See Dr. Mayne's typical case of cancer of the lung, Trans, of Dub. Path. Society, 
 vol. iii. ; also Guttman's Handbook of Physical Diagnosis, p, 116.
 
 41 
 
 SECTION II. 
 
 BBONCHITIS. 
 
 This affection, in its simple or more complicated forms, presents 
 the strongest claims to our attention. In fact, its study 
 furnishes us with a key to thoracic pathology, as in a great 
 number of pulmonary, and even cardiac diseases, the inflam- 
 mation of the mucous membrane of the lung seems to be the 
 first link in the chain of morbid action ; a circumstance illus- 
 trative of the proposition of Broussais, that the various external 
 morbid influences which affect the system are first exercised on 
 one of the surfaces of relation, viz. : the skin, the bronchial, and 
 the gastro-intestinal mucous membrane. 
 
 When we reflect on the various forms of this disease, and on 
 the number of secondary affections to which it may give rise, its 
 importance is obvious ; and we shall find that many examples of 
 diseases, which have received a separate name, have commenced 
 by this lesion, or are complicated with it. We frequently find 
 it a prominent feature in what have been termed the nervous 
 affections of the lung ; we know that it may give rise to dilata- 
 tions of the air cells and tubes, and to pulmonary emphysema ; 
 that it may have been the first lesion in many cases of ulceration 
 of the cartilages ; that there is a close connexion between it and 
 inflammation of the substance and the serous membrane of the 
 lung ; that many cases of phthisis seem to commence by this 
 affection, and that it may ultimately cause morbus cordis, and 
 all the evil consequences resulting from obstructed circulation. 
 
 We further find that bronchitis is present, and has a most 
 important share in almost all diseases of the lung, whether acute 
 or chronic. Thus, in most cases of pneumonia, there is distinct 
 evidence of bronchitis ; a complication which, according to cir- 
 cumstances, may be of the greatest advantage or danger to the 
 patient. It is a constant complication in pleuritis, particularly 
 of the chronic form ; while in phthisis, according to the best 
 pathologists, the bronchial mucous membrane rarely escapes
 
 42 BRONCHITIS. 
 
 disease. It occurs in Laeniiec's emphysema, in many cases of 
 pulmonary apoplexy, in cancer of the lung, and other affections. 
 
 Further, it is ascertained that bronchitis is the most common 
 result of the sympathetic irritations of the lung. It forms an 
 important part of the jihenomena of many of the eruptive 
 diseases, while in fever, taken in its ordinary acceptation, it is 
 exceedingly frequent, and too often the direct cause of a fatal 
 termination. From my experience, I would say, that many 
 patients would recover from fever but for the occurrence of this 
 disease. 
 
 In classifying the different forms of bronchitis, we may take, 
 for the basis of our division, the different immediate results of 
 irritation of the mucous membrane and glands. In the first, or 
 most ordinary form, we have a mucous, and afterwards, a muco- 
 purulent secretion ; in the second, we have a secretion bearing 
 the character of lymph, as in some of the forms of croup ; in the 
 third, the secretion is principally serous, as in the different 
 forms of humid catarrh and asthma ; while in the fourth, there is 
 little or no secretion, a disease which has received the name of 
 the dry catarrh. It may be remarked, that in certain cases, the 
 more copious and elaborated the secretion, the greater is the 
 relief produced ; thus a mucous expectoration gives more relief 
 than a watery ; a muco-purulent, more than a mucous ; and a 
 purulent, perhaps, more than any. 
 
 All ages are subject to this disease. It may be even con- 
 genital ; and either as a simple affection, or combined with other 
 inflammations, such as pneumonia, pleurisy, or gastro-enteritis, 
 is not uncommon in the earliest periods of extra-uterine life. It 
 is stated by Billard, that in some cases the disease is extremely 
 latent, and that although an infant may nob present either rale 
 or cough, yet that, on dissection, the finer bronchial ramifications 
 may be found red, and filled with thick mucosities. But this 
 latency of the disease is not constant, as the affection has been 
 observed in children of but fifteen days old, with every symptom 
 and physical sign of the inflammatory bronchitis in the adult. 
 Under these circumstances, the disease may terminate by resolu- 
 tion, or produce death by asphyxia, and on dissection, the 
 pathological appearances observed are similar to those found in 
 the adult subject. The affection may also pass into the chronic 
 form^ and thus continue for an indefinite period, without ap-
 
 BRONCHITIS. 43 
 
 parent injury to tlic general liealtli, while in other cases it lays 
 the foundation of various pulmonary diseases. 
 
 As connected with the subject of infantile bronchitis, I may 
 here allude to the researches of Dr. Joerg, of Leipsig, on a 
 condition of the lung, which according to him, may be induced 
 by a too rapid or a too slow delivery. Under these circumstances 
 a portion of the lung, more or less extensive, remains iininflated, 
 the consequence of which is imperfect respiration, and the pro- 
 duction of various pulmonary diseases. In a difficult delivery, 
 he maintains, that the infant, from the compression of the brain, 
 respires imperfectly, and consequently, but partially expands its 
 lungs ; while in the too speedy delivery, in consequence of its 
 short duration, and the inferior degree of compression of the 
 placenta, he conceives that the foramen ovale is not closed, and 
 hence that the necessity' for respiration is diminished. 
 
 " Under the circumstances above mentioned," says Dr. Joerg, 
 *'we have often seen infants suddenly seized with illness, and 
 sometimes die, in spite of every exertion made to save them, 
 before the real cause of the attack, and the proper method of 
 treatment, were discovered ; and on examination the following 
 appearances were observed, arising all from the same causes, 
 though differing greatly among themselves in many respects. 
 
 "In every case in which we made a 2^<^^^ mortem exami- 
 nation for several years past, a portion only of the lungs, from 
 the greater half to merely an eighth or tenth part, was found 
 filled with air, and of a red colour ; while the remaining portion 
 continued in the same state in Avhich it had been in the ftctus, 
 and was of a liver colour. When the infant had died soon after 
 birth, the condensed portion was susceptible of inflation ; but 
 where death did not occur till several weeks after that event, it 
 was found carnified and incapable of being inflated ; sometimes 
 the partition between the healthy and diseased portion was in a 
 state of inflammation, and the latter contained vomicae : the 
 bronchi, too, were often inflamed and filled with mucus. The 
 great contrast between the bright red of the healthy, and the 
 liver brown of the diseased portions, struck the eye immediately 
 on opening the thorax. In most cases, the foramen ovale was 
 still open, and there were ver}' firm polj-pi in the heart and largo 
 vessels. The brain was frequentl}' gorged with blood, Avhicli was 
 sometimes even eff"used between its membranes and over its
 
 44 BRONCHITIS. 
 
 surface : it also occasionally contained abscesses corresponding to 
 others on the cranium, or fontanelle, that had been produced by 
 the use of instruments, or by violent pressure against the pelvis 
 during delivery. In the rest of the body, there was no particular 
 morbid phenomenon constantly present : however, in the greater 
 number of cases, the skin, particularly on the face, had a bluish 
 cast ; while in some it was withered and emaciated, and the 
 whole body, especially the intestines, pale and bloodless. 
 
 " From these facts, and from observations made of late years 
 during the progress of the disease, we are warranted in describ- 
 ing its nature and terminations in the following manner : The 
 solidification, or continuation in the foetal condition of a greater 
 or less portion of the lungs, so that during inspiration their 
 substance cannot be penetrated by the air. The blood, being 
 still more incapable of penetrating, cannot be supplied with 
 oxygen, and must consequently continue venous, and produce 
 obstructions and dangerous congestions ; while at the same time, 
 from its being unable to afibrd the stimulus requisite to the 
 sj'stem for the continuation of its functions, an atonic senile 
 condition obtains, attended with the utmost weakness, and com- 
 plete atrophy, and terminating in death in hectic fever. The 
 general morbid condition is, consequently, difficulty of respira- 
 tion and impeded circulation, producing dangerous and even 
 fatal congestions. Its terminations are : 1st, recovery ; 2nd, 
 secondary diseases ; and 3rd, death. 
 
 " I. Recovery ensues when the efforts of the infant to inspire 
 are assisted by proper treatment, and the subsequent symptoms 
 properly managed. 
 
 "II. Secondary diseases: — (a) obstruction of the'lungs, inas- 
 much as a portion of them remains condensed, which, without 
 actually producing death, is very oppressive and dangerous : (&) 
 chronic cyanosis, the foramen ovale continuing open, and the 
 infant being liable to constant sufi'ering. 
 
 "HI. Death: — (a) from apoplexy; in consequence of ob- 
 struction and congestion : (h) from suffocative catarrh, when the 
 feeble respiration is not able to expel the mucus secreted in the 
 bronchi, and the violent efforts at full inspiration produce 
 bronchitis, and an over-abundant secretion of mucus, which the 
 patient has not strength to get rid of : (c) from fever, the result 
 of bronchitis : (d) from atrophy ; the production of animal heat
 
 BRONCHITIS. 45 
 
 being prevented by the deficiency of oxygen, and the whole system 
 paralyzed by the want of its requisite stimulus. 
 
 " Symptoms. — When the infant comes into the world, the head 
 is either found greatly swollen, (in which case abscesses often 
 form in the part that has suffered from pressure, and inflammation 
 or violent congestion of the brain ensues,) or else, though quite 
 uninjured, and the delivery having been rapid and easy, it cries but 
 feebly, breathes very short, and exerts the muscles of the thorax 
 greatly; it is presently attacked with a faiutness, and if it had 
 been capable of drinking previously, now loses that power, the 
 voice becomes hoarse and weak, and scarcely audible. Stertor 
 and convulsions soon follow, the little patient becomes quite blue, 
 the eye-balls turn, and the respiration remits, sometimes for so 
 long as five minutes, till the scene at last closes with death. 
 Should the illness continue for some days or weeks, a little short 
 cough, the most certain sign of violent bronchitis, comes on ; 
 together with total weakness, atrophy, and hectic fever ; and the 
 child, at the very latest, four or five weeks after birth, sinks under 
 a violent attack of cyanosis, or bronchitis, or from the effects of 
 the fever and atrophy." 
 
 There can be no doubt that this non-expansion of the pulmon- 
 ary cells must be a powerful exciting cause of congestive and of 
 inflammatory diseases of the lung, as the natural proportions which 
 should exist between the capacity of the lung and the circulating 
 fluid, are thus destroyed ; just as we observe in cases of the ob- 
 literation of one lung, that the opposite one may become 
 ultimately congested and otherwise diseased. I think it not 
 unlikely that the condition of the lung, as described by Dr. Joerg, 
 is a frequent one, and, though it has never struck me to connect 
 its existence with the exciting causes which he has described, yet 
 I have observed it in several cases. In these instances one lobe, 
 or a certain portion of it, was found in a non-crepitating state, of 
 a yellowish colour, somewhat translucent and flabby, and without 
 any appearance of inflammatory vascularity, or efi'usions of lymph 
 on the pleura. In these cases the children died immediately 
 after birth. 
 
 Thus we see, that a child may present the symptoms and signs 
 of pulmonary irritation from the first moment of extra-uterine life, 
 a condition traceable to one of two causes ; first, the existence of 
 an intra- uterine bronchitis, or pneumonia; and secondly, the
 
 46 BKONCHITIS. 
 
 iiou-expansion of a portion of the lung, as described by Dr. Joerg. 
 In this way we may have an explanation of those cases in youth 
 and adult age, in which we are informed that the patient has had 
 a cough from the time he was born. Many of such cases 
 terminate in dilatation of the air cells, and emphysema of the lung, 
 and its train of miserable consequences. 
 
 But the infant, after birth, is subject to many varieties of 
 bronchial inflammation. One of the simplest and mildest forms 
 of this disease occurs about the period of the first dentition, and 
 it seems likely that it is not then a primary disease, but rather 
 the effect of the general constitutional disturbance, as we often 
 observe it arising either along with, or subsequent to the irritation 
 of the gums, and subsiding after the adoption of means calculated 
 to relieve these parts. 
 
 Nor is bronchitis a constant attendant on dentition, for irritation 
 may be localized in the abdomen, the head, or the skin, all which 
 tends to show that the bronchial irritation is not the first link in 
 the chain, and that its occurrence is accidental and secondary. 
 That this doctrine is important in a practical point of view, no 
 one can doubt ; yet whether it may be shown that the bronchitis 
 be the cause or the effect of the fever, the detection of its existence 
 is of importance, and its removal absolutely necessar}'. 
 
 There is no difficulty in recognizing this affection, even though 
 it should exist in an apyrexial form. Under such circumstances 
 the child may be observed to be irritable, his breathing hurried, 
 with a slight wheezing in the throat, and acceleration in the 
 pulse. In more severe cases there is fever and cough, the nares 
 dilate during inspiration, and the act of sucking seems to be 
 performed with difficulty. If we examine the mouth, we often 
 find it hot, and the gums dry and swollen, and one or two teeth 
 may be observed coming forward. I have more than once found, 
 that such an attack supervened in children who had had copious 
 dribbling for a length of time previously, and that the arrest 
 pf this secretion preceded the bronchitis and constitutional 
 disturbance. 
 
 In some cases the cough has a decidedly croupy character, 
 although during the intervals the breathing, though hurried, is not 
 at all stridulous. This character of cough is often a source of 
 great alarm, and may lead to an unnecessary degree of activity in 
 practice. The symptoms, such as have been described, continue
 
 BEONCHITIS. 47 
 
 from four to five days, and often subside rapidly on the appearance 
 of a tooth, although they may be liable to return upon every new 
 irritation of the gums. 
 
 We shall now proceed to examine the occurrence of bronchitis 
 in the more advanced subject, and it must be admitted, that when 
 we consider it in its various forms, whether of an idiopathic, a 
 secondary, or a symptomatic affection, or as occurring compli- 
 cated with many other diseases of the chest, we cannot help 
 admitting it to be one of the most frequent, and often most fatal 
 of diseases. In discussing this subject, I shall not describe the 
 bronchitis of the advanced child separately from that of the adult, 
 inasmuch as its signs, symptoms, and pathology are the same, but 
 having examined into the nature and diagnosis of the idiopathic 
 disease, I shall consider it in its secondary and sj'mptomatic forms. 
 
 We may divide the cases of bronchitis into the examples of the 
 primary, secondary, and complicated forms : the primary, those in 
 which the first morbid influence seems to be exercised on the 
 respiratory mucous membrane, and in which the fever, if it exists, 
 may be considered as purely symptomatic : in the secondary, on 
 the other hand, there has been a pre-existing disease elsewhere, 
 which, in general terms, may be stated to be either the irritation 
 of another organ, which acts by sympathy on the lung, or the 
 existence of that general morbid state which has got the name 
 of essential fever, and of which one of the most remarkable 
 pathological characters is, the production of secondary diseases in 
 the gastro-pulmonary mucous membrane, and also in the solid 
 viscera themselves. Thus, in a typhoid fever we may have an 
 affection of the bronchial mucous membrane, analogous to the 
 secondary inflammation of the stomach and intestines : a disease 
 which, although not the first cause of symptoms, exercises an 
 important part in the progress, and is not unfrequently a cause of 
 the fatal termination of the case. Lastly, by the complicated form 
 we mean the bronchial inflammation which accompanies other 
 diseases of the lung, such as pneumonia, pleurisy, pulmonary 
 apoplexy, tubercle, cancer, &c. 
 
 This complication has been already stated to be exceedingly 
 frequent and important, as yet, however, no certain relation, as to 
 nature, extent, or intensity, has been established between it and 
 the parenchymatous disease in different individuals, or even at 
 different periods of the same case.
 
 48 BRONCHITIS. 
 
 ACUTE PRIMAEY BRONCHITIS. 
 
 This affection may be met with under various conditions. 
 As a mild, and often apyrexial disease, in which the irritation 
 seems to be consecutive to an affection of the lining membrane 
 of the nares and throat, and so slight as to scarcely interfere 
 with the healthy functions, it is not uncommon. In this case, 
 secretion takes place at an early period, and is followed by relief. 
 In fact, it seems to be to the respiratory, what the slight apyrexial 
 diarrhoea is to the digestive system. It is scarcely necessary to 
 remark, that the symptoms of cough, dyspnoea, and internal 
 soreness, vary remarkably, according to the susceptibility of the 
 individual aftected ; thus, in a female, subject to hysterical or 
 spasmodic diseases, a slight catarrh may produce the titssis 
 ferina, while in another subject, who is predisposed to asthma, 
 there may be severe dyspnoea from the same cause. 
 
 There is also the greatest variety with respect to the fre- 
 quency and the character of the cough ; some patients being 
 harassed with continual paroxysms, while others enjoy long 
 intervals of rest. In some cases the exertion of the voice is 
 most distressing, its sound is feeble, and the act of speaking is 
 followed by dyspnoea. In other instances, on the contrary, 
 speaking, unless when long continued, is productive of but little 
 distress. 
 
 One of the most curious symptoms connected with this 
 disease, and which is met with in other forms as well as that 
 under consideration, is the tickling sensation perceived in the 
 trachea, which commonly precedes, and seems to be the cause of 
 cough, and which is referred either to the situation of the 
 bifurcation of the trachea, or that portion of the windpipe im- 
 mediately above it. This is often perceived on the patient's 
 lying down, but may also occur when he is in the erect position, 
 particularly in the morning, when it will continue for a con- 
 siderable time, and cease only after a free expectoration. I am 
 not aware that any author has investigated this curious symptom, 
 except Dr. Graves, who has alluded to it in one of his published 
 clinical lectures, and has suggested it as an interesting subject 
 for inquiry. He observes, that the sensation of tickling or itching 
 seems to be almost exclusively confined to the skin, where it 
 appears to be dependent on slight causes, apparently incapable
 
 BRONCHITIS. 49 
 
 of producing that modification of nervous sensation termed pain. 
 In other cases, as the same author remarks, it seems to be 
 connected with the rise and decHne of inflammatory action, and 
 it does not appear to aftect the mucous tissue, except in a slight 
 degree, and under pecuKar circumstances, and the only liable 
 part of the pulmonary mucous membrane seems to be that of 
 the trachea already referred to. 
 
 In speaking of the symptom of cough, when the patient 
 assumes the recumbent position, Dr. Grraves suggests that this 
 may depend on the fluid secreted by the mucous membrane 
 passing over that part of the trachea where the tickling sensation 
 is felt, the flow of mucus to this part being favoured by the 
 recumbent position ; and I have little doubt, that although the 
 symptom of cough coming on, on the patient's Ij'ing down, 
 may proceed from other causes besides this, yet that the above 
 explanation is applicable in a considerable number of cases. I 
 may observe here, that among the known causes for this symp- 
 tom, one the most remarkable . is the extreme elongation of the 
 uvula, and next to this is the existence of suppurating cavities, 
 which communicate freely with either bronchus. Between these 
 two cases we observe the following remarkable difi'erence, namely, 
 that when the symptom proceeds from an elongated uvula its 
 severity is unafiected by the position of the patient on either 
 side, while in the case of a suppurating cavity, the cough is often 
 worse when the patient lies on the healthy side, a symptom 
 easily understood, when we reflect that this position is the most 
 favouj-able for tha direct passage of the purulent secretion into 
 the bronchial tubes and trachea. 
 
 From a consideration of the symptoms and the stethoscopic 
 phenomena in this disease, it seems highly probable, that in the 
 majority of cases, the smaller bronchial ramifications are un- 
 aff'ected. We find that fever is either absent or extremely slight, 
 and that unless with a complication of decided spasm of the 
 lung, Ave have never any perceptible degree of lividity of the 
 countenance. Further, Ave almost never observe the occurrence 
 of dropsical eftusions, a circumstance Avhich, as far as it goes, 
 jioints out that no notable obstruction to the pulmonary circulation 
 has occurred. With respect to the stethoscopic phenomena, Ave 
 shall describe them presently, and here only observe that they 
 strengthen the aboA-e opinion. 
 
 E
 
 50 BRONCHITIS. 
 
 But in the more severe form of the disease, we find all the 
 foregoing symptoms greatly aggravated ; there may be high fever, 
 with remarkable exacerbations, severe dyspnoea, and difficult 
 exjjectoration, the mucus being sometimes tinged with blood. It 
 is in this affection that lividity of the face is principally observed, 
 a proof of the imperfect arterialization of the blood.* Cerebral 
 and abdominal congestions may also occur, as has been remarked 
 by Laennec, and dropsical swellings are a frequent result. The 
 disease may pass into congestion and inflammation of the 
 substance of the lung, and in many cases stitches are ielt in 
 the sides, which there is every reason to l)elieve, proceed from 
 the occurrence of pleuritis, generally of the dry form, but leaving 
 adhesions more or less extensive according to the violence of the 
 disease. 
 
 This acute stage having continued for a period, the duration of 
 which is extremely variable according to circumstances, the 
 second stage sets in, Avhich is characterized by a change in the 
 nature of the fever ; the inflammatory j)assing more into the 
 hectic type ; the countenance becoming pale and shrunken, and 
 the pulse feeble and often rapid. The patient perspires, and a 
 sour smell may be perceived from the surface ; the cough 
 continues frequent though less distressing, and is followed by 
 copious expectoration of concocted mucus or muco-purulent matter, 
 and the breathing, though hurried, is generally less laborious 
 than in the acute stage. The patient emaciates, and to a person 
 unacquainted with the history of the case, would seem in an 
 advanced stage of suppurative phthisis. There can be no doubt 
 that the recoven- of an individual, under these circumstances, 
 has been in many cases described as an example of the cure of 
 phthisis, and particularly in those cases where the expectoration 
 was copious and muco-puriform. 
 
 On the subject of the expectoration in acute bronchitis I shall 
 be brief. In the earlier forms the secretion is scanty, and 
 consisting of a clear gelatinous mucus, combined with a frothy 
 serum ; according as the disease advances this secretion becomes 
 more opaque, more abundant, and less tenacious ; and at that 
 
 * I have long obsei"ved that lividity is much more an attendant on severe bronchitis 
 than on pneumonia with hepatization, or even pknirisy with copious effusion. This I 
 do not put forward as a novel observation, but may remark that it strengthens the 
 opinion, that the aerating power resides more in the bronchial ramifications than in 
 the air cells.
 
 BRONCHITIS. 51 
 
 period when the inflammatory fever ceases, and is either succeeded 
 by an apyrexial state, or by a hectic condition, we observe a 
 remarkable change in its character. It becomes thick and has 
 considerable consistence, or it may pass into the muco-puriform 
 character, when we observe it in masses of a greenish yellow 
 colour, quite opaque, and though somewhat viscid, yet flowino- 
 together. 
 
 But although in its milder forms the primary bronchitis is a 
 common affection, yet the more violent attacks of the disease are 
 far from being frequent, at least in those of mature age ; for in 
 the great majority of the cases of acute bronchitis which come 
 before us, we see it either as supervening on some chronic 
 affection of the lung, or as a secondary disease, such as that 
 which arises in the course of the eruptive and continued fevers. 
 Indeed the more violent primary bronchitis, though common in 
 the child, is a rare disease in the adult, while with respect to 
 the chronic forms of the affection, the reverse seems to be true, as 
 this latter is common in the adult, and comparatively rare in the 
 child. 
 
 This disease may terminate by resolution, it may pass into a 
 chronic and increasing flux from the bronchial membrane, with 
 or without hectic, giving rise to various alterations of the lung ; 
 it may cause death by a sudden obstruction of a large tube ; it 
 may be accompanied by a rapid, or followed by a slow develop- 
 ment of tubercle ; it may pass into pneumonia, or terminate 
 fatally by an excessive secretion into the bronchial tubes, or bv 
 hydrothorax. 
 
 CHRONIC PRIMARY BRONCHITIS. 
 
 It is not easy to draw the line of distinction between this 
 affection and the second stage of the last variety, as we may 
 observe it either as its continuation, with certain modifications, 
 or as an affection in which there never have been the precursor\- 
 inflammatory symptoms. We may get a good idea of the 
 ordinary form of this disease by considering it as a species of 
 gleet of the mucous membrane, in which the inflammatory 
 irritation, if it exists, is in many cases not so severe as to act 
 sympathetically on the system ; so that patients under these 
 circumstances, although labouring under cough and expec- 
 toration, may yet preserve a good state of general health.— 
 
 E 2
 
 52 BRONCHITIS. 
 
 Nutrition may go on well ; there ma}' be no fever whatever, and 
 even but little dyspnoea, unless upon considerable muscular ex- 
 ertion. In such cases, there is generally a more or less complete 
 remission of the symptoms during the summer season, but when 
 winter approaches, the cough and expectoration become more 
 troublesome, again to subside on the approach of summer. 
 Thus may these patients continue for years, when the duration 
 of the remissions becomes less, their completeness diminishes, 
 and a permanent irritation and flux are established. This may 
 have various terminations, giving rise in one patient to dilatation 
 of the tubes, in another to Laennec's emphysema, and in a third, 
 to the complicatio-i of these affections M'ith phthisis, morbus 
 cordis, hydrothorax, or general dropsy. The sufferings of these 
 patients vary according to the degree of nervous susceptibility of 
 the lung, as we observe that in some, asthmatic symptoms may 
 be established, while in others, the disease never assumes this 
 character. 
 
 Where the flux becomes very considerable, there is often a 
 great degree of emaciation, yet in such cases I have remarked, 
 that the circulating and digestive systems often continue in a 
 singularly healthy state, a circumstance which, as far as it goes, 
 is of importance in the diagnosis between this affection and 
 tubercular phthisis. I have already stated that in certain cases 
 a chronic bronchitis becomes complicated with tubercular disease 
 of the lung, and my experience leads me to conclude that this 
 occurrence is much more frequent than has been hitherto sup- 
 posed. In describing phthisis, I shall return to this subject, 
 and here only remark, that as far as I have seen, this result of 
 bronchitis is more common in individuals who have passed the 
 meridian of life, and although the transition from the state of 
 mere bronchitis into that of the tubercular complication is com- 
 monly slow and indistinct, yet that it is pointed out by a general, 
 though gradual failure of the vital powers, by the pulse becoming 
 accelerated, and by a slow, though decided, emaciation of the 
 patient. Under these circumstances, a careful physical ex- 
 jimination will often enable us to detect some degree of solidity 
 in the upper portion of one lung, advancing slowly, and ulti- 
 mately, though almost always at a remote period, being succeeded 
 by the signs of ulceration of the lung. 
 
 This most unfavourable change in the symptoms and signs, I
 
 BRONCHITIS. 53 
 
 have seen to supervene at so late a period as four years after the 
 first invasion of the bronchitis. The patients appeared to resist 
 the tubercuLar development for a great length of time, and 
 then, in some cases, without any obvious exciting cause, and 
 apparently from the constitution giving way, and in others, after 
 some access of local irritation or general disease, did this fatal 
 complication become slowly but decidedly manifest. 
 
 The characters of the expectorated matter in bronchitis are 
 so varied, that to give any description of them, which would be 
 at the same time clear and succinct, is indeed extremely difficult. 
 But the subject is one of great importance, for we shall find it to 
 be connected with many points in the history, prognosis, and 
 treatment, not only of the disease in question, but of most other 
 pulmonary affections. 
 
 We are as yet ignorant of the pathological laws which regulate 
 the various lesions of secretion in diff"erent diseases, or in 
 different individuals apparently labouring under the same disease ; _ 
 and of the reasons why the bronchial membrane, varying in its 
 products like other tissues, at one time pours out a serous, at 
 another a mucous, and at a third a purulent fluid, we know nothing. 
 But still, by observing the actual condition of the secretion in 
 relation to the symptoms, and studying its changes in connexion 
 with the history of the case, we may, and often do, arrive at most 
 important practical results. 
 
 The secretion from the bronchial mucous membrane may be 
 modified in quantity and in quality, and the extent and number 
 of these modifications are infinitely numerous. As we cannot 
 describe even the principal modifications in connexion with any 
 certain condition of the lung, I shall content myself with 
 enumerating the varieties of secretion which are most commonly 
 observed, and shall make a few comments upon each. 
 
 We may divide the secretions from the bronchial mucous 
 membrane, when in a state of irritation, as follows : 
 
 First. — Transparent mucous secretions. 
 
 Second. — Opaque mucous, or albuminous secretions. 
 a. — Amorphous. 
 h. — Moulded to the form of the tubes. 
 
 Third. — Muco-puriform secretions. 
 
 Fourth . — Puriform secretions. 
 
 Fifth. — Serous secretions.
 
 54 BRONCHITIS. 
 
 Transparent mucous Secretions, 
 
 We meet with this form of secretion most commonly in the 
 earlier stages of acute bronchitis, when, however, we find that 
 previous to its appearance there has been either a dry cough, 
 or a cough with expectoration of a serous fluid. There is 
 considerable variety in the quantity of this secretion formed in 
 different cases, as also in its tenacity, which latter character has 
 been considered as a measure of the violence of the irritation. 
 
 But transparent and adhesive mucus may be formed in other 
 cases of bronchitis. Thus, in some violent cases, long after the 
 expectoration has become muco-puriform, we may observe, as it 
 were, a return of the secretion to its original form. It loses its 
 diffluent character, and its opacity, and its expulsion becomes 
 difficult. This unfavourable change, which is generally accom- 
 panied by constitutional disturbance, may subside in a few 
 hours, and reappear many times in the course of a single case. 
 Under these circumstances we shall often observe a correspond- 
 ing change in the stethoscopic phenomena, to which I shall 
 presently allude. In cases too of ordinary chronic and apyrexial 
 bronchitis, we find that a new attack of bronchial inflammation 
 may altogether arrest the secretion, or change it from the opaque 
 and diffluent to the transparent and viscid character. On the 
 subsidence of the irritation, however, the former character of the 
 secretion returns. 
 
 From a consideration of these facts, we cannot help in some 
 way connecting the occurrence of this transparent and viscid 
 secretion with a condition of irritation in which the morbid 
 action is not relieved by the secretion. We find that the sooner 
 the opaque sputa appear, the sooner shall we observe the 
 convalescence of the patient ; and that in those cases where 
 this salutary change is delayed, the sufferings and danger are 
 proportionally increased. How commonly do we observe this in 
 phthisis, in which the bronchial irritation seems to continue in 
 its first stage for an indefinite length of time, and in which there 
 is every indication of a local but unrelaxed irritation of the 
 lung ; and in the cases of Laennec's emphysema we may see 
 other instances of a bronchial disease which has not been relieved 
 by the more elaborated secretion, and which consequently has 
 continued so as to disorganise the lung.
 
 BRONCHITIS. 55 
 
 Opaque mucous or alhuininoiis Secretions. 
 
 In the characters of this class we do not find much variety, 
 and the circumstances attendant on their appearance are, in 
 general, constant. In almost all cases where these sputa are 
 met, there has been a preceding stage, in which other characters 
 occurred, and in which there was the formation of the transparent 
 secretion, occurring with or without a symptomatic fever. 
 
 In commenting on this kind of expectoration I shall iirst notice 
 the amorphous variety, and next that in which the secreted 
 matter adapts itself to the form of the bronchial tubes, so as to 
 produce, as it were, casts of the air passages. 
 
 In their ordinary form we find these sputa to consist of shape- 
 less masses of a dull white colour, ^^ith a slight yellow tinge. 
 These masses may be expectorated with scarcely any accom- 
 j)anying serous fluid, when they unite, more or less, so as to 
 form a semi-fluid, adhesive mass. In other cases, however, a 
 considerable quantity of serous fluid is expelled along with them, 
 when we observe them more frothy, and presenting the appearance 
 of rounded sputa, floating in a nearly transparent fluid, of much 
 less tenacity, and containing a few albuminous stride, not unlike 
 fragments of vermicelli. 
 
 Lastly, there are cases of chronic bronchitis, in which we 
 observe the expectoration of a vast quantity of opaque albuminous 
 matter, of a whitish colour, and without any tendency to a 
 purulent character. In such cases, when the containing vessel is 
 inverted, we see its contents slowly evacuated in one elongated 
 homogeneous mass, on the surface of which more or less of a 
 frothy serum may be observed. Such cases are generally of 
 extreme chronicity, and present the signs of chronic bronchitis, 
 with dilatation of the tubes, or even the air cells of the lung. 
 
 We shall next consider that form of secretion in which the 
 secreted matter is moulded to the form of the bronchial tube, and 
 acquires a certain degree of consistence. 
 
 Although our knowledge on this subject is as yet but limited, 
 it may be stated, that this formation of inspissated mucus, or of 
 a substance approaching to lymph, may be found either as a very 
 circumscribed or a more general lesion. In the first of these a 
 plug is formed, which by obstructing one of the larger tubes, may 
 bring on a violent dyspncea, and be even a cause of death ; while
 
 56 BRONCHITIS. 
 
 in the second, cylinders of tins substance, corresponding to tlie 
 form of the bronchial tree, are found to folloAv its ramifications 
 most extensively, and to be continuous, as Reynaud has shewn, 
 nearly as far as it was possible to trace the bronchial tube. 
 Under these circumstances the patient may expel casts of the air 
 passages after violent fits of coughing, several cases of which are 
 on record. 
 
 It is not easy to explain the occurrence of this unusual 
 symptom ; and indeed we are still in want of facts to throw light 
 on the subject. Why this plastic disposition is acquired by 
 mucous membranes, in certain cases, while it seems denied to 
 them in others, is still a matter of speculation, and the subject 
 could scarcely be discussed here Avith propriety. When speaking 
 of croup, however, I shall return to it. 
 
 In a case which I lately saw along with Dr. Marsh, this curious 
 symptom was present. The patient, a middle-aged female, had 
 suffered from a chronic affection of the chest, find had lately 
 become liable to this form of expectoration. The casts expec- 
 torated were several inches in length, and seemed to have 
 occupied the bronchial tubes from about their third order to 
 nearly their finest ramifications. They were white, cylindrical, 
 and not hollow ; but between their exterior surfaces and centres 
 there was a remarkable difference, the former being much more 
 consistent and opaque, while the latter seemed formed of a soft 
 and transparent mucus, with comparatively little tenacity. This 
 conformation gave them, at first sight, the appearance of tubes. 
 In the centre of many of them we observed small chains of air 
 bubbles, a circumstance to be expected from the fact, that their 
 expulsion was extremely difficult, and accompanied by violent 
 cough. 
 
 The form of these concretions Avas exactly similar to those of 
 which a plate is given in Dr. Baillie's Morbid Anatomy. Their 
 consistence was by no means so firm as what we observe in cases 
 of true croup. They seemed to have been originally formed as a 
 tremulous mucus, which had filled the tubes, and from some 
 cause had remained there a long time, until their outer surface 
 had become opaque and more consistent ; apparently from that 
 process, by which we see the more fluid parts of secretions 
 absorbed, and their remaining constituents consolidated. 
 
 In another case I have witnessed the expulsion of a cylinder of
 
 BRONCHITIS. 67 
 
 an albuminous substance nearly- tbree incbes in lengtb. Tbis 
 was expelled after a violent and long continued fit of cougbing. 
 
 Tlie science bas been lately enricbed by a most important memoir 
 on this subject, from the pen of ]\I. Reynaud,* a memoir, the 
 value of which can be scarcely estimated. From the researches 
 of this eminent pathologist, it appears that a species of plastic 
 inflammation of the minute bronchia is much more frequent than 
 has been hitherto supposed ; and that it occurs in many cases of 
 phthisis, and of what has been called pneumonia, AYithout 
 directly asserting that as Ave approach the bronchial cells, the 
 character of the lining membrane changes from that of a vascular 
 mucous membrane, endowed with villosities and follicles, to a 
 condition very analogous to that of a serous membrane ; he yet 
 clearly inclines to this opinion, which has been long entertained 
 in the school of Dublin, and he founds on it an explanation of 
 the plastic or adhesive inflammation of the minute tubes. 
 
 When I come to consider the consequences of inflammation on 
 the air tubes, I shall avail myself of these beautiful researches, 
 and here only remark, with reference to our original subject, that 
 if this semi-plastic expectoration have any value in diagnosis, it 
 is that it seems connected, if not with actual tubercle in the lung, 
 at least with a decided tendency to that lesion. It apparently 
 indicates a lymphatic constitution of the lung ; a state in which 
 the white tissues are predominant, and where of course the 
 liability to the '' foyiiuttive injidinmaf ions''' is more developed. 
 In the first case to which I have alluded, decided physical signs 
 of tubercle existed ; and in the second, the case was one of 
 manifest suppurative phthisis, and the diagnosis was verified by 
 dissection. Laennec describes a concretion found in a phthisical 
 subject, and the same has been observed by other authors. But 
 further observations are necessary on this interesting point. f 
 
 Muco-pnriform, and puriforni Secretions. 
 
 I shall consider these forms of expectoration together ; and in 
 the first place observe, that while, in bronchitis, the expectoration 
 
 * Translated and Edited by Dr. Stokes in the seventli volume of the Buhllii Journal 
 itf Medical Science, First Series. (H.) 
 
 f Two interesting cases of plastic bronchitis, with observations by Drs. Cane and 
 Corrigan, were published by the former gentleman in the ■19tli number of the Dublin 
 Medical Journal. Dr. Cane, like Dr. Walshe, controverts the doctrine of its connexion 
 with tubercle, and asserts that mercury is " a certain remedy for its cure." (H.)
 
 58 BRONCHITIS. 
 
 of muco-puriform matter is common, yet that of unmixed pus 
 seems to be very rare. An absolutely puriform expectoration is 
 an unusual circumstance in any of the pulmonary diseases, even 
 in those in which ulcerative or suppurative action has taken 
 place. It is occasionally met with in the advanced stages of 
 phthisis and pneumonia, but is more often absent, and in 
 bronchitis is rarely seen indeed. I do not deny the important 
 fact, that the bronchial mucous membrane is capable of secreting 
 pus, independent of any ulceration of the lung ; but all that I 
 wish to observe is, that when, with respect to frequenc}^, we 
 compare the muco-puriform with the puriform expectorations, we 
 find the first by far the most common. 
 
 The muco-puriform expectoration is more commonly met with 
 in the second stage of acute than in the chronic bronchitis. 
 The disease, too, has commonly occupied the smaller tubes, so 
 as to produce its muco-crepitating rale ; and the appearance of 
 the purulent secretion marks the passage from the first into the 
 second stage of the disease. I may here remark, that even in a 
 violent case of bronchitis we may, by active treatment, so modify 
 the inflammation, that the secretion of pus scarcely occurs, we 
 having, as it were, cut short the disease in its first or mucous 
 stage. But this unfortunately is rare, and an abundant secretion 
 of muco-purulent matter is a common sequence to the first 
 stage. If the disease, in its earlier periods, has been neglected, 
 or if discovered, yet has been treated with timidity, the muco- 
 purulent secretion in the advanced stages will be abundant, and 
 may prove the cause of a mechanical death. I have seen several 
 cases of intense general bronchitis, in which the early treatment 
 had been injudicious. The antiphlogistic means had been 
 insufficient, and were combined with, or too soon changed for, 
 the exhibition of stimulants. In these cases the patients had a 
 long and dangerous struggle, with alternations of inflammatory 
 fever, and a collapsed state ; with viscid expectoration at one 
 time, and profuse muco-purulent discharges at another ; and 
 with the stethoscopic signs of a state of the lung, not far removed 
 from the third stage of pneumonia. 
 
 In order that the change from the mucous to the muco-puri- 
 form secretion be considered a favourable indication, it is 
 necessary that certain circumstances shall attend it. These I 
 have observed to be, the expectoration becoming easier, the pulse
 
 BRONCHITIS. 59 
 
 softer and slower, the breathing easier, and the fever diminishing. 
 With respect to the physical signs, we find the muco-crepitating 
 rale becoming larger, the respiration returning from above down- 
 wards, the action of the heart quiet, and the sound on percussion 
 clear, even in the postero-inferior portions of the lung. 
 
 Ijut in other cases the reverse of all this is observed ; and Ave 
 have the combination of a muco-purulent expectoration Avith the 
 symptoms and signs of intense irritation of the lung. To this 
 case I have just now alluded. 
 
 In a practical point of view, the great value of the symptoms 
 of the change of character of the expectoration is, that it is an 
 index pointing out the time for a change in treatment, of a 
 passage from an antiphlogistic to a stimulating medication. 
 Taken alone, however, it is insufficient ; it must be accompanied 
 by the favourable symptoms and signs, and we may have a case 
 in which, long after the appearance of muco-purulent secretion, 
 it will be right to suspend the stimulating, and resume the 
 antiphlogistic system. 
 
 Before concluding this part of the subject it is right to allude 
 to the occasional foetor of the muco-purulent, or purulent expec- 
 toration, in chronic bronchitis. As I have seen but a single case 
 of this, I shall content myself with referring to the writings of 
 Andral and Laennec on the subject. 
 
 Scrolls Secretions. 
 
 We meet with this form of expectoration in a great number of 
 cases of bronchitis and phthisis, even where other, and very 
 different secretions, are taking place from the lung. We may 
 observe it in the earlier stages of bronchial inflammation, before 
 much mucus has been formed, and Ave may see it again in the 
 advanced stages, when an opaque mucous or muco-purulent 
 matter is abundantly secreted ; lastly, it occurs as the principal 
 secretion, as is seen in many cases of Itumicl asthma, and then 
 may be formed in great quantity indeed. Under these circum- 
 stances Ave may have a sudden congestion of the lung, terminating 
 in a copious flux into the bronchial tubes, or may observe a 
 continual and copious expectoration of a serous or sero-mucous 
 fluid, for a considerable period of time. It is stated by Andral, 
 that patients labouring under this affection ultimately resemble
 
 60 BRONCHITIS. 
 
 individuals who have suffered from great losses of blood. They 
 become emaciated ; there is some swelling of the face, and a 
 general aspect which is truly anemic. The other perspiratory 
 secretions seem nearly suppressed, and the functions of the 
 stomach are languid. The same author relates a case in which 
 a sudden and most copious secretion of serous fluid from the 
 lung coincided with the disappearance of an hydrothorax. 
 
 Laennec, in his division of bronchitis, has described a pituitous 
 catarrh, in which the discharge of great quantities of sero-mucous 
 fluid from the lungs may occur as an acute or chronic disease. 
 Thus he states, that in the course of one or two hours, from two 
 to three pounds of fluid have been discharged. 
 
 I have seen but few cases analogous to Laennec's idiopathic 
 pituitous catarrh. Indeed in almost all the cases of this kind 
 of expectoration which I have witnessed, there was also a dis- 
 charge either of concocted mucus, which was the most common 
 complication ; or of muco-puriform or puriform matters, which 
 were observed in cases of phthisis, particularly where the patient 
 had passed the meridian of life, and had been long affected with 
 the disease. I have not had an opportunity of connecting it 
 with the simultaneous development and ^persistence of miliary 
 tubercles in the lung, as remarked by Bayle and Laennec. The 
 disease, as Laennec mentions, commonly terminates by oedema 
 of the lung, which may continue for a considerable period of 
 time, ultimately, however, ending in inability to expectorate, 
 and asphyxia. 
 
 Physical SiCxNS of Bronchitis. — Before proceeding to con- 
 sider the other forms of bronchial irritation, I shall examine the 
 physical signs of the primary bronchitis, in its acute and chronic 
 forms, in the following order :— 
 
 First. — The results of percussion. 
 
 Second. — Signs discoverable by the sense of touch. 
 
 Third. — Signs discoverable by auscultation. 
 
 With respect to the first of these classes, it is to be remarked 
 that there is no direct sign derivable from percussion, the sound 
 being almost always of natural clearness. The j)rinciple already 
 laid down should be recollected, that other things being equal, 
 the sound on percussion is directly as the quantity of air con- 
 tained within the thorax. Now although the vascularity and 
 turgescence of the inflamed mucous membrane must, to a certain
 
 BRONCHITIS. Gl 
 
 degree, climiuish the aeriform contents, yet we find that this 
 diminution is not sufficient for the production of sensible dul- 
 ness, and hence the sound on percussion in bronchitis, whether 
 acute or chronic, is almost alwa^ys clear. It is probable that if 
 our organs of hearing were endowed with greater delicacy, a 
 certain shade of diflerence could be detected, but in their actual 
 condition, we cannot in most cases distinguish any variation 
 from the healthy sound of the chest. In fact there is but a 
 single case in which simple bronchitis is ever accompanied with 
 decided dulness, namely, that in which a vast secretion of mucous 
 or muco-purulent fluid exists in the bronchial tubes ; but such a 
 case is extremely rare, for a large proportion of the bronchial 
 tubes may contain quantities of secretion, and yet the sound on 
 percussion shall continue without any perceptible diminution. 
 When, however, the disease is combined Avitli affections which 
 have their seat in the areolar structure of thd lung, such as 
 oedema, congestion, pneumonia, or tubercle, the results are of 
 course different, the amount and situation of dulness varying 
 according to circumstances. 
 
 It would be an interesting question, as connected with the 
 want of dulness in bronchitis, to determine whether, pending the 
 turgescence of the bronchial membrane, some degree of dila- 
 tation of the air cells may not exist, so that the air thus 
 accumulated might compensate for that which has been dis- 
 placed by the state of the mucous tissue. Could we thus account 
 for the clearness on percussion, notwithstanding an extensive 
 congestion of the minuter tubes ? 
 
 Yet though percussion gives no direct result in bronchitis, its 
 employment is of importance in the particular diagnosis. Thus, 
 suppose that after the existence for three or four days of fever, 
 cough, hurried and difficult breathing, the chest still sounds 
 well, the great probability is that the disease is bronchitis. The 
 patient has had an acute inflammatory affection of the lung, and 
 but of a few days' standing : this must be either bronchitis, disease 
 of the serous membrane, or of the parenchymatous tissue itself. 
 Here the absence of dulness is of the greatest importance ; for 
 were it a case of pleuritic effusion, or of disease of the substance 
 of the lung, the great probability is, that by this time a degree 
 of dulness would be manifested ; in the one case the lung would 
 be compressed, and its place occupied by a liquid effusion ; in
 
 62 BRONCHITIS. 
 
 another, more or less obliteration of the air cells would take 
 place, from congestion, or from inflammation. The absence then 
 of dulness, icitli the existence of acute irritation of the lung, which 
 has continued for several clays, forms an important argument 
 that the case is one of unconnplicatecl bronchitis. 
 
 But the knowledge of the absence of dulness in mere bron- 
 chitis may be advantageously applied in general diagnosis. The 
 study of symptoms, independent of physical phenomena, will not 
 be sufficient to establish the diagnosis of simple bronchitis, for 
 there are a vast number of examples of disease of different kinds, 
 in which the symptoms are only those of bronchitis, or at least 
 might be referred to this lesion. But as we have before said, 
 if we find, on the examination of any particular case of this 
 kind, a dulness on percussion, either of one jjortion of the 
 chest as compared with the other, or of the whole chest as com- 
 pared with its sound at some former period, we may be certain 
 that something more than mere bronchitis exists. It may be 
 said that a copious effusion of mucus into the tubes will give a 
 dulness of sound, but I can say, from an extensive experience, 
 that this only occurs in the most extreme case, and in the last 
 stages of the disease ; for I have met with cases where the 
 bronchial system was extensively filled with muco-purulent 
 matter, yet in which the sound was generally clear. There is, 
 however, one case in which dulness may be observed, namely, 
 great dilatation of the bronchial tubes, with compression of the 
 intermediate pulmonary substance ; to this we shall hereafter 
 allude, when describing the disease in question. 
 
 From the knowledge of the fact, that in simple bronchitis 
 there is nothing to produce a perceptible dulness of sound, we 
 derive a most important assistance in the diagnosis of tubercular 
 development, whether in the acute or chronic form. The value 
 of this will be seen when we consider the frequent similarity 
 of symptoms between the diseases of tubercular phthisis and 
 bronchitis, a similarity easih' understood, when we recollect that 
 in most cases of tubercular development there is a co-existing 
 catarrh ; but as I shall shew hereafter, the occurrence of a 
 partial, or general and progressive dulness, in a case pre- 
 senting the symptoms of bronchial inflammation, is one of the 
 principal circumstances on ^^llich the diagnosis of tubercle 
 depends.
 
 BRONCHITIS. 63 
 
 Finally, it is plain, that the longer the symptoms of catarrhal 
 inflammation have existed, without the occm-rence of either 
 partial or general dulness, the greater will be the probability 
 that the case is an example of uncomplicated bronchitis. There 
 is a sign discoverable by percussion in cases of bronchitis, par- 
 ticularly in the young subject, which has not been sufficiently 
 noticed; I allude to a metallic resonance, somewhat analogous 
 to the cracked jar sound of cavities, but evidently more diffused. 
 The history of the case, the extent of the phenomenon, the 
 absence of dulness, and of the stethoscopic signs of a cavity, 
 will be sufficient to distinguish it from the above sign. 
 
 With respect to the signs discoverable by the sense of touch, 
 there is not much to be said. In a great number of cases, and 
 particularly after the disease has passed its first stage, a distinct 
 vibratory sensation is perceptible when the hand is laid on the 
 thoracic integuments. This can be detected both during 
 inspiration and expiration, but is generally more distinct in the 
 former than in the latter. It is more evident in the child and 
 the female than in the adult male, although it is not unfre- 
 quently present even in the latter case. It seems to be more an 
 indication of a free secretion into the larger than the more 
 minute tubes, for it will frequently disappear after a cough with 
 expectoration, again to return when the secreted matter accumu- 
 lates, and if while it is present we apply the ear, the loud sonoro- 
 mucous rattle is always perceptible ; in some cases, however, 
 on making the patient draw a deep breath, the vibration is 
 decidedly increased. This vibration is much more distinct in 
 the middle and inferior than in the upper portions of the lung 
 and is not met with in simple pleurisy or pneumonia, although 
 in the former disease a phenomenon may occur which might 
 possibly be confounded with it ; I allude to the sensation of 
 rubbing (frottement) which occurs in certain stages of the dry 
 pleuritis, and which, like the vibration of bronchitis, is in accord- 
 ance with the motions of respiration. But a little practice will 
 enable us easily to distinguish them ; the bronchial vibration 
 giving the idea of air jjassing in many directions through an 
 adhesive fluid, while the rubbing sensation of pleurisy is that 
 of two continuous, though roughened surfaces, moving one upon 
 the other ; lastly, a momentary application of the stethoscope 
 will often determine the point, for in the majority of cases of
 
 64 BRONCHITIS. 
 
 pleuritic friction, the respiratory murmur may be heard without 
 any admixture of rale. 
 
 In considering the signs referrible to the passage of air 
 during the acts of respiration, we find that several causes exist 
 for the modification of the respiratory murmur ; these may he 
 enumerated as follows : 
 
 First. — The turgescence of the mucous membrane, a cause 
 which principally afi'ects the phenomena of the smaller tubes 
 and air cells. 
 
 Second. — The existence of an anormal secretion into the 
 cavity of the tube itself ; and 
 
 Third. — The existence of spasm ; the amount of which is 
 exceedingly variable in different individuals. All these unite in 
 forming the numerous varieties and combinations of Laennec's 
 sonorous, slhilous, and mucous rales. 
 
 In the occurrence and combination of these phenomena there 
 are the greatest possible difierences in difierent cases, but as a 
 general rule it may be stated, that the modifications of sound 
 connected with turgescence of the mucous membrane and spasm, 
 are to be found principally in the first or dry stage, while those 
 produced by the passage of air through fluid in the tubes, are 
 most evident in the second or secretive stage, although even at 
 this period the cooing and sibilous sounds may exist, though 
 combined with a mucous rattle. In some cases the phenomena 
 are universal, and so intense as almost completely to obscure the 
 natural sound of respiration, while in others they may be partial, 
 and only now and then perceptible, and even degenerate into a 
 character of respiration, which can only be appreciated by actual 
 observation, but in which it may be stated that the respiratory 
 murmur dift'ers from its healthy character, in having a certain 
 roughness, I may observe, however, that the case in which this 
 last character is most often perceptible is that of pneumonia, for 
 some time after resolution has taken place ; a state in which there 
 is every reason to believe that the bronchial mucous membrane 
 still labours under a certain degree of irritation. 
 
 As a general rule it may be stated, that in the acute stage, 
 during ordinary resjiiration, the louder and more intense the 
 rales are, the more severe is the disease. But to this rule 
 there is one remarkable and important exception, which I first 
 observed in bad catarrhal fevers. In such cases during ordinary
 
 BRONCHITIS. 65 
 
 respiration, we may hear little or no rale, and yet the disease be 
 in such a state of violence as to threaten the life of the patient. 
 The reason of this seems to be, that the finer ramifications 
 of the bronchial tubes are so turgid, as that, during ordinary 
 respiration, the air does not enter them with sufficient force to 
 produce a tone. But if, under such circumstances, we make 
 the patient take a forced inspiration, we are astonished at the 
 intensity, number, and variety of the sounds produced. Now, 
 in such cases it commonly happens, that as the patient gets 
 better, the rale, during ordinary respiration, becomes distinct and 
 constant, so that here an increase of rale during ordinary 
 breathing points out a decrease of disease. 
 
 In some cases of chronic bronchitis, and particularly in those 
 where a muco-purulent secretion exists, we may hear nothing but 
 a mucous rattle of various degrees of intensity and extent. In 
 most instances the bubbles are large ; but they may be so small 
 as to produce a rale which is almost crepitating. Such cases are 
 not uncommon ; and as I have known them, in some instances, 
 to be confounded with phthisis, I shall dwell shortly on their 
 diagnosis. In both diseases a muco- crepitating rale, of great 
 extent and intensity, may occur, but by attending to certain 
 circumstances, the chances of error will be much diminished. 
 The first, and most important, is the result of percussion. I 
 have already stated that we may have a great amount of bronchitis 
 without perceptible dulness of sound, while in cases of phthisis, 
 so circumstanced as to give an extensive muco-crepitating rale, 
 there is in all cases decided didness, either general or partial. 
 In some cases, which were supposed to be phthisis, I have, 
 from the generally equable and persistent clearness of sound, 
 decided that nothing but bronchitis existed, a conclusion which 
 the perfect recovery of some patients, and the post mortem 
 examination of others, fully verified. 
 
 Again, we may observe in both diseases, that a partial dulness 
 is to be met with ; but in phthisis, even where the whole lung is 
 tubercular, this is almost always greatest in the upper parts of 
 the lung, while in the case of bronchitis the reverse occurs ; the 
 dulness, where it does exist, being generally in the inferior lobes. 
 This seems to arise from the accumulation of mucus in the 
 more depending portions ; and in many cases at least, from the 
 combination of the disease with a certain amount of congestion or 
 
 F
 
 66 BRONCHITIS. 
 
 inflammation of the air cells themselves, a combination, not 
 unlrequent in those cases of intense bronchitis, which produce a 
 general muco-crepitating rale. 
 
 The same remarks apply to the occurrence of puerile respiration, 
 which may be observed in both aftections. In bronchitis, when 
 it does occur, (and it is here much rarer than in phthisis,) it is 
 principally found in the upper portions of the chest, while the 
 reverse is almost always the case in phthisis. Other points of 
 distinction might be described, but they will be better examined 
 when we treat of the diagnosis of phthisis. 
 
 I have already alluded to the kind of exacerbation so likely to 
 occur in certain cases of intense bronchitis, when the opaque 
 muco-puriform expectoration changes its character, and becomes 
 transparent and viscid. Now this change is generally accompanied 
 by corresponding stethoscopic phenomena. The muco-crepitating 
 rale becomes smaller, sharper, and the extinction of the 
 respiratory murmur is more complete, so that there is a close 
 approximation to the phenomena of pneumonia in its permeable 
 stages. The clearness, however, of the sound on percussion, and 
 the want of the bronchial respiration, so common, and so 
 remarkable in the third stage of pneumonia, are differences of 
 great importance ; and in most cases, even on our first seeing the 
 patient, will prevent us from forming an erroneous judgment of 
 the case. 
 
 Before concluding my remarks on the diagnosis, from the 
 secretion into the tubes, I may state, that I have observed a 
 distinct agitation of the muco-purulent secretion in the tubes from 
 the action of the heart. This was most evident in a case of 
 intense bronchitis of the left lung, when the heart was acting 
 strongly. Each pulsation caused a corresponding sound, or rule, 
 continuing when the patient held his breath, and forming with 
 the respiratory phenomena a distinct rhythm in the succession 
 of sounds. This phenomenon is ob^dously analogous to that 
 produced in a ca\aty by the action of the heart, or to the cardiac 
 friction sound of dry pleurisy. 
 
 We now come to another physical sign in cases of bronchitis, 
 namely, the complete suspension of any sound of respiration in 
 certain parts of the lung. In most cases this phenomenon is but 
 temporary, but it may be permanent. In the first instance, it 
 will often disappear after a fit of coughing, a circumstance which
 
 BRONCHITIS. 67 
 
 led Laennec to believe that it cTepended on a temporary obstruc- 
 tion by mucus ; but it is possible tliat spasm may have some 
 effect in producing it, as a similar phenomenon has been observed 
 in cases of hysteria. This is rare in ordinary bronchitis. 
 
 But Andral and Reynaud have shewn that in consequence of a 
 hypertrophy of the bronchial mucous membrane, the sound of 
 respiration may be remarkably modified in the affected portion of 
 the lung. This modification may vary from a slight comparative 
 feebleness, to an almost complete absence of the respiratory 
 murmur. Of the latter circumstance, the following case is an 
 instructive instance : A patient, aged 31, entered the hospital of 
 La Charite, presenting the symptoms of an organic affection of 
 the heart. The respiration was heard posteriorly, and over the 
 anterior surface of the left lung, with considerable intensity, and 
 a mixture of mucous rale ; while under the right clavicle it was 
 extremely feeble, the sound on percussion being generally equal. 
 The patient stated, that for a length of time he had felt a con- 
 striction a little above the right breast, and that, to use his own 
 expression, he did not breathe with the right side of his chest. 
 From the stethoscopic phenomena, it was supposed that emphy- 
 sema of the superior lobe of the right lung existed. The patient 
 died in a little more than a month, with the signs and symptoms 
 of hydrothorax. On dissection, the upper lobe of the right lung 
 presented no trace of emphysema, its tissue appearing healthy, 
 though but little crepitating. At a few lines from the origin of 
 the principal bronchus of this lobe, a constriction, so great as to 
 scarcely admit the passage of a probe, was discovered, beyond 
 which the calibre of the tube became again of its natural diameter. 
 This partial thickening was owing to a hypertrophy of the mucous 
 membrane, as the subjacent fibrous tissue was found natural ; the 
 remaining tubes in this lobe presented their natural calibre. 
 
 Here we find that the pathological appearances were in exact 
 accordance with the signs observed during life ; no cause existed 
 to produce any dulness of sound, and accordingly this phenomenon 
 was wanting, and the diminution of the respiratory murmur was 
 clearly accounted for by the constriction of the bronchus. But, 
 as Andral remarks, the phenomenon cannot be considered as a 
 pathognomonic sign, inasmuch, as it may proceed from other 
 causes. It may be produced, as I have seen, by a localized 
 dilatation of the cells. Other causes for the production of 
 
 F 2
 
 68 BRONCHITIS. 
 
 comparative feebleness of respiration, with equality of sound on 
 percussion, may be enumerated, but as far as I know, in all these, 
 the feebleness of respiration in one lung has been general, 
 differing in this from the case mentioned. Thus, either bronchus 
 may be compressed by melanotic tumours, tuberculous ganglia, 
 or aneurisms of the aorta, and lastly, the existence of a foreign 
 body within the tube may produce the phenomenon in question. 
 
 In other cases this narrowing of the bronchial tubes is more 
 general, but as yet no pathognomonic stethoscopic sign has been 
 observed. In a case of this description, given by Andral, the 
 respiratory murmur was not diminished, though a loud rhonclms 
 was audible in the affected lung. 
 
 But this difference of respiratory murmur with equality of 
 sound on percussion of both sides, may proceed from obstruction 
 by the secretions of the tube itself. Of this, two remarkable 
 examples are given by Andral. In the first case the patient, who 
 had laboured for some time under the symptoms and signs of 
 bronchitis with mucous secretion, was suddenly seized, during a 
 violent fit of coughing, with extreme difficulty of breathing, 
 which continued during the whole of that day and the following 
 night ; on being seen the next morning, he seemed on the point of 
 death from sufibcation. On percussion, the chest sounded every- 
 where clear, with puerile respiration over the whole of the left 
 lung, and the postero-inferior portion of the right ; but on this 
 side anteriorly, and in the sub-spinous fossa, neither respiration 
 nor rale was audible. He shortly after expired, and on dissection, 
 the bronchus leading to the upper lobe was found completely 
 obstructed by a mass of concrete mucus, which thus prevented 
 the entrance of air into that portion of the lung, and afforded a 
 satisfactory explanation of all the phenomena. 
 
 Here, as Andral remarks, the obstruction of a certain portion 
 of the lung caused a sudden and fatal dyspnoea, which is the more 
 remarkable, that in many patients, after a large portion of both 
 lungs has become impermeable, life may be continued for a 
 length of time, even without much dyspnoea. This apparent 
 difficulty is explained by recollecting, that in these latter cases 
 the permeability of the lungs has been gradually diminished; 
 while in the above case the obstruction was sudden. To this 
 point I shall return hereafter. 
 
 The second case was also one of chronic catarrh, Avith abundant
 
 BRONCHITIS. 69 
 
 puriform expectoration, but in which there wus but little dj'spucea 
 until the very last day of existence. This patient had been 
 frequently examined, and presented an equable respiration, with 
 the different varieties of bronchial rales. In the course of a 
 night, after a violent fit of coughing, the respiration became 
 suddenly and violently oppressed, and on the next day no 
 murmur of respiration could be heard in the upper lobe of the 
 right lung ; the parts still sounding clear on percussion. The 
 patient died on the following night, and on dissection, the 
 principal bronchus of the superior lobe was found completely 
 obstructed by a polypiform mucous concretion, which extended 
 into several other bronchial ramifications of this lobe. On these 
 cases the author makes the following observations : " The at- 
 tention being directed to the case just described, the diagnosis 
 should not seem diflficult. We should be led to suspect 
 obstruction of one bronchus, if, on a simple bronchitis, a severe 
 dyspnoea suddenly supervenes, and if, at the same time, respi- 
 ration ceases to be heard over a certain extent of lung ; percussion 
 still giving a clear sound in that region. Pulmonary emphysema 
 is the only disease which can be confounded with this group of 
 signs." 
 
 As I have had no opportunity of studying the cases of bron- 
 chial obstruction described by Andral and Reynaud, I cannot put 
 forward any original observation upon them. Yet I can scarcely 
 agree with the first of these authors, in his opinion that they 
 may be confounded with Laennec's emphysema, for although 
 this particular form of bronchial obstruction has not come before 
 me, yet in cases of foreign bodies in the trachea and bronchial 
 tubes, and in compression of either bronchus by external 
 tumours, I have had many opportunities of studying the stetho- 
 scopic signs which result from complete or partial obstruction of 
 a large tube, and of convincing myself that between the pheno- 
 mena thus produced, and those of bronchitis with dilatation of 
 the air cells, there are generally remarkable differences. 
 
 We may divide the cases of this kind of bronchial obstruction 
 into two classes ; first, those in which it is complete, and next, 
 those where it is only partial. Now, in the first of these cases, 
 the physical signs are totally different from those of Laennec's 
 emphysema ; for we have complete absence of respiratory mur- 
 mur, and of the other signs which indicate permeability of the
 
 70 BRONCHITIS. 
 
 lung-, the sound on percussion remaining unaffected ; circum- 
 stances the very opposite to those in emphysema, in which there 
 is never complete impermeability, and in which the sound on 
 percussion becomes increased in proportion to the extent of the 
 disease. 
 
 In the second class, the phenomena of which may be studied 
 in cases of foreign bodies not completely obstructing the bron- 
 chus, and in those of partial compression of the tube by external 
 tumours ; the signs, in the early periods at least, are also dif- 
 ferent from those of emphysema. The respiration indeed is 
 feeble, but pure, the sound on percussion unaltered, and the 
 peculiar crepitating, sibilous, and mucous rales altogether want- 
 ing. There is no evidence of increase of volume of the lung, and 
 if signs of bronchial irritation supervene, they are consequent to 
 the feebleness of respiration ; the very reverse of what occurs in 
 dilatation of the cells, which, in almost all cases, is produced 
 and preceded by a bronchial irritation. 
 
 Lastly, the history of the case, the accompanying symptoms, 
 and the period of duration of the physical signs, will greatly 
 assist us in forming a correct opinion. 
 
 Before proceeding to some of the other varieties and results 
 of bronchitis, I shall endeavour, according to the plan of 
 this work, to throw into separate propositions the state of our 
 knowledge with respect to the physical diagnosis of simple 
 bronchitis. 
 
 1st. That in almost all cases percussion gives no direct sign. 
 2nd. That an accumulation of mucus in the inferior portions 
 of the lung may give a certain degree of dulness. 
 
 3rd. That in the great majority of cases, in which there is a 
 co-existence of the signs and symptoms of bronchitis with dul- 
 ness, we may infer the existence of some disease, either of the 
 parenchyma or of the pleura. 
 
 4th. That conversely, the absence of dulness with the exist- 
 ence of irritation of the lung, gives a great probability that the 
 case is one of simple bronchitis, 
 
 5th. That a copious effusion of muco-purulent matter may 
 exist in the bronchial tubes, without perceptible dulness of 
 sound on percussion. 
 
 Gth. That in certain cases of bronchitis with effusion, a 
 metallic sound may be produced on percussion. This is some-
 
 BEONCHITIS. 71 
 
 what similar to the bniit de pot felt' of caverns, but is to be 
 distinguished from it by the clearness of sound, its greater 
 diliusion, and the absence of the stethoscopic signs of a cavity. 
 
 7th. That in many cases, on application of the hand, a dis- 
 tinct vibration is felt in accordance with the motions of res- 
 piration. 
 
 8th. That the modifications of respiration, as observed by the 
 stethoscope in bronchitis, seem to be connected with mechanical 
 obstruction more or less complete, and which may proceed from 
 one or all of the following causes : turgescence or hypertrophy of 
 the mucous membrane, the existence of various secretions, and 
 lastly, the occurrence of spasm. 
 
 9th. That in the mode of occurrence of the various phenomena 
 there are the greatest possible diftereuces in different individuals. 
 
 lOtli. That as a general rule it may be stated, that the more 
 intense the sonorous, sibilous, or mucous rales, or any combina- 
 tion of them, be during ordinary respiration, the more severe 
 may the disease be considered. 
 
 11th. But that in certain cases of intense bronchitis of the 
 minuter tubes, the sounds during ordinary respiration cease to be 
 a measure of the intensity of disease, as they become louder 
 during the convalescence of the patient. 
 
 12th. That in the secretive stage of bronchitis the mucous 
 rattle may occur, on the one hand, with large and isolated 
 bubbles, and on the other, may pass into a rale almost crepi- 
 tating, the sound on percussion still continuing clear. 
 
 13th. That in consequence of bronchial inflammation the 
 entrance of air into a certain portion of the lung may be pre- 
 vented, under which circumstances the signs are nullity of 
 respiration, with persistence of clearness of sound. 
 
 14th. That this obstruction may result from an organic change 
 of the mucous membrane, or from the plugging up of the tubes 
 by their own secretion. 
 
 IStli. That in the first of these cases the absence or dimi- 
 nution of the respiratory murmur is permanent, w'hile in the 
 second it may be temporary, and removable by a fit of coughing ; 
 yet even in this case the obstruction by a concrete mucus has 
 continued from the period of its occurrence until the fatal 
 termination. 
 
 16th. That if in a case of mucous catarrh a sudden dyspnoea
 
 72 BRONCHITIS. 
 
 supervenes, with absence or diminution of the respiratory mur- 
 mur in a particular portion of the lung, this portion also 
 preserving its clearness of sound on percussion, we may make 
 the diagnosis of obstruction of the bronchial tube by its own 
 secretion. 
 
 ACUTE SECONDARY BRONCHITIS. 
 
 Having now considered the symptoms and signs of the primary 
 bronchial inflammation, in other words, of that form of disease 
 in which the affection of the mucous membrane seems to be the 
 first link in the chain of morbid action, and the fever consequently 
 sympathetic, I proceed to consider the disease in its secondary 
 form, when we find it either as the result of an influence which 
 seems to act on the whole economj^ ; a specific poison which 
 produces various organic and functional lesions, among which 
 that of the respiratory mucous membrane is by no means the 
 least important ; or as proceeding from a sympathetic irritation, 
 the consequence of local disease in some other s_ystem. I shall, 
 in the first place, examine into the history of the catarrh of 
 typhus fever ; next, into that of the exanthematous diseases ; 
 and lastly, make some observations on those forms of bronchitis 
 which occur in other specific contaminations of the system, and 
 which may be denominated the chronic secondary catarrhs ; and 
 on the sympathetic coughs from irritation of the digestive 
 system. 
 
 Bronchitis of Typhus Fever. — The occurrence of bronchitis 
 in cases of typhus is not constant ; and even when it exists, it is 
 often slight, and easily manageable. But on the other hand, 
 the pulmonary system may be severely attacked, and death 
 induced by asphyxia from excessive secretion of the bronchial 
 membrane. We commonly meet with this severe form under 
 two circumstances ; the one where the symptoms are manifest 
 and distressing, the other in which the disease is latent and 
 insidious. But in one respect both these forms agree, namely, 
 that at an earlier j)eriod than in the idiopathic catarrh, secretion 
 generally comes on in enormous abundance, and is too often the 
 immediate cause of death. As far as I have seen, the great 
 majority of patients in fever, who have died with what is called 
 eff'usion into the chest, owe their death to this disease, which
 
 BRONCHITIS. 73 
 
 has been overlooked, or insufficiently treated. This fact 
 illustrates the want of proportion which commonly exists in 
 typhus fever between the functional alteration and the organic 
 change. With symptoms of an apparently trifling character we 
 may, after death, find universal bronchitis, great congestion, or 
 pneumonia. 
 
 In many cases, as Laennec has observed, a bronchitis shall 
 exist through the whole course of a fever, yet so slight as to 
 merit little notice. But in all these cases we must pay a careful 
 attention to the chest, for we know not the moment at which 
 this trivial disease may assume a dangerous character ; and 
 hence, when we discover any increase in the bronchitic symptoms 
 we should immediately du-ect our attention to the lung, and, if 
 possible, arrest the progress of the local disease. 
 
 In other cases, as I have before mentioned, the bronchitis is a 
 prominent and formidable symptom ; and in addition to the 
 other phenomena of fever, we find the patient with lividity of 
 countenance, cough, hurried breathing, and expectoration. 
 Finally, though these symptoms be but slightly marked, yet the 
 patient may be labouring under a bronchitis, of the intensity 
 and extent of which nothing but a physical examination can 
 convince us. Such a patient may continue for days with but 
 little apparent suff'ering of the respiratory system, and be 
 suddenly cut off by a super-secretion from the bronchial mucous 
 membrane. 
 
 This form of disease is commonly co-existent with more or 
 less of gastro -enteric inflammation, thus forming one of the most 
 fatal varieties of fever in this country. In some instances the 
 disease predominates in the respiratory, in others in the digestive 
 system ; and I have often observed a remarkable alternation of 
 this predominance of disease between the thoracic and abdominal 
 cavities. Thus, suppose to-day we observe the breathing hurried 
 and laborious, the cough troublesome, the expectoration difficult, 
 and the stethoscopic signs well marked, the chances are that the 
 abdominal symptoms are less severe, the abdomen is less swelled 
 and painful, diarrhoea has ceased, the tongue has improved, and 
 that characteristic prostration which attends gastro-enteric 
 inflammation has remarkably disappeared. In two or three 
 days, however, the abdominal symptoms return, with decided 
 diminution of those of the chest, and in the course of a single
 
 74 BRONCHITIS. 
 
 case several alternations of this kind may occur. In such 
 instances death generally takes place by asphyxia ; and I have 
 known cases in which the gastro-intestinal mucous membrane 
 was found in so favourable a state as to leave little doubt, that, 
 as far as its organic change was concerned, the patient would 
 have recovered, but for the bronchitis. I think we ma}^ state, 
 with respect to the pathology of mucous membranes in fever, 
 that although the gastro-intestinal mucous surface may be, and 
 often is affected, while but little, if any, disease exists in the 
 respiratory organs ; yet that the converse of this proposition is 
 seldom true, a point of the utmost importance in practical medi- 
 cine, as bearing on the application of general, local, and specific 
 treatment. 
 
 Physical Signs. — In this form of disease it is often difficult 
 to draw the line of distinction between the disease in the mucous 
 membrane, and a congested or even inflamed state of the pul- 
 monary parenchyma ; and hence, the physical signs cannot be 
 so accurately defined as in cases of simple idiopathic bronchitis. 
 Thus, although the sound on percussion is generally clear 
 throughout the whole disease, yet in certain cases we observe 
 a diminution of sound generally occupying the lower portion 
 of one side, but never amounting to complete dulness. In some 
 cases, indeed, it is so slight as only to be ascertained by careful 
 comparison. This is an unfavourable sign, as shewing that we 
 have something more to contend with than bronchitis, and point- 
 ing out that congested state of viscera so dangerous in the 
 progress of a typhus fever. The stethoscopic signs are subject to 
 the same irregularities, and the rales become sometimes so fine 
 as to be hardly distinguishable from those of pneumonia, a 
 circumstance attributable to the complication with pulmonary 
 congestion. We may also observe that the position of the 
 patient has a remarkable influence on the physical signs, which 
 is rarely observable in the idiopathic bronchitis. Thus, if the 
 patient has lain all night on the left side, we may find this 
 portion of the chest somewhat duller on percussion, with more 
 intense rales, and less vesicular murmur. To this subject I 
 shall return when speaking of pneumonia, and shall merely 
 remark, that the fact is explicable by the debility of the patient, 
 and probably also by the dissolution of the fluids which occurs 
 in such cases ; and accordingly on dissection, we find the lower
 
 BRONCHITIS. 75 
 
 portions of the lung, more or less in a state of congestion, 
 bordering upon hepatization : the tissues also present a 
 remarkably livid hue, and are generally softened. 
 
 In describing the stethoscopic signs of this form of bronchitis, 
 I may observe, that there is no essential difference between 
 them and those of the primary species. All the varieties and 
 combinations of the dry and humid rales are met with, their 
 intensity being regulated by that of the diseased action. But 
 independent of the mere characters of physical phenomena, we 
 find some accompanying circumstances of difi'erence between the 
 two affections. 
 
 The first and most important, is the want of proportion 
 between the intensity of the phenomena and the sufferings of 
 the patient ; the former being extreme, while the latter, at least 
 until the last stage, are comparatively trifling. This we find in 
 that variety of the disease, where the bronchitis, quoad its 
 symptoms, is nearly latent, thus constituting a remarkable dif- 
 ference in the disease, as compared with the primary form, in 
 which the proportion between the symptoms and signs is much 
 more direct. 
 
 The second point of difi'erence is closely connected with the 
 former. It is that the intensity of the rale during ordinary 
 breathing is, in many cases, not a measure of the violence of the 
 inflammation or congestion of the air tubes. Thus, during 
 ordinary breathing the rales may be but slight and diffused, 
 and yet on a forced respiration become most intense. This 
 seems owing to the great obstruction of the minute tubes, 
 coupled with the debility of the patient. But as the disease 
 subsides, we have a loud rale during ordinary respiration, so that 
 then the increase of rale points out a decrease of disease. To 
 this point I have already alluded when speaking of the signs of 
 bronchitis. 
 
 A third distinction may be made with respect to the frequency 
 of the occurrence of certain characters of rale. In the primary 
 bronchitis, a mucous rale, so fine as to be scarcely distinguishable 
 from crepitus, is by no means uncommon, and shews that the 
 disease has affected, if not the air cells, at least those finer tubes 
 which pass into them. Now in the bronchitis of typhus, unless 
 when complicated with congestion or pneumonia, when the sound 
 becomes dull, the rjiles are much more of the musical than of the
 
 76 BRONCHITIS. 
 
 crepitating character; from which I would conclude, that the 
 disease more especially affects the large tubes, where the lining 
 membrane has the proper characters of a mucous structure. 
 Louis has shewn, that of the different tissues the serous mem- 
 branes are the least liable to disease in typhus ; and if the struc- 
 ture of the minuter tubes and and air cells approach to that of the 
 white tissues, we may understand why such parts of the lung are 
 less liable to the secondary diseases of typhus. 
 
 Lastly, we find that in the severe bronchitis of typhus fever, 
 the morbid phenomena predominate more remarkably in the 
 lower and posterior parts of the lung ; where, as I have before 
 mentioned, they are occasionally combined with signs indicative 
 of a congested state of the cellular structure of the lung. 
 
 I shall next proceed to consider bronchitis in relation to the 
 exanthematous diseases. 
 
 It seems now established that we may consider these affections 
 as examples of specific fevers, characterized by the production of 
 secondary irritations, not only of the surface, but of the internal 
 parts, the disease of the skin thus forming but a single link in the 
 chain of morbid actions. Nor is the cutaneous irritation the first 
 of the secondary affections, at least in the greatest number of 
 cases, for the viscera seem, in almost all instances, to be the 
 first to suffer, a fact proved by the occurrence of signs of this 
 irritation, superadded to the general symptoms of the precur- 
 sory fever. In this way all the viscera may be affected, and 
 convulsions, cough, vomitting, or diarrhoea are met with. On 
 the appearance of the cutaneous eruption, however, this internal 
 irritation either subsides, or becomes greatly modified ; while 
 in other cases, where the eruption is either wanting or insuffi- 
 cient, the visceral disease may run on to a fatal termination. 
 We find, further, that if the cutaneous irritation, which may 
 be considered as a natural revulsion from the viscera to the 
 surface, be repressed, visceral inflammation is again lighted 
 up, and that this may occur even at the natural period of the sub- 
 sidence of the affection of the skin. 
 
 But while, in the actual state of medicine, we must disbelieve 
 the doctrine of these afiections being purely cutaneous, so, on the 
 other hand, we cannot admit the opinion of the pure solidists, 
 who explain all the phenomena by the sympathetic effects of 
 primary visceral irritation. All the arguments against the
 
 BRONCHITIS, 77 
 
 doctrine of the localization of fever apply equally in the case of 
 the exanthematous diseases, for they agree with typhus in the 
 circumstance of periodicity; and in the local affections not 
 being primary, constant, or in proportion with the general 
 symptoms ; so that we must consider their local irritations 
 as generally analogous in their pathology to those of typhus 
 itself. 
 
 But between these affections we may draw one line of distinc- 
 tion, although, after all, it amounts but to a difference in degree. 
 The secondary irritations in the exanthemata are more violent, more 
 constant, and consequently of more importance in these diseases 
 than in typhus. The inflammations, too, have (at least in measles 
 and the ordinary scarlatina) more of the sthenic character ; and 
 the liability to inflammatory action seems to continue longer 
 after the subsidence of the original disease. 
 
 This complication with visceral disease was not unknown to the 
 older authors, but it is to Broussais that modern medicine owes the 
 most important illustrations of the subject ; and if we leave aside 
 the conclusions into which his pure solidism led him, we find a 
 mass of important observations on the diseases in question. 
 After describing the progress of a case of measles, he observes, 
 " Such is the natural, or, more properly speaking, normal pro- 
 gress of measles, but how many are the chances that cause it to 
 deviate ! Sometimes inflammation, and the spasm consequent 
 upon it, predominate in the bronchial tubes, and destroy the 
 patient by suffocation ; at other times, the bronchitis, which was 
 supposed to be near a termination, involves the parenchyma, and 
 is converted into a pneumonia or pleuritis. In other cases, 
 particularly in adults, whose digestive organs have been long- 
 subject to irritation, gastro- enteritis becomes the predominant 
 phenomenon, or combmes with the pulmonary inflammation in 
 producing a fatal result. Occasionally the irritation is trans- 
 mitted to the encephalon, and the patient suffers from all the con- 
 sequences of such a metastasis. Finally, there are circumstances 
 in which the inflammation becomes chronic and apyrexial, at one 
 time in the air passages, where it causes phthisis, at others, in 
 the digestive tube, where it maintains a chronic inflammation of 
 the stomach, small intestines, and colon. Hence comes the 
 accredited opinion of the older phyiscians, (who knew no other 
 practice than the evacuation of the humours,) that measles
 
 78 BRONCHITIS. 
 
 require, after their disappearance, the repeated use of purga- 
 tives." 
 
 I have quoted this passage, as it forcibly and truly describes 
 the circumstances which attend so many cases of these eruptive 
 diseases, and strongly directs the mind of the practitioner to the 
 state of the viscera. It is to be regretted that as yet the import- 
 ance of these considerations has not been sufficiently insisted on 
 in our schools of medicine, and that so many practitioners con- 
 tinue to regard these diseases merely as affections of the skin, 
 forgetting, that as it is by the viscera we live, so it is by them 
 we die. Almost all the erroneous practice in these affections can 
 be traced to the overlooking of this most essential point. Here, 
 however, I feel happy in bearing my testimony to the fact, that 
 among the British systematic writers on medicine, Dr. Mackin- 
 tosh is the only one who has fully developed the general patho- 
 logy of the exanthemata ; and his writings on this subject must 
 be productive of the most extensive and still increasing benefit. 
 
 When we consider the phenomena of the different exanthemata, 
 we must observe, that although there is no constant relation 
 between their separate species, and the affections of particular 
 viscera ; yet that, in many cases, there is evidence of some 
 greater connexion with disease of certain organs than with that of 
 others. Thus, with respect to the pulmonary system, its irrita- 
 tions are more commonly met with in measles and scarlatina than 
 in variola or erysipelas, which seem more closely connected with the 
 digestive system. That we may have pulmonary irritations, occur- 
 ring with these latter diseases, and abdominal affections with the 
 former, is fully admitted ; but still the rule seems to hold good, 
 that the poisons of measles and scarlatina, in their operations on 
 the economy, fall more on the respiratory than on the digestive 
 system. We find that previous to the eruption, in almost all 
 cases, and in some, even before any fever is established, there 
 are signs of irritation of the bronchial mucous membrane. 
 These often go on increasing until the eruption makes its appear- 
 ance ; when, as it were, by the revulsion to the surface, a degree 
 of relief is afforded to the pulmonary system. Should the erup- 
 tion be repelled, we see the bronchitis again lit up ; and even at 
 the period when the cutaneous efflorescence should naturally 
 subside, there is the greatest liability to dangerous inflammation 
 of the chest.
 
 BRONCHITIS. 79 
 
 Au iiiterestiug question here presents itself : is the inflam- 
 mation of the mucous membrane in these diseases specifically 
 different from that in idiopathic bronchitis ? This is a point 
 on which anatomy sheds no light, nor is it probable that it ever 
 will. We want a series of observations on the symptoms and 
 history of the pulmonary irritations of the exanthemata, as com- 
 pared with idiopathic affections, which might throw great light 
 on the subject. Until this is done, we can only conjecture. 
 But this much may be said, that while, on the one hand, we 
 meet with many instances in which the visceral irritation is mild 
 and not extensive, so, on the other, we find that some of the 
 most violent and intractable cases of bronchitis, and its con- 
 secutive pulmonary irritations, are met with in connexion with 
 these diseases. 
 
 Under these circumstances we find intense bronchial inflam- 
 mation ; the combination of this with pneumonia ; or, as I have 
 witnessed more than once, pleuritis, with a copious and rapid 
 sero-purulent eft'usion. We may also have a general development 
 of tubercle, in which case its connexion with the inflammatorv 
 action is too obvious to be overlooked. 
 
 I have before alluded to the differences in the several 
 characters of the secondary irritations of the ordinary measles 
 and scarlatina, as compared with those of typhus, and have shewn 
 that they have more of a sthenic character. But in one respect 
 they may be said to differ anatomically, namely, that in these 
 affections there is a much greater likelihood of the serous 
 membranes becoming engaged than in typhus. Arachnitis, 
 pleuritis, and peritonitis are not unfrequent ; a fact of great 
 importance in our prognosis and treatment, and one of interest 
 in connexion with the statement of Louis, to which I have 
 already alluded, when speaking of the physical signs in the 
 bronchitis of typhus fever. 
 
 CHRONIC SECONDARY BRONCHITIS. 
 
 In discussing this subject I shall content myself with briefly 
 pointing out the most remarkable instances of bronchial irritation 
 connected with those slower actions which result from chronic 
 constitutional disease, and then notice the subject of the sym-
 
 80 BRONCHITIS. 
 
 pathetic affections of the lung consequent upon abdominal 
 irritations. 
 
 I quite agree with Dr. Graves in regretting that this essential 
 question in the pathology of bronchitis should have been so 
 much neglected by investigators on the subject. We have seen 
 what an important part the affections of the bronchial membrane 
 take in those contaminations of the system which we call fevers ; 
 and there can be no doubt, that in many other specific affections 
 there are corresponding diseases of this tissue. Thus, the gouty, 
 scrofulous, syphilitic, and scorbutic contaminations, may, and no 
 doubt do, produce their specific forms of bronchial inflammation. 
 And even though as yet pathological anatomy has not revealed 
 any organic differences in these lesions, whether as compared 
 with the idiopathic disease, or among one another, jet that their 
 peculiar character is shewn in their history, symptoms, and the 
 result of treatment, every unprejudiced and practical man must 
 allow. 
 
 Thus, in the gouty habit we see attacks of irritation in various 
 organs, among which the bronchial membrane may be affected, 
 and the patient labour under a severe and obstinate cough. 
 And even, as has been well remarked, an attack of bronchitis 
 from cold, in the same diathesis, will often shew itself with the 
 peculiar characters of a gouty affection. 
 
 The gouty irritations of the lung occur under various forms 
 and circumstances. Thus, cough, dyspnoea, and expectoration 
 may precede a fit of gout, and rapidly and completely subside on 
 its appearance ; on the other hand, these symptoms may follow 
 the subsidence of the arthritic attack. A patient may present 
 all the symptoms which have been supposed to belong to 
 hydrothorax^ but which are really the consequence of puhnonary 
 congestion and inflammation, and these shall alternate with 
 gout. Or we may see a case, in ivldch such symptoms having 
 been removed hy approirriate treatment, a fit of gout has imme- 
 diately appeared. We may further observe more complicated 
 cases, such as the succession of epilepsy, gout, and fatal bron- 
 chitis ; or inflammation of the trachea, slight general arthritis, 
 glandular enlargements, gout. Other examples might be given, 
 but enough has been stated to prove, that the respiratory system 
 may be affected, either primitively or consecutively, by the gouty 
 irritation. Whether in such cases the lesion is in any anato-
 
 BRONCHITIS. 81 
 
 mical character different from idiopathic bronchitis is still to be 
 determined, but it seems probable, that like other analogous 
 affections, its specific character will be found more in its mode 
 of invasion and amenability to certain remedies, than in its 
 anatomical nature or seat.* 
 
 I shall next allude to a form of secondary bronchitis, which, 
 though as yet little understood, demands a full and most careful 
 investigation, I mean a peculiar bronchial irritation, arising in 
 consequence of the syphilitic contamination of the system, a 
 disease which seems by no means unfrequent. 
 
 That the syphilitic virus should affect the viscera, seems so 
 probable from analogy, that it is strange how this part of its 
 history should have been so long unexplored. In fevers, in the 
 exanthemata, in scrofula, in gout, and other constitutional affec- 
 tions, we see visceral diseases taking a most prominent part in 
 the morbid phenomena ; and that syphilis should constitute an 
 exception to a law so general seems in the highest degree impro- 
 bable. The pathologist has examined its effects on the external 
 parts, and the bones, &c., but has done little indeed in a field 
 perhaps equally important. His researches on internal syphilitic 
 disease have been crude and scanty ; and the affections of the 
 pharynx, the windpipe, the rectum, and the genito-urinary sys- 
 tem, are all that have arrested his attention. 
 
 It seems to have been believed by those authors who have 
 opposed the doctrine of a syphilitic virus, that the viscera 
 escaped the disease. t " Nothing," says Broussais, " proves 
 that such a virus may be preserved and reproduced in the 
 economy, so as to cause visceral inflammations or sub-inflam- 
 mations." Yet the same author soon after speaks doubtingly 
 on the subject, and declares, that new researches and experiments 
 are necessary. We might suppose, from the general silence of 
 authors on the subject, that these specific visceral irritations 
 were rare, and probably often confounded with idiopathic 
 affections. Yet the records of medicine are not deficient in 
 examples of cures of pectoral and abdominal consumptions, 
 
 * An interesting case in whicli crystals of lithic acid were detected in the sputa of 
 a gouty patient, was published by Dr. J. W. Moore in the Irish Hosjntal Gazette, 
 July 15, 1873. (H.) 
 
 t " As far as my information goes," says Dr. Walshe " the credit of originally 
 shewing that the virus of syphilis may affect the bronchial mucous membrane 
 belongs to Drs. Graves and Stokes, followed by Dr. Munk." 
 
 G
 
 82 BRONCHITIS. 
 
 presumed to be syphilitic, by the use of mercury. The opposers 
 of the doctrine of a virus refer the occurrence of such diseases to 
 the treatment as much as to the disease, but give a melancholy 
 instance of bad reasoning and prejudice, in also attributing the 
 cure by mercury to a revulsive counter-irritation. Mercury then, 
 according to them, produced the disease which they afterwards 
 cannot deny that it cured. 
 
 In these diatheses, or morbid constitutional states, we may 
 observe the occurrence of local disease under tAvo circumstances : 
 in the one, it seems to be the immediate effect of the contami- 
 nation, as we see in the pustules of variola ; and in the other, 
 we find that in a sj^stem already contaminated, other causes 
 acting, a disease may be developed, which is so modified by the 
 constitutional state as to show itself in some different form from 
 its idiopathic characters. Thus, in the scrofulous or gouty 
 diathesis, common exciting causes will produce inflammations 
 of peculiar characters, and so it is probably in the syphilitic 
 state. 
 
 But to come to our subject, the syphilitic poison, in its action 
 on the viscera, seems more often, or at least more prominently, 
 to aftect the respiratory system. Thus, the frequency of 
 laryngeal afi'ections in syphilis has been long admitted, to Avhich 
 I shall again allude, in speaking of the diseases of the windpipe. 
 With respect to the bronchial system, we rasij observe the 
 disease as an acute, or more chronic affection. In the first 
 instance, it is analogous to the bronchial irritations of the 
 exanthemata, of which I have seen a few interesting examples ; 
 while in the second, there is a chronic irritation, which, when 
 combined with the syphilitic hectic, and with periostitis of the 
 chest, closely resembles true pulmonary phthisis. 
 
 In the first of these cases I have observed, that after a period 
 of time from the first contamination, the duration of Avhich has 
 not been determined, the patient falls into a feverish state, and 
 presents the symptoms and signs of an irritation of the bronchial 
 membrane. These having continued for a few days, a copious 
 eruption, of a brownish red colour, makes its appearance on the 
 skin, and the internal aftection either altogether subsides, or 
 becomes singularly lessened. Here we see the bronchial 
 membrane taking on an action which is peculiar, and very different 
 from its ordinary irritations. There is an inflammation, only
 
 BRONCHITIS. 83 
 
 analogous to that of the exanthemata, and no doubt can exist 
 that it is connected with the syphiHtic poison. 
 
 My friend, Dr. Byrne, whose situation as medical officer to the 
 Lock Hospital, gives him the greatest opportunities of observation, 
 informs me, that he has, in many instances, seen patients, who 
 had been formerly diseased, and who had come into hospital 
 either for new sores, or for gonorrhoea, attacked with intense 
 bronchitis, and fever. This attack would come on suddenly, and 
 the distress was so great, that bleeding had to be performed. 
 The effect of which was, that soon after a copious eruption, 
 often combining the lichenous and squamous forms, made its 
 appearance, with complete relief of the chest. In some of these 
 patients, on the day before the eruption, the stethoscopic signs 
 had been those of the most intense mucous irritation ; and yet, 
 when the skin disease appeared, the respiratiun became either 
 perfectly pure, or only mixed with an occasional rhonchus in the 
 large tubes. The same gentleman has observed the reverse of 
 this : as when a syphilitic eruption has been repressed, the 
 bronchial membrane has become much engaged, and the patient 
 affected with general febrile symptoms. These phenomena 
 subsided after bleeding and mild diaphoretics, which had the effect 
 of restoring the cutaneous eruption. Here we have an additional 
 evidence in favour of the analogy between this syphilitic bronchitis 
 and that of the exanthemata. No doubt the occurrence of an 
 idiopathic bronchial irritation might cause the temporary sus- 
 pension of the skin disease, but still the fact above stated adds 
 great weight to the opinions which I have advocated. Other 
 medical friends have mentioned to me, that they have observed 
 similar cases ; and I shall only add, that the subject promises a 
 fair field for pathological inquiry, and practical improvement. 
 
 The attention of the profession has been recently called to the 
 more chronic form of the disease, by Dr. Graves, in his pub- 
 lished lectures. He remarks, that the possibility of syphilis 
 attacking the pulmonary system was not unknown to the older 
 authors, but that since it had been placed by systematic writers 
 among the diseases of the skin, this idea seems to be abandoned 
 or forgotten. He entertains a firm conviction, that the syphilitic 
 poison may affect the pulmonary, as well as the osseous, 
 cutaneous, or mucous tissues, a point of doctrine which I look 
 upon to be completely established. Dr. Graves' observations on 
 
 G 2
 
 84 BEONCHITIS. 
 
 the diagnosis are too important to be omitted here. He says, 
 *' If the patient's sufferings have commenced at the period of 
 time, after primary sores on the genitals, when secondary 
 symptoms usually make their appearance ; if some of his com- 
 plaints are clearly traceable to this source ; if, along with 
 debility, night- sweats, emaciation, nervous irritability, and 
 broken rest at night, we find cough ; and if this group of symp- 
 toms have associated themselves with others, evidently syphilitic, 
 such as periostitis, sore throat, and eruption on the skin, then 
 we may, with confidence, refer all to the same origin, and may look 
 upon the j)atient as labouring under a syphilitic cachexy, affecting 
 the lungs as well as other parts. In forming this diagnosis 
 much caution and care are necessary, and we must not draw our 
 conclusion until we have repeatedly examined the chest by means 
 of auscultation and percussion ; if these fail to detect any 
 tangible signs of tubercles, we may then proceed to act upon our 
 decision with greater confidence, and may advise a sufficient but 
 cautious use of mercury. Under such circumstances it is most 
 pleasing to observe the speedy improvement in the patient's 
 looks and symptoms ; the fever, night- sweats, and watchfulness 
 diminish, he begins to get flesh and strength, and, with the 
 sj'mptoms of lues, the cough and pectoral affection disappear. 
 I am not prepared to say which of the pulmonary tissues is most 
 usually attacked by the venereal poison, but I believe that it 
 chiefly tends to the bronchial mucous membrane, although, like 
 other animal poisons, e.g., those of measles and scarlatina, it 
 may also occasionally produce pneumonia." 
 
 To these valuable observations it is unnecessary for me to 
 express my assent ; but I cannot sufficiently impress the import- 
 ance of making a careful physical examination of the chest. The 
 great frequency of phthisis, and the liability to its supervention 
 in the strumous habit, when s}q)hilis and mercury combine to 
 undermine the constitution, are circumstances never to be lost 
 sight of. To this point I shall return when I describe phthisis, 
 and here only remark, that the principal ground on which I rely 
 for the diagnosis between this syphilitic irritation of the bronchi, 
 and tubercle, is the want of accordance between the physical signs 
 and the constitutional sijnqitoms. The latter are often those of 
 phthisis in an advanced stage, while the former point out no 
 amount of disease at all commensurate with the sj'mptoms.
 
 BRONCHITIS. 86 
 
 The value of this is at once seen when we recollect, that in almost 
 all cases of true phthisis, which have gone on to the production 
 of decided hectic and emaciation, there are manifest physical 
 signs of tubercle. 
 
 In concluding my observations on the secondary constitutional 
 irritations of the bronchial membrane, I feel that I have by no 
 means done justice to this most important subject. Thus I have 
 not dwelt on the connexion of bronchitis with scrofula and scor- 
 butus, as alluded to by Dr. Graves, or with erysipelas, which has 
 been so strongly dwelt on by Dr. Mackintosh. But if what I 
 have said be sufficient to draw attention to the general history 
 and pathology of the constitutional affections of the lung, I shall 
 be satisfied, and conclude by pointing out what seem to me to be 
 the desiderata of the subject. These are — 
 
 First. To determine what are the tissues engaged in each of 
 these cases. 
 
 Second. To ascertain whether any anatomical difference can be 
 shewn between these diseases and the idiopathic bronchitis ; and 
 
 Third. To determine how far the ordinary treatment of bron- 
 chitis should be modified according to its constitutional exciting 
 cause. 
 
 Sympathetic Cough. — Under this head I shall notice two 
 principal forms of this affection, in both of which the primary 
 irritation resides in the digestive system. These are, first, the 
 cough which results from gastric inflammation, and next that 
 from intestinal worms. 
 
 Much, if not all, of our knowledge on the first of these varieties 
 is owing to Broussais, who has so successfully developed the 
 general subject of sympathies, and has shewn how by their 
 preponderance a disease of the digestive, respiratory, circulating, 
 or nervous systems may be simulated. Among these morbid 
 sympathies, one of the most remarkable is that under considera- 
 tion ; for an acute or sub-acute gastritis may produce cough, 
 and if this be violent or long-continued, actual inflammation of 
 the lung. 
 
 Before giving the results of my experience on this subject, I 
 shall examine some of M. Broussais's cases, which he has 
 published in his PJdegmasies CJiroiiiques. In the firsi case, the 
 patient had been exposed to great mental and bodily fatigue, and 
 for some time had used red wine for his breakfast in place of
 
 86 
 
 BRONCHITIS. 
 
 coffee. He became attacked with fever, and in the course of a 
 few daj-s complained of severe pain in the chest, and epigastric 
 constriction. There was a constant desire to cough, but the pain 
 prevented its indulgence. On the eighth day, the fits of coughing 
 were violent and unceasing, and the epigastric pain worse. Some 
 leeches were applied to the epigastrium, which removed the 
 pectoral symptoms almost completely, but in two days the fever 
 was again lit up, and the cough reappeared. Violent symptoms 
 now set in, unconsciousness, sighing, stupor alternating with 
 restlessness, and fruitless attempts to cough. The patient died 
 on the eighteenth day. 
 
 On dissection the lungs were perfectly healthy, but the stomach 
 was found gi'eatly contracted, and its mucous membrane of so 
 deep and livid a colour as in manj" points to be almost black. 
 The intestines were also contracted, and with great vascularity 
 of the mucous membrane. 
 
 The next case detailed by this author is not clearly illustrative 
 of the point in question, as it seems one of those constitutional 
 affections, marked by diffuse cellular inflammation, and the 
 occurrence of inflammatory action in many of the viscera. 
 
 In his third case M. Broussais gives the history of a young 
 man who was attacked with bilious derangement, and distressing 
 cough ; on the sixth day he had high fever, dyspnoea, redness of 
 the malar eminences, and a violent cough, not in fits, but in 
 single shocks at each inspiration. This caused great pain, and 
 an expectoration of some frothy and bloody mucus. He had no 
 fixed pain, but the anterior portion of his chest was very tender. 
 There was great anxiety, and the patient uttered plaintive cries, 
 and complained of extremely disagreeable sensations in the 
 mouth. 
 
 The patient was twice freely bled, and a blister aj^plied to the 
 thorax, but although the vascular action was reduced, the other 
 symptoms continued, and he died on the sixteenth day of his 
 illness. 
 
 On dissection the lungs were found engorged, but not indu- 
 rated; the stomach was intensely inflamed. 
 
 From these cases, as well from others, which are not given, 
 M. Broussais gives the following as the characters of this gastric 
 cough. 
 
 It comes on with violent shocks, {a sccovsses), which occur at
 
 BRONCHITIS. 87 
 
 each inspiration, and those violent paroxysms, which would pro- 
 duce swelling and lividity of the countenance, are never observed. 
 It is more alleviated by cooling and slightly acidulated drinks 
 than by bleeding ; and lastly, with reference to the expectoration, 
 it may be present or absent according to the degree of the bron- 
 chial irritation, but its excretion ma.j be suspended by means 
 calculated to relieve gastritis, and this suspension is advantageous 
 to the patient. 
 
 I shall now state the results of my experience on this interest- 
 ing subject. 
 
 As the sympathetic irritations of gastritis vary according to the 
 intensity of the disease and the local and general susceptibility of 
 the patient, it is obvious that they will shew themselves under 
 different characters in different individuals ; and while, in the 
 one case there may be high excitement of the cerebro-spinal, in 
 another the same may occur with respect to the respiratory or 
 circulatory systems. Of the cause of these peculiar predisposi- 
 tions we are at present ignorant. 
 
 The nature of these sympathetic affections seems to be that they 
 are at first only lesions of function, but that when violent, or 
 long-continued, they become complicated with organic change ; 
 or, in the language of Andral, the lesion of innervation is followed 
 by that of circulation, nutrition, and secretion : under these cir- 
 cumstances, cough, or palpitation, or cerebral symptoms, which 
 were at first only sympathetic and uncomplicated with organic 
 change in the suffering organ, may become combined with actual 
 disease, the violence, or long-continuance of the symptom, being 
 the conditions for this modification. 
 
 Now, with respect to the lungs, we find that their functions 
 may be injured, and a sympathetic cough excited, either by an 
 acute or chronic disease of the gastro-intestinal surface. In the 
 first case the symptom is generally more violent ; and, from the 
 fi-equent existence of fever, much more likely to become com- 
 plicated with pulmonary inflammation. For it seems certain, 
 that the supervention of inflammation in mere functional lesion 
 is much more probable when a febrile state exists. 
 
 We may see a patient with the most aggravated cough, yet 
 with a chest clear on percussion, and the murmur either pure, 
 or mixed here and there with a little sonorous or mucous rattle. 
 This want of proportion between the physical signs and the
 
 88 . BRONCHITIS. 
 
 functional lesion leads us at once to the principle of diagnosis, 
 which may he announced to he, That ichcii distressing pectoral 
 symptoms exist, the morbid physical signs being either absent, or 
 if present, yet revealing an amount of disease too slight to account 
 for the symptoms, ive may make the diagnosis of sympathetic 
 irritation. 
 
 Here the period of duration of symptoms will often be an 
 important element in deciding the question ; for it is plain, that 
 the longer the symptoms have lasted, without corresponding 
 physical signs, the less is the chance of acutal disease of the 
 lung. If a patient has had fever, cough, and hurried breathing, 
 for three or four days, and that even then no commensurate 
 signs exist, we may be tolerably sure that there is no actual or 
 progressive inflammation, for if there were, it would have by 
 that time, at least, fully manifested itself. 
 
 The negative results of the examination in this case are of the 
 greatest value ; indeed a more beautiful and practical application 
 of the stethoscope can hardly be mentioned. From the similarity 
 of the symptoms the disease is constantly mistaken for bronchitis 
 and pneumonia. The characteristic symj)toms of gastritis are 
 overlooked, and its sympathetic relations alone attended to. In 
 consequence of this error in diagnosis the most fatal mistakes 
 are committed. Patients labouring under gastritis, or gastro- 
 enteritis, have been largely bled, and thus thrown into a typhoid 
 state ; or the abdominal inflammation has been exasperated 
 by the use of remedies intended to relieve the pulmonary 
 irritation. 
 
 In making this diagnosis the following are the principal points 
 which must be attended to in order to avoid error : 
 
 First. Whether the symptoms or signs of incipient tubercle 
 are absent. 
 
 Second. Whether there is reason to suspect disease of the 
 larynx or trachea. 
 
 Third. Whether the uvula be or be not relaxed. 
 
 Fourth. Whether the patient (if a female) be subject to 
 hysteria. 
 
 I have given the above cases, as they constitute the principal 
 sources of phenomena similar to those in the sympathetic cough 
 of gastritis, or of worms. If the result of the investigation is 
 against the existence of any of these causes, we may safely.
 
 BKONCHITIS. 89 
 
 indeed, conclude upon the abdominal origin of the cough ; and 
 it will not be difficult to decide between gastritis and the irri- 
 tation of worms, 
 
 I have observed this sympathetic disturbance of the lung 
 from gastric irritation or inflammation, more often as an acute 
 than a chronic disease. And in all these patients the cough 
 was relieved, and the pectoral distress removed, by treatment 
 directed to the stomach. In most of the cases which I have 
 seen, the disease had not been modified by any previous treat- 
 ment, and these yielded to the usual means for the cure of 
 gastritis. In others, the efforts of the practitioner had been 
 entirely directed to the lung, and general bleeding performed. 
 Leeches, cupping, or counter-irritation had been used to the 
 chest, and the ordinary internal remedies successively and 
 unavailingly employed. Under these circumstances, the omis- 
 sion of all internal stimulants, the application of leeches to the 
 epigastrium, the use of iced water, and a bland diet, have com- 
 pletely and rapidly removed a cough which had resisted the 
 ineans, which, in the primary catarrh, would have, in all pro- 
 bability, succeeded. 
 
 Lastly, I have observed, that in cases of gastritis with sympa- 
 thetic cough, and acceleration of breathing, which had done 
 well, an excess in diet, during convalescence, brought back the 
 original symptoms ; and these again yielded, in some cases, 
 merely to a change in regimen, while in others, more decided 
 measures had to be employed. 
 
 But the discovery of a sympathetic cough should not put the 
 practitioner off his guard with respect to the chest, for so long as 
 this continues, the lungs will be liable to organic disease. In an 
 acute case, he must, from day to day, examine the chest, so as to 
 assure himself that the change from functional to organic disease 
 has not occurred, 
 
 I have seen this change to occur so rapidly that decided dulness 
 has been produced in a single day. Here the importance of 
 physical diagnosis is obvious, for there is often no characteristic 
 change in the symptoms. 
 
 In the chronic irritations there is reason, among other lesions, 
 to suspect the growth of pulmonary tubercle. 
 
 I shall lastly make some observations on the sympathetic 
 cough, which occurs from the irritation of intestinal worms, and
 
 90 BRONCHITIS. 
 
 which, although not a constant, is by no means an unfrequeut 
 symptom. Thus, most of the systematic works contain examples 
 of cough apparently connected with this aifection, inasmuch as it 
 resisted the ordinary means directed to the chest, and subsided 
 under the use of anthelmintics. But the subject has not been 
 investigated with sufficient attention, and I regret that in this 
 place I can only give the result of my passing observations, 
 rather than that of any connected inquiries on the point. 
 
 This affection seems to exist under tAvo principal forms ; in one 
 of which there is decided inflammation or irritation of the mucous 
 membrane, while in the other, this is either absent, or if pre- 
 sent, seems so inadequate for the production of the pulmonary 
 distress, that we cannot help looking upon it as accidental, and 
 probably consecutive to the functional disturbance. Under the 
 latter circumstances there may be a great variety in the cough, but 
 in general its character is more or less spasmodic, occurring in 
 fits, or it may be solitary, hard, and loud ; and it is generally 
 either dry, or with a very scanty mucous expectoration. This 
 cough may co- exist with the other symptoms of worms, or may 
 be the prominent indication ; and in most cases that I have seen, 
 it occurred without fever. 
 
 Such cases are often mistaken, and the patient injured by 
 a variety of ineffective and violent treatment ; and until the 
 history of the disease is more accurately determined, such 
 errors will be unavoidable. We may enumerate, however, certain 
 circumstances, which should lead us to suspect the true cause 
 of the cough. These are : 
 
 First. Its character, the cough, whether it be laryngeal or 
 pulmonary, being generally spasmodic, often violent, and almost 
 always dry. 
 
 Second. The absence of physical signs of pulmonary disease ; 
 or if they be present, their want of proportion to the symptoms. 
 In this investigation both the active and passive signs must be 
 carefully examined. It is obvious that the longer this want of 
 accordance between the physical signs and functional lesion has 
 existed, the greater will be the probability that the cough does 
 not proceed from primary irritation of the lung. 
 
 Tldrcl. The absence of symptoms of laryngitis, or organic 
 disease in the vicinity of the trachea. 
 
 Fourth. The healthy state of the pharynx.
 
 BRONCHITIS. 91 
 
 Fifth. The failure of treatment directed to the chest, whether 
 of an antiphlogistic or antispasmodic nature. 
 
 The combination of these circumstances in a young person, 
 and particularly one in whom, from other considerations, we 
 might suspect worms, should lead us strongly to the belief in 
 their existence. If the i^atient be a female we should carefully 
 examine whether she has been of an hysterical habit, or whether 
 any symptoms of hysteria accompany the cough ; for although 
 this protean disease may itself proceed from worms, yet this is 
 comparatively rare : so that the combination of hysterical symp- 
 toms with the cough would tend to invalidate the diagnosis. 
 
 But in the first variety there is such an amount of mucous 
 irritation, as to give a character to the disease quite distinct 
 from the last. I have observed this sympathetic bronchitis 
 principally in children ; and have found that it was, in some 
 cases, a continued, while in others it shewed itself as a dis- 
 tinctly remittent inflammation. 
 
 In the first case a decided bronchitis may be established, which 
 may go on to the production of parenchymatous disease ; and in 
 this way I have seen it to induce chronic pneumonia and 
 emphysema of the lung. In several cases, too, 1 think I have 
 been able to trace the occurrence of phthisis to this cause. This 
 form of pulmonary irritation from worms seems, however, the 
 rarest ; that which I am about to describe appears much more 
 common. 
 
 It is now several years since I first observed the existence of 
 this remittent irritation of the lung, and connected it with the 
 existence of intestinal irritation. The followino: case will o-iye a 
 good idea of its characters, 
 
 A child of a lymphatic constitution had laboured for some time 
 under a severe cough, with frothy mucous expectoration, which 
 Avas always worse at night, when a violent exacerbation came on, 
 accompanied with great dyspnoea, wheezing, restlessness, and 
 high fever. These exacerbations had of late become better 
 marked. After his admission into hospital I found that there 
 were the greatest differences in the stethoscopic signs, accordinf^ 
 to the period when the examination was performed. If the 
 chest was examined at night, when the constitutional and 
 local symptoms were severe, the most intense sonorous rale 
 was audible over the entire chest, so as to obscure all vesicular
 
 92 BRONCHITIS. 
 
 respiration ; but as the day advanced, and the fever sub- 
 sided, this phenomenon also disappeared, leaving the respira- 
 tory murmur almost free. When the child was seen in the 
 afternoon he was quiet and cheerful, and appeared free from all 
 pulmonary disease ; but as night approached the symptoms and 
 physical signs would return, and for a period of twelve hours or 
 upwards the stethoscope indicated the most acute bronchial 
 inflammation. These symptoms continued for many days, during 
 which the ordinary treatment for bronchitis was carried into the 
 fullest effect, but without the slightest success. At this time an 
 accidental circumstance led me to take a different view of the 
 case ; the belly had become swollen and tympanitic, and to relieve 
 this condition I administered a dose of castor oil and turpentine, 
 which was followed by the evacuation of a number of small thread 
 worms {oxyuris vermicularis) : that night the breathing was less 
 difficult, and the sonorous rale not so intense as previously. The 
 nature of the case was now more evident, and reflecting on the 
 failure of our former treatment, I thought it probable that the 
 case was really one of worm fever, with a sympathetic bronchitis 
 occurring at each exacerbation. Under these circumstances, I 
 determined on following up the anthelmintic plan, and the 
 turpentine having produced too severe a purging, with prolapsus 
 ani, the syrup of cowhage, alternately with small doses of castor 
 oil, was substituted. He continued to pass the worms in enor- 
 mous quantities, and each morning the bronchitic rales were less 
 and less evident. In about twelve days the symptoms and signs, 
 which from their severity had threatened the life of the patient, 
 had completely disappeared, leaving the respiratory murmur 
 perfectly natural. 
 
 Since the occurrence of this case I have seen many others pre- 
 senting the same phenomena, though not in so violent a degree ; 
 and in several of them the remittence of the bronchial irritation 
 has been a most important element in the discovery of the 
 nature of the disease. 
 
 There is lastly one remark to be made, which applies to all 
 these forms of bronchial irritation, namely, that the more severe 
 be the sympathetic affection, the less the likelihood of our finding 
 the usual symptoms of gastritis in the one case, or of worms in 
 the intestines in the other. This is merely an illustration of 
 one of the most important and extensively applicable laws in
 
 BRONCHITIS. 93 
 
 pathology ; that when the sympathetic affections of any local 
 irritation become prominent and severe, the proper or usual 
 symptoms are proportionably diminished or obscured. Their 
 absence, then, in such a case, does not necessarily imply the 
 absence of the disease, which may be present, but shew itself by 
 other functional lesions. 
 
 Having now examined into the symptoms and physical signs 
 of the simple bronchitis, and taken a sketch of it in its secondary 
 forms, I should proceed to examine into some of the more 
 remarkable consequences of this lesion, such as the obliteration 
 of the tubes, their opposite condition, or dilatation, and lastly, 
 the dilatation of the air cells. But as these lesions may be 
 described separately, and as they are peculiar results, I shall 
 reserve their consideration until we have examined into the 
 treatment of the disease itself. 
 
 TREATMENT OF BRONCHITIS. 
 
 In discussing the treatment of bronchitis, we shall first handle 
 that of the simple and mild form, which is commonly met with 
 about the period of the first dentition of children. I have already 
 stated my opinion that this is not a primary disease, but rather 
 secondary to the constitutional disturbance of dentition. Yet as 
 the treatment of the bronchitis scarcely involves the determination 
 of this question, I shall speak of it here. I have already described 
 the symptoms of this affection, and have only to add, that on 
 percussion the chest sounds clear, and that the wheezing rales, 
 of various intensity, mixed with puerile respiration, may be heard ; 
 these rales are sometimes partial, in others more general, and 
 often disappear for a time, although the constitutional symptoms 
 continue. 
 
 In the treatment of this afi'ection the physician should first 
 satisfy himself as to the existence or absence of fever ; for if this 
 be absent his apprehensions need not be much excited, and milder 
 treatment will suffice. 
 
 In the apyrexial form our first step is to have the gums freely 
 and completely divided. If it seem probable that more than 
 one tooth will soon appear, the incision should have a corres- 
 ponding extent, by which the chances of subsequent attacks will 
 be lessened. Objections have been made to this operation, in
 
 94 BRONCHITIS. 
 
 consequence of the danger of haemorrhage ; yet this must be a 
 very rare occurrence. I have never myself witnessed it, though I 
 have seen the operation performed hundreds of times. It will, 
 however, be advisable that the child's mouth be examined at 
 short intervals of time, after the operation, so as to detect any 
 haemorrhage, should it occur. The child should be restricted to 
 the use of breast milk, and take some of the hydrargyrus c. creta, 
 Avith rhubarb, followed by a little castor oil, if necessary. These 
 measures having been premised, we then find that the exhibition 
 of ipecacuan in minute doses, has an excellent effect. I direct a 
 grain of ipecacuan with twenty-four of sugar, to be divided into 
 eight parts, one of them to be given every hour; this remedy will, 
 in a few days, generally effect a cure. In cases where the cough 
 is troublesome, and the child restless, I have seen great advantage 
 from the exhibition of a grain, or a grain and half of Dover's 
 powder, and the same of James's powder, at bed-time ; this I 
 have constantly given with the greatest safety. 
 
 But we meet with bronchitis in the infant under a much more 
 severe form, where it is accompanied with fever and with the 
 greatest danger to life. This disease is most commonly met 
 with in children who are kept within doors for months from their 
 birth, from which an extreme susceptibility to bronchial irritation 
 is created. The necessity and the safety of bringing the young 
 infant into the open air, in the course of a few days after its birth, 
 is not sufficiently known, and many lives are thus sacrificed to 
 an absurd, ignorant, and destructive prejudice. In such cases 
 we find the child fretful, and with an anxious expression of 
 countenance. The face is often swelled and livid ; the breathing 
 is hurried and high ; the cough often frequent ; the respiration 
 wheezing ; the skin hot ; and the pulse full and strong. In 
 some cases the digestive system is deranged, and the child 
 labours under thirst, vomiting, or diarrhoea ; while in others these 
 symptoms are absent, and the case may be looked upon as simple 
 pulmonary irritation, with sympathetic fever. We often observe 
 that the child has great difficulty in sucking, a circumstance 
 explicable by the dyspnoea which forces it to let go the nipple, 
 and to inhale by the mouth. In some of these cases the 
 schneiderian membrane is irritated, so that the breathing through 
 the nose cannot be eftccted by the patient. 
 
 In the treatment of such a case, the first consideration must
 
 BRONCHITIS. 95 
 
 be the employment of bloodletting. When the disease occurs in 
 a robust child, and particularly when it has passed the age of a 
 year, it will be often proper to bleed both generally and locally. 
 Blood may be taken from the arm, the back of the hand, or the 
 jugular vein ; but we are not to look upon this remedy otherwise 
 than as a preparative for local bleeding, for this seems to be the 
 most important remedy we can have recourse to. 
 
 We almost always find that after the leeching the child's 
 breathing becomes easier, the face less swelled, and the skin 
 cooler ; and I have frequently observed the physical signs of 
 bronchitis to be distinctl3' modified immediately after the opera- 
 tion. 
 
 The next thing we have to consider is the use of internal 
 remedies ; the two principal of which are the tartrate of antimony, 
 and the combination of calomel and ipecacuan. With respect to 
 the relative advantages of these, I have little doubt that in simple 
 bronchitis, and where the inflammatory symptoms are high, the 
 first is the most important. Indeed there is no remedy that 
 possesses such a decided power over acute bronchitis as this. It 
 may be administered in small or in the larger doses, according to 
 circumstances, but success will depend on the proper selection of 
 the case. If the disease be simple, and in particular free from 
 any gastric complication, if it be in the early stages, before much 
 secretion has taken place, and if bloodletting has been premised, 
 then, indeed, w^e may often observe an heroic action. The 
 remedy may be persevered in for two, three, or four days, 
 according to circumstances, and should, in general, be omitted 
 gradually. 
 
 As the principles of treatment of the second, or secretive stage 
 of the disease in children, are the same as those of a similar 
 condition in the adult, we shall omit their mention in this place, 
 merely observing, that in the employment of blisters, we must 
 use the greatest caution ; that they should almost never be 
 applied in the first instance, and that their efiicacy will be always 
 insured and increased by the previous employment of blood- 
 letting, and the exhibition either of the tartrate of antimony, or 
 the combination of calomel and ipecacuan. 
 
 Treatment of Bronchitis in the Adult. —In describinw 
 the treatment of any disease it is obvious, that to lay down a plan 
 applicable to all cases is impossible ; all that we can do is to
 
 96 BRONCHITIS. 
 
 inculcate the mode of treatment which experience has shown to 
 be adapted to the majority of cases. This may serve as a 
 landmark, from which in practice we may deviate, according to 
 circumstances. Thus, although the general principle be the 
 same, its application must vary in the young and the robust, in 
 the old and weakly subject, or when the disease is complicated 
 with some acute or chronic affection of the lung or other parts. 
 Let us for the standard, take the inflammatory form of the 
 disease ; occurring in a young and robust man, at an early period, 
 and before the affection has been modified by treatment. This 
 is a case which often demands the use of the lancet ; and here, 
 as in inflammatory aft'ections of the digestive tube, we bleed with 
 the view of reducing the general fever, and preparing the patient 
 for local treatment ; and by diminishing the congestion of the 
 lung, we diminish the chance of pneumonic complication. It 
 must always be recollected, however, that by general bleeding we 
 seldom succeed in cutting short an inflammation of a mucous 
 tissue ; and hence it is, that to other means we must look for the 
 reduction and removal of the disease,* 
 
 It will always be advisable to empty the patient's bowels as 
 speedily as possible, so as to allow the free descent of the dia- 
 phragm. I have seen some cases, in which the employment of 
 judicious means, directed to the chest, totally failed in giving 
 relief until this measure was adopted. But the remedy which 
 will least often disappoint the practitioner is local bleeding, which 
 should scarcely ever be omitted. There can be no doubt, that 
 the local detraction of blood has a more powerful influence on 
 the disease than the general. Its efficacy, however, will be 
 enhanced by being preceded by general bloodletting. In severe 
 cases the patient should be cupped under the clavicles, or between 
 the scapulae, or a number of leeches may be applied under the 
 clavicles, or into the axillae. As a general rule it may be stated, 
 that local depletion will be more advantageous when exercised 
 over the upper than the lower parts of the chest. It is not easy 
 to say Avhy this should be the case, but the eflicacy of depletions 
 of the larger bronchial tubes in pulmonary disease, and the great 
 
 * In this respect we observe a remarkable difference between mucous membranes, 
 and the parenchymatous organs, or even the serous membranes. For in these two 
 last cases, experience shews that general bleeding has a much more direct influence on 
 the disease, in some cases indeed so complete, that the inflammation is cut short by 
 the bleeding alone.
 
 BRONCHITIS. 97 
 
 utility of treatment directed to the upper lobes of the lung, both 
 in relieving the symptoms of bronchial inflammation and in 
 preventing the development of tubercle, were long since pointed 
 out by Broussais, although subsequent authors have advocated 
 this mode of practice as if it were original with them. He has 
 shewn the intimate relation that exists between bronchitis of 
 the superior lobes, pneumonia, and the development of tubercle ; 
 and has announced, that in many cases of incipient phthisis the 
 disease may be put an end to by local depletion of the upper 
 portions of the lung. Such a proposition as this is full of 
 importance, and my experience tends strongly to confirm its 
 truth. When speaking of phthisis, I shall return to this 
 important subject. 
 
 It is scarcely necessary to remark, that under certain circum- 
 stances, local bleeding maybe repeated even in an advanced stage 
 of the disease. As for instance, suppression of expectoration, 
 when this coincides with increase of fever and irritation ; * 
 increase of dyspnoea, when this is not produced by over secretion, 
 a point easily determined by the stethoscope ; and lastly, the 
 occurrence of local dulness, which in cases of intense bronchitis 
 may occur, and is owing to congestion of the substance of the 
 lung. 
 
 Next to the means already detailed, we have the employment 
 of internal remedies ; there seems to be but little doubt, that in 
 cases adapted for it the solution of the tartar emetic has by far 
 the pre-eminence, but in its exhibition certain considerations 
 must always be attended to : thus, the more robust the patient ; 
 the more acute the disease ; the more bloodletting has been 
 indicated, and the better it has been borne ; the more inflam- 
 matory be the blood ; the earlier the period at which the disease 
 has been met by treatment ; and last, though not least, the more 
 simple and uncomplicated the affection, particularly with abdominal 
 diseases, the greater will be the certainty of this remedy exer- 
 cising that singularly sanative action, which has justly obtained 
 for it the name of heroic. On the other hand, where the disease 
 has occurred in a debilitated constitution, where the pulse has 
 not been strong, nor the skin very hot, where the teeth are 
 
 * I use here the term suppression in contradistinction to that of retention. The 
 first of these terms has been long misapplied, with respect to the chest ; for it is 
 obvious, that we should use it w'ith the same signification as in uiinary affections. 
 
 H
 
 98 BRONCHITIS. 
 
 aifected with sordes, and the tongue in a very morbid condition ; 
 where the belly is swelled and tender in the epigastric and ileo- 
 coecal regions ; where there have been diarrhoea or vomiting, and 
 pain in the abdomen ; in such a case, the tartar emetic will either 
 not be borne at all, or if retained on the stomach, will exercise 
 comparatively little influence on the pulmonary disease, and too 
 often increase the gastric symptoms. It is on the existence of 
 these symptoms of gastro-intestinal irritation that the question 
 of the exhibition of the remedy in any case, in a great measure, 
 must turn. Laennec, indeed, has declared, that the co-existence 
 of the gastro-enteritis of fever with pneumonia, does not contra- 
 indicate the employment of tartar emetic, for which he has been 
 censured, perhaps too severely ; and it is supposed, that he 
 allowed his better judgment to be warped, from his hostility to 
 the doctrines of the physiological school. To this point I shall 
 return hereafter. 
 
 It would seem, however, that mere prostration should not 
 necessarily prevent us from having recourse to the remedy. 
 Indeed cases are recorded, in which the patient, at the time 
 he was ordered the tartar emetic, was almost in articulo mortis. 
 I have never seen such a case, but have often found in the 
 advanced stages of acute diseases of the pulmonary parenchyma 
 and mucous membrane, when other means have either failed, or 
 proved, in a great measure, inefficient, and where the patient was 
 necessarily much debilitated, that the exhibition of the tartar 
 emetic was followed by the happiest results. My experience, at 
 present, leads me to conclude, that where the debility is merely 
 traceable either to the disease or to antiphlogistic treatment, 
 and not the result of its complication with decided abdominal 
 inflammation, we may often have recourse to the antimonial 
 solution ; and we shall find, that when managed with judgment 
 and caution, it will then, perhaps, more than at another time, 
 exhibit its almost specific power on the capillaries of the lung. 
 
 In the formula which we have used for some years at the 
 Meath Hospital, we have to a certain degree imitated that of 
 Laennec. It is so constituted as to contain an aromatic and an 
 opiate combined with the antimony, and of this solution each 
 ounce contains a grain of the remedy.* Of this solution we 
 
 * The following is the foiinula : ^ Tartratis antimonii gr. vi. Aq. cinnamomi 5vi. 
 Tinctnrae opii acetatis gutt. xii. in.
 
 BRONCHITIS. 99 
 
 begin by ordering half an ounce every hour, or second hour, so 
 that, if possible, the whole of the six grains may be consumed 
 in the course of the twenty-four hours. In many cases, from 
 various accidental circumstances, this quantity is not exhibited, 
 but even where from three to four grains have been used, we have 
 often seen marked benefit to follow. 
 
 The results of this treatment are various. In a few cases 
 violent vomiting with purging is produced ; but in a great 
 majority there is only a degree of nausea felt, principally when 
 the patient moves. Either of these results is seldom seen after 
 the first day, and the " interval of tolerance" of Easori com- 
 monly occurs. In other cases, as Laennec has noticed, almost 
 no apparent effect is produced, and the remedy might be con- 
 sidered as inert, were it not for the disappearance of the symptoms 
 and signs of the pulmonary disease.* In the management of 
 the remedy, as to dose, &c., I have pretty closely followed the 
 instructions of Laennec, though but few cases have occurred to 
 me in which it was necessary to increase the dose beyond eight 
 or ten grains in the twenty-four hours ; in the event of too 
 violent vomiting or purging this remedy is at once omitted, and 
 an opiate exhibited. But in all cases in which its action has 
 been salutary, and particularly where it has been found necessary 
 to continue its use for several days, its omission must be con- 
 ducted gradually. For I have seen many cases in which the 
 sudden leaving ofi' of the remedy was followed by a return of the 
 symptoms. This remark, however, is more applicable to cases 
 of pneumonia and congestion, than to those of mere bronchitis. 
 
 As far as I have seen, the efi^ect of this medicine on bronchitis 
 is two-fold. It may either, as it were, cut short the inflammation, 
 so as to leave hardly a symptom or sign behind it, or it may 
 cause its early passage into the second or secretive stage. In the 
 first case the oppression and wheezing cease, the cough becomes 
 trifling, the lividity disappears, the pulse falls to its natural 
 standard, and the respiration is found everywhere pure, equal, 
 and healthy, with the exception, perhaps, of a slight, sonoro- 
 mucous rale, which is now and then audible : the patient recovers 
 his appearance, and declares that he is quite well. 
 
 In the second case, after the use of the remedy for several days, 
 
 * I have fi-equently seen patients who were using from six to ten gi-ains of the 
 tartar emetic daily, yet with a good appetite for their food. 
 
 h2
 
 100 BRONCHITIS. 
 
 we find the patient looking pale and miserable; he perspires 
 copiously, and has often a rapid, small pulse ; the breathing, 
 though less difficult, is hurried, and the cough, though less 
 painful, is so frequent as to allow of but little rest. It is followed 
 b}- a copious expectoration of opaque mucus, or of a muco- 
 purulent secretion. On percussion the chest sounds clear, but 
 the respiration is generally marked by mucous rales, of various 
 intensities, in some cases combined with the sonorous, in others 
 passing almost into the crepitating character ; at this period 
 antiphlogosis can be used no longer, and a cautious but decided 
 employment of the stimulating and tonic treatment must be had 
 recourse to. But even in this instance, though the exhibition of 
 the tartar emetic has not, as in the former case, restored the 
 lung to a state of health, yet it has not been without its advan- 
 tages, inasmuch as experience shows that now the exhibition of 
 stimulants and tonics will have the best possible effect. This 
 fact, among many others, seems to me illustrative of a general 
 rule in therapeutics, that in almost all local diseases the successful 
 employment of stimulation depends on the previous use of a 
 general or local antiphlogistic treatment. 
 
 Treatment of the Second Stage of Bronchitis. — Before 
 entering on the mode of treatment, which experience has pointed 
 out as best for this affection, I find it necessary to premise some 
 general pathological observations. I do not propose entering 
 into the hackneyed question of the nature of inflammation, but 
 shall employ the attention of my readers much better in the 
 examination of certain circumstances connected with it, which are 
 of the utmost importance in practical medicine. We find that in 
 a vast number of general and local diseases two stages are 
 observed, the nature of which cannot be expressed by any know- 
 ledge to which the mere anatomist can arrive, but whose existence, 
 duration, and succession are pointed out by the results of treat- 
 ment. With the first of these, pathologists have long been 
 familiar ; but of the existence, nature, and frequent occurrence 
 of the second, they have not yet taken sufficient notice. In the 
 first of these stages antiphlogosis is necessary, and stimulation 
 injurious. In the second, antiphlogosis is insufficient, and often 
 injurious, while stimidation becomes necessary. 
 
 Although much had been done in this field before, yet 
 Broussais had the great merit of shewing, that a vast number of
 
 BRONCHITIS. 101 
 
 local diseases, before supposed to be separate entities, could be 
 reduced to the first of these stages, the difference of symptoms 
 being principally referrible to the sympathies of organs ; but his 
 great error was in stopping short here, and in not recognizing 
 the existence, in almost all local diseases, of a state in which 
 the symptoms do not yield to that treatment which was found 
 advantageous in the earlier periods of the case ; or if they do 
 yield, it is only at a great expense to the constitution. As a 
 result of this omission, the treatment of local diseases by the 
 physiological school, was for too great a length of time, purely 
 antiphlogistic, and hence their repeated bleedings and protracted 
 starvations in almost all diseases, and their unfounded dread of 
 any thing which could have the slightest stimulating effect. 
 
 But experience has shewn, that this treatment, though so 
 applicable in the first, is often inapplicable or insufiicient in 
 the more advanced stages of the disease ; that its effects will 
 be to reduce the powers of life, while effusions and super-secre- 
 tions are running down the patient, and throwing the nervous 
 system into extreme asthenia. It has also shewn, that these 
 symptoms must be met by an omission of all reducing treatment, 
 and by the employment of remedies, the use of which would 
 be highly injurious in the first stages of the disease : but 
 as the period of supervention, and the symptoms of this 
 second, or asthenic state, vary in different individuals, according 
 to a vast variety of circumstances, it is plain, that in the detec- 
 tion of this passage from the first into the second stage, and in 
 the omission of one kind of treatment and the adoption of 
 another, the skill and success of the experienced physician will 
 be best seen. 
 
 Of the different tissues, the mucous membranes, in their 
 pathological state, best illustrate the foregoing propositions, 
 and next to them the skin ; but I have almost no doubt that 
 they will be found to apply to the parenchymatous organs, both 
 in cases of local and more general disease. Andral has sug- 
 gested that the success of tonics and stimulants, in the advanced 
 stages of fever, may be thus explained ; and when we consider 
 that in most cases of that disease there are affections of the 
 mucous membranes, and also of the parenchymatous organs, 
 there seems to be great reason for adopting his opinion. 
 
 As yet we know but little of the laws which regulate the
 
 102 BRONCHITIS. 
 
 passage of the first of these stages of disease into the second ; 
 but of the truth of the following views, an investigation, con- 
 ducted with the greatest accuracy' that I was capable of, has 
 full}' convinced me. 
 
 It is obvious that any change in the nature of a local disease, 
 which would render it not only less amenable to antiphlogistic 
 treatment, but in which such a treatment would lose all effect 
 except in lowering the powers of life, must be of the utmost 
 importance. Now when we inquire what are the circumstances 
 which seem to govern this change, we find that they are various. 
 In some cases the chronicity of the disease is presumptive 
 evidence that such a change has occurred ; in others, we find it 
 a very early period of the morbid state ; and in a third, the first 
 stage continues for an indefinite length of time. The state of 
 the constitution too, has a decided influence, for in some 
 indi-sdduals a local inflammation will require tonics and stimu- 
 lants much sooner than in others, although the seat and nature 
 of the disease be apparently the same. Nor are these the onl,y 
 circumstances, for we find much to depend on the previous 
 treatment, and on the seat of irritation. 
 
 I shall conclude this digression, by stating, in the form of 
 propositions, those points of doctrine which seem to bear most 
 directly on the treatment of pulmonary disease. 
 
 First. That in some cases an antiphlogistic treatment may 
 cut short the disease in its first stage ; but that in most in- 
 stances, particularly in the afi'ections of mucous membranes^ its 
 efi"ect is to bring on the occurrence of the second stage. 
 
 Second. That the principal circumstance on which the suc- 
 cess of stimulants depends, is their having been preceded by 
 antiphlogistic treatment. 
 
 Third. That in many cases disease will continue for a great 
 length of time, and yet (as shewn by the result of treatment) be 
 in its first stage. Although chronic as to its period of duration, 
 it is still acute when tested by the effect of treatment. 
 
 FourtJt. That this result is most frequently seen under the 
 following circumstances : 
 
 ((/) Cases of local disease, with but little injury to the 
 general health, 
 
 (h) Diseases of tissues, where there is but little relief by 
 secretion.
 
 BRONCHITIS. 103 
 
 (c) Diseases of organs which have been neglected, or exas- 
 perated by too early stimulation. 
 
 Fifth. That in many cases, Avhere the disease has been 
 neglected or exasperated, it will be necessary to precede all stimu- 
 lants by an antiphlogistic treatment, either general or local. 
 
 I wish to be clearly understood, as not putting these views 
 forward as very original. I shall be content if they are thought 
 important. In the treatment, not only of the pulmonary, but I 
 believe of all other forms of the diseases of irritation, they will 
 be found so applicable, as to furnish the true key to successful 
 management, and on the importance of any principle which has 
 a general application in the science of medicine I need not here 
 dilate. The overlooking of this second stage, and the doctrine 
 that disease did not change in its characters or nature, seems 
 to me to have been one of the greatest errors of the physiological 
 school. It was, however, but one of many false conclusions, 
 which the attempt to simplify disease, by reducing it to a 
 common formula, rendered inevitable ; and the doctrine, which 
 led to the denial of specific affections, is the same as that which 
 declares for an antiphlogistic treatment throughout the course 
 of a disease, and that one of the most injurious maxims of 
 medicine is that which refers to the necessity of tonics in the 
 advanced stages of bronchitis. 
 
 We shall find, that the foregoing views have an important 
 application in the treatment of the second stage of bronchitis, 
 which we may now examine. 
 
 We shall lirst speak of counter-irritation, which may be con- 
 sidered inapplicable in the earlier periods of the disease, so long 
 as the skin is hot, the pulse strong, the expectoration scanty 
 and difficult ; in fact, so long as the first stage of the affection 
 continues, that stage in which bleeding and tartar emetic are 
 useful, blisters are inefficacious, and often hurtful. It may be 
 laid down as a general rule, that the longer we can with safety 
 postpone the application of a blister, the greater certainty will 
 there be of its favourable action. I have always found that 
 blisters acted best when they were applied shortly after the 
 change from the first to the second stage of the disease ; but 
 even then they might be injurious, if the affection had not been 
 sufficiently modified by preceding antiphlogistic treatment. It 
 is to be regretted, that in this country blisters are too often
 
 104 BRONCHITIS. 
 
 employed with erroneous views of their mode of action. They 
 are commonly applied in the early periods, and even before 
 any antiphlogistic means, capable of modifying the inflam- 
 mation, or reducing the general febrile state, have been em- 
 ployed ; and hence, as might be expected, their application so 
 far from relieving, not unfrequently aggravates the local disease.* 
 
 In employing blisters, I find that the method of Bretonneau is 
 by far the best, as saving the patient from much torture during 
 the process of vesication, but particularly in the after stages of 
 the sore. In the mode alluded to, the blister is not allowed to 
 remain on after its action has been distinctly felt by the patient. 
 The part is then dressed, and full vesication subsequently occurs. 
 Another great improvement by the same physician is the cover- 
 ing the blister with a single sheet of fine silver paper, through 
 which the vesicating principle from its solubility in oil easily 
 acts ; and all the evils which result from the mechanical action 
 of the cantharides are prevented. Stranguary almost never 
 occurs ; and I think it will be found that in many cases this 
 mode of blistering may be used at a much earlier period of 
 disease than under the old system. 
 
 In selecting the situation for the blister we should be guided 
 principally by the physical signs, and in particular by the active 
 and passive auscultator}' phenomena. 
 
 I have found it necessary in a few cases to employ the seton, 
 
 * It has often stiiick me that we take but a limited view of the operation of blisters. 
 We have contented ourselves with considering their revulsive action merely, but have 
 not sufficiently investigated another result, namely, their stimulating effect on the 
 diseased organ. That this effect does occur is known to all practical men, but it is 
 onlj' the injurious result which is recognized, and we never chink that there may be a 
 time when this stimulation may have the best effect. The experience of the stimulat- 
 ing action, at all events, proves the fact in question ; but whether the stimulation be 
 the consequence of the excitation of the whole system reacting on the suffering organ, 
 or whether it is more directly transmitted, we at present know not. But we find 
 that at a period when other stimulations are injurious, a blister may do harm ; and 
 it seems most probable, that when the second stage of a disease sets in that then, 
 at least, the utility of blistering is in part explicable by the stimulus given to the 
 affected capillaries, and that it acts in the same salutary manner as internal tonics and 
 stimulants. 
 
 It might be urged in opposition to this view, that it seems improbable that a blister, 
 which on the surface produces heat, determination of blood, vesication, &c., should 
 exercise any salutary influence on the capillaries of the lung ; but the answer to this 
 is found in the different results of stimulation at different periods, according to the 
 state of the organ ; and thus a stimulus, which may produce the worst results on a 
 healthy surface, or on one in the first, or acute stage of inflammation, may produce 
 the best effects when exercised on a tissue in that state which is no longer accessible 
 to antiphlogosis.
 
 BRONCHITIS. 
 
 105 
 
 and it has, in these instances, answered all my expectations. The 
 cases which seem to require it are those where the minute tuhes 
 have heen affected, where the convalescence is slow and doubtful, 
 and where there are alternations of an hectic and inflammatory 
 state. In some of these cases the early treatment had not been 
 judicious, and the antiphlogistic had been too soon changed for 
 the stimulating plan. The physical signs were, persistent muco- 
 crepitating rale, and often a degree of dulness in the lower or 
 middle portion of one side. 
 
 Here I may allude to the practice of applying large poultices 
 to the chest, so strongly recommended by Broussais. I have 
 little doubt that in certain cases this measure would be found 
 most efficacious, but having no experience of it, I can only give 
 the statements of others. The above author relates a case of 
 bronchitis, which for thirty-six days had resisted the applica- 
 tion of five or six blisters, placed in different parts of the chest, 
 yet which yielded almost immediately to a large cataplasm applied 
 over the front of the chest. Fomentations, according to this author, 
 have nearly the same effect ; but the danger of giving the patient 
 additional cold renders them not so advisable as the cataplasms. 
 
 From the decided advantage obtained from emollient applica- 
 tions on the abdomen in the treatment of enteritis, it seems more 
 than probable that the same practice, directed to the chest, would 
 be useful in bronchial and pneumonic inflammations. 
 
 In discussing the subject of the internal remedies adapted 
 to this stage I shall do little more than point out generally the 
 class of agents best adapted to the disease. These may be 
 stated to be tonics, and general and local, or specific stimulants. 
 
 Among the two first classes may be enumerated, improvement 
 in regimen, change of air, the use of wine, and in some cases of 
 bark, or the preparations of iron. Of the local or specific 
 stimulants, on the other hand, so many have been proposed, 
 that I shall merely mention those to which, from experience, I 
 have become most attached. Among these remedies I know 
 none to be compared with the decoction of the polygala senega, 
 in combination with carbonate of ammonia and the camphorated 
 tincture of opium and squill.* 
 
 * The formula which I commonly employ is as follows : — 
 
 I> Decoct. Polygal. jv. Syrup. Tolut. Ess. Tinct. Op. Camp. Tinct. Scill. aa. 311. 
 Carb. Ammon. gr, xv. vel. xx. m.
 
 106 BRONCHITIS. 
 
 I may safely state, that of all the remedies for the second stage 
 of bronchitis, this, when exhibited at the proper period, has 
 least often disappointed me. Under its influence the expectora- 
 tion diminishes without increase of dyspnoea ; the pulse becomes 
 slower and fuller, the respiration in the upper portions of the 
 lung becomes pure ; and this change, extending from above 
 downwards, Ave may find that, in a very few days indeed, all 
 morbid signs will disappear fron the lung. 
 
 The whole nicety of the treatment consists in not having 
 recourse to the remedy too soon, in previously modifying the 
 disease by general and local antiphlogistic measures, and by the 
 use of the antimonial or mercurial treatment, as the case may 
 be. 
 
 I need scarcely observe, that the above remarks apply not 
 merel}' to the exhibition of the polygala, but to that of the 
 other remedies of this class. Among these the following are 
 most important : the balsams, and the preparations of gum 
 ammoniac, myrrh, aud squill. I have placed the balsams first, 
 as I look on them to be next in value to the senega. But I 
 must state here, that the use of this class of remedies b}- inhala- 
 tion has always seemed to me full of danger. I have now known 
 several cases where a chronic bronchitis was converted into an 
 acute, and, as might be expected, fatal pneumonia, by the use of 
 the turpentine inhalations. 
 
 It is not difficult to know whether these remedies will be 
 serviceable, even at an earl}' period of their exhibition ; and it is 
 the duty of the physician to carefully watch their eftects, at least 
 for the first few days. He must never forget, that in all those 
 cases where the cure consists in the arrest of a secretion from 
 an extensive surface, there is a danger either that a new inflam- 
 mation will be set up in the affected tissue, or that some other 
 disease, generally of an acute nature, will be produced ; for as 
 the sudden arrest of a diarrhoea may produce ascites, or perito- 
 nitis, or hepatitis, so that of a bronchial flux may induce a fatal 
 pneumonia, a pleurisy, or an hydrothorax, and to this our atten- 
 tion must always be directed. Experience tells us that these 
 distressing consequences are best avoided by attending to the 
 following circumstances : — 
 
 First. To provide that the stimulating remedy shall be pre- 
 ceded by a fit antiphlogistic treatment.
 
 BRONCHITIS. 107 
 
 Second. To combine it with a revulsive plan, such as blister- 
 ing, cupping, warm bathing, &c. 
 
 Third. To omit the remedy on the slightest appearance of new 
 irritation, either in the affected part or in any other vital organ. 
 
 On the importance of the first of these I have already suffi- 
 ciently dilated ; and shall only add here that in a single case 
 we may have to return to the antiphlogistic treatment, even 
 more than once. The combination of counter-irritation with 
 the internal remedy seems to have the best effect in preventing 
 these accidents ; and the same may be said of means calculated 
 to promote perspiration. In these cases, with this view, I always 
 order the patient to wear flannel so as to promote the insensible 
 perspiration. At this period of the case the exhibition of stimu- 
 lants may not produce that happy result which I have above 
 described. A state of new irritation may be produced, rendering 
 their omission necessary, or the hectic condition and the super- 
 secretion may continue. The indication in the first of these 
 cases is obvious ; in the second, however, we find that this will 
 be the time for a change of air, the remedies being still continued, 
 and we may then see recoveries under apparently the most hope- 
 less circumstances. 
 
 I shall next make a few observations on the treatment of the 
 apyrexial form of chronic primary bronchitis, considering it 
 merely as an affection of the mucous membrane, independent of 
 any of its other consequences on the organisation of the lung. 
 In these cases, when the disease has continued for a length of 
 time, we often find that a cure is impossible, and our efforts 
 must be directed merely to palliate, and to delay the further 
 progress of disease. 
 
 In cases where the disease has not lasted more than a year or 
 two, in which the summer remission has been complete, or nearly 
 so, we may hope to do good. And if we find no evidence of 
 tubercle, dilated tubes, or enlarged air cells, our prognosis will 
 be still more favourable. If, on the other hand, the affection 
 has lasted several years, that the summer remission has become 
 extremely slight, that there is permanent dyspnoea, and that on 
 examination we find the signs of the above diseases, or of 
 morbus cordis, then indeed we must not hope for cure, but we 
 may palliate suffering, and, in many cases, prolong life to a 
 ffreat extent.
 
 108 BRONCHITIS. 
 
 The physical signs which are favourable may be stated to be, 
 that the bronchial rales are of a musical rather than a crepi- 
 tating character ; that they are not very intense, nor increased 
 on the patient's taking a deep breath ; that the respiratory 
 murmur may be heard of equable strength, free from the 
 character of puerility on the one hand, or feebleness on the 
 other; that the sound on percussion is equal, without local 
 dulness, or the morbid clearness of dilatation of the cells ; that 
 there are no morbid phenomena of voice ; and lastly, that the 
 motions and sounds of the heart are tranquil and natural. 
 
 Under these circumstances the indications are to change the 
 action of the mucous membrane at the slightest possible risk to 
 the constitution. I have nothing to add to the therapeutic 
 means already so well knoMu ; but I shall make a few brief 
 remarks on the various classes of remedies which have been 
 found useful in thewdisease. 
 
 On the subject of i-evulsives it may be stated, that their 
 employment is generally useful, and that we may thus by per- 
 severance often produce the best effects. The remarks which I 
 have already made on this point will be found to apply in this form 
 of disease, as well as in the second stage of the acute bronchitis. 
 
 I have been for some time in the habit of employing a 
 mode of treatment, which I can recommend strongly, not only 
 in this disease, but even in confirmed phthisis. It consists in 
 sponging a large surface of the chest daily with a liniment com- 
 posed of the spirit of turpentine and acetic acid, so as to keep 
 out an erythematous state of the skin ; and I do not know 
 a more easily manageable or efficacious remedy. From nume- 
 rous observations I have concluded, that this liniment not 
 only acts beneficially, by its counter-irritating properties, but 
 that the ingredients are absorbed by the surface, so as to act on 
 the mucous membrane as direct stimuli. My reasons for this 
 opinion are, that I have seen it to produce effects of the most 
 favourable description, even when but little redness of the surface 
 was produced ; the relief being much more than could have been 
 expected from the mere amount of counter-irritation. In several 
 cases too the secretion of the kidneys has been increased.* 
 
 * The following is the formula which I employ : — 
 
 B Sp. Terebinth, ^iii. Acid. Acet. jss. Vitell. Ovi, i. Aq. Rosar. ^iiss. 01. Limon. 
 31. i».
 
 BRONCHITIS. 109 
 
 In addition to this treatment, I have often ordered the patient 
 to inhale the vapour of water impregnated with a narcotic. 
 Twelve or fifteen grains of the extract of hemlock are diffused 
 in a proper inhaling apparatus, and the vapour drawn into the 
 lungs for a quarter of an hour, once or twice a day. 
 
 Many other remedies of the stimulant, tonic, astringent, and 
 sedative classes are found useful in this disease. I shall allude 
 briefly to those of whose efficacy there appears good evidence. 
 
 Among the most efficacious of the stimulants the terebin- 
 thinate preparations stand prominent. The various balsams, 
 exhibited, either alone, or in combination with a sedative and 
 tonic, often act well ; and next to them we have the gum resins, 
 such as ammoniac and myrrh. From the efficacy of strychnine 
 in the analogous affection of the digestive mucous membrane, 
 there seems good reason to hope, that in the pulmonary disease 
 it would prove useful. Its remarkable power too, of stimulating 
 the muscular tissue to contract, may be found of great utility in 
 many chest affections ; and we might hope that effects would be 
 produced similar to those of galvanism in asthma in the hands 
 of Dr. Philip, or in chronic mucous catarrh, as stated by Dr. 
 Forbes. The tonics which may be often employed when the 
 powers of Hfe are low, and particularly in cases where a strict 
 antiphlogistic system has been pursued, are principally the pre- 
 parations of quinine and iron. Of the utility of both these 
 remedies I have seen many examples. The combination of the 
 myrrh and iron mixture with the laurel water has been a favourite 
 with me in such cases for a length of time. 
 
 I have very seldom employed the directly astringent sub- 
 stances in this disease. But in cases where the flux is excessive 
 there seems reason for their cautious exhibition. From the 
 great powers and safety of the acetate of lead, I would prefer it 
 to most others ; and there is abundant evidence in favour of its 
 astringent action on the capillaries of the lung. Thus in the 
 passive bronchial haemorrhage nothing can be more striking 
 than its powers over the disease ; and on the continent it has 
 been exhibited with such great success in cases of chronic 
 puriform expectoration, as to be looked on us a means of curing 
 consumption. 
 
 But in cases of super-secretion, unless, from age or disease, 
 the patient be in a state of extreme debility, the emetic plan
 
 110 BRONCHITIS. 
 
 is always to be preferred to the astringent. There can be no 
 doubt that the emetic class of medicines act most beneficially 
 on the diseased bronchial tubes, and not only get rid of the 
 super-secretion mechanically, but also exert a favourable action 
 on the cause of its production. These remarks apply more 
 particularly to the preparations of antimony and ipecacuan ; 
 and it is often excellent practice to administer an emetic fre- 
 quently in the treatment of a chronic catarrh, where the secretion 
 is superabundant. By this means the tubes are emptied, so 
 that an emetic is often to the lungs what a laxative is to the 
 digestive tube ; the air is freely admitted, and the arterialization 
 of the blood, as shewn by the rapid subsidence of lividity, again 
 takes place with freedom ; the bronchial muscles are stimulated, 
 and time and opportunity gained for other treatment. 
 
 After speaking of cases, in which the use of means, really 
 efficacious, is too soon given up by the practitioner, Laennec 
 says: "Among these means there is no one more frequently 
 useful than emetics, repeated according to the patient's strength, 
 and his power of supporting their action. I have cured in this 
 way catarrhs of very long standing in old persons, and still more 
 in adults, and children. In the case of an old lady of eighty- 
 five, who had laboured under a chronic catarrh for eighteen 
 months, with an expectoration amounting to two pounds daily, I 
 prescribed fifteen emetics in one month, and with complete 
 success, as the patient lived eight years afterwards, free from 
 the complaint.*' This author further recommends, that after 
 the use of the emetics, tonics should be exhibited, and in this I 
 fully concur. 
 
 The latest authority on the use of emetics in this disease is 
 Dr. Giovanni de Vittis, and as his treatment consisted almost 
 entirely in their employment, the results have great interest. 
 In a recent number of the Annali Universali di Med. we find 
 that his mode of proceeding is to administer as much of a 
 solution of tartar emetic, in the proportion of half a grain to the 
 ounce, as will produce vomiting. This is repeated morning and 
 evening, and the patients are supported on a farinaceous and 
 milk diet. When it produced too much action on the bowels it 
 was suspended, and grain doses of roasted ipecacuan, with the 
 same quantity of digitalis, were given at short intervals until the 
 diarrhoea ceased.
 
 BRONCHITIS. Ill 
 
 The author's accoant of his success, not only in chronic 
 catarrh but in phthisis, is almost too favourable. In all pro- 
 bability many of his cases were only examples of that form 
 of bronchitis to which I have already alluded, where the minuter 
 tubes are engaged, and the disease but little removed from 
 suppurative pneumonia. In such cases, when we consider both 
 the specific and the emetic action of the remedj^ I feel certain 
 that the practice is probably the best that could be adopted. 
 
 When I speak of the treatment of the secondary bronchitis 
 of typhus I shall return to the subject of emetics in this 
 disease. 
 
 The last point of treatment to which I shall allude is the 
 use of the sedative and narcotic medicines. Of these there are 
 few that have not the best effect in the variously modified cases 
 of chronic catarrh. Their use, however, is particularly demanded 
 when the cough is severe, and the expectoration not abundant. 
 We may use the various preparations of opium, hyosciamus, 
 or hemlock ; and the combination of these, with a small por- 
 tion of belladonna, will be found to have excellent effects. I 
 have found the combination of small doses of ipecacuan with 
 hemlock and belladonna to be most useful in a vast number 
 of cases. 
 
 We may also use this class of remedies by inhalation. To 
 this I have already alluded. 
 
 It has been already shewn that the success of stimulants 
 and tonics, in mucous irritations, depends greatly on the pre- 
 vious employment of an antiphlogistic system. And in the 
 disease before us, we are not to refrain from thus preparing the 
 patient for the specific stimulant merely on account of its chro- 
 nicity. It is only in cases Avhere there is hectic fever, and that 
 the patient is emaciated, that the above treatment will be hazard- 
 ous. Yet even here, local depletion, by means of cupping, will 
 often have the best effect. 
 
 Finally, we have to consider a point of considerable interest ; 
 but it must be confessed, that further and more exact researches 
 are necessary for its elucidation. It is, that the more the 
 disease approximates to a parenchymatous affection, the less 
 will be the influence of the stimulating treatment. In these 
 cases there exists a condition closely ai^proaching to chronic 
 pneumonia or tubercle. The murmur of respiration is sup-
 
 11 '2 BRONCHITIS. 
 
 planted by a fine muco-crepitatiug rale, and there is a degree 
 of dulness on percussion, circumstances which point out that 
 the minuter tubes are engaged. In such cases, and particularly 
 when the above signs were partial, I have often found that 
 after the failure of a stimulating treatment, the disease yielded 
 to an antiphlogistic one ; on the other hand, my observations 
 lead me to conclude, that the more the disease predominates 
 in the larger tubes the sooner may we have recourse to the 
 stimulating treatment. It seems as if the insufficiency of mere 
 antiphlogosis, for the removal of disease, is most evident in the 
 vascular tissues, such as the skin and the mucous membranes, 
 properly so called. And hence we may understand why one 
 principle of treatment applies more to the disease of the large 
 tubes, and another apparently to that of the minuter ramifi- 
 cations. 
 
 Treatment of Secondary Bronchitis. — In discussing this 
 part of our subject I shall merely speak of the treatment of the 
 disease as occurring in typhus fever. For although there can 
 be little doubt that its existence, under other morbid conditions 
 of the system, will be found to require special modifications of 
 practice, yet as this field is but little explored, I refrain from 
 entering it, as it is much better, in a work like this, to dwell on 
 points which are ascertained with greater certainty. 
 
 Now, although the principles of treatment in the catarrh of 
 typhus, are the same as in the idiopathic disease, yet in their 
 application to practice, certain variations are to be attended to. 
 These may be stated as follows : 
 
 First. That the antiphlogistic treatment is not to be employed 
 so boldly nor so long. 
 
 Second. That the stimulating treatment may be resorted to- 
 at un earlier period, and with much greater boldness. 
 
 TJiird. That the use of blisters may be employed also at an 
 earlier period. 
 
 Fourth. That as a general rule we are not to expect so much 
 from internal remedies, as in the idiopathic afiection. The cause 
 of this is often the complication with abdominal disease. 
 
 The employment of the lancet in this disease requires great 
 caution. Indeed for many years I never had recourse to it, but 
 contented myself with the use of local bleeding; more lately, 
 however, I have used the lancet in a few cases, Avitli advantage.
 
 BRONCHITIS- 113 
 
 and certainly without injury. In these instances the disease 
 existed in young, and extremely robust subjects, was in its early 
 stage, not exasperated by neglect, or modified by bad treatment. 
 But when it occurs in the advanced stages of a low typhoid 
 fever, with stupor, lividity, and prostration, the lancet is to be 
 avoided, and we are to trust principally to local depletion. 
 Indeed, in both these cases, it is from local depletion, and 
 particularly by cupping, that the patient seems to derive the 
 greatest relief. In bad cases I commence by cupping on both 
 sides of the chest, and the depletions are afterwards repeated 
 in different situations, according to the stethoscopic signs of 
 predominance of disease. Should the belly be tympanitic, a 
 foetid and turpentine enema is to be employed, the operation 
 of which will be followed by great relief to the respiratory 
 symptoms. 
 
 These measures having been pursued, we may at once apply 
 blisters to the chest; and I may remark, that I have always 
 found that their application between the scapulae or to the sides, 
 gave more relief than to the front of the chest. If the patient, 
 however, be much prostrated, and lying on the back, it is better 
 to apply them to the sides, or anterior portion. As a general 
 rule it may be stated, that the lower the patient be, and the 
 cooler the skin, the sooner may we employ this treatment, which, 
 as well as the cupping, will require to be repeated frequently in 
 most cases. 
 
 It is of the greatest importance to attend to the strength of 
 these patients ; and it will not unfrequently happen, that we 
 must administer wine and nourishing broths, while we are 
 depleting the congested lung. 
 
 The question, as to the best internal treatment in this disease, 
 is still somewhat uncertain. I have employed both the mer- 
 curial and antimonial plans in a vast number of instances, and 
 the result of my experience leads me to conclude, that where 
 there is a decided complication with enteric inflammation, it is 
 better to use the mercurial preparations, so as slightly to affect 
 the gums, and then at once to have recourse to the stimulants, 
 such as the polygala, with carb. ammonia, or others of that 
 class. On the other hand, where the digestive system is free, 
 I have little hesitation in recommending the antimonial treat- 
 ment, even in advanced stages of typhus, and its exhibition for 
 
 I
 
 114 BRONCHITIS. 
 
 a time varying from a day to three or four days, will often bring 
 the disease under the control of the stimulating treatment. 
 That the tartar emetic may be used without injury, even in the 
 advanced stages of fever, has been satisfactorily established by 
 my colleague. Dr. Graves, who has successfully employed it in 
 combination with opium, for the removal of nervous delirium 
 and restlessness. To this subject I shall return, when speaking 
 of the treatment of the typhoid pneumonia. 
 
 Among the stimulants, which we may exhibit after the mer- 
 curial or antimonial treatment, I think that the polygala mixture, 
 of which I have already given the formula, and the turpentine 
 emulsion are the most preferable. In one case, where the 
 symptoms were apparently hopeless, the latter remedy had 
 most surprising effect. 
 
 It is of the utmost importance to preserve a warm state of the 
 surface, and promote the insensible perspiration ; and hence I 
 order all my patients, particularly those in hospital, to wear a 
 new flannel shirt next the skin, and have had repeated occasion 
 to observe its good effects. We may use wine freely, particularly 
 when the skin is cool and clammy, and the pulse small, rapid, 
 and compressible, and its good effect will be shewn by this, that 
 while the skin becomes warm, the pulse diminishes in frequency 
 and increases in volume, and these favourable circumstances 
 correspond with improvement in the respiratory symptoms. 
 
 Patients labouring under this disease should be as much as 
 possible prevented from lying on their back; they should be 
 turned from side to side, and propped by means of soft pads ; 
 and should the stethoscope indicate a decided predominance of 
 disease in either lung, it will be advisable to keep them from 
 lying on that side. The smaller the rales the greater will be the 
 necessity for this precaution. 
 
 But it occasionally happens, that notwithstanding all our 
 endeavours, a super- secretion shall come on at an advanced period 
 of the fever, and the patient rapidly fall into a state of imminent 
 suffocation ; he then lies on his back, the sputa rattle in his 
 throat, he is nearly insensible, and, if not relieved, must in- 
 evitably perish. Under these circumstances, emetics have been 
 strongly recommended by Dr. Mackintosh. But my hopes from 
 the use of these remedies have been so often disappointed, that 
 although I would administer them in all such cases, yet I would
 
 BRONCHITIS. 115 
 
 estimate the chance of recovery as exceedingly small. The cases 
 in which I have used this practice myself, or seen it employed hy 
 others, may be divided as follows : 
 
 First. Those in which the action of the emetic was followed 
 by recovery, this is by far the smallest class. 
 
 Second. Those in which the emetic produced full vomiting, 
 and the patient appeared, as it were, to be snatched from the 
 jaw5 of death, so great, and for a time so complete, was the 
 relief produced. Yet in the course of twenty- four or thirty- six 
 hours, the accumulation again recurred, and the situation of the 
 patient was as bad as, or worse than, before. Under these cir- 
 cumstances the emetic may again and again produce its full 
 effect, but at length the disease is triumphant, and a protracted 
 struggle closes this melancholy, and to the thinking physician, 
 most humbling scene. In one of my cases the disease occurred 
 in a young and robust girl, and great relief was given, no less 
 than four times, by the use of emetics, while in the intervals no 
 means that my ingenuity could devise, were neglected to moder- 
 ate the disease. But our efforts were in vain, and the patient 
 ultimately sunk with tracheal rattle. On dissection, the whole 
 bronchial system was filled with reddish frothy mucus, and the 
 lining membrane was universally red. 
 
 Third. Those in which no vomiting whatever was produced, 
 even by the administration of the most powerful emetics ; of 
 these cases I have seen a considerable number. In some the 
 powers of life were certainly much sunk, and the blood in a very 
 unarterialized state ; but I have also seen cases where there was 
 still much vigour, and where not the slightest action was pro- 
 duced on the stomach, even by the most powerful emetics. Can 
 this be explained by the doctrine of the physiological school, that 
 the plus vitality or irritation of one organ implies a minus state 
 of others ? In such cases I have observed, that no apparent 
 effect either on the pulmonary symptoms, or on the gastro- 
 intestinal system, was produced by the emetic ; and I have seen 
 ipecacuan wine, tartar emetic, sulphate of zinc, and sulphate of 
 copper, administered successively to the same patient. 
 
 The latest writer on this important subject is Dr. Graves, who 
 has proposed the employment of a combination of tonics and 
 opium in the form of enema, with the intention of checking the 
 superabundant secretion. In the epidemic influenza of 1833, 
 
 I 2
 
 116 BRONCHITIS. 
 
 many examples of this suffocative catarrh occurred ; and in 
 several of them the administration of an enema, containing ten 
 grains of sulphate of quinine, and twenty drops of laudanum, 
 had, in his hands, the happiest effects. He gives the detail 
 of three cases where the patient was moribund, and in whom 
 life was distinctly saved by this treatment. Before leaving 
 this subject I cannot do better than insert his concluding ob- 
 servations. 
 
 " To conclude, I must observe that this form of disease will 
 often baffle the most skilful practitioner, and therefore the reme- 
 dies I recommend will of course, like all others, frequently fail. 
 An accumulation of mucous secretions in the air passages pro- 
 ducing the rattles, forms the closing scene of almost all diseases, 
 however different in their nature. To exhibit remedies for this 
 would be ridiculous ; it is only when this accumulation is the 
 direct consequence of actual disease attacking the air passages 
 themselves that Ave can hope for its removal. In such cases we 
 must try every thing that experience has proved to be even occa- 
 sionally useful, and must carefully watch the effect of each new 
 medicine, for it must not be concealed that very different results 
 are obtained from the same remedies under circumstances 
 apparently similar. The injection of sulphate of quinine and 
 laudanum possesses, as appears from the cases I have detailed, 
 very great powers, and for that ver}^ reason must be used with 
 circumspection, for if exhibited at an improper period of the 
 disease, or in cases where expectoration is at all scanty and diffi- 
 cult, it may produce dangerous consequences." 
 
 We have now examined into the history of the primary and 
 secondary forms of bronchitis, but it must be considered in a 
 different point of view, namely, as a complication with other 
 diseases of the thoracic viscera. It is obvious, however, that 
 were we now to examine the complications of the various diseases 
 of the heart and lungs with bronchitis, Ave should feel a difficulty 
 from not having yet iuA'estigated these subjects alone. And 
 hence it Avill be better to describe the complication Avith bronchitis 
 in the separate affections as they come before us.
 
 BRONCHITIS. 117 
 
 ORGANIC CHANGES OF THE TUBES AND AIR CELLS CONSIDERED IN 
 RELATION TO BRONCHITIS. 
 
 These may be enumerated as follows : 
 
 First. Narrowing of the calibre ; obliteration. 
 
 Second. Dilatation of the tubes. 
 
 Third. Ulcerative destruction of the tubes. / 
 
 Fourth. Enlargement of the air cells. 
 
 Fifth. Atrophy of the lung. 
 
 Before proceeding to examine these lesions I must premise, 
 that I do not contend for their inflammatory origin in every case. 
 I do not deny that a process, different from the inflammatory, 
 may produce obliteration or dilatation of the tubes or air cells ; 
 but when we look at the whole subject, these instances seem to 
 form the exception to a general rule, and a great amount of 
 evidence goes to shew that the connexion between these lesions 
 and an inflammatory process is seen in a vast majority of cases. 
 
 It will be necessary here to take a brief view of the structure 
 of the lung, as connected with the bronchial tubes. The views 
 of Malpighi, subsequently confirmed by Eeissessen,* and more 
 lately established by Eeynaud,t must be now adopted. Indeed 
 the opinions of Helvetius, Haller, and others, which held that at 
 the termination of the bronchi they ceased to exist as ramifying 
 tubes, but were lost in a spongy tissue, whose cells communi- 
 cated in all directions, were not only at variance with accurate 
 anatomy, but opposed to that analogy of structure which Miiller 
 has shewn to exist in all glandular organs, among which the 
 lung, from its structure and functions, must be classed, and the 
 coincidence between two such anatomists as Reissessen and 
 Miiller, each on a separate path of investigation, was all that was 
 wanting to set the question at rest. 
 
 This structure, so far as the air tubes or excretory ducts of 
 the gland are concerned, may be stated to be, that there is a 
 progressive subdivision of the bronchial canals until their ulti- 
 mate ramifications terminate in culs de sac, which we call the 
 air cells. Thus, the tubes continually subdivide, but never 
 anastomose. J 
 
 * De Fabrica Pulmonum, a Eeg. Acad. Scient. prsem. ornat. Berolini, 1822, 
 
 •)• Memoires de I'Academie Royale de Medecine, torn, iv. 1835. 
 
 J As the work of Reissessen is but little studied in this country, I shall give his
 
 118 BRONCHITIS. 
 
 Although I have not made any observations on the normal 
 structure of the lung, which could confirm or shake this doc- 
 trine, yet I have been convinced, from the examination of 
 morbid parts, that the views of Malpighi and Reissessen are 
 
 conclusions on this subject in his own words. After detailing the experiments on 
 which his opinions are founded, he adds :— 
 
 1. " Fistula igitur spiritalis in ramos dividitur certa constantissimaque ratione et 
 diametro decrescentes et numero augescentes, usque dam coecis terminetur finibus 
 iisdemque rotimde clausis. 
 
 2. ''Nee ideo in telam cellulosam abit hujusve naturam recipit, ged propriam ipsius 
 fabricam ad extremos usque fines servat, quibus ut dixi clausis, cellulas refert, sive 
 vesiculas aeriferas. 
 
 3. " Cartilagenia tantum persistit, quoadusque fabricas subtilitas cartilaginem fert, 
 deinde membranacea excurrit." Op. Git. p. xi. 
 
 I shall also subjoin the observations of M. Reynaud. 
 
 " I have repeatedly examined the lungs of the fcEtus that had not respired, and on 
 passing mercury into the tubes, if I found very fine lobnles at the edge of the inferior 
 lobe, I could distinctly see a fine air tube entering them, dividing necessarily into 
 many branches, each of which again subdivided in the same manner, and so on re- 
 peatedly. These divisions, shortening and diminishing in diameter, termmated by 
 becoming pitted, as if a vast number of little culs de sac, or depressions arose from 
 their sides, and their extremities were rounded and closed. Beyond this point the 
 mercury could not penetrate. It presented a perfectly regular arborescent form, whose 
 terminal ramifications had no lateral connexion, as proved by the fact that even when 
 these ramifications were pressed close to one another no admixture of the mercury 
 took place. When the quicksilver was pressed into one of the minute tubes, the fine 
 bronchial tree could be seen forming before the eye. And what proved that these 
 canals, through which the mercury had penetrated, really pre-existed was, that on 
 removing the pressui-e the mercury retired, again to return to its previous position- 
 But on its reaching its final termination it could be forced no farther, nor did the 
 pressure employed cause any of the minute terminal globules to be confounded. 
 
 " In many other instances, even where I employed no injection, or any other prepara- 
 tion whatever, I have seen the same disposition in the adult lung of animals and man, 
 whose bronchial termmations are much larger than in the fcEtus. In a portion of the 
 lung of an ape, which I removed from the anterior edge of the organ, and dried upon 
 glass, so that the air was continued in its last bronchial ramifications, the disposition 
 above described could be most plainly seen. 
 
 " What prevents us observing so easily this mode of termination of the bronchial 
 tubes in the recent human lung is, that the last ramifications terminate perpendicularly 
 to the pleura, from which we can only see their terminal culs de sac, and the trunks 
 from which these have been derived. In a considerable number of lungs, however, 
 I have observed that in certain points of their surface there existed a curious disposi- 
 tion which allowed me to observe the trajet of several bronchial ramifications through 
 the pleura. From some cause, which I cannot explain, a certain number of tubes, 
 longer than the others, had not the pleura for their limit, but having arrived at that 
 membrane, in place of terminating perpendicularly to it, they turned and ran parallel 
 to it for a distance varying from two to five lines, or upwards. Under these circum- 
 stances, the air contained in them, like the meicury, as above stated, formed a perfectly 
 regular tree, the arborescent form of which was continued to a point, beyond which 
 pressure could no longer force it, and which obviously shewed the termination of the 
 tree.'' — Memoires de V Acad. Hoyah de Medecine, tom. iv. Fas. 11. The same author 
 adds a confirmatory dissection, which it is unnecessary to insert here.
 
 BRONCHITIS. 119 
 
 correct. To this point we shall just now return, when 1 shall 
 describe a singular variety of pneumonia, since noticed by 
 Eeynaud, which gives a beautiful demonstration of the pul- 
 monary structure, and the relation of the air cells to the 
 tubes. 
 
 NARROWING AND OBLITERATION OF THE BRONCHIAL TUBES. 
 
 Hitherto the diminution in capacity, and obliteration of the 
 bronchial tubes, have been merely noticed as curious points of 
 pathological anatomy, and it was reserved for M. Reynaud to 
 call the attention of pathologists more especially to this most 
 important lesion. Yet even this distinguished physician goes 
 little farther than to describe the various species of obliteration, 
 declaring that as yet he is ignorant of its symptoms, and even in 
 doubt as to its causes. To me it appears that there can be little 
 question as to its cause in the great majority of instances, and 
 that to its existence we are to attribute many hithei'to unex- 
 plained auscultatory phenomena, of importance, not onlj in the 
 diagnosis of bronchitis, but more especially in that of the early 
 stages of pulmonary consumption. 
 
 It is obvious that when inflammatory action seizes on a 
 bronchial tube, its effect, considered anatomically, will vary 
 according to the diameter of the canal. In the larger tubes, 
 whose parietes are guarded with strong cartilaginous plates, 
 nothing but a great local hypertrophy of the mucous membrane 
 could cause an obliteration, while in the minuter tubes, whose 
 per\-iousness is not so provided for, the same process would 
 much sooner produce obliteration. 
 
 Indeed, in the diseases of what may be called tubular or- 
 gans, experience shews, that when we can compare canals of 
 different diameters, as, for instance, in the circulating system, 
 the liability to obliteration is directly as the smallness of the 
 tube. We accordingly find that in the lung it is the minuter 
 tubes which are commonly the seat of the obliterating process, 
 and when we reflect on the frequency of pulmonary irritations, 
 and the extreme minuteness of the ultimate ramifications of the 
 tubes, it seems strange indeed, that the lesion does not more 
 often occur. It is obvious, however, that in the respiratory 
 motions, both of inspiration and expiration, but particularly the
 
 120 BRONCHITIS. 
 
 first, there is an important provision against the obliteration 
 of the air passages while in a state of disease. 
 
 But the subject must be considered in another point of view, 
 namely, as connected ■\\ith original structural differences in the 
 lining membrane of the large tubes and smaller ramifications. 
 It seems now established, that in following the bronchial rami- 
 fications, from their origin to the pleura, we may observe, if not 
 a complete transformation from mucous to serous membrane, at 
 least a decided tendency to it, which increases as we approach 
 their terminations. In the larger tubes we find a vascular 
 mucous membrane, endowed with villosities and glands, but as 
 we advance into the substance of the lung, this tissue gradually 
 loses its original characters, until at its ultimate point, if it be 
 not completely serous membrane, it closely approaches to it in 
 appearance and function. If we now add these considerations 
 to the preceding, we get at once a sufficient explanation of the 
 point in question. As M. Eeynaud remarks, we may expect the 
 plastic inflammation, the more the affected tissue approaches to 
 white structure, and hence another cause of the greater liability 
 of the minute tubes to obliteration. 
 
 A diminution of the calibre of the air passages may arise 
 from various causes ; among which the following are recognized 
 by pathologists : 
 
 First. A thickening of the mucous membrane. This may 
 result from inflammatory turgescence, congestion, or oedema, or 
 be caused by a permanent organic chgiuge, in which there is 
 actual hypertrophy of the membrane. These changes are most 
 evident in the affections of the larger tubes. 
 
 Second. We observe this change as a result of the se- 
 cretions of the tube. This is seen either in cases of croup, or 
 of that form of bronchitis in which casts of the tubes are ex- 
 pelled. In the latter instance very large tubes may be affected, 
 so that we can hardly agree with Andral in his opinion, that 
 unless when the larj'nx in children, or the minute bronchi in 
 them and the adult are engaged, this cause hardly affects the 
 capacity of the tube. 
 
 Third. The compression of the tubes by external tumours. 
 
 Fourth. The existence of foreign bodies within the tube. 
 
 Such are the causes enumerated by Andral ; but it is with 
 the two first classes that we have at present to do. It is plain.
 
 BRONCHITIS. 121 
 
 that if any of these causes be carried to a certain point, oblite- 
 ration of the tube must ensue ; but we find that this termination 
 is much more often a result of disease of the interior than of 
 the exterior of the tube. 
 
 Obliteration of the Bronchi.— In considering the relation 
 of this disease to inflammatory action, we shall first advert to 
 some important points established by M. Reynaud. 
 
 If we commence at the termination of the tube or the air 
 cell, and proceed towards the trachea, it is found that oblite- 
 ration may take place at almost all points of the bronchial tree. 
 I have already alluded to a case by Andral, where the ob- 
 struction, which was owing to a local hypertrophy of the mucous 
 membrane, took place only a few lines from the origin of the 
 principal bronchus of the upper lobe. I do not know of any 
 case of obliteration, or even great internal obstruction of the 
 primary divisions of the trachea, but with this exception, the 
 disease has been met with in the remaining portions of the 
 tree. 
 
 In all cases, except where the tube was extremely minute, 
 it was found, that just at the commencement of the obliteration 
 a cul de sac existed, beyond which the tube was converted 
 into a solid fibrous cord, furnishing also ramifications which 
 answered to the originally pervious tubes. 
 
 In some cases these culs de sac formed dilatations of the 
 tube, a fact principally observed when the larger canals were 
 engaged ; while in others, the tube terminated more or less 
 abruptly, without any perceptible dilatation, and was replaced 
 by a solid fibrous cord, which when it sprung from a large 
 tube, could be seen to be conical, gradually diminishing in 
 volume, and traceable near to the surface of the lung, or even 
 under the pleura. In other respects the disposition of these 
 cords was very variable ; in some instances their subdivisions 
 were as regular as those of the bronchial tubes themselves, and 
 terminated near the pleura by a vast number of minute fila- 
 ments ; while in others, a single cord passed onwards to the 
 pleura, from the sides of which secondary filaments were seen 
 to emanate. 
 
 These observations, it must be borne in mind, apply chiefly 
 to that form of obliteration in which the sides of the tube ad- 
 here, without the presence of any foreign matter in their cavity.
 
 122 BRONCHITIS. 
 
 The condition of the mucous membrane, in the vicinity of the 
 obHteration, was various ; in some cases being healthy, in others 
 inflamed. 
 
 One of the most interesting points connected with these re- 
 searches, was the state of the pulmonary tissue and bronchial 
 tubes in the vicinity of the obliteration. In the eff'ects pro- 
 duced on these structures we may see some analogy to the re- 
 sults of obstruction of the arterial system, namely, atrophy, and 
 a collateral circulation. Thus, although proceeding from causes 
 widely different from those alluded to, we find a dilatation of 
 the neighbouring tube and an atrophy of the pulmonary tissue 
 in these cases of obliteration. But it is plain that when we 
 recollect the structure of the lung, we at once see that this 
 dilatation of the neighbouring tubes has no analogy to the 
 collateral circulation in arterial obstruction. 
 
 It is found that in the vascular system the circulation can 
 be continued collaterally, or even into the original trunk below 
 the point of obliteration. But as Reynaud well remarks, this 
 can never occur in the case of the bronchial tube, there being 
 no collateral communication between its branches. Hence 
 there is a diminution in the extent of respiratory surface equi- 
 valent to the impermeable portion of the organ. But as the 
 inspiratory effort is undiminished, its effect must be to dilate 
 the tubes in the vicinity of the obliteration. According to this 
 view, the dilatation is a purely mechanical process, how far 
 we are to consider it as such in all cases, must be hereafter 
 examined. 
 
 As might be expected, those parts of the lung to which the 
 obliterated tubes extend, have been found to present a sunken 
 appearance, so as to cause depression of various depths on the 
 pleural surface. The mechanism of this change is obvious. 
 In the neighbourhood of the obliterated canals, however, the 
 air cells were frequently found dilated, while in other instances, 
 the tissue was dense and impermeable. 
 
 It would appear that we may consider this obliteration of 
 the bronchial tubes in two points of view : first, as commencing 
 in the finer, and proceeding by continuity of disease to the 
 larger tubes ; and secondly, as the result of obstruction of a 
 large trunk, and the consequent obliteration of the tubes to 
 which it gave birth, by a process similar to that observed in
 
 BRONCHITIS. 123 
 
 arteries after ligature. Of these species the first is the most 
 frequent and important ; and I cannot help thinking that its in- 
 vestigation will not only go far to clear up the long controverted 
 point as to the nature and origin of tubercles, but also throw 
 light on other subjects of thoracic pathology. 
 
 M. Reynaud draws a distinction between the cases in which 
 the obliteration has taken place by simple adhesion of the pa- 
 rietes, and those where it is produced by a substance formed 
 and accumulated in their interior. But this distinction seems 
 unnecessary ; for if, as I apprehend we shall find to be the case, 
 there is an analogy between these obliterations and those of 
 serous membranes, there seems to be no more reason for this 
 distinction in the former than in the latter case. In inflam- 
 mations of the pleura or pericardium, &c., we may have the 
 cavity destroyed either by simple adhesion, or with an inter- 
 vening layer of the products of the inflammation ; yet, in either 
 instance, the nature of the disease does not seem different. Of 
 course I do not mean to deny, that in certain cases a foreign 
 matter, not the result of the disease of the affected tube, but 
 proceeding from other sources, might, in its trajet, obstruct and 
 obliterate the canal. 
 
 This disease has been met with as a chronic, or an acute 
 affection. As a chronic disease it will be frequently found in 
 connexion with tubercle. It is an interesting fact, that it occurs 
 much more frequently in the upper than the inferior portions 
 of the lung, and its connexion with the development and phe- 
 nomena of tubercle is too obvious to be overlooked. When 
 discussing the question, as to how far we can distinguish be- 
 tween bronchitis and phthisis, we shall return to this point, and 
 here only remark, that the advance of medicine is strongly tending 
 to shew how artificial many of our distinctions have been. 
 
 As yet but very few cases of the disease, in its acute form, 
 have been described. But there can be no question, that this 
 has arisen from the careless mode in which dissections of the 
 lung are commonly made. I have little doubt, that oblite- 
 ration of the minute tubes occurs in many cases of pulmonary 
 disease ; and that thus the pent up secretions of the air cells 
 represent, in some cases, the acute granular tubercle, and in 
 others, where the affection is more general, the suppurative 
 pneumonia.
 
 124 BRONCHITIS. 
 
 Thus, in a patient of Louis', who died of pneumothorax, 
 after small-pox, numerous tubercles were found throughout the 
 perforated lung. On dissecting the small bronchial tubes which 
 led to them, these canals were found very red, and lined with 
 a firm layer, which filling their cavities, continued to their 
 terminations, thus giving them a granular appearance. Along 
 their course the blood vessels were black, and the pulmonary 
 tissue of a deep reddish brown colour. There was no har- 
 dening of the lung, nor the semi-transparent infiltration, but 
 the entire lung was filled with small cavities containing pus. 
 'One of these cavities was lined with a whitish membrane, which 
 was prolonged into the mouth of the bronchus that opened into 
 the cavity. "This plastic material," says the author, "pre- 
 sented the same characters as that contained in the small bronchi, 
 which by their reunion formed those apparently tuberculous 
 masses which we have spoken of above." 
 
 With respect to that form of disease, in which it represents 
 the suppurative pneumonia, I have to remark, that in the third 
 volume of the Dublin Medical Journal,* four years before M. 
 Reynaud's memoir appeared, I described a form of pneumonia, 
 at that time unlmown, but which since has been noticed by 
 M. Reynaud. Of the nature of this aifection I was ignorant, 
 but I now feel no doubt, that it was an example of this 
 ''plastic C7'oup" of the air cells and minute bronchial tubes, 
 and quite analogous to the case described by the above author. i" 
 
 A young man entered the Meath Hospital on the 13th of 
 April, 1832, labouring under the usual symptoms of acute 
 pneumonia, which were of three days' standing ; the disease was 
 found to occupy the lower lobe of the left lung, which had 
 passed into the stage of hepatization. We employed general 
 and local bleeding, and put him on the use of free doses of 
 calomel and opium. The blood drawn did not present any in- 
 flammatory appearance, and although his general symptoms 
 seemed alleviated, yet the stethoscope did not shew any im- 
 provement in the condition of the lung. In the course of the 
 third day of his treatment, a violent exacerbation took place, 
 subsequently to which a moist crepitus was heard mixed with 
 
 * Contributions to Thoracic Pathology. Notice of an hitherto undescribed ter- 
 mination of pneumeuia. Op. cit. p. 50. 
 t Memoii-es de I'Acad. Royale. «fcc.
 
 BRONCHITIS. 125 
 
 the bronchial respiration over the dull portion, and the right 
 lung became affected with a general bronchitis. These circum- 
 stances, combined with the fact that no ptyalism whatever had 
 occurred, induced me after two da^-s to make the diagnosis of the 
 third stage of pneumonia. About this time a remarkable change 
 took place in the stethoscopic phenomena. A large rale was 
 heard about the root of the lung, and the bronchial respi- 
 ration here became so peculiarly modified, that even after 
 repeated examinations I declared to the class, that I could not 
 satisfy myself of its exact nature, and, therefore, could not say 
 whether or not an abscess had formed ; the dulness continued. 
 On the seventh day copious sweatings, preceded by rigors, 
 supervened ; these continued till the twelfth day from his 
 admission, when he sunk. 
 
 On dissection, we found the bronchial mucous membrane 
 universally inflamed, and recent adhesions of the pleura, parti- 
 cularly the left. On removing the left lung, its upper lobe was 
 found crepitating, though engorged, but the lower, when viewed 
 exteraally, represented a bag of matter, the yellow colour of 
 which was seen plainly through the pulmonary pleura. This 
 being opened, displayed the substance of the lov/er lobe com- 
 pletely dissected from its pleura, by the suppurative inflam- 
 mation of the sub-serous cellular membrane. This process also 
 was found to have invaded extensively the iuter-lobular and in- 
 ter-vesicular cellular tissue, so as to cause this part of the lung 
 to represent nearly the structure of a bunch of grapes. All 
 these nearly isolated lobules were surrounded by puriform mat- 
 ter, in which they hung from their bronchial pedicles. There 
 was no air in the cavit}' thus formed within the pleura, 5'et ex- 
 ternal to the lung, nor could I find any evidence of any bronchial 
 communication with it. 
 
 At the period of this dissection I was not able to find any 
 description of this termination of pneumonia, and merely re- 
 marked that the case was one which might be appealed to by 
 those who hold that the original seat of pneumonia is in the 
 inter-lobular and inter-vesicular cellular tissue, and that the air 
 cells are secondarily affected. Here we found the sub-serous 
 and mter-vesicular tissue extensively suppurated, so as to pre- 
 sent a JDeautiful dissection of the lung, while the pulmonary 
 vesicles were comparatively intact, but remained, as represented
 
 126 . BRONCHITIS. 
 
 by the bunch of granules, immersed in the surrounding puriform 
 matter. 
 
 I shall now give an abstract of M. Reynaud's case of the 
 same form of disease. 
 
 " A patient, aged 35, died after a rapid acute pneumonia. 
 The left lung was entirely hepatized, the top of the organ alone 
 being free from alterations. On cutting into the lung its tis- 
 sue was red, interspersed with yellow and black patches. In 
 some portions the colour was uniformly grey, or like that of pus. 
 The organ, covered by a recent yellow false membrane, did 
 not collapse on opening the chest ; its density and specific 
 gravity might be compared to that of the liver ; it was com- 
 pletely deprived of air, and broke under the finger. By these 
 characters it was easy to recognize the second stage of pneu- 
 monia and its passage into the third or suppurative stage. 
 So far the lung presented nothing that could make it distin- 
 guishable from other lungs in the stage of red or grey hepati- 
 zation ; but closer attention discovered consistent cylinders 
 projecting from the interior of the bronchi of the second and 
 third order, as is often seen to occur with respect to the dis- 
 coloured coagula observed in blood-vessels, and for which at first 
 sight these were mistaken. As this matter formed in the inte- 
 rior of the bronchi solid cylinders which penetrated all their 
 divisions, it could be taken out in a very arborescent form, the 
 perfect cast of the bronchial ramification itself. xA.t a short 
 distance from the periphery of the organ these branches of 
 plastic matter still presented the arborescent appearance, and 
 by careful dissection might be followed to the terminal vesicles 
 within half an inch of the pleura, where there appeared on 
 them small lateral swellings, round, regular, at first isolated, 
 afterwards more numerous, so that they appeared festooned on 
 their borders. Some of these projections occurred at only one 
 side, and in this particular instance they gave off other and 
 more numerous bulbs, presenting the appearance of bunches of 
 grapes. A very slight pulling on the principal cord from which 
 they sprung sufficed to remove them without any dissection of 
 the cavities which contained them. 
 
 " According as we approached closer to the pleura, the little 
 cylinders, of which we have spoken, became divided into 
 branches, shorter, more numerous, and swollen at their ex-
 
 BRONCHITIS. 127 
 
 tremity, so as to appear knotty ; and immediately under the 
 pleura they appeared in form and colour similar to those gi-a- 
 nules that are observed in some of the forms of hepatiza- 
 tion of the lung, which this patient exhibited in the highest 
 degree. , 
 
 " This appearance was not only observable on the surface of 
 the lung, but internally and on all the points of the incised 
 surface. All the bronchi that were examined were in the same 
 state as those I have described. The smaller the bronchi were 
 the more full were they ; thus in the branches the plastic 
 matter did not occupy two-thirds of their calibre, while their 
 terminations were accurately filled in their whole diameter. 
 
 " In its external characters the contained substance resem- 
 bled fibrine ; it was of a slightly yellowish white colour, resist- 
 ing, elastic, and capable of being separated into filaments. It 
 appeared under the microscope to be composed of a multitude 
 of uncoloured and perfectly round globules, like those of the 
 blood, excepting that in the terminations of the tubes, where it 
 was grey or of a dirty black colour. This matter differed in 
 appearance in those parts of the lung affected with the second 
 and with the third stage of pneumonia. In the latter the fila- 
 ments were much more moist, less resisting, and thinner, and 
 filled less exactly the cavities of the tubes. 
 
 " The bronchial parietes offered nothing remarkable either in 
 colour or thickness ; some tore with more facility than would be 
 expected in the healthy state ; towards their terminations their 
 colour was similar to the contained matter." 
 
 To dwell on the close similarity of these cases would be 
 superfluous ; but we might inquire whether this form of disease 
 is not more common than would at first appear. I cannot help 
 thinking that it is to be met ^^dth in many, if not all cases of 
 the interstitial suppurative pneumonia (Laennec's third state), 
 and that adventitious circumstances prevent our seeing the 
 peculiar appearance of the bunches of granules. Indeed, Andral 
 explains the granular structure of the lung when thus aflected, 
 by an enlargement and thickening of the cells ; and I have little 
 doubt, that by a process similar to that by which we demon- 
 strate the cellular membrane of the brain, the structure of the 
 lung could also be shewn. I think it will be found if a 
 drop of water be let fall continually on a lung in an advanced
 
 128 BRONCHITIS. 
 
 stage of pneumonia, that the purulent matter between the 
 minute bronchi and air cells will be washed awaj^ and the above 
 appearance produced. 
 
 When we consider the structure and functions of the lung, 
 it seems probable that its minute bronchial tubes, or excretory 
 ducts, might be plugged up by secretions of the cells, independent 
 of inflammation in the parietes either of the tubes or cells. Yet 
 we cannot help looking on the obliteration as principally con- 
 nected with inflammation. In fact, the preponderance of the 
 latter process, in the vast majority of internal diseases, gives 
 alone a great probability that the lesion in question is one of its 
 results. But when we find it occurring in an organ and tissue, 
 of all others the most liable to this action ; when we recollect 
 that the adhesive process is always preceded by increased action ; 
 when we see this most evident in that part of the tube in which 
 the white tissues are predominant, and perfectly analogous to the 
 same process in serous inflammations ; when we observe so close 
 a resemblance between this disease and the inflammations of 
 other tubular organs, such as arteries, veins, and lymphatics ; 
 when we find it in most cases occurring with other signs of 
 chronic irritation of the lung, as in phthisis, or as a distinct 
 result of acute inflammation, we cannot avoid coming to the 
 conclusion, that it is a frequent and most important result of 
 bronchitis ; and that before we can consider the diagnosis 
 and pathology of this disease as established, its phenomena 
 must be studied with reference to the obliteration of the minute 
 tubes. 
 
 I need hardly say, that the diagnosis of this lesion is still to 
 be investigated. But although not possessing any particular 
 observations on the point, we may, to a certain degree, anticipate 
 its signs. They will of course depend on various circumstances, 
 such as the number of tubes affected, the state of the air cells, 
 and so on. If but a few tubes are afi'ected, it is probable 
 that no perceptible physical sign would be produced ; but if the 
 contrary, then we would have a proportional feebleness of 
 respiration. Under these circumstances, if the air cells con- 
 tinued unaff'ected, or but little engaged, the sound on percussion 
 would be clear, and thus would be produced a combination of 
 phenomena, commonly found in the earlier stages of phthisis. 
 
 On the other hand, if a great number of the terminal ramifica-
 
 BRONCHITIS. 129 
 
 tions, or cells, became plugged up by their own secretions, the 
 combination of feebleness of respiration with a degree of dulness 
 would be produced ; and this combination, as every one knows, 
 is the most common sign of incipient phthisis; and the similarity 
 is completed when we recollect that the seat of tubercle and 
 obliterated bronchi is most often the upper lobes of the lung. 
 Indeed there can be little doubt, that we have been long observing 
 the physical signs of phthisis under a false idea of their nature, 
 and that many of them, at least, are to be attributed to this 
 lesion. When I come to the subjects of pneumonia and phthisis, 
 this point shall be again brought before the reader ; and I shall 
 examine whether the lines of distinction, which have been drawn 
 between these affections, are in all cases so well defined as some 
 pathologists have supposed. 
 
 DILATATION OF THE BRONCHIAL TUBES. 
 
 I have already, when speaking of obliteration of the tubes', 
 alluded to the analogy between that disease and affections of the • 
 circulating system. Thus, in the obliteration by adhesion, in 
 the plugging up by the results of morbid secretion, in the 
 atrophy of the parts of the tube beyond the obstruction, and in. 
 its reduction to a solid fibrous cord, we see circumstances com- 
 mon to disease both of the bronchial tubes, and the arteries in 
 general. We might also extend this analog}'' to the case of 
 dilatation of these canals, and trace a resemblance between the 
 bronchial and arterial diseases. In both we may see dilatation, 
 either partial or more general ; in both there is a loss of elasticity, 
 produced in most instances by chronic inflammation, and allow- 
 ing of enlargement of the canal by the action of the fluid which 
 passes through it. Further, we see in either case obliteration of 
 the smaller trunks in the vicinity of the diseased tube, while in 
 other instances they are pervious. even when springing from the 
 dilated portion ; and we observe compression and atrophy of the 
 surrounding parts. In these observations I only allude to the 
 true aneurism ; although I think it not improbable that the false 
 aneurism of the bronchial tubes may yet be discovered. 
 
 Authors have described various forms of this disease, which 
 in general terms are reducible to three varieties : first, that in 
 which the tube is continuously dilated, so as to be nearly the 
 
 £
 
 130 BKONCHITIS. 
 
 same diameter at its termination as its commencement. When 
 this disease is general, and that we lay open the bronchial sys- 
 tem, the tubes present the appearance of the fingers of a glove. 
 In the next variety, we may have a series of dilatations in the 
 course of a single tube, an appearance which has been well 
 compared by Laennec to the common bladder-wrack (fucus 
 vesiculosus.) And lastly, a bronchial tube may be dilated into 
 one large cavity, which gives the signs of, and is often with 
 difficulty distinguished from, a phthisical abscess. As yet 
 but little is known of the causes which determine these different 
 forms. 
 
 But a more important division is that which is based on the 
 existence or absence of inflammatory action in the tissue itself. 
 In some cases decided marks of chronic inflammation are found, 
 such as thickening, ulceration, opacity, puriform secretion, and 
 so on ; while in others, the tubes are found thinned, so as to 
 become almost transparent. It is not improbable, but that in 
 the first of these cases the dilatation is owing to a long-continued 
 morbid action in the affected portion of the tube itself, which, 
 while it has hypertrophied the tunics, has destroyed their tonicity, 
 while that in the other case, the dilatation will be found to be 
 passive, and produced not so much by disease of the tube itself, 
 as by the obliteration of other canals, which, as Reynaud has 
 shewn, in consequence of the respiratory effort continuing the 
 same, is a powerful cause of dilatation of the unaffected tubes. 
 At the same time we must admit, that a process, similar to that 
 of the softening and thinning of the stomach might also occur in 
 the bronchial tubes, and thus produce a dilatation independent 
 of increased nutrition or vascular action. 
 
 The explanations that have been given as to the cause of this 
 disease are, to a certain degree, various ; Laennec held, that the 
 dilatation was produced by the stasis of a large sputum in the 
 tube, which, from its frequent repetition, ultimately produced 
 enlargement. But this explanation has been considered too 
 mechanical by subsequent authors. Thus Andral* declares, that 
 it must be referred to some vital action of the parts, and Roche f 
 and Williams J to inflammation, which, by diminishing the 
 
 * Clinique Medlcale, torn. ii. 
 
 f Dictionnaire de Medicine et de Chirurgie, Art. Bronchite. 
 
 X Cyclopaedia of Practical Medicine.
 
 BRONCHITIS. 131 
 
 cohesion of the tissues, causes them to yield to the impressions 
 of respiration and cough.* 
 
 In examining this question, we should begin with recollecting 
 the tissues which form the bronchial tubes. These are mucous 
 membrane, cellular tissue, cartilaginous plates, and the two 
 orders of fibres, first accurately investigated by Reissessen, the 
 one longitudinal, and the other circular. Now, if the views of 
 this author, as to the muscularity of the lung, be correct, and 
 that they are so seems admitted, we may divide the bronchial 
 structures into the non-muscular, and the muscular layers. 
 Among the first are to be enumerated the cartilaginous plates, 
 and also those longitudinal fibres, which he has shewn to be 
 analogous to the elastic coat of arteries ; and in the second, we 
 have the circular fibres, which are to be considered as muscular. 
 If we now study the eftects of irritation on each of these classes 
 of tissues, we find that on the non-muscular it produces loss of 
 elasticity, as is observed in the case of arteries, causing their 
 aneurismal dilatation ; and in this way we can understand the 
 enlargement of the bronchial tubes, by the repeated impulsion of 
 respiration and cough. 
 
 But another cause may exist, and it is one as yet not alluded 
 to by any author, I mean a paralysis of the muscular structure 
 itself, the result of the inflammatory action ; and which, like the 
 paralysis of the intestine in enteritis, or ileus, is followed by a 
 dilatation of the tube. Dr. Abercrombie has shewn, that ileus 
 may occur without mechanical obstruction ; that the dilatation 
 of the tube may be referred to a lesion of the muscular apparatus 
 itself ; t and further, that the collapsed parts are almost inva- 
 riably found healthy at all periods of the disease, the morbid 
 appearances being confined to the distended portions. 
 
 There can be no doubt of the fact, no matter how we explain 
 it, that where muscular structures are in close connexion with 
 other tissues which are inflamed, their functions sufl'er, and we 
 observe, first, an increase of innervation, as shewn by pains and 
 spasms, and next a paralysis, more or less complete. When we 
 
 * Dr. Gairdner considers that " almost all the so-called bronchial dilatations and all 
 those of the abrupt sacculated character are in fact the result of ulcerative excavations 
 of the lung communicating with the bronchi," and becoming lined with a membrane 
 " not exactly resembling the mucous membrane of a bronchus." See Monthly Jour, 
 of Med. Science, vol. xiii, p. 248. (Ed.) 
 
 t Diseases of the Stomach and Abdominal Viscera, p. 185. « 
 
 k2
 
 132 BRONCHITIS. 
 
 come to speak of empyema, diaphragmitis, and inflammation of 
 the heart, we shall see of what importance these considerations 
 are. At present it appears that we may hope to elucidate some 
 points in the symptoms and treatment of bronchitis by having 
 recourse to this view. May not this paralysis explain the diffi- 
 culty of expectoration in certain cases ; the stasis of matters in 
 the tubes, and the liability to asphyxia in bad catarrhal fevers ? 
 And we might further inquire, how far its existence should lead 
 us to modify our treatment, and seek for some agent which 
 would stimulate the bronchial muscles to contract. Abercrombie 
 relates a case of distention of the bowels, in which galvanism 
 had the best effect ; and I have already alluded to the use of the 
 same agent in pulmonary disease by Drs. Philip and Forbes. 
 Now, as the lung derives a large portion of its nervous supply 
 from the cerebro-spinal system, we might hope, by the exhibition 
 of such remedies as strychnine, to act beneficially upon it when 
 its innervation was injured. 
 
 There remains for examination another interesting point con- 
 nected with this subject. It has been shewn by Purkinje and 
 Valentin,* that the vibratory motions produced by cilia on the 
 surfaces of many of the invertebrated animals and reptiles, is a 
 phenomenon common to the respiratory and generative mucous 
 membranes of the warm-blooded animals. These motions were 
 first observed by Steinbuchf in the larvae of the Batrachian rep- 
 tiles more than thirty years ago, and since, it may be said^ 
 re-discovered by Dr. Sharpey of Edinburgh, who, in a paper 
 published in 1830, t pointed out the existence of the motion in 
 question in the larva of the frog and salamander, in most of the 
 tribes of mollusca, and in the annelida and actinia. He endea- 
 vours to prove that it was a provision extensively present among 
 aquatic animals, serving chiefly to maintain a^flow of water along 
 the surface of their respiratory organs, but in some cases also to 
 convey food to the animal, discharge the ova, or assist in loco- 
 motion. According to this physiologist, the characters of the 
 motion were, first, that the fluid was moved along the surface of 
 the parts in a determinate direction ; second, that the impelling 
 
 =• Miiller's Archiv. filr Anatomic, No. V., ]831. See also Dublin Medical and 
 Chemical Journal, May, 1835, 
 
 t Analecten neuer Beobachtungen und Untersuchungen f iir die Naturkunde. FUrth, 
 1802, 
 
 J Edin. Med, and Surg, Journal, vol. xxxiv.
 
 BRONCHITIS. 133 
 
 power resided in the surface over which the fluid was conveyed, 
 which in all instances, as subsequent observations proved, is 
 covered with moving cilia ; and, lastly, that it continued for 
 some time in detached portions of the tissue, the impulsion of 
 the fluid taking place in the same direction as before the separa- 
 tion of the parts. 
 
 In a subsequent paper * Dr. Sharpey has published some 
 additional observations on this subject, and states several facts, 
 in which he had been anticipated by previous observers ; thus 
 illustrating what has been the case in many instances, that our 
 most useful discoveries have resulted from the observations of 
 more than one individual, and may be justly termed progressive. 
 It would be improper, in a work like this, to enter into any 
 lengthened details ; let it suffice to state, that according to 
 the experiments of Purkinje and Valentin, this vibratory motion 
 occurs only in two systems of organs, namely those of respiration 
 and generation ; and that, in the latter case, it has been ob- 
 served only in the female. All parts of the internal surface of 
 these organs in mammalia, birds, and reptiles present this 
 action, which as yet has not been found in any part of the 
 intestinal canal of vertebrated animals. It has been demon- 
 strated on the mucous membrane of the respiratory passages, 
 from its commencement to its termination, — over the whole 
 lining membrane of the windpipe and its branches, even to the 
 smallest divisions which admit of investigation. It is also con- 
 spicuous in the nose, but no trace of it can be discovered in the 
 lining membrane of the mouth, pharynx, glottis, or its ligaments. 
 These observations have been lately confirmed by Dr. Sharpey, 
 who has not only demonstrated the existence of the ciliary motion 
 in mammalia, birds, and perfect reptiles, but has shewn in cer- 
 tain cases, the direction in which matters are impelled along the 
 surface, in consequence of these vibrations. t 
 
 It is probable that we have not as yet learned all the uses of 
 these ciliary vibrations, but that they possess a power of impell- 
 ing matters along their surface, seems established. " Although," 
 say MM. Purkinje and Valentin, "the vibratory motion is to be 
 regarded more as a general morphological phenomenon, yet we 
 
 * Edinburgh New Philosophical Journal, July, 1835. 
 
 t Account of the Discovery by Purkinje and Valentin of the Ciliary Motions, drc, 
 by Wm. Sharpey, M.D. Ibid.
 
 134 BRONCHITIS. 
 
 cannot entirely overlook its particular uses. For by its means 
 the secretions of those mucous membranes on which it occurs, 
 may be conveyed onwards, and many singular phenomena may be 
 accounted for in this way. Thus, for instance, when the bronchial 
 mucus accumulates during a long uninterrupted sleep, and is 
 afterwards discharged, we do not bring it up from the interior 
 of the lungs, but only from the larynx, or top of the windpipe ; 
 but we refrain from pointing out further applications, that we may 
 avoid the field of mere hypothesis, which is here so tempting." 
 
 Without entering farther into this subject, we may remark, 
 that the pathology of bronchitis and of pulmonary disease in 
 general, must be studied with reference to these motions. "VVe 
 can understand, as connected with the subject of dilatation of 
 the tube, how, by allowing of the stasis of secretion, a paralysis 
 of the circular muscles may be followed by the disease ; and if 
 this be true, may not the same occur with respect to these 
 vibratory cilia ? May not their action be at first increased, and 
 afterwards destroyed by inflammation, or may they not, under 
 certain circumstances, acquire an undue development ? Reynaud 
 has described a condition of the bronchial membrane in a patient 
 who had long laboured under catarrh, where it presented 
 numerous villosities standing out from its surface, so as to give 
 the idea, that aliments would have been digested had they been 
 laid on its surface. 
 
 We have now taken a view of the possible causes of the lesion, 
 and have seen that it depends in most cases on a morbid action, 
 generally inflammatory, which, while it hypertrophies the tissues, 
 permits them to yield to forces, against which, in their healthy 
 state, they have various natural provisions. In others, it may 
 be the result of atrophy ; and in a third order perhaps, it pro- 
 ceeds from causes, which, as far as the dilated tube is concerned, 
 are purely mechanical, such as the obliteration of other tubes, 
 or violent cough from an irritation, existing elsewhere. 
 
 In examining into the history of the disease, we find that it 
 may occur at all ages, from two months upwards. Guersent is 
 of opinion that it is occasionally congenital, and a predisposing 
 cause of pulmonary disease.* With respect to the important 
 inquiry as to duration of disease, we may divide the cases 
 into three classes. In the first, we find that dilatation may 
 
 * Diet, de Medicine, Art. Coqueluche, tome vi.
 
 BRONCHITIS. 135 
 
 occur to a great extent in a comparatively short time. This 
 has been principally observed in young children affected with 
 hooping cough, in whom the period of two or three months is 
 sufficient to produce the fullest development of the disease. 
 On considering the circumstances of these cases it is plain, that 
 everything is combined which could bring about such a result. 
 There is a bronchial irritation, accompanied by violent cough, 
 and this occurring at a period of life when the tissues are still 
 imperfect, and the muscular apparatus not yet fully developed, 
 is so powerful a cause, that it seems only wonderful that the 
 lesion does not more often occur. 
 
 In the next class, Ave may place those cases in which la 
 bronchial irritation has continued for many years, in certain 
 cases, indeed for the greater part of the life of the individual. 
 Thus, in three cases of this description, given by Laennec, the 
 duration of the disease was fifty, forty-one, and twenty years. 
 In a case which I observed it had lasted forty years. Andral 
 relates cases of four, five, and six years' duration, and other 
 authors detail similar instances. 
 
 Lastly, we have this lesion as a common accompaniment of the- 
 tuberculous disease of the lung. Here the period of duration 
 is of course various. Whether the dilatation proceeds from the 
 obliteration of other tubes, as noticed by Reynaud, or is a result . 
 of the accompanying bronchitis of phthisis, and assisted by the 
 passage of the secretions and cavities, remains to be determined, , 
 but most probably it will be found that all these causes act. It 
 would be an interesting point of inquiry to ascertain how far 
 the emaciation of viscera, which we see so commonly in phthisis,, 
 may predispose to this lesion. May there not be a condition 
 of the tubes and their muscular fibres, analogous to that of the 
 heart and stomach ; a state of atrophy, highly favourable for the 
 occurrence of passive dilatation ? 
 
 We may next consider the nature and amount of the expectora- 
 tion. It need scarcely be stated, that in a disease occurring 
 under such different circumstances, there is no characteristic 
 expectoration, and accordingly the various forms of mucous, 
 muco- serous, muco-purulent, and purulent secretions, have been 
 met with. The sputa may be foetid and nummular, and hae- 
 moptysis may occur, even in cases without tubercle. 
 
 A more important inquiry is that relating to the quantity of
 
 136 BEONCHITIS. 
 
 the secretion, the more especially as Laennec has dwelt strongly 
 on this point in speaking of the causes of the disease. Now 
 without denying the influence of a superabundant secretion in 
 producing this disease, yet we must admit it as a cause which 
 is not constant, and even by itself incompetent for the effect. 
 Dilatation has been met with where the secretion has been 
 scanty, or even wanting, and an abundant expectoration may 
 occur without the lesion in question. We must then seek for 
 other causes which may assist in the production of the disease. 
 To some of these I have already alluded, and future investi- 
 gations must determine how far in addition to the chronicity, 
 violent cough, and abundant expectoration, described by Laennec, 
 the organic changes resulting from hypertrophy or inflammation 
 of Andral, or the mechanical dilatation consequent on the 
 obliteration of other tubes, which Keynaud has shown to be 
 perhaps the most common cause, other circumstances may act. 
 And it seems highly probable that among these we shall yet 
 reckon the loss of tonicity of the longitudinal fibres, and the 
 paralysis of the circular muscles of Reissessen, and even of the 
 cilia of Purkinje and Yalentin. 
 
 This disease is met with uncomplicated or combined with 
 other affections, particularly tubercle : we have the authority of 
 Laennec for stating that its most ordinary seat is in the upper 
 lobe of the lung, although it may exist in every portion of the 
 organ, a fact strongly bearing on its connexion both with obli- 
 teration of the minute tubes and tubercle. Indeed in most of 
 the cases where it has occurred in the inferior portions, its first 
 seat seems to have been above, as shewn by the greater amount 
 of the lesion. Andral, however, details one case, in which the 
 dilatation existed in the middle lobe of the right lung ; but even 
 here a calculous concretion was found in the upper portion. 
 With this latter affection it is commonly combined ; indeed I 
 do not remember a single instance where I have found pulmo- 
 nary calculi without a corresponding bronchial dilatation. We 
 shall see hereafter how strongly this bears on the subject of 
 tuberculous disease. 
 
 But there is another combination which has not been suffi- 
 ciently noticed, namely, that with dilatation of the air cells, the 
 vesicular emphysema of Laennec, of which the following is a 
 remarkable example. A man, aged 40, was admitted into the
 
 BRONCHITIS. 
 
 137 
 
 Meath Hospital, labouring under the sj-mptoms of chronic 
 bronchitis, with paroxysms of orthopncea, and with copious ex- 
 pectoration of masses of a yellow colour, flowing together like 
 the white of eggs. He stated that he had been subject to an 
 asthmatic cough since boyhood. It was obsei-ved that he con- 
 stantly lay on the left side, which presented nothing remarkable 
 in form, but the right was singularly convex, particularly on its 
 anterior portion, where a remarkable prominence existed, ex- 
 tending from the middle of the third to that of the seventh rib. 
 On percussion, the right side sounded morbidly clear, but the 
 respiratory murmur was generally feeble, and over the whole 
 thorax nearly replaced by a sibilous rale ; the heart's impulse 
 was strong, and felt over the anterior portion of the right side, 
 and with violent pulsation at the ensiform cartilage. 
 
 This case, which was sent in as an example of hydrothorax, 
 we considered to be one of Laennec's emphysema, with severe 
 bronchitis and hypertrophy of the heart. After he had remained 
 in hospital some time we observed that the postero-inferior 
 portion of the left side was dull, and that over this side 
 considerable resonance of the voice, though not amounting 
 to pectoriloquism, could be heard. Soon after this the patient 
 sunk. 
 
 On dissection the lungs did not collapse, but appeared firmly 
 bound down by adhesions so universal, that the cavities of the 
 pleurae were completely obliterated. In both lungs the lobes 
 were united, but this union must have been the consequence of 
 recent inflammation, as the coagulable lymph thrown out was 
 soft, and the interlobular pleura beautifully injected with red 
 vessels. The adhesions between the pulmonary and costal 
 pleurae, on the contrary, appeared to be the consequence of a 
 former aifection, as they were exceedingly strong, and on the 
 antero-superior part of the right lung the membranes were 
 converted into a thick, white, and cartilaginous substance. The 
 whole of the right lung was in a state of emphysema, all the air 
 cells appearing dilated, and the pleura raised in many places 
 into vesicles the size of a walnut ; when cut into, these vesicles 
 were found divided by membranous septa, perpendicular to the 
 surface of the lung. The volume of this lung was double that 
 of the left, its bronchial tubes filled with muco-purulent fluid, 
 and their lining membrane of a bright red colour. The left
 
 138 BRONCHITIS. 
 
 lung was much dimmislied in size ; the upper part covered 
 with large vesicles, the lower of a pale colour and flabby con- 
 sistence, but still presenting the dilated air cells. Upon cutting 
 into this portion of the lung, we thought the knife had entered 
 an abscess, as a large quantity of a viscid and yellowish fluid 
 flowed out, and displayed a cavity in the pulmonary tissue, 
 capable of containing a moderately sized apple ; but on closer 
 examination this cavity proved to be an enormously dilated 
 bronchial tube, as it was lined by a delicate mucous membrane 
 continuous with that of the bronchial tubes, and beneath which 
 traces of the cartilaginous rings, peculiar to these canals, could 
 be observed. All the bronchial tubes on this side were more or 
 less affected, so that the lung appeared to contain many small 
 abscesses. Posteriorly the pulmonary tissue was of a dark grey 
 colour and cartilaginous hardness, evidently the product of 
 former inflammation. In the immediate neighbourhood of the 
 dilated tubes, however, it was solid, but of a red colour and 
 soft consistence, the consequence of more recent inflammation ; 
 the heart was more than twice its natural size, the right ventricle 
 greatly enlarged and thickened, the left thickened without 
 alteration of its capacity. Dilatation of the auricles ; no 
 disease of the valves ; aorta healthy. 
 
 I have inserted this case as it illustrates some interesting 
 points in the history of the disease. It shows that in the same 
 subject a chronic bronchitis may produce very different effects 
 upon each lung ; thus in the right lung the lesion was essen- 
 tially a dilatation of the air cells, the bronchial tubes being 
 scarcely, if at all, affected, while in the left the very reverse had 
 occurred; and the bronchial tubes were so dilated as to repre- 
 sent pulmonary abscesses. It is difiicult indeed to conjecture 
 as to the progress of disease in this patient. It seems pro- 
 bable, from the occurrence of the sub-pleural vesicles, that a 
 degree of dilatation of the air cells in the left lung had once 
 existed ; in other words, that the state of the air cells in both 
 lungs was, at one time, similar, but that from some cause the 
 bronchial tubes in the left entered into a separate pathological 
 condition, and by their gradual but extreme dilatation pro- 
 duced a real atrophy of the lung. That the lung was actually 
 atrophied was shown by the fact, that its absolute size was 
 diminished, a diminution which appeared more remarkable
 
 BRONCHITIS. 139 
 
 when the organ was contrasted with the right lung, and fully 
 explained the remarkable difference of size of either side of the 
 chest, observed during the life of the patient. 
 
 In discussing the diagnosis of this affection it must be 
 admitted, that it is surrounded with difficulties, inasmuch as 
 there is no point of absolute difference between its symptoms 
 and physical signs, and those of other diseases, in which cavities 
 are formed in the lung. We see it occurring at all ages, with a 
 great variety of symptoms, whether we consider the constitu- 
 tional suffering or the secretions of the lung, and produc- 
 ing changes whose physical signs are commonly identical with 
 those of ulcerous cavities communicating with the bronchial 
 tubes. Further, it is to be recollected, that more or less of 
 the lesion is to be met with in many of the chronic diseases 
 of the lung, so that it is only when it becomes excessive and 
 prominent that its sejoarate diagnosis will be called for. Now 
 as the symptoms and signs consist of cough, expectoration, and 
 indications of cavities, it is plain that in most cases the question 
 will be between this disease and phthisis. 
 
 Before entering further into the diagnosis, let us recollect the 
 changes produced in this disease. These are, first, a continuous 
 dilatation, next, a succession of local dilatations, and, thirdly, a 
 great enlargement of a tube, so as to represent a pulmonary 
 abscess. Now it is plain, that these lesions must give different 
 physical signs ; with those of the first we are, as yet, not suffi- 
 ciently acquainted. In all probability they will be found to 
 consist in an extensive bronchial respiration without the dnlness 
 of solidification, and a strong but diffused resonance of the voice. 
 This form of the lesion will not present the signs of excavations 
 containing fluid, and communicating with the bronchi, and hencg 
 will be less likely to be confounded with phthisis. 
 
 In considering the diagnosis of the latter varieties, it cannot 
 be denied that it is one of great difficulty ; yet the subject is 
 full of interest, as we here first meet with an illustration of one 
 of these fundamental principles of physical diagnosis to which 
 I have briefly alluded in the first section of this work, I mean 
 that of successive observation. But previous to our entering on 
 the physical signs, let us inquire whether the constitutional 
 symptoms can guide us in distinguishing the disease from 
 phthisis.
 
 140 BRONCHITIS. 
 
 To him who has only studied the subject of phthisis in 
 books, or whose actual experience is limited, it would appear 
 an easy matter to draw the line. But in truth, the tuberculous 
 disease is so protean an affection, that comparatively little value 
 is to be placed in the absence of auj^ of its more charac- 
 teristic sj^mptoms. The advance of medicine has shewn that 
 this diagnosis is not so easy as Laennec conceived it to be ; 
 and that cases will occur in which, in the present state of our 
 knowledge, it is difficult, if not impossible, to avoid error. 
 The absence of the constitutional symptoms of phthisis, and 
 the long duration of the aff"ection, are the points principally 
 relied on ; but we find that any of these symptoms may be 
 absent in true phthisis ; that this aff"ection may last for many 
 years ; and that cases, which seem to have been nothing but 
 bronchitis for years together, terminate by tuberculization and 
 ulceration of the lung. On the other hand, there is no symptom 
 of phthisis which may not occur in dilatation of the tubes ; pain, 
 haemoptysis, cough, all varieties of expectoration, fever, emacia- 
 tion, atrophy of the lung, &c. 
 
 I do not mean to say, that these symptoms are of as common 
 occurrence in dilatation of the tubes as in phthisis ; such a 
 statement would be far from the truth, but that they may occur 
 is certain ; and hence, the absence of the usual symptoms of 
 phthisis will not assist us in all cases. The same remark 
 applies to the duration of the disease, though not so strongly ; 
 for although dilated tubes may occur in a few months, and 
 phthisis last for many years, yet it cannot be denied, that these 
 are the exceptions rather than the rule. And it is to be borne 
 in mind, that the cases of acute dilatation are principally met 
 with in children. 
 
 As illustrative of the occasional similarity of symptoms 
 between this disease and phthisis, I shall abstract a case by 
 M. Audral, which was considered by M. Lerminier to be one 
 of chronic phthisis. In this patient, a disposition to contract 
 bronchitis had existed for several years, and during the year 
 1821, he complained of a slight oppression. In December he 
 had haemoptysis for the first time, and in the course of two 
 months his expectoration became abundant, puriform and foetid, 
 these symptoms were succeeded by pain of the left side. 
 During the month of April following, the expectoration lost its
 
 BRONCHITIS. 141 
 
 nummular character, but became extremely abundant and fcBtid ; 
 prostration and emaciation continued, and the patient was 
 attacked by shiverings in the evening, followed by burning 
 heat during the night, but it was observed that he never 
 sweated, a circumstance which excited some surprise, as it was 
 considered that he laboured under pulmonary phthisis : diar- 
 rhoea succeeded, and the patient sunk in the month of June 
 following. Here, with the exception of the absence of sweat- 
 ing, all the other symptoms, both in their character and mode 
 of succession, were very similar indeed to those of suppurative 
 phthisis. Nor did the study of the physical signs throw more 
 light on the subject ; the respiration was feeble on the left and 
 loud on the right side ; the voice resounded strongly over the 
 whole left side, and in the mammary region and at the inferior 
 angle of the scapula, there was evident pectoriloquism. Yet 
 on dissection no tubercles were found, but the disease was shewn 
 to be an example of extreme dilatation of the bronchial tubes of 
 the left lung with the same disease, though in a less degree, in 
 the right. 
 
 I apprehend that in the present state of diagnosis the true 
 nature of such a case could not be determined by the most ex- 
 perienced observer ; the disease wanted the extreme chronicity 
 which we are taught is necessary for the production of great 
 dilatation of the bronchial tubes. There was haemoptysis in its 
 early periods, purulent expectoration, emaciation, hectic fever, 
 and diarrhoea, and the physical examination shewed feebleness 
 of respiration, with the signs of cavities in one of the lungs. It 
 is true, that the foetor of the expectoration, the absence of 
 sweating, and the situation of the cavities, were circumstances 
 somewhat differing from those of ordinary phthisis. But there is 
 not one of them which might not occur in phthisis ; and when the 
 other signs and symptoms existed, it is plain tbat from these 
 alone no physician could have determined that the case was one 
 of dilated tubes, and not of phthisical or other ulcerous cavities. 
 
 This case shews the difficulty that may attend the question as 
 to the symptoms merely. In the same way were we to base our 
 diagnosis on the duration of the case, we might also fall into 
 error; for as I have before stated, we may have true phthisis 
 advancing for many years, and when occurring in the adult, 
 often without its usual constitutional symptoms. Bronchitis,
 
 142 BKOXCHITIS. 
 
 on the other hand, may, after a period of several years, pass im- 
 perceptibly into tuberculous disease of the lung ; and although 
 it might be urged, that if the patient was of a tuberculous 
 diathesis, that disease would have shewn itself before a period of 
 several years had elapsed ; yet I have now seen so many cases of 
 bronchitis, which continued for years as such, and ultimately 
 terminated in tuberculous ulceration of the lung, that I place 
 but little confidence in such an argument. 
 
 Thus, if we suppose a case presenting symptoms of cough, 
 wasting, and puriform expectoration, and in which we detect a 
 cavity or cavities, it appears to me, that in determining the 
 nature of these cavities we shall be but little assisted by the 
 knowledge that the patient has had cough for four, eigh^t, or ten 
 years, for he may have had a bronchitis passing into phthisis, or 
 primary tuberculous disease of the lung ; and the cavities which 
 we discover may have been but recently fonned, and, for all we 
 know, advancing by ulceration. 
 
 But is the question of time of no importance in determining 
 this point ? I would answer, that taken alone, or even in com- 
 bination with a solitary observation of the case, it has but little 
 value. Here we see an instance of the necessity of successive 
 observations, and the difficulty which often attends diagnosis 
 when we see a patient for the first time. But if we had made 
 several successive observations, if we had ascertained that the 
 signs of cavities had existed for years with but little change, 
 and without the usual symptoms of phthisis, or the signs of 
 tubercular extension, then indeed the question of time is of great 
 importance, and of course the greater the period of duration the 
 more certain the diagnosis. 
 
 Physical Signs of Dilatation of the Tubes. — It is obvious 
 that the signs of this disease must vary, not only according to 
 the extent of the lesion, but also with its nature. Thus the 
 signs of the simple continuous dilatation of many tubes will differ 
 from that in which local distentions are produced, so large as to 
 represent pulmonary abscesses. In addition to the signs result- 
 ing from these forms of dilatation, we have further those from 
 the compression of the j)ulmonary tissue, so that the sources of 
 the signs are, first, simple enlargement of the bronchial tubes, 
 next, the existence of cavities, and thirdly, the compression and 
 atrophy of the lung.
 
 BRONCHITIS. 143 
 
 It would appear, that when the disease is confined to a single 
 bronchial tube it may escape detection ; thus, in one of Andral's 
 cases, the patient had suffered for five or six years from bronchitis. 
 During the two last years an organic disease of the stomach 
 supervened, which ultimately proved fatal, but during his stay in 
 hospital no physical sign of dilatation Avas detected ; the chest 
 sounding clear, and the respiration being heard on both sides, 
 mixed with the usual bronchial rales. On dissection, a cal- 
 careous concretion was found in the upper portion of the right 
 lung, and the mucous membrane of the bronchi presented 
 numerous red patches, the tubes being filled with mucus. In 
 the middle lobe of the right lung a bronchial tube was found 
 dilated to nearly three times the diameter of that from which it 
 arose. The lesion was confined to this particular tube, and was 
 not pointed out by any physical sign. The same author details 
 another case, in which an obstinate cough, with abundant puri- 
 form expectoration, had existed for a length of time. In this 
 patient a marked mucous rattle existed on the left side, being 
 heard in the subspinous fossa and the mammary region : here 
 the sound on percussion was clear, and there was no morbid 
 resonance of the voice. It was found on dissection that the 
 bronchial tubes of the inferior lobe were inflamed, filled with 
 puriform mucus, and in many places presenting small dilatations. 
 Here, as Andral remarks, the seat and extent of the bronchitis 
 was pointed out by auscultation, but there was no sign which 
 could lead to the suspicion of bronchial dilatation. 
 
 I have already stated, that we are not yet sufiiciently informed 
 as to the physical signs of the extensive but continuous dilatation 
 of the bronchi. In a case of this kind, however, recorded by 
 the author from whom I have just quoted, the physical signs 
 were a resonance of the voice, not amounting to true pecto- 
 riloquism. In the same situation he states that a species of 
 bronchial respiration occurred, as if the individual was blowing 
 strongly at the extremity of the cylinder, while everywhere else 
 the respiratory murmur was heard as usual. On dissection, 
 in the situation corresponding to this phenomenon, namely, the 
 upper lobe of the right lung, all the tubes were found dilated. 
 To those who are familiar with stethoscopic investigations the 
 relation between the signs and organic changes must appear 
 sufficiently obvious. In some cases, as Laennec has described.
 
 144 BEONCHITIS. 
 
 this puffing or blowing respiration gets that character which he 
 denominates veiled, by which is meant a modification, giving the 
 idea of a thin veil, or septum, interposed between the observer 
 and the seat of the sign, and moving at each act of respiration. 
 
 In the third variety, cavities of different sizes are produced, 
 which contain a fluid, and communicate freely, not only with 
 the original trunk, but with minor branches, and consequently 
 their physical signs are identical with those of ulcerous cavities 
 of the lung. They present cavernous respiration, gurgling, and 
 pectoriloquism ; and if anything was wanting to add to the 
 resemblance between this disease and phthisical cavities, it is, 
 that the seat of both lesions is most commonly in the upper 
 lobes of the lung. 
 
 It is obvious that all these physical signs are common to other 
 diseases of the lung, and hence it is only by their existence in a 
 case in which the duration and nature of the symptoms are 
 opposed to the idea of ulcerous caverns, that we can arrive at 
 the probable diagnosis of dilated tubes. But, on the other 
 hand, where the symptoms, both local and constitutional, re- 
 semble phthisis, as closely as in the cases described by Andral 
 and Louis, it seems impossible to arrive at a certain diagnosis, 
 at least on a first examination ; and the probabilities as to 
 frequency being always in favour of phthisis, we must, unless 
 some more certain sign be discovered, always incline to the 
 opinion that the case is one of softened tubercle. 
 
 But the facility of arriving at a diagnosis in any case turns on 
 other circumstances than the mere observation of signs and 
 symptoms, with which we have become acquainted for the first 
 time. Much depends on the observation of the progress of 
 the case, and the modification of signs, which has occurred in 
 any given space of time. For example, we are called to a patient 
 who presents the signs of a cavity, but from some peculiarity in 
 the symptoms it becomes a question whether this is a phthisical 
 ulcer or a dilated tube. Now this can be often determined by 
 successive observations of the case, by which, if we discover an 
 extension of the cavity too rapid to be explained upon the 
 hypothesis of dilated tubes, we may at once arrive at the diag- 
 nosis of phthisis. I have frequently had recourse to this mode, 
 and always with success. It is obvious that the cavity may 
 remain stationary, or may extend, and that it is only in the
 
 BRONCHITIS. 145 
 
 latter case that this diagnosis can be made available, but when 
 we can employ it, is almost always pathognomonic, and forms an 
 excellent illustration of the value and certainty of physical signs. 
 
 Another source of diagnosis of a similar character may be 
 drawn from the observation by percussion. In a considerable 
 number of cases of phthisical abscess, the signs of the cavity are 
 often preceded by absolute, and in all by comparative dulness. 
 This we can understand, when we recollect that the phthisical 
 abscess is formed by the suppuration of turberculous masses 
 and of solidified lung. But these conditions do not precede the 
 dilatation of the bronchial tubes, for which solidity of the pul- 
 monary tissue is by no means a necessary antecedent. On the 
 contrary, if dulness should occur, it would be in the advanced 
 stages of the disease, when the intervening pulmonary tissue 
 had become compressed and carnified. Hence we say, in general 
 terms, that in phthisis tve have first dulness, and then cavity, 
 while in dilated tubes we have first cavity, and then dulness. 
 
 But the bronchial tubes may be sufficiently dilated to give 
 pectoriloquism and bronchophonia without any dulness. Of 
 this the following case, taken from the work of Louis,* is a 
 striking example. 
 
 A patient, aged 55, Avho had been subject to dyspnoea from 
 infancy, had laboured under a chronic bronchitis for several 
 years. This affection was always worse in winter, and at that 
 period he emaciated considerably. During the last month he 
 had lost his appetite, and the cough had become more trouble- 
 some ; the debility had increased, but there had been neither 
 pain of the chest nor haemoptysis. 
 
 On admission he presented the following symptoms : he was 
 pale ; the lower extremities slightly cedematous ; the belly large, 
 and obscurely fluctuating : pulse but little accelerated : cough 
 moderate : sputa opaque and greenish : tongue of a dirty white 
 in the centre, with thirst, and complete anorexia. During the 
 last fifteen days he laboured under diarrhoea and night sweats. 
 
 On percussion the chest was everywhere sonorous, yet the 
 respiration was almost perfectly tracheal. In the upper portion 
 of the right lung, both anteriorly and posteriorly, there existed 
 a large crepitus ; and in these situations the resonance of the 
 voice amounted to imperfect pectoriloquism. 
 
 * Recherches Anatomico-Pathologiques sur la Phthisic, Obs, II. 
 L
 
 146 BRONCHITIS. 
 
 Until the period of his death, which took place on the 19th 
 of December, his debility was progressive, the dyspncea became 
 every day worse, and during the last week his sputa resembled a 
 greenish pus. The physical signs on the right side underwent 
 no change, but after he had been a week in hospital, the left 
 sub- clavicular region presented a mucous rale, mixed with 
 gurgling. Posteriorly the sound of respiration was strong, and 
 the resonance of the voice considerable. 
 
 On dissection the upper portion of the right lung seemed to 
 be converted into a great number of cysts, varying in size from 
 that of a pea to that of a large nut. These proved to be nothing 
 but dilated tubes, containing a reddish mucus, mixed with a 
 yellow opaque fluid. They were in opposition, and were formed 
 of a very thin mucous membrane, which was red, firm, and 
 ^continuous with that of the bronchial tubes, which were other- 
 ^wise perfectly healthy. The same lesion existed on the upper 
 portion of the left lung, and extended about an inch and a half 
 from the summit ; the dilatation here was less decided than in 
 the right lung ; no tubercles nor tuberculous matter could be 
 . anywhere discovered. 
 
 This patient was considered by M. Louis to labour under an 
 organic disease of the abdomen, and a chronic and circumscribed 
 phthisis. He states, that the perfect sonoreity of the upper 
 portion of the chest made him at first doubtful, but the results 
 of auscultation were greatly in favour of the existence of 
 tuberculous caverns. Thus the tracheal respiration, the muco- 
 crepitating rale, and the imperfect pectoriloquism, and above 
 all, the situation of these signs, seemed to point out an an- 
 fractuous tuberculous cavity. He candidly admits his error, and 
 remarks, that if the affection was tuberculous, and that it had 
 lasted so long as ten years, it should by that time at least have 
 produced an induration of the lung sufficient to give a dull sound 
 on percussion. He further remarks in a note, that he is not 
 ignorant of the fact, that a tuberculous cavity, with indurated 
 parietes, may exist with clearness of sound on percussion, but 
 that in such cases the cavity must be of great size. That the 
 last observation is true I feel fully satisfied ; I have never seen 
 a tuberculous cavity which gave a clear sound on percussion, 
 unless where the cavity was very large and well defined, and 
 even here the sound on percussion, though clear, is not similar
 
 BRONCHITIS. 147 
 
 to that of the pulmonary cells, but has a somewhat tympanitic 
 character. On the other hand, anfractuous phthisical cavities, 
 such as would produce the phenomena detailed in this case, are, 
 as far as my experience goes, always accompanied by dulness of 
 sound on percussion ; so that if this rule be general, it would 
 follow, that the occurrence of the signs of anfractuosities with 
 clearness of sound on percussion, will be diagnostic of dilated 
 tubes : of course such a diagnosis should be corrected by the 
 history of the case and the actually existing symptoms. I may 
 observe further, that in this case a combination of certain signs 
 occurred, which I have never found in any case of phthisis, nor 
 can I conceive its existence possible in that disease. I allude to 
 the combination of extensive tracheal resinration with clearness 
 of sound on percussion. In phthisis the existence of the first 
 of these signs is accompanied by decided dulness in almost 
 every case. To this I shall return when describing the signs of 
 pulmonary tubercle. 
 
 As the treatment of this aifection does not in any shape differ 
 from that of chronic mucous catarrh, I shall not further allude 
 to it here, but at once proceed to sum up the state of our 
 knowledge of its diagnosis. It may be stated : 
 
 1st. That the cases of this disease which have been described 
 by authors, may be divided into three classes. 
 
 (a) Cases in which symptoms of chronic catarrh, with copious 
 expectoration, have existed for a number of years, varying from 
 ten to fifty, or even more, and without the constitutional 
 symptoms of phthisis. 
 
 (&) Cases presenting the symptoms of phthisis, in which the 
 constitution suffers severely ; the disease may last from five 
 months to five or even ten years. This last case has been 
 principally observed in adults. 
 
 (c) Cases which may be termed acute. These are to be ob- 
 served in children after hooping cough, and the disease has 
 occurred in the space of three months. 
 
 2nd. That we meet with this affection as an uncomplicated 
 disease, or in conjunction with other lesions, of which obliteration 
 of the bronchi and tubercle are the most common. 
 
 3rd. That dilatation of the bronchial tubes may be accom- 
 panied by an atrophy of the air cells, and thus the affected side 
 of the chest be diminished in volume. 
 
 l2
 
 148 BRONCHITIS. 
 
 4th. That in the same case we may observe a predominance 
 of dilatation in the bronchial tubes of one lung, and of the air 
 cells in the other. 
 
 5th. That the continuous dilatation may affect a single tube 
 without presenting any marked physical signs. 
 
 6th. That we may even have numerous small dilatations 
 without other phenomena than those of ordinary bronchitis. 
 
 7th. That when the continuous dilatation is decided and 
 extensive, the phenomena which have been observed are the 
 blowing respiration and extended resonance of the voice. In 
 some cases too the veiled puff has been observed by Laennec. 
 
 8th. That when the local dilatations are decided, the phe- 
 nomena are those of suppurating cavities communicating with 
 the tubes. 
 
 9th. That although it is extremely difficult, on account of 
 the similarity of the physical signs, and in some cases of 
 symptoms, to distinguish this disease from phthisis with sup- 
 purating cavities, yet by observing the mode of combination 
 and the succession of the signs, the rate of increase of the 
 cavities, and the connexion of these with the history of the 
 case, we may, in some cases at least, arrive at a diagnosis which 
 shall be correct. 
 
 10th. That where a number of tubes are dilated in one lobe, 
 the case may be distinguished from tuberculous anfractuosities 
 by the clearness of sound on percussion. 
 
 11th. That in cases where we have had an opportunity of 
 examining the patient from an early period, the fact of dulness 
 not having preceded the signs of a cavity may enable us to dis- 
 tinguish the disease from phthisis. 
 
 12th. That in the same manner the combination of extensive 
 tracheal respiration with clearness of sound,* seems to be diag- 
 nostic of dilated tubes. 
 
 * From the very improper mode of examining the post mortem appearances in the 
 lungs, which is commonly adopted in this country, a difference of opinion as to the 
 actual nature of the cavities may occur ; and I have seen instances in which, after 
 this irregular dissection, it was not easy to determine the question. I have been 
 in the habit of directing the attention of my pupils to the follbwing points, which 
 enable us to set the matter at rest. The lung should be dissected by means of a 
 fine pair of scissors, in which the end of one blade is blunt, and turned upwards. 
 This instrument may be called a hronchotome. The operator, beginning at the bifm-- 
 cation of the trachea, should follow the tubes to the surface of the lung, and lay 
 as many of them open as possible. For the finer tubes he may use a slender 
 grooved director and a Daviel's scissors. Now if the case be one of simple dilated
 
 BRONCHITIS. 149 
 
 ULCERATION OF THE BRONCHIAL TUBES. 
 
 I shall not occupy many pages on this subject, which is one 
 of more interest to the pathological anatomist than to the 
 student of diagnosis. As yet, indeed, we are ignorant of any 
 symptom or sign which may be considered pathognomonic of 
 the lesion in its simple form, where the ulcerative process 
 has commenced in, and is confined to, the mucous surface of 
 the tube. And even in these more complicated cases of ulce- 
 ration and perforation of the lung, we recognize the occurrence 
 of bronchial ulceration, less by any signs proper to it as by 
 phenomena resulting from other mechanical conditions, which 
 have resulted from the primary disease. Thus in phthisical 
 abscesses, and in pneumothorax by perforation, the signs of 
 gurgling and metallic tinkling point out a communication with 
 the bronchial system ; but while the process which produced 
 that communication was going on, there were no characteristic 
 or proper symptoms or signs. 
 
 When we compare the frequency of ulceration in the respira- 
 tory and gastro-intestinal mucous membranes, we are struck with 
 the great preponderance of the latter. This is particularly 
 observed in the acute diseases, in which we find that the in- 
 testinal surface so often runs into extensive ulceration, a character 
 very different from that of the lung, in which acute bronchitis 
 commonly destroys life Avithout a perceptible ulceration of the 
 surface. Indeed the great majority of bronchial ulcerations are 
 the result of a chronic disease. 
 
 The greater liability of the digestive mucous membrane to 
 ulcerate may be understood, when we reflect on the much more 
 extensive development of the mucous glands in that system, 
 the greater necessity for their activity in the normal state, 
 their being open to the action of a great variety of heterogeneous 
 matters, and the varied sympathetic actions which the numerous 
 abdominal viscera exercise upon them. 
 
 tubes, he will observe, that all the cavities are in the direction of the tubes, that no. 
 transverse division of there can be observed at their junction with the cavity, and 
 that the mucous lining of the tube is perfectly continuous with that of the cavity, 
 which may also present the cartilages, and the longitudinal and circular fibres in a 
 state of hypertrophy. These cavities also differ remarkably from phthisical excava- 
 tions in never presenting the transverse bands; and should tubercles be absent in 
 other portions of the lung, the point will be set completely at rest.
 
 150 BRONCHITIS. 
 
 Andral states, that these ulcerations are more frequent in the 
 larynx than in the bronchial tubes, and more common in the 
 latter than in the trachea. This statement seems certainly true 
 with respect to primary ulceration ; but if we take in the cases 
 of tuberculous phthisis, we shall find a great preponderance in 
 favour of the bronchial tubes over even the larynx. The same 
 author has divided the cases of bronchial ulceration into two 
 classes, according to the point as to whether the tube has been 
 destroyed from within outwards, or the reverse. I shall not 
 enter further into this discussion, and shall conclude this short 
 notice by enumerating some of the principal instances of 
 bronchial fistulae. 
 
 (a) Suppurated tubercle, and other ulcerous cavities of the 
 lung. 
 
 (b) Empyema opening into the lung. 
 
 (c) Evacuation of an hepatic abscess through the bronchial 
 tubes. 
 
 (d) Communication between an aneurism of the aorta and the 
 lung. 
 
 (e) Communication between the oesophagus and trachea. 
 (/) Fistulae of the tubes opening into the bronchial glands.* 
 (^f) Communication between the thyroid gland and trachea. 
 (h) Perforation of the pulmonary artery.f 
 
 Other cases have been met with, but in the above list we have 
 the most frequent and best attested examples of the lesion. It 
 may be observed finally, that the communications thus formed, 
 in most instances at least, result from ulceration, commencing 
 either within the bronchus, and ^perforating outwards, or external 
 to the tube, and taking the reverse direction. 
 
 DILATATION OF THE AIR CELLS. EMPHYSEMA OF THE LUNG OF 
 
 LAENNEC. 
 
 It seems to me that in adopting the name of dilatation of the 
 air cells for this disease, we avoid much error and confusion. 
 The term emphysema of the lung, given to it by Laennec, is 
 improper, inasmuch as emphysema is not the principal character- 
 istic of the disease, and though a frequent, yet still by no means 
 
 * Les Maladies tuberculeusea des Glandes Bronchiques, par J. M, Berton. 
 t Berton, op. cit.
 
 BRONCHITIS. 151 
 
 a constant complication. Indeed it seems certain, that even if 
 we admit the existence of the pleural vesicles of Laennec to have 
 been produced by rupture of the cells, yet that this may exist 
 without true general emphysema of the lung. And it is 
 difficult to conceive how emphysema could exist in the lung 
 without becoming diffused over the body. 
 
 That these vesicles under the pleura are often formed by the 
 distention or by the coalescence of many distinct air cells, rather 
 than by the effusion of air into the subserous cellular membrane, 
 is, I am sure, true in a considerable number of cases. For 
 although we may, in some cases, succeed by pressure in changing 
 the position of the vesicle, yet we shall often fail, shewing that 
 the air is confined, and in no respect under the same conditions 
 as in the true emphysema of cellular membrane. 
 
 We may consider this affection under three heads. 
 
 First. Simple dilatation of the cells without rupture. 
 
 Second. Dilatation of the cells, with rupture of their parietes ; 
 so that several shall coalesce, and form a cavity of some extent. 
 
 Third. The combination of the second condition with a true 
 emphysema of the inter-lobular cellular texture, but which is 
 generally very slight. To this subject I may hereafter return. 
 
 This disease consists essentially in a dilatation of the air cells. 
 The lung becomes enlarged, and the whole quantity of air within 
 the thorax is increased. Like the preceding affection it is most 
 commonly the result of a chronic irritation of the mucous mem- 
 brane of the lung ; but it differs from it in these particulars, 
 that while in the former disease the irritation engaged the 
 larger tubes, and was generally accompanied by copious secretion, 
 in the latter we find that the most minute tubes, and even the 
 air cells are the cavities affected, and the secretions more often 
 scanty, viscid, and unelaborated. 
 
 Various explanations have been given of the formation of this 
 disease.* It has been conceived that the long continued and 
 violent coughing acts in distending the air cells beyond their 
 ordinary dimensions, and from this frequently repeated and long 
 continued dilatation they at last become permanently enlarged. 
 In addition to this, it is held, that the viscid secretion that exists 
 in the minute bronchial tubes acts in blocking these up during 
 expiration, the force of which is not so great as that of inspi- 
 * See Appendix, Note A,
 
 152 BRONCHITIS. 
 
 ration, and hence assists in producing dilatation of the air cells 
 by keeping them in a permanently distended state. There 
 can be little doubt that both these causes act, and their 
 combination seems sufficient to explain the lesion. The 
 existence of an additional cause has been suggested by M. 
 Meriadec Laennec, namely the expansion of the inspired air 
 in consequence of the temperature of the body. Under this 
 supposition the air entering the cell at a lower temperature 
 of course soon assumes that of the lung, but as its exit is 
 prevented or impeded by the inspissated mucus lining the 
 minute tubes, its rarefaction must act in dilating the air cell. 
 That this cause may have some effect I do not deny, but it 
 seems probable, that the period of its action must be very 
 limited ; and when we recollect the number of passages, through 
 the most vascular organ of the body, that the inspired air has 
 to traverse before reaching the cell, it seems hardly possible 
 that any rarefaction, which it may undergo there, would be at 
 all sufficient to dilate its cavity. It appears to me that there 
 is an additional cause not sufficiently dwelt on, and which 
 is connected with the common complication with spasmodic 
 symptoms. Under these circumstances the circular fibres of the 
 bronchi become increased in strength and in irritability, and 
 their irregular action, it is obvious, must interfere with res- 
 piration, and tend to preserve a dilated state of the chest.* 
 
 To the practical physician, however, the great point of 
 consideration is, that this disease of the lung is the result of 
 bronchitis ; and that for its prevention, alleviation, or cure, if 
 that were possible, the treatment must be conducted upon this 
 principle. These patients labour under a persistent bronchitis, 
 but are liable to repeated exacerbations, which are often 
 erroneously supposed to be spasmodic, and hence constantly 
 maltreated, but which are in all cases the result of, or accom- 
 panied by, an increase of the bronchial irritation ; the spasmodic 
 symptoms being the necessaiy result. 
 
 The facility with which we can recognize this disease depends 
 generally on its degree of development. In its slighter forms 
 
 * It is to be observed that emphysema is usually the result of a special form of 
 bronchitis — capillary — the dry catarrh of Laennec. This result is also favoured in cases 
 of hereditary emphysema by a disturbance of nutrition, which as Hertz has pointed 
 out explains its occurrence in children without previous bronchitis and its increased 
 frequency with the advance of age. — Ziemssen's Cyclopedia, vol. v. p. 357. (Ed.)
 
 BRONCHITIS. 153 
 
 it may often escape detection, but when it becomes advanced or 
 extensive its diagnosis is easy. But there is another condition 
 of great importance to be considered, namely, the amount of 
 yielding of the thoracic ivalls ; and I think I shall be able to 
 prove, that in some important respects the stethoscopic, and 
 even other signs, depend greatly on this circumstance. 
 
 Patients labouring under this disease are affected with an 
 habitual dyspnoea, which, in the earlier periods, is often 
 mitigated in summer, to return with violence during the 
 winter; they are also liable to repeated attacks of what might 
 be termed a congestive bronchitis, during which the difficulty 
 of breathing becomes extreme. 
 
 The physiognomy of these individuals is almost characteristic. 
 The complexion is generally of a dusky hue, and the counte- 
 nance, though with an anxious and melancholy expression, has 
 in several cases a degree of fulness which contrasts remarkably 
 with the condition of the rest of the body. It is probable that 
 this results from hypertrophy of the cellular membrane and 
 respiratory muscles of the face ; the first produced by repetitions 
 of venous obstruction, and the second by the violent exertion 
 of the whole system of inspiratory muscles. The nostrils are 
 dilated, thickened, and vascular. The lower lip is enlarged, 
 and its mucous membrane everted and livid, giving a peculiar 
 expression of auxiety, melancholy, and disease to the counte- 
 nance. The shoulders are elevated and brought forward, and 
 the patient stoops habitually, a habit contracted in his various 
 fits of orthopnoea and cough, and the relief which is experienced 
 from inclining the body forwards. Thus, even in bed, we often 
 find these patients sitting up with their arms folded and resting 
 on their knees, and the head bent forwards, the object of which 
 seems to be to relax the abdominal muscles, and to substitute 
 the mechanical support of the arms for that of muscles which 
 would interfere with inspiration. To such a degree does this 
 habit of stooping alter the conformation of the chest, that I have 
 seen several cases in which the acromial, inter- scapular, supra 
 and sub- spinous surfaces had become nearly horizontal. Under 
 these circumstances the apices of the scapulae are remarkably 
 projected ; anteriorly we observe the clavicles arched and 
 prominent, and the triangular spaces which answer to the inser- 
 tion of the sterno-mastoid, and scaleni muscles are singularly
 
 154 BRONCHITIS. 
 
 deep. The cellular membrane and adipose tissue of the neck 
 seem to be absorbed, but the muscles of inspiration, and par- 
 ticularly the sterno-mastoid and scaleni are hypertrophied, and 
 the thyroid cartilage is generally prominent and hard, so as to 
 feel as if ossified. When we examine the chest we discover 
 other and remarkable changes ; the sternum has lost its flatness, 
 or its relative concavity, but is thrown forward and arched both 
 in a longitudinal and transverse direction ; the intercostal spaces 
 are widened, but not dilated as in empyema : on the supero- 
 anterior portion, indeed, the chest seems smooth and convex, 
 but this is owing to the hypertrophied state of the pectoral 
 muscles, a condition induced by the long-continued difficulty of 
 respiration. When we examine the side, however, we see the 
 intercostal spaces deeply marked, and presenting no indication 
 of protrusion ; so that if we compare the disease of dilatation 
 of the cells and empyema, with respect to the external 
 conformation of the chest, we find that in the first, the appear- 
 ance of smoothness and dilatation is most evident superiorly, 
 while in the latter the reverse occurs. The lateral portions of 
 the chest are remarkably deep, and their convexity not at all 
 proportioned to that of the anterior or posterior portions of the 
 thorax. On applying the hand to the inferior sternal region we 
 generally find that the heart is pulsating with a violence which 
 we would not expect from the examination of the pulse at the 
 wrist, which is often small and feeble, while the impulses of the 
 right ventricle are given with great strength. These phenomena 
 are generally owing to an hj^pertrophied state of the right 
 cavities of the heart, which so commonly attends this disease, 
 an affection, frequently attended with a violent impulse and 
 feeble pulse. But I have observed two other causes for the pro- 
 duction of this symptom or sign, the knowledge of which is of 
 importance, inasmuch as that they may produce the phenome- 
 non in question without disease of the heart actually existing. 
 The first of these is the displacement of the heart by the dilated 
 lung, which pushes it downwards, so that its impulses become 
 manifest in the epigastric region, not from disease, but from 
 displacement. This should be observed more remarkably when 
 the pulmonary disease predominates in the left side ; in the 
 cases which I have seen, the disease afi'ected both lungs equally. 
 The other cause for this symptom is a congested and enlarged
 
 BRONCHITIS. 155 
 
 state of the liver, which not unfrequently accompanies the 
 disease, from causes sufficiently ohvious. 
 
 On examining the epigastrium, and indeed the whole of the 
 supero-anterior portion of the abdominal cavity, we commonly find 
 it full and resisting, although without any perceptible or distinctly 
 localized tumour. On percussion the right hypochondrium and 
 the epigastrium sound dull, and in certain cases we are able to 
 trace the margin of the liver below the false ribs. This may 
 depend on two causes, either an enlargement of the organ, or its 
 displacement by the flattening of the diaphragm. To the latter 
 condition of this muscle I shall presently direct the attention of 
 the reader. 
 
 Physical Signs of Dilatation of the Cells. — The physical 
 signs of this disease are few, but in most cases, where the disease 
 is established, are so well marked, and so obvious, that there 
 is hardly a disease to which physical diagnosis is more easily 
 applicable. The following are the sources of the physical signs 
 in this aff"ection : 
 
 1st. The increased quantity of air within the thorax. 
 
 2nd. The increased volume of the lung,* and the resistance 
 of the thoracic parietes. 
 
 3rd. The displacement of the heart and abdominal viscera. 
 
 4th. Bronchitis of the minute tubes. 
 
 5th. Congestion of the lung. 
 
 6th. The existence of the sub-pleural vesicles of Laennec. 
 
 On percussing the chest, in a case where the disease is decided, 
 we observe that the sound is morbidly clear. It is not, however, 
 tympanitic, as in pneumothorax, but may be described as the 
 maximum of the true pulmonary sound. t In a case of extensive 
 disease this clearness is general, but it may be partial, and merely 
 correspond to the most affected portion of the lung. It is but 
 little, if at all, increased on a deep inspiration, in which it differs 
 remarkably from the sound of the healthy lung, but agrees with 
 that of its solidified state. In fact, this character, though oc- 
 curring in states of the lung so opposite as its rarefaction and 
 solidification, is yet owing to the same cause in both, namely, 
 
 * Although this and the preceding condition may be said to imply the same state of 
 things, yet it is necessary to separate them, as the first is the source of the passive, and 
 the second an important modifier of the active auscultatory phenomena. 
 
 f The percussion sound is tersely described by Dr. Walshe as "mass of tone 
 increased; pitch lowered, quality exaggerated." 4th edition. (Ed.)
 
 156 BKONCHITIS. 
 
 the greatly diminished volume of air which can enter at an 
 inspiration. 
 
 We may further ohserve^ that the sound on percussion is often 
 clear down to the lowest portion of the thorax. The natural 
 hepatic dulness of the postero-inferior portion of the right side 
 disappears, and unless where the heart is much enlarged, the 
 sound of the cardiac region is remarkahly clear. This Avill be 
 particularly the case if the lung overlaps the pericardium to any 
 extent, of which we can easily satisfy ourselves by means of the 
 stethoscope. 
 
 But in almost all cases of such extensive disease, we find a 
 complication with enlargement of the heart, the result of the long- 
 continued and increasing obstruction to the pulmonary circulation, 
 and this will give an increase of dulness over the organ, 
 particularly at its right side. We then tind that there is dulness 
 from tlie situation of the apex of the left ventricle as far as the 
 right side of the sternum ; and as Piorry has remarked, the extent 
 of this dulness may be found to vary according to the degree of 
 pulmonary obstruction. This is the most common case ; but in 
 a few instances, even though the enlargement of the heart be 
 considerable, we find in these regions a clear sound on percussion, 
 or, at all events, a want of dulness commensurate with the heart 
 disease, a circumstance explicable by the increased volume of the 
 lung, which, by throwing the parietes forwards, buries the heart 
 in the thoracic cavity. In such cases the impulse of the organ 
 ceases to be a measure of its disease, and we are surprised at 
 finding an hypertrophied heart, although, during life, the impulse 
 at the side' and lower sternal regions had been slight. As a 
 general rule we may state, that where this complication exists 
 with a distinct impulse, the sound, on percussion of the cardiac 
 region, will be dull. 
 
 But the morbid clearness of the chest is not met with in all 
 stages of the disease ; it is only observed when the afi'ection has 
 arrived to an advanced degree, and may be altogether wanting in 
 the earlier periods. A patient may have a degree of dilatation of 
 the air cells sufficient to give decided feebleness of respiration, 
 without any perceptible increase in the clearness of sound. Of this 
 I saw a remarkable instance in a patient who was admitted into my 
 wards, and who presented a group of symptoms and signs which 
 led me to suspect the existence of an aneurism of the aorta ; his
 
 BRONCHITIS. 157 
 
 complaints had been of about five months' standing., up to which 
 time he had enjoyed good health ; he then contracted cough, 
 followed by severe dyspnoea on exercise, and some pain in the back 
 and upper portion of the chest. We found that both sides 
 sounded equally upon percussion, nor was the sound at all 
 morbidly clear. The respiration in the right lung was puerile, 
 while in the upper portion of the left it was exceedingly feeble. 
 The impulse and sound of the heart, as observed below the 
 mamma, seemed natural, but a double pulsation could be heard 
 at the upper portion of the left side ; there was no bruit de 
 soufflet, dysphagia, or laryngeal breathing. 
 
 Here was a group of symptoms and signs, which I thought 
 might possibly depend upon a small aneurismal tumour, com- 
 pressing the left bronchus. But I made no positive diagnosis in 
 the case. The patient some time afterwards died with effusion 
 into the chest ; and on dissection it was found that there was no 
 aneurism, but that partial dilatation of the air cells existed, 
 affecting only the upper portion of the left lung, and that the 
 right cavities of the heart were dilated and somewhat hyper- 
 trophied. The feebleness of respiration was clearly attributable 
 to the dilatation of the air cells ; and the case shews, that 
 this lesion may exist to such a degree as to give distinct 
 stethoscopic signs, although the sound on percussion be not 
 perceptibly increased. In other cases too I have found on 
 dissection, dilatation of the air cells to some extent, although 
 during life percussion gave no unusual results. 
 
 I now proceed to consider the remaining sources of physical 
 signs in this disease, or those which are the principal causes of 
 the active auscultatory phenomena. I shall, in the first place, 
 dwell on the increased volume of the lung, and consider it first in 
 relation to the stethoscopic signs, and next, as causing displace- 
 ment of adjacent parts. And we shall inquire how far the degree 
 of resistance afforded by the thoracic parietes tends to influence 
 both the auscultatory signs, and those more obvious ones, Avhich 
 proceed from the displacement of surrounding organs. 
 
 The modifications of the sounds of respiration in this disease 
 depend on the following causes : 
 
 1st. The increased volume of the lung. 
 
 2nd. The existence of bronchitis, principally aff'ecting the 
 minute tubes, and often complicated with congestion of the lung.
 
 158 BRONCHITIS. 
 
 3rd. The formation of the sub-pleural vesicles.* 
 The first of these sources of modification of the respiratory- 
 phenomena being the most important in the diagnosis, I shall 
 dwell particularly upon it. 
 
 One of the first circumstances which strikes the observer in this 
 affection, is the want of accordance between the inspiratory 
 efforts, and the sound of pulmonary expansion ; the first being 
 evidently excessive, and the latter extremely feeble. When he 
 employs percussion he will at once discover that the cause of this 
 feebleness cannot be any solidification of the lung, as the sound 
 is either natural, or clearer than natural, and under these circum- 
 stances he must seek for some other cause to explain the pheno- 
 menon. It appears to me, that in the increased volume of the 
 lung, he will find the cause of this important sign : for the organ 
 being in a permanent state of enlargement, the dilatation of 
 the chest can be hut little added to hy the inspiratory effort, and 
 hence the sound of respiration becomes proportionahly feeble. 
 Hence this feebleness of respiration, coinciding with clearness of 
 the chest and increase of the inspiratory efforts, becomes the 
 most important physical sign of the disease in question. Other 
 causes, however, have been enumerated, particularly the thicken- 
 ing of the mucous membrane, the result of that chronic bron- 
 chitis which so constantly attends this afi'ection. Thus Laennec 
 has stated, that in the dry catarrh, which so commonly produces 
 this disease, the mucous membrane of the minuter tubes is often 
 extremely thickened, which, to a certain degree, explains the 
 feebleness of respiration, and also the fact that when we compress 
 the lungs taken from an emphysematous patient, we find greater 
 difficulty in reducing them to their state of flaccidity than if they 
 were in their ordinary condition. In fact, ceteris paribus, the 
 sound of respiration is directly as the facility of the entrance 
 of the air, and any mechanical obstruction, whether in the 
 trachea, the larger or the more minute bronchial tubes, 
 will cause a corresponding feebleness of the respiratory murmur. 
 This has been long known ; I remember seeing an interesting 
 example of this in a patient whose chest I was requested to 
 examine previous to the performance of tracheotomy. The his- 
 tory of the case was such as might warrant the supposition of the 
 
 * This source of signs is given on the authority of Laennec, and it is to be recol- 
 lected, that these vesicles are not necessarily attendant on the disease.
 
 BRONCHITIS. 159 
 
 existence of a pulmonary emphysema. On percussion the chest 
 sounded everywhere extremely clear, but the vesicular murmur 
 was feeble, notwithstanding the violent efforts of the patient ; yet 
 on the trachea being opened, it became at once loud, even to 
 puerility, and continued with this character for some time after 
 the operation.* But without denying that this thickening has an 
 effect, I cannot help thinking, that we must also attribute much 
 to the increased volume of the lung for the following reasons : 
 
 First. In cases of ordinary bronchitis, even when the minute 
 tubes are engaged, this remarkable disproportion between the 
 inspiratory efforts and sound of expansion is either not observed, 
 or occurs in a much smaller degree. In these cases we hear either 
 a mixture of the vesicular murmur with various rales, or observe 
 that the murmur is almost masked by the rales ; but in both 
 cases the phenomena indicate full expansion and contraction of 
 the lung, and their intensity can be remarkably modified by the 
 efforts of the patient. Yet in cases of dilatation of the cells this 
 is not observed, and the phenomena are but little modified 
 whether the patient breathes in his ordinary manner, or makes 
 an increased effort at inspiration. In the former case the air cells 
 may be considered as unaffected, and on the obstruction which 
 results from the thickening of the bronchial membrane, or the 
 presence of secretion in the tubes being overcome, the lung 
 expands, and this expansion is evident to the auscultator. 
 
 Secondly. I have obseiTed that in confirmed dilatation of the 
 air cells, the sign of feebleness of respiration is but little affected 
 by the increase or diminution of the bronchitis, at least as far as 
 we can judge of the latter by the physical signs and constitu- 
 tional symptoms. Thus, it not unfrequently happens, that such 
 patients are attacked with exacerbations of the bronchial irritation, 
 which may subside under treatment, but during their continu- 
 ance the physical signs are less an increase of the feebleness of 
 respiration than of the various rales ; and on the other hand, 
 when they subside, that feebleness is scarcely, if at all, dimi- 
 nished ; in fact, the sign of feebleness is but little affected by the 
 increase or diminution of the bronchitis, a circumstance quite in 
 accordance with my view of its cause, namely, the diminished 
 quantity of air that enters the affected portion of the lung. 
 I have already stated, that the feebleness of respiration in this 
 * See Beau, Archivea Generales, 1835.
 
 160 BRONCHITIS. 
 
 affection is owing to the increased 'volume of the lung, by which 
 the amount of the inspiration is diminished ; for if the lung be 
 thus hypertrophied, so as to press strongly on the chest, and 
 preserve that cavity distended, even after expiration, it is obvious, 
 that on the next inspiration the volume of air entering will be 
 minus the expanding of the lung from its own distending 
 force. 
 
 Let us suppose that the area of the healthy chest, after expi- 
 ration, to be equal to 10, and the maximum of its expansion to be 
 equal to 15, it is plain, that if from the disease the lung acquires 
 a volume in rest equal to 12^, the inspiration would be diminished 
 by one-half; hence a cause of feebleness of respiration, as part 
 of the inspiratory effort, is supplied by the expansion of the lung, 
 which results from its being kept compressed in the state of rest. 
 
 It is obvious, however, that the physical signs of the pulmonary 
 compression must vaiy according to the rigidity of the thoracic 
 walls. If we take two cases of Laennec's emphysema, and suppose 
 that in one the chest yields ^^ayi passu with the enlargement of 
 the lung, while in another it is rigid and unyielding, it is plain 
 that the physical condition of the lung, and of course the physical 
 signs of its actions, must be different. If the feebleness of 
 respiration depend upon the compression of the lung, it should 
 follow, that if in any case the chest yielded easily and fully to the 
 pulmonary enlargement, we might have great and extensive 
 dilatation of the cells, without the sign which is supposed to be 
 characteristic, so that the feebleness of respiration would seem 
 more a measure of compression of the lung than a direct sign of 
 dilatation of the cells. Of these views the following case is 
 strongly illustrative, and I place the more value on it as the 
 patient has been at different periods under my observation. 
 
 A young man, of feeble muscular development, and considerably 
 below the middle size, entered the Meath Hospital, labouring 
 under the usual symptoms of Laennec's emphysema ; the chest 
 was enormously enlarged on both sides, but the principal yielding- 
 seemed to have taken place in the upper and anterior portions ; 
 the circumference at the mammary regions being three feet and an 
 inch, an increase of at least seven inches above its natural 
 development. The sternum and clavicles were arched, the 
 scapular regions nearly horizontal, and the development of both 
 sides equal. Yet, in this case, the characteristic signs existed
 
 BRONCHITIS. 161 
 
 only in the supero-anterior portion of the right side, while over 
 the rest of the thorax the respiration could be heard loudly, and 
 after the individual had been treated for bronchitis it was pure. 
 In this case the symptoms had lasted for upwards of five years, 
 and after the second year the enlargement of the chest became so 
 manifest as to excite the attention of all the patient's friends. 
 
 Here there was a case in which the yielding of the chest was 
 more remarkable than any we had ever witnessed, and yet over 
 the greater portion of the thorax the respiration was anything 
 but feeble ; and it is a most curious and interesting fact, that 
 with the absence of the signs, there was also absence of the 
 symptoms of compression. There was no evidence of disease of 
 the heart ; there had never been oedema ; the jugular veins were 
 not distended ; the liver was not depressed ; and the patient, so 
 far from being embarrassed by exercise, was always better after 
 walking a considerable number of miles. A short time before 
 entering the hospital he performed a journey of forty miles on 
 foot in the course of a single day. His only inconvenience was 
 the recurrence of bronchitic attacks, but when these were absent 
 his general health was excellent. 
 
 It might here be inquired, what was then the cause of the 
 feebleness of respiration in the anterior portion of the right lung ? 
 I think that in all probability there was here rupture of the air 
 cells, and that in this condition we have a cause, in addition to 
 that of compression of the lung, for the ordinary feebleness of 
 respiration. 
 
 We shall now consider some of the other physical signs, which 
 result from the enlargement of the lung, and which, like the 
 preceding, vary with the amount of resistance of the thoracic 
 walls. 
 
 Signs connected with the Intercostal Muscles and Dia- 
 phragm. — The next result of the increased volume of the lung, 
 which we now consider, is its effect in displacing the more 
 yielding parts of the thorax. These may be considered to be the 
 mediastinum, the intercostal muscles, and the diaphragm ; and 
 we shall find, that although the mediastinum yields in cases of 
 the disease occurring in a single lung, yet that the muscular 
 expansions exhibit a great power of resistance, and in many 
 cases do not yield, even after the chest has been much enlarged. 
 In this respect we observe a remarkable difference between this 
 
 M
 
 162 BRONCHITIS. 
 
 disease and empyema, in which the yielding of the muscular 
 expansions forms one of the most important signs. 
 
 When we examine the intercostal spaces in this affection, 
 even after great dilatation of the chest has occurred, we see them, 
 so far from being obliterated, deeply marked, and the muscular 
 fibres acting powerfully, so as to elevate the ribs, and assist in 
 the imperfect inspiration. I have never seen an exception to 
 this, and the rule applies to every intercostal space ; and as a 
 point of difference between the two diseases of accumulation, 
 empyema, and Laennec's emphysema, it is of the greatest 
 interest;. When I come to consider empyema I shall point out 
 the causes of this difference, which have not been hitherto 
 understood.* 
 
 But the same remarks cannot be made with respect to the 
 diaphragm, which, in certain cases, yields before the enlarged 
 lung, so as greatly to increase the cavity of the chest down- 
 wards. This circumstance may be taken as a most important 
 distinguishing mark in cases of this disease, which may be 
 divided into those with, and those without, diaphragmatic dis- 
 placement. 
 
 From the position of the muscle, and its inferior mechanical 
 support, we should expect, a priori, that it should yield more to 
 mechanical pressure than the intercostals. And such I have 
 ascertained to be the fact, as while I have often seen dis- 
 placement of the diaphragm, in no case did I find that the 
 iatercostals were similarly affected. 
 
 Between the two cases of Laennec's emphysema, with and 
 without this displacement, I have observed some striking dif- 
 ferences as to symptoms and signs. Of those in which the 
 diaphragm is not affected, we have an excellent example in the 
 case which I have described of great yielding of the thoracic 
 walls. Here the signs of pressure on the lung were much less 
 diatinct, and there existed no indication of hepatic displacement, 
 the epigastrium, so far from being tumid, being actually col- 
 lapsed. But in the case with displacement of the diaphragm we 
 observe that there is much more distress in breathing ; that the 
 
 * '• It must be confessed," says Dr. Walshe, " that the piiblished experience of 
 physicians generally does not accord with that of Dr. Stokes in respect of the 
 bolging of emphysema ; both Louis and Woillez are wholly opposed to Dr. Stokes on 
 this point."— Page 326. 4th edition. (Ed.)
 
 BRONCHITIS. 163 
 
 epigastrium is full and resisting, and that tlie heart is pushed 
 down sometimes so far as to be on a level with the ninth, or 
 even tenth intercostal space. 
 
 Under these circumstances the postero -inferior portion of the 
 chest, and the regions of the liver and heart anteriorly, give a 
 perfectly clear sound, which is explicable by the displacement of 
 these viscera, and also by the condition of the lung. 
 
 When these patients are stripped, and lying on the back, a 
 remarkable character of respiration may be observed. We see 
 the thorax powerfully elevated upwards, and the abdomen as 
 powerfully protruded downwards ; but there is this remarkable 
 difference from forced respiration in the healthy state, that the 
 abdominal protrusion does not begin so high, and while the 
 umbilical and hypogastric regions move upwards and forwards, 
 the epigastrium and upper portions of both hypochondria remain 
 comparatively motionless, while the corresponding ribs are 
 drawn in. This is explicable by the new position of the dia- 
 phragm ; it has descended, and carried the abdominal viscera 
 before it ; and its contraction takes effect at a point lower in 
 proportion to its displacement. 
 
 That this displacement is a purely mechanical result, and not 
 analogous to that in empyema, shall be shewn hereafter. It 
 varies so remarkably with the volume of the lung, that I have 
 seen the heart, after the subsidence of a bronchitic attack, 
 mount from the tenth to the eighth intercostal space. 
 
 On the subject in general, we want some accurate dissections. 
 I regret that my experience is but limited, but I shall state it. 
 It would appear that much will depend on whether the disease 
 predominates in the upper or lower lobes ; if in the latter, the 
 shape of the lung is altered, and I have found in this way, that 
 from the great enlargement of the cells, and the formation of 
 sub-pleural vesicles, the lower surface, from being concave, had 
 become flattened, or even convex. Under these circumstances 
 the diaphragm must of course yield. 
 
 In a patient who died in the Meath Hospital, the following 
 appearances were found : the liver was in its natural situation, 
 but the left ala of the diaphragm was pushed far down, so as to 
 become convex towards the abdomen.* But a source of fallacy 
 
 * For this dissection I have the authority of my friend, Dr. Hudson, who then 
 acted as clinical clerk in the medical department of the institution. 
 
 M 2
 
 164 BRONCHITIS. 
 
 exists in this case, and in all dissections made to clear up this 
 point, it must be borne in mind that the diaphragm may have 
 yielded post mortem, merely from the pressure which, during life, 
 it had been able to resist.* 
 
 Signs from the Displacement of the Mediastinum. — In 
 considering these signs we find, that although they may exist so 
 as to be demonstrable during life, yet that they are less remark- 
 able than those in empyema. In certain cases where the disease 
 is confined to one lung, the morbid signs extend across the mesian 
 line to a distance proportioned to the extent of the disease ; and 
 as in empyema we have dulness and absence of respiration ex- 
 tending across the mesian line from disease of one pleura, so 
 in the dilatation of the air cells we have the morbid clearness 
 and characteristic respiration, under the same circumstances ; 
 and if anything was wanting to complete the analogy, it is, 
 that the displacement of the mediastinum can be observed to 
 vary with the state of disease in either case. 
 
 Thus, when the dilatation of the cells is confined altogether, or 
 nearly so, to one lung, percussion gives a peculiarly clear sound 
 over the affected side ; and if the disease has displaced the medi- 
 astinum this clearness will be found across the whole sternum, 
 and it may be for an inch or so beyond it. This line, which is 
 well defined, having been passed, we then observe the natural 
 pulmonary sound, which an experienced ear will have no difficulty 
 in distinguishing from that of the diseased lung. If the observer 
 now applies the stethoscope over the aff"ected side, and carries 
 the instrument across the chest, he will find that the peculiar 
 phenomena of respiration do not disappear until he passes the 
 sternocostal articulations of the opposite side, where, like the 
 clearness on percussion, they suddenly cease, and are replaced 
 by the natural respiratory murmur. 
 
 I must state here, that although we should expect a priori 
 that these signs always exist in the advanced stages of the disease, 
 when confined to one lung, yet that I have only verified them in 
 a single instance, and that additional observations will be neces- 
 
 * " There are some cases," says Dr. "Waters, "in which the floor of the chest yields 
 greatly to the expanding lungs, the diaphragm being pushed down, &c " — Diseases of 
 the Lungs, p. 148. " Whenever," says Hertz, " the elasticity of the lung is 
 diminibhed or altogether lost, and the lung remains in a permanent inspiratory 
 position, the air being forced out of it in very inconsiderable quantity, the diaphragm 
 cannot rise and resume its expiratory position." — Ziemssen's Cyclopaedia, vol. v. (Ed.)
 
 BRONCHITIS. 165 
 
 sary to ascertain their exact value or constancy. I have little 
 doubt, however, from the analogy of the disease in question with 
 empyema, that they will he found to occur in all cases of con- 
 firmed dilatation of the cells, when the disease occupies but a 
 single lung. 
 
 But although in both instances; the mediastinum be displaced, 
 yet in the disease before us the change is seldom seen in so strik- 
 ing a manner as in empyema. One reason for this may be the 
 fact, that in most cases of decided dilatation of the cells, the 
 disease exists in both lungs, while double empyema is one of 
 the rarest of diseases. Another will be admitted when we 
 recollect that the inflammatory action of pleuritis, by softening 
 the serous membranes, will render them more likely to yield in 
 that disease than in Laennec's emphysema, where no such action 
 exists. 
 
 The heart, of course, will follow the displaced mediastinum, 
 and its position vary with the affected lung and the amount of 
 disease. My experience, however, leads to the conclusion, that 
 in this affection lateral displacement of the heart is rarely seen to 
 any remarkable degree, another circumstance of difference be- 
 tween this affection and empyema, and to be explained by the 
 preceding considerations. This remark, however, does not apply 
 so much to the displacement downwards, which, as I have 
 shewn, may occur to a very great degree. Under these circum- 
 stances the preecordial region is clear on percussion, and the 
 impulse of the heart may be altogether wanting in its natural 
 position, but occur as low down as the tenth rib, and between 
 the costal cartilages and mesian line. 
 
 It is now admitted that most of the patients affected with 
 this disease die with symptoms of morbus cordis and general 
 dropsy, and it is not difficult to understand why disease of the 
 heart should be so common a complication. The cause of this 
 seems to reside almost altogether in the great enlargement of 
 the lung, which must have a deleterious effect upon the heart 
 in the following respects. 
 
 First, as I have already shewn, by its interference with the 
 process of inspiration. The experiments of modern physiologists 
 have shewn the great influence which is exercised by the respi- 
 ratory process on the venous circulation ; but in the disease 
 before us we find the chest in a state of permanent dilatation, to
 
 166 BRONCHITIS. 
 
 which the inspiratory effort can add but little, the manifest 
 consequences of which must be an accumulation of blood at the 
 right side of the heart, and consequent disease of its pulmonary 
 cavities. The vena cava becomes loaded, the hepatic veins 
 engorged, and the liver consecutively engaged. Under these 
 circumstances the muscular parietes of the heart become hyper- 
 trophied, and an active aneurism of the auricle and ventricle is 
 produced. 
 
 Secondly, it seems more than probable that the same pressure 
 which has distended the chest and displaced the diaphragm, 
 must act directly in impeding the circulation through the 
 pulmonary artery and its ramifications, and thus we see an 
 additional cause for the production of hypertrophy of the right 
 cavities of the heart. 
 
 Lastly, we must recollect that the heart itself is under the 
 influence of anormal pressure. It is removed from its natural 
 situation, and to a certain degree deprived of its natural pro- 
 tection by the bony and elastic parietes of the chest, and is 
 compressed between the distended lung, on the one hand, and 
 the distended abdomen on the other. Under these circum- 
 stances its actions of dilatation and contraction must be mate- 
 rially interfered with, the auricles will experience a powerful 
 impediment in filling the ventricles ; and if these cavities have 
 an active power of dilatation, this must also be materially 
 impeded. Thus, many circumstances concur to derange the 
 pulmonary, cardiac, venous, and hepatic circulation. And we 
 can only wonder at the powers of nature in prolonging life under 
 such a complication of evils. In the great majority of cases 
 such patients die with symptoms of what is commonly called 
 hydrothorax, to the disappointment of the practitioner, who 
 prescribes according to the rules of the nosological writers, 
 and a j^ost mortem examination will reveal the causes of his 
 failure, and the error of his teachers."** 
 
 Signs feom the Existence of Bronchitis. — On the subject 
 of the signs manifestly proceeding from bronchial irritation I 
 have to remark, that there is not one of them which can be 
 considered as pathognomonic of the complication with dilated or 
 
 * To the above causes must be added the obliteration of numerous small branches 
 of the pulmonary artery consequent on the dilatation and obliteration of the air 
 cells. See Hertz in Ziemssen's Cyclop., vol. v. pp. 879 and 880. Also Waters on 
 Emphysema. (Ed.)
 
 BRONCHITIS. 167 
 
 ruptured air cells, inasmuch as we may find tliem all in cases 
 where no such aifection exists. None of them are constant ; 
 and when they do occur, scarcely differ from what is observed in 
 simple bronchitis : we may have all varieties of the sonorous, 
 sibilous, mucous, and muco-crepitating rales in this affection, 
 and the occurrence and mode of combination of the phenomena 
 are infinitely various. The two most common are, the dry 
 sibilous, and a diffuse mucous rale. Laennec has stated that 
 there is one form of rale which is pathognomonic of the inter- 
 lobular emphysema, although it may also occur in the simple 
 dilatation ; this he calls the dry crepitating rale ivith hirge 
 hubbies, and describes it as conveying the impression of air 
 entering and distending lungs which had been dried, and of 
 which the cells had been unequally dilated. He compares it 
 to the sound produced by blowing into a dry bladder ; and 
 states farther, that it is similar to that observed in common 
 sub-cutaneous emphysema when we press the stethoscope on 
 the affected portion. Now, without at all calling in question 
 the extraordinary tact of Laennec, I would say, that this is 
 a sign, which, if it does exist, must be so easily confounded 
 with other phenomena, such as those proceeding from bron- 
 chitis, that an ordinary obseiwer would not be safe in founding 
 a diagnosis on its supposed existence. I have never been able 
 to satisfy myself that I had recognized it, and have even found 
 the interlobular emphysema in the lungs of persons, in whom 
 during life I was not able to distinguish the rales from those 
 of simple catarrh. He states, however, that the phenomenon 
 is not common, and when it exists is of short duration, and 
 observed in points of only small extent. On this subject further 
 observations are necessary. 
 
 I shall lastly allude to the sign of the rubbing sound, or 
 frottement, which has been described by Laennec as an indication 
 of those sub-pleural air vesicles which occur in the interlobular 
 emphysema, and which, according to him, when occurring with 
 the other symptoms of dilated cells, may be looked on as 
 diagnostic of the lesion in question. But this point of diag- 
 nosis, like the last, requires still further investigation ; * and 
 
 * This subject is fully discussed and Laennec's statement confirmed by Dr. Gairdner 
 in his lecture on emphysema, Clinical Medicine, p. 430. I have met with a similar 
 case in which sub-pleural emphysema was found after death at the site of friction 
 sound heard by me during the patient's life. (Ed.)
 
 168 BRONCHITIS. 
 
 indeed it seems difficult to understand how the existence of 
 an air vesicle could give rise to the rubbing sound. We know 
 that in the healthy condition of the internal surfaces of serous 
 membranes, the friction of their opposite faces is so diminished 
 by their smoothness, and their being lubricated by the serous 
 exhalation, that no perceptible sound accompanies their motions. 
 It is only when the surfaces are rendered dry by an arrest of 
 secretion, or roughened by the effusion of lymph, that their 
 motions produce sounds perceptible to the ear. Now, even 
 where extensive vesicles exist, we commonly find that the serous 
 surface, as far as smoothness and lubrication are concerned, 
 continues in its natural state ; and I cannot help agreeing with 
 Meriadec Laennec, that the sign of frottement is to be looked 
 on more as an indication of slight pleurisy than of these sub- 
 pleural vesicles. I have never observed this phenomenon unless 
 in cases where the serous surface was roughened ; and as it is 
 admitted, both by the above author and by M. Reynaud,* that 
 the sound in pleurisy is undistinguishable from that described 
 by Laennec in this disease, we have, I think, sufficient reasons 
 for extreme caution in the diagnosis of sub-pleural vesicles from 
 the existence of the sign in question. 
 
 It might be supposed that the permanence of the sign and the 
 absence of pain would prove diagnostic marks, but the truth is, 
 that even these circumstances will not be sufficient. Thus I 
 have seen cases in which the frottement of pleuritis continued for 
 a month with scarcely any alteration, and in which, after the 
 first week, the patient felt no pain, and only complained of the 
 rubbing sensation produced during respiration, in the affected part. 
 
 Before leaving this subject I shall describe another sign which 
 promises to be of the greatest importance in diagnosis. It is 
 founded on the difficulty of expiration which occurs in this 
 disease, a difficulty by some attributed to the obstruction of the 
 minute bronchial tubes, and more lately by Majendie to the 
 diminished elasticity of the lung itself. 
 
 I have at present under my care, a patient aged upwards of 
 sixteen years, who has been subject to cough and dyspnoea from 
 infancy. The right side is enlarged, and very convex anteriorly, 
 the sternum somewhat arched, and the clavicle elevated. Over 
 this side the sound is morbidly clear on percussion, and the 
 
 * Bee Journal Hebdomadaire, No. 66.
 
 BRONCHITIS. 169 
 
 clearness extends across the sternum ; yet on applying the 
 stethoscope during ordinary respiration, nothing is heard but a 
 muco-crepitating rale, occasionally combined with Laennec's 
 rale crepitant a grosses hulles ; these signs are audible during 
 inspiration, while expiration is marked by a dry prolonged 
 wheeze. On a forced inspiration, however, a distinct sound of 
 pure pulmonary expansion follows the rales above-mentioned. 
 
 From these observations I concluded that the case was one of 
 Laennec's emphysema, which had not yet arrived at its most 
 extreme stage, inasmuch as that by a forced inspiration the lung 
 could be still considerably distended. It then struck me that 
 by making the patient perform a number of forced inspirations 
 rapidly, the lung might be so far distended with air as to prevent 
 the occurrence of any natural sound of pulmonary expansion for a 
 time, and that thus we might obtain a direct proof of the difficulty 
 of expiration. This experiment I put into effect, and found that 
 after four or five inspirations, rapidly performed, the respiratory 
 murmur altogether disappeared, nothing being heard but the 
 crepitating rales, and even these in a diminished degree. The 
 patient was now allowed to rest and to breathe naturally for a 
 certain number of times, when on the experiment being repeated, 
 the first inspiration was distinctly followed by the murmur, which, 
 however, diminished at each successive effort, until at length it 
 became extinct as before. 
 
 The results of this experiment are easily explained by referring 
 to the difficulty of expiration, proceeding from either or both of 
 the causes already alluded to. In fact, the repetition of the 
 inspiratory efforts caused such an accumulation of air in the 
 diseased portion of the lung, as ultimately to nearly prevent its 
 further expansion, and thus hinder the sound of the respirator}' 
 murmur. But on the cessation of these efforts the air was 
 gradually evacuated, and the lung restoredto its original condition. 
 If this sign be found constant, it will be a most valuable addition 
 to our means of detecting the emphysema of Laennec, but the 
 frequent repetition of the experiment must be avoided. 
 
 TREATMENT OF DILATATION OF THE CELLS. 
 
 The first point to be examined into in discussing this part of 
 the subject, is whether a cure of the confirmed disease be
 
 170 BRONCHITIS. 
 
 possible ; the next, whether we are in possession of means 
 capable of relieving the affection to a certain degree, or of 
 preventing its further extension ; and the third, supposing the 
 disease capable of modification or cure, to determine what are 
 the indications and proper modes of treatment, I shall examine 
 these important questions in succession. 
 
 Can we expect, after the disease is established, that the 
 dilated air cells can ever resume their natural condition ? Now 
 we find that some patients have laboured under this disease, or 
 its causes, from infancy, while in others it is brought on by 
 bronchitis at a late period of their lives, and after many years of 
 previous health. In the first case, it seems scarcely possible 
 that any efi"ort of medical skill can restore the lung to its original 
 condition, and all that we can hope for is to palliate the symptoms. 
 But in cases of a comparatively recent origin, to give up all hope 
 of cure seems scarcely in accordance with our knowledge of analo- 
 gous affections. We may consider the pathological condition of 
 the air cells in the same point of view that we look upon chronic 
 dilatations of other hollow organs, such as those of the stomach, 
 colon, bladder, and heart. In these cases we commonly observe 
 the two following circumstances to occur : first, that the cause of 
 the dilatation is some mechanical obstruction to the exit of their 
 natural contents ; and next, that if this obstruction be long con- 
 tinued, what was first a mere dilatation or distention of the organ 
 becomes a combination of this Avith an organic alteration of the 
 parietes, which is in most cases an increase in their thickness 
 and strength. Hence the hypertrophy of the muscular fibres of 
 the stomach when the pylorus is obstructed ; of the bladder when 
 the urethra or prostate are diseased ; of the colon in stricture of 
 the rectum ; and of the right cavities of the heart in afi'ections of 
 the lung. This change from mere dilatation to increase of growth 
 seems to be a condition very unfavourable for cure, and the 
 chances of its production may be stated to be directly as the 
 length of time the obstruction is allowed to continue ; for we 
 know that in the earlier periods of these mechanical dilatations, 
 the removal of the obstruction is often followed by the return of 
 the cavity to its natural dimensions. Appl3'ing these considera- 
 tions to the case of dilatation of the air cells, it seems not impos- 
 sible that in the earlier periods the removal of the obstruction 
 would be followed by a subsidence of the disease ; for when Ave
 
 BKONCHITIS. 171 
 
 inquire into the causes of tlie affection, we find these to be prin- 
 cipally obstructions to the free exit of the contents of the cavities ; 
 the viscid mucus and the turgescence of the bronchial tubes being 
 to the air cells what pulmonary obstruction is to the heart, or 
 urethral to the bladder ; and the distention in these cases being 
 perfectly analogous. 
 
 We may then admit that where actual change of structure has 
 not occurred, a cure, or a great alleviation of the disease is not 
 impossible. Our next inquiry is, whether there is evidence of 
 such ever occurring. On this question Laennec speaks doubt- 
 ingly. After alluding to the combination of extravasation of air 
 with dilatation of the air cells, he observes, that it is of slight 
 consequence as compared with the latter affection, as we can 
 hope for its removal by absorption as in other similar cases, 
 whilst we cannot well see in what manner either nature or art 
 can remedy the other morbid derangement. " At the same time," 
 he continues, "I do not think we are justified in considering 
 this affection as altogether incurable. In several instances I 
 have fancied that I discovered the traces of cicatrization of rup- 
 tures of the pulmonary tissue of the kind above described. In 
 the case of subjects aftected with asthma I have several times, 
 during the fits, detected a crepitous ronchus with large bubbles, 
 which ronchus entirely disappeared afterwards ; and it is quite 
 intelligible, that if we can diminish the intensity of the cause 
 which keeps up the habitual distention of the cells, we may in the 
 end hope, that these will be actually lessened in volume."* The 
 same author, when describing the treatment of dry catarrh by 
 alkalies, states, that many persons who had already emphysema 
 of the lungs, and either incessant dyspnoea, or very frequent fits 
 of asthma, have been restored by this treatment to a state of 
 health so comfortable, that they hardly exhibited any signs of 
 disease. 
 
 The question as to the curability of Laennec's emphysema has 
 been scarcely agitated in medical circles ; and Dr. Osborne 
 deserves gr^at credit for bringing this subject forward in an 
 excellent paper on the pathology and treatment of dropsy, which 
 he read at one of the late meetings of the King and Queen's 
 College of Physicians, in which he states his conviction, that this 
 disease is at all events susceptible of great amelioration, on 
 
 * See Dr. Forbes's Translation.
 
 172 BRONCHITIS. 
 
 the ground that in certain cases he observed the feebleness of 
 respiration, and morbid clearness of sound, to subside, or become 
 greatly diminished, after treatment calculated to remove the 
 obstruction, and diminish the frequency and violence of cough. 
 On this subject I can only bring forward the observations of a 
 few cases, but which, as far as they go, are of great importance 
 in elucidating the question. In the patient, to whose case I have 
 already alluded as illustrative of the diagnosis from mediastinal 
 displacement, I found that after certain treatment, calculated to 
 relieve bronchial irritation and diminish cough, that coincident 
 with great relief of symptoms, the following changes in the phy- 
 sical signs took place : first, that the morbid clearness of the 
 affected side, though not removed, was diminished, and that it 
 terminated at the mesian line in place of extending, as before, 
 beyond the opposite side of the sternum. Secondly, that the 
 rales became more humid and larger, and the vesicular respira- 
 tion was manifestly increased. And thirdly, that the stethoscopic 
 phenomena, like those of percussion, ceased to be heard beyond 
 the mesian line of the sternum, when they had been before audible, 
 and that in this situation they were replaced by the healthy 
 murmur of the opposite lung. These alterations in the signs, so 
 characteristic of diminution in the obstruction and volume of the 
 affected lung, were accompanied by the most marked improvement 
 in the symptoms ; the cough, dyspnoea, and acceleration of breath- 
 ing being wonderfully diminished, and the condition of the patient 
 in every respect improved. 
 
 The treatment pursued was the employment of local bleeding 
 and counter-irritation, with the exhibition of the tartar emetic for 
 several days, followed by sedative and demulcent remedies. 
 
 That in this case the volume of the affected lung was reduced 
 by treatment, there can be no doubt ; and when we connect the 
 results of the case with those obtained by Dr. Osborne, and with 
 the observations of Laennec on the treatment of dry catarrh, we 
 have decided evidence in favour of the possibility of the diminution 
 of the disease, and are consequently justified in considering it as 
 not altogether incurable. In another instance I have seen the 
 heart, which was so much displaced downwards as to pulsate at 
 the cartilage of the tenth rib, after a few days of treatment, 
 remount towards the thorax, and correspond to the eighth 
 intercostal space.
 
 BRONCHITIS. 173 
 
 Some important questions here arise. Is the mere diminution 
 or even removal of the obstruction all that is necessary for the 
 restoration of the lung to its natural condition, or may there not 
 be some other morbid state to be overcome before we can bring 
 about so fortunate a result? Does a paralysis or atony of the 
 circular fibres of the_mQiejmimitfijLiibes exist ? Or, as Majendie 
 has suggested, is the natural elasticity of the lung destroyed or 
 injured ? It seems not improbable but that both these circum- 
 stances may occur, the muscular structure being paralyzed, as we 
 see in the case of the bladder or the intestinal tube, and the 
 longitudinal fibres losing their elasticity from the persistence of 
 chronic irritation, just as the elastic coat of arteries loses its 
 property when chronic disease afi"ects these vessels. 
 
 It is plain that farther observations are necessary to clear up 
 these points ; and I shall merely remark, that after the use of 
 treatment calculated to remove congestion, inflammation, or other 
 obstruction of the minuter tubes ; after the adoption of the means 
 which Laennec has pointed out for the relief of the dry catarrh ; 
 and lastly, after using all means which could moderate the cough, 
 or render it less frequent, we might then have recourse to 
 measures calculated to stimulate the contractile tissues of the lung. 
 As yet we are not in possession of means capable of restoring 
 elasticity to such tissues as the longitudinal fibres of the lung, or 
 the middle coat of the arteries ; but we do know of remedies 
 capable of stimulating muscular fibre to resume its vital contrac- 
 tility, at least of that portion of the muscular system which is 
 supplied by the cerebro-spinal nerves. It has been suggested to 
 me by my friend and pupil, Mr. Martin, that in the exhibition of 
 strychnine this object might be attained. This practice would 
 be well worthy of trial, for if, as there is reason to believe, the 
 pulmonary branch of the vagus is a nerve of motion to the lung, 
 we might expect that the stimulation exercised by the remedy on 
 the cerebro-spinal centres would have a beneficial effect in paralysis 
 of the bronchial muscles. - 
 
 I shall now give the general conclusions which may be drawn 
 from what has been stated. 
 
 1st. That the disease consists essentially in an enlargement 
 of the air cells. 
 
 2nd. That the rupture and coalescence of several cells is not 
 a constant occurrence.
 
 174 BRONCHITIS. 
 
 3rd. That the disease mcreases the volume and rarefaction of 
 the lung. 
 
 4th. That it may occur uncomplicated with any affection 
 except bronchitis, or exist along with other diseases which are 
 generally chronic. 
 
 5tli. That it may co-exist Avith great dilatation of the tubes. 
 
 6th. That it may be partial or general. 
 
 7th. That percussion gives a morbidly clear sound when the 
 disease has attained a certain extent. 
 
 8th. But that the cells may be so enlarged as to give feeble- 
 ness of respiration without change on percussion. 
 
 9th. That the physical signs of bronchitis which occur, 
 though pointing out the existence of disease in the smaller 
 ramifications, are not characteristic of the affection. 
 
 10th. That the stethoscopic indication is the want of propor- 
 tion between the sound of vesicular expansion, the results of 
 percussion, and the efforts of inspiration. 
 
 11th. That a most important source of physical signs is to be 
 found in the increased volume of the lung. 
 
 12th. That this increase of volume can be ascertained by 
 measurement of the chest, by the displacement of the medias- 
 tinum, by the depression of the diaphragm, and by the lateral 
 displacement, and the depression of the heart. 
 
 13th. That although in this disease, as in empyema, there 
 is pressure from within, yet that it differs from the latter affec- 
 tion in the absence of paralysis of the inspiratory muscles, as 
 shewn in the comparative states of the intercostal muscles and 
 diaphragm. 
 
 14th. That the physical signs from auscultation are greatly 
 modified by the degree of yielding of the thoracic parietes, the 
 characteristic feebleness of respiration appearing to be directly 
 as the amount of resistance to the increased volume of the 
 lung. 
 
 15th. That in the same way the signs resulting from the 
 displacement of the mediastinum, heart, and diaphragm, will 
 vary with the amount of resistance of the thoracic parietes, and 
 be more obvious the greater the resistance. 
 
 16th. That the intercostal spaces are not protruded in this 
 disease, but preserve their relative positions with respect to the 
 ribs.
 
 BRONCHITIS. 175 
 
 17tli. That the cases of the disease may be divided into two 
 classes, viz., those in which the diaphragm is unaffected, and 
 those in which it is depressed. 
 
 18th. That in the first class the abdomen is collapsed, and 
 without tumefaction or dulness of sound in the epigastric or 
 hypochondriac regions. In these cases the heart is found in its 
 natural position. 
 
 19th. That in the second class the reverse occurs ; the liver 
 is depressed, and the heart so displaced, as that it has been 
 found to pulsate so low as the ninth intercostal space. The 
 postero-inferior portions of the chest sound clear even to the 
 last rib. 
 
 20th. That under these circumstances the diaphragm being 
 flattened, its contraction acts in diminishing the circumference 
 of the trunk in the region between the eighth and tenth ribs, 
 so that we observe expansion of the upper portion of the chest 
 and of the umbilical region, while the portion above-mentioned 
 manifestly contracts. 
 
 21st. That the volume of the lung varies remarkably at 
 different periods. 
 
 22nd. That when it is greatest all the physical signs are 
 most evident. 
 
 23rd. That the cause of its increase is an exacerbation of 
 the bronchitis. 
 
 24th. That under treatment calculated to remove bronchial 
 irritation the vesicular murmur may return, and the volume of 
 the lung is diminished. 
 
 25th. That these facts are in favour of the opinion, that the 
 disease is susceptible, if not of cure, at least of great alle- 
 viation.* 
 
 ATROPHY OF THE LUNG. 
 
 As yet the investigations as to the general causes of this 
 change have been very limited. The frequency of the alteration, 
 however, has awakened attention, and, in certain cases, its 
 
 * In these propositions I have not alluded to the nibbing sound of Laennec, inas- 
 much as I feel that this point of diagnosis is not as yet established ; neither have I 
 alluded to the sign described in the text of the singular feebleness of the expiratory 
 murmur produced after forced inspirations. Further observations are necessary on 
 both these subjects.
 
 176 BRONCHITIS. 
 
 causes have been ascertained. We are here, however, to inves- 
 tigate its relation to bronchitis, of which, as yet, but little is 
 known. Atrophy of the lung has been recognized in a variety 
 of diseases, such as tubercle, pneumonia, cancer, and pleurisy; 
 but its direct connexion with bronchitis has not been sufficiently 
 examined. 
 
 It would appear on a general view, that independent of that 
 senile atrophy which the lung undergoes in common with other 
 organs, the condition which is most closely connected with its 
 morbid atrophy is impermeability. The lung indeed is of all 
 organs that in which we might expect the most rapid diminu- 
 tions of bulk from disease ; for independent of the action of that 
 law of atrophy, which operates on organs after they cease to 
 fulfil their functions, there is a cause, as it were, peculiar to 
 the lung, and resulting from its structure. It is easy to see 
 that when the air tubes are obstructed, the cells to which they 
 lead, will diminish in volume. Here we see a difference in this 
 case from that of obstructions of the circulating system. In the 
 air tubes there are no anastomoses, and hence no collateral 
 means of inflating the cells. These diminish, and at last 
 disappear, and the volume of the organ must proportionably 
 suffer. 
 
 Now we have seen that obliteration of the minute tubes is a 
 common occurrence in bronchitis, and hence can understand 
 how this disease may produce atrophy of the lung. It is plain, 
 however, that we here take bronchitis in its most extended sense, 
 and consider it as a disease almost of the parenchyma. It seems 
 more than probable that in this way we can explain the rapid 
 atrophy of the lung in phthisis, the close connexion of which 
 with bronchial obliteration has been so well demonstrated by 
 Key n and. Here it would seem that the obliteration of a number 
 of minute tubes was an early effect of the disease, and the 
 tubercular accumulation and atrophy of the cells its direct 
 consequence. 
 
 But in the ordinary acceptation of the term, bronchitis seems 
 a disease but little likely to induce this lesion. Indeed one of 
 its common effects is the very opposite condition, or hypertrophy. 
 But it would appear that obstruction of a large tube, when 
 permanent, may be followed by atrophy, of which Andral relates 
 an example. I have not made any observations on this subject.
 
 BRONCHITIS. 177 
 
 and shall content myself with pointing it out as a point for 
 investigation. To the consideration of atrophy of the lung, 
 however, I shall return when describing the physical signs of 
 phthisis.* 
 
 Note A. 
 
 The explanation generally accepted by the profession seems 
 to be that originally suggested by Dr. Williams and modified 
 and generalized by Dr. Gairdner, who defines emphysema as 
 " a secondary mechanical lesion dependent on some condition 
 of the respiratory apparatus leading to partially diminished 
 bulk of the pulmonary tissue, and consequently disturbing the 
 balance of air in inspiration." 
 
 Dr. Williams believes that while the air cells communicating 
 with plugged bronchia escape distention, those adjoining and 
 possessed of free communication with the trachea dilate in 
 consequence of the extra work and pressure thrown upon 
 them. " This relationship and this localization," says Dr. 
 Walshe, "are supported by the position occupied by emphysema 
 secondary to adjoining tubercle as originally insisted on by Dr. 
 Carswell." f 
 
 Since the publication of the first edition of this work, another 
 form of emphysema, having a different origin, has been observed ; 
 namely, rapid and general dilatation of the air cells associated 
 with embolism. 
 
 The first case of which I am aware was communicated to the 
 Pathological Society of Dublin by Dr. Stokes in March, 1839. 
 The second by Sir D. Corrigan in December, 1841, and the 
 third by Dr. Gordon in December, 1855. In Dr. Stokes' 
 case and in Dr. Gordon's large and firm coagula were found in 
 the right ventricle, and extending into the pulmonary artery and 
 its branches. In the other this is not expressly stated, but is 
 implied. Dr. Gordon alone noticed the character of the res- 
 piration murmur, which he states was feeble. This is contrary 
 to my own experience, as in the cases I have observed the 
 respiration murmur was intensely puerile. A priori we should 
 
 * See Appendix, Note P. 
 
 t Walshe on Diseases of the Lung;-", p. 321. 
 
 N
 
 178 . BRONCHITIS. 
 
 expect this to be so, as we presume the dilatation of the air 
 cells is caused by exaggerated efforts to effect the confluence 
 of air and blood which constitutes the act of respiration. 
 
 Note B. 
 
 "It is difficult," says Dr. Gairduer, " to conceive anything 
 more completely exhaustive than this memoir of Reynaud, 
 when considered purely in an anatomical point of view and 
 
 solely with reference to the air passages But M. 
 
 Reynaud's researches, though full of anatomical truths are 
 strangely barren, at least in his own hands, of real pathological 
 interest, which arises chiefly from his having too exclusively 
 pursued the enquiry relative to the bronchi themselves, and not 
 having sought to connect their alterations with those of the 
 pulmonary tissues, with which they are according to my 
 experience, as well as that of others, constantly and indis- 
 solubly associated. Somewhat of the same objection applies 
 to Laennec's observations on dilatation of the bronchi, which 
 first gave to this disease a place in pathological anatomy. 
 Accordingly it has been reserved for future observers to discover 
 that both the dilatation and contraction of the bronchi are 
 almost always secondary lesions, or at least invariably con- 
 nected with some kind of disorganization of the pulmonary air 
 cells." — Monthly Journal of Medical Science, vol. xiii. 
 
 Of the observers here referred to Sir D. Corrigan deserves 
 especial mention as the original propounder of the theory of 
 the relation of dilatation of the bronchi to changes of lung 
 structure now generally accepted. The true merit of Corrigan's 
 observations is well expressed by Dr. Bastian. " Whilst 
 Laennec in his admirable account of dilatation of the bronchi — 
 a morbid state which had never been previously described — looked 
 upon the condensation of tissue around the dilated tubes as 
 being invariably secondary to, and the effect of the dilatation, 
 Corrigan, on the other hand, maintained that in a certain 
 number of cases, which he proposed to range under the name 
 ' cirrhosis of the lung,' the fibroid metamorphosis and induration 
 was the primary and essential anatomical lesion, and that the 
 dilatation of the bronchi was only a secondary effect. Omitting 
 for the present the consideration of the question as to whether
 
 BKONCHITIS. 179 
 
 Cori-igan was correct in the explanation he offered of the mode 
 of origin of the bronchiectasis, I may state that his main 
 position appears to have been a correct one. It seems to be un- 
 doubtedly true that, in a certain number of cases in which 
 dilated bronchi have been met with after death, an original 
 fibroid conversion and shrinking of the lung tissue has entailed 
 this as a consequence ; the bronchiectasis has been secondary 
 and not primary."* 
 
 * Art. Cirrhosis, Russell and Reynold's System of Medicine, vol. iii. 
 
 N 2
 
 180 
 
 SECTION III. 
 
 DISEASES OF THE LARYNX AND TRACHEA. 
 
 We may consider tliis subject under the following heads : 
 1st. Acute inflammation of the larynx and trachea. 
 2nd. Chronic inflammation. 
 3rd. Specific irritations. 
 4th. Spasm. 
 
 5th. Foreign bodies in the larynx, trachea, and bronchial 
 tubes. 
 
 6th. Pressure on the windpipe by external tumors. 
 
 ACUTE INFLAMMATION OF THE LARYNX AND TRACHEA. 
 
 This afi'ection may arise either in the child or adult, but is 
 more frequent in the former. In the child its results are gene- 
 rally different from those in the adult, as in the former the 
 production of lymph is most commonly observed. It is this 
 afi'ection which has got the name of croup, but we find it de- 
 scribed under other denominations. Thus, by some authors it 
 is called the pellicular, by others the plastic inflammation of 
 the larnyx, terms which are intended to express the formation of 
 an albuminous covering or cast of the cavity itself. 
 
 We may meet this disease under two essentially different 
 forms. It may occur in the first place, as a primary, idiopathic, 
 and active inflammation of the respiratory mucous membrane, in 
 which the accompanying fever is symptomatic. In the second 
 place, we have it preceded by fever, and the formation of false 
 membranes in the pharynx and cavity of the mouth, which, by 
 extending downwards into the glottis and larynx, produce the 
 symptoms of croup in the advanced stage of another and totally 
 different disease. 
 
 The greatest confusion has arisen in consequence of authors not 
 carefully separating these two forms of disease in their descrip- 
 tions of croup, and in their opinions as to its treatment. For
 
 DISEASES OF THE LARYNX AND TRACHEA. 
 
 181 
 
 the sake of clearness, I shall arrange their symptoms in pairs of 
 opposite characters, distinguishing the affections by the names 
 of primary and secondary croup. 
 
 PRIMARY CROUP. 
 
 1. The air passages primarily 
 engaged. 
 
 2. The fever symptomatic of 
 the local disease. 
 
 3. The fever inflammatory. 
 
 4. Necessity for antiphlogistic 
 treatment, and the frequent suc- 
 cess of such treatment. 
 
 5. The disease sporadic, and 
 in certain situations endemic, but 
 never contagious. 
 
 G. A disease principally of 
 childhood. 
 
 7. The exudation of lymph 
 spreading to the glottis, from 
 below upwards. 
 
 8. The pharynx healthy. 
 
 9. Dysphagia either absent or 
 very slight. 
 
 10. Catai'rhal symptoms often 
 precursory to the laryngeal. 
 
 11. Complication with acute 
 pulmonary inflammation common. 
 
 12. Absence of any character- 
 istic odour of the breath. 
 
 SECONDARY CROUP. 
 
 1. The laryngeal affection 
 secondary to disease of the pharynx 
 and mouth. 
 
 2. The local disease arising in 
 the course of another affection, 
 which is generally accompanied 
 by fever. 
 
 3. The fever typhoid. 
 
 4. Incapability of bearing an- 
 tiphlogistic treatment ; necessity 
 for the tonic, revulsive, and 
 stimulating modes. 
 
 5. The disease constantly epi- 
 demic and contagious. 
 
 G. Adults commonly affected. 
 
 7. The exudation spreading to 
 the glottis, from above down- 
 wards. 
 
 8. The pharynx diseased. 
 
 9. Dysphagia common and se- 
 vere. 
 
 10. Laryngeal symptoms su- 
 pervening without the pre-exist- 
 ence of catarrh. 
 
 11. Complication with such 
 changes rare. 
 
 12. Breath often characteristi- 
 cally foetid. 
 
 From the consideration of these characters we must admit, 
 that independent of minor differences, there is a broad line of 
 distinction between these affections of the throat. In the one 
 the windpipe is the seat of an idiopathic, primary, and highly 
 inflammatory disease ; while in the other its affection is accidental,
 
 182 DISEASES OF THE LARYNX AND TRACHEA. 
 
 inconstant, and secondary to a diseased state of the pliaiynx, 
 which, in its turn, is either symptomatic of, or closely connected 
 with, a morbid state of the whole system. Yet, as I said before, 
 the want of an accurate distinction between these affections has 
 led to the greatest misapprehension ; and we see British physi- 
 cians ridiculing the opinions and treatment of the continental 
 practitioners, and vice versa. The error all the while arising 
 from the confounding of two essentially different affections. In 
 the croup, as described by British authors, the utility of an 
 antiphlogistic treatment has been proved by experience.* 
 
 I shall then divide the disease into primary and secondary 
 croup, and endeavour to point out somewhat more in detail the 
 differences in the signs, symptoms, and treatment of these 
 affections. 
 
 Primary Croup. — The symptoms of this affection are reducible 
 to an irritation of the respiratory apparatus, in which the upper 
 portion of the tube is severely and prominently affected. The 
 disease has been described and generally considered, as an 
 affection of the larynx and trachea alone; and even those who 
 admit an extension of disease, yet look on it as accidental and 
 unimportant, and hence have arisen certain modes of treatment, 
 which the progress of medicine has shewn to be erroneous. The 
 general expression of the diagnosis of this disease may be stated 
 to be the combination of laryngeal cough, succeeded by stridulous 
 breathing, in a joatient labouring under inflammatory fever. If 
 these symptoms have been preceded by signs of catarrh, and if the 
 pharynx presents no morbid appearance, we make the diagnosis 
 of acute inflammation of the larynx, which may terminate, in 
 some cases, by an eftusion of serum into the submucous cellular 
 tissue, but in most instances is followed by the exudation of 
 lymph. Should the disease occur in the child, there will be a 
 strong probability in favour of the latter result. 
 
 Three stages of this affection have been noticed by the best 
 authors; and although they are not always distinctly marked, yet 
 they are so frequently observed that it is necessary to notice them 
 
 * Dr. Stokes' views on this much controverted question are in accordance with those 
 of Niermeyer, who says, " the division of diseases according to the pathologico- 
 anatomical changes they induce is onlj' a makeshift. In all cases where, as in genuine 
 and diphtheritic croup, we find that two anatomically similar disturbances of nutrition 
 depend on very different causes we should consider them as distinct." — Text Book, 
 vol. ii. p. 615.
 
 DISEASES OF THE LAKYNX AND TRACHEA. 183 
 
 briefly. The first lias been termed the catarrhal, the second the 
 confirmed, and the third the suffocative stage. In the first, we 
 have often merel}^ the signs of a slight bronchial irritation, in 
 which there is nothing that could lead us to anticipate so 
 formidable a termination. In other cases, however, a little 
 hoarseness, or a peculiar resonance of the cough may excite alarm, 
 but there is no stridulous breathing, or sign of mechanical 
 obstruction in the Avindpipe; nor is there any circumstance 
 connected with this precursory irritation which can distinguish 
 it from the more ordinary forms of bronchitis. 
 
 The duration of this stage is exceedingly various ; it may 
 continue but for two or three hours, or last as many days, when 
 the second or confirmed stage sets in, characterized by a great 
 increase of fever, anxiety, and distress, and by indications of 
 mechanical obstruction in the larynx itself. Indeed, one of the 
 most remarkable circumstances connected with the disease, is the 
 rapidity with which this latter symptom shall occur, a fact 
 strongly confirmatory of the opinion, that the mere effusion of 
 lymph is not the principal cause of the obstruction, but that it is 
 owing to the inflammatory spasm of the part ; an opinion to which 
 I have no hesitation in subscribing, inasmuch as we find the 
 symptom of stridulous breathing coming on suddenly, and at a 
 period too early for us to suppose that lymph had formed ; and 
 also that after death the aperture of the glottis is almost never 
 found completely obstructed. Indeed Dr. Cheyne states, that, 
 in almost all cases, three-eighths of the glottis are found pervious, 
 l)ost mortem ; so that in explaining the sudden death, we must 
 refer to a spasm of the glottis. 
 
 The symptoms of the confirmed croup in the child have been 
 so accurately detailed by authors, and in particular by Cheyne 
 and Porter, that I shall not occupy much space in describing 
 them, feeling that I shall do more justice to the subject by 
 referring to the writings of these distinguished j)athologists. 
 Suffice it to say, that all the phenomena point out the existence 
 of an acute inflammation, with mechanical obstruction to j-espi- 
 ration, as shewn by the fever and increasing stridulous breathing. 
 As the disease advances there is excessive anxiety, slow and 
 convulsive respiration, loss of voice, distressing cough, and 
 scanty expectoration ; and if the patient is not relieved, he 
 sinks in a collapsed and comatose state.
 
 184 DISEASES OF THE LARYNX AND TRACHEA. 
 
 In a few cases casts of tlie air passages have been expelled by 
 coughing, with relief to the symptoms. Such instances, however, 
 are exceedingly rare. 
 
 There can be little doubt that croup, properly so called, is a 
 simple inflammatory disease. We observe it arising from the 
 same cause as other internal inflammations, accompanied by 
 inflammatory symptoms, frequently complicated with other in- 
 flammatory diseases of the respiratory system, and yielding to 
 ordinary antiphlogistic treatment. One of the most remarkable 
 circumstances in its history is the fact of its being more prevalent 
 among children than adults. Indeed it appears that pure croup 
 is rarely met with after the age of puberty, a fact the more 
 remarkable, as we know that although in the adult, chronic 
 irritations of the larynx are more frequent than the acute, yet 
 that the latter form does often occur. Its results, however, are 
 different ; and the formation of lymph in idiopathic laryngitis 
 seems peculiarly connected with the general conditions of child- 
 hood, or, at all events, with that imperfectly developed state of 
 the larynx which precedes the period of puberty.* 
 
 * As yet no satisfactorj' explanation of the greater frequency of croup in the 
 infant has been given. Yet of the fact of this greater frequency experience does 
 not permit us to doubt. And we know further, that the observation appUes to the 
 young of other animals, as well as to that of man. Can we, by combining physio- 
 logical with pathological considerations, throw any additional light upon this obscure 
 point? 
 
 We have here a disease in a young animal, in which there is an albuminous product, 
 assuming the form of the organ which has given birth to it, and so far we may observe 
 an analogy with the reproductive powers of the invertebrated animals, and the same 
 phenomenon in the white tissues of the higher organizations. Here I shall quote from 
 Dr. Graves. 
 
 " The white structures of the higher animals resemble the solids of white-blooded 
 animals, and not only in health, but disease. Thus the power of reproduction of parts 
 destroyed by accident or disease, so remarkable in the lower orders of animals, is in 
 the higher enjoyed only by white structures, such as cellular membrane, for proper 
 muscular fibre when once destroyed is not reproduced, condensed cellular membrane 
 being employed to repair solutions of continuity, in this as well as all more highly 
 organized tissues. 
 
 " In white-blooded animals, we often see a new limb appear in the place of one 
 destroyed by accident, and in man it is not unfrequent to observe a neic white oi'gan 
 produced when the old has become useless, or been destroyed. Thus in unreduced 
 dislocations, we have new burste mucosEe, capsular ligaments, synovial membranes, &c., 
 produced so as to form almost all the appendages necessary either to the strength or 
 motion of the new joint. The same happens in ununited fractures. CartUage is thrown 
 out to supply the place of bone removed by operation or disease, and under favourable 
 circumstances, this cartilage itself becomes ossified, and, as happens in Necrosis, an 
 entirely new bone is sometimes produced. In all such cases, the mould of the bone, 
 or that part of it to which the new bone owes its form and bulk, is composed of a
 
 DISEASES OF THE LAKYNX AND TKACHEA. 185 
 
 But croup has been described as occurring in the adult. 
 Here we again see an example of the confusion which has arisen 
 from not carefully separating the primary and secondary forms 
 of the disease ; for, without denying the possibility of the 
 occurrence of primary croup in the adult, it will, I think, be found, 
 that the great majority of cases so described are not of this kind, 
 but are examples of what I have called the secondary in 
 contradistinction to the primary croup; a disease in which the 
 formation of false membranes seems to point out a condition of 
 the system, the very opposite to that to which antiphlogistic 
 measures are applicable. 
 
 I shall now return to the primary inflammatory croup of 
 children. Here one of the most important considerations is the 
 
 white structure, chiefly coagulated albumen : this is first formed, and afterwards the 
 bony particles are deposited in it from red vessels. 
 
 " This facility of reparation forms a very striking analogy between the white parts 
 in man and other red-blooded animals, and the general structure of the solids in white- 
 blooded animals. In point of vitality, the analogy is most striking. The white parts 
 in man, when not inflamed (then they for a time become red parts, and have a corre- 
 sponding increase of vital energy), enjoy but a low vitality. They are scarcely, if 
 at all, sensible ; do not possess initability ; and probably, also, the circulation of the 
 white blood through them is much slower than that of the red blood through the red 
 parts ; at least the circulation of the white venous blood in the lymphatics appears much 
 less rapid than that of the red venous blood in the veins.'' — A Lecture on the Functions 
 of the Lymphatic Syste7]i, p. 19. 
 
 From these facts we are led to conclude, that the chief reproductive power in the 
 higher classes of animals is enjoyed by the white tissues. Now the younger a child 
 is the greater analogy does it bear to an animal composed of white solids (see Serres, 
 GeofErey St. Hilaire, Andral, &c., &c.), and hence we may suppose the gi-eater will be 
 the amount of this local rejiroductive poicer. When we consider the organization of 
 lymph effused upon serous membranes, it seems not improbable that the same might 
 occur in the case of croup, were such a process compatible with life. Again we have 
 seen, that of the different solids the white tissues are those in which the reproductive 
 power is most commonly seen ; and it is a remarkable fact, that the portion of the 
 respiratory apparatus most liable to croup is that in which cartilage is most predomi- 
 nant ; and that as we recede from this point the plastic infiammation becomes less and 
 less developed. How commonly we observe, in cases of croup, that in the larynx 
 there exists an exact cast of the tube, that in the trachea this degenerates into a 
 puriform exudation, and that in the bronchial tubes we have nothing but a mucous 
 secretion. In the child too there may be a greater relation between the physiological 
 and consequently the pathological states of the mucous membrane of the larynx and 
 trachea, and their subjacent tissues, than in the adult ; and the same condition which 
 determines the progressive development of the larynx up to the period of puberty, may 
 also predispose the mucous surface to the plastic or formative irritations. 
 
 I wish to be understood as putting forward this view merely as a subject for inves- 
 tigation, and am fully aware of facts, which seem at first view, at least, to bear against 
 it ; as, for instance, the formation of false membranes in the diphtheritis of the adult, 
 and also in certain enteric irritations. But the subject is one which deserves a further 
 and an impartial inquiry.
 
 186 DISEASES OF THE LARYNX AND TRACHEA. 
 
 complication icith inflammation in the remaining portions of the 
 respiratory apparatus, a fact of vast importance, and one by no 
 means sufficiently recognized by medical men. In a considerable 
 number of cases tlie laryngitis is preceded by some inflammatory 
 affection of the lung, "which continues during its progress, but 
 which is overlooked in consequence of the prominence of the 
 croupy symptoms. I have little doubt, that many children that 
 die with symptoms of croup, are carried oflF as much by disease of 
 the lungs as by that of the larynx and trachea; for I have seen 
 many instances in which, during life, the stethoscope indicated 
 unequivocally the existence of intense bronchitis or pneumonia, 
 and have invariably found that the diagnosis was confirmed by 
 dissection. Indeed the whole respiratory apparatus may be some- 
 times engaged ; so that, as Dr. Cheyne observes, we may find the 
 lung filled with mucous secretion, sometimes hepatized, and with 
 a fluid effusion into the cavity of the pleura. 
 
 I have the notes of one remarkable case, in which it was 
 proposed to perform tracheotomy. I saw the patient in consulta- 
 tion, and satisfied myself of the existence of general bronchitis, 
 and even double pneumonia. The operation was not performed, 
 and the patient soon afterwards sank. The dissection accurately 
 verified the diagnosis, for we found the bronchial mucous mem- 
 brane universally red, and the tubes filled with viscid and bloody 
 mucus. The upper lobes were in the state of active congestion, 
 and the lower red, solid, and softened, with a copious exudation 
 of albuminous lymph upon the surface of the pleura. 
 
 On the subject of this complication Dr. Mackintosh remarks, 
 that the occasional co-existence of bronchitis must be always 
 kept in view when considering the probability of affording relief 
 by the operation of bronchotomy. " I have seen," saj^s he, " the 
 lungs inflamed in various degrees, and almost always considerable 
 portions are in a state of engorgement, owing, perhaps, to the 
 mechanical impediment to respiration." * 
 
 Without denying that the mechanical obstruction of the glottis 
 may produce an engorgement of the lung, yet I cannot help 
 believing that this pathological state is generally the result of the 
 pulmonary inflammation, which often precedes, and almost always 
 accompanies the laryngitis. My reasons for this belief are, that 
 in many cases I have been able to detect this engorgement by 
 * Elements of Pathology and Practice of Physic, vol. i. 1831.
 
 DISEASES OF THE LARYNX AND TRACHEA. 187 
 
 physical signs before the striclalous breathing was fully estab- 
 lished ; and that the changes in the lung and the effusions on 
 the pleura are quite similar to those observed in ordinary cases 
 of pneumonic inflammation. 
 
 Physical Signs of Croup. — It is obvious, that in cases where 
 the disease is confined solely to the larynx and trachea, the pas- 
 sive signs will furnish only negative information ; for so long as 
 the lung remains free from congestion or pneumonia, the sound on 
 percussion will continue clear. But we are not to conclude from 
 this, that the performance of percussion is to be neglected in 
 croup ; for whether it leads to positive or negative results the 
 information is in the highest degree valuable with respect to 
 diagnosis and treatment. Thus, if in a case of croup we find the 
 sound clear, we may be tolerably sure that as yet no impor- 
 tant amount of congestion or of pneumonia has taken place, and 
 we may modify our prognosis and treatment accordingly, while 
 on the other hand, if we find a local or general dulness, we may 
 be satisfied that there is something more than laryngitis, and 
 that the cause of dulness is either an intense congestion, or hepa- 
 tization, or an effusion into the pleura. Every practical man 
 will see the importance of this investigation ; and it happens for- 
 tunately that percussion can be practised with great facility in chil- 
 dren, particularly when used over the posterior, and consequently 
 less yielding portions of the thorax. In making this investiga- 
 tion, the operator must be careful not to be misled by the dulness 
 of the lower parts of the chest, which may arise from an enlarged 
 liver, or from the pushing up of the diaphragm by a distended 
 abdomen ; and must also bear in mind, that the prgecordial region 
 gives naturally a dull sound. I shall only add, that the value of 
 the clearness of sound, as a ground of favourable diagnosis, is 
 directly as the period of duration of sj-mptoms. If pulmonary 
 or laryngeal irritation have existed for twenty-four or thirty-six 
 hours, the chances are, that if there was a pneumonic complica- 
 tion we could discover some degree of dulness. 
 
 Active Signs. — I cannot agree with Dr. M. Laennec in his 
 opinion of the inutility of stethoscopic examination in the true 
 croup.* It is true that in the advanced stages of the disease, 
 when the breathing is slow, difficult, and stridulous, it becomes 
 next to impossible to distinguish the vesicular murmur, less from 
 * See his Notes on the Work of Lr.ennec, Art. Croup.
 
 188 DISEASES OF THE LARYNX AND TRACHEA. 
 
 the sound produced in the larynx, than from the feebleness of the 
 pulmonary expansion. But in the earlier periods of the case, and 
 at the time too when such knowledge would be useful, we 
 can easily determine the condition of the lung by the stethoscope. 
 We may then hear the various bronchial rales, and accurately 
 judge of their extent and intensity ; and even in the cases with 
 pneumonic complication, the signs of the disease, according to its 
 stage or extent, may be easily observed. 
 
 The active physical signs, referrible to the lung, which I 
 have had an opportunity of detecting, have been as follows : 
 First. A diffuse sonorous rale, not so intense as to extinguish the 
 vesicular murmur. Secondly. The same rale, but with more 
 intensity, indicative of disease in the more minute tubes. Thirdly. 
 A combination of the sonorous and mucous rattles, causing a loud 
 sound, and a feeling of vibration when the hand is applied to the 
 chest. Fourthly. The crepitating rale of pneumonia in one or 
 both lungs; in some cases with distinct dulness of sound on per- 
 cussion. I have not heard the bronchial respiration of hepatiza- 
 tion, or the frottement of pleurisy, but there can be no doubt, 
 that if these conditions existed before the laryngeal disease had 
 attained its maximum, their signs would be distinctly audible. 
 It is true, that the sound of stridulous breathing will interfere 
 with those of the lung, but in the earlier periods this inter- 
 ference is by no means so great as has been represented, and a 
 very little practice indeed will enable the stethoscopist to recog- 
 nize the above phenomena, even when a considerable amount of 
 stridulous sound exists. 
 
 As illustrative of the opinion, that the cause of obstruction in 
 this disease is more spasm than the effusion of lymph, I may 
 remark, that the act of vomiting is often followed by a tempo- 
 rary suspension of the stridulous breathing ; and that if the 
 stethoscopist avails himself of this interval he will be able to 
 determine the condition of the lung Avith the greatest accuracy, 
 even in a case where a short time before, none, or almost none, 
 of the pulmonary jihenomena could be detected. 
 
 But in addition to the stridulous breathing, there is another 
 cause tending to obscure the pulmonary signs. This is the violent 
 action of the heart, the loud and rapid contractions of which may 
 be heard over the entire chest. Yet even this does not cause any 
 important difficulty, at least to the practised stethoscopist.
 
 DISEASES OF THE LARYNX AND TRACHEA. 189 
 
 As the disease subsides the stridulous sound disappears, and 
 we almost always observe a pretty general sonorous rale, 
 which may cease without j^assing into, or becoming combined 
 with the mucous rattle. This is particularly observed where 
 the treatment is persevered in after the disappearance of the 
 larj^ngeal symptoms. 
 
 Treatment. — The treatment may be considered with respect 
 to the precursory, or catarrhal, and the confirmed stages. We 
 have seen in many cases, that the obstruction of the larynx does 
 not come on suddenly, but is preceded by a stage of slight 
 irritation of the mucous membrane, generally afi'ecting both the 
 larynx and bronchial tubes. Now, if at this period the physician 
 interferes with judgment, he will generally succeed in cutting 
 short the attack. The circumstances that should excite alarm 
 are the wheezing respiration, with slight hoarseness, and some 
 change in the character of the cough. These symptoms may 
 exist although the child seems cheerful and free from fever, yet 
 be not the less premonitory of a severe laryngitis. Under these 
 circumstances the child should be confined to his room, all 
 stimulating food withheld, and an emetic immediately prescribed 
 so as to secure its full and speedy operation ; for this purpose we 
 may employ the vinum ipecacuanhse, as recommended by Dr. 
 Cheyne, or the tartar emetic. I much prefer the latter on account 
 of its greater certainty and unstimulating nature, as well as from 
 its known power of controlling bronchial inflammation. After 
 the vomiting the child should be kept in bed, the bowels opened, 
 he should drink warm diluents, and the exhibition of small doses 
 of ipecacuan will generally place him in safety. 
 
 But on the setting in of the confirmed stage our treatment 
 must be prompt, decided, and energetic ; for in most cases the 
 life of the patient depends on what is done in the first six or 
 eight hours of this attack. Now the remedies on which Ave may- 
 place the greatest confidence are general and local bleeding, and 
 the exhibition of tartar emetic. 
 
 In performing general bleeding we may open a vein in the arm, 
 or perform the operation on the jugular itself; and in consequence 
 of the turgid state of the latter vein it will be often easier to 
 bleed from this situation than in the arm. There are some 
 objections, however, to bleeding from the jugular vein, the prin- 
 cipal of which is the difficulty of commanding the haemorrhage ;
 
 190 DISEASES OF THE LARYNX AND TEACHEA. 
 
 and it may happen, even after the most careful arrangement of 
 the Avound, that the act of vomiting shall cause a fresh discharge 
 of blood, which may be repeated so often as to endanger the life 
 of the patient. This circumstance alone is a strong argument 
 against opening the jugular vein, unless when the practitioner 
 can remain with his patient ; for if from the fear of vomiting we 
 suspend the exhibition of the tartrate of antimony, we deprive 
 ourselves of the most powerful agent in the treatment of the 
 disease. After the general bleeding leeches should be applied to 
 the region of the larynx, in numbers proportioned to the age and 
 strength of the patient, and their application should be renewed 
 again and again, until a decided impression is made on the disease. 
 But though a warm advocate of the importance of general and 
 local bleeding, jet I look on them as merely assistants to the 
 principal remedy, which is the tartar emetic, the exhibition of 
 which may be commenced from the very first period of the treat- 
 ment ; and I would advise that the medicine should be so exhi- 
 bited as to produce free vomiting, at least once in every three- 
 quarters of an hour. In this state the patient should be kept for 
 several hours, when, according to circumstances, the remedy may 
 be given less actively. The solution which I employ contains 
 one grain of the salt to each ounce of distilled water, and of this 
 a dessert spoonful is given every quarter of an hour, or half hour, 
 according as the case may be. I am aware that in advocating 
 the treatment by repeated vomiting I am at issue with a high 
 authority on this subject, Mr. Porter, who has recommended the 
 remedy in smaller doses, and so managed as to keep up a state 
 of permanent nausea, without vomiting. But without at all 
 impugning this practice, which indeed I could not do after having 
 witnessed its success so frequently, I must declare, that I have 
 seen more cases of marked and rapid relief where vomiting had 
 been produced, than where the patient had been kept in mere 
 nausea. This is the treatment which has been recommended by 
 Dr. Cheyne, and to its efficacy I can bear the fullest testimony. 
 That distinguished physician, in describing the treatment of the 
 disease, advises that " the dose of tartar emetic mjiy be from 
 a quarter to a half grain, and this may be repeated according to 
 its effect, and to the urgency of the attack." He adds, " that 
 sickness ought to be excited, and hence the dose, if it have no 
 such efiect, ought to be repeated in half an hour ; and if great
 
 DISEASES OF THE LARYNX AND TRACHEA. 191 
 
 prostration bs not produced, the dose ouglit afterwards to be 
 repeated hourly while symptoms of inflammation continue. * 
 
 For the introduction of this inestimable remedy in the treat- 
 ment of croup, the science is indebted to Dr. Cheyne. In his 
 essay on Cynanche Trachealis, published in Edinburgh in the 
 year 1801, we find the treatment recommended ; and it is no 
 small evidence in its favour, that in the year 1832, after an expe- 
 rience greater than falls to the lot of most men, the opinions 
 of this philosophical investigator of disease have remained un- 
 altered. How changed would be the character of medicine, if in 
 support of many of our remedies, there could be brought forward 
 such evidence and such an advocate. 
 
 I shall not dwell on the mercurial treatment of croup, as I 
 believe it to be insufficient and unnecessary. The uncertainty 
 of the action of calomel, the difficulty of producing ptyalism in 
 violent acute inflammations, the shortness of the period for the 
 exhibition of the remedy, and the various injurious efi"ects of 
 mercurial action on the system at large, are sufficient reasons 
 against the employment of this treatment in the croup of 
 children ; and where we have so valuable a remedy as the tartar 
 emetic, it seems scarcely justifiable to tamper with the case by 
 the attempt to produce mercurial action. 
 
 It is a common practice to apply a blister to the throat in the 
 early periods of this disease, but I have no doubt that such a 
 proceeding is fraught with danger. Here I may refer to the 
 observations I have already made on the action of blisters in 
 local inflammations ; and with reference to the case before us, I 
 feel happy in quoting from, and entirely agree with Mr. Porter, 
 who declares that they cannot be resorted to at an early period 
 without considerable risk of doing mischief. He further remarks, 
 that " it is always hazardous to apply a blister in the immediate 
 neighbourhood of inflammation, and particularly so if the consti- 
 tution has not been previously brought down by bleeding and 
 evacuation. In the latter stages of croup, when the lungs are 
 congested, and there is a tendency to efi^usion within them, there 
 can be no objection to try the application of blisters to the chest, 
 but scarcely under any circumstances will they be found bene- 
 ficial if applied near to the part affected, "f 
 
 * Cyclopaedia of Practical Medicine, Art. Croup. 
 
 t Observations on the Surgical Pathology of the Larynx and Trachea. Dublin, 1826.
 
 192 DISEASES OF THE LARYNX AND TRACHEA. 
 
 When describing the treatment of bronchitis, I dwelt particu- 
 larly on the all-important practical point, that there was a period 
 in the disease when the antiphlogistic treatment could be no 
 longer employed, but in which we must change to the tonic and 
 stimulating plan ; and so in croup, which is but a variety of the 
 disease, a period will arrive when we must have recourse to the 
 stimulant and revulsive medications. The coldness of the sur- 
 face, the feebleness of the respiratory efforts, the failure of the 
 pulse, the sinking of the eye, and the pallor of the countenance, 
 all point out that the period for depletion has passed by ; and 
 that if there be any hope it must be from the exhibition of stimu- 
 lants. Wine, brandy, opium, and ammonia may be employed. 
 Hot turpentine stupes may be applied to the chest and extremi- 
 ties, and now and then the reward of the nil desperandum 
 practice may be unexpectedly obtained. 
 
 On the performance of tracheotomy in this disease I have little 
 to say, more than to express my decided dissent from it. Indeed, 
 all the best authorities are now agreed on this point. Experience 
 has shewn that the operation has failed in the great majority of 
 cases ; and it is obvious, that with our present knowledge of the 
 nature of the disease, we can scarcely hope for good from its per- 
 formance. Among other causes for failure there is one which 
 will always exist, and which by itself is generally sufficient to 
 explain its inutility. There is always that kind of feeling con- 
 nected with a surgical operation in acute diseases, which prevents 
 its being proposed, assented to, or performed, unless under nearly 
 desperate circumstances, and when all other means have failed. 
 In the case before us, the operation is performed at a time when 
 the situation of the patient is the worst possible for success ; 
 when the nervous system has been profoundly injured, and the 
 lungs, even though no primary complication may have existed, 
 have become extensively congested. But in original complication 
 with pulmonary disease, whether it be pneumonia, ordinary 
 bronchitis, or the plastic inflammation, spreading from below 
 upwards, we have another and scarcely less important explanation 
 of the failure of this operation ; for even after the opening into 
 the trachea has given a temporary relief, the patient sinks from 
 an inflammation of the lungs, which preceded or accompanied the 
 laryngeal disease. It might be argued, that the operation has 
 been always performed too late, but in this respect it is like that
 
 DISEASES OF THE LARYNX AND TRACHEA. 193 
 
 for empyema ; and, in either case, will almost never be undertaken 
 at the earlier periods of the affection. I am far from decrying the 
 operation of tracheotomy generally ; on the contrary, it must be 
 admitted, that in many diseases it is the only mode of saving 
 life, but everything turns on the proper selection of the case. 
 Thus, in the instance of foreign bodies in the trachea, of oedema 
 of the glottis, and of other forms of disease, commencing in, 
 and confined to the upper portion of the windpipe, where 
 the lungs are not diseased, nor have become congested from 
 the laryngeal obstruction, we have a set of cases in which the 
 operation may be undertaken with a fair prospect of success, and 
 indeed is the only means of saving the patient from a speedy 
 death. 
 
 I shall conclude this part of the subject by quoting from two 
 of our most eminent authors on the pathology of the larynx, 
 both of whom are strongly opposed . to the performance of the 
 operation. "Before having recourse," says Dr. Cheyne, "to 
 the operation, supposing it easy, safe, and likely to end in the 
 extraction of the adventitious membrane, it will be proper to ask, 
 is the false membrane in the larj^nx, which it is the object of this 
 formidable operation to remove, in general the cause of the 
 patient's death? We apprehend not. First, because in several 
 dissections which were long ago made, with a view of determining 
 the effect of the membrane of croup in obstructing the larynx, it so 
 happened that within that membrane a space was left for a current 
 of air sufficient to support life. In these bodies the cellular sub- 
 stance of the lung was distended Avith serum, the ramifications of 
 the bronchi were filled with puriform matter, by which the air was 
 excluded, and the bronchial membrane was universally inflamed, 
 thereby preventing the arterialization of the blood : the children 
 had perished from the lungs being unable to contain a quantity of 
 air sufficient to support the circulation, and from the bronchial 
 membrane being unable to act on that reduced quantity. 
 Secondly, because when the membrane of croup fully formed is 
 expectorated the disease is generally fatal, even when all the 
 benefits of the operation are obtained. If the disease were con- 
 fined to the larynx, then, and then only, would bronchotomy be 
 advisable." * 
 
 I shall next quote from the work of my friend and colleague, 
 * Cyclopaedia of Practical Medicine, Art. Croup. 

 
 194 DISEASES OF THE LARYNX AND TRACHEA. 
 
 Mr. Porter,* a work distinguislied for originality, accuracy, and 
 extensive investigation. 
 
 " To the casual success of such an operation I would attach 
 no professional reputation, whilst I think much character may be 
 lost to the individual, and general obloquy heaped on the pro- 
 fession, by the too frequent performance of operations thus under- 
 taken at a hazard, and almost always at a period of the disease 
 when its efficacy (if it ever possessed any) must be exerted too 
 late. 
 
 "But bronchotomy has in many cases of croup been successful. 
 True — but where are the thousand and one instances to the con- 
 trary, that might be brought against each single one of these ? 
 I have performed the operation myself on the child, and have 
 seen it frequently done by others, and in no one case has the life 
 of the patient been saved. I have known and heard of it often, 
 but never understood that it produced a recovery ; and I should 
 .suppose that my experience on the subject only resembles that 
 -of most men who have had opportunities of seeing and treating 
 -the disease. Most practitioners are fond of publishing cases of 
 ■successful operations, but are not so willing to make known those 
 .of an opposite description, from an idea that these supposed 
 failures might lower them in public estimation, but these 
 •detached and solitary expositions of fortunate surgery are calcu- 
 lated to produce very serious injury if they encourage others to 
 similar attempts, in the hope of similar results. If it was possible 
 to place a list of those cases in which bronchotomy had not 
 proved serviceable, in array against those wherein it had seemed 
 to be useful, it would be scarcely necessary to advance any 
 farther argument in proof of its uncertainty ; and medical men 
 would rather turn their attention to the improvement of that 
 internal treatment which will generally be efficacious if resorted 
 .to in time, than look for advantage in the performance of an 
 operation from which experience holds out such slender hopes." 
 
 But the operation has been suggested with other views than 
 merely to facilitate the entrance of air into the lung. Thus 
 Bretonneau,t after having ascertained the value of topical appli- 
 cations, in the diphtheritis of the pharynx, has proposed their 
 direct introduction into the larynx by means of an opening into 
 
 ♦ Surgical Pathology of the Larynx and Trachea, by W. H. Porter. 
 t Dea Inflammations Speciales du Tissu Muqueux.
 
 DISEASES OF THE LARYNX AND TRACHEA. 195 
 
 the windpipe, so that in this way he might attain a double 
 object, viz., the free entrance of air, and the action of specific 
 agents directly applied to the diseased membrane. Thus, in 
 reference to a particular case, after describing certain modifica- 
 tions, which he proposed in the operation, he adds, " I hoped 
 farther, by means of the artificial opening to be able to apply 
 calomel at once on the affected surfaces, and I avow that I had 
 great confidence in the effects of a remedy which has such 
 remarkable eftects in many ulcerous inflammations of the skin. 
 I was also convinced, that in the case where the mercurial 
 treatment had failed, the diphtheritic inflammation had been 
 dissipated in all those points where the surface came directly in 
 contact with calomel," 
 
 The case to which these remarks apply was one of what I have 
 called the secondary croup, where the affection of the larynx and 
 trachea succeeded to the formation of false membranes in the 
 cavity of the pharynx, and in which the symptoms resisted treat- 
 ment, so that on the seventh day they became sufficiently alarm- 
 ing as, in the opinion of Bretonneau, to demand the operation. 
 The opening into the trachea was followed by relief of the 
 symptoms, and some fragments of concretion were expelled 
 through the canula. Eight grains of calomel were blown into 
 the trachea by means of the canula. For the further reports of 
 this interesting case I refer to the work itself ; it will suffice to 
 state, that the child was convalescent on the twentieth day of the 
 disease, and the thirteenth of the operation, but for nine or ten 
 days after the operation the situation of the patient was often 
 extremely critical. The direct introduction of calomel was 
 repeated three times ; the mode employed being to introduce it 
 along with water into the canula, when by the efforts of inspira- 
 tion it was sucked into the trachea. 
 
 It is plain that this case is not sufficient to establish the 
 efficacy of the direct action of calomel as a remedial agent in the 
 disease. During the progress of the case hardly a day elapsed 
 without the expulsion of some of the false membrane, and without 
 denying the possibility of the specific action of the remedy, it 
 seems more probable that the recovery was attributable to the 
 gradual decline of the disease in a patient whose immediate 
 death was prevented by the operation of tracheotomy. The case, 
 however, is full of interest, and deserves a careful study. 
 
 2
 
 196 DISEASES OF THE LAEYNX AND TRACHEA. 
 
 Acute Laryngitis in the Adult. — The principal difference 
 between this and the preceding affection is in the result of the 
 inflammation, which in place of the formation of lymph, termi- 
 nates in an cedematous state of the mucous membrane and its 
 subjacent cellular tissue. This fact has been recognized by 
 various writers, from the time of the second Monro ; and the 
 rarity of the production of lymph in the larynx of the adult is 
 now fully admitted ; the plastic inflammation then may be con- 
 sidered as in some way connected with that lower development 
 which precedes the period of puberty. 
 
 But there is another point of difference which has not been 
 sufficiently noticed. In the adult the disease is more confined to 
 the larynx ;* it is in reality a laryngitis, while, as we have seen, 
 the croup of children is commonly complicated with inflammation 
 of the trachea and bronchial tubes. And thus we have at least 
 one reason for the much greater success of tracheotomy in the 
 laryngitis of the adult than in that of the child. Yet lymph has 
 been found to line the windpipe, even in advanced age, and cases 
 of this kind have been published as instances of croup in the 
 adult. Without denying the possibility of a primary irritation of 
 the larynx forming lymph, even under these circumstances, it 
 must yet be admitted, when we compare the analogous diseases of 
 laryngitis in the child and adult, that the secretion of lymph in 
 the latter instance is extremely rare. In the great majority of 
 cases described under the name of croup in the adult, the 
 affection of the larynx was secondary to some general or local 
 affection. The exudation of lymph formed first in the j)harynx, 
 aifid extended from this to the windpipe, and the disease thus 
 produced was what I have already described under the name of 
 the secondary croup. 
 
 In most of these cases the disease occurred under the form of 
 the diphtheritis of Bretonneau ; in the putrid sore throat, or 
 lastly, as an affection supervening in the progress, or towards the 
 close of other diseases. For the most accurate researches on this 
 subject we are indebted to M. Louis,t and a review of his cases 
 will confirm the above positions. 
 
 In his memoir eight cases are detailed ; the first is that of a 
 robust man, aged twenty-three years, who, on tho eighteenth 
 
 * Porter, Op. Cit., p. 94. 
 
 t Recherches Anatomico-Pathologiques. Du Croup considere chez I'Adulte.
 
 DISEASES OF THE LARYNX AND TRACHEA. 197 
 
 day of a typhus fever, became attacked with pain in the throat, 
 soon followed by the formation of a false membrane, covering the 
 tonsils, soft palate, and pharynx. On the twentieth this mem- 
 brane had become more opaque, and the voice was altered, but 
 the respiration continued natural ; in two days, however, he had 
 the croupy voice, and brazen respiration, the breath was fcetid, 
 deglutition impossible, and the patient soon after sunk ^ith 
 delirium. 
 
 On dissection the cervical glands were found enlarged, and the 
 pharynx, uvula, velum palati, epiglottis, and laiynx were lined by 
 a false membrane. 
 
 In the second case, the patient, aged nineteen, had laboured 
 for upwards of three months under a chronic pleurisy, when it 
 was observed that the sputa were mixed with portions of j'ellow 
 false membranes. On the following day he complained of a pain 
 in the throat, and the posterior portion of the mouth was seen 
 lined with a semi-transparent false membrane. Soon after this 
 the neck became slightly swelled, the voice altered, there was 
 extreme distress referred to the larynx. To these symptoms 
 succeeded the vox rauca, stridulous breathing, suffocation, and 
 death : four days having elapsed between the invasion of the 
 diphtheritic symptoms and the fatal termination. 
 
 The appearances on dissection, as far as the pharynx and 
 windpipe were concerned, were the same as in the former 
 instance. 
 
 The third case is an example of a similar disease supervening 
 in the course of a gastro-enteritis, with a gangrenous ulceration 
 of the right tonsil, and some oedema of the glottis. In the fourth 
 and fifth false membranes occupied the posterior cavity of the 
 mouth, the nasal fossae, the larynx, and trachea. In the sixth a 
 similar affection supervened in the last periods of pulmonary 
 phthisis ; and in the eighth they occurred during a typhus fever. 
 The ages of these five last patients were respectively twenty-nine, 
 sixty-two, twenty-two, thirty- two, and fifteen years. In all the 
 cases false membranes existed in the pharynx, and the disease is 
 admitted by Louis to have spread from above downwards. Indeed, 
 he records but one observation where this production was con- 
 fined to the windpipe alone. This was a female, aged thirty-two, 
 exhausted by misery and starvation, who died with symptoms 
 of angina, accompanied with prostration. On dissection, a thick
 
 198 DISEASES OF THE LARYNX AND TRACHEA. 
 
 * 
 
 false membrane lined the larynx and trachea, and even descended 
 to the third ramifications of the bronchial tubes. It did not 
 occur on the tonsils or soft palate, where nothing was found but 
 a small quantity of greyish-coloured mucus. 
 
 It must be admitted that these cases, excepting the seventh, 
 were examples of a disease vei*y different from the inflammatory 
 croup of children. A great similarity exists among them ; the 
 formation of false membranes in the cavity of the mouth, and its 
 spreading from above downwards ; the disease, secondary to 
 other local affections, or to fever ; the prostration, the typhoid 
 state, and the age of the patients, form a group of circumstances 
 decisive as to the nature of the disease. 
 
 Acute laryngitis may vary from the production of but a slight 
 hoarseness, without stridulous breathing, and with little or no 
 fever, to a violent irritation of the mucous membrane and sub- 
 jacent cellular tissue of the glottis, epiglottis, and upper portion 
 of the larynx ; an oedematous state of the mucous membrane and 
 cellular tissue of the glottis is produced, and death results from 
 the direct closure of the tube. Rapid and formidable from its 
 nature and situation — the situation of all others where the least 
 extent of disease is the most dangerous, it demands a prompt and 
 energetic treatment. 
 
 The disease in its worst form is characterized by a hoarse 
 cough, with increasing difficulty of breathing, ; the respiration 
 becomes rapidly stridulous ; the voice is altered until it is only 
 a painful whisper, and the distress and anxiety of the patient 
 are extreme. There is often great dysphagia, and the drinks are 
 returned through the nose. In these cases the epiglottis maybe 
 felt swollen, turgid, and erect, and on inspection is seen red and 
 shining.* 
 
 This affection has been described under the name of the 
 cedema of the glottis, but it is better in medical nomenclature to 
 have reference to causes than effects. Besides we may have 
 oedema of the glottis without violent inflammation. 
 
 In the advanced periods of this affection the situation of the 
 patient is truly dreadful from the painful, laboured, and insuffi- 
 cient breathing, and the paroxysms of cough ; his voice is too 
 feeble to express his sufferings, but in his anxious and suppli- 
 cating countenance we may read that he demands relief at any 
 
 * See Wilson in Med. Chir. Tra'js., vol. v.
 
 DISEASES OF THE LARYNX AND TRACHEA. 199 
 
 price. The eyes are staring and tearful, the face pallid, and the 
 skin often cool. If he falls asleep for a moment he suddenly 
 awakes in the greatest agitation, and if relief be not speedily 
 aflforded he soon sinks by coma. 
 
 The fatal termination may occur suddenly and rapidly, or 
 more slowly, when it seems to arise from the non-arterializatiou 
 of the blood. And even after the air has been freely admitted by 
 bronchotomy, the patient may sink apparently from the shock 
 which the brain has received.* Such a result is more likely 
 when the operation has been long delayed. 
 
 An oedematous swelling of the neck has been enumerated 
 among the symptoms of this disease, but with what degree of 
 justice remains to be settled. I have seen the affection more 
 often without than with this swelling ; and in the cases where it 
 did occur, it was not symptomatic of the disease, as in these 
 patients there had been either erysipelatous inflammation, or 
 bad scarlatina, and the swelling of the neck manifestly preceded 
 the laryngeal symptoms. 
 
 In a patient operated on successfully by Mr. Porter, the 
 integuments of the neck were swollen consecutively to the laryn- 
 gitis ; but here the swelling was from emphysema, and was a 
 source of great embarrassment in the operation. This obviously 
 proceeded from the violent efforts of cough and respiration, but 
 whether the lesion took place in the lung or windpipe is not 
 known. Louis observed a similar occurrence in a case of foreign 
 body in the trachea. t 
 
 This formidable disease, however, may occur under other 
 conditions than as an acute inflammatory disease. (Edematous 
 obstruction of the glottis is an afiection arising from many 
 causes, of which the following may be enumerated. 
 
 It may occur — 
 
 1st. From acute primary inflammation, as in the form just 
 described. 
 
 2nd. As a result of erysipelatous inflammation aff'ecting the 
 system generally. 
 
 3rd. From diffuse inflammation of the neck. 
 
 4th. As a result of the lower forms of scarlatina, and other 
 exanthemata. 
 
 * See Cyclopaedia of Pract. Medicine, Art, Laryngitis, by Dr. Cheyne. 
 t Med. de I'Academie de Chirurgie, tome iv.
 
 200 DISEASES OF THE LARYNX AND TRACHEA. 
 
 5th. Consequent on the disease called parotiditis, so common 
 after fever.* 
 
 6th. Occurring after the long existence of organic tumours 
 in the neck. 
 
 7th. After great operations on the neck-t 
 
 In fact it would seem likely to arise in all cases of tumour of 
 the neck, particularly those where an irritation of the cellular 
 membrane has occurred, and the fever may he inflammatory or 
 typhoid. 
 
 OEdema of the glottis then is not a disease which we can 
 always meet by a bold antiphlogistic treatment, and an accurate 
 investigation into its causes and history must be made before 
 its treatment can be determined on. 
 
 But besides this formidable disease, there are other acute 
 irritations of the larynx, which differ from it in their history, 
 symptoms, and danger. 
 
 In these following forms may be enumerated — 
 
 1st. Simple recent hoarseness, without stridulous breathing or 
 fever. 
 
 2nd. Hoarseness and fever, with slight stridulous breathing. 
 
 3rd. Hoarseness, incessant cough ; some stridor, with pain and 
 soreness of the larynx, dysphagia, not proceeding from tumefaction 
 of the epiglottis, occasional spasmodic exacerbations. 
 
 4th. Symptoms similar to the preceding, but occurring in the 
 course of typhus or gastric fever, and in all the phenomena 
 analogous to the other secondary affections of fever. 
 
 5th. Laryngeal symptoms arising in the course of the exan- 
 thematous diseases, such as measles, scarlatina, and small-pox.;]; 
 
 6th. Laryngeal symptoms arising from the spreading down- 
 wards of an exudation of lymph formed in the pharynx and cavity 
 of the mouth. This is the diphthcrlte tracheah of Bretonneau,§ 
 
 * Of this disease I have made many dissections, and in no case was the parotid 
 gland affected. The affection was in all an cedematous inflammation of the cellular 
 membrane posterior to the angle of the jaw. 
 
 f For these last two instances I am indebted to Mr. Cusack. In the Museum of the 
 Park Street School of Medicine there is an excellent specimen of the disease, which 
 occurred in a patient labouring under a cancerous tumour below the jaw ; there the 
 mechanical obstruction to the circulation had probably much to do in the disease. 
 
 X See Tweedie, Clinical Illustrations of Fever, with reference to this and the last 
 variety. In typhus fever I have never seen the disease produce stridulous breathing. 
 
 § Des Inflammations Speciales du Tissu Muqueux, par P. Bretonneau, Paris, 1826. 
 This author has described a remarkable epidemic of this affection, which occurred at 
 Tours in 1818. To the original disease he gives the name of the scorbutic gangrene,
 
 DISEASES OF THE LARYNX AND TRACHEA. 201 
 
 and may be seen in cases of the putrid or malignant sore throat. 
 The disease may only produce some hoarseness or stridor, or, on 
 the other hand, cause death by laryngeal obstruction. 
 
 7th. Laryngitis from the spreading downwards of the plastic 
 inflammation, caused by the action of corrosive agents on the 
 cavity of the mouth and pharynx. 
 
 The diseases which may be confounded with acute idiopathic 
 laryngitis are not numerous. But in making our diagnosis we 
 must know them so as by the method of exclusion we may form a 
 true opinion. They may be enumerated as follows. 
 
 I. Secondary inflammation of the larynx, arising in the course 
 of angina maligna, diffuse inflaminations, tyi^hus fever, the 
 exanthemata, &c. 
 
 We distinguish this class of affections by their previous history, 
 by the character of the fever, and by the pre-existence of signs of 
 local disease in the pharynx, or in the cellular membrane of the 
 neck. The occurrence of diffuse inflammation, of the exanthe- 
 mata, or typhus fever^ are also most important in the diagnosis. 
 
 II. Foreign Bodies in the Larynx. — As I shall dedicate a 
 separate chapter to the diagnosis of this occurrence, I shall not 
 now dwell longer on it than to remark, that in general the sud- 
 denness of the attack, the absence of fever, or other constitutional 
 disturbance, the healthy state of the epiglottis, while the signs 
 of obstruction are increasing, the singular remissions, and the 
 completely characteristic stethoscopic phenomena, are sufiicient 
 to lead to an accurate conclusion. 
 
 III. Acute Pericarditis. — In a few instances this affection has 
 simulated laryngitis remarkably.* In most of them, however, 
 the pharynx and epiglottis have been found healthy, and the 
 disease was longer in running its course than the ordinary acute 
 
 or angina maligna. He gives the dissections of eighteen cases, in which the air 
 passages were engaged. In five, the disease occurred in children aged from eight 
 months to seven years, and in them all the exudation was first formed in the 
 pharynx. In one case it descended into the minute hronchi. The remaining thirteen 
 cases present the disease (with a single exception) proving fatal by attacking the air 
 passages, and in the great majority first engaging the pharynx. In one case the 
 laryngo-bronchial membrane seemed alone affected. 
 
 * On the curious fact of this and the two next affections simulating laryngitis, I 
 shall dwell more fully when I treat of pericarditis. See Morgagni, Epist. Med. xvi. 
 Art. 40. Also J. P. Frank de Curand. Hominum Morbis. Testa, de la Malattie' del 
 Cuore, Bologna, 1811, vol. iii. And lastly, Portal, Mem. sur la Nature et le Traite- 
 ment de Plusieurs Maladies, Paris, 1819.
 
 202 DISEASES OF THE LARYNX AND TRACHEA. 
 
 laryngitis of adults. If to these we add the fact, that the 
 diagnosis of pericarditis no longer rests on negative evidence, 
 ■we have sufficient means to prevent our confounding the two 
 aff'ections. 
 
 IV. Acute Pneumonia and Pleuritis. — These diseases are not 
 so liable to simulate laryngitis as the last. As to diagnosis I 
 shall only say, that the physical examination of the chest, which 
 should never be omitted in any case of laryngitis, will, in almost 
 all cases, suffice to establish the distinction. 
 
 V. Aneurismal Tumours comj^ressing the Trachea. — The 
 chronicity of these cases, the absence of fever, and the existence 
 of pectoral disturbance, such as pain, palpitation, dyspnoea, and 
 cough, long before the laryngeal symptoms set in, will generally 
 point out their nature. But there are other circumstances which 
 must be attended to. Thus we may observe the tippet-like 
 swelling of the neck,* the tumefaction of one or both jugular 
 veins, and the occurrence of deejj-seatecl dysphagia. The upper 
 portion of the sternum and one clavicle will be generally dull on 
 percussion, and the stethoscopic signs of aneurism will be here 
 audible. Lastly, if the patient has been under observation 
 previous to the setting in of laryngeal symptoms, and that we 
 have discovered a more than natural difference between the 
 intensity of the vesicular murmur in either lung, while there is no 
 physical sign of disease in these organs, we may be certain that 
 the obstruction was not originally in the windpipe, but first 
 aff"ected one bronchus, and from that extended upwards. 
 
 VI. Abscesses external to, and compressing the Larynx. 
 These aff'ections may be recognized and distinguished from 
 
 laryngitis by local tumefactions in the superior portion of the neck, 
 which are tender to the touch, and cause an inability to open the 
 mouth. From the confinement of the matter under the strong 
 fascia of the neck fluctuation is seldom perceived, but an 
 cedematous condition may exist. According to Mr. Porter,t the 
 difficulty in breathing, though great, does not resemble that 
 occasioned by laryngeal obstruction, it is not sibilous or whistling : 
 the approach of the suff'ocating symptoms is in general gradual, 
 and there is no appearance of inflammation in the fauces. 
 
 * Dub. Jour, of Med. and Cliem. Fcience. On the Diagnosis and Pathology of 
 Aneurisms of the great Vessels, by W. Stokes, M.D., vol. v. 
 t Porter, Op. Cit., pp. 127, 130.
 
 DISEASES OF THE LARYNX AND TRACHEA. 203 
 
 Further, as the above author has observed, we find that in pressing 
 the hir3aix backwards against the spine, a feeling of fuhiess and 
 elasticity is often imparted, and when we move the organs 
 laterally, the sensation of the rubbing together of two firm 
 substances is no longer produced. 
 
 VII. Spas)iiodic Exacerbations in Chronic Laryngitis. 
 
 It is scarcely necessary to dwell on this case as distinguished 
 from acute laryngitis ; for the previous history, the suddenness of 
 the attack without increase of fever, and the condition of the 
 fauces, will at once enable us to determine the nature of the 
 symptoms. 
 
 VIII. Hysteric Spasm. 
 
 Like the preceding, it is generally easy to distinguish the 
 nature of this attack. It most commonly occurs in females, who 
 have already shewn a manifest hysterical or spasmodic tendency. 
 It is generally accompanied by other hysterical symptoms ; and 
 though the obstruction seems excessive, yet the patient is free 
 from fever. On the subject of spasm of the glottis I shall here- 
 after dwell more fully. 
 
 Physical Signs of Laryngitis in the Adult. — I shall defer 
 the consideration of this subject until we examine the history of 
 chronic laryngitis. I do this in order to avoid repetition, for the 
 causes and nature of the physical signs are nearly similar in both 
 diseases. 
 
 Treatment of Acute Laryngitis in the Adult. — There is 
 abundant evidence to shew that in a certain period of the 
 idiopathic disease Ave may succeed in reducing the inflammation 
 by vigorous antiphlogistic treatment. It is hardly necessary to 
 observe, that this treatment is only proper or safe in the earlier 
 periods, while the strength of the patient is but little impaired, 
 and particularly while the blood is sufficiently arterialized. But 
 after long-continued stridulous breathing, or even when it is recent, 
 but severe and increasing, and when we find the countenance waxy 
 or livid, and the lip pale, it becomes nearly useless, and often 
 dangerous, to draw blood.* Then we must not lose time, but 
 
 * See Chejme, Cycl. of Pract. Medicine, Art. Laryngitis. Also Armstrong, Practi- 
 cal Illustrations of Typhus Pever. Porter, Surgical Pathology of the Larynx and 
 Trachea, p. 101. Dr. Cheyne remarks, after detailing some successful cases of blood- 
 letting in laryngitis, that in none of them had lividity occurred ; and also, that where 
 bleeding is performed, it should not, as Baillie has advanced, be carried so far as to 
 cause syncope.
 
 204 DISEASES OF THE LARYNX AND TIIACHEA. 
 
 give the patient his best chance, namely, the performance of 
 tracheotomy. There is no disease of an inflammatory nature in 
 which the period for antiphlogosis is so short ; for the result is 
 generally oedema, and the organ, as compared with others, that 
 in which the least amount of tumefaction or effusion causes the 
 greatest depressing effects. 
 
 In the milder forms of the disease we may often apply leeches 
 with benefit, but I have seldom seen them of advantage in the 
 more violent cases. Dr. Cheyne has suggested that they should 
 be applied to tbe mucous membrane, as near as possible to the 
 epiglottis ; and certainly this mode would be thab most likely to 
 afford relief if such is to be obtained by local bleeding.* With 
 respect to blistering, there is as yet no evidence in its favour as a 
 remedial measure in this disease. 
 
 In fact if the inflammation does not yield to the early and 
 vigorous use of the lancet, the operation of tracheotomy must not 
 be delayed ; and it is consoling to know that it aftbrds an ex- 
 cellent chance for recovery. And further, that even under circum- 
 stances apparently the most hopeless, it may be successfully 
 performed. In a case quoted by Dr. Cheyne, the operation was 
 performed by Mr, Goodeve, after the pulse had ceased at the wrist, 
 the face suffused, and the lips livid, yet recovery took place. I 
 shall not soon forget the case of a gentleman, aged upwards of 
 sixty years, who had recently recovered from a violent pneumonia, 
 and was attacked with the most violent form of acute laryngitis, 
 which baffling all efforts to control it, brought the patient into the 
 jaws of death in little more than twelve hours. It was determined 
 that Mr. Porter should be sent for to operate, but before he 
 arrived the patient had become nearly insensible. The operation 
 was proceeded with, but respiration ceased before the trachea was 
 opened. The operator paused, it was a fearful moment, and then 
 rapidly opened the trachea, yet no sound of inspiration followed. 
 Applying his mouth to the wound he inflated the lungs, and 
 produced artificial respiration at least seven times, when a loud 
 and rattling inspiration, followed by full and free breathing, 
 proclaimed the triumph of art. The occurrence, strange and un- 
 expected, excited at the moment feelings of a higher order ; and 
 among those who participated in them there Avas none more 
 
 * See a paper on the Aj plicaf on of Leeches to Internal Surfaces, by P. Crampton, 
 M.D.. Dub. Hosp. Reports, vol. ii .
 
 DISEASES OF THE LARYNX AND TRACHEA. 205 
 
 sincerely affected than the intrepid, experienced, and scientific 
 operator himself. 
 
 In these cases it sometimes happens that the obstruction 
 rapidly subsides after the operation ; but in many others it is 
 necessary to insert a canula, so adapted that it may be worn 
 for a length of time. For further information on this point I 
 beg again to refer to Mr. Porter's book, and shall conclude by 
 observing, that general or local antiphlogistic treatment seems 
 inefficacious in all the forms of oedema of the glottis excepting 
 the first ; how far the performance of the operation may be 
 trusted to in such cases must be determined by future experience. 
 
 Finally, it is to be remarked, with respect to those milder 
 forms of laryngitis, in which the disease seems to consist of a 
 slight thickening of the mucous membrane, that the best treat- 
 ment consists in enjoining silence and repose, in the repeated 
 application of leeches in small numbers to the part, in the use 
 of mild diaphoretics, and lastly, in the exhibition of mercury, 
 in moderate doses, so as gently, but decidedly, to affect the 
 system. During this treatment the strength of the patient is 
 to be supported by a mildly nutritious diet ; and if he has been 
 accustomed to the use of wine, or spirituous liquors, we must 
 (particularly if it be necessary to draw much blood by leeching) 
 allow him a certain proportion of his accustomed stimulus. 
 
 The necessity of this will be admitted by any practitioner who 
 has had to treat the embarrassing complication of laryngitis, 
 with delirium tremens from exhaustion, or deprivation of the usual 
 stimulus. I have seen a case of this kind, and can hardly 
 conceive a more unfortunate complication ; for the loquacious- 
 ness and excitement of the patient is peculiarly hurtful in a 
 disease in which silence and repose are so absolutely necessary.* 
 
 CHRONIC DISEASES OF THE LARYNX AND TRACHEA. 
 
 Under this denomination are included a number of chronic 
 diseases, affecting the innervation, the mucous membrane, and 
 
 * For valuable observations on the topical application of solution of nitrate of 
 silver in acute laryngitis, and on the superior advantage of laryngotomy, as compared 
 with tracheotomy, in cases of oedema of the glottis, I may refer to Dr. J. Staunus 
 Hughes' edition of Sir H. Marsh's clinical lectures, and more especially to his own 
 observations " on cedema of the glottis, its clinical history, pathology, and treatment." 
 Dublin, 1872. (Ed.)
 
 206 DISEASES OF THE LA.RYNX AND TRACHEA. 
 
 the more deep seated tissues of the larynx. The greatest 
 variety exists in the characters, consequences, and complications 
 of these affections, and I shall not attempt to give more than a 
 sketch of the subject. 
 
 Like the preceding form, we may have chronic irritation of 
 the larynx_as an idiopathic disease, or depending on some specific 
 condition of the system. In the first instance we see it arising 
 from the ordinary causes of internal disease in an uncontami- 
 nated constitution, while in the second it is met with as a result 
 of syphilitic or scrofulous disease, and often combined with 
 chronic afi"ections of the lung. 
 
 The eff"ects of chronic irritation on the larynx vary from a 
 slight vascularity and thickening to changes so extensive as to 
 completely obliterate and destroy the natural appearance of the 
 cavity. 
 
 In commenting on these various alterations I need scarcely 
 remark, that in many instances several of them may occur in 
 the same case, either primarily or consecutively. A simple 
 mucous inflammation may in one patient be followed by changes 
 very different from those in another ; and nothing can be more 
 various than the combinations of morbid alteration which may 
 thus arise. 
 
 Slight Thickening and Vascularity of the Mucous Mem- 
 hrane. — I have placed this condition the first in the list, as it 
 represents the simplest form of the disease. Its symptoms are in 
 general a slight degree of hoarseness, both of voice and cough, 
 some soreness on pressure, and slight dysphagia. When recent, 
 and occurring in a healthy constitution, it will generally yield to 
 a mild antiphlogistic and mercurial treatment ; but when chronic, 
 or when it arises in the scrofulous constitution, whether that be 
 remote or acquired, it becomes a most serious disease. 
 
 But this disease may exist in the trachea without producing 
 even the symptoms above-mentioned. In fact, of the whole 
 tube, this portion seems the least sensible, a fact proved by the 
 phenomena of disease, and also by those of foreign bodies in 
 the trachea. I have seen many cases of a chronic inflammation 
 of the trachea, in which the diagnosis was made on negative 
 grounds, there being no evidence of laryngitis on the one hand, 
 and no symptoms or signs of bronchitis on the other. 
 
 The expectoration was mucous or muco-puriform ; and in
 
 DISEASES OF THE LAKYNX AND TRACHEA. 207 
 
 several cases a tenderness of the tube ou pressure existed. In 
 these cases treatment directed to the trachea had the best effect. 
 Louis, however, has observed, and I can corroborate the as- 
 sertion, that where the irritation is acute, heat and pain are felt 
 along the course of the tube. His observations were made in 
 cases of phthisis.* 
 
 Purulent Secretion from the Surface. — We consider this 
 affection in its simplest form, occurring independent of any 
 structural change, except perhaps thickening and vascularity. 
 But under these circumstances it is exceedingly rare, so rare, 
 indeed, that the co-existence of laryngeal symptoms with purulent 
 expectoration may be looked on as almost decisive of ulceration 
 of the larynx, or what is more common, of this combined with 
 tuberculous ulceration of the lung. In certain cases, however, 
 it arises from the opening of abscesses into the larynx, which 
 have followed upon disease of its cartilages.! 
 
 Hypertrophy and Induration of the Sub-mucous Cel- 
 lular Tissue. — This interesting form of disease has been met 
 with in cases of chronic irritation of the larynx, when it 
 materially interferes with the action of the muscles both of 
 phonation and respiration : when it affects the epiglottis, the 
 form and volume of the organ are changed, and dysphagia 
 produced.^ 
 
 It will probably be found that this form of disease coincides 
 with ulcerative affections of the canal. I have seen it most 
 remarkably in a case where ossification and caries had affected 
 both the laryngeal and tracheal cartilages, and the hypertrophy 
 extended from the larynx down to the bifurcation. 
 
 Lesions of the Muscles and Ligaments of the Larynx. — 
 Of the pathological anatomy of laryngeal disease this is the 
 portion which has been most neglected. Andral has noticed the 
 atrophy and softening of the muscles, and has found them in- 
 filtrated with mucus, pus, or tuberculous matter. Softening 
 may also affect the ligaments, and thus cause important alter- 
 ations in the voice. This author describes the softening and 
 degeneration into an inorganic pulp of the thyro-arytenoid liga- 
 ments, which ultimately disappear, leaving the muscles bare. 
 
 * Louis, Eecherches, Anat. Path, sur la Phthisie, p. 385. 
 
 t Porter, Op. Cit., p. 134. 
 
 I Andral, Precis d'Anatomie Pathologique, torn, ii,, part ii.
 
 208 DISEASES OF THE LARYNX AND TRACHEA. 
 
 On this subject the same author observes, that iu certain 
 cases of complete aphonia no lesion whatever could be discovered 
 on the internal surface of the larynx, but that on examining the 
 fibres of the thyro-arytenoid muscle he found them atrophied and 
 separated by morbid depositions either of pus or tubercle.* 
 
 But the action of disease in destroying the tension of the 
 whole fibro-elastic expansion of the internal surface of the 
 larynx, must have a powerful effect in causing alterations of the 
 voice. Professor Lauth has well remarked that this tissue 
 fulfils a special function, namely, to increase the sound by its 
 vibrations ; so that in the larynx there are two sounding boards, 
 one external, cartilaginous, elastic, and but little moveable, the 
 other, internal, but thin, supple, moveable, yet elastic.f 
 
 In connexidh with this subject, the following case, which is 
 recorded by Dr. Graves, possesses the greatest interest. I shall 
 give it in his own words. 
 
 " A young gentleman of delicate constitution, and who is now 
 about sixteen years of age, continued to enjoy tolerably good 
 health up to his sixth year. When about six years of age, he 
 went to bed one night in health, and without any unusual symp- 
 tom, but, on getting up in the morning, it was observed that he 
 had lost his speech, and was unable to articulate a single word. 
 His family became alarmed, and sent for a physician immediately ; 
 the boy got some internal medicine and a stimulant gargle, and 
 recovered his speech in a few days, without the occurrence of 
 any symptom of laryngeal inflammation or cerebral disease. 
 But what was remarkable in the case was this : the boy, who 
 up to this period had spoken well and distinctly, now got a 
 terrible stutter. This resisted all kinds of treatment, and for 
 ten years he continued to stammer in the most distressing way, 
 and was so annoyed by it himself, that when a boy he used to 
 stamp on the ground -svith vexation whenever he failed in utter- 
 ing what he wished to express. In the month of May last he 
 got an attack of chronic laryngitis of a scrofulous character, and 
 evidently the precursor of phthisis. Indeed he is at present 
 labouring under phthisis ; Dr. Stokes and I have examined him, 
 and we feel convinced that tubercular deposition is going on iu 
 
 * Ibid., p. 494. 
 
 f Remarques sur la Structure du Larynx, &c. Mem. de rAcademie Royale de la 
 Medecine.
 
 DISEASES OF THE LARYNX AND TRACHEA. '209 
 
 the lungs. But what is most curious in the case is this — 
 after he got the laryngitis, a very peculiar change took place ; 
 the laryngeal inflammation modified the tone of his voice so as 
 to make it a little husky, hut the stanwiering has completely 
 ceased.'''^ 
 
 In this case Dr. Graves supposes that the alteration in 
 structure or vitality of the mucous memhrane covering the deh- 
 cate muscular fibres, so modified the disposition of the parts, as 
 to render them mcapable of undergoing those rapid contractions 
 necessary to produce stammering, by closing the glottis at the 
 moment it should remain open. On this interesting point 
 further observations are necessary. It is obvious that morbid 
 anatomy and pathology have not been sufficiently applied to the 
 subject of phonation. The field is open, and promises a rich 
 harvest. 
 
 Linear Contraction of the Ventricles. — In this condition, which 
 I have found to be exceedingly common in a variety of chronic 
 diseases of the larynx, the ventricles are narrowed in the trans- 
 verse direction ; so that in the more advanced stages of the 
 disease they are represented merely by a depressed line. This 
 seems to arise from the thickening and approximation of the 
 edges of the cavities ; and it is not improbable that this ap- 
 proximation may be m part owing to a paralyzed condition 
 of these muscular fibres, which act in dilating the ventricles. 
 A condition similar to that of which I have already spoken, 
 as afi'ecting the circular muscles of Reissessen, probably occurs 
 also in the larynx, and by the paralysis of those portions oi" 
 the thyro-arytenoid muscles, which dilate the ventricles, their 
 cavities become gradually obliterated. 
 
 Morbid States of the Epiglottis. — The simplest form of disease 
 of the epiglottis is its enlargement and thickening. We have 
 seen what an important share this condition has in the 
 phenomena of the acute laryngitis of the adult ; yet in the more 
 chronic forms, although the lesion occurs to a certain degree, it 
 is more an hypertrophy of the epiglottis than a mere oedema, and 
 I have never known it to produce such symptoms as dysphagia 
 or stridulous breathing, although Andral states that it may 
 produce the first of these symptoms. In the acute laryngitis of 
 
 * London Medical and Surgical Journal, No. 174, vol. vii. Clinical Lectures 
 delivered at the Meath Hospital. / 
 
 P
 
 210 DISEASES OF THE LARYNX AND TRACHEA. 
 
 the adult a sudden tumefaction occurs, which may subside with 
 equal rapidity ;* hut in the chronic disease this increase of thick- 
 ness goes on slowly, and not to the same degree as in the acute 
 form. 
 
 Strongly contrasted with this lesion is another, which may be 
 described as its opposite ; I allude to a condition which I propose 
 to call the leaf-like expansion of the epiglottis. This has not 
 been described by any author, but a most remarkable preparation 
 of the disease exists in the Museum of the School of Anatomy 
 and Medicine in Park Street. The epiglottis is thinned, and 
 singularly elongated, and its form so altered, as to represent the 
 shaj)e of a battledore, the narrow extremity being next the 
 glottis. In the preparation alluded to, it is fully two inches in 
 length, and coincides with double perforating ulcers of the ven- 
 tricles. Nothing is known as to the history of the case, but 
 I have seen more or less of a similar alteration in other cases 
 of lar3'ngeal disease. 
 
 We have next to consider the contraction and shrivelling of the 
 epiglottis, and its ulceration. The first of these conditions is by 
 no means uncommon, and the organ assumes a crescentic shape, 
 with the concavity looking upwards ; I have never seen it without 
 ulceration, and other organic disease of the larynx. We are still, 
 as in the preceding case, ignorant of the symptoms which this 
 condition would produce. 
 
 The laryngeal surface of the epiglottis is very liable to 
 ulcerate ; but as a simple disease this form is seldom seen. 
 ■Combined in most cases with organic disease of the larynx and 
 lung, it becomes difiicult to study its symptoms separately, and 
 indeed its constant complication with disease of the rima seems 
 to preclude such an analysis. 
 
 These ulcers are generally small, irregularly circular, and 
 with little depth, giving a cribriform appearance to the epi- 
 glottis. 
 
 In a remarkable case, which fell under my observation, the 
 patient, an adult man, suffered for a great length of time under 
 the worst form of tussis ferina. No disease could be discovered 
 in the fauces, the voice was but little affected, and there was no 
 
 * Thus in a patient operated on in the Meath Hospital, the tumefaction of the 
 epiglottis subsided so rapidly, that within a few hours after the operation, respiration 
 could be performed through the glottis, and the enormously swollen epiglottis was no 
 longer ■visible.
 
 DISEASES OF THE LARYNX AND TRACHEA. 211 
 
 stridor, except during the paroxysm. The disease resisted every 
 treatment, and after continuing for nearly a year, the patient 
 sunk from an attack of dysentery. On dissection, we found 
 numerous small yellow ulcers, with raised and indurated edges, 
 affecting the whole of the laryngeal face of the epiglottis. 
 There was no other perceptihle disease of the respiratory 
 system. 
 
 In M. Louis' celehrated work on the Pathology of Phthisis, 
 we find the suhject of ulceration of the epiglottis handled with 
 that spirit of philosophical research, which so distinguishes the 
 learned author. In all his cases the patients laboured under 
 tuberculous disease of the lungs ; but as some of them presented 
 no perceptible lesion of the larynx or trachea, the symptoms 
 having reference to disease of the epiglottis may be studied with 
 advantage. I shall give the general results in his own words. 
 
 " Of eighteen cases, which fell under our observation, there 
 were six in which the larynx and trachea were free from disease. 
 Among these four of the patients complained of pain, more or 
 less violent, occurring in the superior part of the thyroid 
 cartilage, or between this cartilage and the os hyoides. This 
 pain was compared to the sensation of a sore, to a pricking feel- 
 ing, or a heat in the part ; and in some cases it had lasted for 
 a month or two, while in others it occurred but a few days 
 before death. In these cases, although the pharynx was healthy, 
 there was difficult deglutition, the drinks sometimes even coming 
 through the nose." 
 
 " Of the twelve patients, who had at once ulcerations in the 
 epiglottis, larynx, and trachea, there was dysphagia, and pain 
 in some cases, and in one the drinks were partly returned through 
 the nose." 
 
 " Thus we are led to conclude, that the symptoms of ulcera- 
 tions of the epiglottis are a fixed pain either in the superior 
 portion of, or immediately above, the thyroid cartilage, difficulty 
 of deglutition, and the return of drinks through the nostrils,"* 
 
 But the epiglottis may be entirely destroyed by ulceration, 
 with or without destruction of the root of the tongue. Of this 
 disease there are many curious examples in the Park Street 
 Museum. In some of these the disease was cancerous. 
 
 Ulcerations of the Larynx. — Considered merely in an 
 
 * Kecherches Anatomico-Pathologiques sur la Phthisie. Paris, 1825, p, 255. 
 
 p 2
 
 212 DISEASES OF THE LARYNX AND TRACHEA. 
 
 anatomical point of view, it may be seen that the greatest variety 
 exists in the size, number, seat, and complications of these 
 ulcerations. In fact, the disease may vary from a slight abrasion 
 or minute follicular ulceration, to such a destruction and de- 
 facement of the cavity, as that its natural appearance is altogether 
 destroyed. The disease may further vary in its exciting cause, 
 as in some it is traceable to a syphilitic origin ; in others, to a 
 scrofulous ; while in a third, it results from inflammation in an 
 apparently uncontaminated constitution. 
 
 I shall not enter at any length into the history of laryngeal 
 ulceration, but shall merely dwell on some points not generally 
 understood. 
 
 One of the simplest forms, and which may be an idiopathic 
 affection, is the existence of small ulcers immediately below 
 the rima, and not extending far into the cavity. This disease 
 is accompanied by a secretion of lymph, and is a chronic and 
 apyrexial affection ; and as its j)rincipal symptom is a violent and 
 apparently spasmodic cough, it is often mistaken for pertussis, 
 or other nervous affections of the larynx. 
 
 We are not in possession of facts to enable us to state 
 whether there exists any fixed anatomical difference between 
 the specific ulcerations of the larynx. It is a difficult question^ 
 as many of the cases have occurred in constitutions in which the 
 destructive influences of scrofula, syphilis, and mercury have 
 been united. In the preparations of the Park Street Museum, 
 however, those which seem to have been simply syphilitic, 
 present spreading ulcers of the mucous membrane, or a cribri- 
 form condition ; but in both instances combined with watery 
 excrescences, which so far seem peculiar to the syphilitic 
 disease. 
 
 In the phthisical ulceration of the larynx I have never seen 
 these watery tumours ; here the common form is a deep ulcera- 
 tion occupying each ventricle, or a number of minute super- 
 ficial ulcerations affecting the ventricles and cordte vocales. Of 
 these forms, however, the first, in this country at least, is by 
 far the most frequent. Indeed in cases of phthisis pulmonalis, 
 when in the advanced stages the voice becomes hoarse, and 
 the breathing and cough laryngeal, we may diagnosticate this 
 ventricular ulceration with almost complete certainty. In one 
 case, however, that of a deaf and dumb man, the ulcers did not
 
 DISEASES OF THE LAEYNX AND TRACHEA. 213 
 
 affect the ventricles, but occurred immediate^ below the rhna. 
 To this subject I shall presently return when describing the 
 physical signs of laryngeal disease ; and shall merely mention 
 here, that the symptoms vary from a slight hoarseness to com- 
 plete aphonia. There is seldom a great degree of stridor, but 
 pain, soreness, and dysphagia are commonly observed. Hectic 
 fever and purulent expectoration are present in most cases, but 
 their source, in the great majority of instances, is the tubercu- 
 lous and ulcerated state of the lung itself. Indeed what is 
 called phthisis laryngea seems to be, in almost all cases, 
 phthisis pulmonalis ; the affection of the windpipe being, in a 
 few cases primary, but in a far greater proportion secondary to 
 tubercle of the lung. How much of suffering to the patient, 
 and disgrace to the physician, would be obviated, were the truth 
 of this more generally recognized. 
 
 Ulcerations of the Trachea. — These have been but little 
 studied as yet. It may be remarked, however, that though much 
 less frequent than the two last varieties, they are often met 
 with, and occur with or without disease of the cartilages. Louis 
 states that in phthisis the site of the ulcerations is commonly 
 along the musculo-membranous portion of the tube, a fact which 
 he seeks to explain by referring to the irritating action of the 
 expectorated matter. Without wishing to defend or adopt this 
 doctrine, I may mention a fact strongly corroborative of it : I 
 have in numerous cases, where a chronic phthisical abscess 
 existed in the lung, observed that ulcerations were found towards 
 the bifurcation of the trachea ; these could be traced to the 
 first division of the bronchus, when they became only perceptible 
 in one tube, which in all cases, 2cas that leading to the 
 excavation. In other instances, where one lung was full of 
 ulcerous cavities of some standing, while the other only con- 
 tained crude, or recently softened tubercle, I have found 
 ulcerations in the trachea, evidently extending upwards from 
 the bronchus of the excavated lung. These ulcerations were 
 numerous, while in the opposite tube, not even an abrasion 
 could be found. 
 
 The cure of extensive ulceration of the trachea by cicatri- 
 zation, has been observed by Mr. Porter. The patient recovered 
 under the use of mercury, and after enjoying good health, for 
 upwards of a year, died of another disease. On dissection, an
 
 214 DISEASES OF THE LARYNX AND TRACHEA. 
 
 extensive but perfect cicatrix was found in the upper portion of 
 the tracheal' 
 
 On the remaining diseases of the larynx and trachea, and in 
 particular those affecting the cartilages, I shall not offer any 
 observations, feeling that in so doing I could only repeat what 
 has been already said by others. On this subject I would refer 
 the reader to the works of Porter, Andral, and Cruvelbier, but in 
 particular to the first. The diseases of these important portions 
 of the respiratory apparatus were but little known previous to its 
 appearance, and to the author is due the merit of first describing 
 the mortification of the laryngeal cartilages, a disease even still 
 by no means sufficiently recognized by pathologists. 
 
 To enter into a description of the symptoms observed in these 
 various cases of disease would far outstrip the limits of this work. 
 It is sufficient to observe, that although possessing some general 
 similarity, they vary in many particulars. The symptoms in 
 general consist in various alterations of the voice ; cough of a dis- 
 tressing, loud, and peculiar character, with or Avithout expecto- 
 ration, which may be mucous or purulent ; and signs of mechanical 
 obstruction about the glottis. Of this last symptom it may be 
 remarked, that it is exceedingly various. Thus, in some cases, 
 the stridulous breathing goes on increasing to sufi"ocation, while 
 in others, even until the fatal termination, it is so slight as to be 
 scarcely perceptible. In one point of view, the existence or ab- 
 sence of this symptom has a great practical importance, namely, 
 in determining the condition of the lung. We shall find that 
 much of the facility of this diagnosis turns on the amount of the 
 mechanical obstruction to respiration ; that where it is prominent 
 a stethoscopic examination of the lung becomes next to impossible, 
 while it is not prevented by extensive laryngeal disease, so long 
 as the entrance of air is not materially obstructed. 
 
 I shall first examine the physical signs of chronic laryngitis, 
 and then point out the mode of diagnosis, when the question of 
 pulmonary complication is to be determined. 
 
 Physical Signs of Chronic Laryngitis. — Although this part 
 of physical diagnosis has been neglected, yet we may derive 
 advantage from its investigation ; for I have seen, in cases of 
 
 * Of these ulcerations of the epiglottis, larynx, and trachea, M. Louis observes, that 
 they are twice as frequent in men as in women ; and that facts lead to the conclusion, 
 that they are almost peculiar to phthisis. — Louis, Op. cit.
 
 DISEASES OF THE LAKYNX AND TRACHEA. 215 
 
 laryngeal disease, enougli of variation, both in the passive and 
 active signs, to persuade me of the importance of the subject. 
 
 The sound on percussion of the healthy larynx, has a peculiar 
 hollow character, which does not convey that idea of depth or 
 elasticity given b}^ the pulmonary sound. The best mode of ex- 
 amining it is to throw the head back, so as to stretch the neck, 
 and the head being then supported by an assistant, we may use 
 mediate ]3ercussion over the thyroid and cricoid cartilages. A. 
 good mode of percussion is to place the back of the nail of a 
 finger on the pulp of the thumb, and to make a fillip on the part. 
 
 The laryngeal sound is loud in proportion to the development 
 of the larynx; and it may be observed to vary in the same 
 individual, being loudest when, from the raising of the soft palate, 
 the communication between the glottis and cavity of the mouth 
 is free.* The point where it is loudest is exactly that selected 
 for the operation of laryngotomy, namely, the space between the 
 cricoid and thyroid cartilages. 
 
 I have not made sufficient observations to announce the 
 alterations in this sound produced by disease ; but I have seen 
 enougli to conclude that disease modifies the sound. Thus in a 
 patient, whose thyroid cartilage was torn by the bursting of a shell, 
 the sound, on percussion of the larynx, is perfectly dull. Yet 
 when a fistula which exists in the trachea, is closed, he breathes 
 through the glottis with perfect ease, and his voice is unaffected. 
 On the other hand, we may find that such affections as do not 
 diminish the capacity of the larynx, may coexist with the natural 
 sound on percussion, as we find in the ulceration of the ventricles,, 
 so common in phthisis. 
 
 The subject is one open for investigation, and I shall merely 
 remark, that in the few observations Avhicli I have made, the 
 sound did not seem lessened in old persons, nor was it diminished 
 by the existence of a considerable oedema of the neck. 
 
 The active signs are those of respiration and voice ; and, as in 
 most cases, both are affected, we must study their phenomena 
 carefully. I have already alluded to the division of laryngeal 
 diseases into those with and those without notable mechanical 
 obstruction. Few cases, indeed, occur without some degree of 
 
 * See a Paper, by Professor Jacob, on the structure of the mammary gland in the 
 Cetacea, with Observations on the mechanism of the mouth and soft palate, as 
 applied by the young animal in sucking. Dublin Med. and Chem. Journal, No. xxiii., 
 1835.
 
 -^IG DISEASES OF THE LARYNX AND TRACHEA. 
 
 Stridor, which is sometimes only perceptible on a forced inspira- 
 tion ; but there is an extensive class in which the patient hardly 
 suffers from laryngeal obstruction, and in which the stridulous 
 breathing is barely perceptible. In these cases death takes 
 place, not from laryngeal, but from pulmonary disease. 
 
 On the other hand, great mechanical obstruction, and its 
 consequent distressing stridor, are more allied to laryngeal 
 disease, without pulmonary complication. In such cases the 
 ear at once points out that the obstruction is in the upper part 
 of the windpipe, very different indeed from another case of stridu- 
 lous breathing, where, as in the pressure of an aneurismal tumour 
 on the trachea, the sound proceeds from its inferior extremity. 
 
 The stethoscopic signs are the altered character of the laryn- 
 geal sounds of inspiration and expiration, and the existence of a 
 rale m the larynx. With respect to the first, we find that the 
 sound of respiration loses its softness and smoothness, and 
 becomes harsh, conveying the idea of a roughened and rigid 
 state of the laryngeal surface. This is perceptible even when no 
 stridulous breathing exists. 
 
 In noticing the existence of a rale in the larynx I must 
 observe that I have examined the phenomenon in but a limited 
 number of cases. It does not occur in all instances, but when 
 present is extremely characteristic. I have found it most evi- 
 dent immediately above the aire of the thyroid cartilage, where it 
 resembles the rapid action of a small valve, combined with a deep 
 thrumming sound. It is quite peculiar, it disappears as we 
 descend to the bronchial tubes, and may even exist on one side 
 of the larynx without being perceptible on the other, as if it there 
 corresponded to a circumscribed ulceration. 
 
 When the obstruction, however, is considerable the loud pro- 
 longed respiration sufficiently points out the disease. Under 
 these circumstances the next most important result of ausculta- 
 tion is the great feebleness of the pulmonary expansion, as com- 
 pared with the violence of the inspiratory efforts. The impor- 
 tance of this fact, and the difficulties which it throws in the way 
 of physical diagnosis, were first noticed in a Report of the Meath 
 Hospital by Dr. Graves and myself,* in which we pointed out 
 how a laryngeal obstruction rendered the detection of pulmonary 
 
 Hospital, by R. J. Graves, M.D., and W. Stokes, M.D., vol. v.
 
 DISEASES OF THE LARYNX AND TRACHEA. 217 
 
 disease a matter of great difficulty. These observations, however, 
 apply only to the active auscultatory signs ; and it is fortunate, 
 indeed, that the above cause does not interfere with percussion. 
 
 In laryngeal disease the vesicular murmur becomes feeble in 
 proportion to the obstruction. In severe cases it can hardly be 
 perceived ; and this feebleness, or almost complete absence of 
 vesicular murmur, is observed over the ivhole chest. On the latter 
 point I would particularly dwell, as it forms the ground of a 
 diagnosis, which I first pointed out between laryngeal disease and 
 the pressure of aneurismal, or other tumours on the trachea.* 
 
 This diagnosis is founded on the observation of the case, 
 'previous to the appearance of strididous breathing. In aneurisms 
 of the aorta it often, though not always, happens, that the com- 
 j)ression is first exercised on one of the bronchi, so that an 
 inequality of respiration is produced, the murmur being feeble in 
 one lung, and of increased intensity in the other. As the disease 
 advances, however, the pressure is exercised on the trachea, and 
 stridulous breathing produced. 
 
 Now in this primary inequality of respiration we have a diag- 
 nosis between the two aftections, for nothing of the kind can occur 
 when the obstruction is in the windpipe from the first. In such 
 a case, as the air enters both lungs with equal difficulty, the 
 vesicular murmur is equally feeble. 
 
 It would appear that the intensity of the vesicular sound is 
 directly as the force by which the cell is dilated. M. Beau has 
 endeavoured to prove, that the respiratory murmur of Laennec is 
 not produced by the expansion of cells, but by the air striking 
 against the fauces and pharynx, thus causing vibrations which 
 are communicated downwards through the larynx and trachea. 
 He holds that the mere expansion of the cells produces no sound, 
 and supports this doctrine by adducing the fact, that where the 
 individual breathes so as to inflate the lungs without producing 
 the guttural sound, the vesicular murmur ceases to be heard. He 
 draws an analogy between the guttural sound and its consequent 
 vesicular murmur ; and the sound of the voice, and consequent 
 bronchophonia, both, according to him, being produced by the vibra- 
 tions in the tubes of sounds which are transmitted downwards.f 
 
 * Researches on the Diagnosis and Pathology of Aneurisms of the Great Vessels. 
 Dub. Med. and Chem. Journal, 183i. 
 
 t Beau, Archives Generales de Medicine, Eecherches sur la CauiC dea Bruits 
 Respiratoires, tome v., Aoul", 1834.
 
 218 DISEASES OF THE LARYNX AND TRACHEA. 
 
 I have carefully repeated the experiments of M. Beau, and feel 
 convinced that his conclusions are erroneous, hecause I have 
 found that in all cases in which his respiration silencieux was 
 performed, I could plainly hear a murmur of expansion in the 
 lung. It is certainly not so loud as natural ; hut the reason 
 of this is manifestly the fact, that to produce silent respiration 
 we must inflate the chest more gently, and of course with less 
 impulse on the cells or minute tuhes. When Ave come to con- 
 sider the phenomena of puerile and hronchial respiration in local 
 disease of the lung, we shall find that many circumstances totally 
 disprove this doctrine. 
 
 I shall here allude to a single fact, which, in itself, is sufficient 
 to overturn the theory ; it is that we can hear a natural respira- 
 tory murmur in patients who do not hreathe through the mouth 
 or nostrils. Of this M-e can easily satisfy ourselves hy examining 
 a person who has been operated on for laryngeal obstruction, and 
 who breathes through a fistula in the trachea. I have now 
 examined eight of such cases, and found that in all the res- 
 piratory murmur could be heard with ease. In one instance, 
 indeed, where great obstruction existed previous to the operation, 
 I found that for a considerable time after the opening of the 
 trachea the murmur continued intensely puerile.* 
 
 Examination of the Lung in Cases of Chronic Laryn- 
 geal Disease. — It need hardly be observed, that the first step in 
 
 * I may here subjoin the stethoscopic examination of a case of permanent iistula in 
 the trachea without mechanical obstruction in the larynx. 
 
 P. K., aged 30, while engaged in the Burmese War under Sir. A. Campbell, was 
 struck by the explosion of a canister shot, which tore the thyroid cartilage, and 
 formed a wound six inches long. There was great ha3morrhage, followed hy delirium. 
 The wound was dressed by suture, and healed, with the exception of a fistula 
 immediately below the situation of the cricoid cartilage. 
 
 At present the region of the larynx is hollow, no trace of pomum Adami being 
 visible. The sound is dull on percussion. Immediately below the cricoid region there 
 is a fistula capable of admitting a goose-quill, lound which the skin is puckered. 
 This communicates directly with the trachea, but occasionally small quantifies of 
 drink and soft food pass through it. There is no dysphagia. The patient wears a 
 soft pad over it, and is thus saved from all inconvenience. 
 
 When the fistula is closed the voice is natural and powerful, nor is there any 
 stridor; but when it is open the voice is scarcely articulate, and is combined with a 
 whistling Eound. On closing the mouth and nostrils he can breathe without 
 difficulty through the fistula, yet the effort, after some time, fatigues him. 
 
 There are no thoracic symptoms, and when the fistula is closed the vesicular 
 murmur is heard with its natural character. When it is open it obtains in the upper 
 part of the chest a slightly tracheal character. Posteriorly and superiorly the voice 
 resounds strongly ; and when the fistula is open its vibrations are preceded by a 
 hissing sound.
 
 DISEASES OF THE LARYNX AND TRACHEA. 219 
 
 forming our prognosis and in determining our treatment of laryn- 
 geal disease, will be to ascertain the condition of the lung ; and 
 there are few situations more embarrassing than to be called on to 
 declare how far the lung is diseased when a chronic affection of 
 the larynx is present. It is true that where the mechanical 
 obstruction is but slight, we may use the stethoscope with 
 facility and exactness ; but even in cases where the lung is fully 
 and freely inflated it will be occasionally next to impossible to 
 determine (even after several examinations) whether the symptoms 
 proceed from laryngeal disease alone, or from its combination 
 with an affection of the lung. This I know from an extensive 
 experience, nor have I been able to satisfy myself as to its cause. 
 The first element in deciding this important question is the fact 
 of the frequent complication of laryngeal and pulmonary disease. 
 Let it be borne in mind from the outset, that of the cases with- 
 out, and those with, disease of the lung, the latter are by far 
 the most numerous ; and that even where the larynx has been 
 first engaged, that the lung may become secondarily affected, 
 and that where both diseases exist they mutually obscure each 
 other. 
 
 If there be one form of disease more than another to which 
 these observations apply, it is that termed phthisis laryngea. 
 I agree with Andral and Louis as to the fact of the almost con- 
 stant complication of this disease with pulmonary tubercle ; and 
 I can avow, that after ten years of hospital and private practice, 
 I never saw a case presenting the symptoms of laryngeal cough, 
 purulent, or muco-purulent expectoration, semi-stridulous breath- 
 ing, hoarseness or aphonia, hectic and emaciation, in which the 
 patient did not die with cavities in his lung. In some the 
 laryngeal affection seemed to be primary, but in the great 
 majority, symptoms of pulmonary disease existed previous to its 
 appearance. 
 
 It is true that in the abscess and mortification of the cartilages 
 we may have symptoms of laryngeal cough, purulent expec- 
 toration, and even hectic ; but these cases differ in their symp- 
 toms, as well as their pathological anatomy, from the ordinary 
 phthisis laryngea, particularly in the prominence and rapidity of 
 the purely laryngeal symptoms. 
 
 The first step in the investigation will be to accurately examine 
 into the history of the case, and in particular to determine
 
 220 DISEASES OF THE LAEYNX AND TRACHEA. 
 
 whether the laryngeal aifection was primary, or supervened on an 
 already existing disease of the lung. We must examine what 
 were the very first symptoms, and whether they were referrible to 
 the larynx or lung ; we must inquire into the past and present 
 state of the fauces, and also whether a syphilitic taint exists. Now 
 should it be found that the first symptoms were those of a larnygeal 
 character, that the voice had been altered from the outset of the 
 disease, or that a syphilitic taint did really exist, we have a good 
 probability, not that the lungs at the time of examination are free, 
 but that the first morbid action was exercised on the larynx. But 
 if, on the other hand, we find that previous to the occurrence of 
 any hoarseness or stridor, or dysphagia, there has been cough 
 without the laryngeal character, particularly if it was at first dry, 
 and afterwards followed by expectoration ; if hectic has existed, 
 although the expectoration continued mucous ; if there have been 
 haemoptysis, pain in the chest or shoulders ; and lastly, if the 
 patient has emaciated previous to the setting in of the laryngeal 
 symjitoms, we may be almost certain that tubercle exists, and 
 that the case, so commonly called laryngeal, is in reality pul- 
 monary phthisis. And if it appears that the patient is of a 
 strumous habit, or has already lost brothers or sisters by 
 tubercle, we may form our diagnosis with a melancholy 
 certainty, even though at the time we can detect no certain phy- 
 sical sign of j)ulmonary tubercle.* 
 
 But in many cases a physical examination of the chest decides 
 the question. I shall first speak of the active auscultatory signs. 
 I have already stated, that with respect to the case of 
 diagnosis, we may divide laryngeal diseases into two classes, 
 namely, those with and those Avithout severe stridulous breathing. 
 In the first of these all the phenomena of respiration are 
 obscured, less from the loudness of the stridulous sound than 
 from the feebleness with which the air penetrates the lung : so 
 great is this in some cases that we can hear almost nothing of 
 the vesicular murmur, and so cannot judge of its different local 
 
 * It may be observed here tliat purulent expectoration, in any quantity, is seldom 
 seen from simple disease of the mucous membrane of the larynx. From its small 
 •dimensions and constituent tissues, its secretions, both in health and disease, are 
 scanty ; and it may be stated, that in cases of laryngeal disease, with copious puri- 
 form discharges, there is either an abscess in the neighbourhood, and communicating 
 with the larynx, or what is much more frequently the case, suppurating tuberculous 
 cavities in the lung.
 
 DISEASES OF THE LAEYNX AND TRACHEA. 221 
 
 intensities, and we lose all the sounds of mucus in the tubes, 
 and the signs of anfractuosities, or larger excavations. The 
 voice, to©, being injured, we cannot avail ourselves of the vocal 
 phenomena with satisfaction, and we lay aside the stethoscope in 
 despair. 
 
 But it is fortunate that in the obstruction of the larynx there is 
 nothing to interfere with the use of percussion. In this observa- 
 tion we are first accurately to compare the sound given by one 
 clavicle with the other, and in the same way the antero-superior 
 regions, the spines of the scapulae, the axillae, and the interscapular 
 regions. This comparison of corresponding opposite portions 
 having been made, we next compare the upper with the lower 
 parts of the chest, and the observation is complete. Now, if co- 
 existent with the symptoms of laryngeal cough, muco-purulent 
 expectoration, semi-stridulous breathing, and hectic, we find a 
 notable difference between the sounds of opposite corresponding 
 portions, we need scarcely go farther for evidence of tuberculiza- 
 tion of the lung. It may be stated generally, that there are but 
 two diseases which produce the combination of the physical signs 
 of dulness of a clavicle, with the symptoms of stridulous breath- 
 ing and laryngeal cough ; these are aneurism of the aorta or 
 innominata, and the disease under consideration, and it will 
 rarely hapj)en that these can be confounded. Under any cir- 
 cumstances the localized dulness points out that there is some- 
 thing more than laryngeal disease, and we know from experience, 
 that that something more is in the great majority of cases, the 
 tuberculization of the lung. 
 
 I may here remark, that this is one of the cases in which the 
 mode of investigation by successive observations, is often 
 extremely applicable ; and thus, although at our first examina- 
 tion no direct evidence of pulmonary disease can be obtained, yet 
 on the second or third time of its performance the change may 
 become manifest. Under these circumstances the gradual loss of 
 sonoriety of either clavicle or scapular ridge will at once declare 
 the nature of the disease. 
 
 There is one case which closely resembles this disease, namely, 
 the hectic of syphilis, with a secondary affection of the larynx. 
 Here nothing but an accurate investigation of the history and 
 period of duration of symptoms will suffice to clear up the diag- 
 nosis. With respect to particular symptoms, I have only to
 
 222 DISEASES OF THE LARYNX AND TRACHEA. 
 
 remark, that in this case I have never seen purulent expectora- 
 tion, nor is there any evidence of solidification of the upper 
 portions of the lung. On the other hand, we must never forget 
 that many of such cases end by pulmonary tubercle,* 
 
 Treatment of Chronic Laryngitis. — In all forms of the 
 disease, in which there are grounds for hope of recovery, the 
 physician must insist on the patient using his voice as little as 
 possible. To insist on absolute silence is hardly useful, but 
 all prolonged or constant exertions of the voice must be for- 
 bidden ; and if the patient's profession require such exertions, 
 he must give up its practice for a considerable period of time.f 
 He should remain within doors, except during the finest 
 weather, and guard against all exposure to fresh cold. 
 
 The medical treatment best calculated to relieve, may be stated 
 to be the repeated application of leeches, in small numbers, to 
 the trachea and larynx, with continued counter-irritation, by 
 means of small blisters, and the tartar emetic ointment. In 
 some cases the seton has had a good effect. 
 
 Of internal remedies the most powerful is undoubtedly mercury, 
 more especially in the syphilitic cases, and particularly if it has 
 not been used before, or only sparingly employed. But the most 
 careful examination must be made previous to having recourse to 
 this means ; for if a tubercular disposition exist, there is nothing 
 so likely to call it into action as the effect of mercury. I do not 
 know any case in which such caution is necessary in its exhibi- 
 tion as this. It is, however, a remedy of great value, and may 
 be used as well in the idiopathic cases as in the secondary syphi- 
 litic affections. 
 
 * The differential diagnosis in these cases will be much aided by the laryngoscope, 
 but apart from its use the difference on external examination between the tubercular 
 and the syphilitic larynx is veiy striking. The former being not enlarged and feeling 
 loose and disintegrated from ulceration, while the latter is thickened and firm, the 
 cartilages being welded together by copious fibrous deposit. (Ed.) 
 
 t Although accurate returns are still wanting, it would appear that individuals of 
 the two professions, in which public speaking is most requu-ed, namely, lawyers and 
 clergymen, the latter are most liable to laryngitis. The explanation of this seems to 
 be, that the clergyman begins to exercise his vocal organs at a much earlier period 
 than the lawyer. The young clergyman, often of a feeble and nervous constitution, 
 and acting under conscientious motives, to the neglect of bodily health, not only reads 
 the service, and preaches once or twice, or even more often in the week, but is 
 exposed to night air and the inclemency of weather. He is compelled to do so, while 
 both the larynx and constitution of the lawyer have, in general, full time for 
 maturity before he need employ the one or expend the other in the duties of his 
 profession.
 
 DISEASES OF THE LARYNX AND TRACHEA. 223 
 
 As to its mode of exhibition, we may employ it either by 
 inhalation, or administer calomel and opium internally. In 
 some cases I have seen the mildest preparations of mercury act 
 well.* 
 
 The state of the pharynx is to be carefully attended to ; for in 
 many cases, particularly of the syphilitic or scrofulous character, 
 it may exhibit various lesions, such as superficial or deep-seated 
 ulcerations, affecting the velum, back of the pharynx or tonsils ; 
 relaxations of the uvula ; cedematous and vascular conditions 
 of the parts, &c. To the importance of applying direct remedies 
 in these cases the attention of medical men has been strongly 
 directed by Dr. Graves. We may employ, according to circum- 
 stances, either a solution of nitrate of silver, containing from 
 ten to fifteen grains to the ounce ; the caustic solution of iodine, 
 as recommended by Lugol, or the inhalation of the vapour of 
 iodine, combined with a narcotic. 
 
 After these remedies have been carried into effect, we may 
 advantageously exhibit the sarsaparilla decoction with nitric acid; 
 or, in some cases, the Fowler's solution. Counter-irritation 
 should be still kept up, and continued for a length of time after 
 the subsidence of the laryngeal symptoms. 
 
 In some cases spasmodic exacerbations occur, so severe as to 
 threaten the life of the patient. These are more frequently met 
 with in females, and demand a careful study. The suddenness 
 and violence of the attack, the absence of corresponding fever, 
 and of tumefaction of the epiglottis, will, in general, suffice for 
 diagnosis. I have often seen cases in which the suffering was so 
 severe, as that the instant performance of tracheotomy Avas 
 advised, yet in which the breathing was restored to its ordinary 
 condition by the following simple treatment : the feet were 
 plunged in warm water, the body enveloped in blankets, and a 
 draught, consisting of camphor mixture, ammonia, valerian, 
 ether, and opium, exhibited, and repeated according to circum- 
 stances. Under this treatment symptoms will rapidly subside, 
 which, from their character and continuance, would seem to 
 demand the knife ; and I would advise, that in all cases, previous 
 to the performance of tracheotomy in chronic laryngitis, the 
 
 * The perchloride in minute doses seems to act better than any other preparation of 
 mercury in these cases, nor does the complication with disease of the lung always 
 contraLndicate its employment. (Ed.)
 
 224 DISEASES OF THE LARYNX AND TRACHEA. 
 
 question be carefully investigated, as to whether the urgent 
 symptoms are the result of spasm or organic obstruction. Let 
 it never be forgotten, that even where organic disease and 
 thickening of the larynx exist, spasm may supervene, and be 
 met by appropriate treatment. We are too much attached to the 
 doctrine of diseases being necessarily separate, but experience 
 tells us that nothing is more common than to see spasm follow- 
 ing organic disease, or organic disease occurring after a purely 
 nervous lesion. 
 
 In cases shewing this liability to spasm, the belladonna, or 
 other anodyne plasters, may be usefully employed. -•■ 
 
 I cannot leave this part of the subject without alluding to the 
 effect produced by relaxation and elongation of the uvula in pro- 
 ducing symptoms of laryngeal irritation. This fact has been long 
 known, and I shall here merely enumerate the various forms of 
 symptoms which I have known to be relieved by the simple 
 operation of removing the lower, or non- muscular portion of this 
 process. 
 
 1st Case. Cough coming on at night on the patient's lying 
 doTVTi. It is incessant, and accompanied by wheezing, dyspnoea, 
 and restlessness. Nearly complete absence of symptoms during 
 the day. 
 
 2nd. Cough of a laryngeal character, ■s\dth a feeling of stuffing 
 and tickling of the throat ; alteration of voice, and hawking up of 
 mucus. 
 
 3rd. Symptoms very analogous to humid asthma, with a loud 
 sonorous rale over the chest. 
 
 4th. Sj'mptoms of the dry catarrh in old persons, without 
 laryngeal cough, stridor, or alteration of voice. 
 
 5th. Symptoms of chronic laryngitis, hoarseness, some stridor, 
 loud cough. 
 
 6th. The preceding symptoms, combined with hectic and 
 purulent expectoration, so as to resemble true phthisis laryngea. 
 7th. All the usual constitutional symptoms of phthisis, such 
 as cough, puriform and bloody expectoration, hectic, emaciation, 
 quick pulse, yet without the physical signs of pulmonary 
 tubercle. 
 
 Such a variety of effects only exemplifies the variety of consti- 
 
 * Dublin Hospital Reports, vol. v. Report of the Meath Hospital, by R. J. Graves 
 M.D., and W. Stokes, M.D.
 
 DISEASES OF THE LARYNX AND TEiCHEA. 225 
 
 tufcions ; and without doubt a more extended experience will 
 discover other modifications of symptoms. In all these, the ordi- 
 nary treatment either altogether fiiiled, or was but partially suc- 
 cessful, and this result may often lead to the suspicion of the 
 disease. But, in truth, the physician who neglects the examina- 
 tion of the fauces in any case of pulmonary disease is neither 
 doing justice to his patient nor himself. 
 
 As might be expected, the removal of the exciting cause does 
 not always produce the beneficial effect immediately. In almost 
 all chronic functional lesions more or less of organic change 
 occurs ; and in the case before us it may hapj)en, that even in- 
 curable mischief may be thus produced. Still in the great 
 majority the relief is most remarkable, and simple palliative 
 treatment will suffice to restore the patient's health. 
 
 SPECIFIC IRRITATIONS OF THE LARYNX. 
 
 In the present state of our knowledge we can do little more 
 than announce the existence of these forms of disease ; for their 
 history and diagnosis are still to be established, and their patho- 
 logical anatomy to be investigated. Suffice it to observe, that 
 the various morbid constitutional states may produce their 
 secondary local effects on the tissues of the larynx, and thus 
 cause symptoms, the treatment of which requires an investiga- 
 tion into the exciting cause and diathesis. Gout, syphilis, 
 scrofula, and scorbutus, may attack the larj'nx; and so also 
 in typhus fever, in erysipelas, and the other exanthemata, there 
 may be laryngeal diseases whose characters are peculiar. But 
 though promising so rich a harvest this field is still unexplored. 
 
 SPASMODIC AFFECTIONS OF THE LARYNX. 
 
 Endowed with a curious and complicated muscular apparatus, 
 and with an exquisite sensibility, the larynx is liable to various 
 forms of neurosis ; of these the active have only, as yet, been 
 investigated, while of the existence of the passive forms scarcely 
 any notice has been taken.* Under the first head we may class 
 
 * I here adopt the classification of neuroses into active and passive, as given by 
 Broussais — Comment, sur les Propositions de Pathologie. By active neuroses are 
 meant those -with increased innervation, such as spasm, convulsions ; while the 
 passive imply a minus degree of innervation, or paralysis. 
 
 Q
 
 22G DISEASES OF THE LARYNX AND TRACHEA. 
 
 the spasmodic croup of children, the spasm of the glottis in 
 hooping-cough, and the various forms of hysterical, nervous, and 
 sympathetic cough ; while of the second we can only say, that 
 paralysis of the muscles of phonation is seen in certain cases of 
 cerebral disease ; and that reasoning from analogy, we may 
 further admit the existence of another form of paralysis, similar 
 to that of the intestines in ileus, and of the intercostal muscles in 
 pleurisy, and resulting from the same cause, namely, the inflam- 
 mation of a tissue in connexion with the muscular fibre. 
 
 Spasm of the Glottis of Children. — This disease, con- 
 sisting essentially in a spasm, or active neurosis of the glottis, 
 seems to result in all cases from cerebral irritation, wJiich may 
 he either primary or secondary to some other disease. Its 
 existence has been recognized since the middle of the last 
 century, and a host of authors have described or alluded to its 
 symptoms, but of these the latest is Sir Henry Marsh, of whose 
 researches* I shall avail myself. 
 
 This disease may shew itself as a simple spasmodic affection 
 of the larynx, independent of any other perceptible lesion ; but 
 this is the rarest case. In others it is connected with the irrita- 
 tion of dentition, or of deranged digestive function ; while in a 
 third class, it is symptomatic of primary cerebral disease. Many 
 circumstances concur to distinguish this disease from the laryn- 
 gitis of children. In the first, or mildest variety, there are 
 paroxysms of stridor ; but in the interval, the little patient may 
 be free from all distress, and without any fever, or signs of 
 mucous irritation. In the second, although the general health 
 may be much deranged, yet the symptoms are not these of an 
 irritation of the respiratory system. The child may have remit- 
 tent fever, or a deranged state of the bowels or liver, with nervous 
 irritation ; but the laryngeal symptoms occur in paroxysms, 
 between which the breathing remains free. In such a case the 
 child may labour under the symptoms for months, and the 
 disease either subside, or become complicated with more 
 decided signs of irritation of the brain, such as convulsions, 
 strabismus, and coma. Indeed, in this form a symptom is com- 
 monly observed, first described accurately by Dr. Kellie,t namely, 
 
 * Dublin Hoi?pital Reports, vol. v. On a peculiar disease of children, which may 
 be termed spasm of the glottis, by H Marsh, M.D. 
 t Edin. Med. an! Surg. Jouinal, October, 18i().
 
 DISEASES OF THE LABYNX AND TRACHEA. 227 
 
 the spasmodic flexure of the thumb across the palm of the hand, 
 and also an analogous state of the toes. This, it is unnecessary 
 to observe, points out an excited state of the nervous centres. 
 Lastly, in the third form, there are generally decided evidences 
 of cerebro- spinal irritation, such as frequent fits of convulsions, 
 and the usual train of symptoms of meningeal or encephalic 
 irritation. Here the spasm of the glottis is as symptomatic of 
 the cerebral disease, as are the convulsions of the extremities. 
 
 Kepeated fits of a crowing respiration, not followed by cough, 
 as Cheyne has remarked, and occurring either without consti- 
 tutional symptoms, or co-existing with dentition, digestive or 
 cerebral irritation, form the characteristic features of this disease, 
 which is easily distinguished from the true croup. If to these 
 we add the absence of laryngeal obstruction between the fits, 
 and also that of the physical signs of bronchitis we can have no 
 difficulty in forming our diagnosis. 
 
 NERVOUS AFFECTIONS OF THE LARYNX IN THE ADULT. 
 
 We meet with spasm of the glottis in the adult, either with or 
 without organic disease of the larynx, though in most cases it 
 supervenes on chronic laryngeal affections. In females, however, 
 we find it as one of the symptoms of the protean hysteria, when 
 it may be a transient or long-continued affection. Here, as in 
 the disease already described, the spasm is commonly during 
 inspiration. 
 
 I have not materials to enable me to enter into an account of 
 the various hysterical and nervous afi'ections of the larynx in 
 females, but shall merely enumerate those which I have often 
 observed, most of which have been long known. 
 
 1st. Simple aphonia, supervening on mental excitement. Its 
 duration is exceedingly various, and its disappearance often as 
 sudden as its invasion. 
 
 2nd. Fits of croupy breathing. 
 
 3rd. Long-continued stridulous breathing, without fever. 
 
 4th. A hard, loud, solitary cough, without any stridor. In 
 its more violent forms this has got the name of tussis ferina. 
 
 5th. A similar cough, followed by an inspiration, not stridu' 
 lous, but with the exjyiration long, sonorous, and groaning, so as 
 to resemble the howling of a dog. 
 
 Q 2
 
 228 DISEASES OF THE LARYNX AND TRACHEA. 
 
 6th. A short but teasing cough, occurring in the most rapid 
 succession ; and during the paroxysm causing the greatest distress 
 and exhaustion. 
 
 7th. The most violent form of the tussis ferina, with greatly 
 increased action of the heart and arteries, hurried breathing, 
 loud puerile respiration, and profuse sweatings. In such a case 
 I have seen the disease continue to form more than a year, yet 
 there was no emaciation. 
 
 Other forms may also occur, but the above are those which 
 have fallen under my own observation. With respect to diag- 
 nosis the points of importance are, the co-existence of other 
 hysterial phenomena, or their having preceded the symptoms, 
 the absence of fever, the character of the cough, the want of the 
 regular succession of 'phenomena, as observed in laryngitis, the 
 frequent absence of hoarseness, and lastly, the resistance of the 
 symptoms to ordinary antiphlogistic treatment. 
 
 A spasm of the glottis, however, may occur independent of any 
 hysterical tendency. Thus, in a lady whose case was mentioned 
 to me by Mr. Goodall, there have been attacks of this kind for 
 many years, some of which have been so alarming as to excite 
 fears for life. The patient is now sixty years of age, and exhibits 
 no signs of hysteria. We are not in possession of facts to prove 
 that spasm of the glottis ever occurs in the adult male, without 
 the previous existence of organic disease. 
 
 We are indebted to Mr. Kirby for a case in which death 
 was apparently produced by spasm of the glottis, in consequence 
 of obstruction of the oesophagus by pieces of meat and bone.* 
 The largest morsel lay immediately behind the cricoid cartilage ; 
 but its pressure, nor that of another portion, which was low down 
 in the oesophagus, had not diminished the calibre of the windpipe. 
 The epiglottis almost completely concealed the cavity of the 
 glottis, Avhich was so diminished by the forward inclination of the 
 arytenoid cartilages as to be scarcely discernible, and the rima 
 was altogether closed. 
 
 Although it is doubted whether the symptoms of suffocation, 
 in the case of a foreign body lodghig in the oesophagus, are pro- 
 duced by a spasm of the glottis,t yet I incline to the possibility of 
 
 * DuV>lin IIo?pital Reports, vol. ii. A case in which suffocation was produced by a 
 portion of solid food in the oesophagus, by J. Kirby, A.B., &c., 1818. 
 ■\ Surgical Pathology of the Larynx and Trachea, p. 2'24.
 
 DISEASES OF THE LARYNX AMD TRACHEA. 229 
 
 sucli an event, not merely from the case just alluded to, but from 
 my having]; seen an instance in which a piece of money was 
 lodged in the oesophagus, and where croupy breathing, and other 
 laryngeal symptoms, were manifestly the result. In this instance 
 the foreign body was not lodged in the fauces or pharynx. 
 
 But in the adult the spasmodic afiections of the larynx are met 
 with most commonly in connexion with organic disease either of 
 the windpipe or lung, or of both combined. In by far the greater 
 number the organic lesion has been antecedent, and the nervous 
 afiection is shewn by spasmodic exacerbations of the laryn- 
 geal breathing, which are full of danger. To these I have already 
 alluded, and shall merely add, that in a few cases the reverse may 
 occur, and a disease, at first functional, pass into organic change ; 
 nor should the long continuance of symptoms of a decidedly 
 nervous or hysteric character put the practitioner off his guard ; 
 of this the following case is a striking illustration. 
 
 A young female entered the Meath Hospital labouring under 
 fever, from which, after a relapse, she recovered, but it was to 
 become affected with a new and singular train of nervous symp- 
 toms. She had hysteria, in almost all its forms. Epileptic 
 convulsions, violent spasms, coma, screaming, tympanitis, para- 
 lysis of the bladder, intractable vomiting, succeeded one another 
 in a miserable succession ; yet after many months of suffering her 
 flesh and appearance were singularly preserved : she lastly was 
 attacked with a cough having every resemblance to the hysteric 
 form, and relieved by antispasmodic medicines. This subsided on 
 the appearance of an eruption of varicella, followed by a typhoid 
 state, with, for the first time, emaciation. This subsided, but 
 the cough returned, and continued for nearly three weeks, when 
 she sunk, with symptoms of suffocation. On dissection, an 
 abscess, of the size of a Spanish nnt, was found involving the 
 cricoid ; and though all the cavities were minutely examined 
 no other disease could be discovered. Had this been recognized, 
 tracheotomy might have prolonged her miserable life. 
 
 In this case death took place by organic change of the larynx 
 itself. But in severe or long-continued spasmodic affections of 
 the windpipe, the brain is also in danger of organic lesion. It 
 is a curious fact, that in three of the most extraordinary cases of 
 hysteric or nervous cough which I have witnessed, there was evi- 
 dence of such an occurrence. In one of long-continued cough and
 
 230 DISEASES OF THE LARYNX AND TRACHEA. 
 
 Spasm during expiration, the patient, a young female, after 
 having recovered of this, died with latent meningitis. In the 
 second case, the symptoms were frightful paroxysms of a tearing, 
 incessant cough, followed by fever, headache, strabismus, and 
 the other symptoms of hydrocephalus. This patient recovered 
 under antiphlogistic treatment, and the use of mercury. In the 
 third, there were long-continued paroxysms of the most severe 
 stridulous breathing, tussis ferina, and convulsions. This patient, 
 after years of suffering, recovered, but died suddenly. All these 
 patients were young females, of lymphatic temperaments. From 
 these cases, and others which might be quoted, we derive the 
 practical rule, that even after puberty, the spasmodic affections of 
 the larynx may be indicative of cerebral disease. 
 
 I have often found, even in cases where manifest organic 
 disease both of the larynx and lung existed, that the cough was 
 best relieved by antispasmodic medicines ; and in chronic phthisis 
 our best cough mixtul-e will often be a combination of powerful 
 antispasmodics. And I have more than once observed, that 
 where tuberculous phthisis supervened on hooping-cough, the 
 cough preserved its character even after extensive cavities were 
 formed in the lung, and until the fatal termination of the disease. 
 From these facts, and others which might be quoted, we derive 
 the rule that the existence of organic disease should not make us 
 neglect the use of antispasmodics ; nor the fact of long-continued 
 and apparently functional affections of the larynx, even occurring 
 after puberty, make us overlook the possible supervention of 
 organic change in the larynx, or even in the brain itself. 
 
 FOREIGN BODIES IN THE LARYNX, TRACHEA, OR BRONCHIAL TUBES. 
 
 As yet we have no monograph on this subject ; and the student 
 must wade through a mass of periodicals to arrive at the know- 
 ledge he seeks, and after all, he will find no general principle of 
 diagnosis laid down, but merely a number of cases, certainly of 
 great interest, but still not calculated to satisfy his mind. The 
 memoirs of Pelletan,* and Louis, t and the work of Mr. Porter, J 
 in which the subject is introduced, will be the principal sources 
 
 * Clinique Chirurgicale, torn. i. Mem. 1, 
 
 f Memoire sur la Broncbotomie. Memoires de I'Acad. Royale de Chirurgie, torn, xii. 
 
 J Surgical Pathology of the Larynx and Trachea.
 
 DISEASES OF THE LARYNX AND TRACHEA. 231 
 
 of his information. Almost all the rest will consist of isolated 
 examples, puhlished by practitioners who have met with an acci- 
 dental case, and have not devoted themselves to any original 
 investigation of the symptoms and treatment of this affection. 
 
 Before entering on the different symptoms, I shall allude to a 
 few particulars as connected with the entrance of the foreign 
 body into the air passages, and its nature. 
 
 It would appear that bodies of a size so large as to exceed the 
 ordinary diameter of the glottis, have yet passed through that 
 aperture, and lodged in the larynx, trachea, or bronchial tubes. 
 This fact was first satisfactorily explained by Dr. Houston, in his 
 remarks on a case of this description.* After observing on the rarity 
 of the case, and its interest, as shewing that a body apparently 
 much larger than the aperture of the rima glottidis, and one even 
 of different form, could find a passage through that fissure, Dr. 
 Houston says : "To understand aright how a body of greater 
 apparent dimensions than the rima glottidis, could have found a 
 passage through that aperture, it is only necessary to reflect for a 
 moment on the nature of the process of inspiration. The intro- 
 duction of air to the lungs with every breath, is consequent upon 
 the enlargement of the chest ; the weight of the atmosphere pressing 
 the adjacent column into the cavity, with a rapidity proportioned 
 to the suddenness and extent of the dilatation, and with a force 
 sufficient to carry along in the current any light moveable body 
 which may happen to come in the way. A small body, so inter- 
 cepted, will readily pass with the air through the rima, and be 
 lodged in a part of the tube lower down. A body of inordinate 
 dimensions may stick so firmly in the aperture, that the full 
 weight of the atmosphere is unequal to its propulsion onwards, 
 and death from suffocation will be the inevitable consequence, if 
 the foreign body be not instantly shot back again by a powerful 
 expiratory effort, or removed by operation. And a body of interme- 
 diate size, viz., one of such moderate dimensions as to be capable 
 of passing through the rima by stretching and divaricating 
 the sides of that aperture, may, when pressed heavily by the 
 atmosphere, as it would during a forced inspiration, be driven 
 past the obstruction, and thence into the trachea, or bronchial 
 
 * Dublin Journal of Medical and Chemical Science, No. XXIII., account of a case in 
 which a large molar tooth passed into the larynx, during the operation of extraction, 
 by John Houston, M.D., &c.
 
 232 DISEASES OF THE LARYNX AND TRACHEA. 
 
 tubes. Such latter was no doubt the mode by which the tooth, 
 in the case above related, found a passage into the bronchus. 
 The man holding his breath during all the time of the operation, 
 suddenly at the moment in which the extraction was completed, 
 took a full inspiration; upon which the tooth, partly by its gravity, 
 (the head being at the time thrown back,) and partly carried by the 
 air rushing to the windpipe, fell over the aperture leading into that 
 tube. The obstruction caused thereby to the further entrance 
 of air, induced a spasmodic increase of action in the muscles of 
 inspiration, and a consequent increase of pressure by the air at 
 the opening, by which the tooth was driven with force through 
 the fissure." 
 
 The foregoing considerations may explain why it is that a 
 foreign body that has entered the larj^nx during inspiration is so 
 seldom expelled by expiration, notwithstanding the most violent 
 efi'orts of coughing ; but that it will remain in the air passages, 
 and unless removed by operation, bring on a train of formidable 
 and generally fatal symptoms. It is obvious, that in the case of 
 a body which has only passed the glottis by stretching and divari- 
 cating that aperture, the forces accessary to its introduction must 
 be infinitely greater than those which could be brought to bear on 
 its expulsion ; for in the first case it is acted on by the pressure 
 of the atmosphere, while the powerful respiratory muscles are in 
 the highest state of exertion, while in the latter, there is nothing 
 to expel it but the comparatively feeble eftbrts of expiration. The 
 dilated state of the glottis during a forced inspiration, is also 
 a condition favouring the entrance, though not availing for the 
 expulsion of the body. 
 
 With respect to the nature of the orifice itself, it is to be 
 observed, that the common idea of its being a pyramidal opening, 
 whose summit varied in its orifice according to the degree of 
 dilatation or contraction in which it was examined, is now dis- 
 proved, and the researches of Liscovius and Malgaigne have been 
 recently verified and extended by Professor Lauth of Stras- 
 burgh. 
 
 According to this author, the length of the glottis increases 
 with the volume of the larynx, according as we examine it in the 
 infant, the adult female, or the male. In the adult, according to 
 the sex, the extent from before backwards varies from seven to 
 thirteen lines, the dimensions being taken at the period of repose :
 
 DISEASES OF THE LARYNX AND TRACHEA. 233 
 
 he has never found it so long as fifteen lines, as described by 
 Malgaigne. But the length of the opening is not always greater 
 in man than in woman, for it has been found, even in tall men, 
 but from seven to eight lines, while in women it has been met 
 with from eight to nine lines in length. 
 
 It is further shewn that the lips of the opening are not straight, 
 but nearly at the centre project towards the mesian line, in con- 
 sequence of the prominence of the anterior apophysis of the 
 arytenoid cartilage. The base of the glottis is also terminated 
 by a line, curving inwards, so that in the state of rest the form 
 of the glottis may be compared to that of the steel of a halbert. 
 
 In consequence of this disposition, the opening may be con- 
 sidered as formed of three parts, the anterior, middle, and pos- 
 terior, and in a glottis eleven lines in length, the anterior with its 
 portion of middle, measures seven, and the posterior, with its 
 portion of middle, four lines. The width in the middle portion 
 is two lines and a half. 
 
 But by the contraction of its muscles its dimensions are 
 altered: it may be elongated or widened. Lauth has found, that 
 in a glottis of eleven lines in length, the opening may become 
 twelve lines, while its width is diminished to two. In its 
 transverse enlargement, however, it becomes of a lozenge shape, 
 and while the arytenoid cartilages can be separated to so much 
 as five lines and three-fourths, the length of the opening shall 
 remain the same. It is plain that this condition will be the most 
 favourable for the entrance of a foreign body, inasmuch as now 
 the opening exhibits its greatest possible enlargement, and this 
 change is produced by an inspiratory muscle — the posterior crico- 
 arytenoid, which, as Lauth remarks, repeats on the larynx the 
 action of the intercostals on the ribs. 
 
 The situations in which the foreign body may remain can be 
 enumerated as follows : it may be impacted in the rima itself, or 
 pass and become entangled in the ventricles of the larynx; it 
 may pass into the trachea, and from thence into the bronchial 
 tubes, particularly the right, and from these situations, by the 
 efforts of coughing, be forced upwards into the larynx, again to 
 return to its former position. 
 
 When the body is met with in the bronchial tubes, it has 
 been observed in the great majority of instances, to be contained 
 in the right bronchus, and this circumstance, so interesting in a
 
 234 DISEASES OF THE LARYNX AND TRACHEA. 
 
 general point of view, I shall shew to be of the utmost importance 
 "with respect to diagnosis. It has been supposed that the cause 
 of this phenomenon is to be found in the greater size of the right 
 bronchial tube, but this explanation appears insufficient. It 
 might explain the lodgment of a foreign body in the right bronchial 
 tube, that was too large to enter the left, but would throw no 
 light on the fact, that bodies small enough to enter the left, are 
 yet most commonly found in the right tube. 
 
 I apprehend that the true explanation of this interesting fact 
 will be found in the anatomical disposition of the trachea at its 
 bifurcation, where we may observe that the projection or septum 
 dividing the right and left bronchi, is not in the mesian line, but 
 decidedly to the left of it. So that a body passing through the 
 glottis, will be thus directed into the right bronchus.* Another 
 explanation has been founded on the different directions of the 
 two tubes, the right being more vertical than the left, but the 
 difference is scarcely sufficient to explain the phenomenon. It 
 might be farther supposed, that as the right lung has a greater 
 capacity than the left, the force of the air entering through the 
 bronchus would be proportionally augmented ; but this opinion 
 loses much of its weight, when we reflect on the different dia- 
 meters of the tubes. 
 
 When the foreign body has passed into the air passages, 
 various results may be observed. It may be violently expelled 
 through the glottis, after a period of time varying from a few 
 moments to many years. It may produce death by suffocation, 
 in consequence of its becoming impacted in the larynx ; it may 
 cause acute inflammation of the whole lung,t and the patient 
 die before abscess has formed ; it may form an abscess in the 
 lung; or lastly, produce death with the symptoms of chronic 
 consumption. 
 
 We are not in possession of facts competent for the explana- 
 tion of these different results ; but they seem to shew, that even 
 if we admit with Desault, that the trachea and bronchial tubes 
 possess a much less degree of animal sensibility than the glottis, J 
 yet that their organic sensibility is decided, inasmuch as we find 
 
 * For this observation I am indebted to my friend, Mr. Goodall. 
 
 t According to Juergensen catanhal not croupous pneumonia. " Anatomical investi- 
 gation teaches that tlieae pneumonias, though superficially most closely resembling the 
 croupous form, are not croupous 'n character." — Ziemssen's Cyclop., vol. v. p. 194. (Ed.) 
 
 J Oiluvres Chirurg'cales, torn, ii.
 
 DISEASES OF THE LARYNX AND TRACHEA. 235 
 
 disease to result from the presence of foreign bodies extremely 
 various in their characters. And it would also appear, that this 
 organic sensibility of the air passages varies remarkably in different 
 individuals, as in some an acute, and in others an extremely 
 chronic disease is induced by bodies of a similar nature, and it is 
 further observed, that in some individuals there is fixed pain, 
 while in others the most enormous disease may occur without any 
 local pain whatever. 
 
 In certain cases the expulsion of the foreign body, even after 
 the long continuance of consumptive symptoms, has been followed 
 by recovery, but in many this favourable result does not occur, 
 and the patients sink from the chronic disease induced by the 
 accident. 
 
 It has been conceived that the physical characters of the foreign 
 body influence the violence of the symptoms ; a sharp and rugged 
 substance, it is supposed, will cause greater distress than one 
 with a smooth surface, and it is true, that in many of the most 
 remarkable cases of pain and distress, occurring from the first, the 
 foreign body has been of the former description ; but on the other 
 hand, bodies of irregular forms have remained in the air passages 
 without the production of pain. 
 
 In considering this subject, we must separate the mere occur- 
 rence of pain from that of the other distressing symptoms. Facts 
 are wanting to throw light on the occurrence of pain, but I have 
 little doubt, that the great cause of distress will be found to reside 
 in the degree of mechanical obstruction produced by the foreign 
 body. This we should a priori expect, but in confirmation of the 
 opinion I may observe, that in all the cases which I have seen, 
 the distress was directly as the feebleness of murmur in the 
 afi^cted lung. 
 
 Thus if a smooth body, such as a bean, enters the bronchus, 
 and from the efforts of inspiration so obstructs the tube, as 
 totally to preclude the entrance of air, the distress is enormous, 
 the patient being suddenly deprived of the use of half of his 
 lungs ; while on the other hand, an irregular body, such as a 
 tooth, may exist long in the same situation, with comparatively 
 little distress, because, though to a certain degree obstructed, 
 the tube is not impermeable. I have had repeated oppor- 
 tunities of confirming this opinion, and it appears that the 
 smoother the body, the greater the liability of complete occlu-
 
 236 DISEASES OF THE LARYNX AND TRACHEA. 
 
 sion of the tube. In one of the most remarkable instances 
 which I witnessed, the foreign body was a peeled kidney-bean, 
 and the extinction of the respiratory murmur was complete and 
 permanent. In two cases, however, in which plum-stones had 
 entered, I observed complete extinction of respiration, and it is 
 probable that a spasmodic closing of the tube around the body had 
 then taken place. We may also understand, that an irregularly 
 formed body, which can neither directly plug up the tube, nor be 
 completely grasped by its spasmodic contraction, will be less likely 
 to be driven into the trachea by the effort of expiration, much of 
 the effect of which will be expended from the pervious state of 
 the tube. Here we have a cause of the production of chronic 
 symptoms, by extraneous substances of an irregular form. 
 
 It is an interesting fact in corroboration of this opinion, that 
 in the great majority of cases, in which chronic consumptive 
 symptoms were produced, the foreign body was of an irregular 
 form. The patients escaped rapid death, because the air passage 
 was not completely obstructed, and their symptoms resulted 
 from the long-continued irritation of the foreign body. 
 
 In considering the diagnosis of this accident, I shall not enter 
 into an analysis of the numerous cases on record, in which 
 foreign bodies have entered the windpipe. For however interest- 
 ing these may be, the observation of the symptoms is not suffi- 
 ciently accurate, nor has there been, until our own time, any 
 attempt to combine the evidence of symptoms with that of phy- 
 sical signs. I shall therefore content myself with giving a sketch 
 of such symptoms as have been observed previous to the discovery 
 of auscultation, and then examine the state of our knowledge as 
 to the physical indications. 
 
 Diagnosis of Foreign Bodies in the Windpipe. — It has 
 been long observed, that when the foreign body remained impacted 
 in the larynx, the symptoms from the first were more violent 
 and distressing. Incessant cough of a spasmodic character, 
 croupy breathing, pain in the region of the larynx, paroxysms of 
 suffocation, are the ordinary symptoms. The termination of the 
 case may be by sudden death, in consequence of the obstruction 
 of the rima ; or the foreign body may be expelled, or fall into the 
 trachea, and an interval of comparative ease be induced, succeeded 
 either by a return of the laryngeal symptoms, or by an acute or 
 chronic irritation of the lung itself.
 
 DISEASES OF THE LARYNX AND TRACHEA. 237 
 
 The violence of these symptoms, however, does not altogether 
 depend on the fact of the foreign hody being lodged in the larynx ; 
 much depends on the degree of mechanical obstruction, and the 
 nature of the offending body. La Martiniere has detailed a case 
 in which a piece of gold remained in one of the ventricles of the 
 larynx for years without these distressing symptoms.* Never- 
 theless, as a general rule, the lodgment of the body in the 
 larynx produces the greatest suifering. 
 
 In this respect we may divide the cases into two classes, those 
 in which the foreign body has remained, from the first, impacted 
 in the larynx ; and those in which, after having passed this 
 portion of the tube, it is driven upwards from the trachea to 
 be temporarily entangled in the larynx, again to descend into 
 the trachea or bronchial tubes, producing those remarkable alter- 
 nations of suffering and comparative ease, so commonly observed 
 in cases of this accident. 
 
 But when the body has descended into the trachea, two orders 
 of symptoms are induced, and we may observe violent and acute 
 suffering, or symptoms of a much more chronic character. 
 
 In the first case, the symptoms are in general more or less 
 remittent, at least in the earlier period, and we observe 
 violent paroxysms of cough and suffocation, alternating with 
 a state of calm, often so complete, as for a time to banish all 
 apprehension from the minds of ordinary observers ; thus after a 
 paroxysm so violent as to threaten the life of a child, we may see 
 him return with eagerness to his play, without the existence of 
 any external symptom or sign, which could reveal the dreadful 
 accident that has befallen him. The paroxysms, however, become 
 more frequent and severe, and inflammation of the mucous 
 membrane begins to appear. At length the irritation becomes 
 permanent, and if relief be not speedily afforded, the patient 
 sinks under the aggravated sufferings of obstructed respiration. 
 
 In these cases the symptoms of fever are consecutive to those 
 of the local irritation, and the paroxysms of suffering are 
 induced either by the body being driven upwards into the larynx, 
 or by its being impacted in the bronchus, so as suddenly and 
 completely to obstruct the tube, and in a moment, as it were, 
 deprive the patient of one lung. From the secretion of the 
 mucous membrane, a rattling takes place in the throat, and as 
 
 * Memoires de 1' Academic Eoyale de Chirurgie,
 
 238 
 
 DISEASES OF THE LARYNX AND TRACHEA. 
 
 the disease advances the respiration becomes stridulous. Accord- 
 ing to Mr. Porter, however, the sound is never so loud nor harsh 
 as in acute cynanche traehealis. Louis has described the occur- 
 rence of emphj'sema above the clavicles, but this is one of the 
 rarest symptoms. Lescure,* however, has mentioned a case in 
 which the lungs were found emphysematous throughout their 
 whole extent. 
 
 As might be expected, the cerebral circulation suffers in 
 consequence of the violent cough. Thus convulsions are com- 
 monly observed, and even apoplexy, particularly if the patient be 
 advanced in years. 
 
 In other cases the brain may be so injured, as that death shall 
 take place with cerebral symptoms, even after the removal of the 
 foreign body. 
 
 In the second class of cases, or those in which the foreign 
 body remains in the windpipe or bronchus, the greatest variety 
 of symptoms may be produced. And of the recorded cases the 
 following are the most remarkable : 
 
 1. Chronic inflammation of the larynx and trachea. 
 
 2. Chronic phthisis. 
 
 3. Pulmonary abscess. 
 
 4. Bronchitis, with or without hemoptysis. 
 
 5. Acute pleuro-pneumonia. 
 
 6. Acute phthisis. 
 
 7. Asthmatic symptoms. 
 
 The subjoined table, into which I have thrown the most 
 remarkable cases on record, will establish the above positions. 
 
 AUTHORITY. 
 
 SYMPTOMS. 
 
 FOREIGN 
 BODY. 
 
 RESULT. 
 
 Houston, t 
 
 Sudden laryngeal irrita- 
 thm after the removal 
 of the second molar 
 tooth ; disappearance of 
 the tooth ; tendency to 
 Bieh ; occasional cough ; 
 no hoarsenef-s or stri- 
 dor ; respiration in 
 right lung feeble, wiih 
 a littk bronchitic rale. 
 
 The root & 
 fangs of 
 the tooth. 
 
 Death in eleven days by 
 bronchitis and pleuro- 
 pneumony, commenc- 
 ing in the right lung 
 and invading also the 
 left. The tooth was 
 found in the right bron- 
 chus. The right lung 
 was hepatized. 
 
 * Memoires de I'Academie de Chiru-gie, tome v. 
 
 j- Dublin Journal of Medical and Chemical Science, vol. T., 1S34,
 
 DISEASES OF THE LARYNX AND TRACHEA. 
 
 239 
 
 AUTHOKITT. 
 
 SrMPTOMS. 
 
 FOREIGN 
 BODY. 
 
 RESULT. 
 
 BONETUS.* 
 
 Cough and sense of suf- 
 focation. 
 
 A cherry- 
 stone. 
 
 Expulsion after three 
 weeks. Recovery. 
 
 ARNOT.f 
 
 Symptoms of phthisis. 
 
 A piece of 
 bone. 
 
 Expectoration of the 
 bone two months after 
 it had entered the 
 windpipe. Recovery. 
 
 GiLBOY.J 
 
 Sudden laryngeal irrita- 
 tion while at dinner; 
 violent coiigh, with 
 threatened suffocation. 
 Tliese soon subsided, 
 but slight cough and 
 soreness at the top of 
 the sternum remained. 
 After five weeks, fe- 
 ver, with violent cough 
 when on assuming the 
 erect position ; hectic ; 
 purulent expectoration ; 
 foeLor of the breath. 
 
 A portion of 
 chicken- 
 bone 
 weighing 
 sis grains. 
 
 Death in about three 
 months from the en- 
 trance of the bone, 
 which was found in the 
 right bronchus. The 
 bronchial tube commu- 
 nicated with a large 
 abscess, containing 
 about twenty ounces 
 of pus, and occupying 
 the right lung. 
 
 Lo-cis.§ 
 
 Cough. Fever. Hae- 
 moptysis. 
 
 A portion of 
 veal bone. 
 
 After four months, expec- 
 toration, with reco- 
 very. 
 
 LENGLET.y 
 
 Severe cough, suddenly 
 supervening ; haemop- 
 tysis, and consequent 
 fcEtid and purulent ex- 
 pectoration ; pain in 
 the left side. 
 
 A sharp 
 
 piece of 
 
 bone. 
 
 The bone was expectora- 
 ted after many months, 
 but the patient died 
 with abscess of the left 
 lung. 
 
 PELLETAN.f 
 
 Violent cough with pneu- 
 monic symptoms ; fail- 
 ure of bleeding, eme- 
 tics, and blisters to re- 
 lieve it. The foreign 
 body could be felt ex- 
 ternally. 
 
 A piece of 
 flint. 
 
 The operation was per- 
 formed after twenty- 
 two days, and the fo- 
 reign body driven out 
 by expiration. The 
 cough continued ; pu- 
 rulent expectoration 
 supervened. Death, 
 with phthisical symp- 
 toms in eight months 
 from the accident. 
 
 * Med. Septem. Collect., lib. ii. sect. 9. De Affect. Asp. Art. cap. viii. 
 
 f Edinburgh Med. Essays, vol. ii. 
 
 X Edmburgh Med. and Surg. Journal, vol. xxsv., 1831. 
 
 § Mem. de I'Academie de Chirurgie. 
 
 II Mem. de I'Academie de Chirurgie, torn. v. 
 
 "^ Clinique Chirurgicale, torn. i.
 
 240 
 
 DISEASES OF THE LARYNX AND TRACHEA. 
 
 AUTHORITY. 
 
 SYMPTOMS. 
 
 FOREIGN 
 BODY. 
 
 RESULT. 
 
 Desault.* 
 
 Sudden and violent cough, 
 with dyspncEa and pain, 
 coming on while the 
 person was eating cher- 
 ries. Passage of these 
 symptoms into those of 
 laryngeal phthisis. 
 
 A cherry- 
 stone. 
 
 Death in two years. The 
 foreign body was not 
 expectorated. 
 
 t 
 
 Violent cough subsiding 
 in a few hours. In 
 a year, return of the 
 cough, with fever. 
 
 A cherry- 
 stone. 
 
 Expectoration of a mass 
 of calcareous matter, 
 with the cherry-stone 
 in the centre. Copious 
 purulent expectoration, 
 and death soon after- 
 wards. 
 
 Craigie.J 
 
 Violent laryngeal irrita- 
 tion passing into the 
 chronic state. 
 
 An artificial 
 tooth. 
 
 After two years, expecto- 
 ration of the foreign 
 body ; partial recovery ; 
 haemoptysis, and death, 
 with symptoms of 
 phthisis. 
 
 DONALDSON.§ 
 
 Sudden & violent cough- 
 ing, followed after some 
 days by vomiting & foe- 
 tid expectoration, with- 
 out fever. After some 
 time the pulse rose. 
 Sensation as of a rough 
 substance parsing up 
 and down the sternum. 
 
 A head of 
 
 grass, (cy- 
 
 nosurus 
 
 crisiatus.) 
 
 Expectoration of the fo- 
 reign body in about 
 seven weeks. Rapid 
 recovery. 
 
 HOCHSTETER.|| 
 
 Hoarseness and emacia- 
 tion, supervening on 
 the entrance of a coin 
 during sleep. 
 
 A Portugal 
 ducat. 
 
 Expectoration after two 
 years and a half. Reco- 
 very. 
 
 Bartholin.^ 
 
 The patient laughed while 
 swallowing a nut. Sud- 
 den violent cough, fol- 
 lowed by fever and 
 emaciation. 
 
 A nut. 
 
 Expectoration after two 
 months. Recovery. 
 
 * Oi^uvres Chirurgicale?, tom. ii. 
 
 t Ephemerides. Curios. Nat. Decad. 11, Ann. x. Obs. Ixxii. 
 
 X Edin. Med. and Surg. Journal, No, cxx., 1834. 
 
 § Ibid. 
 
 II Observ. Decad. C, cap. x. 
 
 ^ Hist. Anat. Cent. ii. Hist. 27.
 
 DISEASES OF THE LAKYNX AND TRACHEA. 
 
 241 
 
 AUTHORITY. 
 
 SYMPTOMS. 
 
 FOREIGN 
 BODY. 
 
 RESULT, 
 
 Lettsom.* 
 
 Urgent cougli ; hoarse- 
 ness ; dyspnoea ; ex- 
 pectoration of dense 
 mucus ; night sweats ; 
 emaciation. 
 
 A button. 
 
 Expectoration of the but- 
 ton after seven or eight 
 months, with recovery. 
 
 NOOTH.f 
 
 Sense of weight and ful- 
 ness in the left side, 
 with some dyspnoea ; 
 urgent cough ; expec- 
 toration of dense mu- 
 cus ; hectic, and irre- 
 gular pulse. 
 
 A leaden 
 shot, one- 
 eighth of 
 an inch in 
 diameter. 
 
 Expectoration of the fo- 
 reign body after many 
 months, Recovery, 
 
 BORELLI.J 
 
 Consumptive. 
 
 A piece of 
 nutmeg. 
 
 Expectoration, and reco- 
 very. 
 
 TtJLPlUS.§ 
 
 Obstinate cough, with 
 great dyspnoea. 
 
 A nutshell. 
 
 After seven years the fo- 
 reign body was ex- 
 pelled during a violent 
 fit of coughing. 
 
 Broussais.II 
 
 The patient received a 
 ball in the neck, fol- 
 lowed by a liability to 
 cough, without injury 
 of his general health 
 for six years. 
 
 A musket 
 baU. 
 
 After seven years from 
 the date of the acci- 
 dent, death, with symp- 
 toms of severe ataxic 
 fever. For the two 
 last years some dysp- 
 noea, cough, and night 
 sweats ; slight pains in 
 the chest, and a ten- 
 dency to lie on the left 
 side. The left, lung was 
 found solidified, with 
 seven or ei^hc absces- 
 ses. The ball was en- 
 cysted, and lay near 
 the root of the lang. 
 
 * Memoir of the Life and Writings of Dr. Lettsom, by T. J. Pettigrew, 1817 
 vol. iii. p. 82. 
 
 t Transactions of a Society, &c., vol. iii., London, 1812. See also Dr. Craigie's paper, 
 Edin. Med. and Surg. Journal, July, 183 J. 
 
 I Hist. Med. Phys. Cent, Hist., Paris, 1656. 
 § Lib. ii. Obs. vii. 
 
 II Histoire des Phlegmasies Chronique^, tome ii. p. 105. In this case some doubt 
 may exist as to whether the ball was the cause of the fatal symptoms. It was 
 perfectly encysted, and the surrounling tissue dense and callous. There was no 
 marasmus. 
 
 B
 
 242 
 
 DISEASES OF THE LARYNX AND TEACHEA. 
 
 ArTHORITT. 
 
 SYJIPTOMS. 
 
 ! 
 
 FORETG.V ' TESI'LT 
 BODY. UESILT, 
 
 HOWSHIP.* 
 
 Sudden and incessant 
 irritation, pain and 
 cough ; mucous and 
 bloody expectoration ; 
 wasting; fixed pain in 
 the right lung confined 
 to a point ; frequent 
 haemoptysis. 
 
 An iron 
 nail. 
 
 After nearl}' four months, 
 duiing a violent fit of 
 congliinj, with copious 
 haiiuoptv.-is, the nail 
 was driven into the ca- 
 vity of ilie mouth. The 
 patient lecovered, but 
 fur m^ny years was 
 subject lo cough, with 
 slifciht hije iioptysis, and 
 ]irtin iu the old situa- 
 
 UkjU. 
 
 ABERCROMBIKt 
 
 Sudden laryngeal irrita- 
 tion ; gasping ; cough 
 and dyspnoea recurring 
 in fits, for some time 
 after the accident; these 
 ■were succeeded by fre- 
 quent cough, dense mu- 
 cous expectoration and 
 rapid pulse. 
 
 An arlitjcia". 
 tooth. 
 
 The foreign body was 
 expectorated in two 
 3 ears ami s-even months 
 afier it»5 entrance into 
 ihe windpipe. Much 
 rflif f fo lowed, and the 
 patient's health and 
 s-tiength were to a cer- 
 tain degree restored ; 
 but cough and expecto- 
 raiion continued, with 
 great susceptibility to 
 bronchitis ; bajmoptysis 
 supervened ; and death 
 in the early part of the 
 fourth year from the 
 accident. 
 
 HOLMAR.J 
 
 Cough; haemoptysis; hec- 
 tic ; diarrhoea. 
 
 A fragment 
 of bone, 
 Itlisor an 
 inch long. 
 
 After fifteen years co- 
 pious hsemoptysis oc- 
 curred, followed by the 
 expectoration of the 
 bone. Recovery. 
 
 SrE.§ 
 
 While in the act of eating 
 a pigeon, a portion of 
 the back bone entered 
 the trachea ; sudden 
 acute pain below the la- 
 rynx supervened. This 
 gradually subsided, but 
 a rattle continued, par- 
 ticularly on speaking. 
 Thus she continued for 
 
 A portion of 
 the ver- 
 tebral co- 
 lumn of a 
 pigeon. 
 
 After the seventh year 
 the pa n changed its si- 
 tuation, and was felt in 
 the upper part of the 
 chei^t. The rale and 
 hi-siug sounds subsid- 
 ed, and she was re- 
 lieved from dyspnoea 
 for four months. Vio- 
 lent cough and liaemop- 
 
 * Practical Observations in Surgery, <tc. London, 1816. 
 
 f See Dr. Craigie's Paper, Edin. Med. and Surg. Jourral, ISSi. 
 
 J London Medical Journal, vol, iii, 
 
 § Mem, de I'Acad. Royale de Chirurgie, tome v. p. i)33.
 
 DISEASES OF THE LARYNX AND TRACHEA. 
 
 243 
 
 AUTHORITY, 
 
 SYMPTOMS. 
 
 FOREIGN 
 BODY. 
 
 RESULT. 
 
 
 t 
 
 seven yeara, the pain 
 being occasionally vio- 
 lent, and relieved by 
 bleeding. 
 
 
 tysi^ then supervened, 
 which for five years 
 recurred every two or 
 three months. For the 
 next three months there 
 was only a slight pam 
 in the chest, with some 
 haemoptysis. Tlie hec- 
 tic symptoms then re- 
 appeared ; and after 
 two years of great suf- 
 fering the lone was ex- 
 pectorated, having re- 
 mained seventeen years 
 in the air passages. 
 Some relief followed. 
 Hectic and emaciation 
 followed and death in a 
 year and a half after- 
 wards. 
 
 Although this collection of cases might be enlarged, it is 
 sufficient to shew the general features of the subject. We learn 
 from it that there is a considerable variation in the symptoms 
 produced by foreign bodies in the air passages ; and that in their 
 symptoms no regular order or succession can be stated to exist. 
 In almost all the phenomena supervened suddenly, and this was 
 even observed in cases where the foreign body remained for a 
 great number of years. In some, as in the cases by Pelletan, 
 Broussais, Gilroy, and Houston, the symptoms were those of 
 pneumonia ; in the three first cases, followed by abscess, with 
 foetid and purulent expectoration, and in the last causing hepa- 
 tization, with lymph on the pleura, and incipient disease in the 
 opposite lung. These cases were all fatal. With respect to the 
 instance recorded by Broussais, it is highly probable that the 
 pneumonia with abscess under Avhich the patient sunk, was a 
 recent affection, inasmuch as five years had elapsed between the 
 receipt of the ball and the pneumonic symptoms, and the ball 
 was firmly encysted. The patient seems to have died of typhoid 
 pneumonia, which, as we shall hereafter find, commonly engages 
 the left lung. 
 
 In a few, signs of chronic laryngeal, rather than of pulmonary 
 disease, were the result, but in the great majority the symptatns 
 were those of chronic irritation of the lung. 
 
 R 2
 
 244 DISEASES OF THE LARYNX AND TRACHEA. 
 
 In many of the cases, such as those by Howship, Lenglet, 
 Giboy, Donaldson, and Sue, pain was felt, apparently in the 
 situation of the foreign body, and it is interesting to observe, that 
 in all these instances the foreign body was of a sharp and irritating 
 nature. The same circumstances occurred in a case mentioned 
 by Dr. Brown, of a child in whom a piece of delft was forced into 
 the right bronchus. There was a fixed pain in the upper part of 
 the thorax on the right side, rather below the level of the upper 
 bone of the sternum. The operation was not permitted, and the 
 child died on the third day.* But we are not to conclude that 
 such bodies uniformly cause local pain, for in several instances 
 where the body was of this description, local pain was absent, 
 as in the case recorded by Houston, where the offending 
 substance, a large molar tooth, though it produced a fatal 
 pneumonia, did not cause any local pain.f lu other instances 
 no mention is made of local pain, so that it may be regarded 
 as a symptom by no means constant. In the case by Sue we 
 observe a remarkable change in the situation of the pain, and 
 the symptoms correspond with the different situations of the 
 foreign body. 
 
 The removal of the foreign body by expectoration, was not 
 always followed by recovery; thus in the cases by Lenglet, 
 Pelletan, Craigie, and Sue, the foreign body was expelled, and 
 although a certain amount of relief was in some instances 
 afi"orded, the patients subsequently died of pulmonary disease. 
 Lastly, we learn from the case by Su'e, that even with a foreign 
 body remaining for many years in the air passages there may be 
 the most singular remission of all the symptoms. 
 
 If we now examine the fatal cases with respect to the duration 
 of symptoms we find that this is exceedingly various, whether we 
 consider the case in which the foreign body was expectorated or 
 those where it remained in the lung until the fatal termination : 
 thus in Dr. Houston's case, death occurred on the eleventh day, 
 while in that recorded by Sue eighteen years and a half elapsed 
 
 * An inquiry how far the operation of tracheotomy may be considered advisable 
 in those instances in which a foreign body is lodged in either bronchus, &c., Edin. 
 Med. and Surj^. Journal, vol. xxxv., 1831. 
 
 f The crown of this tooth had been broken off at the first attempt of the dentist at 
 extraction, at the second it was started from its socket, and thtn passed into the 
 trachea. For the tirst few days the patient suffered almost nothing, for although the 
 body lay in the right bronchus it did not altogether impede the entrance of air.
 
 DISEASES OF THE LARYNX AND TRACHEA. 245 
 
 after the entrance of the foreign body, before death took place, 
 and seventeen years before it was expectorated. 
 
 It has been considered by some that a great specific gravity of 
 the foreign body would prevent its expectoration. But although 
 in the majority of cases, the body expectorated was of a light 
 nature, yet instances are not wanting in which very heavy sub- 
 stances were thus expelled. It is true that in the case by 
 Broussais, in which probably the heaviest body on record entered 
 the lung, it was not expectorated, but although it is likely that 
 even if its size had permitted it to enter the trachea in the usual 
 way, its weight would have prevented its expulsion, yet it must 
 be recollected, that the case was one of gun-shot wound, and that 
 the ball was probably soon encysted. On the other hand we find, 
 that as in the case by Nooth a leaden shot may be expectorated. 
 In Hochsteter's case a Portugal ducat was coughed up, in 
 Howship's an iron nail, and in Abercrombie's an artificial tooth ; 
 so that there is sufficient evidence for stating, that however great 
 be the specific gravity, the foreign body may yet be expectorated. 
 Finally, we may observe, that these cases aff'ord additional 
 evidence of the much greater liability of foreign bodies to enter 
 the right bronchial tube.* 
 
 In considering the application of the stethoscope and percussion 
 to the detection of a foreign body in the windpipe or lung, we 
 find that the diagnosis is founded on the combination of physical 
 signs with the history of the case, and the local and general 
 symptoms. It is true that previous to the introduction of 
 auscultation, instances are not wanting of successful diagnosis of 
 the accident, but in many cases the question was most difficult, 
 and the scientific surgeon could not demonstrate the nature of the 
 case, with the certainty requisite to convince ignorance, and re- 
 move the " op2)ositio)i meiirtricre "t on the part of other medical 
 attendants, whose confidence was greater than their knowledge. 
 But in the application of the stethoscope and percussion to this 
 purpose, we have one of the most splendid examples of their 
 utility, and to Mr. Key is due the merit of having first employed 
 
 * There is another class of cases of foreign bodies in the lung which I shall merely 
 mention, namely those in which various substances are introduced by wounds of the 
 thorax or neck. With the exception of that by Broussais, all the cases in the fore- 
 going table exemplify the entrance of the offending substance through the aperture 
 of the glottis. 
 
 t Louis, Mem. de I'Acad. de Chirurgie, tome v.
 
 246 DISEASES OF THE LARYNX AND TRACHEA. 
 
 these means and of pointing out the essential physical indi- 
 cations. 
 
 The observations which I have to offer npon this subject have 
 reference solely to acute cases. I have had no opportunity of 
 examining any case in which the foreign body had remained long 
 enough to produce consumptive symptoms. 
 
 The grounds of the diagnosis are, that in a case, the history 
 and symptoms of which lead to the suspicion that a foreign body 
 entered the windpipe, we discover — • 
 
 1st. Signs of obstruction of the right bronchus, the obstruc- 
 tion being either partial or complete, permanent or inter- 
 mitting. 
 
 2nd. Signs of an irritation in the right lung. 
 
 3rd. Evidence of the alternation of the stethoscopic signs of 
 bronchial obstruction, with the symptoms of violent laryngeal 
 irritation and spasm. 
 
 •4th. The occurrence of all or any of these signs in a sudden 
 manner, and in a patient previously healthy. 
 
 We shall consider each of those classes of signs briefly. When, 
 as is almost always the case, the foreign body is lodged in the right 
 bronchus, one of two effects is produced ; it either closes the tube 
 completely, permitting no air to pass, or it lies loosely in its 
 cavity, so as to admit to a certain degree, the passage of air into 
 the lung. In the first case no vesicular expansion whatever can 
 be heard in the affected side ; the sound on percussion continues 
 clear, while in the opposite lung the respiration is intensely 
 puerile ; and thus is formed a group of signs which does not occur 
 in any other affection of the lung. 
 
 The most remarkable instance of this which I have witnessed, 
 was in the case of a child who was brought to the Meath Hospital, 
 with the symptoms and signs of a foreign body in the windpipe : 
 after some hours the alternating signs of laryngeal and bronchial 
 obstruction disappeared, and the body became fixed in the right 
 bronchus. No respiration zvhatsoever could he heard in the 
 ajfected lung. Tracheotomy was performed, but the foreign 
 body was not expelled, nor could it be removed with the 
 forceps. After more than twelve hours of intense suffering, 
 it was obvious that life was fast ebbing, when after passing 
 in a bullet probe, the foreign body, a peeled kidney bean 
 was suddenly ejected, and recovery followed. This complete
 
 DISEASES OF THE LARYNX AND TRACHEA. 247 
 
 closing of the tube was also observed in the cases by Professor 
 Macnamara.* 
 
 During this perfect obstruction of the bronchus there is no 
 stridulous breathing, nor are any signs of bronchitis observable 
 in the aifected lung. The obstruction and its consequent signs 
 may be permanent or intermittent, and there is not in the whole 
 range of stethoscopy a more striking phenomenon, than the 
 sudden rush of air into the lung, on the foreign body passing 
 into the windpipe, or the equally sudden disappearance of all 
 sound of expansion, natural and morbid, when the bronchus 
 becomes again obstructed. 
 
 But the signs are different when the tube is but partially closed ; 
 we have then, in the affected lung, a murmur diminished in 
 proportion to the obstruction. 
 
 In this way a difference of murmur in either lung, greater than 
 natural, and incapable of being accounted for on any other 
 supposition than that of a foreign body, is discoverable. f This 
 difference, occurring in a case of suspicion, and in a person who 
 had been previously healthy, and coinciding with equal clearness 
 of sound on both sides, is an important diagnostic of i:)artial 
 closing of the tube.i 
 
 The next evidence is founded on the existence of signs of irri- 
 tation in the trachea and upper portion of the lung. As might 
 be expected, a mucous irritation, spreading from the large to the 
 smaller tubes, is soon produced, and we discover a sonoro-mucous 
 rattle in the trachea and upper portion of the lung presenting the 
 feeble respiration. For reasons already stated, these signs are 
 almost always met with in the right lung, so that under the 
 circumstances in question the sudden occurrence of bronchitic 
 rales in the trachea and upper portion of the right lung, forms 
 an additional diagnostic of the nature of the case. Of course 
 these phenomena can be only met with in the lung, when the 
 closing of the bronchus is incomplete. 
 
 * Cases of foreign bodies in the trachea. Dublin Hospital Reports, vol. v. 
 
 t It must be always borne in mind, that the vesicular murmur in the right lung is 
 often a shade less loud than that in the left. I have found this difference most often 
 in young females. 
 
 :j: There are but three affections capable of producing signs, at all similar to those 
 mentioned in the text, these are aneurismal tumours compressing the bronchus, 
 organic tumours of other descriptions, the obstritction of the tube by an hypertrophy 
 of the mucous membrane, or lastly, a copious secretion of adhesive mucus or 
 lymph.
 
 248 DISEASES OF THE LAKYXX AND TEACHEA. 
 
 The amount of tliis irritation will of course vary according 
 to many circumstances, and the physical signs may proceed 
 from the evidences of a slight bronchitis to those of congestion, 
 solidification, and abscess. 
 
 Observations are still wanting to shew how far the existence of 
 a foreign body may modify the physical signs of these advanced 
 stages of irritation. 
 
 The next source of diagnosis, namely, the alternation of the 
 stethoscopic signs of bronchial obstruction with the symptoms of 
 laryngeal irritation, forms, when available, the most important 
 and conclusive diagnostic. 
 
 While the foreign body is lodged in the bronchus, at least in 
 the early stages, the patient is in comparative ease, unless the 
 obstruction be complete, and we observe a diminished murmur in 
 the affected lung. But on the body being removed by coughing, 
 and driven into the larynx, all these circumstances are changed, 
 the suffering of the patient is extreme, his existence seems 
 threatened by the violence of the cough and spasm, and the lungs 
 may be observed to he equally filled during inspiration. After a 
 time the foreign body may again descend, and thus alternately 
 produce a train of phenomena not to be met with in any known 
 case of idiopathic pulmonary disease. 
 
 I need hardly comment on the value of the last source of diag- 
 nosis, namely, the suddenness of the symptoms. We here apply 
 to the detection of a foreign body, the principle by which internal 
 solutions of continuity are discovered, namely, the suddenness of 
 the aj^pearanee of neio and striking symptoms in a pterson cither 
 previously healthy, or labouring under symptoms of a totally 
 different class ; and in one respect there is a similarity between 
 the accident under consideration and the internal solution of con- 
 tinuity, namely, the entrance into a cavity, of a substance foreign 
 to that cavity, so that we have an analogy between the entrance 
 of the fiecal matter into the peritoneum, and the foreign body 
 into the trachea. 
 
 I need hardly remark, that although the sudden supervention 
 of new and violent s3'mptoms is seen in the majority of cases, yet 
 it is not so constant as to be uniformly available. On the other 
 hand, I may add, that although suddenness and violence of 
 symptoms are generally combined, the latter is not unfrcquently 
 absent ; yet here the sudden supervention of even mild symptoms,
 
 DISEASES OF THE LAEYNX AND TRACHEA. 249 
 
 particularly if under suspicious circumstances, is of the utmost 
 value in diagnosis. 
 
 Hitherto we have studied the sims of foreim bodies in the air 
 passages, with reference to their lodgment on one side, so as to 
 admit of the diagnosis by comparison. I shall now detail a case 
 in which the trachea itself was obstructed, producing similar 
 phenomena on either side. 
 
 A gentleman aged twenty, who had previously enjoyed the best 
 health, while conversing in the act of eating a piece of cheese 
 after a hearty dinner, suddenly fell from his chair in a state 
 of insensibility. On the supposition that a foreign body had 
 become fixed in the oesophagus, a probang was speedily passed, 
 and after about ten minutes he partially recovered. Soon after, 
 however, the attack recurred with great violence, the fa^e was 
 strongly congested, and the breathing spasmodic and stertorous. 
 He was then freely bled, but no improvement followed. Stimu- 
 lating injections and a second bleeding were employed, but still 
 without relief, the situation of the patient becoming every 
 moment more critical. A loud rattling in the throat now super- 
 vened. ,The patient tossed himself on the bed, and threw his arms 
 about so as to extend the chest as much as possible. All the 
 muscles of inspiration were in the most violent action ; and the 
 surface of the body became pale and cold. Hours had now 
 elapsed : the failure of all means employed led to the suspicion 
 that the case might be one of asphyxia from tracheal obstruction, 
 and a stethoscopic examination having been made, the following 
 circumstances were observed. 
 
 The chest sounded everywhere clear, but the vesicular murmur 
 could scarcely be perceived in any portion of the lungs, the 
 feebleness being equal and universal, notwithstanding that the 
 patient made the most violent efforts of inspiration. A loud 
 sonoro-mucous rattle, every moment increasing, was heard in the 
 trachea, while the slight dilatation of the chest compared with 
 the respii-atory efforts clearly pointed out some obstruction in the 
 windpipe. 
 
 The question then arose, what was the nature of this obstruc- 
 tion: had a morsel of food passed into the trachea, or were the 
 symptoms produced by a spasm of the glottis, consequent on 
 cerebral irritation '? The failure of treatment calculated to relieve 
 the brain, and the evident secretion into the trachea, as shewn by
 
 250 DISEASES OF THE LARY.NX AND TRACHEA. 
 
 the loud rattle at the top of the sternum, were strongly in favour 
 of the first opinion, and it was obvious that as the patient was 
 dying of laryngeal or tracheal obstruction, something should be 
 done to give immediate relief. The operation of tracheotomy was 
 then performed, and a crucial incision made through the tube, 
 and on the angular portions between the incisions being re- 
 moved, a mass of pultaceous matter was forcibly ejected through 
 the opening, with complete and instantaneous relief to the symp- 
 toms. Respiration became easy, the expansion of the lung full 
 and audible, the patient breathed through the glottis, and re- 
 covered without a bad symptom. 
 
 In about four weeks, however, he was attacked with symptoms 
 of cerebral irritation, and had a fit resembling epilepsy; during the 
 next three months these attacks recurred several times, becoming 
 gradually less severe. They then altogether subsided; and for 
 the last four years he has had no return of the disease. The 
 treatment consisted in small bleedings, cold to the head, and the 
 use of turpentine. 
 
 It must be confessed, that there is some difficulty in coming to 
 a conclusion as to the nature of this case, yet, although its subse- 
 quent history, and the fact of the foreign body not being producible, 
 seem to favour the idea that the disease was from the first cere- 
 bral ; there are circumstances which prove that it was in reality 
 one of foreign body in the trachea, and that many of the symp- 
 toms during the attack were caused by obstructed respiration. 
 
 In the first place, the attack came on while the individual was 
 eating, and at the same time conversing, circumstances likely to 
 cause the entrance of a foreign body into the windpipe. 
 
 2nd. Although in certain cases of disease in children and in 
 adults of a high nervous temperament, spasm of the glottis is 
 symptomatic of cerebral disease, yet in a young and robust man 
 such a symptom is exceedingly rare. 
 
 3rd. We have the important symptom of copious secretion 
 from the mucous membrane. I believe that this is quite conclu- 
 sive against the opinion that spasm of the glottis existed ; such 
 an occurrence is not seen in the nervous afi"ections of the tube, 
 but as one of the symptoms of a foreign body in the trachea, and 
 resulting from its direct irritation, it has the highest value.* 
 
 * Of this symptom, Pelletan says, " wne ralement, signe characteristique de la 
 maladie." — Ciinique Chirurgicale.
 
 DISEASES OF THE LARYNX AND TRACHEA. 251 
 
 4th. The result of the operation may well be appealed to ; 
 sudden and complete relief followed the expulsion of a soft inatter 
 from the trachea, which, from its nature, and the violence of its 
 expulsion, was scattered so as to render it impossible to obtain 
 it, but tJw jxiticnt breathed easili/ through, the glottis, from the 
 moment of the operation. No means were used to keep the orifice 
 open, and unless the making of a wound in the trachea could be 
 supposed capable of relieving violent and increasing cerebral 
 disease, there is no alternative but the belief in the existence of a 
 foreign body. 
 
 5th. It must be recollected how completely the physical signs 
 and history of the case coincide with the phenomena which a 
 foreign body would produce. For myself I have no doubt of 
 the true nature of the case, and consider it as a decided example 
 of foreign body in the air passages. 
 
 But without impugning the foregoing observations, or the 
 operation, we iiiaj take another view of the case, and inquire 
 whether the original attack was not really cerebral, and that the 
 foreign body entered the windpipe during the convulsion.* To 
 this opinion Mr. Read, who treated the case throughout, now 
 inclines. The question is a diflicult one : the subsequent history 
 of the case tells both ways ; for we might expect that after such 
 a violent and protracted struggle, some cerebral injury would be 
 inflicted ; and the complete disappearance of the attacks after 
 three months strengthens the opinion, that they were but the 
 echoes of the first invasion, which was induced by the mechanical 
 impediment to respiration. f 
 
 As illustrative of some novel and curious points in the history 
 of foreign bodies in the windpipe, the following case, abridged 
 from the paper of Professor Macnamara, has considerable interest. 
 
 A boy was brought to the Meath Hospital on the 5th of 
 September, 1829. It appeared that three days before, he had 
 been whistling through a plum-stone, which was pei-forated upon 
 each side, and the kernel removed, this being placed across the 
 lips passed during a strong inspiration through the glottis, and 
 
 * It has been found that in animals that have been killed by a blow on the head, 
 portions of food pass into the trachea. — See Med. Jurisprudence, by Paris and 
 Fonhlanque. 
 
 t For permipsion to publi-h these particulars, I am indebted to Mr. Read, President 
 of the Royal College of Surgeons, to whose judgment and dejision in this most 
 embarrassing case, I feel happy in bearing my testimony.
 
 252 DISEASES OF THE LARYNX AND TRACHEA. 
 
 became fixed transversely in the larynx. So little inconvenience 
 did this produce, that on his finding even in this situation he 
 could whistle through the stone, he went about for some hours, 
 pleased with his new and convenient mode of producing sound. 
 During three days previous to his entrance into hospital, he 
 sufiered but little inconvenience, except that he was now and then 
 disturbed with suffocative cough, but he was able to run about, 
 and occupy himself in his childish amusements. On admission 
 he did not complain of pain on deglutition. He said that the 
 cough caused pain in his throat, but only during severe 
 paroxysms : he had a dull pain in the epigastrium, a bloated 
 countenance, and a pulse at 106. The fits of coughing resembled 
 those of suffocative catarrh, and were followed by white frothy 
 expectoration. Chest clear on percussion, and the vesicular 
 murmur natural. In this case the whistling sound in the trachea 
 being sufficient to establish the diagnosis, the operation of laryn- 
 gotomy was performed, but during the struggle and convulsive 
 cough which followed the opening, the patient declared that he 
 had coughed up the stone and swallowed it. 
 
 That such was the fact seemed to be proved by the relief of the 
 symptoms, and the disappearance of the whistling ; but it was 
 found that according as the wound healed, the distress and 
 whistling sound returned, proving that the foreign body must 
 have been placed above the opening, and that the disappearance 
 of the whistling in the first instance, was owing, not to a 
 removal of the foreign body, but to the admission of air below the 
 point in which it was fixed. Soon after this it was found to 
 change its situation, and to pass down the right bronchus, again 
 to be driven upwards into the larynx. By a second operation 
 it was finally extracted, and the patient recovered without any bad 
 symptom. 
 
 From what has been now stated it would appear — 
 
 1st. That bodies of greater volume than the ordinary size of 
 the glottis would seem to admit, may be forced through that 
 aperture by the eff'orts of inspiration. 
 
 2nd. That the foreign body may remain impacted in the 
 glottis, or become entangled in the cavity of the larynx ; it may 
 remain in the trachea either free or fixed, or pass into either 
 bronchial tube. 
 
 3rd. That the cases in which it enters the right bronchus are
 
 DISEASES OF THE LARYNX AND TRACHEA. 253 
 
 SO much more numerous than those in which it occupies the 
 left, as to make the signs of irritation and obstruction of the 
 right lung, important diagnostics of the accident in question. 
 
 4th. That the sj^mptoms vary according to the situation and 
 form of the foreign body. 
 
 5tli. That the diagnosis depends on a careful comparison of 
 the history and symptoms of the case, with the physical signs. 
 
 6th. That the physical signs depend — 
 
 a. On the situation of the foreign body. 
 
 h. On the amount of obstruction which it offers to the entrance 
 of air.* 
 
 c. On the irritation of the mucous membrane which its 
 presence causes. 
 
 7th. That when the foreign body remains in the larynx 
 or trachea, its physical signs are more obscure than when it 
 occupies but one bronchus, there being no difference of 
 phenomena in either lung. 
 
 8th. But that when it enters the bronchus it may close the 
 tube either partially or completely. 
 
 9th. That hence the vesicular murmur in the corresponding 
 lung is either gi'eatly lessened or altogether extinguished, while 
 the sound on percussion remains the same, and the opposite 
 lung presents the puerile respiration. 
 
 loth. That the signs of partial or complete obstruction of the 
 tube may suddenly disappear, and as suddenly return. 
 
 11th. That in cases where the foreign body has completely 
 obstructed the bronchus, its passage into the trachea is followed 
 by a return of vesicular murmur in the affected lung. 
 
 12th. That the physical signs of irritation, consisting in a 
 sonorous, or sonoro-mucous rattle, may be found at the top of 
 the sternum, and in the situation of the right bronchus. 
 
 13th. That the physical signs in the commencement are those 
 of mucous irritation, varying according to the physical changes 
 of the lung. 
 
 14th. That the physical signs of irritation precede the con- 
 stitutional disturbance. 
 
 15th. That in the alternation of the stethoscopic signs of 
 
 * Some have stated that they have been able to hear a sound produced by the 
 movements of the foreign body in the trachea itself. Indeed I once believed that I 
 had heard this sound, but as further observations seem necessary to establish it, I have 
 not included it in the list of physical signs.
 
 254 DISEASES OF THE LARYNX AND TRACHEA. 
 
 bronchial obstruction, with the ordinary symptoms of laryngeal 
 distress, we have a most important diagnostic of the accident 
 in question. 
 
 16th. That in certain cases, the bronchial obstruction (hitherto 
 observed only in the right tube) differs from all other examples 
 of the same j)hysical condition from other causes, in its being 
 so complete and sudden. 
 
 17th. That the sudden appearance of irritation of the larynx 
 and bronchus, in a patient who had before presented no evidence 
 of thoracic disease, is strong evidence that a foreign body has 
 entered the air passages. 
 
 18th. That a foreign bodj^ may be immediately expelled by 
 coughing, or remain in the air passages so long as seventeen 
 years. 
 
 19th. That where a foreign body becomes lodged in the 
 bronchial tube, it causes symptoms of acute irritation, or of 
 more chronic disease. 
 
 20th. Tbat in the acute cases, the patient may die of pleuro- 
 pneumony, without suppuration of the lung. 
 
 21st. That in other cases an abscess is formed, and the patient 
 has foetid and purulent expectoration. 
 
 22nd. That in the more chronic cases, there is a predominance 
 of either laryngeal or pulmonary irritation. 
 
 23rd. That in the latter case, hiemoptysis, emaciation, and 
 hectic are commonly observed, while in a few instances, the 
 symptoms have more of an asthmatic character. 
 
 24th. That the situation of the foreign body may be pointed 
 out by local pain, but that this is not a constant symptom, even 
 when the body is of an irritating nature and irregular form. 
 
 25th. That the removal of the foreign body is not always 
 followed by recovery from the symptoms which it has produced. 
 
 26th. That an almost complete remission of the symptoms, 
 even for years, may occur, although the foreign body still 
 remains in the lung. 
 
 27th. That a great specific gravity of a foreign body does not 
 prevent its expectoration. 
 
 As the treatment of this accident is essentially a surgical 
 question, I shall not discuss the subject at any length. It has 
 been pi'oposed to use emetics in such cases, and instances are 
 on record, where the use of stimulating and emetic medicines,
 
 DISEASES OF THE LARYNX AND TRACHEA. 255 
 
 was followed by the expulsion of the foreign body. On the other 
 hand, such treatment has frequently failed ; and when we 
 consider the formidable nature of the accident, and the impor- 
 tance of a speedy extraction, it seems unjustifiable to delay the 
 operation. It must be recollected, that circumstances favour the 
 entrance of a body through the glottis, much more than its 
 expulsion ; for in the first case, the aperture is dilated to its 
 greatest extent, and the body carried in by the force of the in- 
 spired air, while in the second, it must be expelled during ex- 
 piration, when the irritation on passing through the larynx will 
 probably produce a spasmodic closing of the glottis. Under 
 these circumstances, by causing the offending substance to 
 become impacted in the glottis, the act of vomiting might pro- 
 duce sudden death. Let us further recollect, that the foreign 
 body may not be presented to the rima in the same position as 
 that in which it entered.* A plum-stone may pass through 
 the glottis with ease, because it enters with its longest axis fore- 
 most, when were it placed transversely, it could never pass the 
 aperture. Now the expulsion of such a body by vomiting, would 
 require that it should be presented to the glottis in its first 
 direction, and it is obvious, that we have no means of insuring 
 such a result. AVe learn from the case by Professor Macnamara, 
 that even after such a substance has lodged in the bronchus, in 
 which, as shewn by the physical signs, it must have lain in 
 the direction of its longest axis, it may, when driven into the 
 trachea or larynx, change its direction, and lie transversely in 
 the tube. 
 
 If there be any case in which the emetic plan would appear 
 justifiable, it would be that of a foreign body much smaller 
 than the glottis during expiration ; of a smooth surface and 
 rounded form, and one not likely to increase in bulk by remaining 
 in the air passages. An inspection of the table which I have 
 given, will shew how rarely such a combination of circumstances 
 will be met with ; and it must be always recollected that the 
 earlier the operation is performed, the better the chance of 
 success, whether we consider the extraction of the body, or the 
 prevention of the consequent injurious results on the lung, 
 windpipe, or brain. 
 
 On the performance of tracheotomy in these cases, and the 
 
 * Surgical Pathology of the Larynx and Trachea, p. 201.
 
 256 DISEASES OF THE LARYNX AND TRACHEA. 
 
 diflferent modifications of the operation, I refer the reader to the 
 writings of Louis,* Desault,t Pelletan,J Burns,§ Porter, |1 and 
 Brown,^ 
 
 TUMOURS EXTERNAL TO, AND COMPRESSING THE WINDPIPE. 
 
 Under this head may be classed many affections, which 
 though agreeing in their physical effect on the trachea, yet 
 differ greatly in nature, and consequently in their progress and 
 symptoms. 
 
 We may classify these tumours as follows : — 
 
 a. Tumours of the neck. 
 
 b. Deep seated tumours. 
 
 Under the first class we may place — 
 
 1. Abscess of the neck. 
 
 2. Hydrocele of the neck. 
 
 3. Enlargement of the lymphatic glands. 
 
 4. Hypertrophy of the thyroid. 
 
 5. Aneurism of the carotid and thyroid arteries. 
 
 6. Solid tumours of the neck ; often of a malignant nature. 
 In these cases, the situation of the disease at its commence- 
 ment is above the clavicles. In the next class, however, although 
 the tumours may rise up so as to deform the neck, and dislocate 
 the windpipe, yet the disease begins within the chest and 
 proceeds upwards. Of these tumours the following have been 
 observed : 
 
 1. Aneurisms of the aorta and innominata. 
 
 2. Cancerous tumours of the posterior mediastinum and 
 lung. 
 
 3. Hypertrophy of the bronchial glands. 
 
 4. Melanotic and tuberculous alterations of these glands. 
 
 5. Hypertrophy, and other diseases of the thymus. 
 Considered with relation to the trachea, we find that between 
 
 the first and second class of tumours, there is a difference with 
 respect to the probability of compression. In the first case 
 
 * Memoires de I'Acad. Royale de Chirurgie, I. sii. 
 
 f CEuvres Chirugicale?, tome ii. 
 
 J Cliiiique Chinirgicale, tome i. 
 
 § Surgical Anatomy of the Head and Neck. 
 
 \\ Op. cit. 
 
 •jl Edinburgh Medical and Surgical Journal.
 
 DISEASES OF THE LARYNX AND TRACHEA. 257 
 
 enormous tumours may form without encroaching on or displacing 
 the windpipe, a fact explicable by the yielding of the integu- 
 ments of the neck, so that unless in some cases of bronchocele, 
 and hydrocele of the neck,* we seldom witness tracheal com- 
 pression from tumours which have sprung from above the 
 clavicle. 
 
 But in the second class the circumstances of the tumour are 
 different, and we find it surrounded by resisting parietes, no 
 matter whether it has sprung from the anterior or posterior 
 mediastinum. Confined anteriorly by the clavicles and sternum, 
 its pressure must be directed inwards, so as to engage not only 
 the windpipe, but the great blood vessels, while on the other 
 hand should it grow from behind forwards, it has the spine and 
 posterior portions of the thoracic walls to force it against the 
 same parts. These considerations explain why the tumours of 
 the first class so rarely cause tracheal breathing, and why this 
 with other evidences of compression is so common in the second. 
 
 It must be borne in mind, that although the symptoms of 
 tracheal compression and distress are a frequent result of these 
 diseases, yet that they are not necessarily present in any of 
 them, and in many only appear in the advanced stages. Li 
 these cases the phenomena referrible to the windpipe are few, 
 but striking. 
 
 They may be comprehended under the heads of compres- 
 sion, displacement, and lesion of innervation. In most cases 
 where one of these phenomena is met with, others either 
 
 * This dif5ease, consisting in the formation of a number of aqueous cysts in the 
 neck, which increase so as to form a tumour of considerable size, was first accurately 
 described by Professor Maunoir of Geneva, in his memoirs entitled, Sur les Amputa- 
 tions, V Hydrocele du Cou, et V Organizution de VIris, Greneva et Paris, 1825. The 
 only other author who has written on this subject is Dr. O'Beirne of this city, who has 
 given several cases similar to those by Maunoir, and successfully treated on the prin- 
 ciples of the Grenevese Professor. — See the Dublin Journal of 3Iedical and Chtmical 
 Science, vol. vi., 1835. It would appear that the origiaal memoir was neglected, in 
 consequence of the celebrated Baron Percy having reported unfavourably of its merits 
 to the Academy of Natural Sciences m 1817. 
 
 This disease is essentially difEerent from bronchocele, as after the evacuation of 
 the tumour, the thyroid has been found perfectly healthy. The tumom- may enlarge 
 so much as to seriously iaterfere with respiration and swallowing, as was the case in 
 several of the instances related by Maunoir. In those by Dr. O'Beu-ne, the respiratory 
 function was not inj ured, which may be explained by the fact, that in his cases the 
 disease occupied the side rather than the front of the neck, whQe in most of Maunoir'a 
 examples, the tumour, though commencing at the side, had extended to the front of 
 the neck, so that its weight oppressed the trachea. 
 
 S
 
 258 DISEASES OF THE LARYNX AND TRACHEA. 
 
 accompany or speedily follow it, and in their invasion, succession, 
 and mutations, there is the greatest variety, not only among cases 
 of different natures, but even those of the same disease. I have 
 found in most cases, and I think it will be found in all, that 
 when the symptoms of tracheal compression can be observed, 
 the signs of pressure on other parts are also evident. The 
 patient may have dysphagia, turgid jugulars, or displacement of 
 the lung, and these indications will be often observed to vary 
 with those referrible to the windpipe : at the same time the 
 existence of one of these evidences of compression does not 
 necessarily imply that we shall then meet with the others ; 
 dysphagia may occur without tracheal breathing, and so on with 
 the rest. 
 
 In almost all the intra-thoracic tumours, their phenomena are 
 in the first instance manifest at one side ; thus we may often see 
 one jugular distended and tortuous, while the other remains 
 natural or nearly so ; an observation of great interest, as giving a 
 diagnosis between these partial obstructions referrible to com- 
 pression or obliteration of a venous trunk, and those produced by 
 disease of the heart. 
 
 In the instances of oesophageal and pulmonary compression, 
 the same may be observed. The patient often feels that the ob- 
 struction to his swallowing is at one side ; and with respect to 
 the lung, I have always found that the pressure of the tumour 
 is greatest at one side, a point easily demonstrated by the 
 stethoscope. In more advanced cases these circumstances of 
 course change. Thus when the vena innominata becomes com- 
 pressed, distention of both jugulars is observed, and a tumour, 
 which at first only compressed a bronchus, may affect the trachea 
 itself. 
 
 Although this pressure on the trachea must, from an early 
 period, cause more or less of dislocation, yet this is not perceptible 
 until the tumour rises high up and appears above the clavicles. 
 We may then find that the windpipe will be pushed far to the 
 opposite side. In a case of aneurism of the innominata, I have 
 seen the thyroid cartilage so displaced from the mesian line, as 
 to correspond with a line drawn from the posterior angle of the 
 jaw, to the humeral portion of the clavicle. The right carotid, 
 the jugular, and vena innominata, were obliterated, and the vagus 
 atrophied and stretched.
 
 DISEASES OF THE LARYNX AND TRACHEA. 259 
 
 But much of the displacement depends on whether the clavicle 
 is dislocated hy the tumour. This may or may not occur ; and 
 it is hardly necessary to observe that in the latter case, all the 
 sufferings of the patient are greatly aggravated. In the case to 
 which I have just now alluded, there was no yielding of [the 
 clavicle, and the consequence was the extraordinary displacement 
 just mentioned. On the other hand, we observe, that where 
 great suffering from pain, dyspnoea, stridor, and dysphagia have 
 existed, the dislocation of the clavicle, by allowing room for the 
 tumour to expand, has been followed by the temporary cessation 
 of all these symptoms. 
 
 The last general observation I shall make here is with respect 
 to the symptom of stridulous breathing. It is this which so 
 commonly leads to the error of confounding these cases with 
 chronic laryngitis ; but as I have already remarked, it is often 
 easy to observe from the sound produced, that the obstruction 
 is not in the larynx, but really much lower down. The stridulous 
 sound seems to come from the upper portion of the sternal region, 
 and if to this we are able to add the observation of the pre%dous 
 inequality of respiration in the lungs, the diagnosis will in 
 general be an easy one. 
 
 On the subject of alterations of voice, I regret that I have but 
 few cases in illustration. In a case of aneurism I observed that 
 the tone and cbaracter of the voice underwent a series of changes 
 quite unlike anything observable in chronic laryngitis. It was 
 scarcely two days the same, and presented alternations of the 
 most remarkable acuteness, with the deepest tone ; on one day 
 great hoarseness would be observable, which would be succeeded 
 by a shrill whisper, and this would be followed by a return of the 
 voice to its natural tone. These circumstances, easily recou- 
 cileable with the existence of an irritation or intermitting 
 paralysis of the recurrent, are quite different from those observable 
 in chronic laryngitis. 
 
 Of the different tumours enumerated, the aneurismal are those 
 which most frequently simulate laryngeal disease. This may be 
 explained by their greater frequency, the height to which they 
 often ascend in the neck, and their close relation to the wind- 
 pipe. Their pressure causes a stridulous breathing, which, like 
 that of chronic laryngitis, is variable in its intensity, while their 
 action on the recurrent nerve, producing hoarseness or aphonia, 
 
 s 2
 
 260 DISEASES OF THE LARYNX AND TRACHEA. 
 
 completes to the superficial observer the picture of laryngeal 
 disease. 
 
 It would seem that the eifect of pressure on the trachea, varies 
 according to the direction in which it is applied. When we con- 
 sider the structure of the tube, we may compare it to an arch, 
 the convexity of which looks anteriorly, and whose apex is at the 
 mesian line. Here then is its point of greatest strength, and it 
 is here that it has the greatest power in resisting the pressure of 
 external tumours. Thus I have seen a case of violently pulsating 
 aneurism of the aorta, in which the posterior portion of the sac 
 had been absorbed, so that the rings of the trachea formed a part 
 of its walls, and corresponded to the centre of the tumour, in 
 which notwithstanding, there was little or no tracheal distress, 
 nor was the form of the tube perceptibly altered. On the other 
 hand, I have found that in all the cases where aneurismal 
 simulated laryngeal disease, the pressure on the windpipe 
 was from the first lateral, or in the direction most likely 
 to diminish the calibre of the tube, and engage the recurrent 
 nerve. 
 
 When pressure is thus exercised on the trachea, the ends of 
 the rings next the tumour are bent inwards, and the musculo- 
 membranous portion folded upon itself ; and though their direc- 
 tion is changed, the ends of the rings are approximated, and the 
 calibre of the tube diminished. If we now examine the recorded 
 cases of aneurism, with respect to th« direction of their pressure 
 on the trachea, we shall find that those in which the pressure was 
 lateral greatly preponderate over the others, a fact of great im- 
 portance in diagnosis. 
 
 Without entering into the subject of aneurisms in general, 
 which will of course occupy a separate chapter, I shall here point 
 out briefly the grounds of diagnosis between laryngeal disease 
 and the pressure of an aneurismal tumour on the trachea ; of 
 course I do not mean to state that the following phenomena 
 occur in all cases, but some of them are always present. 
 
 ] st. Evidence of internal incssure. 
 
 a. Signs of compression of one bronchus. 
 
 h. Dysphagia, always deep-seated. 
 
 c. Turgescence of one or both jugular veins. 
 
 d. (Edema of the neck. 
 
 €. Signs of displacement of the lung.
 
 DISEASES OF THE LAEYNX AND TRACHEA. 261 
 
 2nd. Evidence of solidity more or- less extensive in the upper 
 portion of the thorax. 
 
 a. Dulness of sound of the upper sternal or either clavicular 
 regions. 
 
 h. Bronchial or tracheal respiration, in the situation of the 
 dulness. 
 
 c. Loud resonance of the voice in the same situation. 
 
 3rd. Proper signs of an aneurism, such as pulsation, belloivs 
 murmur, dc, dx., generally observable in the sternal, or sub- 
 clavicular regions. 
 
 4th. Difference of the radial pulse. 
 
 I feel no doubt that were these points carefully attended to, it 
 would rarely haj)pen that so great a mistake as the confounding 
 an aneurism with a chronic laryngitis, would ever be committed. 
 
 Cancerous Tumours of the Posterior Mediastinum. — I have 
 seen two instances in which this disease produced symptoms, 
 not unlike those of aneurismal tumour. In one case, indeed, 
 the stridulous breathing from below was well marked, and the 
 tone of the voice altered. As I iiitend, however, to devote some 
 pages to this disease, I shall for the present omit its further 
 consideration. 
 
 Diseases of the Bronchial Glands. — Although as yet no 
 separate investigation on this subject exists, yet from the cases 
 recorded by various authors, we may conclude that these glands, 
 when hypertrophied or otherwise diseased, seldom produce any 
 striking symptoms. Thus in a case recorded by Audral, where 
 an enormous mass of melanosis compressed the right bronchus, 
 so as to diminish its diameter by one-half, there was no stridulous 
 breathing, the signs being a feeble respiration in one lung, with 
 intense puerility in the other ;* and Berton, who is the latest 
 author upon the subject, dwells strongly on the fact, that the 
 bronchial glands may be greatly hypertrophied without causing 
 compression of the blood-vessels or air tubes. Andral, however, 
 states that tumours of the bronchial glands frequently cause 
 tracheal and bronchial compression. I myself have never met 
 Avith any instance of stridulous breathing, or even bronchial 
 compression, produced by this disease, but the subject requires 
 a more extended investigation. It is obvious, however, that so 
 far as the question between laryngeal disease and the existence 
 
 * Clinique Medicale, tome i.
 
 262 DISEASES OF THE LARYNX AND TRACHEA. 
 
 of a tumour compressing the trachea is concerned, the diagnos- 
 tics which apply to aneurism, with the exception of its proper 
 signs, are equally availahle in the case under consideration.* 
 
 Enlargements of the Thymus Gland. — As this affection 
 has been frequently noticed in connexion with lesions of the 
 respiratory function, we may take a brief review of the subject, 
 which from the researches of Sir Astley Cooper, f in this 
 country, and of M. HaugstedJ on the continent, has acquired 
 the greatest interest. 
 
 Placed in the closest relation with the trachea, and great 
 arterial and venous trunks, and not unfrequently extending so 
 high as to be connected with the thyroid, and even to touch 
 the larynx, and furnished with arteries, veins, absorbents, and 
 nerves, which latter seem connected with one of the most im- 
 portant nerves of respiration, it is not surprising that in its 
 
 * An important subject is hei'e somewhat summarilj' dismissed. A reference to 
 Dr. Walshe's observations on tuberculization of the bronchial glands, and to Dr. 
 Quain's exhaustive memoir on their diseases {Brit. Med. Journ., Dec. 14th, LS78)) 
 ■will shew that these are not infrequent nor their symptoms and physical signs by any 
 means insignificant or unimportant. As the signs of pressure are common to these 
 cases and to aneurism their differential diagnosis is sometimes a matter of difficulty. 
 
 (In one remarkable case which was witnessed by Dr. Stokes while under my care 
 in the Meath Hospital, the symptoms and physical signs being, tortuous distention of 
 the veins of the neck, shoulder, and right chest, absence of respiratory murmur over 
 the upper portion of the same side, stridor, with ringing cough, and recurring hemop- 
 tysis, no diagnosis of the exact lesion was made during life, it being in both our 
 minds uncertain whether the signs of pressure were due to mediastinal tumour or to 
 aneurism. On examination after death we found a small aneurism springing from 
 the right side of the arch, and a bronchial gland of the size and shape of a small 
 chestnut; pressure on the right bronchus having been caused by one, and on the vena 
 innominata by the other.) 
 
 Of the secondary consequences of disease in these glands two interesting examples 
 were communicated to the Pathological Society of London by Dr. Moxon. — See Trans., 
 vol. xxiv.) In one of these it is stated — "In a woman who died of emphysema of 
 the lungs with dilated heart and dropsy, the right pleura shewed a considerable 
 recent pleurisy on the lower lobe, as is not unfrequent in such cases. The lymph in 
 the pleural cavity had the usual characters of ' plastic lymph,' but the pleura itself 
 was marked by a network of yellowish lines. These proved to be lymphatics full of 
 pus which the microscope shewed to be recent and laudible. A large old glandular 
 abscess was found below the right bronchus. The abscess wall was thick and the 
 contents degenerate. Dr. Moxon observed that as such suppuration of Ij'mphatics is 
 very rare, its association with old glandular obstruction shews that the bad drainage 
 due to this obstruction is a cause of local disease whose importance should be 
 recognised." (Ed.) 
 
 t The Anatomy of the Thymus Gland, by Sir A. Cooper. London, 1832. 
 
 J Thymi in Homine ac per seriem animalium, descriptio anatomica, pathologica, 
 et physiologica, &c. Auct. F. C. Haugsted, 1832. See also Archives Generales de 
 Medicine, 1834.
 
 DISEASES OF THE LAEYXX AND TRACHEA. 263 
 
 morbidly large and otherwise diseased condition, it should 
 excite severe symptoms, the more important, as they will he 
 commonly observed in the scrofulous constitution. 
 
 In order to give clear ideas on this subject, a short sketch of 
 the development of the thymus may be here introduced ; this 
 gland, the functions of w4iich are still to be established, is 
 obviously connected with the conditions of infancy, and like 
 other organs connected with the progressive development of the 
 body, each phase of its evolution may be observed, and its per- 
 fection, decrease, and disappearance be followed out through 
 their different stages. 
 
 The researches of Haugsted have shewn that the thymus has 
 its greatest development wdthin a certain period after birth, 
 and that it is not one of those organs which acquire their highest 
 development at the period of foetal life, and from the moment 
 of birth become useless and begin to decrease. 
 
 More exact observations have shewn that the thymus does 
 not begin to diminish from the first period of extra-uterine life, 
 but until the age of one or two years, it grows with the other 
 organs of the body, and at the end of that time attains its 
 greatest magnitude.* From this period, until the eighth or 
 tenth year, the volume of the organ undergoes but little change, 
 a point of physiology in which Haugsted is opposed to the 
 authority of Meckel,t Burdach,;|: and Hewson.§ 
 
 But although its volume remains unaltered, some change 
 takes place in its structure ; its cells become smaller, and 
 their fluid contents are diminished ; its specific gravity becomes 
 less and less, yet it continues to live, and its vessels are not 
 obliterated ; nor is it until the second period of childhood, when 
 the permanent teeth have been developed, that the process of 
 atrophy decidedly begins. From the twelfth to the sixteenth 
 year, the changes of the organ are rapid, until it is completely 
 atrophied, and nothing left but some adipose tissue, and a few- 
 particles of brownish matter. 
 
 This process seems to commence inferiorly, and proceed 
 
 * See on this subject the work of Verheyen, Anat. Corp. Hum. tract, iii. cap. vi. ; also 
 Morand. Mem. de I'Acad. des Sciences, 1759, who denies the doctrine tliat the thymus 
 is obliterated as soon as the infant breathes. 
 
 t Manuel d'Anat. Gen. Descript. et PataoL, tom3 lii. 
 
 J Die Physologie als Erfahrungs^-issenschaft. 
 
 § Experimental Inquiries, vol. iii, p. 87.
 
 264 
 
 DISEASES OF THE LARYNX AND TRACHEA. 
 
 upwards, so that in the adult the last portion is found under 
 the upper extremity of the sternum. 
 
 I shall not apologize for introducing the following table, 
 abridged from that of M. Haugsted. It is constructed so as to 
 shew the size of the human thymus at different ages. 
 
 
 
 Thymus. 
 
 
 AGE. 
 
 
 
 
 
 
 
 
 
 
 Length. 
 
 Breadth. 
 
 Thickness. 
 
 Weight. 
 
 A new]y bom child well 
 developed, (female). 
 
 li line to 3 
 inches, 
 
 1 to 2 
 inches. 
 
 2 to 4 lines. 
 
 240 Grains. 
 
 
 li of an 
 inch. 
 
 i to li 
 inch. 
 
 2^ lines. 
 
 84 Grains. 
 
 (male). 
 
 A male child small and 
 thin, of four weeks. 
 
 2 inches. 
 
 7 to 9 lines. 
 
 2 lines. 
 
 120 Grains. 
 
 strong and well de- 
 veloped, of nine months. 
 
 2^ inches. 
 
 1^ inches. 
 
 4 lines. 
 
 270 Grains. 
 
 
 2i to 3 
 inches. 
 
 1 inch. 
 
 IJ lines. 
 
 110 Grains. 
 
 years. 
 
 A female, thin and scro- 
 fulous, of ten years. 
 
 2 to 2i 
 inches. 
 
 7 lines. 
 
 1 line. 
 
 36 Grains. 
 
 A boy, of seventeen years. 
 
 1| inch. 
 
 5 of inch. 
 
 J of an inch. 
 
 90 Grains. 
 
 of twenty-one years. 
 
 ... 
 
 ... 
 
 
 40 Grains. 
 
 In the present state of our knowledge we may enumerate the 
 diseases of the thymus, which have produced laryngeal symp- 
 toms, as follows : enlargement, inflammation, and tuberculous 
 degeneration ; of these several examples are recorded. 
 
 In almost all these instances, the symptoms produced were those 
 of dyspnoea and croupy breathing, varying in their mode of invasion 
 and character, according to the age of the individual ; thus in 
 young children, the disease which has got the name of the asthma 
 infantum, the crowing disease, spasm of the glottis, &c., &g., 
 has been occasionally found to co-exist with an enlargement of the 
 
 thymus gland ; this fact is alluded to by John Peter Frank, and 
 
 more recently by Kopp, who has given to this disease the name 
 
 of asthma thymicum. 
 
 In this affection it is held, that any sudden emotion, causing a 
 
 quick or forced inspiration, may bring on an attack of dyspncea
 
 DISEASES OF THE LARYNX AND TRACHEA. 265 
 
 and suffocation, and even in some cases convulsions, so that in this 
 way sudden death may supervene in a child, to all appearance 
 perfectly healthy. 
 
 As yet the etiology of this disease is by no means established, 
 and further researches are necessary to shew how the condition 
 of the thymus produces so remarkable an effect ; does it take 
 an active part in these attacks, or is its permanent enlarge- 
 ment a passive cause for the injury ? No data exist to 
 answer these questions, but from the similarity of cases of the 
 crowing disease, with those in which an enlarged thymus has 
 been found, it seems probable that a morbid state of the 
 thymus ta'ies occasionally some part in causing the symptoms of 
 Miller's asflama infantum. 
 
 But with respect to the cases of sudden death in infants, in 
 whom an eiJarged thymus gland has been found, we are 
 not yet justified in attributing the death to this cause. The 
 symptoms, if p-oceeding from pressure on vessels or nerves, 
 must result fron a sudden, an almost instantaneous enlargement 
 of the gland ; yei its low innervation, its structure, and scanty 
 supply of vessels, militate strongly against the chance of such 
 an occurrence. Tie thymus has little analogy with the erectile 
 organs ; in these st-uctures we observe large vessels, a highly 
 vascular structure, axd a great sensibility; but in the thymus 
 nothing of this kind occurs, and the subsidiary apparatus of 
 erection is wanting. 
 
 If the measurements of Haugsted be correct, we must be 
 cautious how we take the^atural for the diseased volume of the 
 gland. That this has bt^n done with other organs, we have 
 abundant evidence of; ancit is yet to be proved whether the 
 coincidence of the symptom in question with the appearance on 
 dissection, has not been acciantal. 
 
 The enlargement of the thymus may be met with alone, or in 
 combination with other anormal^tates, of which the most remark- 
 able is the persistence of the foet\ condition of the heart. Thus 
 in many of the recorded cases the'^oramen ovale was found open, 
 so that one arrest of development \q associated with the other. 
 But this is by no means constant, a.^ as has been before stated, 
 the enlarged thymus may exist in a cii^i otherwise healthy. 
 
 When the gland, however, become^ indurated and otherwise 
 diseased, it may produce even in the-^tlult all the formidable
 
 266 DISEASES OF THE LARYNX AND TRACHEA. 
 
 symptoms of pulmonary and tracheal compression, and thus 
 induce death by asphyxia. 
 
 In a case of this kind recorded by Sir A. Cooper, the patient, 
 a young female, suffered under severe dyspnoea in the recumbent 
 position ; and if she fell asleep she started up in a few moments, 
 and struggled violently for breath. A large tumour was found to 
 occuj^y the inferior part of the neck, projecting above either 
 clavicle ; this had existed many years, but of late had suddenly 
 increased. The symptoms became more and more distressing, 
 until at length she could only breathe with her head inclined 
 forwards, and supported by assistants. 
 
 In this case, the thymus was found greatly enlarged, extending 
 from the curvature of the aorta to the thyroid. The trachea was 
 compressed,* and its transverse diameter lessened. 
 
 As no stethoscopic examination in a case of diseased thymus 
 has yet been published, the physical signs must remain undeter- 
 mined. It is obvious, however, that the princi'les of diagnosis 
 of other intra-thoracic tumours, will apply to thf chronic enlarge- 
 ments of the thymus gland. 
 
 * Sir A. Cooper considers both the thymus and thyroid to have been disea^sed in 
 this case. — The Anatomy of the Thymus Gland, cfc. Londov 1832. It -btII probably be 
 found that these diseases are often associated ; and the couplication may exist ia those 
 cases of bronchocele, in which stridulous breathing or-urs at an early period. In 
 Haugsted's memoir, we find references to cases similar '-> this. Thus in one described 
 by Meckel, the paroxysms, as in Sir A. Cooper's case increased after an interval of 
 great remission. He quotes a remarkable instance iom. Tozetti, Raccolta dl opuscuU 
 Med. Pract., in which the disease had continued f-^' twenty years, and termmated 
 in dropsical effusions ; the thymus weighed some r-inces. Other instances are given, 
 so that there is sufficient evidence to lead to the fispicion of the disease, in certaia 
 cases of djspncea, without apparent cause.
 
 PNEUMONIA. 267 
 
 SECTION lY. 
 
 PNEUMONIA. 
 
 [This chapter consists parti}' of the text of the original work, and partlj' of passages 
 from the note book of the author.] 
 
 If we take the general anatomy of the lung as a basis for the 
 classification of its inflammatory diseases, we find that the line 
 of distinction between it and bronchitis is undefined, and it be- 
 comes difficult to say where bronchitis ends, and pneumonia 
 begins. The statement that the first is an affection of the 
 mucous membrane merely, while the second engages the paren- 
 chyma, is satisfactory only to the theorist or superficial inquirer. 
 When we find that this parenchyma is made up almost altogether 
 of air cells and minute bronchial tubes, and when we examine a 
 lung in which pneumonia has passed into the more advanced 
 stages, and observe the filling up and distention of the cells, and 
 the exudation into, and obliteration of the minute tubes, we 
 must admit that he who would call pneumonia a bronchitis of 
 the terminal tubes would be hardly guilty of a misnomer. 
 
 We may describe pneumonia as the inflammation of the cells 
 and minute tubes, and believe that it differs from bronchitis in 
 the ordinary acceptation of the term, merely in the occurrence 
 of the phenomena of a parenchymatous inflammation, such as 
 solidification, suppuration, and abscess, phenomena not pro- 
 ceeding from any inherent difference in the diseases, but a 
 result of anatomical structure. The close approximation of the 
 cells and minute tubes is so increased by the disease, that parts 
 which in health are separate, such as the pulmonary lobules, 
 unite under the influence of a morbid action, and a solid is 
 formed out of a cellular or tubular structure.* Like the other 
 inflammatory diseases of the lung, pneumonia may occur as a 
 primary or secondary afi"ection, and its characters must be studied 
 with reference to this distinction. 
 
 * I do not deny the influence v.liich the inflammation of the inter-vesiculai-, and 
 inter-lobular cellular membrane may have in giving a character to pneumonia different 
 from bronchitis. This tissue, however, is so sparingly supplied, in comparison with 
 the air cells and minute tubes, that its afirections are probably of little importance, 
 and ItB participation would give no pathological difference between the two diseases.
 
 268 PNEUMONIA. 
 
 ACUTE PRIMARY PNEUMONIA. 
 
 Before entering on the diagnosis, I shall first examine the 
 different stages of this disease. 
 
 Laennec has described three stages of pneumonia mth their 
 corresponding symptoms and signs, and his statements have been 
 verified by all subsequent experience. In his first stage, the 
 lung is engorged with blood, and a crepitating rale is heard ; in 
 the second, solidity takes place, with its accompanying physical 
 signs ; and in the third, we find the interstitial suppuration of 
 the lung, or the condition which precedes the formation of 
 abscess. 
 
 Without impugning the accuracy of this description, we may 
 inquire whether a stage previous to that which Laennec calls the 
 first, does not exist. The following considerations seem to prove 
 that Laennec's first is really the second stage of the disease. 
 
 No one can doubt that the crepitating is but the diminutive of 
 the mucous rale ; it is a phenomenon produced by the passage 
 of air through a viscid fluid, secreted by the irritated cells, or 
 terminal tubes, and its peculiar characters result from the 
 bubbles being necessarily so minute. The existence of this sign, 
 then, points out that secretion has taken place into the cells and 
 minute tubes ; so that Laennec's first is in reality the secretive 
 stage of the inflammation, and every analogy favours the opinion 
 that a stage of irritation has existed previous to the secretion 
 which caused the crepitus. 
 
 Further, I have repeatedly seen a condition of the lung which 
 seems really the first stage. The pulmonary tissue is drier 
 than usual, not at all engorged, as in Laennec's first stage, and 
 of a bright vermilion colour, from intense arterial injection. I 
 have found this condition in the upper portions of lungs, in the 
 middle and lower parts of which Laennec's first and second 
 stages existed. It is obvious that this appearance will be but 
 rarely met with, as a more advanced stage occurs before death ; 
 and it is often obscured by cadaveric congestion. I have found 
 it in cases of pneumonia, where death occurred from other causes. 
 In a child who died of an extensive burn, we found nearly the 
 whole of the lung in this state ; and I have seen the same 
 condition in subjects who died of acute phthisis, with severe 
 inflammatory symptoms.* 
 
 * Ste Appendix, Note A.
 
 PNEUMONIA. 269 
 
 [The study of this first stage of pneumonia involves considera- 
 tions not only important from their extent, but also from their 
 application to practical medicine. We have here a condition, 
 which though it is to be followed by physical changes with 
 their attendant signs, yet is not revealed by any mechanical 
 phenomenon with which we are acquainted. I formerly stated 
 that a local puerility of respiration appeared to indicate this 
 condition in certain cases, but I have not been able to add to 
 the evidence on this point. In the present state of our know- 
 ledge therefore we ^may consider this stage of pneumonia, as 
 preceding that in which any products of inflammation are 
 formed, and as one without certain, or necessary physical signs. 
 It may be termed the progenetic stage of pneumonia, or that 
 preceding the exudation of blood, serum, coagulable lymph, or 
 any form of plasma. 
 
 Yet we cannot look on the establishment of this condition as 
 a question of pathological inquiry merely, and as having no 
 bearing on practice, for if it be true that the recognition of the 
 second stage of the disease, by the discovery of a crepitating rale, 
 is of importance to enable us to contend successfully with the 
 disease, how much more important would it be if we could direct 
 our remedial measures against progenetic conditions. 
 
 In the present state of our knowledge on this subject we 
 must be content with suggesting, rather than establishing the 
 diagnosis of this condition ; and I think it will be found usually 
 to consist in the co-existence of fever and local special symptoms 
 with absence of physical signs ; that, in other words, the pro- 
 genetic condition is indicated by vital symptoms, distinguishable 
 from mere neurotic phenomena by their connexion with fever, 
 which symptoms may exist for a certain period of time without 
 any physical sign of disease. 
 
 The phenomena of the two first stages of acute disease will 
 then be grouped as follows : — ■ 
 
 I. Progenetic stage — fever, symptoms, absence of physical 
 phenomena. 
 
 II. Fever — symptoms, development of physical signs. 
 
 I do not wish to be understood as stating that in every ex- 
 ample of this condition we have the combination of fever and 
 vital symptoms, or that the existence of symptoms alone without 
 fever may not indicate the very first stage of disease, but only
 
 270 PNEUMONIA. 
 
 tliis, that where we have the comhination in question the diag- 
 nosis of disease may often he made, although no physical signs 
 be present. It is most important to bear this in mind, as it 
 may save the practitioner from the error of declaring the absence 
 of disease in consequence of the absence of any physical signs of 
 its presence. — Author's Note Book.] 
 
 We may hence enumerate the stages of pneumonia as fol- 
 lows : — 
 
 1st. The lung drier than natural ; with intense arterial in- 
 jection. No effusion of blood into the cells. 
 
 2nd. (Laennec's first.) The cells engorged with blood. No 
 change of structure. 
 
 3rd. (Laennec's second.) Solidity and softening. (Ramol- 
 lissement rouge of Andral.) 
 
 4th. (Laennec's third.) Interstitial suppuration. 
 
 5th. Abscess.* 
 
 On the subject of Laennec's first stage, it is to be observed 
 that it does not necessarily precede hepatization. We may have 
 complete solidity produced in a lung that has never presented 
 the crepitating rale, and the disease pass on into the stages of 
 suppuration and abscess. This circumstance, so important in 
 diagnosis, is met with in certain cases of the typhoid pneumonia, 
 in which a sudden and extensive congestion of blood affects the 
 lung. It may then occur, that a lobe which to-day was perfectly 
 permeable, and presenting no morbid signs, shall in twenty-four 
 hours be solidified, and present dulness with absence of vesicular 
 murmur, bronchophonia, and bronchial respiration. 
 
 Such cases, however, are comparatively rare, and I need 
 hardly observe, are full of danger. The suddenness and extent 
 
 * It may be remarked that Dr. Stokes does not include gangrene among the 
 stages or terminations of pneumonia. In this he follows Laennec, who says " it can 
 scarcely be ranged among the terminations of the pulmonary inflammation, and still 
 less can be considered as the consequence of its intensity, since we find in cases of 
 this kind the inflammatory character very slightly marked, as well in regard of the 
 symptoms as of the engorgement of the pulmonary substance." We have however 
 abundant proof that it does occur in pneumonia of the typhoid or congestive tj-pe, in 
 several forms of blood dyscrasia, and in pneumonia associated with sources of in- 
 fection. On this point Juergensen observes, — " If stasis take place in the vessels, 
 local death or neurosis ensues in the tissues nourished by them. Cohnheim's views 
 again furnish us with an explanation of this let^ion. Gangrene of the lungs is pro- 
 duced in the part which is withdrawn from the influence of the restorative power of 
 the living organism, its decomposition resulting from its exposure to the action of the 
 air and of the parasitic bodies which excite putrefaction ; a process similar to the de- 
 composition of albuminous bodies under the same conditions outside of the body." (Ed.)
 
 PNEUMONIA. 271 
 
 of the solidificatiou, and the prostrated condition of the patient, 
 combine to increase the danger, and in some cases give rise to 
 a rapid gangrene. I have never seen this rapid congestion, or 
 solidification, in the ordinary sthenic pneumonia. All the cases 
 were examples of a secondary disease of the Inng, supervening 
 on typhus fever, or that condition of the system in which diffuse 
 inflammations are liable to ensue. Thus it is seen in cases of 
 bad erysipelas, and often in connexion with analogous diseases 
 of other viscera. Its most frequent termination is in the stage 
 of interstitial suppuration, but in two cases I have known a 
 gangrenous abscess to be rapidly formed ; and when we reflect 
 on the circumstances of the disease, such a termination seems 
 easily intelligible. 
 
 The third stage * of the disease, according to my views, is but 
 the maximum of the second ; and we must agree with Andral in 
 the opinion, that the solidity of acute pneumonia arises not from 
 any deposition of lymph, but merely from an excessive congestion 
 of blood. Indeed, any one who has witnessed the rapidity with 
 which all the phenomena of solidity will appear and subside, 
 must be of this opinion. In the course of twenty-four hours a 
 lung which was perfectly free from morbid signs, may become 
 dull, and its vesicular murmur be exchanged for bronchial res- 
 piration ; and the picture is often reversed, and we see these 
 phenomena as rapidly disappearing under the influence of treat- 
 ment, or a metastasis of disease. 
 
 Here it is necessary to remark, that although the sudden 
 solidification is peculiar to the typhoid or secondary pneumonia, 
 yet that we may observe the rapid resolution of the disease in 
 the primary and sthenic cases. 
 
 I have nothing of importance to offer on the subject of the 
 interstitial suppuration of the lung, and shall pass on to consider 
 the fifth stage, or that of abscess.. 
 
 It is not difiicult to understand why this instance of visceral 
 abscess should be so rarely met with ; inflammation is rarely 
 circumscribed in the lung, and hence one important condition 
 for the formation of abscess is wanting. From the spreading 
 of the disease, it happens, that by the time the lower portion is 
 about to form abscess, the upper is often solidified, and the 
 disease extending to the opposite lung, death occurs before 
 * Laennec's second, or that of hepatization. (Ramollissement rouge.)
 
 272 PNEUMONIA. 
 
 an abscess can be formed ; the fatal result being induced less by 
 the suppuration, than the earlier stages of disease. 
 
 But it is in the anatomical structure of the lung that we 
 find the true explanation of the point in question. If we compare 
 the viscera with respect to the liability to form abscess, we find 
 that in those in which the earlier jDroducts of the inflammation 
 can be got rid of, there is the least liability to abscess. In the 
 brain,' which has no excretory duct, abscess is a common result 
 of inflammation ; abscess of the liver is less common than 
 that of the brain, and more so than that of the lung ; abscess 
 of the kidney may be placed next in the scale, and that of the 
 lung decidedly the last in the order of frequency. Considering 
 the bronchial tubes as excretory ducts, we must admit that of 
 all the viscera, the lungs have the most extensive apparatus for 
 excretion, whether we consider it in a vital or mechanical point 
 of view. From the first, the products of irritation are got rid of 
 by expectoration, and even in the suppurative stage, the accumu- 
 lation of the matter is prevented by the universal permeability 
 of the lung. 
 
 But the rarity of pneumonic abscess has been overrated. I 
 have no doubt of the accuracy of Laennec's observations on this 
 subject, and although in almost all his cases the evidence rests 
 on physical signs, yet I would be sorry to believe that he had 
 been '* deceived hy auscidtation ;" this I say from the confidence 
 which experience has given me in Laennec's signs of pulmonary 
 suppuration, signs always valuable, but nearly infallible, when 
 as in most cases they succeed physical indications of the earlier 
 stages, which precede the formation of abscess. I have now 
 witnessed several cases in which this succession of physical 
 signs was observed, and the disease traced from its earlier stages 
 to the formation of abscess ; and though even an experienced 
 stcthoscopist might err, as to the signs of a cavity in a case seen 
 foi- the first time, it becomes next to impossible that the error 
 could be committed when the physical signs have coincided with 
 the successive stages of the disease. The actually existing pheno- 
 mena derived a great value from those which have preceded them. 
 
 I have observed pneumonic abscess under various circum- 
 stances ; it more frequently occurs in the lower, than in the 
 upper lobes ; it may be the result of a localized phlegmonous 
 inflammation, or of that extensive, but complete sohdification
 
 PNEUMONIA. 273 
 
 already described. To this subject I shall return when speaking 
 of the secondary pneumonia, and here only observe, that in 
 the diflfase erysipelatous inflammations, abscess of the lung has 
 frequently occurred in Dublin.* Lastly, I possess anatomical 
 evidence of its cure by cicatrization, of which the following case 
 is an example : 
 
 A 3'oung man of strong habit was admitted into hospital 
 for a pulmonary affection of some weeks' standing. The antero- 
 superior region of the right side sounded dull, and in this 
 situation, and likewise over the shoulder, all the signs of an 
 extensive cavity were observable ; over the rest of the thorax, 
 signs of bronchitis existed. 
 
 In a short time the patient regained his looks, health, and 
 strength, the pulse became natural, his appetite was restored, 
 and he left the hospital declaring himself perfectly well, although 
 all the signs of abscess continued unchanged. 
 
 After a few weeks he returned to the hospital, the signs of 
 the abscess remaining as before ; after some days he was again 
 discharged, and resumed his occupation of a smith. We then 
 lost sight of him for a twelvemonth, when he was again admitted, 
 labouring under severe pleuropneumony, which had been 
 neglected, and was of five days' standing. It appeared that 
 after his last dismissal, he had enjoyed the most perfect health, 
 although toiling at his laborious occupation, until five days 
 before admission, when he was seized with pain of the side, 
 cough, dyspnoea, and fever ; he continued to work until his 
 sufferings obliged him to desist. 
 
 He then presented all the symptoms of the fourth stage of 
 pleuropneumony of the right lung. On percussion, the whole 
 of this side, both anteriorly and posteriorly, sounded completely 
 dull, except in the subclavicular region, where it was compara- 
 tively clear. This it will be recollected was the former seat of 
 the abscess. Over the dull portion, bronchial respiration mixed 
 with an intense muco-crepitatiug rale was audible, but on 
 examining the subclavicular region, we found to our great sur- 
 prise, that all the phenomena of a cavity had disappeared, and 
 zvere replaced by a imerile respiration. 
 
 * This is confirmatory of the observations of Laennec, who states that ■svhile in the 
 course of the year 1823 he met with more than twenty cases of partial peripneumony 
 terminating in abscess, he knew of only two other well authenticated cases ha'sdng 
 occurred in France in twenty years. (Ed.) 
 
 T
 
 274 PNEUMONIA. 
 
 Here was a case full of difficulty. It was plain that the 
 greater portion of the lung was solidified, and had passed into 
 the fourth stage, but why a small portion of it should have 
 escaped the disease when the rest was so far advanced, and that 
 this portion should be that formerly occupied by an abscess, was 
 indeed difficult of explanation. 
 
 All treatment proved inefficacious, and the patient sunk on 
 the third day, the stethoscopic phenomena having continued 
 unaltered. 
 
 On dissection we found the right lung solid over the whole 
 extent indicated by the stethoscope. From the fourth rib down- 
 wards, the pleura was covered with coagulable lymph, which 
 being removed, allowed us to see the lung, of a yellow colour, 
 through the serous membrane. In the superior portion the 
 adhesions were evidently old, as considerable force was required 
 for their separation. On the summit and autero-superior sur- 
 face, a deep puckering existed. 
 
 The lung was then divided, in a line corresponding to the 
 angles of the ribs, so as to separate it into two portions, con- 
 nected only at the root of the lung. This gave us at once an 
 explanation of the physical signs. The supero-anterior portion, 
 for a space of three square inches, was perfectly-crepitating, and 
 not all engorged. This was separated from the rest of the organ 
 by the cicatrix of the abscess. The cavity had been obliterated 
 by adhesions of its walls, so as to form a cartilaginous septum, 
 superiorly half an inch in thickness, and inferiorly diminishing 
 to about two lines ; the whole length of this septum was about 
 three inches ; it commenced at the summit of the lung, running 
 from behind forwards and downwards, and terminated where 
 the large bronchus gives off its branch to the upper lobe ; 
 this septum throughout its whole extent consisted of two 
 layers, connected only by some fine cellular membrane, and 
 easily separable. 
 
 It was obviously the cicatrix of the abscess ; from its situation 
 it had isolated the subclavicular portion of the lung, or that 
 in which puerile respiration was audible. A bronchial tube 
 passed from the larger trunks, immediately below the cicatrix, 
 so as to admit air into this portion of the lung, which differed 
 in no respect from healthy lung, except that the interlobular 
 septa were remarkably hypertrophied. The remainder of the
 
 PNEUMONU. 275 
 
 upper, with the middle and inferior lohes, were solid, of a 
 yellowish gray colour, and infiltrated with pus. The most 
 careful examination failed to detect tubercle in any part of 
 the system. 
 
 That this abscess was really the result of phlegmonous inflam- 
 mation, there can be little doubt. The absence of the symptoms 
 of phthisis in the first attack ; the formation of the cavity, after 
 but a few weeks' illness ; the perfect recovery of the patient, all 
 combine to establish its nature ; and if additional evidence was 
 wanting, the absence of a trace of tubercle in any part of the 
 body, is sufficient to shew that the cavity was not phthisical. 
 
 I have given this case at length, as no instance of the cicatri- 
 zation of a pneumonic abscess is recorded, and as its diagnosis 
 is so full of interest. 
 
 Without reference to those purulent collections in the lung 
 which result from venous absorption, I have seen acute pneu- 
 monic abscess under three forms. In the first, the abscess is 
 encysted, and has all the characters of true phlegmon. In the 
 next we find purulent cavities, communicating with the tubes, 
 but without any cyst ; the walls of the abscess being formed of 
 the solidified lung. This form is seen in the secondary or 
 erysipelatous pneumonia, and I have observed its formation 
 by the stethoscope, and verified the diagnosis. 
 
 But in the third form which I first described, and of which 
 a case is given in the chapter on bronchitis, the anatomical 
 characters are peculiar. The pulmonary tissue is separated 
 from the pleura, and the lobules dissected, so as to shew the 
 structure of the lung. The lung lies bathed in pus, and we 
 have an abscess under the pleura, but external to the lung. 
 
 Although in most cases of pneumonic abscess, the disease is 
 referrible to acute irritation, yet we may find abscesses of a 
 chronic character, which are not tuberculous ; an abscess some- 
 times of considerable size occupies the lower portion of the 
 lung ; its walls are firm, and of an iron-gray colour, and the 
 surrounding lung is in the state of chronic induration. We have 
 now seen several of such cases ; the patients did not present the 
 usual symptoms of phthisis, the pulse was slow, and the breath- 
 ing easy ; there was little or no cough, and an absence of fever ; 
 indeed, with the exception of emaciation, and a certain hectic 
 appearance, there were no evidences of constitutional disease. 
 
 T 2
 
 276 PNEUMONIA. 
 
 On tlie upper portions of the chest, both the passive and active 
 auscultatory signs were natural ; but the lower lobe of one lung, 
 (generally the right) presented complete dulness and absence 
 of vesicular murmur, and gave all the signs of a cavity with free 
 bronchial communication. 
 
 It is, however, yet to be determined, whether in these cases 
 the abscess originated in an acute pneumonia, or was the i-esult 
 of a more chronic process.* 
 
 Connected with the pathology of pneumonia, we may examine 
 its seat and resolution. 
 
 Seat of Pneumonia. — From the combined observations of 
 Andral, Chomel, and Lombard, Dr. Forbes has shewn, that out 
 of a total of 1,131 cases, the right lung was engaged in 562, 
 the left in 333, and in 236 the disease was double ; the general 
 result of which would be, that out of every ten cases, five would 
 be of the right, three of the left, and two double. This result 
 is probably near the truth, and corresponds pretty closely with 
 my experience ; but it will be found that the double pneumonia 
 is more frequent than appears from the above statement. It 
 commonly happens, that notwithstanding a great preponderance 
 of disease in one lung, a careful physical examination will detect 
 more or less of it in the other, even though no local pain or 
 distress exist, which could lead to its detection. 
 
 Under these circumstances, the first effect of any general 
 treatment will be seen on the lung least engaged. 
 
 A long experience leads me to conclude, that when we connect 
 the seat and character of pneumonia, we find that the disease in 
 the right lung is more often of the sthenic, and that of the left 
 of the typhoid character. Either lung may present both forms 
 of disease ; but in the tj^jhoid pneumonia, the left is most often 
 the seat of the lesion. When discussing the secondary pneu- 
 monia, I shall return to this point. 
 
 Although pneumonia commences in the lower lobes, in a 
 much greater proportion than in the upper, we may often see 
 the disease under the latter circumstances ; and it is a curious 
 fact, that we have observed an epidemic tendency to pneumonia 
 of the upper lobes. Thus during the summer of 1833, a great 
 number of cases of this description occurred in the Meath 
 
 * The occurrence of chronic abscess of the lung has been noticed by Laennec, as 
 we see in his observations on chronic pneumonia.
 
 PNEUMONIA. 277 
 
 Hospital. The disease was in almost all cases of the typhoid 
 character, and in the adult male subject.* I have seen it, how- 
 ever, in females, and not unfrequently in children, in whom it is 
 often mistaken for phthisis.! 
 
 Resolution of Pneumonia. — It is now established, that reso- 
 lution may take 'place at any stage of this disease ; but the 
 periods at which this change begins and is perfected, are exceed- 
 ingly various. Thus the signs of complete dulness and absence 
 of vesicular murmur may disappear within twenty-four or thirty- 
 six hours ; while in other cases many weeks elapse before the 
 lung is restored to a natural condition. 
 
 Among the many singular results of auscultation there is 
 none more remarkable than the discovery of the rapid changes 
 which the lung undergoes in certain cases of pneumonia. I 
 have frequently seen all the signs of solidification subside 
 within two days, and have even observed great modifications 
 in the course of a few hours. I have found out of twenty-four 
 cases in which the period of resolution, or in other words, the 
 time in which all physical signs of disease had disappeared, was 
 accurately observed, that in nine it occurred within the first 
 week of the disease ; in nine within the fortnight ; in five within 
 three weeks ; and in one in a month from the period of 
 invasion. In eighteen of these cases hepatization had occurred, 
 and in one there was abscess, the signs of which disappeared in 
 fourteen days. Lastly, I may add that my researches do not 
 shew any difference in the rapidity of resolution comparing the 
 disease of the right or left lung. 
 
 [My experience is that the disease is capable of resolution at 
 any stage of its progress, short of abscess, and that it may be 
 often witnessed even when the whole of one lung, and part of 
 the other are engaged, and when the fourth or suppurative con- 
 dition is extensively established, provided that the antiphlogistic 
 treatment has not been pushed too far at first, and that the 
 advanced stages are treated by revulsives, and the use of stimu- 
 lants. Under these circumstances the recovery is often singu- 
 
 * An intelligent American physician, who -visited Dublin about that time, stated to 
 me that a similar tendency to pneumonia of the upper lobes had been observed in some 
 of the cities of the United States, and also in Paris, during the same year. 
 
 •|- In eighty cases of pneumonia, Andral found fifty-seven of the lower lobe, thirty 
 of the upper, and eleven in which the whole lung was engaged. I think this propor- 
 tion much greater than what occurs in this country.
 
 278 PNEUMONIA. 
 
 larly rapid, and without any sign of injury liaAdng been done 
 to the pulmonary structure, the lung rapidly regains its sonoriety, 
 and the vesicular murmur is frequently restored, either without 
 the appearance of the crepitus redux of Laennec, or, with its 
 existence in a very trifling degree. It appears to me that the 
 progress of resolution, in place of being, as is generally supposed, 
 merely from above downwards, is rather from the circumference 
 to the centre ; we not unfrequently have seen cases in which 
 the resolution was complete, or nearly so, in the upper and the 
 lowest portions of the lung, while the dulness and bronchial 
 respiration lingered about the root of the lung, and were last 
 observed in that situation. — Author's Note Book.] 
 
 Symptoms of Pneumonia. — So various are the circumstances 
 under which we meet with this disease, that it becomes difficult 
 to give any condensed account of its symptoms ; and although 
 we may enumerate fever, arterial excitement, cough, viscid, 
 bloody, or purulent expectoration, dyspnoea and accelerated 
 breathing, as its symptoms, still there is not one of these that 
 may not occur in other diseases, or be absent in pneumonia 
 itself. Further, we know that in most cases inflammation of the 
 serous and mucous tissues complicates that of the parenchyma, 
 so as to make it difficult to say what are the symptoms of pneu- 
 monia simply considered. 
 
 But the true source of diagnosis is our finding the combina- 
 tion of irritation of the respiratory system, with the physical 
 signs of pneumonia ; of which signs it may be said, that although 
 taken singly, any of them may occur in other afi"ections ; yet 
 that in pneumonia, their mode of succession is quite charac- 
 teristic. 
 
 [For example, in no other disease do the signs of pulmonary 
 consolidation follow the development of true crepitating rale 
 over a large surface, the disease being acute and accompanied 
 by fever. In no other disease do the signs of hepatization, 
 dulness, bronchial respiration, and absence of vesicular murmur, 
 pass into those of that morbid permeability which occur in the 
 fourth stage. And in no other affection are the signs of abscess 
 preceded by those of the four anterior conditions of pneumonic 
 disease. Hence the only true source of diagnosis is the com- 
 bination of the general and varied symptoms of pulmonary 
 irritation with the physical signs of pneumonia, considered not
 
 PNEUJIONIA. 279 
 
 only in their inherent characters but in their order of suc- 
 cession. 
 
 It may be stated as a general rule, that if we compare cases of 
 acute pneumonia with cases of acute pleurisy, the former will be 
 found to be accompanied with less suffering, at least at first ; the 
 pain is more deep-seated, and less like that of pleurodynia, and 
 there is not the same tenderness of the integuments ; the pulse 
 is generally more developed, and the cough is bronchial, and at 
 an early period accompanied by expectoration. There is less 
 dyspnoea indeed after antiphlogistic measures have been used ; 
 the respiration may become perfectly tranquil, even though 
 extensive hepatization exist. We cannot, then, measure the 
 amount of obstruction by the degree of dyspnoea. — Author's 
 Note Book.] 
 
 Although the sanguinolent and viscid character of the expec- 
 torated mucus is observed in many cases of pneumonia, yet 
 it is anything but constant. In fact, pneumonia may occur with 
 all varieties of expectoration, from a scanty and colourless mucus, 
 to the most diflerent characters of secretion. It often occurs 
 without any characteristic expectoration, and may thus pass 
 even to its advanced stages. Generally speaking it may be said 
 that the " crachats rouilles" of the French are found in the 
 more active cases of pneumonia, which occur in robust habits ; 
 but I am convinced that in a large proportion of the hospital 
 cases, in which the disease occurs in feeble constitutions ; in 
 the child, or as a complication or a sequel to fever, the appearance 
 of the expectoration has little value. It is believed that the red 
 and viscid sputa occur only at the height of the disease. This is 
 generally true, but an exception to the rule has been recorded 
 by Andral, in which for eight or nine days after the subsidence 
 of the symptoms and signs of pneumonia, the sputa continued 
 red, and extremely viscid. He suggests, whether in this case 
 there might not have been a central pneumonia, which could not 
 be detected, and which kept up the secretion. Such an opinion 
 seems improbable from the disappearance of constitutional 
 symptoms. I have seen a case similar to this, which illustrates 
 how little value can be placed on a particular symptom. A 
 woman was admitted into the Meath Hospital for an injury of 
 the chest ; several ribs had been broken. She was attacked 
 with intense pleuro-pneumony, accompanied by the red and
 
 280 PNEUMONIA. 
 
 viscid expectoration in quantity. All the physical signs of 
 pneumonia supervened, and in a short time the lung was ex- 
 tensively hepatized. Under a most active treatment, however, 
 the symptoms disappeared, with the exception of the expectora- 
 tion. The dulness ceased, and the vesicular murmur was 
 restored, but for weeks she had an expectoration of red mucus, 
 presenting all the characters which it had in the first stages, 
 and so abundant that on some days several pints were evacuated. 
 Its tenacity was so great, that a dressing tray in which she ex- 
 pectorated, of twelve inches in breadth, and not more than two 
 in depth, could, when full, be inverted without a drop escaping ; 
 yet repeated examinations discovered nothing more than the 
 ordinary signs of bronchitis. 
 
 But in the suppurative stages the expectoration is generally 
 characteristic ; it then occurs under two forms, in the one we 
 observe a purplish red muco-puriform fluid, while in the other 
 we find that the matter coughed up has all the characters of the 
 laudable pus of authors. It is of a light yellow colour, perfectly 
 homogeneous, and of the consistence of cream. I have never 
 seen this expectoration unless in the suppurative pneumonia, 
 and it forms almost the only instance in which an expectoration 
 of pure pus is met with. 
 
 As far as we have observed there is no anatomical difierence 
 between the cases with prune juice sputa, and those in which 
 there is a secretion of healthy pus ; but it will often be found, 
 that in the former case the disease exists in a lower type, and 
 in broken down constitutions, while I have never seen the latter 
 except in cases of active pneumonia in the young and robust 
 individual. 
 
 Either of these forms, but particularly the latter, are charac- 
 teristic of the fourth stage of the disease, a condition which 
 seems more often attended with a peculiar expectoration than 
 any of the preceding stages. With reference to pulmonary 
 abscess, I have only to remark, that in most of the cases I have 
 seen the expectoration was not by any means characteristic. In 
 two cases nothing was coughed up but a little bronchial mucus, 
 while in the others it had very different characters. I have 
 found it foetid, or devoid of smell, mucous, or muco-puriform, 
 collected into masses which floated in serum, or resembling the 
 ordinary expectoration of chronic bronchitis.
 
 PNEUMONIA. 281 
 
 As a symptom of pulmonary irritation, dyspnoea is much 
 more prominent in bronchitis or pleurisy, than in pneumonia. 
 Indeed, the respiration in this aflfection, particularly after anti- 
 phlogistic measures have been employed, is in most cases singu- 
 larly easy, even though a large portion of lung has become 
 hepatized, so that the amount of obstruction cannot be measured 
 by the degree of dyspnoea. 
 
 In localized pneumonia two causes exist for dyspnoea v^^ith 
 accelerated breathing, namely, its complication with extensive 
 bronchitis ; and that inflammatory excitement which affects the 
 whole lung. Many cases will be met with in which both con- 
 ditions exist ; but the second may occur independently of the 
 first. 
 
 Hence there are three- cases in which the difficulty and ac- 
 celeration of breathing are no measure of the extent of pneu- 
 monic disease. In the first there is an extensive bronchitis ; 
 in the next, the combination of this with the functional excite- 
 ment of the lung ; and in the third, this condition exists with 
 scarcely any bronchial irritation. From ignorance of these facts 
 we may commit great errors in practice ; for in all these cases 
 the first effect of treatment is seen less on the pneumonia than 
 on these accompanying states ; on the bronchitis, on the one 
 hand, and on the inflammatory spasm or excitement on the 
 other.* 
 
 * The value here assigned to the rational symptoms is perhaps scarcely adequate. 
 In acute sthenic pneumonia the group of symptoms attending and following the in- 
 vasion are eminently characteristic, and as has been remarked by many observers 
 frequently constitute both the only available, and the suflBcient, data for our diagnosis. 
 Thus we have (a) the initiatory rigor, sudden, single, and severe, followed by sudden 
 rise of temperature gradually mounting up from 102° to 105°, with that sensation of 
 pungent heat communicated to the hand, first noticed by Dr. Addison, and as Wun- 
 derlich observes sometimes continuing for two or three days unattended by any 
 auscultatory signs of the disease. 
 
 (b) The aspect of the patient during this stage is peculiar : he has an anxious 
 muddled look, and the face and brow are commonly sufEased, the appearance resem- 
 bling that of a person who has fallen asleep before a large fire, 
 
 (c) The respiration is painful and shallow, and, as Dr. Walshe first pointed out, is 
 peculiar to pneumonia in the altered relation to the rate of pulse. 
 
 {d) The cough and expectoration are characteristic, the fonner being short, frequent, 
 and painful, and brought on by any change of posture, thus controlling the feverish 
 restlessness which might otherwise be expected. 
 
 It may be added that not unfrequently our diagnosis of the true nature of a sup- 
 posed case of tubercular phthisis will be assisted and its successful treatment suggested, 
 by a careful inquiry into the history of the symptoms of the invasion, by which its 
 inflammatory origin may be ascertained. (Ed.)
 
 282 PNEUMONIA. 
 
 Physical Signs of Pneumonia. — The sources of physical 
 sigus in this disease may be thus enumerated : — 
 
 1st. Evidences of a local excitation. 
 
 2nd. Evidences of sanguineous congestion. 
 
 3rd. Evidences of the diminished quantity of air in the affected 
 lung. 
 
 4th. Signs of increasing solidity of the lung. 
 
 5th. Phenomena of voice. 
 
 6th. Phenomena referrible to the circulating system. 
 
 7th. Evidence of accompanying lesions of the pleura. 
 
 8th. The diminished volume of the lung. 
 
 In the above catalogue, no mention is made of the signs of 
 accumulation or visceral displacement, so valuable in other 
 diseases. These signs are wanting in pneumonia, for although 
 the observation of Broussais, as to the impression of the ribs on 
 the inflamed lung, may be often verified, yet the increase of 
 volume goes no farther. The appearance is not constant, and I 
 have only observed it in cases where the whole lung had passed 
 into interstitial suppuration. These depressions are seldom 
 more than three lines in depth, and hence, though their existence 
 shews that some tumefaction has occurred, it is plain that it 
 cannot interfere with diagnosis, and make us confound a solid 
 lung with a distended pleura ; so far we may agree with Laennec, 
 but his denial that any tumefaction occurs in pneumonia is not 
 borne out by observation.* 
 
 Signs of the first Stage. — The physical signs of the first 
 stage of pneumonia are still to be determined with accuracy. 
 Without possessing a sufficient number of observations to deter- 
 
 * See Dr. Forbes's translation, page 185. It is difficult to explain how Laennec 
 should have taken up his opinion so strongly on this subject, for the appearance is by 
 no means unfrequent, and we should expect it from all the analogies of disease. In 
 all my cases, the pleura had been inflamed, and the marks of the ribs produced by two 
 causes, one the depression in the lung, and the other the less degree of organisation 
 wkich thii lyviph corresponding to each rib had undergone. Thus we have an alterna- 
 tion of comparatively transparent and opake spaces, as if the contact with the rib was 
 less favourable to organization than that with the intercostal muscles. Looking at the 
 analogies of disease, it appears that if we examine the influence of inflammation in 
 altering the volume of organs, we find that tumefaction is commonly observable in the 
 earlier stages. In the chronic irritations, on the contrary, although an hypertrophy 
 sometimes results, yet diminution oj volume is more frequently met with ; and in the 
 same case the affected organ may first exceed, and afterwards be reduced far below its 
 natural dimensions. This occurs in the lung ; inflammation produces a tumefaction 
 and afterwards an atrophy of the organ, which we can verify by measurement of the 
 chest.
 
 PNEUMONIA. 283 
 
 mine tlie point, I am led to the belief that an intense j)uerility 
 of respiration in the affected iiart will be found to be the principal 
 phenomenon.* In cases in which inflammation was spreading 
 upwards, I have often found that a puerile respiration preceded 
 the crepitating rale for some hours ; and that this was not a 
 general but a partial condition was shewn by its being much 
 more intense in the vicinity of the disease than in the opposite 
 lung. Indeed in cases presenting great puerility of respiration 
 with fever, we may often prognosticate the occurrence of the 
 crepitating rale. Thus, in a case in which numerous inflamma- 
 tions successively occurred, and in which the disease attacked 
 both lungs as well as the pericardium, I observed this sudden 
 a^jpearance of intensely puerile respiration on three distinct oc- 
 casions ; in two it was followed by the crepitating rale, and other 
 signs of pneumonia, and in one was removed by bleeding before 
 the above signs had occurred. 
 
 From these and many other observations, I would conclude 
 that we may diagnosticate the first stage of pneumonia by the 
 sudden occurrence of a local puerility of respiration, combined 
 with fever and excitement of the respiratory system. 
 
 The circumstances which give value to this phenomenon, as a 
 sign of pneumonia, ai-e obviously its sudden appearance, localiza- 
 tion, and combination with fever. 
 
 Signs of the second Stage, — The crepitating rale, and the 
 gradually diminishing vesicular murmur constitute the signs of 
 this stage, and it is the combination of these phenomena which 
 gives them their value. It must be admitted that Laennec has 
 not succeeded in establishing the crepitating rale as an invariable 
 phenomenon in this disease. It is neither invariable nor posi- 
 tive, but like all other physical signs, derives its value from the 
 preceding and accompanying phenomena. As a physical sign, it 
 only points out a secretion or effusion into the pulmonary cells, 
 and to determine that this is pneumonic, we require the increas- 
 ing dulness and gradual obliteration of the respiratory murmur. t 
 
 Laennec has stated, that the resolution of solidity is invariably 
 
 * I have used the term puerile respiration ia treating of this condition. Perhaps 
 we should use that of exaggerated. We are still ignorant of the immediate cause of 
 this modification of the respiratory murmur, which must be different from that of 
 ordinary puerile respiration. Or have we been in error in considering the latter as 
 the result of purely mechanical conditions ? {Author's Note Book.) 
 
 ■j- The crepitating rale has been compared to various sounds ; of these comparisons,
 
 284 PNEUMONIA. 
 
 announced by a return of the crepitating rale {ronchus crepitans 
 redux), but my experience is altogether opposed to this state- 
 ment, for I have often observed the change from complete 
 dulness of sound and bronchial respiration, to clearness and return 
 of respiratory murmur, without any crepitus of resolution ; and 
 this may be seen in all varieties of pneumonia ; nor does the 
 absence of the phenomenon necessarily imply a rapid resolution, 
 for it may be absent in cases in which weeks elapse before the 
 dulness of sound is removed. But the sign is common where 
 the disease has passed into an advanced stage, where early treat- 
 ment has been neglected, or the vital powers much depressed. 
 
 [I formerly believed that Laennec erred in stating that the 
 crepitating rattle necessarily preceded the signs of hepatization. 
 I had founded this opinion on the fact of the occurrence of 
 sudden consolidation without any previous crepitus, so that it 
 would appear that in certain cases of pneumonia the disease 
 actually commenced by hepatization. Subsequent experience, 
 however, leads me to believe that in many of these cases of 
 sudden consolidation, even though the after stages of inflammation 
 may he produced in them, and though in their resolution they 
 exhibit the ordinary signs observable in sthenic pneumonia, yet 
 that their pathological nature is very different from that of 
 ordinary pneumonia, and I now believe that in this latter disease 
 the crepitus will be almost invariably found to precede the signs 
 of consolidation. The following observations of Dr. Walshe are 
 of great practical importance : " When at its maximum the 
 crepitant ronchus accompanies the entire act of inspiration ; 
 when first developed, and when about to be superseded by 
 blowing respiration, it appears before the close of the inspiration 
 only. Under all circumstances it is to say the least rare to 
 find this ronchus co-existent in any degree with expiration ; the 
 statement that it may generally be heard to a diminished amount 
 with this division of the respiratory act appears to me to have 
 originated in the confusion Avhich long prevailed between the 
 crepitant ronchus of pneumonia and the small bubbling, ronchus 
 of capillary bronchitis." In speaking of the persistency of the 
 
 that by Dr. Williams is most accurate, namely, the sound produced by rubbing a lock 
 of hair close to the ear. This may be observed both in the commencement and reso- 
 lution of the disease ; but all varieties of crepitating and muco-crepitatiixg rales may 
 occur in pneumonia.
 
 PNEUMONIA. 285 
 
 sign, he observes that " other ronchi are manifestly influenced 
 in the regularity of their production by the occurrence of ex- 
 pectoration, for example, but over true crepitation this appears to 
 exercise no immediate control, at least the ronchus persists 
 with all its characters as before after the patient has relieved 
 himself by expectoration. The first effect of a fit of coughing, 
 indeed, is to render the ronchus more distinct and abundant even 
 than before." — Author's Note Book.] 
 
 The crepitus of resolution (generally having much larger bub- 
 bles than in the earlier stages) is to be heard during the whole 
 inspiration, and in a diminished degree during expiration. But 
 in other cases the first part of the inspiration is pure, and the 
 rale only appears at the termination of the effort.* In one case, 
 however, I have observed the reverse of this, for we had first 
 rale, and then pure vesicular murmur. 
 
 Signs of the third Stage. — In this condition, the cells 
 being obliterated, while the large tubes remain pervious, dulness 
 of sound, bronchial respiration, and a loud resonance of the voice 
 are produced, and tvithin certain limits, the extension or in- 
 tensity of these signs furnish an accurate measure of the extent 
 or intensity of the disease. With respect to the bronchial 
 respiration, there are some circumstances not generally under- 
 stood ; it requires for its production not merely the solidity of 
 the lung, but a certain expansion of the side during respiration. 
 Thus we find that if the whole lung become solid, the bronchial 
 respiration ceases, the side is fixed, an evident result of the non- 
 expansion of the lung. In such a case the phenomenon goes 
 on increasing to a certain point, after which its diminution 
 points out the extension of the disease, until the whole lung is 
 solidified, when the signs are universal dulness, absence of 
 respiration, and resonance of the voice. If now the upper 
 portion begins to resolve, or if an abscess be formed, in either 
 of which cases air again rushes through the bronchial tubes, 
 we have a return, and for some time an increase of the bronchial 
 respiration, indicative of resolution on the one hand, or abscess 
 on the other. These phenomena I have repeatedly verified, 
 and have observed that for the reproduction of the bronchial 
 
 * Some have conceived that the crepitating rale arose from the effusion of air into 
 the substance of the lung; the phenomenon just mentioned is a strong argument 
 against this opinion.
 
 286 PNEUMONIA. 
 
 respiration it is not necessary that the permeable portion should 
 be of great extent. Thus in the case of cicatrized pneumonic 
 abscess which I have given, the permeable portion did not form 
 a sixth of the whole lung, and was yet sufficient to induce 
 bronchial respiration in the solidified parts. 
 
 In cases where the lung is universally solidified, the disease 
 might be confounded with an extensive empyema, particularly if 
 the previous history and succession of physical signs were not 
 observed ; but even here the diagnosis can be made, for I have 
 never seen a case of empyema so extensive as to cause general 
 dulness, in which there were not the signs of visceral displace- 
 ment, which, with the absence of the phenomena of voice, are 
 quite sufficient to guide the diagnosis. 
 
 In the ordinary pneumonia, the dulness of sound and bronchial 
 respiration are preceded by the crepitating rale, but I have 
 already spoken of a most important variety, in which a rapid 
 solidification occurs, not preceded hy the usual signs. Under 
 these circumstances, the lung may pass in the course of a few 
 hours from apparent health to complete solidification. The 
 disease begins by hepatization, and often runs its course with 
 great rapidity, and it requires some diagnostic skill to distin- 
 guish this case from pleurisy with copious effusion. This fact, 
 so important an exception to Andral's rule, that sudden dulness 
 without crepitus is pathognomonic of pleurisy with effusion, I 
 was aware of, and taught in my lectures many years ago, and 
 my observations have been since confirmed by Dr. Hudson. 
 
 The principal physical diagnosis between this typhoid solidity 
 and a pleural effusion is, that with the dulness and absence of 
 respiration of a great effusion, the signs of eccentric displacement 
 are wanting; the heart is not displaced, the epigastrium and 
 hj'pochondria are concave, and the intercostal muscles unaffected. 
 But we can be assisted by other points ; the phenomena of 
 voice, the greater frequency of bronchial respiration, the occa- 
 sional occurrence of rale here and there will assist in the 
 diagnosis, the grand source of which, however, consists in the 
 application of the first rule which I have given in a case pre- 
 senting the symptoms of typhoid pneumonia. 
 
 [Signs of the fourth Stage — Interstitial Suppuration. — 
 While the constitutional symptoms continue severe, it is found 
 that a certain change takes place in the physical signs caused
 
 PNEUMONIA. 287 
 
 by the production of permeability to a certain extent. This 
 change consists in the combination, which is almost peculiar, of 
 bronchial respiration with a sharp and intense muco-crepitating 
 rale ; phenomena, which when taken in connexion with the pre- 
 vious history, and actual symptoms, leave no doubt as to the 
 nature of the pathological condition. 
 
 Should the disease be still spreading we may observe a com- 
 bination of the inflammatory symptoms of the earlier stages with 
 those indicative of suppuration,* while if it be localized, we find 
 a species of acute hectic supplanting the first inflammatory 
 fever. The respiration continuing to be distressed, the pulse 
 rapid, and feebler than before, and the expectoration either of the 
 prune juice character, or consisting of yellowish, creamy, homo- 
 geneous pus. The fact of the spreading of disease in other 
 portions of the lung or its opposite, is most important in the 
 diagnosis of this condition. We rarely see resolution in one 
 portion, and increase of disease in another, so that if the new 
 permeability of the hepatized lung is accompanied by signs and 
 symptoms of spreading disease in new portions of the lung, 
 there is a great probability that interstitial suppuration is 
 taking place in the part originally engaged. 
 
 But again the return of permeability is not accompanied by 
 that of the sonoriety of the chest ; and the bronchial respiration 
 so far from disappearing, becomes in many cases even more dis- 
 tinct. We may compare the two cp.ses of returning permeability, 
 the one from resolution, the other from interstitial suppuration, 
 in pairs of characters, and thus get a clear idea of all the 
 phenomena. 
 
 Reso 1 1 itive Permeability. 
 
 I. Subsidence of Fever. 
 
 II. Distress of the respiration 
 ceasing. 
 
 in. Expectoration ceasing and 
 becoming bronchitic. 
 
 IV. No physical signs of ex- 
 
 Supimrative PerineabiliUj. 
 
 I. Increase of Fever and change 
 in its general character. 
 
 II. Distress increasing ; Dysp- 
 noea augmented ; Cough frequent. 
 
 III. Expectoration copious, pu- 
 rulent, or puro-sanguinolent. 
 
 IV. Evidence of the spreading 
 
 * " As long as the inflammation increases," says Laennec, " the crepitous rattle 
 extends daily round the hepatized part, or arises in new points ; it precedes the signs 
 of hepatization, which commonly are found, on the following day, very distinct in 
 those points where the crepitous rattle had existed the day before." (Ed.)
 
 288 
 
 PNEUMONIA. 
 
 tension of disease in other por- 
 tions. 
 
 V. Dulness disappearing. 
 
 VI. Bronchial respiration be- 
 coming less distinct, and finally 
 subsiding. 
 
 VII. Sub-crepitating rale (cre- 
 pitus redux) gradually subsiding, 
 and replaced by vesicular mur- 
 mur. 
 
 of the earlier states of pneumonia, 
 either in the affected lung or in 
 the opposite ; these are commonly, 
 but not constantly present. 
 
 V. Dulness maintained. 
 
 VI. Bronchial respiration re- 
 maining, and of a most distinct 
 and intense character. 
 
 VII. Intense and permanent 
 muco-crepitating rale. 
 
 Signs of Resolution. — The signs of resolution usually ob- 
 served, are the gradual return of clearness of percussion sound 
 over the dull portion, such return corresponding with the order 
 of resolution ; and the occurrence of crepitus of resolution mixed 
 at first with bronchial breathing, and giving place gradually to 
 feeble, but pure respiratOjiy murmur. 
 
 The order of these phenomena may be varied in several ways 
 • — as by the absence of crepitus. In the first edition of this work 
 the fact was announced that complete dulness of sound and 
 bronchial respiration will often pass into clearness, and return of 
 respiratory murmur without the occurrence of any crepitus of 
 resolution. The truth of this observation, founded on no small 
 number of cases^ has been questioned by some subsequent 
 writers, amongst others by Grisolle, who argues that this sign of 
 resolution may have been overlooked, and may really have been 
 present during the interval between the several examinations. 
 It is a sufficient answer to this objection, that admitting the 
 crepitus of resolution to be a very fugacious sign, it could scarcely 
 have escaped observation in so large a number of instances, as 
 have occurred before and since the above passage was written ; 
 and that this number more than compensates for the supposed 
 long interval between two explorations in any single case. 
 
 Another variation in the process of resolution is sometimes 
 presented in the order in which it occurs. As a general rule, 
 resolution commences in the part last hepatized ; to this, how- 
 ever, there are numerous exceptions, in which instances the 
 crepitus redux appears first in the part of the lung first in- 
 flamed.
 
 PNEUMONIA. 289 
 
 A difficulty sometimes arises from the extension of pneu- 
 monic crepitus to other parts of the lung, while resolution is 
 progressing in the portion originally engaged ; this condition 
 is ascribed by Dr. Alison * to the extension of an exudation 
 of a modified character and so attenuated as to be easily 
 reabsorbed. 
 
 We sometimes meet with the persistence of bronchial respira- 
 tion in portions of the side for a long time after pure respiratory 
 murmur has replaced it in the remainder, while in other, but rare 
 instances, puerile respiration continues for a while over the 
 affected portion. 
 
 Lastly, the occurrence of frottement over the inflamed portion 
 at an advanced period of the stage of resolution must be con- 
 sidered as a variation from the strictly normal order of signs 
 though one of frequent occurrence. 
 
 Signs of fifth Stage — Abscess. — As the physical signs of 
 phlegmonous abscesses which communicate with the bronchial 
 tubes, do not essentially differ from tuberculous caverns, we need 
 not dwell upon them here. There are, however, in the collateral 
 circumstances some points of difference. These relate — 
 
 I. To time. 
 
 II. To the preceding physical signs. 
 
 III. To the rapidity of changes, whether we refer to the ad- 
 vance, or the cure of the disease. 
 
 If the duration of the case from the first appearance of morbid 
 phenomena to the production of the signs of abscess be con- 
 sidered, it will be found greatly less than what is observed in 
 tuberculous suppurations. A tuberculous cavity competent to 
 give cavernous respiration, gurgling, and pectoriloquism, may 
 take many weeks, or even months for its production, but in 
 pneumonic abscess the signs are much more rapidly developed, 
 so that this principle obtains — that the more rapid is the sign of 
 cavity dating from the first appearance of disease, the greater is 
 the probability it results from a suppurative pneumonia. Acting 
 on this principle, I have more than once given a favourable 
 prognosis in cases which were considered to be examples of 
 tuberculous caverns — in which, the question of time had not 
 received the attention which it deserves. In these cases a rapid 
 and complete recovery took place. 
 
 * Edinb. Month. Jour., 1850. 
 U
 
 290 PNEUMONIA. 
 
 The pre-existing physical signs in the two affections are gene- 
 rally very different, the intense crepitus, the dulness generally 
 occupying the inferior portion of the lung, and the bronchial 
 respiration, constitute a group of signs, hardly ever found to 
 precede the formation of a tuberculous abscess. 
 
 Finally we may observe in many cases of pneumonic abscess 
 that the signs of cavity having arrived at their maximum, may 
 yet disappear with a singular rapidity — so that, day by day, we 
 may trace the diminution of the capacity of the abscess. This, 
 which is one of the most interesting of all the results of ausculta- 
 tion, is, I believe, never seen in the case of tubercular cavity ; I 
 have repeatedly observed the disappearance of the signs of cavity, 
 certainly within ten days of the first development, this change 
 coinciding with the convalescence of the patient. 
 
 In cases where the abscess occupies the upper portion of a 
 lung, there will be a greater liability to mistake the case for one 
 of phthisis ; but even here, I am persuaded that if there has 
 been an opportunity of studying the disease from its commence- 
 ment, its true nature may be often determined ; and even when 
 the patient has not been previously under observation we may 
 often, if but a very short time has elapsed, between the very first 
 S3'mptoms of pulmonary disease and the occurrence of the signs 
 of cavity, make a diagnosis in favour of pneumonia, which will 
 probably be correct. 
 
 If we compare the phlegmonous abscesses with those occurring 
 in the asthenic forms of pneumonia, it wiU appear that the latter 
 are formed with greater rapidity, which is characteristic of this 
 type of disease. 
 
 In the case of dissecting abscess already detailed, where the 
 lobules were dissected from the pleura, the symptoms indicated 
 suppuration, while the proper signs of cavity were absent. In 
 Louis's case, as given by Reynaud, no diagnosis was recorded, so 
 that the indications of this form are still to be determined. 
 
 Observations are wanting on the stethoscopic signs of cica- 
 trization in the case given above ; it will be recollected that the 
 signs were the total disappearance of cavernous phenomena, and 
 the substitution of the natural vesicular murmur. 
 
 Phenomena of Voice. — These signs, which are of compara- 
 tively little value, are most evident when dulness of sound and 
 bronchial respiration co-exist. We have then Laennec's accidental
 
 PNEUMONIA. 291 
 
 bronchophony always most evident in the posterior and superior 
 portions. It is easily distinguished from pectoriloquism by its 
 greater extent, and by the absence of gurgling or cavernous 
 respiration. I have found its character to be remarkably modified 
 under two circumstances when it approaches to the oegophony of 
 pleuritis : these are when the lung has passed into the fourth 
 stage, or when it is resolving from the third. In the latter 
 case, indeed, the cegophonic character is sometimes very re- 
 markable. 
 
 A remarkable symptom in certain cases is the loss of voice, 
 and this without any marked indication of laryngeal disease. 
 We have seen aphonia to occur as one of the first symptoms in 
 a case of pneumonia of the right lung and continue up to the 
 period of resolution. Some years ago I attended a gentleman 
 who complained of complete loss of voice, which he ascribed to a 
 cold contracted some weeks previously. He had some cough 
 with mucous expectoration, but no dyspnoea or fever. The case 
 was considered and treated as one of laryngeal disease, but not 
 the slightest change in the voice was produced. It was then 
 discovered that hepatization of the lower lobe of the right lung 
 existed ; on this being removed by treatment, and on the lung 
 regaining its sonoriety the voice returned although no treatment 
 had been directed to the larynx for a length of time. It would 
 be interesting to determine whether a pneumonia may affect 
 the larynx by inflaming the recurrent nerve, as we see in 
 aneurisms. — Author s Note Book.] 
 
 Phenomena keferrible to the Circulating System. — Our 
 knowledge on this subject is as yet very limited. Two pheno- 
 mena, however, have been described, which must be here 
 mentioned, namely, the occurrence of a bellows sound in the 
 heart during pneumonia, and the throbbing of a large portion of 
 the chest, synchronous with the heart, pending the earlier stage 
 of disease. Both these circumstances occurred in a case of 
 acute pneumonia recorded by Dr. Graves. The bellows' sound 
 was distinct, not merely in the region of the heart, but over the 
 front of the chest. It did not exist in the subclavian or carotid 
 arteries, and continued without any abatement for several days, 
 subsiding with the inflammation. As Dr. Graves has left to 
 others the explanation of this phenomenon, I may state my 
 opinion that the heart was probably inflamed, either in the forms 
 
 u 2
 
 292 PNEUMONIA. 
 
 of pericarditis or the endocarditis of Bouillaud, in either of 
 which a bellows sound may occur, and the complication with 
 pneumonia maj have caused the latency of the carditis. 
 
 In the same case it was found that each pulsation of the heart 
 was felt all over the front of the right lung, and this occurring 
 when the lung was not hepatized, renders Laennec's explanation 
 unsatisfactory. Dr. Graves observes, that if the pulsation was 
 propagated through a solid body, its strength at any one point 
 would be weakened in proportion to the size of that body, and 
 further, that in this case the impulse was not lateral, but 
 diastolic, so as to simulate an aneurismal pulsation. " In the 
 soft, engorged, and semifluid state," to use the words of Dr. 
 Graves, "it is easy to conceive why the lung, connected with 
 the heart by such vast vessels, should pulsate with a strength 
 almost equal to that of aneurism ; the brain pulsates notably 
 at each stroke^of the heart, and cerebriform and fungoid tumours 
 on the surface of the limbs and body have, for this very reason, 
 occasionally a pulsation so strong and distinct, as at times 
 to have deceived the surgeon into the belief of their being 
 aneurismal." 
 
 Owing to the kindness of Mr. Carmichael, I have seen a 
 case which corroborates the opinion of Dr. Graves ; a large 
 cerebriform tumour had sprung from the posterior mediastinum, 
 and displaced the upper lobe of the left lung. During life, 
 the corresponding portion of the thorax, though presenting 
 no external tumour, gave so distinct and eccentric a pulsation, 
 as to leave little doubt on my mind as to the existence of an 
 aneurism ; this opinion was strengthened by other circumstances, 
 which shall be hereafter detailed. On dissection, it was found 
 that the disease engaged the root of the lung, and surrounded 
 the left division of the pulmonary artery, the pulsations of which 
 were thus transmitted over the entire tumour.* 
 
 From these observations we may infer, that in a semifluid 
 condition of the lungs, the pulsations of the heart may be pro- 
 
 * In some cases of this nature, says Dr. Graves, the action of the heart is sufficient 
 to induce pulsation and throbbing, not merely in the inflamed lung, with which it is 
 directly connected by means of enlarged vessels, but also in the superficial veins of 
 the extremities, an occurrence proving the correctness of the explanation of pul- 
 monary throbbing which I have given. Thus, in the case of a gentleman labouring 
 under pneumonia, attended by Mr. M. CoUis and myself, the action of the heart was 
 very powerful, and a distinct pulsation, corresponding to each stroke of the left ven- 
 tricle, was perceptible in all the veins of the back of the hand. — Op. ciL, p. 54.
 
 PNEUMONIA. 293 
 
 pagated through these organs, and cause phenomena analogous 
 to those of aneurism.* 
 
 Phenomena refekrible to the Pleura. — In this disease 
 there are three conditions of the pleura which produce physical 
 signs ; these are the effusions of lymph ; of sero-purulent fluid ; 
 and, lastly, the eifusion of air. I have arranged these in the 
 order of their frequency ; the first is almost constant, the next 
 is comparatively rare, and out of many hundred cases, I have 
 onl}^ seen one example of the third. 
 
 The occurrence of lymph on the pleura does not necessarily 
 induce corresponding physical signs ; hence the frottement of 
 Laennec is not a common sign of pneumonia, and is rarely 
 observed in the advanced stages, or at the resolution of the 
 disease. I have never found it after the lung had become 
 solid. In a few cases, however, of acute and extensive pleuro- 
 pneumonia in the earlier stages, I have observed it over a large 
 surface. In a case where both lungs and the heart were engaged, 
 frottement existed in the pericardium, as well as in both pleurae. 
 For some time the belly was tympanitic, which gave to the rub- 
 bing sounds a completely metallic character, constituting the 
 most singular modification of a stethoscopic phenomenon which I 
 have ever had occasion to observe. But this was a rare case, for 
 even where pain in the side occurs, frottement is commonly 
 absent. Is this owing to the diminished motion of the inflamed 
 lung, or to the rapid obliteration of the cavity, by that mode of 
 almost direct adhesion, in which little or no lymph is effused ? 
 The absence of frottement during resolution is in favour of this 
 supposition. 
 
 As the combination of pneumonia with liquid effusion presents 
 some interesting points connected with the diagnosis of empyema, 
 I shall return to it when considering that subject. 
 
 * A case has been recently published by Dr. Popham of Cork, of pneumonia in 
 the upper lobe of the left lung, attended with loud bellows murmur and increased 
 pulsation of the subclavian artery of the same side. The signs and symptoms of the 
 pneumonia were well marked. The patient recovered, but nine months afterwards 
 was attacked with typhus fever, and secondary inflammation of the lower lobe of 
 the same lung, of which she died. " On a post mortem examination," says Dr. Popham, 
 " I was desirous to see the state of the upper part of the left lung which had formerly 
 been attacked with inflammation. It had contracted such adhesion to the margLn of 
 the sternum and the costal walls that no degree of force could detach it, so that it was 
 obliged to be cut out ; the lower part of the same lung adhered, but the adhesions 
 were recent and allowed separation. The upper part was of a steel-grey colour, 
 tough, and much more fleshy than the lung feels when healthy." — Author's Note Book.
 
 294 PNEUMONIA. 
 
 But of all these signs, the most remarkable is the tympanitic 
 clearness over the diseased lung, a phenomenon evidently pro- 
 ceeding from an effusion of air by secretion into the serous 
 cavity. The first writer who has noticed this subject is Dr. 
 Graves, who published early in 1835 the remarkable case to 
 which I before alluded, of pneumonia with bruit de soufflet and 
 throbbing of the chest. On the fourth day of the disease, after 
 hepatization had occurred, the antero-superior portion of the 
 affected side gave a preternaturally clear and hollow sound, and 
 as no respiration whatever could be heard in this region, he con- 
 cluded that the lung was here pushed back, and compressed by 
 an effusion of air. In the course of sixteen hours, the region 
 which presented this singular sign had become as dull as pos- 
 sible, and a feeble murmur, with some crepitus, could be then 
 heard. The patient ultimately recovered. 
 
 Dr. Graves has also described a case of pneumonia in a child, 
 in which the heart was dislocated to the right side, without any 
 evidence of liquid effusion into the left pleura ; over the cardiac 
 region, on the contrary, a morbidly clear sound existed, as if an 
 effusion of air had displaced the heart. The patient recovered, 
 but the heart had returned to its natural situation many days 
 previous to the resolution of the pneumonia. 
 
 Subsequently to the publication of Dr. Graves's papers. Dr. 
 Hudson, in an admirable memoir on typhoid pneumonia,* has 
 given four cases, in which, according to him, this phenomenon 
 existed. As two of these occurred in the Meath Hospital, the 
 patients being, in fact, under my own care, I must observe that 
 in neither of them, in my opinion, did the sign in question 
 exist. In the first case, the tympanitic resonance proceeded 
 obviously from the stomach, while the second was an example 
 of solidified lung, with mucus in the tubes, giving the bruit de 
 pot fele. Dr. Hudson states that the other two cases which he 
 observed in his own hospital were similar to the first which I 
 have noticed. If this be so, I can only say, that I quite agree 
 with him as to the absence of air in his cases. 
 
 I have only once observed this phenomenon : a female, long 
 addicted to the use of ardent spirits, was attacked with a severe 
 typhoid pneumonia, in which the lung ran rapidly into hepati- 
 zation. On the eighth or ninth day of the disease, the antero- 
 
 * Dublin JoiuTial of Medical Science, vol. vii.
 
 PNEUMONIA. 295 
 
 superior portion of the left side, where, on the day previously, 
 there had been a complete dulness, gave a clear, sonorous, tym- 
 panitic sound, similar to what is produced by the stomach in 
 the highest degree of flatulent distention ; this extended from 
 the clavicle to the cardiac region ; immediately under the cla- 
 vicle a slight murmur was audible, while about the eighth rib 
 the pulmonary friction sound could be heard. On the next 
 day the tympanitic clearness had extended to the postero- 
 superior portion of the chest, but on the day following, all had 
 subsided, and the chest was again dull, with absence of vesicular 
 murmur. 
 
 This patient recovered, but as is usual in the tj^phoid pneu- 
 monia, her convalescence was extremely slow ; the lung con- 
 tinued long hepatized, and an irregular hectic existed. The 
 disease took five months to run through its course, but the 
 recovery was ultimately perfect. 
 
 This case is decisive as to the question, how far the tympanitic 
 resonance in pneumonia is to be referred to a distended stomach : 
 that such was not the case here is evident, for the sound only 
 existed in the upper portions, and the region of the stomach was 
 never tympanitic. We had further physical signs of irritation of 
 the pleura, in the continuation for two days, of the friction sound, 
 audible below the effusion of air. 
 
 It is not, however, to be denied, that when the lower lobe 
 of the left lung becomes solidified from any cause, an accu- 
 mulation of air in the stomach will produce a characteristic 
 change in the sound on percussion, varying with the amount, 
 and subsiding with the disappearance of the air ; but this sound 
 is altogether different from that of pneumothorax in pneumonia. 
 I might say, and stethoscopists will appreciate the distinction, 
 that the one is a tympanitic dulness, the other a tympanitic 
 clearness.* 
 
 I have known some instances in which this clearness from 
 a distended stomach was mistaken for the natural sound : such 
 an error can only happen to very inexperienced stethoscopists ; 
 the clearness and distention of the region of the stomach, the 
 bronchial respiration, the voice, will, independent of the character 
 of the sound, suffice to prevent the error. 
 
 Signs referrible to the diminished Volume of the Lung. 
 
 * See Appendix, Note B.
 
 296 PNEUMONIA. 
 
 "We have already seen that between pneumonia and empyema 
 there was this difference, that the signs of accumulation did 
 not occur in the first disease.* In most cases of empyema the 
 side is enlarged, but the increase of volume, which occurs in 
 pneumonia^ is not to be appreciated during life. 
 
 But in the advanced stages of these diseases, a curious simi- 
 larity in physical signs may be observed : the contraction of the 
 chest after the cure of empyema has been long known, but it is 
 not generally understood, that the same circumstance may occur 
 in chronic pneumonia ; the analogies of disease would lead us to 
 anticipate this result, but I am not aware that the fact has been 
 noticed by any writer.i" "We may observe it in cases where the 
 lung has been long indurated, and still continuing impervious, 
 and it may even co-exist with a gradual, and ultimately perfect 
 resolution of disease. I have observed this, particularly in a 
 case of asthenic pneumonia, which was under my daily observa- 
 tion for nearly three months, and in which the contraction was 
 as great as in any case of empyema that I have seen. In this 
 case there was not the slightest appearance of liquid effusion 
 into the cavity of the pleura, and the only difference between 
 the contraction here, and that of empyema, was, that it seemed 
 to affect the whole side more than what is generally found in 
 pleurisy. 
 
 In other cases, however, the contraction is very similar to 
 that of empyema ; it occurs in the lower j)ortiou, the ribs are 
 approximated, the angle of the scapula, as it were, tilted out, 
 and the sound on percussion comparatively dull, with feeble 
 respiratory murmur. In all cases of this contraction which I 
 have observed, the primary disease had been of the typhoid 
 character, and the contraction seemed to result from that slow- 
 ness of resolution, so remarkable in this affection : — 
 
 [I have already alluded to a not unfrequent case of con- 
 solidation of the lung in which the signs of the earlier stages of 
 pneumonia being wanting, there may arise a difficulty in the 
 differential diagnosis between this lesion and effusion into 
 
 * I am satisfied that both enlargement and subsequent contraction of the side may 
 occur in plastic pneumonia. In the case of a young gentleman under my care, the 
 right side was much enlarged, and the liver displaced during the illness, while after 
 convalescence it became equally contracted. See also the case of Eliza Helson — 
 Appendix, (Ed.) 
 
 t See Walshe, p, 354.
 
 PNEUMONIA. 297 
 
 the pleura; whether we are to consider such as cases of true 
 pneumonia, is a question which we must hereafter examine. 
 
 It was long considered, that in the ahsence of enlargement of 
 the side, no difficulty could arise, this sign belonging exclu- 
 sively to empyema ; while there was nothing in pulmonary 
 consolidation that could produce it. Subsequent researches, 
 however, have discovered that we may meet with the signs of 
 eccentric pressure even in a case of pneumonia. 
 
 It is no doubt true, that in the greater number of cases of 
 pneumonia, no enlargement of the side, or other signs of eccen- 
 tric pressure, sufficient at least to be detected, ever occurs ; a 
 fact of great importance in practical medicine. But that even 
 in ordinary hepatization some swelling of the lung takes place 
 is probable from the fact, first observed by Broussais, though 
 denied by Laennec, that depressions corresponding to the ribs 
 are to be seen on the surface of the solid lung. I have verified 
 this observation of Broussais ; but to produce such depressions 
 a very small amount of swelling of the lung is necessary. 
 
 More recently, Grisolle has advanced the opinion that inde- 
 pendently of pleuritic effusion, an inflamed lung may cause 
 general or partial dilatation ; in one of his patients, slight 
 bulging of the infra-clavicular region (the disease occupied the 
 upper lobe, and especially its anterior part) was detected on the 
 patient's admission, the third day of the afiection. This bulging 
 gradually increased with the progress of hepatization. M. Gri- 
 solle considers himself justified in referring its appearance to 
 the inflammation of the lung ; the post mortem examination 
 proved the absence of pleuritic effusion. In another instance, 
 l)ulging of the infra and post clavicular regions was observed to 
 subside gradually with the resolution of the disease. 
 
 Dr. Walshe, from whom I quote, properly observes, that 
 neither of these cases proves the fact of general expansion — as 
 is admitted by Grisolle — though, as far as they go in establish- 
 ing that of partial expansion, there seems no plausible objection 
 to the cases, but thinks that we must have more evidence before 
 the general expansion can be considered as established. 
 
 But the question of general enlargement, as occurring at 
 least in one form of pneumonia (the plastic, or that accompanied 
 by a copious fibrinous exudation) has been set at rest by 
 Professor Smith, in a communication made by him to the
 
 298 PNEUMONIA. 
 
 Pathological Society of Dublin in 1840. A man, aged fifty, was 
 admitted into the Kichmond Hospital complaining of dyspnoea, 
 cough, and acute pain of the side. His expectoration was puru- 
 lent. His health had been deranged for three months pre- 
 viously, and the symptoms under which he had laboured had 
 existed in a mitigated form; but shortly before admission he 
 was suddenly attacked with acute pain in the side, increase of 
 cough with dyspnoea, and purulent expectoration. The entire of 
 the afi"ected side was perfectly dull on percussion, with extensive 
 muco-crepitating rale, and bronchial respiration. Over the oppo- 
 site side the respiratory murmur was distinct. He died two 
 days after his admission into hospital. On inspection, Professor 
 Smith was struck with the great difference between the two 
 sides of the chest, the right side being fully an inch and a-half 
 in circumference more than the left, and the hepatic region was 
 extremely full, giving the appearance as of enlargement of the 
 liver. The right pleural cavity was found to be completely 
 obliterated ; the lung solid and of unusual size pressed down the 
 diaphragm, so as to displace the liver, and also intruded upon 
 the left lung. Although the left lung was emphysematous, it 
 was not more than half as large as the right. On cutting into 
 the right lung a remarkable modification of grey hepatization 
 was everywhere predominant, and on the cut surfaces were 
 observed a countless multitude of yellow granular bodies, 
 each circumscribed in a distinct cavity lined by a membrane. 
 These bodies possessed a considerable degree of firmness, 
 their external coating being found to consist of coagulable 
 lymph, while their interior was soft and composed of pus in 
 various states of fluidity. It was easy to ascertain that the cells 
 in which these globules were deposited were the air cells. The 
 granules could be picked out of them with the point of a needle ; 
 but in picking them out it was perceived that some portions of 
 the granule were more adherent than the rest. These points 
 of adhesion presented a fine pedicle which stretched into a minute 
 ramification of the bronchia. Professor Smith observed that 
 though he had succeeded in tracing the projection into the 
 ramifications, he believed that the arrangement was general. 
 The air cells were, in fact, enlarged, and filled with lymph in a 
 state of considerable solidity, and when it was considered that 
 the whole substance of the lung was thus engaged, it would be
 
 PNEUMONIA. 299 
 
 easy to understand how the lung was enlarged in every direc- 
 tion. It was obviously twice as large as its fellow, and the 
 impressions of the ribs, on the surface of the lung, were unusually 
 deep. 
 
 In this case, the most conclusive of any on record which bear 
 upon the point at issue, we see a general enlargement of the 
 lung, causing such eccentric pressure as to dislocate the liver, 
 and extrude the mediastinum. The state of the intercostal 
 spaces is not noted, but the physical signs of the disease cor- 
 respond to those of empyema, with the exception of the exist- 
 ence of general muco-crepitating rale. 
 
 The disease was probably chronic, though the patient's death 
 was induced by an exacerbation of the affection. It will be seen 
 that the disease was one of a chronic and truly plastic pneu- 
 monia, a croup, as it were, of the cells and minute tubes. It 
 was essentially a disease of accumulation and an engorgement, 
 as it were causing an accumulation of lymph and pus, not in 
 the pleurae, but in the air cells of the lung. It is difl&cult to 
 say why this affection is not of more frequent occurrence, but it 
 appears more than probable that many of the cases in which a 
 granular condition is exhibited by the hepatized lung, are exam- 
 ples of the early stage of the affection, in which, had the patient 
 lived long enough, the simulation of empyema by the increasing 
 pressure of the enlarged organ would certainly have occurred. 
 
 The condition of lung described in the preceding cases has 
 been noticed by various authors. I have myself, in the year 
 1833, recorded a case in which the granular condition of the 
 lung was observed, while at the same time a suppurative process 
 had dissected the lung from the pleura, so that the pulmonary 
 cells, hanging in groups like bunches of grapes, lay bathed in 
 purulent matter. The researches of Reynaud, Andral, Williams, 
 and others may be also referred to on this subject ; and more 
 lately Dr. Blakiston has described cases which he terms acute 
 and chronic plastic pneumonia, in which granulations in great 
 quantity, easily separable from matrixes, existed in the lungs ; 
 but neither Dr. Blakiston, nor other writers on this variety, have 
 connected with it the important sign of dilatation of the side. 
 
 It appears to me extremely probable that there exist two 
 forms of sthenic pneumonia, just as we see two forms of 
 bronchial inflammation. In the one coagulable lymph is
 
 300 PNEUMONIA. 
 
 secreted on tlie internal surface of the cell, which is admitted 
 to be a white tissue, and which there takes the form, while it 
 distends its containing sac ; in the other, either all the structures 
 are simultaneously engaged, or the force of the disease is thrown 
 on the intervesicular cellular membrane. In these latter cases 
 the production of lymph, and its accumulation in the cells, is 
 either wanting or takes place in a comparatively trivial degree. 
 There is no perceptible enlargement of the lung during life, but 
 that some augmentation has occurred appears probable from the 
 existence of the costal depressions on the surface of the inflamed 
 lung. 
 
 I have already stated my belief in the correctness of Broussais' 
 opinion, that the tumefaction of the lung in pneumonia, although 
 not sufficient to be discovered by measurement, is the cause of 
 these markings in many cases ; for as less pressure is exercised 
 in the intercostal spaces than on the ribs, depressions are pro- 
 duced corresponding to the ribs themselves. 
 
 Contraction of the side from diminished volume of the lung is 
 a phenomenon more frequent in chronic than in acute pneu- 
 monia. I have, however, witnessed its occurrence during the 
 convalescence from some forms of the acute disease ; an example 
 of which was given in the former edition of this work. 
 
 In this case, which was under my daily observation for three 
 months, the contraction was as great as in any case of empyema 
 that I have ever seen, the only difference being that it seemed to 
 affect the whole side more than is generally found in pleurisy. 
 In other cases, however, the contraction was very similar to that 
 of empyema, occurring in the lower portion, the ribs being 
 approximated, the angle of the scapula, as it were, tilted out, 
 and the sound on percussion comparatively dull with feeble 
 respiratory murmur. 
 
 Dr. Walshe confirms the above observation by a case of ex- 
 tensive pneumonia of the left side, in which indisputable de- 
 pression of the latero-anterior part of the chest gradually took 
 place during the progress of recovery. And he meets the 
 objections of Woillez and Grisolle, who maintain that such 
 depression can only originate from pleuritis. " Perhaps, all 
 things considered, the most efficient agent in producing de- 
 pression of the chest after pleurisy is the contraction of the 
 plastic matter exuded on the pleural surfaces. Why should not
 
 PNEUMONIA. 301 
 
 the same contraction (occurring as a law of its existence) of 
 exudation poured into the substance of the lung cause similar 
 alteration in the form of the thorax ? " "It appears curious that 
 M. Grisolle, who professes to have seen the size of the lung 
 enlarged by interstitial exudation solely, gi-adually return to its 
 natural state, should maintain depression of the surface to be 
 impossible. What is to prevent the tendency to diminution of 
 bulk from gi-adually bringing the lung to a less volume than in 
 health ; and this once effected, will not depression of the parietes 
 inevitably follow ? " My own opinion is that atrophy of the lung 
 tissue is a cause of depression more influential than is com- 
 monly supposed. Were the contraction of plastic exudation the 
 sole, or even the principal cause of depression of the side after 
 empyema, it would be difficult to understand the return of 
 expansion, so often witnessed in young persons who have re- 
 covered from that disease. I therefore believe that this de- 
 pression is in such cases due rather to non-expansion of the 
 lung than to the presence of an exudation whose tendency would 
 be to go on contracting. — Author's Note Book.] 
 
 RECAPITULATION. 
 
 I. That in the first stage, the physical signs seem often to be, 
 puerile or exaggerated respiration, with clearness of sound on 
 percussion, preceding the crepitating rale. 
 
 n. That in the second stage, Laennec's first, the signs are 
 the crepitating rale, the gradually diminishing respiratory mur- 
 mur, and the comparative dulness of sound on percussion. 
 
 III. That in some forms of the disease the signs of the third 
 stage (Laennec's second), namely, dulness on percussion, bronchial 
 respiration, and bronchophony, may occur without being preceded 
 by the crepitating rale of the second. 
 
 IV. That the diminution of bronchial respiration, in extensive 
 solidification, may indicate an increase of the disease ; while its 
 return may indicate returning permeability, produced either by 
 local resolution, or by abscess communicating with the bronchial 
 tubes. 
 
 V. That perfect dulness may be suddenly replaced by tym- 
 panitic clearness over the solidified portion, without any appre- 
 ciable change in the condition of the part ; and that in these 
 cases the clearness appears and disappears in a sudden manner.
 
 302 PNEUMONIA. 
 
 VI. That in the fourth stage bronchial respiration is generally 
 combined with sharp muco- crepitating rale, and complete dulness 
 of sound. 
 
 VII. That the signs of pneumonic abscess do not differ from 
 those of tubercular cavities, but that the diagnosis is to be 
 drawn from their history, situation, and rapidity of formation. 
 
 Vin. That the formation of pneumonic abscess is preceded 
 by more complete and extensive dulness than that of phthisical 
 cavities. 
 
 IX. That pneumonia may resolve either in its acute or 
 chronic form without the crepitus of resolution. 
 
 X. That when this sign exists, it may be combined with, pre- 
 ceded or followed by the natural respiratory murmur. 
 
 XI. That the muco-crepitating rale in the fourth stage is 
 to be distinguished from that of resolution by its sharper and 
 more viscid character, but principally by its combination with 
 bronchial respiration, great dulness of sound, and the signs of 
 extension of disease in other parts of the lung. 
 
 XII. That notwithstanding the frequency of adhesions, the 
 friction sound is comparatively rarely observed in pneumonia. 
 
 XIII. That in certain forms of the disease appreciable enlarge- 
 ment of the side may occur, with eccentric displacement of other 
 organs. 
 
 XIV. That while, therefore, in a large majority of cases the 
 absence of the signs of displacement of the heart, diaphragm, or 
 intercostals, with the phenomena of voice, are sufficient, taken 
 along with the previous history to distinguish between universal 
 solidity of the lung and empyema, the diagnosis is not equally 
 certain in cases where an extensive fibrinous deposit takes place 
 in the lung, producing all the signs of accumulation. 
 
 XV. That diminished volume of the lung and depression of 
 the side may occur under certain conditions, more especially in 
 the slow convalescence from asthenic forms of pneumonia. 
 
 XVI. That with respect to the circulating system two remark- 
 able signs have been observed, viz., a bellows sound over the 
 heart and anterior portion of the chest, and a throbbing of the 
 lung analogous to that of aneurism. 
 
 XVII. That the secretion of air into the cavity of the pleura 
 is pointed out by the sudden appearance of tympanitic resonance 
 over the affected portion of the lung.
 
 PNEUMONIA. 303 
 
 XVIII. That this sound has an essentially different character 
 from the bruit de pot fele of caverns or of solidity, and that it 
 also differs from stomachal clearness.* 
 
 ACUTE ASTHENIC INFLAMMATION OF THE LUNG. 
 
 This is the disease to which the term typhoid or putrid pneu- 
 monia has been given ; and there is still a great difficulty in 
 drawing the line between it and consolidation of the lung occur- 
 ring in the course of and clearly secondary to typhus fever ; but 
 this much is certain, that in many cases signs and symptoms of 
 pneumonic inflammation set in at a very early period of a case, 
 which, whether it be typhus fever or not, exhibits two apparently 
 opposite conditions, the one great activity or malignity of pul- 
 monary inflammation, and the other the symptoms of prostration 
 in a marked degree. 
 
 We have had abundant opportunities of observing this disease 
 in Ireland, and its frequency may in part be explained by the 
 tendency of so many local inflammations and other diseases to 
 assume of late years the typhoid condition. We cannot say 
 that there is any specific typhoid pneumonia, but we find that 
 under a variety of depressing circumstances, conditions of the 
 lung more or less analogous may be induced, presenting the 
 characters of the disease as given by various authors. 
 
 The occurrence of this disease as affecting great numbers in 
 a particular locality was observed in this city some years since, 
 and its history is full of interest. The persons attacked were 
 young and healthy men, privates in the constabulary force, who 
 were quartered at the then newly-erected barracks in the Phoenix 
 Park. It may be mentioned, as bearing on the question, how 
 far the typhoid character of disease in Ireland is attributable 
 to deficient nutriment and lodging, that the disease appeared in 
 a large body of young men who were well fed and clothed, and 
 might be considered as possessing the greatest strength and 
 vigour. 
 
 It is a remarkable circumstance, that at the time of the ap- 
 pearance of this disease many cases of another and extraordinary 
 
 * The introduction of new matter derived from Dr. Stokes' MS. into this chapter 
 has necessitated several alterations in the above summary as it appeared in the former 
 edition. (Ed.)
 
 304 PNEUMONIA. 
 
 affection was observed in the poorhouses and hospitals in and 
 near Dublin. I allude to the cerebro- spinal arachnitis, of which 
 accounts have been given by Drs. Darby and Mayne, and it is 
 important to mention that several cases of this disease occurred 
 in the force contemporaneously with those of the pneumonia. 
 
 The general characters of this latter disease were suddenness 
 of invasion and great rapidity of progress. The lung rapidly 
 passed into hepatization, yet the symptoms were not those of 
 sthenic pneumonia ; the pulse was often rapid and weak, and 
 the countenance pallid and collapsed. It was found that the 
 patient bore any reducing treatment badly, and the resolution of 
 the disease was singularly slow in many cases, especially in those 
 in which venesection had been employed. 
 
 The character of the disease was much more that of the 
 diffuse or erysipelatous than the more sthenic form, suppuration 
 rarely occurred, the fatal cases appearing to run a course too 
 rapid for the production of this condition. 
 
 The principal differences between this disease and the mani- 
 festly secondary affection of typhus may be stated to be — 
 
 I. That the symptoms, particularly those of pain and dyspnoea, 
 occur at a much earlier period of the case. In some instances, 
 indeed, the disease sets in with these symptoms, while in others 
 they appear after one or two days of general ailment. 
 
 II. That the whole character of the disease seems to be closely 
 related to the local lesion, that is to say, its severity increases 
 with that of the pneumonia ; while, on the other hand, the 
 mitigation of the pulmonary symptoms is attended with corre- 
 sponding improvement in the general condition. 
 
 III. The constitutional symptoms do not correspond exactly 
 to those of typhus fever ; petechia may be absent, while the 
 other symptoms are principally those of prostration. The patient 
 complains of great weakness, the countenance is generally sunken, 
 and the surface may be cold ; headache, delirium, and vomiting 
 are often frequent, the pulse is generally rapid and feeble, with 
 weak action of the heart, and the tongue may be clean. In other 
 cases, the skin is hot and dry, with tenderness of the epigastrium, 
 furred tongue, and high-coloured urine. 
 
 It is, however, certainly true that in many of these cases the 
 constitutional symptoms singly considered have the closest 
 resemblance to typhus fever.
 
 PNEUMONIA. 305 
 
 The expectoration is by no means so characteristic as in 
 ordinary pneumonia ; it may be purely catarrhal, or of a mixed 
 kind, consisting of catarrhal and pneumonic sputa. Dr. Hudson 
 has noticed the occurrence of red viscid patches floating in serum ; 
 and I have seen the expectoration consist of a bloody serum, 
 with shreddy patches floating in it. This occurred in a case in 
 which a gangrenous cavity formed, and the expectoration became 
 ultimately sanious and foetid. The same condition has also 
 been noticed by Dr. Hudson, and in a similar case. 
 
 That in this disease a true inflammatory process is present 
 appears plain when the pathological appearances are considered. 
 The pleurae are found covered with coagulable lymph, red and 
 grey hepatization of the lung, often of great extent, are commonly 
 observed, and we have noticed also the granular appearance of 
 the cut surface ; this appearance, however, may not be so well 
 marked as in ordinary pneumonia. The lung is friable, and the 
 bronchi generally of a deep red colour. Finally, as Dr. Hudson 
 remarked, the physical signs may be rapidly modified by local 
 antiphlogistic treatment (as by cupping). 
 
 On the other hand, the deeper colour of the lungs, occurrence 
 of petechial spots on the heart, and the greater liability to 
 gangrenous action, all indicate a state of the system different 
 from that in ordinary sthenic pneumonia. 
 
 Of the occurrence of foetid expectoration and breath, coincident 
 with the signs of a cavity, I have seen one remarkable instance, 
 which occurred in the Meath Hospital. This case has been 
 published by Dr. Hudson in the memoir already referred to. In 
 another case given by the same gentleman the patient recovered, 
 although he had presented all the signs of a gangrenous cavity. 
 
 Like all the other varieties above mentioned, we observe re- 
 markable differences in the physical signs in this disease, more 
 especially we observe that the signs of consolidation may appear 
 without having been preceded by the crepitating rale, and this in 
 a manner so rapid, and over so large a surface, as to closely 
 resemble those of pleuritic effusion. In fact, a few hours only 
 may intervene between the period when the lung was clear on 
 percussion and without rale, and that, when it has become 
 absolutely dull, with well-marked bronchial respiration and reso- 
 nance of the voice. 
 
 It is not to be understood, however, that in all cases of this 
 
 X
 
 306 PNEUMONIA. 
 
 disease the signs are developed in this unusual manner for in 
 many the crepitus will be found to precede the dulness. In one 
 remarkable case it was found that before any crepitus was heard 
 there was great feebleness of the vesicular murmur all over the 
 right side ; in fact, it was nearly absent in the upper and anterior 
 portions ; but on the following day these parts presented the 
 crepitating rale, the right lung in almost its entire extent became 
 solid before death, the disease appearing to advance from above 
 downwards. 
 
 In the difficulty which will sometimes arise in distinguishing 
 this form of hepatization from pleuritic effusion, in consequence 
 of the non-existence of previous crepitus, a consideration of the 
 following points may assist us. 
 
 I. That in this country typhoid pneumonia is a much more 
 common affection than typhoid pleurisy. 
 
 II. The signs of consolidation are often developed from above 
 downwards, so that while the dulness and bronchial respiration 
 exist either in the middle or the upper portion of the lung, or 
 in both, the lowest may yet be clear on percussion, and give no 
 sign beyond feebleness of respiration. 
 
 m. (Egophony will be absent. 
 
 IV. In many cases, at least, a deep inspiration will develop 
 a rale over the dull portion. 
 
 V. We may be assisted by considering the general characters 
 of the disease, and the appearance of the expectoration. 
 
 VI. In most of the cases of this disease the existence of the 
 signs of bronchitis, to a considerable amount, will aid in the diag- 
 nosis. The complication with bronchial inflammation is much 
 more constant and important in acute diseases of the parenchyma 
 of the lung than in those of the pleura, at least in the early 
 periods. 
 
 In some of the most remarkable cases of this disease which 
 have been observed at the Meath Hospital, the upper lobes of 
 the lung were the parts first and principally engaged ; we cannot 
 even offer a suggestion to explain this curious circumstance. 
 The inflammatory process does not appear to have the same 
 degree of tension as in the ordinary cases, and resolution is 
 often slow, uncertain, and vacillating, not unfrequently accom- 
 panied by slight attacks of dry pleurisy, indicated by the occur- 
 rence of friction signs before alluded to. The local symptoms.
 
 PNEUMONIA. 307 
 
 such as pain, are generally better developed than the constitu- 
 tional, which are sometimes slight ; prostration, and a low, but 
 apparently not important fever, being the principal phenomenon. 
 I incline to the opinion that the disease seldom, at least when 
 it has been recognised, and treated at a sufficiently early period, 
 runs on to the fourth or fifth stages. 
 
 It happens not unfrequently, when the disease has engaged 
 the upper lobe, and that the patient is not seen until after the 
 first symptoms have subsided, while the lung remains in a state 
 of semi -solidity, that an erroneous opinion is formed as to the 
 nature of the disease. The dulness, the want of healthy vesi- 
 cular murmur, and the existence of a muco-crepitating rale, 
 all closely resemble the signs of tubercle, and it is at once con- 
 cluded that the patient's case is hopeless ; in a few daj's, how- 
 ever, the physical signs disappear, even although no curative 
 treatment may have been adopted, and a perfect recovery takes 
 place. 
 
 A similar error is often committed in cases of circumscribed, 
 or even general pleuritic effusion, and it mainly arises in both 
 instances from the neglect of considering the physical signs in 
 their relation to time. The duration of the illness may have 
 been but a few days ; the period at which there were no symp- 
 toms or signs of pulmonary affection may be quite recent. If 
 the physical signs proceeded from tubercle they would indicate a 
 great amount of disease, an amount which would imply a long- 
 continued process, and which would be probably accompanied by 
 important symptoms. But if the observer did not allow himself 
 to be misled by the similarity of the signs to those of tubercle, 
 but corrected his observation by reference to the actual duration 
 of the disease, he would avoid the error so often committed of 
 mistaking a recent, and even spontaneously, curable disease, for 
 such an affection, as the tubercular degeneration of the whole or 
 even a large portion of the one lung. 
 
 ACUTE ASTHENIC PNEUMONIA WITH INDUEATION OF THE LUNG. 
 
 This is a singular form of disease which has only recently 
 attracted much attention. Induration, as contrasted with the 
 soft solidity of ordinary solidification, has been hitherto held to 
 result from a chronic process; there is no doubt that under 
 
 x2
 
 308 PNEUMONIA. 
 
 certain circumstances an acute induration of the lung may be 
 produced. 
 
 In the commencement of the year 1841, Dr. Corrigan brought 
 before the Pathological Society of Dublin a case which he desig- 
 nated as a rare form of pneumonia. The symptoms were 
 decidedly asthenic, and the patient, a female, had been largely 
 blooded before coming under his care ; so great was the debility 
 that stimulants had to be exhibited from the first period of her 
 admission into hospital. The diseased portion of the lung 
 was of a deep blue, bordering on purple ; it did not crepitate 
 under the finger, and in general it was found that it sank in 
 water ; there was no efi'usion of lymph on the pleura, and no 
 appearance of purulent secretion. Another case of the same 
 kind was communicated by Dr. Corrigan during the same ses- 
 sion. The patient, a lad aged fourteen, was six days ill on 
 admission. His surface gave the sensation of the calor mordax ; 
 pulse 140, and the respiration sixty in the minute ; he had 
 cough and extreme pain in the side. The posterior portions of 
 both lungs were dull on percussion, with some crepitus; these 
 signs were succeeded by extensive bronchial respiration over the 
 dull portions, as high as the spines of the scapulae, with bron- 
 chitic rales over the remaining portions of the chest. The lung 
 in this disease presents a dark blue colour, which, according to 
 Dr. Corrigan, is very evanescent, and disappears within a few 
 hours after the parts have been removed. The diseased lung 
 was firm, heavy, and sank in water ; when grasped feeling like 
 muscle ; there was no trace of red or grey hepatization. 
 
 Dr. Corrigan observes that this disease is remarkable for its 
 bad and intractable character, and from its being accompanied 
 by that state of the vessels characterised as the state of passive 
 congestion. The diseased lung differs from the carnified lung in 
 retaining its original bulk. In carnified lung the pressure of the 
 liquid expels not only the air, but also the blood, and there is 
 consequently a considerable reduction in size. All these cir- 
 cumstances and the resistance of the disease to treatment, would 
 go to establish the existence of a peculiar form of disease. 
 
 I have now witnessed a considerable number of cases con- 
 firmatory of these opinions. Shortly after the period of Dr. 
 Corrigan's communication I submitted to the Pathological 
 Society two specimens of acute induration of the lung, one from
 
 PNEUMONIA. 309 
 
 a case which I myself witnessed, the other occurring in the 
 practice of Dr. Lees. In my case the patient was a child, and 
 the disease was found totally unamenable to treatment. The 
 lung was firm and solid, grey, exceedingly tough, and not exud- 
 ing any quantity of blood on being cut. There was no lymph on 
 the pleura, and, in fact, none of the characters of ordinary acute 
 hepatization. The disease had lasted about a fortnight, when 
 the patient sunk apparently from exhaustion. 
 
 In Dr. Lees' case, the patient, who had suffered from hepatic 
 disease in India, was attacked with inflammation of the lung, 
 and notwithstanding the production of full mercurial action, the 
 disease proved fatal on the eighth day. The lung was solid, 
 exceedingly heavy, and of an iron-grey colour, such as we might 
 find in a case of chronic pneumonia. The cut surface was not 
 granular, and the lung, so far from being friable, required great 
 force to break it down. There was no trace of lymph on the 
 pleura. The crepitus which ordinarily precedes pneumonia did 
 not occur in this case, and this we have observed in several other 
 instances. 
 
 Dr. Corrigan inclines to the opinion that a stasis of blood 
 owing to local debility of the vessels is the principal pathological 
 element of the disease. And Dr. Gordon, in a recent memoir 
 on this form of pneumonia, says, " The physical signs are very 
 constant ; there is a dull sound on percussion over the affected 
 portion of the lung or lungs, and at first very feeble respiratory 
 murmur, which, however, maintains somewhat its vesicular cha- 
 racter, but soon becomes very decidedly bronchial. The peculiar 
 crepitus of vesicular pneumonia is never audible. If the patient 
 recovers, the progress of the physical signs is very remarkable ; 
 sometimes within twenty-four hours the extreme bronchial 
 respiration and bronchophony are replaced by a feeble or even 
 ordinary vesicular murmur, proving that the air cells merely 
 suffered obliteration from pressure, which being removed, they 
 again expanded." 
 
 COMBINATIONS OF PNEUMONIA. 
 
 Under this head, we shall examine some of the cases in which 
 acute pneumonia is rendered, if not latent, at least obscure,[by 
 the co-existence of other acute diseases, which affect either^ the 
 entire system or present themselves in groups of local irritations.
 
 310 PNEUMONIA. 
 
 The rule that the existence of several points of irritation in the 
 whole system modifies the proper symptoms of any one of 
 them is of course found to be true in lung disease as well as in 
 other afi'ections, and as pneumonia may occur as a complication 
 in a great number of acute general or local diseases, so we have 
 an extensive catalogue of cases, the symptoms of which, so far 
 as the disease of the lung is concerned, are extremely various. 
 
 It may occur in cases of fever, delirium tremens, arthritis, 
 gastro-enteritis, erysipelas, and many others, in all of which 
 there is more or less of latency, quoad, the proper symptoms of 
 the affection. 
 
 But so far as the physical signs are concerned, this may be 
 said, that they remain if not wholly, nearly as well developed 
 as in cases of the simpler forms of the affection. Indeed, in 
 these cases the disease is only overlooked from ignorance of the 
 liability to it which exists, and from the neglecting to make a 
 physical examination of the lungs, on the grounds that the 
 prominent symptoms of the case happen not to be those of 
 pneumonic inflammation. 
 
 THE PNEUMONIC COMPLICATION OF TYPHUS. 
 
 The pulmonic complications of typhus may be observed under 
 three forms : in the first, bronchitis exists for a few days and 
 passes ultimately into a pneumonia, the lower part of one side 
 becoming gradually dull with a humid crepitus ; in the second 
 variety we observe no difference in the mode of invasion or the 
 physical signs, from those of the ordinary disease ; while the 
 third presents that form of sudden solidification which we are 
 now to consider, namely, the asthenic consolidations of the lung 
 occurring in typhus — and manifestly belonging to the secondary 
 phenomena of that disease. 
 
 Although we describe this lesion under the general head of 
 pneumonia, and though in the first edition of this work I have 
 designated it as typhoid pneumonia, yet it may be questioned 
 whether this is in reality a form of pneumonia, or is not rather 
 the filling up of the lung by the typhic deposit in a non-concrete 
 form accompanied by more or less congestion. Analogy would 
 teach us that in such a condition when inflammation takes place 
 it is of the same kind as that observed in the secondary gastro-
 
 PNEUMONIA. 311 
 
 intestinal affection, and truly of a reactive nature, deposit having 
 first taken place in the tissue of the organ. These cases are 
 perhaps of a mixed nature, but unquestionably they follow, in 
 many instances, the course of the secondary diseases of tj^phus, 
 and the inflammatory conditions which follow them have the 
 characters of the dothin-enteritis, which, when arising in typhus, 
 at least is secondary not only to the general, but also to the local 
 disease. 
 
 The chain of phenomena may be arranged as follows, fever 
 (essential typhus), deposit (with or without accompanying con- 
 gestion), inflammation (reactive, low, tending to gangrene). 
 
 The history and symptoms of these affections of the lungs in 
 typhus are more easily understood by adopting this view, than 
 by the supposition of an inflammation arising in a lung pre- 
 viously unaltered. 
 
 If we pass in review the circumstances in which the disease 
 often occurs, and compare them with the ordinary conditions of 
 acute primary pneumonia, we cannot help admitting that they 
 indicate a morbid state of a very different nature. 
 
 In the first place the signs of pulmonary disease are preceded 
 by fever, it may not be until many days have elapsed that 
 symptoms of lung disease set in ; secondly, this fever is ob- 
 viously an essential fever, existing without or with petechise, and 
 it may be without or with other complications ; thirdly, the 
 disease sets in as it were spontaneously, and without any 
 external exciting cause ; fourthly, its invasion, though often 
 unaccompanied by new symptoms at first, is sudden, and signs 
 of consolidation are among its very earliest physical phenomena ; 
 fifthly, well-formed concrete or non-concrete purulent matter is 
 rarely if ever produced ; sixthly, there is a tendency to gan- 
 grene — in some cases large eschars form in the lung with great 
 rapidity ; seventhly, we remark a greater liability to bronchial 
 complication in typhus with pneumonia than in the primary 
 sthenic inflammation ; eighthly, in most cases the condition of 
 the heart is different, it is either not excited in any remarkable 
 way, or it may exhibit towards the close of the case, what may 
 be called the typhous excitement of the heart. Typhus softening 
 of the heart is, however, so far from being peculiar to this con- 
 dition that the best marked cases have occurred, rather in the 
 bronchial, than the pneumonic complication of the disease.
 
 312 PNEUMONIA. 
 
 John Peter Frank has described a form of the disease to 
 which he has given the name of Peripneumonia nervosa : he 
 considers it to be a combination of nervous fever with inflam- 
 mation of the lung. The disease according to him is sometimes 
 epidemic, causing the most terrible ravages. It sets in w'ith 
 extreme prostration, pallor of the face, terror, and other 
 symptoms of the " versatile or stupid nervous fever," rigors, 
 followed by dyspnoea, with a frequent cough and scanty ex- 
 pectoration of serous, bloody, or sanious sputa are among the 
 first symptoms accompanied by a severe pungitive pain of the 
 chest, which is exasperated by the slightest touch, and is so 
 severe as almost to suspend respiration. The nervous symptoms 
 are severe pain in the head, particularly in the occiput, vertigo, 
 furious delirium, continued want of sleep, subsultus tendinum 
 and hiccough, bilious symptoms supervene, and dark coloured 
 ptechise, miliary eruptions, and fatal hasmorrhages may occur. 
 The blood is in general without cohesion, and the pulse either 
 not excited or frequent, small, and very variable ; and the patient 
 may sufi'er from excessive thirst, faintings, and aphthae of the 
 mouth. 
 
 It is very difficult to draw a line between the disease described 
 by Frank and typhus fever with pulmonary complication, our 
 knowledge of the connexion between the typhus and local 
 disease is still too imperfect to enable us to declare whether this 
 disease is not an example of the secondary efl'ect of typhus deve- 
 loped at an unusually early period, a state, in fact, the reverse of 
 what commonly happens, namely that the constitutional precedes 
 the local affection. In the case Avhich we have just now ex- 
 amined, the after symptoms of typhus did not appear, so that it 
 would seem to establish that under particular circumstances 
 inflammation of the lung may induce a train of neurotic symp- 
 toms of great severity which are purely sympathetic. 
 
 COMPLICATION WITH DELIRIUM TPvEMENS. 
 
 This combination is observed so far as I know only in the 
 cases of delirium tremens from excess ; there is no reason for 
 believing that it arises in the more purely nervous form of the 
 disease which is caused by want of stimulus, and even in the 
 first variety, I apprehend that it is a rare occurrence, unless the
 
 PNEUMONIA. 313 
 
 patient be labouring under symptomatic fever, or as we have 
 sometimes seen, a combination of the symptomatic fever of 
 delirium tremens with typhus. 
 
 In almost all the cases of the disease that I have seen, the pneu- 
 monia, though a very important element in the case was but one 
 of a group of inflammations ; and disease cc-existed in the brain, 
 heart, digestive organs, bronchi, pulmonary tissue, and pleurae. 
 The general condition was more or less typhoid, and the symp- 
 toms so complicated and multifarious as to be incapable of being 
 reduced to any nosological formulae. The nervous symptoms 
 were seldom so well developed, as in simpler cases of the disease, 
 but delirium sometimes violent, and at other times of the low 
 and muttering character, convulsion and tremor were often 
 present ; there appears to be less of sleeplessness or watchfulness 
 than in ordinary cases, and stupor or a semi-comatose sleep 
 might occur not followed by any subsidence of the symptoms. 
 
 In cases such as I have described, the pathological condition 
 of the lung resembles that of the asthenic or typhoid forms of 
 disease ; this may arise from the previously depraved state of 
 the patient's constitution. I once saw, however, a case in which 
 violent pneumonia associated with other inflammations occurred 
 in a man of a good constitution, and who had previously been 
 sober ; he drank at a debauch committed on his arrival in town 
 a quantity of ardent spirit, which appeared almost incredible. 
 
 He was brought into hospital in a profound coma, from which 
 he could not be roused even by the application of the actual 
 cautery. Next day his senses returned, and he remained for 
 several hours apparently free from disease, when symptoms of 
 the most violent inflammatory fever, soon followed by the local 
 phenomena of many visceral inflammations suddenly exploded. 
 The disease ran a rapid course, and on dissection the brain and 
 its membranes, the spinal cord, the lungs, the pleurse, bronchi, 
 the pericardium, and endocardium, the stomach, intestines, liver, 
 spleen, kidneys, and bladder, were all found in a state of the 
 most intense inflammation. The disease in the lung had entered 
 on the fourth stage, and the character of the inflammation was 
 that of the highest degree of sthenic disease in a healthy 
 subject. 
 
 It need hardly be observed that in most of these cases the 
 lung disease is more or less latent, or only becomes manifest
 
 314 PNEUMONIA. 
 
 when it has attained a very advanced stage. It is therefore most 
 necessary in the management of a case of deUrium tremens from 
 excess, and particularly when there is fever, that careful and 
 repeated physical examinations both of the lungs and heart 
 should be made by the medical attendant.* 
 
 There is a form of pneumonia which bears a close resem- 
 blance not only to the complication of pneumonia with delirium 
 tremens, but also to the latter disease in its uncomplicated form. 
 In other words, pneumonia may be attended by a train of nervous 
 symptoms so similar to those of delirium tremens as to lead 
 easily to an erroneous diagnosis. Of this the following case is 
 an example. 
 
 A man, aet. 29, was admitted March 1st, 1839, with symptoms 
 which were supposed to be those of delirium tremens. He was 
 not violent, but was obliged to be confined by the strait waist- 
 coat, in consequence of his continued efforts to get out of bed. 
 He had considerable tremor and subsultus ; the countenance 
 was wild and anxious ; he had a continual muttering delirium, 
 yet when addressed he answered in a perfectly collected and 
 
 * The following typical case by Dr. Banks of typhoid pneumonia with delirium 
 tremens from excess deserves to be noted as illustrating the latency of symptoms and 
 physical signs in this form of disease. A man aet. forty years was admitted into 
 hospital on the 10th of April, 1850. He stated that he had been drinking spirits 
 freely during the last few days but was not a habitual drunkard. Four days since 
 was attacked by shivering, sickness of stomach, and general depression followed by 
 loss of sleep. He had slight cough with some dyspnoea, husky voice, anxious counte- 
 nance, was uneasy and fidgety, and complained of a stitch in the right side. " The 
 respiration was natural and the whole of the thorax resonant on percussion, with the 
 exception of the base of the right lung, where a certain amoimt of dulness, some 
 feebleness of respiration, and a friction sound were observed." At night he was 
 sleepless and delirious walking about the ward, and " on the following morning it was 
 observed that the dulness which was at first confined to the very base of the lung 
 had extended upwards. No crepitating rale could be heard, but the greater part of 
 the right side was dull on percussion and respiration was totally inaudible." He passed 
 the 11th and 12th without much change, but at 10 P.M. the delmum passed into coma, 
 ending in death at 5 a.m. of the 13th— the third day after admission. 
 
 At the autopsy " the greater part of the right lung was found in a state of solidifi- 
 cation, and in some places had passed into the third stage of pneumonia. On making 
 a section of this lung a number of yellow patches were observed in different portions 
 of the pulmonary structure which broke down under the slightest pressure. Lymph 
 had been effused on the base of the right lung and also on the adjoining pleura." Dr. 
 Banks observed that the existence of pleuritic friction sound rapidly followed by ex- 
 tensive dulness without crepitating rale might have led to the mistake of supposing 
 the case to be one of pleuritis with effusion. The characteristic sputa, the extreme 
 rapidity of the diseased phenomena, and the knowledge of the frequency of the com- 
 plication with delirium tremens led him to the diagnosis of typhoid pneumonia which 
 the autopsy proved to be correct. — Dub. Path. Soc. Transactions, 1850. (Ed.)
 
 PNEUMONIA. 315 
 
 rational manner, and appeared cheerful and contented with him- 
 self and those around him. He had no symptoms of sanguineous 
 determination to the head ; there was no flushing congestion of 
 the eyes or alteration of the pupils ; he did not complain of 
 headache, and the action of the temporal arteries was natural. 
 He had no thirst, yet his tongue was red and dry, but not 
 tremulous ; the belly was not painful, but hard, as if the muscles 
 were in a state of spasm. The pulse was 140 and exceedingly 
 feeble ; the respirations thirty-four in a minute ; he coughed 
 occasionally and expectorated a small quantity of frothy mucous 
 which, though not viscid, had a decided rusty tinge. 
 
 There was no evidence that this patient had been indulging 
 in the use of ardent spirits ; and he was able to give a consistent 
 account of his disease for a short time, when his mind wandered, 
 and he became unable to preserve coherence. He stated that in 
 returning from his occupation, which was that of a coachman, 
 he was suddenly attacked with pain in the right side, followed 
 by cough, and he invariably pointed to the inferior portion of the 
 right side to indicate the seat of pain. He never varied in this 
 statement, which he continued to make after his complete recovery. 
 
 We found the physical signs of pneumonia in the third stage 
 accompanied by a slight friction sound over the postero-inferior 
 portion of the right lung, from the interscapular region down- 
 wards. The patient was treated by blisters, ammonia, and the 
 external use of mercury. The nervous symptoms rapidly sub- 
 sided, and the resolution of the pneumonia, which was very 
 extensive, was complete in about a fortnight after his admission. 
 
 It should be mentioned that the patient was never inoculated, 
 and that want of sleep and optical illusions were present during 
 the early stage of the disease. 
 
 The opinion which 1 formed of this case was, that it was not 
 delirium tremens combined with pneumonia, but rather asthenic 
 pneumonia with true symptomatic nervous symptoms ; and this 
 opinion was founded on the following grounds : — 
 
 I. The want of evidence that the patient had committed 
 excess. 
 
 II. The fact that the symptoms set in with pain in the side. 
 
 III. The manifest existence of pneumonia. 
 
 IV. The want of accordance between the case and those which 
 we have already observed of delirium tremens, in this, that we
 
 316 PNEUMONIA. 
 
 had here but one seat of inflammation, while in the compli- 
 cated cases of delirium tremens we commonly find evidence of 
 irritation in many organs. 
 
 The treatment and complete recovery of the patient warrant 
 the opinion that the original malady was pneumonia, inducing a 
 train of violent nervous symptoms. 
 
 But even in cases where a debauch has been committed, the 
 symptoms of pneumonia may be manifest, and be, indeed, the 
 very first indications of illness. We have seen the most violent 
 pain and other symptoms precede the delirium tremens, and it 
 commonly happens in such cases that the use of copious bleedings, 
 without reference to the previous circumstances of the case, pro- 
 duces deplorable results. The delirium tremens explodes after 
 the symptoms of pneumonia have been well established. The 
 latter disease takes the typhoid type, and the patient sinks from 
 nervous prostration. 
 
 This combination then is of two kinds : — 
 
 I. Pneumonia, generally latent, and combined with other local 
 inflammations, arising in the course of delirium tremens. 
 
 II. Pneumonia, with manifest symptoms, preceding the deli- 
 rium tremens. ' 
 
 ERYSIPELATOUS COMBINATION. 
 
 This, which is one of the most insidious and dangerous forms 
 of disease, is more likely to occur in that low and spreading 
 form of erysipelas, which has got the name of difi"use inflamma- 
 tion, than in the more sthenic and localised varieties of the 
 afi'ection. It is characterised principally by rapidity of invasion, 
 and the speedy consolidation of the lung. 
 
 Anatomically the disease differs from that of ordinary pneu- 
 monia in this, that the pleura is often smeared with a soft and 
 bloody lymph, and the solidified portions, though soft and friable, 
 are not so vascular as in ordinary hepatization, nor does the 
 surface of the incision present the granular aspect, at least to 
 the same degree. I have seen them perfectly smooth, of the 
 palest red colour, and of a somewhat sizy appearance. 
 
 This disease, I believe, may arise primarily in the lung, with- 
 out any external appearance of erysipelas, and it may be looked 
 for during the prevalence of an epidemic of erysipelas, or where
 
 PNEUMONIA. 317 
 
 the disease has become located in the wards of an hospital. I 
 can say little as to the physical signs of its earlier stages, but 
 I believe that consolidation of the lung will be often the first 
 recognizable morbid condition. This afterwards passes into 
 interstitial suppuration. In one case of diffuse inflammation, I 
 observed a dry friction sound over a large portion of the right 
 pleura, but this was not followed by signs of further alteration. 
 
 COMBINATION WITH PURULENT SYNOVITIS AND PERIOSTITIS. 
 
 We owe to the late Dr. Ephraim M'Dowel of this city any 
 knowledge which we possess of this subject. He has described 
 a peculiar form of arthritis attended with a group of special 
 symptoms, and eventuating in the copious production of purulent 
 matter, not only in the cavities of the joints, but engaging the 
 periosteum in their vicinity. These cases do not appear to be 
 examples of phlebitis, although in their progress, the viscera 
 suffer in a manner very similar to that observed in venous 
 inflammation. It was found that in many of these cases, symp- 
 toms of pulmonary irritation supervened, as shewn by cough, 
 dyspnoea, and bronchial effusion ; and on dissection, recent inflam- 
 mation of the pleurae with adhesions was discovered ; the lymph 
 being sometimes in considerable quantities and reticulated, the 
 bronchise inflamed, and the substance of the lung congested, or 
 presenting red hepatization, while numerous small abscesses 
 were discovered, more or less contiguous to the surface. These 
 cavities were sometimes lined by a thin coating of lymph, and in 
 one case the entire of both lungs was inflamed and condensed. 
 
 These cases appear to be not merely examples of purulent 
 absorption and deposition of pus in the lung, but rather of intense 
 pleuro-pneumony, with the singular phenomenon of numerous 
 small abscesses. No physical examination of the lungs in these 
 cases is recorded. The character of the fever and the constitu- 
 tional symptoms bore a striking resemblance to those which 
 accompany inflammation of the lining membrane of the veins. 
 In some instances, vascularity and thickening of the synovial 
 membrane and periosteum were discovered, and the latter struc- 
 ture was frequently extensively detached from the bone, and in 
 one instance was found covered with reticulated lymph resem- 
 bling that seen in pericarditis.
 
 318 PNEUMONIA. 
 
 PUEKPERAL COMBINATION. 
 
 Of this form I have seen a great many examples. Yet the 
 works on obstetrical science are very deficient in accurate 
 observations on the subject. The cases which I have seen are 
 divisible into two classes. 
 
 First, where pneumonia arises, as it were, spontaneously soon 
 after parturition. 
 
 Secondly, where it has been preceded by symptoms of puer- 
 peral fever, with or without the manifest signs of phlebitis. 
 
 The prognosis in the latter variety must be most unfavourable ; 
 and particularly so if the disease arises within the first eight 
 days after parturition, for in addition to the constitutional 
 affection, we have to deal with a pneumonia which has all the 
 intractable character of the diffuse inflammations. 
 
 In the first variety we sometimes observe that on the subsi- 
 dence of the pneumonic attack, phlegmasia dolens of the lower 
 extremities becomes developed. The rule in prognosis seems 
 to be, that if the pneumonia be the first symptom of disease 
 after parturition, we may have more hope than when it has been 
 preceded by the fever with or without the manifest signs of 
 phlebitis. 
 
 A full series of researches on the puerperal inflammations of 
 the thoracic viscera is still a desideratum in medicine. 
 
 COMBINATION WITH GASTRO-ENTERIC AND HEPATIC DISEASE. 
 
 I am not aware that there is anything worthy of special notice 
 in this form of complication, so far as the physical signs of 
 disease are concerned. The symptoms partake of the character 
 of latency, which belongs to all examples of local disease, when 
 there are many seats of irritation co-existing, and this applies 
 not only to the symptoms singly considered, but to their group- 
 ing, and to the character of the fever which attends them. The 
 purely inflammatory fever is seldom seen in this combina- 
 tion, at least in this country, but is replaced by a more or less 
 typhoid form, with or without the presence of bilious symptoms ; 
 and it is often extremely difficult, if not impossible, to distin-
 
 PNEUMONIA. 319 
 
 guish these cases, in which both the pneumonia and enteric 
 disease are but the result of a general malady, and those in 
 which the modifications of each group of symptoms is owing to 
 the mutual reaction of the disease. 
 
 In this form the pain is often trifling, or it may be absent. 
 The expectoration in the second and third stages, at least, is 
 seldom characteristic ; nor is the distress of respiration com- 
 monly observed until the disease has engaged a large portion of 
 the lung, or until some bronchial effusion becomes prominent. 
 I incline to think that the activity of the inflammatory process 
 in the lung is much less than in the sthenic pneumonia. The 
 consolidation is rarely so complete, and it is not in these cases 
 that we are to look, at least generally, for the well-marked signs 
 of the fourth or fifth stages of the disease. 
 
 In such cases the arterial reaction is comparatively feeble, 
 and the whole character of the disease is that of asthenia. The 
 tartar-emetic treatment is seldom applicable, nor can depletions 
 be had recourse to in the same manner that we may employ them 
 in the simple forms of the disease. 
 
 But on the other hand we have seen a case of the distinct 
 combination of enteric inflammation with pneumonia, in which 
 the symptoms were of a high inflammatory character, requiring 
 very active treatment. The combination then does not neces- 
 sarily produce the asthenic character. 
 
 COMBINATION WITH EXANTHEMATA. 
 
 Symptoms and signs of pneumonia may precede, accompany, 
 or follow measles, scarlatina, or small-pox. In the two first of 
 these the characters of the disease are commonly more active or 
 inflammatory, while the pneumonia which is associated with 
 variola has a typhoid character. In measles the disease com- 
 monly occurs at an earlier period than in scarlatina, and in the 
 ordinary forms it has a highly sthenic character, occasionally 
 running on to the formation of abscess. In scarlatina it is more 
 commonly observed after the disappearance of the eruption, and 
 it may be then a very violent and intractable afi"ection. It is by 
 no means an uncommon complication in the anasarcous condi- 
 tion which follows scarlatina, a condition in which, at least so
 
 320 PNEUMONIA. 
 
 long as fever remains, there is a strong tendency to the repe- 
 tition of intense and varied local inflammations, affecting not 
 only the parenchyma of organs, but the serous membranes 
 also. 
 
 COMPLICATION WITH GOUT. 
 
 Our information on this subject is still very limited ; I shall 
 therefore content myself with simply indicating its existence. 
 I have seen a few cases in which, although no actual gouty 
 disease of the articulations existed, yet the disease occurred in 
 constitutions which were essentially gouty. It need hardly be 
 observed that in such cases the principles of treatment will 
 differ from those which are applicable in the ordinary forms of 
 the disease. 
 
 TREATMENT OF PNEUMONIA. 
 
 Under this head we shall consider the treatment of three 
 important conditions of the disease, namely — 
 
 I. The acute sthenic pneumonia in its early stage. 
 
 II. Unresolved hepatizations resulting from acute pneumonia, 
 the fever and advance of the disease having ceased. 
 
 III. The asthenic or typhoid pneumonia. 
 
 We shall then describe our ordinary practice in cases of typhus, 
 or other acute disease with secondary pneumonia. 
 
 It is obvious that to lay down rules for the treatment of each 
 variety or complication of pneumonia would be impossible, and 
 it must be admitted, so far as we know at present, it would 
 appear to be unnecessary. As met by the practical physician, 
 they may be divided generally into two great categories, dis- 
 tinguished not only by their symptoms and pathology, but by 
 the results of treatment. In the first may be placed the cases of 
 acute inflammatory pneumonia occurring in a healthy subject 
 and with a purely symptomatic fever. While in the second we 
 may group with the acute asthenic pneumonia, a vast number of 
 cases of the disease complicating typhus fever, or other con- 
 stitutional or local affections. 
 
 It may be laid down as a general rule that in this second 
 category the principles of treatment are different from those that 
 apply to the first, and the difference may be thus expressed,
 
 PNEUMONIA. 321 
 
 that while in the first class general and local antiphlogistic treat- 
 ment is applicable, in the second this treatment must he adopted 
 with extreme caution, and our principal reliance must he placed 
 on counter-irritation, mercurials, stimulants, and tonics, and that 
 tbe greatest attention must he paid to supporting the strength 
 of the patient, who in many cases labours under a constitutional 
 disease in itself as formidable, or more so, than the local 
 disease. 
 
 ACUTE STHENIC PNEUMONIA. 
 
 Let us suppose a case of this disease occurring in a young and 
 healthy man, and that the patient is seen about the third or 
 fourth day of the disease, when we may suppose the fever high, 
 the pain of the chest severe, while the physical signs indicate 
 that the disease has passed into its second or third stages, the 
 lower portion of the side is becoming dull, and the crepitating 
 rale is spreading upwards, the disease has not been modified by 
 previous treatment, the skin is hot, the pulse full and bounding, 
 the force of the heart considerable, and the expectoration rusty. 
 
 The first question to be discussed would be the propriety of 
 bleeding, and, I believe, that under the circumstances indicated, 
 and particularly if the case be an accidental one, and not occur- 
 ring under the influence of any epidemic tendency, venesection 
 may be performed with safety and advantage ; but our experience 
 is quite opposed to very large or repeated bleedings, as recom- 
 mended by Bouillaud. We believe that copious depletion is not 
 only unnecessary, but mischievous, and it must never be for- 
 gotten that in acute as well as chronic diseases the great 
 object of the physician should be to cure the patient at the least 
 possible expense to his constitution. 
 
 If venesection has produced a favourable alteration in the 
 pulse, if it has permanently diminished the force of the heart, 
 lessened the heat of the skin, and relieved the dyspnoea, the mere 
 circumstance of the extension of physical signs ought not to 
 induce us necessarily to repeat the blood-letting. And again, 
 the fact that while the constitutional symptoms are reduced, 
 still the physical signs remain unchanged, is not to be taken as 
 an indication for further general depletion. 
 
 Although it is true that in certain cases a complete and rapid 
 resolution of the disease both as to symptoms and signs follows 
 
 Y
 
 322 PNEUMONIA. 
 
 on bold bleeding from tlie arm, yet sucli a case is comparatively 
 rare, and a sufficient experience enables us to declare that the 
 ordinary effect of general bleeding in acute diseases of the lung — 
 particularly pneumonia and pleurisy — is less the removal of the 
 affection than the rendering it latent so far as its vital symptoms 
 are concerned. It would be well if this proposition were more 
 extensively considered, for there cannot be a doubt that a large 
 portion of the chronic diseases of the lung are the result of acute 
 affections recognized and for the time properly treated by anti- 
 phlogistic measures, but in which the latent condition has been 
 mistaken for recovery, and the disease allowed to pass on into 
 chronic and incurable disorganization. The great rule appears 
 to be that in these cases of the apparent removal of disease by 
 antiphlogistic treatment physical examination must be had re- 
 course to, to determine the point as to whether the cure be real 
 or fallacious. 
 
 In pneumonia the effect of early bleeding may be to remove 
 every symptom, yet the lung may remain hepatized, and the 
 result be a slow and doubtful resolution, a chronic and incurable 
 hardening, or the development of tubercle in the diseased lung. 
 In pleurisy, too, the symptoms may in like manner be overcome, 
 and yet the effusion remain in a passive state, or slowly increase 
 till a great empyema is produced. 
 
 From all this we learn, that under these circumstances not 
 only may the original disease remain, but that it may slowly 
 progress, or take on new pathological characters. 
 
 It is seldom necessary to repeat the bleeding, which is to be 
 considered more as a preparation for other treatment than a 
 means for removing the disease. 
 
 The next step will be the use of local bleeding, which of all 
 modes of treatment has the most marked effect on the disease. 
 CujDpiug, where the tenderness of the side permits it, is pre- 
 ferable to the use of leeches ; but either of these methods may 
 be used and repeated again and again according to circumstances. 
 And in many cases, but particularly^ if the disease be asthenic, 
 we should fully support the strength by food and wine, even at 
 a time when we are using local depletion. 
 
 We obtain great advantage from the use of poultices to the 
 affected side. They may be employed at all periods of the 
 disease, and their efficacy is almost always manifest. The best
 
 PNEUMONIA. 323 
 
 material is the linseed meal, or bran, which has the advantage of 
 greater lightness, and it is more easily managed. The poultices 
 should be large and warm, and covered with oiled silk. 
 
 I do not know any period of the disease in which poulticing 
 may not be used with advantage, even in cases of unresolved 
 hepatizations. When the fever and pain have subsided, and 
 the pulse is quiet, we find that the rapidity of the resolution is 
 greatly accelerated by their employment. 
 
 There are two modes of internal medication, namely, the use 
 of tartar-emetic, as recommended by Laennec, and that of mer- 
 cury with or without opium, the selection of which is often a 
 subject of some difficulty to the practising physician. We are 
 not to believe, however, that either of these are absolutely re- 
 quired in the treatment of pneumonia, for in many cases the 
 ajBfection can be conquered without their aid. 
 
 On the subject of Laennec's use of the tartar-emetic, we have 
 nothing to add to what has been already stated. And our 
 present opinions must depend less on recent than on former 
 experience, for it is a remarkable fact that of late years we have 
 had very few examples of the simple inflammatory sthenic 
 pneumonia in this city. But when such cases were more fre- 
 quent we did find that the efficacy of the treatment was abund- 
 antly proved, and that we could verify almost every one of 
 Laennec's statements. We seldom exhibited more than six 
 grains in the course of the twenty-four hours, and our results 
 were satisfactory. 
 
 But in no case were other means neglected, and general and 
 local bleeding, with counter-irritation, were employed. The fol- 
 lowing circumstances were found to be favourable to the use of 
 the tartar-emetic treatment. 
 
 I. The disease having arisen in a young and robust subject. 
 
 n. The disease not having passed its earlier stages. 
 
 III. The fever being inflammatory and symptomatic. 
 
 IV. The heart acting with energy. 
 
 V. The disease being uncomplicated either with local disease 
 in the abdomen or with the various constitutional affections. 
 
 Indeed, the only proposition of Laennec's that we had to 
 dissent from was that in which he states the existence of the 
 gastro-enteritis of fever to be no contra-indication for the use of 
 the remedy. 
 
 t2
 
 324 PNEUMONIA. 
 
 But in the great majority of the cases met in the Meath 
 Hospital for the last fifteen years we have not employed the 
 tartar-emetic treatment. More or less of a typhoid character 
 attended the inflammation, and the mercurial treatment was 
 generally adopted. This change of practice arose, however, less 
 from any direct experience of the injurious effect of the tartar- 
 emetic than from our increasing caution as to any proceeding 
 calculated to lessen the strength of the patients. 
 
 The mercurial treatment consisted in the use of repeated 
 moderate doses of blue pill or calomel, or a combination of 
 them ; small quantities of opium or Dover's powders were added, 
 and the remedy continued until decided mercurial action was 
 produced. The inunction of mercurial ointment, and the dress- 
 ing of blistered surfaces with the mercurial ointment we have 
 found valuable. It is in many cases unnecessary to push the 
 medicine to the production of full ptyalism. It often happened 
 that resolution took place with scarcely any perceptible mercurial 
 action either on the gums or in any other way. Mercurial 
 iarrhoea sometimes preceded or accompanied the resolution ; 
 while in certain cases a most violent and long-continued ptyalism 
 ensued. 
 
 We have in several cases used both the tartar-emetic and 
 mercurial treatment at different periods of the same case. In 
 some instances, where the tartar-emetic failed, or that the cura- 
 tive action seemed to be suspended, the use of mercury has 
 produced a most rapid improvement. And, on the other hand, 
 we have found that when, after a certain amount of mercury 
 had been exhibited without manifest change, that the use of 
 the tartar-emetic was followed by a singularly rapid and complete 
 recovery. Dr. Hudson has published a case which strikingly 
 corroborates the efficacy of tartar-emetic given after mercurj'. 
 Some of my friends employ a combination of these remedies, 
 but of this mode I can say nothing from my own experience.* 
 
 * The case referred to in the text was published in the eleventh volume of the 
 Dublin Medical Journal, First Series. The patient had suffered an attack of pneumonia 
 a month previous to my seeing him, for which he had been actively treated with, for 
 a time, apparent benefit. For a week before I saw him there had been no improve- 
 ment, but the contrary. He had then cough, with sanguinolent expectoration, very 
 marked dyspnoea, feeling of weight and oppression in the side, &c. He had been 
 salivated, so that the further exhibition of mercury was out of the question, and at my 
 suggestion he was given tartar-emetic in grain doses every third hour. After the 
 first dose he had the most perfect tolerance of the medic'ne, which he took regu-
 
 PNEUMONIA. 325 
 
 The exhibition of mercury in very large doses at long in- 
 tervals, and its use in very minute quantities frequently repeated 
 have their respective advocates in Dr. Graves and Dr. Law. 
 
 But in whichever way we use the remedy, we should consider 
 it only as an adjuvant, and one whose employment is not always 
 necessary. Its true action seems to be less in arresting inflam- 
 mation, than in accelerating the removal of the products of 
 inflammation. And thus the production of mercurial action 
 apj)ears, in a great number of cases, to be rather a consequence 
 than a cause of the arrest of the disease. Whatever may be its 
 value, it is not to be considered as our sheet-anchor, nor is its 
 exhibition to be pressed to the neglect of other measures. To 
 this I shall refer when we speak of the treatment of the asthenic 
 forms of the disease. 
 
 There are many cases, too, in which the use of mercury must 
 not be attempted, or at least adopted with extreme caution ; of 
 these the following instances may be taken as examples out of 
 others : — 
 
 I. When the disease occurs in persons who have recently 
 suffered from acute disease, more particularly if in that disease 
 they have been mercurialised. 
 
 II. When the scorbutic diathesis exists, as we often see in 
 certain families ; and again, where signs of imperfect hrema- 
 tosis are actually existing, as shewn by spongy or bleeding 
 gums, foetid breath, epistaxis, or splenic congestions. 
 
 larly for a week. On the third day the commencement of resolution was indicated 
 by a line crepitus in the solidified part, which became gradually more distinct for 
 a few days, then was mixed with respiratory murmur, by which it was replaced 
 and resolution perfected in the course of a fortnight. 
 
 I have since seen many examples of the successful treatment of unresolved hepati- 
 zation by tartar-emetic. In two of these, in-patients under my care in the Meath 
 Hospital, the disease was of long standing — in one six weeks, in the other three 
 months — and had caused general dropsy, a consequence of this form of hepatization 
 noticed by Rokitansky, who says : " This condition may exist for a long time, and is 
 always followed by cachexia, and especially by dropsical symptoms, and it often 
 proves fatal." 
 
 In these cases the anasarca rapidly disappeared with the hepatization under the 
 antimonial treatment. According to Rokitansky " the curative process in indurated 
 hepatization is somewhat analogous to the resolution of pneumonia in the second 
 stage, for an exhalation of serous fluid takes place from the inner wall of the air cells, 
 and acts as a menstruum which gradually corrodes and absorbs the indurated granu- 
 lations." This view is in accordance with Laennec's theory of the action of tartar- 
 emetic, namely, that it " increases the activity of the interstitial absorption," which 
 it probably does by its power of increasing the exhalation from the capillaries of 
 the lungs. (See Headland on the Action of Medicines, p, 371.) (Ed.)
 
 326 PNEUMONIA. 
 
 III. When we have to deal with persons of a scrofulous habit, 
 or even, though they shew no marks of scrofula, if they belong 
 to a family subject to the disease. We must also be especially 
 cautious in using the mercurial treatment when the patient has 
 at any former time been threatened with phthisis, or has had 
 any near relations carried off by that disease. In such cases 
 nothing but the resistance to all other treatment will justify us 
 in resorting to mercury. 
 
 I believe that by a judicious use of depletion, counter-irrita- 
 tion, poultices, and stimulants, a great number of cases of acuie 
 pneumonia may be successfully treated, without our having 
 recourse to either tartar-emetic or mercm*y at any period.* 
 
 On the other hand we often observe that while the fever con- 
 tinues high, a complete resistance to mercurial action exists, 
 and precious time may be lost in the attempt to salivate, when a 
 direct antiphlogistic treatment would have modified the disease, 
 and induced the ptyalism. It will always be found that the 
 facility of salivation will be directly as the reduction of the fever. 
 
 TREATMENT OF UNRESOLVED HEPATIZATIONS. 
 
 The condition now indicated is one which we are frequently 
 called on to treat. It is not uncommon in cases where the 
 recovery has been erroneously inferred from the subsidence of 
 the vital symptoms of pneumonia. 
 
 Its discovery is often accidental, as it is often productive of no 
 symptoms beyond dyspnoea on exertion, or a difficulty of lying 
 on one side. 
 
 We shall generally succeed in removing the obstruction by 
 adopting the following course : — 
 
 We may commence with one or two cuppings over the dull 
 portion, abstracting from six to twelve ounces of blood at each 
 operation ; or if the loss of blood be considered unadvisable we 
 may use dry cupping with great advantage. Poultices are then 
 
 * It maybe objected that the opinions stated in the text, are at variance with those 
 which I formerly expressed on the use of mercury in threatened phthisis, and the views 
 of Dr. Graves as given in his Clinical Medicine appear different. But the questions as 
 to the use of mercury in incipient phthisis and in pneumonia in a scrofulous subject 
 are clearly not the same. When we speak of tubercle I shall return to this point, and 
 here only remark, that, as late experience shews me, that we can manifestly treat 
 many cases of pneumonia without the use of mercury — its employment in a decidedly 
 scrofulous paiient should if pos sible be avoided. {Anthor'^s Note Book.)
 
 PNEUMONIA. 327 
 
 to be applied for one or two days, followed by the use of blisters 
 of moderate size, so that they may be applied successively over 
 various parts of the dull region. The parts may be dressed with 
 mild mercurial ointment, and at the same time we may give 
 small doses of a mercurial with Dover's powders, so as to 
 produce a slight degree of action, which if it can be kept up 
 conveniently for a few days wdll often have the best effect. 
 
 Should the dulness remain obstinate, or be only partially 
 removed, the use of iodine internally and externally is to be 
 adopted ; five grains of the iodide of potassium may be given 
 three times daily, and the side is to be brushed over with the 
 tincture of iodine, by means of a broad, flat camel's-hair brush. 
 This is to be repeated every day, or second, or third day accord- 
 ing as it is borne by the patient. 
 
 Great attention must be paid to position in this case, and the 
 patient must be encouraged to avoid lying on the affected side. I 
 have reason to think that, where, as is often the case, the solidity 
 occupies the posterior portions, while the anterior remains free, 
 that advantage would be derived by making the patient lie on 
 his face for such periods of time as he could bear without incon- 
 venience. 
 
 The seton has been recommended in this condition. I have 
 not used it for many years. It is a cruel and disgusting 
 remedy, and one the efficacy of which appears very doubtful. 
 It may perhaps be more applicable in this condition than in 
 phthisis, in which its employment is altogether to be repre- 
 hended. 
 
 The general health of the patient should be carefully attended 
 to. He should be placed in pure air, and be allowed to take 
 passive exercise out of doors. His diet should be sufficiently 
 nourishing, and a moderate quantity of wine may be given if it 
 does not excite the circulation. 
 
 TREATMENT OF THE FOURTH AND FIFTH STAGES OF PNEUMONIA. 
 
 We have had a considerable number of examples of perfect 
 recovery after the extreme interstitial suppuration of the lung, or 
 at least after the co-existence of the proper symptoms and signs 
 of this condition. And the treatment has not been different 
 from that of the earlier stages, with this exception, of course.
 
 328 PNEUMONIA. 
 
 that general bleeding was not performed. If the subject be of a 
 good constitution, and if signs of spreading inflammation are 
 discoverable, either in the first affected or in the opposite lung, 
 he will derive great advantage from cupping, with the scarifi- 
 cator, or from dry cupping, and above all from decided blistering 
 and poultices ; mercury should be employed both internally and 
 externally, alternating with the exhibition of carbonate of 
 ammonia, in doses of from two to three grains ; and the strength 
 of the patient may be supported by wine, brandy, and broths. 
 
 We must not despair of our patient, or refrain from the use of 
 decided measures, because we find that interstitial suppuration 
 has occurred. The only difference in the treatment being, 
 that much greater attention must be paid to supporting the 
 powers of life, and that in many cases we should use stimulants 
 freely. 
 
 In many cases resolution will be rapid and complete after this 
 treatment, in others a bronchial flux remains. We may then 
 make use of the decoctions of bark, myrrh, and polygalffi, and 
 the addition, to each of these remedies, of the carbonate of 
 ammonia, and the camphorated tincture of opium will generally 
 be found to answer well. 
 
 As might be expected from its efficacy in cases of muco- 
 purulent discharge from the bronchi, the spirit of turpentine 
 is a valuable remedy in interstitial suppuration, particularly in 
 cases in which the patient has been previously treated by 
 mercury. 
 
 In the treatment of abscess of the lung, to allay cough, and to 
 support the patient's strength by tonics and pure air, are the 
 chief indications. The various preparations of bark with the 
 mineral acids are useful, and when the discharge becomes fcotid, 
 we may give the chlorides of lime and soda in combination with 
 opium.* 
 
 But it is to be remembered that in some of these cases, as in 
 those recorded by Dr. Graves, recovery took place, although no 
 treatment of a special nature had been adopted. In others 
 which I have witnessed the treatment was either purely pallia- 
 tive or mildly tonic. In young persons it appears very probable 
 
 * It is scarcely recessary ti remark on the superior efficacy of the svilphocarbolates 
 of lime and soda, first suggested by Dr. Sansom ; especially when conjoined with the 
 inhalation of the vapour of carbolate of iodine, or of oil of turpentine as recommended 
 by Skoda, (to.)
 
 PNEUMONIA. 329 
 
 that the efforts of nature alone are sufficient to bring about a 
 cure ; while in adults or elderly persons, particularly if the 
 patient has been a free liver, great attention must be paid to 
 supporting the strength, and in some cases wine may be liberally 
 employed. 
 
 TREATMENT OF TYPHOID PNEUMONIA. 
 
 From what has been said it will be unnecessary to dwell long 
 on this part of the subject ; for the principles which should 
 guide us must be evident to every practical man. I believe that 
 it will be hardly even necessary to perform venesection in this 
 disease, and I am satisfied that in most cases the practice is full 
 of danger ; at the same time, I should state that I have myself 
 used bleeding cautiously, and have known instances where it has 
 been employed by others with greater boldness, and where a 
 recovery has followed, but for many years I have avoided the 
 practice, which appears to me to be almost always unnecessary, 
 and often distinctly injurious. 
 
 We may employ local bleeding in conjunction with stimulants, 
 the use of the latter being particularly indicated when there is 
 prostration with a weak heart and typhoid expression. In many 
 cases we need not draw blood at all, but may trust to dry 
 cupping followed by counter-irritation and poulticing. These 
 measures, with the use of mercurials, ammonia, and the diffusible 
 stimuli, will effect a cure, and the rapidity of the resolution will 
 in general be proportioned to the degree in which v>'e have 
 economised the vital forces of the patient. 
 
 To conclude — the greatest practical improvement which 
 modern medicine owes to clinical study, is our disuse of the 
 lancet in a vast number of cases, not only of pneumonia but of 
 other diseases, local and general ; or at least our ceasing to 
 regard its employment as a matter of course in diseases of an 
 inflammatory nature ; the day of prescribing for names has 
 gone by, and a more philosophical method of considering and 
 treating disease has succeeded. We have returned to the old 
 system of husbanding the strength of the patient, and of con- 
 sidering the general, as much at least, as the local condition. 
 We have learned that stimulants are often the best antiphlo- 
 gistics, as is exemplified in the subsidence of many active
 
 330 TNEUMONIA. 
 
 inflammations arising iu a depressed state of the system, wlien 
 treated by wine, brandy, and ammonia, while the spontaneous 
 recovery of many cases has led us to be more cautious in 
 attaching too great a value to particular modes of treatment. 
 
 There is a circumstance connected with the use of mercury iu 
 typhoid pneumonia which it is important to notice as it bears 
 not only on the modus oiievandi of mercury, but is of great 
 value in prognosis. I allude to the repeated appearance in the 
 course of the case of abortive attempts at mercurial action. A 
 patient who has been using calomel, say from twentj^-four to 
 thirty-six hours, will have slight sponginess of the gums, and 
 mercurial fcEtor of the breath promising a full and as is gene- 
 rally hoped, a sanatory mercurial action, yet in a short time, 
 sometimes within three or four hours, all these signs will dis- 
 appear, although the use of the medicine has been continued iu 
 the meantime ; two, three, or four of these attempts at salivation 
 will occur in the course of the case, and nothing can be more 
 remarkable than the sudden disappearance of every symptom of 
 mercurial action. In some cases this was accompanied by a 
 distinct exacerbation of the disease, but we cannot say that this 
 was observed in every instance. 
 
 With regard to j)rognosis, we attach great importance to this 
 symptom, for, with a very few exceptions, the cases which pre- 
 sented it proved fatal. It is yet to be determined whether this 
 arises from some intensity in the original local disease, or from 
 the springing up of new inflammations. 
 
 I have not yet made any researches with the view of deter- 
 mining what the actual condition of the heart is in this disease, 
 and whether the rules, as to the use of stimulants, drawn from 
 its state in typhus fever, will be found to apply in typhoid 
 pneumonia. But in a great number of instances, the heart's 
 action is certainly weakened, and it is almost certain that the 
 recognition of this state, by the same means which we employ 
 in typhus fever, will greatly assist us in determining on the use 
 of stimulants, and the period when they should be had recourse 
 to. If the impulse be greatly diminished or absent, if the first 
 sound be lessened, and above all if we find these changes pro- 
 gressive, I apprehend that there should be no question as to the 
 free and decided use of stimulants. 
 
 It will probably be found that the cases with copious bronchial
 
 PNEUMONIA. 331 
 
 flux will more especially require stimulants than tliose without 
 this condition.* 
 
 I have no experience in the treatment by large doses of 
 quinine as recommended b}^ Dr. Corrigan. I must therefore 
 refer the reader to his paper on this subject in the Dublin 
 Hospital Gazette.^ 
 
 * On this subject the following conclusions of Juergensen deserve consideration: — 
 
 " The danger in croupous pneumonia threatens principally the heart of the patient. 
 Death results from insufficiency of the heart. 
 
 " And now for the proof of this opinion. 
 
 " I, The exudation in pneumonia produces an increased resistance in the pulmo- 
 nary circulation, and consequently increased effort on the part of the right ventricle. 
 
 " II. The changes produced in and near the lung by pneumonia diminish the total 
 amount of force to be furnished by this organ for the movement of the blood. 
 
 " III. In pneumonia the surface over which blood and air come in contact 
 with each other is diminished by the exudation, and this fact necessitates increased 
 labour on the part of the forces which impel the blood and air whenever an abundant 
 exchange of gases is required. 
 
 " IV. The fever first brings to expression the local disturbances produced by the 
 pneumonia. 
 
 " Y. The fever induces increased labour on the part of the heart, and at the same 
 time inflicts a direct injury upon it. 
 
 " Prom all sides the threads run together to a central point. It is the heart, and 
 always the heart, ^ipon lohich the burden is ultimately throivn. It is, therefore, the 
 duty of the physician to enable the heart during pneumonia to perform the additional 
 labour made necessary by the disease ; this duty involves two sub-divisions — 
 
 " 1. Prophylaxis against exhaustion of the heart. 
 
 " 2. Control of already existing exhaustion. 
 
 " The fever is the first point of attack for treatment," &c. (Ziemssen's Cyclopedia, 
 vol. V. pp. 153— 15G.) 
 
 This treatment, according to Juergensen, should consist in the cold bath, the exhibi- 
 tion of stimulants, and of quinine, which he gives in doses ranging from thirty to 
 seventy-seven gi-ains every second evening. (Ed.) 
 
 t The following strong testimony to the efficacy of this mode of treatment is given 
 by Dr. Gordon : — " Perhaps one of the best marked features of this disease is its 
 not being amenable to any of the usual modes of treatment; I need not here aUude 
 to the more than inefficacy of abstraction of blood in any form to meet its require- 
 ments. The treatment by tartar-emetic is equally inapplicable ; and the mercurial 
 plan of treatment, as it is termed, is also powerless to control this formidable affec- 
 tion. The treatment by the internal use of oU of turpentine, so advantageous in 
 the suppurative stage of vesicular pneumonia, does not appear to have any influence 
 on this form of disease. Wine and the usual diffusible stimulants support the 
 patient's strength and add to his vital energy, and so are of use, but they seem to 
 have no specific power over the disease, such as is evidently exercised by the sulphate 
 of quina. During the last eight months I have treated with quina all the cases of 
 this form of pneumonia which I have witnessed, and I have had the opportunity of 
 observing several cases similarly treated by Dr. Corrigan in the Hardwicke Hospital. 
 The result of this treatment has been that of the cases which came under observation 
 before effusion had taken place into the bronchial tubes, none proved fatal ; while 
 some few recovered, even after the lips had become blue, the face congested, and 
 mucous rales were audible in the bronchial tubes." — On Pneumonia, Dublin Quarterly 
 Journal, vol. xxii, (Ed.)
 
 332 PNEUMONIA. 
 
 CHRONIC PNEUMONIA. 
 
 Considered as an original affection, there can be no doiiLt tliat 
 simple chronic pneumonia is a rare disease ; but it is difficult to 
 define the exact meaning of the term chronic pneumonia, or to 
 draw the line of distinction between it and that low irritation 
 of the lung which is followed by the tubercular infiltration. It 
 seems not unlikely that there are two forms of the disease, the 
 one producing the iron-grey and indurated lung, and the other 
 forming, or ultimately passing into, tubercular solidity. 
 
 These forms of disease difier remarkably in their liability to 
 produce suppuration. In the scrofulous afi"ection, suppuration, 
 though slow in its occurrence, is almost sure to supervene ; 
 Avliile in the simple form, abscess is seldom observed, the ter- 
 mination being in that hard and semi-cartilaginous condition, 
 the " induration gris" of Andral. 
 
 The existence of this disease is inferred much more from the 
 appearance of certain pathological conditions than from any 
 observation of proper symptoms. Portions of the lung more 
 or less extensive are found indurated, nearly impermeable to air, 
 and of an iron-grey colour. This condition may be the sole patho- 
 logic state, or exist in connexion with tubercle or other diseases. 
 Hasse remarks that grey induration " is mostly associated with 
 the development of tubercle ; and in the few marked instances 
 which came in my way, I was unable to draw the precise limits 
 between pneumonic induration and grey tubercular infiltration. 
 The former was distinctly recognizable in the lower half of the 
 lung, the latter in the upper half ; at the apex were several small 
 cavities, precisely resembling those of tubercular phthisis. There 
 v/cre at the same time traces of the tubercular constitution in 
 other organs. The transitions and combinations of the two 
 diseases are probably numerous, whilst chronic pneumonia is 
 sufficiently rare to render the discrimination in a given case 
 a difficult task."' 
 
 But there seems to be little analogy between this state of 
 parts and that in pneumouia properly so called, which is essen- 
 tially a condition of change and of activity, advancing towards 
 suppuration or gangrene on the one hand, or resolution on the 
 other. It is possible, however, that some of these indurations 
 owe their origin to unresolved hepatizations, and that softening
 
 PNEUMONIA. 333 
 
 has changed into a grey induration ; but it appears probable that 
 this change having occurred, there is a suspension of further 
 morbid action in the part, and the disease in such case is less 
 chronic pneumonia than a particular change of a hepatization, 
 which was essentially the result of acute disease. 
 
 Perhaps no better definition of this affection could be given 
 than that of Dr. Walshe : " I mean," he says, " by chronic 
 pneumonia that form of disease in which an impermeable tissue 
 is infiltrated Avith toughly solid exudation (in the state of indura- 
 tion matter), and where there is no tendency to a softening pro- 
 cess ; these are its main characters." 
 
 The symptoms of this form of disease are seldom marked or 
 determinate ; dyspnoea is not usually urgent, cough and expec- 
 toration are variable in frequency, quantity, and quality, the 
 latter seldom resembling that of the acute primary disease. 
 There is occasionally slight haemoptysis. The fever is irregular 
 in its type, but the emaciation is, it may be said, a constant and 
 progressive symptom, which, with the physical signs, renders 
 the diagnosis from phthisis a task of difficulty, more especially 
 when the upper lobe is the seat of disease. 
 
 The physical signs may be briefly stated to be, depression 
 of the side, marked dulness with resistance, weak respiratory 
 murmur, with more or less of a bronchial character, occasional 
 sub-crepitus and muco-crepitus, sibilant and sonorous rale. 
 
 The treatment may be briefly stated to be that adopted for 
 unresolved hepatization, as already described. 
 
 APPENDIX TO ABOVE CHAPTEPt. 
 
 Note A. 
 
 No portion of Dr. Stokes' work has elicited such a variety of 
 opinion from subsequent writers as this. 
 
 Eokitansky thus expresses his disbelief: " There is no other 
 and earlier stage than that which we have described as the stage 
 of stasis, for the condition described as such by Stokes is in no 
 respect inflammatory. The bright red colour of the lungs or of 
 portions of them which Stokes regards as the earliest stage of
 
 331 PNEUMONIA. 
 
 inflammation and attributes to arterial injection is dependent on 
 anaemia which is frequently very highly dev^eloped," &c.* 
 
 Skoda adopting Rokitansky's view says : " It is certainly true 
 that loud vesicular respiration occasionally precedes the crepi- 
 tating rale ; but this is no reason for setting up an especial 
 first stage of pneumonia, this symptom being even less constant 
 than crepitating rale." 
 
 On the other hand, Dr. Walshe says : " My opinion coincides 
 with that held by Dr. Stokes. The vivid arterial tint in ques- 
 tion is seen to perfection in rapidly fatal cases of acute miliary 
 tuberculization, in persons presenting none of the acknowledged 
 characters of anaemia, but many of those of pulmonic irritation. 
 Besides it may exist in one lung and be absent in the other 
 — a fact which seems to me, even taken alone, to settle the 
 question. Its characters are essentially those of acute active 
 
 congestion." t 
 
 Dr. Addison expresses his assent, having recently met with a 
 case in which for other reasons he anticipated pneumonia — which 
 afterwards took place — and in which this excited state of the 
 respiration and a loud but rough respiratory murmur in the lung 
 about to be affected were strongly marked. " Further observa- 
 tion," he adds, " is still required to establish Dr. Stokes' position 
 fully and satisfactorily." 
 
 Dr. Wilson Fox admits that "there is reason to believe in 
 the probability that such a state may precede the subsequent 
 changes of the inflammatory period, and the auscultatory signs 
 of harsh respiration which have been described by Dr. Stokes 
 as attending it have been recognized by many and different 
 authors." J 
 
 Dr. Waters says : " Of the earliest morbid conditions I agree 
 with the conclusions arrived at by Dr. Stokes, that there is a 
 stage prior to that of engorgement characterized by dryness, 
 intense arterial injection, and consequently a bright vermilion 
 colour of the pulmonary membrane. In proof of the probability 
 of this condition I must appeal to the facts furnished by auscul- 
 tation, namely the existence of a harsh puerile respiratory 
 murmur preceding the crepitating rale." 
 
 * Pathological Anatomy, vol. iv. p. 75. Syd. Soc. Ed. 
 
 t Diseases of the Lungs, p. 346. 4th Ed. 
 
 J Reynolds' System of Medicine, vol. iii. p. GC2.
 
 PNEUMONIA. 335 
 
 Dr. Waters gives two cases in wliich lie observed this murmur 
 and offers an elaborate explanation of its production.* 
 
 Grisolle gives the following qualified assent to Dr. Stokes' 
 views : — t 
 
 " D'apres M, Stokes I'eugouement inflammatoire que je 
 viens de decrire ne devrait point constituer le premier degre de 
 la pneumonic, puisque suivent cet auteur il serait consecutif a 
 une autre alteration. Le Medecin de Dublin donne comme 
 marquant la premiere periode du travail inflammatoire des 
 poumons un etat de secheresse de durete du tissu avec une injec- 
 tion arterielle intense, ce qui lui donne une coloration vermeille 
 eclatante sans aucune effusion de sang dans les cellules. M. 
 Stokes pretend avoir trouve cet etat au voisinage des pneumonies 
 arrivees au premier et au deuxieme degre il convient d'ailleurs 
 qu'on I'observe rarement, ou qu'il passe inapercu etant masque 
 facilement par les congestions cadaveriques. ' CependantM. Stokes 
 ne me parait pas avon demontre d'une maniere rigourouse que 
 I'engoument inflammatoire fut reelement un etat consecutif; 
 pour moi, je n'ai encore rien observe qui justifie son opinion ; 
 je sais bien qu'en theorie elle parait fondee car il est rationnel de 
 supposer que le premier degre de Laennec caracterise par un 
 etat de secretion ou d'exhalation morbide dans les vesicules pul- 
 monaires a du etre precede d'une periode d'irritation pendant 
 laquelle le tissue simplement congestionne presente au contraire 
 plus de secheresse que d'habitude. Nous verrons plus tard que 
 cette opinion semble aussi justifiee par I'etat symptomatique. 
 Toutefois nous n'avons encore a ce sujet aucune douee certaine 
 
 Je n'ai jamais observe au dchut de la pneumonic et 
 
 comme premier phenomene stethoscopique la respiration puerile 
 que ]\I. Stokes dit avoir rencontree cliez plusiers de ses malades. 
 Toutefois j'admets quelle pent exister dans quelques cas rares, 
 puisque, comme je le dirai plus tard j'ai moi memo rencontre ce 
 phenomene plusieurs fois dans les points des poumons qui furent 
 envahis consecutivement. La faiblesse du bruit respiratoire ou 
 le respiration puerile, apres avoir persiste pendant deux, six, 
 douze ou vingt-quatre heures, sent generalement remplacees par 
 d'autres phenomenes stethoscopiques et presque toujours par le 
 rale crepitant." 
 
 * Diseases of the Chest, pp. 31—37. 2nd Edition. 
 t Traite pratique de la Pneumonie, pp. 9 and 232.
 
 336 PNEUMONIA. 
 
 It appears that while the accuracy of Dr. Stokes' observation 
 is admitted by these writers, none of them have adopted his 
 classification, or changed that of Laennec by the addition of a 
 fifth stage. (Ed.) 
 
 Note B. 
 
 It is generally admitted that Dr. Graves' case of displacement 
 of the heart, in a young gentleman, was a true example of 
 pneumatosis in the pleural cavity occurring in the course of pleuro- 
 pneumonia, a conclusion abundantly confirmed by cases since 
 recorded by Dr. W. S. Little, Dr. Keller, and Dr. Walshe ; but 
 I believe that his other case — referred to by Dr. Stokes — was not 
 of this character, but was an example of the tympanitic or 
 amphoric resonance on percussion over a solidified lung, which 
 was observed in cases first recorded by me, and subsequently 
 by Drs. Banks, Walshe, and Hayden, and more recently by 
 Juergensen. 
 
 As some confusion still exists among authors with regard 
 to the conditions under which this phenomenon occurs, and 
 its explanation, it may not be amiss to give a short sum- 
 mary of the observations hitherto made, and of the explanations 
 offered. 
 
 The first, in order of time, were my own. 
 
 Case I. — M. M., a female, admitted with pneumonia of left 
 lung. On the morning of the fifth day, the upper portion of the 
 side, previously dull on percussion, presented a muffled tym- 
 panitic clearness, while the lower third continued quite dull. On 
 my again visiting her at 10 p.m., the entire side, to the base of 
 the lung, presented, on percussion, a clearness not at all inferior 
 to that of the other side, but of a tympanitic character. On the 
 sixth and last day it was noted that the same tympanitic clear- 
 ness existed fully to as great a degree as in pneumothorax. 
 Autopsy showed the lung to be universally adherent to the 
 costal pleura ; heavy, and solid throughout, with exception 
 of part of the inferior lobe, which was engorged, but still 
 crepitous.* 
 
 Case II. — C. S., admitted on the tenth day of pneumonia of 
 left lung. On percussion, the sound on the right side was clear; 
 the left gave anteriorly a sound exactly like that produced by 
 
 * Dublin Medical Joiurnal, 1st series, vol. vii.
 
 PNEUMONIA. 337 
 
 piercussing over the stomach or csecum, while posteriorly the side 
 was dull over the spine and dorsum of the scapula. 
 
 During the last two days of life the tympanitic sound 
 became gradually more muffled and less clear, while the signs 
 of crepitation and tubular breathing extended from above 
 downwards. 
 
 Autopsy showed the lung adherent by recently-formed lymph, 
 the superior lobe solid and heavy, presenting a marbled appear- 
 ance on the surface, and on section, grey, softened, granular, and 
 oozing from its cut surface a large quantity of thin grey fluid. 
 The lower lobe much engorged. 
 
 Case III. — A young woman was admitted into hospital on the 
 sixth day of pneumonia of the upper portion of the right lung 
 and a small portion of the inferior lobe of the left. She appeared 
 to be dying, but survived for two days. On the second day after 
 admission, the right side, previously quite dull, on percussion, 
 yielded a remarkably clear sound of a tympanitic character. On 
 autopsy the right lung was found to be adherent to the costal 
 pleura, and solid throughout, the red passing in spots into grey 
 hepatization.* 
 
 Some years after the occurrence of the last case, I was called 
 to see, in consultation, a gentleman in whom the latency of the 
 pulmonary symptoms with the highly marked icteroid tinge of 
 the surface (so well described and explained by Hasse), had led 
 his medical attendant to diagnose hepatitis, and to treat the 
 patient accordingly. I was of opinion that the entire of the 
 right lung was in a state of hepatization, as the side yielded, on 
 percussion, a sound clearer than that of the left side, but of a 
 highly tympanitic character ; while, on auscultation, no inspi- 
 ratory murmur or crepitus was audible. As my friend doubted 
 the correctness of my diagnosis, I appealed for its confirmation 
 to the future progress of the case, anticipating, from my expe- 
 rience of similar cases, that on the commencement of resolution 
 the side would become as dull as it was then morbidly clear. 
 This anticipation was realized ; at our next meeting the entire 
 side was dull on percussion, while the stethoscopic signs of 
 resolution were present, and my friend acknowledged the value of 
 a sign which he had not previously thought worthy of attention, 
 but which he afterwards recognized in other instances. 
 * Dublin Medical Journal, 1st series, vol. xi. 
 Z
 
 338 PNEUMONIA. 
 
 In 1838, Dr. Williams, in his " Lectures on the Physiology 
 and Diseases of the Chest," London Medical Gazette, March 31st, 
 thus alluded to the phenomenon : — " It is a kind of tympanitic 
 sound, and as in one of these cases there was also a sort of 
 amphoric respiration heard in this spot, I concluded the case to 
 be one of pneumothorax, from the perforation of the lung. This 
 patient, whom I saw with my friend. Dr. Roscoe, surprised me 
 by soon getting well, and losing all these signs, which made me 
 reflect more on the matter ; and having since met with a similar 
 case, which proved fatal, I have satisfied myself as to the cause 
 of the phenomenon. Dr. Hudson, of Dublin, has also recently 
 described cases in which a loud tympanitic sound on percussion 
 was presented in the upper part of the chest of a patient affected 
 with pneumonia. Now, you will understand how this sound is 
 produced, if yo'u listen to this tracheal sound, whicli I got by 
 filliping on my windpipe above the sternum. The windpipe also 
 lies under the sternum, and it divides into the two great bronchi, 
 which spread between one and two inches below the clavicles. 
 Here, however, the porous lung lies over these tubes, and inter- 
 cepts their resonance on percussion ; but let this portion of lung 
 be perfectly condensed by a liquid efi"usion, or perfectly con- 
 solidated by hepatization, and you will then get the bottle-note 
 of the tubes, just as you do of the windpipe where no lung inter- 
 venes. The reason why this phenomenon does not occur more 
 frequently is, that it does not often happen that the compression 
 of solidification of the upper lobe is complete enough ; but, since 
 my attention has been drawn to it, I have met with several cases 
 of both pleurisy and pneumonia, in which it existed in smaller 
 degree ; and I had occasion to notice in the last lecture that it 
 sometimes occurs with dilated bronchi," 
 
 Dr. Stokes regarded tympanitic resonance in pneumonia as 
 impossible, and inconsistent with the received doctrine of per- 
 cussion, unless when caused by pneumothorax, or by transmission 
 of the sound of a distended stomach. 
 
 On these causes, Dr. Walshe remarks (having previously stated 
 that he had observed two positive examples of temporary tym- 
 panitic note over pneumonic consolidation at the right base) : — 
 " True tympanitic resonance is excessively rare over pneumonic 
 consolidation, and I have scarcely ever observed it at the upper 
 part of the chest, where pleural fluid had accumulated below.
 
 PNEUMONIA. 339 
 
 When such resonance occurs at the base of the chest, great 
 distention of the stomach or colon might be suggested in expla- 
 nation ; but, in point of fact, the stomach and colon are rarely 
 distended enough for the conversion of their common amphoric 
 into tympanitic quality ; and in the only two positive instances 
 I have observed of pneumonic tympanitic sound, the consolidation 
 was on the right side above the liver. I am satisfied the 
 phenomenon does not depend on temporary secretion of air by the 
 pleural sac."* 
 
 Skoda appears to regard the phenomena as due entirely to 
 diminished quantity of air in the lung. He says : " The sound 
 is, moreover, in many cases remarkably tympanitic, even when 
 the diminution of the quantity of air in the lung is the effect of 
 an increase in its fluid or solid constituents ; and this, too, 
 whether the lung retains its normal volume or becomes larger 
 than natural. When the lung is much reduced in volume 
 by compression, but still contains air, its sound is invariably 
 tympanitic. "t Skoda, however, as Dr. Walshe remarks, no- 
 where defines the meaning of the term tympanitic, as used by 
 him. 
 
 In March, 1853, Dr. Banks presented to the Pathological 
 Society of Dublin a case of pneumonia, in which this phenomenon, 
 was observed. In the report it is stated that on the second day 
 after the patient's admission into hospital, the whole of the 
 anterior-superior portion of the side, previously dull on percussion, 
 presented a remarkably tympanitic resonance, best heard by a 
 light, smart percussion. The sign continued up to the death of 
 the patient, on the fourth evening after admission. 
 
 "On opening the chest," says Dr. Banks, "I found that the 
 right lung had been the seat of universal solidification. It oc-- 
 cupied a very great extent of the chest ; it crossed the mesial 
 line, covered the heart, and overlapped a portion of the opposite> 
 lung ; it was solid from its apex to its base, with the exception 
 of the lower edge of the inferior lobe, which was emphj^sema- 
 tous. There was no purulent infiltration. The left lung was 
 healthy." 
 
 Dr. Walshe mentions a case of acute tuberculization and con- 
 solidation, in which amphoric resonance was olrerved over a solid 
 
 * On Diseases of the Lungs, p. 73. 
 . f Translation by Markham, p. 13. 
 
 z 2
 
 340 PNEUMONIA. 
 
 portion lying over the main bronchial tube, forty-eight hours 
 before death, but not at the autopsy.* 
 
 A most important contribution to this subject is the paper 
 "On Typhoid Pneumonia associated with Muffled Tympanitic 
 Resonance," by Dr. Hayden.f 
 
 In the case of James Osborne, on the sixth day after admission, 
 the report states, that " from base of thorax to right nipple there 
 is complete dulness, with crepitus ; from nipple to clavicle the 
 percussion is of a mixed and very singular character — it is that 
 of dulness, qualified by a metallic resonance, and communicates 
 the sensation of a solid, but resonant, body under percussion. 
 Over the region which presents this remarkable modification of 
 dulness, respiration is bronchial, accompanied by crepitus on full 
 inspiration. 
 
 On the tenth day the right side was observed to be more pro- 
 minent in front than the left, with less respiratory movement ; 
 and over the anterior surface, and extending slightly to the left 
 of the mesial line, the percussion sound was tympanitic, and of 
 a somewhat metallic character. Over entire posterior right side 
 percussion was perfectly dull, with fine crepitus, over resonant 
 region ; in front respiration is bronchial, as it has been for the 
 last three days. 
 
 The patient died on the eleventh morning, and the following 
 is a summary of the observations made on autopsy, three hours 
 after : — 
 
 1st. The right side was remarkably prominent, and still yielded 
 tympanitic resonance, but a shade less marked than before 
 death. 
 
 2nd. The body being immersed in water, face upwards, and 
 the right side punctured, the pleura was found to be adherent, 
 and no air escaped, until after separation of its surfaces the lung 
 was punctured, when bubbles of air freely escaped. 
 
 3rd. The chest being laid open in the usual manner, the right 
 lung was fully distended, so as to keep that side of the chest in 
 a state of maximum distention ; its colour was dark grey, and its 
 anterior edge was thickened, and overlapped the pericardium. 
 The superior and middle lobes yielded on percussion a somcivhat 
 muffled metallic ring. The percussion note of the same portion 
 
 * On Diseases of the Lungs, p. 75. 
 f Dublin Quarterly Journal, vol. xli.
 
 PNEUMONIA. 341 
 
 was similar when the lung was removed from the body, while 
 percussion of the inferior lobe yielded a perfectly dull sound. 
 
 On section, the cut surface was light-grey in colour, somewhat 
 darker at the base; no fluid escaped from it, but, on pressure 
 with the flat surface of the knife, thin purulent matter streamed 
 out. Placed in water, the lung sunk at once. 
 
 Dr. Hayden gives two other cases of typhoid pneumonia, in 
 one of which, the upper lobe of the left being engaged, this 
 phenomenon was observed, while in the other, the upper portion 
 of the right being engaged, it was entirely absent. 
 
 The conclusions (says Dr. Hayden) deducible from these cases, 
 as regards the phenomenon of mufiled tympanitic resonance, are 
 both negative and positive. 
 
 NEGATIVE. 
 
 1st. The phenomenon is not due to transmitted resonance 
 from a healthy through a solidified portion of lung substance. 
 {a.) Because in Case No. II., in which it was best pronounced, 
 
 the entire lung was solid. 
 (&.) Because in Case No. III. it did not exist, although the 
 
 inferior and posterior portion of the lung was physically 
 
 healthy. 
 2nd. It was not the result of gastric resonance transmitted 
 through a solid lung. 
 
 (a.) Because it existed in Case No. I., in which only the 
 
 superior portion of the left lung was hepatized, the in- 
 ferior lobe being in a healthy condition. 
 (h.) Because in Case No. II. it existed only in the superior 
 
 portion of the right lung, notwithstanding that the entire 
 
 organ was solid ; and it likewise existed in the isolated 
 
 lung, as proved by jwst-mortem test. 
 3rd. It was not due to pneumothorax, 
 (a.) Because in Case No. II. it existed up to death ; and after 
 
 death, lung was found universally adherent to chest, and 
 
 no air existed in the pleura. 
 
 POSITIVE. 
 
 1st. The phenomenon was intrinsic in the lung, and had its 
 seat in that portion of the organ in which it was manifested.
 
 342 PNEUMONIA. 
 
 (a.) Because percussion of the lung removed from the body 
 afforded proof of its existence in the isolated organ, and 
 even in a thin layer of it resting on a solid body. 
 
 (b.) Because percussion showed dulness in that portion of the 
 lung, after removal from the body, over which dulness 
 existed during the patient's illness. 
 
 2nd. The resonance of the solidified lung was associated with 
 the presence of air in its tissue. 
 
 (a.) Because air freely escaped from an opening made with the 
 finger, under water, in that portion of the lung which 
 yielded t3'mpanitic resonance. 
 
 3rd. Simple pneumothorax, whether pneumonic or pleuritic, is 
 characterized by absence of respiratory sound, co-extensive with 
 tympanitic resonance, and by displacement of the heart if the 
 aeriform effusion be abundant, as in the cases of Graves and Little. 
 
 4th. The resonant or tympanitic dulness of pneumonia, due to 
 air implicated in the tissue of the lung, is distinguished from 
 pneumothorax by the qualified or muffled character of the reso- 
 nance, and by the presence of bronchial respiration and of crepitus, 
 as in Dr. Hudson's cases and in mine.^' 
 
 Of more recent writers on pneumonia, Niemeyer follows Skoda. 
 Waters does not allude to the phenomenon. Sturges mentions it 
 as one of the occasional misleading abnormalities of the stage of 
 solidification still awaiting explanation, when " the solid lung, 
 instead of yielding to percussion the usual dull wooden note, 
 gives a resonance which suggests the neighbourhood of an empty 
 
 cavity Cavernous respiration will often concur with this 
 
 metallic note, while the conclusions to which such signs point 
 may be yet further strengthened by the existence of very perfect 
 pectoriloquy. Whatever may be the true explanation of these 
 signs, it is quite certain that they may be met with in lung that 
 is simply consolidated." * 
 
 Lastly, Juergensen contributes the following important obser- 
 vations t : — " Biiumler, to whom we are indebted for a very read- 
 able article on this subject, thinks that Williams's tracheal tone 
 cannot occur in infiltrations of the lower lobe. This is contrary 
 to my experience, which is based upon two cases, one of which 
 recovered, and the other proved fatal." 
 
 * Oa Pneumonia, p. 49, 
 
 ■}• Art. Pneumonia, Ziemssen's Cyclopedia, vol. v. p. 79.
 
 PNEUMONIA. 343 
 
 *' A few words in regard to the latter case, in which the evi- 
 dence was conclusive. It was one of pneumonia of the lower 
 lobe of the left lung, occurring during the course of the secondary 
 fever in a patient with small-pox, in the middle of his twentieth 
 year. When the plessimeter was placed at the level of the sixth 
 to seventh ribs, exactly midway between the spinal column and 
 the posterior axillary line, and was struck with a strong and short 
 blow, an exquisitely tympanitic note was heard, which quite un- 
 mistakably changed its note of vibration whenever the mouth was 
 opened or closed. We suspected a cavity from j^athological 
 causes, such as abscess or gangrene, and were astonished when 
 the autopsy revealed no other lesion than a solid infiltration in 
 the stage of yellow hepatization. The case was observed by 
 Bartels and myself in the Medical Clinic of Kiel. Afterwards, 
 I saw another similar case in the Kiel Polyclinic, and showed it 
 to my assistants. It was a pneumonia of the right inferior lobe, 
 which run throughout a normal course. 
 
 " I am very willing to admit that these cases are rare ; for, out 
 of the very large number of cases of pneumonia seen by me 
 during many years, and carefully examined in regard to this point, 
 the above are the only instances in which the evidence was 
 entirely clear. Another reason why a perfectly pure tympanitic 
 note, unless it be traceable to Williams's tracheal tone, cannot 
 usually be obtained in croupous pneumonia, may be, that in the 
 difterent parts of the lung percussed at the same time the sound 
 is controlled sometimes by the elastic membrane, and sometimes 
 by the columns of air inclosed in the bronchi, and that the waves 
 thus produced belong to different systems, and have different 
 rates of vibration." 
 
 Wlien I first offered an explanation of this phenomenon, I did 
 not attach due importance to the condition of the parietes of 
 the chest, which, in Dr. Banks' and Dr. Hayden's cases, were 
 observed to be rendered tense by the tumefaction of the affected 
 lung. Attention was first directed to it by Dr. Williams, whose 
 opinion is controverted by Skoda.* Its importance was, however, 
 recognised by Dr. Graves, who first, so far as I am aware, ob- 
 served the occurrence of dilatation of the side and tympanitic 
 resonance over the displaced lung in a case of pericarditis with 
 effusion in a young person. "In this case (says Dr. Graves) 
 
 * Markham's Translation, pp. 5 and 14.
 
 344 PNEUMONIA. 
 
 there was an evident dilatation of tlie left chest exactly corres- 
 ponding to the distended pericardium, which, pushing before it 
 the flexible parietes, formed a well-marked and evident promi- 
 nence. This likewise rendered the parietes of the superior por- 
 tions of the left side of the chest more tense than natural, an 
 occurrence sure, for reasons well explained by Dr. Williams, to 
 occasion increased resonance on percussion." * 
 
 A similar case was published by Dr. R. Todd, in the Medical 
 Times of December 18th, 1852. On the eleventh day after ad- 
 mission — the symptoms and signs of increasing effusion in the 
 pericardium being present — " a new sign," says Dr. Todd, 
 " attracted our attention, and puzzled us not a little. We found 
 gi-eat resonance of the lower half of the left side behind : in fact, 
 it had become tympanitic. The chest was also tympanitic on 
 percussion at the left side, in front, and in the lateral region." 
 
 In a paper " On the Signs of Accumuhition in some Thoracic 
 Diseases," in The Dublin Quarterly Journal of 1856, I offered 
 the following observations on the occasional occurrence of general 
 dilatation of the side in pericarditis and pneumonia, and its 
 accompanying phenomenon, increased or tympanitic clearness on 
 percussion, as it is defined by Dr. Walshe : — " The note clear ; 
 the duration considerable ; the resistance of the walls tense, 
 drum-like, highly elastic." This is the percussion sound of the 
 upper portion of the chest in the commencing stage of jjleuritis 
 with effusion, before the quantity of fluid is become so consider- 
 able as to interfere with chest vibration, and so cause the sound 
 to become amphoric or tubular. It resembles the sound on per- 
 cussion in the bronchitis of the young, and in some cases of 
 emphysema with dilatation, in which the parietes are rendered 
 tense, partly by the pressure from within, and partly by the 
 heightened action of the iutercostals. 
 
 I believe that the conflicting observations on this point are to 
 be reconciled by taking into account the existence of different 
 forms of pneumonia, in one of which, at least — that, namely, 
 attended with plastic exudation into the lung — well-marked sif^ns 
 of accumulation are present. The following are the grounds 
 for this opinion : — 
 
 First— The remarkable case presented to the Pathological 
 Society of Dublin, by Professor Smith, which, we may say, bears 
 
 * Clinical Medicine, vol. ii. p. 28(;.
 
 PNEUMONIA. 
 
 345 
 
 much the same relation to the diagnosis of pneumonia as that of 
 Dr. Graves, abeady quoted, does to pericarditis. In this patient 
 tlie external signs of enlargement of the lung were, dilatation of 
 the sids to the extent of an inch and a-half, and down\Yard pro- 
 trusion of the liver. On jyost-mortem examination it was found 
 that the diaphragm was pushed down, and the opposite lung 
 compressed, and the surface of the lung indented hy the ribs to 
 an unusual depth; the increase of hulk being owing to the depo- 
 sition of lymph in the air-cells of the lung, constituting that 
 form of disease since described by Dr. Blakiston under the term 
 " plastic pneumonia." " This case," as Professor Smith observes, 
 " places the fact, denied by many authors, of actual enlargement 
 of the lung, beyond doubt." 
 
 Second — The occurrence, under my own observation, at 
 difterent times, more especially during the past year, of cases in 
 which positive dilatation of the side, ascertained by measure- 
 ment, existed, with other signs of accumulation, and in which 
 other characters of the disease resembled those of plastic pneu- 
 monia : such as absence of the crepitus of the first stage, absence 
 of the rusty expectoration of pneumonia,* and rapid solidification, 
 with remarkable chronicity of disease — all the cases extending 
 over many weeks, several over months. (In this particular they 
 resembled Professor Smith's case, which was of three months' 
 duration.) In three young persons, in whom the disease occurred 
 in the left lung, this side measured from half to three-fourths of 
 an inch more than the right ; and in two of these, in whom it 
 M'as confined to the upper lobe, the heart was sensibly displaced 
 downwards, and to the right, as in emphysema of the same part. 
 In one of these, a young lady, aged ten, the dilatation and dis- 
 placement were witnessed by her medical attendant. Dr. Travers, 
 as well as by myself. 
 
 In three fatal cases both lungs were engaged — two of these 
 were gentlemen of previously-dissipated habits and broken con- 
 stitution ; unfortunately, no opportunity was aflbrded of ascer- 
 taining the truth of the diagnosis by post-mortem examination ; 
 but, in the third, which was under the care of Dr. Aquilla Smith, 
 this was done. 
 
 Eliza Helson, aged nine, had measles six weeks since, after 
 which cough and dyspnoea supervened, and have since continued. 
 * This absence was also remarked in Dr. Hayden's second case.
 
 346 PNEUMONIA. 
 
 When examined, after admission into Sir P. Dun's Hospital 
 (February lOtli), she presented the dusky face, with dark flush, 
 and the pungent heat of skin of pneumonia ; her breathing was 
 oppressed, but not laborious, 36 in the minute ; pulse 108, 
 small and feeble. On inspection of the chest both sides seemed 
 to expand equally during the inspiration, but the right, 
 posteriorly, was evidently rounder and fuller than the left ; and 
 being carefully measured by Dr. Smith, Dr. R. M'Dermott, and 
 myself, was found to be fully an inch larger. Both over the 
 rounded part and over the mammary region, it gave a tympanitic 
 sound on percussion, so clear, that it was remari^ed at the time 
 how easily one previous^ unacquainted with this modification of 
 the percussion sound, might mistake the natural resonance of the 
 left side for comparative dulness, from its contrast to the abnormal 
 clearness of the right. Over the low^er third, posteriorly and 
 laterally, there w^as a loose muco-crepitus, mixed with feeble 
 bronchial respiration, while superiorly the bronchial respiration 
 was pure and unmixed with rale ; over the spine of the scapula 
 and under the clavicles, respiration was puerile. Gradually the 
 breathing became more hurried, the pulse more rapid, the cough 
 more frequent, and the expectoration more purulent and copious. 
 Each time that the chest was examined the measurement of the 
 side was found to be less, while, on percussion, it sounded duller 
 and more amphoric, and the muco-crepitus became looser and 
 mixed with gurgling. Ten days after her admission the measure- 
 ment of the sides was equal, and the signs of cavity in the lower 
 part of the side (cavernous respiration and garqouillent) fully 
 established. She continued much in the same state for three 
 weeks longer ; when, on the 2'2nd of March, she w^as suddenly 
 seized wdth acute pain in the side and great increase of dyspncea, 
 and died on the following day. 
 
 On dissection, the diagnosis made during life, of plastic pneu- 
 monia and abscess in the lung, with recent opening into the pleura, 
 was found to be correct ; the appearance of the upper and middle 
 lobes was exactly similar to that in Professor Smith's preparation 
 and drawing ; the deposit, which studded every portion of these 
 lobes, was contained in cysts, varying in size from a pin's head 
 to a horse-bean. On this substance being submitted to exami- 
 nation, under the microscope, by Dr. M'Dermott, it was found to 
 consist of fibrinous exudation, without any trace of tubercle.
 
 PNEUMONIA. 347 
 
 The entire lower lobe was converted into an abscess, lined by a 
 smooth pyogenic membrane, and communicating by a small rent 
 with the cavity of the pleura. It should have been mentioned, 
 that three weeks before death signs of solidification had appeared 
 in the upper part of the left side, where some of the same deposit 
 was found in a crude state. 
 
 In one of the other fatal cases the course of the disease was, 
 in some respects, similar to the above. . . . Solidification, 
 first of the lower lobe of the left lung, with tympanitic resonance, 
 then of the upper lobe of the right, ending in the formation of a 
 large abscess in the former situation. In the third case the 
 disease also commenced in the left lung, then attacked the right, 
 the chest becoming dilated and rounded, as in emphysema, 
 and everywhere preternaturally clear on percussion ; respiration 
 being effected entirely upwards, and by the diaphragm ; the heart 
 was carried down, and pulsated under the lower edge of the 
 sternum. It is worthy of remark, that both these patients had 
 extensive and obstinate diphtherite of the mouth and pharynx — 
 an indication, perhaps, of the blood crasis w^hich determined this 
 peculiar form of pneumonia.* 
 
 From a review of the cases which I have from time to time 
 observed, as well as of those published by others, I would offer 
 the following conclusions : — 
 
 I. That three varieties of tympanitic sound have been observed, 
 differing in degree, but not always distinguished from each other; 
 namely : — 
 
 (a). The absolutely clear resonance of pneumothorax, yielded 
 in some rare cases by a lung entirely solidified. 
 
 (b). The muffled tympanitic, or amphoric, sound yielded by a 
 lung partially hepatized, or compressed by a moderate amount of 
 fluid in the pleura, or a proportionally large amount in the peri- 
 cardium. — (Skoda's tympanitic sound ; Bruit Scodique of the 
 French.) 
 
 (c). The tubular or tracheal sound yielded by the upper por- 
 tion of the chest in more copious pleural efi"usion, or in some 
 cases of consolidation of the upper lobe from jDueumonia or 
 phthisis. — (Williams : see remarkable case, reported by Walshe, 
 p. 75, 4th ed.) 
 
 * It may be observed that all these cases occurred during a limited epidemic 
 period. Neither previously, nor during twenty-five subsequent years, have I met 
 with any similar example of plastic pneumonia.
 
 348 PNEUMONIA. 
 
 II. That this sign is not peculiar to the first stage and that of 
 resolution, as erroneously stated by Guttman,* but, on the con- 
 trary, has been invariably observed to occur during the stage of 
 hepatization, disappearing more or less completely on the com- 
 mencement of resolution, and declining during the stage of grey 
 softening, thus rendering it probable that an amount of uniformity 
 of consistence is requisite for the transmission of the vibrations 
 of the parietes to the bronchus and its divisions, to produce this 
 resonance, changes of media being well known to interrupt 
 sonorous vibrations. 
 
 III. That its disappearance and the change to dulness on the 
 commencement of resolution may be due in part to the filling up 
 of the minute bronchi by serous exudation, their permeability 
 being regarded by Dr. "Walshe as necessary for the production of 
 a tubular sound. 
 
 * Handbook of Physical Diagnosis, p. 99.
 
 349 
 
 SECTION V. 
 
 GANGRENE OF THE LUNG. 
 
 [This chapter consists of two parts : the first, a reprint of the brief chapter in 
 the first edition of this work ; the second, of a more elaborate memoir in the 
 Dublin Quarterly Journal of February, 1850,] 
 
 Part I. 
 
 I HAYE placed tliis disease after pneumonia independent of 
 any theoretical considerations. Its close connexion with pneu- 
 monia and congestion of the lung, however, will justify an 
 arrangement adopted principally for convenience. 
 
 I shall not discuss the nature of this affection, but content 
 myself with giving an abstract of a few cases which have fallen 
 under my own observation. 
 
 Case I. — A middle-aged man was attacked with symptoms 
 of pneumonia, in consequence of a contused injury of the right 
 side ; from these he partially recovered, when he was thrown 
 from a car, and received a second injury on the same side. 
 Cough, with a dark coloured and offensive expectoration, and 
 occasional haemoptysis, set in. He was admitted into hospital 
 in the seventh v.'eek of his illness, with extreme prostration ; 
 the countenance was of a leaden hue ; the respiration seventy- 
 two in a minute ; breath foetid ; the cough constant, with 
 expectoration of a yellowish-white purulent matter. By the 
 stethoscope a large cavity was detected in the right lung. 
 The patient died on the fourth day after admission. 
 
 Inspection. — A vast gangrenous abscess occupied the whole 
 posterior part of the right lung : the cavity was eight inches in 
 length, four in breadth, and two in depth ; this contained a 
 large, moist, and soft slough of an extreme foetor, and the upper 
 part of the cavity was lined with a distinct layer of coagulable 
 lymph. 
 
 This cavity had extensive communication with the bronchial 
 tubes. Having placed it under water, we found, by inserting a
 
 350 GANGRENE OF THE LUNG. 
 
 blow-pipe into the pulmonary artery, that air in great quantity 
 could be made to rise from the surface of the cavity ; the left 
 lung was extensively inflamed. 
 
 Case II. — A man, aged 28, of a full habit, laboured for a 
 year under palpitation, cough, and pains of the sides ; he was 
 admitted into hospital, stating that on the day before he had had 
 rigor with great increase of pain. He had frequent cough with 
 dark coloured expectoration ; the pulse was rapid ; he lay on the 
 right side ; the breath had the characteristic foetor of gangrene, 
 and there was a cadaverous smell from the whole body ; coun- 
 tenance of a leaden hue ; lips livid ; the right side sounded 
 dull, and a cavity was detected in the mammary region. In 
 five days after admission he was attacked with severe inflamma- 
 tion of the left lung ; copious haemoptysis followed ; and he 
 died on the ninth day after admission. 
 
 Inspection. — The right lung was solid and strongly adhe- 
 rent ; the upper lobe presented the third and fourth stages of 
 inflammation. At about four inches from the summit an anfrac- 
 tuous cavity existed, having three prolongations extending in 
 diflerent directions ; most of this cavity was filled with a sub- 
 stance resembling putrid flax, of an exceedingly foetid odour. 
 This cavity was evidently chronic, as its walls Avere firm, and 
 lined with a cartilaginous membrane. Many of the bronchial 
 tubes were dilated ; the lower half of the left lung was in a state 
 of deliquescent sphacelus, the afi"ected part being surrounded by 
 a baud of hepatization, beyond which the tissue was health}^ and 
 crepitating. 
 
 Case III. — A man, aged 26, who had been previously 
 healthy, and not subject to cough, while intoxicated and very 
 warm, bathed and remained for a considerable time in the water ; 
 on coming out he felt very cold ; he again indulged in drinking, 
 and became a second time intoxicated ; he partly undressed, 
 and lay for the whole day on the left side, on a cold and 
 damp floor ; on the following day he was attacked with violent 
 symptoms of pleuro-pneumonia, and in about three weeks coughed 
 up some dark-coloured fluid blood ; he then became hectic, 
 and was admitted on the 1st of September. He was greatly 
 emaciated, had extreme i^rostration of strength, and coughed 
 up large quantities of a foe "id greenish matter ; the b]-eath was 
 extremely foetid, and the skin hot ; the supero-anterior portion
 
 GANGRENE OF THE LUNG. 351 
 
 of the left side sounded dull, while between the third and fifth 
 ribs a cavity could be easily detected. 
 
 This patient was treated by the chloride of lime, with wine 
 and opium. The most rapid and marked amendment followed ; 
 in a few days the foetor of breath and expectoration had disap- 
 peared ; no inconvenience whatever was experienced from the 
 remedy. We also directed the covering of the bed to be sprinkled 
 with a solution of the salt. The remedy being omitted, in two 
 days the foetor returned, and fever began to appear ; but these 
 symptoms again subsided with rapidity on his resuming the 
 medicine. The patient was ultimately discharged, greatly im- 
 proved in strength and flesh ; he, however, some time afterwards 
 relapsed, and died in the country. 
 
 Case IV. — A labourer, aged about thirty-two, habitually in- 
 temperate, while intoxicated fell into a canal, and after sitting 
 for some time in his wet clothes, was seized with a rigor ; on the 
 next day he had cough, pain in the side, and difficulty of 
 breathing, and was admitted into the Meath Hospital on the third 
 day after the accident. He presented the usual symptoms of 
 typhoid pneumonia, the anterior and lateral portions of the right 
 side sounding dull, with absence of respiration. In the course 
 of the day, t]ie dulness extended over the whole of tlie right side, 
 without any preceding crejntus being ohsei'ved. On the next daj' 
 the prostration was extreme, and the breath slightly foetid ; the 
 foetor increased remarkably towards CA'ening, and a copious 
 expectoration of dark-coloured sanious fluid took place. The 
 foetor was much increased after coughing ; the countenance be- 
 came sunk ; but the peculiar leaden hue was never observed. 
 On the next day the signs of a cavity were detected, and the 
 patient died on the following evening. 
 
 Inspection. — The right lung was generally adherent ; exter- 
 nally it appeared solid, but there existed a large cavity in the 
 anterior portion, extending backwards and downwards ; this 
 cavity occupied the lower lobe ; it was not lined by any false 
 membrane, but contained a quantity of sanious fluid, similar to 
 what had been expectorated. Its walls were formed by the pul- 
 monary tissue, which Avas solid, softened, and of a dirty reddish 
 colour, but not presenting the granular appearance of ordinary 
 pneumonia. 
 
 On comparing these cases, they will be found more or less
 
 352 GANGRENE OF THE LUNG. 
 
 analogous ; and they all present inflammation preceding and 
 accompanying the disease. It is yet to be determined whether 
 the occurrence of gangrene depends on the suddenness and com- 
 pleteness of congestion, or on the general morbid state of the 
 patient. No doubt both causes influence its production. In all 
 the cases which I have seen, the patients were long addicted to 
 the use of spirits. With respect to the violence of congestion, 
 the exciting causes of the disease would favour such an occur- 
 rence. In the first case, the patient received two contused 
 injuries of the chest ; and I have known of others in which 
 gangrene followed this accident. In the third and fourth cases 
 the circumstances are just such as would produce intense con- 
 gestion ; and the fourth is also an example of the typhoid 
 pneumonia which I have described as producing solidity without 
 preceding crepitating rale. 
 
 Notwithstanding the general similarity of my cases, their 
 history presents some interesting points of difference which may 
 be thus enumerated : — 
 
 1st Case. — Enormous gangrenous abscess succeeding to con- 
 tused injury of the chest. 
 
 2nd Case. — Chronic circumscribed gangrene, with an isolated 
 slough in one lung, succeeded by acute sphacelus in the other. 
 
 3rd Case. — Gangrenous cavity occurring under circumstances 
 calculated to produce extreme congestion of the lung. 
 
 4th Case. — Acute gangrenous abscess, supervening on typhoid 
 pneumonia. 
 
 I have not found any peculiar physical signs in the gangrenous 
 abscess of the lung. I believe that the only pathognomonic 
 symptom is the extraordinary and disgusting odour of the breath 
 and expectoration, making the patient loathsome to himself and 
 all around him ; the stench, however, is not constant, for during 
 the progress of a case it may disappear more than once. In 
 some cases the expectoration is foetid, while the breath is free 
 from odour, and it will be often necessary that the patient be 
 made to cough in order to produce the stench.
 
 GANGRENE OF THE LUNG. 353 
 
 Part II. 
 
 Under the term gangrene may be included all cases in which 
 a putrefactive process, accompanied by death of a portion of the 
 lung, takes place. The disease is met with in the acute and 
 chronic forms, and also in that of continually recurring acute 
 attacks ; it may be a primary idiopathic affection, or arise in the 
 course of some constitutional disease, or be the result of a 
 previous acute or chronic disease within the chest. Under 
 whatever form it occurs, it is one of the most terrible and un- 
 manageable of the diseases of the lungs. 
 
 The following are some of the forms of this disease : — 
 
 1. A gangrenous eschar rapidly produced from causes which, 
 under ordinary circumstances, would cause simple pneumonia or 
 pleurisy. 
 
 2. Gangrene of the lung occurring as a consequence of diffuse 
 or erysipelatous inflammation. 
 
 3. Arising from long exposure of the surface to cold. 
 
 4. Occurring in the consolidation of the lung observed in 
 bad cases of typhus fever. 
 
 5. Induced by contused injuries of the chest. 
 
 6. Repeated distinct attacks of acute gangrenous disease, with 
 severe symptoms of irritation and high fever. The attacks, with 
 the exception of the first, not having any apparent exciting cause, 
 and continuing to recur for a great length of time. 
 
 7. Chronic gangrenous cavity with great diminution of 
 volume. 
 
 8. Recent sphacelus of one lung supervening on a chronic 
 gangrene of the oj^posite lung. 
 
 9. The result of pressure of the nutrient vessels and nerves of 
 the lung by aneurismal or cancerous tumours. 
 
 There are other forms of the affection, but the above are those 
 which have come under my observation.* 
 
 The general symptoms have a close similarity in the various 
 forms of the affection, consisting in cough, with an extreme and 
 perfectly peculiar foetor of the breath. There is generally copious 
 expectoration of a sanious or muco-purulent character ; but 
 neither with this nor with the breath is the foetor constantly 
 associated, for it is found to appear and to subside in singularly 
 
 ♦ See Appendix. 
 A A
 
 354 GANGRENE OF THE LUNG. 
 
 short spaces of time. This foetor is of all stenches the most 
 terrible. It is commonly perceived during a fit of coughing, 
 and appears to be produced rapidly by the use of stimulating 
 food or drinks. It may subside fOr a great length of time, 
 and be again produced without our being able to explain the 
 cause of its re-appearance. The system seems to suffer from 
 the effects of a septic poison, and a weakened and leuco- 
 phlegmatic condition is observed in most of the chronic cases of 
 the disease. 
 
 We would, however, fall into error if we were to consider all 
 cases of cough, with fcetid breath and expectoration, as cases of 
 true gangrene of the lung. Dr. Graves has shown that these 
 symptoms may come on in chronic bronchitis.* Dr. Williams 
 describes cases of foetid abscess of the lung with recovery, a disease 
 which I have also observed in the pneumonia following measles. 
 I have more than once observed a distinct gangrenous odour on 
 the breath of a lady who had recently suffered from slight 
 bronchial haemorrhage. And in cases where an empyema opens 
 through the lung the discharge has sometimes an extreme 
 degree of foetor. In such cases there is no sphacelus of the 
 tissues, and we have only putrefaction of a secreted fluid occur- 
 ring after it has occupied its containing cavity. 
 
 We may here pause, even at the risk of digression, to inquire, 
 why it is that this change does not more often occur, both in 
 bronchial effusions and also in the fluid contents of an empyema ? 
 In the case of an empyema with closed sac, we may presume 
 that the want of contact with air is the cause of absence of 
 putrefaction ; but in copious bronchial effusions, in the fluid 
 contents of open tuberculous abscesses, and, above all, in the 
 case of empyema and pneumothorax with pulmonary fistula, the 
 preservation from a septic state of the secreted matters is one of 
 the most singular of pathological phenomena. 
 
 In the case of empyema with pulmonary fistula we may have 
 many pints of a highly animalized fluid, mixed with floating 
 fragments and shreds of lymph, kept at a high temperature and 
 in contact with atmospheric air, which is more or less renewed 
 at every inspiration. And yet this fluid remains for months, or 
 even more than a year, without putrefying; when, if it were 
 withdrawn and kept at the same temperature and in contact with 
 * Clinical Medicine, 2nd ed,, vol. ii. p. 52.
 
 GANGEENE OF THE LUNG. 355 
 
 air outside the body, it would run rapidly into decomposition. 
 We can only explain this by assuming that actual organic con- 
 nexion is unnecessary for a certain degree of inherent vitality, or 
 that there is a vital irradiation from surrounding parts. The 
 organization of effused lymph, and its transformation into fat, or 
 cancerous, or bony structures, seem to favour these views. 
 
 It is many years since I saw a case which, as bearing on these 
 points, is worthy to be placed on record. A gentleman past 
 middle age had for some months laboured under the ordinary 
 form of tuberculous phthisis. In the course of some months 
 empyema and pneumothorax with fistula occurred with the usual 
 symptoms, and he remained for a great length of time with the 
 usual symptoms and signs of this condition : there were no 
 evidences of putrefaction. The liquid effusion slowly increased 
 until the pressure was so great as to cause extreme distress, and 
 the operation of paracentesis was performed by Mr. Porter, 
 merely as a palliative measure. As is usual, however, in such 
 cases, there was but little relief given. The fluid drawn off was 
 of the ordinary sero-purulent tint, and had not the slightest un- 
 pleasant odour. The liquid effusion again accumulated, and a 
 fluctuating tumour appeared at the situation of the cicatrix of 
 the puncture. This was opened by a lancet, and a great quantity 
 of matter given exit to, still free from foetor. Soon after this 
 the patient complained of great internal distress ; his strength 
 rapidly sank, he began to cough up foetid matter, and his breath 
 had an intense gangrenous stench. He died in a few days after 
 the second operation. On dissection a quantity of dark-coloured 
 and putrid fluid was found in the pleural cavity; the serous 
 membrane had passed into a state of universal sphacelus, and 
 hung in blackened shreds ; the periosteum was also mortified, 
 and the ribs appeared in a state of necrosis. The fistula was 
 easily found, passing into a tuberculous cavern in the antero- 
 superior portion of the lung. 
 
 It would appear that, in this case, gangrenous action spread 
 from the wound to the pleura, Avhich was then deprived of its 
 vitality ; and, consequently, the fluid in the cavity passed rapidly 
 into putrefaction. We cannot suppose that this change was 
 produced by the admission of air, as, for many months before 
 the operations, air had been freely entering through the pul- 
 monary fistula. 
 
 A a2
 
 356 GANGKENE OF THE LUNG. 
 
 I formerly entertained the opinion that this disease was most 
 frequently met with in persons addicted to the abuse of spiritu- 
 ous liquors ; but I have since seen many instances where it 
 occurred in the most temperate individuals. I have not met 
 with any examples of the disease in the child. 
 
 One of the most singular and not uufrequent characters of the 
 disease is the extreme severity of the pain which attends its 
 invasion. We observe this not only in patients who have expe- 
 rienced but a single attack, but in another form, which I shall 
 just now describe, and which I have noticed as the ninth in the 
 catalogue of forms of this disease, given at the commencement 
 of this paper. This pain is more severe than that in ordinary 
 acute pleuritis, and the extent of serous inflammation is by no 
 means commensurate with the amount of suffering. In the 
 recurrent form of the aflection, I have seen each attack accom- 
 panied by this agonizing pain, and this at a time when the 
 patient was reduced to almost the last stage of exhaustion. 
 
 In my work on diseases of the chest I have noticed some 
 forms of gangrene of the lung. Since then I have met with 
 several cases presenting the disease under conditions, which 
 may be described as follows : — 
 
 I. Gangrenous eschar, in typhoid pneumonia. 
 
 II. Circumscribed sphacelus, in cases of diffuse inflam- 
 mation. 
 
 III. Chronic gangrene, producing dexiocardia. 
 
 IV. Frequently recurring attacks of gangrenous disease of 
 the lung. 
 
 Of the first of these my friend Dr. Hudson has given a good 
 example, which was observed in our wards, and I therefore need 
 not here do more than refer to his paper.* The second form 
 may be illustrated by the following case : — 
 
 A young female was attacked with a low form of spreading 
 erysipelas, which extended from the legs upwards to the trunk ; 
 the respiration became impeded, and the right lung soon pre- 
 sented the signs of consolidation in its posterior and inferior 
 portions, without the usual signs of progressive pneumonia. 
 Bronchial effusion soon set in, and the patient sank. There 
 was but little pain, nor was there ever fcetor of breath or ex- 
 ectoration. On dissection, the lower lobe of the right lung was 
 
 * On Typhoid Pneumonia. Dublin Journal, First Series, vol. vii, p. 372.
 
 GANGRENE OF THE LUNG. 357 
 
 found solid, of a yellowisli-grey colour, soft, impermeable, 
 leaving a smooth surface under the scalpel, from which a sero- 
 purulent fluid could be expressed. Within about an inch of the 
 outer surface, and towards the lower portion, we found a cavity 
 completely filled with sanious pus, having the most extreme 
 foetor. There was no bronchial communication, nor any air in 
 the cavity, the sides of which were formed by the condensed 
 lung, and presented a broken and shreddy surface. This cavity 
 was well-defined, and could have contained a large walnut. 
 
 This case is of importance, as exhibiting a true gangrenous 
 cavity, although there was no communication with the external 
 
 (jangrenous Cavity in the uj^jier jwrtion of the Eight Lung, %vith 
 Dexiocardia from the diminished volume of the organ. 
 
 I have met with but one example of this hitherto undescribed 
 form. The patient was an old man, who had for many months 
 laboured under cough, emaciation, and foetid expectoration. He 
 l^resented, on admission to hospital, the ordinary signs of a 
 circumscribed cavity below the right clavicle ; gurgling and 
 cavernous respiration being distinct. The heart was found 
 pulsating to the right of the sternum ; and though its action 
 was feeble, there was no difficulty in recognizing it, owing to the 
 emaciation of the patient. On dissection, a gangrenous cavity, 
 nearly the size of a goose-egg, was found in the supero-anterior 
 portion of the upper lobe, communicating with the bronchial 
 tubes, and exhaling an abominable odour. There was another 
 appearance which I had never before seen. We found, scattered 
 over the anterior surface of the lung, superficial sloughs between 
 the lung and pleura, not communicating with the bronchial 
 tubes. They were about a third of an inch in depth, and about 
 an inch in length ; their form, an elongated oval. In one of 
 these, the blood-vessels, still pervious, were found to traverse 
 the cavity ; while in another, which lay on the anterior face of 
 the middle lobe, a large mass of nearly detached and putrid 
 cellular structure was discovered. On the side, the superficial 
 eschars resembled at first view the ordinary markings of the ribs 
 on the lung. The heart lay completely to the right of the 
 mesian line.
 
 358 GANGRENE OF THE LUNG. 
 
 We may then add gacgrene of the lung to the list of causes 
 of dexiocardia from diminished volume of the right lung. 
 
 Frequently recurrivg attacls of local Gangrenous Disease, 
 accompanied on each occasion hy severe constitutional Dis- 
 turbance. 
 
 Of this extraordinary form I have seen two well-marked 
 examples ; and I am not aware that its symptoms and history 
 have as yet been described in any work on pulmonary diseases. 
 In one instance, which occurred in a female of middle age, the 
 disease proved fatal after a continuance of many months. The 
 other example was in the case of a young man who, after a long 
 struggle with the affection, seemed to have recovered perfectly. 
 He left this country, and remained in the South of Europe, free, 
 as I understand, from any symptoms of his former malady ; but 
 was attacked in the ensuing summer with symptoms of acute 
 pneumonia, under which he sank. 
 
 This form of the disease may be described as consisting in a 
 succession of distinct attacks, with high fever and general con- 
 stitutional disturbance, followed by copious expectoration, which 
 exhales the most intense foetor, with or without blood. The 
 breath becomes foetid, and the patient's condition, during, as it 
 were, the paroxysm of the disease, is distressing in the highest 
 degree. In both these cases intervals of apparently complete 
 recovery were observed. The pulse, which had presented all the 
 characters of inflammatory fever, would become tranquil, the 
 respiration quiet, the cough would almost wholly subside, and 
 the appearance of the patient improve so much as to lead to the 
 belief of perfect recovery ; when another attack, like that which 
 had preceded it, would set in, and run a course precisely similar 
 to that of the last invasion of the disease. The physical pheno- 
 mena in both these cases were in the early stage of the disease 
 singularly obscure, and, in their character and extent, quite in- 
 commensurate with the violence of the symptoms, and the 
 severity and danger of the disease. To this subject I shall 
 recur. 
 
 The first case was that of a lady, past thirty-five years of age. 
 She had never before been subject to pulmonary disease, when, 
 after a long exposure to a cold sea-fog, she Avas attacked with
 
 GANGRENE OF THE LUNG. 359 
 
 symptoms of bronchitis, accompanied by the sensation of pain 
 and oppression referrible to the lower portion of the left side. 
 Within a week of the attack she expectorated some foetid matter, 
 after which she appeared to improve. She bore a long journey 
 to Dublin Avithout any inconvenience, and I saw her within a 
 month of her recovery from the first attack. Her circulation 
 was then tranquil, her cough very trilling, with mucous ex- 
 pectoration, which was free from any fffitor, as was also her 
 breath ; in fact, she had no appearance of disease, beyond the 
 slightest possible cachectic hue. The chest sounded everywhere 
 perfectly clear, and there was no stethoscopic indication of 
 disease beyond a slight and diffused mucous rattle in the inferior 
 portion of the left lung, which was clear on percussion. She 
 appeared to improve for about a fortnight, when, without any 
 apparent exciting cause, she was attacked with most agonizing 
 pain in the situation first affected. The pulse became full, 
 rapid, and resisting ; the skin burning hot ; the cough constant ; 
 the breath extremely foetid ; and she expectorated great quan- 
 tities of muco-purulent fluid, often tinged with blood, and 
 exhaling the most extreme foetor. Notwithstanding the violence 
 of the symptoms, physical examination gave but slight results ; 
 there were no signs of dry pleurisy, no appreciable dulness, and 
 the only change was an increase in the amount of the mucous 
 rattle. The symptoms continued with great severity for about a 
 week, and then subsided ; moderate local bleeding, and opiates, 
 being the principal means employed. She had then an interval 
 of ease and apparent recovery, when another attack succeeded, 
 precisely similar in every character to its predecessor. This 
 attack came on without any apparent exciting cause, and thus 
 the disease continued for many months ; the attacks slightly 
 varying in severity, but agreeing in the general characters of 
 agonizing pain, high fever, and foetid expectoration. No treat- 
 ment that was adopted seemed in the least to control the 
 disease ; yet, in its intervals, the patient continued able to use 
 nourishment, to sleep well, and to take equestrian exercise. 
 The intervals of the attacks became less, and a permanently 
 febrile state was established, notwithstanding which the remit- 
 tent character of the local disease continued manifest. I have 
 never witnessed more acute suffering from mere pain than this 
 lady experienced during each attack of this terrible disease ; and
 
 360 GANGRENE OF THE LUXG. 
 
 yet it was not till within two or three months of her death that 
 any important change in the condition of the lung could be 
 detected. The lowest portion became gradually dull ; and this 
 change advanced upwards with extreme slowness. The mucous 
 rale gradually passed into obscure gurgling, but it was not until 
 within a few weeks of tlie patient's death that signs of a cavern 
 were established. The attacks continued with unmitigated 
 violence up to a period not more than a few days before death, 
 and the sufferings from the pain were, if possible, greater as the 
 patient's strength gave way. 
 
 At no time did physical examination indicate disease over a 
 space of more than about four fingers in breadth and three in 
 depth in the postero-inferior portion of the lung. 
 
 There was no post mortem examination. 
 
 In the second case the exciting cause was also a long exposure 
 to cold, but under different circumstances. The patient, a 
 young man of fair complexion and soft fibre, Avhile bathing in 
 the sea on a cold and windy day, was carried to a considerable 
 distance from shore by a tide-current ; and it is believed that he 
 was nearly an hour in the water before he reached a landing- 
 place, when, as might be expected, he was in a state of extreme 
 exhaustion and collapse. He remained in a weak state for some 
 days, with a slight cough, and then suddenly expectorated some 
 foetid matter. The disease in this case ran a course very similar 
 to that in the former instance, except that it was not accom- 
 panied by the extreme and unaccountable pain, and that almost 
 every attack of the fever and foetid expectoration was accompanied 
 by hiemoptysis. Like the first case, there were the singular 
 intermissions, with complete absence of foetor, and apparent 
 return , to health, and the attacks would come on without any 
 exciting cause. It also presented the singular want of coinci- 
 dence between the symptoms and physical signs. At first, 
 indeed, there were evidences of a congested state of the lower 
 lobe, but these soon subsided, and then for many months the 
 physical phenomena remained almost perfectly normal, except 
 that during the attacks a sonoro-mucous rattle was developed in 
 the lower portion of the lung. The attacks gradually lessened 
 in severity, and occurred at longer intervals, and, after a period 
 of about five months, the patient was so far recovered as to be 
 able to leave this country for the south of Europe. He regained
 
 GANGRENE OF THE LING. 361 
 
 his strength and appearance during a winter passed in Kome, 
 but, as I before stated, died of pneumonia, as was reported in 
 the ensuing summer. 
 
 I am anxious here to draw attention to a circumstance of very 
 great importance in practice ; namely, the singular obscurity of 
 physical signs in the earlier periods of this disease. This was 
 exemplified in the two cases which have been just now given ; 
 and I have had examples of the same difficulty in many other 
 instances. 
 
 From considering all the facts of these cases it appears very 
 probable that in the earlier periods of this disease there is no 
 solution of continuity, nor much consolidation of the lung. 
 This, of course, does not apply to that form described by Dr. 
 Graves, where a lung previously hepatized from pneumonia 
 takes on a gangrenous action ; a most important variety, which 
 we shall presently examine. Nor is it applicable to some of 
 the cases of hremoptysical gangrene, established by Dr. Law. 
 But in many of the cases of gangrene occurring in a lung not 
 previously diseased, or in what may be termed j^^imai'y gan- 
 grene, we see the disproportion between the existing physical 
 signs, and the violence and importance of the disease, in a very 
 remarkable degree. 
 
 Is this a disease commencing in points with intervening- 
 healthy tissue ? If it were so w^e should expect to meet all the 
 difficulties which attend the detection of analogous changes, 
 such as the first stage of tubercle or isolated cancers. Yet there 
 must be something more, for the great phenomena of the disease 
 are high febrile reaction and copious secretion of a foetid matter. 
 I am of opinion that the portion of the organ which suffers 
 death must be at first very insignificant, but that the surface 
 which secretes the putrid fluid is extensive. It seems almost 
 certain, too, that this fluid is originally poured out in a putrid 
 condition, and the disease at first is essentially one of secretion. 
 
 Professor Wood, of Philadelphia, in his Treatise on the 
 Practice of Medicine, states, that after the expectoration of 
 foetid matter, a cavity must be held to have formed, and that 
 we can detect it by the usual means. My experience leads 
 me to an opposite opinion on both these points. I have known 
 the expectoration of putrid matter to occur within so short a 
 time after the operation of the exciting cause as thirty-six or
 
 362 GANGRENE OF THE LUNG. 
 
 forty-eigiit hours, that it is difficult to conceive the formation 
 of a cavity so rapidly ; and I repeat that months may elapse 
 ^vith the best-marked symptoms, and yet no physical sign of a 
 cavity be discoverable. 
 
 From what has been stated we thus draw one practical con- 
 clusion. It is, that in any case cohere a sudden foetid expectora- 
 tion has occurred, lue arc not justified in pronouncing the lungs 
 healthy, or the 2>«^icyii in a safe position, because physical 
 examination, even tJie most accurate, fails to detect disease. 
 
 This aphorism I would most earnestly impress on the minds 
 of all who may have to deal with cases of this description. 
 
 This peculiarity in many cases of gangrene of the lung did 
 not escape Laennec. In speaking of the physical signs he says : 
 " I have been several times assured that the crepitous ronchus 
 did not exist until after the production of the eschar, thereby 
 indicating the formation of the inflammatory circle, which was 
 to operate its detachment." He further observes, that " the 
 invasion is usually characterized by symptoms of slight pneu- 
 monia ; but this is attended by a degree of prostration of 
 strength, or anxiety quite disproportioned to the severity of the 
 local symptoms, and to the small extent of space over which the 
 respiratory murmur and sound on percussion are wanting." I 
 quote from Forbes's Translation. 
 
 Of the two next forms of gangrene which I shall notice here I 
 have not myself met any example. In the first, which has been 
 described by Dr. Graves, gangrenous action seizes on a lung 
 which had been for some weeks previously in a state of unre- 
 solved hepatization ; * while, in the form described by Dr. Law, 
 the putrefaction of the effused blood in pulmonary apoplexy 
 appears to be the first cause of the disease. 
 
 Of gangrene attacking hepatized lung. Dr. Graves gives a 
 remarkable instance in his Clinical Medicine. The patient was 
 an old man who had been attacked with symptoms of pleuro- 
 pneumonia, and was admitted with the usual j)hysical signs of 
 consolidated lung and pneumonia. Under a moderate anti- 
 phlogistic treatment, and the use of calomel and opium, the 
 progress of the disease was checked, the pain ceased, and the 
 respiration became less frequent, but still continued at the rate 
 of thirty in a minute, while the stethoscope indicated no 
 
 * Quei-e, is not case two an example of such ? (Ed.)
 
 GANGEEXE OF THE LUNG. 363 
 
 tendency to resolution. In this state the patient continued 
 for a week, when he was attacked with symptoms of laryngitis, 
 with copious muco-purulent expectoration. This was speedily 
 followed by extreme prostration, the countenance became 
 sunk and livid, the breath exceedingly foetid, and the exjDec- 
 toration greenish, ichorous, and intolerably fcetid. The patient 
 died within forty hours after the commencement of the last 
 attack. 
 
 In addition to the gangrene of the lung the posterior 
 surface of the larynx was found destroyed by gangrenous 
 sloughing.* 
 
 The putrefaction of blood previously effused into the substance 
 of the lung, as in cases of pulmonary apoplexy, has been con- 
 sidered by Dr. Law as constituting au important variety of 
 pulmonary gangrene. I have not seen any cases of the change 
 from one of these diseases into the other ; and I apprehend 
 that the occurrence must be rare. I would say further, that 
 where a clot of blood effused into the lung putrifies, this change 
 is in itself a proof of a gangrenous disposition pre-existing ; and 
 I feel satisfied that the haemorrhages in cases of gangrene have 
 no relation to pulmonary apoplexy. 
 
 That an effusion of blood into the lung does not more often 
 end in putrefaction of the fluid is certainly an extraordinary 
 fact ; but not more so than the rarity of putrefaction in abscesses, 
 tubercular cavities, or empyema and pneumothorax. That it 
 is rare, appears from the fact that neither Laennec, nor many 
 other writers on pulmonary apoplexy, mention gangrene as a 
 
 * In his observations on this case Dr. Graves inquires, " How are we to account 
 for this sudden supervention of gangrene ? There was nothing in the nature of the 
 pneumonic inflammation to dispose it to terminate in this way. It had lasted for 
 three weeks, and had arrived at a stage in which inflammation very rarely assumes 
 the gangrenous character. To what then are we to attribute it? Partly to the 
 debility of the man's constitution, and partly to an erysipelatous tendency in the air, 
 which was at the time prevalent. Except there was something to dispose the 
 lungs to gangrenous disease, as an enfeebled habit and vitiated quality of atmosphere, 
 we could not, under the existing circumstances, have expected such a termination. 
 That this view of the subject is correct, is shewn by the simultaneous occun-ence of 
 gangrene in another part which had not been previously diseased or subject to 
 inflammation, except shortly before the man's death — I allude to the larynx. 
 
 " What I wish to impress on you is, that though the inflammation of the lungs 
 ended suddenly in gangrene, it was not in consequence of the inflammation having 
 in itself any such tendency, but in consequence of the change produced in the man's 
 constitution by atmospheric influence, and w hich was favoured by his advanced age 
 and great debility."
 
 364 GANGRENE OF THE LUNG. 
 
 result of tbe disease ; which, besides, is in many instances 
 connected with disease of the heart, producing either an active 
 or passive congestion of the lung. The production of gangrene, 
 however, seems in no way connected with lesion of the heart. 
 We may also refer to the rarity of putrefaction of bloody efiusions 
 in the brain and in other parts of the system, even where the 
 quantity of blood effused is enormous, as in cases of long- 
 existing diffuse anaurisms. 
 
 I do not wish to be understood as denying the possibility of 
 the passing of a pulmonar}' apoplectic clot into putrefaction ; 
 but that the accidental putrefaction of blood effused in the lungs 
 is to be reckoned as even an ordinary cause of pulmonary gan- 
 grene, I feel great reluctance to admit.* 
 
 Mr. OTerrall, adopting generally the views of Dr. Law, goes 
 a step further, and describes a non-putrefiictivc gangrene of the 
 sanguineous clot, and also states that the clot may undergo the 
 process of puriform softening ; a condition in itself not gan- 
 grenous, so far as the clot is concerned, but which may be 
 attended with sloughing of the surrounding tissues. Without 
 denying the accuracy of these observations, I apprehend that 
 Mr. O'Ferrall's distinctions are, perhaps, too finely drawn ; and 
 it is, at all events, clear that, in the present state of our know- 
 ledge, there is no practical benefit to be derived by the attempt 
 to distinguish between the ordinary forms of gangrene, and 
 that in which sloughing of the pulmonary tissue complicates 
 or succeeds to the puriform softening, as described by Mr. 
 O'Ferrall. 
 
 The researches of these gentlemen, however, are of great value, 
 as still further corroborating the opinion already announced by 
 
 * How otherwise do contused injuries lead to gangrene? According to Hertz "it 
 may be found to occur from severe contusions of the thorax — for instance, injuries to 
 tl:e shoulder. The elasticity of the chest wall allows the contusion to act on the 
 lung and thus to produce effusion of blood followed by gangrenous sloughs." (Art. 
 Gangrene, Ziemssen's Cycloptdia, vol. v. p. 412.) 
 
 la a case which was receudy under my care, and which was also seen by my friend 
 Dr. James Little, the patient, a gentleman aged 35, while engaged in the amusement 
 of throwing a heavy sioae from his shoulder, was seized with hsemoptysia, which 
 recuiTcd repeatedly at intervals, and was replaced by a grumous purulent expectora- 
 tion, which, as well as the breath, had a strongly fcetid odour. The signs of 
 pneumonic consolidation were succeeded by those of cavity in the upper portion of 
 the right lung, and after a few weeks by those of pneumothorax, the occuiTence of 
 perforation being indicated by sudden severe pleuritic pain. The disease ended 
 fatally ten M'eeks after the attack of hajmoptysis. (En.)
 
 GANGRENE OF THE LUNG. 365 
 
 LaenneCj that gangrene of the lung does not necessarily imply a 
 previously intense inflammation.* 
 
 There is a great difficulty in drawing the line between what 
 has been termed foetid abscess of the lung and true gangrene. 
 Are they cases of original gangrenous action, or examples merely 
 of putrefaction of the fluid contents of a pulmonary abscess ? 
 Are they examples of gangrenous action speedily formed, and as 
 speedily arrested? for we know that many such cases have 
 eventuated in recovery. Further investigation alone will suffice 
 to clear up these points. With the sudden formation of gan- 
 grenous action every practical man is familiar, but its sudden 
 cessation is a circumstance not yet sufficiently recognized ; yet 
 we may observe this singular phenomena in certain cases of 
 typhus fever, when the occurrence of local gangrene is manifestly 
 under the operation of a law which regulates the general morbific 
 state arising in the progress of that conditiou, and suddenly 
 ceasing with its termination. 
 
 We may see a patient presenting every day new bed-sores in 
 every part of the body, where even the slightest pressure has 
 been exercised ; a condition so apt for the gangrenous state, 
 that the mark of the hand may be imprinted in mortification on 
 the face if the patient has lain but for an hour with the cheek 
 supported by the hand. Every day new cutaneous gangrenes 
 are formed up to a certain period, when, as if this tendency, like 
 the other secondary effects of fever, was under a law of periodicity, 
 not only are no new gangrenes produced, but those already 
 formed at once take on a healthy action. May not the same 
 condition occur in local disease of the lung ? How many of 
 these diseases, supposed to be idiopathic, are really secondary 
 to an unrecognized morbid state of the entire system. 
 
 Practically, however, we may form this conclusion, that, in 
 any case of fcetid expectoration, the earlier we discover the 
 physical signs of cavity, or of manifest local disease, preceding 
 the cavity, the better should our prognosis be. 
 
 * See Dr. Law's paper, Transactions of the Association of the King and Queen's 
 College of Physicians, New Series, vol. i. Also Mr. OTerrall's Observations in the 
 Transactions of the Pathological Society, Dublin Journal of Medical Science, First 
 Series, vol. six. p. 121. 
 
 The converse of this does not hold good. On this Juergensen remarks, " Rindfleisch 
 states that an exudation which contains much blood is apt to produce gangrene. This 
 fact may be explained by Cohnheim's observation, that the number of red corpuscles 
 in an exudation increases with the intensity of the inflammation." (On Croupoua 
 Pneumonia, Ziemssen's Cyclop., vol. t. p. 49.) (Ed.)
 
 363 GANGRENE OF THE LUNG. 
 
 It would be difficult, aud, in some cases, perhaps, impossible, 
 to make an accurate diagnosis between foetid abscess of the lung 
 and gangrene ; especially when the case is seen for the first 
 time, and the fffitid expectoration established. If the manifest 
 signs of the cavity appear at a very early period of the case, say 
 within a week or ten days of the first invasion of disease, we 
 ought to lean to the more favourable opinion of abscess. It must 
 be remembered, however, that this is the more rare condition, 
 and that, as in the case of typhoid consolidation, a gangrenous 
 eschar may form rapidly, and present the signs of cavity. 
 
 An important case, illustrative of these remarks, is given by 
 Dr. Hudson. The patient had been attacked with pneumonic 
 symptoms ten days before he came under observation. The 
 lower lobe of the right lung was solidified, while cavernous 
 respiration and pectoriloquism existed at the angle of the scapula. 
 Next day the breath and expectoration were foetid, and all the 
 signs of a cavity very distinct. In about twenty-four hours the 
 foetor ceased, and the seventh day after his admission to hospital 
 the signs of cavity had disappeared. 
 
 We have in this case two circumstances leading to the diag- 
 nosis of foetid abscess rather than of true gangrene ; first, the 
 early formation of a cavity, and secondly, the existence of well- 
 marked physical signs of extensive recent solidification. 
 
 Of a similar nature is the example recorded by Dr. Williams 
 in the Cyclopasdia of Practical Medicine. 
 
 In addition to such cases of foetid abscess there are two other 
 examples of disease which may be mistaken for gangrene of the 
 lung : one the perforation of the pleura by an empyema, and the 
 evacuation of the fluid through the lung; and the other, that 
 which is commonly described as the opening of an hepatic 
 abscess into the bronchial tubes. It does not invariably occur, 
 however, in either of these diseases, that the fluid evacuated is 
 putrid, so that where this character is absent it is not likely 
 that the case would be confounded with gangrene. We only 
 know that in certain cases belonging to either of these categories 
 the patient at some period, either earlier or later in the disease, 
 expectorates for a considerable time a quantity of the most 
 offensive matter, has a foetid breath, and presents symptoms 
 which may be attributed to the presence of a septic poison acting 
 on the economv.
 
 GANGRENE OF THE LUNG. 367 
 
 If we compare these two cases with regard to the faciHty of 
 diagnosis, we shall find much less difficulty in the first than in 
 the second example. Indeed, our knowledge as to this last class 
 of cases is still extremely imperfect, as will be seen when we treat 
 of perforations of the lung. 
 
 The diagnosis of the first is in general not difficult, and rests 
 upon three considerations : — 
 
 I. The early symptoms, which are those of pleuritis with 
 effusion. 
 
 II. The physical signs observable before the occurrence of 
 any foetid expectoration, which are indicative of a manifest and 
 extensive lesion. 
 
 III. The coincidence of the phenomena of pneumothorax, 
 complicating those of empyema, coincident with the occurrence 
 of foetid expectoration. 
 
 In such cases we are not yet able to say whether the putres- 
 cence of the empyematous fluid existed before the perforation of 
 the pleura, or occurred subsequently to the admission of air, 
 but it appears that in some instances the signs of putrescence 
 have rapidly followed those of the perforation of the pleura. 
 
 Of this condition I saw a remarkable instance some years ago 
 (which will be found narrated in the chapter on diseases of the 
 pleura). 
 
 Our knowledge of the second class of cases is still so limited 
 that we can do little more than indicate their general character. 
 A patient suffers, or is supposed to suffer from acute hepatitis, 
 followed by constitutional symptoms indicating suppuration. 
 After a time he begins to expectorate purulent matter, which 
 may or may not be putrid. These cases have been hitherto sup- 
 posed to be examples of perforation of the diaphragm and lung, 
 and direct evacuation of the hepatic pus ; but there is reason to 
 doubt the existence of this triple lesion in many instances, and 
 it seems probable that we may often refer the phenomena to 
 vicarious secretion, independent of any solution of continuity. 
 In such a case, no matter how great the foetor, we should be 
 extremely slow in assuming the existence of a pulmonary 
 gangrene. 
 
 The attention of the physician in such cases should be 
 directed to the following points : — 
 
 I. The pre-existence of symptoms of hepatic disease.
 
 368 GANGKENE OF THE LUNG. 
 
 II. The fact that though the symptoms are those of confirmed 
 gangrenous abscess, the physical signs of such a condition are 
 wanting. 
 
 III. The rarity of hfemoptysis in these cases, as compared 
 with those of ordinary gangrene of the lung. 
 
 It may be stated that in these three cases of pneumonic abscess, 
 empyema opening into the lung, or hepatic abscess, with or 
 without a perforation of the lung, we are utterly in the dark as 
 to the causes which determine putrescence in some, and its 
 absence in other examples of these diseases. 
 
 If, on the other hand, we have been able to observe the case 
 from its commencement, and traced the symptoms and signs of 
 a pneumonia to its suppurative stage, we might then, on the 
 occurrence of foetor, diagnose putrid abscess. I have never seen 
 any case of true primary gangrene of the lung preceded by the 
 signs of the successive stages of pneumonia. 
 
 In most of these cases it is only with reference to prognosis 
 that the determination of the question is of importance, for the 
 treatment of the disease in either case should not materially 
 differ. 
 
 An important case of gangrene of the lung, and purulent 
 deposits, is mentioned by Dr. Inman, in the Reports of the 
 Liverpool Pathological Society,* The patient, a female of rather 
 intemperate habits, had been liable to chronic cough. Slie was 
 attacked with what was probably diffuse inflammation of the 
 vulva, which soon took on a gangrenous character. She died in 
 three weeks, and it was found that the lower lobe of the right 
 lung contained three gangrenous cavities which did not com- 
 municate with the bronchial tubes. 
 
 The left lung contained many small circumscribed deposits of 
 yellowish purulent matter, not gangrenous. 
 
 Can we interpret the phenomena in this case by supposing 
 the absorption of gangrenous matter, and recent gangrene of the 
 lung thus induced ? The fact of the co-existence of the disease 
 with purulent deposits would seem to strengthen this supposi- 
 tion, to which Dr. Inman appears to incline.f 
 
 The following conclusions appear justifiable from the present 
 state of our knowledge on this subject. 
 
 * Dublin Medical Journal, First Series, vol. xxvi. 
 f See Appendix.
 
 GANGRENE OF THE LUNG. 369 
 
 1. The gangrene of the lung is met with under a variety of 
 forms, differing from one another not only in the duration and 
 violence of the symptoms, hut also in their relations to various 
 local and constitutional diseases. 
 
 2. That in a great proportion of the cases the disease is 
 attended with putrefactive action engaging the necrosed portion 
 of the lung, and affecting its secretions. 
 
 3. That in the progress of a case we may observe the septic 
 action singularly variable. It is increased by over- stimulation of 
 the system. 
 
 4. That we cannot explain the symptoms in many cases of 
 this disease, without assuming, either that a spot of mortifica- 
 tion, so small as to be undiscoverable by physical means, causes 
 severe symptoms, and is attended with super-secretion ; or that 
 a process of putrefactive secretion precedes, in many cases, the 
 death of the lung. 
 
 5. That pain of the most extreme kind may attend- this 
 disease ; and, in the remittent form, appear on each access of 
 the affection with unmitigated violence. 
 
 6. That the contact with air is not necessary for the formation 
 of a gangrenous eschar or cavity. 
 
 7. That haemoptysis commonly attends each access of the 
 remittent disease. 
 
 8. That in the earlier periods of this disease, auscultation 
 and percussion often fail in detecting any signs of organic 
 change ; or if such is discovered, it appears incommensurate 
 with the gravity of the symptoms. 
 
 9. That in many cases the evidences of congestion and paren- 
 chymatous infiltration seem to follow, rather than precede, the 
 symptoms of gangrene. 
 
 10. That dexiocardia, from diminished volume of the lung, 
 may occur in gangrene of the right lung. 
 
 11. That gangrene may attack a lung previously hepatized 
 from ordinary inflammation, or in a chronic tubercular con- 
 dition. 
 
 12. That from the pre-existence of signs and symptoms of 
 the stages of pneumonia, or from the early appearance of signs 
 of excavation, we may be able to distinguish between foetid 
 abscess of the lung and gangrene. 
 
 13. That in certain cases of chronic bronchitis the breath and 
 
 B B
 
 870 GANGRENE OF THE LUNG. 
 
 expectoration may become foetid, and yet no gangrene appear to 
 have formed. 
 
 14. That the diseases with which gangrene may he found 
 complicated are divisible into general and local affections ; but 
 that its occurrence in the class of general diseases, termed putrid 
 or asthenic, is much more rare than might be expected. 
 
 15. That it is rarely observed in the typhus fever of this 
 country, even where the secondary bronchial affection is intense ; 
 but that in typhoid pneumonia it may be occasionally observed. 
 
 16. That it may be directly induced by the pressure of a 
 tumour on the nutrient vessels and nerves of the lung, so that 
 in cases of cancerous or aneurismal tumour, the patient may 
 die, not from the extension of the original disease, but from its 
 inducing a rapid mortification of some portion of the lung. 
 
 17. That the disease, though always of a formidable character, 
 is not necessarily fatal. 
 
 APPENDIX. 
 
 Of other forms of the affection the following are worthy of 
 notice : — 
 
 I. Gangrene of the lung consequent on bed sores in fever. 
 
 II. Gangrene due to purulent infection from caries of the 
 temporal bone. 
 
 III. Gangrene due to putrefaction set up in the brochi either — 
 (a) From fistulous communication with the oesophagus. 
 
 (h) From the entrance of food particles during the artificial 
 feeding of lunatics or paralyzed persons. 
 
 (c) From the putrefaction of the contents of a bronchiec- 
 tasis and extension of infection and inflammation to sur- 
 rounding lung. 
 
 IV. Due to the lowered state of the general nutrition in 
 insanity and cerebral disease, and the cachexia of Bright's 
 disease, and of diabetes, or of chronic alcoholism. 
 
 V. Due to embolism and hsemorrhagic infarction. 
 
 YI, Due to prolonged exposure to cold and moisture while 
 under the influence of alcohol.
 
 GANGRENE OF THE LUNG. 371 
 
 I. Cases of this category are noticed by Dr. Murcbison, 
 cbiefly in patients wbo bad previously suffered from starvation, 
 and by Dr. Graves, wbo regards tbe pulmonary gangrene as 
 secondary to tbat of tbe sacrum, and adds tbe important remark 
 tbat altbougb gangrene of external parts in fever sometimes 
 occurs in tbose not liable to pressure, tbat be " never knew sucb 
 parts to become gangrenous except after some other 'portion of 
 the integument had mortified evidently in consequence of pres- 
 sure." 
 
 On tbis secondary infection Niemeyer observes tbat " tbe 
 transition of necrosis into gangrene is materially promoted 
 if a ferment (a bit of putrid material) come in contact witb 
 tbe mortified part. Tbis explains wby circumscribed gan- 
 grene of tbe lungs is common in metastatic infarction caused 
 by an embolus from some region wbere putrefaction is going 
 on."* 
 
 II. In cases of gangrene following caries of tbe temporal 
 bone, Traube, quoted by Hertz, twice observed clots adbering 
 to tbe wall of the corresponding internal jugular vein along with 
 hemorrhagic infarction of tbe lungs. A similar case was reported 
 to tbe Pathological Society of Dublin in December, 1854, by- 
 Dr. B. G. McDowel. 
 
 A boy, aged thirteen, was admitted into the Whitworth Hos- 
 pital on tbe 3rd and died on tbe 5th. He had for ten years bad 
 otorrboea. A fortnight since had been struck on the ear. Four 
 days after bad headache and vomiting ; then appeared stupid, 
 raved occasionally, and screamed at night. The otorrboea had 
 ceased. 
 
 " On opening up tbe right lateral sinus a round opening was 
 found leading from tbe interior of the mastoid portion of the 
 temporal bone, which was excavated by caries, into tbe cavity of' 
 the sinus. A soft coagulum occupied the venous channel . . . 
 On the surface of the lungs were numerous gangrenous spots, 
 over each of which the pleura was elevated, forming a dark 
 bulla," &c. 
 
 A similar case was reported by Dr. J. S. Hughes on tbe 12th 
 of April, 1856. 
 
 A girl, aged eleven, was subject to deafness and otorrboea for 
 nearly two years. Five weeks before her death she was seized 
 
 * Text Book of Medicine, vol. 1. p. 203. 
 B B 2
 
 372 GANGRENE OF THE LUNG. 
 
 with, severe pain in the ear, rigors, and fever, followed by 
 convulsions and severe pain in the head. For a fortnight 
 before her admission into Jervis Street Hospital there had 
 been no discharge from the ear. Two days before death she 
 had dry cough, rapid respiration, and strong foetor from the 
 breath. 
 
 Among the morbid appearances in the head the petrous por- 
 tion of the temporal bone was found carious and cribriform, the 
 groove for the lateral sinus carious and covered with purulent 
 matter, the sinus filled with coagulated blood. 
 
 " When the thorax was opened some foetid air escaped, and 
 the right cavity of the pleura was found to contain purulent 
 matter. The edge of the lower lobe and the lower border of the 
 upper lobe each presented two small spots of gangrene covered 
 by cribriform pleura, and the left lung contained a large gan- 
 grenous abscess." 
 
 III. (a) In an illustrative case of this lesion presented to the 
 Pathological Society by Mr. J. Hamilton, January 12th, 1860, 
 a communication was found between the oesophagus imme- 
 diately above a scirrhous stricture and a large gangrenous abscess 
 in the adjoining portion of the left lung. 
 
 On this occasion Professor K. Smith stated " that he had 
 seen not less than five cases previous to the present, this being 
 the sixth, wherein abscess of the lung, generally of a gangrenous 
 character, co-existed with ulcerated stricture of the oesophagus ; 
 and in every one of these cases a communication had been 
 formed by ulceration between the tube and the pulmonic abscess, 
 the latter being the secondary affection." 
 
 (b) According to Hertz, " foreign bodies which have found 
 their way into the lung through the trachea, especially particles 
 of food which rapidly decompose under the influence of heat, 
 air, and moisture, may establish bronchopneumonia accom- 
 panied by abscess or gangrene of the lung. This frequently 
 occurs during the artificial feeding of lunatics or j)aralytics, and 
 in disease of the larynx, or imperfect closure of the epiglottis."* 
 
 (c) According to Dr. Wilson Fox this secondary inflammation 
 in the surrounding indurated parts is not uncommon, and is 
 prone in some instances to take on a gangrenous action. Traube, 
 indeed, regards this process as one of the most common causes 
 
 * ZiemEsen's Cyclopedia, vol. iv., Art. Gangrene of the Lung.
 
 GANGRENE OF THE LUNG. 373 
 
 of gangrene of the lung." (See also Juergensen ; Ziemssen, 
 vol. V. p. 48.) 
 
 IV. Hertz considers it " a doubtful question whether lower- 
 ing of the general nutrition can by itself lead to gangrene." " It 
 would rather appear that this condition produces an increased 
 receptivity and want of power of resistance. Thus there may 
 easily arise asthenic pneumonic infiltrations, which are often 
 overlooked owing to the paucity of the symptoms or the insuffi- 
 cient examination of the patient. Pneumonia in this class of 
 persons often leads, as above stated, to gangrene, and the lung 
 affection is not recognized until it betrays itself by the stinking 
 sputa," 
 
 Whether w^e consider the lowering of the general nutrition in 
 Bright's disease, diabetes, chronic alcoholism, insanity, or para- 
 lysis as the sole cause, or as a predisponent, there can be no 
 question of its frequent pre-existence or of its influence in mask- 
 ing and rendering latent the symptoms and physical signs of 
 the pulmonary aftection. 
 
 Of this latency a remarkable example was communicated to 
 the Pathological Society of Dublin, January 30th, 1858, by Dr. 
 Gordon. 
 
 The patient had been for some days under treatment for dia- 
 betes, not complaining of cough or dyspnoea, and presenting no 
 sign of thoracic disease. 
 
 On the 21st inst. he complained of having caught cold, 
 and of feeling weak, and wished to remain in bed. On 
 the 22nd he had some pain in the right side, but still no 
 cough nor dyspnoea. Some dulness was found on the right 
 side posteriorly, with slight bronchial breathing. On the 
 23rd he complained of sudden violent stitch, with intense 
 dyspnoea and collapse, the physical signs of pneumothorax 
 being found. 
 
 On the 24th he died. 
 
 The post mortem appearances were air and lymph, without 
 fluid, in the pleura, a large rent in the upper and posterior por- 
 tion of the lung, around which the pleura was of an ashy grey 
 colour, and through which the pulmonary structure protruded 
 in loose shreds, the lung in the vicinity being in a state of 
 gangrenous suppuration. 
 
 In a valuable paper by Dr. McDowel on the connexion between
 
 374 GANGRENE OF THE LUNG. 
 
 pneumonia and renal disease, he adduces twelve cases in proof 
 of the following conclusions : — 
 
 1. That in fatal cases of pneumonia, renal disease is very 
 frequently found to exist. 
 
 2. That where such a combination of disease exists, suppura- 
 tion of the lung will be very constantly met with. 
 
 3. That a similar morbid condition of the kidney is often 
 found in gangrene of the lung. 
 
 4. Stated conversely — that where pneumonia supervenes in a 
 person in whom renal disease has previously existed, it is very 
 apt to assume the suppurative or the gangrenous form.* 
 
 In the course of his observations on a rare example of universal 
 gangrene of the lungs, which he communicated to the Patho- 
 logical Society of Dublin in December, 1866, Dr. Banks said : 
 "With respect to the great comparative frequency of gangrene 
 of the lung amongst the insane, my experience does not support 
 the statement made by foreign physicians. 
 
 "I have seen cases of foetid abscess of the lung in the insane, 
 but I have never seen a case of true gangrene. My friend Dr. 
 Lalor, the medical superintendent of the Kichmond Asylum, who 
 has been engaged for twenty years in the treatment of the insane, 
 informs me that he has never seen a case in nearly 3,000 which 
 have passed under his observation." (Dublin Quarterly Journal, 
 vol, xliii.) 
 
 Y. Embolism and haemorrhagic infarction. " Interruption to 
 the circulation in the lungs," says Hertz, " may also be produced 
 by an embolus which may either arise from a clot in the right 
 heart, or owe its origin to some thrombus in the veins of the 
 ffeneral circulation. The haemorrhagic infarction which results 
 from this can produce putrefaction, destruction, and gangrene of 
 the lung tissue by causing complete stasis in the neighbouring 
 vessels. When both the agents — pneumonia and embolus — exist, 
 the development of gangrene becomes still more probable, as 
 occurred in the case published by me." f 
 
 Besides the infectious thrombi arising from gangrenous bed- 
 sores, caries of the temporal bone, &c., Mr. O'Ferrall has directed 
 attention to the occasional connexion between purulent cysts in the 
 heart and gangrene of the lung. In February, 1839, he com- 
 
 * Dublin Quarterly Joumcol, May, 185G. 
 t Loc. cit.
 
 GANGRENE OF THE LUNG. 375 
 
 municated to the Pathological Society a case of several softened 
 purulent cysts (one of which contained nearly two drachms of 
 pus) in the heart, with a gangrenous cavity in the lung, and in a 
 subsequent communication he argues that blood extra vasated into 
 the tissue of the lung undergoes a similar process of puriform 
 softening, leading to the formation of gangrenous abscess. 
 
 VI. This cause has scarcely met with the attention it merits 
 from its frequency and importance. 
 
 (a) As regards its frequency. On my once remarking to Dr. 
 Stokes that nearly every case in my experience had been thus 
 caused, his reply was, " At least six out of seven in mine"; and in a 
 valuable communication to the Dublin Pathological Society, in 
 March, 1864, Dr. Law remarked that " all the cases of gangrene 
 of the lungs that had come under his observation occurred either in 
 persons of intemperate habits, or in those who at the time of 
 exposure to cold were more or less under the influence of drink." 
 One of the prepai-ations which he exhibited was an example 
 of circumscribed gangrene involving almost the entire lung. 
 Almost the whole pulmonary structure was reduced to a mere 
 shreddy pulp. 
 
 The dead sloughy portion was contained in a distinct cavity, 
 whose walls were formed of a thin stratum of the pulmonary 
 tissue. In this cavity, too, there was a quantity of blood in a 
 state of decomposition. The patient before his death had had 
 profuse haemoptysis. The subject of this case had lain out on 
 damp hay while in a state of intoxication. 
 
 Another fatal case occurred to a man who, when not sober, in 
 coming on shore from a vessel in the Lifi"ey along the quay wall, 
 fell into the water. He, too, had profuse haemoptysis, and the 
 blood emitted a most foetid smell. 
 
 (h) It is important in its bearing on the proper prophylactic 
 treatment. Owing to the propinquity of Jervis Street Hospital 
 to the river and Custom House Docks, persons who have fallen 
 into the water while intoxicated, or who, being unable to swim, 
 have been long immersed, are usually carried thither. These 
 persons are frequently livid and collapsed when admitted, and 
 reaction, unless under suitable treatment, has been followed by 
 congestive pneumonia, and not unfrequently by gangrene. To 
 obviate this result no measure has been found so effectual as 
 general blood-letting, and accordingly this practice, adopted at
 
 876 GANGRENE OF THE LUNG. 
 
 first by the late Mr. Stapleton and Dr. J. Staunus Hughes, is 
 usually resorted to. In a communication with which he has 
 favoured me, Dr. Hughes says, " The treatment we have adopted 
 in cases of submersion for years past, is as follows : as soon as a 
 sufficient amount of reaction has been established to justify us in 
 doing so, we have recourse to general blood-letting from the arm, 
 with the view of removing pulmonic congestion, and thus pre- 
 venting the accession of inflammation, and probably of gangrene 
 of the lungs. At times, when the patient was young and healthy, 
 and the symptoms urgent, Ave have bled him a second time ; in 
 other cases, after one general bleeding, we have had the patient 
 cupped over the base of the affected lung. 
 
 " We conceive that by the foregoing treatment many lives 
 have been saved." 
 
 Dr. Hughes has kindly forwarded the notes of a case by his 
 former colleague. Dr. Cooley, Avhich well illustrates the practice. 
 *' Whilst I was attached to Jervis Street Hospital," writes Dr. 
 Cooley, " I had the advantage of seeing three cases of immersion 
 treated by the late Dr. Stapleton, and I was so favourably im- 
 pressed by the result that I should adopt his method in any 
 suitable case. 
 
 " In one the patient had been taken out of the river a few hours 
 previously quite insensible, but had revived, and was apparently 
 well when taken into the hospital. Almost immediately after 
 admission, difficulty of breathing came on, and in three or four 
 hours he was insensible, with hurried and forced respiration and 
 congested face. I may remark that the pulse was quick and so 
 weak that no man, unless one with great confidence in the method 
 of treatment, would have dared to bleed." However, Mr. Staple- 
 ton in my presence opened a vein at the bend of the elbow. At 
 first the blood would hardly flow — a few drops thick and tarry in 
 appearance trickled from the wound, and soon began to run in 
 a stream, gradually becoming more fluid and red in colour. 
 When about six ounces had flowed the respiration became less 
 oppressed, the pulse fuller and stronger, the face lost its duskj^ 
 hue, and in a few minutes more the patient opened his eyes 
 and was restored- to consciousness. No further pulmonary 
 symptoms supervened, and he left perfectly well in a few days. 
 
 " It may be well to mention that Mr. Stapleton lays down the 
 rule very definitely as to the time at which the bleeding should
 
 GANGRENE OF THE LUNG. 377 
 
 be done to be most effectual. He used to say it could only be 
 depended upon at the beginning of the secondary insensibility, 
 which I have mentioned Isefore. When the lungs are beginning 
 to fail from too much blood being in them, or from an altered 
 state of that blood, or from defective innervation due to poisoned 
 cerebro-spinal centres. If the engorgement of the lung have 
 passed on to extravasation, or the patient survived long enough 
 for true inflammation to supervene, he had not the same confi- 
 dence in the remedy." 
 
 Dr. Hughes considers that " the rationale of the advantages 
 derived from general blood-letting after immersion " is to be found 
 in the fact that as man does not enjoy " those provisions which 
 amphibious animals are endowed with in the shape of vast venous 
 reservoirs formed by the inordinate size of their venae cavse, 
 venae hepaticoe, veins of the spinal canal, together with a mass of 
 large coiled vessels on the back part of the neck, in which the 
 living liquid blood is stored temporarily away while the animal is 
 under water — in him the blood is necessarily driven by the 
 combined effects of pressure and cold from the surface of the 
 body to some internal vital organ, and notably to the cerebrum, 
 the lungs, and the liver; and hence general blood-letting acts 
 by relieving the congested organs." 
 
 Note, — There is one fact worthy of remark which I do not 
 remember to have seen noticed. It is the destructive influence 
 on the vitality of the blood, of long continued immersion, espe- 
 cially when with this is combined unusual exertion, such as, e.g., 
 ineffectual attempts to reach land. I have seen several examples 
 of this while residing in the country. In one remarkable case a 
 young man in the unsuccessful endeavour to extricate himself 
 from a mass of weeds in the river Boyne, became exhausted and 
 insensible. In that condition he was rescued, and carried into a 
 neighbouring house. The recovery of consciousness was almost 
 immediately followed by profuse haemoptysis and intense heat of 
 the surface, and these by death within twenty-four hours. 
 
 In two other instances, wading for many hours was suc- 
 ceeded by necramia, proved by the rapid appearance of petechiae, 
 boils containing grumous blood only, and by fatal haemorrhage 
 from the gums, lungs, bowels, and kidneys. (Ed.)
 
 378 
 
 SECTION VI. 
 
 PERFORATING ABSCESS OF THE LUNG. 
 
 We may thus designate those cases where purulent collections 
 form exterior to the lung, hut afterwards perforate its tissue, and 
 are evacuated by the bronchial tubes. This termination may be 
 observed in the following cases : — 
 
 1st. Abscess of the thoracic or abdominal integuments passing 
 across the pleura by adhesion, and forming a fistulous com- 
 munication with the lung. 
 
 2ndly. Purulent collections in the serous membrane, opening 
 directly into the lung. 
 
 3rdly. Hepatic abscess perforating the diaphragm, and being 
 discharged through the bronchial tubes.* 
 
 Of these the last is the most frequent. As its diagnosis is of 
 importance in a practical point of view, I shall dwell upon it here. 
 
 We may apply to the diagnosis of the opening of hepatic 
 abscess into the lung, the same principles which guide us in all 
 cases where the matter is evacuated internally. The grounds 
 of the diagnosis are, the occurrence of ncio and extraordinary 
 symptoms, co-incident loith the subsidence of the hepatic disten- 
 tion. Now we may make two divisions of the internal openings, 
 according as these lead into shut sacs, as the serous membranes, 
 or into cavities having external communications, such as the 
 digestive canal or bronchial tubes ; the cases of the first class 
 being almost always fatal, while in those of the second, recovery 
 is by no means unfrequent. 
 
 In applying these views to practice, we find that the sudden 
 occtirrence of inflammation of a serous membrane, points out the 
 
 * With reference to the subject of perforation of the lung, I would refer to the 
 essay of M. Berton on Bronchial Phthisis. 8ee the translation of his memoir in the 
 Dublin Journal of Medical Science, vol. vii. In the same volume there is a valuable 
 paper by Dr. Froriep of Berlin, on abscesses of the neck, in which be gives a case of 
 abscess of the anterior mediastinum, communicating with the vena cava and lung. Ste 
 the Medizinifiche Zeitung, July, 1834.
 
 PERFOKATING ABSCESS OF THE LUNG. 379 
 
 rupture into a shut sac ; wliile purulent discharges from the 
 rectum or stomach mark the opening into the gastro-intestinal 
 tube. Lastl}', a copious, sudden, and purulent expectoration 
 shews that the lung has been made subservient to the evacuation 
 of the matter. Empyema rarely results from this perforation, 
 for, in consequence of adhesions, the matter almost always 
 crosses the pleural cavity, and enters the pulmonary tissue. No 
 case of empyema from this cause has ever come before me, 
 while I have seen several in which the matter was completely 
 expectorated, and in which perfect recovery followed. 
 
 When I speak of pleuritis, I shall allude to the second case 
 of perforation, in which an original collection in the serous 
 membrane opens into the lung. Of the first variety the following 
 case is a singular instance. 
 
 Case I, — Abscess of the Abdominal Parietes resting on the 
 convex surface of the Liver, opening externally, and also 
 perforating the Diaphragm, and forming a fistulous com- 
 munication 2vith the Bronchial Tubes. 
 
 A woman, aged 23, was attacked with cough and haemoptysis, 
 followed, after some days, by fever. Soon after this she com- 
 plained of pain in the right side of the chest and hypochon- 
 drium, increased by coughing, pressure, or motion. She had a 
 distressing short cough, Avith yellow, tenacious expectoration. 
 The inferior portion of the right side sounded dull ; and the 
 respiration was here almost inaudible, except on a forced in- 
 spiration. The symptoms having continued for about a fortnight, 
 an uncircumscribed tumour appeared between the second and 
 third ribs of the right side ; the haemoptysis returned, with a 
 hard teasing cough, but the fever disappeared. Poultices were 
 diligently applied to the tumour, which rapidly enlarged, and 
 became fluctuating. It was opened on the thirteenth day, when 
 a great quantity of matter mixed with blood, was discharged ; at 
 this time the haemoptysis ceased. In about three weeks, how- 
 ever, the abscess again appeared, and rapidly increased to a size 
 much greater than before ; it was again opened, and a large 
 quantity of purulent matter given exit to. Next day it presented 
 the appearance of an enormous anthrax, with edges about two 
 inches high, from which a quantity of whitish slough could be
 
 380 PERFORATING ABSCESS OF THE LUNG. 
 
 detached by pressure. The patient was now emaciated ; had 
 diarrhoea with cough ; and sauguiuoleut and puriform expec- 
 toration. We endeavoured to trace the extent of the disease, by 
 introducing a probe ; but although this was found to pass 
 extensively under the muscles and cellular substance, yet it 
 could not be introduced either into the thoracic or abdominal 
 cavity. After some time it was found, that when the patient 
 coughed, air escaped with great violence from the base of the 
 ulcer. A circular fistula was now discovered, through which a 
 probe could be j^assed upwards for about three inches, when it 
 met vnth a solid resisting body. The infra-mammary region 
 sounded clear, while the respiration was cavernous, and accom- 
 panied during inspiration by a sound like the tick of a watch. 
 When the patient coughed or made a forced insim'ation, a loud 
 gurgling was audible; there was no metallic tinkling, bour- 
 donnement, or pectoriloquism ; but the voice resounded strongly 
 from the sixth rib upwards, while anteriorly and posteriorly 
 the respiratory murmur appeared natural. She soon after 
 sunk. 
 
 Inspect ion. — Great emaciation ; the external sore extended 
 from the sixth to the tenth rib, and was about four inches in 
 breadth. Between the eighth and ninth ribs the fistula was 
 plainly observable. The peritoneum was healthy, with the 
 exception of that portion which covered the liver laterally and 
 superiorly. Here the liver adhered to the diaphragm. 
 
 On the centre of the convex surface of the liver, we found the 
 base of the abscess, formed by a circular portion of thick, false 
 membrane of about tAvo inches in diameter, external to the 
 hepatic peritoneum , but producing a depression on its surface. 
 The costal portion of the diaphragm, for an extent corresponding 
 to the base of the abscess, was destroyed, but adhered round its 
 edges. This abscess communicated with the right lung by a 
 jjerforation through the diaphragm, of the same size as the ex- 
 ternal fistula, which led into a cavity in the lower lobe, narrow, 
 elongated upwards, and presenting many of the characters of 
 a pneumonic abscess. It had no lining membrane, and com- 
 municated with numerous bronchial tubes. Ai-ound it the 
 pulmonary tissue was of a greyish white colour, softened, but 
 not granular ; the diseased portion did not terminate by any 
 distinct line, and occupied about two-thirds of the lower lobe,
 
 PERFORVriNG ABSCESS OF THE LUNG. 381 
 
 which adhered to the diaphragm and costal pleura; the remainder 
 of the lung was healthy.* 
 
 This is the only case in which I have had an opportunity of 
 examining the mechanism of the transit of pus across the lung. 
 An ulcerous cavity communicating with the bronchial tubes, and 
 being itself the continuation of the diaphragmatic fistula, was 
 found to exist, and its presence during life was easily detected 
 by auscultation. It may be inquired whether the cavity in the 
 lung was the result of the purulent infiltration merely, or caused 
 by a distinct attack of pneumonia. It seems more probable that 
 the lower lobe of the lung suffered simultaneously with the liver, 
 and that thus it was prepared for the irruption of a foreign 
 substance into the bronchial tubes. I do not affirm that this 
 occurs in all cases, for I have seen several instances in which 
 the symptoms left no doubt as to what had happened, yet in 
 which the stethoscope failed to detect the cavity. Viewed with 
 reference to physical diagnosis, the case furnishes an example 
 of large abscess in the lung without pectoriloquism. I once 
 thought that this was explicable by the fact of the cavity having 
 an external opening which would prevent the reverberations 
 of the voice, but I have since seen several cases of phthisical 
 cavities, in which this phenomenon was wanting, although free 
 bronchial communication existed. Further observations are 
 necessary to determine the conditions which regulate the occur- 
 rence of pectoriloquism. 
 
 The next case is a remarkable instance of the extent of organic 
 lesion, compatible with life. 
 
 Case II. — Fistulous ojienmgs from the Pleura into the Lung and 
 Liver ; Gangrenous Abscess of the Lung ; Empyema and 
 Pneumothorax ; fstidous opening of the Liver into the trans- 
 verse arch of the Colon. 
 
 A middle-aged man had for some time laboured under the 
 symptoms of empyema, when it was proposed to remove the fluid 
 by paracentesis ; he was then seen by a late distinguished friend 
 of mine, who ascertained the presence not only of empyema, but 
 pneumothorax, with pulmonary fistula. In addition to these 
 symptoms it was found, that on sitting up, the patient was 
 
 ■•' Clinical Report of the Meath Hospital, Dub. Hosp. Reports, vol. v. See the 
 Cyclopaedia of Practical Medicine, Art. Inflammation of the Liver.
 
 382 PERFORATING ABSCESS OF THE LUN'G. 
 
 immediately attacked with a tendency to diarrhoea, and discharged 
 a sero-purulent fluid in considerable quantity, per anum ; on 
 lying down the discharge always ceased. On dissection the 
 following lesions were found : a gangrenous cavity existed in the 
 upper portion of the right lung, communicating with the bron- 
 chial tubes and pleura ; this sac, the upper part of which con- 
 tained air in quantity, was about half filled with a yellowish and 
 foetid liquid, in which were found the debris of numerous hyda- 
 tids. A large opening passed through the diaphragm into the 
 substance of the liver, and from this cavity another fistula pro- 
 ceeded to the ascending colon ; so that a false passage was 
 formed from the bronchial tubes to the colon and rectum, and 
 the singular symptom of diarrhoea in the ei-ect position, satisfac- 
 torily explained.* 
 
 The next case illustrates the opening of an hepatic abscess into 
 the left lung. 
 
 Case III. — Fever ivith Jaundice ; subsequent hepatic abscess 
 ' opening into the left Lung. 
 
 During the epidemic fever of 1826 and 1827, which occurred 
 in Dublin, a man, aged 28, was attacked on the fourth day of his 
 fever with jaundice, and the formidable symptoms of yellow fever, 
 
 * Professor Carswell has recorded a case very similar to the above. He says : 
 ''When the diaphrngtn adhei-es to the abscess, and is perforated, three conseqaences 
 may follow: the contents of the abscess may pass into the cavity of the chest; 
 into the bronchi from a ponion of the lung which had adhered to the diaphragm, 
 having been destroyed by ulceration or sloughing ; or into the cavity of the chest and 
 bronchi at the same time. We have only seen one case of the last variety of perfora- 
 tion of abscess of the liver, or, more correctlj' speaking, of a purulent cyst con- 
 taining a great number of hydatids. Although these vesicular animals have some- 
 times been expectorated in cases of this kind, such did not happen in the case to which 
 we allude. The communication between the bronchi and cyst took place first, followed 
 by a yellow-coloured expectoration, which, because of the e.\.istence of the cyst in 
 the liver having previously been detected, was supposed to be owing to the passage 
 of the bile into the bronchi from perforation. Soon afterwards symptoms of pleurisy 
 manifesttd themselves, accompanied with those of effusion and pneumothorax, the 
 real nature of which was not understood until after death. Only one opening was 
 found in the diaphragm, where it covered a cyst from six to seven inches in diameter, 
 containing a yellow, puriform fluid, and hydatids ; this opening, sufficiently large to 
 admit the fore-finger, communicated with an excavation formed in the inferior lobe 
 of the lung, which adhered but slightly to the diaphragm. In the bottom of this 
 excavation there were several openings, some of them, which were small, com- 
 municating with the bronchi, others larger, leading into the cavity of the pleura. This 
 cavity contained a quantity of air, yellow sero-purulent fluid, and a great number 
 of large and small hydatids. The lung v*-as considerably compressed, and the pleura 
 covered with recent coagulable lymph." — Cyclopaedia of Practical Medicine, Art. Per- 
 foration of Viscera.
 
 PERFORATING ABSCESS OF THE LUNG. 383 
 
 to which so many at that time fell victims.* The symptoms 
 were subdued by the most active treatment, and after some time 
 he Avas discharged. In about a fortnight, however, he was 
 admitted, labouring under hectic fever, with a continued dry 
 cough. Fearing that he was becoming phthisical, I repeatedly 
 examined both lungs with the greatest care, but in no part of 
 the thorax could I find anything that Avould account for the 
 symptoms. His distress increased, when he suddenly began 
 to expectorate large quantities of purulent matter ; and during 
 the first night he discharged nearly two pounds of perfectly formed 
 pus. On the following morning, the left lung, icliich the day 
 previously had presented no morbid sign whatever, either by the 
 stethoscope or percussion, was found over the whole region of the 
 lower lobe completely dull, and with extinction of the respiratory 
 murmur. There was no bronchial respiration, resonance of the 
 voice, dilatation of the side, nor displacement of the heart ; nor any 
 symptom of either pleuritic or pneumonic inflammation. The 
 patient continued to expectorate copiously for some days ; after 
 the second day the morbid phenomena began to subside. We 
 had, first, a mucous rattle audible at the root of the lung, which 
 gradually extended over the dull portion, and was followed by a 
 return of the respiratory murmur and resonance of the voice. 
 
 This stethoscopic observation, for the accuracy of which I 
 pledge myself, is explicable only by the sudden filling of all the 
 bronchial tubes with purulent matter. Let us observe, first, the 
 sudden supervention of dulness, and absence of respiration in a 
 patient whose chest, the day before, presented no morbid phe- 
 nomenon ; this is accompanied by a copious expectoration of 
 purulent matter ; and there are no constitutional symptoms of 
 pleurisy or pneumonia. The absence of these symptoms is of 
 great importance, because if the disease had proceeded from either 
 of these lesions, it must have been of extraordinary violence, and 
 would have certainly been accompanied by high constitutional and 
 local symptoms. Dilatation of the side, and displacement of the 
 heart, were wanting, so that the diagnosis lay between hepa- 
 tization of the lung, and the sudden Jilling of the tubes ^vith pus ,- 
 but there was no bronchial respiration, nor resonance of the voice, 
 which would have occurred had it been hepatization, but which 
 
 * Se3 Clyclopsedia of Practical Medicine, Art. Enteritis, for a brief account of this 
 extraordinary and fatal form of diseasa.
 
 384 PERFOKATING ABSCESS OF THE LUNG. 
 
 were absent because the large tubes were completely filled. 
 Further, during the recovery of the patient, the phenomena of 
 the voice were exactly the reverse of those in pneumonic resolution. 
 In the latter, the resonance decreases, while in this case it 
 increased ; in hepatization, because the air cells recover their 
 permeability, and the morbid subsides into the natural bron- 
 chophony ; in the case under consideration, on the other hand, 
 because the emptying of the tubes permitted the return of the 
 natural resonance of the voice. In the majority of cases the 
 matter discharged from the chest consists of well formed pus. In 
 one, however, recorded by Annesle}', the opening of an hepatic 
 abscess was followed by a copious purulent and bloody expectora- 
 tion. The patient experienced a great sense of suffocation Vt'hen 
 he lay on his back ; and on dissection, a vast hepatic abscess was 
 found communicating with the posterior portion of the lung. We 
 have witnessed a case of the same lesion, in which, whenever the 
 patient turned on the left side, a large quantity of purulent matter 
 was discharged from the mouth. 
 
 It is hardly possible to confound this accident with any disease 
 of the lung properly so called, particularly if by stethoscopic 
 observation we have been satisfied of the previously healthy con- 
 dition of the organ. The only cases which might be confounded 
 with it, are the rare instances of the opening of an empyema into 
 the lung, or the sudden secretion of purulent matter in quantity, 
 by the bronchial membrane, of which a few instances are recorded. 
 
 We have now seen, with reference to auscultation, that three 
 cases of perforating abscess of the lung may be distinguished, viz. 
 — those with signs of excavation ; next, those in which pneumo- 
 thorax occurs ; and lastly, cases presenting the phenomena of a 
 complete filling of the bronchial tubes Avith purulent matter. 
 
 But there is a fourth class in which, although no doubt can 
 exist of the emptying of an hepatic abscess through the air tubes, 
 the stethoscopic signs are unsatisfactory. I have now seen two 
 cases in which the trajet of the purulent matter was not marked 
 by any auscultatory sign ; can it be, that in such cases, the 
 matter passing through the posterior mediastinum enters the 
 trachea at its jiosterior portion, and is thus evacuated without 
 involving the lung ? * 
 
 * It •« ill be seen liereafter that Dr. Stokes ascribes the evacuation of the pu8 in 
 Fome of tliepe cafes to vicarious secretion by the bronchial mucous membrane. (See 
 chapter on DlEcafes of the Pleura.) (Ed.)
 
 385 
 
 SECTION VII. 
 
 CANCER OF THE LUNG. 
 
 [■This chapter consists of two portions, namely, the text of the first edition, with 
 the exception of a few passages and the conclusions ; and of the m:ijor part of a 
 memoir on the subject by the author in the twenty-first vohmie of the Dublin Medical 
 Journal, First Series, omitting passages previously published in his treatise, &c.] 
 
 Part I. 
 
 Cancerous disease of the lung is met with in two forms ; in 
 the first, a degeneration of the lung occurs, and the organ is 
 transformed into a cancerous mass without the production of 
 any tumour. In the second, the scirrhous or encephaloid matter 
 forms a tumour, at first external to, and ultimately displacing 
 the lung. In neither case can we apply any direct diagnosis ; 
 and I do not know how the first could be determined with 
 certainty. The symptoms are always obscure ; and the physical 
 signs being merely those of solidity, more or less extensive, 
 the greatest difficulty exists in making an accurate diagnosis. 
 Repeated observations, indeed, might lead us to doubt whether 
 the lesion was any ordinary disease — and the existence of external 
 cancer would give a probability that the internal affection was of 
 the same nature. But in a case seen for the first time, and in 
 which no such external disease existed, we have no means by 
 which its nature could be positively determined. 
 
 But, in the second case, the physical condition of parts is 
 different, and we have a mass producing compression, displace- 
 ment, and obliteration of organs, and all the physical signs of 
 an intra-thoracic tumour. The lung may be displaced, the 
 oesophagus, trachea, or bronchial tubes compressed, the subcla- 
 vian or carotid arteries, or the vena innominata obliterated, 
 
 c c
 
 386 CANCER OF THE LUNG. 
 
 leaving no doubt of the existence, of a tumour, the nature of 
 which must he determined by other means. 
 
 As illustrative of these principles, the following eases may be 
 studied. The first shews the difficulty of diagnosis in the simple 
 degeneration of the lung.* 
 
 A man, aged thirty-six, about a year previous to his final 
 admission into the Meath Hospital, was attacked with occasional 
 stitches of the right side, followed by cough, hoarseness, dysp- 
 noea, and scanty mucous expectoration — after some time a little 
 tinged with blood. The face and neck became oedematous, and 
 the swelling was observed to be greater on the right side. He 
 came under my care in the spring of 1832, and remained about 
 six weeks in hospital, during which time, after most careful and 
 repeated examinations, I remained undecided as to the nature of 
 the disease. He left the hospital somewhat relieved, but without 
 any change in the physical signs, which were that the ichole side 
 sounded dull, yet without the accompanying physical signs of a 
 great empyema on the one hand, or of pneumonia or tuhercidar 
 solidity on the other. I successively formed and abandoned 
 many opinions, and ultimately gave up the attempt to determine 
 the nature of the disease. 
 
 Soon after this he came under Dr. Graves's care, labouring 
 under extreme dyspncea. He could only lie on the right side ; 
 he had cough, with occasional scanty expectoration, slightly 
 tinged with blood, pain of the right shoulder, and slight stitches 
 of the side. He experienced some difficulty of swallowing, 
 and referred the obstruction to the lower part of the throat ; 
 the face was bloated, pale, and slightly oedematous, which, 
 with an appearance of the eyes as if the balls were protruded 
 from the sockets, and a marked dilatation of the nostrils during 
 breathing, gave his countenance an expression of distress and 
 sufi"ering. The right jugidar vein loas much distended, as 
 were the veins in the right axilla; hut this symptom was chiefly 
 remarkable on the surface of the belly, tvhere two veins cor- 
 responding to the situation of the superior epigastric artery 
 jmrsued a rcmarkahly tortuous course along each side of the 
 linea alba, being turgid and dilated to the size of swan quills. 
 
 * See Dr. Graves's Paper, Dublin Medical Journal, vol. iv., from which I have 
 abridged the above case; the patient was first under my own, and afterwards his 
 observation.
 
 CANCER OF THE LUNG. 387 
 
 His bowels were constipated and subject to griping pains ; urine 
 scanty and bigb coloured ; loss of appetite ; nigbt sweats ; slight 
 thirst ; tongue clean ; pulse 100, regular and compressible. 
 
 The intercostal spaces on the left side were more distinct, 
 deeper, and more dilated in respiration, than those on the 
 right : the latter, however, although not so well marked, were 
 by no means obliterated or distended by pressure from within. 
 The right side of the chest measured about half an inch less 
 than the left. The left side sounded everywhere clear, to within 
 an inch of the sternal median line where it became dull. Right 
 side, universally, as dull as possible. Over the whole left side 
 the respiration was puerile, except on approaching the sternal 
 median line, where it assumed a tracheal character. This 
 tracheal respiration was observed over a great part of the right 
 side anteriorly, where it was very loud and distinct above the 
 mamma, feebler immediately below it, and almost entirely lost 
 still lower. Posteriorly, the respiration was not so decidedly 
 tracheal. 
 
 No rales were audible in any part of the chest. 
 
 At the upper and anterior part of the right side, the voice 
 was resonant, approaching to, if not identical -sdth bronchophony ; 
 elsewhere nothing remarkable was observed. 
 
 The heart pulsated in its natural situation, but its sounds 
 were audible under both clavicles, and over the whole of the 
 right side. The right side of the chest, during respiration, 
 obviously moved much less than the left ; and when he spoke, 
 the hand placed on it felt the vibrations caused by the voice to 
 be feebler than on the left. 
 
 " The physical phenomena here detailed," says Dr. Graves, 
 " remained unvaried until his death, except that all traces of 
 bronchial respiration soon disappeared from the right side of 
 his chest, except at one spot near the spine, and where anything 
 Avas heard in other parts, it was now evidently a tracheal wheez- 
 ing which masked all other sounds. 
 
 " When this patient entered the hospital on the 1st May, 
 the abdomen felt natural, and no enlargement of the liver could 
 be felt, but after some time the liver appeared to have been 
 rapidly altered, and could be distinctly felt far beyond its usual 
 limits, and forming a hard visible tumour in the hypochon- 
 driac and epigastric regions. At the same time his stools 
 
 c c 2
 
 388 CANCER OF THE LUNG. 
 
 became clay-coloured, and he was jaundiced. The yellow colour, 
 however, was not of a deep, but of a light lemon shade. 
 
 "Another remarkable phenomenon developed itself before 
 the termination of the disease ; whenever he lay down, that 
 instant a loud wheezing was heard in his chest, accompanied by 
 a sensation of imminent suffocation ; the dysphagia increased 
 likewise, but was never very urgent. 
 
 "Three tumours had been observed on his body, and they 
 had latterly increased in size with great rapidity. They were 
 immediately under the skin (which was of the natural colour), 
 were smooth, of a round form, of the size of walnuts when 
 first observed, but now are very nearly as large as oranges. 
 They were slightly moveable at first, more fixed afterwards, 
 and never accompanied by the least pain or soreness ; at first 
 they felt solid, but afterwards more elastic, as if they were dis- 
 tended with fluid contained in a firm capsule ; they occurred on 
 the forehead, the ramus of the lower jaw, and near the lumbar 
 spinous processes. 
 
 "Dissection. — Chest. — Left lung collapsed, perfectly healthy. 
 Right lung, or rather the contents of the right side of the 
 thorax, adhere everywhere to the parietes, by means of an 
 intimate adhesion between the pleura co stalls and pulmonalis. 
 The pleura is exceedingly thickened and dense. In place of the 
 right lung was found a solid mass, weighing more than six 
 pounds, with an irregular, somewhat nodulated surface ; this 
 mass filled completely the right cavity, but did not protrude 
 between the ribs, so as to distend, notably, the intercostal 
 spaces ; it encroached, however, upon the other pide of the chest, 
 extending a little beyond the median line, enveloping, and nearly 
 concealing from view, the pericardium, great vessels, and trachea. 
 This solid mass was removed with difficulty on account of the 
 adhesions, and was found to present, over a small portion of its 
 posterior surface, a thin stratum of lung, nearly impervious to 
 the air. The solid mass was found to be everywhere homo- 
 geneous, firm, of a white colour slightly stained with bile, and 
 tolerably firm and consistent in its structure, which resembled 
 a brain partly hardened by artificial means. When cut, each 
 section exhibited an oozing of the softer brain-like fluid from 
 the exposed surfaces, which oozing was much increased by 
 pressure ; so much, indeed, that it was obvious that the soft
 
 CANCER OF THE LUNG. 389 
 
 cerebriform matter, bore a large proportion to the cellular and 
 other structure in which it was lodged, and upon which the firm- 
 ness and apparent solidity of the whole depended. The mass was 
 somewhat lobulated posteriorly, and contained a few small cysts 
 filled with a jaundiced serum. The right bronchial tube could 
 be traced for a short distance into the substance of the mass, but 
 was considerably diminished in calibre ; the heart was pale, 
 and rather atrophied : its great vessels seemed to run through 
 the substance of the mass which surrounded the base of the 
 heart, so that only its lower part was visible. 
 
 " Contrary to expectation, the liver was found perfectly natural 
 in size, but the gall bladder was enormously distended with bile, 
 and was at least three times its natural size. The apparent 
 tumefaction of the liver was owing to its beiog depressed by the 
 thoracic tumour. A tumour, consisting of several smaller ones, 
 occupied the situation of some of the mesenteric glands, and 
 equalled two fists in size. It consisted of the same cerebriform 
 substance as that observed in the chest, and appeared to have 
 arisen from degeneration of the mesenteric glands. This tumour 
 pushing the transverse arch of the colon upwards, and the small 
 intestines downwards, pressed upon the ductus communis chole- 
 dochus, so as to prevent altogether the passage of bile into the 
 duodenum, while its lateral portions extending to the kidneys 
 pressed upon these organs. The substance of the liver was 
 healthy but green, being injected with bile." 
 
 In this important case, the want of agreement between the 
 physical signs, aad those of the ordinary affections of the lung, 
 the absence of the signs of the earlier stages of pneumonia, 
 while the lung advanced to solidity, and the contraction of the 
 side, while the dulness extended beyond the mesian line, made 
 strongly against the opinion that the disease was hepatization. 
 
 In the next place, the phenomena did not accord with those 
 of tubercular solidity. The disease spread from below upwards ; 
 the solidity was complete, and no sign whatever of tubercular 
 softening was observed ; if we add to these the healthy state of 
 the opposite lung, and the absence of symptoms of phthisis, we 
 have a group of cu-cumstances opposed to the phenomena of 
 tubercle. 
 
 Lastly, it was at one time supposed that the case was em- 
 pyema, but with this the signs were also irreconcileable ; the
 
 390 CANCER OF THE LUNG* 
 
 side was contracted, the intercostal spaces unaffected, the vibra- 
 tion of tlie voice was not extinguished, position made no 
 difference in the signs, the heart was in its natural situation, 
 and the liver not displaced until a short time hefore death. 
 The dulness and absence of respiration, if lyrocced'mg from 
 empyema, woidd point out the greatest possible effusion, yet 
 the remaining phenomena were inconsistent ivitli this condition. 
 
 But other unusual circumstances existed : namely, the varicose 
 state of the subcutaneous veins, the dysphagia, the predominance 
 of oedema on the right side, the apparent enlargement of the 
 liver, and the growth of those external tumours which were, 
 doubtless, of the same nature as the internal lesion. We must 
 then admit that there was here a group of phenomena irrecon- 
 cileable with those of pneumonia, phthisis, or empyema, but 
 which were explained by the condition of the lung. 
 
 The next case is illustrative of the second form, or that in 
 which the cancerous disease forms a compressing tumour. A 
 woman, aged thirty, had laboured some months under cough, 
 mucous expectoration, and gi-eat debility. On admission into 
 hospital the countenance was livid and anxious ; dyspnoea con- 
 siderable ; pulse quick and small. She had frequent cough 
 with mucous expectoration, but presented no symptom of ab- 
 dominal disease. Next to the cough, she complained most of 
 difficulty of swallowing, which she referred to a lump in her 
 throat, existing under the top of the sternum. This had ex- 
 isted for some months, but had lately much increased. The 
 pharynx appeared healthy, and no tumour could be felt by 
 external examination. 
 
 The clavicle, antero-superior, and infra-spinous regions of the 
 left side sounded completely dull ; the respiration was here dis- 
 tinctly bronchial, and the resonance of the voice approached to 
 perfect pectoriloquism. Over the rest of the lung the sound on 
 percussion was clear, but respiration was masked by bronchitic 
 rales. In the right lung the respiration was jjuerile. 
 
 From these observations we concluded that the superior portion 
 of the left lung was solid, in all j^robabilitj' from tubercle. We 
 could not, however, explain the dysphagia. She exj)ired on the 
 night following her admission. 
 
 The left lung was found compressed from above downwards, 
 by an extensive encephaloid tumour, which filled the posterior
 
 CANCER OF THE LUNG. 391 
 
 mediastinum, and extended into the upper portion of the left 
 thoracic cavitj^ The trachea and oesophagus, from the lower 
 portion of the neck downwards, were enveloped by this mass. 
 At the left side, exactly at the situation to which the patient 
 referred the obstruction in swallowing, the tumour formed three 
 lobes or masses, each about the size of a pigeon's egg. One of 
 these so pressed on the oesophagus as to form an elevation on its 
 internal surface, and considerably diminish its calibre. The 
 sub-clavicular and acromial regions were filled by the tumour, 
 which answered exactly to Laennec's description of the non- 
 encysted ccrchriform masses : no softening had commenced in 
 any portion of it. The lung proportionably diminished in size, 
 contained numerous masses of the same nature, varying from 
 the size of a pea to that of a kidney bean. The right lung was 
 healthy.* 
 
 When describing the pulsation of the lung in pneumonia, I 
 alluded to a case of encephaloid tumour, with a diastolic throb- 
 bing which simulated an aneurism of the aorta. I shall now 
 detail this novel and important case. 
 
 The patient, a man aged forty-five, of full habit, had for the 
 four years previous to his death, complained of occasional severe 
 pains in the left side. These attacks were generally attended 
 with haemoptysis, and yielded to general bleeding, nauseating 
 doses of tartar emetic, and other antiphlogistic measures. He 
 was recovering from one of these attacks, when he was seized 
 with convulsions, followed by paralysis of the left side. The 
 attack frequently recurred with many of the characters of epi- 
 lepsy, during which the dyspnoea increased. The pains of the 
 side became more constant, and extended to the shoulder and 
 inter- scapular region ; he complained of oppression, wheezing, 
 and some palpitation, and had a continued mucous and bloody 
 expectoration. 
 
 I saw this patient with Mr. Carmichael two months previous 
 to his death ; he was not emaciated, nor hectic. He complained 
 of some dyspnoea, with severe pain in the left shoulder. The 
 respiration was tracheal and of the character which I have 
 described when speaking of the pressure of tumours on the 
 windpipe ; voice unaifected. There was some dysphagia, and 
 
 * Clinical Report of Cases in the Medical Wards of the Meath Hospital, &c., Dub. 
 Hos. Reports, vol. v.
 
 392 CANCEK OF THE LUNG. 
 
 the pulse of the left radial artery was exceedingly small, while 
 that of the right was full and developed. The whole antero- 
 superior portion of the left side, and the corresponding scapular 
 ridge, sounded completely dull. In these situations there ex- 
 isted a distinct tracheal respiration ; the respiratory murmur 
 was audible over the lower lobe, but was extremely feeble when 
 compared with that of the right lung.* 
 
 But the most remarkable circumstance in this case was, that 
 a distinct double pulsation, a little subsequent to that of the 
 heart, and accompanied by the bellows-murmur, existed in the 
 upper sternal and sub-clavicular regions. The sounds were 
 almost identical with those of a deep-seated aneurism, and 
 although there existed no external tumour, a distinct diastolic 
 pulsation could be perceived by the hand when pressed on the 
 chest. This pulsation manifestly succeeded that of the heart, 
 the action of which was natural, so that the existence of two 
 distinct centres of pulsation within the chest did not admit of 
 the slightest doubt. 
 
 No signs of tubercular softening could be found in any part of 
 the chest. 
 
 The diagnosis in this case was full of difficulty. Some ex- 
 tensive organic disease obviously existed ; the pains, the dulness 
 of sound, the hasmoptysis, and the absence of vesicular murmur, 
 seemed at first to favour the opinion that tubercular solidity 
 existed, while the absence of emaciation, of hectic, and of the 
 signs of cavities, did not accord with such an idea. 
 
 On the other hand, there were signs altogether inconsistent 
 with the existence of mere pulmonary disease. The tracheal 
 breathing, the dysphagia, the smallness of the left pulse, and 
 the pulsation of the upper part of the thorax, all indicated that 
 a tumour existed within the cavity. 
 
 Some time previous to his death he suddenly expectorated 
 foetid purulent matter ; this continued to be copiously discharged 
 for several days, giving the impression that a gangrenous abscess 
 had formed. 
 
 Dissection. — Upon laying open the cavity of the thorax, a large 
 tumour was observed occupying the left lung from its apex to 
 
 * For observations on the importance of feebleness of respiration in one lung in 
 ca?es of iiitr.i-thoracic tumour, I would refer to the section on Diseases of the Larynx ; 
 also to my paper on the Diagnosis of Aneurism, Dublin Journal of Medical Science, 
 
 vol. T.
 
 CANCER OF THE LUNG. 39B 
 
 its root ; it closely adhered to the parietes of the chest ; it was 
 of a globular form, larger than an orange, perfectly white in 
 colour, remarkably elastic to the feel, and of different degrees of 
 firmness, but nowhere possessing the hardness of a scirrhous 
 structure ; it completely surrounded the left branch of the pulmo- 
 nary artery, and projected into the pericardium. When a section 
 was made through the tumour, the trunk of the pulmonary artery 
 was seen compressed and flattened, its section presented an 
 elliptical form, and its calibre was so much diminished as to 
 admit only a full-sized catheter ; the lung beneath the tumour 
 Avas in an inflamed condition, and at one part there existed a 
 cavity, which in appearance and in the nature of its contents 
 resembled a gangrenous abscess ; there were no tubercles in the 
 lungs ; both hemispheres of the brain were extensively softened 
 in then- interior, as were also both lobes of the cerebellum.* 
 
 The great interest of this case consists in the cancerous mass 
 forming a second centre of pulsation, and in its other signs 
 agreeing so closely with aneurism : — that a tumour of some 
 kind existed, appeared evident to Mr. Carmichael and me, long 
 previous to the disease, and with the knowledge I then possessed, 
 I could only explain the phenomena on the supposition of aneurism. 
 It is true that no external tumour existed, and that the pulsation 
 was feebler than what occurs in most cases of this disease. 
 
 There were two circumstances, however, which did not agree 
 with the symptoms of aneurism, the one, tJie continued liccmop- 
 tysis, and the other the jvant of jJroportion between the apparent 
 ■size of the tumour and the strength of its pulsations. We know 
 that the violence of pulsation is in general proportional to the 
 size of the tumour, so that the combination of extensive dulness 
 Avith but feeble pulsation, may indicate cancerous rather than 
 aneurismal disease. 
 
 The preceding facts shew that there would be grounds for 
 suspecting the existence of cancerous disease in two cases. 
 
 First. — Wliere there were evidences of simple solidification 
 without the signs of pneumonia or tubercle. 
 
 * It would be interesting to examine whether in this instance the pulsation was 
 from the vessels of the cerebriform mass, or communicated by the pulmonary artery. 
 I incline strongly to ihe latter opinion. The nature of the pulsation of cancerous 
 tumours is still to be determined, but if it iippears that the thoracic cancers only pulsate 
 when embracing a large vessel, the value of the sign as indicative of tumour, will be 
 so far diminished.
 
 394 CANCKIl OF THE LUNG. 
 
 Secondly. — Where there were evidences of an iutra-thoracic 
 tumour ; in which case the diagnosis would lie between a pul- 
 sating cancer and an aneurism of the aorta. 
 
 It need scarcely be observed, that the existence of external 
 cancerous disease would aid in settling the question, but such 
 a combination is by no means constant, and even when present, 
 the visceral may precede the external cancer, as in the case which 
 I have given. 
 
 But there is a point connected with the physical signs, which 
 must not be passed over. In none of our cases were there any 
 evidences of cavities forming in the cancerous mass ; and there 
 is no instance (hitherto) recorded in which the stethoscopic signs 
 of ulceration have been observed. In my third case, indeed, a 
 gangrenous cavity formed a little before death, but this engaged 
 the lung, it did not occur in the cancerous structure, and was 
 evidently accidental. Bayle details a case of ulcerated cancer of 
 the lung, but does not state whether the cavities communicated 
 with the bronchial tubes. I subjoin an abstract of this case. In 
 the same author we find an instance recorded of the combination 
 of tubercle and cancer : here the diagnosis, from physical pheno- 
 mena at least, would be impossible. 
 
 Under the name of cancerous phthisis, we find three cases of 
 the disease related by Bayle. 
 
 Case I. — A man, aged 55 years, of a bilious temperament, was 
 attacked with dyspnoea, a dry cough occurring in paroxysms, and 
 pains of the chest. The skin became gradually yellow, although 
 the conjunctiva preserved its natural colour. Towards the tenth 
 month of his disease the skin became dry and rough, and the 
 cough, which was frequent, was followed by scanty mucous 
 expectoration, after some time succeeded by slight haemoptysis, 
 which continued for seventeen days. 
 
 Fifteen months elapsed, yet the patient's strength was scarcely 
 diminished, the expectoration became purulent, and he some- 
 times felt severe pains in the chest. Soon after this, he was 
 attacked with adynamic fever, from which he recovered in about 
 a month ; the cough increased, the expectoration became more 
 abundant, and the patient rapidly emaciated. At this time, a soft 
 and fluctuating tumour, unaccompanied by pain or change of colour 
 of the sldn, appeared above the humeral extremity of the right 
 clavicle. The patient sunk in the eighteenth month of his disease.
 
 CANCEll OF THE LUNG. 395 
 
 Dissection. — Both lungs were found to contain numerous 
 tumours of a rounded form, and of a structure similar to that of 
 fresh lard, they had a shining white colour, and were of various 
 degrees of hardness : some red capillaries, similar to those of the 
 brain, could be seen ramifying in their substance ; from some 
 of these tumours a whitish pus of a creamy consistence could 
 be expressed, while others were converted into true ulcerations, 
 around which the pulmonary tissue was slightly hardened : 
 abdominal viscera healthy. 
 
 Case II. — A man, aged 35 years, was afflicted with a tumour 
 on the forearm, which, after continuing for ten years, increased 
 so rapidly as to render amputation necessary ; but the opera- 
 tion was postponed on account of dyspnoea which had existed 
 for some time ; on this subsiding, the operation was performed, 
 but the pectoral symptoms returned, and the patient died with 
 suffocation on the twentieth day after operation. 
 
 The lungs contained numerous tumours of the cerebriform 
 matter, of different degrees of consistence, and supplied by 
 capillaries. In some, excavations could be perceived, filled with 
 a serous or bloody fluid ; some of which were lined with a delicate 
 and vascular membrane, while others seemed to result from the 
 destruction of the cerebriform matter itself. 
 
 The pulmonary tissue between the tumours was perfectly 
 healthy. 
 
 Case III. — A man, aged 72 years, had enjoyed good health 
 until within six weeks of his admission into hospital ; his disease 
 set in with pains affecting the whole body, but principally 
 engaging the chest and epigastrium. A slight cough, with a 
 white and opaque expectoration, set in, the appetite failed, and 
 the bowels became obstinately costive ; the liver was enlarged 
 and irregular, filling the epigastrium, and extending almost to 
 the umbilicus. Three hard, indolent, moveable bodies, of about 
 the size of nuts, were found to exist in the epigastric and right 
 hj^ochondriac regions. 
 
 On dissection the lungs presented few adhesions, and appeared 
 externally healthy. On cutting through them the root of the 
 left lung was found occupied by a mass of shining white 
 appearance, in the interior of which red capillary vessels could be 
 seen. In the centre of this substance, which resembled brain, 
 and also in^tlie lung itself, tuberculous masses could be detected,
 
 39G CANCER OF THE LUNG. 
 
 easily distinguished from the cancerous matter by their yellow 
 opaque appearance ; several small tuberculous cavities were found 
 in the remainder of the lung. The liver contained numerous 
 ccrebriform masses, and the moveable subcutaneous bodies were 
 evidently of the same nature as the internal tumours.* 
 
 Part II. 
 
 When I published my observations on the Diagnosis of Cancer 
 of the Lung in my treatise on Diseases of the Lung, I endea- 
 voured to express the state of our knowledge of the subject at 
 the time. Since that period, however, I have been enabled to 
 arrive at a direct diagnosis of the first form of cancer. I have 
 also been fortunate enough to meet with a remarkable case of 
 ulcerated cancer of the lung, and have extended my observations 
 upon cancerous tumours within the thorax. So that we can now 
 affirm without presumption, that in many cases of this disease, 
 whether it affects the lung simply, or occurs as a mediastinal 
 tumour, a direct diagnosis can be arrived at. By direct diagnosis 
 I mean the discovery of the internal disease, in cases where there 
 is no recognized cancer in other situations, such as the mamma, 
 uterus, extremities, &c. 
 
 We may now enumerate the different forms of thoracic cancer 
 which have fallen under our observation. It is scarcely necessary 
 to say that some of these have already been noticed by others. 
 
 1st. Isolated and generally well-defined enccphaloid tubercles 
 of a rounded form, the intervening tissue healthy, and the 
 tumours equably distributed through both lungs. 
 
 '2nd. Isolated masses of irregular forms ; sometimes coincid- 
 ing with a mass of complete cancerous degeneration. 
 
 8rd. Tubercles of various species of cancer co-existing, such 
 as scirrhus, the encephaloid, and the black spongiform cancer. 
 
 4th. Simple degeneration of the whole or part of a lung into 
 the homogeneous enccphaloid matter. 
 
 5th. Enccphaloid tumours of the posterior mediastinum com- 
 pressing the lung. 
 
 Gth. The same condition combined with cancerous degenera- 
 tion, and cancerous tubercles of the lung itself. 
 
 * Recherches sur la Phtbisie Piilmonaire, par G. L. Bayle. Paris, 1810.
 
 CANCER OF THE LUNG. 397 
 
 7th. Cancerous tumour of the anterior mediastinum. 
 
 8th. Tumours of fluid white cancerous matter perfectly en- 
 cysted, and surrounding the trachea and oesophagus, combined 
 with a white cancerous infiltration of a portion of the lung, and 
 cancerous coagula of the bronchial tubes. 
 
 9th. Cancerous degeneration of the whole lung, with deep- 
 seated and superficial ulcerous action, extensively separating the 
 lung from the pulmonary pleura. 
 
 Before proceeding further, I will enumerate the combinations 
 with other diseases, which have fallen under my observation. 
 They are — 
 
 1st. The combination of homogeneous cancer of the lung with 
 empyema. 
 
 2nd. Cancerous tumour of the posterior mediastinum with 
 gangrene of the lung. 
 
 3rd. Cancer of the mediastinum and lung, in combination 
 with dilated tubes. 
 
 4th. Cancerous tubercles of the lung with bronchitis. 
 
 With respect to those cases of pulmonary cancer, in which the 
 malignant matter is deposited in the form of isolated tubercles 
 throughout the lungs, our information is still extremely scanty. 
 The tumours in some cases are purely encephaloid ; in others 
 they are found of scirrhous hardness; and in a third class, these 
 varieties are combined in various degrees.* Of this last variety, 
 an interesting specimen was exhibited by Dr. Law, at the Patho- 
 logical Society, during the Session 1838-9 ; and at the first 
 meeting of the Society, Sir Philip Crampton exhibited the 
 recently removed parts in a case of this disease. The lungs con- 
 tained a lai-ge number of encysted tumours, the contents of which 
 consisted of two substances ; the one a soft and spongy structure 
 of a dark brown colour, the other a dark coloured fluid, which 
 spurted out when an incision was made into the tumour. The 
 structure of the tumour exactly resembled that of the left testis, 
 which had been removed by Sir Philip Crampton three months 
 
 * " The relative frequency," says Dr. Walshe, " with which the different species of 
 cnncer grow in the lungs is shewn in the following arrangement of 106 cases, 58 
 formerly coUecteil by myself, 48 by Aviolat : — 
 
 Encephaloid 60 Hfematoid ]. 
 
 Sc nhus 16 Fibroplastic 1 
 
 Mixed 20 Doubtful .5 
 
 Colloid 3 (On Diseases of the Lunge, p. 516.) (Ed.)
 
 398 CANCER OF THE LUNG. 
 
 previous to death ; bronchial glands healthy. A remarkable 
 instance of the latency of this form of cancer is given by Dr. 
 Hughes in his third case. Here the disease of the knee-joint, 
 however, may have prevented the occurrence of pulmonary 
 symptoms. 
 
 A girl, aged 14, was admitted into Guy's Hospital, for an affec- 
 tion of the knee, January 6th, 1841. She died six months after. 
 During her stay in the hospital, she never had cough, dyspnoea, 
 haemoptysis, or any other symptom referrible to the chest. 
 
 Dissection. — The knee-joint was converted into a large cance- 
 rous mass ; the lungs contained numerous tubercles, about the 
 size of peas and chestnuts ; firm, roundish, nodular, semi-carti- 
 laginous, somewhat translucent, and some very earthy ; the heart 
 was small.* At the first meeting of the Pathological Societvfor 
 1839-40, Professor Harrison exhibited the recent parts in a case 
 of medullary tumour of the pelvis. In this case, the lungs con- 
 tained a great number of small tubercles and masses, which pre- 
 sented the characters and structure of medullary sarcoma ; the 
 intervening pulmonary tissue was healthy; a large medullary 
 tumour existed in the pelvis. The subject of the case was a 
 young woman, aged 20, of a robust and healthy appearance. 
 About a week before her death she complained of some dyspnosa ; 
 but the stethoscope did not indicate the existence of any organic 
 lesion. She died rather suddenly. 
 
 There are two circumstances common to all the cases of this 
 disease which we have seen ; one, the nearly equable distribution 
 of the cancerous deposits over both lungs ; the other, the healthy 
 condition of the intervening tissue. We shall return to this 
 subject when speaking of the general diagnosis, and here merely 
 remark that the physical conditions above stated throw great 
 difficulty in the way of direct diagnosis. 
 
 CANCEROUS DEGENERATION OF THE LUNG. 
 
 Of the different forms of thoracic cancer this seems to be, per- 
 haps, the most frequent. The first case in which any accurate 
 physical examination was instituted is that published by Dr. 
 Graves, of which I have already given an abstract. In this case 
 the most remarkable phenomena were : 1st. The absence of rale. 
 2nd. The want of coincidence between the physical signs and 
 
 * Guy's Hospital Reports, 1841,
 
 CANCER OF THE LUXG. 399 
 
 those of pleurisy, pneumonia, or tubercle. 3rd. The contraction 
 of the side with extension of dulness beyond the mesial line. 
 4th. The varicose condition of the veins. 5th. The appearance 
 of external cancerous disease towards the close of the case. 
 
 Cancerous Degeneration of the ivhole Left Lung ; . displacement 
 of the Heart; appearance of External Tumours two months' 
 before death.* 
 
 A peasant, aged 24, of strong and healthy constitution, and 
 who had always enjoj'ed good health, was attacked in the autumn 
 of 1834 with pleurisy, which yielded to antiphlogistic treatment. 
 In the following December he had a second attack ; he com- 
 plained particularly of dyspnoea, and of acute pain in the left 
 side every time he took in a deep breath. These symptoms 
 were aggravated by coughing, or by change of position to the left 
 side. General and local bleeding relieved the pain, but the cough 
 resisted all treatment. He got a fresh attack of cold, followed 
 by increase of suffering. He had the most severe pains shooting 
 through the affected side, extending from the shoulder down to 
 the short rib, and from the sternum to the vertebral column. 
 Antiphlogistic treatment was again resorted to without any 
 benefit. I saw him now for the first time. He was lying on his 
 back, having the right side of the chest a little elevated ; he had 
 a frequent dry and short cough, accompanied with great dvspnoea. 
 The left side of the chest was fixed during inspiration and expi- 
 ration ; the sternum was pushed forward and towards the right 
 side ; there was a remarkable dilatation of the left side, just 
 below the mamma ; percussion gave a dull sound over the left 
 side, and a clear one over the right ; over the left side the respi- 
 ratory murmur was lost ; over the right it was loud, though un- 
 equally so. The patient could get up and walk about his room 
 with less distress than lying on the left side produced ; pulse 
 quick, small, variable, but not intermitting ; sleep disturbed 
 and interrupted by the cough ; loss of appetite ; slight thirst ; 
 tongue clean ; countenance expressive of suffering ; surface lead 
 coloured and livid; breath free from foetor ; slight emaciation ; 
 skin dry. A month after, a tumour appeared on the front of the 
 left side of the chest, about the size of two fists, resembling the 
 female breast ; no change in the physical signs, the pulsations of 
 * Heyfelder's ArcMves Generales,
 
 ■iOO CANCER OF THE LUNG. 
 
 the heart were felt to the rifi;ht of the sternum, and a visible 
 pulsation was observed both in the carotid and temjDoral arteries ; 
 the left side more dilated ; the voice was weak and without reso- 
 nance ; the patient could not lie on the right side ; left side fixed 
 during inspiration ; cough dry and persistent ; colour of surface 
 leaden ; expression of countenance more indicative of distress ; 
 pulse unstead}' and intermitting ; d^yspnoia increased. " I con- 
 fess," says Heyfelder, " I could not form any satisfactory opinion 
 as to the nature of the complaint. The want of cegophony, the 
 size of the chest, the shape and situation of the tumour, pre- 
 vented me considering it an empyema." From this time out I 
 saw the patient daily. Two months before his death the axillary 
 glands became enlarged and hardened, and two tumours formed 
 under the left clavicle. The patient died dropsical, having, up to 
 the moment of death, the harassing cough, attended with expec- 
 toration of a glairy mucus. 
 
 Dissection. — The right pleura was fall of serum, and the lung 
 was engorged and adherent to the diaphragm ; it was free from 
 tubercle. The heart was compressed, and smaller than natural, 
 and in every situation adherent to the pericardium, which latter 
 adhered to both lungs. The left lung was fixed to the ribs ; it 
 was converted into one mass, completely tilling the left pleural 
 cavity, and extending over into the right one. It was trans- 
 formed into a solid white lardaceous mass, totally devoid of 
 nerves, blood vessels, and small bronchial tubes. Towards the 
 centre the mass was soft and brain-like, and of a greyish-white 
 colour, presenting an opening, the remains of the large bronchial 
 tube. The pulmonary arteries and veins were obliterated or 
 changed into ligamentous bands, up to their attachment to the 
 heart. Our external examination of the left side in front dis- 
 closed a large mass of the same lardaceous character, softened 
 towards the centre, and communicating with the disease inside 
 the chest, the intervening ribs being displaced and separated. 
 There was no trace either of pectoral or intercostal muscles, and 
 the ribs themselves were atrophied to an extreme degree. All 
 the abdominal viscera were healthy. The left testicle and epi- 
 didymis were occupied by scirrhus. The tumours under the 
 clavicle and the axilla are not particularly described. One of 
 the most interesting circumstances in this case was the growth 
 of the external tumour during the last period of the patient's
 
 CANCER OF THE LUNG. 401 
 
 illness ; a similar phenomenon was observed in the case pub- 
 lished by Dr. Graves, in which, towards the close of the disease, 
 three tumours appeared, and increased with great rapidity ; they 
 were on the forehead, the ramus of the lower jaw, and on the 
 lumbar spinous processes ; and, as in Bayle's case, they were 
 unaccompanied by pain, soreness, or any inflammatory phe- 
 nomenon. The first case in which the precedence of the visceral 
 to the external cancer was recognized is that by Dr. Graves, 
 and the fact of its having now been observed in three instances 
 is quite sufficient to make it an important element in the 
 diagnosis. It is very probable the occurrence has been often 
 overlooked, from the singular latency and freedom from inflam- 
 matory action under which these external tumours occur. In 
 the first case the discovery of these tumours was purely acci- 
 dental. The two following cases are given by Dr. Hughes in 
 the communication already quoted : — 
 
 Conversion of the Right Lung into a nearly Homogeneous 
 Mass of Cancer. 
 
 A man, aged 43, was admitted into Guy's Hospital, labour- 
 ing under cough, pain in the right side of the chest, with 
 expectoration of a frothy nature, tinged with blood ; his legs 
 were cedematous, as were also the right arm and right side of 
 the chest, and his eyelids were puffy. He constantly lay on the 
 right side, from the occurrence of severe dyspnoea when he 
 turned to the left. The tongue was pale and moist, the skin 
 dry, and the pulse frequent and feeble. 
 
 Physical Signs. — Complete dulness of the right, except just 
 under the clavicle. It was also full and prominent, but in con- 
 sequence of the oedema of the parietes, it could not be ascer- 
 tained whether the intercostal spaces were protruded ; complete 
 absence of respiration at the lower part. In the mammary 
 regions it was tubular and distant, and under the clavicles harsh 
 and hoarse ; behind there was complete dulness, with absence 
 of respiration in the subscapular region. In the scapular the 
 respiration was tubular, with bronchophony ; no vibration on 
 coughing or speaking, either before or behind ; the left side of the 
 chest appeared healthy, and the sounds natural, except that the 
 respiration was puerile. The oedema of right arm and side in- 
 creased, and his dyspnoea prevented the least change of position. 
 
 D D
 
 402 CANCER OF THE LUNG. 
 
 Dissection. — The right pleura was universally and strongly 
 adherent ; the entire of right lung, except a small portion at 
 its apex, was converted into a fungoid mass, which was generally 
 white and pultacious, except near the centre, Avherc it was of a 
 pink colour, and reduced to a diffluent pulp : and opposite the 
 scapula, near the surface, where there was an irregularly- shaped 
 cavity, containing little or no fluid. In the bronchial tubes was 
 much viscid secretion, and the mucous membrane was slightly 
 congested. The left pleura was partially adherent from old 
 disease ; but the lung and the bronchial tubes on this side were 
 healthy. Several bronchial glands were much enlarged, but did 
 not appear to have assumed any of the characters of the malig- 
 nant disease. The right auricle of the heart appeared con- 
 siderably flattened, and the entire organ was pushed considerably 
 to the left side by the pulmonary tumour. There was nothing 
 remarkable in the abdomen, except that at the head of the 
 pancreas was an enlarged gland, about the size of an orange, 
 which contained a straw-coloured fluid. 
 
 Cancerous Degeneration of the upper portion of the Right Lung. 
 
 A woman, aged 50, caught cold two years before her death, 
 during which time she suffered frequently from haemoptysis. 
 She was admitted into Guy's Hospital August 19th, 1841, when 
 she presented the following appearances : — her countenance was 
 pale and sallow, with a few enlarged cuticular veins in the cheeks ; 
 her legs were swollen ; she had no pain, nor was sbe particu- 
 larly emaciated. She lay on her back, with the shoulders rather 
 raised, and somewhat inclined to the right, but could turn to 
 either side, or get up without inconvenience ; she complained of 
 cough, accompanied with shortness of breath, and sanguineous 
 expectoration ; her tongue slightly coated and moist ; her skin 
 unctuous and soft ; her pulse frequent and feeble ; her bowels 
 regular. The expectoration consisted of white frothy mucus, 
 with light crimson blood mixed through it. She had one ab- 
 sorbent gland, nearly as large as a pigeon's e^g^, in the rigbt 
 axilla, and a smaller one under the right clavicle ; but had not 
 been aware of their existence until they were pointed out to her. 
 The superficial cutaneous veins of the right side of the abdomen 
 were considerably increased in size, and rather tortuous. 
 
 Physical Signs. — Evident flattening below the right clavicle,
 
 CANCER OF THE LUNG. 403 
 
 extending down to the mamma ; the ribs moved very little, and 
 were elevated en masse during inspiration ; there was complete 
 dulness and absence of respiratory murmur over the upper 
 portion of this lung, both before and behind ; occasionally there 
 was heard bronchial respiration, and now and then slight rale ; 
 there was an imperfect pectoriloquy with an increased tactile 
 vibration. The morbid phenomena appeared to terminate at a 
 defined line, just above the mamma, and to pass round the whole 
 of the right side of the chest ; the lower portion of the right 
 and entire left lung appeared healthy. Her symptoms gi-adually 
 increased in severity ; her legs began to swell, and orthopnoea 
 set in, and two months after admission she died. 
 
 Dissection. — The left pleura was slightly adherent ; the left 
 lung was crepitant throughout, and partially emphysematous ; 
 the right pleura was universally firmly adherent, and superiorly 
 altered in texture by a white, flaky, malignant deposit ; the 
 entire upper part of the right lung was converted into a mass of 
 medullary fungus, the cut surface of which exhibited a dead 
 white, cheesy substance, intersected with bands of cellular tissue. 
 By slight pressure a creamy fluid exuded, together with portions 
 of soft, brain-like matter from cells, varying in size from a pin's 
 head to a marble. The middle lobe contained some portions of 
 the malignant growth, appearing like elongations or processes 
 of the diseased mass above them, from being clearly connected 
 with and traceable into it, and separated from each other by the 
 intervention of healthy, or simply compressed lung. The inferior 
 lobe contained a few small detached masses of fungoid matter, 
 and was posteriorly firm, dark-coloured, and lacerable, probably 
 from gravitation. In the branch of the right pulmonary artery, 
 going to the upper lobe, there was a small pedunculated medul- 
 lary tubercle, and another on its external surface. The heart 
 and pericardium were healthy. 
 
 Abdomen. — The liver had the nutmeg character, and presented 
 one patch of malignant disease. Both kidneys and renal cap- 
 sules presented small masses of medullary matter, and near the 
 OS uteri were found three pea-like scirrhous tubercles. The 
 gland in the axilla was clearly affected with the same disease. 
 
 In a case given by Dr. Carswell, almost the whole of the left 
 lung was converted into a dense substance, resembling a section 
 of fresh pork. The lobular structure, however, of the organ was 
 
 D D 2
 
 404 CANCEE OF THE LUNG. 
 
 very conspicuous ; but the blood vessels and bronchi were either 
 greatly compressed or obliterated. Towards the upper extremity 
 of the lung, the carcinomatous deposit was seen extending from 
 lobule to lobule, and had made its way through the bronchi. 
 The pleura costalis and pulmonalis were studded with tumours 
 of the same kind, varying from the size of a pin's head to that of 
 a walnut. Several of these tumours were seen on the pleura 
 pulmonalis, the largest arose by a broad base, the others were 
 . round or pyriform, and attached by a peduncle. 
 
 In the next variety of the disease, we find cancerous tumours 
 of the posterior mediastinum not unfrequently co-existing with 
 the degeneration of the lung and isolated tubercles in its sub- 
 stance. These tumours are of various sizes, and are commonly 
 of the encephaloid structure, and I have seen no example of their 
 ulceration. As might be expected, they may produce all those 
 effects of excentric pressure which are commonly observed in 
 deep-seated aneurisms ; thus, they may displace the lung, press 
 on and diminish the calibre of the trachea or bronchial tubes, 
 compress the oesophagus, so as to cause a fatal dysphagia, and 
 obliterate the subclavian artery. I have seen no instance, how- 
 ever, of their inducing absorption of the bones, or forming 
 external tumours, as is so commonly the case in aneurism. The 
 occurrence of these signs of excentric pressure, renders the 
 diagnosis of this form of the disease comparatively easy. 
 
 I have noticed but two varieties of this afiection. In the first, 
 which is not uncommon, the tumour is of a pure encephaloid 
 structure, presenting rounded, but irregular masses, involving 
 the trachea, oesophagus, and great vessels ; while in the second, 
 of which I have seen but a single instance, a ring of tumours, 
 varying from the size of a hazel nut to that of a hen's egg, 
 existed immediately above the bifurcation of the trachea. These 
 tumours were all encysted ; some containing a perfectly fluid 
 creamy matter, while others contained a dark grumous liquid. 
 The lungs contained many tumours of the same kind ; there was 
 no tubercle, but in various parts of the lung we observed portions 
 infiltrated with a white liquid, perfectly similar to the contents 
 of many of the tumours. Some of these portions were more 
 than an inch and a half in length, and half an inch in depth. 
 In many of the bronchial tubes, deposits of a pearly white 
 cancerous matter, in a semi-fluid state, were discovered, having
 
 CANCER OF THE LUNG. 405 
 
 more consistence than that of the tumours, but not adhering 
 with any force to the mucous membrane. This is the only 
 instance of cancer of the bronchial tubes which I have seen ; but 
 I find that Professor Carswell, in a case of the isolated form of 
 cancer, gives a representation of a cancerous tumour attached to 
 the mucous membrane of a large bronchial tube.* It might be 
 supposed that the case above stated was one of ulcerated cancer, 
 but I entertain an opposite opinion, from the fact that in none of 
 the masses could the transition from a hardened to a liquid state 
 be observed ; and this view is borne out by the infiltration of 
 portions of the lung with a liquid precisely similar to that 
 contained in the cysts, and by the analogous deposits in the 
 bronchial tubes themselves. 
 
 In my work on Diseases of the Chest, I have given two cases, 
 in which the encephaloid matter formed a compressing tumour ; 
 in one the lung was engaged. In both these cases the sign of 
 inequality of respiration, induced by the pressure of the tumour, 
 was observed, and the situation of the disease was established by 
 manifest dulness on percussion ; but as in aneurism this last 
 physical sign is not always present. We read, in Andral's 
 Clinique Medicale, the particulars of a case in which a mass of 
 melanosis compressed the right bronchus so as to diminish its 
 calibre to nearly one-half; the respiratory murmur oji the left 
 side was extremely feeble, but on the right puerile ; the sound 
 on percussion on both sides was equal. The two following 
 cases are taken from Dr. Syms' paper, in the 18th vol. of the 
 Medico-Chirurgical Transactions. 
 
 Encephaloid Tumour of the Posterior Mediastinum, Cancerous 
 Degeneration of the Plight Lung, dc, d-c. 
 
 A tall, well-formed young woman, aged 23, and who had enjoyed 
 good health till near the period when her present disease was first 
 noticed. A short time before her death she complained of great 
 difficulty of breathing, frequent cough, and considerable pain in the 
 chest, with other symptoms supposed to indicate a severe inflam- 
 matory affection of the lungs. The usual remedies were had re- 
 course to for her relief, but the symptoms did not give way to the 
 treatment adopted, and in a short time others appeared of a more 
 formidable character. She had also swelling in the lower part 
 ♦ Elementary Forms of Disease, Fase 3, Fig. 8, Plate II.
 
 406 CANCER OF THE LUNG. 
 
 of the abdomen, and on examination, several distinct and large 
 tumours could be felt rising out of the pelvis. Above the 
 clavicles, and along the blood vessels of the right side of the 
 neck, there were a number of enlarged lymphatic glands of 
 various sizes. Her disease advanced rapidly ; she got ascites ; 
 the tumours rose higher, and increased in magnitude ; the lower 
 extremities became oedematous ; the dyspnoea increased, and 
 also the cough, but she had no expectoration. A remarkable 
 symptom now occurred ; the sounds of the ventricles were per- 
 ceived in their usual situation, but the impulse of one or both 
 ventricles was equally distinct over a considerable part of the 
 right side of the thorax anteriorly. Her right arm became 
 painful and enormously swollen, presenting all the signs of 
 phlegmasia dolens from inflamed veins ; she constantly lay on 
 her back, and was unable to vary her position. She soon after 
 died. 
 
 Dissection. — On opening the thorax, a tumour of very con- 
 siderable size was found imbedded in the right lung ; it was 
 closely attached to the great vessels at the base of the heart. It 
 was moveable within the thorax. On making sections through 
 it, some portions appeared firm and fibrous, and others softer 
 and brain-like. Its colour was of a dirty white, intermixed with 
 streaks of a lead colour, apparently in the direction of its few 
 blood vessels. It closely involved the bronchi and blood vessels 
 at the root of the right lung, and was firmly attached to the 
 pericardium and vessels immediately issuing from the heart. 
 Nothing remarkable was observed in the left lung, or the texture 
 of the heart. On dissecting out the right subclavian vein, it 
 was found to be filled with successive layers of fibrine, the 
 product of inflammation, and the valves at its junction with the 
 jugular were seen distended with this deposit. Several tumours 
 of a similar nature were attached to the uterus and its appendages. 
 
 Encephaloid Tumour of the Posterior Mediastinum, produci)i() 
 depression of Diaphragm and displacement of the Heart ; 
 cancerous degeneration of the Right Lung. 
 
 A strong athletic man, aged 43, was attacked about a year 
 before his death with hemoptysis, cough, dyspnoea. The hae- 
 morrhage frequently recurred, but he was able to follow his usual
 
 CANCER OF THE LUNG. 407 
 
 occupations for several months after, wlien his symptoms hecame 
 much aggravated, and he was then admitted into St. Marylebone 
 Infirmary. He novy laboured under severe dyspncea and cough, 
 attended with mucous expectoration, and he had frequent attacks 
 of hasmoptysis ; a considerable part of the right side of the thorax, 
 anteriorly, sounded dull on percussion, and respiration was 
 inaudible ; the jugular veins were dilated to three times their 
 usual size, and, with part of the subclavian, presented large 
 tumours above the clavicles, alternately increasing and diminish- 
 ing in size ; his face was swollen, he complained of severe head- 
 ache, sharp pulse, very little emaciation, bowels costive. Two 
 months from the date of admission he died, previous to which 
 his sufferings had been excessive. 
 
 Dissection. — On raising the parietes of the thorax a large 
 tumour, several inches in circumference, came into view on the 
 right side. The tumours of the right lung occupied about two- 
 thirds the capacity of the entire chest, the diaphragm was pushed 
 down, and the space for the left lung was occupied by the tumours 
 from the opposite side ; the heart was situated several inches lower 
 than usual, and pushed much beyond the mesial line ; the left lung 
 contained much black matter, and in some situations was indu- 
 rated, and presented a red hepatization. There was no trace of 
 any other disease in this lung. The right lung occupied a con- 
 siderable space, for the morbid growth from it encroached upon 
 the abdomen ; a great portion of it was consolidated, apparently 
 from old hepatization, and some parts presented an infiltration 
 of pus. The tumour was extensively attached to this lung, it 
 also pressed upon the trachea and completely surrounded the right 
 bronchus, with several of its bifurcations. It also pressed upon 
 the posterior part of the right auricle, so as to burst it inwards, 
 and, in one part, a small tubercle, about the size of a pea, had 
 penetrated ; it had also made its way into the cavity of the left 
 auricle, and two tubercles, suspended by narrow peduncles, hung 
 down from the tumour into this cavity. All the great vessels 
 were connected to the tumour except the inferior cava. The 
 tumour presented various degrees of consistence ; in some situa- 
 tions it was hard and cartilaginous, in others it was soft, 
 though solid, and in a third it was pulpy and fluctuating, but 
 retained its cellular or fibrous appearance. On making a section 
 of any part of it a milk-white fluid escaped, resembling cream.
 
 408 CANCER OF THE LUNG. 
 
 The firmest portions of the tumour were connected with the 
 disease of the lung, the softest portion was that situated between 
 the trachea and bronchi, the great vessels, and attached to 
 the heart ; it was almost entirely of a milk-white colour, in some 
 places slightly tinged by the ramification of minute blood vessels, 
 whose number was extremely small ; in some parts the tumour 
 could be removed from the lung, and a membrane resembling 
 the pleura was observed to intervene. The abdominal viscera 
 were all healthy. 
 
 The foregoing cases by Dr. Syms present some interesting 
 points for consideration, to which we shall briefly allude. In 
 the first case we see a patient attacked with severe symptoms 
 of pulmonary disease which resist ordinary treatment. This 
 circumstance is not without its value in the diagnosis of the 
 heterologous diseases of the lung. I have elsewhere shown its 
 importance in the diagnosis of the acute development of tubercle ; 
 and in cancer of the lung the accompanying signs of irritation are 
 observed to be either uninfluenced by treatment, or, if they are 
 removed, they return again and again without apparent cause. 
 Whether the cancerous masses themselves form foci of irritation, 
 or that the irritation itself is of a specific character, and, like 
 other afi"ections of this kind, but little influenced by ordinary 
 treatment, remains to be determined. I incline strongly to the 
 latter opinion, from the fact of finding, in maiiy cases of isolated 
 cancer of the lung, the intervening tissue in a perfectly normal 
 state. There are three circumstances in this case of great im- 
 portance in the diff'ereutial diagnosis — viz. : 1. The rapid 
 formation of internal and external tumours. 2. The occurrence 
 of ascites and cedema. 3. The transmission of the impulses of 
 the heart over the diseased side. It is hardly necessary to 
 remark that the combination of all these circumstances forms a 
 group of phenomena for which there is no parallel in any recorded 
 cases of pneumonia, tubercle, or pleuritic efi"usion. The pulsa- 
 tion of the lung has been, for the first time, described by Dr. 
 Graves in a case of acute pneumonia. In this instance the 
 pulsation of the heart was felt all over the right lung, at a 
 time when the organ was in an engorged, and, as it were, semi- 
 fluid state ; but it is unlikely that, in the diagnosis of cancer, 
 any difficulty will arise from the knowledge of this fact, in- 
 asmuch as the pulsation in Dr. Graves' case occurred at an.
 
 CANCEE, OF THE LUNG. 409 
 
 early period, and in an acute disease, so that the expression of 
 our knowledge on this subject will be that an extensive pulsation 
 of the lung in an acute case points out an engorged condition, 
 but, in a chronic case, has only been observed in cancer. In the 
 second case the frequently recurring hgemorrhage and the absence 
 of emaciation in so cbronic a case, are circumstances not in 
 accordance with the usual diseases of the lung. I have noted 
 similar facts in another case already spoken of, and if to these be 
 added the very extensive dulness and absence of respiration, com- 
 bined with the extreme dilatation of the jugular veins, the existence 
 of a group of phenomena, belonging only to cancer of the lung, 
 must be admitted. 
 
 CANCEEOUS TUMOURS OF THE ANTERIOR MEDIASTINUM. 
 
 On this subject I cannot at present give any original observa- 
 tions. Cruveilhier and others have recorded examples of cancerous 
 deposits beneath the sternum in cases of malignant diseases of 
 the breast, but we want observations of primary cancerous disease 
 in this situation. It is probable, however, that the diagnosis 
 would not be found to be difficult, at least in cases where the 
 tumour was sufficiently large to compress the trachea or great 
 vessels, for in this situation the aneurismal or non-aneurismal 
 character of the disease would be easily determined. 
 
 ULCERATED CANCER OF THE LUNG. 
 
 That ulceration of cancers of the lung is a rare occurrence, 
 must be admitted on examining the recorded cases of the affec- 
 tion ; I have only seen one example of it, which I will presently 
 describe. I have never met with it in any case of mediastinal 
 tumours, even where the lung itself was engaged ; and it seems 
 probable that some of the cases of supposed ulcerated tubercles 
 of the lung were but examples of original deposits of cancerous 
 matter in different varieties and degrees of consistence. Ba3de 
 has described two cases in which the lung contained tumours of 
 cerebriform matter, in which excavations existed, seemingly the 
 result of ulceration of the cancer. I have stated in my work, that 
 no instance was recorded in which the stethoscopic signs of ulcera- 
 tion had been observed, and this, which sufficiently shows the rarity 
 of the occurrence, will be found to have been hitherto the case.
 
 410 CANCER OF THE LUNG. 
 
 Ulcerated Cancer of the Lung, ivith extensive Separation of the 
 Pleura ; singular variations of the Physical Signs. 
 
 A woman, aged 35, was admitted into my wards on the 
 21st of May, 1838. Four months previously she had been in 
 the enjoyment of good health, when she was exposed to cold, 
 and, for the first time, was attacked Avitli cough and severe pain 
 in the right side, which continued up to the period of her ad- 
 mission. Her complexion was sallow, and she had a remarkably 
 cachectic appearance ; she complained of a constant, troublesome 
 cough, with copious viscid mucous expectoration, frequently 
 mixed with blood, and she stated that spitting of blood had 
 frequently occurred during the course of her illness ; the pain 
 was referred to the right mammary region, to the postero-inferior 
 part of the right side, and to the shoulder. In the two first of 
 these situations the integuments were so tender, that she could 
 scarcely bear the apj^lication of the stethoscope. Decubitus on 
 the left side ; pulse 108 ; night sweats. 
 
 Physical Signs. — Over the anterior portion of the right side 
 the sound on percussion was distinctly tympanitic ; this extended 
 from the clavicle to below the mamma ; there was no bruit de 
 ■pot fcl('\ nor was the sound similar to that given by a large 
 t-avity; it was a true tympanitic clearness, but such as is 
 observed in cases of empyema and pneumothorax, when the 
 liquid effusion has so far increased as to leave but a thin 
 stratum of air within the pleura ; bronchial rales were heard 
 over the surface of the lung, and an obscure bronchio-cavernous 
 respiration could be perceived along the sternum ; the voice was 
 very resonant over the whole surface, and a strong vibration 
 communicated to the hand, but there was no pectoriloquism ; 
 posteriorly, the lung was everywhere dull, with a very feeble 
 murmur, mixed with muco-crepitating rale; the. left side gave a 
 natural sound on percussion, and the murmur was puerile, un- 
 mixed with any rale. The next report was made on the 28th of 
 May. The general symptoms and signs remained the same, 
 except that the tympanitic sound was less distinct. In the 
 recumbent position, the respiration anteriorly was exceedingly 
 feeble ; but when she sat up, a loud musical rale was heard over 
 the right side. On coughing, a large mucous nile, ai^proaching 
 to gargouillement, could be heard under the third rib.
 
 CANCER OF THE LUNG. 411 
 
 dlst. — The cavernous character of the respiration appeared t> 
 increase, and the degree of tympanitic sound has varied more or 
 less from day to day. 
 
 June 6th. — The tympanitic sound has disappeared, the antero- 
 superior portion heing completely dull, while helow and to the 
 side of the mamma the respiration is decidedly cavernous. 
 The pain in the side was last night extremely severe, extending 
 to the stomach. 
 
 9th.- — The tympanitic sound has in some degree returned. 
 
 10^/t. — On this day complete dulness was found extending 
 from the clavicle to the inferior line of the mamma ; but from 
 this point to the last false rib there was manifest tympanitic 
 clearness. The patient expectorated a large quantity of blood. 
 
 12//t. — Another change in the phenomena was observed ; under 
 the clavicle the sound was what we have elsewhere described as 
 tympanitic dulness ; lower down there was complete dulness, 
 and at the most inferior portion the t^'mpanitic clearness re- 
 mained ; here the respiration was feeble and accompanied by a 
 large mucous rattle ; about the centre of the lung it had a 
 tracheal character, while under the clavicle it was feeble, but 
 apparently vesicular. 
 
 ISth. — The sound of the sub-clavicular region has become 
 completely dull, while the tympanitic clearness observed inferiorly 
 has extended up to the third rib. 
 
 17^/t. — All tympanitic sound has now disappeared, and from 
 the clavicle downwards there is complete dulness. From this 
 period but little change took place in the physical phenomena, 
 except that on the 3rd of July the posterior part of the chest, 
 gave at different points some of the tympanitic sound on per- 
 cussion. During this period the principal symptoms were, the 
 sweats, diarrhoea, severe pain, and tenderness of the lower part of 
 the right side, dyspnoea, and oedema of the face, eyelids, lower 
 extremities, and the left hand. She died on the 12th of July, 
 the duration of her illness being between five and six months. 
 
 Dissection. — The pleural cavity was found completely obli- 
 terated ; but, through the serous membrane, the lung could 
 be seen not collapsed, apparently solid, and of a yellowish-white 
 colour. The whole organ was converted into a mass, having 
 less consistence than is observed in ordinary encephaloid disease ; 
 nor was its structure homogeneous, but rather granular, and
 
 412 CANCER OF THE LUNG. 
 
 exliiLiting traces of the pulmonary lobules and cells, infiltrated 
 everywhere with a pearly- white gelatinous fluid, giving it a semi- 
 transparent appearance. A large portion of the lung was bur- 
 rowed by anfractuous excavations, communicating on the one 
 hand with the bronchial tubes, and on the other terminating 
 in fistulte, running in various directions to the surface of the 
 lung, where they terminated in superficial cavities, containing 
 air and a whitish purulent fluid, bounded on the one hand by 
 the posterior surface of the pulmonary pleura, and on the other 
 by the degenerated pulmonary substance. This dissection of 
 the pleura from the lung extended over almost the lower two- 
 thirds of the organ. Towards the rest of the lung there was a 
 mass, exhibiting the cancerous disease in its more ordinary 
 aj)pearance ; part of this was white, another portion more red 
 and vascular, and a part of it was quite broken down. The 
 pericardium contained a large quantity of fluid ; the left lung 
 and pleura were healthy, with the exception of a few small 
 hydatids, which existed in diff'erent portions of the lung. I 
 have given this case at considerable length, as an example of 
 an hitherto undescribed condition of the lung, as the physical 
 phenomena presented combinations and modes of succession 
 which have never before been observed. And as in this 
 case I never ventured on giving a diagnosis, the account of 
 the physical signs may be received with greater confidence. 
 Many opinions were formed as to the nature of the disease by 
 the members of the class, and by several practitioners who 
 visited the patient ; thus, some conceived it to be an example of 
 tuberculous phthisis ; others, chronic pneumonia, with ulcera- 
 tion ; some, empyema and pneumothorax. It was conjectured, 
 at one time, that there was a hernia of the abdominal viscera 
 through the diaphragm ; at another period, it was supposed that 
 the liver was in a state of emphysema, of which a remarkable 
 example had occurred some time previously in the hospital ; and 
 it was also suggested that the case might be an example of the 
 tympanitic sound occurring in typhoid solidifications, which has 
 been described by Dr. A. Hudson. When I first examined the 
 patient, soon after admission, I conjectured that the physical 
 phenomena might be explained by the existence of a superficial 
 layer of dilated cells anteriorly, while tubercle in great quantity 
 existed in the rest of the lung ; but, on ray second examina-
 
 CANCER OF THE LUNG. 413 
 
 tion, on the 28tli of May, the phenomena were such as to 
 render this notion quite untenable. We see in this case the 
 singular phenomena of an empyema and pneumothorax com- 
 municating with the bronchial tubes, yet not in the cavity of the 
 pleura, but between the lung and the pulmonary layer of that 
 membrane ; and it is obvious, that the singular variations of 
 .the phenomena were attributable to the varying proportions of 
 liquid and asriform effusions in the cavities which separated the 
 pleura from the subjacent lung ; and the extended resonance of 
 the voice, and strong vibration communicated to the hand, 
 ■together with the tracheo-cavernous respiration, are all explained 
 by the condition of the parts. 
 
 Finally, we may observe, that although with physical pheno- 
 mena totally different from anything hitherto observed, the 
 same general principle is applicable to this as well as many 
 other recorded cases of cancer, viz., that in cases where the 
 phenomena in their nature or combinations are different from 
 those of pneumonia, tubercle, pleurisy, and pulmonary apoplexy, 
 we have good reason to suspect the existence of cancer. 
 
 GENERAL PRINCIPLES OF DIAGNOSIS. 
 
 In examining the principles of diagnosis, we may take three 
 physical conditions of the cancer for consideration : 1st, cancer- 
 ous tubercles ; 2nd, degeneration of a part or the whole of a 
 lung into the homogeneous cancer ; 3rd, mediastinal tumours. 
 In many of the first form of cases we are deprived of some 
 valuable sources of physical diagnosis. Thus, it often happens 
 that we cannot avail ourselves of the signs of irritation, so 
 important in ordinary tubercle, for, although great quantities 
 of cancerous masses exist, the intervening tissue may preserve 
 a singularly healthy condition. There is a much more intimate 
 association between ordinary tubercle and inflammation of the 
 organ in which it is deposited, than in this affection. 
 
 In the next place, we are commonly deprived of all the signs 
 of ulceration so valuable in phthisis. I have never met with a 
 case of isolated cancerous tubercles in a state of ulceration, and 
 if anything was wanting to increase the difficulties, the test of 
 comparison is often inapplicable in these cases, from the nearly 
 equable distribution of the cancerous tubercles over the whole of
 
 414 CANCER OF THE LUNG. 
 
 both lungs, so that it is possible that a large quantity of can- 
 cerous masses might exist, and the sound on. percussion be 
 everywhere equal, and not dull. 
 
 I have no experience of this form of the disease in relation to 
 diagnosis ; but, even in this difficult case, assistance is afforded 
 us by auscultation, in the discovery of bronchitis, coming on 
 without any apparent cause ; at first, amenable to treatment, 
 l)ut returning almost immediately, though the patient has not 
 been exposed to any of those influences that usually give rise to 
 bronchitic inflammations. These attacks will recur with great 
 frequency ; at first, slightly, but gradually getting worse, till at 
 last, a severe bron(;hitis is established, resisting all means of 
 treatment, and terminating in the patient's death. This has 
 been the case in two very remarkable examples of this form of 
 cancer of the lung which occurred in this country. If with these 
 frequent attacks of bronchitis we have evidence of cancer in any 
 other situation, we may, in such a case, pronounce with con- 
 siderable confidence, that the j^atient labours under cancer of the 
 lung (presenting itself in isolated tubercles equally distributed 
 throughout the lung). We may safely anticipate that the same 
 principles of diagnosis which are applicable to acute tubercle, 
 will be found to apply to this affection ; and state that if, wdth 
 the symptoms and signs of bronchitis we find the chest to be- 
 come dull ; if this dulness be extensive, yet incomplete, the 
 stethoscope showing that the lung is still permeable, the solidity 
 only occurring in points, we may make the diagnosis either of 
 acute tubercle or of this form of cancer ; and as the symptoms 
 of acute phthisis are generally strikingly marked, there would 
 be probably no difficulty in determining on the nature of the 
 aff'ection. 
 
 I have already given the state of our knowledge of the second 
 form, at the date of the publication of my work, 1837, in which 
 I stated, that neither in the cancerous transformation of the 
 lung nor the mediastinal tumour, could we apply any direct 
 diagnosis, and that in a case seen for the first time, and in which 
 no external cancer existed, there were no means by which we 
 could determine the point. The following case, bowever, will 
 show that our knowledge of this subject has advanced since this 
 period. The following is an abstract of the notes and details of 
 this case, for which I am indebted to Dr. Carroll, of Waterford,
 
 CANCER OF THE LUNG. 415 
 
 with whom I saw the patient in consultation with Drs. Mackesj 
 and Conolly : — 
 
 Encephaloid Degeneration of the Right Lung, in combination 
 7vith Empyema. 
 
 Mr. J., the subject of the following report, was about forty- 
 four years of age ; of middle height and robust frame ; with a 
 well-formed chest ; temperament neuro-bilious ; eyes and hair 
 dark. He had always enjoyed good health, with the exception 
 of a tic doloureux in the gums which followed the extraction of a 
 molar tooth. 
 
 June nth, 1839. — He returned from Dublin, complaining of 
 uneasiness in the right hypochondrium ; stools clay-coloured ; 
 breathing hurried, particularly in the evening ; took hydrarg. c. 
 creta for a few days. The functions of the liver were restored. 
 
 Julg dth. — Difficulty of breathing having much increased, 
 attended with cough, he applied a blister to the chest, and was 
 bled to 5 xiv ; blood very slightly buffed ; breathing relieved. 
 He at this time was going about his ordinary business ; appetite 
 and digestion good. 
 
 August 7th. — I visited him for the first time ; he expectorated 
 some bloody mucus for the first time, and was attacked with a 
 severe lancinating pain in the right side of the chest, between 
 the fourth and sixth ribs, shooting backwards to the scapula. 
 Pulse 70 and regular ; respiration twenty-six in a minute ; 
 tongue clean and moist ; skin cool ; bowels free ; appetite good ; 
 unable to make a full respiration in consequence of the severe 
 pain which it produced. On inspecting the chest both sides 
 were found perfectly symmetrical. On percussion the left side 
 sounded well near the median line ; the entire of the anterior 
 and inferior portion of the right side sounded dull, as did the 
 posterior and inferior on percussion, dulness rather greater 
 behind. From a point corresponding to the fifth rib upwards, 
 the sound on percussion was clear and good, respiration puerile 
 in the left lung ; in the upper part of the right side, both before 
 and behind, respiration was natural, from the nipple downwards, 
 throughout the entire right side it was very feeble, but distinct, 
 accompanied with a loud sonorous rale, more properly termed a 
 wheeze giving the impression of a compressed condition of the
 
 416 CANCER OF THK LUNG. 
 
 bronchial tubes, no mucous or crepitating sounds. The sputa 
 was very peculiar, such as I never saw before ; they presented 
 the appearance of black currant jelly, being not unlike it in con- 
 sistence. They had none of the viscidity of pneumonic sputa, 
 but gave the notion of pure mucus and pure blood mechanically 
 blended. He lies chiefly on the back, being unable to lie with 
 comfort on either side for some time. 
 
 August 'ilth. — Since last report the pain has continued wiLh- 
 out any relief. Observed two large veins corresponding to the 
 epigastric arteries ramifying on the abdomen ; the superficial 
 veins of the thorax manifestly enlarged. Pulse 112 ; respira- 
 tion 30 ; dulness of the right side, increasing in extent 
 (upwards) and in degree ; respiration in the same region nearly 
 extinct ; in the superior portion of the lung, it is becoming of a 
 bronchial character. 
 
 August 28^/i. — Dyspncea greatly increased, coming on in 
 violent paroxysms, threatening suffocation, obliged to be projiped 
 up in bed with pillows ; at his own request, an accurate physical 
 examination was made, when amid a great deal of uncertainty, 
 from the anomalous nature of his symptoms, we arrived at the 
 conclusion that his disease was either a tumour of or in the 
 lung, compressing it and so interfering with its functions, or an 
 empyema the result of the pleuritis. The latter we adopted as 
 most probable, and its peculiar symptoms subsequently in- 
 creasing, we thought no more of a tumour. 
 
 September lOtk. — Orthopnoea ; confusion and giddiness of 
 the head during the exacerbation of dyspnoea. 
 
 October 2ncL — On examining the chest, found right side on 
 measurement two inches larger than the left ; slight oedema of 
 the chest and face ; legs considerably swollen ; intercostal spaces 
 not obliterated, though in less action than the other side ; veins 
 greatly enlarged, and two, corresponding to the internal mam- 
 mary vessels, meet those on the abdomen ; entire right side 
 sounds dull ; respiration absent over the entire side from the 
 fourth rib down ; it is bronchial above. Both before and behind 
 great resonance of voice ; pressure on the epigastrium causes an 
 insufferable sense of suffocation. 
 
 November 6th. — Has been rather improving since last report ; 
 feels altogether more comfortable, and can lie much better in the 
 horizontal posture. On measurement both sides are found of
 
 CANCEK OF THE LUNG. 417 
 
 equal girth ; there is no displacement of the liver ; intercostal 
 spaces more distinct ; oedema of side and face gone. 
 
 November 7th. — Visited by Dr. Stokes, who pronounced his 
 opinion, that he laboured under malignant disease of the lung 
 together with an empyema, and that he could not recover. 
 
 November 20th. — The affected side is now found to be about 
 half an inch less in circumference than the other. 
 
 During the months of January and February there was a pro- 
 gressive decline of strength and flesh, notwithstanding that his 
 appetite was good during that time. Towards the last week or 
 fortnight he complained very much of oppression at the epi- 
 gastrium, as if a heavy weight were there. The liver could be 
 plainly distinguished ; his legs swelled again, and face became 
 (Edematous. For three days before his death, he sat in a chair 
 in the most distressing state of orthopnoea, with a pillow on his 
 knees and his elbows leaning on the pillow. He had no pain at 
 the struggle. There was no tumour or other mark of disease on 
 his body." 
 
 I did not see this patient again, but in the following March 
 the account of the dissection was given in a letter I received from 
 Dr. Carroll. " I opened his body thirty-three hours after death, 
 in presence of several practitioners of this city, and I was greatly 
 gratified to find your diagnosis verified to the letter. The fol- 
 lowing were the appearances observed : the body was much 
 emaciated ; the legs infiltrated with serum ; the superficial veins 
 which ramified on the surface of the thorax and abdomen, and 
 which were enormously enlarged during life, had almost disap- 
 peared. 
 
 " On opening the thorax, a quantity of pure pus, amounting 
 to about three pints, was found occupying a space in the right 
 side of the chest, extending from the sixth rib to the diaphragm. 
 The cavity in which it was contained was lined throughout by a 
 very thick and smooth membrane. The lung compressed into 
 the upper part of the chest was found intimately adherent to 
 the parietes and all the surrounding parts ; so much so as to 
 resist every attempt at separation with the fingers, and was only 
 removed by the knife. On cutting into its substance it presented 
 a very remarkable appearance, being converted throughout into a 
 solid, heavy fibro-cartilaginous mass of brilliant white brain-like 
 colour, interspersed with black spots, of the diameter of a six- 
 
 E E
 
 418 CANCER OF THE LUNG. 
 
 pence, each contrasting singularly with the white portion. On 
 close examination, this white substance was found to be fibrous 
 in its texture, and radiated like (but not so distinctly) as scirrhus ; 
 and notwithstanding its extreme closeness and density, a white, 
 creamy fluid exuded from the surface on incision. The black 
 patches were of a soft, semi-fluid consistence, and it appeared 
 doubtful whether they were melanotic deposits, which sometimes 
 occur in conjunction with encephaloid tumours, or merely the 
 remains of bronchial glands. I rather incline to the former 
 opinion. There were some few traces of vascularity in some 
 parts of the lung, and these confined to the apex, the lesser 
 bronchial tubes were obliterated, while the larger ones in the 
 upper and posterior part were dilated. There was no ulcerous 
 cavity. In the left pleura about a pint of clear serum was 
 found. The lung at that side was free from adhesions, and 
 presented a healthy appearance on the surface, and crepitated 
 on pressure ; it was, however, much compressed, and pushed up 
 by the diseased mass at the other side ; a section of it exhibited 
 a slightly whitish appearance, which, in all probability, was 
 the commencement of a similar disorganisation as that which 
 existed in the right. There was some bronchitis. The peri- 
 cardium contained about eight ounces of serum ; the heart was 
 perfectly healthy ; the liver was sound, but somewhat enlarged, 
 and projected about three inches below the cartilages of the 
 ribs, and at the point of contact with them presented a very 
 deep sulcus, such as you have described in your ' Observations 
 on the Diagnosis of Empyema' ; the remaining abdominal viscera 
 were healthy. The brain not examined." 
 
 When I saw this patient he was sitting in an arm-chair, with 
 his body bent forward ; he had orthopnosa and oedema of the 
 legs. The question had been agitated, as to whether para^ 
 centesis of the chest might be advisable. We found, however, 
 that both sides of the chest were of equal size, the right 
 being covered with" a network of large varicose veins, which 
 could not be attributed to the pressure of the empyema, as they 
 had been increasing since the return of the side to its ordinary 
 dimensions. It was obvious, that even admitting the existence 
 of a pleuritic eff'usion, some other disease must be present to 
 account for the venous obstruction. The side sounded com- 
 pletely dull in every portion, and in the upper part there was
 
 CANCER OF THE LUNG. 419 
 
 a total absence of respiration. The upper portion then of the 
 lung was completely solid, and it was not unlikely that some 
 remains of the empyema still existed inferiorly ; but at this 
 period the point could not be absolutely determined. I may 
 now enumerate the different points leading to the diagnosis of 
 cancer in this instance. 
 
 1. The violent attack of pain in the side, the pulse remaining 
 natural. 2. The peculiar currant-jelly-like sputa. 3. The 
 resistance of the symptoms and signs to treatment. 4. The 
 continuance of symptoms of pulmonary distress, after the sides 
 had become symmetrical, pointing out that some new disease of 
 the substance of the lung had formed and was progressing. 
 5. The existence of the varicose veins, and their increasing 
 after the return of the side to its natural size. 6. The total 
 impermeability of the upper portion of the lung, and the com- 
 plete absence of all signs of ulceration. 
 
 Of these, the three most important were the obstinacy of the 
 symptoms, the complete consolidation, and the varicose state of 
 the veins.* 
 
 On the subject of the pulsation of cancerous tumours I have 
 nothing new to communicate, and beg to refer to my work on 
 the Diseases of the Chest. It may be stated, however, that the 
 pulsation is not a constant attendant on these tumours, and 
 that, in my case and in that by Dr. Syms, the pulsation was 
 obviously communicated to the tumour, as we so commonly 
 see it in the abdomen. No mention of bruit de soufflet is made 
 by Dr. Syms. The disease of cancer of the lung may be a 
 primary affection, or succeed to cancer of some of the external 
 parts. We yet want facts to determine the comparative frequency 
 of the two cases. Its most common form seems to be the dege- 
 neration of a portion of the lung into homogeneous encephaloid 
 matter, and in that of isolated tubercles, which I think, if the 
 patient lives long enough, may increase so as to form a vast 
 
 * A case which strikingly resembled the above in many particulars is admirably 
 reported by Dr. Mayne in the third volume of the Dublin Pathological Society's 
 Transactions. The characteristic symptoms and physical signs are thus summarized 
 by Dr. Mayne : — " Severe thoracic pains gradually progi-essive, and never attended by 
 fever ; progressive emaciation without sweating, without diarrhoea, and almost with- 
 out expectoration ; scanty slate-coloured sputa ; enlarged thoracic and cervical veins ; 
 constant cough, extreme dyspnoea, and an amount of dulness and inelasticity of the 
 side to which I had never before seen a parallel, were the prominent signs and 
 symptoms." 
 
 E E 2
 
 420 CANCER OF THE LUNG. 
 
 mass of cancer. Yet not quite homogeneous, but presenting a 
 congeries of very large tumours, touching one another, and com- 
 pressing the intervening lung. I will now give the general 
 conclusions to which we have arrived, marking with an asterisk 
 those which I already stated in my work on the Diseases 
 of the Chest, and with two asterisks those which have been 
 modified. * That the facility of diagnosis mainly depends 
 on the anatomical disposition of the disease. ** That we 
 may divide the cases with a view to diagnosis into those 
 in which isolated tubercles exist, with the intervening 
 tissues healthy; those in which simple degeneration occurs 
 without ulceration and with ulceration ; and those in which a 
 tumour of the mediastinum exists, causing compression. That 
 the diagnosis in the first case is difiicult, from our being seldom 
 able to avail ourselves of the signs of irritation and ulceration, 
 so important in ordinary tubercles, and the fact of the equable 
 distribution of the disease preventing comparison. That in 
 some cases of isolated cancerous masses, the diagnosis may be 
 founded on the same general principles as that of acute phthisis. 
 #* That in simple cancerous degeneration of the lung, the prin- 
 <5ipal physical signs are the gradual diminution of the vesicular 
 murmur, without rale ; its ultimate extinction, and the signs of 
 perfect solidification. That the evidences of perfect solidifica- 
 tion are better found in this disease than in any other pulmo- 
 nary affection. That this form of the disease may exist, 
 simply, or in combination with empyema, and may be secondary 
 to cancerous tumours of the mediastinum. That the sides may 
 be symmetrical in this affection, and that either dilatation or 
 contraction of the side may occur. That the mediastinum may 
 be displaced, even though the side be contracted. * That 
 under these circumstances we may have the signs of perfect 
 solidification, accompanied by imperfect pectoriloquism, and 
 increased vibration to the hand. ** That the mediastinum 
 may be displaced and the liver depressed without protrusion of 
 the intercostal spaces. That the heart may be compressed and 
 dislocated in this form of disease. — Hughes, Syms, Houston.f 
 That the flattening of the upper part of the chest may occur 
 from degeneration of the upper lobe. — Hughes. ** That the 
 absence of signs of ulceration is very characteristic of this 
 f Dublin Medical Journal, vol. iii., First Series.
 
 CANCER OF THE LUNG. 421 
 
 disease. That we have observed these signs in but a single 
 case, and that the phenomena, though they might be produced 
 by other diseases causing the same physical conditions of the 
 lung, have never before been met with. That cancerous tumours 
 of the mediastinum generally co-exist with either degeneration 
 of the lung, or isolated tubercles in its substance. That they 
 may be solid or fluid. That they may co-exist with can- 
 cerous infiltration of the lung, or the deposit of cancer in the 
 bronchial tubes. That they are to be recognized more by the 
 signs of the tumour than by those of disease of the lung. 
 ** That dysphagia, tracheal stridor, feebleness of one pulse, 
 difference of respiratory murmur from pressure on the bronchial 
 tube, displacement of the diaphragm, and dilatation of the heart, 
 may occur in this form of the disease. ** That a cancerous 
 tumour may exhibit pulsation with or without bellows murmur, 
 but that pulsation is not always attendant on it. * That though 
 the previous existence of external cancer may assist in diagnosis, 
 yet that the disease may be all through internal, or the visceral 
 precede the external cancer. *That the feebleness of pulsation 
 connected with the extent of dulness may assist in distinguishing 
 the disease from aneurism. That in the advanced periods, as 
 in aneurism, gangrene of a portion of the lung may supervene. f 
 That the following symptoms are important as indicative of this 
 disease : pain of a continued kind ; a varicose state of the 
 veins in the neck, thorax, and abdomen ; oedema of one 
 extremity ; rapid formation of external tumours of a cancerous 
 character ; expectoration similar in appearance to currant jelly ; 
 resistance of symptoms to ordinary treatment. 
 
 That though none of the physical signs of this disease are, 
 separately considered, peculiar to it, yet that their combinations 
 and modes of succession are not seen in any other afi"ection of the 
 lung. 
 
 f My friend, Mr. MacDonnell, has shewn that from the anatomical disposition of 
 the nutritive arteries of the lung, pressure upon any part of the main bronchus 
 might cause the death of the lung. Of course, the liability to this is greater in 
 the case of mediastinal tumours than in the simple degeneration. Dr. Greene has 
 met with this gangrene, from the same physical causes, in aneurism. See the 
 Transactions of the Pathological Society.
 
 422 
 
 SECTION VIII. 
 
 TUBERCLE OF THE LUNG. 
 
 In conformity with the phiu of this work, I shall confine my- 
 self solely to the diagnosis and treatment of phthisis, and only 
 discuss the pathology of tubercle incidentally, and so far as may 
 be necessary for the elucidation of the subject. 
 
 The diagnosis in this affection is drawn from the study of the 
 former and actually existing symptoms considered in relation to 
 the i)hysical signs and their mutations. It is to be recollected 
 that there are no physical signs peculiar to tubercle ; it is in 
 their combinations, situation, successive changes, and connexion 
 Avith pure symptoms that they have their value. 
 
 It is not to be denied, that a correct diagnosis of phthisis may 
 be frequently made without the aid of physical signs, for there 
 are abundant cases presenting such a combination of circum- 
 stances, as to render the existence of tubercle all but certain ; 
 these are the more obvious, ordinary, and advanced cases. But 
 in the earlier periods, when the diagnosis is practically useful, 
 and in that vast category of cases in no respect corresponding to 
 the description of books, the symptomatologist is continually at 
 fault. We shall not enter, therefore, into a detailed account of 
 symptoms, for it would be a hopeless task to frame any descrip- 
 tion which would apply even to the majority of cases, but after 
 having examined the sources of the physical signs, we shall com- 
 bine and study the symptoms and signs of the more prominent 
 varieties of the disease. 
 
 As in phthisis all the structures of the lung may be engaged, 
 so in a single case we may meet every known auscultatory sign of 
 disease of the mucous membrane, parenchyma, and serous invest- 
 ment. These occur in infinitely various combinations, according 
 to the degree of irritation, the number of tissues engaged, the 
 extent of ulceration, and the chronicity of the disease. 
 
 In the first section of this work I have shewn how comparison
 
 TUBERCLE OF THE LUNG. 423 
 
 aids us in physical diagnosis, and there is no disease in which 
 it is so applicable as phthisis. In this respect an important 
 division may be made, of those cases, on the one hand, in which 
 comparison subserves to diagnosis ; and those in which the 
 phenomena being similar and universal, the principle is inap- 
 plicable. In the first class, or that in which the disease is 
 originally local, may be placed by far the greater number of 
 cases, for those in which the disease engages the whole lung in a 
 nearly equable manner are exceedingly rare. 
 
 For example, the existence of tubercle of the upper portion 
 of one lung is recognized by the difference between its physical 
 signs and that of the lower lobe ; in other words, by applying 
 comparison. And in like manner, if the whole of one lung be 
 diseased we recognize the lesion by comparing it with the other. 
 But when tubercle is scattered equably throughout both lungs, 
 and accompanied everywhere by the same amount of irritation, 
 then the diagnosis becomes difficult indeed, and can only be 
 arrived at by successive observations. 
 
 Let us now enumerate the physical signs of pulmonary phthisis. 
 
 1st. Signs of irritation. 
 
 (a.) Of the mucous membrane, (b.) Of the air cells, or 
 parenchyma, (c.) Of the serous membrane. 
 
 2nd. Sig)is of solidification. 
 
 3rd. Signs of ulceration, 
 
 4th. Signs of atrophy. 
 
 5th. Signs referrihle to the circulating system. 
 
 (a.) Action of the heart, (h.) Of the arteries, (c.) Dis- 
 placement of the heart. 
 
 I shall examine these sources of diagnosis separately. 
 
 SiONS OF Bronchial Irritation. — In the great majority of 
 cases these precede and accompany the development of tubercle, 
 and the rales occur in every degree of intensity and variety of 
 combination. In some a single occasional mucous bubble is the 
 only sign, while in others the respiration is altogether masked 
 by a combination of the sonorous, sibilous, and muco-crepitating 
 rales. These signs are audible under the clavicle, in the axilla, 
 or in the acromial or supra-spinous regions ; in some cases 
 accompanying the ordinary breathing, in others only audible on 
 a forced inspiration, and thus it commonly happens that the 
 signs escape the superficial observer, for the murmur may be
 
 424 TUBERCLE OF THE LUNG. 
 
 pure during ordinary breathing, and yet intense bronchial rales 
 be revealed by a forced expansion.* 
 
 Of these rales the most common are, the mucous and muco- 
 crepitating, next in frequency are the sibilous, while the rarest 
 are the deep-toned sonorous rales. These results we might 
 expect from the tuberculous irritation first engaging the minute 
 air tubes. Connected with this we find that although these 
 phenomena may exist simultaneously in the subclavicular, 
 axillary and postero-superior portions, yet that their existence in 
 one of these situations does not imply that we can detect them 
 in the others. The utility of this rule in examination is obvious, 
 but in most cases we may content ourselves with exploring the 
 anterior and posterior faces of the lung. 
 
 Combined with the direct signs of bronchial irritation we find 
 in most cases a feebleness of the vesicular murmur, and a shade 
 of dulness of the clavicle or spinous ridge. The less musical 
 the rale the greater the probability that these signs shall accom- 
 pany it, but we may have a loud musical rale, or scattered 
 mucous bubbles, with clearness of sound, and even a puerile 
 respiration. 
 
 Now if it be asked, what gives these signs of bronchitis their 
 value as diagnostics of incipient tubercle, the answer is, that it 
 is not by their mere characters (for these do not differ from 
 ordinary bronchitis), but it is from their situation, localization, 
 and combination with comparative dulness of sound that they 
 derive this value. The same phenomena scattered over, or even 
 existing intensely throughout the lung, but being equable and 
 unaccompanied by dulness, would not only have no value in the 
 diagnosis of phthisis, but would render the existence of tubercle 
 improbable. 
 
 Simple bronchitis is seldom circumscribed, while that of the 
 consumptive is commonly so ; the latter begins in the upper 
 portion of the lung, remains obstinately fixed in the air tubes, 
 gradually spreads downwards, and while in its first stages in the 
 lower lobe, is combined with tuberculous ulceration in the 
 upper ; it may be intense in the upper lobe while the lower is 
 altogether free, or engage the whole of one lung while the other 
 
 * To Dr. Forbes is due the great merit of first pointing out the importance of in- 
 vestigating the respiration in the earliest stages of phthisis, a subject which Laennec 
 comparatively neglected.
 
 TUBERCLE OF THE LUNG. 425 
 
 is scarcely aflfected. These are not the characters of ordinary 
 bronchitis. 
 
 These observations apply to the ordinary cases in which the 
 tubercle and bronchial irritation are at first local and advance 
 together, but the whole lung may be simultaneously and equably 
 tuberculated, when of course these principles do not apply. The 
 cases may be divided into two classes, the acute and chronic. 
 As these cases shall be hereafter considered, I shall now allude 
 to them only in connexion with bronchitis. 
 
 In the first or acute form a patient previously in good health 
 is suddenly attacked with the most violent symptoms ; there is 
 high fever, extreme dyspnoea, lividity, and tenacious expectora- 
 tion. In the early periods the chest sounds clear, but the 
 signs of the most intense bronchitis affecting the tubes of all 
 diameters are universally audible. The symptoms and signs 
 continue with unabated violence, and after a few days tJie whole 
 cJtcst presents a certain degree of didness. The patient dies 
 from the violence of the pulmonary inflammation, and on 
 dissection every bronchial tube is found inflamed, and the lung 
 equably and closely studded with the miliary and granular 
 tubercles. In the second or chronic case, the lung becomes, as 
 in the former, equally tuberculated, but with a much lower 
 degree of bronchial irritation ; the disease goes on for a long 
 period ; the bronchial signs scarcely predominate in any one 
 part of the lung, but are accompanied by general, and sometimes 
 decided dulness. 
 
 When the upper lobe contains a sufficient quantity of tubercle 
 to give dulness of sound, a large mucous or muco-crepitating rale 
 is often observable over the lower portions, and hence we 
 commonly find that while cavities or aufractuosities exist 
 superiorly, the signs of bronchitis alone are to be observed below ; 
 and I have often been led to the discovery of tubercle in the upper 
 lobe, by this lurking bronchitis confined to the lower portion of a 
 single lung. 
 
 Signs of Irritation of the Parenchyma. — It is sometimes 
 difficult to distinguish between these and the preceding signs. 
 The crepitating rales, feebleness of respiration, and dulness of 
 sound, may be enumerated as the phenomena of this class ; yet 
 of these the first alone can be properly said to indicate parenchy- 
 matous inflammation ; the second may be explained on other
 
 426 TUBERCLE OF THE LUNG. 
 
 principles ; and the third has characters very different from that 
 in simple pneumonia. 
 
 But the crepitating rale of pneumonia is rarely observed in 
 phthisis, and I have never heard it unless on a forced inspiration; 
 it is then accompanied with a degree of dulness ; unlike the rale 
 of pneumonia it hardly ever disappears, to he replaced by 
 bronchial respiration, but passes imperceptibly from the finest 
 crepitus to the gurgling of anfractuosities. 
 
 Even when acute pneum-onia of the lower lobe succeeds to 
 chronic phthisis, the crepitation continues much longer than in 
 the ordinary disease. 
 
 There is in phthisis a remarkable character of the crepitating 
 and finer muco-crepitating rales which must be noticed ; these 
 signs may occur in a very circumscribed portion of the lung, and 
 after existing twenty-four or forty-eight hours, disappear, but 
 again to return in about the same time ; and they may thus recur 
 and subside many times in the course of a few weeks. I look 
 upon this recurrent crepitus as an excellent diagnostic in many 
 obscure cases, and in one, although the place of its first appear- 
 ance was not in the superior portion, yet it satisfied me that 
 tubercle existed, and dissection verified the opinion. 
 
 Lastly, we find that local depletion frequently removes these 
 finer rales for a time, and this is almost always accompanied by 
 diminution or removal of the hectic, and a general relief. When 
 on the treatment of phthisis, I shall return to this subject. 
 
 Let us now examine the important sign oi feebleness of resjnra- 
 tion. 
 
 Of the different signs of incipient phthisis there is none more 
 important than this ; it is to be ascertained by comj)arison of the 
 corresponding portions of the lungs, and of the upper with the 
 lower lobes, the observation being made on the forced, as well as 
 the ordinary respiration. 
 
 I have found that in many individuals there is a natural 
 difi"erence between the intensity of the murmur in either lung, 
 and in such cases, with scarcely an exception, the murmur of 
 the left is distinctly louder than that of the right lung. This 
 character is particularly evident in females, and nervous indivi- 
 duals, and has not been noticed by Laennec. It is of the greatest 
 importance to bear it in mind, as we may thus be often relieved 
 from the anxiety which such a discovery might produce. The
 
 TUBERCLE OF THE LUNG. 427 
 
 following circumstances serve to distinguish this natural feeble- 
 ness of respiration. 
 
 1st. Its occurrence in the right lung. 
 
 2nd. Its being unaccompanied by rale or dulness of sound on 
 percussion. 
 
 3rd. Its being the same over the whole lung, and not confined to 
 the upper portion merely, as in incipient phthisis. 
 
 It need scarcely be added, that the value of feebleness of respi- 
 ration is greater when it occurs in the left than the right lung. 
 
 So many cases concur to produce morbid feebleness of respira- 
 tion that it is difficult to explain it by a reference to any one of 
 them. All the pathologic states of the lung in incipient phthisis 
 tend to this result. The' bronchial irritation, the adhesive 
 obliteration of the minute tubes, and the deposition of tubercle, 
 would all produce a feeble respiratory murmur. Of these, however, 
 the second cause is probably the most important, and the fact of 
 feebleness of respiration occurring at so early a period, is what 
 we might expect from the obliteration of a certain number of 
 minute tubes before the air cells had been filled up or the inter- 
 vening tissue consolidated.* To this subject I have already 
 alluded in the section on Bronchitis. 
 
 But there is a feebleness of respiration which is difficult of 
 explanation, and which seems to result from a spastic state of the 
 lung. The following is a remarkable instance of this : — 
 
 A boy, aged 12 years, after recovering from a succession of 
 eruptive fevers, by which he was greatly reduced, became sud- 
 denly affected with glandular swellings on the right side of the 
 neck. These increased rapidly ; the whole chain of lymphatic 
 glands from the clavicle to the mastoid process became enlaro-ed 
 and indurated, causing considerable deformity. In little more 
 than a fortnight, however, the tumours had nearly disappeared 
 when he was attacked with a violent cough, difficulty of breathino- 
 and acceleration of pulse. I saw him on the third day of this 
 new illness ; all traces of the glandular swellings had subsided 
 the breathing was hurried, and the cough dry. Both sides of the 
 chest sounded perfectly well ; hit ichile the resjnration was loud 
 over the left lung and lower half of the right, it 2oas totally absent 
 
 * See M. Eeynand's Memoir on Obliteration of the Minute Bronchial Tubes 
 Me'moires de I'Acade'mie Royale de Me'decine, torn, iv., 1835. The paper is translated 
 in the Dublin Journal of Medical Science, vol. vii.
 
 428 TUBERCLE OF THE LUNG. 
 
 over the ivliole right upper lobe. Bleeding from the arm was per- 
 formed, and the axilla was fr*eely leeched ; and on the next day 
 the respiratory murmur had returned with nearly its natural 
 intensity. The lymphatic swellings now hegan to re-appear, and 
 in less than a week had attained their former magnitude, the 
 chest heing completel}^ relieved. Iodine was now used both 
 externally and internally. For upwards of two weeks the 
 tumours resisted the remedy, when they suddenly began to dis- 
 appear, and in three days nothing was left but a slight induration 
 above the clavicle. Cough, pain, acceleration of breathing, and 
 quickness of pulse set in, and the respiration of the upper lobe 
 became as before extinct, while it was intensely puerile in the 
 other portions. 
 
 Leeching and blistering were employed on the affected portion ; 
 the symptoms were again removed, and again, in the course of a 
 Aveek, did the cervical swellings return. These of course were no 
 longer interfered with, and by a steady perseverance in constitu- 
 tional treatment the boy gradually recovered ; but a year elapsed 
 before the lymphatic tumours had disappeared. 
 
 In this important case we see the alternation of scrofulous 
 action between the neck and upper portion of the right lung, for 
 that the patient was twice on the point of passing into acute 
 phthisis no one can reasonably doubt. 
 
 But the nature of the feebleness of respiration remains to be 
 ascertained. It occurred as the sole phenomenon ; neither rale 
 nor dulness accompanied it, and its subsidence under treatment 
 was followed by the re-appearance of lymphatic irritation of the 
 neck. AVas the obliteration of the tubes the result of inflamma- 
 tory spasm, or a combination of this with the adhesive process?* 
 
 In the ordinary cases the feebleness of respiration is almost 
 always modified, and often removed, by a timely antiphlogistic 
 and revulsive treatment, and there can be no doubt, that in this 
 way many a patient can be saved from impending consumption. 
 
 Connected with this subject we may notice the interrupted 
 respiration, "respiration entrecoupee " of Laennec, in which the 
 inspiratory murmur is broken into a succession of efforts. It 
 indicates the first stage of tubercular irritation, and may be 
 removed by local treatment. As a diagnostic, however, it has 
 
 * But may not the extinction of tlie respirafon sounds have been caused by com- 
 pression of the bronchus by alternating enlargement of the bronchial glands ? (Ed.)
 
 TUBEECLE OF THE LUNG. 429 
 
 no value, unless when it is local, and occurring in a case in 
 which tubercle has been already recognized, when it becomes 
 the avant courier of more unequivocal signs.* 
 
 Signs of irritation of the Serous Membrane. — Although 
 pleural adhesions so commonly attend pulmonary tubercle, yet 
 the physical signs of pleuritis are comparatively rare. I have 
 never found them in the earlier periods, even when the signs of 
 bronchial and parenchymatous irritation were manifest. 
 
 It is in the advanced stages when the upper lobe contains 
 ulcerated tubercle, that the "frottement" of Laennec is some- 
 times discovered in the mammary, lateral, or postero- inferior 
 portions. It is most commonly ushered in by pain of the side, 
 but continues long after this has disappeared ; indeed, some of 
 the most remarkable instances of the persistence of frottemeiit 
 may be seen in pulmonary j)hthisis, and the phenomenon may 
 continue for several weeks without decided change. 
 
 * The interesting phenomenon of the contraction of the muscular fibres of the chest 
 on percussion, must be here noticed. " Some time ago, on percussing a patient who 
 had laboured under a pectoral affection, with several symptoms indicative of tubercular 
 development, we were surprised to observe that after each stroke of the ends of the 
 fingers a number of little tumours appeared, answering exactly to the number and 
 situation of the points of the fingers where they had struck the integuments of the 
 chest. These having continued visible for a few moments, subsided ; but could be 
 again made to appear on repeating the percussion. In this case percussion excited 
 a good deal of pain ; the situation in which these little tumours were most apparent 
 was in the subclavicular region, and over the great pectoral muscle. Since this 
 observation we have seen the same phenomenon in a number of cases. 
 
 " How far this phenomenon may be connected with, or depending on, internal 
 disease, is yet to be ascertained. It is seldom met with unless in cases where the 
 patients are emaciated to a certain degree. In these individuals we often find, on 
 using percussion quickly and with some force, that after each blow a degree of pallor 
 is observed in the parts struck, exactly answering to the points of the fingers ; this is 
 instantly succeeded by the return of redness, and the erection of a little tumour, which 
 has often a slight quivering motion, and which subsides in the course of one or two 
 seconds. 
 
 " We have observed this to occur most frequently in the superior and anterior 
 portions of the chest, but have also met with it in other situations ; such as the arms, 
 back, &c. In some cases the patients complained much of pain on percussion ; while 
 in others they did not appear to suffer more than usual." — Clinical Report of Cases in 
 the Medical Wards of the Meath Hospital, during the Sessio7i o/' 1828 and 1829; 
 Dublin Hospital Rejiorts, vol. v. 
 
 There is nothing in this muscular irritability peculiar to phthisis, but that it is 
 commonly connected with irritation of the lung, or pleura, there can be no doubt ; 
 and in this waj% like the other signs of irritation, it becomes available in the diagnosis 
 of phthisis. It is always more evident in the earlier periods; thus in incipient 
 phthisis it occurs over the primary seat of irritation, while in the confirmed and 
 chronic cases we may often find it absent over the lung first diseased, and strikingly 
 marked on the side last and least engaged.
 
 430 TUBERCLE OF THE LUNG. 
 
 It almost always exists with clearness of sound, and a per- 
 ceptible murmur. The patient is frequently conscious of the 
 rubbing, on drawing a deep inspiration — a sensation quite inde- 
 pendent of pain. In the earlier periods, the sensation is com- 
 municated to the hand, but the sound may continue for weeks 
 after the signs from touch have disappeared. 
 
 The same causes which produce the rarity of frottement in 
 pneumonia operate also in phthisis. There is a great similarity 
 between the mode of adhesion in both cases, and the surfaces of 
 the membrane may unite without the conditions which best 
 induce the friction sound.* 
 
 If the phenomena of dry pleuritis be rare in phthisis, those 
 of liquid effusion are still more so.f The signs are the following : 
 rapid dulness of the lower portion and absence of respiration 
 ivithout the signs of progressive pneumonic solidity. I have no 
 observations to determine how far the previously tuberculated 
 state of the upper lobe may modify the signs of displacement. 
 
 Signs of Solidification. — In phthisis condensation of the 
 lung occurs in two forms. In the first it is complete ; in the 
 second incomplete, or, as it were, interrupted. Of these the 
 first is rare, the second extremely common; consequently the 
 physical signs of complete solidity are rarely observed, and this 
 constitutes an important diff'erence between the signs of phthisis 
 and pneumonia, or cancer of the lung. 
 
 Even in cases of the tubercular infiltration, inducing a homo- 
 geneous structure, complete solidity is seldom observed, in con- 
 sequence of ulceration causing an auormal permeability. 
 
 A slight dulness of one clavicle or scapular ridge is one of 
 the earliest signs, and can often be detected only by the most 
 delicate comparative percussion. It may exist with or without 
 stethoscopic signs, and in the earlier periods may vary to a 
 certain degree. "VVe may diminish, or for a time remove, the 
 dulness of sound by treatment, which proves that in the earlier 
 stages it is owing more to the congestion or inflammation of 
 the lung than to the existence of tubercle. 
 
 * The existence of the ordinary pains of the side in consumptive patients does not 
 by any means imply that we can detect the friction signs. The nature of these pains 
 is still obscure, but that injury is commonly done by treating them as if they arose 
 from pleuritis in every case, there can be no doubt. May they not often be neuralgicj 
 or analogous to cancerous pains ? 
 
 t The case of empyema with pneumothorax and fistula is of course excluded.
 
 TUBERCLE OF THE LUNG. 431 
 
 As in the case of the bronchitic signs, we cannot infer the 
 amount, or existence of dulness of the posterior portion, from 
 the examination of the anterior; or vice versa, both clavicles 
 may sound equally well, yet a distinct difference be observed in 
 the ridges of the scapula ; and it is obvious that the reverse 
 may happen. In a few cases the dulness begins at about the 
 third rib anteriorly, or the sub-spinous region posteriorly, and 
 spreads upwards ; and in a still rarer class we have first dulness 
 of the lower, and afterwards of the upper lobe ; but in these 
 cases the disease begins with pneumonia, a chronic hepatization 
 is produced, and the lung becomes slowly tuberculated from 
 below upwards. 
 
 The clavicular dulness is almost always accompanied by a 
 corresponding feebleness of respiration. But the reverse of this 
 may occur, and a tubercular dulness of the clavicle coincide tvith 
 a puerile respiration. This happens when the posterior half of 
 the lung is greatly condensed, while the anterior remains per- 
 meable. As the disease advances, however, the apparent anomaly 
 disappears. 
 
 In a few cases the dulness coincides with a bronchial or 
 tracheal respiration. I have already shewn why this sign is 
 comparatively rare in phthisis ; when it exists, however, it is 
 always most distinct in the erect position, and may then be 
 pure, or what is more frequent, combined with the muco- 
 crepitating or mucous rales. I have often found that the 
 respiration was merely feeble, and without the slightest bron- 
 chial character, when the patient was lying down, but on his 
 getting up the bronchial respiration became evident. 
 
 As in pneumonia, this appearance of the bronchial respiration 
 proceeds from the greater expansion of the lung. 
 
 But the equal sonoriety of both clavicles may co-exist with 
 tubercle. It may arise from a small but equal quantity of 
 tubercle in both lungs, or its predominance in one lung pos- 
 teriorly. In the first case comparison must be instituted between 
 the lower and upper lobes. Delicate and successive percussion 
 of each rib from the sixth upwards must be performed, when the 
 disease will be often discovered. 
 
 In doubtful cases condensation can often be detected by the 
 following manoeuvre. Having noted the ordinary sound of the 
 clavicle, we are to direct the patient to inspire deeply, and hold
 
 432 TUBERCLE OF THE LUNG. 
 
 in liis breath ; from obvious reasons, percussion will now detect 
 a difference of sound before imperceptible. 
 
 As disease advances, the dulness extending downwards, may 
 occupy the entire lung, but it rarely happens that the whole side 
 is equally dull, the lower generally sounding clearer than the 
 upper portions. General dulness of one side may, however, be 
 met with ; I have observed it from the following causes. 
 
 First. General tuberculization of the lung, the tubercles being 
 in the crude or ulcerated condition. 
 
 Second. Pneumonic solidity of the lower lobe. In most cases 
 the pneumonia is the primary affection. 
 
 Third. Effusions into the pleura. 
 
 Fourth. Complication with enlarged liver. This only applies 
 to the right side. 
 
 Fifth. General solidity, with great atrophy of the whole- lung, 
 causing contraction of the side. 
 
 Of these cases the first is by far the most common ; that of 
 unresolved pneumonia passing into tubercle, is next in frequency. 
 The others are exceedingly rare. The dulness being established 
 is modified in two modes. In the first, ulcerous cavities forming 
 in the lung diminish the dulness, although without restoring the 
 natural sound. When the cavity is empty, the sound is somewhat 
 tympanitic, and often accompanied by the bruit de pot fele. 
 When it is large, the sound might be confounded with the 
 natural resonance, but the stethoscope will at once detect the 
 error. The second cause has been already mentioned under 
 the head of Pneumonia. The distention of the stomach with 
 air gives a peculiar resonance to the left lung, and this false 
 clearness, which can be dissipated by a carminative draught, is 
 often made the ground of unfounded hope, and the source of 
 bitter disappointment. It need hardly be observed, however, that 
 to the experienced stethoscopist the mere character of the sound 
 suffices to prevent error. 
 
 General acute Development of Tubercle. — Hitherto we have 
 studied the signs of solidification in their ordinary progress, the 
 tubercle being at first localized, and gradually extending. But 
 when the whole lung is equably and simultaneously tuberculated, 
 the diagnosis by comparison becomes impossible. Here the 
 diagnosis is drawn from the succession of physical signs ; the 
 chest, as before stated, becomes' dull without the usual signs of
 
 TUBERCLE OF THE LUNG. 433 
 
 pneumonia and pleurisy, and in most cases with the phenomena 
 of bronchitis merely. This principle will be elucidated when 
 we discuss the symptoms of phthisis in connexion with physical 
 signs. 
 
 In the general chronic tubercular development the facility of 
 diagnosis depends mainly on the suppuration of the tubercle : if 
 it be nearly equally developed in both lungs and still in the crude 
 granular condition, the diagnosis is difficult ; this may be seen 
 in the general cachexia and in old persons. Bronchial rales, 
 equally diffused, exist, and from the emaciation of the patient, 
 the dulness of sound may escape observation. These cases, too, 
 being almost always of long duration, dilatation of the air cells 
 often occurs, the clearness of which compensates for the dulness 
 of the tubercle. But when suppuration exists the difficulties are 
 removed, and we have either the signs of cavities in the upper 
 portions, or a general mucous or muco-crepitating rale, at once 
 distinguishable from that of mere bronchitis by the general and 
 extreme dulness which accompanies it, for in this suppurative 
 phthisis the dulness is always more decided than in the granular 
 variety. 
 
 Let us now enumerate the different modes and circumstances 
 of tubercular dulness : — 
 
 1st. Slight variable dulness of the clavicle or scapular ridge, 
 occurring in the first stage, and influenced by treatment. 
 '2nd. Comparative permanent dulness of these situations. 
 3rd. Both clavicles dull — one more so than the other. 
 4th. Both clavicles equally dull. 
 5th. The same with respect to the scapular ridges. 
 6th. Eight clavicle and left scapular ridge dull. 
 7th. Left clavicle and right scapular ridge dull. 
 8th. Dulness of the clavicle, the corresponding scapular ridge 
 clear. 
 
 9th. Dulness of the scapular ridge, the cori-esponding clavicle 
 sounding clear, 
 
 10th. Dulness most evident at the third rib anteriorly, and the 
 sub-spinous or inter-scapular region posteriorly. 
 11th. Dulness of the whole upper lobe. 
 12th. Dulness of the whole lung, most evident superiorly. 
 13th. Dulness at the root of the lung, extending upwards. 
 14th. Dulness of the lower lobe proceeding upwards. 
 
 F F
 
 434 TUBERCLE OF THE LUNG. 
 
 15th. Equal dulness of the whole lung, the opposite sounding 
 clear. 
 
 16th. Equal dulness of one lung and of the opposite upper 
 lobe. 
 
 17th. Comparative dulness with feeble or interrupted respira- 
 tion. 
 
 18th. The same with mucous, or muco-crepitating rale. 
 19th. The same with semi-tracheal respiration. 
 20th. The same with puerile respiration under one clavicle. 
 21st. Complete dulness of one lung with the rale of anfrac- 
 tuosities. 
 
 22nd. The same with the usual signs of a well defined 
 cavity. 
 
 23rd. Incomplete dulness with the resonance on percussion of 
 a cavity. 
 
 24th. Incomplete dulness in the upper lobe from a large 
 excavation ; perfect dulness of the lower, from tubercular solidity. 
 25th. Incomplete dulness, varying with the quantity of fluid 
 contained in an excavation. 
 
 26th. General but incomplete dulness of both lungs super- 
 vening on bronchitis, or with crepitating rale persisting to the 
 fatal termination. 
 
 Other combinations may of course occur, but I have verified 
 the connexion between the above and tubercle in a great number 
 of cases. Of these the most interesting are the sixth and seventh, 
 the twentieth and twenty-sixth cases. The dulness of a clavicle 
 and the opposite scapula is one of the most interesting of the 
 passive signs, it is by no means uncommon, and I have never 
 observed it unless from tubercle. 
 
 Signs of Ulceration. — In most cases the signs of irritation 
 precede and pass into these phenomena. In some, however, 
 the latter appear at once, unpreceded by any actiA'e auscultatory 
 sign. 
 
 In general nothing can be more gi-adual than the transition 
 from the crepitating to the muco-crepitating rales, from these to 
 a large mucous rattle, which passes into the rale of anfrac- 
 tuosities, and ultimately the gurgling of a cavity. This is the 
 ordinary course, and a cavity may thus form, comphte dulness 
 Uavincj never existed. In other cases, however, more or less of 
 dulness having existed, the signs of excavation at once appear ;
 
 TUBERCLE OF THE LL'NG. 435 
 
 this occurs from the softening of a large tubercle or a mass of 
 tubercular infiltration. 
 
 On the formation of a cavity in the upper portion, we may 
 often detect smaller ulcerations, or the earlier stages of tubercle 
 in the lower part of the affected lung, and in the upper lobe of 
 the opposite. So rarely, indeed, is tubercle confined to one lung, 
 that the existence of a cavity almost certainly implies disease in 
 the opposite side, even though no physical sign of it should exist. 
 
 The signs of an excavation vary according to its situation, 
 size, contents, bronchial communication, and the condition of 
 its walls. The principal are cavernous respiration, rale, and 
 pectoriloquism ; of these the two first are by far the most im- 
 portant, for pectoriloquism, about which so much has been 
 written, and on the discovery of which so much importance is 
 placed, is of all the physical signs of phthisis, the least constant, 
 certain, or useful. If the ear be well accustomed to the cavern- 
 ous respiration and cough, and to the gurgling rales of a cavity, 
 the investigation of pectoriloquism may be safely neglected. Of 
 the circumstances which modify cavernous respiration and rale, 
 the most important is the state of the bronchial communication ; 
 the fewer and larger the tubes which open into the cavity the 
 better marked will the signs be, while the communication of a 
 great number of smaller orifices obscures the cavernous respira- 
 tion, and in place of gurgling produces the intense mucous rale 
 of a cavity, peculiar indeed, but very difi'erent from the large 
 cavernous rale. In a few cases the temporary obstruction of the 
 tubes obscures the cavernous phenomena, which may be restored 
 on the patient's coughing ; and we thus explain the variation of 
 the physical signs according to the position of the patient.. 
 Cases will occur in which the recumbent position obscures the 
 signs of a cavity plainly evident when the patient sits up ; the 
 reverse of this is also observed. 
 
 The signs are rarely perceptible beyond the situation of the 
 ulcer, and hence the removal of the stethoscope for a single 
 intercostal space shall make us lose them. In the same way, a . 
 cavity may be plainly perceptible under the clavicle, and yet, 
 without the slightest indication of it posteriorly ; nay, we may 
 find a small excavation at the sternal end of the clavicle, while 
 below the humeral the signs are wholly wanting. 
 
 When ulceration commences it may be pointed out by a 
 
 F F 2
 
 43G TUBERCLE OF THE LUNG. 
 
 single but well definecl bubble, occurring in a situation with 
 feeble or puerile respiration and some dulness. Wben this is 
 constant "we may diagnosticate a cavity of the size of a Spanish 
 nut. As new ulcerations form the rale is multiplied, presents 
 bubbles of various sizes, and is heard over a greater extent. 
 The sound is now more dull, and the respiration either very 
 feeble or semi-tracheal, but cavernous respiration and pectori- 
 loquism are absent, and we make the diagnosis of anfractuo- 
 sities. At this period the dulness is often very considerable, 
 but the tracheal breathing is not in proportion to it. In some 
 cases the hndt de ])otfeU exists. 
 
 A well defined cavity being formed with sufficient bronchial 
 communication, cavernous respiration is produced. This must 
 be explored during ordinary and forced breathing and cough. 
 Upon cavernous respiration and gurgling depend the diagnosis 
 of a cavity. 
 
 As yet we know little of the conditions which regulate pec- 
 toriloquism, but as a sign of phthisis, it has little value. Its 
 occurrence in cavities of all kinds, ulcerous or not ; its varieties ; 
 its similarity to morbid bronchophonia, often so great as to make 
 it difficult or impossible to distinguish them ; its existence as a 
 natural phenomenon in the upper portions of the lungs of many 
 individuals ; and its total absence in cases presenting every 
 apparent physical condition for its existence, have long made 
 me consider it as the least important and most fallacious of 
 all the physical signs of phthisis. Doctor Forbes has long come 
 to similar conclusions. Taken alone, it is absolutely without 
 value ; but when in combination with other signs, it strengthens 
 the diagnosis. It is to be explored during the ordinary and 
 whispering voice. 
 
 In certain cases the existence of strong pectoriloquism is 
 perceptible to the patient, who, from the resonance of his voice, 
 can point out the situation of the cavity. 
 
 When the cavity is close to the anterior surface of the lung, 
 the agitations of its fluid contents are often perceptible before 
 we apply the ear to the chest. In this way sounds are produced 
 by the respiration and the action of the heart. In the first case 
 the phenomena are twofold, we may have a distinct gurgling 
 from many bubbles, audible during inspiration and expiration — 
 it is a sort of churning, or, which is more common, we hear a
 
 TUBERCLE OF THE LUNG. 
 
 437 
 
 single bubble corresponding to the inspiration, and similar to the 
 tick of a small clock, or watch. In some cases, upon coughing, 
 this is for a short time removed. 
 
 But a more curious phenomenon is the agitation produced 
 by the action of the heart ; it is the rarer of the two. Each 
 pulsation is accompanied with a tick in the cavity, loud enough 
 to enable us easily to reckon the pulse ; this is not always audible 
 without the stethoscope, but where the cavity is large, and the 
 chest attenuated and elastic, we may hear it at a distance of a 
 foot or more from the patient. In a case of the most protracted 
 consumption with extreme emaciation, this sound became pain- 
 fully loud, and of a metallic character on the patient opening the 
 mouth. 
 
 This cardiac gurgling may occur in both lungs. I have heard 
 it in the postero-superior portion of the right lung, while it is 
 commonly absent even when the cavity lies upon the pericardium , 
 
 When the cavity becomes much enlarged, the metallic 
 character may be communicated to the gurgling, cavernous 
 respiration and voice ; of these the metallic gurgling is most 
 common, and the first perceived, for the bubbles will receive 
 the metallic character from a cavity not yet sufficiently large to 
 communicate it to the respiration or voice. 
 
 These characters are confined to the situation of the cavity, 
 and hence, where cavernous respiration and gurgling exist under 
 the clavicle, and over the scapula, yet with the metallic cha- 
 racters only audible in one situation, we may diagnosticate two 
 or more cavities, one much larger than the others. 
 
 When a cavity exists in the lower portion of the left lung, 
 the distention of the stomach with air may cause the phenomena 
 to become metallic. 
 
 The diagnosis between the metallic phenomena of a large 
 cavity, and those of pneumothorax with fistula, is not difficult. 
 I shall arrange their characters in opposite pairs. 
 
 LARGE CAVITY WITHIN THE LUNG. 
 
 1. Metallic phenomena much 
 less developed. 
 
 2. Signs supervening gradually. 
 
 PNEUJIOTHOKAX, FISTULA, EM- 
 PYEMA. 
 
 1. Metallic phenomena intense. 
 
 2. Phenomena suddenly deve- 
 loped.
 
 438 
 
 TUBERCLE OF THE LUNG. 
 
 3. Side not dilated. It may be 
 contracted. 
 
 4. Sound on percussion dull, or 
 with the resonance of a cavity. 
 
 5. No lateral displacement of 
 the heart. 
 
 G. Cavernous rale large. 
 
 7. Sound of fluctuation absent, 
 or indistinct. 
 
 8, Pectoriloquism often present. 
 
 3. Side generally dilated. 
 
 4. Percussion exactly indicating 
 the extent of air and liquid. 
 
 5. Lateral displacement com- 
 mon. 
 
 G. Cavernous rule absent. 
 
 7. The reverse. 
 
 8. Pectoriloquism absent. 
 
 With respect to any of these characters, occasional exceptions 
 may occur. In a case seen for the first time, we must never 
 neglect percussion, mensuration, and the signs of cardiac or 
 hepatic displacement. 
 
 The second character is almost always available ; yet I have 
 known of an instance where the sudden development of metallic 
 signs did not proceed from pneumothorax.* The ordinary 
 signs of a cavity had existed for some time, when, during a fit 
 of coughing, the patient was seized with a sudden and violent 
 pain in the side, and felt as if something had given way. The 
 signs became metallic, and the patient soon afterwards sank ; it 
 was found that there had been two cavities divided only by a 
 thin partition ; this had been ruptured during the fit of coughing, 
 and a cavity was thus produced sufficiently large to cause metallic 
 sounds. 
 
 Laennec has given two cases of phthisical cavities producing 
 metallic phenomena. In the first there was distinct pectorilo- 
 quism, and when the patient coughed or spoke, the tinkling was 
 heard. The cavity occupied the upper half of the lung, and 
 branched into many anfractuosities. It contained about two 
 spoonfuls of liquid. 
 
 In the second case there were also pectoriloquism, and the 
 metallic tinkling on coughing. A large cavity containing a very 
 little liquid was diagnosticated. Three cavities were found 
 communicating with one another, none of them larger than a 
 pullet's egg. In neither of these cases did succussion produce 
 any sound. 
 
 I have found the metallic signs in a few cases. In one the 
 
 * This case did not occur under my own observation, but has been communicated 
 to me by a gentleman about whose accuracy there can be no question.
 
 TUBERCLE OF THE LUNG. 439 
 
 patient had laboured under chronic phthisis of the right lung, 
 when an extensive cavity rapidly formed in the left. The 
 respiration was cavernous, and accompanied by a tinkling sound, 
 similar to that produced by the falling of a pin into a cup or 
 glass. A vast excavation was found in the upper portion of the 
 left lung, communicating with many smaller ones by winding- 
 canals. In the lower lobe there was another cavity of the size 
 of a hen's egg.* 
 
 In another case, the left side sounded everywhere dull, while 
 over the infero-lateral portion the metallic tinkling was audible 
 after speaking, when a succession of metallic bubbles could be 
 heard. This was not excited by the cough, nor was the voice 
 itself metallic ; there was no amphoric resonance nor sound upon 
 succussion, nor was the heart displaced. The patient soon after 
 sunk, the tinkling having more than once subsided and re-appeared 
 during the course of a few days. 
 
 We found the left lung universally adherent, and so excavated 
 as to resemble a bag of liquid more than a lung. Two large 
 cavities existed, one in the upper, the other in the lower lobe ; 
 these communicated by a fistula into which the finger could be 
 introduced. The upper cavity extended from the interlobular 
 fissure to the summit of the lung ; the lower could contain a 
 middle sized orange ; both presented numerous anfractuosities, 
 and the lower was nearly filled with a grumous, purulent fluid. 
 They were both traversed by numerous vessels lined with a 
 strong cartilaginous membrane, and had the most extensive and 
 free bronchial communication. In the upper cavity particularly, 
 the tubes seemed as if accurately cut across with a knife. The 
 left lung contained a quantity of crude tubercle. 
 
 In a third case, the metallic tinkling occurred in the last 
 stage of a chronic phthisis. Gurgling and cavernous respiration 
 had existed over the left mammary region ; but during the last 
 fortnight of existence, an occasional metallic tinkling became 
 audible. The cavity extended nearly from the apex of the 
 lung to its base ; it could contain more than a pint of fluid ; 
 its anterior wall was formed of little more than the pleura, 
 and it was crossed by several obliterated blood-vessels. The 
 remainder of the lung was nearly solid from tubercle, which also 
 existed in small quantity in the upper portion of the right lung. 
 * See Dublin Hospital Reports, vol. iv,, a Selection of Cases, »fec.
 
 440 TUBERCLE OF THE LUNG. 
 
 From these facts, it is obvious that the mechanism of the 
 metaUic signs is not yet estabhshed. These sounds may be inter- 
 mittent, and may accompany the voice, inspiration, cough, and 
 action of the heart, or exist in connexion with only one of these 
 actions ; further, although they generally indicate a large cavity, 
 yet even in this case they are not always present, and may even 
 proceed from several moderately sized excavations, as in the case 
 recorded by Laennec. 
 
 It is remarkable that in several of these cases the cavities 
 were multilocular, the divisions being caused by septa of the 
 pulmonary tissue, perforated by fistulse, or by bands of obliterated 
 vessels. Can this condition have any effect in producing the 
 metallic sounds ? * 
 
 Signs from Atrophy of the Lung. — That the volume of 
 the lung is diminished in phthisis was recognized by Bayle, but 
 the subject has never been sufficiently studied. Laennec states, 
 that a contraction of the chest may be observed in very chronic 
 cases, when large cavities are tending to cicatrize. 
 
 Numerous observations, however, have convinced me, that 
 the contraction of the chest resulting from atrophy of the lung, 
 begins and may be appreciated at a much earlier period than 
 has been supposed ; and further, that in chronic cases, great 
 falling in of the chest may occur from interstitial atrophy, 7vith- 
 out the formation of any cavity ivhatever. Atrophy of the lung 
 I believe always to attend the earlier stages of tubercle, and 
 is probably produced by the operation of that law, by which an 
 organ loses its volume when its functions are rendered less 
 energetic ; and thus as the obliteration of the minute air tubes 
 described by Raynaud advances, the cells become useless, and 
 ultimately disappear.f 
 
 But whatever be the mechanism of the change we can recog- 
 nize it at an early period by accurate measurement of the antero- 
 posterior diameter of the thorax, and in this way measurement 
 is found a most important means of diagnosis in the earlier 
 
 * I shall recur to this subject when on Pneumothorax, and in the meantime refer 
 to the work of Dr. Williams, and the Memoir of M. Beau, Archives Generales de 
 Medecinc, tome iv., 11 Serie, Mars 1834. 
 
 f An interesting illustration of this is recorded by Andral. In dissecting a monkey, 
 M. Reynaud found that one bronchus was compressed by a large ganglion, so as 
 greatly to diminish its calibre ; the coiTesponding lung was singularly atrophied, and 
 the side fallen in as in the absorption of pleuritic effusion. — Precis d'Anatomie 
 Pathohgique.
 
 TUBERCLE OF THE LUNG. 441 
 
 stages of phthisis. It should never be neglected. By means of 
 a spring callipers, one knob of which is fixed on the scapula, 
 and the other below the clavicle, the comparative depths of the 
 upper lobes can be at once determined and the most minute 
 difference detected. The circumference of the chest above the 
 mamma, and the distance of the clavicle from the nipple, 
 must also be observed. In the earlier stages the difference 
 varies from the eighth of an inch to half an inch, and there is 
 no visible alteration except a flattening or slight hollowing under 
 the clavicle. 
 
 But in the more chronic cases distinct deformity takes place. 
 The antero-superior region becomes extensively flattened or con- 
 cave, the shoulder depressed, the clavicle flattened, and its lower 
 edge everted, the ribs closely approximated or even overlapping, 
 and the apex of the scapula tilted out as in contraction from 
 empyema. The heart ascends in the thorax, and in one extreme 
 case I have found it to pulsate under the second rib. All these 
 signs are more connected with the chronic solidity than the 
 suppuration of the lung, for the latter, by permitting some 
 expansion to take place, may delay the process of contraction. 
 
 This condition may exist with complete dulness of sound 
 and bruit de jiot feU, but without the signs of cavities, or may 
 coincide with gurgling and cavernous respiration in their different 
 modifications. 
 
 Signs from the State of the Circulating System. — Active 
 organic disease of the heart and aorta being among the rarest 
 complications in phthisis, it happens that we can seldom avail 
 ourselves of signs drawn from the circulating system ; Louis 
 found, out of a hundred and twelve cases, only three in which 
 the heart was enlarged. It is more often diminished in volume, 
 pale and flabby, as if participating in the general muscular 
 atrophy. This applies to the chronic cases, for in the acute I 
 have often found the heart red, and in no way altered from its 
 natural condition.* 
 
 Notwithstanding the atrophied state of the heart in phthisis, its 
 action is occasionally violent and distressing. In most cases, 
 indeed, its impulse is somewhat increased, and if there be 
 
 * The slowness with which the pulmonary obstruction occurs in chronic cases 
 explains the rarity of morbus cordis ; for as Louis has remarked, the fluids dimmish 
 with the obstruction. — Reclierches sur le Phthisie Pulmonaire, See also Broussais' 
 Histoire des Phlegmasies Chroniques, tom. i.
 
 44^ TUBEECLE OF THE LUNG. 
 
 emaciation, and much tubercle of the left hmg, the impulse is 
 distinctly double, the second stroke coinciding with the second 
 sound. 
 
 In a few chronic apyrexial cases the heart's action is per- 
 fectly tranquil, while in a still rarer class the palpitations are 
 violent and irregular, so as to lead to the belief of great organic 
 disease. Of this Dr. Townsend has recorded a case, in which 
 the symptoms were almost precisely those of morbus cordis ; 
 there were violent palpitations on exertion ; a rapid, full, and 
 bounding pulse ; tremulous motion of the jugulars ; extreme 
 dyspnoea and orthopnoea ; lips and nails of a dark leaden 
 colour; and the heart's action so tumultuous, as to cause the 
 whole anterior surface of the chest to vibrate. The heart was 
 found perfectly well proportioned ; the foramen ovale not com- 
 pletely closed ; both lungs were extensively tubercular with 
 intercurrent pneumonia, which had been diagnosticated before 
 death.* 
 
 How far the open state of the foramen ovale may have influ- 
 enced the S3'mptoms in this case is still to be determined. I 
 have seen a case of tuberculization of both lungs, where the 
 inter-ventricular septum was deficient, the aorta arising from 
 both ventricles ; the cardiac symptoms were severe, but there 
 was no permanent cyanosis.f 
 
 But one of the most interesting signs connected with the 
 circulating system, is an increased action, often accompanied 
 with bruit de soujjiet, which, when the upper lobe is diseased, 
 may be occasionally observed in the corresponding subclavian 
 artery, and which has not been noticed by any author. 
 
 * Transactions of the Association of the King and Queen's College of Physicians, 
 vol. V. 
 
 t The particulars of this case were communicated by Dr. Graves to Dr. Houston ; 
 the boy, aged three years, had had frequent attacks of bronchitis, and was admitted 
 into hospital with signs of tubercular cavities and bronchitis ; the heart's action was 
 violent, the pulse feeble, and the skin cold. The face, hands, and feet were of a dark, 
 livid hue ; liit it appeai-ed that this colour icas not habitual, and only came on when he 
 laboured under pectoral affections. 
 
 On dissection, besides the usual appearances of phthisis, the heart was found 
 malformed ; a well defined opening, suflBciently large to admit the little finger, led 
 from the right ventricle through the septum into the upper part of the left ; this 
 passage was twice as wide as that leading into the pulmonary artery ; the left auricle 
 was small, the right large ; the left ventricle of the same size and thickness as the 
 right ; the aorta was unusually capacious ; and the ductus arteriosus diminished in 
 size, but not obliterated.— Pathological Observations, by John Houston, M.D. Dublin 
 Hospital Reports, vol. v.
 
 TUBEKCLE OF THE LL'NG. 443 
 
 Two causes obviously exist for this increased action of the 
 subclavian in phthisis ; viz., the falling in of the subclavicular 
 region, and the consolidation of the lung ; but I have little 
 doubt that there is a third, namely, sympathetic irritation, 
 something similar to the sympathy of contiguity of Hunter, for 
 I have found that in certain cases it was distinctly remittent, 
 its appearance coinciding with signs of pulmonary excitement 
 and irritation ; I observed it to subside after a copious hamop- 
 tysis, and have repeatedly removed it by leechim/ the subclavi- 
 cular or axillary regions : and the fact of its being often accom- 
 panied by the bellows murmur, inaudible in any other part of 
 the circulatory system ; and, like the pulsation, cajxible of being 
 modified by the antiphlogistic treatment, leaves little doubt of 
 the correctness of my view. Under these circumstances it occurs 
 in cases with but little contraction or consolidation ; and the 
 bellows sound is often exceedingly sharp, though ceasing in the 
 brachial artery, and altogether wanting in the heart, aorta, 
 carotid, or opposite subclavian. 
 
 Vaeieties of Phthisis. — Under this head we shall study the 
 symptoms in connexion with the physical signs, of the more 
 prominent varieties of the disease. The following cases may be 
 enumerated : — 
 
 1st. Acute inflammatory tuberculization of the lung without 
 suppuration. 
 
 '2nd. Acute suppurative tuberculization. 
 
 3rd. Chronic progressive tubercle, with signs of local and 
 general irritation ; pulmonary ulceration. 
 
 4th. Chronic progressive ulceration succeeding to an unre- 
 solved pneumonia. 
 
 5th. Tuberculous ulceration succeeding to chronic bronchitis. 
 
 6th. Tubercle consequent on the absorption of an empyema. 
 
 7th. Chronic phthisis complicated with pneumothorax from 
 fistula. 
 
 8th. Tubercle complicated with disease of the larynx. 
 
 9th. Latent progressive phthisis. 
 
 10th. Chronic, latent but partial tuberculization. 
 
 11th. Chronic general tuberculization. 
 
 12th. Cicatrization of cavities. 
 
 Acute Inflabimatoky Tubercle without Suppuration. — 
 All the cases of this which I have seen, occurred as sequelae or
 
 444 TLBERCLE OF THE LUNG. 
 
 complications of the fever of this country. In most the symp- 
 toms supervened after the fever, an interval existino- between the 
 crisis and the new attack. In others, the disease commencing 
 with the symptoms of the ordinary gastro-catarrhal fever pro- 
 ceeded uninterruptedly to its fatal termination. 
 
 The symptoms are undistinguishable from the more violent 
 forms of bronchitis. High inflammatory fever, with severe 
 cough and extremely hurried respiration, sets in ; the expectora- 
 tion is scanty, viscid, and often tinged with blood ; the face is 
 swollen and livid, and the nares dilate, the action of the heart is 
 violent, and the pulse extremely rapid ; there are shooting pains 
 in the side, and the patient has often copious sweatings and 
 delirium. In some instances these symptoms are complicated 
 with others referrible to the abdomen; the tongue is dry and 
 red, the abdomen swollen and tender, extreme thirst, drawing 
 up of the knees, and diarrhoea. It is singular that in a case 
 where these symptoms were best marked we found the gastro- 
 intestinal tube healthy, while all the parenchymatous organs 
 were filled with granular and miliary tubercles. In another 
 instance, peritonitis from numerous perforations had occurred, 
 yet the abdominal were nearly masked by the thoracic symptoms.* 
 
 In a second class, the symptoms are more pneumonic, while 
 in a third, which may be termed the hfemoptysical variety, the 
 first symptom is a copious discharge of blood, followed by a 
 rapid development of tubercle, but without the violent signs of 
 irritation which occur in the two former instances. 
 
 In the two first cases the diagnosis is difficult, for the tubercle 
 being often equably developed, comparison cannot be employed, 
 and the want of the signs of ulceration adds to the difficulty. 
 There is nothing characteristic in the symptoms, and the stetho- 
 scopic signs, taken alone, or considered without reference to 
 time, are insufficient. In the first variety we have the most 
 intense sonorous, sibilous, and muco-crepitating rales ; every 
 part of the bronchial system seems engaged. In the second the 
 musical rales are comparatively wanting, while the crepitating 
 and muco-crepitating are extensively audible ; yet, by successive 
 observations, and considering the phenomena with reference to 
 time, the diagnosis can be made. 
 
 * See Transactions cf the Association, &c., vol. iv. ; also the Clinical Report of 
 the Meath Hospital, Dublin Hospital Reports, vol. v.
 
 TUBERCLE OF THE LLNJ. 445 
 
 I published tlie first instance of this diagnosis as far back 
 as 1828. The case was one of a young female who became 
 attacked with \ioleut symptoms of gastro-catarrhal fever, which 
 resisted all means of relief. The stethoscopic signs were of 
 intense bronchitis ; yet we found that the chest became rapidly 
 and extensively dull. This could only be explained on the sup- 
 position of an extensive crop of tubercle, which diagnosis was 
 made at the time. 
 
 On dissection, both lungs were found completely stuffed with 
 small granular and miliary tubercles, in such quantity as to 
 obscure the condition of the intervening tissue, but they were 
 generally crepitating, and nowhere presented complete solidity. 
 This progressive general, though not complete duluess conse- 
 quent on the signs of bronchitis, has led me in many cases to 
 announce the acute general development of tubercle. 
 
 In the second or pneumonic variety the patient, though not 
 suflering so much from dyspnoea, is in equal danger. The 
 musical rales are either absent or very slight ; but an intense 
 and extensive crepitating rale is to be heard. As in the former 
 case, dulness advances, and the phenomena are only distin- 
 guishable from those of ordinary pneumonia by the absence of 
 the signs of hepatization. The rale continues to the end, and 
 bronchial respiration is not observed. 
 
 The third or hsemoptysical variety is never so rapid as the 
 two former, and hence we can often avail ourselves of the signs 
 of ulceration. 
 
 A remarkable feature in the inflammatory cases is the resist- 
 ance of the symptoms and signs to treatment even of the most 
 active and varied description. The disease seems to defy all 
 medical treatment. 
 
 We may now state the general principle of diagnosis. 
 If in a case presenting the symptoms and signs of intense 
 hroncliitis, or if crepitating rale has been present, yet persisting 
 to the last, we find the chest becoming dull ; if this dulness he 
 extensive, yet incomplete, ivithout hronchicd respiration, the 
 stethoscope showing that the lung is everywhere permeable, the 
 solidity only occurring in points ; or if the crepitus he so slight 
 as not to account for the dulness, ive may make the diagnosis of 
 the acute inflammatory development of tubercle. 
 
 Acute suppurative Phthisis. — In the preceding variety, the
 
 446 TUBERCLE OF THE LUNG. 
 
 absence of suppuration is owing not to any inherent character of 
 the disease, but arises simply from the rapidity of the asphyxia. 
 The cases now under consideration are those described by Louis 
 as the acute phthisis ; one case only of the first variety is given 
 by him. 
 
 In this affection the symptoms set in as in the former case ; 
 they continue with great violence, and resist treatment. The 
 expectoration soon becomes purulent ; the fever is high, but 
 after a time becomes a sort of mixture of the inflammatory and 
 hectic forms. 
 
 The stethoscopic signs of the earlier stages are the same as 
 in the last variety, but the deep toned rales are not so often 
 observed. After the tubercles suppurate, mucous rales passing 
 into gurgling are heard. The musical rales, however, are not 
 removed ; a sibilous sound during inspiration and expiration 
 is audible, and this, when the action of the heart is strong, is 
 influenced by it so as to produce a distinct musical rhythm : of 
 course dulness rapidly advances. 
 
 In the cases given by Louis, death occurred in three, four, 
 five, six, and seven weeks. I have seen two cases in which no 
 pulmonary symptoms existed before the occurrence of fever, yet 
 in which death occurred within three weeks from the first 
 invasion, and the lungs were found fall of tuberculous anfrac- 
 tuosities. 
 
 Louis remarks, that notwithstanding its rapid development 
 this disease is accompanied by those secondary lesions which we 
 see in the more chronic forms ; ulcerations of the epiglottis, 
 trachea, oesophagus, and small intesthie have been observed. 
 In one case he found the mucous membrane of the stomach 
 softened and thinned ; in another the liver was fatty ; and in a 
 third the lymphatic glands of the neck and mesentery contained 
 tuberculous matter.* 
 
 The diagnosis of this affection has been in part given by 
 Louis. By combining his observations with mine, we may state 
 it to be the following. 
 
 If in a case ivhich has 2ircsenicd violent and generally uncon- 
 controllahle si/niptoms and signs of hroncltitis, or of imeumonia 
 continuing in its first stage; ivitli a fever at first inflammatory, 
 and afterwards passing into severe hectic, we find an extensive 
 
 * Op. cit., p. 439.
 
 TUBERCLE OF THE LUKG. 447 
 
 dulness to supervene, more partial, hut more complete than in 
 the preceding form, accompanied with a large mucous rale, and 
 supervening in. a few weeks from the first invasion, of the disease ; 
 we may diagnosticate the acute suppurative jihthisis. 
 
 In the third oi' hfemoptysical variety, the disease is not so 
 rapid, nor are the signs of irritation at all so violent. There is 
 sometimes an absence of rale, although the dulness seems as it 
 were to grow daily, and advance downwards. The hfemoptysis 
 seems to relieve the mucous irritation, but the tubercle advances. 
 In this form I have observed the contraction of the chest at a 
 very early period ; it would seem as if the terminal tubes being 
 plugged up by minute coagula, atrophy of the cells occurred 
 long before ulceration. 
 
 Chronic progressive Tubercle, with local and general 
 Irritation, Pulmonary Ulceration. — This is the common 
 form of consumption, properly so called. Its symptoms have 
 been stated so often, that their description here would bo 
 unnecessary ; we shall, however, take a brief view of the 
 symptoms and signs conjointly, in three stages of the affection, 
 it being always understood that their combinations and charac- 
 ters are capable of great modification. 
 
 We may divide the disease into three stages ; in the first the 
 tubercle is developed, but not yet suppurated ; in the second 
 small ulcerations are formed ; and in the third we have vast 
 caverns excavating great portions of the lung. Between these 
 stages there is no exact line of demarcation, but when estab- 
 lished, they have each symptoms and signs which are somewhat 
 peculiar. 
 
 First stage. — The more prominent symptoms are those of 
 irritation ; cough, pain, and quickness of pulse, which in certain 
 cases are preceded, but in the greater majority followed, by an 
 unaccountable emaciation ; the cough is almost always dry 
 during the first few weeks, unless where the tubercle has suc- 
 ceeded to catarrh ; it may occur in every variety, but is most 
 commonly a slight, frequent, and irritating cough, referred by 
 the patient to a tickling sensation in the trachea. The ex- 
 pectoration, when occurring, is scanty, and consisting of a thready, 
 greyish, and nearly transparent mucus, occasionally dotted with 
 blood; a slight wheezing sometimes accompanies the cough. 
 With these symptoms the patient frequently complains of
 
 448 • TUBERCLE OF THE LUNG. 
 
 pain, winch may be situated in any part of the side. In some 
 instances it is only felt in the lower, while in others it occupies 
 the upper part of the chest, shooting from the clavicle to the 
 subscapular regions, and often occupying the articulation of the 
 shoulder, when it is often mistaken for rheumatism, or the pain 
 of hepatic disease ; it occurs with various intensities, is generally 
 remittent, and often relieved by anodyne, or slightly stimulating 
 applications. I have known it to be regularly intermittent, 
 coinciding with the paroxysms of hectic, so that the disease was 
 taken for ague, and treated accordingly. This pain is commonly 
 accompanied with tenderness of the subclavicular region, and 
 often with that irritation of the muscular fibres which causes 
 their contraction on percussion ; the respiration is slightly 
 hurried, and the first approaches of hectic can be perceived. 
 The continuation of pain in the shoulder with quickness of 
 pulse should always excite alarm. 
 
 Under these circumstances we may have one of two results 
 from a physical examination ; we shall either find that there 
 is no sign of disease, or that some of the various phenomena 
 of tuberculous irritation may be discovered. 
 
 In the first case the absence of physical signs has no value 
 unless considered in relation to time ; thus if the duration of 
 the symptoms be only a few weeks, the absence of commensu- 
 rate signs would be rather an argument in favour of tubercle, 
 while if they had continued for months, and particularly if there 
 existed any other local or constitutional cause of hectic, the 
 
 absence of signs would so far justify the opinion that the disease 
 
 "was not pulmonary tubercle. 
 
 But in the second case the existence of any of the following 
 
 signs is almost enough to reveal the too fatal disease : — 
 
 Comparative dulness of the clavicle, scapular ridge, or inter- 
 scapular region. 
 
 Feebleness of respiration, most valuable when occurring on the 
 
 left side, and occurring with or without puerile breathing in the 
 
 other portions of the lung.* 
 The interrupted respiration. 
 The various rales combined with a feeble or puerile respiration 
 
 and confined to the upper portion of the lung. 
 
 * To ■which should be added the valuable sign of exaggerated and prolonged 
 expiration murmur, first observed by Dr. Jackson. (Ed.)
 
 TUBERCLE OF THE LUNG. 449 
 
 Increased resonance of the voice, most valuable on the left 
 side. 
 
 Loudness of the sounds of the heart in the upper portions, 
 most valuable at the right side. 
 
 The friction sound audible in the antero-superior portions.* 
 
 If we now compare the symptoms with the physical signs we 
 must be struck with their agreement in pointing out a progressive 
 irritation and disposition, but without further destruction, or any 
 supersecretion from the part. 
 
 Second stage. — This is characterized by the establishment of 
 decided symptoms ; the emaciation increases ; the pulse continues 
 quick ; the countenance becomes characteristic ; the sweatings 
 are more profuse ; the cough looser, the expectoration becoming 
 puriform, tubercular, and often bloody. The digestive system 
 now begins to suffer ; thirst, loss of appetite, and abdominal 
 pains torment the patient, and the first indications of the 
 wasting and persistent diarrhoea appear ; the patient feels that he 
 can lie better on one side than the other, and begins to feel pain 
 in the opposite side of the chest, a sure sign that his terrible 
 disease has invaded the remaining lung.f 
 
 The physical signs are the following : — 
 
 Increase and extension downwards of the dulness on percus- 
 sion. 
 
 The respiratory murmur is feeble or changed into a semi- 
 tracheal breathing, most audible in the erect position. This is 
 
 * As this is the rarest of the physical signs, I have placed it last in the 
 catalogue. 
 
 t Notwithstanding all this, it will commonly be found that this is the period at 
 which the patient seems to feel the greatest relief, and shews the greatest confidence 
 in recovery ; two causes seem to concur towards this result ; the first, that the gastro- 
 intestinal disease acts as a revulsive, and relieves the pulmonary irritation to a 
 certain degree, as in the case of fistula in ano, and we have a painless but yet 
 revulsive discharge. 
 
 In the next place, the pulmonary irritation is relieved to a certain degree by 
 the secretion of pus from the ulcers and bronchial tubes, and thus if no new 
 inflammatory crop of tubercle is developing a period of comparative ease is 
 produced. 
 
 But there is a third and mechanical cause to be noticed ; according as the suppu- 
 ration of the tubercles extends, and the excavations enlarge, the cough often becomes 
 much less frequent and troublesome ; it no longer occurs in fits, but singly, followed 
 by the easy expectoration of a mass of muco-puriform and tuberculous matter • 
 this is traceable to the free bronchial communication with the ulcerous cavities. The 
 destruction of the lung causes a relief to the patient, and too often may we hear 
 the voice of hope and confidence reverberating in the cavity which seals the patient's 
 doom. 
 
 G G
 
 450 TUBERCLE OF THE LUNG. 
 
 often combined with deep seated or superficial cavernous 
 breathing ; the bruit de soupape and cavernous rales. When 
 the ulcerations are small and numerous, the cavernous 
 phenomena are indistinct ; and dulness of sound, with a large 
 mucous rale, increased by coughing, and a semi-tracheal breath- 
 ing, are the principal signs. 
 
 When the cavities are sufficiently large, some form of pectori- 
 loquism may occur ; but most commonly there is nothing but an 
 increased and undefined resonance of the voice. These signs are 
 most distinct in the postero-superior portions- 
 All varieties of the crepitating, mucous, and cavernous rales 
 occur, the size of the bubbles generally diminishing from above 
 downwards ; and in certain cases the rales are modified by the 
 action of the heart, or occasionally suspended by bronchial 
 obstruction. 
 
 The respiration in the lower lobe, or opposite lung, is puerile ; 
 and we have the signs of atrophy, evident generally in pro- 
 portion to the chronicity of the case. 
 
 Third stage. — In this condition the patient is often apyrexial, 
 and the perspirations cease, particularly if the digestive system 
 remains healthy : the pulse may be slow, though generally 
 becoming again accelerated before death : emaciation proceeds to 
 the last extremity. The voice is sometimes lost ; at others 
 hollow and melancholy : the cough is loose ; the respiration 
 tranquil and expectoration easy : apthse appear on the tongue, 
 and spread over the cavity of the mouth : the limbs become cold : 
 the breath gets a heavy odour, and the appetite in general fails. 
 Yet the painful tenacity of life continues for a length of time, 
 as if the patient wanted strength to die. The physical signs 
 of this condition are so graphically described by Sir James 
 Clark, that I cannot do better than give tbem in his own words. 
 " The chest, at this advanced period of the disease, is found 
 to be remarkably changed in its form ; it is flat, instead of 
 being round and prominent : the shoulders are round, and 
 brought forward and the clavicles are unusually prominent, leaving 
 a deep hollow space between them and the upper ribs. The 
 subclavicular regions are nearly immoveable during respiration ; 
 and when the patient attempts to make a full inspiration, the 
 upper part of the thorax, instead of expanding with the sponta- 
 neous case peculiar to health, seems to be forcibly dragged
 
 TUBEKCLE OF THE LUNG. 451 
 
 upwards. Percussion gives a dull sound over the superior parts 
 of the chest, although the caverns which partially occupy this 
 part of the lungs, and the emaciated state of the parietes, may 
 render the sound less dull than in the preceding stage. The 
 stethoscope affords more certain signs, the respiration is obscure, 
 and in some places inaudible ; while in others it is particularly 
 clear, but has the character of the bronchial, or tracheal, or 
 even cavernous respiration of Laennec. There is a mucous 
 rhonchus ; coughing gives rise to a gurgling sound {gargouille- 
 ment) ; and pectoriloquism is generally more or less distinct, for 
 the most part on both sides, though more marked on one than 
 the other. In this state the patient may still linger for weeks, 
 or even months, reduced almost to a skeleton, and scarcely able 
 to move, in consequence of debility and dyspnoea." '•' 
 
 To this succinct but lucid description there is but little to 
 be added. When the cavities are large, there is often an absence 
 of pectoriloquism ; and the cavernous respiration, whether from 
 the size of the cavern or the feebleness of breathing, becomes 
 often indistinct, and as it were distant. It is at this period 
 that the metallic phenomena are generally audible, while the 
 respiratory murmur which had been puerile in the healthier 
 portions of the lung, at length loses this character. 
 
 Chkonic Tuberculous Ulceration, succeeding to an 
 UNRESOLVED Pneumonia. — In this case the progress of the 
 tubercle is insidious ; and where the seat of pneumonia has been 
 in the lower tube, it is reversed, beginning below and proceeding 
 upwards. Tubercle may supervene on the sthenic or asthenic 
 pneumonia, but much more frequently on the latter. Indepen- 
 dent, however, of any constitutional tendencies, there are three 
 cases in which this termination may be observed, — the first in 
 which a sthenic pneumonia has been neglected, or exasperated 
 in its early stage ; the second, a case in which auscultation has 
 not been employed, and the disease only rendered latent by 
 treatment ; and the third, the typhoid variety, when the strength 
 is profoundly injured. 
 
 In such cases the lung remains solid, or we may observe 
 attempts at resolution to occur more than once. A considerable 
 portion of the lung may resolve, yet the process be arrested, and 
 one part continue dull on percussion. 
 
 * Treatise on Pulmonary Consumption. Lon'on: 1835. 
 G g2
 
 452 TUBERCLE OF THE LUNG. 
 
 Under these circumstances, the patient seems, for an indefi- 
 nite period, in a state of imperfect convalescence : his pulse 
 may have become slow, but it begins to rise : he does not gain 
 flesh ; some cough remains ; obscure fever manifests itself ; the 
 breathing becomes hurried ; and by degrees the usual symptoms 
 appear : and he generally sinks in from three to six months from 
 the first attack of pneumonia. 
 
 When the lower lobe is engaged, the physical signs are the 
 following : — 
 
 Hepatization continuing for about a month, we find a mucous 
 rattle generally near to the root of the lung : the respiration 
 of the upper lobe, which had been puerile, gi'adually becomes 
 feebler, from below upwards, either without rale or with a few 
 mucous or muco-crepitating bubbles : every day we observe the 
 dulness to advance ; the bubbles at the root of the lung become 
 larger, and ultimately a cavity appears : then the ulcerative 
 process stretches upwards, and new excavations appear in various 
 portions. 
 
 When the upper lobe has been engaged, the same circumstances 
 occur ; and vacillations in resolution may be observed even after 
 ulcerations have formed. After middle age, the process is 
 extremely slow, and may coincide with a singularly tranquil state 
 of the heart. 
 
 Tubercle coisSequent on a chronic Bronchitis. — This 
 combination is much more frequent than has been supposed : 
 a great number of cases, called bronchitis, occurring after the 
 meridian of life, are of this nature. 
 
 The cases may be divided into two classes, according to the 
 expectoration. In the first it has been for years concocted, or 
 muco-puriform. In the second, it consists of a scanty serous, or 
 sero-mucous fluid. Tubercle may supervene in both cases, but 
 is more common in the first than the second form. 
 
 In the first case, a chronic catarrh having existed for many 
 months or years, passes insidiously into phthisis : or, what is 
 more common, a peculiar change of symptoms marks the com- 
 mencement of the tuberculous disease. A patient shall have had 
 cough and expectoration for three or four years, yet preserving his 
 flesh and appearance, and with a quiet pulse. He may then be 
 attacked with haemoptysis ; his pulse becomes quickened, and 
 emaciation advances slowly, and he by slow degrees passes into
 
 TUBERCLE OF THE LUNG. 458 
 
 plithisis : or a tubercular complication may supervene, without 
 any apparent change in symptoms. The pulse may continue 
 tranquil, and hectic be absent ; and the disease be only detected 
 by physical signs. 
 
 It is in these cases, but particularly the last, that we observe 
 the extreme chronicity of phthisis. It may be advancing from 
 five to fourteen years, or even longer ; a fact to be explained, in 
 part at least, by the copious expectoration which acts as an 
 issue, and the healthy state of the digestive system. To these 
 must be added the important conditions stated by Sir James 
 Clark, of the absence of constitutional disposition, rendering the 
 progress of disease slower.* In some instances, the disease 
 advances steadily, and almost imperceptibly ; while in others 
 there are frequent exacerbations with haemoptysis, and great 
 increase of dyspnoea and expectoration. 
 
 I have no observations to illustrate the early stages of the 
 transition from bronchitis to phthisis. In all cases which I have 
 seen, the disease was local, and comparison could be employed. 
 We may then apply the diagnostics as in the third variety. 
 Dulness and signs of anfractuosities are found, and the diagnosis 
 will lie between dilated tubes and phthisical ulcerations. The 
 progression of the signs, the rale, and the absence of the bronchial 
 respiration, and resonance of the voice as in dilated tubes, will in 
 general sufl&ce for diagnosis. Of these principles, the first is the 
 most important. In some advanced cases, great deformity is 
 produced by the contraction of the chest. 
 
 Tuberculization of the Lung, consequent on the Ab- 
 sorption OF AN Empyema. — We may suspect this occurrence in 
 all cases where, after the absorption of an empyema, the cough 
 is renewed, and the pulse becomes permanently accelerated. In 
 neglected cases, yet in which absorption occurs, independent, or 
 nearly so, of treatment, it is a common termination. In a few 
 instances an interval of quiescence intervenes between the sub- 
 sidence of the first and the commencement of the second disease : 
 while in others, the phthisical symptoms and signs supervene 
 immediately on the removal of the effusion. Without possessing 
 a sufficient number of cases to determine the point, I would say 
 that the rapid absorptions are more likely to be followed by a 
 fatal development of tubercle than those more chronic. And it 
 
 * Op. cit., p. 62.
 
 454 . TUBERCLE OF THE LL'NG. 
 
 may be inquired, whether the " doubtful convalescence " of 
 Laennec is not often produced by the formation and evacuation 
 of a small quantity of this consecutive tubercle. I have often, in 
 such instances, been kept in a state of great apprehension, by the 
 recurrence of rale and feeble respiration several times in the 
 upper portion of the lung. In two cases I found that although 
 tubercle existed in both lungs, it was in much greater quantity 
 in the side opposite to that where the pleurisy had occurred, as 
 if the pressure had diminished the liability to tubercle. It is a 
 curious fact, but not without analogies, that the occurrence of an 
 empyema and pneumothorax from fistula, suspends the progress 
 of tubercle in a remarkable manner. 
 
 The physical diagnosis is often difficult from our inability to 
 apply comparison. The pleurisy has altered the symmetry of 
 the chest, and has caused physical phenomena, depending on 
 the contraction ; hence in the earlier periods, the dulness and 
 feebleness of respiration may not be tubercular, and may even 
 occur on the side where least tubercle exists. This I have more 
 than once verified : but when with the symptoms of a new pul- 
 monary disease, with hectic, and a quickened pulse, we find the 
 opposite clavicle or scapular ridge becoming dull, and with some 
 of the active signs of irritation, we may diagnosticate tubercle. 
 When the disease, however, predominates in the affected lung, 
 a curious change of phenomena is observed : the dulness and 
 feebleness of respiration, as it were, change seats, and in place 
 of existing inferiorly, are perceived in the upper portion, 
 while the lower becomes not really clearer than it was, but 
 comparatively so. 
 
 But tubercle may supervene, even although the empyema is 
 not absorbed. The opposite lung is then the seat of disease, 
 which may pass into ulceration. In this way large cavities may 
 exist in one lung, with an original empyema of the other. In 
 some of these cases the puerile respiration of the tuberculous 
 lung is beyond everything intense, so that a large cavity may 
 exist, yet without our being able to detect either the cavernous 
 respiration or gurgling. This must be borne in mind, in all 
 examinations of the lung, previous to the operation for empyema. 
 In more chronic cases, however, with great emaciation, and 
 less puerility of breathing, the progress of tubercle in the oppo- 
 site lung can be easily recognised by the usual signs.
 
 tubercle of the lung. 455 
 
 Phthisis complicated with Empyema and Pneumothorax 
 FROM Fistula. — I shall not enter here into the history of this 
 triple lesion, but remark, in the first place, on the interesting 
 fact, that the proper symptoms of phthisis are in many cases 
 arrested, and singularly modified, by the occurrence of the new 
 disease. I have often found that after the first violent symptoms 
 had subsided, the hectic ceased, the phthisical expression dis- 
 appeared, the flesh and strength returned ; and in this way the 
 patient has enjoyed many months of comfortable existence, and 
 was only disturbed by dyspnoea and the sound of fluctuation on 
 exercise. 
 
 To explain this, we must recollect the compression exercised 
 on the lung, which by diminishing its vascular supply, causes its 
 atrophy, and arrests its disease. The pleuritis, too, may have a 
 revulsive effect ; and perhaps the increased action of the opposite 
 lung, by preventing the obliteration of the minute tubes, may 
 hinder the accumulation of tubercle. 
 
 In chronic cases, where the lung is, as it were, anchored to 
 the parietes of the chest by adhesions, the cavity from which the 
 fistula has passed can be easily detected. With respect to the 
 opposite lung, there is nothing to interfere with direct diagnosis, 
 unless it be the puerility of respiration. Under the circum- 
 stances, however, any sign of irritation of the opposite lung is 
 sufficient to point out tubercle. 
 
 Phthisis, complicated with Laryngeal Disease. — I have 
 already stated the frequent combination of ulceration of the 
 larynx with tubercle of the lung.* The common case of phthisis 
 laryngea is in most instances pulmonary consumption, with 
 ulcerations of the larynx, either preceding or following the tuber- 
 cular disease. 
 
 With respect to diagnosis, the early history must be examined, 
 so as to discover whether pulmonary as well as laryngeal disease 
 exists. If there have been cough, pain of the chest or shoulder, 
 hfemoptysis, difficulty of lying on one side, copious expectoration, 
 any degree of emaciation, quickness of pulse, or hectic fever 
 before the laryngeal symptoms, there is the gi-eatest probability 
 of tubercle existing ; or if these symptoms distinctly supervened 
 on the laryngeal affection, forming a new train of sufferings, 
 the same conclusion may be come to. Many cases also will 
 
 * See the Section ou Diseases of the Larynx and Trachea.
 
 456 TUBERCLE OF THE LUNG. 
 
 be found to have commenced by an influenza, a bronchitis, 
 or pneumonia — in all of which the complication commonly 
 exists. 
 
 The physical diagnosis is in general ieasy, except in old 
 persons, or when great stridor exists. A certain degree of stridor 
 does not prevent a stethoscopic examination ; and when the 
 obstruction is great (a rare case), we can use percussion and 
 measurement. In most cases the tubercle predominates on one 
 side, and comparison can be employed. 
 
 Acute affections of the larynx are rare in phthisis. The fol- 
 lowing case presents symptoms which are somewhat difficult 
 of explanation : — 
 
 A gentleman in the last stage of chronic phthisis, with dulness 
 of the upper lobe of the left lung, and the signs of a cavity under 
 the clavicle, was suddenly seized with dreadful dyspnoea, followed 
 by a slight convulsive fit. The respiration was tracheal, but the 
 obstruction seemed to be low down. In this state he continued 
 for twenty-four hours, with occasional slight remissions. The 
 difficulty of breathing then increased so much that the opening 
 of the trachea was contemplated as a means of temporary relief. 
 The operation, however, was not performed. Next morning the 
 symptoms being somewhat relieved by a blister and other treat- 
 ment, I was enabled to make an examination. The right lung 
 sounded everywhere clear, but respiration was unusually feeble ; 
 while the left, which before presented feeble respiration and the 
 signs of a cavity, now gave the most intense puerile murmur, 
 masking the cavernous signs. In fact the phenomena of the 
 chest were completely reversed. By degrees the tracheal 
 breathing subsided ; the signs of a cavity returned ; the right 
 lung expanded as before, but a general bronchial rale preceded 
 death for a few days. 
 
 These phenomena can only be explained by the temporary 
 obstruction of the right bronchus. 
 
 Chronic latent Forms. — Cicatrization of Cavities. — I shall 
 not dwell at any length on the remaining varieties of phthisis. 
 Like other diseases, pulmonary tubercle is occasionally a latent 
 disease ; but I have never known it latent when considered as 
 to local symptoms, general symptoms, and physical signs, 
 combined. The first may be wanting, the second absent or 
 anomalous, and the physical signs obscure ; but by combining all
 
 TUBERCLE OF THE LUNG. 457 
 
 the phenomena the disease can he detected in almost every case. 
 What has heen ah-eady said is sufficient to guide the diagnosis 
 in most cases of the senile phthisis. 
 
 On the signs of cicatrization I have nothing to add to what 
 has heen already stated hy Laennec. A certain feehleness of 
 respiration, a little duluess of sound, and a somewhat tracheal 
 character of the vesicular murmur are the phenomena commonly 
 ohserved. 
 
 In the examination of a patient supposed to he phthisical, 
 the following points demand attention hefore proceeding to the 
 physical signs : — 
 
 1st. The age, habit, and diathesis of the patient, and whether 
 phthisis or scrofula have existed in his family. 
 
 2ud. The exact date of his illness. 
 
 3rd. Whether this has been the first attack, and how far he 
 has been liable to bronchitis. 
 
 4th. Whether the disease commenced by laryngeal, tracheal, 
 or bronchial irritation, or followed a pneumonia, a pleurisy, or a 
 continued fever. 
 
 5th. Whether there has been haemoptysis, and if so, its nature, 
 repetitions, and whether it preceded or followed the other pul- 
 monary^ symptoms. 
 
 Gth. Whether the cough was at first dry or followed by ex- 
 pectoration.* 
 
 7th. The nature and quantity of expectoration, and whether 
 there has been a change from a mucous to a purulent character, 
 coinciding with the symptoms of ulceration ; whether any cal- 
 culous matter has been expectorated. 
 
 8th. Whether there has been pain ; if so, its seat and 
 nature ; whether it has afiected the shoulder, side, or calf of 
 the leg. 
 
 9th. The existence of hectic, emaciation, and acceleration of 
 breathing ; the state of the pulse, and decubitus. 
 
 10th. The condition of the digestive system. 
 
 11th. The state of the pharynx, larynx, and trachea. 
 
 12th. Whether there be any syphilitic taint; if so, examine for 
 periostitis of the chest. i^ 
 
 * To which we may add, whether it leads to retching or vomiting. 
 
 t Secondary syphilis simulates phthisis when the syphilitic hectic exists with the 
 bronchial irritation which I have described. If, as is often the case, there be also 
 P'.riostitis of the ribs or sternum, the symptoms are almost identical.
 
 458 TUBERCLE OF THE LUNG. 
 
 13th. Whether the patient (if a female) be hysterical ; * the 
 state of the uterine system. t 
 
 14th. Whether if there has been any external disease of a 
 scrofulous nature, the symptoms have succeeded to its removal 
 or diminution. 
 
 With the information thus obtained we may proceed to the 
 physical examination, which must be conducted in as delicate 
 and rapid mode as possible. It is almost never necessary to 
 uncover the whole chest, the baring of the upper portion is 
 sufficient. Before percussion, gentle pressure should be made 
 on the subclavicular regions, to discover whether any tenderness 
 exists, which would render its use painful. Percussion must 
 then be performed, the patient being in the erect position, and 
 without the head being inclined to either side. It is always to 
 be comparative and strictly so, and we get much better results 
 by the most delicate than by forcible percussion. The best 
 pleximeter is the index finger, the back of which is laid on the 
 chest. In this way the clavicles, subclavicular regions, and 
 ridges of the scapulae are to be explored. If necessary, we may 
 use percussion at the end of a forced inspiration, and compare 
 the sound of the upper and lower portions ± For the active 
 signs the stethoscope is absolutely necessary, for the results of 
 immediate auscultation are not sufficiently accurate ; the respira- 
 tion, cough, voice, and sounds of the heart, are to be explored 
 rapidly; and an observation being made of the external appearance 
 of the chest as to contraction, the examination is completed. 
 
 * The practitioner must not build too mucli on the comphcation with hysteria. 
 Nothing is more common than to attribute the symptoms of tubercle to this affection ; 
 .an error injurious to the patient and to the reputation of the physician. The com- 
 plication of the hysterical cough with fever should always excite alarm. In phthisis, 
 if there be any cause for spasmodic cough, this character often continues to the end. 
 Thus where tubercle succeeds to pertussis, the original character of cough may con- 
 tinue long after great cavities are formed. There is, however, a singular hysterical 
 affection with violent cough and lijsmoptysis, excitement of the pulse and respira- 
 tion, and copious sweatings. The respiration is intensely puerile; but though the 
 symptoms continue for months, defying all treatment, there are no signs of con- 
 solidation. 
 
 t " The origin of phthisis in pregnancy, after delivery, or in the course of lactation, 
 has been fouiid to exercise a peculiar influence on the disease, and to generate a form 
 of tuberculosis, fraught with peculiar danger, and attended often from the beginning 
 with symptoms of urgency and rapidity." (See Pollock on Prognosis in Consumption, 
 p. G3.) (Ed ) 
 
 J A difference of tone not otherwise appreciable may be easily detected if the 
 patient's mouth be kept open.
 
 TUBERCLE OF THE LUNG. 459 
 
 In the nervous female, and in cases in which there has been 
 recent htemoptj^sis, the examination must be performed as ex- 
 peditiously as possible ; and in the latter case, all fatigue to the 
 patient and forced inspirations are to be avoided, lest a new 
 haemorrhage should be induced. 
 
 Before considering the treatment, we shall recapitulate the 
 facts of the physical diagnosis. Of course many of these have 
 been already observed by authors. 
 
 1st. That there are no physical signs peculiar to tubercle. 
 2nd. That every known auscultatory sign, active or passive, 
 may be met with in phthisis. 
 
 3rd. That in the great majority of cases comparison can be 
 used, in consequence of the predominance of disease in one 
 portion of the lung. 
 
 4th. That where comparison cannot be employed, there is 
 much greater difficulty of diagnosis. 
 
 5th. That the earliest, and consequently most important, signs 
 are in the great majority of cases those of irritation. 
 
 6th. That these may exist in any of the tissues of the lung. 
 7th. That the bronchitic signs derive their value principally 
 from their localization and combination with dulness on per- 
 cussion. 
 
 8th. That the crepitating rale of pneumonia is rarely observed 
 in the portion of the lung first tuberculated. 
 
 9th. That when it occurs it is either recurrent or continued, 
 and in the latter case it persists much longer than in ordinary 
 pneumonia. 
 
 10th. That feebleness of respiration is one of the most com- 
 mon physical signs. 
 
 11th. Tliat though commonly combined with other signs, it 
 may occur as the sole phenomenon. 
 
 12th. That the interrupted respiration receives its value solely 
 from its localization and co-existence with other signs. 
 
 13th. That of the signs of irritation, those of the serous mem- 
 brane are the rarest. 
 
 14th. That complete solidity of the lung is rare in phthisis. 
 15th. That in the early stages it can often only be ascertained 
 by comparison ; it proceeds from above downwards, and may 
 exist with a feeble or puerile respiration. 
 
 16th. That perfect tracheal respiration is rare in phthisis.
 
 460 TUBERCLE OF THE LUNG. 
 
 17tb. That when it exists it is most evident in the erect 
 position. 
 
 18th. That one side is rarely observed to be equally dull. 
 
 19th. That the formation of cavities gives a tympanitic cha- 
 racter to the sound on percussion. 
 
 20th. That in cases of solidity of the left lung a somewhat 
 similar character is given by the distention of the stomach with 
 air. 
 
 21st. That in the universal development of tubercle the sound 
 is generally but not completely dull. 
 
 22nd. That a great quantity of tubercle, when equally diffused, 
 may coincide with but little dulness on percussion. 
 
 23rd. That in ordinary phthisis the greatest variety may exist 
 as to dulness. 
 
 24th. That the signs of irritation, and of solidification in its 
 early stages, may be modified or even removed by an antiphlo- 
 gistic or revulsive treatment. 
 
 25th. That in the early stages of the case these phenomena 
 only shew that tubercle is about to form. 
 
 26th. That the signs of ulceration may imperceptibly succeed 
 those of irritation, or appear at once. 
 
 27th. That they rarely exist without the signs of the earlier 
 stages of tubercle in other parts of the lung. 
 
 28th. That they may be temporarily obscured by obstruction 
 of their bronchial communications. 
 
 29th. That they are not audible to any distance beyond their 
 actual situation. 
 
 30th. That the action of the heart may produce an audible 
 agitation of the fluid contents of a cavity, 
 
 31st. That the metallic phenomena are generally perceived 
 when the cavity is large, but may occur from several small but 
 inter-communicating ulcerations, and may be absent even in very 
 large cavities. 
 
 32nd. That atrophy of the lung causes contraction of the 
 chest at an early period, and independent of the formation of 
 cavities.* 
 
 33rd. That in very chronic cases it may produce a deformity 
 greater than what occurs from the cure of empyema. 
 
 * On the other hand, as Dr. Walshe has pointed out, the contrary condition of the 
 parietes is sometimes seen in the early stage of phthisis. (Ed.)
 
 TUBEBCLE OF THE LUNG. 461 
 
 34tli. That the action of the heart seldom furnishes signs of 
 value in phthisis.* 
 
 35th. That in cases of tubercular deposit in the upper portion 
 of the right lung, the sounds of the heart are often heard more 
 loudly in this situation than under the left clavicle. 
 
 36th. That in certain cases the sounds of the heart and those 
 produced by its impulses on the diseased lung cause a distinct 
 rhythm. 
 
 37th. That in cases of extreme atrophy of the upper lobe of 
 the lung, the heart ascends high in the thorax.f 
 
 38th. That the subclavian artery corresponding to the affected 
 side occasionally, presents an increased pulsation with bruit de 
 souffle t, which can only be explained by some sympathetic irrita- 
 tion of the vessel. 
 
 39th. That the supervention of dulness, with the stethoscopic 
 signs of bronchitis, indicates tubercle. 
 
 40th. That in this way we may discover tubercle in cases 
 not localized, and consequently not admitting of comparison. 
 
 41st. That the crepitating rale of acute phthisis is not suc- 
 ceeded by signs of hepatization, as in pneumonia. 
 
 42nd. That the dulness of the acute suppurative phthisis is 
 greater than in the non- suppurative cases. 
 
 43rd. That in the hsemoptysical variety of acute phthisis there 
 is often a want of proportion between the signs of solidification 
 and those of pulmonary irritation. The first being well marked, 
 and the latter comparatively wanting. 
 
 44th. That in the ordinary progressive phthisis the physical 
 signs accurately correspond with the successive changes. 
 
 * This observation by no means applies to the right side of the heart. On the contrary, 
 there is perhaps no more certain or valuable sign of irritation or of obstruction from 
 copious deposit of tubercle than augmented accentuation of the sounds of the pul- 
 monary valves, as compared with those of the aortic. It is in cases of intercurrent 
 pneumonia and of haemoptysis that this sign is of most value. I have known it to 
 be the only one portending danger, as in a recent case in which sudden and fatal 
 haBmorrhage occurred within three days after I had observed and pointed it out to 
 the patient's medical attendant. On the other hand, the most hopeful cases are those 
 in which this sign is absent and the pulmonary sounds duly proportioned in intensity 
 to those of the aorta. (Ed.) 
 
 f This observation applies to the left lung especially, since the heart does not seem 
 to suffer that displacement in tubercle of the right lung, which is so remarkable in 
 cases of absorbed empyema and of cirrhosis. In fact, the difl'erential diagnosis 
 between ciirhosis and tubercle is very much determined by the presence or absence 
 of dexiocardia, it being so much more marked in the former afEection. (Ed.)
 
 462 TUBERCLE OF THE LUNG. 
 
 45th. That where tubercle succeeds to an unresolved pneu- 
 monia of the lower lobe, there are, coincident with the signs of 
 softening in the unresolved portion, evidences of the spreading 
 upwards of condensation. 
 
 46th. That the supervention of dulness in a case of chronic 
 bronchitis, followed by the signs of anfractuosities, points out that 
 tubercle is developed.* 
 
 47th. That where the expectoration is scanty, and the disease 
 very chronic, the occurrence of dilated cells may obscure the 
 signs of tubercle. 
 
 48th. That where anfractuosities form, we may distinguish 
 them from dilated tubes, by the dulness which has preceded 
 them, by the signs of their extension, f and by reference to time. 
 
 49th. That the discovery of tubercle, in cases of absorbed 
 empyema, is often difficult from the condition of the lungs having 
 been altered. 
 
 50th. That where a great empyema exists, the intensity of 
 the puerile respiration in the opposite lung may obscure the 
 signs of disease of its substance. 
 
 51st. That in cases with empyema with pneumothorax, where 
 adhesions prevent the collapse of the lung, the original cavity 
 may be still detected. 
 
 52nd. That in this complication, the signs of irritation of the 
 opposite lung are almost always indicative of tubercle. 
 
 53rd. That in the laryngeal complication, the physical 
 diagnosis is in general easy, unless where great stridor exists. 
 
 TREATMENT OF PHTHISIS. 
 
 We may consider this treatment under two heads, viz. — the 
 
 * Here it is necessary to observe, that in certain cases of bronchitis, where the 
 minute tubes are engaged, and with profuse puriforni expectoration, the lodgment of 
 the secretion causes occasionally a dulness of sound. But this cannot be cjnfounded 
 with that of tubercle, for it almost always occurs in the lower portions, is constantlj' 
 varying, and may be removed (tor a time) by an emetic, or a blister. I have ouly 
 seen one case in which this lodgment caused a temporary dulness of the upper lobe. 
 It was evident in the morning, but disappeared in a few hours, leaving the respiratory 
 muimur natural. 
 
 \ When I wrote the article on dilatation of the tubes, I was not aware that 
 Dr. Williams had already stated the differential diagnosis between this disease aiid 
 tubercular cavities, as drawn from the signs of extension. — Rational Exposition of the 
 Signs of Diseases of the Lung and Pleura, also Encyclopedia of Practical Medicine 
 Art. Bronchitis.
 
 TUBERCLE OF THE LUNG. 463 
 
 curative and the palliative : the first, the attempt to eradicate 
 the disease by active treatment ; the second, the relieving the 
 various distressing symptoms of a hopeless consumption. And 
 however differing in detail, the principle of both methods is the 
 same, namely, the removal of irritation from the lung, and the 
 improvement of the general health. 
 
 It unfortunately happens that the palliative treatment is that 
 which we must generally follow ; but there can be no doubt that 
 as medicine advances, the cures of consumption will be much 
 more frequent ; its nature will be better understood, its first 
 stages more commonly recognized, and the disease j)revented 
 from proceeding to incurable disorganization. 
 
 The first, the most important point in preparing ourselves for 
 the successful treatment of phthisis, is to have clear notions as 
 to its connexion with irritation. 
 
 Without adopting the opinion of Broussais, that phthisis is 
 nothing but a chronic pneumonia,* but rather holdino- with 
 Andral, Carswell, Forbes, and Clark, that the tubercular matter 
 results from a lesion of secretion, we must admit its connexion 
 with a state of irritation in most cases. There are some, indeed 
 where the matter seems deposited without any such action but 
 these are comparatively rare. 
 
 Before entering on this subject, I shall state the division of 
 cases of phthisis which I have generally followed with relation 
 to treatment. They may be separated into two classes, the con- 
 stitutional and accidental phthisis. In the first, tubercle super- 
 venes either with or without precursory irritation, in persons 
 strongly predisposed to it by hereditary disposition or orio-inal 
 conformation. In these the disease is generally rapid, invades 
 both lungs, and is complicated with lesions of other systems. 
 The disease is constitutional, and the affection of the lung 
 though the first perceived, seems but a link in the chain of 
 morbid actions. 
 
 In the second, we meet the disease in persons not of the 
 strumous diathesis, and who have no hereditary disposition to 
 tubercle. The disease results from a distinct local pulmonary 
 irritation, advances slowly, and the digestive and other systems 
 show a great immunity from disease. 
 
 * Histoire des Phlegmasies Chroniques, vol. ii. See also his Commeutaires sur les 
 Propositions de Pathologie.
 
 464 TUBEKCLE OF THE LUNG. 
 
 In both cases we may effect a cure ; but tbis result will be 
 more often obtained in the latter than in the former class. The 
 value of early treatment is of course greater in the constitutional 
 than the accidental case. In the early stages of the constitu- 
 tional disease, recovery is only to be effected by treatment ; in 
 the advanced cases, when it does occur, it seems almost 
 independent of treatment. 
 
 In the accidental phthisis, the lesser tendency to abdominal 
 and other complication, allows time for the vital powers to act ; 
 while in the constitutional variety, tubercle is commonly deposited 
 throughout the body, and the patient dies rapidly in consequence 
 of such extent of disease. 
 
 But to return to the connexion with irritation, we find it in 
 the great majority of cases to precede, accompany, and accelerate 
 the disease ; and further, that within certain limits, it is by 
 removing irritation that we best succeed in effecting a cure. 
 Without this principle we have no key to the treatment of 
 phthisis. Tubercle is preceded by irritation. This is seen in 
 the history of almost every case ; an ordinary cold, an attack of 
 influenza, a pneumonia, a pleurisy, the bronchial irritation of 
 hooping cough, or the exanthemata — these admitted conditions 
 of irritation are commonly the first links in the chain of con- 
 sumptive symptoms. How commonly in the strumous diathesis 
 do we see individuals continuing free from phthisis for many 
 years, till an attack of pulmonary irritation occurs, and then we 
 can trace the first growth, and progress of tubercle. And, if 
 further evidence is necessary, let us recollect the effect of injuries 
 of the chest, and the phenomena of the acute inflammatory 
 tubercle. 
 
 That tubercle is accompanied by irritation hardly demands 
 proof. Fever, cough, excitement of the lung, and acute pain, 
 declare the inward disease. Or if we turn to anatomy, we find 
 actual inflammation of the tissues of the lung, redness, thickening, 
 softening, and ulceration of the mucous membrane, purulent 
 secretions, vermilion redness of the inter-tubercular tissue, 
 solidification of the lung, and lymph on the pleura. Finally, 
 it is not uncommon to see the patient suddenly cut oft' by 
 some violent inflammation, pneumonia, pleurisy, cerebritis, or 
 enteritis. 
 
 But tubercle is not only preceded and accompanied by irrita-
 
 TUBEECLE OF THE LUNG. 465 
 
 tiou, but it is hastened by it. Every new attack of irritation 
 is followed by increase of the tubercular symptoms, unless it be 
 of the surface, when a revulsive action, proving the general 
 proposition, is occasionally seen. 
 
 Lastly, experience shews, that it is by means calculated to 
 diminish irritation of the lung at the least expense to the con- 
 stitution, that we can best palliate or delay the progress of 
 phthisis ; and I trust to be able to shew that the antiphlogistic 
 treatment is the true mode of arresting the disease in its early 
 periods. 
 
 Thus the proposition is proved by the study of symptoms, by 
 the results of anatomy, and by the experience of treatment. It 
 is hardly necessary to repeat that there are cases of extensive 
 tubercular formation, in which irritation is either absent, or 
 but little marked. These are always incurable, happily they 
 are rare. 
 
 On being called to a case of phthisis, the practitioner has to 
 decide whether to adopt the curative or palliative treatment. 
 The following are the circumstances which may induce him to 
 attempt the cure. 
 
 1st. The absence of the strumous diathesis, or an hereditary 
 disposition. 
 
 2nd. The fact of the disease being recent, for lohere physical 
 signs of tubercle exist, the chance of recovery is inversely as the 
 duration of symptoms. 
 
 3rd. The want of proportion between the extent of disease as 
 indicated by physical signs, and the duration of symptoms. If 
 the extent be slight, although symptoms have existed for months, 
 it shows a power of resistance in the economy. 
 
 4th. The calmness of the pulse, 
 
 5th. The absence, or slight degree of emaciation or hectic. 
 
 6th. The healthy state of the digestive system.* 
 
 7th. The fact of the disease having distinctly supervened on a 
 pneumonia or bronchitis. 
 
 8th, The occurrence of free expectoration from the first 
 period of the cough, f 
 
 * In all the extremely chronic cases which I have observed, the digestive system 
 continued healthy, and I have never heard of a recovery after diarrhoea had oc- 
 curred. 
 
 t An important character, as shewing an early attempt to relieve the irritation by 
 secretion. 
 
 H H
 
 466 
 
 TUBERCLE OF THE LUNG. 
 
 9th. The healthy state of the larynx.* 
 
 10th. The disease, as shewn by physical signs, being confinei 
 to one lung, and to a small portion of that lung. 
 11th. The absence of the signs of cavities. f 
 12th. The absence of puerile respiration in the healthy 
 portions of the lung.;]: 
 
 13th. The absence of the signs of atrophy. 
 It is not meant that a case should present all these characters 
 in order to justify our hopes and attempts of cure : any of them 
 are of value. Of course the more of them present the better ; 
 and, excluding the first character, they may be all available in 
 any case of phthisis, whether constitutional or not. 
 
 Incipient curable phthisis is met with in one of three forms, 
 which may be designated as the Localized Bronchitic, the 
 Tracheal, the Haemoptysical, and the Pneumonic varieties. We 
 shall discuss the treatment of these separately. 
 
 Localized Bronchitic Variety.— This is shewn by the 
 existence of the signs of bronchial irritation already described. 
 They occur in the upper portion, are combined with vesicular 
 murmur, and with slight dulness. The pulse is quickened, the 
 cough is generally dry, but the hectic is not yet confirmed, nor 
 is emaciation decided. 
 
 At this stage the experience of a great number of cases 
 enables me to say that a cure can be performed. This is the 
 period for exertion on the part of the physician, but that in 
 which precious time is commonly lost. 
 
 There is a local irritation to be subdued; tubercle may or 
 may not have formed. In the first case its quantity is so small, 
 that nature often is able to throw it off; in the second case, it 
 is threatened, and every day, by promoting irritation, increases 
 the chance of its deposition. 
 
 The patient must be confined to his room, and all exertions 
 of the lung forbidden. If he be of a robust habit, and that 
 the pulse is inflammatory, a single bleeding from the arm is to 
 
 * Most importmt. The combination of even a small quantity of pulmonary 
 tubercle, in laryngeal disea-e, is alwnys fatal. 
 
 t This requires explanation. We know that recovery happens after the formation 
 of cavitie,., but m most cases their existence implies tha^of tubercle in great quantity 
 occupying other portions of the lun<r. ' 
 
 t This character is of value as shewing that a small part of the lung is obliterated 
 and mdicatiiig a quiescent btate of the other portions. '
 
 TUBERCLE OF THE LUXG. 467 
 
 be performed ; the bowels must be kept gently open, and tlie 
 diet consist of milk, farinaceous substances, and light vegetables. 
 
 Leeches are to be applied in small numbers alternately to 
 the subclavicular and axillary regions of the affected side. This 
 depletion is to be repeatedly performed, the cupping-glass being 
 occasionally used over the bites. Under this treatment the rale 
 will be commonly removed, the vesicular murmur increased in 
 strength, and the dulness diminished, and all this with corres- 
 ponding relief to the symptoms. We ai-e now to commence the 
 use of blisters, which are to be continually applied under the 
 clavicle and over the scapular ridge. Their size should not ex- 
 ceed that of a dollar, and they must in all cases be covered with 
 silver paper. A blister is to be applied about every three days. 
 This counter-irritation is to be persevered in for several weeks, 
 when the blister under the clavicle may be converted into a 
 superficial issue, by dressing the surface with a disc of felt, and 
 a combination of mercurial and savine ointments. During this 
 treatment the cough is to be allayed by mild sedatives.* 
 
 As soon as the issue is established, the regimen may be im- 
 proved. The patient may now commence the friction with the 
 turpentine liniment, •f' and if necessary, use inhalations of the 
 vapour of water, impregnated with a narcotic extract. From 
 twelve to fifteen grains of the extract of cicuta may be employed, 
 at each time of inhalation. In mild weather, horse exercise 
 should be taken, and the invalid, to perfect his recovery should 
 remove to a milder climate, and frequently change his situation. 
 
 Such is the treatment of the most common form of incipient 
 consumption. We owe the principle of local depletion to> 
 Broussais, and among the many boons which he has conferred 
 on practical medicine, there is none greater than this. On this, 
 subject I shall quote two of his propositions. 
 
 '^ Les sangsues placees a la partie inferieure du con, entre 
 Ics insertions dcs muscles sterno-masto'idiens, enlevent le catarrlie.- 
 hronchique et previennent la phthisie pidmonairc. 
 
 " Les sangsues placees autour dcs clavicules et sous les aissclles 
 arretent les progres d'un catarrhe qui vient de s'introduire dans 
 
 * The following is the formula which I employ at this stage ;— R. Mucilaginls Arab, 
 vel Tragacanth. 5iii. ; Syrup. Limon. 3ss. ; Aq. purte, Siiss. ; Aq. Lauro-Cerasi, 
 5SS. — 5i. ; Acetatis Morphise, gr. i. This can be permanently used without deranging 
 the stomach. 
 
 t The formula for this has been given in the chapter on Bronchitis. 
 
 H H 2
 
 468 TUBERCLE OF THE LUNG. 
 
 le lohe superieur et qui aurait infailliblemejit jnoduit la j^hthisie 
 pulmonaire. Un son mat ou moins clair, tout recent, annonce 
 que le catarrhe a penetre dans le parenchyme, et indique qiCilfaut 
 inslster sur Ics saignees locales.^' * 
 
 Incipient Tracheal Irritation. — A person of a strumous 
 habit, some of the members of whose family have been cut off 
 by phthisis, which set in with symptoms precisely similar to his, 
 is attacked, after exposure to cold, with a loud ringing cough, 
 occurring in distressing and uncontrollable paroxysms. He has 
 pain and soreness of the Avindpipe, loses flesh, and is feverish at 
 night. There is frequently pain of the chest and shoulder, and 
 some acceleration of breathing. The pharynx is healthy, or 
 only slightly vascular. On percussion both lungs sound well 
 and equally, and the respiratory murmur is everywhere audible. 
 
 The treatment in this case must be active and decided, for if 
 neglected the disease runs into the miserable complication of 
 pulmonary tubercle with laryngeal ulceration. 
 
 The patient must be confined to bed, or to a warm room, 
 and placed on a milk diet ; all exertions of the voice are to be 
 prohibited. Leeches are to be applied daily to the windpipe, 
 beginning with from eight to ten, and diminishing the number 
 for four or five days ; blisters may then be applied to the nape 
 of the neck and sternum. 
 
 But these remedies, though successful in a few cases, may fail 
 unless we adopt the mercurial treatment first recommended by 
 Mr. Porter in sub-acute laryngitis. By the use of mild but 
 frequently repeated doses of the ordinary mercurials, in combina- 
 tion with opium, we are to affect the gums gently, but decidedl}' ; 
 when it will commonly happen that all tracheal and pulmonary 
 irritation shall subside. 
 
 Thus by the use of mercury we prevent the development of 
 tubercle. This brings us to the important subject of the mer- 
 curial treatment of incipient phthisis. Before entering on it, 
 however, we shall notice the two remaining cases for treatment. 
 
 HiEMOPTYSiCAL VARIETY. — An individual in perfect health, or 
 labouring perhaps under a slight cold, is attacked with copious 
 ha3moptysis, accompanied with great excitement of the heart. 
 The hsBmorrhage having nearly subsided, we find the breathing 
 
 * Examen des Doctrines Medicales, vol. i. ; Propositions de MedecLne, prop, cclxxii. 
 ^clxxiii. See also his Commentaires sur lea Propositions de Pathologic,
 
 TUBEKCLE OF THE LUNG. 4G0 
 
 and circulation quick ; cough continues, and there may be 
 local pain. The upper portion of one side sounds dull, and here 
 the respiration is decidedly feeble, although generally with little 
 rale.* 
 
 In these cases the tubercular development is often astonish- 
 ingly rapid, no interval occurring from the first invasion. In a 
 few, however, there is an interval of calm between the cessation 
 of the haemorrhage and the phthisical symptoms. 
 
 For controlling the haemoptysis the best treatment is general, 
 followed at once by local or revulsive bleeding. Guided by the 
 stethoscope, we apply a great number of leeches over the affected 
 part, and repeat this treatment frequently. In a few cases I 
 have seen leeching the feet, followed by the pediluvium, to have 
 an excellent effect ; but it is decidedly inferior to local bleeding. 
 It is always better to control the bleeding in this way than by 
 direct astringents ; if, however, we must have recourse to these 
 remedies, we may employ the acetate of lead in full doses, com- 
 bined with opium, and a little excess of acetic acid, or we may 
 use the sulphuric acid and alum. I have never applied cold to 
 the chest. The patient is to be kept perfectly at rest, and all 
 unnecessary examinations avoided. 
 
 Dr. Cheyne has given the weight of his testimony strongly in 
 favour of bleeding in the haemoptysical variety of phthisis, and 
 in cases of bronchial haemorrhage threatening consumption, he 
 recommends small bleedings at intervals of a week. He con- 
 siders bleeding to be justified during haemoptysis, or any 
 symptom or sign of inflammation. In such cases he exhibits 
 tartar emetic in nauseating doses, or the combination of one- 
 fourth of a grain of tartar emetic with ten or fifteen grains of 
 nitre, a combination in which he places great confidence. t In 
 such cases I have not used emetics, from a dread of their 
 increasing haemorrhage. I have seen death to occur in a case of 
 haemoptysis, in consequence of an enormous eruption of blood 
 after vomiting, induced by a very small portion of tartar emetic. 
 
 * This interesting fact has been already alluded to. The absence of rale probably 
 proceeds from the obstruction of the minute tubes by coagula. In a case of pul- 
 monary apoplexy, I found every tube that coulJ be traced plugged up by a bloody 
 coagulum. But in certain cases of the strongly marked strumous diathesis we see a 
 rapid advance of tubercle without the stethoscopic signs of mucous irritation, particu- 
 larly when repeated bleedings have been performed. 
 
 I A letter on Hfemoptysis, &c , Dublin Hospital Reports, vol. v.
 
 470 TUBERCLE OF THE LUNG. 
 
 The hsemorrliage being controlled, the indication is to restore 
 the lung to health as speedily as possible. All the means 
 pointed out in the treatment of the first variety are to be used, 
 but ^Yith greater activity. I shall presently notice a case in 
 which mercury was employed.* 
 
 Pneumonic Variety. — This has been already alluded to when 
 describing the succession of tubercle to an unresolved pneumonia. 
 But the case of pneumonia occurring in a strumous habit, and 
 particularly when engaging the upper lobe, may bo arranged 
 under the same head. In this case the disease may be primary, 
 or occur in the secondary form. The treatment is to consist 
 in repeated local bleeding with the cupping-glass, continued 
 counter-irritation, the use of the seton, and the employment of 
 mercury and sarsaparilla, as in the case of chronic pneumonia. 
 
 Mercurial Treatment of Incipient Phthisis. — The idea of 
 arresting the progress of scrofulous inflammation of the lung by 
 mercury occurred about the same time, and without any mutual 
 communication, to my friends Drs. Graves and Marsh, and to 
 myself, and for the last few years these gentlemen and I have 
 treated with mercury several cases of incipient pulmonary disease, 
 which would in all probability have ended in phthisis. t But a 
 great number of observations must still be made in order to 
 establish the actual value of this practice, and it must be recol- 
 lected that in the case thus treated other and active means were 
 employed to remove the local disease. 
 
 Independent of the case of tracheal irritation, I have observed 
 
 * "The treatment," says Dr. Cheyne, "which I would recommend in incipient 
 phthi^*i8 may be stated in a few lines. Jom-neying, if practicable, or what is better 
 still, in fine weather going from shore to shore in the steamers ; short residences at 
 Mallow, or the Cove of Cork, or some favourite spot in England, or dnring the 
 summer, in Scotland. Diet as generous as the state of the lungs will permit ; in some 
 cases a glass or two of claret, and small bleedings. Sponging the chest and arms 
 with very dilute nitro-muriatic acid, or with five parts of Mindererus's spirit, and one 
 of spirit of rosemary ; an issue over the most suspected portion of the lungs, or a 
 succession of blisters, after each bleeding, each not much larger than a dollar; a light 
 bitter two or three times a day, with twenty or thirty drops of laurel water, or the 
 nitro-muriatic acid internally, or perhaps some preparation of iron. If I had time 
 I would explain my reasons for rarely sending patients in any stage of consumption 
 to the continent of Europe." — Op. cit., p. 364. 
 
 t This subject is alluded to in Dr. Graves's Clinical Lectures, published in the 
 Medical Gazette of this year. The facts stated in Dr. O'Beirne's valuable paper on 
 the use of mercury in diseases of the cartilages (Dublin Medical Journal, vol. v.), 
 first led to the hope, that by similar treatment a strumous inflammation of the lung 
 might be arrested.
 
 TUBERCLE OF THE LUNG. 471 
 
 the action of mercury in some instances where tlie lung was 
 clecidedly engaged ; in two, permanent recovery followed ; in one 
 the disease was arrested for some months, after which it re- 
 turned with its former symptoms, and the patient died tuber- 
 culous ; and in one, although mercury was thrice employed, 
 no good effect whatever followed ; and on its last exhibition 
 the remedy manifestly disagreed. I shall briefly notice these 
 cases. 
 
 A gentleman, aged twenty-four, was attacked with violent 
 hi-emoptysis ; in a week afterwards he presented the following 
 symptoms : the respiration was hurried, the cough troublesome, 
 with a scanty, mucous, and bloody expectoration ; the pulse 
 quick, and the action of the heart strong ; fever of a remittent 
 character, with a tendency to perspiration, existed ; the patient 
 lost flesh, looked pale and haggard, and complained of pain in 
 the upper portion of the left side. 
 
 The antero- superior portion of the left side sounded com- 
 paratively dull ; the respiration was here very feeble, with an 
 obscure rale evident on deep inspiration ; clearness of sound and 
 puerile respiration existed over the remaining portion of the 
 chest. 
 
 No doubt could be entertained that if the symptoms and 
 signs were not removed, a rapid consumption would ensue. The 
 patient was confined to bed ; bleeding, both general and local, 
 was repeatedl}^ performed, and mild mercurials exhibited at short 
 intervals of time. The constitutional symptoms were much re- 
 lieved, but the local signs continued unchanged, and the system 
 resisted the mercurial action ; calomel was now exhibited, and 
 ptyalism at last produced, when a marked amendment took 
 place, the sound became much less dull, and the respiration 
 louder. The remedy was now omitted, and a large open blister 
 established, and the patient was removed to the country. His 
 convalescence was slow, but satisfactory ; the pulse was kept in 
 check by prussic acid ; and in the course of a year his health 
 was restored. During this time several slight relapses took 
 place, but they yielded to local depletion and counter-irritation 
 over the affected part. A slight degree of atrophy of the sub- 
 clavicular region occurred. 
 
 A gentleman, aged thirtj^ was affected for several months 
 with severe dry cough, which was frequently aggravated by
 
 472 TUBERCLE OF THE LUNG. 
 
 exposure to cold and fatigue ; be became pale, bis pulse was 
 quickened, and be presented all tbe appearances of approacbing 
 consumption. Tbe rigbt clavicle and scapular ridge sounded 
 sligbtly but decidedly dull ; tbe respiration in tbe upper portion 
 of tbis lung was feeble, and mixed witb an obscure mucous rale ; 
 no signs of broncbitis existed in any otber portion of tbe lung. 
 Tbese circumstances, and tbe fact of tbe patient baving lost two 
 brotbers in consumption, excited tbe greatest alarm. 
 
 Tbe tracbea was repeatedly leecbed, and mercury, first in tbe 
 form of blue pill, and afterwards in tbat of calomel, exbibited : 
 after a considerable time, full ptyalism was produced, wben all 
 tbe symptoms subsided, tbe cbest regained its sonoriety, and tbe 
 rales altogetber disappeared ; tbe patient regained bis flesb and 
 strengtb. Several montbs are now elapsed, and be remains in 
 tbe enjoyment of perfect bealtb. 
 
 A middle-aged female was admitted into tbe Meatb Hospital 
 witb acute pbtbisis, under wbicb sbe speedily sank ; tbe lungs 
 were found tuberculated. It appeared tbat about tbree montbs 
 before ber final attack sbe bad been seized witb symptoms pre- 
 cisely similar to tbose Avbicb usbered in ber last illness ; tbese 
 were subdued by mercury, and during tbe interval of tbe two 
 attacks sbe bad remained free from all pectoral symptoms. 
 
 A woman was admitted into tbe Meatb Hospital, labouring 
 under violent symptoms of pneumonia, principally affecting tbe 
 upper portion of tbe left lung, wbicb resisted repeated bleedings, 
 botb general and local, and tbe use of tartar emetic ; tbe disease 
 extended to tbe left lung, witbout, bowever, passing into bepa- 
 tization in tbe rigbt ; mercury was now exbibited, and tbe moutb 
 made sore, but witbout any alleviation of symptoms, copious 
 expectoration came on, and tbe jjatient died in about tbree weeks 
 in great agony. Botb lungs contained numerous small trans- 
 parent tubercles, tbe intervening tissue was of a greyisb wbite 
 colour, and tbe lung infiltrated witb an enormous quantity of a 
 wbite serous fluid. 
 
 A gentleman was attacked witb basmoptysis, followed by violent 
 and distressing cougb. Under tbe supposition tbat tbe liver was 
 diseased, mercury was exbibited, but witbout improvement ; be 
 tben came to town ; be bad cougb, boarseness, emaciation, and 
 a quickened pulse, and tbe rigbt clavicle presented a sligbt 
 degree of dulness. It was determined to again employ mercury,
 
 TUBERCLE OF THE LUNG. 473 
 
 but the medicine distinctly disagreed, no ptyalism was induced, 
 the tubercular symptoms rapidly advanced, and the remedy was 
 of course omitted. 
 
 A gentleman residing in France was attacked with severe 
 cough, with a pain in the chest, and tendency to hectic. A 
 s,yphilitic affection had previously existed, but in its primary 
 form at least had been removed. The symptoms continuing, he 
 came to Dublin. He was emaciated, had incessant tracheal 
 cough, with great irritability of the nervous system. The fits of 
 coughing were most distressing. In addition to these, he had 
 severe pain in the upper sternal and right subclavicular regions, 
 which seemed to proceed from periostitis, a diagnosis rendered 
 more probable from the fact of his having distinct periostitis of 
 the scalp, accompanied by maddening headaches. From the 
 violence of the cough an accurate stethoscopic examination could 
 be scarcely made. 
 
 A mild mercurial course completely removed all these 
 symptoms. The patient felt for several weeks restored to a 
 state of health to which he had been long a stranger. He re- 
 gained his flesh, strength, and appearance, his pulse became 
 perfectly quiet, and he returned to the continent. In little more 
 than two months he died of pulmonary tubercle. 
 
 I have now stated my experience of this matter. As to 
 the general employment of mercury in incipient phthisis, I am 
 anything but sanguine ; yet that by its assistance in removing 
 irritation from the mucous membrane and parenchyma, we maj' 
 occasionally arrest the development or progress of tubercle, 
 seems more than probable ; for there can be little doubt that in 
 the scrofulous habit there is more danger of tubercle from the 
 persistence of irritation of the lung, than from the action of 
 mercury on the system ; but the remedy is a two-edged sword, 
 and its exhibition must not be lightly attempted. Extensive 
 numerical investigations must be made before the treatment can 
 be considered as in any way established.* 
 
 After the early stages of treatment, if an arrest of s^^mptoms 
 
 * The subject is one of the greatest importance. In all cases it must be remembered, 
 that under treatment physical signs will disappear, or become less evident ; and that 
 this proceeds from the removal, not of tubercle, but of intercurrent irritation of the 
 lung. We must, therefore, use the greatest caution in prognosis ; and in all investi- 
 gations bearing on the point, the subsequent history of the patient for months or years, 
 must be if possible ascertained.
 
 474 TUBERCLE OF THE LUNG. 
 
 be happily produced, an issue or seton should be established ; 
 and the patient should travel, and choose for the next season a 
 temperate winter residence. 
 
 Treatment after Excavation has formed. — In a few cases, 
 even after excavation has formed, I have seen a recovery. In 
 these cases there was no evidence of the advance of tubercle, 
 and the larynx and digestive system escaped disease. In 
 other instances treatment has distinctly prolonged life for many 
 years. The principal remedy employed was the seton, with 
 frequent changes of air, or sea voyaging. In some cases the 
 patients confined themselves to a millc and farinaceous diet, 
 while in others they lived freely, indulged in wine, and entered 
 into all the enjoyments of society. In one case where a large 
 cavity existed, the symptoms subsided on the occurrence of 
 fistula in ano. The individual is now in robust heahli. Two 
 of his brothers died of phthisis. 
 
 In a case with cavity, yet in which the symptoms and signs 
 are not progressive, the patient's best chance I believe to be 
 the use of the seton, and travelling. If he does not recover, his 
 life will be probably prolonged. He should take as little 
 medicine as possible ; he should adopt all strengthening means, 
 and use such a regimen as experience points out as the best. 
 Heated rooms, cough mixtures, acid draughts, inhalations, 
 narcotics, "repeated counter-irritation," and all the varied and 
 harassing treatment which ignorance supposes to be curative, 
 these are not the means of recovery. So long as a drain from 
 the chest does not weaken, it is clearly useful, and all the other 
 means should be calculated to give enjoyment to the mind and 
 to strengthen the body.* The patient's winter residence should 
 be, if possible, in a temperate climate ; but his occupation in 
 summer and autumn months should be travelling. The tem- 
 perate and even colder countries may be visited with advantage. 
 
 In the essential point of equability of temperature the Cove 
 of Cork is surpassed by few places. Eecent observations have 
 
 * See Dr. Forbes's notes to the translation of Laennec's work, article Phthisis 
 Pulmonalis. It is no little gratification to nie to find my views of treatment of con- 
 firmed phthisis coinciding so closely with those of this distinguished physician, to 
 whose exertions British medicine owes so deep and lasting a debt. Our experience of 
 the use of issues is different ; but only so far, that in a certain number of cases, verj' 
 limited indeed, 1 have known recovery, or great prolongation of life, to occur after 
 their employment. In the vast majority of cases, however, they seem worse than 
 useless.
 
 TUBERCLE OF THE LUNG. 4/D 
 
 shewn that the mean difference of temperature of the days and 
 nights rarely exceed four or five degrees, and often in the 
 winter months does not exceed one degree. The town is com- 
 pletely sheltered from the north wind, and from its southern 
 exposure, receives the full influence of the sun and the southern 
 breeze. 
 
 It is only within the last few years that Cove has attained its 
 celebrity. It is now the resort of many invalids. Of course, 
 as in all places of the kind, the good effects of the climate are 
 seen more in the temporary improvement in the health of 
 patients than in their final or permanent cure." Such, however, 
 is the penalty which all places of the sort must pay for their 
 celebrity. Patients in the advanced stages of disease are con- 
 tinually arriving, and the favoured climate is expected to eflect 
 impossibilities. 
 
 I shall not enter further into the subject of climate, but refer 
 with pleasure to the works of Sir James Clark ; works which 
 must ever be the guides of the consumptive, and the text books 
 of the student of consumption. 
 
 Palliative Treatment. — I shall here shortly allude to some of 
 the more distressing symptoms, such as hectic, pain, cough, 
 expectoration, hoemoptysis, and diarrhoea. 
 
 The hectic is more a measure of the irritation than the sup- 
 puration of the lung. It will be often relieved or suspended 
 by local depletion, by an haemoptysis, or by the adoption of 
 a less stimulating regimen. When the hectic is severe in the 
 early and middle stages, the patient should stay as little as 
 possible in bed. He should not sit during the day in his 
 sleeping-room, which should be a large airy apartment. The 
 chest should be sponged with tepid vinegar and water ; frequent 
 changes of linen are to be provided, a fresh garment being put 
 on when the sweating commences ; his diet must be of the least 
 stimulating kind, and the digestive system carefully regulated. 
 In a few cases some of the preparations of bark answer Avell, 
 particularly where the fever assumes an intermittent character ; 
 but we cannot persist long in their use. We cannot too strongly 
 denounce the attempt to moderate the hectic sweating by medi- 
 cines merely, without attention to other circumstances. If the 
 season be mild, the patient should go out every day. 
 
 The pains are best relieved by a few leeches, or what is as
 
 476 TUBERCLE OF THE LUXG. 
 
 good, a small blister over the affected part, wliicli may after- 
 wards be dressed with the ointment of morphia. The applica- 
 tion of turpentine sprinkled on a hot cloth will often succeed ; 
 and in many cases, the belladonna or other anodyne liniments 
 will remove the pain. When, however, the pain is accompanied 
 with the friction signs, the best treatment will be a few leeches 
 or a blister.* 
 
 In the course of a single case we must have recourse to 
 various remedies to allay the cough. All the different forms of 
 demulcents and opiates may be employed ; of the latter, the most 
 preferable are the different preparations of opium, hyosciamus, 
 cicuta, and belladonna. Inhalations of the vapour of water, 
 containing a narcotic extract, are often useful. 
 
 AVhere the cough resists these means, a few leeches applied 
 to the trachea on the principle advocated by Broussais, and 
 more lately adopted by Dr. Osborne, will often give relief ; and 
 in some chronic cases, where even all these means fail, I have 
 often found that the common anti-spasmodic mixture of camphor, 
 valerian, opium, ammonia, and aether, gave the greatest relief. 
 
 But the greatest caution must be used in adopting measures 
 to check expectoration, for it is the natural relief of the lung, 
 and unless its quantity is so great as to run down the patient's 
 strength it should not be interfered with. Its arrest too often 
 lights up new irritation in the lung, or produces the enteric 
 complication. I have seen the most dreadful consequences 
 from the use of stimulating inhalations, carelessly or too long 
 employed. Those of which I have had much personal experience, 
 are the inhalations of iodine, chlorine, and tar. They all act 
 in arresting the secretion of the lung, and are consequently 
 hazardous. They have no specific action on tubercle, but by 
 arresting purulent secretion they cause a more rapid development 
 of the disease. I have seen the chlorine inhalations used in a 
 number of cases, and always with bad effects ; fresh irritations 
 of the lung, pains of the side, tightness of the chest, sudden 
 anorexia, diarrhoea, and sopor, have followed its use. 
 
 * There is a curious neuralgic affection of young females which simulates the pain 
 of phthisis. The patient complains of severe pain of one clavicle, generally the right ; 
 the pain is remittent or intermittent, and accompanied with exquisite tenderness; the 
 diagnosis is drawn from the absence of the stethoscopic signs of pulmonary or pleural 
 irritation, the clearness on percussion, and the absence of constitutional symptoms. 
 The value of these diagnostics is of com-se directly as the chronicity of the case.
 
 TUBEBCLE OF THE LUNG. 477 
 
 If there be any means likely to diminish the chance of injury 
 from inhalation, it is the combining it with decided and extensive 
 counter-irritation . 
 
 When haemoptysis occurs, its treatment must vary according 
 to the accompanying circumstances. In the active variety, or that 
 accompanied with much fever or excitement of the heart, our best 
 treatment will be small general and local bleedings, the applica- 
 tion of leeches to the feet, the internal use of ice, and the different 
 astringents, particularly sulphuric acid, alum, and the acetate of 
 lead in free doses. 
 
 The diarrhoea, proceeding as it almost always does from an 
 enteritis, is best treated by attending carefully to regimen ; in 
 the early stages it can be generally commanded by the ordinary 
 cretaceous and opiate medicines, but these soon lose their effect. 
 We must then use the metallic astringents combined with opium, 
 and have recourse to small anodyne enemata ; when even these 
 fail, I have often seen the most marked advantage from the 
 application of a blister to the abdomen. In many cases the 
 diarrhoea was permanently arrested, and the comfort of the patient 
 materially improved.* 
 
 In the preceding pages I have not dwelt on the characters of 
 expectoration in phthisis, for two reasons, first, that these have 
 been so fully described by Andral, Laennec, Forbes, and others, 
 and next, that I have not made any original observation upon 
 them. The student of consumption must, however, recollect 
 that there is no constant relation between the appearances of 
 
 * It ia scarcely necessary to observe that the above section on treatment is imperfect 
 and behind the time, it having been written long before the introduction of cod liver 
 oil and other analeptic remedies. No more decided testimony to the value of this 
 newer treatment could be adduced than that of Dr. Williams. In his work on con- 
 sumption he states the results as to the prolongation of life during 40 years, (a.) " In 
 the first decennial period" (from 1830 to 1840) "the beneficial effects of treatment 
 were very limited, being chiefly confined to incipient cases, &c., and life was rarely 
 prolonged beyond the duration of two years, assigned by Laennec and Louis as the 
 ordinary limit of the life of the consumptive." 
 
 (6.) " In the next period of ten years a marked improvement took place in the results 
 of treatment, apparently in connexion with the allowance of a more liberal diet, and 
 the liberal use of mild alterative tonics, as they might be termed, particularly iodide 
 of potassium, with sarsaparilla or other vegetable tonic." 
 
 (c.) Of the influence of the gradual introduction of cod liver oil during the latter 
 half of this period, Dr. Williams says, " When I state that the average duration of 
 life in phthisis has, during my experience of 40 years, been at least quadrupled, or 
 raised from two to eight years, I say what is below the actual results as calculated 
 by my son ; for of the 1,000 cases SU2 were still living at the last report, and many of 
 these are likely to live for years to come." (Ed.)
 
 478 TUBERCLE OF THE LUNG. 
 
 the expectorated matter and the state of the lung ; that in many 
 cases the expectoration is not characteristic ; that it may he 
 mucous, while great cavities exist in the lung, or purulent from 
 bronchial irritation merely. It may be scanty, or copious, or 
 even absent, although the lung be full of excavations. If we 
 inquire whether there be any kind of expectoration more pecu- 
 liarly allied to phthisis, I would say, it is that described by Dr. 
 Forbes, in which globular ragged masses are expelled.* I do not 
 recollect a single case in which I observed this character, that did 
 not turn out to be phthisis. 
 
 I have observed several cases of calculous expectoration, in 
 which a great quantity of tubercle seemed to have undergone 
 the cretaceous transformation. The patients after having under- 
 gone an attack of severe bronchitis affecting the small tubes, 
 became hectic, and expectorated purulent matter in quantity. 
 No signs of excavation existed, but one side presented a cer- 
 tain degree of dulness, with a muco-crepitating rale. These 
 symptoms continuing for several weeks, small calculi began to 
 appear in the expectoration. These gradually increased in 
 number until a vast quantity were expelled. Their size was 
 generally about that of a large pin's head, and often two were 
 connected by a stalk so as to have an hour-glass form. The 
 discharge of these calculi continuing for a month or six weeks, 
 the patients began to recover, and ultimately regained their flesh 
 and strength, until a new attack. Tbe attack may recur several 
 times, between which a chronic bronchitis continues. The disease 
 is more likely to affect middle-aged than old persons. 
 
 * Trarslation of Laennec, p. 322, The entire note is of great importance.
 
 479 
 
 SECTION IX. 
 
 DISEASES OF THE PLEURA. 
 
 [This chapter is compounded of that in the first edition, with some trivial 
 omissions, and of new matter gathered from Dr. tStokes' notes, embodying his 
 subsequent experience, up to the year 185G.] 
 
 We shall arrange this subject as follows : 
 
 1st. Simple adhesions by inflammation. 
 2ncL Pleuritis with effusion. 
 3rd. Ulcerations of the Pleura. 
 4th. Passive or mechanical efl"usions. 
 
 Before, however, we enter on these subjects it will be necessary 
 to premise some observations on the structure of the pleura, and 
 to develope my views as to the influence of disease on the 
 muscular expansions of the chest. 
 
 It has been long taught, that while the pericardium could be 
 demonstrated to be a fibro-serous membrane, at least in that 
 portion not reflected over the heart, the pleura was a serous 
 membrane, between which and the pulmonary tissue nothing 
 intervened, except the sub-serous cellular tissue. 
 
 That this opinion is grounded on an imperfect examination of 
 the parts, I have for several years satisfied myself; and I have 
 repeatedly demonstrated the existence of a strong capsule be- 
 tween the serous membrane and the lung, and which completely 
 envelopes this latter organ. In the healthy state, this capsule, 
 though possessing great strength, is transparent, a circumstance 
 in which it differs from the fibrous capsule of the pericardium, 
 and which has probably led to the fact of its being heretofore 
 overlooked. 
 
 The first instance in which I discovered this membrane, was 
 in dissecting the lung of a patient who had died of chronic pneu- 
 monia. On dividing the organ with a sharp knife, through the 
 pleura, I observed three distinct layers. One, the pleura ; another, 
 apparently the sub-serous cellular tissue, much thickened and 
 hardened ; and a third of great density, and nearly opaque. This 
 was the tunic in question. Since then I have several times
 
 480 DISEASES OF THE PLEURA. 
 
 observed it in the diseased, and also have succeeded in demon- 
 strating it in the healthy lung. But it is always more perceptible 
 in the case of disease, when the tissues are more or less hyper- 
 trophied and rendered opaque. 
 
 In the healthy lung, however, it is not difficult to exhibit it. 
 The mode which I adopt is the following : A portion of the lung 
 being made, to a certain degree tense, by grasping the subjacent 
 ])arts, so as to inflate the more superficial layer of cells, I make 
 with a sharp scalpel the lightest possible scarification of the 
 figure of an U. This divides the serous membrane, but leaves 
 the fibrous untouched. The lower edge of the serous membrane 
 is then to be seized with a delicate forceps, and by gentle traction, 
 and an occasional division of the true sub- serous cellular tissue, 
 a flap of the pleura can be turned up, leaving the air cells still 
 protected by the strong though transparent fibrous coat. The sur- 
 face of this latter investment, even after the removal of the serous 
 membrane, is still smooth and shining. The knife is now to be 
 carried through the fibrous coat, and it is to be turned back in 
 the same mode. Its great strength is at once apparent, on its 
 being grasped with the forceps, or raised upon the point of the 
 knife, and the surface of the lung then displayed is irregular and 
 fleshy. 
 
 This tunic invests the whole of both lungs, covers a portion 
 of the great vessels, and the pericardium seems to be but its 
 continuation, endowed in that particular situation Avith a still 
 greater degree of strength, for purposes sufficiently obvious. It 
 covers the diaphragm, where it is more opaque, and in connexion 
 with the pleura lines the ribs, and turning, forms the mediastina, 
 which thus are shewn to consist of four layers, two serous and 
 two fibrous. 
 
 This description of the investments of the lung is interesting 
 in a physiological and pathological, as well as an anatomical 
 point of view. It establishes an additional analogy between the 
 lung and the parenchj-matous and glandular organs of the 
 abdomen, which have their fibrous capsules, and illustrates the 
 general law, of the constant association of serous and fibrous 
 membrane, as we see to occur with respect to the arachnoid, 
 pericardium, peritoneum, tunica vaginalis testis, and the synovial 
 capsules. Considered pathologically, it may explain the pain of 
 pleurodyne and pleuritis, and the rarity of perforations of the
 
 DISEASES OF THE PLEURA. 481 
 
 pleura, so remarkable when considered in connexion with the 
 frequency of ulcerations of the lung, which constantly approach 
 so close to the surface as to be bounded by the fibro-serous 
 membrane alone. In pleuritis with effusion, its existence may 
 assist in explaining the binding down of the lung and its 
 corrugated appearance after the removal of the effusion ; and as 
 has been suggested to me, it may be the seat of ossifications of 
 the pleura. 
 
 But notwithstanding this structure of the pulmonary tunics, 
 we find that the pleural cavities are capable of great dilatation, 
 and that the mediastinum is not that resisting septum which it 
 has been supposed. On the contrary, we find it to yield rapidly 
 to the pressure of intra-thoracic accumulations, and I have 
 repeatedly'- observed this to occur long before any yielding of the 
 muscular j^arietes. Hence it is that in empyema of the left side, 
 displacement of the heart occurs long before the intercostal 
 spaces are obliterated, or the diaphragm depressed ; and that in a 
 case of dilatation of the cells, as I have already shewn, an attack 
 of bronchitis causes the morbid clearness to extend beyond the 
 mesian line. It is not improbable, however, that the strength of 
 the fibrous tissues varies in different individuals ; indeed, with 
 respect to the perieardium, the greatest difference of strength 
 exists, for in some subjects we find it dense and opaque, 
 while in others it is nearly transparent.* 
 
 We may now proceed to consider the effects of internal accu- 
 mulation on the muscular parietes of the chest. 
 
 The diseases of accumulation may be divided into two classes. 
 In the first the quantity of air within the thorax is increased ; in 
 the second, it is diminished. Of the first, we have examples in 
 Laennec's emphysema, and in pneumothorax, and of the next 
 in empyema, hydrothorax, effusions into the pericardium, and 
 occasionally intra-thoracic tumours ; hence the diagnosis of these 
 affections depends, on the one hand, on the evidences of accu- 
 mulation, and, on the other, on the physical properties of the 
 accumulated matter. In empyema, there is accumulation, and 
 pressure from a non-elastic fluid ; while in Laennec's emphysema 
 
 * The greater or less extensibility of the pericardium may influence the phe- 
 nomena which result from sudden effusions into the sac, as in cases of rupture of the 
 heart or aorta. In a case of the latter description, with sudden death, I found the 
 pericardium, which had not been previously distended, containiDg upwards of a 
 pound of blood. 
 
 I I
 
 482 DISEASES OF THE PLEURA. 
 
 and in pneumothorax there is also accumulation, hut from an 
 elastic medium ; hence we arrive at the first step in the diagnosis 
 of these lesions. In empj^ema we have, in addition to all the 
 evidences of displacement of the lung, the side, the mediastinum, 
 and diaphragm, proofs of a diminution of the quantity of air, 
 which may amount almost to its total absence from the affected 
 side, the sound on percussion heinr/ dull. In the other affections 
 we have also displacement which, as far as the non-muscular 
 portions of the chest are concerned, is similar to that in empyema, 
 hut there is evidence that the air has not only not been dimi- 
 nished, but that it is increased, the sound on percussion being 
 clear, or morbidly clear. 
 
 When we compare the chests of two individuals, the one 
 affected with empyema, and the other with this dilatation of the 
 cells, we observe that in both there is evidence of accumulation, 
 the side being distended, and the mediastinum displaced. But 
 when we investigate this point more closely, we find some 
 interesting points of difi'erence between the results of these 
 diseases on the thoracic parietes, imrticidarly with reference to 
 their muscular iiortions. 
 
 I have already published my views as to the mechanism of the 
 muscular displacement in empyema, and endeavoured to shew 
 that the phenomena are inexplicable by the formerly received 
 doctrine of simple pressure from within ; but that a loss of tone, 
 a paralysis of the fibres, was necessary before they yielded to 
 pressure. "^ Subsequent observations have only confirmed me in 
 tbese opinions. 
 
 The peculiar smoothness of the side in empyema has been 
 long described as a pathognomonic sign of the disease. It proceeds, 
 as every cue knows, from a yielding of the intercostal muscles, 
 so that the spaces become obliterated, and thus the smoothness 
 is produced. Further we find, as I have shewn in a former paper, 
 that in like manner the diaphragm yields until it may even become 
 concave towards the chest, and convex towards the abdomen ; 
 pushing before it the viscera which lie in the upper portion of that 
 cavity. 
 
 But these phenomena are by no means so marked in the dila- 
 
 * See Transactions of the British Association, vol. v., also my Observations on 
 Paralysis of the Intercostal Muscles and Diaphragm considered as a new source of 
 Diagnosis, Dublin Journal of Medic.il Science, vol. is.
 
 DISEASES OF THE PLEURA. 483 
 
 tation of the air cells, in which, as I have already shewn, the 
 disease may exist to a great amount, and the chest he extremely 
 dilated, without any one of the appearances ahove mentioned. 
 The intercostal spaces continue, in all cases, well and deeply 
 marked ; and in one class of cases the diaphragm remains 
 unaffected, even though the pressure be so great as to change the 
 form of the chest. 
 
 Let us now inquire why it is that this remarkable difference 
 exists. By examining the circumstances of either case we may 
 arrive at the explanation. 
 
 In empyema, there is a combination of vital and mechanical 
 causes. We have inflammation followed by jpressure, and pressure 
 from a liquid. 
 
 In the dilatation of the cells we have only pressure, and this 
 from an elastic fluid. 
 
 Now in this circumstance of inflammation of the pleura, which 
 causes the effusion in empyema, and which continues to act long 
 after the effusion has set in, it appears to me that we have the 
 explanation of the dilated state of the intercostals, and the yield- 
 ing of the diaphragm. 
 
 When a tissue such as a mucous or serous membrane is 
 inflamed, we find that certain effects are produced on the mus- 
 cular expansions or masses with which it is closely connected ; 
 their functions suffer, and we observe, first, an increase of inner- 
 vation, as shewn by pain and spasms ; and next, a paralysis 
 more or less complete. The same circumstances occur when the 
 inflammation is seated in the muscular structure themselves, or 
 in the cerebro-spinal centre from which they derive their inner- 
 vation. In all these cases, whether of contiguous inflammation, 
 of actual disease of the muscular fibre itself, or of inflammation 
 of the brain or spinal marrow, we have produced, first, a j^^us, 
 and afterwards a minus state of innervation. When the latter 
 condition supervenes, the muscular fibres lose their contractility ; 
 and if the organ be a tube surrounded by fibres, it dilates ; or if 
 an expansion similar to the intercostals or diaphragm, it yields 
 easily to pressure.* 
 
 Now the true explanation of the protrusion of the intercostals 
 
 * Abercrombie has shewn that in Ileus, the contracted portions of the tube are 
 healthy, and that the morbid appearances are confined to the dilated parts ; the loss 
 of power being the true cause of the constipation. 
 
 ii2
 
 484 DISEASES OF THE PLEURA. 
 
 and diaphragm will be found to be, that they are affected with 
 this paralysis following inflammation of a contiguous structure, 
 that their contractile powers are lost, and that hence they yield 
 easily to a pressure, which, in their healthy state, (as we see in 
 the vesicular emphysema, in hydrothorax, and the first stage of 
 pleurisy), they effectually resist. 
 
 But we must examine into the evidence of this theory of dis- 
 placement of the thoracic muscles in empyema. 
 
 The first point of evidence is obvious when we reflect on the 
 general effect of irritation on muscular fibre. Now in the case 
 before us we may observe, that the phenomena are in accordance 
 with this admitted effect. In the first stage of pleuritis we have 
 great pain ; difiiculty of respiration ; hurried breathing ; pain 
 increased on a deep inspiration ; and all this ivithoiit jprotrusion 
 of the intercostal spaces or diaphragm, but rather with a 
 spasmodic state of these expansions, conditions which accurately 
 correspond to the plus state of innervation observable in the first 
 stage of muscular irritation. 
 
 But in the more advanced periods, the reverse of all this occurs. 
 The pain ceases, the dyspnoea greatly diminishes, the breathing 
 becomes slower, the diseased side is comparaiively motionless, 
 ivhile the healthy one is acting with great power, and the inter- 
 costal spaces and diaphragm yield ; the first causing the charac- 
 teristic smoothness of the side, and the next, the depression of 
 the abdominal viscera. I need hardly remark, that these circum- 
 stances correspond with the minus condition of innervation, 
 or paralysis of the muscular fibres. 
 
 The next and most importaiit evidence is the fact, that mere 
 pressure seems insufficient for the phenomenon in question. If 
 the theory which I have given be true, it should follow, that in 
 other diseases of accumulation, where inflammation of the pleura 
 was not present, but where there was merely pressure, this mus- 
 cular protrusion should either not occur, or be much less marked. 
 Now such may be observed to be the fact. Let us take Laennec's 
 emphysema, hydrothorax, and enlargement of the liver as 
 examples ; in all of which there is pressure from within. Thus, 
 in Laennec's emphysema, we have already studied the great 
 enlargement of the chest, and the displacement of the medias- 
 tinum and heart, and have seen that even 2chcn the diaphragm is 
 flattened, {as occurs in a certain class of cases), its innervation is
 
 DISEASES OF THE PLEURA. 485 
 
 not destroyed. In hepatic enlargement we may see, also, evi- 
 dences of pressure from the great tilting out of the side, and the 
 state of the lung ; while in hydrothorax, the pressure is demon- 
 strated by the diminished volume of the lung, which, though 
 a muscular organ, cannot avail itself of its powers in resisting 
 pressure from without. 
 
 But notwithstanding this pressure, it will be found that in all 
 cases of emphysema and enlargement of the liver, and in many, 
 at least, of hydrothorax, the intercostal spaces do not yield ; a 
 fact which may be constantly verified. I have lately observed 
 three cases of symptomatic hydrothorax, in which, although the 
 effusion amounted to several pints, and the corresponding lung 
 was reduced in volume, neither the intercostals nor diaphragm 
 were affected. The same occurs in the earlier stages of pleuritis, 
 and the sub-acute effusions. In all these cases we may have 
 groat displacement of the side or thoracic viscera ; yet there is 
 merely pressure, and though the ribs are dilated, the intercostal 
 spaces preserve their relative positions. 
 
 The last point of evidence is the fact, that in some cases of 
 empyema there occurs a sudden yielding of the diaphragm, which, 
 up to a certain period, had preserved its natural position. This 
 yielding may be as extensive as sudden, and is not necessarily 
 accompanied by increase of effusion. How much more easily 
 can we explain this interesting fact. On the supposition adopted, 
 than on that of gradual pressure on a vitally resisting medium. 
 
 From these observations we may safely conclude, that in 
 empyema the protrusion of the intercostal spaces and diaphragm 
 results from a paralysed state of these expansions, and that 
 pressure is secondary to inflammatory action causing paralysis, 
 in inducing the yielding of the muscles. 
 
 In my original paper on this subject, I suggested that the 
 amount of intercostal paralysis might furnish a measure of the 
 intensity of the disease, and be thus made available in prognosis; 
 since then two instances have occurred, in which, from the 
 absence of intercostal paralysis, I prognosticated the rapid 
 recovery of the patients. In both, acute pleuritis had been 
 followed by an effusion sufficiently great to cause extensive dul- 
 ness of the left side, and to push the heart to the right of the 
 mesian line ; in one the disease was of ten days, in the other of 
 nearly there weeks' standing ; in neither were the intercostal
 
 486 DISEASES OF THE PLEUKA. 
 
 spaces or diaphragm protruded, but, on the contrary, these 
 muscles were acting with vigour. In the first case, little was 
 done, except confining the patient to bed, the heart returned to 
 its position on the third day, and in a week all efi"usion was 
 removed ; in the second, on the seventh day of treatment, the 
 posterior portion of the chest was clear, and presenting the 
 friction sound. The recovery in both instances was rapid and 
 permanent. 
 
 In the diagnosis of pleural disease, we may divide the cases 
 into those without effusion sufficient to cause displacement of 
 surrounding parts, and those with signs of accumulation. 
 
 Dry Pleuri.tis. — This term has been given to that form in 
 which nothing is effused but lymph. The characters of the case 
 may in general be stated to be, that the constitutional and local 
 distress is comparatively slight, that organization rapidly ad- 
 vances, that the sound is clear on percussion, — the phenomena 
 of accumulation or displacement wanting, and the friction signs 
 evident. 
 
 We meet with dry pleurisy under various circumstances. It 
 may occur as an uncomplicated and original disease, or as 
 secondary to a general morbid state, such as fever, erysipelas, or 
 the diffuse inflammation ; it may be combined with or succeed to 
 any of the affections of the lung, or occur as a complication of 
 cardiac or hepatic disease. 
 
 The j^^iysical conditions of dry pleurisy, howevei*, may be met 
 with in two stages of the ordinary disease; namely, in the earliest 
 periods, before effusion takes place, and in the latter stages, when 
 the liquid effusion is absorbed. In the first case the duration of 
 the friction phenomena depends on the rapidity of effusion ; in 
 the second, on the vigour of the constitution* which influences 
 the process of organization. 
 
 * It must be admitted that the opinions of Laennec, with respect to the rarity 
 of dry pleurisy, and the influence of mechanical pressure in preventing it, were 
 erroneous ; for the friction phenomena occur rei^eatedly in cases where no solidi 
 fication exists. In the case of tubercle of the upper lobe, the friction signs are 
 found much more often over the clear than the dull portion of the lung. The fol- 
 lowing are Laennec's observations on this point : " I am even doubtful whether 
 dry pleurisies exist in which there is simple secretion of a false membrane, without 
 any tendency to serous exhalation at the same time. All the cases mentioned may 
 be reduced to two kinds, — that in which the effused serum has been absorbed 
 before death, and that in which its exhalation has been mechanically prevented by 
 an indurated lung." — Foubes's Translation, 1834, p. ii97.
 
 DISEASES OF THE PLEUKA. 487 
 
 The characters of this friction sound are various, but in all 
 instances it conveys the idea of two rough and dry surfaces, 
 moving with an interrupted motion upon another. It accom- 
 panies the inspiration and expiration, and may be absent during 
 ordinary breathing, but become manifest on a forced expansion of 
 the lung. In the early periods of the disease, pain is often felt 
 in the situation corresponding to the phenomenon ; but this soon 
 disappears. In many instances the rubbing sensation is perceptible 
 to the patient for a length of time, but we may repeatedly observe 
 the sound to continue long after the patient ceases to perceive the 
 obstruction. 
 
 The sound in the early stages of the simple disease, or imme- 
 diately after the absorption of an empyema, is frequently accom- 
 panied by the rubbing sensation, perceptible to the hand. Like 
 the former sign, this may be absent during ordinary breathing, 
 but become manifest when the patient inspires deeply. In the 
 progress towards cure of simple dry pleurisy this is the first 
 of the physical signs to subside ; it is obviously connected with 
 the most unorganized condition of the effused lymph. 
 
 Although these phenomena are precisely analogous with those 
 of the dry pericarditis, their characters are not so variable as in 
 that affection, nor are they so speedily and curiously modified by 
 treatment. The organization of lymph seems to advance much 
 more rapidly in the pericardium than the pleura. The sound, 
 however, is susceptible of certain modifications : thus, in a case 
 of absorbed empyema in a very emaciated subject, the friction 
 sound, which existed extensively over the side, was similar to 
 that produced by the rubbing of a wet finger on a tambourine ; 
 it was so loud as to be audible for more than a foot from the 
 patient's chest, particularly when he sneezed, coughed, or laughed. 
 A case has been already mentioned in which the friction pheno- . 
 mena existed both in the pleura and pericardium with a distinctly 
 metallic character, in consequence of the distention of the stomach 
 and colon with air.* The creaking sound, bruit cle cuir neuf, is 
 rare in pleurisy : I have only observed it in two instances ; in 
 both an effusion had been absorbed, but the phenomenon was by 
 no means so characteristic as that in inflammatioji of the heart 
 or peritoneum. 
 
 Until very lately, I had believed and taught that the friction 
 
 * Researches on the Diagnosis of Pericarditis, Dublin Medical Journal, vol, iv.
 
 488 DISEASES OF THE PLEURA. 
 
 sounds were always accompanied by clearness on percussion, or 
 with a slightly diminished resonance — pulmonary expansion, 
 pure, or mixed with rales, being always audible. But I have 
 lately witnessed a case of empyema, in which, although great 
 and universal dulness of the side existed, the phenomena were 
 audible, and even perceptible to the patient in the postero-inferior 
 and lateral portions of the chest. They may, then, co-exist 
 with extensive liquid effusion. This, however, must be con- 
 sidered as an exception to the general rule, that after the absorp- 
 tion of an empyema, the friction sound coincides with clearness 
 on percussion. 
 
 The duration of the friction phenomena, depending on the 
 absorption of the liquid, and the rapidity of organization, varies 
 remarkably in different individuals : it is comparatively short in 
 the young and robust ; while in the feeble and cachectic, the 
 phenomena may continue without changing for uj)wards of a 
 month : thus, in a case of phthisis senilis, the friction sound 
 continued for upwards of five weeks audible from the third to 
 the seventh rib. "When, however, it succeeds to the absorption 
 of an effusion, it may continue for a period varying from three 
 days to as many weeks. In one case the phenomenon continued 
 unabated for this space of time, but on the patient being sent to 
 the country, it at once subsided. The organization went on 
 rapidly on the improvement of the vital force. 
 
 As might be expected, the friction sound is generally more 
 audible over the central than either the upper or lower portions 
 of the chest. I have never found it in the acromial or supra- 
 spinous regions, but have observed it immediately below the 
 clavicle. The case was one of aneurism of the innominata, with 
 pleuritis of the upper portion : dissection verified the diagnosis. 
 In a case of empyema, in progress of absorption, the friction 
 phenomena existed posteriorly down to the very lowest boundary 
 of the thorax. 
 
 The rarity of these signs in the upper portion is explicable 
 by the less degree of motion of the pulmonary on the costal 
 pleura.''' 
 
 * In discussing the subject of organization of the false membranes, Andral 
 observes, that this process may occur with an incredible rapidity in some instances, 
 while in others months may elapse without the change occurring: " L' organisation 
 lies fansses meml/7-anes ve depend done pas sevkmeni du levips pins on mains long qui 
 s'est ecovle depuis leur formation, et aucune regie generale ne saurait vtre posee sur
 
 DISEASES OF THE PLEUEA. 489 
 
 When describing the phenomena of dilatation of the air cells, 
 I alluded to Laennec's opinion, that the murmur of ascent and 
 descent proceeded from the friction of sub-pleural vesicles, and 
 stated my reasons for agreeing with Meriadec Laennec in his 
 dissent from this opinion, and without denying the possibility of 
 its occurrence, I must observe that I never met it in any case of 
 Laennec's emphysema, and that in the instance recorded by 
 Eeynaud, in which the friction signs coincided with an emphy- 
 sematous state of the lower lobe in a phthisical patient, the facts 
 are far from conclusive.''' 
 
 The rarity of the friction phenomena in pneumonia has been 
 already noticed. In no case have I found them after hepatization 
 had formed ; and their co-existence with the crepitating rale in 
 the early stages is extremely rare. 
 
 A case of acute hepatitis shall be presently noticed, in which tho 
 friction signs existed extensively over the right side and region 
 of the liver : the pleura and peritoneum were both engaged. 
 
 But one of the most interesting combinations is that of dry 
 pericarditis and pleuritis of the left lung. On this subject we 
 want some more accurate information. In a case of dry peri- 
 carditis, with acute pneumonia of the lower portion of the left 
 lung, a singular phenomenon occurred, which could only be 
 explained by the combination of the cardiac and pulmonary fric- 
 tion sounds. During inspiration, the rubbing sounds over the 
 heart became intense and rasping, while at the end of expiration, 
 they approached to the bruit de soufflet ; in this way a rhythm was 
 produced, and that it was connected with the respiration was 
 evident, as it ceased whenever the latter was suspended. In this 
 instance there was probably a double frottement proceeding from 
 
 le moment oil cette organisation commence. 11 semble qv!il y a sous ce rapport des 
 dispositions individuelles insxplicables, qui, cJiez les tins, accelerent VepOque du travail 
 d'organisation, et qui, chez les autres, le rttardent. Btmarquerons-nous ici en passant 
 que la plus grande analogic existe entre le mode de developpenient des vaisseaux dans 
 lesfausses membranes, et leur mode de pii'oduction dans la membrane du jaune chez 
 le poulet. Notons toutefois une remarquable difference, savoir, Tinconstance, Virre- 
 gidarite du travail d' organisation dans les pseudo-membranes, et, au contraire, la 
 Constance et la regularite de ce travail dans la membrane du jaune." — Clinique Medicale, 
 vol. ii., Maladies de Poitrine, 
 
 * We owe the discovery of the friction phenomena of dry pleurisy to M. Reynaud. 
 See his original memoir, Sur 1' Auscultation de la VoMxine, Journal Eebdomadaire de 
 Medicine, torn, v., 1829, The science of auscultation has been much enriched by the 
 labours of M. Reynaud on this subject.
 
 490 DISEASES OF THE PLEURA. 
 
 the pericardium and pleura ; and when we recollect the relative 
 frequency of the lung and heart, we can understand the produc- 
 tion of a rhythm in the sounds. 
 
 When the lower portion of the left pleura is inflamed while the 
 pericardium remains healthy, the action of the heart may produce 
 a rubhing sound, the result of its impulses on the mediastinum. 
 This sound is synchronous with the heart, and is not interrupted 
 by the stoppage of respiration ; it is heard not over the region of 
 the heart, but a little beyond the situation of the pericardium ; 
 and in one case in which it occurred, the lower portion of the 
 pleura was covered with recently effused lymph, and the pericar- 
 dium perfectly healthy. In another case, however, of double 
 pleuritis and pericarditis, this curious phenomenon did not occcur, 
 although the friction signs were evident. 
 
 Causes of the Friction Sounds. — On this subject there has 
 been some difierence of opinion among pathologists ; but when 
 we consider that there is a perfect analogy between the pheno- 
 mena of inflammation of the pleura, pericardium, and peritoneum, 
 we can have little hesitation in adopting the opinion of Eeynaud, 
 that in these diseases the friction signs are caused by the 
 existence of unorganized lymph on the surface of the serous 
 membrane.* 
 
 In my memoir on the diagnosis of pericarditis, f I have demon- 
 strated, I trust, satisfactorily, the dependence of the friction 
 phenomena on the effusion of lymph, and the state of its orga- 
 nization. In the occurrence of the rubbing sounds, and of 
 vibrations communicable to the hand ; in their re-appearance 
 after the absorption of fluid from the pericardium ; in the con- 
 tinuance of sounds, after the sensation of rubbing is no longer 
 perceptible to the hand, and in their modification by antiphlo- 
 gistic treatment, there is the most complete similarity between 
 the signs of the dry form of inflammation of the pericardium and 
 of the pleura. 
 
 PLEURITIS WITH LIQUID EFFUSION. 
 
 This disease may be met with under various circumstances. 
 It may occur primarily, in a healthy constitution, and accom- 
 panied by high inflammatory symptoms, which demand, and 
 
 * Journal Hebdomadaire de Medicine, tome v. 
 
 t Dublin Journal of Medical Science, vol. iv., 1st series.
 
 DISEASES OF THE PLEUKA. 491 
 
 bear, a vigorous antiphlogistic treatment. It may supervene in 
 the more delicate or lymphatic subject, without great severity of 
 symptoms, and with but little fever. It may comphcate acute 
 or chronic diseases of the lung or liver, or succeed to the metas- 
 tasis of an inflammatory rheumatism. 
 
 But there are other forms in Avhich Ave find it accompanied 
 with much greater danger. In most of these a typhoid state 
 has preceded, and accompanies the disease. The liquid effusion 
 is rapid and copious, and nature makes little if any effort to 
 absorb the fluid, or organize the lymph. 
 
 This secondary or typhoid pleuritis, is met with in the follow- 
 ing cases — 
 
 1st. Typhus or maculated fever. 
 
 2nd. Occurring in the course of the exanthemata. 
 
 3rd. Complicating diffuse inflammation, or bad erysipelas. 
 
 4th. Consequent on phlebitis, or purulent absorption. 
 Lastly, we have a pleuritic inflammation from perforation of the 
 serous membrane, analogous to peritonitis from a similar cause. 
 This we shall examine when describing ulcerations of the pleura. 
 Acute Sthenic Inflammation. — Fever, acute pain of the 
 side, hurried and interrupted breathing, and dry cough, with a 
 hard resisting pulse, are the prominent symptoms of this disease 
 in its early stages. The pain is often intense, all motions of the 
 thorax increase it, and the affected side is fixed and motionless. 
 The patient complains of intense heat within the chest, and there 
 is not unfrequently an extreme tenderness of the integuments. 
 The pain occurs in various situations. The infra-mammary, and 
 inferior lateral regions are the most common, but it may be 
 most severely felt in the shoulder, the axilla, the lumber region, 
 or lower portion of the right hypochondrium or hypogastrium. 
 In many cases it is accompanied by a puffy tumefaction of the 
 integuments, threatening superficial abscess. In a case of this 
 kind, where the shoulder was the seat of pain, I have seen the 
 sterno-clavicular articulation loosened, and the clavicle extensively 
 dislocated. 
 
 The pain, after continuing for foi-ty-eight or sixty hours, in 
 general diminishes or ceases altogether, and this coincides with 
 an effusion. But in some severe cases the pain continues with 
 slight remissions, long after copious effusion has occurred, or 
 even remains unabated up to the period of death.
 
 492 DISEASES OF THE PLEURA. 
 
 During this first stage the patient seldom lies on the affected 
 side, in consequence of the position causing increase of pain. The 
 rule generally is, that in the first stage the decubitus is on the 
 healthy, in the second on the diseased side. But to both these 
 observations many exceptions occur. Thus, in the second stage, 
 when pain ceases, and copious effusion occurs, we may often see 
 the decubitus on the healthy side* As might be expected, 
 the respiration is more hurried and difficult during the persist- 
 ence of the pain. I have long been satisfied, that in this disease, 
 as well as in pneumonia, the acceleration of breathing was to be 
 explained more by the excitement of the lung attending acute 
 inflammation, than by pain on the one hand, or mechanical 
 obstruction, as from hepatization or effusion, on the other. There 
 are of course cases of sudden extensive solidity, or enormous 
 and rapid effusions, where a mechanical cause must be admitted, 
 but these are not the ordinary cases, in which (with respect to 
 dyspnoea and acceleration of breathing) we see a great similarity 
 between pneumonia and pleurisy. In one an improvement in 
 breathing may coincide with an extensive hepatization, the patient 
 being apyrexial, and in the other, even with a copious eflusiou, 
 there may be great ease of respiration. 
 
 Indeed, nothing can be more singular than the slight degree of 
 sufiering, which may coexist with an extensive recent efiusion. 
 I have often been consulted by patients, in consequence of their 
 finding the heart pulsating at the right side. They had never been 
 confined to bed, nor supposed themselves unwell, further than 
 that they found a little shortness of breath on exercise. They 
 confessed having had a slight cold some time back, but nothing 
 sufficient to make them change their ordinary habits. I have 
 seen a copious recent effusion, of which no symptom existed but 
 a collapsed countenance; fever, pain, and cough were absent; 
 yet in a week the heart had been displaced ; nay, further, it may 
 coexist with a good appetite, and perfectly healthy appearance. 
 
 The disease, when established, runs one of two courses. The 
 
 * On this subject Andral remarks, that the decubitus is most commonly on the 
 back with a slight tendency to one side, (decubitus dlaijonal.) I cannot agree with 
 him in his statement, that during the existence of fever and dyspnoea, the decubitus on 
 the healthy side is impossible. But every practical man must coincide in his opinion 
 that the decubitus gives us no sign by which we can recognize the disease. — Clinique 
 Medicale, Maladies de Poitrine, tome ii. When speaking of chronic pleurisy, I shall 
 return to this subject.
 
 DISEASES OF THE PLEL'RA. 
 
 493 
 
 effusion may increase rapidh' ; and between the first attack and 
 fatal termination, no interval of ease is afforded to the patient ; 
 or, more frequently, as in other visceral irritations, a change of 
 symptoms occurs, characterized by diminished suffering, and a 
 transition from the inflammatory to a hectic, or nearly apyrexial 
 condition. The s^Tuptoms vary according as the effusion is on 
 the increase, or stationary. In the first case we observe the 
 cough continuing with increase of dyspnoea on motion ; the 
 patient emaciates ; the countenance becomes pale, or sallow, and 
 contracted ; palpitations are complained of ; and the feet or ankles 
 become slightly swollen. In this condition the side will be found 
 extensively duU ; the mediastinum displaced ; and in all proba- 
 bility, protrusion of the intercostals or diaphragm will be found 
 to exist. 
 
 But when the effusion is not very extensive, nor on the 
 increase, it may coincide with a constitutional state, but little 
 removed from health. The patient may gain flesh and strength 
 up to a certain point ; his countenance shall not be expressive of 
 visceral disease ; he shall have little or no hectic ; and be enabled 
 to take exercise. In this way the patient may go on for months. 
 The disease is almost always mistaken, and treated as debility, 
 consumption, remittent fever, liver disease, or morbus cordis; 
 and too often it happens that the neglect and exasperation of the 
 disease produces the affection for which it was first mistaken. 
 
 I have known a case to pass through all its stages, from 
 effusion to absorption and cure, where the lesion was never 
 suspected. The real nature of the disease was learned acci- 
 dentally long after recovery had taken place. While the child 
 was in "the act of dressing, its mother, in sHppiug off the shurt, 
 perceived the deformity of the left side. I saw this case, and 
 never before witnessed such great contraction, otherwise the 
 recovery was perfect. In the young female there is no error 
 more common than treating this disease for phthisis, proceeding 
 from suppressed uterine action. In several instances I have been 
 able to correct this important error in time. In all, the effusion 
 was confined to the lower lobe ; and the uterine action returned on 
 the removal of the effusion. 
 
 There is nothing characteristic in the expectoration. In the 
 early periods the cough is dry, or there is nothing expelled but a 
 little transparent mucus ; in the advanced stages, the discharge
 
 494 DISEASES OF THE PLEURA. 
 
 is more copious ; and under these circumstances, the case is often 
 supposed to he one of confirmed phthisis. 
 
 The disease may terminate hy asphjTiia, in consequence of an 
 enormous accumulation. The fluid may he evacuated hy an 
 ulcerative opening in the thoracic integuments, or into the lung 
 itself, or pass through the diaphragm into the ahdomen. The 
 effusion may be absorbed rapidly or with extreme slowness, and 
 the patient be restored at once to health, or pass through the 
 doubtful convalescence of Laennec, under which circumstances, 
 he runs the greatest risk of pulmonary consumption. 
 
 Such is the history of the simplest form of this disease ; but it 
 presents numerous modifications, according to its violence, situa- 
 tion, and extent, and also the susceptibility of the patient : to one 
 of the most remarkable of these cases the name of diaphragmatic 
 pleurisy has been given. 
 
 Diaphragmatic Pleurisy. — When the diaphragmatic pleura is 
 engaged there is generally orthopnoea, and it was taught in the 
 older books that delirium and the risus sardonicus occurred as 
 symptoms of inflammation of the diaphragm. Modern observa- 
 tions have shewn that those symptoms are by no means constant, 
 and not more indicative of diaphragmitis than of other diseases. 
 Andral has given the following symptoms, as indicative of this 
 disease. A severe pain, increased by pressure, inspiration, and 
 by every effort, is felt along the edge of the false ribs ; it extends 
 into the hypochondria, and is accompanied by complete immo- 
 bility of the diaphragm. There is extreme anxiety, alteration 
 of the countenance, and the patient sits bent forward : any 
 attempt to change his position producing intolerable pain ; in 
 some cases hiccup, nausea, and vomiting, have been observed. 
 
 The same author has given four cases of this aftection. In 
 the first, inflammation of the right diaphragmatic pleura, in 
 addition to the other symptoms, was accompanied with bilious 
 vomiting and jaundice : the liver was displaced. In the 
 second, a chronic phthisis had existed, on which pleuritis of the 
 left side supervened. From this time till the lyeriod of death 
 the respiration teas imrehj costal. A vast collection of pus was 
 found in the left pleura : the diaphragm was perforated, and the 
 purulent matter effused behind the peritoneum. In the last 
 two cases, the symptoms supervened in the progress of disease, 
 in the one instance, of the pleura ; in the other, of the lung itself.
 
 DISEASES OF THE PLEURA. 495 
 
 In the case of pleuiitis, the disease was nearly latent until 
 the diaphragm became engaged. 
 
 It is obvious that symptoms such as the above do not neces- 
 sarily belong to inflammation of the diaphragmatic pleura, as 
 they are seldom or never met with in ordinary empyema, when 
 the whole pleura is equally engaged. On this subject additional 
 facts are required. 
 
 Other forms of partial pleurisy have been observed,* viz. : — 
 
 Inter-lohular pleuritis, forming a collection of pus, simulating 
 pneumonic abscess. 
 
 Circumscribed inflammation of the costo-pulmonary pleura. — 
 This aff"ection is much more common than the preceding. It may 
 occur in the upper,. lateral, or inferior portions of the chest. 1 
 have seen it, when existing in the antero- superior portion, mis- 
 taken for pulmonary tubercle. 
 
 In such cases, perforation of the pulmonary or costal pleura 
 may occur, and the matter be expectorated, or evacuated through 
 the integuments. I have seen three cases in which a fluctuating 
 tumour existed externally for a great length of time, the tume- 
 faction of which varied with the respiration, being greatest during 
 expiration, while the tumour fell in on inspiration ; and it seems 
 probable that this would occur in all cases where the matter had 
 perforated the thoracic walls, and was confined only by the 
 external muscles and integuments. I have seen a case in which 
 matter in great quantity had already existed in the right pleura, 
 displacing the liver. A fluctuating tumour appeared over the 
 lower sternal region, which was considered to be connected with 
 the internal empyema. On examination, a distinct circular per- 
 foration could be felt over the last bone of the sternum. The 
 abscess was opened, a small quantity only of scrofulous matter 
 was evacuated, and the apparent orifice turned out to be the 
 raised edges of the base of the abscess, which had resulted from 
 sternal periostitis, and had no connexion whatever with the 
 pleural collection. 
 
 Here the tumour, though fluctuating, had nothing of the 
 alternating collapse and puffing out, corresponding to the acts of 
 respiration. 
 
 Acute pleuritis may be complicated with pneumonia, bronchitis, 
 
 * Clinique Medicale, Maladies de Poitrlne. See also J. P. Frank, De Curandis 
 Eominum Morbis, who has accurately described the disease.
 
 496 DISEASES OF THE PLEUKA. 
 
 inflammation of the pericardium, or peritoneum. M, Tarral has 
 taught that the comphcation of pneumonia is more frequent than 
 has heen supposed ; and that in many cases, by changing the 
 position of the patient, we can discover a crepitating rale, before 
 inaudible. He believes that pleurisy with effusion never exists 
 without pneumonia.* My experience is altogether different : it 
 is true I have seen this complication, but never in the simple 
 original pleuritis. In my cases, a chronic inflammation of the 
 parenchyma preceded the pleurisy, or the disease was of the 
 typhoid or secondar}^ form, which has been already noticed. 
 
 Laennec has described three varieties of this complication. The 
 first, is the ordinary one of pneumonia, with slight dry pleuritis. 
 In the second, inflammation of the compressed lung may occur, 
 producing that variety of hepatization, which he has denominated 
 carnification ; while in the third, severe inflammatory action 
 affects both the pleura and lung. This is by far the rarest 
 case.f 
 
 My experience of the complication with pericarditis is but 
 limited, but, as far as it goes, is different from that of Broussais. 
 In my cases, however, the pericarditis was of the dry form, in 
 which the symptoms are never so violent as in that with effusion. 
 I have observed this complication in cases of acute pleuritis, and 
 in two instances of very chronic empyema : in the latter cases, 
 the usual symptoms of pericarditis were completely wanting, 
 and no new suffering marked the invasion of the disease, which 
 was only to be discovered by a,uscultation.:t 
 
 The observations of Broussais apply rather to cases with copious 
 effusion : he dwells particularly on the precordial pains, the great 
 anxiety, and want of sleep. The patient sits bending forward, 
 with his head resting on his knees ; and yet, notwithstanding 
 great concentration of the pulse, there is a tendency to fainting, 
 and almost complete absence of fever. § I have no doubt that, 
 under such ch'cumstances, the complication in question might be 
 safely diagnosticated. 
 
 Chronic Uncircumscribed Pleurisy, with Effusion. — To 
 
 * Eecherches sur la Diagnostique des Maladies, Joiimal Hebdomadaire de Medicine, 
 vol. vii., 1830. 
 
 ■f Laennec, Forbes's Translation. 
 
 i See my Ilesearches on the Diagnosis of Pericarditis, Dublin Medical Journal, vol. 
 vi. Also Dr. Law's Pathological Obervations, ibid., vol. vii. 
 
 § Traitd des Phlegmasies Chroniques, torn. i.
 
 DISEASES OF THE PLEURA. 497 
 
 this condition, whether supervening on an acute and violent 
 attack, or from the first with suh-acute symptoms, the name of 
 empyema has been long given. And although the composition of 
 the fluid effused is often different from that of pus, it being 
 sometimes bloody or serous, yet the term is applied conven- 
 tionally to these as well as to the purulent effusions. 
 
 Chronic effusion, compressing the lung, and displacing the 
 mediastinum, may exist with or without distressing constitu- 
 tional symptoms. In the first case, if we separate the physical 
 signs, we find nothing characteristic in the symptoms alone ; 
 hectic may or may not be present ; and no characters of the cough ; 
 expectoration, respiration, decubitus, or, with a single exception, 
 the appearance of the patient, are sufficient to distinguish this 
 from other diseases of the lung. The exception alluded to, is the 
 dilatation of the side and intercostal spaces — a subject which 
 we shall just now handle. 
 
 But if, in addition to the symptoms of pulmonary irritation 
 and obstruction, as shewn by cough ; dyspnoea, increased by 
 exertion, and by lying on the healthy side ; and a sense of fulness 
 and oppression referred to one side, which is often cedematous, 
 we find the physical signs of accumulation, compression, dis- 
 placement, and paralysis of the thoracic muscles, we may safely 
 diagnosticate the disease in question. 
 
 In certain instances, however, the symptoms are all but want- 
 ing. I have repeatedly known persons with copious effusions, 
 to look well, to be free from fever, pain, or any local distress ; to 
 lie equally well on both sides ; to have a good appetite, which 
 they could indulge without apparent injury ; and all this when 
 the heart was pulsating to the right of the sternum. 
 
 Thus it appears, that in both classes of cases, the physical 
 signs are of the last importance. Indeed, in pleuritic effusion, 
 physical signs have greater value than in any other thoracic 
 disease. Most cases of bronchitis, of pneumonia, and of phthisis, 
 can be at least recognized without these aids ; but such is not 
 the case in pleurisy; and it is fortunate that its physical signs 
 are more simple, numerous, and striking than those of any 
 other of the uncomplicated diseases of the lung. 
 
 In the failure of the attempt to found any differential diagnosis 
 on the symptoms of chronic pleurisy, considered apart from 
 physical signs,- we must study the latter with care, and the more 
 
 K K
 
 498 DISEASES OF THE PLEUEA. 
 
 SO as the statements on empyema contained in surgical books, 
 are exceedingly loose and insufficient. 
 
 As a symptom of copious effusion, we meet witli it more 
 frequently in the chronic cases : yet even here it is often absent. 
 As a sign it is anything but pathognomonic : as a constant 
 symptom I have only observed it in extreme cases, and where 
 the mediastinum and diaphragm were extensively displaced. 
 Facts are still wanting to clear up. the cause of this symptom. 
 Eicherand, believing that the mediastinum was a strongly 
 resisting septum, denied the doctrine of Le Dran, that the 
 difficulty of lying on the healthy side, arose from the pressure 
 of the superincumbent fluid, and attributed it solely to the 
 obstruction to dilatation of the healthy side, in consequence of 
 its being placed undermost. 
 
 But the extensibility of the mediastinum cannot be denied. 
 The fact, which I have often observed, of displacement of the 
 heart before that of the iutercostals, or diaphragm, is sufficient. 
 On this point Dr. Townsend observes, that in cases of pneumo- 
 thorax, with empyema, we have direct proof of the influence of 
 the weight of the fluid. 
 
 " The patient can generally lie on the sound side so long as 
 the effusion is principally gaseous ; but as the proportion of 
 ponderable fluid increases, decumbiture on the sound side 
 becomes impossible. In like manner in cases of empyema, 
 the dyspnoea is in general greatly aggi-avated by lying on the 
 sound side ; but when the fluid is evacuated, the patient is imme- 
 diately enabled to turn on the sound side, although the necessity 
 for its free dilatation continues as great as before, the disease 
 being still in a state of perfect inaction. In the case of pneumo- 
 thorax with empyema, related in the fifth volume of the Dublin 
 Transactions, in which the operation of paracentesis was performed, 
 the patient was enabled to lie on the sound side the night after 
 the fluid was drawn off, though it was ascertained by auscultation 
 that the side was then filled with air, and the necessity for the 
 free dilatation of the sound side consequently as great as before 
 the operation. 
 
 " These observations render it probable that the difficulty of 
 lying on the sound side arises from the load which is thereby 
 thrown on the mediastinum, as well as from the obstruction 
 which the muscles of inspiration experience when the side which
 
 DISEASES OF THE PLEUKA. 499 
 
 they have to dilate is placed under the weight of the hody. To 
 avoid this inconvenience, patients labouring under effusion into 
 the chest generally lie on the diseased side, or else on the back, 
 with a slight inclination of the body towards that side. This latter 
 position is the more general of the two, and is so very charac- 
 teristic, as to lead in some cases to a suspicion of the disease, 
 even before any further examination has been made. This posi- 
 tion, however, is not so constantly observed, but that we meet 
 with frequent deviations from it. When the fever has completely 
 subsided, and the thoracic viscera have become habituated to 
 the pressure of the effusion, the patient can sometimes lie 
 indifferently on his back, or on either side ; and there are even 
 some cases on record, where the patient lay constantly on the 
 sound side. J. F, Isenflamm relates a remarkable case of this 
 kind, in which a patient, presenting all the usual symptoms of 
 empyema, lay generally on the right side, which, for this reason, 
 was supposed to be the seat of the disease : accordingly, the 
 operation of paracentesis was performed, but no pus was found.* 
 The patient died ; and on dissection, it was discovered that the 
 . left side was the seat of the empyema. Morgagni relates a case 
 of this kind on the authority of Valsalva ; and M. Baffos records 
 another instance.f These, however, may be considered as excep- 
 tions to a general rule, and probably depend on some adhesions 
 which confine the effusion, and prevent its gravitating to the 
 most dependent part of the chest. "J 
 
 There seems reason for admitting both the explanations 
 if Kicherand and Le Dran, as adopted by Dr. Townsend ; for 
 although the decubitus on one side interferes less with respiration 
 of the corresponding lung than we would a priori suppose, yet 
 it has some effect ; and, on the other hand, it is easy to conceive 
 a case in which the fluid, by lying on the mediastinum, would, 
 by its weight, oppress the heart and affected lung. In an extreme 
 case, however, where the pleural sac was at its maximum of 
 distention, it seems possible, if the patient had become habituated 
 to the new condition of the mediastinum, that decubitus on the 
 healthy side would not cause so much distress as in cases with 
 less effusion. 
 
 * Versuche einer praktischen Abhandlung ueber die Knochen. Erlangen, 1782. 
 
 ■f Dissertation Inaugurale sur I'Empyeme. Paris, 1814. 
 
 X See Dr. Townsend's Essay on Empyema, Cyclopaedia of Practical Medicine. 
 
 kk2
 
 500 DISEASES OF THE PLEURA. 
 
 But there is another cause as yet unnoti(3ed, namely, the 
 effect of change of position on the ahdominal viscera. In a case 
 with protrusion of either ala of the diaphragm, the turning 
 on the healthy side would, hy increasing the pressure on the 
 ahclominal viscera, impede the descent of the opposite portion of 
 the muscle, and consequently produce distress of breathing. It 
 would have the same effect as we see from accumulations in the 
 bowels, or from external pressure, as accurately observed by Dr. 
 Townsend, who, in testing the statements of Bichat and Roux, 
 that pressure on the side of the abdomen corresponding to the 
 effusion caused extreme distress, by forcing up the fluid, and 
 increasing its pressure on the lung, found that the very reverse 
 was the fact ; for, while no uneasiness was produced by 
 pressing up the diaphragm on the side where the effusion existed, 
 any attempt to stop the motion of the opposite ala of the muscle 
 caused extreme and immediate distress.* 
 
 Considering the great weight and mobility of the liver, 
 we should expect that in empyema of the right side, there would 
 be f^reater distress from the cause now pointed out than in the 
 opposite case. 
 
 As the physical signs of the primary sthenic, and secondary or 
 typhoid varieties of pleurisy are the same, it will be right to 
 discuss them before we examine the latter forms of the disease. 
 Indeed so latent, quoad symptoms, are many cases of the typhoid 
 pleurisy, that it is only by physical signs that the disease can be 
 recofrnized. 
 
 THYSICAL SIGNS OF EFFUSION INTO THE PLEURA. 
 
 The physical signs of pleurisy, in its different stages, will 
 be easily intelligible, if we arrange them in the following 
 
 manner : 
 
 1st. Passive auscultatory signs. Loss of sonoriety of the 
 
 chest. 
 
 2ud. Active auscultatory signs. 
 a. Phenomena of respiration. 
 h. Phenomena of voice. 
 
 * CvclopsEdia of Practical Medicine, article Empyema: also Professor Chomel, 
 Dictionnaire de Medicine, art. Pleurisie. This eminent and accurate observer's 
 experience coincides with that of Dr. Townsend.
 
 disi:ases of the pleura. 501 
 
 3rd. Signs of liquid accumulation, causing compression and 
 displacement. 
 a. Of the ribs. 
 h. Mediastinum and heart. 
 
 c. Intercostal muscles. 
 
 d. Diaphragm and abdominal viscera. 
 
 The earliest sign is loss of sonoriety of the portion of the 
 chest, corresponding to the effusion. This dulness, supervening 
 much more rapidly than in ordinary pneumonia, and unaccom- 
 panied or unpreceded by the crepitating rale, generally points 
 out pleuritic effusion. 
 
 When describing pneumonia, I shewed that the occurrence of 
 dulness, mthout preceding crepitus, -was not, as Laennec has 
 taught, necessarily indicative of pleurisy, as it was met with in 
 the typhoid solidit.y. The constitutional state of the patient, the 
 expectoration, and the absence of the signs of displacement, will, 
 in general, suffice to distinguish this typhoid solidity from 
 pleuritic effusion.* 
 
 The dulness is first perceived in the postero-inferior portion, 
 and in the earlier periods is more valuable when occurring in the 
 left than in the right side ; it extends upwards, engages the 
 lower portion of the side and infra-mammary region ; and 
 as the effusion advances, may extend to the scapular ridge ; 
 or anteriorly to the third rib. I have even seen universal dulness 
 produced by a comparatively recent effusion. 
 
 In the early periods of the case, and before adhesions occur, 
 the lung, as it were, floats on the fluid, which is permitted to pass 
 freely around it. Hence is derived the interesting. sign of varia- 
 
 * The following is the statement of Laennec on this subject: — "This complete 
 disappearance of respiration, after the existence of disease for a few hours, is quite 
 pathognomonic of pleurisy with copious effusion, whether there exists pain in the 
 side or not. In pneumonia, the disappearance of the respiration is gradual, and 
 is perceived to be unequal in different parts of the chest ; it is scarcely ever 
 quite wanting below the clavicle ; and when this takes place, it is not till after 
 some days, or even weeks. It is further preceded for twenty-four or thirty-six 
 hours by the crepitous rhonchus, which is quite characteristic. In pleurisy with 
 copioTis effusion, on the contrary, the loss of the respiratory murmur is sudden, 
 equable, uniform, and so complete, that no effort of inspiration can render it percep- 
 tible."— Forbes's Translation. 183-), p. 4(55. In his excellent article on pleurisy, Dr. 
 Law makes the same statement : — ■' We may state that the sudden, equable, and 
 uniform absence of respiration, and dulness of sound, are peculiar to pleuritic 
 effusion."— (TycAj/jopc^/rt of Practical Medicine. In Dr. Hudson's paper on Typhoid 
 Pneumonia there are some iateresting examples illustrative of this point.- See Dublin 
 Medical Journal, vol. vii.
 
 502 DISEASES OF THE PLEURA. 
 
 tions in the sound on percussion, corresponding to the position 
 of the patient. Under these circumstances, we may tind that 
 when the patient turns on his face, the postero-inferior portion, 
 which had been dull, becomes clearer ; and in a few instances I 
 have observed a return of clearness to the lateral portions when 
 the patient turned on the opposite side, so as to allow the fluid 
 to accumulate along the mediastinum. But these signs, although 
 so satisfactory and unequivocal, are by no means so often met 
 with as might be expected : and I have long believed that the 
 change of situation of the fluid is prevented by an agglutination 
 of the pleurae, sufficient for this purpose, though }delding to the 
 gradual accumulation of fluid. The sign, however, is a favour- 
 able one ; and the more so in proportion to the chronicity of the 
 case, as shewing but a small amount of eflusion, and a sub-acute 
 inflammation. We must then admit, with Piorry,* Reynaud, 
 and Forbes, that the opinion of Laennec, with respect to the 
 immobility of the fluid in pleurisy, was incorrect ; but it is 
 certain, as I have before stated, that the sign is not so frequent 
 as we might a priori expect. 
 
 The dulness is generally complete ; and when the effusion 
 is partial, terminates by a well-defined (transverse) line, a circum- 
 stance which is never observed in progressive pneumonia. At 
 this line, particularly in cases of absorption, I have sometimes 
 observed the hridt depotfele; but I do not know whether this is 
 the same as the son Jiumorique ohseryed by Piorry in hj^dro-pneu- 
 mothorax.'t' I do not recollect any case in which the distention 
 of the stomach produced the peculiar tympanitic sound which 
 occurs in hepatization. 
 
 I have already stated that when the efi'usiou is copious, the 
 entire side may be dull from the clavicle down. I have seen 
 this to coincide with but little distress, and mild constitutional 
 symptoms. Under these circumstances, the respiration may be 
 extensively bronchial, or feebly vesicular in the upper half of the 
 thorax ; and in consequence of the displacement of the medias- 
 tinum, the dulness extends beyond the mesian line. 
 
 This extensive dulness is often, as Piorry has remarked, a 
 precious sign of pleuritic eff"usion. J 
 
 * De la Percussion Mediate, etc., etc., Paris, 1828, page 80. The author well 
 remarks, that Laennec, when speaking of egophonia, admits the change of position of 
 the fluid. But, even in recent pleurisies, the sign is rarer than M. Piorry teaches. 
 
 t Op. cit., p. 93. t Op. cit.
 
 DISEASES OF THE PLEURA. 503 
 
 Active Auscultatory Signs. — We shall first examine tlie 
 phenomena of respiration, and afterwards those of voice. 
 
 With reference to respiration, the cases may be divided into 
 four classes. In the first, all respiratory phenomena disappear 
 over the dull portion of the chest ; while in the remaining 
 portions, the respiration may or may not be puerile. 
 
 In the second, a feeble respiratory murmur may be extensively 
 heard, gradually diminishing as we approach the lowest portion 
 of the thorax. 
 
 In the third, a feeble murmur is heard only along the spinal 
 column, as observed by Laennec. 
 
 In the fourth, an extensive and well-marked bronchial respira- 
 tion, most audible in the posterior and lateral portions, is heard 
 from an early period. 
 
 Of these cases, the two last always coincide with extensive 
 dulness on percussion. 
 
 The sign of bronchial respiration has been considered too much 
 as peculiar to solidity of the lung. It is by no means uncommon 
 in pleuritic efiusion, and may be observed in the most recent as 
 well as in chronic cases. Its mechanism is not yet understood. 
 In two cases observed by Dr. Graves, the usual phenomena of 
 pleurisy were so well marked, and the cases of so urgent a 
 nature, that paracentesis would have been performed but for 
 the occurrence of this bronchial respiration, which was to be 
 heard distinctly over the anterior portion of the chest, particularly 
 in a line drawn vertically through the mammary region ; the 
 same was observed posteriorly above and below the scapular 
 ridge, and nowhere was the sound of respiration absolutely null. 
 
 These phenomena occurred in two cases, and on dissection 
 the appearances were almost precisely similar in both. 
 
 A very strong and uninterrupted adhesion extended from 
 about two inches below the clavicle of the affected side, in a line 
 passing through the middle of the mammary region, nearly to 
 the bottom of the anterior part of the lung. 
 
 This adhesion, about two inches in breadth, was very firm 
 and close, so as to form an intimate union between the pulmo- 
 nary substance and the anterior parietes of the chest, and 
 extended nearly from the apex of the lung to its base. Along 
 this line, the pulmonary tissue formed a plate of compressed 
 lung, about two inches in thickness, which, like a vertical par-
 
 504 DISEASES OF THE PLEURA. 
 
 tition, divided the pleural cavity into two chambers, each filled 
 with sero-purulent matter, and separated by the lung extending 
 from its root to its anterior adhesions. 
 
 It is to be observed, that these two cavities communicated 
 towards the clavicle, where the adhesion was wanting, and were 
 still further divided by other adhesions posteriorly, extending 
 upwards from the root of the lung to the superior lobe. 
 
 The lung forming these difterent partitions was red, com- 
 pressed, and totally destitute of crepitus. The air cells were 
 rendered impermeable by the pressure of the pleuritic effusion ; 
 but the bronchial tubes were not obliterated, and could easily 
 be traced to within a line or two of the parietes of the chest.* 
 
 In a remarkable case of empyema which I have seen, a some- 
 what similar state of parts occurred. A musket-ball had pene- 
 trated the lung from above, downwards and forwards, entering 
 at the supra-spinous region, and lodging at the anterior attach- 
 ments of the diaphragm. A violent pleuritis, followed by copious 
 effusion, was the result ; and after a few days the heart was dis- 
 placed. In this case, as in the two former, the occurrence of 
 intense bronchial respiration posteriorly created doubt as to the 
 nature of the disease, which was supposed by some to be hepa- 
 tization of the lung. The knowledge of the two preceding cases, 
 however, and the fact of the dislocation of the heart, made me 
 conclude that the case was one of empyema, notwithstanding the 
 singular circumstance of the side being much contracted. On 
 dissection, a vast quantity of pus was found in the pleura; 
 the trajet of the ball formed a long funnel-shaped cavity, dis- 
 tended by purulent matter, and inferiorly communicating with 
 the pleural sac by a wide opening. The lung adhered along the 
 mediastinum ; and in the upper and lateral portions, its tissue 
 was much condensed. 
 
 Thus, we have three cases in which the sign of bronchial 
 respiration coincided with a bilocular empyema, with consoli- 
 dation and adhesion of the lung ; but that it may occur without 
 any such physical conditions, I have no doubt, as I have 
 frequently found it at a very early period in persons before 
 liealthy, and in whom the inflammation was of an acute character. f 
 
 * Dublin Hospital Reports, vol. v. 
 
 f Andral has noticed the occurrence of bronchial respiration in pleurisy, and 
 attributes it to the condensation of the air vesicles by the pressure of the fluid ; but 
 we have still to learn why the phenomenon is not constant.
 
 DISEASES OF THE PLEURA. 505 
 
 In these cases a speedy recovery followed ; and it seems pro- 
 bable that we must consider bronchial respiration as a favourable 
 sign in pleurisy, as shewing that the lung is not wholly con- 
 densed, but admitting some passage of air into the cells. 
 
 The bronchial respiration of pleurisy is to be distinguished 
 from that of pneumonia by its concomitant signs. The absence 
 of rale, and the concurring signs of displacement, are those on 
 which we are most to rely. Its disappearance in pneumonia is 
 generally accompanied by the crepitus of resolution ; but this is, 
 of course, absent in pleurisy. 
 
 Phenomena OP Voice. — I have little to add to the observations 
 of Laennec on this subject ; but I quite agree with Andral, that 
 the word egophonia is but a generic term, under which must be 
 comprehended numerous modifications of sound, in which the 
 voice has a peculiar vibratory character. In some, the peculiar 
 vibration accompanies every word of the sentence ; in others, 
 only certain words have the peculiar thrill; while in a third 
 class, it is only heard as a sort of echo, at the end of particular 
 words. These phenomena are always best heard about the 
 scapular regions. I have never heard them in the lateral or 
 anterior portions. They may be heard in the earlier periods of 
 the case, or persist throughout to the fatal termination, as in 
 the case recorded by Andral.* In many instances we never find 
 them, and even when present they are extremely inconstant, and, 
 taken alone, have but little value in diagnosis. It must always 
 be recollected, that between the egophonic sounds and those from 
 hepatization, there is often the closest resemblance ; indeed, 
 in a few cases of pneumonia, in the stage of resolution, I have 
 found an almost perfect egophonia : these signs, too, are fre- 
 quently absent, and may even mislead from the circumstance 
 that some persons have a voice naturally egophonic. In such 
 cases, before determining as to the morbid sign, the sound of 
 the voice, heard without the stethoscope, and its characters over 
 the healthy portions of the lung, must always be observed. 
 
 The pectoriloquism of phthisis, and the egophonia of pleurisy, 
 are the least valuable of the physical signs of these diseases. 
 
 There is another phenomenon of voice, however, of far greater 
 value. It is a negative rather than a positive sign. We find, 
 
 * Clinique Medicale, Maladies de Poitrine, torn. ii. obs. xxi.
 
 506 
 
 DISEASES OF THE PLEURA. 
 
 where a quantity of fluid has been effused sufficient to give dul- 
 ness, that when the hand is placed over the affected side while 
 the patient is speaking, no vibration is observed; or, if it be 
 present, that it is singularly diminished. In this way, by placing 
 a hand under each scapula, we can detect a pleuritic effusion by 
 the absence of vibration over the dull portion."* It is an 
 exceedingly useful sign, and assists much in the diagnosis of 
 pleural effusion, hepatization, and enlargement of the liver. In 
 the second case, however, I have found, although bronchophony 
 existed over the dull portion, yet that the vibration perceived by 
 the hand was less distinct than on the healthy side. Hepatization 
 of the lung seems in some cases to diminish, but not remove this 
 vibration. 
 
 In the case of enlarged liver, we may have considerable 
 dulness, the vibration continuing; yet, in extreme cases of 
 enlargement upwards, it is probable that the sign would not 
 apply- 
 Lastly, we find that this test is inapplicable in many cases of 
 females, and boys, previous to the change of voice. In these 
 subjects the vocal vibrations, although audible, are not sufficiently 
 powerful to be felt by the hand. 
 
 Signs of Accumulation of Fluid causing Compression and 
 ExcENTRic Displacement. 
 
 Dilatation of the Side. — This sign, which is to be ascer- 
 tained by measurement and inspection, may be observed at a 
 very early period of disease. Laennec has found it distinct after 
 two days' illness ; Andral on the fourth or fifth day. I have 
 never observed it at so early a period ; but often within the first 
 fortnight. Its greatest amount seems to bo within two inches. 
 It may exist without protrusion of the intercostal spaces ; a fact 
 which I have recently ascertained, and which is opposed to the 
 
 * This obsei-vation was first made in this country by Dr, Hudson, and published by 
 me in 1833, in my Researches on the Diagnosis of Empyema, Dublin Medical Journal, 
 vol. iii. The discovery of the sign, however, is due to M. Reynaud, of whose 
 researches neither my friend Dr. Hudson nor myself were aware at tlie time above 
 mentioned. The observation in question, with others of importance, will be found in 
 M. Reynaud's Inaugural Thesis, Paris, 1819. In most cases where the lungs are free 
 from disease, the vibrations of the right lung will be found stronger than those of the 
 left, and corresponding with the greater resonance of voice. In a few, however, the 
 vibrations are equal ; and I have observed some cases in which there was the greatest 
 reeonanceon the side where there occurred least vibration, as perceived by the hand.
 
 DISEASES OF THE PLEURA. 507 
 
 statements of Andral, who describes the dilatation as always 
 existing with this condition. I shall recur to this point when on 
 the differential diagnosis, particularly with reference to the case of 
 enlarged liver. But dilatation of the side is by no means a 
 constant sign, even where copious effusion exists. The lung 
 may be compressed, and the heart displaced, without any notable 
 amount of dilatation. 
 
 I have ascertained from a number of observations, that the 
 right is often larger than the left side. The average result of the 
 most accurate measurements of twenty chests of persons not 
 labouring under lung disease gave for the right side 17.86 
 inches ; and for the left 17.23, or more than half an inch in 
 favour of the right lung. Of these, the most capacious chest, 
 measured 22 inches for the right, and 21.50 for the left. In 
 one case only was the left side larger than the right ; and in 
 three the sides were symmetrical. 
 
 In the case of greater development of the left side, the man 
 was left-handed ; and the left biceps measured half an inch in 
 circumference more than the right. 
 
 This greater development then of the right side must be 
 always borne in mind ; and we deduce two practical rules from 
 these observations : 
 
 First, that the sign of dilatation is more valuable, as indicative 
 of empyema, of the left than the right side. 
 
 Second, that in empyema of the right side, we are not to 
 place confidence in the occurrence of dilatation unless it is more 
 than half an inch. 
 
 Displacement of the Heart. — This important sign occurs 
 from the earliest periods, and exists long before any protrusion of 
 the intercostals or diaphragm. In effusions of the left side, the 
 heart crossing the mesian line is a phenomenon so singular as 
 commonly to awaken the attention of the patient ; and is one of 
 the circumstances which render the discovery of empyema of the 
 left side more easy than that of the right, in which the heart may 
 be scarcely altered from its position, or if it be, its movement 
 for an inch or so more to the left often escapes observation. 
 
 There is nothing more interesting than to follow the dis- 
 placement of the heart in effusions of the left pleura : we 
 observe, first, that the apex strikes in a situation about mid- 
 way between its natural position and the upper portion of
 
 508 DISEASES OF THE PLEUKA. 
 
 the xiphoid cartilage. As the distention goes on, the heart 
 buries itself under the sternum, and its impulses for a time are 
 greatly diminished, and have wholly disappeared from their 
 natural position ; presently the heart reappears from the right 
 side of the sternum, and then pulsates between the fifth and 
 seventh ribs, at about an inch from the sterno-costal articulations ; 
 the pulsations are often visible, and the patient conscious that the 
 heart is displaced. The hand, applied under the left mamma, 
 perceives no impulse whatever, but the sounds are generally 
 feebly audible, increasing in loudness as we carry the stethoscope 
 upwards and across the chest, till we arrive at the situation of 
 the heart, where they are at their maximum. 
 
 The experience of upwards of twenty cases has convinced me, 
 that this dislocation of the heart, even when at its greatest degree, 
 does not cause any alteration in the natural sounds of the 
 organ ;* indeed, it is singular how little its action is excited in 
 many of these cases. In two instances I have observed the dry 
 pericarditis to supervene in the last stages of empyema. The 
 friction signs were evident, but the action of the heart was scarcely 
 excited. 
 
 Displacement of the heart to the right side by no means implies 
 complete obliteration of the left lung, on the contrary, the 
 upper lobe may present distinct vesicular murmur, while the 
 heart pulsates to the right of the sternum. I have also observed 
 extensive bronchial respiration in these cases. 
 
 It appears to me that Laennec, and most subsequent -tti-iters 
 on auscultation, have paid too little attention to this sign, which, 
 from its frequency of occurrence, and facility of recognition, forms 
 the most important of the signs of excentric displacemeat.f 
 
 * That they are sometimes changed is proved by the observatious of Drs. Hope and 
 Walshe. The former states, that in a case of effusion into the left pleura the aorta 
 was felt to pulsate between the second and third ribs on the right side an inch from 
 the sternum, and here a murmur was licard with the first sound, which disappeared 
 with the restoration of the heart to its natural situation by the absorption of the fluid. 
 "In a most interesting case," saj's Dr. Walshe, "for many successive daj's during the 
 heif'ht of left pleural effusion, both sounds of the heart (pushed to the right of the 
 sternum) were more or less masked by blowing murmurs. These mxtrmurs when the 
 heart was restored, or very nearly restored, to its natural position, almost completely 
 disappeared." (See Dr. Walshe on Diseases of the Ltings, p. 259, 4th cd.) (Ed.) 
 
 f It is not alluded to by Laennec in his account of the signs of pleurisy ; he 
 mentions it incidentally under displacement of the heart : Andral has observed a 
 single case of it. Dr. Townsend, in the Cyclopajdia of Practical Medicine, in his 
 articles on Empyema and Displacement of the Heart, dwells strongly on its im- 
 portance.
 
 DISEASES OF THE PLEURA. 509 
 
 I have observed that during recovery the heart returns to its 
 natural situation -with great rapidity, and long before the 
 posterior and lateral portions of the side have become clear on 
 percussion. 
 
 To Dr. Townsend is due the merit of first observing that, in 
 copious effusions of the right pleura, the heart may be pushed 
 towards the left axilla. In a case of pleuro-pneumothorax of 
 the right side, he saw and felt the heart pulsating between the 
 fourth and fifth ribs, near the left axilla, from which it gradually 
 returned to its natural position as the pressure was removed by 
 drawing oft' the fluid from the opposite side.* 
 
 When describing the phenomena of absoi'ption, I shall notice 
 the interesting fact, which I have lately observed, of displacement 
 of the heart to the right side, in consequence of the absorption of 
 an effusion into the right pleura. : 
 
 From our knowledge of displacements of the heart, we might 
 anticipate that the mediastinal protrusion could be ascertained 
 by percussion, and thus a diagnosis be drawn between the 
 accumulation of fluid and solidification, v/ithout change of 
 volume : this is what really occurs ; and the dulness in the first 
 affection extends beyond the mesian line, and this even in the 
 upper sternal region. As in the dilatation of the air cells we 
 may have morbid clearness beyond the mesian line, so in 
 empyema, the mediastinum being displaced by liquid, dulness 
 extends as far as the mediastinal displacement. 
 
 Displacement of the Intercostals. — After a certain period, 
 shorter in proportion to the violence of the disease, we find the 
 intercostal spaces becoming obliterated ; the side becomes smooth, 
 and this, when the patient is emaciated, contrasts remarkably 
 with the appearance of the opposite ribs. I have never found the 
 intercostal spaces to rise beyond the ribs, as described by some 
 authors, unless when an empyema opened externally. 
 
 This smoothness of the side seems peculiar to pleurisy in its 
 advanced stages ; it is not met with in the earlier periods of the 
 disease : and an effusion sufficient to dilate the side and dis- 
 place the heart, may exist for weeks ivithout producing it. It is 
 not met with in Laennec's emphysema, in pneumonia, simple 
 hydrothorax, or enlargement of the liver, and hence becomes 
 one of the most valuable of the physical signs of advanced pleurisy. 
 
 * Cyclopccdia of Practical Medicine, Art. Displacement of the Heart.
 
 510 DISEASES OF THE PLEUKA. 
 
 It must always, liowever, be borne in mind, that it is not 
 invariably present in cases with even a copious effusion. 
 
 On the absorption of the fluid, the intercostal depressions 
 again appear ; but for a length of time the action of the muscles 
 continues feeble. I have often thought that at this period we 
 might, by electricity, more rapidly remove the paralysis produced 
 by inflammation. 
 
 This phenomenon of muscular displacement in empyema ap- 
 pears to me to be inexplicable by the formerly received doctrine 
 of simple pressure from within ^ but a loss of tone, a paralysis of 
 the fibres seems to be necessary before they can yield to the 
 pressure. In evidence of this theory, let us reflect on the 
 general effect of irritation on muscular fibre. When a tissue 
 such as a mucous or serous membrane is inflamed, we find that 
 certain effects are produced on the muscular expansions or 
 masses with which it is closely connected ; their functions 
 suffer, and we observe, first, an increase of innervation as shewn 
 by pain and spasms ; and next a paralysis more or less complete. 
 The same circumstances occur when the inflammation is seated 
 in the muscular structure themselves, or in the cerebro-spinal 
 centre from which they derive their innervation. In all these 
 cases, whether of contiguous inflammation, of actual disease of 
 the muscular fibre itself, or of inflammation of the brain or 
 spinal marrow, we have produced first a plus, and afterwards a 
 minus state of innervation. When the latter condition super- 
 venes, the muscular fibres lose their contractility : and if the 
 organ be a tube surrounded by fibres, it dilates ; or if an 
 expansion similar to the intercostals, or diaphragm, it yields 
 easily to pressure. 
 
 Now in the case before us we may observe, that the phenomena 
 are in accordance with this admitted effect. In the first stage 
 of pleuritis we have great pain ; difficulty of respiration ; hurried 
 breathing ; pain increased on a deep inspiration ; and all this 
 without protrusion of the intercostal spaces or diaphragm, but 
 rather with a spasmodic state of these expansions ; conditions 
 which accurately correspond to the plus state of innervation 
 observable in the first stage of muscular irritation. 
 
 But in the more advanced periods, the reverse of all this 
 occurs. The pain ceases, the dyspnoea greatly diminishes, the 
 breathing becomes slower, the diseased side is comparatively
 
 DISEASES OF THE PLEURA. 511 
 
 motionless, wliile the healthy one is acting with great power, 
 and the intercostal spaces and diaphragm yield; the first 
 causing the characteristic smoothness of the side, and the next, 
 the depression of the ahdominal viscera. I need hardly remark 
 that these circumstances correspond with the minus condition of 
 innervation, or paralysis of the muscular fibres. 
 
 The next and most important evidence is the fact, that mere 
 pressure seems insuSicient for the phenomenon in question. If 
 the theory which I have given be true, it should follow, that in 
 other diseases of accumulation, where inflammation of the pleura 
 was not present, but where there was merely pressure, this 
 muscular protrusion should either not occur, or be much less 
 marked. Now such may be observed to be the fact. Let us 
 take Laennec's emphysema, hydrothorax, and enlargement of 
 the liver as examples ; in all of which there is pressure from 
 within. Thus, in Laennec's emphysema, we have studied the 
 great enlargement of the chest, and the displacement of the 
 mediastinum and heart, and have seen that even when the 
 diaphragm is flattened (as occurs in a certain class of cases), 
 its innervation is not destroyed. In hepatic enlargement we may 
 see, also, evidences of pressure from the great tilting out of the 
 side, and the state of the lung ; while in hydrothorax, the 
 pressure is demonstrated by the diminished volume of the lung, 
 which, though a muscular organ, cannot avail itself of its powers 
 in resisting pressure from without. 
 
 But notwithstanding this pressure it will be found that in all 
 cases of emphysema, and enlargement of the liver, and in many, 
 at least, of hydrothorax the intercostal spaces do not yield ; a 
 fact which may be constantly verified. I have observed cases of 
 symptomatic hydrothorax, in which although the effusion 
 amounted to several pints, and the corresponding lung was 
 reduced in volume, neither the intercostals, nor diaphragm were 
 affected. The same occurs in the earlier stages of pleuritis, and 
 the sub-acute effusions. In all these cases we may have great 
 displacement of the side or thoracic viscera ; yet there is merely 
 pressure, and though the ribs are dilated, the intercostal spaces 
 preserve their relative positions. 
 
 The last point of evidence is the fact that in some cases of 
 empyema there occurs a sudden yielding of the diaphragm, 
 which up to a certain period had preserved its natural position.
 
 512 DISEASES OF THE PLEUKA. 
 
 This yielding may be as extensive as sudden, and is not neces- 
 sarily accompanied by increase of effusion. How much more 
 easily can we explain this interesting fact on the supposition 
 adopted than on that of gradual pressure on a vitally resisting 
 medium. 
 
 From these observations we may safely conclude that in 
 empyema the protrusion of the intercostal spaces, and diaphragm, 
 result from a paralysed condition of these expansions, and that 
 pressure is secondary to inflammatory action causing paralysis, 
 in inducing the yielding of the muscles. 
 
 But these phenomena are by no means so marked in the dilata- 
 tion of the air cells, in which the disease may exist to a great 
 amount, and the chest be extremely dilated, without any one of 
 the appearances above mentioned. The intercostal spaces con- 
 tinue in all cases well and deeply marked ; and in one class of 
 cases the diaphragm remains unaffected, even though the 
 pressure be so great as to change the form of the chest.* And 
 we may arrive at the explanation, why this remarkable difference 
 exists ; by considering, that in empyema there is a combination 
 of vital and mechanical causes ; inasmuch as we have inflamma- 
 tion followed by pressure, and pressure from a liquid ; while in 
 the dilatation of the cells we have only pressure, and this from 
 an elastic fluid. 
 
 On the absorption of the fluid, the intercostal depressions 
 again appear ; but for a length of time the action of the muscles 
 continues feeble. 
 
 DISPLACEMENTS OF THE DIAPHRAGM. 
 
 The protrusion of this muscle follows the same course and is 
 influenced by the same laws, as that of the intercostals. We 
 recognize it by exanaining the upper portion of the abdomen, 
 Avhich is often found full and resisting. If the empyema be of 
 the right side, the liver is pushed downwards, forwards, and 
 across the abdomen ; if of the left, the spleen is displaced. Of 
 the first I have seen many examples ; but of the second I have 
 no experience. This observation I first made in 1822. f 
 
 * See Walshe's remarks on this question, p. 32G, 4tli edition. 
 
 t For full particulars of these observations, I beg to refer to my papers on the
 
 DISEASES OF THE PLEUEA. 513 
 
 When the liver is displaced we find a tumour in the right 
 hypochondrium, answering to the volume of the liver, and often 
 accompanied by a distinct sulcus immediately below the ribs, 
 and above the upper boundary of the tumour. This results 
 from the space left by the touching of the two convex bodies, 
 namely, the upper portion of the liver and the protruded 
 diaphragm. On the absorption of the fluid the liver ascends 
 and the sulcus disappears. 
 
 But the disappearance of this sulcus does not uecessarily 
 imply the ascent of the liver to its natural position, for the 
 organ may yield to the pressure of the diaphragm, and become 
 deeply concave on its upper surface. This interesting circum- 
 stance occurred in a case where the liver was softened and 
 engorged ; so that the rule is that the disappearance of the 
 sulcus is only favourable when accompanied by the ascent of 
 the hepatic tumour. 
 
 PHENOMENA OF ABSOEPTION. 
 
 When the effusion has caused dulness so high as the scapular 
 ridge, or clavicle, its removal is first pointed out by alterations 
 in the respiration which may occur while the sound continues 
 dull. If perspiration has been absent, a feeble but increasing 
 murmur in the upper portions of the side both anteriorly and 
 posteriorly ; this gradually spreads downwards and may become 
 universally, though feebly audible, even though the side con- 
 tinues extensively dull ; should bronchial respiration have 
 existed, the character of the sound is first lost in the portions 
 of the lung furthest removed from the root ; here it passes into 
 the vesicular murmur, and every day its situation becomes more 
 and more circumscribed, by the advance of vesicular murmur 
 towards the centre. 
 
 In recent and sub-acute cases, clearness on percussion 
 generally coincides with the return of respiration ; in such 
 
 Diagnosis of Empyema and Pericarditis, Dublin Journal of Medical Science, vols. iii. 
 and iv. 
 
 (Dr. Walshe justly observes that "No matter how copious the effusion, whether 
 acute or chronic, nor how complete the evidences of centrifugal or dilating pressure, 
 signs of centripetal pressure are, as a rule, absolutely wanting — the trachea, oesophagus, 
 and larger veins escape serious encroachment. Hence the detection of the latter class 
 of signs in a case of pleuritic effusion may be accepted as proof of some additional 
 disease, such as tumour or aneurism within the chest." — Loc. cit.) (Ed.) 
 
 L L
 
 514 DISEASES OF THE PLEURA. 
 
 cases the friction sounds are generally audible, and the vibra- 
 tions can be perceived over an extensive surface. The more 
 rapid the absorption, the greater the probability of these 
 phenomena existing. In some cases, however, where the 
 effusion seemed to be principally serous, I have observed its 
 rapid absorption without consequent friction signs.* 
 
 When an effusion into the left pleura, sufficiently copious 
 to displace the heart to the right of the sternum begins to be 
 absorbed, the organ retraces its steps, and returns, often with 
 rapidity, to its normal situation. I have seen this to occur within 
 four days. The dulness of the sternum subsides and we have 
 no longer the signs of mediastinal displacement. But this 
 return of the heart by no means implies the complete removal 
 of the effusion, for it will be commonly observed, while dulness 
 continues up to the third rib. 
 
 In cases of complete absorption, we may observe variations 
 with respect to the position of the heart. In some its apex 
 strikes in the original situation, while in others the organ 
 remains manifestly closer to the sternum ; and further, I have 
 ascertained, that the absorption of effusions into the right pleura 
 may so modify the position of the heart, as to cause its extensive 
 displacement, and thus produce the singular phenomenon of the 
 displacement of the heart to the right side, consequent on the 
 removal of an effusion of the right side. Of this, the following 
 .case is a most interesting illustration. 
 
 A man, aged 40, was admitted into the Meath Hospital in 
 December, 1835, labouring under pleuro-pneumony of the right 
 lung of five days standing. On the seventh day the signs were 
 those of a copious effusion into the pleura, he complained prin- 
 cipally of pain in the shoulder ; a puffy swelling occupied the 
 right sterno-clavicular articulation, the clavicle was dislocated 
 forwards, and for several days its sternal extremity could be 
 moved upwards and downwards. On the eighth and ninth days 
 
 * Dr. Graves long ago directed my attention to a peculiar rustling crepitation heard 
 over the site of a lung expanding after temporary compression by fluid in the pleura. 
 I have since frequently heard, and pointed out to others, this peculiar phenomenon, but 
 only in cases of temporary compression by, and rapid absorption of, the effused fluid. 
 It is very fugacious, seldom to be observed after the second day, disappearing from 
 above downwards as the air ceUs expand, to be replaced by pure vesicular respiration. 
 
 Dr. Walshe says that in absorption without retraction, friction-sound, mixed or not 
 ■with pleural pseudo-rhonchus, or pulmonary pseudo-crepitation, reappears for a variable 
 period. (Ed.)
 
 DISEASES OF THE PLEURA. 515 
 
 a distinct crepitus existed over the postero-superior portion of 
 the side. The patient had become affected with mercury, his 
 fever had subsided, and on the thirteenth day of his ilhiess the 
 following observations were made. The left side was everywhere 
 clear, even over the left mammary region, where no pulsation 
 could be felt. 
 
 The right mammary, lateral and postero-inferior portions of 
 the right side sounded completely dull, respiration being absent, 
 the upper portions were tolerably clear and with a feeble murmur 
 mixed with rale in the sub-clavicular, axillary, and supra- 
 scapular regions. The sounds of the heart were distinctly 
 perceptible in the right mammary region. On the eighteenth 
 day the heart could be seen and felt pulsating to the right of the 
 sternum, in the fourth and fifth intercostal spaces ; here the 
 sound was completely dull, and without any rale or vesicular 
 murmur; the left mammary region was perfectly clear on per- 
 cussion, and the heart's impulses were here quite imperceptible. 
 In the course of the next week the respiration had returned to 
 the upper middle and lateral portions of the right side ; and 
 although the heart's action was less excited, its situation 
 obviously remained unchanged. Up to the period of death, no 
 bruit de soufflet or morbid sound accompanied its actions ; the 
 right side recovered its sonoriety, with the exception of the 
 mammary region, which over a space exactly corresponding to 
 the size of the heart, remained perfectly and permanently dull. 
 
 The patient became affected with mercurial eczema, after 
 which he fell into a cachectic state, with frequent diarrhoea ; 
 under careful tonic treatment he at last seemed to improve, when 
 the head became suddenly engaged, and he died in two days, 
 with all the symptoms of violent arachnitis. From the invasion 
 (of the first disease to his death, about eight weeks intervened. 
 
 Not having seen this patient during the first periods of his 
 illness, I experienced some difficulty in determining the nature 
 of the displacement of the heart. Physical signs shewed that it 
 was not owing to any accumulative disease of the left lung or 
 pleura. Here there was no emphysema, no tumour, pneumo- 
 thorax or liquid effusion. The question naturally arose, was it a 
 case of congenital displacement, in which the heart had remained 
 st the right of the sternum, unknown to the patient, and only 
 made evident by the excitement of disease '? This question was 
 
 L L 2
 
 516 DISEASES OF THE PLEURA. 
 
 settled by reference to a principle never before employed in sucli 
 a case. In every recorded instance of congenital displacement 
 there has been a universal transposition of viscera, the stomach 
 occupies the right, the liver the left hypochondrium. The case 
 was investigated with this view and no evidence of any hepatic 
 tumour in the left side could be detected ; and although it was 
 somewhat difficult to ascertain the presence of the liver in its 
 natural situation, yet I was satisfied that it was not transposed. 
 
 We could only then conclude, that in consequence of the rapid 
 removal of the effusion (no time being allowed for contraction of 
 the chest, while the lung, probably from its inflamed state, or 
 being bound by adhesions could not again fill the cavity of the 
 chest), the heart had been drawn across the mesian line, and the 
 left lung enlarged, so as to assist in occupying the vacant space. 
 This diagnosis proved to be correct ; the right lung was found 
 permeable but reduced to less than a third of its natural volume. 
 The pleural cavity was obliterated, and a large quantity of 
 coagulated lymph occupied the lower and posterior portions of 
 the side. In this effusion a purulent collection of about an 
 ounce, apparently the last remains of the empyema, existed. 
 The heart lay to the right of the sternum in a transverse direc- 
 tion, and its base corresponded to the fourth and fifth ribs ; it 
 was perfectly healthy ; the left lung was much enlarged, and 
 stretched far across the mesian line ; no lesion of its structure 
 could be detected. 
 
 Thus while empyema of the left side forces the heart to the 
 right of the mesian line, the rapid absorption of an empyema of 
 the right side draws it in the same direction. This circumstance 
 is obviously favoured by the rapidity of the absorption, when 
 there is not time for the side to contract. It will be probably 
 found to occur more or less in many cases but particularly in 
 those of a combination of an acute or chronic disease of the lung, 
 with a pleuritis, the effusion being rapidly absorbed. 
 
 Dexiocardia, then, when not congenital, may be of three 
 kinds. 
 
 I. Where the heart is pressed across the mesian line, but not 
 permanently fixed in its new situation. It returns to its original 
 situation, or nearly so, on the absorption of the fluid. 
 
 n. Where the heart remains permanently fixed at the right 
 side, notwithstanding the removal of the fluid.
 
 DISEASES OF THE PLEUEA. 517 
 
 III. Where the dexiocardia is induced not by pressure from 
 accumulation in the left pleura, but from the diminished volume 
 of the right lung, induced by an effusion into the corresponding 
 pleura. 
 
 With relation to the modified position of the heart after the 
 cure of empyema, I have made the following interesting observa- 
 tion. A gentleman, aged 20, recovered from acute empyema 
 of the left side. The heart had been pushed far to the right, 
 but returned to its former position early in the progress of cure. 
 It is now three months since he recovered, with a clear sounding 
 chest. From this time he observed, that whenever he turned on 
 the right side, the heart seemed to fall over, and pulsate at the 
 right of the sternum. This curious phenomenon still continues. 
 In the erect position, the heart occupied a situation midway 
 between the usual position and the sternum ; but when he turns 
 on the right side immediately the pulsations can be felt to the 
 right of the sternum, whilst they cease at the left side. The 
 sound on percussion, too, varies with the position of the heart.- 
 In this case, there can be no doubt that the mediastinum 
 stretched by the empyema, has not recovered its tone, and 
 permits by its extension, this extraordinary change of the situa- 
 tion of the heart. 
 
 In connexion with this subject the following case is inter- 
 esting : — A young man was treated for typhus fever in the 
 Meath Hospital. He was maculated, but presented nothing 
 unusual in his symptoms. The second sound of the heart pre- 
 dominated, and the impulse was feeble. On the tenth day of his 
 fever, it was found that the left pulse was much stronger than 
 the right. The case went through the usual course of typhoid 
 affection of the heart, and on the fifteenth day, the cardiac 
 sounds had nearly returned to their natural state. He was 
 convalescent on the sixteenth day. Three days after this period, 
 it was found that when the patient lay on the right side, the 
 impulse of the heart could be heard and felt to the right of the 
 sternum at a point situated one inch to the left of the right 
 nipple. No impulse could be perceived in the cardiac region, 
 and the sounds were much louder at the right than the left side 
 of the sternum. When he turned to the left side the heart could 
 be seen and felt in its ordinary situation — the impulse entirely 
 disappeared from the right side, and the sounds became feeble
 
 518 DISEASES OF THE PLEUEA. 
 
 in that situation. These phenomena continued up to the time 
 when the patient left hospital. 
 
 Was this a case of relaxed mediastinum ? There was no 
 evidence of any former attack of pleurisy ; hut the patient'^ 
 chest was generally narrow, and it may he that the case only 
 exemplifies in a remarkable degree, the greater distinctness of 
 the heart's impulse when a patient, labouring under typhoid 
 softening, turns to the left side. It may be that in such a case^ 
 the pressure of the ribs against the heart, by bringing them into 
 closer opposition to the heart, enables us to feel an impulse 
 otherwise indistinct, and in a man with a very narrow chest we 
 might suppose the same to occur when the right ribs were 
 compressed. But this would not explain the want of impulse at 
 the left side when the patient lay on his right. 
 
 CONTKACTION OF THE SIDE. 
 
 This condition, first properly investigated by Laennec, is met 
 with in those cases, where after the inflammatory action has 
 ceased, and absorption is going on the lung does not re-expand 
 so as to regain its original volume. The causes of this deficient 
 expansion of the lungs are various. Some having reference to 
 the condition of the lung itself ; others to that of the parietes of 
 the chest. Laennec has considered the question solely in con- 
 nexion with the state of the lung. Yet though this is obviously 
 a most important element, in the explanation of the result in 
 question, it must be taken only, as one of the conditions which 
 produce contraction of the side. 
 
 I have known many cases of pleurisy to recover, without con- 
 traction of the side, or depression of the shoulder : these were 
 cases of sub-acute inflammation, or where the efi"usion had been 
 rapidly removed. In other instances, the contraction has been 
 confined solely to the lower portion of the chest, while the 
 shoulder was not depressed : and in several, where the disease 
 occurred in young persons, the deformity was either removed in 
 process of time, or so much diminished, as to be scarcely 
 perceptible. 
 
 The return of a dilated side to its natural circumference is 
 sometimes exceedingly rapid. I have known a dilated side to 
 lose as much as an inch and a half in eight days. In some, the
 
 DISEASES OF THE PLEURA. 519 
 
 contraction is shewn merely by the flattening of the anterior 
 portion, causing visible deformity, yet with but little alteration 
 of size. In others, the affected side becomes of a triangular 
 form, the base of the triangle corresponding to the mesian line, 
 and the apex to the centre of the ribs. Even this condition, 
 when occurring in the young person, may be much improved by 
 time. 
 
 But contraction of the chest, in connexion with empyema, 
 may occur under circumstances very different from those described 
 by Laennec and subsequent authors. It may coincide zvith an 
 increasing empyema, and occur at a very early period of the case. 
 This interesting circumstance I have known to occur in two 
 cases. In both, pleuritis with effusion followed on injury, and 
 long after effusion there was exquisite pain whenever the patient 
 attempted to expand the side. In one case the patient, up 
 to the period of death, kept himself strongly bent on the 
 affected side ; so that the case presented the singular com- 
 bination of a vast empyema, with extreme contraction of the 
 affected side. 
 
 Before going further, it may be laid down that the liability to 
 contraction, is directly as the violence of the inflammation, and 
 the length of time that the disease remains uninfluenced by 
 treatment, or the curative efforts of nature. Hence it is, that we 
 find the greatest liability to contraction is met with in the cases 
 which have been overlooked or treated improperly. The occur- 
 rence of the condition then is in many cases a proof of some 
 error in commission, or omission, on the part of the attendant. 
 That this is in most cases true, I believe, but there is a case in 
 which apparently from the very violence of the inflammation 
 contraction results, although no ftiult has been committed. 
 These cases we shall presently examine. 
 
 There are, at least, three conditions of the lung itself which 
 tend to the result of contraction of the chest. 
 
 I. Its being bound down by organized adhesions, or by great 
 masses of coagalable lymph. 
 
 II. Its atrophy, or real loss of substance, caused by long- 
 continued pressure and disease. 
 
 III. The occurrence of a fistula, as where an empyema opens 
 through the pulmonary pleura. 
 
 That the existence of the two first conditions should act in
 
 520 DISEASES OF THE PLEURA. 
 
 preventing the lung assuming its former bulk is sufficiently 
 obvious, and we derive from this additional proofs of the 
 importance of early treatment in the case of pleurisy with 
 effusion ; and of perseverance in the effort to remove the effusion 
 after the constitutional symptoms have subsided. 
 
 The operation of the third cause is merely mechanical, so long 
 as the fistula remains open, the respiratory efforts cannot act in 
 re-expanding the lung. The fluid escapes through the lung, the 
 side falls in unless permanent empyema and pneumothorax 
 be established (which is one of the rarest of cases under the 
 circumstances), and it is not until the fistula is closed that any 
 Te-expansion of the lung can take place ; but as this generally 
 takes place only in the advanced periods of the case, and as the 
 contracting process has been going on, during all the period 
 previous to the closure of the fistula, I believe that these are the 
 ■cases in which we shall find the greatest amount of permanent 
 deformity of the chest. 
 
 I have said "permanent deformity," for there are cases of 
 deformity resulting from the cure of pleurisy in which the con- 
 traction either wholly, or nearly altogether disappears. 
 
 In the second class of causes — which are independent of the 
 • mere condition of the lung — the most important appears to be the 
 paralysed condition of the intercostals and the diaphragm, and 
 thus, the same inflammation, which tends to bind down the lung 
 and produce its atrophy, acts also in destroying the only influence 
 by which it can be restored to its natural size. I suggested this 
 explanation in my former memoir on empyema ; a more full con- 
 sideration has convinced me of its truth, and I find that Hasse 
 has adopted it ; he says, speaking of the contraction of the chest 
 in pleurisy, " a more influential cause is, however, in all pro- 
 bability the paralysis of the diaphragm and intercostal muscles 
 assigned by Stokes, for these muscles remaining inert during the 
 process of absorption the lung cannot inhale sufficient if any air, 
 and atmospheric pressure will consequently compel the wall of 
 the thorax to fill up the void caused by the removal of pleuritic 
 efi'usion. The more intensely the muscles are afiiected the longer 
 will their paralysis endure, and the more striking during that 
 period be the deformity of the trunk, confirming Stromeyer's 
 theory as to the origin of lateral curvatures of the spine." 
 
 These considerations furnish the key to many circumstances
 
 DISEASES OF THE PLEURA. 521 
 
 connected with cases of pleurisy. We can understand how, even 
 when the lung is not bound down by adhesions, there may be 
 contraction, even to a great degree ; we can see why it is that the 
 contraction is not always permanent, but in many cases becomes 
 less, or may finally disappear. If the disease of the pleura has 
 been violent, and that the inspiratory muscles remain long 
 inactive, there will be contraction arising from all the causes now 
 specified acting in combination, and again if the force of the 
 disease has been principally on the costal and diaphragmatic 
 pleura, there may be contraction although the inflammation of 
 the lung has been comparatively slight, and the period of com- 
 pression short. 
 
 The circumstance of cases of contraction in sub-acute pleurisy 
 is thus explained, and finally it appears probable that the dilata- 
 tion of the bronchial tubes, so commonly resulting when the 
 original disease of the pleura has been neglected, is to be 
 explained by the return, though at a late period, of the force of 
 the inspiratory muscles ; the lung having now lost much of its 
 vesicular structure from atrophy, this dilating force is exerted 
 upon the larger air tubes. 
 
 A remarkable case occurred to me some time since illustrative 
 not only of the history of contraction in pleurisy, but of the 
 disease generally. 
 
 The patient was a young lady of fair complexion and full habit, 
 she was attacked with severe pleuritis of the left side, which 
 soon produced a copious efi'usion, with dislocation of the heart; 
 from this she recovered in about the course of a month, the 
 lower portion of the side being contracted to a slight degree ; 
 within a short time symptoms of an acute attack of peritonitis 
 set in, and in a few days the abdomen became swelled and 
 fluctuating ; under this new attack she remained for several weeks, 
 but ultimately the disease subsided, and the copious abdominal 
 eftusion was absorbed ; she was then much reduced and exhausted, 
 but free from any indication of inflammatory action, when she was 
 seized with acute pleuritic pain in the right side, the disease ran 
 the same course as in the left ; she laboured for weeks under an 
 efi'usion so copious as to cause dulness up to the spine of the 
 scapula, but from this third attack she also recovered, and from 
 this time her convalescence was steady and progressive. Great 
 contraction of the right side and depression of the shoulder made
 
 522 DISEASES OF THE PLEUKA. 
 
 its appearance, yet even this ultimately disappeared, and after a 
 few months this lady's figure regained its symmetry. I never 
 before saw a case at which contraction occurred at so early a 
 period, and in which it so greatly disappeared, and it may be 
 concluded that in cases of contraction the earlier the deformity 
 appears the greater will be the chance of its subsiding. In those 
 cases in which it is slow in appearing there is probably not 
 only paralysis, but atrophy of the inspiratory muscles. 
 
 I believe that in certain cases the contraction of the chest may 
 commence at an extremely early period of the case, and while 
 accumulation of fluid is actually going on. This seems to 
 occur under the double influence of an intense inflammation, and 
 the bending down of the chest from the pain of inspiration. The 
 following case, illustrative of this, is worthy of study. 
 
 A boy, aged 19, accompanied a party of soldiers to their 
 firing ground, where they practiced at a mark, and was occupied 
 with several of his companions in picking up the bullets which 
 fell wide of the target ; while stooping he received a ball in the 
 right acromial region, and was brought into the Meath Hospital 
 in a state of great agony of pain referred to the left mammary 
 region ; in the course of ten days his symptoms were so urgent 
 as to suggest the propriety of an operation. By some it was 
 considered that a great empyema had formed, but this opinion was 
 by others doubted, from the fact that the affected side was greatly 
 contracted. I had no doubt whatever as to the nature of the 
 case, as the heart was found pulsating under the right mamma. 
 The operation was determined on ; Mr. Cusack and I, taking 
 into consideration the extreme contraction of the side, strongly 
 urged that the puncture should be made at a point much higher 
 up than that usually selected ; we were apprehensive that the 
 diaphragm would be wounded. Our advice, however, was not 
 taken, and the operation was performed in the usual place, and in 
 the old manner — viz., by making a free division of the integuments, 
 and then puncturing the sac with the bistoury. In this case no 
 purulent matter followed, and it was then determined to pass a 
 trocar upwards and inwards so as to reach the sac of the empyema. 
 A few drachms only of purulent matter followed this attempt, and 
 the operation was evidently a failure. The patient soon after 
 began to sink, and died within a few hours in collapse. On dis- 
 section it was found that the capsule of the left kidney had been
 
 DISEAbES OF THE PLEUEA. 523 
 
 deeply wounded by the knife, and a profuse haemorrhage had 
 taken place into the surrounding cellular tissue. More than a 
 pound of blood was thus effused. The diaphragm had been 
 punctured from below, but the vast empyema remained. The 
 lung had been perforated by the ball through its Avhole extent, 
 and the trajet of the ball distended by the effusion gave abilocular 
 ajjpearance to the sac. 
 
 It is improbable that, even under more favourable circumstances, 
 the operation of paracentesis would have succeeded in this case, 
 for the lung was so much compressed and altered by the effect 
 of the wound that it would hardly have ever recovered any notable 
 amount of permeability. But the case was rendered unfit for 
 operation, from the fact that the entire system had suffered so 
 deeply in consequence of a violent disease being allowed to run 
 on so long. Had the affection been recognized at an early 
 period, and the force of the disease reduced by treatment, a 
 different result might have occurred. 
 
 I owe to Mr. Hamilton another case, in which conLraction of 
 the side appeared at the commencement of the disease. A man 
 suffered from fracture of the fourth, fifth, and sixth ribs ; in this, 
 as in the preceding case, there was extreme pain of the side, 
 and total inability to extend it. After twenty-four hours of 
 suffering all the signs of copious effusion into the pleura set in. 
 The patient was ultimately discharged, but the side remained 
 contracted all through the case. 
 
 From a consideration of these cases it appears probable that in 
 certain cases, where the pain is extreme, we may have a con- 
 traction from the first periods of the case, and we may, therefore, 
 recognize two forms of contraction in pleurisy with effusion, one 
 active, the other passive, one occurring at the commencement of 
 the disease, the other indicative of its termination, and it is 
 very probable that in certain cases, where contraction exists 
 all through the case, it may proceed from these essentially 
 opposite causes at different .periods, the one acting in the 
 beginning, the other towards the termination of the case. 
 
 In 1843 Sir D. Corrigan exhibited to the Pathological Society 
 two casts illustrative of the occurrence of empyema with con- 
 traction of the side, one on the right, the other on the left side of 
 the chest, and he has re-expressed my observations that in such 
 cases the contraction goes on from below upwards as well as from
 
 524 DISEASES OF THE PLEURA. 
 
 without inwards, and that the safety of the operation for empyema 
 must be materially influenced by this circumstance. In one of 
 his cases had the puncture of the side been made in the usual 
 place of election the great curvature of the stomach must have 
 been wounded, and he adds the important practical remark that 
 if the constitutional symptoms indicating recovery do not proceed, 
 jMii ])assu, with the contraction of the parietes of the thorax, 
 considerable danger is to be apprehended. 
 
 The contraction of the side may be described generally as 
 taking one of two forms, the one that is so well described by 
 Laennec, characterized by depression of the shoulder, and general 
 diminution of the volume of the side ; in the second there is little 
 or no depression of the shoulder, but we observe a remarkable 
 flattening of the antero-inferior portion of the side. In some 
 cases indeed a distinct hollowing, or depression, engaging two 
 or three ribs may be seen, the lateral portion has lost its rounded 
 form and has become sharj)ly angular, constituting a condition to 
 which I have given the name of the " knife-edge " contraction 
 of the side. Viewed from behind, the scapula of the affected side 
 appears much more marked and prominent, and when both 
 hands are passed upwards, under the inferior angles of the scapulae, 
 the hand corresponding to the aff"ected side meets with little 
 resistance in passing under the bone. I bave seen cases where 
 the hand would be passed nearly to the line which corresponds 
 to the scapular spine ; the lower part of the chest is comparatively 
 dull, with a feeble and confused respiratory sound, and the heart 
 beats strongly against the anterior wall of the chest, often with 
 a double impulse, and the peculiar vermicular motion per- 
 ceptible both by the hand and eye. The second impulse, of 
 course, coinciding with the second sound, and perceptible at 
 the base rather than at the apex of the heart. 
 
 In forming our opinion, not only as to the intensity of the 
 original inflammation, but also as to the remote prognosis, we 
 may derive important assistance from observing the state of the 
 intercostal muscles and diaphragm. If in the early stages of the 
 case we find that the intercostal spaces continue distinct, while 
 their muscles are in active contraction, we may, notwithstanding 
 the existence of a copious cfi'usion sufficient to dilate the side 
 and dislocate the heart, diagnose a sub-acute inflammation, the 
 cfi'usion from which is in all probability of a serous nature. It
 
 DISEASES OF THE PLEURA. 525 
 
 is not uncommon to find within a week from the first attack of 
 pain the posterior and infero-lateral portions of the side perfectly 
 dull on percussion, yet on examining the front of the chest to 
 discover that the thorax is resonant and the intercostal muscles 
 are acting with force. We may also ohserve that the epigastrium 
 is hollow, and that there is no sign of hepatic displacement, from 
 which we are justified in concluding that the diaphragm and a 
 large portion of the intercostal muscles are unaffected, and it will 
 generally happen under these circumstances that the disease will 
 yield to ordinary treatment, and that little, if any, contraction of 
 the side will attend the cure. In many of such cases the effusion 
 appears to be limited by adhesions, not changing its place with 
 the varying position of the patient, and if there be no friction 
 phenomenon, anteriorly or laterally, we may safely conclude that 
 a large portion of the costal pleura and the intercostal muscles 
 has not participated in the disease. 
 
 If we exclude those cases in which, from the great accumula- 
 tion of fluid or the severity of the constitutional symptoms, 
 the patient's sufferings are considerable, we find that the class of 
 cases presented for consultation are those in which the process of 
 cure has already gone on to some extent. Of such cases, there- 
 fore, I will make the following groups, arranging them, with 
 reference to their variations in local or general conditions, and 
 indicating the prominent features of some instances, so that each 
 individual case presented to us may meet with its type in one or 
 other of these groups. 
 
 I. The fluid has been absorbed with more or less contraction 
 of the affected side ; the ribs are approximated ; and the shoulder 
 may or may not be depressed. There is nothing remarkable in 
 the condition of the heart, though in some cases its apex beats a 
 little nearer than natural to the mesian line. The contraction 
 may not amount to more than some flattening of the antero-in- 
 ferior portion of the chest — or it may be in that greater degree 
 indicated by the laiife-edge formation, and the falling away of 
 the ribs from the inferior surface of the scapula. The cure in 
 such a case is often perfect and permanent, and it frequently 
 happens that the physician is consulted, not on account of any 
 constitutional suffering, but from the alarm experienced by the 
 patient or his friends at the appearance of the contraction. 
 Disease of the heart is sometimes apprehended from the causes
 
 526 DISEASES OF THE PLEURA. 
 
 already indicated. Or, lastly, the cause of complaint may be a 
 frequently recurring pain in the lower portion of the side. This 
 pain is excited by fatigue, cold, mental emotion, or indigestion, 
 and appears to be an example of that form of neuralgia which 
 affects parts that have previously been the seat of inflammation. 
 
 II. In more extreme cases of contraction, the shoulder is 
 depressed, and the physician is consulted, not with reference to 
 any supposed affection of the chest, but under the idea that the 
 patient has got disease of the spine. Laennec has well indicated 
 the diagnosis of this affection. 
 
 III. There is a case, which I believe to be extremely rare, but 
 of which I have seen a few examples. The process of absorption 
 is arrested, and a circumscribed and perfectly indolent empyema 
 remains occupying generally the postero-inferior portion of the 
 side. I have reason to believe that patients may continue with 
 this condition for a very great length of time, and there are few 
 cases the positive diagnosis of which is so extremely difficult. 
 From the apparently complete indolence of this condition, from 
 the absence of any pathological transformation of the contents of 
 the sac, and the nearly complete absence of local symptoms, this 
 lesion might be compared to those serous cysts which sometimes 
 follow the absorption of apoplectic clots. 
 
 IV. There is a class of cases of more frequent occurrence than 
 the last, in which, after a very copious effusion has taken j)lace, 
 the recovery of the patient proceeds favourably up to a certain 
 point. The upj)er part of the chest regains its sonoriety, and 
 permeability, and the general health is to all appearance re- 
 stored. But we find that the lower half of the affected side, or 
 in some cases the postero-inferior and lateral portion remains 
 absolutely dull, presenting neither contraction, nor dilatation ; 
 and by no means in our power can we remove this condition (I 
 do not here speak of paracentesis). This is a case in which 
 notwithstanding the long-continued absence of any local or 
 general symptom of disease, we should make an unfavourable 
 prognosis, for there is great danger of its turning out to be one 
 in which the transformation of an empyema into cancer may be 
 apprehended. 
 
 If we have had an opportunity of studying such a case from 
 its commencement, there will be, of course, less difficulty in 
 the general view which is to be taken of it. But when the
 
 DISEASES OF THE PLEURA. 527 
 
 physician, as often happens, is for the first time called to see a 
 patient in the condition now described, he will experience the 
 greatest difficulty in coming to an accurate conclusion. In fact 
 such a case is one of those the nature of which can only be deter- 
 mined by successive observations. But as this opportunity is 
 seldom given to the consulting physician his best course will be 
 to abstain from any positive diagnosis — simply pointing out that 
 one of these conditions most probably exists, viz., an extraor- 
 dinary deposit of coagulable lymph ; the circumscribed empyema 
 which we have just now indicated ; or the earlier stages of the 
 encephaloid disease. I object to the practice of making an ex- 
 ploratory puncture, either by Weiss's needle, or a capillary 
 trocar, in such cases, and on these grounds — that if the case be 
 not cancerous there is no need for interference, for the respiration 
 is not embarrassed, and the general health is good ; while on the 
 other hand if the malignant transformation has been set up, we 
 run the double risk of converting the indolent disease into a 
 more active condition, and of producing an external fungus at 
 the point of the orifice. This terrible accident I have known to 
 occur, a sad example of officious and unnecessary interference. 
 
 V. A not uncommon case, in which the physician is called by 
 the patient after the pleuritic disease has gone through its stages 
 of invasion, accumulation, and absorption, all of which have been 
 either unsuspected or unrecognized, is, that in which alarm is 
 first created by the accidental discovery of concentric dislocation 
 of the heart. The transverse dislocation is that which most 
 commonly excites attention, and belongs to the diminished 
 volume of the right lung ; while the vertical is observed where 
 the empyema has existed in the left side. In both of these 
 cases there may be disease of the lung as shewn by diffuse gur- 
 gling, comparative dulness, which indicate atrophy of the lung 
 with dilated tubes, or again the combination of this state with 
 chronic tubercle ; and I am disposed to believe that in the con- 
 centric dexiocardia, there is a greater chance of the lung remaining 
 healthy, than in the upper vertical displacement which follows 
 the unrecognized disease of the left pleura. 
 
 Our knowledge of empyema would be very limited if we con- 
 fined ourselves to the study of the symptoms and physical signs 
 of those cases in which we observe only the phenomena of accu- 
 mulation and absorption. There are other conditions of great
 
 528 DISEASES OF THE PLEUKA. 
 
 importance which claim our attention, especially those which are 
 connected with the efforts of nature to evacuate the fluid, by 
 direct means, or by the establishment of a vicarious secretion 
 from the mucous membrane of the lung. 
 
 These important subjects will be most advantageously studied 
 by the patient investigation of cases which illustrate some of the 
 above conditions. These shall be given in as succinct a manner 
 as may be consistent with the objects we have in view. 
 
 Case. — Ohs. — Chronic empyema — oldening externally — caries of 
 several ribs — pneumothorax — aneurism oj the aorta, and pul- 
 monary tubercle. 
 
 In September, 1838, a woman named Egan, aged 28, was 
 admitted with symptoms of hectic fever and cough. For the two 
 previous years she had been subject to a dry cough. After 
 exposure to cold she had been attacked with severe pain under 
 the left mamma, soon after which the symptoms of cough, 
 dyspnoea, and hectic fever made their appearance. She pre- 
 sented the following physical signs, the whole left side was dull, 
 but this was best marked on the inferior portions. The vesicular 
 murmur was generally feeble, especially in the inferior portion, 
 where it was extremely indistinct. Two peculiar auscultatory 
 sounds could be heard, the one resembling friction, during in- 
 spiration, while during expiration its character changed so as to 
 resemble a series of short metallic crepitations. The other 
 sound was like the ticking of a watch, it continued when the 
 patient held her breath, and was synchronous with the action of 
 the heart. This latter was very distinct and audible over the 
 whole chest. 
 
 The heart's sounds were more distinctly audible under the 
 left clavicle than in the cardiac region, and so distinct over the 
 right side that if the pulsations had not been seen under the 
 edges of the left ribs, it might have been supposed that the heart 
 was at the right of the sternum. No murmur accompanied 
 either sound. The ticking sound was not constant, nor was 
 each tick equally loud. There was no oegophony, and change of 
 position of the patient made no alteration in the percussion 
 sound. The side was not dilated, there was puerile respiration 
 in the right lung. Decubitus on left side. 
 
 In the course of three days, well marked metallic tinkling
 
 DISEASES OF THE PLEURA. 529 
 
 became developed in tlie cardiac region. It was observed that 
 tbe vessels about the right sterno-clavicular articulation pulsated 
 with violence, while nothing of this kind was observed on the 
 left. 
 
 Little change occurred during the next ten days. The patient 
 complained principally of pain in the shoulders, cough, and 
 abundant mucous expectoration. Her breath now exhaled a 
 gangrenous odour, and her expectoration, now resembling thin 
 flummery, also became foetid. The left side of the chest was 
 oedematous, and there was slight pain beneath the left breast, 
 where there was also considerable tenderness, but no redness of 
 the integuments was observed. The patient was aphonious. 
 On the following day a small portion of integument immediately 
 below the left nipple was observed to be swollen and exceedingly 
 tender. In the course of three days this part (which had been 
 poulticed) exhibited a distinct tumour manifestly containing 
 fluid. The whole side was extremely tender, and- when the 
 patient coughed the tumour was protruded against the fingers, 
 conveying the sensation given by a hernia ; in its centre a 
 diastolic throb could be felt corresponding to the action of the 
 heart. The breath continued horribly foetid — there was no 
 sweating, and the pulse was about 100 and feeble. Decubitus 
 on back. 
 
 The tumour daily increased, feeling elastic, and still pulsating. 
 The whole of the anterior and lateral portion of the side was 
 excessively tender and completely dull on percussion. In the 
 upper portion of the left lung gurgling could be heard. She 
 now became afi'ected with diarrhoea. The tumour continued to 
 enlarge and pulsated vdth. much force ; when pressed upon 
 extreme pain darting round to the spine and shoulder was pro- 
 duced, and the shoulder itself was exquisitely tender. The 
 tumour soon became red at the point, and surrounded by large 
 veins, it became exceedingly prominent when she sat up or 
 coughed, and a diastolic pulsation could now be felt over its 
 whole surface. 
 
 The respiration under the left clavicle was bronchial, and the 
 same character existed posteriorly where loud resonance of the 
 voice and a muco-crepitating rale were perceived. Her pulse 
 rose to 130 — no sweating was present. The cutaneous veins 
 formed a complete network over the afi'ected side.
 
 530 DISEASES OF THE PLEURA. 
 
 On the 20th October she expectorated a large quantity of 
 opaque puriform matter, which was horribly fcetid ; it was 
 mixed with white flakes like curd. The diarrhoea continued. 
 The following day the tumour burst, and discharged not less than 
 six pounds of purulent matter of most extreme fcetor. The 
 diarrhcfia now ceased, the cough became less troublesome, and 
 the expectoration was diminished. 
 
 Thus within forty-eight hours two modes of evacuation were 
 established — one by the lung, possibly by a vicarious secretion — 
 the other by perforation of the integuments. 
 
 The second stage of the case may be held to commence at this 
 period. More than a pint of puriform matter continued to be 
 discharged daily frona the orifice. The opening was about a 
 quarter of an inch in length, and the eighth of an inch in breadth ; 
 and the passage of the external air through it was attended with 
 some remarkable phenomena. At every inspiration the air rushed 
 in, while during expiration the integuments were puffed out. On 
 applying the stethoscope, extraordinary sounds were observed to 
 attend the passage of air through the fistula. They were com- 
 pared by the reporter of the case to a distant caterwauling, while 
 they sometimes resembled the whistling of the wind through a 
 ruined house. It was remarked that these sounds were only pro- 
 duced for about half-a-minute after the patient sat up — they then 
 ceased, and were replaced by a feeble respiratory murmur. We 
 could reproduce them by making the patient lie down for a short 
 time, and then resume the erect position. Her general condition 
 was now improved, her appetite returned, her looks and sleep were 
 better, and her pulse 95, and stronger. 
 
 This amendment did not^ however, long continue. Copious 
 discharge took place from the opening whenever the patient 
 coughed. She had abundant expectoration of a greenish mucus. 
 The physical signs continued the same, with occasional metallic 
 phenomena, heard posteriorly, or in the front of the chest. The 
 sounds of the heart now became louder over the left than the 
 right side. There was no sweating, the diarrhoea had ceased, 
 and the expectoration had lost its foetor. Her weakness increased. 
 On the 30th October, a copious discharge of purulent matter 
 mixed with blood escaped from the wound, leaving her in the 
 lowest state of debility. From this period to the time of her 
 death, which occurred on the 10th December, her symptoms
 
 DISEASES OF THE PLEURA. 531 
 
 underwent but little change ; copious discharges of foetid matter, 
 often amounting to four pounds in the day, took place from the 
 orifice. The whistling sounds and metallic phenomena were 
 occasionally audible for a few moments after she sat up — the 
 latter could be heard posteriorly where the respiration was bron- 
 chial, and the sound clear on percussion. There was a strong 
 pulsation present at the right sterno-clavicular articulation ; the 
 heart's sounds continued loud, and it communicated its impulse 
 to the entire chest. Her appetite became good, but she had 
 diarrhoea occasionally. At one time the passage of air through 
 the aperture produced a gurgling sound, so loud as to be audible 
 at a distance from the patient's bed. 
 
 Towards the close of the case, the discharge greatly diminished, 
 but owing to the extreme debility of the patient, we made no 
 additional examinations of the chest. It was observed, hovv^ever, 
 about a fortnight before her death, that the sounds of the air 
 passing through the fistula assumed a new character, resembling 
 in a remarkable manner the feeble cries of a new-born infant. 
 During the latter period of her life, she had neither diarrhoea, or 
 night sweats, and her appetite continued good. A sudden dis- 
 charge of about six pounds of purulent matter took place from 
 the opening three days before her death, and she sank exhausted 
 on the 10th December. 
 
 Examination. — The whole body was exceedingly emaciated, 
 and percussion over the left side of the chest elicited perfect 
 bruit de pot fcle. On turning the body on the left side about 
 three pints of a thin blackish fluid unmixed with puriform 
 matter escaped from the opening. The fourth, sixth, and seventh 
 ribs were so perfectly carious as to break down under the pressure 
 of the fingers ; the fifth was discoloured, but resisted pressure. 
 The left lung, greatly diminished in volume, was bound by strong 
 adhesions to the posterior portions of the chest and medias- 
 tinum. It was covered with dark-coloured lymph. Some softened 
 tubercle was found in the upper portion of the lung, but there 
 was no abscess or cavity ; nor could we detect any pulmonary 
 fistula. The heart, pericardium, and right lung were healthy, 
 but a small false aneurism was found at the arch of the aorta, 
 about the size of a filbert, and presenting evidences of the des- 
 truction of the internal and middle coats of the artery. The liver 
 was greatly enlarged, and formed adhesions with the spleen. 
 
 M M 2
 
 532 DISEASES OF THE PLEUEA. 
 
 This case, tliough greatly reduced from the original report, 
 may be by some considered as given too much in detail, but this 
 Avill not be the feeling of the earnest student of medicine. It 
 exhibits two distinct periods — one antecedent to the formation of 
 the external fistula — the other subsequent to this occurrence. In 
 the first of these periods, in addition to the symptoms and signs 
 of empyema following an attack of pleurisy, we observed some 
 unusual phenomena, viz. : — 
 
 I. The fine and superficial metallic crepitations. 
 
 II. The ticking sound corresponding to the action of the heart, 
 and only occasionally audible. 
 
 III. The strong pulsations at the right sterno-clavicular arti- 
 culation, contrasting strongly with the condition of parts at the 
 left side. 
 
 IV. The metallic tinkling in the cardiac region. 
 
 V. The occurrence of foetid expectoration. 
 
 VI. The extreme pain and tenderness over a large surface of 
 the affected side. 
 
 VII. The appearance of the external abscess, with a gradually 
 extending diastolic pulsation, and a varicose state of the cutaneous 
 veins. 
 
 The second stage of the case is marked by the almost simul- 
 taneous occurrence of copious evacuations by the lung, and the 
 bursting of the external abscess. 
 
 The signs of pneumothorax now became Avell-marked, and 
 singular acoustic phenomena are found to attend the entrance and 
 exit of air through the external fistula. 
 
 There are, however, some indications of relief. The diarrhoea 
 nearly ceases, and the appetite returns ; but the patient gradually 
 sinks, and finally dies exhausted from the discharge, which was 
 not only unceasing, but occasionally took place by a sudden erup- 
 tion of a vast quantity of puriform and foetid matter. 
 
 It is difficult to say whether the metallic phenomena observed 
 during the first period of the case, were indicative of any pul- 
 monary fistula, or whether they proceeded from decomposition of 
 the secretion existing in the pleura. It is true that we dis- 
 covered no fistula on dissection, but it is possible that such might 
 have existed in the earlier periods of the case, and have become 
 obliterated or hidden during the progress of the disease. On the 
 other hand, the absence of the more ordinary signs of pneumo-
 
 DISEASES OF THE PLEURA. 533 
 
 thorax from fistula, combined with the foetid character of the 
 secretion from the lung, makes it probable that the air was pro- 
 duced by the decomposition of the fluid. It is very likely that 
 death of the rib took place at a very early period, and that a 
 putrefactive process had engaged the whole of the empyema long 
 before the occurrence of the external opening. 
 
 It is further probable that the secretion from the mucous mem- 
 brane, not only of the lung, but also of the intestinal surface, 
 was more or less vicarious. On this subject we will speak further 
 hereafter. 
 
 The last point in this case worthy of the practical physician's 
 notice, is the temporary alleviation of symptoms which followed 
 the discharge through the external fistula. Is this to be accounted 
 for by assuming that the patient was relieved from the pressure 
 of a vast quantity of fluid ? Or should we take a less mechanical 
 view of the matter, and suppose that the getting rid of a quantity 
 of putrid fluid was followed by relief of those constitutional 
 symptoms which arise from the absorption of a septic poison. It 
 is probable that both causes acted. We see in cases of para- 
 centesis of the thorax in empyema with pulmonary fistula, that a 
 temporary relief is sometimes produced, although the lung is 
 unable to expand — a circumstance which sometimes misleads the 
 physician by inducing him to believe that the operation was suc- 
 cessful or at least justifiable. And, on the other hand, we know 
 that in gangrene of the lung, suspension of putrefactive action is 
 followed by great alleviation of the constitutional symptoms. 
 
 I think we may divide cases of empyema into three classes : 
 in the first, absorption and cure take place ; the second differs 
 from the first in this, that although inflammatory action ceases, 
 absorption does not take place, and a condition similar to chronic 
 abscess is induced, an unchanging passive condition ; while in 
 the third case, we may observe a constant pathological activity 
 tending to the reproduction of morbid secretion, to the dis- 
 organization of the surrounding parts, to the irritative nutrition, 
 or to venosis of the ribs, and attended by various efforts of 
 nature to get rid of the purulent secretion. The vicarious 
 secretions, the oedema of the surface, the perforation of the 
 lung, the mortification or hyperosteosis of the rib, the formation 
 of the subcutaneous abscess with or without destruction of the 
 pleura, are all indicative of an unceasing pathological process,
 
 534 DISEASES OF THE PLEURA. 
 
 the symptoms and signs of which, though reducible to a general 
 expression, greatly vary not only in different cases, but also at 
 different periods of the same case ; nor can we always find on 
 dissection the explanation of the various and singular phenomena 
 which have occurred during life ; for where the disease exists 
 for a great length of time, successive changes are constantly 
 occurring, while the disease process, in developing new altera- 
 tions, obliterates the signs of former changes. I have made use 
 of the expression "effort of nature" rather because it is com- 
 monly used than from any belief that it implies any special new 
 or directly sanative vital action. If there be any meaning in 
 the term, vis medicatrix nature, it must be that it implies an 
 influence antagonistic to, and therefore different from that of 
 disease. But in closely studying these cases of evacuations of 
 the fluid of empyema by solutions of continuity it appears that 
 the result in question follows from the continuation, and perhaps 
 aggravation of the original disease, rather than from the setting 
 up of any new process. Practically we find that in these cases 
 the disease has been either unusually violent or improperly 
 treated at the commencement. The diseased action once set 
 up, seems never to cease or change, and it appears difficult to 
 call that a sanative process which, while it may indeed cause an 
 evacuation of the fluid, converts the whole side of the chest into 
 a bony cuirass, sets up mortification of the ribs, and hopeless 
 disorganization and atrophy of the affected lung. These results 
 then are less to be considered as efforts of nature than as the 
 disorganization of uncured and progressive inflammation. 
 
 There are other important points illustrated by the case of 
 Egan ; the simulation of tubercular abscess, the pulsation of 
 the empyematous tumour, the development of a local emphy- 
 sema in the walls of the chest, and vicarious secretion from the 
 mucous membrane of the lungs. 
 
 As to the first, it appears probable that pending the existence 
 of a chronic empyema, two conditions may arise, which will 
 cause the development of the signs of a pulmonary cavity ; and 
 yet on dissection no satisfactory evidence of such a lesion shall 
 be discovered. Air may really exist in the compressed lung, 
 and after exhibiting the usual signs become obliterated, either 
 by compression or other pathological causes, so tbat on dissec- 
 tion it will be impossible to demonstrate that any such lesion
 
 DISEASES OF THE PLEUEA. 535 
 
 had existed. But this appears to be the exceptional case, and 
 there can be but little doubt, that in most instances, "wheij, 
 in combination with a decided case of empyema exhibiting the 
 signs of excentric pressure, we find distinct and circumscribed 
 gurgling, the sign is caused by a copious secretion, which is 
 generally vicarious, in the compressed lung. There is some- 
 times added bronchial respiration, easily mistaken (under the 
 circumstances) for cavernous breathing, and the voice may be 
 almost articulate, so that the simulation of the signs of cavity 
 is so complete as easily to deceive an observer, who is not aware 
 of these facts. Indeed, so complete is the resemblance of the 
 signs to those of a cavity that even an experienced stethoscopist 
 is obliged to trust for his opinion as to their cause less to 
 their actual character than to the circumstance of co-existing 
 empyema. 
 
 The communication of impulse to the fluid of empyema has 
 been, I believe, in most cases observed when the effusion occu- 
 pied the left side. At least such cases as I have seen and read 
 of were of this description. But it is by no means impossible 
 that a pulsating empyema might occur on the right side. Such 
 an occurrence might be expected if the heart was greatly dis- 
 placed towards the left, and especially if, in addition, its action 
 was much excited. 
 
 The pulsations are of two kinds — general and local. In the 
 first, the whole sac pulsates ; in the second, this sign appears to 
 be confined to the tumour, which has made its way through 
 the ribs, constituting the " emjjyema of necessity " of authors. 
 
 Dr. M'Donnell has published three remarkable cases of the 
 latter form of disease, to which he has given the name of " pul- 
 sating empyema of necessity." One of these cases occurred in 
 the Meath Hospital, and two were under the care of Dr. Graves 
 in private practice. 
 
 In the first of these cases, the patient had laboured under 
 chronic pleuritic efi"usion for about ten weeks, when the signs of 
 external pointing became manifest. A small tumour, whenever the 
 patient coughed, shewed itself below the nipple, where previously 
 there had been tenderness, but without dislocation or oedema. 
 When she lay on the left side the tumour became enlarged, but 
 receded when she turned on the right. It had a distinct pulsation, 
 and it soon increased in size. In about a fortnight it equalled that
 
 536 DISEASES OF THE PLEURA. 
 
 of an orange. The tumour was red and shining, and had a strong 
 diastolic pulsation, which was equally vehement at every point. 
 There was neither soufflet nor fremitus. In a few days the 
 tumour burst, and an external fistula was established, with the 
 signs of pneumothorax. After some time she sank, exhausted, 
 from the discharge. Dissection shewed the lung compressed, 
 shrivelled, and bound down by strong adhesions. Its upper 
 portion contained softened tubercles. The fourth and sixth 
 ribs were carious and their periosteum in a state of slough. 
 The external integuments M^ere separated from the ribs for a space 
 of about two inches in diameter. 
 
 In Dr. M'Donuell's second case, two pulsating tumours 
 existed ; one over the region of the heart's apex ; the other 
 posteriorly, and appearing between the tenth and eleventh ribs, 
 at a distance of about two inches from the si^ine. Both these 
 tumours had the size of a Seville orange, and presented some 
 enlarged veins around their bases. They had a visible diastolic 
 pulsation, without bruit de soufflet, or thrill, and the force of the 
 anterior tumour was, when I saw the patient, extremely great. Dr. 
 M'Donnell observed that percussion on one tumour caused evident 
 liuctuation in the other. The integuments were not inflamed 
 or oedematous, nor was any pain felt by the patient when these 
 tumours were handled. The afl'ected side, when Dr. M'Donnell 
 saw the patient, was not increased in size, nor had it the barrel 
 shape so often observed in emj^yema. Mr. Cusack saw this 
 patient in consultation with Drs. Graves, M'Donnell, and 
 myself, and the tumours were successively punctured. It was 
 found that though the pulsation was greatly diminished, it still 
 was perceptible in the collapsed state of the abscess, and that 
 after some time the anterior tumour pulsated as strong as in 
 the first instance. After a period of some weeks this patient's 
 health greatly improved, but he finally sank with symptoms of 
 phthisis. There was no dissection. 
 
 The third case was also an example of double pulsating tumours, 
 presenting in the same, or nearly the same, situations, as in the 
 last example, and like it, characterized by the diastolic throb, 
 and absence of souffiet or fremitus. To comj^lete the resem- 
 blance, these tumours were indolent, and unattended by any 
 indication of integumental disease. The case appeared originally 
 to have been one of empj-ema and pneumothorax.
 
 DISEASES OF THE PLEURA. 537 
 
 If we now take a review of these three cases, we find iu them 
 examples of localized pulsating tumours, where the impulsive 
 force was communicated by a dislocated heart. In one, the 
 pathological condition of parts was peculiar, as shewn by the 
 rapid disorganization, the perforation of the integuments, and the 
 caries of the ribs ; while in the two last, the pathologic process 
 appears to have been arrested, leaving an abnormal condition of 
 a purely mechanical nature. We cannot yet say with certainty 
 whether in these cases the diastolic pulsation was communicated 
 to the contents of the pleural sac ; but that it must have been so 
 to a certain degree, although perhaps imperceptible to observation, 
 appears clearly from the fact that the superficial tumours ex- 
 hibited this strong pulsation, a pulsation which we cannot but 
 believe to have been analogous to that of false aneurism, and 
 produced by the operation of the same hydrostatic law. 
 
 Our practical and anatomical knowledge of this condition is 
 limited ; but comparing these pulsating tumours with false 
 aneurisms, we find a certain resemblance in the mechanical 
 relations and conditions of both ; in both we have a sac con- 
 taining fluid, and communicating by a fistula with another 
 reservoir also containing fluid. Here, however, the analogy 
 becomes less distinct, inasmuch as, that in aneurism, the second 
 reservoir or the artery exhibits a current of fluid, while in 
 empyema there is no current, but simply a succession of 
 impulses from without. And accordingly we find that as yet 
 no case has been observed of murmur or fremitus in these 
 pleural aneurisms, if we may use such a term. 
 
 This communicated pulsation in empyema may also be classed 
 with that of the fluid or semi-fluid cancers which lie in contact 
 with great vessels, the phenomena of wiiich, as occurring in the 
 thorax, I first described some years since. 
 
 We are yet unable to say why it is that in one case of the em- 
 pyema of necessity there should be pulsation, while in another 
 this condition is absent ; but it must not be forgotten that in 
 many cases we only observe and record the maximum state of 
 phenomena, whose existence is overlooked in their minor degrees 
 of development, from inattention on the one hand and from defi- 
 ciency in our means of observation on the other. On this subject it 
 is interesting to remember that in the second case a feeble 
 pulsation remained in the tumour after it was punctured.
 
 538 DISEASES OF THE PLEURA. 
 
 We must then admit three cases of empyematous pulsation. 
 
 I. Pulsating tumour with progressive disorganisation of the 
 integuments, indicated by pain, tenderness, a red and shining 
 state of the skin, and terminating speedily in external fistula. 
 
 II. Pulsating tumour of a very chronic nature, without integu- 
 mental irritation, and apparently exhibiting no tendency towards 
 external fistula. The duration of this condition may be very 
 considerable. 
 
 III. Pulsation of the entire empyematous sac, occurring with- 
 out any subtegumental abscess. Of this very singular condition 
 the following is a striking example : — 
 
 Obs. — Acute pleurisy with effusion — passage into the chronic 
 condition — dislocation of the heart to the right side — great accu- 
 mulation of fluid, attended by diastolic pulsation of the entire 
 left side of the thorax — operation of paracentesis thrice repeated — 
 return of the pulsation ivith each accumulation of fluid. 
 
 A gentleman, aged about twenty-five, was attacked, after 
 attending the races at Newmarket, with symptoms of acute in- 
 flammation of the left pleura, which in a short time passed into 
 that fallacious state of latency, so fertile a source of dangerous 
 error to the patient and the physician. After some weeks, how- 
 ever, the sj^mptoms of accumulation became too manifest to be 
 overlooked, and he was again placed under medical care, yet with- 
 out any impression being made on the disease. He came to 
 Dublin with the left pleura completely filled, the lung compressed, 
 and the heart pulsating two inches to the right of the sternum. 
 Notwithstanding this great amount of local disease, his consti- 
 tutional symptoms were but trifling, his strength was consider- 
 able, his appetite excellent, and his spirits and sleep unimpaired. 
 It soon became manifest that nothing could be expected from 
 medicine, for the period at which its effects could have been bene- 
 ficial had long passed by. We found that a general but not very 
 violent pulsation could be felt over the whole of the left side. It 
 was not stronger in one portion than another, nor did there appear 
 any tendency towards the formation of an external abscess. The 
 side was dilated to a considerable extent, absolutely dull on per- 
 cussion ; while the suffering of the patient from the mechanical 
 pressure of the fluid, was every day increasing. 
 
 The chest was punctured in the usual situation, and several 
 pounds of a serous fluid drawn off. The operation was followed by
 
 DISEASES OF THE PLEURA. 539 
 
 great relief of the dyspncea. The pulsation of the side ceased, 
 and the anterior portion of the chest became sonorous on per- 
 cussion. The sound, however, was not that caused by a healthy 
 lung, but rather of that tympanitic character which we observe 
 in cases of empyema and pneumothorax, when a thin stratum of 
 air is interposed between the liquid and the parietes of the chest. 
 It was however found that little or no change took place in the 
 position of the heart, nor did the stethoscope indicate any decided 
 expansion of the compressed lung. 
 
 Notwithstanding these circumstances the patient experienced 
 extraordinary relief for many days, so much so, indeed, as to in- 
 duce him to believe that his disease had been finally removed. 
 He went into society, and took active exercise daily : but it soon 
 became evident that the effusion was on the increase. The tym- 
 panitic sound anteriorly disappeared, and was replaced by com- 
 plete dulness, and the pulsation of the affected side became not 
 only manifest, but increased daily, until it reached a degree of 
 violence never presented before the operation. The throbbing of 
 the side could be seen when the patient was dressed, or even when 
 he lay in bed covered with bed clothes. When the hand was placed 
 on any portion of the left side, an impulse as strong as that of a 
 large false aneurism was perceptible. This was equally observable 
 in the acromial region, as in the lateral, and most inferior portion 
 of the chest. The heart pulsating in the right mammary region 
 conveyed the idea of a somewhat excited action ; there was at least 
 greater excitement than is ordinarily seen in dexiocardia. 
 
 The operation was a second time performed, though with a 
 diminution of the resulting benefit ; the fluid now drawn off was 
 more turbid, and the quantity removed not less than from seven 
 to eight poujids. This second operation, like the fii-st, was fol- 
 lowed by temporary relief, and by the same modification of the 
 physical signs. The heart, however, seemed fixed in the right side 
 of the chest — at least it certainly never passed the mesian line. 
 A third time the chest filled, and with greater rapidity than 
 before, and the pulsation became so violent as to disturb the 
 patient's rest from the throbbing of the side. It is difl&cult to 
 convey an idea of this extended diastolic pulsation. 
 
 At the urgent entreaty of the patient, the operation was a 
 third time performed, and a vast quantity of sero-purulent matter 
 mixed with the colouring particles of the blood, was withdrawn.
 
 540 DISEASES OF THE PLEURA. 
 
 On this occasion, however, but little relief was afforded ; the 
 system was evidently giving way ; the fluid re-accumulated ; 
 irritative fever set in ; and the throbbing of the side was re- 
 established, though not with the same violence as before. The 
 patient sunk exhausted, and wdth bronchial effusion. 
 
 The operations in this case were performed by Mr. Cusack, but 
 after the result of the first puncturing of the chest, neither that 
 eminent surgeon nor I entertained any hopes of the patient's 
 recovery. For the non-expansion of the lung, while the heart 
 remained little if at all changed in its position, to say nothing of 
 the rapid refilling of the pleura, were grounds for the most un- 
 favourable prognosis ; the subsequent operations were performed 
 solely W'ith a \'iew of giving the patient some temporary relief. 
 
 The great interest in this case consists in the occurrence of the 
 extraordinary diastolic throbbing of the affected side. Of the 
 force of this pulsation, it is difficult to convey an idea, exceeding 
 as it did in strength and extent that of the largest aortic aneu- 
 risms I have ever seen, and the force of this pulsation was always 
 observed to be at its maximum, when the effusion and conse- 
 quently the pressure was at its greatest height. The diminished 
 throbbing, in the latter stages of the case, may be attributed to 
 the lessening energy of the heart ; and it appears not improbable 
 that this communicated pulsation does really occur in many cases 
 of empyema, with dislocation of the heart, but remains unrecog- 
 nized, either from its feeble development, or from the fact that 
 observers being ignorant of its existence take no pains to dis- 
 cover it. 
 
 In cases, such as Egan's, where the heart was to the right of 
 the sternum, and pulsations could be seen, felt and heard in the 
 left submammary region, I have no doubt that the sounds w^ere 
 those of the heart transmitted across the lymphic effusion ; but 
 it is still a question whether sounds shnilar to those of aneurism 
 do really attend pulsations of an empyema. 
 
 Connected with the subject of the external pointing of an 
 empyema, the development of a local emphysema in the walls of 
 the chest, is a condition deserving of some special consideration. 
 It would appear that in certain cases the attempt at the formation 
 of an external abscess is abortive, or at least, that after a certain 
 period the evidences of the latter condition disappear, ^vhile those 
 of the original effusion remain unchanged. Some peculiar cir-
 
 DISEASES OF THE PLEURA. 541 
 
 cumstances attend tliis effort, especially the coexistence of the 
 sign of an seriform secretion in a circumscribed portion of the 
 chest, corresponding to tlie situation of the threatened abscess. 
 Good reasons exist for believing, whatever may be the source of 
 this gaseous secretion, that it is influenced in its quantity and 
 motions by the respiratory acts. Its existence is made manifest 
 by an emphysematous crackling over the part affected, by crepi- 
 tation of a metallic character, and evidently superficial, and lastly, 
 by those extraordinary acoustic phenomena, which were observed 
 in the case of Mason. With respect to the source of this air, w^e 
 are in doubt, and we are not yet in a position to say whether it 
 proceeds from a pure secretion, or is communicated through some 
 fistula, or solution of continuity, between the bronchial tubes 
 and the pleura. I had once an opportunity of witnessing a case, 
 where a tortuous fistula had been established, in consequence of 
 some adhesion of the lung between the bronchial tubes and an 
 external abscess. 
 
 The patient had suffered from symptoms of tubercular disease, 
 and had for some time presented the ordinary signs of cavity in 
 the upper portion of the lung. He became affected with pain and 
 swelling of the soft parts of the shoulder ; the tumefaction ex- 
 tended in a short time as far as the apex of the scapula. When 
 I saw this patient he presented an oblong flattened tumour 
 extending from the acromial to the infra-scapular region. On 
 percussion this tumour rendered an exaggerated bruit de j^ot fele, 
 while the touch conveyed the idea of a large quantity of liquid 
 and air. A singular metallic gurgling sound was everywhere 
 audible, and the volume of the tumour as well as the physical 
 signs were influenced by the cough and respiration. The signs 
 of the pulmonary cavity remained unchanged, while the ex- 
 amination of the lower portion of the chest shewed that no 
 separation of the pleura had taken place. 
 
 On dissection a fistulous passage was discovered, springing 
 from the tuberculous cavity, and passing upwards from the 
 anterior edge of the clavicle, towards the acromial process, where 
 it opened into a wide irregular cavity, containing purulent matter 
 and air, bounded by the integuments on the one side, and by the 
 layers of the scapular muscles on the other. 
 
 We may now turn our attention to the interesting subject, of 
 vicarious secretion from the bronchial mucous membrane, an
 
 542 DISEASES OF THE PLEUEA. 
 
 example of which is met with in the case of Egan. The late 
 Professor Greene in his memoir On Empyema, details some 
 cases of the empyema of necessit}^ remarkable amongst other 
 circumstances, for the fact that a vicarious secretion was 
 established. In his three first cases, coincident, or nearly so 
 with the appearance of the tumour, a profuse muco-purulent 
 expectoration existed ; but which greatly subsided, or altogether 
 disappeared after the puncture of the abscess. No evidence of 
 pneumothorax or pulmonary fistula existed in these cases, nor 
 is there the slightest reason to believe that there was any per- 
 foration of the pulmonary pleura. In one of these cases, when 
 the discharge from the wound was temporarily arrested, there 
 was a return of the secretion from the bronchial tubes ; his 
 fourth case has this peculiarity, that it presents the same phe- 
 nomena of vicarious secretion as in the former instances, which 
 also ceased, after the operation; notwithstanding that both lungs 
 were studded with tubercles, which in the left lung, the one 
 unafi'ected by empyema, were actually in a state of softening 
 to such an extent as to leave excavations of the size of large peas. 
 This case is also of great importance as showing that the 
 expectoration did not proceed from a communicated abscess in 
 the lung, or from a fistulous communication with the cavity of 
 the pleura. Dr. Greene expresses his opinion that its sudden 
 disappearance, after an external opening for the matter had been 
 made, proves that it was not the result of bronchitis. 
 
 Another singular fact connected with this subject has been 
 noticed by Dr. Graves, who observed it in two cases ; one of which 
 he communicated to the Dublin Pathological Society — it was, 
 that the foetor of the expectoration ceased on the external opening 
 having been effected ; and in one of these cases, the temporary 
 closure of the wound was followed by the return of the fdstor in 
 the bronchial secretion. 
 
 Are we to consider these cases as examples of chronic bron- 
 chitis superadded to pleurisy, or is the copious discharge an 
 excretion rather than a secretion of the mucous membrane ? 
 The latter opinion is espoused by Drs. Greene and Hutton, both 
 of whom find in the analogies of other forms of purulent col- 
 lections, very strong grounds for the adoption of it. And, 
 indeed, to sum up this interesting subject, we cannot do better 
 than insert here, some of the conclusions, to which Dr. Greene
 
 DISEASES OF THE PLEURA. 543 
 
 was led, from an examination of the cases published in his 
 memoir. 
 
 " I. That in cases of effusion into the pleural cavity a copious 
 and purulent expectoration, is a frequent accompaniment, 
 depending, in some instances, on a fistulous communication 
 established between the seat of the collection, and a bronchial 
 tube, and that when such a communication has taken place, it 
 may be recognized by well known and characteristic signs. 
 
 "II. But that, in other instances, the expectoration may be 
 equally copious, and purulent, while all the physical signs of 
 such a communication are absent, and where, consequently, the 
 symptom in question cannot be referred to such a lesion. 
 
 "III. That an expectoration of a similar character will also 
 occur in some cases of empyema, uncomplicated with tubercular 
 excavations, or with abscesses, the result of pneumonia, as can 
 be proved — first, from the absence of the physical signs indicative 
 of these lesions ; and secondly, by a consideration of the follow- 
 ing phenomena : — 
 
 " IV. That remarkable changes take place in the expectoration, 
 as soon as a free external outlet is afforded for the matter : it 
 will be then observed to have rapidly diminished in quantity, 
 and to have changed from the puriform to the mucous character, 
 and in some instances to have lost its fcetor. 
 
 " V. That if the external opening becomes closed, the expec- 
 toration will again become copious, and will re-assume its 
 puriform character and fcetor. 
 
 " VI. That as these phenomena cannot be accounted for on 
 the supposition that the expectorated matter is the product of 
 bronchitis, or that it is received into the bronchial tubes by their 
 communication with purulent deposits in the lung, or with the 
 collection in the pleural sac, an explanation must be sought for 
 in some general law which establishes a reciprocity of morbid 
 actions between serous and mucous surfaces. 
 
 " VII. That many examples of the force of this law are afforded 
 in what have been termed ' criticalevacuations ' ; as for instance, 
 where morbid collections in the peritoneum have been suddenly 
 transferred to the intestinal mucous surface, independently of the 
 processes of adhesive inflammation and ulceration ; and that 
 there is no reason, a priori, why this law should not occasionally 
 obtain between the respiratory, serous, and mucous membranes.
 
 544 DISEASES OF THE PLEURA. 
 
 " VIII. That a recollection of tliis law may be of practical 
 importance, because in cases where the physical signs of cavities 
 in the lung are obscure, we should not allow our opinion to be 
 biased in favour of these lesions, by taking the expectoration, 
 however copious and purulent, into consideration, inasmuch as 
 it may be the result of the general law just referred to, and if so, 
 should not form a ground of objection to the operation of 
 paracentesis. 
 
 " IX. That even when the physical signs of a cavity appear to 
 be better marked, they may be still deceptive, owing first to the 
 great accumulation of matter in the bronchial tubes ; and, 
 secondly, to the compressed condition of the lung around thcra, 
 whereby the natural phenomena of the voice and respiration 
 are so modified, that when, combined with the loud gurgling 
 nile in the tubes, they may be mistaken for the signs of a cavit3\ 
 
 " X. That these fallacious signs will be found in greatest 
 intensity at the root of the lung, and will disappear more or less 
 quickly after the operation, in proportion to the power of 
 expansion possessed by the lung, when the fluid in the pleura, 
 which is the cause of the compression, is removed. 
 
 " XI. That one of the grounds for diagnosis, in such cases, is 
 the proximity of the signs to the root of the lung ; if they 
 diminish in intensity from this situation, they will depend on the 
 causes just assigned ; if on the contrary they are found at the 
 apex of the lung, or any part distant from the root, they may 
 either depend on cavities, or on an enlarged bronchial tube." 
 
 The subject of the vicarious secretion in empyema leads us 
 naturally to examine that class of cases in which an hepatic 
 abscess is supposed to open into the lung, and evacuate its 
 contents, through the bronchial tubes. There seems to be good 
 grounds for believing that these cases are of two kinds ; in one, 
 certainly, a direct passage through the diaphragm takes place ; 
 on this subject, we must refer to where we speak of perforating 
 abscess of the lung ; in the second class, there is no solution of 
 continuity of the diaphragm or lung, but the latter organ takes 
 on the vicarious action. Dr. Corrigan in the Transactions of the 
 Pathological Society of Dublin, has recorded a case, in which 
 there was no perforation of the pleura, yet where the lung secreted 
 a matter of the same nature, as that which was found in the 
 hepatic abscess.
 
 DISEASES OF THE PLEURA. 545 
 
 When a patient, who has already been labouring under empyema, 
 with or without those sufferings which arise from the mechanical 
 pressure of the fluid, is suddenly, and for the first time, attacked 
 with the symptoms of suffocative catarrh, attended by copious 
 expectoration of purulent fluid, we may suspect that a fistulous 
 passage has been formed between the pleura and bronchial 
 tubes. In forming this diagnosis, however, we must not neglect 
 the possibility of it being a case of the vicarious secretion just 
 now spoken of. 
 
 The fluid discharged in these cases is sometimes inodorous 
 and sometimes foetid ; after the lungs have recovered from the 
 first shock of the accident, and especially if the discharge have 
 not the gangrenous foetor, a favourable result may be anticipated. 
 Even in the case in which the fluid, as originally discharged, has 
 the gangrenous odour, and where this condition is developed after 
 a certain period of time, recovery not unfrequently takes place. 
 
 I am not in a position to state what proportion of these cases 
 presents for a time the signs of fistular pneumothorax. Reason- 
 ing, a priori, we should say that this complication would neces- 
 sarily occur in all cases, but I think it almost certain that we 
 may have the opening of an empyema into the lung without 
 consequent pneumothorax. When, however, it does occur, it is 
 temporary, and we hence derive a distinction between the cases 
 of empyema and pneumothorax, most important in relation to 
 prognosis. 
 
 First. Formation of the fistula from without, iuM-ards, as in 
 the case of a simple empyema bursting into the lung. 
 
 Secondly. Formation of the fistula from within, outwards, as 
 where a tuberculous, or gangrenous cavity, perforating the 
 pulmonary pleura, directly induces an empyema and pneumo- 
 thorax. 
 
 In the first of these cases, a cure is possible and probable ; 
 in the second, from obvious considerations, such a result is 
 hardly to be expected. 
 
 Of the first form, the following case is a good illustration : — 
 
 Case. — Obs. — Acute pleurisy passing into the chronic stage — 
 opening of the empyema through the lung — extraordinary foetor 
 of the discharge — fistular pneumothorax — signs of recovery, with 
 singular contraction of the side. 
 
 A gentleman, aged 23, after having been attacked with 
 
 N N
 
 546 DISEASES OF THE PLEURA. 
 
 symptoms of acute pleurisy, presented the usual phenomena 
 of chronic indolent effusion into the left pleura. The disease 
 resisted treatment, and the side remained extensively dull, when 
 he suddenly hegan to expectorate foetid muco-purulent fluid in 
 great quantities. I saw him soon after this change in the 
 symptoms. So intense was the foetor, that the odour could he 
 perceived in every part of his large mansion. He was in a state 
 of extreme weakness, and consumed hy a low remittent hectic. 
 The weather was extremely hot, and the sufferings of the patient 
 from fever and exhaustion so great as to cause the most serious 
 apprehensions. I recommended a tonic regimen, and that he 
 should be brought out every day into the open air. Pills of chlo- 
 ride of lime and opium were also prescribed, with a view of correct- 
 ing the septic action. It was remarkable that on the first and 
 second occasions of his attempt to take the air in an open car- 
 riage, he and his attendants were literally driven back by the 
 myriads of flies which, attracted by the odour, pursued and 
 settled on his person and equipage. This gentleman finally 
 recovered, but with a degree of contraction of the side and 
 depression of the shoulder greater than has been, so far as I 
 know, ever recorded. Many years have now elapsed since the 
 attack, and he has enjoyed an excellent state of health ; and, 
 singular to say, has presented no symptoms even of chronic 
 bronchitis, much less of phthisis, or cirrhosis of the lungs ; 
 his left shoulder has remained permanently depressed to the 
 extent of nearly three inches below the right. 
 
 It is easy to understand how, under the circumstances of this 
 case, the cure would not be possible without an extreme con- 
 traction of the side. This patient had a lung long compressed, 
 and diminished in volume by a copious pleuritic effusion, which 
 was removed, not by absorption, but by direct evacuations 
 through the lung, an accident which by the formation of the 
 fistula presented an insuperable obstacle to the re-expansion of 
 the organ, so that the extreme degree of contraction was a neces- 
 sary condition of the final removal, by the efforts of nature, of 
 the liquid and air in the cavity of the pleura. 
 
 Differential Diagnosis. — The diseases which may be mis- 
 taken for pleuritis with effusion, or vice versa, are- 
 Tubercle of the lung. 
 Pneumonia, in the stage of hepatization.
 
 DISEASES OF THE PLEUEA. 547 
 
 Enlargement of the liver. 
 
 Hydrothorax. 
 
 Cancer of the lung, or mediastinum. 
 
 Hydatid of the lung. 
 
 The cases generally mistaken for tubercle are of two kinds : 
 there is either a circumscribed and chronic effusion, -which may 
 exist without much eccentric displacement, or there may be a 
 copious subacute effusion compressing the lung, and occurring 
 in a lymphatic subject. 
 
 In the first case, we generally find that the health does not 
 suffer in proportion to the extent of the disease as indicated by 
 the stethoscope. The dulness is complete, as is also the absence 
 of rale, and often of respiration ; although when these signs 
 occur in the lower portion of the chest, we have a group quite 
 unlike the phenomena of phthisis ; yet when they are produced, 
 by a circumscribed empyema, at the upper portion, as occa- 
 sionally occurs, the difficulty of diagnosis is much greater.* 
 
 Examples of the second case are by no means unusual ; a 
 child of the lymphatic temperament is attacked with pain in the 
 side, fever, and cough. Phthisis is apprehended from these 
 symptoms, and after a fortnight or three weeks, the whole side 
 is discovered to be dull. The diagnosis between this condition 
 and tubercle will be aided by a due consideration of the followinsr 
 circumstances : — 
 
 I. The absence of the constitutional suffering usually present 
 in cases of acute phthisis. 
 
 II. The fact of complete dulness of the side occurring in so 
 short a time. 
 
 III. The lung being impermeable, except perhaps in the upper 
 portion, where a feeble murmur -without rale can be heard. 
 
 IV. The signs of mediastinal displacement and distension of 
 the side. 
 
 * I some years since met with a case illustrating the above observation. A gentle- 
 man, aged 45, while in his usual state of health, was attacked with hemoptysis, which 
 recurred frequently for about a week, and was followed by the usual signs of tubercular 
 consolidation of the right apex. He shortly after passed under the care of an eminent 
 London physician, by whose advice change of climate, and other measures were resorted 
 to, but without avail. On examination of the body after death, which occurred within 
 two years from the attack, no trace of tubercle was discovered, but a circumscribed 
 collection of matter between the thickened pluera in the upper part of the chest. 
 (Ed.) 
 
 N N 2
 
 548 DISEASES OF THE PLEURA. 
 
 HEPATIZATION OF THE LUNG. 
 
 The case of pneumonia most likely to be confounded with 
 pleuritic effusion, is the rapid typhoid solidity already described. 
 In the ordinary variety, however, a doubt sometimes exists, as 
 to whether the signs proceed from effusion or solidity. 
 
 In a case, seen for the first time, with the previous history of 
 which we were unacquainted, presenting bronchial respiration, 
 and with an effusion just sufficient to compress the lung, without 
 displacing the mediastinum or side, there might be a difficulty. 
 But such a case is rare ; and in the majority of instances, the 
 phenomena of voice, and the existence at all periods of some 
 form of crepitating rale, in conjunction with bronchial respira- 
 tion, will distinguish pneumonic solidity from liquid effusion. 
 
 ENLARGEMENT OF THE LIVER. 
 
 An enlarged liver may dilate the side and cause dulness of 
 sound up to fourth rib ; in most cases, however, the dulness 
 only extends to a little above the mamma. The following cir- 
 cumstances will assist in diagnosis. 
 
 I. The absence of intercostal paralysis, or protrusion. 
 
 II. The clearness on percussion of the upper and middle por- 
 tions of the chest. 
 
 III. The loudness of respiration in the postero-inferior 
 portion, which is much greater than could be anticipated from 
 the amount of dulness. 
 
 IV. The absence of lateral displacement of the heart and the 
 existence, in many cases at least, of the vertical displacement 
 upwards. This is principally seen when the left lobe of the 
 liver is engaged. 
 
 V. The fact of the interlobular fissure being parallel mth the 
 mesian line ; for, in displacement of the liver, the pressure 
 being exercised on the right lobe, the interlobular fissure is 
 dh-ected towards the left side, and forms a considerable angle 
 with the mesian line. 
 
 VI. We find in cases of hepatic tumour, without pleuritis, that 
 the dulness of the postero-inferior portion of the side disappears 
 on the patient taking a deep inspiration, returns upon expiration,
 
 DISEASES OF THE PLEURA. 549 
 
 and remains fixed during ordinary breathing. I have never wit- 
 nessed this phenomenon in any case of empyema. I believe, 
 however, that the test is not applicable when the lower portion 
 of the pleura has been obliterated by adhesions. 
 
 TYPHOID PLEURITIS. 
 
 A close analogy exists between this afi'ection and the different 
 forms of typhoid or asthenic pneumonia ; like that disease, it 
 occurs in the debilitated, or broken down habit, or is secondary 
 to typhus fever, or some other morbid constitutional state ; it is 
 generally latent, and often pointed out more by the sinking of 
 the powers of life, than by any new suffering ; though forming 
 suddenly it is slow to be removed, is seldom uncomplicated, but 
 rather one of many secondary lesions, and does not admit of 
 active antiphlogistic treatment. 
 
 This secondary or typhoid pleuritis is met with in the follow- 
 ing cases : — 
 
 I. Typhus, or maculated fever. 
 
 II. Occurring in the course of the exanthemata. 
 
 III. In diffuse inflammation, and in bad erysipelas. 
 
 IV. In phlebitis, or purulent absorption. 
 
 Pleuritis must be considered as a rare complication of essen- 
 tial typhus. In those examples, which I have witnessed, it was 
 first pointed out, by sudden, and unaccountable sinking ; in one 
 case the effusion occurred on the sixth day, and occupied a large 
 portion of the left pleura, without pain, or distress of breathing. 
 The patient recovered from the fever, and the effusion was sub- 
 sequently absorbed ; his pulse however remained quick ; cough 
 appeared ; and phthisis was apprehended. He was carried off 
 by a sudden attack of encephalitis, and on dissection the lungs 
 were found to contain miliary tubercle ; while the left pleura was 
 obliterated. 
 
 In another case, on the fourteenth day of a severe maculated 
 fever, a sudden sinking was observed, and frottement discovered 
 over the left side. On the next day, the patient, a young female, 
 had the appearance of an individual in cholera ; she had sweated 
 copiously, and was covered with miliary eruption ; there was 
 severe orthopnoea and she speedily sank. A double effusion 
 had existed.
 
 550 DISEASES OF THE PLEURA. 
 
 The left pleura contained a large quantity of whey-coloured 
 fluid ; while in the right, the effusion was more sanguinolent 
 and serous. In both lymph occurred in a reticulated form over 
 the whole serous membrane, and also in th'e pericardium. 
 
 Similar circumstances occur in puerperal fever. Dr. Lee 
 mentions three cases in which the symptoms, during life, were 
 exceedingly obscure, yet where copious effusions occurred, and 
 the pleura was covered with false membrane. In one the 
 pleura had given way by sloughing. Similar appearances have 
 been observed by other authors. 
 
 We observe this form of disease most frequently, in the erysi- 
 pelatous diseases, particularly those of a low type ; in the diffuse 
 inflammations, and purulent phlebitis. In these cases purulent, 
 or sero-sanguinolent collections are commonly found in the 
 pleura, although during life, symptoms of pleurisy were either 
 absent, or very slightly marked. In some instances, however, I 
 have observed the invasion of the disease to be accompanied by 
 severe pain. 
 
 There is an affection which may be termed typhoid arthritis, 
 in which this secondary typhoid pleuritis is liable to occur. 
 The late Dr. M'Dowel v^^as, I believe, the first to describe this 
 disease, of which the principal characters are — the rapid tume- 
 faction and suppuration of many of the large joints, accompanied 
 with a typhoid fever, and followed by affections of the brain, 
 lungs, heart or digestive system. In such cases I have more 
 than once observed, purulent collections in the pleura, lung, and 
 pericardium. 
 
 TREATMENT OF PLEUEITIS. 
 
 It is scarcely necessary to allude here to the treatment of that 
 mild form of the disease which is known as dry pleuritis — a 
 disease not so often a primary idiopathic affection as an inter- 
 current disease, or as one coming on during the convalescence 
 from other and often totally different affections. 
 
 It is characterised by the want of severe constitutional symp- 
 toms. The pain is often trifling or may be wanting, the 
 respiration but little disturbed, and, in many cases, would elude 
 detection but for its characteristic physical signs, which are 
 the dry rubbing sound, with clearness on percussion. In such
 
 DISEASES OF THE PLEURA. 551 
 
 cases, it is often only necessary to watch the patient, so that we 
 may not be surprised by the occurrence of a liquid effusion, a 
 circumstance, however, by no means of common occurrence. 
 
 In most of these simple, dry cases the disease subsides spon- 
 taneously ; but its disappearance will be accelerated by the use 
 of a few leeches, or slight counter-irritation, or the application 
 of poultices to the side. Should the disease not yield to these 
 simple measures, change of air should be advised, and small 
 doses of the iodide of potassium given in some of the prepara- 
 tions of bark or sarsaparilla. 
 
 But the treatment of pleurisy with effusion requires a more 
 decided course of action, and we must endeavour to bring about, 
 in as short a space of time as possible, that remission of the 
 constitutional symptoms which is indicated by the cessation of 
 febrile heat and over-excitement of the pulse. Yet I am not an 
 advocate for the free or indiscriminate use of the lancet in this 
 disease. Every day's experience will make the observing prac- 
 titioner in this country more and more cautious in the adoption 
 of copious general blood-lettings. 
 
 As we cannot specify the cases in which bleeding from the 
 arm is really proper or imperative, it must suffice to point out 
 such circumstances as should induce us to use the lancet in acute 
 pleurisy. They may be stated to be — 
 
 I. The existence of a high inflammatory fever, with a strong, 
 hard pulse, and excited action of the heart. 
 
 II. The fact that the disease is in a very early stage, and occur- 
 ring in a person of good constitution, and one who has been 
 previously healthy. We cannot specify any exact time beyond 
 which the remedy should not be used, but the fact that some 
 e£fusion has already occurred is not to deter us from bleeding, 
 which is a measure the fitness or unfitness of which is to be 
 regulated much more by the constitutional state and the period 
 of duration of the disease than by the results of physical examina- 
 tion. 
 
 I believe that even when we determine on the use of the 
 lancet, it must be looked on less as our main remedy than as a 
 preparative of other treatment ; and it will generally be found 
 that one or two moderate bleedings will suffice. It appears 
 certain that after the first or second bleedings we must trust to 
 other means, and take great care not to lower the strength too
 
 552 DISEASES OF THE PLEURA. 
 
 much. There is much more danger from over depletion in this 
 disease than in acute pneumonia ; but there will be little danger 
 of error on this point if the practitioner is impressed with the 
 opinion that he is to consider bleeding more as a preparative 
 for other remedies than as the chief remedy. 
 
 Local bleeding may be performed by cupping or leeching. 
 When the pain is severe, and the covering of the chest very 
 spare, cupping will be found inconvenient and painful, and 
 leeches should be used. It is a good practice to apply them in 
 relays, and to use poulticing between the periods of application. 
 
 There are few measures of more immediate advantage than 
 the diligent employment of large warm poultices. In most cases, 
 when they are used, the poultice is too small. It should cover 
 a large portion of the side. We shall find linseed meal or bran 
 the best materials. I prefer the first, and the poultice should 
 be spread on oiled silk, and this again covered with flannel. 
 The spongio-piline may also be used, but I have found it more 
 advisable in cases of abdominal than of thoracic inflammation. 
 
 The general rules as to the application of blisters need scarcely 
 be here repeated, as all admit that their use during the early 
 inflammatory tension is improper. I once saw in a case of acute 
 pleuro-pneumonia, where a blister had been applied at a very 
 early stage, a perfect mass of the blister exhibited on the lung 
 by an extreme vascularity of the surface. But when depletions 
 by general or local bleedings, or both, have been performed, and 
 the heat of surface and violence of the pain lessened, we may 
 use repeated blistering with great advantage. It is excellent 
 practice to lay a poultice over the blistering plaister, as well as 
 over the dressing of the blistered surface. 
 
 The use of mercury must be left to the discretion of the 
 attendant, and if he can cure our patient without its employment 
 it will be all the better. Under most circumstances, we should 
 employ it with caution, and not force on its use if we find a 
 resistance to its ordinary action. In the anaemic and scrofulous 
 conditions, and in persons who have had near relations the sub- 
 jects of consumption, he should try to cure the disease, at least 
 in its acute stage, without employing mercury. 
 
 In some cases, and I believe the number to be greater than 
 many might suppose, the disease will disappear, as shewn by 
 the returning sonoriety of the chest in a short time after the
 
 DISEASES OF THE PLEURA. 553 
 
 use of the treatment. This may he especially looked for when 
 all pain has subsided and the pulse has become natural. But 
 in others the dulness remains obstinate, and if the case be 
 neglected, the effusion may insidiously increase, till a great 
 amount of eccentric pressure is produced. This increase of the 
 effusion often goes on, without any corresponding constitutional 
 symptoms. The entire side becomes dull from the clavicle to 
 the lowest portion, and the life of the patient may be placed in 
 the greatest jeopardy from the want of respiration. This, how- 
 ever, is not the most common case, and is seldom met with 
 where the disease has been recognized and properly treated at an 
 early period. In most of these latter cases we find dulness to 
 remain occupying one-half or two-thirds of the affected side, and 
 our efforts must be steadily devoted to remove this condition. 
 
 If the patient has not had mercury in the earlier periods of 
 the case, it will generally be proper to give the medicine in a 
 mild form until a very slight action is produced. We may give 
 three grain-s of mercury with chalk combined with two of Dover's 
 powder three or four times in the day. Or we may use poultices 
 over the side, with mild mercurial ointment. When a slight, 
 but evident mercurial action is produced, the remedy is to be 
 omitted, and the patient allowed to rest for one or two days. 
 
 We may often observe in cases where mercury has pro- 
 duced its effects on the mouth a remarkable diminution of the 
 symptoms and the sufferings of the patient. This is not always 
 attended with immediate signs of absorption, for we may find the 
 line and amount of dulness remaining unchanged ; and I believe 
 that the effusion may be in some cases actually on the increase. 
 
 We may then commence the use of iodine externally and 
 internally. The tincture of iodine is to be brushed over the 
 surface every morning, or every second morning, according as 
 the patient bears it. I advise the morning as the best time, for 
 it sometimes happens that pain and itching follow the applica- 
 tion, which would interfere with the rest were the remedy used 
 at bed time. Small doses of the iodide of potassium should be 
 given in a diluted form. I find that from five to eight grains of 
 the remedy given three times a day will be generally sufficient ; 
 and if the kidneys be inactive we may combine with it a diuretic, 
 such as juniper, broom, and the spiritus aetheris nitrici. 
 
 A good form in many cases is that of Lugol's mineral water,
 
 554 DISEASES OF THE PLEUEA. 
 
 which we may prepare by adding one grain of iodine and five or 
 ten grains of iodide of potassium to a pint of water. The whole 
 of this should be taken in the day ; it often acts as a good 
 diuretic where the early inflammation has been severe. We 
 should use the iodide in larger doses, as specified above. Should 
 the action of the heart be excited, the preparations of digitalis, 
 such as the infusion or tincture, may be advantageously added 
 to the medicine. And we must not forget to support the 
 patient's strength by proper nourishment. 
 
 In this way we shall find in most cases that the dulness will, 
 after a few days, begin to lessen, and finally disappear, with or 
 without the occurrence of the dry friction sound indicative of the 
 re-apposition of pleural surfaces. 
 
 It sometimes happens that the process of absorption seems to 
 come to a standstill, and resists the treatment. Our best 
 course will then be to apply a blister, which may be dressed 
 with mercurial ointment ; and again, when the parts are healed, 
 to use the iodine lotion. I have considerable confidence in this 
 mode of treatment. The curative efi'ects of iodine after the use 
 of mercury are well exemplified in such cases. 
 
 Pending the absorption of the fluid, or for some time subse- 
 quent to its removal, the patient may be liable to vei-y profuse 
 night sweats, which often have an extremely weakening effect. 
 Against this condition I have found that opium is the best 
 remedy; and the powers of this medicine in controlling the 
 perspirations are often most remarkably seen. I have known 
 the tendency to perspire to continue for more than six weeks 
 after the side had become clear on percussion, so that the opiate 
 had to be administered every night. The omission of the 
 remedy was certain to be followed by the most profuse sweatings, 
 while on the nights on which it was used no perspiration 
 occurred. Opium, too, has the power not only of preventing 
 but of checking the symptoms, as where a copious sweat has 
 occurred, which if not interfered with would continue the whole 
 night, we found that the use of the medicine promptly put an 
 end to the discharge. A draught containing from twelve to 
 twenty drops of the sedative solution of opium will generally be 
 found sufficient. 
 
 Another symptom which is occasionally troublesome is the 
 excited action of the heart. I have not been able to connect
 
 DISEASES OF THE PLEUKA. 655 
 
 this condition with any anatomical change of the organ ; and its 
 history and physical signs are more those of a functional than an 
 inflammatory disease. We find simply that the heart begins to 
 act with great force, and that the patient complains of palpita- 
 tion, and of the increased action of the carotids and temporal 
 arteries. The action, though forcible, is regular, and I have 
 never found that any valvular murmur attended it. This is 
 to be met by modifications of the patient's diet, by the omission 
 of any stimulating medicine, such as iron, bark, or iodine, and 
 by the exhibition of digitalis, or hydrocyanic acid, in properly 
 adjusted doses. Cases may arise in which the use of a few 
 leeches or a blister might be employed with advantage. 
 
 So much has been written on the subject of operation in 
 empyema that it will be unnecessary for me to do more than 
 simply indicate those conclusions to which I have been led, by 
 such observations as I have had an opportunity of making on 
 this matter. That the operation is often a justifiable one, is not 
 to be denied, and cases occur where from the rapid accumulation 
 of fluid and the consequent urgency of the symptoms, no choice 
 is left us but to puncture the chest as the last resource of art. 
 
 But it appears to me that in the majority of cases requiring 
 operation, there has been some error of omission or commission 
 in the early treatment of the disease. At least it is certain that 
 in every instance with which I have been acquainted, the disease 
 was either wholly overlooked in the commencement, or improperly 
 and insufficiently treated. 
 
 The early stages of inflammation are constantly overlooked ; 
 for I believe that the proportion of cases of pleuritic effusion 
 where the early symptoms are insidious, obscure, or, it may be, 
 wanting, is unfortunately greater than those attended with the 
 characters commonly laid down in books. The nature of the 
 disease being unsuspected, physical examination is not made, or 
 is performed in a careless manner, and so the disease creeps on, 
 every day becoming more intractable, not only to medical, but 
 surgical treatment. 
 
 Again it often happens that even where an acute pleurisy has 
 been recognized and treated, the subsidence of the pain, dyspnoea, 
 and fever is taken as a proof that the patient is cured ; yet it too 
 often happens that with the disappearance of the ordinary symp- 
 toms we have really a progressive advance of the effusion ; we
 
 556 DISEASES OF THE PLEURA. 
 
 liave scotclied the snake not killed it, and the very relief afforded 
 by lulling the patient and his attendant into a false security, 
 actually increases the danger. 
 
 It will occasionally happen that the effusion will advance 
 steadily for several days, notwithstanding the use of proper 
 treatment, until the sufferings of the patient from its pressure 
 become extreme. This I believe to be a proper case for para- 
 centesis ; yet I have known a case of pleurisy in which, on two 
 occasions, the urgency of the patient's sufferings seemed to call 
 for surgical interference, yet in both of which it was found that 
 the dyspnoea subsided, after lasting about twelve or fourteen 
 hours ; so that although everything was got ready for the 
 operation, it was thought better to postpone it. This was a 
 case of pleurisy of the right side, which set in somewhat 
 insidiously, but yet one in which treatment was employed at 
 an early period. This case ultimately did well, perfect absorp- 
 tion having been effected, with but a very slight degree of 
 contraction of the side attending the cure. 
 
 In considering the operation for empyema I have dealt with 
 that case in which no extracostal tumour or abscess (empyema of 
 necessity) is formed. Most of the recorded cases of successful 
 operation have been of the latter kind. A question may still be 
 raised as to whether the occurrence of an empyema of necessity 
 is in itself a sufficient reason for immediate operation. I have 
 seen the curious phenomenon of the retrocession of these tumours, 
 and it appears justifiable to say that in determining on the 
 performance or non-performance of the operation, we must 
 take other circumstances into consideration, besides the mere 
 appearance of the external tumour. If there be but little consti- 
 tutional suffering, and if the respiration be not much disturbed, 
 we may safely wait. But on the other hand, if there be an 
 increasing dyspnoea, or severe hectic, if there be great suffering of 
 the opposite lung from eccentric pressure ; and if the bronchial 
 tubes are overloaded by vicarious secretion^ which sometimes 
 threatens asphyxia, then no doubt can exist as to the fitness of 
 the operation. 
 
 I have no experience of the employment of caustic as a means 
 of opening the empyema of necessity. In the ordinary forms 
 there seems to be no reason for adopting it. And I believe that 
 in all cases the lancet, or lancet and trocar, will be found greatly
 
 DISEASES OF THE PLEURA. 557 
 
 preferable. In using the trocar and canula, we should avoid the 
 large sized instruments, as in most cases the fluid will be found 
 to have sufficient tenuity to pass through a very small canula. 
 It is of importance that the sac should not be wholly emptied. 
 It is better by repeating the puncture to draw off the fluid by two 
 or three operations ; and it sometimes happens that an operation 
 by which only a moderate portion of fluid is withdrawn is fol- 
 lowed by a favourable absorption of that which remains. 
 
 With respect to the admission of air through the canula I 
 believe that the apprehensions entertained on this head were 
 founded on a mistaken theory rather than actual experience. 
 
 I can only say that I never saw the operation for empyema per- 
 formed, even where great care was taken to prevent the admission 
 of air, that a rush of air did not take place into the pleura 
 towards the close of the operation ; but I never saw any 
 bad consequences to result from it. It will generally be 
 found that at first the fluid flows in a continued stream, then its 
 force begins to slacken ; it becomes, as it were, intermitting in 
 correspondence with the respiratory effort, and finally during the 
 period of its lessened force, which is that of inspiration, a rush 
 of air takes place into the cavity. It is very probable that the 
 proper period for removing the canula would be that immediately 
 preceding this occurrence, but this rule has no reference to any 
 danger that may result from the introduction of air. The cir- 
 cumstance maybe taken as showing that a point has been at the 
 time arrived at when there is no further expansion of the lung. 
 
 We apply to the operation of paracentesis of the chest the 
 same rules which now guide us in tapping the belly. When I 
 was a student the latter operation always appeared to me to be 
 one of the most dangerous kind ; the great proportion of those 
 who were tapped for the first time falling victims to acute perito- 
 nitis, and such a result was to be expected, a large trocar was 
 used, and the greatest exertions made to evacuate every drop of 
 the fluid ; the patient was turned on his side, or almost on his 
 face. The belly was compressed by a roller, which was tightened 
 as the liquid flowed from the canula, or it was kneaded by the 
 hands of the assistants. The very violence of these proceedings 
 would be sufficient to cause inflammation, to say nothing of the 
 effect of bringing into contact two serous surfaces, which had so 
 long been separated. The operation is now comparatively safe,
 
 558 DISEASES OF THE PLEUEA. 
 
 owing to our using a small trocar, to our avoiding all unnecessary 
 manipulations, and to the most important circumstance that the 
 surgeon does not seek to remove the whole of the fluid. 
 
 We are not yet in a position to lay down any rule drawn from 
 a sufficient numher of cases as to the propriety of closing or 
 keeping open the wound. But it appears there is less advantage 
 to he expected, when the fluid is serous, from keeping the wound 
 open, than when the discharge is purulent. 
 
 PASSIVE OR MECHANICAL EFFUSIONS. 
 
 The advance of medicine has shewn, that so far from idiopathic 
 hydrothorax heing a common afi"ection, it is in reality one of the 
 rarest of pulmonary diseases. I have never seen any case of it. 
 Almost every instance in which it was supposed to exist has 
 turned out to he bronchitis, pneumonia, congestion, oedema of the 
 lung, Laennec's emphysema, or morbus cordis. We owe much 
 to Laennec for his discovery of this most important fact. 
 
 But the mechanical efiusions are much more common, yet 
 even these are rarer than might be supposed ; and we shall ob- 
 serve efi'usions into every cavity of the body, except the pleura. 
 And it must not be forgotten, that there are no symptoms peculiar 
 to this disease : even in the dropsical diathesis, the symptoms, as 
 given in nosological works, depend much more on other diseases. 
 
 In most respects, the physical signs agree with those of 
 empyema. But there is one remarkable exception ; I have never 
 observed dilatation of the intercostal spaces, or protrusion of the 
 diaphragm. And this fact, among others, I have adduced as an 
 argument in favour of my views of the cause of muscular dis- 
 placement in emj)yema. 
 
 In general, where the serous effusion is not too copious, we 
 observe the change of sound varying with the position of the 
 patient. In one instance, however, I have seen an exception to 
 this ; it was the case of a multilocular hydrothorax, the septa 
 being formed by previous and old adhesions. 
 
 Lastly, mechanical hydrothorax may be confined to one pleura. 
 I have more than once verified this fact ; so that the a -priori 
 conclusions of Dr. Darwall on this subject cannot be admitted.* 
 
 * Dr. Darwall gives the dulness and absence of respiration at one side only, as a 
 distinguishing mark between empyema and hydrothorax. See Cyclopsedia of Practical 
 Medicine, art, Hydrothorax.
 
 DISEASES OF THE PLEURA. 559 
 
 ULCERATION OF THE PLEURA. 
 
 We may divide the perforations of the pleura into two classes. 
 
 1st. Those in which the ulcerative disease has first engaged 
 other parts, and the serous memhrane is perforated from its 
 posterior surface. 
 
 2nd. Those in which the ulceration results from original dis- 
 ease of the pleura, and begins at its interior surface. 
 
 Of these cases. the first are by far the most frequent. In this 
 category we may enumerate the perforations from tubercle, 
 gangrene, and abscess of the lung, the ulcerations from hepatic 
 abscess, and from anthrax or other disease of the thoracic 
 parietes, while in the second we have those cases in which 
 purulent collections having formed from pleuritis, are discharged 
 by an opening through the costal, pulmonary, or diaphragmatic 
 pleura. 
 
 In the section on Perforating Abscess of the Lung, I have 
 given some examples illustrative of the first variety. I shall 
 now examine the subject of fistulous openings in the pulmonary 
 pleura. 
 
 Tuberculous ulceration is the most common cause of this 
 lesion ; or of empyema and pneumothorax occurring in phthisis, 
 next in frequency is that resulting from gangrene of the lung, 
 and lastly, those where there is first simple empyema, which is 
 ultimately complicated with pneumothorax from the consecutive 
 perforation of the pleura. 
 
 EMPYEMA AND PNEUMOTHORAX OCCURRING IN TUBERCULOUS 
 
 PHTHISIS. 
 
 Since the discovery of the stethoscope, a great number of 
 cases of this quadruple lesion have been observed; and the 
 researches of Reynaud, Louis, Beau, Forbes, and Houghton, 
 have added much to our knowledge of its pathology and 
 diagnosis. 
 
 The disease may set in with violent symptoms, or be so 
 latent that we cannot determine the date of its invasion. In 
 the first case, there may be rapid sufi"ocation ; but in many in- 
 stances, a period of comparative, and often singular tranquillity 
 succeeds the first violent symptoms.
 
 560 DISEASES OF THE PLEURA. 
 
 Like other internal solutions of continuity, this lesion is 
 generally pointed out by sudden, new, and extraordinary symp- 
 toms. These proceed from the new inflammation of the pleura, 
 on the one hand, and the collapse of the lung, on the other. 
 But as pleuritis, even under these circumstances, may be latent, 
 and as the collapse of the lung varies much in different cases, 
 we can understand how, in a case without pain, and with at first 
 but little collapse of the lung, the suffering should be but 
 trifling. 
 
 In some cases, the collapse of the lung is sudden, and nearly 
 complete ; while in others this is prevented by adhesions or 
 solidity : the lung yields gradually to pressure, and even in 
 chronic cases may never become completely impermeable. This 
 is the most common case. 
 
 The symptoms commonly observed are the following : — A 
 sudden, new, and violent pain, with a sensation as if something 
 had given way, is felt in the lower portions of the side ; followed 
 by dreadful dyspnoea, suppression of expectoration, extreme 
 anxiety, and general collapse. In addition to these, there may 
 be loss of voice, and impossibility of lying on one side. In the 
 more violent cases, death may occur, with aggravated suffering 
 on the day of the accident ; but this is rare, for a diminution of 
 symptoms is commonly observed, and the system accommodates 
 itself to the new condition of the lung. The side becomes 
 dilated ; the mediastinum is displaced ; and the peculiar physi- 
 cal signs of the disease are manifested. 
 
 As a diagnostic of perforation of the lung, the occurrence of 
 sudden and overwhelming dyspnoea, accompanied with pain, has 
 been strongly dwelt on by Louis ; but in phthisis these symptoms 
 often occur without any such lesion. Thus, I have frequently 
 suspected a pneumothorax, and yet found the physical signs 
 wanting ; so that we must never trust to the symptoms, unless 
 they can be verified by physical signs. The pain may occur 
 with every degree of intensity, and is generally aggravated by 
 lying on the affected side. It is independent of the previous 
 sensation of something giving way. Thus, in a patient of mine, 
 the first sensation was that of a sudden crack, extending from 
 above downwards, and accompanied by a feeling, as if liquid was 
 shed out into the chest : acute pain in the side afterwards set in. 
 Similar phenomena have been observed by others. In a case
 
 DISEASES OF THE PLEURA. 561 
 
 recorded by Louis, the patient, at the moment of perforation, 
 and shortly preceding the pains, felt as if air was circulating in 
 the chest from below upwards, clearly atti-ibutable to the passage 
 of air into the left pleura.* In the sixteenth epistle of Mor- 
 gagni, a case is noticed, on the authority of Willis and Lower, 
 which presented analogous phenomena, both as to the first 
 sensation of something giving way, and the dropping, " stilUci- 
 (liiun " into the chest, perceptible not only to the patient, but 
 also audible by the bystanders. 
 
 Notwithstanding the pain, it often happens that the patients 
 lie on the affected side. Dr. Houghton remarks, " that the 
 violence of the pleuritic pain forces the patients to turn to the 
 sound side, in spite of the increased oppression which the change 
 induces. We have witnessed a case in which the struggle 
 between the pain, augmented by lying on the affected side, and 
 dyspncea, aggravated by changing to the opposite, was extremely 
 distressing ; but here the want of breathing triumphed over the 
 pain, and compelled the poor patient to endure the latter as the 
 lesser evil. When the intensity of the pain has passed, if a 
 change has taken place during its continuance, decubitus on the 
 iiffected side is usually resumed." 
 
 In several instances I have observed a complete change in the 
 character of the cough, and a cessation of expectoration. The 
 latter symptom seems peculiar to those cases in which the 
 expectoration had been furnished by the lung which was sub- 
 sequently perforated. I have seen a case in which the expecto- 
 ration, being previously copious, ceased on the occurrence of 
 fistula, and only returned when tubercular ulceration had invaded 
 the opposite lung. A gentleman, labouring under this disease, 
 assured me that he was often unable to expectorate, in conse- 
 quence of the fluid, on reaching the trachea, falling, as he 
 expressed it, down into the opposite side. 
 
 But one of the most singular circumstances connected with 
 this subject, occurred in the case of an elderly man, who lived 
 for many months after the occurrence of the fistula. For a 
 length of time his principal — indeed only suffering, was from 
 dyspnoea, occasioned by the increase of the liquid efi"usion. 
 Whenever the symptom became too urgent, he relieved himself 
 by the extraordinary manceuvre of placing his head on the 
 * See Louis on Phthisis, Tr. Cowan's Translation. 

 
 562 DISEASES OF THE PLEUKA. 
 
 ground, and tlien elevating his heels against a wall until the 
 reversed position was nearly vertical, when a vast quantity of 
 sero-purulent fluid was expectorated, and relief given for a con- 
 siderable period of time. 
 
 It was for a long time believed, and is still the opinion of 
 many, that the occurrence of a pulmonary fistula from any cause 
 was necessarily followed by pleuritis and effusion. Recent 
 observations have shown that such is not always the case, and 
 that we may have a pneumothorax from perforation of the lung 
 without its being attended by empyema. In the year 1840 I 
 communicated to the Pathological Society a specimen of perfora- 
 tive pneumothorax from the rupture of a sub-pleural vesicle in a 
 case of Laennec's emphysema. The physical signs were well 
 marked during life, and the pleura was found without the slightest 
 appearance of inflammation, dry, pale, and transparent. Con- 
 sidering the source of the rupture in this case, and that no foreign 
 matter besides air was introduced, the absence of pleuritis may 
 be accounted for.* But a still more remarkable example is that 
 communicated by my friend, Mr. O'Ferrall, to the same Society. 
 The subject was a female, aged 40, who had been admitted into 
 St. Vincent's Hospital in the last stage of phthisis. Two days 
 before her death she complained of a stitch in the left side, which 
 was found to be tympanitic on percussion, both anteriorly and 
 posteriorly. Amphoric resonance was present, but there was no 
 metallic tinkling ; the heart was not displaced. In this state 
 she lived for forty-eight hours. The left lung was found small 
 and compressed, containing a large tubercular cavity, in the 
 anterior and upper portion of which an opening was discovered 
 passing into the cavity of the pleura. The latter was unusually 
 dry, and exhibited no marks of inflammation. Mr. OTerrall 
 observes that "this case was remarkable, as being one of pure 
 pneumothorax, in which there had been no escape of fluid into 
 the pleural sac, because the opening into the tubercular cavity was 
 near its upper part; for there having been no pleuritic efi"usion, 
 probably in consequence of the short time that the patient survived 
 
 * (In March, 1865, Dr. Stokes presented a similar example of simple pneumothorax. 
 In this case the patient survived the occurrence of the lesion for two days. On dissection 
 the lung was found compressed and lying against the spine, the pleura full of air, but 
 no inflammation or vascularity of this membrane. At the very apes of the lung was 
 a cluster of large and fully distended emphy.'ematous vesicles, two of which seemed to 
 have ruptured and collapsed.) — Dub. Quart. Joum., vol. xl.
 
 DISEASES OF THE PLEURA. 563 
 
 the accession of the pneumothorax, and lastly, from the ahsence 
 of any displacement of the heart. As there was also the absence 
 of metallic tinkling, it might be worthy of inquiry whether this 
 symptom is not to be considered as connected only with pneumo- 
 thorax when there is also an effusion into the pleura." * The 
 great interest of this case consists in its exhibiting the opening 
 of a tubercular cavity into the pleura producing pneumothorax 
 without empyema ; and both cases go to prove that the mere 
 admission of air into a serous sac may be unattended by any 
 inflammatory action. And I am inclined to believe with Mr. 
 O'Ferrall that metallic tinkling is not a sign of pneumothorax, 
 even though it proceed from perforation, unless we have the 
 combination wdth liquid effusion. 
 
 Pm'suing the consideration of these fistula we shall be able, by 
 referring to their mechanical relations, to explain some remarkable 
 circumstances connected with the progress of the disease, and 
 of the amount of suffering and of immediate danger to the patient. 
 Duncan first published the remarkable observation that the 
 bronchial tube communicating with the fistula is found to open 
 obliquely from above downwards, the eff'ect of which is to convert 
 the orifice of the opening into a valve or valvular structure. 
 Houghton has confirmed this, and has added that, as it were to 
 aid in the accomplishment of this object, the superior rim of the 
 opening is sometimes observed to be prolonged downwards for a 
 short space over it. To the practical physician, however, it will 
 be sufficient if we state that fistulae are of two kinds, the one 
 valvular, the other nou- valvular or permanently patent, and that 
 upon these conditions of the opening depend many of the 
 immediate or remote circumstances of the case. In comparing 
 together the recorded cases of this accident we cannot fail t© 
 remark that while in some cases the symptoms of pressure from 
 within proceed rapidly and uninterruptedly to a fatal termination, 
 in other cases there is none of this violence of symptoms at any 
 period, or if there be, it is only for that short time during Avhich 
 the system may be supposed to suffer from the sudden develop- 
 ment of an acute pleurisy and an extravasation of air into the sac. 
 These diff"erences can only be explained by reference to the con- 
 dition of the fistular opening ; if it be valvular so as to impede 
 the exit of air, it is plain that every forced inspiration will add to 
 
 * Trans. Path. Soc. of Dublin, 1842-43. 
 2
 
 564 DISEASES OF THE PLEUKA. 
 
 the amount of exceutic j)ressure, and again, that as the liquid 
 effusion increases, while the air is not permitted to escape, all the 
 worst effects of accumulation must be produced. Patients under 
 such circumstances present an almost uninterrupted series of 
 sufferings from the moment of the accident to that of the termi- 
 nation of life. But this case fortunately is not the most frequent, 
 at least I may say that in my experience the great majority of 
 patients within a period of time generally less than a week exhibit 
 a freedom from suffering which is very remarkable, there is little 
 or no dyspnoea when the patient is at rest, nor is the breathing 
 much if at all hurried. No signs of increasing pressure from air 
 are observed, and the reason of this is obviously that the 
 fistula is not valvular, so that the air passes freely backwards and 
 forwards from the sac into the bronchial tubes or cavity, or vice 
 versa. If under these circumstances the liquid effusion should 
 increase, the air is expelled in proportion as the fluid rises in the 
 sac. The opening is permanently patent, and as the fluid rises 
 the air is easily forced backwards through the fistula. Indeed 
 nothing can present a greater contrast than these two • cases, 
 the one presenting irremediable and extreme sufiering, which 
 advances rapidly to fatal asphyxia, the other exhibiting freedom 
 from distress incredible to those who have not had a large 
 experience of these cases. 
 
 There is reason for believing that with the progress of disease 
 the mechanical relations of the fistula may alter, and that an 
 opening which is at first valvular may become permanently 
 patent. How far the reverse of this is possible I am not prepared 
 to say. Houghton conceives that he has observed an attempt 
 of nature to close an old fistula, but without denying this I 
 may say that I have never seen or heard of the occurrence of the 
 signs of aeriform accumulation resulting from the closure of a 
 fistula which had once been open. 
 
 In these cases of permanently patent fistulas we distinguish two 
 classes, in which the progress of the symptoms is chiefly connected 
 with the amount of the liquid eflusion. In one (and this is a 
 fact of great importance, and diflicult to bo explained) the liquid 
 effusion after having attained to a certain amount ceases to 
 accumulate, and in this way may remain stationary for many 
 months. This is a very common case. In the second class, 
 however, a gradual accumulation of fluid takes place so as greatly
 
 DISEASES OF THE PLEURA. 565 
 
 to change tlie proportion between tlie liquid and aeriform contents 
 of the sac, and when this passes a certain point the distress 
 may become extreme, but it arises from the pressure of the liquid 
 alone, and not from any confinement of air, inasmuch as from 
 the permanently open state of the fistula the air is expelled in pro- 
 portion as the fluid rises. I have already noticed the singular fact 
 that in some cases where the liquid accumulation had become so 
 great as to cause suffering from dyspnoea, the patient was able 
 to evacuate the empyema through the pulmonary fistula. This 
 has occurred in two cases. One of them was that of an old man, 
 who after labouring under phthisis for a length of time became 
 affected with empyema and pneumothorax in the usual way. 
 In this condition he lived for many months. The fistula was 
 permanently open, and on several occasions he emptied the 
 sac of its liquid contents, and was thus freed from the urgency of 
 his symptoms. His method was to place himself in a sitting 
 position on the edge of his bed, and then to raise his legs 
 upwards on the wall of his chamber, while he depressed the 
 throat till his head touched the floor. In this way the sero- 
 purulent fluid poured from his mouth without producing any 
 distress, and he would evacuate many pounds of liquid at a time. 
 This patient was under my observation during the entire period 
 of his disease. 
 
 If we now inquire as to the possibility of a cure by agglutina- 
 tion of these fistulfB we find that the e\ddence of such having 
 ever occurred is very meagi*e and unsatisfactory. In some 
 chronic cases it is true that we experience great difficulty in 
 finding the perforation on dissection, and the possibility of an 
 occlusion of the fistula is not to be denied. But if we exclude 
 the case of original empyema opening into the lung and confine 
 ourselves to those of fistular empyema and pneumothorax from 
 preceding pulmonary disease, we shall find that in most cases 
 the orifice once formed remains open up to the time of death, 
 and even if a closure of the fistula was probable or possible it 
 would not follow that the patient would be in a much better 
 position, for in the great majority of cases he will die of the 
 tubercular disease which affects both lungs, and indeed his entire 
 system. Its progi-ess has been interrupted or modified by the 
 accident, but sooner or later the disease becomes again 
 developed.
 
 566 DISEASES OF THE PLEUEA. 
 
 And this leads us to consider the very curious fact that in 
 many cases the occurrence of an empyema and pneumothorax 
 is followed by the suspension of many of the constitutional 
 symptoms of phthisis. If the patient be not overwhelmed by 
 the immediate effects of the accident a period arrives of 
 comparative calm. The colliquative sweats cease, the cough 
 becomes trifling, and the expectoration disappears. The very 
 aspect of the patient changes, and his countenance loses the 
 characteristics of consumption. The pulse becomes tranquil, 
 and, as in the case of the bricklayer which occurred in the Meath 
 Hospital, and which was published by Dr. Houghton, the patient 
 may regain his flesh and strength to a surprising degree. In 
 this case on more than one occasion this singular improve- 
 ment took place, and the man returned to his laborious occupa- 
 tion of a mason. I have already alluded to another instance 
 of this kind in the first edition of this work. A young man 
 of a rather full habit became attacked with symptoms of 
 phthisis, and after a short time exhibited the usual signs of 
 tubercular softening in the supra-anterior portion of the right 
 lung. The deposit appeared to be circumscribed. He was sent 
 to Dr. Cane, where he remained under the observation of my 
 lamented friend Dr. R. Townsend. In the course of a few months 
 it was found that his constitutional symptoms were improving. 
 There was no evidence of any extension of tubercular deposit, 
 and everything appeared to promise that in this gentleman's case 
 a cure might be expected. At this time, when the hopes of his 
 physician and his friends were at the highest, he was suddenly 
 seized with the symptoms indicative of the opening of a 
 softened tubercle into the pleura. For several days he suffered 
 from dreadful pain and from dyspnoea, threatening suffocation. 
 The physical signs of pneumothorax Avere speedily developed. 
 After some days, during which the patient's life was despaired 
 of, the symptoms were mitigated, the pain ceased, the respiration 
 became more tranquil, and although the existence of an 
 empyema and pneumothorax was but too evident, the patient's 
 health gradually improved, until at length he was to all appear- 
 ance in a much more promising condition than he had been 
 previous to the accident. He- returned to Dublin at the com- 
 mencement of the summer presenting all the appearances of the 
 most perfect and indeed flourishing health ; he had become fatter
 
 DISEASES OF THE PLEURA. 567 
 
 and more muscular than lie was previous to the original illness, 
 his breathing was quiet, he was not troubled with cough, and his 
 pulse was strong, full, and perfectly regular in every respect : 
 he was indeed a picture of health and manly vigour ; he 
 entered into all the pleasures of society, and was able to take 
 active exercise on horseback, and he declared to me that were it 
 not for the annoyance of a splashing sound in his chest, which 
 attracted the attention of his partner in the waltz, and of his 
 companions during equestrian exercise, he suffered no annoy- 
 ance whatsoever, yet, notwithstanding all this, the well-marked 
 metallic tinkling, the amphoric resonance, the tympanitic sound 
 on percussion, and the loud sound of fluctuation, all revealed the 
 terrible and complicated disease. So confident was this patient 
 of his restoration to health that he renewed a matrimonial 
 engagement which had been broken off on the occasion of his 
 first illness. After some time I lost sight of this gentleman. 
 Under the impression that his liver had become implicated he 
 employed a course of mercury, and soon afterwards sunk. It is 
 probable that the liver had become displaced by paralysis of the 
 diaphragm. 
 
 Of the temporary suspension of the symptoms of phthisis in 
 cases of perforation there have been now many examples. If 
 the perforation has occurred in a case where tubercle was not 
 yet deposited in great quantity, and above all, where it had not 
 yet appeared in the opposite lung, the accident in question 
 really produces a temporary cure of consumption. The diseased 
 lung is compressed, its nervous and vascular supply nearly cut 
 off, and hence the morbid processes going on in it are averted, 
 and it is possible that the new irritation of the pleura may have 
 a beneficial action. But I have never seen a real cure of the 
 original disease, although, as in the case which Dr. Houghton 
 has published, the patient was to all external observation free 
 from constitutional disease on more occasions than one. A man 
 under these circumstances may live for months, or for more than 
 a year, but he ultimately sinks. This result appears to spring 
 from various causes. Thus it may happen that after remaining 
 for a great length of time in a j)assive and unchanging state 
 the liquid effusion begins at last to increase, until at length life is 
 perilled by its pressure. Again, a slow tuberculous process may 
 become developed in the opposite lung, and the patient presents
 
 568 DISEASES OF THE PLEUKA. 
 
 then the usual progressive symptoms of phthisis. And lastly, 
 the lymph lining the perforated pleura itself may become trans- 
 formed into tubercular matter. This I once saw well exem- 
 plified in the case of an unhappy soldier who had twice under- 
 gone severe punishment in the West Indies, from the effects of 
 which he appeared never to have fully recovered. He was 
 brought to Europe, and having attempted the life of his officer, 
 was tried and sentenced to transportation. His health was fast 
 giving way, and when the permit of his transportation arrived he 
 was found to be too ill to bear removal. He was brought to the 
 Meath Hospital, and I found that he had pneumothorax with 
 fistula, but we were not able to determine the date of the 
 accident. It had doubtless been of long standing. The wretched 
 man sunk, and we found the whole of the left pleura lined with 
 a thick layer of lymph of a yellowish colour. This presented on 
 the sectional face an irregular and flocculent surface, but when 
 viewed through the pleura was seen to be connected with a 
 congeries of tuberculous matter, extending over all parts of the 
 sac and shining through the pleura. They appeared like split 
 peas, closely approximated, and gave a striking illustration of the 
 tuberculous transformation of effused lymph. 
 
 This suspension of the constitutional symptoms of phthisis 
 consequent on the collapse and compression of the lung may be 
 analogous to the suspension of a similar condition after the 
 removal of a diseased joint or a cancerous tumour. To all these 
 cases, at all events, there is one thing in common, namely, that 
 a suspension of constitutional symptoms follows the removal 
 of the diseased portion, or what is tantamount to that, its being 
 placed in a new condition. As might be expected, the cessation 
 of the phthisical symptoms is best marked when the collapse or 
 compression of the lung has been most complete. But this 
 sudden and extreme collapse of the lung is not so common an 
 occurrence as might be expected from theoretical considerations. 
 I have often observed that the disappearance of all signs of 
 pulmonary expansion on the affected side was a gradual process, 
 and we may sec many cases in which, notwithstanding the ex- 
 istence of the signs of fistular pneumothorax, the evidences of a 
 pulmonary cavern still remain. In these instances the fistula 
 has occurred in the advanced periods of the case, when the lung 
 has been much disorganized, and when, doubtless, adhesions,
 
 DISEASES OF THE PLEURA. 569 
 
 more or less decided, have been formed. The diminution of the 
 volume of the lung in such cases is less owing to a sudden 
 collapse than to a gradual process of compression and atrophy, 
 while, on the other hand, when the perforation occurs in an 
 early period of the disease, as from a superficial suppurating 
 tubercle when the amount of deposit in the lung is but trifling, 
 and adhesions but slightly if at all developed, the collapse of the 
 lung is much more sudden and complete. It is also probable, 
 although I cannot state this from actual observation, that in 
 such cases the suspension of the symptoms of phthisis will be 
 more decided and of longer continuance. If we confine our- 
 selves to those cases in which, as Laennec has demonstrated the 
 tubercular matter appears by successive crops or eruptions, we 
 shall find that perforation of the pleura is rarely produced in 
 connexion with the first production of the heterologous deposit. 
 Pathological anatomy has shewn that in most cases the seat of 
 the fistula is at a point considerably below the superior portion 
 of the lung. I once saw an example of fistular pneumothorax 
 from a perforation which occurred almost at the summit of the 
 lung. Such a case, however, appears to be extremely rare, 
 inasmuch as the complete adhesions w^hich commonly surround 
 the summit of the lung in the early stages of phthisis clearly 
 tend to prevent the occurrence of this unfortunate accident. 
 
 It is next to be observed that cases of this complication, that 
 is to say, where a tuberculous abscess opens into the pleura, 
 present a certain variety in their history and symptoms. In 
 studying this disease we may derive some light from examining 
 cases of perforation of the intestine, and the analogies of the 
 two classes of cases will be found much more strict than has 
 been hitherto supposed. In both we find that the perforation is 
 often attended with the symptoms peculiar to internal solutions 
 of continuity, namely, that they are new, sudden, violent, and 
 dangerous. But in both classes of cases we find perforation of 
 the hollow viscera to occur under difi"erent circumstances from 
 those now specified ; and we have the pneumothorax and 
 pleurisy on the one hand, and the pneumoperitoneum and peri- 
 tonitis on the other, produced in a manner almost completely 
 latent. This is more remarkably the case with respect to the 
 thorax than the abdomen, and there is nothing more common 
 than a discovery by the physician of a fistular empyema in
 
 570 DISEASES OF THE PLEURA. 
 
 pneumothorax in persons who were quite unaware of the ex- 
 istence of such a lesion, or who had not suffered any unusual 
 symptoms at the time of its occurrence. 
 
 If we now examine the symptoms of the first variety we find 
 them to he the sudden supervention of a new and extraordinary 
 pain of the side. This is not unfrequently produced during a fit 
 of coughing, or any other condition which induces forced and 
 violent respiration. The patient feels as if he was ahout to die 
 from suffocation, and in many cases a fearful struggle for life 
 marks the early period of the aeriform effusion. How much of 
 this difficulty of breathing depends on the sudden pleurisy, or 
 on the collapse of the lung, is not yet determined. If we com- 
 pare such cases with those where foreign bodies are impacted 
 in the main bronchus of either lung, we cannot help believing 
 that the terrible suffering in certain cases of perforation is owing 
 to something besides the sudden occlusion of one lung. It 
 is rather to be attributed to the nervous excitement and spasm 
 not only of the affected lung but of the opposite lung, as well 
 as the occurrence of sudden and extensive pleurisy. As happens 
 in perforative peritonitis the escape of a foreign substance 
 into the serous sac produces at a hloiu an extensive inflamma- 
 tion. 
 
 We may inquire, does the entrance of the air assist the 
 inflammation ? This is a difficult question. We know that the 
 entrance of air by the canula during paracentesis is a matter of 
 trivial moment ; but the cases are different, vitally and me- 
 chanically. In the one the air enters a sac which has been 
 previously diseased, covered with lymph and semi-organized 
 deposits ; while in the other it is forced into a j)leura which has 
 never before felt the presence of any foreign body or fluid what- 
 soever. This may make some difference in its susceptibility 
 to inflammation from the entrance of air. 
 
 The liquid foreign matter sent from the lung into the sac will 
 consist of tubercular matter, pus, and bronchial mucus. We 
 might believe on comparing these substances with the contents 
 of the intestinal tube that they were of a less irritating nature, 
 for we know that in addition to the bile and mucus of the tube, 
 the ingesta often escape into the peritoneal sac. But the 
 secretions in advanced phthisis are not without acridity. It is 
 a curious fact that in many of the perforative cases the expectora-
 
 DISEASES OF THE PLEURA. 571 
 
 tion, which before had been copious, almost altogether ceases, 
 and thus the patient continues for a great length of time. We 
 are not, however, to believe that this is wholly to be attributed 
 to the passage of the secretions into the sac through the fistula, 
 but rather that there is an amount of secretion from the whole 
 surface of the diseased lung, both as i-egards its cavities and 
 bronchial surface. This is one of that group of circumstances 
 which contribute to the fallacious appearance of recovery from 
 consumption exhibited by many patients who have suffered from 
 this accident. I have observed cases in which the expectoration, 
 which had been previously copious, ceased altogether on the 
 occurrence of the fistula, and only returned when the opposite 
 lung had become affected with tubercular softening. 
 
 But that in some cases a dropping of the secretions of the 
 diseased lung, through the fistula and into the sac, takes place 
 appears sufficiently certain. I have known a case in which 
 this appeared to be felt by the patient, who laboured under 
 tubercular softening in both lungs. \\Tien he coughed he 
 declared that it often happened that he was unable to expecto- 
 rate from the matter, as he expressed it, falling down into the 
 opposite side. 
 
 One of the forms of the metallic tinkling is manifestly 
 produced by a dropping from the upper portion of the chest 
 into the fluid below. But whether this dropping proceeds 
 from the secretions of the diseased pulmonary pleura, or from 
 the secretions which pass through the fistula, or from both 
 these sources, it is difiicult to determine. 
 
 To return to the pain attendant on the accident. It may 
 exhibit every degree of intensity — and it is sometimes at the 
 first moment attended with the sensation of something cracking 
 or giving way, and next of the pouring out or shedding of a 
 fluid into the sac. " The violence of the pleuritic pain," says 
 Dr. Houghton, " forces the patient to turn to the sound side in 
 spite of the increased oppression which the change induces. 
 We have witnessed a case in which the struggle between the 
 pain, augmented by lying on the affected side, and dyspnoea 
 aggravated by changing to the opposite, was extremely dis- 
 tressing, but here the want of breathing triumphed over the 
 pain, and compelled the poor patient to endure the latter as 
 the lesser evil. When the intensity of the pain has passed, if
 
 57*2 DISEASES OF THE PLEUEA. 
 
 a change has taken place during its continuance, decubitus on 
 the affected side is usually resumed." 
 
 But the indication of the accident by the occurrence of a 
 group of extraordinary and painful symptoms is by no means 
 so constant as many would suppose ; and there is nothing more 
 common in clinical experience than the discovery of a pneumo- 
 thorax and empyema in persons who are supposed to be simply 
 phthisical, and who are not able to refer to any special symptoms 
 as having attended the j)erforation. 
 
 We need not dwell at any length on the physical phenomena 
 of this condition. The two most important are the amphoric 
 respiration and the sound of fluctuation. Next in value may be 
 placed the want of vesicular respiration over a large extent of the 
 side, as also that of the different rales which existed before the 
 collapse of the lung. The less th6 lung has been disorganized 
 before the perforation the more complete will be the dis- 
 appearance of its proper phenomena. I have known a case in 
 which apparently but a single tuberculous concretion existed. 
 It was superficial and produced a fistula, followed by a speedy 
 and complete disappearance of all the pulmonary signs. On 
 the other hand, where the lung has contained a great quantity 
 of tubercle, attended as is commonly the case with local 
 adhesions, its volume will, of course, be much less diminished, 
 and its proper signs, more or less modified, may continue to 
 exist. We have more than once observed the co-existence of 
 well-marked, cavernous respiration and gurgling in the upper 
 portion of the lung with all the signs of fistular pneumothorax 
 in their usual situations. 
 
 The next in importance of the physical characters is the 
 metallic sound given to all the acoustic phenomena. The 
 sound of the voice, the sounds of the heart, the vesicular 
 murmur and rales in the affected lung (when they exist) may 
 all exhibit the metallic character, or it may be confined to but 
 one or two of them. As to the metallic tinkling, properly so 
 called, we have already observed that one form of it at least 
 seems to be produced by the dropping of fluid from the upper 
 portion of the cavity. Single metallic sounds are thus pro- 
 duced which occur at irregular periods and without any 
 synchronism with the motion of the chest. The second form 
 is more singular, and is held by recent authors to depend upon
 
 DISEASES OF THE PLEUKA. 573 
 
 the bursting of bubbles of air on the surface of the fluid. This 
 is occasionally synchronous with inspiration, and conveys the 
 idea of the successive breaking of a series of extremely minute 
 bubbles. It is highly probable that these bubbles proceed 
 from the secondary cribriform perforations to which I have 
 alluded. If this be true we ought not to find the phenomena 
 in question at the early periods of these cases, but on this 
 point I have no certain observation to produce. 
 
 As might be expected, percussion affords valuable assistance 
 in the diagnosis of this disease. But the results obtained are 
 various. The universal and exaggerated tympanitic resonance 
 is not often met with, especially in chronic cases and where 
 the fistula is not valvular. IMore or less, however, of this 
 character will be generally discovered. It is generally most 
 evident about the middle third of the chest. The sound of 
 the upper portions being modified by the lung, and of the 
 lower by the liquid eflusion. It is very remarkable, however, 
 that in certain cases, were we to be guided by the sound on 
 percussion, we would conclude that no liquid whatever existed 
 in the cavity, the sound continuing morbidly clear down to 
 the lowest portion of the thoracic region ; yet in such cases on 
 making the Hippocratic succussion we are astonished at the 
 evidence of a great quantity of liquid. This can be only 
 explained by supposing that there is a paralysis of the 
 diaphragm, and that the liquid is to a great degree contained 
 in the pouch thus formed which looks towards the abdominal 
 cavity. As connected with the entire subject I do not know a 
 circumstance more curious than that now stated. 
 
 It is not always an easy matter to produce the sound of 
 fluctuation in these cases. In some persons it is true that 
 almost any swaying motion of the body will cause the sound. 
 In others the patient's own exertions are necessary, and it is 
 done by a sudden jerking and semi-rotatory motion of the 
 trunk. I have seen cases where the sound could not be pro- 
 duced while the patient sat in bed, but when he was placed 
 on a wooden form or chair it was always easy to produce the 
 sound. 
 
 When, as sometimes happens, the liquid effusion increases 
 to a great amount, both the sound on percussion and the 
 tympanitic resonance disappear. Percussion may then give
 
 574 DISEASES OF THE PLEURA. 
 
 a dull sound, or what is more common, we have over the 
 anterior portions the muffled tympanitic sound, or what we 
 have elsewhere called the tympanitic dulness. 
 
 Let us now examine some cases of this affection. The first 
 case recognized in Duhlin after the introduction of mediate 
 auscultation is recorded by my lamented friend Dr. Eichard 
 Townsend. This case gives so clear an idea of the physical 
 phenomena of the disease that I consider an abstract of it to be 
 desirable in this place. 
 
 In this case the patient, a tall man, aged 30, had laboured 
 under symptoms of pulmonary disease for more than five 
 months, when he was seen by Dr. Townsend. He was up and 
 dressed, but he complained of weakness and want of breath 
 when he walked. He was emaciated, and had profuse night 
 sweats, diarrhoea, thirst, and anorexia. Pulse 120, respira- 
 tions 30 in the minute. There was cough with mucous 
 expectoration, but the sputa had considerably diminished for 
 three weeks, from which period was also dated the aggravation 
 of the dyspnoea. The right side of the chest appeared con- 
 siderably more dilated than the left, especially at its inferior 
 portion, anteriorly and laterally. Over this dilated surface 
 percussion elicited a clear hollow sound. In this space, too, 
 the respiratory murmur was perfectly inaudible, but imme- 
 diately after coughing, a peculiar sound resembling the vibra- 
 tions of a porcelain jar when gently struck was distinctly heard 
 in a space corresponding to the posterior convexilus of the 
 sixth, seventh, and eighth ribs. This sound was not produced 
 either by inspiration or speaking. Percussion did not produce 
 the sound of fluctuation, although the patient said he felt water 
 dashing against his side. In the superior part of the same 
 side of the chest the dilatation was scarcely if at all perceptible. 
 The sound on percussion was not particularly sonorous, and the 
 respiratory murmur was audible posteriorly. At the left side 
 the sound on percussion was natural, though considerably duller 
 than at the right ; the respiration was distinctly audible all over 
 the lung, except in the space corresponding to the superior lobe, 
 where cavernous respiration and cough with perfect pectoriloquy 
 were to be found. He had no pain. The cough was peculiarly 
 deep and hollow. In this case the sound on percussion was 
 found to be hollow inferiorly even in the region usually occupied
 
 DISEASES OF THE PLEURA. 575 
 
 by the liver. He did not recollect any sudden aggravation of 
 his symptoms about the period when his breathing became 
 materially affected, nor did he ever suffer much pain of the 
 right side. In fact the left side for the last three months giave 
 him uniformly the greatest uneasiness of the two. In a few 
 days percussion showed that the liquid was accumulating in the 
 right pleura. Above the sixth rib, however, the sound on per- 
 cussion was hollow, and the ordinary respirations sounded like 
 the blowing of air into a bottle. Expectoration was followed by 
 a musical sound like that of the vibrations of a fine wire 
 chord. The sound like the ringing of a porcelain jar attended 
 the cough, and a certain degree of the same character was 
 produced in speaking. At this time percussion produced the 
 usual sound, but it could not be heard unless by the stethoscope, 
 although the sound was audible to the "patient. When he was 
 suddenly raised from the recumbent position three or four 
 drops were heard to fall successively from above on the surface 
 of the fluid. 
 
 The thorax now became more distended, and all the inter- 
 costal spaces were protruded. The metallic sounds were compared 
 by Dr. Graves to the tones of a musical snuff-box, but the 
 vibrations of a tuning key would convey the best idea of the 
 sound. The patient soon afterwards sunk. On removing the 
 sternum a vast unoccupied space was discovered in the anterior 
 part of the thorax, capable of containing fully two quarts of 
 water. This space had been occupied by air. Just above the 
 surface of the liquid which occupied the posterior portion of the 
 thorax appeared the lung, closely compressed against the spine, 
 and seemingly reduced to one-third of its natural dimensions. 
 The fluid effused might be in quantity about two quarts. It 
 was of a yellowish green colour, tolerably clear at its surface, 
 but rendered turbid at bottom by numerous fragments of opaque 
 puriform flocculi of albumen. The nozzle of a bellows being 
 introduced into the trachea, air was found to pass freely through 
 the lung, appearing in bubbles on the surface of the fluid. 
 This was done before the lung was touched. The whole surface 
 of the lung, except when it was attached, was coated with an 
 albuminous exudation of a dirty white colour of several lines in 
 thickness. Its surface was crumpled, and not unlike the rind 
 of a shrivelled apple. The costal, mediastinal, and dia-
 
 576 DISEASES OF THE PLEURA. 
 
 pliragmatic portions of the pleura were still more thickly 
 coated with this exudation, which though firmly attached to, 
 and apparently incorporated with the subjacent pleura, might 
 by careful dissection be separated from it, leaving the membrane 
 underneath in a state of perfect integrity. The fistulous orifice, 
 capable of receiving the little finger, was discovered at about 
 two inches from the summit of the upper lobe. It had a well- 
 defined, rounded, and nearly cartilaginous margin. A probe 
 introduced passed readily through a series of small tubercular 
 cavities into one of the principal bronchia. At intervals of half 
 an inch below this fistulous orifice existed three small oval 
 superficial ulcers which did not appear to communicate with the 
 bronchia. They were evidently formed by softened tubercles 
 developed immediately below the pleura, for on different parts of 
 the lung's surface there were several oval nests of tubercles, 
 some not yet softened, others quite soft and elevating the pleura, 
 through which they had not as yet forced a passage. Posteriorly 
 and near the root of the lung, about the base of the superior 
 lobe, was another fistulous opening of half an inch in diameter, 
 which communicated by a long sinuous passage with a large 
 tubercular abscess occupying nearly the upper lobe. This 
 passage was lined all through with a highly vascular membrane, 
 exactly similar to that which lined the tubercular abscess. 
 Into the latter was traced one of the principal bronchial 
 divisions, the entry of which into the cavity was within a few 
 lines of that of the sinuous passage above described. The left 
 lung exhibited tubercular deposits in all their stages, from the 
 miliary to the suppurative, and the heart and abdominal 
 organs had the appearances usually observed in cases of 
 advanced phthisis. 
 
 I have given this case at some length not only because it was 
 the first instance in which this complicated lesion was diagnosed 
 in this country, but because it furnishes such an accurate 
 picture of the physical signs of the affection. It, too, is illus- 
 trative of some important features in the history of the disease, 
 not only with respect to symptoms, but also in connexion with 
 the pathological changes. No distinct aggravation of suffering 
 marked the occurrence of the fistula, and indeed the only 
 circumstance which nppears to indicate the time of its occurrence 
 was the diminution of the expectoration and a certain increase
 
 DISEASES OF THE PLEUKA. 577 
 
 of the difficulty of breathing. The patient referred his sufferings 
 principally to the opposite side, and in point of fact had no pain 
 referrible to any portion of the right pleura. 
 
 Anatomically considered the case is interesting as exhibiting 
 not only two fistulae, both of which appeared to be permanently 
 patent, but also those oval depressions on the pulmonary 
 surface, the nature of which we cannot yet positively declare ; 
 the first of these circumstances tends still further to render this 
 disease analogous to the perforation of the digestive tube, in 
 which case there is nothing more common than the existence 
 of several fistulae. It is yet to be determined whether by any 
 of the resources of physical diagnosis we may be enabled to 
 pronounce upon the existence of more than one of these false 
 passages. 
 
 The following cases were published in the first edition of 
 this work : — 
 
 Case I. — Chronic Phthisis. Sudden Perforation, ivith conse- 
 quent Empyema and Pneumothorax continuing for five 
 months. 
 
 A female, aged 25, after labouring under phthisis for several 
 months, felt, during a fit of coughing, a sensation as of a sudden 
 crack, extending from above downwards, followed by the feeling 
 of something having been shed out into the cavity of the 
 chest. The usual symptoms of empyema and pneumothorax 
 set in, and at the end of a fortnight the heart pulsated to the 
 right of the sternum. She remained in a low, semi-hectic con- 
 dition for five months, during which the sound of fluctuation 
 and the various metallic phenomena existed with but little 
 variation. 
 
 Dissection. — The left pleura contained upwards of a quart of 
 an opaque fluid, not by any means putrescent. The fistula 
 existed in the upper lobe, communicating with a tuberculous 
 cavity of the size of a pullet's egg. The opposite lung was also 
 tubercular. 
 
 Two interesting subjects present themselves for consideration 
 in this case : one, its duration, and the other (not peculiar, 
 indeed) the absence of putrefaction of the efi"used fluid. The 
 patient lived five months and thirteen days from the occurrence 
 
 p p
 
 578 DISEASES OF THE PLEURA. 
 
 of the fistula. I shall just now detail other instances of a still 
 greater duration. 
 
 The absence of putrefaction in the efiused fluid is, indeed, 
 difficult of explanation, when we reflect that every circum- 
 stance of heat, moisture, and air concur to favour such a result. 
 I believe it to be one of the many facts which show that organic 
 connexion is not absolutely necessary for the transmission of 
 vitality. This absence of putrefaction is commonly observed, 
 and would seem to prove, that when decomposition does occur, 
 it is owing to some other conditions than the entrance of air. Of 
 this the following is a good example. 
 
 Case II. — Phthisis, with Consecutive Fistula, Empyema, and 
 Pneumothorax. Operation for Empyema, suhseqiient Gan- 
 grene of the Pleura. 
 
 A gentleman under my care for phthisis was attacked 
 suddenly with overwhelming dyspnoea, and dreadful anxiety. I 
 saw him shortly after, and found absence of respiration over the 
 lower portion of the left side, without alteration of sound on 
 percussion, or metallic signs ; next day, however, these were 
 evident. The liquid effusion increased, and in about a month 
 his sufferings from dyspnoea were so severe as to warrant the 
 operation. In consultation with Mr. Porter, I found that the 
 effusion was already pointing externally, between the fourth and 
 fifth ribs. The tumour was opened, and a large quantity of fluid, 
 without any foetor, given exit to. He remained, to a certain 
 degree, relieved for several weeks, when his distress returned, and 
 the fluid in the pleura again pointed at the original situation. A 
 second opening was made, and a foetid sanious fluid evacuated : 
 
 soon after this the patient sunk. 
 
 On dissection, we found an almost universal gangrene of the 
 pleura ; there was but little fluid in the cavity, but the serous 
 
 membrane was sphacelated in many situations, and several of 
 
 the ribs completely denuded, not only of pleura, but periosteum. 
 
 The whole cavity exhaled a horrible foetor ; both lungs were 
 
 full of tubercles : the fistula was easily perceptible. 
 
 This case, with others, leads me to believe that the mere 
 
 entrance of air is not the cause of putrefaction in the fluid after 
 
 operation, even in simple empyema.
 
 DISEASES OF THE PLEURA. 579 
 
 Case III. — Acute Phthisis, with Pneumothorax. 
 
 A man, set. 25, three weeks before admission was attacked with 
 severe pain in the chest, cough, and expectoration. On 
 admission, he had a continual harassing cough, copious muco- 
 purulent expectoration, great dyspnoea, disturbed sleep, with 
 night sweats ; he was much emaciated ; pulse 112 ; respiration 
 44 ; the chest sounded well on percussion ; bronchitic rales 
 were heard throughout both lungs, but chiefly in the right, where 
 the respiration was very feeble. 
 
 In this state he continued for ten days, when metallic tinkling 
 was observed when the patient inspired, coughed, or spoke, 
 extending over the greater part of the right side anteriorly, 
 diminishing posteriorly, and entirely disappearing in the upright 
 position ; no cavernous respiration or gurgling ; sputa thick, 
 and scanty ; cough not so severe. 
 
 The intercostal spaces of the right side soon became prominent, 
 with dulness on percussion ; decubitus on this side impossible ; 
 integuments oedematous ; superficial veins much enlarged. 
 
 He died within three weeks from the period of perforation. 
 The right side of the chest measured two inches more than the 
 left ; the pleural sac of the right side was distended, and covered 
 with a layer of lymph towards the mediastinum ; the membrane 
 was in the normal condition ; the sac contained a very great 
 quantity of sero-purulent fluid and air; the lung was exceedingly 
 atrophied, and coated with lymph ; it was adherent by a small 
 strap to the second rib anteriorly, beneath which the fistulous 
 opening was observed, leading obliquely upwards into the lung, 
 and full of caseous matter ; the. left lung was tubercular, 
 and adhered to the pleura ; there were some slight interlobular 
 adhesions ; the pericardium contained a reddish-looking fluid ; 
 the heart was healthy. 
 
 The interest of this case consists in its shewing the occurrence 
 of death from phthisical pneumothorax in so short a time from 
 the first illness. 
 
 Case IV. — Simple Empyema from Injury. Perforation of the 
 Lung, and consequent Empyema and Pneumothorax. 
 
 A man, aetat. 23, received a strain in his right side, followed 
 by slight pain ; his breathing became then afiected, and the pain 
 
 p p 2
 
 580 . DISEASES OF THE PLEURA. 
 
 distressing. On admission, a fortnight after, he complained of 
 severe pain in the right side, increased on making a full inspira- 
 tion ; some cough at night, with pituitous expectoration ; skin 
 hot and dry ; pulse 110, full and strong ; can lie only on 
 his back. On percussion, the chest sounds dull on the right side 
 posteriorly, from the scapula downwards, and in this situation 
 there can he heard only a very feeble respiration ; the left side 
 appears healthy, as also the anterior part of the right. There is 
 no rale audible in any part of the lungs. 
 
 On the next day, 23rd of December, pain' is diminished ; 
 can lie on either side ; some epistaxis ; sputa thin ; the entire 
 posterior portion of the right lung is dull on percussion ; respira- 
 tion feeble, with well-marked egophony ; pulse full and soft, 108; 
 skin, cool and moist. 
 
 24th. Had some sleep ; constant hard cough, without ex- 
 pectoration ; refers the pain to the antero-inferior region of the 
 chest; dulness continues posteriorly, but the egophony has 
 disappeared. While he lies on the left side, respiration becomes 
 audible in the antero-inferior and lateral regions of the right 
 side, and disappears when he lies on the back ; respirations 
 30, chiefly thoracic. 
 
 25th. Pain relieved by leeching ; respiration can be heard now 
 in the infra-mammary region, with frottement ; the stethoscopic 
 phenomena of the posterior portion the same as yesterday. 
 
 26. Frottement has disappeared; posteriorly the egophony has 
 returned. 
 
 27th. Passed a restless night, from coughing ; this morning is 
 feverish ; pulse strong and full ; dulness continues posteriorly, 
 with some resonance of the voice. When the patient lies on his 
 face, the respiration is more audible. 
 
 28th. Gums sore ; some salivation ; passed a restless night 
 from cough, with mucous expectoration ; pulse 96, strong, full, 
 and soft ; the right side is dilated nearly an inch ; no change in 
 the stethoscopic phenomena since yesterday. 
 
 March 1st, Kespiration more hurried, with severe pain in the 
 side ; considerable tenderness and fulness in the region of the liver ; 
 pulse soft, full, and weaker than yesterday. 
 
 Four o'clock p.m. — Since the visit this morning he has been 
 much worse ; the countenance is sunk, and the body covered with 
 a clammy sweat ; great prostration ; a copious expectoration of
 
 DISEASES OF THE PLEURA. 581 
 
 sero-purulent fluid, emitting a horrible foetor ; on succussion 
 fluid is heard dashing about in the cavity of the pleura ; there is 
 great dyspnoea, and constant cough. An operation to evacuate 
 the matter from the chest was proposed, but the patient would 
 not accede to it. 
 
 2nd. The expectoration has in a great measure ceased ; at the 
 postero-inferior region of the right side the tintement metallique 
 is heard ; dyspncea very great ; general sinking. He died in the 
 course of the day. His friends would not allow a post-mortem 
 examination. 
 
 The above case is an excellent example of the evacuation of a 
 simple empyema by gangrenous eschar of the pleura. Active 
 treatment was employed, but without effect. The system had 
 been brought under the influence of mercury a short time before 
 the perforation. 
 
 That individuals have recovered by expectoration of the fluid 
 efi'used does not admit of any doubt. I have myself seen a case 
 of this kind, which was under the care of Sir Philip Crampton. 
 But that the perforation is in all cases the result of gangrene 
 seems very doubtful. In the favourable cases it is probably by 
 simple ulceration. 
 
 Case V. — Gangrene of the Lung, Empyema, and Pneumotho- 
 rax ; Paracentesis ; Gangrenous Destruction of the Costal 
 Pleura ; Passage of the Fluid behind the Peritoneum. 
 
 A gentleman, set. 36, generally very healthy, with a large, 
 well-formed chest, had occasionally complained, for the last few 
 months, of pain in the chest, at one period very severe ; he had 
 been cupped and blistered, but without relief; at length hectic 
 symptoms set in, with restless nights ; soon after he felt as if 
 something gave way in his side, and immediately expectorated a 
 horribly foetid matter. A similar attack occurred in a few days, 
 with the same foetid discharge, but accompanied by prostration, 
 lividity of the countenance, and dyspnoea. I saw the patient 
 along with Sir H. Marsh and Sir P. Crampton. We found the 
 chest to contain air and fluid ; and in consultation made the 
 diagnosis of gangrene of the lung, and advised paracentesis. 
 The operation was performed between the seventh and eighth 
 ribs, a little below and external to the right mamma ; the with-
 
 582 DISEASES OF THE PLEURA. 
 
 drawing of the trocar gave issue to a quantity of foetid air ; a 
 probe was introduced, and met by an elastic resisting substance ; 
 this was apparently perforated, and about three quarts of dirty, 
 grey-coloured, foetid fluid given exit to. Great relief followed the 
 operation. The patient, however, passed a wretched night, with 
 hectic paroxysms ; no discharge occurred from the wound. 
 
 17th. The trocar and canula were introduced, and a quart of 
 the same foetid matter came away — patient felt easier ; passed a 
 bad night. 
 
 18th. A pint of foetid matter was taken away ; spent a most 
 uneasy night, with incessant cough and frothy expectoration, the 
 act of coughing sending the foetid air and matter through the 
 external opening in great quantities. 
 
 19th. Much exhausted ; said he felt as if there was a well in 
 his chest ; he was sensible of a constant dropping of fluid ; 
 pulse 120 ; great weakness ; heat and soreness in the side. 
 
 20th. Mr. Colles saw him, in consultation with the other 
 attendants. Anodyne enemata and stimulants were ordered ; he 
 passed a better night, but had great dysuria ; ordered mucila- 
 ginous drinks. 
 
 21st. Passed a bad night; pulse 144, and weak during a fit 
 of coughing, which brought on the usual discharge from the 
 wound ; about a cupful of blood gushed out. 
 
 22nd. The introduction of a gum elastic tube gave exit to no 
 fluid, but a great quantity escaped while the patient coughed ; 
 the abdomen became tense and tympanitic, with exacerbation 
 of all the symptoms, and the patient died in about thirty-six 
 hours. 
 
 Dissection. —Externally the body presented some livid marks 
 at the right side, and a slight fulness in the right inguinal region 
 and side of the scrotum. The right pleural sac contained above 
 a quart of foetid purulent fluid ; the lung was of a dark greenish 
 hue, smeared with a creamy substance, its lower and back part 
 destroyed by gangrene, leaving a large greenish-coloured cavity, 
 the size of the hand. The .substance of the lung near this was 
 easily broken down, and the vessels and bronchial tubes were 
 seen passing through it ; the remainder was gorged with a frothy 
 dark sanies ; the whole lung was reduced to half its size ; some 
 adhesions united it to the mediastinum, almost forming a circum- 
 scribed cavity ; the costal pleura was in some places highly vas-
 
 DISEASES OF THE PLEURA. 583 
 
 cular ; in others, covered with lymphy secretion ; in some places 
 very tenacious. In one patch, destroyed by gangrene, the inter- 
 costal muscles were laid bare for the space of several inches, and 
 were in one part sloughy, forming an opening at the inferior 
 and posterior part, at which place nature had attempted an outlet 
 for the fluid, the latter having made its way into the cellular 
 tissue, beneath the skin, and between the peritoneum and abdo- 
 minal muscles, down the side of the abdomen to the scrotum. 
 The general cavity of the right side was much diminished by the 
 liver having been displaced upwards by the flatus of the intes- 
 tines ; the liver was in such close apposition with the lung as to 
 be in danger of being wounded by the trocar, thus accounting 
 for the fluid not coming off by the canula in the first instance. 
 
 Case VI. — Empyema of the Right Side ; opening by Anthrax ,- 
 Pneumothorax by external Fistula. 
 
 A labourer, eighteen months ago, became affected with cough 
 and haemoptysis. Seven months past he received a severe con- 
 tusion of the right side, followed by severe pain and cough ; con- 
 tinued ill for six weeks, with dyspnoea aggravated by exercise. 
 The dyspnoea continues, and obliges him to lie constantly on the 
 right side. Four months ago he perceived a tumour on the upper 
 part of the abdomen ; and, within the last month, oedema of the 
 lower extremities has supervened. 
 
 October 11th. There is perfect dulness of the whole right side, 
 from the clavicle to the short ribs, extending to the left side 
 of the sternum for its whole length. In the right infra-clavicular 
 region a feeble tracheal respiration, with some slight sonorous or 
 sibilous rales, is audible. The same can be heard in the supra- 
 clavicular region. Over the rest of the side there is nullity of 
 respiration. No gargouillement, muco-crepitus, nor bronchial 
 respiration whatever. The voice sounds strongly in the supra 
 and infra -clavicular regions. The whole side is dilated somewhat 
 more than an inch ; the intercostal spaces are raised, giving 
 complete smoothness to the side ; over the left lung respiration 
 is completely puerile. The whole of the upper portion of the 
 abdomen is occupied by a large and prominent tumour, whose 
 greatest eminence appears along the mesian line, and extends 
 into the left hypochondrium.
 
 584 DISEASES OF THE PLEURA. 
 
 20tli. He complains of pain in the lower portion of the right 
 side, just below the short rib. There is some tenderness, tume- 
 faction, and a slight blush. 
 
 November 1st. The superficial veins of the right side are 
 enlarged ; the heart is displaced upwards, and about three inches 
 to the left side. 
 
 Thus he continued for a month, when the tumour was found 
 to have increased in size, to be quite soft, and surrounded by a 
 dark, livid redness. A lancet was plunged into it, giving exit to 
 a small quantity of bloody sanies. Patient complained of great 
 pain. 
 
 3rd. A serous fluid is constantly draining in great quantity 
 from the sore. The patient's lower extremities and abdomen, 
 which were anasarcous, are becoming rapidly devoid of fluid. 
 
 6th. Anasarca nearly gone. On attempting to make a more 
 free opening in the tumour, the patient lost about twelve ounces 
 of blood from the vessels of the integuments : but the pain in the 
 tumour was greatly relieved. 
 
 7th. The discharge is increased, and is sero-purulent ; the right 
 side is dull, anteriorly and posteriorly, as high as the mamma; 
 from that up it is natural : and over this space respiration is dis- 
 tinctly audible, loud, and with something of a tracheal character 
 immediately below the clavicle ; feeble, as we approached the 
 limits of the clear sound ; below this, nullity of respiration. The 
 heart now pulsates in its natural situation. In the abdomen the 
 tumour formerly evident, is now not so perceptible to the eye, 
 but is easily distinguished by the hand, and its boundaries dis- 
 tinctly defined by percussion. The liver, especially the left lobe, 
 appears enlarged. There is considerable heat of skin, and a 
 tendency to rigors. The patient sweated copiously last night. 
 
 10th. Patient complains more of dyspnoe'a ; anteriorly, and in 
 the axilla, on a level with the sixth rib, the sound of the chest is 
 morbidly clear : below this, perfect dulness ; nullity of respiration 
 complete, except over the root of the lung, and in a small space 
 to the right of it ; here it has a bronchial character. The cough 
 and voice are distinctly metallic. 
 
 13th. The sloughs have come away, and the sore looks healthy. 
 Patient complains greatly of dyspnoea, and a "feeling of wind 
 jiassing in and out of the hole," and air can be heard gurgling 
 along with the sero-purulent discharge ; but the flame of a wax
 
 DISEASES OF THE PLEUKA. 585 
 
 taper applied to the aperture is not sensibly affected. He con- 
 stantly presses his hand strongly above the aperture, and says 
 this relieves his breathing very much. Had a slight rigor to-day, 
 with tendency to syncope, and afterwards sweated. The sero- 
 purulent discharge continues ; and when he sits up, or goes to 
 stool, it comes away in gushes. 
 
 14th. Discharge has become very foetid ; the fistulous opening 
 appears near an inch wide at its commencement ; a probe may be 
 introduced its whole length with facility. Compresses of dry lint 
 were lightly strapped down along the course of the fistula. The 
 sore was dressed with nitrate of silver and dry lint ; and, over all, 
 a broad roller was applied to the chest, with considerable tight- 
 ness, from which the patient expressed great relief. 
 
 15th. Slept pretty well, without sweat. The discharge had 
 diminished ; but, on the patient sitting up, and having the 
 sore dressed, fully a pint of very foetid sero-purulent matter was 
 evacuated, during the flow of which he complained of agonizing 
 pain, compared by him to burning by hot iron, and causing him 
 to scream aloud. The discharge was followed by about an ounce 
 of bloody sanies. 
 
 25th. At this time I found that respiration was audible only 
 along the spine and sternum, and confined to a very narrow 
 space ; the sound of air making its way through the fistulous 
 opening, and simulating respiration, was generally audible over 
 the whole of the right side; with the metallic character as before. 
 The patient expired on the 29th December. 
 
 Dissection. — Body generally very much emaciated ; oedema of 
 the lower extremities. The external sore and fistulous opening 
 were situated exactly above the last false rib, near the spinal 
 column ; through these a bougie was introduced with great facility, 
 passing upwards, and to the left side, appearing to enter 
 the fight pleural ca\ity. In raising the sternum, it was necessary 
 to divide a considerable extent of old adhesions, which connected 
 the antero-inferior third of the right lung to the parietes. On 
 laying open the thorax completely, the left lung appeared per- 
 fectly healthy ; the right lung lay along the spine, greatly reduced 
 in volume, but of its natural length, and connected to the dia- 
 phragm by a very firm adhesion, about three inches in breadth. The 
 pleura was lined with pus, of which the cavity contained four 
 ounces, mixed infe^^iorly with large membranous shreds of lymph.
 
 586 DISEASES OF THE PLEUEA. 
 
 among which the point of the bougie was seen protruding, having 
 entered by an opening large enough to admit the tip of the little 
 finger, situated in the most depending portion of the cavity, 
 about an inch from the spine, in the angle formed between the 
 diaphragm and the parietes. No other breach of continuity 
 could be discovered in the pleura. The substance of the right lung 
 was carnified, and generally studded with tubercles in different 
 stages. The left lung was also tubercular in its superior lobe. 
 The liver was of a dirty yellowish colour, nodulated, and greatly 
 enlarged ; the right lobe extending down to the umbilicus, and 
 the left far into the left hypochondrium. 
 
 This last case is interesting as exemplifying the occurrence of 
 metallic signs in pneumothorax from external fistula, and 
 without the existence of fluid. The signs continued after every 
 drop of fluid had drained through the opening in the side. The 
 fact that the presence of liquid is unnecessary for the existence of 
 metallic signs, has been already established by Dr. Williams. 
 With the exception of the signs of dropping or bubbling, all 
 that is wanting to cause metallic sounds, is a cavity of sufficient 
 size containing air. 
 
 I may here remark, that in the early periods of the disease the 
 lung may not be completely fixed. Thus, we may observe in 
 cases, in which, during the erect position the signs are evident 
 posteriorly and superiorly, that they disappear when the patient 
 turns on his face, and are replaced by vesicular murmur, although 
 they continue in the anterior and inferior portions. This can 
 only be explained by supposing that, as the liquid accumulates 
 along the mediastinum, it forces the lung against the posterior 
 portion of the costal pleura. 
 
 We may attempt a classification of cases of pneumothorax, 
 founded principally on the nature of the afi"ection which has 
 preceded the fistula. And I wish it to be understood that in 
 arranging these in the order of frequency, I depend merely on 
 my own experience of the disease. 
 
 I. In this class of cases the tuberculization of the lung and 
 the consequent formation of superficial cavities precede the 
 formation of pneumothorax. That the accident of a fistula is 
 not more frequent is explained by the great liability of the 
 pleura to form adhesions in connexion with any subjacent dis- 
 ease. Were the pleura as little disposed to this process as the
 
 DISEASES OF THE PLEURA. 587 
 
 peritoneum, perforation of the pleura would be one of the most 
 common of accidents, and the cure of consumption scarcely pos- 
 sible. In most cases the fistula is not produced until the disease 
 has become a chronic affection. We find it generally more 
 towards the centre than the upper part of the pleura. So that 
 it appears probable, if we adopt the opinion of Laennec, that the 
 tubercle is developed by successive crops, that the fistula is con- 
 nected less with the first or second than with subsequent deve- 
 lopments of the disease. There may be more than one fistula, 
 but in these cases it is not likely that the perforations have 
 formed simultaneously. Finally, we have in this class of cases 
 those secondary fistulas forming from without inwards, and which 
 are to be attributed to the diseased process set up in the pleural 
 sac in consequence of the chronic empyema. 
 
 II. A gangrenous eschar having formed in the lung may 
 communicate with the bronchial tubes on the one hand, while it 
 perforates the j^ulmonary pleura on the other. All the mecha- 
 nical conditions of the first form are thus produced ; and it 
 appears very probable that the products of the pleuritic disease 
 have from the first a putrefactive character. 
 
 III. A simple empyema having formed may open into the 
 lung. We cannot say whether in every such case a temporary 
 pneumothorax is produced, but that such a complication may 
 occur, and yet the patient subsequently recover must be ad- 
 mitted. I have seen two remarkable examples which confirm 
 this statement. But on the other hand it occasionally happens 
 that, the fistula remaining permanently open while the luno- 
 from its physical condition is unable to expand, a permanent 
 fistular pneumothorax is established. 
 
 IV. We may have pneumothorax by external fistula. A 
 patient is operated on for empyema ; a large quantity of fluid is 
 withdrawn, while the lung is either incapable of any expansion, 
 or can only enlarge itself to a certain degree ; the wound re- 
 mains open, admitting air during inspiration, on the one hand, 
 and pouring out a sanious pus on the other. There is yet 
 another case of pneumothorax in which we have the curious 
 combination of pulmonary and intercostal fistula. This condi- 
 tion I have observed in a case of the ordinary empyema and 
 pneumothorax in a phthisical patient. An anthrax formed on the 
 side through which the liquid contents of the sac drained, so
 
 588 DISEASES OF THE PLEURA. 
 
 that the singular combination of an external and an internal — 
 fistula was produced. The patient inspired through two canals 
 — one the larynx, the other the intercostal fistula. 
 
 There are two points still worthy of notice in connexion with 
 this subject : one, the question as to how far the mere rupture 
 of the pleura and efi"usion of air into the sac is competent to 
 produce the combination of empyema and pneumothorax, and 
 the other, the supervention of this accident in cases of protracted 
 hooping-cough. The possibility of the occurrence of fistular 
 pneumothorax without empyema is a question on which much 
 difference of opinion exists. But the case I communicated to 
 the Pathological Society in 1840, establishes the possible occur- 
 rence of such a condition.* 
 
 This case is at all events illustrative of the doctrine that even 
 with a violent solution of continuity of the pleura the effusion of 
 air and collapse, or compression of the lung, are not necessarily 
 followed by inflammatory action. And so far as it goes it tends 
 to support the opinion, which is every day more generally ad- 
 mitted, that the mere entrance of air into the cavity of the 
 pleura is, so far as it tends to excite serous inflammation, a 
 matter but of slight importance. In the case in question we 
 had fistula, collapse of the lung, and pneumothorax, and yet the 
 pulmonary pleura was totally free from the slightest mark of 
 inflammatory action. In this case, as in that of the double 
 fistula, just now alluded to, there was no pleuritic effusion, at 
 least at a certain period of one case, and during the entire 
 progress of the other. Yet in both these cases the metallic 
 phenomena of respiration and of voice were distinctly produced. 
 The presence of a liquid then is not necessary for the production 
 of these signs. The metallic tinkling and the sound of suc- 
 cussion were of course absent, but the essential characteristics of 
 air confined in an elastic cavity were present. 
 
 Before proceeding to the consideration of the medical treat- 
 ment, a few observations may be added which have reference to 
 the subject in general, and which may be considered as supple- 
 mentary to what has been already said. Perforative pneumo- 
 thorax and empyema may sometimes occur under unusual 
 circumstances. My friend Dr. Towusend related a case to me 
 in which but one, or at the most but two, tuberculous concre- 
 
 * See Trans. Path. Soc, vol. i.
 
 DISEASES OF THE PLEUEA. 589 
 
 tions of a small size existed in the lung ; and there was little if 
 any reason to suspect that the patient was phthisical. From 
 one of these concretions, which was superficial, the perforation 
 actually took place. The patient ultimately sunk, although 
 the lungs could scarcely be said to contain any tuberculous 
 deposit. 
 
 I have stated that in most cases the fistula occurs at a point 
 considerably removed from the summit of the lung — a circum- 
 stance which, placed in connection with others, seems to warrant 
 the opinion that the accident is very rare during the development 
 and maturation of the earlier tubercular deposits. I have, 
 however, seen one remarkable exception to this, in which a 
 small cavity existed at the very summit of the lung, and the 
 communicating perforation was within an inch of the apex. 
 Such a case must be considered as one of extreme rarity, as in 
 most cases the secondary adhesions are strong and complete 
 around the summit of the lung. I have witnessed another case 
 illustrative of the unexpected occurrence of perforative pneumo- 
 thorax. A young lady, several of whose family had suffered from 
 phthisis, was attacked with hooping-cough, attended by a good 
 deal of bronchial inflammation and fever. The character of the 
 cough remained unchanged, but the febrile state with a rapid 
 pulse continued for many weeks. The medical attendants and 
 friends of the patient misled by the persistent characteristics of 
 the cough never dreamt of the existence of any organic disease. 
 It happened however on one occasion that, after one of the ordi- 
 nary paroxysms of pertussis, the patient was seized with agonizing- 
 dyspnoea ; she was seen by an eminent practitioner of this city, 
 who at once recognized that a perforation of the lung had taken 
 place. I also saw her within a few hours after this gentleman 
 had discovered the nature of the affection, and the patient had 
 then the unequivocal signs of pneumothorax with liquid effusion. 
 She died in a few days — the opening being apparently valvular, 
 and the consequent oppression and distention of the chest causing 
 the greatest amount of oppression and suffering. Here the 
 error arose from the ignorance of two important pathological 
 facts, one that while the apyrexial hooping-cough is generally 
 innocuous, the complication of the disease with fever of any type 
 should always excite alarm — nay, even if fever be absent, or but 
 slightly developed, yet if the pulse continue rapid in a case of
 
 590 DISEASES OF THE PLEURA. 
 
 pertussis there is just ground for apprehension. The second 
 ground of error was the overlooking the important fact that 
 where an organic change succeeds to a specific disease, the pecu- 
 liar symptoms of the latter may continue unchanged up to the 
 last period of life. Thus in a case of hooping-cough which 
 comes to he complicated with tuhercle, it will often happen that 
 the cough will continue unchanged, although the lungs are far 
 advanced in disorganization. Ignorant of this fact, and also 
 ignorant of the great law that specific diseases, especially when 
 complicated with fever, are too apt to be followed by heterologous 
 deposits in the viscera, the practitioner continues blinded as to 
 the actual state of his patient, or only discovers his error when 
 the saving of his patient's life and that of his own reputation are 
 equally impossible. It is supposed that because the patient has 
 hooping-cough no other disease exists — a doctrine by which no 
 one who understands the law of combination of disease should 
 permit himself to be misled. I have repeatedly witnessed cases 
 of fatal suppurative phthisis which had commenced by hoop- 
 ing-cough, yet in which the peculiar character of the cough 
 remained unchanged throughout the entire course of the case ; 
 we may lay it down as a practical rule, that if in any case of 
 hooping-cough any of the three following circumstances occur, 
 we should expect the occurrence of organic disease, and espe- 
 cially that of tuberculization of the lung. 
 
 Istly. That the cough preserving its special character con- 
 tinues for a period of unusual length. 
 
 2ndly. That it resists treatment. 
 
 Srdly. That it is attended with rapidity of pulse. 
 
 4thly, and lastly. That a febrile state exists. This condition 
 may have attended the cough from the first, or may become 
 developed at some advanced period of the case ; it may be in- 
 flammatory or irritative, remittent^ intermittent, or truly hectic ; 
 but in whatever form it may occur, its combination with pertussis 
 is to be looked upon as a source of the most grave prognosis. 
 In some cases the local change may be detected by the stetho- 
 scope, while in others little can be found but the signs of a 
 remittent or resistent bronchitis ; yet, even under these circum- 
 stances, I would impress strongly on the mind of the practitioner 
 that where he has to deal with a case of hooping-cough of long 
 standing, and complicated with fever of any description, the
 
 DISEASES OF THE PLEURA. 591 
 
 negative result of a physical examination will not justify him in 
 considering the lungs free from organic disease. 
 
 The question of the curahility of pneumothorax and empyema 
 from fistula has heen mooted by Dr. Houghton ; and, doubtless, 
 in his case there was an attempt towards cure. The records of 
 surgery shew that the mere existence of fistula is not always 
 hopeless; but we must draw a careful distinction between cases 
 of wounds of the thorax, where the lung was previously healthy, 
 and those where the fistula has proceeded from idiopathic lesion. 
 We know further, that the opening of a simple empyema into 
 the lung has been followed by recovery; and in such a case the 
 chances are better. But where the disease has proceeded from 
 the opening of a gangrenous or tuberculous abscess into the 
 pleura, the chances of recovery, even without reference to the 
 condition of the pleura, must be infinitely small ; and, I believe, 
 there is no recorded instance of such an event. 
 
 Finally, little is to be hoped from an operation in this disease; 
 and it should never be undertaken unless when the distress is 
 distinctly traceable to the enormous accumulation of liquid, as 
 shewn by extensive dulness and diminution of the metallic signs ; 
 and even in such a case the relief is much less than might be 
 expected ; and there is the greatest liability to gangrene of the 
 pleura. This I have repeatedly verified ; and the rapidity of 
 the destruction of the serous membrane is truly singular. I 
 have given a case, in which, previous to the operation, no 
 symptom of gangrene existed, where the fluid withdrawn had 
 no foetor whatever, yet where the whole pleura was destroyed in 
 a few days ; the ribs were actually denuded, and seemed in a 
 state of necrosis. 
 
 We may here recapitulate some of the points which have been 
 discussed, referring especially to those which have a practical 
 bearing, not only on treatment, but also on diagnosis and 
 prognosis.* 
 
 1st. It is certain that pleuritis may occur under a variety of 
 conditions ; that it may be on the one hand latent, both as to 
 local and general symptoms, while on the other it may be a 
 most violent and manifest disease. 
 
 * This recapitulation is compounded of that which concludes the chapter in the 
 former edition, and of a longer and more elaborate resume in the author's note book; 
 care having been taken to select the most important deductions in each, and so to 
 arrange them as to avoid, so far as possible, needless repetition. (Ed.)
 
 592 DISEASES OF THE PLEURA. 
 
 2nd. That even in tlie latent and apyrexial cases bad results as 
 to the contraction of the side or to the subsequent development 
 of tubercle may follow. 
 
 3rd. That this latent, subacute form may be a primary or a 
 secondary affection, and is liable to be confounded with many 
 diseases, of which phthisis is the most common. 
 
 4th, That physical diagnosis is indispensable in judging of 
 the extent, progress, retrocession, or cure of pleuritic disease. 
 
 5th. That these physical signs are fourfold, embracing the 
 signs of simple exudation of lymph, the evidences of excentric 
 pressure or displacement, of concentric displacement, and lastly, 
 of intercostal or diaphragmatic paralysis. 
 
 6th. That the dulness of a pleuritic effusion generally occurs 
 more rapidly than that of pneumonia, and is unpreceded by 
 crepitating rale. 
 
 7th. That these characters are not always available for 
 differential diagnosis. 
 
 8th. That as a sign of incipient effusion dulness is more 
 valuable when occurring at the left than at the right side. 
 
 9th. That when partial it terminates by a well-defined (trans- 
 verse) line. 
 
 10th. That the respiratory murmur may be totally ex- 
 tinguished, feebly audible, or distinctly bronchial. 
 
 11th. That the bronchial respiration is to be distinguished 
 from that of pneumonia by the concurrent phenomena. 
 
 12tii. That the egophonic sounds are extremely various and 
 inconstant. 
 
 13th. That the absence of vocal fremitus as perceived by the 
 hand is an important sign. 
 
 14th. That when the voice is acute and feeble this test is 
 inapplicable. 
 
 15th. That the signs of excentric displacement are the most 
 valuable of the physical indications. 
 
 IGth. That displacement of the heart occurs before that of 
 the intercostals or diaphragm. 
 
 17th. That this is not necessarily accompanied by disturbance 
 of the heart's action. 
 
 18th. That as a sign of effusion dilatation is of more value 
 when occurring at the left than at the right side. 
 
 19th. That the efiects of excentric pressure are first seen on
 
 DISEASES OF THE PLEUEA. 593 
 
 the non-muscular portions of the thoracic walls, dilatation of the 
 mediastinum and of the ribs preceding that of the intercostals 
 and diaphragm, the less vital portions of the thorax yielding 
 before the muscular structures. 
 
 20th. That the mediastinal displacement can be ascertained 
 by percussion as well as by the position of the heart. 
 
 21st. That the yielding of the muscular expansions implies 
 paralysis, which may be induced by two causes — one the effect 
 of active inflammation of a contiguous tissue — the other long- 
 continued pressure affecting the innervation and circulation of 
 the muscular tissue. 
 
 22nd. That the period at which the yielding of the muscular 
 structures takes place may furnish an approximative measure of 
 the intensity of the inflammation. 
 
 23rd. That dexiocardia in connexion with empyema is of three 
 kinds : (a) when the heart is temporarily displaced and returns 
 to its natural position, or nearly so, on the absorption of the 
 fluid ; (b) when, notwithstanding the removal of the fluid by 
 operation, it does not change its situation ; and (c) when in 
 consequence of the absorption of an empyema of the right 
 pleura it is drawn over to the right side and there becomes per- 
 manently fixed. 
 
 24th. That after absorption of empyema of the left pleura the 
 mediastinum may be so relaxed as to allow of the heart changing 
 its position under the influence of gravitation. 
 
 25th. That contraction of the side is not a necessary conse- 
 quence of an empyema, but that the earlier it appears the 
 greater will be the chance of its diminution or ultimate disap- 
 pearance. 
 
 26th. That it may coincide with persistent and even increasing 
 effusion. 
 
 27th. That the liability to permanent contraction is directly 
 as the violence of the inflammation and the lengtli of time that 
 the disease has been allowed to remain uninfluenced by treat- 
 ment, and that paralysis and atrophy of the intercostals and 
 diaphragm is an important part cause of the contraction in such 
 cases. 
 
 28th. That besides the two groups of acute and subacute 
 pleurisy a third is to be recognized in which severe constitu- 
 tional and local suffering exist all through the case. It is in 
 
 Q Q
 
 594 DISEASES OF THE PLEURA. 
 
 this class that we most usually ohserve complication with one or 
 more local diseases, and also the strong liability to pathological 
 transformations in the products of the disease. 
 
 29th. That in certain cases of contraction after empyema it 
 is difficult to determine to what point the absorption has gone 
 on ; whether an encysted empyema remains, or whether a 
 pathological transformation of the products of disease has really 
 taken place. 
 
 30th. That three causes appear to assist in producing contraction 
 of the side, namely, diminished volume of the lung, the occurrence 
 of a fistula from without inwards, as when an empyema opens 
 into the lung, and the temporarily paralysed state of the inter- 
 costal muscles and draphragm. 
 
 31st. That the contraction is in certain cases truly concentric, 
 and goes on from below upwards as well as from above down- 
 wards or without inwards, and that this consideration is of 
 importance as bearing on the operation of paracentesis, and 
 especially as regards the place of election. 
 
 32nd. That when the return of the force of the respiratory 
 muscles has been long deferred, and the lung has been bound 
 down by adhesions, it may act in producing a dilated state of all 
 the bronchial tubes, and we may thus explain the occurrence of 
 dilated tubes in a case of primarily cured empyema. 
 
 33rd. That there are three modes in which elimination of the 
 effused matter in cases of empyema is observed to occur — (a) by 
 absorption, (b) by evacuation through the lung by means of a 
 solution of continuity of the pulmonary pleura, (c) by evacuation 
 through the external parietes. 
 
 34th. That in the case of evacuation through the lung, the 
 perforation of the pleura is indicated by the signs of empyema 
 and fistular pneumothorax, more especially by the sound of 
 fluctuation on succussion, followed subsequently by contraction 
 of the chest. 
 
 ' 35th. That in the early periods of perforation, absence of 
 respiration may precede the metallic signs. 
 
 36th. That the metallic phenomena may be observed in the 
 dropping of liquid, in the brealdng of bubbles on the surface, and 
 in the voice, respiration, cough, rale, and action of the heart. 
 
 37th. That for the production of the metallic voice, cough, and 
 rale, it is not necessary that liquid should exist in the cavity,
 
 DISEASES OF THE PLEURA. 595' 
 
 and that these may be metallic in pneumothorax by external 
 fistula. 
 
 38th. That morbid clearness is not always coexistent with the 
 effusion of air. 
 
 39th. That (as pointed out by Dr. Greene) vicarious secretion 
 from the bronchial mucous membrane is not uncommon in cases 
 of empyema, and sometimes to such an extent as to lead to the 
 supposition that an opening into the lung has formed, and that 
 similarly many cases of the supposed opening of an hepatic abscess 
 through the lung, are examples of this vicarious discharge of pus. 
 40th. That under these circumstances the physical signs 
 ordinarily attributed to soften tubercle are often produced, and 
 liable to mislead the practitioner ; such are well-marked gurgling 
 and large rale confined to a certain portion of the lung. 
 
 41st. That this vicarious discharge from the bronchial tubes 
 may cease on the formation of an external outlet, and reappear 
 whenever that outlet is closed. 
 
 42nd. That in the case of evacuation through the integuments 
 there may be a simple fluctuating abscess communicating with 
 the pleural sac (empyema of necessity), or a carious state of the 
 ribs may be induced, in which case the external fistula continues 
 to pour out matter which is often foetid, and the result is 
 generally unfavourable. 
 
 43rd. That an exaggerated diastolic pulsation may attend on 
 the empyema of necessity. 
 
 44th. That pulsation may attend on empyema although no 
 local or subtegumental collection be formed. In other words, that 
 there are two forms of pulsating empyema. One in which there 
 is simply a large collection of fluid with a displaced heart, the 
 other where the empyema of necessity, has formed. 
 
 45th. That the pulsations of the empyema of necessity are 
 not accompanied by any murmur or fremitus. 
 
 46th. That these pulsating tumours may be attended with an 
 inflamed condition of the integuments, or be perfectly indolent so 
 far as the condition of the skin is concerned. 
 
 47th. That in the case of pulsation of the entire empyematous 
 sac, the force of the pulsations seems to be in the direct ratio of 
 the amount of the effusion. 
 
 48th. That with regard to prognosis, we may draw a distinc- 
 tion between those cases of a fistula of the lung opening into the
 
 •596 DISEASES OF THE PLEURA. 
 
 pleural sac, and those where the reverse process takes place, as 
 when an empyema opens into the lung ; since in the first of these 
 cases the pneumothorax is permanent, while in the second it may 
 be only temporary. 
 
 49th. That tubercle and gangrene are the most frequent causes 
 of the first form, and that of these, tubercle is by far the most 
 frequent form of disease. 
 
 50th. That the signs of the original tubercular cavity may 
 continue long after the perforation of the pleura and other lesions 
 have occurred. 
 
 51st. That perforation of the pleura and consequent pneumo- 
 thorax is not necessarily attended with pleurisy and empyema ; 
 simple perforative pneumothorax having been observed both in 
 the rupture of dilated cells, and even in a case of phthisis. 
 
 52nd. That on the valvular or non- valvular character of the 
 fistula, will in a great measure depend the amount of consequent 
 suffering, and the immediate danger from the accident. 
 
 53rd. That the cases with permanently patent fistula may be 
 divided into two classes. In the one the amount of liquid 
 effusion remains stationary for a great length of time, while in 
 the other there is a progressive increase of the fluid, so that the 
 relative proportions of air and fluid are ultimately reversed with 
 the result of increasing the distress of the patient. 
 
 54th. That in a case of phthisis with well marked constitu- 
 tional symptoms, the occurrence of fistular pneumothorax and 
 empyema has occasionall}" been followed not only by long con- 
 tinued suspension of the symptoms of phthisis, but also by great 
 improvement in the general health. 
 
 FINIS. 
 
 LONDON; y. 
 
 Printed by Jas. Trcscott and Hon. 
 Suffolk Lane, City.
 
 UNIVERSITY OF CALIFORNIA LIBRARY 
 
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