Digitized by the Internet Archive in 2010 with funding from Open Knowledge Comrnons http://www.archive.org/details/pathologicalreseOOIoui PATHOLOGICAL RESEARCHES O N PHTHISIS. DR. CLARKE ON PHTHISIS. " We cannot conclude this section without expressing our obligations to M. Louis the able author of the " Traité de la Phtiiisie." We are so much indebted lo this zealous and indefatigable physician for all our more precise knowledge of the pathological anatomy of Phthisis, that we think it due to him to acknowledo-e the great assistance we have derived from his researches in the com- position of this article ; and we beg to refer our readers for more full informa- tion to his treatise, as they will not only find therein the best account of the mor- bid anatomy and symptoms of the disease, but will moreover learn to admire, and perhaps to imitate, the industry, the zeal, and the scrupulous veracity of this most accurate and philosophical observer." — Cyclop. Pract. Med. Part xxii. p. 306. " M. Louis certainly ranks as the first physician of France and probably of Europe." — Marshall Hall. PATHOLOGICAL RESEARCHES PHTHISIS. By p. CH. Doctor in Medicine of tlie Faculties of Hospita) of La Pitié ; President for Lifa Member of the Royal Academy of medi(Sne ; Correspondenrtf the Royal Academy of Marseilles, of the Imperial Medico-Chirurgical Academy of St. Petersburgh, and of the Royal Medical Society of Edin- burgh, Member of the Legion of Honor. TRANSLATED FROM THE FRENCH, WITH INTRODUCTION, NOTES, ADDITIONS, AND AN ESSAY ON TREATMENT. By CHARLES COWAN, M. D., E. M. D., P. M, R. C. S., E. Member of the Society tor Medical Observation ; Bachelier en-Lettres of the Sorbonne; Elève of the Hospitals of Paris and of the Ecole Praclique ; Ex-President of the Hunlerian Society, and Member of the Royal Medical and Ethical Societies of Edinburgh. REVISED AND ALTERED By henry I. BOWDITCH, M. D. Fellow of the Massachusetts Medical Society and Member of the Society for Medical Observation at Paris. BOSTON HILLIARD, GRAY AND CO 1836. ill ^ (X/\/^^ — ■ (^VV^_^^ ] Entered according to the Act of Congress, in the year 1836, by Henry I. Bowditch, In the Clerk's Ofl&ce of the District Court of the District of Massachusetts- BOSTON, PRINTED BY 1. R. WILLIAM STOKES, M. D. PHYSICIAN TO THE MEATH HOSPITAL, PROFESSOR OF CLINICAL MEDICINE, &c. &c. &c. AND HENRY RILEY, M. D. PHYSICIAN TO THE BRISTOL INFIRMARY, LICENTIATE OF THE ROYAL COLLEGE OF PHYSICIANS, &c. &c. &c. PROM THEIR GRATEFULLY OBLIGED FRIEND, THE TRANSLATOR CONTENTS American Editor's Preface, xxi Translator's Introduction, xxv Author's preface, Ixi PART I. PATHOLOGICAL ANATOMY CHAPTER I. Respiratory Organs, . .... 3 Art. I. Of the Lungs, ib. Obs. L Tubercular Cavity, including three-fourths of the Right Lung, 16 Obs. IL Mass of organized Fibrin filling a moderately sized Tubercular Excavation, 22 vin CONTENTS. Obs. III. Healthy Fragment of Pulmonary Parenchyma, unat- tached, in the midst of an Excavation, . . 27 State of the Bronchia, 36 Acute Inflammation of the Substance of the Lungs in the last stage of Phthisis, 37 Acute Inflammation towards the close of other Chronic Dis- eases, 38 Art. II. Of the Pleurae, ....... 39 Adhesions of the Pleuree in Phthisis, .... ib. " in cases fatal from other Diseases, . . 41 Acute Pleurisy towards the close of Phthisis and other Chronic Affections, 42 Art. III. Of the Epiglottis, Larynx and Trachea, . . ib. Sec. 1. Ulcerations of the Trachea, .... 43 2. « " Larynx, 46 3. " " Epiglottis, .... ib. State of these Organs in Subjects dead from other Chronic Diseases, ........ 48 CHAPTER II. Organs o"^ Circulation, 49 Art. I. Of the Heart and Pericardium, .... ib. State of the Heart in other Chronic Diseases, . . 52 Art. II. Of the Aorta, ib. State of the Aorta in other Chronic iseases, . 54 CHAPTER III. Digestive Organs, ^ 57 Art. I. Of the Pharynx and Œsophagus, . . . . ib. State ofthc.se Organs in other Chronic Diseases, . 58 PATHOLOGICAL ANATOMY. IX Art. II. Stomach, 59 Sec. 1. Of the Volume and Situation of the Stomach, . ib. " " " " " in other Chronic Diseases, ib. Sec. 2. Softening with diminished Thickness of the Mucous Membrane of the Stomach, .... 60 Sec. 3. Redness combined with thickening, with a Mamillated State or Softening of the Mucous Membrane, and occurring in the anterior portion of the Stomach, 64 Sec. 4. Redness with Softening of the Mucous Membrane lining the great Cul-de-sac of the Stomach, . 65 Sec. 5. The mamillated appearance and greyish color of the Mucous Membrane of the Stomach, . . . 67 Sec. 6. Ulcerations of the Mucous Membrane of the Stomach, 68 Sec, 7. Some other morbid changes of the Mucous Membrane of the Stomach, 69 Tabular View of the different Lesions of the Gastric Mucous Membrane, ..>..... 70 Tabular View of the different Lesions of the Gastric Mucous Membrane in other Diseases, .... 71 Art. III. Of the Duodenum, 72 IV. Of the Small Intestine, . ... . . . 73 Sec. 1. Of the Mucous Membrane of the Small Intestine in its healthy state, 74 Sc 2. Pat hology of the Small Intestine, .... 78 Obs. IV. Large Intestinal Ulcerations, Perforation of the Small Intestine, 84 State'of the^Sraall Intestine in other Chronic Diseases, 90 Art. V. Large Intestine, 91 State of the Large Intestine after other Chronic Diseases, 99 2 X CONTENTS. CHAPTERIV. Lymphatic Glands, 99 Art. r. Of the Mesenteric Glands, 100 II. Of the Mesocascal, Mesocolic, and Lumbar Glands, 104 III. Of the Cervical, Axillary and Bronchial Glands, . 105 State of the Lymphatic Glands after other Chronic Diseases, 106 CHAPTER V. Biliary Apparatus, . 107 Art. I. Of the Liver, ........ ib. State of the Liver after other Chronic Diseases, . . 108 Art. II. Of the Bile and Gail-Bladder, .... 112 State of the Bile and Gall-Bladder after other Chronic Dis- eases, 114 CHAPTER VI. Spleen, 114 State of the Spleen after other Chronic Diseases, . 116 CHAPTER VII. Urinary Organs, 117 Obs. V. Tubercular Matter in the Right Kidney and corres- ponding Ureter, 118 In other Diseases, 121 CHAPTER VIII. Genital Organs, . ..... 122 Art. I. Of the Male Genital Organs, . . , . .. ib PATHOLOGICAL ANATOMY. XI Ob S. VI. Tubercular Matter in the Prostate, Vesiculse, and Vas Deferens, 122 State of the Male Genital Organs after other Acute or Chronic Diseases, J 28 Art. II. Of the Female Genital Organs, . ; . 129 State of the Female Genital Organs after other Chronic Diseases, 130 CHAPTER IX. Peritoneum, 130 Obs. VII. A thick layer of the Tubercular and Grey, Semi- transparent Matter in the Epiploon and Mesocolon, ib. State of the Peritoneum after other Chronic Diseases, 138 CHAPTER X. Brain and its Membranes, 139 State after other Chronic Diseases, .... 142 Obs, VIII. Hydatids in the upper part of the Brain, . . 145 IX. Tubercles in the Cerebrum and Cerebellum, . 151 Summary, 157 XII CONTENTS. PART II. SYMPTOMS. CHAPTER I. Symptoms of Phthisis, 165 Table of the duration of Phthisis, .... J69 Cough, 171 Expectoration, ib. Hsemoptysis, 176 Obs. X. Copious Haemoptysis unsuccessfully treated by Bleed- ing, 179 Dyspnœa, 185 Pain 186 Fever, 189 Sudamina, 193 Thirst, . 194 Appetite, ib. Diarrhoea, J95 Emaciation, J99 Face, &c., 201 SYMPTOMS. XUl CHAPTER II. Diagnosis, ......... 201 Diagnosis of the first period of Phthisis, . . . 202 Obs. X. (bis). Phthisis recognised the seventeenth day from its invasion, 205 Diagnosis of the second period of Phthisis, , . . 210 Obs. XL Bronchial Dilatation in the summit of the Lungs mis- taken for a Tuberculous Excavation, . , 212 CHAPTER III. Pneumonia and Pleurisy occurring shortly before DEATH, 217 CHAPTER IV. Symptoms of Ulcerations of the Epiglottis, Larynx AND Trachea, 219 Art. I. Symptoms of Ulcerations of the Epiglottis, . ib. Obs. XIL Ulcerations of the Epiglottis unaccompanied by those of the Larynx and Trachea, .... 220 X in. Complete destruction of the Epiglottis, . . 225 XIV. Deep Ulcerations of the Epiglottis and Larynx, 230 Art. II. Symptoms of Ulcerated Larynx, . . . 237 III. Symptoms of Ulcerated Trachea, .... 239 Obs. XV. Large Ulcerations of the Trachea. Symptoms very indistinct, 240 XVI. Extensive and deep Ulcerations of the Trachea. Destruction of portions of the Cartilaginous Rings. No Symptoms, 246 XIV CONTENTS. Inflammation of the Lining Membrane of the Trachea with- , out Ulceration, 252 CHAPTER V. Symptoms of the various alterations of the Gastric Mucous Membrane, 253 Art. I. Symptoms of Softening with diminished Thickness of the Mucous Membrane of the Stomach, . 254 Ob&. XVII, Predominance of Gastric Symptoms, . . 256 Art. II. Symptoms of Inflammation of tlie Mucous Mem- brane of the Stomach when limited to its anterior surface, 263 Obs. XVIII. Strongly marked Gastric Symptoms, . . 264 Art. III. Symptoms observed when the Mucous Membrane of the Stomach is red and softened in the great Cul- de-sac, ... .... 270 Obs. XIX. Few and slightly marked Gastric Symptoms, . 271 Art. IV. Symptoms of Simple Ulcerations of the Gastric Mucous Membrane, 275 Obs. XX. Rather prominent Gastric Symptoms, , . ib. State of the Digestive Functions when the Gastric Mucous Membrane was Mamillated and Greyish, also when it was perfectly sound, 280 Summary of the four preceding Sections, . . . . 281 Obs. XXI. Incomplete Cicatrix of the Gastric Mucous Mem- brane, 283 XXII. Transformation of a portion of the Muscular Coat into a Semi- cartilaginous Substance, . . 286 Art. V. State of the Tongue, ..... 293 Obs. XXIII. Tongue of a deep red, at first moist, afterwards dry. Gastric Mucous Membrane healthy, .. 294 SYMPTOMS. XV CHAPTER VI. Functions of the Genital Organs, . . . . 302 Art. I. Generative Functions in Men, , . . . ib. n. « « in Women, ... 303 CHAPTER VII. Cerebral Symptoms, 306 Obs. XXIV. Ventricular Arachnitis. Symptoms prominent, ib. XXV. Circumscribed Sub-arachnoidean Inflammation ; partial softening of the Brain, . . . 311 XXVI. Partial softening of the Brain, .... 315. CHAPTER VIII. Varieties ■which Phthisis presents in its Progress, 318 Obs. XXVII. Phthisis latent during Twelve Months, . 319 XXVIII. " " " Eight " . . 322 XXIX. « " " Thirty " . . 327 XXX. " " very chronic, overlooked, . 333 XXXI. « " Encysted Tubercles, . . 340 XXXI t. " " Tuberculous Patches between Per- itoneal False Membranes, .... 345 Summary of the six preceding Observations, . . 349 Acute Phthisis, 352 Obs. XXXIII. Phthisis fatal on the Thirty-fifth day, . . ib. XXXIV. Acute Phthisis. Consecutive Pneumonia the cause of Death, ..... 357 XVI CONTENTS. XXXV. Phthisis Mal in Fifty Days, . . . 362 ^ XXXVI. « " in Forty-eight Days, . . 368 Summary of the preceding Observations, . . . 372 Obs. XXXVII. Phthisis fatal in Thirty Days, ... 374 CHAPTER IX. Symptoms of Perforation of the Lcng by Tuberculous Softening, ....... 379 Obs. XXXVIII. Excavation communicating with the Pleurae and Bronchia. Death, Thirty Days after the Per- foration, ib. XXXIX. Excavation communicating with the Pleurse, but not with the Bronchia. Death, Three Days after the Perforation, . . . 383 XL. Excavation communicating with the Pleurse and Bronchia, 387 XLI. Excavation communicating with the Pleurse and Bronchia. Death, Eighteen days after the Perforation, .... 390 XLII. Excavation only communicating with the Pleu- rae. Death, Thirty-six Hours after the Per- foration, ...... 394 XLI 1 1. Excavation communicating with the Pleurae and Bronchia. Death, Twelve Hours after the Perforation, 398 Analysis of the preceding Observations, . '. . 401 Obs. XLIV. Excavation communicating with the Pleurae and Bronchia. Death, Six Days after the Perforation, 4U3 Continuation of the Analysis, 407 SYMPTOMS. XVll CHAPTER X. Sudden Deaths, 414 Art. I. Unexpected Deaths, which may be explained more or less plausibly by the state of the Organs after Death, ib. Obs. XLV., ib. XLVI., 418 Art. I. Sudden Deaths, -which are not accounted for by the post-mortem appearances, .... 422 Obs. XLVIL, ib. XLVIIL, 425 XLIX., 429 L., 433 CHAPTER XI. Causes of Phthisis, . . . . . . . 437 Influence of Sex, 438 " of Pneumonia and Fleurisy, ... . ib. " of EroncLitis, 441 " of Dress, ....... 445 Hereditary Influence, 446 Influence of Age, • 447 CHAPTER XII. Treatment, . 448 XVlll CONTENTS. APPENDIX. Translator's Appendix, 457 A. Origin and Development of Phthisis, ... ib. B. Diagnosis of Phthisis, ...... 460 C. Influence of Sex in the Production of Phthisis, 464 D. " of Pneumonia, .... 466 E. " of Bronchitis, 467 F. « of Dress, 468 G. « of Age, 469 " of Dust, 473 " of Moisture, 477 " of a Dry and Hot Atmosphere, . . 479 " of Animal Emanations, ... ib. « of Vegetable, « .... 480 " of Mineral, " . . . . ib. " of Impure Air, ib. " of Active Life in Open Air, . . 481 " of Sedentary Life with confined posture of the Body, ib. Exercise of the Vocal Organs, .... 482 Influences which predispose to Phthisis, . . 483 Preservative Influences, 484 SYMPTOMS. XIX Influence of Climate, 484 Contagion of PliLhisis, 1'Y; Influence of Season, ..... 4f8 H. Essay on Treatment, 4?9 American Editor's Appekdix, 5i3 AMERICAN EDITOR'S PREFACE This edition of Louis's work on Phthisis is called the re- publication of Dr. Cowan's translation, and such it substan- tially is. Yet I should feel that I was wanting in my duty as Editor, did I not make the following statements. There are many omissions in the English translation, some of which are not very important, while others materially alter the significa- tion of the original work. All of ^hese have been supplied. Dr. Cowan has also fallen into some errors. These statements are mere assertions I allow, but were it necessary, I could give a list of errata ; it is of little moment, however, for me to state any thing farther than this, that the re-publication differs very materially from the English translation. It will be seen that I have placed all Dr. Cowan's additions ja the form of an appendix, instead of having them scattered in various parts of the work. Some sections of this appendix are very valuable, as for example, C, D, E and G. These contain the analyses of facts collected by such men as Parent Duchatelet, Benoiston-Chateauneauf, hard laborers in the cause of science, and who never lay down a principle without having it rest upon a firm foundation of facts. These sec- tions contain likewise summaries of valuable memoirs by Dr. Lombard of Geneva, he. These summaries are in general XXll AMERICAN EDITOR S PREFACE. made correctly, but in one case there are so many dis- crepancies between the statements of Dr. Cowan and the original paper of Dr. Lombard (vide page 472), that 1 have found it impossible to correct Dr. Cowan's remarks without altering the whole paragraph or omitting it altogether. The Essay on Treatment, H, 1 candidly confess I should have preferred not to have seen appended to a work written by Louis. Let me be understood. I do not doubt that many valuable remarks are contained therein, for where is there any effort of the human mind which does not contain some truth? But in quoting, as Dr. Cowan has, from works which are written as differently as possible from the strict method pur- sued by Louis, he has implied that he himself is not so de- voted a disciple of the Numerical School, as we were led to expect from his having undertaken to translate a work of this kind. It may be said that I wish to excite a partisan spirit by this remark. Far be it from me to wish for sects and intolerance either in medicine or religion. 1 wish to see one boldly express his opinion and act up to it. It is the peculiar charm of the Numerical School that it Invites all to become laborers to ad- vance the holy cause of truth ; it tells all that if they will strictly follow its rules success will be the result. It teaches every man that he ought not to consider any principle ascertain which has not been proved. Dr. Cowan quotes from many who do not hold this maxim to be true. I have given in this re-publication all that is contained in the original English translation, but 1 would particu- larly invite the reader to judge of Louis's method as it stands developed in the text, and after his decision let him peruse all the addenda in which, as I have already stated, are some valuable principles, and very many important facts. AMERICAN EDITOR S PREFACE. XXIU The original work on Phthisis was written and published before that on Ty{)hus was commenced. This is the reason why the former has not such a finished aspect as the latter. It is not, in fact, so philosophically written ; the Numerical Method is less perfectly displayed in it than in the two vol- umes on Typhus ; but it bears upon its face, as the whole of Louis's writings do, mathematical exactness. Need 1 say more than this to induce any lover of truth to peruse this volume attentively ? It will depend upon the reception these works meet with from the public, whether the translation of the remainder of Louis's writings be undertaken, but I hope ere long that the whole of them, which have not yet been published in this country, will appear in the present shape. TRANSLATOR'S INTRODUCTION.* " The foundation of all knowledge must be a careful and extensive acquisition o? facts ; and the first duty of an inquirer, in any depart- ment of science, is to bind himself down to such a patitnt accumula- tion, bewaring of all premature attempts to combine and generalize them." — Vide Jlhercrombit on the Intellect. Powers, page 375. "Ce que se rattache à l'espèce humaine, considérée en masse, est de l'ordre des faits physiques; plus le nombre des individus qu'on observe est grand, plus la volonté individuelle s'efface et laisse pré- dominer la série des faits généraux." — Quetelet de V Influence des Saisons sur VHomme. Bruxelles, 1832, Whether we give publicity to our own researches, or become the means of disseminating the opinions and investi- gations of others, we should be alike actuated by a conviction * Since much of the information scattered through the course of this introduction, respecting the author and the method he has pursued, to be correct, must have required pecuhar opportunities, the translator feels call- ed upon to say, that he has spent nearly four years in the hospitals of Paris ; that he assiduously followed the visits, post-mortems and lectures of M. Louis, at La Pitié, for twelve months ; that he has been honored with the private intimacy of the author, and by his kindness inspected the tables from which the present volume was composed, as also those for his researches on the " Affection Typhoide." These various sources have all conspired to im- press him with a deep conviction of the value of M. Louis's works and method, and his presenting the English reader with the present volume is a simple consequence of his sincerity. 4 XXVI TRANSLATOR s INTRODUCTION. of their utility in the abstract, the want of further information, and a conscientious impression that the facts they embody are the literal transcript of realities, and not the distorted or partial materials so easily accumulated for the support of a theory or the making prevalent individual opinion. At a moment like the present, when books are daily teeming from the press in almost every department of medical science, any useless addition to their number ought scrupulously to be avoided ; for both time and intellect are wasted in the discrim- ination of what is worthless or mere repetition, instead of being occupied in the acquirement of what really forms an increase to the knowledge we already possess. In the more positive sciences, the evil alluded to is less sensibly felt, the greater precision of the principles on which they are founded, limiting the field for speculation, by giving a necessary convergence to faithfully detailed phenomena, and at the same time acting as guides for the rejection of inaccurate imperfect description, or hasty ill-digested induction. Medicine, for many very evident reasons, has been and continues to be the victim of varied and contradictory hypoth- eses : — the minds of all who have attempted to trace its deviating course, have wearied in the vague conflict of opin- ions, and have either sheltered themselves under the authority of a name, or satisfied their doubts by the creation of a prin- ciple quite as hypothetical and uncertain as any by which they were previously bewildered. This favored progeny of their fancy, like colored media to the vision, soon tinges all intellectual combinations, and falsifies the very evidence of the senses ; facts seem to multiply in its support, and what at first was regarded as probable, soon strengthens with the fond hope of discovery and the assent of eager, uninquiring enthu- siasts, becoming the basis of a system from which dissent TRANSLATOR s INTRODUCTION. XXVll involves error, and opposing facts are either overlooked or discredited. With such a mental bias, the very talents and researches of an individual become injurious to a profession he would otherwise have adorned, and how often in looking back over the history of medicine, can we see, as it were, our pro- gress arrested by some favorite dogma of a powerful but preju- diced mind, until a rival intellect lays bare the fallacy, erects another in its stead, changing little more than the name of what it thought to have annihilated. The " Sohdists," the " Fluidlsts," the " Brownists," the " Cullenists," and the " Broussaists," with many others, have undoubtedly ob- structed the path of rigorous and impartial observation, by limiting the wide field of philosophic inquiry to the too often forced adaptation of facts calculated to support their own peculiar and almost necessarily imperfect conceptions : and although their labors have not been fruitless, and much posi- tive knowledge may be gleaned from the mass of their inves- tigations, who does not feel that its volume has been infinitely lessened, and its value impaired, by the pre-existence of a principle it was intended to establish, rather than eliminate? The ease with which a theory may be proposed and support- ed, is exactly proportionate to the vagueness of our knowledge, to the absence of impartial incontestable facts; and until the latter have enjoyed that natural precedence which has been granted them in every science that deserves the name, our deductions can never be established upon any satisfactory and lasting foundation. Could genius grasp the bearings of those laws which influence the health and modify the diseases of organized beings, still, observation would be necessary to test the truth or falsehood of its inspirations, but from the finite nature and contracted limits of the human faculties, the neces- sity of observation if not more absolute is at least more glaring, XXVIU TRANSLATORS INTRODUCTION. and the conviction of our mental feebleness should make us shrink from all hasty precocious generalization. Let the candid inquirer contemplate the mass of crude amorphous materials which ages have accumulated ; let him glance over those creeds of medical infallibility which have successively risen and waned in the opinion of mankind ; then let him direct his view to the living representatives of systems either stamped with antiquity, or attractive by their modern freshness and apparent novelty, and what are the conclusions he must form ? Let him change his locality and he changes his principles, while every where /act? are their reputed founda- tions. The pure antiphlogistics of the French, the contro stimulantsof the Italians, the omœopathic of the Germans, and the hepatic nostrums of England, all lay claims to his atten- tion, and are all recommended as the fruits of long experience and multiplied observation. The discovery of truth from such conflicting testimonies, if possible, is at least a Herculean task, and he either becomes the bigoted partisan of a sect, or what is far more rarely the case, resolved to have recourse to rigor- ous impartial inquiry. The results of his labors may indeed be unsatisfactory, and must necessarily embrace but a limited portion of the vast field of medical investigation, he will, how- ever, ensure the satisfaction of collecting materials available to others, and have sacrificed the desire of ephemeral reputa- tion, to the far higher motive of being really useful. It is indeed a subject of deep congratulation, that minds such as these are daily multiplying, and in looking back on what a few years have effected, there is every encouragement for future anticipation, and every reason to suppose, that the results to which we shall ultimately arrive, though probably never of any Utopian character, will at least commend them- selves to the reception of every sound and unprejudiced mind. TRANSLATOR s INTRODUCTION. XXIX What names, we would ask, continue to survive the oblivious tendency of time ? The detailers and chroniclers of facts not opinions ; the latter have long " sunk into the abyss of forget- fulness, and truth alone swims over the vast extent of ages." Our author presents an interesting example of the effect produced upon the mind, by the contemplation of the uncer- tain nature of much of our medical knowledge ; and he is also an illustrious proof of what the exertions of a single individual can effect, when, unfettered by theory or system, they are steadily directed to the simple unbiassed observation of facts. M. Louis, from the age of seventeen to thirty-three, studied and practised medicine in Russia with considerable success. Gifted with a naturally active and inquiring mind, the mul- titude of opinions contrasted with the paucity of facts, could not fail to create great dissatisfaction and uncertainty as to the validity of many of the principles most generally admitted, and on which much of our practice was founded. Accidental circumstances at the close of this period bring- ing him to Paris, he soon became acquainted with and eagerly studied the writings of the celebrated Broussais, at the same time assiduously following that distinguished pathologist, both in the hospital and lecture room. The impression produced upon his mind by this direction of his studies, was, that while M. Broussais evidently proved others to be wrong, he was very far from demonstrating himself to be right ; that while he rendered palpable the doubts which might reasonably be en- tertained respecting many of our present principles, he had failed to substitute any thing more satisfactory in their place. From this moment M. Louis resolved to devote himself ex- clusively to observation, solely actuated by a desire to relieve oppressive doubt and uncertainty, and with no intention of ever giving publicity to his labors. He at once decided on XXX TRANSLATOR s INTRODUCTION. remaining at Paris, as affording the best opportunities for prosecuting his intentions, and entered the hospital of La Charité as a clinical c/er/:, under his friend Professor Chomel. For nearly seven years, including the flower of his bodily and mental powers (from the age of thirty-three to forty), he con- secrated the whole of his time and talents to rigorous impar- tial observation. All private practice was relinquished, and he allowed no considerations of personal emolument to inter- fere with the resolution he had formed. For some time his extreme minuteness of inquiry and accuracy of description, were the subjects of sneering and ridicule, and cui bono was not unfrequently and tauntingly asked. The absence of any immediate result seemed for a time to justify their contempt of a method involving too much labor and personal sacrifice to be generally popular or easily imitated; and M. Louis him- self, at moments, almost yielded to the increasing difficulties of the task he had undertaken. No sooner, however, were his facts sufficiently numerous to admit of numerical analysis, than all doubt and hesitation were dissipated, and the convic- tion, that the path he was pursuing could alone conduct him to the discovery of truth, became the animating motive for future perseverance. Many of the results to which he arrived soon attracted general attention, and among those who had formerly derided his method while they admired his zeal, he found many to applaud and a few to imitate. From this mo- ment may be dated, the presence of that strong impression of the necessity of exact observation, by which the school of Paris has been since so distinguished, and which is now grad- ually pervading the medical institutions of the continent and our own country : it is undoubtedly to the author of the pres- ent volume, that we ought to ascribe the practical revival of that system, which had for ages been verbally recognised but TRANSLATOR s INTRODUCTION. XXXI never before rigorously exemplified. For the last five years he has been physician to the hospital of La Pitié ; the num- ber of advanced students (principally English, American, and German), who follow his visits and clinical lectures, are the best testimonies to the indefatigable zeal and talent with which he still pursues his investigations, and, contrasted with the now deserted wards of M. Broussais, forms a practical illustration of the striking change which has been effected in the spirit of medical inquiry. With no preconceived views of his own to establish (and we believe, no one who has^ will observe seven years !) all results from such researches cannot fail to address themselves to our confidence, and in the present instance they have not only the additional value of having been made at a period of life when the judgment is matured and fancy regulated, but by one who, so to speak, began his studies after several years practical experience of their difficulties. He regarded each individual example of disease, as a problem which could only be solved by patient and exact observation ; with this convic- tion, he studied all the functions during life, from the com- mencement of the disease to its termination ; for the same reason he examined all the organs after death ; and when attempting to arrive at any general conclusion, he not only analyzed the facts he had collected relative to that disease, but submitted them to a rigorous comparison with other diseases which were at all analogous. It is evidently one thing to determine the series of symptoms, or alterations of structure, which are present in any particular affection, and another to discover what symptoms or alterations are special and char- acteristic : the one is obtained by confining ourselves to the disease itself; the other can alone result from comparison. A very short time was sufficient to make the discovery that XXXU TRANSLATOR S INTRODUCTION. observation was immensely difficult, a fact which authors hav.e hitherto overlooked, thus plainly proving that they them- selves observed incompletely. The power of correct obser- vation is not the attribute of ignorance, but is ceteris paribus, always proportionate to the knowledge the individual pos- sesses. With what additional profit and success does the painter, the sculptor, the naturalist, observe after a long cul- tivation of their respective arts, and how numerous are the details detected, which would wholly escape the unpractised novice ? Now, if an accurate conception of external char- acters, when passive under the eye of the observer, demands long and patient exercise for its acquirement, how much greater must be the difficulties surrounding the complicated machine of the human frame, under all the varied influences and the innumerable modifications of which it is susceptible ? The phenomena are not only complex and ever varying, but they must often be examined through the distorting medium of a suffering and fanciful mind, and are frequently described with the intention to mislead and deceive. Not to be con- tinually the dupe of such sources of fallacy (and the most practised do not always escape), requires long habit and ex- tensive general knowledge, and no one can have apprenticed himself, as the author in his preface remarks, to the trade of minute and rigorous observation, without a deep conviction of the difficulties attending it and the necessity of long continued perseverance. We are the more anxious to insist on the great difficulty and infinite importance of observation in medicine, since the very impression is an element of success, and of that caution we should never be free from, in the accumulation of facts, by which our own opinions and those of others are to be regu- lated. The general habits of our schools and hospitals render TRANSLATOR s INTRODUCTION. XXXIU the warning still more necessary ; for while observation is nominally recommended to the student, and even sometimes pursued with zeal and partial success in the first years of his medical studies, it is too often thrown aside with the character of student, at a moment when he is just beginning to acquire the power of observing correctly. The very fact that the task is, in the majority of instances, imposed upon those just entering their career, is calculated to impress the mind with a very imperfect and insufficient idea of its importance. The student should be taught as well as allowed to observe, and the results of his first attempts exposed to the strict scrutiny of a master, who has not himself relinquished the occupation. He should be habituated to analyze and compare the cases he has collected : the time and attention necessary for even a small number of facts, to reduce them to order and trace their relations, would convince him of the difficulties he at first little anticipated, and at the same time impress him with the importance of the results a more extensive and correct application of the method would insure. The advice of the illustrious Sydenham on the principles which should guide the observer, should never be forgotten. "In writing," he says, " the history of diseases, every philo- sophical hypothesis which has prepossessed the writer in its favor, ought to be totally laid aside, and then the manifest and natural phenomena of diseases, however minute, must be noted with the utmost accuracy." We should indeed never replace description by opinion,* or employ words and expres- * " Appearances should always be described in terms which involve no opinion as to their causes. These are the objects of separate examination, and will be best understood if the facts are given fairly, without any depend- ence on what should yet be considered unknown ; this rule is very essential where the facts are in a certain degree complicated." — Dugald Stewart. 5 XXXÏV TRANSLATOR S INTRODUCTION. siens, the meaning of which is not definite, but might be inter- preted to coincide with the peculiarities of individual opinion. " Temperament," " pneumonic sputa," " catarrhal expecto- ration," " marked febrile movement," " healthy state of the digestive tube," and an infinity of other expressions, should never be substituted for the simple description of what w& include by the terms. The value of particular phrases is relative, and liable to vary with the daily progress of science ; their real meaning can only be surmised by reference to the prevalent opinions of the time. The observer should always recollect that the reader has no means to judge of his skill, but in proportion to the minuteness and precision of his de- scriptions ; this observation should be sufficiently complete to enable a stranger to understand and employ it, the language should be clear and concise, and in all enumeration of details, the talent of saying a great deal in a few words should be assiduously cultivated. The want of attention to this rule, renders the perusal of the great majority of observations irk- some and fatiguing. Lastly, let him never forget, that mere opinions and unsupported conclusions cannot be admitted as additions to our knowledge, until they have again been ex- posed to the searching ordeal of facts ; while, faithful descrip- tion, can never cease to be valuable, however absurd the hypothesis it may have tended to establish. But observation, however extended and exact, is of itself insufficient to generate conclusions, for, collected as our facts must have been, through a series of months or years, and con- sisting of an infinite variety of details, no memory could recall and no mind could grasp their complicated relation with each other. To accomplish this, the " numerical method" is neces- sary, that is, counting the number of all the individual facts, TRANSLATOR s INTRODUCTION. XXXV comparing their relative frequency in cases of a particular class, and then determining their real value, by a comparison with facts of other classes, which have also been reduced to similar elements. This is the plan pursued by our author, and which must be adopted by all who would seek to establish truth and arrive at general results. Hitherto we have satisfied ourselves with the authority of experience, and its currency in medicine is such, that any distinct definition of its value has scarcely been attempted. But let us inquire what is really included by experience ? Is it not the expression of the con- clusions of the mind upon one or more subjects to which the attention has been habitually directed ? Is it not, simply, the final impression produced by a review of the past ? If the dis- covery of truth be its tendency, why has individual experience been hitherto so discordant? The answer is easy. In a science like medicine, where the difficulties of observation are so great, and the objects to be observed so numerous, where theories bias, and individual peculiarities necessarily exert their influence, nearly all, if not all the conclusions of mere experience are varying and fallacious. Who does not feel himself naturally inclined to study one class of affections more than another, to be arrested by particular symptoms, to be more interested with facts, which apparently coincide with some favorite views he has either adopted from others, or insensibly formed during the course of his studies ? How strongly all extraordinary facts and what we call interesting cases, are engraven upon the mind, and forever prominent in the retrospect, while the great mass of ordinarij and, conse- quently, important occurrences are overlooked and forgotten ? Some unhoped for success attending the means we employ, how firmly has it associated the cure of the disease with the XXXVl TRANSLATOR s INTRODUCTION. specific nature of the remedy, and how easily do we admit as a fact, what the observation of another proves to be the mere expression of coincidence ? Every practitioner has his pecu- liar therapeutics, his favorite dogmas to support, and successes to boast ; and when we reflect on the innumerable opinions which exist on all complicated subjects, where conclusions are founded on the materials of unrecorded individual experience, materials, which opportunity, education, and a thousand acci- dental circumstances are forever modifying ; we cannot, I think, be surprised that the results of experience in medicine, have not been more uniform and satisfactory. While anxious to impress upon the reader our conviction that unrecorded experience can never become the corner stone of any science whatever, we admit that it has justly acquired, in a few rare instances, unusual relative value from the capacious intellect and retentive memory of some highly favored minds. Devoted as we have described our author to have been to the observation of facts, and divested as he was, from the very state of mind which actuated him to the course he so undeviatingly pursued, from all ^preconceived ojpinions, yet it was impossible that, during so long a period of time, his mind should not have been unequally impressed by the phenomena before him, and have unknowingly fixed some in its remem- brance to the exclusion of others, instinctively allotting them a relative value, and arranging them to favor some à priori conclusions. Now no circumstances could possibly have been more favorable to test the value of experience, than those in which M. Louis was placed ; yet, when at the close of his labors, he submitted all his facts to the unerring test of arith- metical analysis, in every instance, were the à priori conclu- sionSf which he had formed from the recollection of his own TRANSLATOR s INTRODUCTION. XXXVU facts, found to he erroneous.* This most remarkable result ought to be indelibly engraven on the mind of every observer, and inspire a doubt as to the validity, not only of the experi- ence of others, but of what he has hitherto perhaps considered almost infallible, Ms own. If science consist of laws which are the expressions of facts, what course ought we to adopt for the purpose of arriving at those laws ? Undoubtedly one which leads to the discovery of the relations of our facts, their differences, and the amount of those differences ; for, a law is only a formula expressing in definite terms the value of a constant relation existing between a certain class of facts. This can only be effected by the numerical or tabular method, against which much ridicule has been directed, but on which every positive increase of our medical knowledge must be founded. M. Louis does not pretend to be its discoverer, but he is fairly entitled to the merit, of having been the first who has rigorously and exten- sively applied it to medicine. We shall briefly describe some of its most distinguishing features. The numerical analysis requires in the first place, a sufficient number of carefully collected facts on the same sub- ject j our object is then to classify their corresponding ele- ments, so that not only are all the details of those facts suc- cessively submitted to the mind, but thoir relative frequency and value more easily estimated. To effect this, synoptical tables are indispensable, and their number necessarily propor- tionate to the complex nature of the facts we are analysing. Each organ, for instance, must have a separate column, which * " Quand je me suis fait une idée, à priori, des faits non encore analysés, j'ai toujours vu, après cette analyse, que mon idée, à priori, était fajtsse.^' — Letter addressed to the Translator from the Author, June 23, 1834. XXXviii TRANSLATOR s INTRODUCTION. includes its description in every case we intend to make use of, adopting as nearly as possible similar terms for similar conditions. This, however, alone would be very inefficient, as in a com- plicated structure like the lungs, where so many alterations may occur, a long series of minute description would defy analysis from simple inspection ; each organ, therefore, in its turn, becomes the subject of a separate table, which also con- sists of subdivisions proportionably numerous as the object we examine is simple or complex. When we have thus arranged all the elements of our facts, we compare the results of our different columns with each other, having it thus in our power to view them in their various relations, while we may at plea- sure refer particular facts to their respective observations, the same number accompanying all the details which are scattered through a variety of tables. It will be remembered there is nothing arbitrary in this mode of proceeding, nothing left to individual caprice or pre- conception ; for, in the arrangement of our tables we perform a purely mechanical operation, indiscriminately putting down all the facts in their respective columns, without any reference to the conclusions to which they ultimately tend. The cor- rectness then, of any opinions we may form, is confirmed or rejected by a test over which we have no control, and the evidence of which no well-regulated mind can resist, while not only the relative importance of many facts to which our attention had been less distinctly directed, or which we had wholly forgotten, is forced upon our consideration, but we are also led to the discovery of what we have only casually or incompletely described. It will at once be perceived that certain laws, require for their elucidation, a much larger number of examples than TRANSLATOR s INTRODUCTION. XXXlX Others : where a hundred observations may in one case be sufficient, three times that number may be required under other circumstances. Indeed, as a general rule, the more complicated the objects we examine, the greater the number of facts necessary to establish our conclusions ; for the same elements not being repeated in all, their relative aggregate number must vary, and their real value can only be estimated by tracing them through a larger number of analogous in- stances. Were we, for example, analysing one hundred cases of pleurisy, the value of any symptom invariably observed would be considerable, and perhaps sufficiently established ; but, were it only present twenty times out of that hundred, its real importance would be much less positive and require an additional number of facts for its determination.* For the appreciation of treatment, the necessity for numer- ous facts is peculiarly apparent, for though a hundred cases would be valuable evidence in favor of any one system of * The translator, as it seems tome, is in error when he asserts that the value of a symptom which occurs only twenty times in a hundred cases is less posi- tive than that which invariably occurs. It may be of less value, I allow, in the history of the disease, and may not give us so much aid in the treatment, but its value, though less in degree, is just as positive as the symptom which occurs every time. A part is less than a whole, its value is less, but our ideas attached to it are as positive as those attached to the whole. How comes this error of the translator ? I cannot account for it save on the sup- position that for a moment he forgot one grand point of the numerical method as pursued by Louis, viz. that in analysing an observation, a symptom must not be supposed to be present or absent unless the presence or absence of such symptom be stated in the original notes of the case. Had not this point been momentarily overlooked, I think the error would not have arisen, for it is perfectly evident, that if, for example, in a hundred cases there be found pain in the side in all, and pain in the head in twenty, while in the eighty that remain there is no pain in the head, it is evident that the re- sult for one symptom is just as positive as for the other. — H. I. B. xl translator's introduction. cure, it is only by comparison with others that its real efficacy can- be decided. There are also other sources of fallacy which must not be overlooked ; such as the severity of the disease, the age and sex of the patient, the state of health at the time; the natural duration of the affection, the epidemic influences which may be present, &c. ; these are all questions to be solved before we can arrive at any positive results. From these rapid reflections, we may form some idea of the numer- ous difficulties which surround every question of therapeutics, and feel the necessity of exercising the greatest caution in ascri- bing any definite value to a remedy before we have well deter- mined, by numerously analysed facts, the exact circumstances under which its action has proved to be beneficial.* No part * " Nothing eminent can be done in the' prognostic and especially in the curative part of physic, without a» accurate and circumstantial history of diseases ; for how is it possible to foretell what will happen in a distemper, and proceed properly in the cure, if we are ignorant of the constant and for- tuitous circumstances attending it, and the general progress of it from the beginning to the end, when nothing intervenes to obstruct its ordinary course, whether from mismanagement, accident, or otherwise ?" — (Vide Sydenham. Swan's Edition, page 9 — note of the editor.) " There will never be any great and considerable advance in the art of healing, till all hypothesis and mechanical reasoning are out of vogue, and till men are come about again to the ancient method of pure experiment, and the common obvious reasoning entire from thence," &c.^ " Not a single medicine has been discovered by hypotheses since the introduction of them into physic, about two thousand years ago, nor have they let in the least light into the affivir of administering medicines properly in particular cir- cumstances, but rather served to bewilder us, to perplex practice, and create disputes, which are never to he decided without having recourse to experi- ence, the true test oj opinions in physic." To experience the author at- taches a very different idea from the general acceptation. He evidently refers to recorded experience, or the tabular method. — Vide Bishop Brown's Procedure oJ the Human Understanding, pages 200—205.) Sydenham, in translator's introduction. xli of medical knowledge is more in want of some rigorous method of investigation than that of therapeutics, and this must ever be the case, until a system analogous to the one we have briefly described shall be generally adopted. It is not our intention, in advocating the numerical method, to conceal for a moment its difficulties ; these are great and numerous, but at the same time they can never form any solid argument against its utility, though they will necessarily curtail the number of its disciples. It is, in fact, the only method in our power to pursue ; it is the only control we can possess over assertion, the only test for opinion, and though not all we can wish, and no doubt will ever be found inadequate for the decision of many questions, yet its application to a sufficient number of facts must inevitably give us the most exact and best possible knowledge of those facts, and we would ask the individual who believes that science is founded upon facts, what more he would require ? " And if," as an eloquent and distinguished writer observes, " after having arrived at the ter- mination of extensive labors, the hope of some important gen- eralization has not been realized, our disappointment may find consolation in remembering that the discovery of a single fact, well observed, well described, and well appreciated, is un- questionably an advance in science, while ingenious and sedu- cing theories, which may be received with general enthusiasm, are of often nothing more than a retrograding." But should his preface, page 18, says, " However, I do not deny, but that the physi- cian ought to attend carefully to the method and medicine he uses in curing diseases, and to set them down for the ease of his memory, as well as the improvement of his knowledge, so that at length, after many years experi- ence, he may fix upon such a method of curing any particular disease, as he need not in the least depart from.^" — Cowan. 6 xlii TRANSLATOR s INTRODUCTION. not one general fact result, we are preparing materials which may be employed by those who succeed us, and if their accumulation and analysis will not ultimately extricate us from the labyrinth of uncertainty in which we are now straying, we may regard the discovery of truth as a vain and hopeless delusion. There is no reason for the expectation on which many seem to rely, that a master mind will arise and dispel the darkness which hitherto has defied our efforts to disperse, for " in the history of science," says Sir D. Brewster, " we see no exam- ple of an individual mind throwing itself far in advance of its contemporaries, but the achievements of intellectual power have ever been the result of combined exertion. The powers of analysis and combination are applied to the humbler labors of observation and experiment, and in the ordeal of rival in- quiry truth is purified from error." Besides, from the clear and distinct contemplation of numerous facts, unthought of affinity is traced and unexpected results are discovered ; results which genius could never have foreseen, or hypothesis embraced ; for while their existence is thus demonstrated, all clue to their explanation seems lost. How could we have ascertained that tubercles in any organ of the body, after the age of fifteen, involved their presence in the lungs ? That phthisis almost invariably commences in the upper lobes ? That it is more frequent in women than in men ? That pneumonia is more easily resolved in a tuberculated than in a healthy lung ? That simple bronchitis commences at the base of the lungs, pursuing a course inverse to that of phthisis ? That chronic peritonitis indicates pulmonary tuber- cles ? That acute affections, when free from complication, are generally confined to one side of the body, or one part of an organ if single ? How could these and many other results, be TRANSLATOR s INTRODUCTION. XlllI obtained but by rigorous observation and numerical analysis? And what theory have we ever heard of, which could have led us to the same conclusions? Had they been advanced as the fruits of speculation, how absurd some of them would have appeared, and their very announcement would have almost ensured their rejection ; but founded as they are on the evidence of facts, our ignorance of the laws on which they depend is no bar to their practical utility. We know of no considerations more directly in support of the numerical method, or more encouraging to all who have the necessary opportunity and perseverance for its adoption, than this almost spontaneous creation of laws, which must have escaped the sagacity of reasoning, from the simple fact, that when demon- strated, they refuse to coalesce with any of our preconceived opinions. But to arrive at any definite and characteristic knowledge of disease, it is not only necessary to have collected numerous observations and exposed them to a rigorous analysis, but to have instituted a comparison of that disease with all others with which it may be confounded, for the purpose of arriving at its specific and distinguishing features. The botanist not only collects a variety of plants, and by strict observation of their physical characters, groups them into classes and families, but by careful comparison seeks to determine those peculiar- ities by which they may be individually distinguished. The chemist, the comparative anatomist, follow precisely the same plan, and in medicine we see it exemplified in the ever-vary- ing classifications of nosologists. The hitherto imperfect state of our pathological knov/ledge has necessarily included that of our classsification ; the latter can never be satisfactory until it may be regarded as the ultimate expression of our facts, rather than a prospective attempt at generalization. We xliv translator's introduction. would, therefore, particularly direct the reader's attention to the comparative results of the author, and when he reflects that the same process was pursued for their attainment as for those of the principal affection, he will be more sensible of their value and more capable of appreciating the time and labor comprehended in a few brief lines. The picture we have drawn of the obstacles opposed to the successful application of the analytical method, is not, we are aware, calculated to ensure popularity, and many will return to the less laborious and less responsible opinion, that anything like certainty in medicine is chimerical ; let it, however, be remembered, that " the difficulty of acquiring accurate knowl- edge, is an admonition of nature, which reminds man of his weakness, and the caution he ought to observe," and for the encouragement of those who coincide in the views we have expressed, we would remark, that while the exertions of any one individual are comparatively insignificant, yet when united with those of others, their value would soon be apparent ; and we feel convinced, that the labors of a hundred medical men, strictly undertaken on the principles we have advocated, during a period of twelve months, would do more for the elucidation of many of our difficulties, than the uncertain materials of the last two thousand years. To justify this assertion, we refer to the solitary labors of M. Louis, whose works will be in- creasingly appreciated with the progress of philosophical in- vestigation, and in durability and value will long survive the ephemeral productions of more popular but theoretical writers. The state of every department of science, the physical means in our power for the examination of disease, are all greatly in favor of success, and whenever we shall be in pos- session of a sufficient mass of unvarnished facts, there are no rational grounds to suppose, that facts in medicine will not, translator's introduction. xlv to a certain extent, effect what they have invariably done in every other branch of human knowledge to which they have been impartially applied. It would be easy to enumerate the obstacles which oppose themselves to the progress of medicine ; the want of experi- ment (though let it be recollected that observation and ex- periment differ rather in degree than in land), and the conse- quent difficulty of tracing effects to their true causes and vice versa ; the presence of casual relations from which we cannot disencumber our facts ; the influence of powers which modify the phenomena of disease, and aid or counteract the action of external agents ; these must all moderate exaggerated ex- pectation, and render a long series of observations a necessary preliminary to our arriving at positive results ; but at the same time they cannot be adduced as arguments against the only method in our power to pursue with any rational hope of success, until the insufficiency of that method has been de- monstrated by a fair and unprejudiced trial : — this has not yet been done. It cannot be objected that the action of morbific influences upon the frame is in many instances not regulated by definite or deducihle laws, and that the variations of diseases are such, as to defy classification, and nullify the extension of our con- clusions from one individual to another. On the contrary, all analogy is against such a supposition, and the little that has yet been done is equally in favor of an opposite inference. Is there no correspondence between the descriptions of Hippo- crates and Aretœus, and what we are observing at the present moment ? Has time, has climate, has civilization, have habits effaced one lineament from the likeness they have faithfully drawn ? It is only when the objects of contemplation are few that individual varieties seem infinite, and as we never could xlvi translator's introduction. have deduced the spherical figure of the earth, by regarding the inequaHties of the surface we are immediately treading, but which from a higher elevation do not interfere with the grand outline characterising the whole, so in medicine, when- ever large masses of facts can be distinctly unfolded to our view, the perplexing individual varieties will be merged in some leading predominant features, acting as guides to diag- nosis, and forming the ground-work of therapeutical indication. Admitting this to be the case, our labors and the number of observations required cease to be indefinite, for such is the uniformity of nature, that many of the inductions of science stand as securely on the foundation of a comparatively few well observed facts, as they could do on the collected obser- vations of every possible individual fact of which they are in- tended to be the expression. We may then, without any enthusiasm, suppose that this in many instances would be the case in medicine, and that the comparative results of a very few individuals would give satis- factory solutions to questions which are now unceasingly re- examined and solved, to suit the views of every inquiring and innovating mind. The last few years have been unusually fertile in the accu- mulation of accurately described facts, but scattered as they are over a wide surface, they are necessarily only partially known, and their aggregate value cannot be appreciated. An immense mass of knowledge is, therefore, constantly lying idle, which, if properly analysed, would frequently embody results by which much useless expenditure of time and talent would be avoided. The application of the numerical method to the facts already in our possession, would be an eminently useful undertaking ; and by thus deducing the history of dis- translator's introduction. xlvii eases, we should make an inventory* of the science, and be enabled to determine the amount and value of the materials we possess. Did we only succeed in demonstrating the pov- erty instead of the riches of medicine, we should at least have more accurate ideas of what we might trust to, and a more certain criterion of what in future may be expected. f Such a survey (Douglas) would advance medicine by the very act of its being made ; the very stirring up of all its parts would conduce to their future productiveness, as the mere turning up of the soil augments its fertility and adds to the plenty of the ensuing harvest. Medicine, while it was surveyed, would be unintentionally enriched, and seeds that had long remained dormant in it, being brought to light, would immediately veg- etate. What was already acquired would gain in value ; and the line would be clear and defined from which others must depart to obtain fresh accessions.! * " Few works of labor would be more conducive to farther advancement than a calendar, resembling an inventory of the state of man, of all the in- ventions which are now extant, out of which doth naturally result a note, what things are yet held impossible or not invented." — Bacon. t This suggestion_has been acted upon by M. Chaponière, in his inaugu- ral thesis at Paris, June, 1832, entitled Essai sw les Causes et le Siège des JVevralgies de la Face. The author spent several months in collecting all the observations he could find in the extensive library of the school and from other sources. He could only avail himself of two hundred and fifty- three, having rejected more than four hundred, which contained little ex- cept the diagnosis, and often did not specify the sex. TV^hile regretting the few satisfactory conclusions to be drawn from his analysis, he attributed his failure entirely to the inexactitude of his materials, and not to the method. He would have infinitely preferred a smaller number of well observed facts. See also a talented thesis by M. Marc d'Espine, of Geneva, on Comment un Median doit il Penser ? Comment doit il -Agir 7 Paris, 1S33. — Cowan. X Such an examination, but in reference to diseases of the brain only, was commenced by the Paris Society for Medical Observation, in 1834. Every work which contains/acis upon the subject is to be analysed. — H. I. B. xlviii TRANSLATOR s INTRODUCTION. Much benefit would we think result were individuals ap- pointed for the special purpose of collecting the scattered in- formation upon different subjects, and arranging it in the tab- ular form ; habit would render the method less laborious, and point out some improvements in the process :* individual labors would thus be constantly converging, and the attention of observers be particularly directed to those questions which required further elucidation. By this means, many investiga- tions which every conscientious practitioner is compelled to undertake for his own satisfaction would be rendered un- necessary ; time would thus be saved, and exact observations more generally collected, not only because the labor of their analysis might be entrusted to others, but the advantages of the system would soon be so apparent, as of themselves to become sufficient inducements. The bigoted supporters of hypothesis would cease to perplex and bewilder, while all the intuitions of genius would find materials by which their truth or fallacy might be determined ; we should at length leave those first principles which are now daily questioned and con- tested, and lay the foundation of future progress by defining the extent of the knowledge already in our possession. It is only (Herschel) by condensing, simplifying, and arranging, in the most lucid possible manner, the acquired knowledge of past generations, that those to come can be enabled to avail themselves to the full of the advanced point from which they will start. The author in his preface has sufficiently enlarged upon * Dr. Todd's book of analysis contains much valuable and ingenious in- formation, and it is worthy attention, how far the labor may be reduced by adopting the ideas of that ingenious writer. We recommend the work to the reader's perusal. — Cowan. tbanslator's introduction. xlix the plan of the work to render any additional remarks un- necessary. As translators we have neither altered nor abridged the original, and have been as literal as the peculiarities of either language would admit. The nature of the subject necessarily excluded great choice or freedom of expression, and the frequent repetition, inevitable in the arrangement of such numerous details, involves a monotony of style which could only have been avoided, by increasing the size of the volume and more or less deviating from the rigorous nature of the system which M. Louis has followed. For the same reason, the difficulties of translation have been augmented, and while we claim the benefit of this consideration, the reader cannot be more dissatisfied with the manner in which our task has been performed than we are ourselves. By omitting many of the observations and condensing the results, we might, perhaps, have rendered the work more popular, but at the same time we felt that this could not be done without lessening its real value. The pathology of phthisis has not as hitherto been limited to the description of the pulmonary organs, and we regard the results arising from the examination of the disease in a general "point of view, and not merely as a local affection, as amongst the leading and most valuable features of the work. The remarks following the individual observations, include much valuable information, and are peculiarly illustrative of the author's reasoning and method ; by either omitting or cur- tailing them, numerous references would have been useless and assertions left unsupported, while the arrangement of the work permits the study of the principal results, independently of the facts on which they are founded. After the accurate researches of Bayle and Laennec, M. 7 1 translator's introduction. Louis has wisely abstained from any lengthened and minute details on the pathology of the lungs ; he has simply described the results of his own observation, and we think satisfactorily proved the dependence existing between the grey, semi-trans- parent granulations and tubercles, which may now be regarded as occasional, not necessary gradations of each other. He has also shown how easily many apparently opposite opinions on this much contested subject may be reconciled, when all the phenomena attending tubercular deposition are fairly appre- ciated. The existence of tubercles in the summit of the lungs, their gradual progress and softening from above downwards, the presence of excavations nearer the posterior than the an- terior surface, the greater frequency of tubercles on the left than the right side, have never been so clearly demon- strated. The observations on the state of the bronchial mucous membrane, and the influence of the contents of the tubercular excavations, are peculiarly interesting, and must materially modify our ideas as to the agency of simple bronchitis in the production of phthisis. The pathology of the larynx has never before been minutely described, and we think the author's investigations important, both from their application to diagnosis, and from their giving clearer ideas of what is really included by the term " laryn- gseal phthisis." The connexion of pneumonia and pleurisy with pulmonary tubercles, the state of the pleurae, the situation of the adhe- sions, their influence in causing thoracic pains, are all deserv- ing attention. The comparative frequency of tubercles in different organs of the body,* and especially the fact that, * We would refer the reader to some highly ingenious and interesting remarks of Dr. Carswell on the localization of tubercles (Cyclop. Pract. translator's introduction. It after the age of fifteen, except in the lungs, they are generally every where at the same stage of development, form impor- tant data in any conjectures we may make as to the nature of the disease. They are powerful arguments in favor of the affection being general, and not depending on inflammation. The pathology of the digestive tube forms perhaps the most valuable part of the volume, and is calculated to modify the usually received opinions expressed under the term " dyspeptic phthisis." The state of the liver contrasted with the usually healthy condition of the spleen, are facts of considerable in- terest, though in the present state of our knowledge they can- not be fully estimated. The comparative examination of the glandular system with the mucous membranes, is particularly worthy the reader's attention, as it directly invalidates one of the most popular pathological doctrines of the day. The chapter on the perforation of the lungs, contains by far the most exact information we possess on this important com- plication, and is a beautiful illustration of the necessity and value of pathological researches. The description of the symptoms, their succession, duration, character, variations, and relative value, merit the practition- er's serious consideration, and should be studied in conjunction with the chapters on acute and latent phthisis. We would particularly point out the observations relative to the cough, expectoration, haemoptysis, hectic, diarrhœa, and emaciation. We have already expressed our opinion on the value of the Med., Vol. xxii. page 261), tending to prove that there are other causes besides inflammation, which determine the presence of tubercnlous matter in particular organs, and more frequently in one portion of an organ than another. — Cowan. lii translator's introduction. chapter on diagnosis, and we believe made some useful addi- tions, by detailing the subsequent experience of the author. The numerous and important additions we have appended to the chapter on the " causes'^ of phthisis, are the best proofs of our individual impression as to its importance. Dr. Clarke, in the preface (page 20) to his valuable work on climate, says, " I am well satisfied that it is only by a knowledge of the causes which lead to it, and by directing our efforts to coun- teract them, that ive shall ever he able to diminish the rav- ages of consumption.^^ "The tubercular diathesis (page 323), is also induced by the operation of external or accidental causes, which I admit to be the most important part of the whole inquiry connected with consumption." " Had the labor and research that have been wasted in fruitless experiments to cure an irremediable condition of the lungs been directed to the discovery of the causes and nature of tuberculous disease, with the view of de- ducing rules for its prevention and treatment, consumption would be regarded in a light very different from that in which it is looked upon at the present period." Coinciding with the opinion expressed by this able writer, we have endeavored to lay before the reader a large mass of circumstantial detail, which has never yet been approximated, and from the recent nature of a great proportion, is probably unknown to the majority of our readers. It cannot fail, we think, materially to modify many of our most generally received and apparently best established opinions, on the origin and nature of phthisis ; and if in some of our deductions we have differed from the con- clusions attempted to be drawn by the authors of the memoirs from which we have quoted, with respect to the modus ope- randi of some particular influences, that difference has not arisen from any depreciation of their facts, but fronr more translator's introduction. liii closely associating them with other conclusions deducible from M. Louis's observations as to the nature and pathology of the disease. Much misconception has hitherto prevailed on this most im- portant subject, and for its satisfactory elucidation there is still great need of minute and patient investigation. No country possesses more means for the determination of the really active causes of phthisis than England, and it would be most de- sirable that government would enable qualified individuals to devote themselves to the examination of those influences, which so extensively react upon the general health. Accu- rate information on this subject would materially aid the pro- gress of medicine as a curative art, and point out a prophy- lactic treatment, the effect of which on the prevalence of national disease, and more particularly of consumption, is incalculable. In estimating the author's remarks on treatment, the reader must not forget the nature of the work or the method so rigor- ously pursued. Nothing is attempted to be advanced not strictly included in the facts before him, and M. Louis has purposely abstained ftom referring to his own peculiar views, either in pathology or therapeutics, unless directly supported by the cases he is analysing. We have already pointed out that the number of the observations is insufficient to arrive at any general therapeutical deduction, and the conditions of a general hospital, combined with the 'advanced stage of the disease in the majority of instances, render the trial of any peculiar curative measures almost impossible. We should regret that this sterihty of treatment should form any argument against the advantages of pathological research, for while it cannot be denied that pathology has alreachj greatly rational- ized the treatment of many diseases, let it be remembered, that liv translator's introduction. there is no necessary or immediate connexion between the knowledge of morbid anatomy and curative indications. Dis- ease includes far more than the physical alterations discovered after death, which often, indeed, fail to explain many of the functional derangements observed during life ; but the knowl- edge, which in the majority of instances is in our power, of what organs are uniformly or secondarily affected under cer- tain circumstances, enables us more clearly to define the essential pathological characters of particular affections, and after we are in possession of this knowledge, to apply our remedies under the most favorable conditions by which their efficacy may be determined. Pathology is, therefore, the predecessor rather than the contemporary of successful thera- peutics ; without its assistance the latter has no other hopes of advancement than the blind chances of empyrical experi- ment: the value of these chances has, perhaps, in the minds of some, been decided by the experience of the last two thou- sand years. But while thus insisting on the necessary ultimate influence of pathology on treatment, it is evident that we cannot defer the application of remedies until our knowledge of disease is complete. Treatment must be tried, whatever obscurity may exist as to the nature of the affection. The absence of certain data from which more rational indications might be drawn, must never paralyze the exertion of our talents and ingenuity in the discovery and apphcation of remedial measures ; we should always endeavor, as far as facts will permit, to arrive at some probable conclusions ; and precisely in proportion as our rem- edies have failed, we are justified in exceeding the bounds of strict logical induction, in the research of other means by which disease may be more successfully combated. It is un- der this impression that we regret the author has not deduced translator's introduction. Iv some general conclusions* as to the nature and treatment of phthisis, and in the imperfect attempt we have made to sup- ply the deficiency, our remarks are confined to a few infer- ential inductions founded on a review of its pathology and causes, and to the simple exposition of those means which have been most generally vaunted in its cure ; rather wishing to afford materials to the judgment of the reader, than to bias him by a selection of what would simply be the expres- sion of our own individual opinion. A popular and too often professional belief that phthisis is incurable, has much interfered with any extensive and well combined efforts for its counteraction ; but surely, the moment when we are just beginning to arrive at some accurate ideas as to its causes, its nature, and its seat, is ill adapted to justify an assumption which has hitherto been but the avowal of our ignorance. The increased information we possess, loudly calls for fresh opportunities for attempting its cure, and to no object could national or individual bounty be more rationally or usefully devoted, than in providing means by which the powers of medicine might be advantageously opposed, to what may be undoubtedly considered as the heaviest penalty which disease exacts from civilized man. When we reflect that from one fourth to one sixth of our bills of mortality, consist of the victims to phthisis, and look * It seems to me that with Louis's strict views of the method to be pur- sued in the study of diseases and of their treatment, he could not, without having departed from these views, have done as the translator regrets he has not done. He gives us all he can gain from a strict deduction from his facts, and leaves to others to try other modes of treatment, and see if they be more useful. Had he made any " general conclusions as to the nature and treatment of phthisis," he would have fallen, as it seems to me, into the same error which most writers on medicine have heretofore fallen into, viz. that of substituting speculation ior proof. — H, I. B. Ivi TRANSLATOR s INTRODUCTION. round on the numerous institutions this country can boast for a variety of very secondary objects, it does indeed seem pass- ing strange, that no systematic attempt has ever been made for diminishing the ravages of consumption. Our Small Pox, our Lock, our Foundling Hospitals, are far less imperatively needed than the establishment of an institution specially adapted for the cure of phthisis: the conditions which it ought to include are quite incompatible with those existing in our ordinary hospitals, and we do not hesitate to say, that unless the general influences by which the patient is sur- rounded are regulated, as well as the application of particular remedies, no rigorous or satisfactory evidence of the powers of medicine in this disease, can ever be obtained. We have no intention of entering into any details on this interesting subject, but we submit the propriety of establishing public institutions expressly for the cure of consumption, as strongly deserving the attention both of the medical profession and of the country at large. In our remarks on treatment, we have insisted upon the immense importance of prophylactic measures, and to encour- age future perseverance, let us remember that we are still in the infancy of medicine, still standing on the shore with the boundless ocean of undiscovered truth in our view ; that the infinite capabilities of science still unfold an inexhaustible field for the exercise of our finite comprehension, we ought, there- fore, to shrink from attaching bounds to our future progress, recollecting that ignorance is the only known limit to our men- tal vision, and that in " whatever state of knowledge we may conceive man to be placed, his progress towards a yet higher state need never fear a check, but must continue till the last existence of society." Medicine is not excluded from this encouraging prospect, and we cannot help anticipating that translator's introduction. Ivii the cure and the comparative extinction of phthisis are an^ong the benefits its future progress will confer upon mankind.* In the fourth volume of the Examen, des Doctrines Médi- cales, by M. Broussais, recently published, one hundred and thirty-five pages are devoted to the examination of the present treatise and other works of our author. The unexpected length of the preceding remarks, and the fact that M . Louis has himself published what we believe will be considered by every impartial mind a victorious reply to the illiberal and prejudiced criticisms of M. Broussais, forbids, and indeed ren- ders unnecessary at the present moment more than a ïevf brief observations.! The most fatal inroads upon the doctrine of irritation have arisen from the labors of those whose impartial observation and accuracy of description give them the highest claims to our confidence. The two fundamental dogmas of the system of M. B , viz., that inflammation, of some kind or other, is the active cause of all morbid alterations, and that glandular disease is consecutive to that of the mucous mem- branes, have been fatally invalidated by their comparison with accurately observed facts. * " It may not be too much to hope," says Dr. Carswell, '' that by means of a more intimate knowledge of organic clieraistry, we may yet be able to detect in the mucous secretions or in the blood those changes which indi- cate the existence of the tubercular diathesis, and thus, perhaps, be led to discover a remedy for the disease before it has effected its localization, and produced changes in themselves incurable." The same pathologist ob- serves, that " pathological anatomy has, perhaps, never afforded more con- clusive evidence in proof of the curability of a di^ca-ie, than it has in that of tubercular phthisis." — Cowan. t Vide Examen, de V Examen, de M. Broussais, relativement à la Phthisic et â V Affection Typhoïde, par E. Ch, A. Louis. Paris, 1834. — Cowan. Iviii translator's introduction. The first we have always regarded as one of those proposi- tions most easily supported, but most difficult to be proved ; and it is only by an indefinite latitude of expression, which admits of being ingeniously moulded into accordance with our theo- retical wants, that so much has been written in the defence of an idea, which too often, when practically applied, has no other foundation than our speculative belief in its existence. By inflammation we must either include a certain combination of essential conditions, or the term must be regarded as destitute of all scientific importance ; to employ it as the expression of whatever we observe contrary to what results from a state of health is to make it the pliant tool of assertion, but a mere bugbear in scientific investigation. It cannot be denied that organic and constitutional changes are constantly occurring without a trace of those phenomena, usually signified by the term inflammation ; and to argue on the presence of a some- thing the existence of which could never have been suspected without the creative powers of a theory is to reduce facts to the bondage of opinion, and make their comparative apti- tude for the support of our own preconceptions, the standard of their value. Much benefit has resulted, we freely admit, from the re- searches of M. B , more particularly from his investiga- tions of those latent forms of inflammation, previously so im- perfectly known and irrationally treated ; but while sensible of his merits, and charmed with the genius displayed in his writings, it is impossible not to trace the warpings of precon- ceived opinions, and feel that we are rather persuaded by the talents and ingenious hypothesis of the writer, than the cool impartial deductions of philosophical inquiry. The dependence of glandular disease on the state of the mucous membranes is still more tangibly opposed to the sim- translator's introduction. lix pie evidence of observation ; and we think, totally irreconcil- able w^ith the varied and numerous facts adduced in the course of this volume. That the alterations of the one may be oc- casionally depending on and consecutive to those of the other, no one will deny, but os a law of the system, it cannot be assented to, until supported by more satisfactory proof than the genius of its inventor. The acrimonious and unfair spirit characterising the criti- cisms of M. B , cannot but be regretted. He has alter- nately impeached the accuracy and veracity of M. Louis, while he acknowledges him as " de lonne foi,^^ when his con- clusions tend in the least to coincide with his own. In one page he speaks of the work as deserving to be read, and in the next styles it as destitute of either pathological, therapeutic, or physiological merit ; in short, his remarks bear the stamp of a foiled and disappointed theorist, and exhibit the workings of a powerful mind in the defence of a system it had toiled to erect, but which is daily tottering under the relentless battery of facts. While thus depreciating the tone of prejudiced and illiberal feeling which pervades the strictures of M. B , we are not anxious about their effects on the volume before us ; its merits are quite independent of individual opinion, it will rise in estimation and shed increasing lustre on its author, in pro- portion as hypothesis becomes subservient to the evidence of impartial and accurate observation.* * We particularly recommend the reply of M. Louis to the reader's atten- tion, as affording a striking contrast, in its cool and searching reasoning, to the impetuous and contradictory efTorts of wounded self-love. To the un- founded and ahsurd allegation that M. L. was the obsequious follower of Laennec, he replies, " What, {Op. Cit. page 5.) have I devoted seven years of my life to discover in observation nothing more than a means of attacking Ix translator's introduction. the opinions of M. Broussais ? Indeed I was actuated by a higher motive. M. 13 was scarcely thought of, and I cared little to what results ob- servation would one day conduct me, confident that when I did methodical- ly investigate the facts I had collected, they would lead me to true I'esults, which were alone important." In reply to the insinuations of M. B against his probity, he remarks with all the consciousness of innocence and the force of truth, "Let the reader judge, if one who for nearly seven years renounced the practice of medicine to devote himself to the observation of facts, let him say whether this individual was guided by the desire to invent.' Whether these seven years of study ought not forever to have sheltered him from such sus- picion .' The reader may regret that he has done so little in so long a period, but assuredly he will not impeach his integrity, he will not imagine that he has been actuated by other than conscientious motives .?" — Cowan. Translator. Bath, Fee. 1835. AUTHOR'S PREFACE. The world will be perhaps surprised at fresh researches upon phthisis, after the still recent labors of Bayle and of Laennec. These pathologists have indeed so accurately de- scribed the leading symptoms and characteristic lesion of this disease, that little appears left for their successors to accom- plish, and it would seem useless to re-handle a subject so skilfully treated, were it only capable of being studied under the same point of view j but the plan we have pursued in the present work is different. Very shortly after we had exclusively devoted ourselves to observation, we ascertained that in the progress of phthisis, as in that of other chronic diseases, the greater number of the functions are remarkably disturbed ; that the organs which dis- charge them are more or less profoundly altered, and that with regard to both these points the history of the disease was very incomplete, or almost wholly neglected ; the hope of supply- ing this deficiency was the source of our present undertaking. Numerous facts early indicated to us, that the history of phthisis could be elucidated by new observations, and this conviction was an additional motive for persevering in those investigations, of which the volume now presented to the reader is the result. Ixii AUTHOR s PREFACE. In order to secure the greatest possible utility to our labors, we have observed phthisical patients with the same care we should have employed in collecting the history of those attacked by any disease but little known ; we have examined the state of all the functions, and reverted as far as possible to their respec- tive derangements, previous to our examination of the patient ; and after death we have studied all the viscera with equal attention. This method was tedious, but simple and certain ; it could not but lead to exact results, and this impression has rendered light the fatigue it necessarily included. Fully convinced of the importance of negative facts, and recollecting the embarrassment and regrets of Morgagni, when, on examining the observations of Walsalva, he found no men- tion of certain facts of this description, we have collected them with as much care as the most interesting of our affirmative ones ; we have even noted down indiscriminately whatever the patients related respecting the alteration of their health at any period of their lives, provided always, that the circum- stances of the recital gave evidence of its truth : we left to future opportunities, and the post mortem examination, the task of pointing out the facts to be retained or suppressed. It is easy to form a just idea of the importance of negative facts, if we reflect that organs, when their structure is extensively modified, frequently give rise to no appreciable symptoms, and that, if this absence of symptoms has not been expressly speci- fied, we cannot form a proper estimate of the value of post mortem appearances. Hence also the necessity of examining all the functions, whether apparently disturbed in their exer- cise or not : — another method may suffice for the verification of what observers have already remarked, but it can conduct us no farther. To remove all doubts as to the value of our notes, we have author's preface. . Ixiii always mentioned the state of the patient's intellectual powers ; quite decided, when we had to investigate facts anterior to the period of our own observation, only to rely on those patients, whose faculties, and more especially whose memory possessed a certain degree of development. We have paid great attention to our mode of questioning invalids, for there are certain questions which almost inevitably dictate the answers. As, for instance, if we wished to discover whether the patient experienced pain, or any uneasy sensation on either side of the chest, we mentioned first the side where we supposed the pain did not exist ; if he then indicated the other side as the seat of the sufferings, we regarded the fact as certain, and entered it as such. For the determination of old dates, important to be ascertained, we frequently recurred to the subject, asking the patient, not, if he had experienced such a symptom from such a time, but how long he had experienced it. It is evident; that to the first question a patient, annoyed or weary, might answer indijBferently yes or no, while at the second he is compelled to reflect, and by a mere hap-hazard reply cannot so easily lead into error. After death, we have described with all the precision of which we are capable, the situation, the form, the color, the consistence, and the thickness of organs ; in a word, every alteration of tissue which they might present. To effect this, we have never examined the viscera, with the exception of the brain, in their natural connexions ; for in this situation they are generally insufficiently illuminated, and in the case of organs which are membranous, thin, and compound in their structure, as the stomach and intestines, their thickness and consistence cannot be properly appreciated, and it is also diffi- cult to examine the whole of their extent ; at the same time many alterations such as small superficial ulcerations, almost Ixiv author's preface. inevitably escape our notice. In these cases, to see clearly, we must not only remove the parts, but free them by repeated washings from the various substances which adhere to them, and, as was almost constantly our practice, immerse them for an hour or two in water. The history of the softening of the brain, is of itself sufficient to point out the importance of examining the different degrees of consistence of our organs. It is well known that the brain may be softened and almost liquefied, without any very sensi- ble change of color, so that were we to limit the examination of this viscus to this single circumstance, our deductions would necessarily be of no importance. The same remark is appli- cable to mucous membranes, which, although retaining their natural paleness, we sometimes find as soft as mucus. It was from applying these principles to ourselves, that we thought it right to relinquish, with respect to certain points, the observations we collected at the close of 1821 and the com- mencement of 1822. At that period we frequently neglected to remark the different degrees of consistence of the mucous membranes, nor had we directed our attention to certain patho- logical states of the stomach, and by using observations thus incompletely detailed, we should certainly have fallen into error, and announced results which were inexact. Lastly, whenever an observation appeared, in any respect, incomplete or destitute of that accuracy which we believe to be necessary, we have set it aside ; this explains why our sura-totals are not always founded on the same number of facts. The thickening of tissues is also one of the circumstances most important to notice, and is sometimes the only appreciable organic lesion ; as in certain cases of hypertrophy of the heart and the thickening of the submucous layer of the large intes- tine, which we shall hereafter describe. author's preface. Ixv Redness, considered by itself, offers much less interest, although many among the most enlightened physicians confine their descriptions of membranous organs to the indications of their color. Redness, in fact, may depend upon various causes, either upon inflammation, or even upon the effects of simple congestion towards the close of life. Of this last asser- tion we have the proof in certain cases of sudden death occur- ring to individuals, who, only a few moments before, appeared in perfect health, and yet whose gastro-intestinal mucous mem- brane was more or less red, but at the same time neither thickened or softened ; while in the majority of cases, where the symptoms of inflammation of this membrane have been prominent, there are redness, thickening and softening. It follows, therefore, that redness signifies nothing, unless ac- companied with some alteration in the consistence and thick- ness of tissues, and where no such change is discoverable, it is only by the aid of the symptoms, that the cause of the red- ness can possibly be conjectured. Let us add, for the pur- pose of better illustrating the importance of the alterations we are referring to, that after death, redness may disappear, while the thickening and softening of our tissues are un- affected.* The observations on which our researches are founded were collected at the hospital of La Charité, commencing from the last three months of 1821. Since that period, we have noted down the history of all the patients admitted into the wards of M. Chomel, containing forty-eight beds, equally * This remark, when extended to softening, is too absolute. There can be no doubt that if softening, Uke redness, cannot be removed after death, it may under certain circumstances be either produced or increased. — Cowan. 9 Ixvi AUTHOR s PREFACE. distributed between men and women. The same plan has been' pursued in the description of every case, and as the ex- actness necessary for such a task did not appear compatible with the practice of medicine, the latter was, for a time at least, relinquished. We have since regularly passed from three to four and sometimes five hours a day at the hospital, devoting at least two hours to each post mortem examination ; and although habit has necessarily familiarised us with ana- tomical researches, we give to them at the present moment, as much time as we did two years ago ; fully persuaded, that to observe well, we must not observe hastily; that the only means to rectify inevitable errors are continually to re-examine, and consequently always to observe an object however familiar, as if presented to us for the first time. By comparing our latest observations with those formerly collected, we have been enabled to convince ourselves of the advantage that results, at least when there is any intention of publishing, from having observed at an age when we can esti- mate things at their real value ; when experience has already warned us against every species of illusion and theory, and when the first mental want is that of truth. Study was not less attractive to us formerly than it is at present, but a theory presented with art was not without its allurements ; precision was less studied, and we devoted less time to the determina- tion of facts. These mental tendencies, so contrary to sound observation, were at once depending on deficient experience and our youth ; very few escape their influence, and, if for no other reason, we ought generally to place less reliance on the labors of young observers, and especially avoid devolving the task of observation exclusively upon them. Independently of the disadvantages of age, it may also be said with truth, that we cannot observe for others with the same zeal, the satrie assi- author's preface. Ixvii duity, the same precision, that we should employ for ourselves. Does the natural philosopher who wishes to advance the pro- gress of science let another make his experiments? Does the chymist confide the operation of analysis to one just entering upon his career ? And if, as indeed is the case, there is a com- plete analogy between the physician who observes, the natural philosopher who experiments, and the chymist who analyses, why should they adopt a different method in their inquiries ? It is not enough to know that individual observations are necessary in medicine, unless we are at the same time con- vinced, that to render them valuable, much zeal, much time, and much practice are required. Practice, we repeat, for to collect observations is a trade, and, like all other trades, must be learned and cannot be divined. The reader will pardon us, perhaps, for having insisted so much on the care we have bestowed on the collection of our facts, and upon the distrust with which part of those daily published ought to be received, if he reflects that the edifice of medicine reposes entirely upon facts, and that truth cannot be elicited, but from those which have been well and com- pletely observed. Then, and then only, we shall be enabled to discover, in a series of observations, the data of a problem consisting of many unknown quantities whose value we are to determine ; and since in mathematics, this value does not vary with the individuals who engage in the solution of the problem, we ought also in medicine to arrive at identical results, by the analysis of the same observations ; always admitting, that where a mind of ordinary power arrives at few general deduc- tions, one of superior capacity, from its power of examining the particular facts under more varied aspects, will discover a greater number ; but it is inevitable that exact observations, studied under the same point of view, must conduct every one Ixviii author's preface. who attentively considers them to identical conclusions. All is no-t then obscure or uncertain in medicine, when the obser- vations which guide us are exact ; but what results can be obtained from the consideration of facts which are doubtful, incomplete, or false ? Besides, the means we employ to arrive at the solution of the problem are in no degree arbitrary or uncertain ; they consist almost wholly in bringing together the symptoms which reveal the disturbance of one and the same function, and, should death occur, in comparing those symptoms with the state of the organ on which the function depended. If the organ be more or less seriously affected, and its lesion either by its char- acter or extent explains the derangement of its function, and if there be no other which will explain it, we are then entitled to regard it as the cause of the symptoms observed ; if, on the contrary, the function has been deranged while the organ has not undergone any perceptible alteration, we must then refer the disturbance either to a sympathetic influence, or to some constitutional peculiarity. Anorexia, for example, is one of the symptoms of gastritis, yet since it is frequently observed in phthisical patients when the mucous membrane of the stomach offers no sensible lesion, we are forced to conclude that under these circumstances it is sympathetic, or depending on some general influence, as for instance the febrile movement ; and that a function may therefore be deranged for a considerable time, while no alteration of structure in the organ on which it depends can be observed. Nothing is more simple, but at the same time nothing is more fatiguing than the m.ethod we have described ; for, what numerous tables, what separate analysis does it not require ? It is almost entirely to this purely mechanical labor, that we have reduced our operations on the facts we have collected ; per- author's preface. Ixix suaded that the most faithful analysis of the greatest possible number of exact observations upon a given subject constitutes the greatest value of a work. Those of which we now offer the result are in number one hundred and twenty-three. Fifty among them have been scattered through the course of the work as witnesses in our favor; and since we believe that the history of a patient is not really complete unless it gives at least a succinct idea of the condition of all the functions, we have described them as briefly as possible, with the state of suffering or otherwise of the different organs. This has appeared to us the more in- dispensable, from the fact that nearly all our observations are examples of complications more or less numerous, and because it is necessary to form a correct idea of their mutual influence. Had we confined ourselves to a single class of symptoms, we must also, in the description of organic lesions, have been reduced to a single class of organs ; but such a method would have deprived our observations of a part of the interest they might otherwise present, and they might also have been con- sidered as negligently collected. We may add that our researches, being in relation to a considerable number of topics, would frequently have appeared wanting in solidity, had the details of each observation been limited to a single point. To avoid unnecessary fatigue to the reader, we have arrang- ed all our cases on the same plan. In the first section we described the state of the functions previous to the entrance of the patient into the hospital, reckoning from the day when he ceased to be in perfect health. In the next division we men- tion what remarkable features the symptoms presented at the moment of our seeing the patient for the first time, and after- wards, in as many separate sections^ we continue the history Ixx author's preface. of each function until death. Lastly, as regards the anatomical lesions, we note whatever the exterior of the body, the head, the neck, the chest and the abdomen, present of importance. In this manner confusion is prevented, each object has a sep- arate place, and if at any time we wish to recur to the symp- toms which belong to any particular lesion, it is only necessary to read a single section. Impossible as it is to give all the observations upon which our researches are based, we have pursued in the exposition of our facts a rather different method from what we should have adopted under any other circumstances. We have divided our work into two parts, and since anatomy is the strongest support of pathology, we have commenced the anal- ysis of our facts by a general description of the visceral lesions. Those of the lungs, bronchia, pleurae, trachea, larynx and epiglottis are successively described ; then those of the diges- tive apparatus, he. he. ; and as it was Important not only to describe all the morbid alterations, but to determine if those which existed elsewhere than in the lungs were peculiar to phthisis, we have investigated the condition of the organs in cases fatal from various other chronic diseases whose histories we have collected ; we have compared facts with each other, and from this additional labor has resulted the knowledge of some general principles not perhaps without importance. We have also mentioned the proportion in which each of the mor- bid changes was observed ; so that our work may be consider- ed, in all its parts, a kind of statistics of phthisis. After the description of almost every organic alteration, we have examined the causes to which they might have been attributed. Finally, in a brief summary we have placed before the view author's preface. Ixxi of the reader the general result of all the facts contained in this first part. The second part is reserved for the history of the synaptoms. We have first described those occurring in phthisis when free from all complication, and we have insisted particularly upon the diagnosis in the early periods of the disease : we have then detailed the symptoms which accompany ulcerations of the epiglottis, larynx and trachea ; those which belong to different lesions of the mucous membrane of the stomach, &;c. he. ; the anomalies which phthisis presents in its acute or latent form, and the accidents resulting from the perforation of the pulmo- nary parenchyma in consequence of tubercular softening, form- ing a communication with the cavity of the pleurae. We have also related several cases of sudden death, and endeav- ored by the comparison of facts, to estimate the value of some of the causes to which the development of pulmonary tuber- cles is attributed. Finally, we have very briefly pointed out the treatment of the cases whose analysis we have given. Our first intention was not to extend our researches beyond the bounds of a memoir, and, consequently, to detail a very limited number of individual facts ; but by pursuing this plan, many of our propositions vpould have remained whhout proof, and we should have failed in the performance of the most essential duty which devolves upon an individual who writes upon any subject whatever. It is by the advice of M. Chomel that we have been induced to extend the plan of our researches ; his assistance has been available in many other ways, for the compilation of the present volume, and we feel happy in giv- ing this public testimony of our gratitude. Finally, and we say it with the consciousness of deep con- viction, though a more skilful hand would perhaps have Ixxii AUTHOR s PREFACE. thrown greater interest over the long series of lesions and symptoms we have described, yet it could not have employed greater accuracy or impartiality.* * This work was presented to the Royal Academy of Medicine, and the report made in relation to it may be found in the Revue Médicale,! Septem- ber, 1825. — Louis. i The reader will find this report in the Appendix by the American editor. — H. I. B. ANATOMICAL AND PATHOLOGICAL RESEARCHES ON PHTHISIS FIRST PART. PART 1. PATHOLOGICAL ANATOMY. I. In this first part we shall successively describe all the lesions observed in the different apparatuses of our organs, and subjoin some considerations on their causes. CHAPTER I. RESPIRATORY ORGANS. ARTICLE I. LUNGS. 2. Bayle divided phthisis into as many kinds as there are organic lesions of the lungs capable, according to him, of causing death. He admitted a tuberculous, a granulated, a cancerous, a melanotic, a calculous, and an ulcerous phthisis. M. Laennec thinks, on the other hand, that there exists but one species, the tuberculous phthisis, that is, but one organic alteration of the lungs which can terminate in death by passing through all the stages of inanition (dépérissement), and with all the symptoms which belong to phthisis. During more 4 PATHOLOGICAL ANATOMY. LUNGS ; [Parti, than three years,* that we have carefully collected the history of all the patients admitted into the hospital of La Charité, in the service of M. Chornel, v^^e have not observed a single subject who died of phthisis whose lungs did not present, as the principal lesion, a greater or less number of tuberculous excavations, tubercles, or of grey, serai-transparent granu- lations ; so that our own observations strengthen those of M. Laennec, and with us as with him, " the existence of tuber- cles in the lungs is the cause, and constitutes the special char- acter of phthisis."! 3. Tubercles are, as we know, tumors of a dull yellowish * The number of patients adffiitted into the wards during the above-men- tioned period was 1960, of which 358 died. Out of these last, 127 were cases of phthisis, and in 40 others who died of various diseases, tubercles were found in the lungs ; — that is, in nearly one half. In one third they constituted the principallesion. Vide Report made to the Royal Academy of Medicine on this work by Chornel, Royer Collard and Bourdois. — Revue Médicale, Sept. 1S25. — Cowan. — Also, Appendix by American editor. — H. I. B. t This proposition is flatly denied by M. Broussais, who asserts that he has frequently seen cases of consumption from chronic inflammation and suppuration of the lungs, where no trace of tubercles existed after death. He confidently refers to ten cases detailed ia his course of lectures during the winter of 1833. This mode of reasoning merely says, that M. Broussais includes more under the tei-m phthisis than the author ; though many of the general symptoms of phthisis may have been, and no doubt were, present in the cases detailed by M. Broussais, we do not hesitate to say that their pro- gress would have distinctly distinguished them from those attending true phthisis. — Vide Examen des Doctrines Médicales, par F. J. V. Broussais, 3d edition, vol. v. page 330". The following assertion of P. Desault, of Bourdeaux, in an essay on phthisis, published in 1733, is remarkable. He says that an ulcer of the lungs is merely an effect and not a cause, and that tubercles constitute the essence of consumption, being generally nnteriov to hcemoptysis. He also notices the frequent affection of the liver. —Cowan. Chap. 1.] TUBERCLES ; MILTARÏ" GRANULATIONS. 5 white aspect, of variable consistence, which soften after a cer- tain time, empty themselves into the bronchial tubes, and give rise to excavations more or less considerable. 4. Almost invariably they were more numerous, larger, more advanced in their development at the summit, than at the base of the lungs ; for in the one hundred and twenty- three cases of phthisis we are going to analyse we have met with only two exceptions to this rule (Obs. 33.) 2. They were associated with a production of a very differ- ent appearance, we mean those small, homogeneous, shining bodies, of marked consistence, more or less rounded, and varying in size from a pea to that of a millet-seed ; bodies which have been designated by the name of " grey, semi- transparent granulations." (Granulations grises demi-trans- parentes.)* These granulations form, according to the beautiful re- searches of Laennec, the first stage of tubercles, through which the latter must pass before assuming those characters which are peculiar to them. As in the case of tubercles, we have found them larger, more numerous at the apex than at the base of the lungs, and limited to the former, if not existing in the whole of their extent. At a certain period of their de- velopment they presented a yellow opaque pointât the centre ; this point was larger in proportion as the granulations were nearer the summit of the lunchs, and in examininçr these vis- cera from below upwards, the lesions were generally seen in the following order : — J st, grey, semi-transparent granula- * Miliary Granulations of Laennec. Vide Dr. Forbes's Translation, page 273. We adapt our references to this work instead of tlie original, as the former is, perhaps, more generally in the hands of the English reader, and its value is much increased by Dr. Forbes's very able and extensive additions. — Cov.'An. 6 PATHOLOGICAL ANATOMY. LUNGS ; [Part I, tions ; 2dly, granulations less clear and yellowish towards the centre, and 3dly, granulations of a yellowish white in their whole extent ; that is, completely tuberculous. These last were in the majority of cases the only ones observed at the summit of the lungs. 6. It was rare to find either tubercles or the grey, semi- transparent granulations existing singly in the lungs. The first of these cases we have only met with twice. The second we have observed in five subjects, though even here there were some granulations more or less milky and yellowish in the centre. These facts appear to us incontestably to establish the trans- formation of the grey, semi-transparent granulations into tuber- culous matter. 7. These granulations, usually scattered, in many cases formed small groups, or even masses of an irregular figure, and very variable dimensions. Most frequently they existed at a certain distance from the pleura. At other times (in about one third of the cases) they were as numerous immediately beneath this membrane as in the more central parts of the organ. We have even met with an instance in which the lung remaining free from all adhe- sions, they were more numerous at the surface than any where else (Obs. 17.) Thus arranged, they gave an uneven appear- ance to the lung. Having passed into the tuberculous state and then become softened, they were converted into abscesses, which formed elevations more or less considerable, externally, occasionally discharging their contents into the cavity of the pleurae, and producing the accidents we shall enlarge upon in our chapter on the perforation of the lungs. 8. The time requisite to enable the granulations to acquire the volume of a small pea (the size most frequently observed), Chap. 1.] SEMI-TRANSPARENT MASSES. 7 isj no doubt, very subject to variation, and almost always im- possible to determine. Yet, some cases of acute phthisis seem to indicate that their development is sometimes very rapid, and that they can acquire the volume mentioned in so short a time as three or four weeks (Obs. 34). On the other hand, a tolerably numerous series of observations inclines us to the opinion that they may remain very small for a long period after their formation. Thus, we have met many indi- viduals, who coughed continually, had been subject to hae- moptysis for many years, &;c., and yet who presented no other lesion of the pulmonary parenchyma than the grey granula- tions, of the volume already indicated, or even much smaller. 9. This grey, semi-transparent matter presented itself also under another form ; it was frequently in irregular masses, sometimes of considerable volume, from about one to two or three cubic inches (Obs. 29). As in those cases where it assumed the rounded form, it was shining, homogeneous and without distinguishable structure. In many subjects, in the middle of these masses, a variable number of miliary points of a dull, yellowish white, in every respect tuberculous, could be observed. In others, the transformation was almost complete, and some small portions of grey substance in the midst of a mass of tuberculous matter were alone discoverable. Thus, whether the grey matter assumed the form of granu- lations or of irregular masses, more or less considerable, it be- came sooner or later transformed into tubercle. 10. We have met, though rarely, the grey matter in other organs ; and in them, as in the lungs, it has appeared suscep- tible of tubercular transformation. We will mention in support of this, the case of the seventh observation, where we found deposited in the great epiploon and mesocolon, in the midst of a large quantity of tuberculous matter, masses more or less 8 PATHOLOGICAL ANATOMY. LUNGS ; [Parti, voluminous, of gi'ey, semi-transparent substance. Is it not probable that this last would eventually have undergone the tuberculous transformation ?* 1 1. Laennec has observed that we do not find vessels, or at least very rarely, in the masses of grey matter. We have frequently verified the truth of this remark by the aid of in- jections (Obs. 29). 12. Around tuberculous excavations, which were rather large, there was found almost constantly a certain quantity of this same grey matter. It also frequently inclosed on all sides some semi-opaques (louches) and yellowish granulations, forming them into a compact mass more or less considerable. In this way we have seen it in three subjects affect a very singular arrangement, and present itself under the form of zones. These were three in number, parallel, situated hori- zontally, occupying the whole thickness of the lungs, they were one inch in height, and separated from each other by a layer of pulmonary tissue of similar dimensions (Obs. 46.) As in the case of granulations, the grey matter in form of masses, was frequently found near the surface of the lungs, or immediately under the pleurae (Obs. 29, 35). 13. In those instances where the progress of phthisis was * The identity of the grey, semi-transparent granulations with tubercle has been a source of much discussion. Bayle thought them cartilaginous, — Andral (Clin. Med. vol. ii. page 5.), indurated pulmonary vesicles, — Cho- mel (Die. de Med. vol. x. Article " Granulation") says, they[are not tuber- cles, but vpithholds his reasons. Bouillaud seems to agree with andral. Lombard entertains a very similar opinion, &c. We only mention these hypotheses to attract the reader's attention to the evidence adduced by our author ; it is, we think, conclusive, and coupled with other facts distributed throughout this volume, demonstrate some necessary i-elation between these two alterations as strongly as it is in the power of facts to witness in favor of two things which are not absolutely identical. — Cowan. Chap. 1.] DEVELOPMENT OF TUBERCLES. 9 rapid, it might be suspected that the tuberculous matter had not been the result of the transformation of the grey matter, but that it was developed primitively under the form of tuber- cle, the necessary time for this transformation appearing to have been wanting. Such would be considered the case of a young girl, who forms the subject of the thirty-fifth observa- tion, where we found a large mass of tuberculous matter, soft- ened, and in part excavated, on the thirty-fifth day of the disease. It is but right, however, to remark that in the case before us there were in the same lung both tuberculous and grey matter; and in many other cases, where the progress of the af- fection was very rapid, (Obs. 36), we found in the centre of one of the upper lobes a certain quantity of grey matter, almost en- tirely transformed into softened tubercle ; and although it might have developed itself consecutively to the tuberculous matter, a contrary supposition is not less probable ; so that doubts as to the real course of the affection in these different instances must necessarily be entertained. It is, however, on the whole, more probable that tubercle is sometimes developed primitive- ly, as such, in the lungs; for, with only two exceptions, it has always appeared to us to affect this mode of production in the other organs. 14. We have also found in the lungs of phthisical patients, and in them exclusively, a substance less firm, more trans- parent than the one we have just described, of a dirty red color, or sometimes nearly colorless, presenting more or less the appearance of jelly (Obs. 2). This substance, which Laennec has described, has never presented tuberculous par- ticles. Is its nature identical with the grey, semi-transparent matter ?* *" Infiltration Tuberculeuse Gelât iniform e" o( Laennec. Vide Forbes' s Transi, page 277. M. Louis's observations are not confirmative of Laen- B 10 PATHOLOGICAL ANATOMY. LUNGS ; [Part I, 15. Almost invariably, tubercles existed more or less nu- merously in both lungs. We have, however, seen this lesion limited five times to the left lung, and twice only to the right. Can we, from this fact, consider the right lung as rather less predisposed to the development of tubercles than the left ? 16. We have remarked that tubercles evinced a kind of preference for the summit of the lungs ; that here they were larger, more advanced, and comparatively more numerous. This observation is still more applicable to the upper lobe, contrasted with the lower, than to the lungs in general. For, besides the large excavations, which are almost exclusively found in the top of the upper lobe, grey granulations, tuber- cles, small cavities, he, are still more numerous and approxi- mated in this point than either in the rest of its extent, or in the corresponding portion of the inferior lobe. We have also frequently found the whole of the upper lobe degenerated into cavities, and into the grey or tuberculous matter, and throughout wholly impermeable to air, whilst at the same level in the inferior lobe we always met with a portion, at least, of the pulmonary parenchyma, capable of continuing respiration, and very rarely with tuberculous excavations. One of our observations of acute phthisis is an example of the morbid disposition we are now describing (Obs. 36). In thirty-eight cases (about one third of the whole), where we have encountered it in nearly a similar state, it existed twenty- eight times in the left side, and only ten times in the right. An additional fact, seeming to point out that the left lung is more favorable than the right for the development of tuber- nec's, who says he has frequently seen small yellow tuberculous points in this substance, which he regards as a mere variety of tuberculous matter. — Cowan. Chap. 1.] ORIGIN OF GREY SUBSTANCE? 11 des, agreeing with what we have mentioned in the preceding paragraph. The history of the perforation of the substance of the Jung (424) is no less in consonance with this con- ckision, for out of eight cases of this lesion (the only ones we have collected) seven have been observed as belonging to the left side.* However, there are some cases (and we are indebted for the remark to M. Chomel) where a part of the grey matter of the upper lobe appears to have been the product of chronic inflammation. Jt had not, it is true, that granulated aspect, which, according to Laennec, forms the anatomical character of the second or third degree of pneumonia ; but it presented a general, milky, semi-opaque appearance, not resulting from miliary granulations, for they were absent ; it was traversed by white dense cellular intersections, as distinct as those we see in pneumonia ; it was more compact than the common grey matter ; and these peculiarities, when well marked, appeared to us sufficient to distinguish these two alterations from each other. And, with respect to the want of the granulated ap- pearance of which we have spoken, there is nothing absurd in the idea that it may be the effect of time,! which so povver- * This opinion is contrary to that of Laennec, but in unison with that of Dr. Stark (Vide Medical Communications , page 35), and also of Dr. Car- michael Smith, who deduces his opinion from a comparison of the cases in the works of Bonetus, Morg-ag;ni, and others. (Vide Forbes's Transi, page 282, note by Dr. Forbes.) The fact is not without interest, since it forms a strong argument against the inflammatory origin of tubercles, as the reader will see, in the section "On the Influence of Pneumonia on Phthisis." — Cowan. t This is the opinion of the youni',er M. Andral. M. Andral thinks likewise that pneumonia has its seat in the minute air vessels of the lungs, and from this we should obtain a very simple explanation of the granulated aspect of the lungs in this disease. This ingenious idea seems to us to be more than a 12 PATHOLOGICAL ANATOMY. LUNGS ; [Parti, fully modifies and changes the characters of all pathological alterations. 17. We have only once met with encysted tubercles.* They were situated at the summit of the lungs, and easily separable from the surrounding tissues (Obs. 31 .) 18. The softening of tubercles took place at very different periods : in some cases from the twentieth to the fortieth day, counting from the commencement of the disease (Obs. 33) ; in general, at a much later period. It presented the same features as the transformation of the grey into tuberculous matter, beginning in the centre of the tumor, and proceeding from the summit to the base of the lungs ; and by examining mere hypothesis. For when we fill the bronchia with injection, and the injected matter has been forced in softly, we iind in the lungs an infinite number of small masses, which, on being divided, present exactly the gran- ulated appearance of which we are speaking, but if the injection has been made with more violence, the lungs then present merely a compact mass, in which the granulated aspect has almost entirely disappeared. Does not this two-fold experiment seem to demonstrate at the same time the granulated aspect of the lungs in acute pneumonia, and its disappearance when the dis- ease is in a chronic state ? — Louis. * Laennec considers them very rare ; Bayle has described them, page 21. The remark is, however, principally interesting as an argument for the organization of tubercles. All secretions not organizable must be expelled or encysted ; therefore, every secretion which does not tend to encyst itself ^ and which can exist a long time without producing irritation, shares in the common life. Is not this very often the case with tubercles ? When tuber- culous matter is rapidly deposited, it then acts as a foreign body, and the ac- cession of general symptoms immediately follows, as we see in acute phthisis. Organized morbid productions, after a time, secrete non- assimilable pro- ducts, which become the cause of their destruction. The softening of can- cer is noûnng more than thisj that of tubercles is sometimes analogous. We refer our readers to an ingenious paper on this subject by Trousseau and Leblanc. — archives Générales de Médecine, 1828. — Cowan. Chap. 1.] cavities; their parietes, he. 13 them in this direction, we successively found, at various heights, excavations, softened tubercles, crude tubercles, and the grey, semi-transparent granulations. Instead of taking place in a gradual manner, the softening sometimes occurred simultaneously over a considerable extent of surface, and the whole of one lobe degenerated into tuber- culous matter, was nearly equally soft, and easily broken down throughout the whole of its extent. These were rare cases, and confined exclusively to acute phthisis (Obs. 36). There was even here an incomplete cavity at the top of the upper lobe, of which the remainder was tuberculous and almost equally softened. 19. We have not found tuberculous excavations entirely empty before the end of the third, or the commencement of the fourth month, counting from the invasion of the disease. At this period, the parietes of the cavities were generally soft, and lined by a false membrane of little consistence and easily separated. The pulmonary tissue itself was very rarely ex- posed. When the disease had a more distant origin, and the cavities were more ancient, (which could be substantiated by the exact history of the symptoms, and the comparative results of auscultation), their sides were almost constantly more or less resisting, formed of tuberculous matter, of the grey, semi- transparent substance, and sometimes of melanosis. These different alterations, either separated by a small quantity of healthy pulmonary tissue, or continuous with each other, were variously combined. The membrane which lined the exca- vation was dense, greyish, almost semi-transparent, semi- cartilaginous, from one third to one fourth of a line in thick- ness, sometimes less, and generally covered by another membrane of very slight consistence, of a yellowish or whitish color, and usually distributed in patches. In one fourth part 14 PATHOLOGICAL ANATOMY. LUNGS ; [Part I, of the cases we have found no membrane at all, and when this was the fact, the pulmonary tissue^ more or less consider- ably modified, was uncovered. 20. Large or small, old or recent, the excavations commu- nicated with the bronchia by a greater or less number of open- ings. The mucous membrane of the latter, and the false membrane of the former, were closely connected at the en- trance of the excavation ; and when the parietes of the bronchia were red, their limits could only be determined by means of dissection. 21. Old excavations still further differed from those which were recent in their being uneven, rugged, and generally com- municating with smaller cavities. They were frequently crossed in different directions by cord-like intersections. These were variable in length, uneven, narrow, from one to two lines in thickness, formed by the grey, semi-transparent matter, interspersed with tubercles, and thinner in their middle portion than at their extremities : it was very rarely that vas- cular ramifications could be detected in them. We have, however, seen them in five cases, either with or without the aid of injection (Obs. 31). 22. The presence of vascular ramifications in the centre of these cord-like prolongations proves the destruction of a cer- tain portion of surrounding tissue ; and this fact is suflîcient to point out, that in all cases of large excavations, some destruc- tion of the pulmonary parenchyma must previously take place. The rupture of bronchial vessels in the neighborhood of these excavations, their obliteration in the parietes, their direction, which often indicated their passage across the space they oc- cupied, may be mentioned as additional proofs. It may happen, also, as Laennec has said, that granulations are developed in the interstices of the pulmonary parenchyma ; Chap. 1.] CAVITIES ; form, situation, &;c. 15 but when they are sufficiently contiguous to excite around them the development of the grey, semi-transparent matter which unites them, a destruction of the parenchyma is here equally a necessary consequence. The tissues comprised between the granulations have disappeared ; so that excava- tions of very moderate dimensions suppose, as in the case of the larger, the destruction of some portion of the substance of the lungs. 23. The great tuberculous excavations of the upper lobe were nearer the posterior than the anterior edge of the lung,* and in many instances we have found their sides in the former direction, almost wholly formed by a false, semi-cartilaginous membrane, from a line to a line and a half in thickness, en- veloping the summit of the organ. Inferiorly, they were sometimes only separated from the pleura which covers the interlobular fissure by a thin layer of pulmonary tissue, more or less modified (Obs. 28), or there was a perforation of their parietes in this point, and communication established between another excavation, situated in the inferior lobe and posteriorly ; for it is worthy of remark, that in no one instance have we met extensive excavations in the centre of the lower lobe. The following observation is a very remarkable example, both of the facts we have last described, and an illustration of the great size tuberculous excavations may attain. * This opinion coincides with Dr. Stark, (Medical Communications, page 369), and with Dr. Young, page 32. — Cowan. 16 PATHOLOGICAL ANATOMY. LUNGS ; [Part I, FIRST OBSERVATION. A GIRL, set. 20, of rather delicate constitution, but generally free from sickness, was admitted into the hospital of La Charité, August 24th, 1824. She had not ceased growing, and had been confined without accident more than eight months pre- viously. With the exception of some pains in the epigastric region, which were complained of during her pregnancy, she enjoyed good health during the first two months following her confinement, after which period she experienced all the symp- toms of phthisis. The cough and expectoration had com- menced together, and had been more urgent the last two months. To this increase of the two principal symptoms was added considerable oppression, with pains between the shoul- ders and at the middle of the sternum. There had been only very slight haemoptysis. The voice had been weak the last, fifteen days, and had finally become extinct ; appetite, varia- ble from the commencement ; frequent nausea, and a more or less painful state of abdomen ; for the last twenty-four hours the patient had vomited without apparent cause. The diar- rhœa had been constant for the last four months ; heat, much augmented; copious sweats during the night, and gradual loss of flesh. Rigors had been present from the first, and had continued almost every day since. On the 25th of April the face was pale and had an ex- pression of fatigue ; slight headache ; sleep, continues inter- rupted, as during the last three months ; intelligence, unaffect- ed. Cough, moderately frequent ; sputa, of a greenish color, imperfectly nummulated (pelotonnés), in small quantity and of a nauseous odor, as was also the patient's breath ; voice, Chap. 1.] SIZE or cavities. 17 feeble, and slightly changed in character; percussion, clear under both clavicles ; sense of heat, pectoriloquy and metallic tinkling during the cough on inspiration and expiration, heard under the right clavicle. Tongue, natural ; incomplete ano- rexia, with sense of weight in epigastric region immediately after eating J habitual pain in the same region; hypogastrium, sen- sible to pressure ; the previous evening, three stools with colic pains. Pulse, small and weak, extremely rapid ; heat slightly elevated ; night perspirations. Great weakness and extreme marasmus. The patient had come to the hospital under a feeling of despair, and expressed much anxiety to be cured. Decubitus on the left side. On the 17th, she complained of a rather acute pain in right side of chest, and on the 18th, at three, p. m., expired, almost without a struggle, retaining her consciousness to the last. Opening of the corpse forty hours after death. Exterior. — Extreme emaciation. Nothing else remark- able. Head. — Two small spoonfuls of serosity in upper portion of the arachnoid; pia mater, slightly red colored; brain, healthy ; half a spoonful of clear fluid in each lateral ventricle. Neck. — Epiglottis, larynx and trachea, natural. Thorax. — The right lung adhered pretty strongly by its summit and posteriorly over the greater part of its extent to the pleura costalis, by means of a strong and moderately thick false membrane. Its external surface instead of being convex, as in the natural state, presented a large and deep hollow formed by an excavation, which we judged to occupy three fourths or four fifths of the total volume of the lungs. It c 18 PATHOLOGICAL ANATOMY. LUNGS : [Pai't I, reached from the summit to within three quarters of an inch of llie base of the organ, and from the posterior part to within half an inch, or nearly so, of the anterior. It contained a moderate- ly thick, turbid substance, of greyish and brownish color, with an odor analogous to that of animal matter after having been some time macerated. Its parietes were extremely uneven ; presenting in many places fragments of pulmonary tissue greatly changed, and on the point of being detached; no false membranes were observed ; the external boundary was from one to three lines in thickness, and sometimes much less. At the part corresponding to the interlobular fissure, the cavity was divided unequally by means of a septum, pierced with numerous large openings, and formed, as the rest of the cir- cumference, by a grey and sometimes bluish and semi-transpa- rent matter studded with tubercles. The right bronchial tube opened into this enormous cavity, about half an inch after its entrance into the lung, and was much more dilated than that of the opposite side. The remainder of the lung contained numerous grey and tuberculous granulations, leaving scarcely a tenth of its volume capable of respiration. The upper part of the left lung adhered slightly to the costal pleura, and present- ed a small cavity capable of containing a walnut, surrounded with grey, semi-transparent matter, but with a still larger pro- portion of tubercles. A great number of grey, semi-trans- parent granulations existed in the lower part of this lobe, con- gregated in small masses, many being very superficial, and giving a nodulated appearance to the lung externally. Very few were found in the lower lobe. Heart, sound ; aorta, red in the whole of its course, and this redness extended, while diminishing in intensity, into the carotid and femoral arteries. No sensible alteration in the thickness and consistence of the arterial coats. Chap. 1.] SIZE OF CAVITIES. 19 Abdomen. — Liver, voluminous, of a dull yellow color, overlapping part of the stomach ; moderately firm, and some- what fatty. The bile was thick and tenacious. The stom- ach presented a bluish tint externally in the part corresponding to the great cul-de-sac. Volume, natural. Although de- tached with the greatest possible care from the spleen and adjacent organs, there was a perforation of nearly an inch in di- ameter, to the left of and posteriorly to the cardiac orifice, with extremely thin and discolored edges, formed of the peritoneum and a very thin layer of submucous tissue. Internally the prin- cipal part of the great cul-de-sac and of the anterior parietes was of a pale bluish color, with the veins strongly defined. The mucous membrane of the same portions was reduced to the consistence of mucus, and not thicker than common blot- ling paper. It was similarly affected, in bands of from three to four lines wide throughout the remainder of its extent ; and in the intermediate spaces was of a tolerably bright red color and moderate consistence. Mucous membrane of the small in- testines, perfectly sound, with the exception often very small ulcerations in the neighborhood of the caecum. Between the mucous and the submucous tissues, were some small whitish indurations, rather larger than millet-seeds, but not of decidedly tuberculous character. In the large intestine the mucous membrane was pale, free from ulceration, slightly thickened and soft as mucus. The mesenteric glands were sound ; spleen, rather softer than natural ; uterus, extremely small, not more than fifteen lines in its transverse diameter. No other appreciable alteration of the various organs. 24. The clearness of percussion below the right clavicle, combined with the pectoriloquy and the metallic tinkling in the same region, proved to demonstration the existence of a 20 PATHOLOGICAL ANATOMY. LUNGS ; [Part 1, vast excavation containing both air and liquid (285). We were, however, far from thinking it so considerable. No doubt, if the weakness of the patient had not prevented the examination of the respiratory phenomena posteriorly, we should have acquired new data for the more exact appre- ciation of the size of the excavation ; but even then it is more than probable that we should not have entirely avoided error, and that we should have ascribed to a large number of cavities communicating with each other, the effects which here depended on one alone. The imperfect septum existing in the upper part of the excavation was formed by the adhesion of the corresponding portion of the upper, middle and lower lobes reduced at this point to a very inconsiderable thickness. The odor of the contained fluid, identical with that of the ex- pectoration, and the half putrefied portions of lung still attach- ed to the sides of the cavity are not less remarkable than its unusual dimensions. This may also be said of the dilated and short bronchial tube which opened into it ; and we can easily conceive how, in similar circumstances, portions of the lung itself may be expectorated. In fact, from some particulars mentioned by the patient's mother, it would appear that some fragments of the pulmonary tissue had been noticed in the expectoration a few days previous to her admission into the hospital. But patients and their attendants, observe with too much prejudice to allow their simple testimony to have much weight in the determination of a fact of this description. Let us also remark, that notwithstanding the great extent of the disorder, there had only been a very slight haemoptysis ; that the progress of the affection was rapid ; and finally, that this observation is an instance of the disproportion so frequent- ly existing in phthisical patients in the relative state of the two lungs. Chap. 1.] CONTENTS OF THE CAVITIES. 21 25. In fact, although in the great majority of cases tuher- culous excavations are found in both lungs, this is not constant. In the sixth part of our observations they only existed in one side or the other, and when found in both there was generally some difference in their extent. In rather less than one tenth they were equally large on both sides, and in another tenth their dimensions, whether moderate or small, were equally distributed. 26. By the term " vast excavations " we understand those whose capacity equals the volume of a goose's egg, a man's closed hand, or is even still larger. They existed either in the right or left lung in the proportion of about one half of the cases, and were equally frequent on either side. The exca- vations of " moderate size'' may be represented by a middle sized apple, or were rather smaller ; the " small ones" by a hazel nut ; both were nearly equally distributed through the remainder of the cases. 27. The contents of the excavations were subject to varia- tion from many causes, among the principal we may mention their chronicity, — the structure of the cavities, and perhaps the state of the circulation shortly preceding death. If they were of recent origin, their contents were thick, yellowish, similar to common pus. If of longer duration and their pa- rietes were broken up and deprived of false membrane, the fluid was of a greyish greenish tint, having a dirty and disagreeable appearance, thin, of moderate consistence, and sometimes tinged with blood, or even of a deep red color. This last coloration certainly took place but a few hours before death, for we frequently found it at the post mortem examination, while it was extremely rare to see similarly colored expecto- ration either during the last one or two days of the pa- tient's life. 22 PATHOLOGICAL ANATOMY. LUNGS ; [Part I, Though in general the contents of the excavations were without any particular smell, it sometimes closely resem- bled that of animal substances after they have been some time macerated. This was independent of the extent of the cavities, for the odor was sometimes absent in those which occupied a fourth or fifth part of the volume of one of the lungs. Neither was it owing to contact with the air, or at least this was not the only cause, for though the excavations were constantly partially filled, the odor was only observed in three cases. In one, the preceding, it seemed to result from the gangrene of some fragments of grey matter incompletely separated from the sides of the cavity. In two others, this particular dis- position did not exist, the excavations were more or less rug- ged in their structure, without any other peculiarity. 28. Instead of air or pus, in one instance we found an organized fibrous body, filling a moderately sized tuberculous excavation. This fact appears to us of sufficient interest to merit notice at the present moment. SECOND OBSERVATION. A STROLLING Organ player, set. 29, of a moderately strong constitution, middle stature and impetuous disposition, was ad- mitted into the hospital of La Charité, April 24th, 1824. He had been ill a year and eight months ; had ceased his usual occupation for twelve months, keeping his bed occasionally during the last three weeks. He attributed his complaint to having taken a glass of cold water when over-heated. It had commenced by a dry cough and dyspnoea ; no expectoration before the second month of its duration, and until the last Chap. 1.] ORGANISED MASS IN CAVITY. 23 eight days he had never had haemoptysis. At this period he was suddenly attacked without any previous fit of coughing, and when he was walking quietly, with so copious a hasmoptysis that he is confident he vomited twenty-four ounces of blood in less than twenty minutes ; after which the sputa only presented a variably intense red color. Rigors, increased heat and per- spirations the last nine months. Very slight diminution of the appetite, though vomiting produced by cough was frequent. Diarrhœa at long intervals, lasting a few days each time. Loss of flesh from the commencement. On the 25th August, marked emaciation ; skin, of a light yellow color, especially that of face ; some oppression ; cough, not very frequent ; expectoration, opaque, tinged with blood, or of a mahogany color. The patient thinks he can feel the sputa detach themselves from the left side of chest, and at every shock caused by the cough he experiences a slight pain at the lower part of the same side ; he has complained of this from the commencement. Percussion perfectly flat for about two inches under the right clavicle ; equally soon the left side, over the whole of the part corresponding to the upper lobe. In the same regions well marked pectoriloquy ; tracheal respiration and on the left side considerable gurgling râle. Auscultation between the shoulders gave the same result. Pulse, rather quick, small and weak ; temperature, rather less than natural ; some appetite ; thirst, not increased ; digestion, easy ; abdo- men, yielding and not painful ; one stool daily, and of good consistence. (Pectoral infusion ; gum potion ; quarter of house allow ance ; no wine.) Sept. 1st. Appetite, increased ; pains in the left side more severe and more constant than usual. In the evening they had diminished in intensity ; but he was attacked with rather acute 24 PATHOLOGICAL ANÂTOMY. LUNGS ; [Part I, pains in hypogastrium and throat ; oppression as before ; no sensible change in the expectoration. The patient referred all his sufferings to the left side of chest. No alteration of voice, and no painful sensation felt in trachea. On the 11th, the respiration became more embarrassed, and during the night he was obliged to retain the sitting posture, and afterwards to leave his bed for the purpose of relieving the dyspnœa. On the morning of the 12th, he experienced behind the left clavicle a very extraordinary sensation, which he compared to that of a hole (un trou) being there. The dyspnœa was extreme, very little appetite, stools regular and of good consistence. He complained of acute pains in the abdomen, remained seated on a chair, the body inclined for- wards and suffering great anxiety. These symptoms continued ; the breathing became very hurried ; appearance of sputa unaltered ; occasional variation in intensity of the abdominal pains ; and he expired in the night of the 16th, without having manifested any delirium. He got up unassisted on the morning of the 16th to relieve the dys- pnœa. During the day and the previous evening we could not detect pectoriloquy under the left clavicle ; the patient said that he had heard a frightful rattling sound in the same point twenty-four hours earlier. Opening of the corpse thirty-two hours after death. Exterior. — Extreme emaciation. Nothing else remark- able. Head. — A thin layer of infiltration beneath the upper por- tion of the arachnoid ; a spoonful of clear serous fluid in each lateral ventricle ; a similar quantity in the base of the skull. The septum lucidum was softened and pulpy, as it were, at its inferior part : the remainder of cerebral mass healthy. Chap. 1.] ORGANISED MASS IN CAVITY. 25 Neck. — No alteration of epiglottis or larynx. Mucous membrane of trachea of a pale, delicate red, interspersed in- feriorly with pretty numerous ulcerations, the larger of which were situated on its fleshy portion. Thorax. — The left lung was intimately adherent to the costal pleura at its apex, and in the rest of its extent, by means of cellular filaments, in the intervals of which there was slight serous infiltration. The upper lobe was indurated, converted into a grey, semi-transparent matter, in the centre of which existed another substance of perfectly uniform structure, of yellowish color, and similar at first sight to jelly, but much firmer and not easily yielding to pressure. Here and there were seen some softened tubercles, more or less excavated, and in the upper part of the same lobe there was an excava- tion capable of containing a middle-sized apple, filled by a mass of fibrine which was red, firm, enveloped in a white, easily torn, false membrane, slightly adhering to the one lining the cavity, and giving off numerous septa reuniting in a central point. Round the excavation and in the middle of the grey substance were vessels of about half a line (un millimètre),* or rather less in diameter. We traced them very easily by means of a fine wire, but without detecting any communica- tion with the excavations just described. A tolerably large, cord-hke prolongation, situated between this cavity and a much smaller one situated posteriorly to it, contained a small vascular ramification, which also did not seem to open into the cavity. A large quantity of grey matter, tubercles and granulations * The unity of French measures is the metre = 39.37079 English inches ; the millimètre is =; 0.039 inches. The French inch is divided into 12 lines, and there are 443^ lines in the metre ; so that a millimetre is regarded as about the l-26th of an inch. — Cowan. 26 PATHOLOGICAL ANATOMY. LUNGS ; [Parti existed in the lower lobe, half of which was still penetrable by air. Cellular adhesions over the whole surface of the right lung : at its summit there were numerous grey granulations, and a moderately sized excavation, at the base of which were some isolated portions of hepatized tissue. Heart and aorta, perfectly sound. Abdomen. — Liver, of a dull red color, more strongly marked than natural, of usual dimensions. Bile in the gall- bladder of moderate consistence. Mucous membrane of stomach covered with a viscid mucus, and of rather a bright red color throughout its whole extent ; of natural thickness and consistence ; its villous appearance distinct. Duodenum, natural. Mucous membrane of small intestine, as if sprinkled with minute particles of fat, in other respects healthy. That of the large intestine was a little softened and somewhat injected throughout. Four small ulcerations in caecum and ascending colon, of a greyish color, caused by the slightly thickened cellular tissue which formed their bottom. The fasces pre- sented a dull, dirty yellow appearance in the caecum, but were elsewhere of a clear yellow color and good consistence. The other viscera of abdomen, healthy. 29. Were we merely to fix our attention upon the apparent organization of the fibrous clot occupying the large excavation of the left lung, we ought, perhaps, to date its origin from the period in which the patient experienced a copious haemop- tysis. But if we recollect the signs furnished by auscultation, and the symptoms observed near the termination of the affec- tion, this will appear very doubtful. For the first time that we saw the patient, eight days after the occurrence of the haemoptysis, pectoriloquy could be distinctly heard under the clavicle, that is, immediately in the point corresponding to the Chap. 1.] PORTION OF» THEM IN CAVITY. 27 cavity, filled by the fibrous coagulum, and this we heard for many days in succession. We attempted in vain to discover it twenty -four to forty-eight hours previous to death. By the sup- position that the fibrous clot was formed during the last days of existence, all would be easily explained. In this case, pecto- riloquy ought to have existed under the left clavicle at the time of admission, and ought to have ceased at a much later period. But the contrary idea leaves every thing unexplained, and forces the admission that pectoriloquy may or may not be present in a completely filled excavation. If we join to these considerations the sudden appearance of other local symptoms, the dyspnœa, the extraordinary sensation complained of be- hind the left clavicle four days before death, we must admit, notwithstanding the difficulty of giving any explanation of these subsequent accidents, that it is infinitely probable that the formation of the fibrous coagulum took place during the last period of the patient's life. With regard to the dyspnœa, it may be remarked that the state of the mucous membrane of the stomach and colon, which we may consider as produced by acute inflammation, had no doubt a greater or less influ- ence in its production (98, 341). 30. We have very recently met with a fact of another de- scription, and much more remarkable. It is connected with the particular subject at present before us, and we shall now relate it. THIRD OBSERVATION. A SEMPSTRESS, Set. 27, of rather delicate constitution, was confined without accident, and at the natural period, fifteen 28 PATHOLOGICAL ANATOMY. LUNGS ; [Part I J days before entering the hospital of La Charité, March 8th, 1825. She had coughed and expectorated the last seven months and a half without any apparent cause and was subject occasionally to pains in the side. Rigors, followed by heat and sweatings, had been complained of during the last periods of pregnancy, but had ceased after parturition. Complete anorexia ; thirst rather urgent the last month ; and for the last three months there had been almost constant diarrhoea. She had not had haemoptysis, and could not recollect when she first began to lose her flesh. On the 9th of March we observed loss of color over the whole body, extending to lips ; considerable feeling of lassi- tude ; movements of body, painful, rarely made and of lim- ited extent ; lies with head raised ; considerable oppression ; cough, not frequent ; expectoration mucous and semi-opaque. Percussion of chest clear every where ; a gurgling sound heard under right axilla and posteriorly between the shoulder and vertebral column of the same side: Inferiorly and to the left in the corresponding part was a slight crepitous râle. In other parts, respiratory murmur, natural. Pulse, small, weak, accelerated (one hundred and ten in a minute) ; heat of sur- face, moderate ; tongue, pale and clean ; mouth, clammy, complete anorexia, no nausea. Epigastrium, and especially the hypogastrium, painful ; pain, much increased by pressure. The patient had lost very little blood after her dehvery. On the fourth day the discharge had become whitish, and had continued so since ; it was not abundant. (Sweetened infusion of violet ; gum potion ; flaxseed tea cnemata ; emollient fomentations upon hypogastrium j a half- julep ; yolk of egg mixed with water.) Until the 5th of April, the day of her death, the thirst was moderate, more complained of at night than during the day ; Chap. 1.] PORTION OF THEM IN CAVITY. 29 expectoration, scanty, and only opaque and nummulated (pelotonnés) in the last twenty-four hours. In the night of the 25th of March, an acute pain was felt in the left side of chest, readily yielding to the application of a few leeches. From that moment there was considerable cough and oppres- sion. Up to this period percussion and auscultation, though frequently repeated, merely confirmed the results of the first examination. The pulse was constantly small and weak, varying from a hundred and eight to a hundred and fifteen. The patient was attacked with a violent rigor in the night of the 25th of March ; and from this time a sensible increase of general temperature took place. We never remarked any perspirations. The thirst was not urgent ; appetite, quite gone. After the 13th of March there were nausea and vomiting of green, bitter substances, or almost tasteless and whitish, either during the cough or in its intervals. This vomiting occasionally ceased for a day or two, but it sometimes occurred several times in the twenty-four hours. The pains felt in abdomen diminished in intensity. No diarrhoea until the last week ; it was then con- siderable, but unaccompanied with colic. The urine became more or less burning, and from the 28th of March to the 2d of April, a complete retention took place, requiring the frequent introduction of the catheter. The discharge from vagina be- came red for a short time at two different periods. The prostration diminished four days after the entrance of patient into the hospital, and the countenance became more animated. On the 12th of March we observed slight œdema of lower extremities, which rapidly increased. On the 25th, she complained of pains in the thighs, which were very acute in the inner and upper part of left, two days 30 PATHOLOGICAL ANATOMY. LUNGS ; [Parti, before death, and the skin of the part had a slight red tinge. Constant dehrium and general agitation during the last night. Death took place at four, a. m. In addition to the first prescription, an infusion of the triti- cumrepens with the syrup of the five roots and aromatic fumi- gations under the bed clothes with juniper berries were had recourse to. For the diarrhoea, the white decoction with quince syrup, some diascordium and a grain of opium, with a narcotic enema afterwards, were prescribed. The only nour- ishment taken was the yolk of eggs with water. Opening of the corpse twenty-eight hours after death. Exterior. — Inferior extremities much infiltrated ; some phlyctenas at the inner and upper part of thighs, where the skin was of rather a bright red color. The crural veins, and especially those of the left side, were distended with firm, fibrous coagula of variably intense red color, either hema- tite or mahogany color, and adhering firmly to the lining membrane, which was of a dehcate rose color and rather thicker than that of another individual of the same age, v/ith which we compared it. The coagula extended into the col- lateral and iliac veins as far as the vena cava superior. Head. — Tolerably abundant infiltration beneath the arach- noid covering the convexity of the hemispheres. Not quite a spoonful of clear serous fluid in each lateral ventricle ; a spoonful and a half of the same fluid in the inferior occipital fossae. The whole of the encephalic mass rather soft. Neck. — One of the lymphatic glands on the left side had acquired the size of an almond in its husk, was firm in texture, of reddish color, and spotted with numerous small, yellow opaque bodies, evidently tuberculous. No change was ob- served in the epiglottis, larynx, or trachea. Chap. 1.] PORTION OF THEM IN CAVITY. 31 Chest. — About two quarts of clear serous and slightly red fluid were found in the cavity of left pleura. The corres- ponding lung was much diminished in volume, and invested, as was the costal pleura, by a red false membrane, moderately consistent, and rather less than half a line in thickness. The substance of the lung was greyish, but healthy and free from air ; bronchia, of a bright red color, without sensible thick- ening. The right lung presented some thinly scattered cellu- lar adhesions, and in its summit an excavation of middle dimensions, partly filled by a muddy and greenish fluid, which surrounded a slightly greyish colored mass, streaked with black lines similar to those we observe in the pulmonary tissue ; its form was oblong, a little flattened, sixteen lines long and ten wide ; it weighed very little, was soft and rather elastic, and of a pale rose color internally ; it was, in fact, exactly similar to a fragment of the lung itself after it has been immersed some time in water. There was no bad odor, or any pedunculated prolongation at its surface. The excava- tion was lined by a false membrane of moderate consistence, a quarter of a line in thickness, and lying upon healthy pul- monary tissue. It presented, in opposite points, two projec- tions, of about a line in height, formed by the extremities of two bronchial ramifications. The remainder of the lung was slightly engorged, free from tubercles or grey granulations, or any other trace of organic disease. The bronchia were pale and thin. The heart was scarcely two-thirds of its usual size ; aorta, healthy. Abdomen. — About a quart of clear lemon colored fluid in the peritoneal cavity. The stomach, of nearly twice its ordi- nary volume, partly filled the left hypochondrium, reaching to the umbilicus. Its mucous membrane was of a yellowish 32 PATHOLOGICAL ANATOMY. LUNGS ; [Part I, brown color in the whole of its extent, with the exception of a zone in the vicinity of the pylorus of about an inch in width ; its consistence was moderate, and it was about half its usual thickness. It was still thinner in the points corresponding to numerous whitish, rounded spots, from one to two lines wide, almost uniformly distributed over its whole surface. Mucous membrane of small intestine, healthy ; that of caecum and colon a little softened. In the remaining portions of the large intestine it was as soft as mucus, and it was red in the rectum only. No ulcerations. Mesenteric and mesocolic glands, healthy. The uterus was twice as large as usual ; its cavity much increased, of blackish color ; its substance more or less red, and as if spongy to the touch and easily broken down ; its parietes were not sensibly thickened, except anteriorly, where they projected about a line on the inner surface. The ovaries were rather soft and larger than natural. The remain- der of abdominal viscera, sound. 31. The presence of a fragment of pulmonary tissue in the midst of an excavation is certainly a very extraordinary fact, and which, perhaps, up to the present moment, has not been observed.* There could be no doubt as to the real nature of what we have just described ; for the color, the consistence, the structure, the mode of tearing, — in short, every thing cor- responded with what characterizes the tissue of the lung itself. The absence of gangrenous odor proved that its complete sepa- ration was rather recent, and we may very well suppose that it * If we may trust the descriptions of Tulpius in his Observations JHedi- ctB, 1641 ; of Aretaeus, in his chapter " On Abscesses of the Lungs ;" of Galen, and of Bontius in his Medicina Indorum, 1G31, the expectoration of portions of the lung and bronchia is not very uncommon. Vide Young on Consumption, pages 124, 139, 167. — Cowan. Chap. 1.] PORTION OF THEM IN CAVITY. 33 adhered for some time to the remainder of the organ by the two bronchial projections already described. Indeed, these two points were the only ones where no false membrane ex- isted, while every where else the latter was continuous with itself; indicating, no doubt, that the separation of the frag- ment had been effected some time, with the exception of the two projecting bronchia. This excavation was remarkable also, on account of the false membrane which lined it being every where in contact with healthy or only slightly engorged pulmonary tissue, which is very rarely the case. 32. But may it not be asked, with some apparent proba- bility, whether this excavation really was the effect of tubercles, and if the patient had phthisis ; for no tubercles or grey granu- lations existed in the lungs ; there were no ulcerations in the larynx, trachea, or intestines, — alterations so frequently occur- ring in this affection ? To this we would reply, that the puru- lent matter of the excavation was exactly similar to what we usually find in tuberculous cavities ; that the false membrane had equally analogous properties ; lastly, and this fact is per- haps one of the most conclusive, a cervical gland was evidently tuberculous, and in the course of these researches we shall find that we have never observed the tuberculisation of lym- phatic glands, except in phthisical patients.* * This mode of reasoning being probably rather new to the reader, we refer him to the one hundred and fifty-eighth section for itssoUition. If ob- servation has demonstrated (and we beheve it has), that after the age of fifteen tubercles in any organ of the body involve their presence in the lungs, the conclusions of the author are both legitimate and necessary, though without this previous rigorous observation, they would have been impossible. — Cowan. E 34 PATHOLOGICAL ANATOMY. LUNGS ; [Partly Among the facts of this observation, over which we shall merely glance, we would recall the pleurisy of the left side, the invasion of which was marked by pretty acute pains ; the partial and general diminution in thickness of the mucous membrane of the stomach, without well marked softening ; the want of consistence, and the change of color of the uterus, produced by inflammation ; finally, the œdema of the lower extremities, which must be attributed to the obstruction of the crural veins. 33. For the purpose of terminating all we intend to remark on the subject of tuberculous excavations, it may be added, that in no one instance have we met, surrounded by healthy pulmonary parenchyma, with cavities communicating with the bronchia, and lined, as are tuberculous excavations of long standing, with a false membrane of a light grey color, semi- cartilaginous and semi-opaque. Such, however, have been observed by M. Laennec, in the examination of persons who had presented the symptoms of phthisis during a space of time more or less considerable ; and judging from their struc- ture, it would be difficult not to believe that tuberculous sof- tening preceded their formation. The previous observation is indeed well adapted for the confirmation of this fact. For here, as in the other cases we are referring to, there was but a single excavation ; the pulmonary tissue was healthy ; and we may conclude, that if the life of the individual had been prolonged for some weeks or months, the false membrane lining the cavity would have presented the characters we have last mentioned. We have also failed to meet at the apex of the lungs with those masses of condensed cellular tissue, in which the bron- chial ramifications, more or less dilated, terminate, and which Chap. 1.] CICATRICES OF CAVITIES. 35 are considered by Laennec as the cicatrices of tuberculous cavities.* 34. The depressions observed in the upper part of the lungs, around which their tissue is, as it were, puckered, do not appear to depend upon any determinate lesion. We have frequently seen them when the pulmonary parenchyma was healthy, or only slightly indurated to a small depth, imme- diately beneath the pleura. They were present also some- times when either crude tubercles, small excavations, or osse- ous concretions existed in the summit of the lungs. 35. We have never found bronchial ramifications in the interior of tuberculous cavities, or in the masses of the grey, semi-transparent matter, so that the first effect of the develop- ment of this substance appears to be, as M. Laennec has remarked, the destruction of the bronchia. It might be thought that this destruction arises from the transformation of the air tubes into the grey or tubercular matter ; but this supposition appears to us very doubtful, from the fact, that we have never * These results are singularly negative, when compared with those of M. Laennec, Andral and others, who hring forward copious and undeniable evidence of cicatrization of tuberculous excavations, and the formation of a fibro-cartilaginous membrane, when the cavity is not obliterated. It must be recollected that M. Louis never forces his conclusions beyond the num- ber of facts he is analysing, and it is remarkable that not one of these has presented an example of cicatrization ; this inclines us to suppose that the presence of a cicatrice has often been hastily admitted ; a supposition con- firmed by the succeeding observations of our author. That a tuberculous excavation is ever capable of cure is an important fact, and highly calculated to encourage us in the research of means which may tend to arrest this hitherto most destructive affection. Vide Andral, CZm. Med. vol. iii. page 382 ; Laennec, pages 299, 323, — and notes by Dr. Forbes. Cottereau, ia tils Essay on Chlorine Inhalation, adduces also some incontestable facta, — Cowan. 36 PATHOLOGICAL ANATOMY. LUNGS ; [Part I, seen this transformation, either near the excavations or the tubercular masses, or in any other part of the lungs, even where the bronchia presented various alterations. It is, then, highly probable that this destruction takes place by absorp- tion. 36. The bronchial mucous membrane sometimes retained, in the neighborhood of tuberculous cavities, its natural pale- ness. In general it was of a bright red color, and this seemed to be caused by the continual passage of the purulent secre- tion of the excavations through the bronchia ; for it was not present, or very rarely so, near the masses of grey or tuber- culous matter not yet in suppuration ; it was less frequent in the bronchia communicating with recent than with old excava- tions, and when existing throughout the lung, it was not more marked around the latter than elsewhere.* 37. When reddened, the bronchial mucous membrane was sometimes a little thickened, and occasionally the seat of small ulcerations. But much more frequently there was dilatation of the air-tubes, and hypertrophy of all their tunics. This hyper- trophy was especially marked in the upper part of the lungs, where the bronchia were often three or four times thicker than natural ; and it is easy to conceive that such various changes would tend to augment the severity of the principal aiFection. j* * Numerous facts are scattered through the volume tending strongly to corroborate the statement that the redness of the mucous membrane of the air-tubes and its ulceration are often depending on the contact of the con- tents of the tuberculous excavations. The fact has not before been demon- strated, and is important in the question of the dependence of tubercles on bronchitis. — Cowan. t The frequency of dilated bronchia in the upper lobes is rather in oppo- sition to what we know of the progress of simple bronchitis from below upwards ; it might naturally be expected to prevail where bronchitis is most Chap. 1.] INFLAMMATION OF. 37 38. Inflammation of the 'pulmonary parenchyma was not rare. We have observed it at the second stage, in a very variable extent in eighteen subjects, or in a httle less than one sixth part of our cases. The pulmonary tissue was red, con- tained no air, was indurated and granulated, in a word, hepa- tized ; and, almost constantly, the hepatization existed in the lower lobe. In nine subjects it occupied a considerable space, from the half to three fourths of one of the lungs. In the others it was much more limited, and presented the appear- ance of small masses more or less disseminated. The exca- vations were very considerable in four of the first-mentioned class. In the others, there were either merely semi-trans- parent granulations or tubercles partially excavated. The characters of the alteration indicated a recent disease ; and the history of the symptoms proved, as we shall see farther on (286), that it had only preceded death a few days. frequent, viz., in the lower lobes. Does the physical condition of the up- per portion of the lung exert any intluence on this morbid peculiarity ?t — Cowan. X 1 doubt the fact which the translator gives as the basis of the previous remark. If the reader will observe, Louis does not say dilatation of the bronchia is most frequent in the upper lobes, but merely that hypertrophy (èpaississement) of their different textures is especially marked in the upper part of the lungs. Again, I have a positive fact which tends to prove that dilatation of the bronchia is more common below than above. In my notes taken of Louis's lectures, delivered at La Pitié, I find mentioned, in two different places, in the lecture upon dilatation of the bronchia, and in that upon the causes of phthisis, the following data. Out of twenty cases of dila- tation of the bronchia, nine had dilatation towards the base of the lungs ; five towards the upper parts ; six had general dilatation throughout the lungs. I cannot doubt, therefore, that the translator has, by chance, given an erroneous view of the text, and rests upon false presumptions, when he spsaksof the " frequency of dilated bronchia in the upper lobes." — H. I. B. 38 PATHOLOGICAL ANATOMY. LUNGS. [Part I, 39. We have found a state of simple engorgement, or the first degree of pneumonia, in twenty-three subjects, and usually not extensive. In four cases only it occupied the greater part of one, or even of both lungs, which were still crepitating, giving vent on incision to a large quantity of red frothy fluid ; the consistence of the engorged part was much diminished, or it was easily torn. In one of the cases where a considerable portion of the lung was thus affected, we observed two days before death pain and a rather fine crepitation in the affected side. These symptoms confirm the inflammatory nature of the affection, and indicate here, as in the preceding cases, that it had com- menced but a few days before death. 40. The development of this complication at a period so shortly before death is not peculiar to phthisical cases. We have remarked it at the termination of other chronic diseases, and in nearly equal proportion. In one hundred and twelve cases where death took place during the last stage of these affections, in twelve we found a portion of one and some- times of both lungs, red, granulated and hepatized. A state of congestion was noticed in ten other instances ; and, as we have shown in the cases of phthisis, the history of the symp- toms proved the inflammation to have preceded death only a few days. It results from this comparison of cases, that tuber- cles and tubercular excavations are nearly without influence over the development of pneumonia in the last stage of phthisis.* * Vide Article " Pneumonia" among the " causes" of Phthisis. — Cowan. Chap. l.J pleura: ; false membranes, he. 39 ARTICLE II, PLEURiE. 41. Nothing was so frequent as «é/Aesion of the lungs to the pleurae ; for in one hundred and twelve cases there only existed one in which the two lungs were perfectly free in the whole of their extent. We have only found the right lung connpletely without adhesions eight times ; the left only seven, and in these cases there were either no tuberculous excava- tions, or only those of very limited dimensions. In twenty-five other cases, the adhesions were cellular, easily ruptured, confined to a small space, and seldom present on both sides. In seven out of this number there was no ex- cavation in the lung corresponding to the adhesions ; in ten others the cavities were small, and in the remaining eight cases they were of moderate or very considerable size. Among the other individuals the adhesions were universal, or nearly so ; formed either by variably dense cellular tissue, or a false membrane ; in both which cases large cavities almost constantly existed. ThuSi there was evidently some relation between the ex- tent of organic alteration and the pleural adhesions ; if the latter were absent, there were neither large nor middle-sized excavations, and in general none whatever. Were they weak and Umited in extent, the cavities were generally very small, rarely large, and sometimes altogether wanting. Lastly, where the adhesions were dense, extensively dis- tributed or even universal, they always indicated excavations 40 PATHOLOGICAL ANATOMY. PLEURA; [Parti, in the lungs, and in the great majority of cases that those ex- cavations were large, or at least of considerable size. 42. The proportion which existed between the size of the tuberculous cavities and the adhesions, demonstrated the in- fluence of the first upon the second. The large excavations constantly occupied the summit of the lungs, approximated closely to their surface, and there only were found those dense resisting false membranes which we have already described (23), as either strengthening the sides of the cavity, or con- stituting them over a certain space. This mutual relation between cavities and adhesions is also pointed out by other facts. Thus, in two cases where the lungs only contained two masses of tuberculous matter immediately beneath the pleura, the adhesions were confined to these points, and were formed by a cellular prolongation, one inch and a half long, and of the same size as the tuberculous masses. 43. We have twice found a false membrane of moderate consistence lining the pulmonary and costal pleurae, converted into tuberculous matter (Obs. 16). Another case has pre- sented us with an example of the same transformation, though of very limited extent, taking place in a false, semi-cartilagi- nous membrane which enveloped the summit of one of the lungs. 44. These adhesions v^^ere the consequences of chronic in- flammation of variable duration ; and, as we shall hereafter see, the period of its commencement could, in many instances, have been determined by the history of the patients (246). 45. In cases of other chronic diseases this was not always the fact, and in the majority of instances we were unable to assign any cause for the adhesions which existed. We have found them thirty-five times out of one hundred and ten, and in twelve cases they were universal, either on both or only on Chap. 1.] FALSE MEMBRANES ; TUBERCULOUS, StC. 41 one side of the chest. Although this proportion is consider- able, it is still very inferior to what we find in cases of phthisis (41) ; an additional proof of the influence of tubercles in the production of adhesions. But what, under this point of view, is altogether peculiar to phthisis is the semi-cartilaginous en- velope covering the summit of the lungs, and the transforma- tion of false membranes into tuberculous matter. 46. As we have already remarked in speaking of pneu- monia, the invasion of pleurisy coincides in a large proportion of our patients with the last days of life, the period of extreme weakness and emaciation. We have observed it in one tenth of the cases. The lung or costal pleura, frequently both, were covered to a greater or less extent by a soft, yellowish, false membrane of variable thickness ; there was an effusion of a certain quantity of a serous, reddish fluid, limpid or other- wise, or even completely purulent. The characters of the alteration indicated its recent nature, and the history of the symptoms proved it could not date farther back than nineteen, twelve, eight, or three days before death (287). 47. Patients dying from other chronic affections have pre- sented the same alterations, preceded by similar symptoms in the last periods of life, only the proportion was rather less, one thirteenth. From what has been said, we may con- clude that pneumonia and pleurisy are frequently developed in the last period of phthisis and of other chronic diseases ; some- times resulting from evident causes, as the application of cold to the surface of the body, but most frequently without any appreciable origin. Their progress is rapid, and they augment the number of causes which hasten the death of consumptive patients ; they also form another argument for being more watchful in our treatment of protracted cases, when near their F 42 PATHOLOGICAL ANATOMY. TRACHEA ; [Part Ij termination, and show the necessity of protecting the patient fronj all those external influences calculated to produce either of the complications above mentioned. 48. We have also frequently observed in the cavity of the pleurae an effusion of clear fluid, in quantity from a quart and upwards. This effusion, which took place in the tenth part of our cases, came on at times very rapidly. Of this we were convinced in two instances, where the thorax gave every where a clear sound on percussion thirty-six hours before death, but where two quarts of clear serum were afterwards found in one side of the chest. The same effusion took place at the close of other chronic diseases, and excepting after affections of the heart, was pres- ent in one fourth of the cases. This difference of proportion corresponds to what we have remarked with regard to the ad- hesions of the lungs to the pleurae, in patients dying from phthisis and other organic affections. It seems to indicate that this species of hydrothorax is unconnected with the nature of the disease. ARTICLE III. EPIGLOTTIS, LARYNX AND TRACHEA. 49. Of these three continuous organs, parts of the same apparatus, very analogous in their structure, and susceptible of the same alterations, the larynx alone has attracted the atten- tion of observers in the history of phthisis. Its ulcerations have been described, but those of the epiglottis have been scarcely mentioned, and those of the trachea almost entirely overlooked. The cause of this omission is no doubt owing to the fact, that there are frequently no symptoms whatever to Chap. 1.] ULCERATIONS. 43 announce this alteration, and also to the practice among many medical men of examining after death those organs only whose functional derangement was more or less prominent during life. Be this as it may, ulcerations of the epiglottis are not uncommon in phthisis ; they indeed are almost as frequent as those of the larynx, for in one hundred and two cases in which the respira- tory tube was carefully examined, they existed with those of the larynx and trachea in the proportion of eighteen, twenty- two, and thirty-one. Sec. ]. — Ulcerations of the Trachea. 50. When the mucous membrane of the trachea was ulcer- ated it was generally of a bright red color. Sometimes, how- ever, and especially when the number of the ulcerations was inconsiderable, it retained its natural whiteness. This was the case in six out oC the thirty-one observations in which we have remarked the alteration alluded to ; and one of them was an example of very extensive ulceration (Obs. 16). It was in the lower half of the trachea, that is, in that portion of it where ulcerations are the largest and most numerous, that the redness was most strongly marked. There were associated with it, in about one fifth of the cases, a slight thickening and inconsiderable softening of the mucous membrane. 51. When the ulcerations were small they were usually equally scattered throughout the circumference of the trachea ; they were of a round or oval form, varying from a line to a little more or less in diameter. The mucous membrane was destroyed by them, their bottom formed by the cellular tissue slightly or not at all thickened, their edges flat, and their gen- eral appearance that of having been made with an instrument. It is now easy to conceive how these small ulcerations, with their flattened edges and pink color, should have escaped no- 44 PATHOLOGICAL ANATOMY. TRACHEA ; [Part I, tice, when the trachea was not minutely examined or pre- viously washed. 5*2. If their dimensions were more considerable, they were unequally distributed. The largest were found in the fleshy portion of the trachea. The mucous membrane retained in their vicinity, as also in that of the smaller ulcerations, the thickness, color, and consistence which it possessed in the rest of its surface. The submucous layer, indurated and thick- ened, formed their lining, or even this was either totally or partially destroyed, and the muscular coat exposed in the cor- responding point (Obs. 15, 16). This last tunic, when thus denuded, was twice or three times as thick as natural, and in a small number of cases we found it more or less deeply ulcerated (Obs. 16). A certain number of the cartilaginous ring-s was sometimes completely denuded, diminished in thickness, and either par- tially destroyed, or their texture entirely divided at one point (Obs. 15, 16). This last alteration we have only ob- served once (Obs. 16) ; while we have seen in five cases the complete destruction of the mucous membrane of the trachea throughout almost the whole extent of its fleshy por- tion. (Obs. 15, 43). 53. The preference which the large ulcerations almost con- stantly exhibited for the posterior portion of the trachea may, perhaps, find a solution in the constant passage of the sputa, and their more or less prolonged contact on this particular part. For, if too exciting liquids produce inflammation and ulceration of the mucous membrane of the stomach, we might expect the same effect on the trachea from the undoubted irri- tating influence of the excreted fluid. Besides, it would be diflîcult to explain on any other grounds, why the ulcerations of the epiglottis exist, as we shall prove farther on to be the Chap. 1.] ULCERATIONS. 45 case, only on its lower surface, the one which is more or less frequently in contact with the sputa.* But while we admit that the expectorated matter may have a decided influence both upon the extent and seat of the ulcer- ations of the trachea, we must recognise also some other cause ; for they are far from being always in proportion to the irrita- ting properties of the expectoration, nor do they constantly exist even when the affection of the lungs is considerable, and the tubercular excavations of long standing. We may also add that the bronchia, in which the expectorated matter circu- lates and remains a greater or less time, are less frequently (we have only found them seven times), the seat of ulceration than the trachea. It is, however, possible that this number is underrated, for, with respect to the present subject of inquiry, we have never examined the bronchia with the same attention as the trachea. 54. In one third part of the cases where this organ was free from ulceration, its mucous membrane was of a red color, in- creasing in intensity according to the proximity of the bifur- cation. It was still more marked in the muscular portion than elsewhere, so that it pursued the same course as the ulcerations, and no doubt partly depended on the contact and retention of the sputa in the trachea. *M. Broussais, in vol. ii. page 176, of his Histoire des Phlegmasies Chron- iques, has ingeniously anticipated the results of M. Louis. He saj's, " La phlogose désorganisatrice de la membrane trachéale et laryngée se présente en troisième ligne (of frequency). Je n'en ai pas étudié les causes détermi- nantes d'une manière bien particulière ; mais on presume assez que les particules acres et fétides qui s'élèvent des foyers purulents doivent en faciliter efiftcacement l'action." — Cowan. 46 PATHOLOGICAL ANATOMY. LARYNX [Part I, Sec. 2. — Ulcerations of the Larynx. 55. These were, as we have already remarked, a little less frequent than the preceding, seldom unaccompanied by them, and present in one fourth part of the cases. Twice only we have observed them uncombined with those of the trachea, and in many instances they sensibly varied in their characters from those_ïof the latter. Seldom superficial or presenting the appearance of artificial formation, they were generally of a certain depth, more or less irregular, and from one to ten lines broad. Their edges, of variable consistence, were sometimes lardaceous, of a greyish or whitish color. The mucous mem- brane was pale and perfectly sound in the rest of its extent. 56. The most frequent seat of these ulcerations was first the junction of the vocal cords, where they were sometimes superficial ; then the vocal cords themselves, especially their posterior part ; then the base of the arytenoid cartilages, the larynx, and the interior of the ventricles, which we have found only once the seat of small, superficial ulcers. In some instances one or more of the vocal cords were com- pletely destroyed, and the base of the arytsenoid cartilages laid bare. When this was the case the cartilages themselves were perfectly healthy. Sec . 3. — Ulcerations of the Epiglottis. 57. We have remarked them eighteen times, or in about one sixth of the cases, and five times unaccompanied by those of the larynx and trachea. This complication, however, ex- isted in the other cases, so that all the examples of ulceration, enumerated in this and the two preceding paragraphs, have been collected from forty-four cases, about four tenths of those whose history we are now analysing. Chap. 1.] AND epiglottis; ulcerations. 47 Sometimes superficial, the ulcerations of the epiglottis were generally of a certain depth, not, however, (with two excep- tions) penetrating the fibro-cartilage beneath. The mucous membrane surrounding those which were superficial did not appear evidently thickened ; when the ulcerations were deep, it was rather harder and thicker than in the natural state, either in the immediate vicinity or in the intermediate space. It was sometimes likewise of a rose color, and in many instances the layer separating it from the fibro-cartilage was more or less puffy in its texture. 58. The ulcerations existed, as we have already remarked, almost solely on the laryngeal surface of the epiglottis, and most frequently on its lower half. Once only we encountered them on its lingual surface (Obs. 12). Their dimensions were from one to two lines, often larger. In some cases even the mucous membrane of the epiglottis was destroyed over the whole extent of the inferior surface (Obs. 8, 14, 15.) In others, the cartilage was destroyed in portions of its circum- ference, giving a festooned appearance to the epiglottis. This we have seen four times. A fifth case has presented an ex- ample of complete destruction of the epiglottis (Obs. 13). 59. We have in no one instance discovered tuberculous granulations in the substance, or on the surface of the epiglot- tis, larynx or trachea ; which fact induces us to believe that we ought to consider inflammation as the most frequent cause of the ulcerations. Another fact of importance to be remarked is, that these ul- cerations were twice as frequent in men as in women. Thus, in an equal number of cases, the women only presented six ex- amples of this state of the epiglottis, seven of the larynx, and nine of the trachea, out of eighteen, twenty-three and thirty- one cases ; and as the proportion is nearly equal for the 48 PATHOLOGICAL ANATOMY. EPIGLOTTIS. [Part 1, three kinds of ulcerations, it is probably not the effect of hazard.* EPIGLOTTIS, LARYNX AND TRACHEA IN OTHER DISEASES. 60. In making an accurate summary of the state of the epiglottis, larynx and trachea, in cases terminating fatally from some other disease than phthisis (particularly chronic affections), we have found in one hundred and eighty in- stances, one example of ulceration of the larynx, and two others when both the larynx and trachea were similarly affect- ed. In the first case the patient had died of pneum.onia, and the l«ngs presented no trace of organic lesion. In the last two they died of cancer and softening of the brain, and had tuberculous cavities in the lungs. From what has pre- ceded, it follows that we must consider the ulcerationsof the larynx, and especially those of the trachea and epiglottis, as alterations peculiar to phthisis. With the exception of three cases of œdema of the glottis (Obs. 46), the changes we have described are the only ones these organs have presented to us in phthisical patients. * The whole of this section may be considered as peculiarly valuable, and contains decidedly the most and only accurate account which we yet possess of the state of these organs in phthisis. The comparative analysis of facts proving that their lesions are almost peculiar to this disease is very valuable, and gives a just idea of what is still frequently described as «' laryngaeal phthisis." There are some interesting researches on this sub- ject in the twenty-second letter of the second book of Morgagni, on the causes and seat of diseases. The reader must not forget that the author's conclusions are confined to chronic diseases, and where syphilis is not pres- ent. The latter has a special action on these organs, and in typhus and some other acute affections they are also occasionally ulcerated, — Cowan. Chap. 2.] HEART AND PERICARDIUM J CONSISTENCE, SlC. 49 CHAPTER II. ORGANS OF CIRCULATION. ARTICLE I. HEART AND PERICARDIUM. 61. Phthisis has been considered as one among the numerous causes of aneurism of the heart ; but this opinion does not appear to us to be supported by facts. In one hundred and twelve cases where death was caused by phthisis, we have only found three examples of an evident increase in the size of the heart. This increase was confined to the left ventricle, and might be estimated at one third or one fourth of the normal size of the organ ; none of the individuals who presented it had experienced aneurismal symptoms.* In the * The absence of symptoms when the aratomical characters of disease are present is not unfrequently the case with the heart ; and to prevent this being brought forward as an argument against the utility of pathological researches, it is only necessary to mention that the variations of size in this organ, when corresponding with the obstructed state of the functions it is destined to discharge, are rather elements of health (if we may so express ourselves) than of disease. Symptoms only appear when the harmony of organ and function is destroyed, either by the change in the former being prolonged beyond the necessity which produced it, or by some primitive aberration in the organ itself from its healthy state. Of course this remai-k only applies to increase or diminution of natural, and not of morbid struc- ture. — Cowan. 50 PATHOLOGICAL ANATOMY. HEART, &tC. [Parti, great majority of cases the heart was under its usual dimen- sions, being not more than one half or two thirds of its natural volume. This last fact is easily conceivable from the general emacia- tion and decrease of the fluids ; but we cannot apply the same reasoning to the dilatation of the cavities of the heart ; for the impeded state of the pulmonary circulation, to which it might be attributed, is gradually produced, and, consequently, being proportionate to the circulating fluid, on that account is not to be considered as a cause of dilatation. Let us add that, if this obstruction was to cause increase of the heart's volume, it would take place on the right side only, which is contrary to observation. 62. Diminution of the volume of the heart was evident in the great majority of instances, both in patients whose disease had progressed slowly, and in others where the fatal termina- tion was not protracted beyond a ïew months.* 63. The heart was in general of good consistence. We have, however, found it more or less flaccid and soft in about one fifth of the cases, and this diminished consistence was not proportionate either to the duration of the disease or the age * M. Broussais, to invalidate the author's conclusion relative to the state of the heart in phthisis, says that he has observed hypertrophy of the heart to be sometimes the cause of phthisis, and that it afterwards becomes atro- phied with the other organs. The proof of this would require numerous detailed facts j the mere assertion of what would be extremely difficult to substantiate is valueless. — (Examen, des. Doct. Med. vol. iv. page 338.) — Dr. Clarke, in his work on Climate, page 318, says, " In hereditary cases of phthisis, I think the powers of the heart are under the ordinary standard. A small, feeble heart 1 consider a strong predisposing cause of consumption." It will ever be thus with what we call facts in medicine, when assertions have no other basis than the impressions of unrecorded experience. — CowAN. Chap. 2.] CONSISTENCE ; hypertrophy, &z;c. 51 of the patient. At other times it was firmer than usual, which generally coincided with the hypertrophy of the parietes of one or other of its cavities. 64. This thickening was remarkably developed in seven cases ; six times in the left, and once only in the right ventri- cle ; inversely to what would be the case were an obstacle to the pulmonary circulation the cause of the phenomenon. In these different instances the cavity of the heart was diminish- ed, though the volume of the organ had not sensibly changed ; it was sometimes even less than natural ; and we might in that case admit that the apparent increase of thickness arose not from hypertrophy, but from the contraction of the parietes on themselves. We frequently observe the same fact in the intestines when they are contracted. 65. Diminished thickness of the ventricles was less fre- quent. We have only observed it twice on the right, and four times on the left side ; so that, under whatever point of view we consider the cavities of the heart, we find that those of the right side less frequently deviate from a healthy state than those of the left ; and all that we can possibly conclude respecting the influence of phthisis on the heart, is, that its volume is diminished in common with that of the other organs. 66. In no instance have we found organic alteration in either of the cavities of the heart ; by which we may infer that the mere activity of an organ is not sufficient to explain the more or less frequent alterations of tissue of which it is susceptible. 67. We have twice met with adhesion of the pericardium to the heart. In a third instance the membrane connecting them was a line in thickness, of moderate consistence, and enclosing in its substance a small quantity of clear fluid. The patient 52 PATHOLOGICAL ANATOMY. AORTA; [Parti, who presented this example of pericarditis (Obs. 19), expe- rienced great palpitations, and her pulse was extremely irreg- ular during the twenty-three days she was submitted to our observation. In a tenth part of the cases there was an effusion of five or six ounces of serum in the pericardium. HEART IN OTHER CHRONIC DISEASES. 68. At the termination of other chronic diseases the state of the heart was nearly the same as in phthisis. Out of eighty cases we found it larger than natural in five ; in nine, it was flaccid and soft ; in eight, the left veijiricle was hypertro- phied ; and in seven it was diminished in thickness, whilst the right ventricle presented only a single example of either of these deviations. Lastly, the volume of the heart was much less than natural in thirty cases, or nearly one third, a higher pro- portion than in phthisis. This difference is to be attributed to the presence of cancerous affections, especially of the stomach and uterus, in which the diminished volume of the heart was both more frequent and more strongly marked than in any other disease whatever. ARTICLE II. AORTA, 69. In the majority of instances it was healthy, and in one fourth of the cases more or less red, either partially, or over the whole of its extent. This redness penetrated to a varia- ble depth in the middle tunic, occupying the whole circum- ference of the vessel, whether it contained little or no blood ; so that we could not consider it the effect of imbibition. It Chap. 2.] ORGANIC DISEASES ; SIZE. 53 sometimes extended into the principal ramifications from the aorta, particularly into the carotids. With one exception it was confined to patients between the ages of twenty and thirty-two (Obs. 1, 19, 30, 40, he). 70. The organic alterations of the aorta ; the soft and yellow, or white and cartilaginous patches ; the ulcerations so frequently resulting from them ; and lastly, the osseous de- posits were rather less frequently observed than the redness ; they were only present in one sixth part of the cases only, either separately or combined, and in individuals from the age of thirty-five to seventy-five. In general they were more ad- vanced in their development, and occurred more frequently at the bifurcation of the aorta than at any other point. 71. In consequence of the diminished quantity of the circu- lating fluids, it was natural to suppose that the arterial system, especially the aorta, would present a less considerable volume in cases fatal from phthisis than from acute affections. This difference was actually found to exist, though less marked than we might at first have presumed. Thus, in twelve persons from twenty to thirty years old, who died of typhus, the aorta had for mean dimensions, counting respectively from the parts corresponding to the free edge of the sigmoid valves, from one inch below the origin of the left subclavian, one inch above the cseliac trunk, and at the point of bifurcation into the two iliacs, twenty-eight lines and nine tenths ; twenty lines and four tenths ; seventeen lines and nine tenths ; and thirteen lines and sixth tenths ; whilst in an equal number of phthisical patients of the same age and measured in a similar way, it was in the same points twenty-seven hnes and four tenths ; nineteen lines and three tenths ; sixteen lines and seven tenths ; and twelve lines and six tenths ; a difference, though certainly slight, yet, however, real and proportioned every where to the volume of 54 PATHOLOGICAL ANATOMY. AORTA ; [Part I, the artery ; so that where the dimensions were the smallest the difference was less than it was any where else, and was precisely one line.* We have instituted this comparison in subjects of the same age, because the aorta at different periods of life varies greatly in its dimensions. Thus, from the age of forty to fifty, it was thirty-four to thirty-five lines wide at the part corresponding to the free edges of the sigmoid valves, in cases fatal from acute diseases ; it was thirty-two lines wide in cases of phthisis, and only thirty in individuals of the same age who died from cancer ; these differences existed throughout the whole length of the artery, proportionately to its diameter, and the last fact merits particular attention, as it coincides with our previous remarks on the smallness of the heart in cancerous affections. AORTA IN OTHER CHRONIC DISEASES. 72. The lesions of the aorta, which we have just enume- rated, were present after other chronic diseases, but not in the same proportion. The redness existed in one eighth part of the cases, and the organic alterations in one half. This differ- ence might favor the supposition that there was some connexion between the different states of the aorta and the nature of the disease, but the consideration of the age explains all. In shoit, whether redness of the aorta was observed after phthisis * The inequality of the dimensions of the aorta in the portion comprised between the left subclavian and the caeliac trunk, proves that this artery is not composed of a succession of cylinders, hut that it is really cone shaped. We have established the same fact for the femoral, the primitive carotid, and some of the smaller vessels. — Louis. — A valuable memoir will ap- pear on this subject by M . Bizot, in the first volume of Memoirs of the Société Médicale d' Observation, to be published the ensuing winter. — Cowan. Chap. 2.] IN OTHEK CHRONIC DISEASES. 55 or any other chronic disease, it was always in individuals from twenty to thirty-five years of age ; and we must recol- lect that the majority of phthisical patients die in the earlier periods of life, while it is generally at a more advanced period that other chronic diseases are fatal. 73. The frequency of organic lesions of the aorta, contrasted with the great rarity of those of the heart,* confirms what we have previously mentioned, viz. (67), that this kind of alter- ation is not always in proportion to the activity of the func- tions of an organ ; for those of the aorta are almost wholly mechanical. ' 74. When the internal membrane of the aorta was red, it was not thickened ; but sometimes, in the points where this tint was deepest, we have found it less consistent and more easily separated from the middle coat than in a state of health. The latter, even when colored, offered no similar alteration ; and as redness (usually the only appreciable change of the in- ternal membrane), is not sufiîcient to characterise inflamma- tion, it seems more prudent, before coming to a decision, to await additional facts. M. Bertin, indeed, in his work on diseases of the heart, relates a case in which he found the in- ternal membrane of the aorta of a bright red, and lined by a coagulated membranous exudation ; or, in other terms, evidently inflamed. But the author has confined himself to the description of the redness, and has omitted to mention the consistence or thickness of the arterial coats ; so that his ob- servation, in other respects so interesting, cannot sanction any * In three hundred and fifty cases, fatal from a great variety of diseases, we have only found two instances of organic disease of the heart, and it con- sisted each time of a partial transformation of its tissue into cancerous matter. Loni3. S6 PATHOLOGICAL ANATOMY. AORTA. [Part I, general conclusion as to when the redness we are now con- sidering may be regarded as inflammatory.* With respect to the yellow or white and cartilaginous spots, &c., of which we have already spoken, their origin seems still more obscure. We only meet them after a certain period of life, (36 or 40), and they are then more or less frequent in almost every instance. From this it appears they are regu- lated by primitive laws, common to all, and the natural conse- quence of age. No symptoms disclose their existence, and we do not see on what foundation they can be regarded as inflam- matory products. To establish such a conclusion, it would be necessary, we think, to demonstrate that there is not, and could not be, any organic lesion independently of inflammation. * We would refer our readers to an able article by Laennec, page 644, on the redness of the lining membrane of the arteries; to Andral's (Clin. Med.) and to a memoir by M. M. Rigot and Trousseau, in the Archives Gen. de Med. vol. xii, and Gendrin. Hist. .ânat. des Injlam. vol. ii. page 9. There is every reason for supposing the phenomenon, when not attend- ed by other changes, to be the result of imbibition. The state of the blood at the moment of death, the temperature and the free or embarrassed state of the respiratory functions, seem among the most active causes of the appearance in question. By Bouillaud, (Die. de Med. Prat. vol. iii.) Berlin, Kreysig and Frank, it has given rise to a theory ofjever, which, with the former at least, is a kind of arteritis. The various opinions enter- tained on this question affords a striking illustration of the pliability ot facts, when arrayed in support of some favorite doctrine. M. Louis (Vide Ex- amen, page 5,) has since concluded from the analysis of a great number of fatal cases from a variety of acute affections, that the redness of the aorta is a special phenomenon of imbibition, depending on an alteration of the blood, — of the arterial tissue, or both, in certain cases. — Cowan. — See Louis on Fever, vol. i. page 291 to 294. — H. L B. Chap. 3.j PHARYNX AND (ESOPHAGUS. 57 CHAPTER III. DIGESTIVE ORGANS. ARTICLE I. PHARYNX AND ŒSOPHAGUS. 75. They were almost constantly healthy. In eighty cases the only alterations we have observed in the pharynx v/ere ulcerations in two instances. These were small, numerous, and nearly uniformly distributed over the whole of the mucous membrane, which was slightly thickened in the intervening portions (Obs. 13, 29). 76. In two other examples we have found ulcerations in the œsophagus. In one of these but a single ulceration, five lines broad and situated in the central part of the organ, could be observed. It was lined by an extremely thin layer of cel- lular tissue, and round its edge the mucous membrane was thickened and detached with the subjacent layer over a space of two lines. In the other instance, there were numerous minute, superficial ulcerations, as if artificially produced (Obs. 34). 77. We have frequently seen the internal surface of the œsophagus lined by a kind of broken up false membrane, very much resembling those apthous exudations so frequent in the H 5S PATHOLOGICAL ANATOMY. PHARYNX, &C. [Part I, interior of the mouth, and of which we shall hereafter speak (354). Here the epithelium had disappeared ; but the mucous membrane presented no alteration in color, consistence, or thickness (Obs. 30). 78. The lower portion of the oesophagus was in three cases softer and thinner than usual ; this lesion equally extending to all the membranes, and also existing in the stomach. 79. We have never detected any symptom which could be referred either to the ulcerations of the pharynx, to those of the œsophagus, or the diminished thickness of the lower por- tion of the latter. The same observation may be made in regard to the soft, pultaceous membrane already mentioned, unless, indeed, it can be considered as the cause of the dys- phagia which existed in one instance for a considerable time (Obs. 30). PHARYNX AND ŒSOPHAGUS IN OTHER CHRONIC DISEASES. 80. In the post mortems of individuals who died of many other chronic affections, there were neither ulcerations nor thin- ning of the pharynx or oesophagus. In cases fatal from acute diseases we have never found ulcerations of the mucous mem- brane of the latter, except in typhus ^ever.* The species of detritus or of false membrane, of which we have spoken, was present more or less frequently after all chronic affec- tions. * See Louis on Fever, vol. i. pages 150 and 15L — H. I. B. Chap. 3.] STOMACH IN OTHER CHRONIC DISEASES. 59 ARTICLE IT, STOMACH, Sec. 1. — Volume and Situation of the Stomach. 81. In both these respects the changes were sometimes remarkable. Out of ninety-six observations, when they were carefully noted, in nine the stomach was twice or three times its natural volume, and situated lower in the abdomen than is usual. In six of these cases its great curve was on a level with the iliac crest (Obs. 18, 19). In the other three it de- scended only a little below the umbilicus. In all, the liver was voluminous, overlapping more or less the anterior surface of the stomach. STOMACH IN OTHER CHRONIC DISEASES, 82. This considerable displacement and increased volume of the stomach, are, if we may so express ourselves, peculiar to phthisis. They are very rarely observed in cases fatal from other affections, which may lead us to presume that they are for the most part to be considered as the consequence of re- peated shocks caused by the cough.* Out of two hundred * The effect of cough on the dilatation of the stomach may certainly be questioned, both from the physical laws which regulate the abdominal cavity, and the fact that in phthisis the cough is not so violent or so chronic as that accompanying some other thoracic affections. In one remarkable instance in the wards of M. Piorry, at La Pitié, the stomach descended nearly to the pubis (which was ascertained by percussion and change of position after the patient had taken a large quantity of fluid), and here there were no symptoms of thoracic disease. — Cowav. 60 PATHOLOGICAL ANATOMY. - — SÏOMACH ; [Part I, and thirty cases of various chronic and acute diseases we have only seen it in two instances. One was a case of diseased heart, — the other caries of the vertebrae. In both the great curvature of the stomach descended as low as the superior iliac spine and the liver was also of large size and low down 5 so that whenever we have encountered this combination there was a constant relation between the liver and stomach. 83. The alterations of the latter were principally in the mucous membrane. This was both thinned and softened, sometimes even destroyed ; in other cases it was more or less rddj and occasionally thickened on its anterior surface ; while again in others the redness, accompanied by very marked softening, existed only in the great cul-de-sac. Ulcerations were sometimes found ; but more frequently there was a re- markable mamillated* appearance of the mucous membrane. We shall now successively describe these alterations. Sec. 2. — Softening with diminished thickness of the Mucous Membrane of the Stomach. 84. This condition of the mucous membrane, which we have already described,! was present in about one fifth of the * What this term includes will be seen by reference to paragraph 94. — ■ Louis. — It corresponds to niarneloriated in the translation of the work on Fever. — H. I. B. t Vide Louis sur Diverses Maladies, Paris, 1826. The memoir referred to is founded on four hundred and fifty post mortems of patients in the warda of M. Chorael ; the morbid alteration forming the subject of this section waa present in one twelfth of the cases taken indiscriminately. This result was confirmed by subsequent facts. " In two hundred cases fatal from chronic diseases, thirty-three presented the lesion in question; twenty-one were women, twelve men. Out of one4iundred and fifteen cases of acute affec.* lions, this condition of tho stomach existed in twelve. In one sixth of the Chap. 3.] SOFTENED, THINNED, PERfORATÉDé Gl cases, or nineteen times out of ninety-six. It was most fre- quently observed in the upper part, and especially in the great cul-de-sac of the stomach. It very frequently extended over half of the mucous membrane, or still farther, while it was occasionally bounded to an extent not exceeding eight or ten square inches (Obs. 1, 3, 4, 7, 26, 27, 32, 35, 39). 85. The affected portions had a pearly or slightly yellow aspect, were destitute of mucus, and remarkable for the great number of large and usually empty vessels, which were chronic cases it was not indicated during life by any symptoms. The alter- ation was always more frequent in women than in men, which seems to prove that the influence of strong, stimulating drinks is not the most usual or energetic cause of serious lesions of the gastric mucous membrane. This idea is strengthened by the examination of facts where corrosive substances have been swallowed, but not in sufficient quantity to cause death. Though oc- casioning the most violent symptoms, the functions of the stomach are per- fectly re-established after a few days. Nearly all the facts in Orfila's Tox' itology may be cited in proof of this ; two hundred patients in the venereal hospital of Paris, were poisoned by an accidental overdose of corrosive sub- limate, of which the minimum was ij. to iij. gr. Atrocious epigastric pains, vomitings and constriction of the throat followed ; but all got well after a few hours by the use of emollient albuminous drinks. In ten or twelve there were slight epigastric pains during a fortnight. Not one was attacked with acute or chronic gastritis of any duration. May we not conclude that the apparent causes of gastritis are only secondary, and that this disease re- quires a very marked predisposition F" Are not the results of stimulants on the stomach often exaggerated ? " Is there not a marked difference between a gastritis from an external and an internal cause ?" Authors do not appear to have sufficiently insisted upon this point, and to our own mind it is at once a quietus to many favorite theories on gastritic inflammation, and a strong reason for considering as merely accidental complications, many local changes which have been frequently regarded as the cause of the gen- eral symptoms instead of as one of their effects. This is, however, not the place for extending our remarks on this subject; we may observe that in the above cases the results of M. Louis as to the correspondence between the tongue and the stomach, mentioned in anotlier part of this work, were fully confirmed. — Cowan. fâ PATHOLOGICAL ANATOMY. STOMACH ; [Part I, occasionally filled by a darkish colored blood. They were flattened, and the mucous membrane was more or less raised about their edges. These peculiarities were obvious, and at once indicated the seat of the morbid alteration we are now considering. In these points the mucous membrane was pale, semi-transparent, sometimes greyish, or of a dull red color. It was extremely softened ; often not firmer than moderately viscous mucus. Its thickness was nearly that of the mucous membrane of the small intestines ; in some cases it was en- tirely destroyed over a certain space. In many cases, near parts which were thinned and softened, there were others which were rather soft than thin, and vice versa. A compar- ative section of the diseased and healthy portions proved the great relative difference of thickness. 86. Instead of constantly occupying a continuous surface, the alterations we are considering sometimes assumed the form of bands, but in this case the deviation from the healthy state was commonly not so strongly marked. These bands were from two to three inches long, of the same and sometimes a greater number of lines in breadth, and were approximated to each other, the intermediate mucous membrane retaining its natural thickness. 87. The cellular tissue under the mucous membrane, which was diseased, was usually sound. In four instances only it was completely softened, yielding to the slightest force, and both the muscular and peritoneal coats were similarly affected in the corresponding points. Thus, we have frequently found the stomach perforated, notwithstanding our employing the greatest precaution when detaching it from the neighboring parts ; while the absence of all effusion into the peritoneum proved that the perforation could not have existed during life (Obs. 7, 32). Chap. 3.] MAMILLATED. 63 88. In the majority of instances the mucous membrane ad- joining the softened part was mamillated, of a red or greyish color, over a considerable extent (Obs. 1, 4, 35), occasionally thickened or ulcerated ; and sometimes, though very rarely, the thinned and softened portion was continuous with another equally thin, but of a bright red color, and becoming gradually thicker (Obs. 39). 89. When there were redness, thickening, and sometimes softening of the mucous membrane, the existence of inflam- mation was evident. The mamillated state, united to a grey- ish color and ulcerations, indicated, as we shall hereafter see (94), a similar lesion, so that in more than one half of the cases, the thinned, softened, and pale mucous membrane was continuous with a part evidently inflamed. From this it is natural to suppose that softening and diminished consistence are among the effects of inflammation ; and what renders this conclusion still more probable is, that when these were alone present, the symptoms observed were those of gastritis. Di- minished thickness and paleness of the mucous membrane are not opposed to the idea of inflammation, for we daily see, after the application of a blister, and frequently but for a short time only, the skin become thin and completely destroyed, and we might expect paleness to accompany approaching de- struction.* We have more frequently remarked this state of the stomach in women than in men (in the proportion of twelve to seven), which seems to indicate that the most cora- * It is rather amusing to find M. Broussais admitting that in this section the author is " de bonne foi," because he does not hesitate to explain these organic lesions by inflammation : that is, whenever he agrees with M. Broussais, he is right, when he differs, he is wrong. This is, throughout, the spirit of M. Broussais's strictures. — Vide Examen, vol. iv. page 339. — Cowan. 64 PATHOLOGICAL ANATOMY. STOMACH ; [Part I, mon exciting causes are not excesses in eating, women being less addicted to them than men.* Sec. 3. — Redness combined with thickening, with a mamillated state or softening of the Mucous Membrane, and occurring in the anterior portion of the Stomach. 90. In eight cases out of ninety-six we have found this species of alteration. The mucous membrane was sometimes smooth, sometimes uneven and mamillated (mamelonnée), and almost constantly covered by a very copious and tenacious mucus, which was here always more viscous and abun- dant than in any other part. In some instances, the con- sistence of the mucous membrane was diminished and its thickness greater than natural. In one of these, the red and thickened part was lined by a soft, yellowish false membrane, not extending beyond the part affected. This modification, evidently inflammatory, existed in individuals of different ages, and the duration of whose disease had varied from three to five years ; it was also much more frequent in women than in men, in the proportion of seven to one (Obs. 10, 18, 29). In the rest of its extent the mucous membrane approximated more or less closely to a healthy state. 91. The situation and volume of the stomach had under- gone some remarkable changes ; its dimensions were very * The author's subsequent experience as to the softened and thinned state of the gastric mucous membrane, (Vide Affect. TypliOide, vol i. page 183, Paris edition, and Translation, page 161, and A-ppendix), incHnes still more to the belief, that in some instances it is not depending on inflammation ; this supposition is founded upon the facts, that around tlie softened parts there are no traces of innammalion, and the submucous layer is equally softened and destitute of all inflainrnatory appearances. He thinks, after the researches of Dr. Carswcll on this subject, that it is doubtful how far chemi- cal changes may take place in this membrane during life. — Cov/an. Chap. 3.] REDNESS WITH SOFTENING. 65 considerable, extending in four cases to the iliac crest, while in others it was enlarged in size without so marked a change of situation. In all, it was covered to a considerable extent by the liver, which was either larger than natural or else descending below its usual limits ; so that we must almost necessarily ad- mit that the liver exercises a certain influence over the inflam- mation of the mucous membrane of the stomach when limited to its anterior surface.* Having once admitted this influence, it would be easy to understand why women, who are subject to enlargement of the liver so much more frequently than men, should be proportionably liable to this particular form of inflammation. When we come to the description of the symptoms, we shall find that in many patients the origin of the affection might be dated one, two, or even three months before death ; that is, at a period less remote than in the previous case (328). Sec, 4. — Redness with softening of the Mucous Membrane lining the great Cul-de-sac of the Stomach. 92. This alteration was present in seventeen out of the nine- ty-six cases we are analysing. The mucous membrane affected by it was usually of a dull red color, sometimes a little thicken- ed, and so soft that it would not bear removal in strips of even the smallest dimensions (Obs. 14, 15, 19). Though rarely confined to the neighborhood of the cardiac orifice, the softening generally extended either over the whole or a considerable * This conclusion of our author is the reverse of M. Broussais's. Let the reader impartially compare the state of the mucous membranes and that of the glands attached to them, and he must admit that the axioms of this pathologist are far from being proved. — Cowan. I 66 PATHOLOGICAL ANATOMY. STOMACH ; [Part I, part of the great cul-de-sac. The remainder of the membrane was either healthy, or with an uneven, mamillated appearance and of a greyish or pink color. There were occasionally small ulcerations on it. 93. This morbid condition of the stomach was very rarely accompanied by characteristic symptoms, but it was of too definite a character to admit of any doubt as to its nature. For intense redness combined with softening and sometimes in- creased thickness, could only be the result of inflammation ; and the absence of symptoms in the majority of instances would favor the idea that this inflammation was developed towards the close of life, as it is often the case with that of the pulmonary parenchyma and pleurae. Doubtless, and we shall have occasion to repeat the remark, weakness does not pre- vent the manifestation of the majority of the pathognomonic symptoms, but it sometimes modifies their expression and de- creases their number.* Thus the pain which accompanies softening and diminished thickness of the mucous membrane of the stomach sometimes disappears several days before death ; also pneumonia occurring in the last periods of phthisis is seldom accompanied by the yellow, rust-colored, viscous, semi-transparent expectoration ; and frequently it is quite * The author might here have remarked that weakness was only one of the causes by which the absence or imperfect manifestation of symptoms might be explained, — the presence of another disease is an important con- sideration, especially in those cases where its irradiated influence through the system causes extensive disturbance of all the functions. The instances are numerous where fatal disorganization has taken place almost unknown and unsuspected, while all the prominent symptoms have directed the atten- tion to some other affection. Cerebral and enteritic diseases may be cited as examples. The absence of symptoms in this particular condition of the stomach depends no doubt in a great measure on the anterior surface being alone affected. — Cowan. Chap. 3.] MAMILLATED STATE OF MUCOUS MEMBRANE. 67 latent. We might make the same remark in regard to pleu- risy. Now what takes place in inflammation of the substance of the lung and pleurae may and would naturally happen in that of the mucous membrane of the stomach ; an additional motive for considering the morbid alteration we have been de- scribing as resulting from an inflammation developed but a short time before death. Surely no one will look upon this redness and softening as a mere post mortem phenomenon ; for the stagnation of blood does not produce softening of our tissues, and we cannot suppose an identical morbid change to arise from two causes so wholly different from each other,* Sec . 5, — The mamillated appearance and greyish color of the Mucous Membrane of the Stomach. 94. We have observed this appearance eighteen times, un- accompanied by the alterations we have just described ; the mucous membrane, instead of its natural, uniform and velvet- like surface, presented prominences of different forms and dimensions, generally rounded, from one to two lines in diam- eter, resembling the fleshy granulations of wounds, and occa- sionally separated by deep fissures of variable length, and a line or rather less in breadth. It was almost always of a grey- ish color, which was frequently mingled with a pale red tint. In some instances we have found it firmer and thicker than natural. It sometimes presented a few small ulcerations, which did not always involve complete destruction of the membrane. * We have already expressed our opinion on the force of this reasoning. Softening may undoubtedly take place under both these conditions. — Cowan. — Softening undoubtedly sometimes comes on after death, but then it is not caused by stagnation of the blood, but by the gastric juice. And I doubt whether even Carswell thinks that redness with softening comes on after death. — H. I. B. 68 PATHOLOGICAL ANATOMY. STOMACH ; [Part I, 95. This mamillated aspect existed in very opposite con- ditions whether the stomach was contracted or not. On this account it could not be attributed to mechanical causes, and recollecting the diminished thickness of the membrane forming the furrows of which we have spoken, its ulcerations, its oc- casional partial thickening and almost constantly altered color, we cannot but consider it as a pathological effect. A similar state of things, to which we may also add the mamillated ap- pearance, existing in cases where there is evident inflammation of the mucous membrane of the stomach, (as for instance when the anterior surface is alone affected) seems to indicate the inflammatory origin of the alteration we are describing ; and, doubtless, judging from the absence or indistinctness of the symptoms (339) and from the greyish color of the membrane so frequent in chronic inflammation and round intestinal ulcer- ations, we may conclude its progress to have been slow. Sec. 6. — Ulcerations of the Mucous Membrane of the Stomach. 96. We have remarked them in a twelfth part of the cases ; they were generally small, few in number, and accompanied with some other morbid state of the raucous membrane ; twice only there was absence of all complication. In one of these a siniile ulceration existed of two inches and a half of surface (Obs. 38). In the other the ulcerations were small, but eighty in number (Obs. 20). In all, with one exception, the mucous membrane retained immediately around the ulcera- tions the same thickness, consistence and color which it pre- sented elsewhere, so that they gave the impression of artificial formation. The exception mentioned, occurred in an indi- vidual who had, near the pylorus, an ulceration with everted Chap. 3.J ULCEBATioNS ; other morbid changes. 69 edges, formed by the red, soft, and thickened mucous mem- brane, the subjacent layers beuig sound. The submucous tissue, which formed the bottom of the ulcerations, was occasionally thickened ; but it was only in the instance where one large ulceration existed, that it was par- tially destroyed. When the ulcerations were unaccompanied by any other morbid change of the mucous membrane, we may conclude, from the history of the symptoms, that they dated from a period considerably anterior to the death of the patient (336). Sec. 7. — Some other Morbid Changes of the Gastric Mucous Membrane. 97. In six cases, where there was no alteration of consist- ence or thickness, it was more or less red throughout its whole extent. This redness disappeared after two or three hours of maceration. In many instances, symptoms of gastritis came on two or three days before death (Obs. 2) ; rendering it pro- bable that this state of the membrane was produced by recent and slight inflammation. 98. We have four times seen the mucous membrane ex- tremely softened in the greater part of the superior extremity of the stomach, without any alteration of color and consistence, or any evident symptoms of gastritis. 99. In one patient who died on the day of his arrival at the hospital, the mucous membrane presented seven large elevations, nearly equally dispersed over its surface, from two to three lines wide and two lines high. Adjoining them the membrane was slightly red, of good consistence, and about one line thick. One inch below the cardiac orifice the mem- brane was slightly prominent and raised for about an inch in extent by a bluish white fluid, rather viscous, very imperfectly 70 PATHOLOGICAL ANATOMY. STOMACH ; [Part 1, soluble in water, and contained in a number of small cells de- veloped in the submucous tissue. 100. Lastly, of two phthisical patients, we have found in one a kind of cicatrization of the mucous membrane of the stomach ; in the other, the transformation of a small portion of the muscular tunic into a cartilaginous structure ; a very rare alteration, and which we shall carefully describe when treating of the symptoms (Obs. 21, 22). On summing up what has preceded, we have found in ninety-six cases, where we have attentively examined and de- scribed the mucous membrane of the stomach, that it was Thinned and softened, . . . .19 times. Red and occasionally thickened, mamillated or softened on its anterior surface, . . 8 " Softened, and of a dull red color in the great cul-de-sac, . . . . . 17 " Mamillated, of a greyish color, sometimes red- dish, thickened, Stc, . . . . 19 " Ulcerated, without other morbid change, . 2 " Softened, but of natural color and consistence, 4 " Of a variably intense red color throughout its whole surface, with normal thickness and consistence, . . . . . . 6 " Raised up by a viscous fluid, &,c., . . 1 " Apparently cicatrized, . . . . 1 " Total, 77 This result is equivalent to saying that the mucous mem- brane was only in a state approaching to perfect health, nine- teen times ; or in a fifth part of the cases.* ■* Ândral says in two fifths. — Cowan. Chap. 3.] IN OTHER CHRONIC DISEASES. 71 IN PATIENTS WHO DIED OF OTHER CHRONIC DISEASES. 101. The morbid changes we have just described are not peculiar to phthisis ; we have seen them resulting from other chronic diseases, but in different proportion. In ninety-four individuals who died from various chronic affections, the mu- cous membrane of the stomach was Thinned and softened, .... 6 times, Red, and with slightly marked inequalities on its anterior surface, . . . . 2 " Softened, and of a dull brown in the great cul- de-sac, . . . . . . 6 " Variably red over its whole extent, but not softened, 18 " Mamillated, greyish, sometimes thickened or ulcerated, . . . . . . 16 " Total, 48 That is, it was more or less affected in one half, whilst in phthisis this took place in four fifths. It may also be no- ticed, that while in phthisical patients the most considerable morbid change, viz., softening, with diminished consistence, and sometimes destruction of the mucous membrane, was one of the most frequent, the contrary was the case in those who died from other diseases ; so that it follows, from this comparison of facts, that phthisis is a predisposing cause to inflammation of the mucous membrane of the stomach, and that in its most intense forms. 72 PATHOLOGICAL ANATOMY. DUODENUM. [Part 1, ARTICLE III, DUODENUM. 102. It seldom deviated from a state of health. Its mu- cous membrane was sometimes of a rose color ; it occasionally- presented a greyish tint, owing to an infinitude of small, black points, thickly dispersed over its surface. The mucous fol- licles were frequently very apparent, doubled or tripled in volume, but not altered in their structure. In three cases out of sixty, ulcerations were present. They were from a line to a line and half in breadth, and in two of the cases of a pale color, and from three to ten in number (Obs. 9). In the third instance, some of them were from two to four lines wide ; their bottom blackish, and formed, as in the preceding cases, by the slightly thickened submucous cellular tissue. The mucous membrane around them presented nothing worth noticing. In both cases, where the ulcerations were very small, there were some not less minute cysts in the liver, containing a greenish and pulpy substance ; but no connexion could be traced between the grey and pink color of the duodenal mu- cous membrane, the enlargement of the mucous follicles, and the fatty degeneration of the liver.* * This result of our author's observations calls forth the ire of M. Brous- sais, who suddenly ceases liis commendations of M. Louis's accuracy, by calling in question his veracity. — (Examen, page 341). Leaving, how- ever, M. Broussais, we would remark, that the relative state of the liver and duodenum ought not to be overlooked, Laennec says, (page 288), " I have seen but a few well marked instances of inflammation of this intestine ; I have frequently found the duodenum very red when the liver was sound, Chap. 3.] SMALL INTESTINE ; ITS HEALTHY STRUCTURE. 73 Once only have we found a fibrous tumor similar to those of the uterus, and of the size of a hazel-nut, in the muscular coat of the duodenum. IN PATIENTS WHO DIED OF OTHER CHRONIC DISEASES. Examined after other chronic affections, the condition of this intestine was nearly the same as after phthisis ; out of sixty-five cases, we have observed but one of ulceration. ARTICLE IV. SMALL INTESTINE.* 103. Before describing the different lesions of the small intestine, we think it useful to fix the attention for a moment on its mucous membrane, and to point out a peculiarity of structure generally overlooked, but which is always present in a state of health. and the fatty disorganization of the latter present, when the duodenum was pale." We are, however, quite aware that this evidence will avail little with certain individuals, who say that if we cannot discover inflammation (where it ought to have existed, according to their laws), that it was there, but has disappeared. Matter of fact people do not pretend to such divina- tion. — Cowan, * There is a close analogy between many of the remarks made in this article and those of M. Billard, in his work On the Gastro-intestinal Mu- cous Membrane. Without attaching undue importance to this portion of our undertaking, which is, in part, a mere confirmation of what is already known, we will mention that our results had been submitted to M. Chomel several months previous to the publication of the above work ; and instead of compressing part of our remarks, we have purposely left them unaltered, as an additional proof that accurate observation necessarily leads to the same results. — Louis. 74 PATHOLOGICAL ANATOMY, SMALL INTESTINE ; [Part I, Sec. 1. — Of the Mucous Membrane of the Small Intestine in its healthy- state. 104. In this condition the parietes of this intestine are very thin, semi-transparent : allowing us, when suspending them over the extremities of the fingers, to detect the small ine- qualities on the skin. However, in this inconsiderable thickness are comprised the mucous, muscular and peritoneal coats, united by a small quantity of cellular tissue. Whenever either of these layers is in any way altered, the semi-transparency disappears. The mucous membrane is naturally rather thicker in the jejunum than in the ileum, where it may be compared in this respect to a sheet of blotting paper. 105. If we slightly detach it with the scalpel, after making an incision,* and then seize it with the extremity of the fingers or forceps, we can tear off fragments from five to ten lines long. This experiment is sufficient to indicate the natural firmness of the mucous membrane ; and whenever similar fragments cannot be obtained with the same precautions, we may consider it as deviating more or less from the healthy state. 106. The uniform structure of this membrane is interrupted at unequal distances, by oval patches of very variable dimen- sions. They may be observed in the three lower fourths, and sometimes throughout the w'hole of the intestine. From twenty to thirty, and occasionally more, may be counted. Situated on the side of the intestine, opposite to tl)e mesen- tery, they are from one to four inches in length, by eight or *This mode of raising a strip of mucous membrane is very faulty, and not pursued by Louis at present. See Appendix to Translation of Fièvre Ty- phoïde, vol. i. page 389. — H. I. B. Chap. 3.] ITS HEALTHY STRUCTURE. 75 ten lines wide, gradually increasing in number and size as they approach the céecum ; they are very slightly elevated, though sensible both to the sight and touch, and have two, three, or four times the thickness of the surrounding mucous membrane. They are completely opaque, of a white or greyish color, and are sometimes studded with small blue points. They do not offer the villous surface of the rest of the intes- tine, but present a great number of white or yellowish granu- lations, smaller than millet-seeds. After detaching these glandular patches v/ith the precautions already described, the granulations are equally visible on their adherent surface ; and on regarding them between the light and the eye, their inter- stices appear thin and semi-transparent, very similar to the other portions of the mucous<^membrane. 107. This structure, which is not always easily demonstra- ble, in certain pathological states of the membrane becomes most distinct ; as, for instance, when it assumes a deep red color, in consequence of an affection of the heart. Then, in- deed, the granulated looking bodies already described retain their naturally white and yellowish color, and, contrasted with the red and injected state of their interstices, are most dis- tinctly visible : then the patches assume their true appearance, viz., that of a collection of small bodies, no doubt glandular, in the substance of the mucous membrane. 108. The blue-colored spots so frequently observed upon the patches are the orifices of the glandular granulations. At least, judging from what takes place in certain pathological casf^s, this appears highly probable, for when these bodies are greatly developed, the blue points are replaced by distinct openings, nearly equalling in size the natural volume of the gland itself. 109. The general appearance of these patches is subject to variation, from differences in the arrangement of the crypts. 76 PATHOLOGICAL ANATOMY. SMALL INTESTINE ; [Part I, If these are confluent, the interstices on which their distinct- ness depended become obUterated ; but the patches are not, on this account, less easily recognised, their color, opacity and elevation distinguishing them from the surrounding mucous membrane. 110. They differ also in the ileum and jejunum, where they interrupt the valvulae conniventes, and have themselves a depressed appearance, from the contrasted elevation of the valves ; they have an areolated surface, and present nearly the aspect of a piece of lace which has been mended. But since in the ileum they are white or greyish, opaque, and less inter- rupted by the valves, they are, on the whole, more easily distinguished in the upper than the lower portion of the intes- tine. The areolated structure mentioned above is rarely ob- served in the ileum. 111. The whitish-colored, isolated granulations, almost con- stantly seen near the termination of the ileum, underneath the mucous membrane, are liable to the same morbid changes as the patches, depending upon similar circumstances for their greater or less distinctness ; their glandular nature is equally probable. 1 12. Although the dimensions of the patches increase as they approach the cœcum, it is not uncommon to find smaller ones interspersed with the larger. Their form, when this is the case, is more circular than oval. Near the caecum they are very numerous, and frequently occupy the whole circum- ference of the intestine. 113. They are only partially affected by the pathological State of the mucous membrane which surrounds them.* We * At this assertion of what facts have denionstrated, M. Broussais makes the following energetic appeal in behalf of his infringed laws. " It is im- Chap. 3.] ITS HEALTHY STRUCTURE. 77 have already remarked, that where it was intensely red in consequence of disease of the heart, the color of the glands was natural. When it was thickened, no change took place in the dimensions of the patches, and their elevated appear- ance had either diminished or disappeared. In certain cases, as in typhus fever, for example, in which the mucous mem- brane was frequently healthy, that covering the patches was greatly thickened ; the glands were enlarged and the orifices open. At first their structure was rendered more distinct ; the}'- soon, however, gradually softened, and while the sub- jacent cellular tissue daily increased in thickness, they ulcer- ated, and were at last completely destroyed. We can now understand why the ulcerations in typhus fever are oval or elliptical in their form ; why they are found in the part of the intestine opposite to the mesentery, and why they almost in- variably exist in the lower portion of the ileum. These patches are also most frequently the seat of ulcerations in phthisis.* They are often exclusively so, the mucous mem- brane around them remaining perfectly healthy. Lastly, it is possible not to despise the author's (M. Louis's) prejudice (prevention), since it has been verified by many, and also by ourselves, during twenty- seven years, that the inflammation of the mucous membrane of the small intestine includes the inflammatory turgescence, alteration and disorganiza- tion of the follicles !" (Examen. Jifed. page 341). It is most unfortunate iYi&t facts thus foster error. But they are indeed " stubborn things ;" and, for ourselves, we confess that three years and a half of unbiassed and re- corded observation have more value than twenty-seven years under oppo- site circumstances. — Cowan. * The ulcerations of the agminated glands, in cases of continued fever and phthisis, may, we think, almost decide the question, whether they are mere consequences or causes of the peculiar symptoms of the former ? — Cowan. 78 PATHOLOGICAL ANATOMY. SMALL INTESTINE ; [Part I, in their centre that the perforations of the small intestines in acute diseases take place.* Sec. 2. — Pathology of the Small Intestine. 114. The lesions were numerous; consisting of softening, thickening, redness of the mucous membrane, small submucous * Vide Mémoire sur la Perforation de l'Intestin Grêle, — Recherches sur Diverses Maladies, page 106, also Typhus Fever, vol. il. chapter on Per- foration of the Small Intestine. Though the perforation of the small in- testine, since our author's researches, has attracted very general attention, and has been specially studied by Messrs. Stokes and Graves, of Dublin, a summary of M. Louis's results may not be unacceptable to the reader. He thinks that we may regard the perforation of the small intestine as certain, when in the course of an acute disease, and under unexpected cir- cumstances, the patient is attacked with a sudden and violent pain in the abdomen, which is increased by pressure, accompanied by a great change in the appearance of the patient, and succeeded by nausea and vomiting. He insists strongly on the aggravation of the pain by pressure, and its rapid extension over the abdomen, as means of diagnosis. We conclude that per- foration has taken place in the small intestine rather than in any other por- tion of the digestive tube, because in acute diseases the former is incompar- ably the most frequent. In one hundred and fifty cases of phthisis it only occurred once. In one hundred and sixty cases of other chronic diseases, two instances were observed. In some rare examples the symptoms are wanting, when the diagnosis is of course impossible. Perforations are, per- haps, more frequent than we generally suppose. Out of four hundred and fifty post mortems there were twenty-two cases of perforation ; nine of the small intestine; eight of the lungs; two of aneurismal tumors; one of an abdominal cyst; one of an hepatic abscess. The examples of perforated stomach in chronic gastritis are numerous. Vide Dr. Abercrombie on Ab' dominai Affections. Dr. Stokes, of Dublin has pi'oposed a mode of treatment in cases of per- foration, and in many other circumstances where there is rapid prostration of the vital powers, consisting in large and fi-equcntly repeated doses of opium ; the evidence adduced in its favor strongly entitle it to the practition- er's attention. Vide Dublin and Medical Journal, May, 1832. No. 2. — Cowan. Chap. 3.] SOFTENING ; granulations. 79 abscesses, semi-cartilaginous or tuberculous granulations and ulcerations. 115. The softening of the mucous membrane was not more common in phthisis than in other chronic diseases. Out of ninety-five cases, we have only met it eight times, and in three of these it was inconsiderable. In five others, the membrane was reduced to the consistence of mucus. — (Obs. 22, 32.) In all of these the softening occupied the whole of the intestine. In three cases it was associated with consider- able thickening and redness ; most evidently in these circum- stances resulting from inflammation. In a fourth, there was thickening without redness. We have only once found it evidently thickened, where it was neither red nor softened (Obs. 19). In thirteen cases it was more or less red, while no alteration of consistence or thickness was observable (Obs. 28, 39). Among five of these the redness was universal ; while in others it was confined to a limited portion ; usually the last two feet (Obs. 41, 47). The mesenteric vessels were never loaded with blood ; so that the redness probably most frequently depended on some other cause than simple con- gestion.* 116. The granulations were, as we have before remarked, of two kinds. They sometimes presented all the characters of tuberculous matter ; in others they were much harder and whiter, offering almost the firmness and aspect of cartilage. The volume of both was inconsiderable ; on the average that of a middle-sized pea, but most frequently smaller : they were * Laennec, (page 288), says the mucous membrane near ulcers is gen- erally pale. Andral {Clin. Med. vol. iii. page 306) has found it pale in about one fifth of all his cases. — Cowan. 80 PATHOLOGICAL ANATOMY. SMALL INTESTINE ; [Part I, developed beneath the mucous membrane, and almost invaria- bly accompanied by ulceration. The semi-cartilaginous gran- ulations (Obs. 13, 29, 35), were in general much more numerous than the others ; sometimes they were dispersed through the whole of the intestine, with intervals varying from one to three inches. When thus universally present, they increased in number and size as they approached the caecum. At other times they were much more numerous near the duo- denum and in the upper third of the intestine than in that im- mediately succeeding, and they were wanting in the latter. When small they had scarcely the volume of a small pin's head, were slightly adherent to the cellular layer, and the mucous membrane surrounding them was perfectly healthy. When about the size of a pea, the membrane was generally more or less red, thickened and softened, or even destroyed, at the point of contact. The granulations themselves then began to decrease in size, and the loss of substance continued until their complete destruction, leaving the edges of the ulcer- ation indurated, white and opaque ; retaining almost exactly the characters of the tumor to which they succeeded : thus pointing out the nature of their cause. The semi-cartila- ginous granulations were sometimes seated upon the patches, but more frequently in their intervals. They were equally distributed over the circumference of the intestine. We have only remarked them immediately underneath the mucous membrane ; they never occupied the interstices of the mus- cular fibres, which induces us to think that they are simply the morbid development of the muciparous glands, as the situation of the latter completely coincides with those just described. ] 17. We have never found tuberculous granulations equal- ly numerous with those just described when they existed in Chap. 3.] ULCERATIONS. 81 large quantities. These were also situated either round the ulcerations, in their centre, or in the interstices of the muscular fibres ; between these and the peritoneum ;* upon patches, or in their intervals ; and were almost constantly more numer- ous near the csecum than elsewhere (Obs. 6, 8, 12, 15, 21, 27, he). We have never found them near the duode- num. These granulations were succeeded by small ulcerations, produced by the same process as are tuberculous excavations of the lungs. The tuberculous matter gradually softened, and the mucous membrane was proportionably red, thickened and softened in the corresponding point ; or it was destroyed, and the contents of the abscess were emptied on the intestinal surface, so that inflammation of the mucous membrane was here an effect and not a cause of tubercles. 118. We have never seen tuberculous matter occupying the intestinal mucous membrane under any other form than that of granulations. 119. Either separately or conjoined, these two species of granulations existed in thirty-six out of the ninety-five cases already mentioned ; and in six of these they were of a semi- cartiiaginous structure, which is much less frequently ob- served than the other kind. 120. Ulcerations were still more common, and on this ac- count seemed very often unconnected with either kind of granulation. We have remarked them in different propor- tions in seventy-eight instances, making them more than twice as frequent as granulations, being present in nearly five sixths * These differences iu the situation of the two kinds of granulations prove that they occupy different tissues. — Louis. 82 PATHOLOGICAL ANATOMÏ. SMALL INTESTINE ; [Pait I, of the cases.* This proportion is rather different from that of Bayle, who has met this alteration in only the sixty-seven hundredths. This difference, however, ought not to cause any doubt as to our own accuracy : we have probably em- ployed more time in properly cleaning the small intestine, and in scrupulously examining it throughout its whole extent ; in this way the smallest ulcerations, which can only be detected when the mucous membrane is well washed, would not have been overlooked ; and to this more than to any other cause our difference may, we think, be attributed. 121. With some few exceptions, the number, dimensions, and depths of the ulcerations, increased as they approached the caecum. Supposing the small intestine to be divided into three equal portions, in the majority of cases ulcerations only existed in the lower third, or in this and the middle third. It was much less common to find them occupying the whole of the intestine. This was, however, the case in rather more than one sixth of the examples ; in only three instances have we seen ulcerations confined to the middle third. 12-2. When small, they were almost exclusively situated opposite the mesentery, in points corresponding to the agmi- nated glands or patches, which were themselves destroyed. In their maximum of development they occupied the whole circumference of the intestine. Their dimensions varied from a line to five or six inches in superficies. Occasionally the same individual presented sev- eral of the larger ulcerations (Obs. 4), while in others the smaller were alone present, or there was only a single ulcer (Obs. 23). * Andral, (Clin. Med. vol. iii. page 175), out of ail the phthisical patients entering the wards oi' M. Lerminicr during five years, found the intestines sound in one fifth only. — Cowan. Chap. 3.] ulcerations: size; color, &.c. 83 123. Their form for the most part, pointed out their origin, and was as variable as their dimensions. When small, they were rounded, as are those which result from the softening of the granulations. When of medium size they presented the elliptical figure of the patches, whose situation they occupied ; and this appearance was the most usual. Next to this, the circular form predominated (Obs. 31, 38, 43). The lineary was the most unfrequent ; we have, however, seen it in seven instances, and almost always in the upper half of the intes- tines ; in these cases the ulceration was from an inch to an inch and a half in length, and a line and a half in breadth at its centre, gradually narrowing towards the extremities. 124. The color of these ulcerations was as variable as their other properties. Usually whitish when small, they were often of a grey color mingled with red, when their dimensions were more or less considerable. Sometimes also, and this pe- culiarity was almost confined to the lineary ulcerations, they were of a blackish or reddish brown color. 125. Their structure varied according to their extent and duration. When small, and, doubtless, recent, the denuded submucous cellular tissue was slightly thickened, smooth, and no evident alteration of the muscular layer was observable. When larger their aspect was less uniform ; some presented an unequal surface, formed by the more or less thickened sub- mucous layer and fragments of the mucous membrane. In others, no trace of the latter existed ; but the cellular layer was alternately thin or thick, partially, or even wholly de- stroyed, and the muscular coat exposed ; the latter also became in its turn more or less thickened, rough, of a greyish or whitish color, and interspersed at times with tuberculous granulations. This increased thickness was often conjoined with partial thinning of the membrane. Its complete destruction was 84 PATHOLOGICAL ANATOMY. SMALL INTESTINE ; [Part I, much less frequently observed ; so that in proportion as any- one of the tissues, entering into the formation of the intestinal parietes, was denuded, it became someivhat thickened and finally ulcerated. 126. The large ulcerations were frequently the result of the junction of smaller ones ; a fact easily demonstrated when the latter were numerous and situated upon the patches. There might then be observed softened tubercles, with small circular ulcerations separated by entire or partially destroyed bands. In others, no remnant of these divisions remained, the cellular membrane was completely denuded, more or less thickened, and presented small, round-shaped depressions of variable depth, corresponding without doubt to the partial ul- cerations just described. Lastly, in a third division of similarly formed ulcerations the submucous layer was either in part or wholly destroyed, and the muscular coat denuded, uneven and thickened. The following case furnishes an example of most of the preceding alterations. FOURTH OBSERVATION. A HOUSE painter, aged 62, entered the hospital of La Char- ité, July 25th, 1824, and died on the first of August following. Born of healthy parents, and himself of naturally thin, spare habit, dated his illness and diarrhosa five months previously. The latter had been violent, causing at first twenty, or a still greater number of stools in the twenty-four hours; these were frequently accompanied by violent colic; cough had been Chap. 3.] ULCERATIONS. 85 present from the middle of the fourth month. Since then the aphonia had been more or less complete, and he complained of a sense of dryness in the larynx. Diminution of appetite al- most from the commencement; the anorexia had subsequently increased ; and, after the fourth month, the cough occasionally excited nausea. Thirst, urgent from the third month. Had experienced no rigors or sense of heat with the exception of the eight days preceding his entrance into the hospital ; emaciation from the first. On the 25th of July, great debility ; memory, good; breath- ing, slightly accelerated ; cough, moderately frequent ; expec- toration, pretty abundant, opaque, greenish, not striated, and with ragged edges (déchiquetés). Percussion of chest good; tracheal respiration under the left clavicle ; coarse and strong under the right, but without any gurgling (gargouillement). Apyrexia; skin, cool; pulse, calm. Tongue, rather pale than otherwise, nearly natural ; no appetite ; thirst, moderate ; deglutition, rather difficult ; occasional sense of oppression in epigastrium ; three liquid stools. On the 31st, at the time of the visit, marked change in features, expression of uneasiness and suffering ; tongue dry ; abdomen very hot, of natural form and volume. For the last hour had experienced acute pains in the region of the gall-blad- der, greatly increased by pressure. The stools had become very frequent, and the pulse and breathing much accelerated. The same symptoms continued during the day, and the patient expired at four the next morning. Opening of the corpse tiventy-eight hours after death. Exterior. — Extreme emaciation. Head. — A good deal of infiltration beneath the upper por- tion of arachnoid : three spoonsful of clear serosity in each 86 PATHOLOGICAL ANATOMY. SMALL INTESTINE ; [Part I, lateral ventricle. One in the lower occipital fossae. The septum lucidum very thin and distended by the same fluid which existed in the middle ventricle ; in all about a drachm. Cerebral substance moderately injected. Neck. — The inferior half of the laryngeal surface of the epiglottis was slightly injected, and had some superficial ulcerations. A very small one was found at the junction of the vocal cords. The mucous membrane of the trachea was red without other alteration. Chest. — The left lung, which was adherent to the costal and diaphragmatic pleurae by an abundant cellular tissue, was congested at its base, and presented in its summit a middle- sized tuberculous excavation, nearly empty. Its parietes were not lined by a false membrane, but principally composed of tu- bercles, granulations, and a grey substance approaching to black, which was abundantly scattered throughout the remainder of the upper lobe. The same alterations, though less numerous, were found in the lower lobe. There was no cavity in the right lung, but a small number of tubercles or granulations with some adhesions. On the same side the bronchia were of a pale pink color ; on the left, where they freely communicated with the excavation, they were of a very dark red. The bronchial glands were not tuberculous ; heart, sound j aortic valves, rather tense and thickened on their free edges. Abdomen. — A little limpid, reddish-colored serosity in the lumbar regions ; a large glass full of thick, yellow-colored in- odorous pus between the bladder and rectum. No where any trace of false membrane. The mucous membrane of the stomach was very thin, almost transparent, and as soft as mucus in the upper portion of the great cul-de-sac, where the subjacent vessels were of a brownish color and much enlarged. Elsewhere it was greyish, more or less mamillated, of normal Chap. 3.] ULCERATIONS. 87 thickness and consistence. Nothing remarkable in the duode- num. The small intestine was rather larger than natural, offer- ing externally many grey, bluish-colored spots, and containing a large quantity of turbid, reddish, and moderately thick fluid. Supposing it divided into five equal parts, the mucous mem- brane was healthy in the first and last. In the remainder there were numerous ulcerations, almost all situated parallel to the direction of the valvulae conniventes. The largest were in the centre of the intestine, interesting the whole of its cir- cumference, and leaving the muscular coat exposed. Two among them presented a superficies of from four to six inches ; they were greyish colored and rugged. The muscular coat in the same point was three quarters of a line thick, its fibres were more brittle and less flexible than natural. Above and below this portion of the gut, ulcerations existed, (not complete- ly encirchng the intestine), whose edges were thick, but whose centres were very thin, so that the muscular coat seemed cut obliquely. The bottom of several consisted wholly of perito- neum, which was itself sometimes destroyed, and perforation had taken place in two spots. Round one of these perfora- tions the serous membrane was of a livid red color, for the space of four or five lines, exceedingly thin, and in all re- spects resembhng those perforations which take place in acute diseases. Around the other it was of natural color and less attenuated, as if rather the result of tearing, (though the greatest precautions were employed), than of any other cause. The contents of the large intestine were similar to those of the small. The muscular coat was denuded in the whole circumference of the cœcum, and for about seven inches of the ascending colon. It was of greyish color, with partial but inconsiderable loss of substance, and one line thick. Below this, even to the middle of the transverse colon, 88 PATHOLOGICAL ANATOMY. SMALL INTESTINE ; [Part I, there were other very extensive ulcerations, exactly similar to the one described, leaving the intervening mucous membrane healthy. This last was pale and slightly softened in the de- scending colon and rectum. The greater part of the mesen- teric glands were much increased in volume and transformed into tuberculous matter. Some among them presented, con- joined with this, variably sized masses, of a white, opaque, shining and resisting substance, in every respect cancerous. The other abdominal viscera were healthy. 127. Notwithstanding the very careful examination of the intestinal tube, and although one of the perforations exactly coincided in its symptoms and pathological characters with what takes place in the best observed and described acute cases of this description, we cannot in the present instance suppose it to have existed during life. It is true that an acute pain was felt in the region of the gall-bladder twenty- four hours before death ; the pulse became accelerated, the abdomen was hot, and a quantity of pus was found in the peritoneal cavity ; in a word, there was peritonitis. But the pus was without odor, of natural color, and had none of those properties which accompany perforation of the small intestine, (properties so marked in respect to odor and color, that they are almost sufficient of themselves to indicate perforation) ; there was not the slighest trace of the turbid, dirty-colored fluid of the small intestine in the peritoneal cavity ; so that this individual fact seems rather an example of one of those cases of peritonitis which come on in the last stage of phthisis (188), than true perforation of the intestine. At all events, this observation is extremely interesting, from the number and extent of the ulcerations in both intestines ; from the thickened state of the corresponding muscular coat ; from its diminished Chap. 3.] ULCERATIONS. 89 thickness and complete destruction in the centre of others, with exposure of the peritoneum and perforation, either actu- ally arrived, or on the verge of taking place. Let us also take notice that there were no tuberculous granulations in the substance of the muscular coat. Were this more frequently the case it is probable that its entire de- struction and peritoneal perforation would be less rarely ob- served. But, as we have already remarked (125), muscular fibres, instead of following the destruction of the mucous and cellular membranes, become gradually thicker, only yielding after a greater or less space of time, and then in comparatively few instances. 128. The parts immediately surrounding the ulcerations were sometimes on their usual level, but in general were more or less raised. When the ulcerations were small and circular, the mucous and cellular tunics forming their edges were very slightly thickened. If they resulted from the semi-cartilagi- nous granulations, the edges were thick proportionably to the progress the latter had made. When large and still recent, the submucous layer not being destroyed, their circumference was rugged and of variable thickness, arising in many cases from the presence of a certain number of softened tubercles. In general, the surrounding mucous membrane was more or less red and softened. Besides the preceding alterations, there were occasionally minute abscesses, of the dimensions of a pea, formed in the sub- mucous cellular tissue. These were sometimes present when neither ulcerations nor tuberculous granulations existed in the small intestine. Their parietes were at times smooth, so that they seemed rather the result of phlegmonous inflammation than of softened tubercle. It is proper, however, to observe, that we L 90 PATHOLOGICAL ANATOMY. SMALL INTESTINE. [Parti, have scarcely found them except in phthisical patients ; and in the two instances where they existed after other diseases, their contents were composed of a very tenacious, yellowish, and semi-transparent substance. 129. When the small intestine was healthy, or presented very few morbid changes, it contained a variable quantity of mucus, of different color and consistence, and sometimes it was stained with blood. When, however, the ulcerations were large and numerous, instead of mucus, there was a tur- bid, dirty, red-colored or greyish fluid of variable consistence, very similar to what we have described in the last observa- tion ; it had strong odor, much resembling that of animal sub- stances in maceration (Obs. 14). IN PATIENTS WHO DIED OF OTHER DISEASES. 130. Many of the morbid alterations now described, as the softening, thickening, redness of the mucous membrane and semi-cartilaginous granulations, are common to phthisis and to a great number of other chronic and acute affections ; but the semi-cartilaginous granulations are more frequent in phthisis than in any other circumstances. The tuberculous granula- tions and ulcerations appear peculiar to this disease. We have never remarked the former except in phthisis ; and if it is not rigorously correct to say that ulcerations of the small intestine are exclusively found in this affection, exceptions are so rare that the proposition is almost literally true. Out of eighty-five cases, consisting of various chronic affections, we have only met six where the small intestine was ulcerated. Three an)ong these were in individuals whose lungs offered either tubercles or tuberculous excavations. Among the three others, one was that of a woman whose principal affec- tion was gastritis ; the other two were cases of dysentery. In Chap. 3.] LARGE INTESTINE ; REDNESS, &£C. 91 the three instances the ulcerations were small and few in num- ber ; so that, if every kind of ulceration of the small intestine is not absolutely peculiar to phthisis, we may consider the asser- tion correct for ulcers of a certain size ; for we are here only referring to chronic diseases, and not including typhus fever.* ARTICLE V. LARGE INTESTINE. 131. With the exception of the semi-cartilaginous granula- tions, this portion of the intestinal canal presented lesions similar to those we have just described. We shall, therefore, only insist on their peculiarities. 132. The whole of the mucous membrane was red, in twenty-seven out of the ninety-five cases we are considering ; that is, in rather more than one fourth. In twelve of these the redness was interrupted ; in fifteen it was continuous through- out; and, when this was the case, it was generally very in- tense. With three exceptions, it coincided with very marked softening of the mucous membrane, which was reduced to the consistence of mucus, and could only be removed in this form. It was often thickened, and more frequently ulcerated. * These results are of a highly interesting nature, and not without marked advantages, both for diagnosis and treatment. In cases of chronic affections of the small intestine, our great object would be (o decide on the presence or absence of phthisis. In the latter case, the presumption of ulcerations not existing would certainly be justifiable, and greatly increase the probability of efficacious treatment. During the eight years which have elapsed since the publication of this work, M. Louis has not examined a single subject who died from a chronic disease and presented ulcerations in the small in- testine, in which he did not find tubercles in the lungs. Vide Examen, de l'Examen, page 18. — Cowan. 92 PATHOLOGICAL ANATOMY. LARGE INTESTINE ; [Part I, 133. Thickening was present even when the natural white color of the membrane was retained ; but was then combined with softening and a certain number of ulcerations. In comparing this and the preceding paragraph, we per- ceive that the thickening of the mucous membrane of the large intestine was always united to some other alteration, and most usually to that of softening. 134. Softening was then very frequently present. It was observed not only in those cases where the mucous membrane was red and thickened, but even where it had preserved its natural color and thickness. We have found it sixty-two times either occupying the totality, or a considerable part of the intestine. In numerous instances the red and softened mucous mem- brane was more or less extensively mamillated (Obs. 17) ; or it was more or less completely destroyed in innumerable minute portions, producing an undulated aspect, sometimes through its whole extent. In two instances it was destroyed over a surface of ten inches ; and, in consequence of the slightly pink tinge of the submucous tissue corresponding to this enor- mous loss of substance, it would, without great attention on our part, have escaped notice. Beyond the limits of this de- struction the cellular tissue was not sensibly modified, and the membrane may, perhaps, have been removed, simply by the friction occasioned by the passage of faecal matter. This is rendered more probable from the fact that, in extreme states of softening of the mucous membrane of the colon, the passing of the back of a scalpel over it is sufficient to remove it en- tirely. 135. The cellular tissue was usually opaque in these cases; its thickness two, three, or four times greater than natural (Obs. 17). In some cases, as we have mentioned (134), it was of Chap. 3.] SOFTENING, &;c. ; causes of? 93 a light rose color, while in the majority it retained its usual whiteness. This last fact appears very remarkable ; for, as will here- after be shown, the softening of the mucous membrane was, in a great number of instances, an evident result of inflamma- tion, which only dated a kw days previous to the death of the patient. The thickening of the submucous cellular tissue was probably consecutive ; it was certainly of the same nature, and yet it is difficult to imagine a membrane thickened by recent and acute inflammation, retaining its natural paleness. This fact, with many others, shows that the thickness of our tissues is one of the most important circumstances to be noticed, and that to confine ourselves to the description of the color of membranes is often useless, and even a cause of error, to tlrose who might draw conclusions from such imperfectly described facts. 136. It may be asked, is the cause of this softening con- stantly the same ? When united to redness and thickening it can scarcely be doubted that it has an inflammatory origin. This is also probably the case when thickening exists alone, for paleness of inflamed structures takes place sooner or later, as is exemplified in the various shades of color of hepatized lung. But when softening is present, without any change of color or thickness, is it then the effect of inflammation ? This, as it seems to us, is also far from impossible ; but at the same time that it is so, is not incontestable, for many organs are fre- quently softened when we cannot suppose inflammation to have been present. Thus, in typhus fever, and in many chronic diseases, the heart is often softened and its color in- creased, without any assignable cause. The spleen presents in numerous instances a state of extreme softening, which we 94 PATHOLOGICAL ANATOMY. LARGE INTESTINE ; [Part 1, have no right to attribute to inflammation. On the other hand, it ought to be noticed that continuous with a red and softened portion of mucous membrane, we often find another equally softened, but without redness. If the first, therefore, is inflammatory, it is probable that the other is so also ; but it is a mere probability, and fresh facts are necessary to decide the question. 137. But at what degree of softening does disorganization take place ? We are not acquainted with any fact which can solve this problem. It appears to us, however, infinitely pro- bable, that very considerable softening may exist, without the affected tissues becoming disorganized ; — the condition of the spleen in typhus fever is very favorable to this opinion. In fact, in a certain number of individuals who have died after a very protracted form of this disease, we have found the spleen voluminous and firm ; and since its softening is an almost con- stant phenomenon in typhus, and that to an extreme degree, we must admit that this had taken place in some of the cases referred to, and, consequently, that the spleen had regained its consistence, and had not been disorganized. 138. When describing the symptoms farther on (264), we shall find, as we have already pointed out (135), that the in- flammation producing the pulpy softening of the mucous mem- brane of the large intestine is developed only a {ew days before deatli, as is the case in inflammation of the pulmon- ary parenchyma, the pleura, and the mucous membrane of the stomach. 139. There were thirteen examples of tuberculous granu- lations ; (that is, they existed in about one-eighth of the cases). These were situated either in the centre or circum- ference of the ulcerations, and not in their intervals. Chap. 3.] ULCERATIONS ; SIZE. 95 We have never observed the semi-cartilaginous granula- tions, 140. Ulcerations were frequent. They were present in seventy cases, which makes them nearly as common here as in the small intestine ; and since softening of the mucous mem- brane often existed without ulceration, we have necessarily very rarely found this membrane perfectly healthy in its whole extent. It was so only tliree times. 141. Usually the ulcerations were small, from three to six lines, or less, in diameter. The largest, (and we have already seen how considerable their dimensions were occasionally), formed only about one fourth of the cases. The smaller, in ten cases, were almost uniformly distributed throughout the whole of the intestine. When more considerable, (one or two inches, or rather more in surface), this was the case in only one instance. In other examples, the number of the ulcerations diminished from the caecum to the ascending colon, and from the transverse to the rectum, in the ratio of seventeen, eleven, eight, four. If we would now know the aggregate of cases in which ulcerations were present in each division of the intestine, (including the small ulcerations), the respective figures for the caecum, the ascending, transverse, de- scending colon and rectum will be thirty-four, thirty-seven, twenty-five, eight, thirty-two cases, that is, in an equal propor- tion of cases they are nearly equally common in the caecum and rectum. But here the analogy ceases ; for the differ- ence, as to the size and number of the ulcerations, was very great (142). When small, they were usually rounded, with flattened edges, as if artificially produced. Their bottom was greyish, approaching to black, sometimes but rarely of a pink color; this last tint would have often led us to overlook them, had we not 96 PATHOLOGICAL ANATOMY. LARGE INTESTINE ; [Part I, been in the habit of scrupulously washing the intestine. They " were lined by the cellular tissue, either thickened or much thinned, and in three instances only, by the healthy muscular coat ; which latter disposition we have not yet observed in similarly sized ulcerations in the small intestine. Instead of a rounded form, both the small and middle-sized ulcerations were sometimes much elongated, being from one to two inches in length by two or three lines wide ; or even less. In direction, they were either transverse, longitudinal or ob- lique. These varieties of form were sometimes all combined when the ulcerations were numerous and clustered together, and the intervening mucous membrane more or less thickened, the general aspect very much resembled the chapped integu- ments of the hand. 142. The form of the large ulcerations was irregular, in- dentated or radiated ; often attacking the whole circumfer- ence of the caecum, ascending, transverse colon and rectum. They not only very frequently extended round the caecum and ascending colon, but an ulcer occupied longitudinally a space of from eight to nine inches or more (Obs. 4, 12). Now and then, in the midst of these immense ulcerations, there were zones of intestine perfectly healthy, except a slight and partial softening of the mucous membrane; here and there were seen small insulated portions, formed by the more or less thickened fragments of the mucous and cellular tissues. The other divisions of intestine have in no instance pre- sented ulcerations of equal dimensions. The largest we have ever observed in the rectum, were from an inch and a half to two inches in length, encircling the gut, and situated im- mediately above the anus. Both the large and middle-sized ulcerations were of a grey- ish color. They were sometimes lined by the more or less Chap. 3.] ULCERATION, SIZE, FORM, COLOR. 97 thickened, indurated, and easily torn sub-mucous membrane. This was much softened only twice ; most frequently it was destroyed, and the muscular membrane exposed. This de- struction was almost invariably complete and universal in the large ulcerations. The muscular layer under these circum- stances was always thickened more than a line, and of a variably deep grey color; its fibres were more or less brittle and indurated, forming prominent fasciculi, sometimes with tuberculous granulations in their interstices, and presenting, in some points, a commencement of destruction. Examples occurred, where the mucous membrane and the cellular membrane under it were detached to a greater or less extent around the ulcerations, or they formed elevations which connected the ulcers together. 143. When the ulcerations were very large and numerous, and the muscular coat extensively denuded, there was fre- quently an odor similar to that from animal substances which have been some time in maceration. The faeces were reddish, turbid, and liquid, often resembling putty in color. A few days previous to death, the stools sometimes presented a similar odor and color. Were the ulcerations few in number, of mo- derate size, and limited to the caecum or commencement of the colon, the faeces were often soft, dirty colored, and sometimes smeared with blood in these parts ; while in the rectum they were very dark, or of a bright yellow color. We must there- fore conclude, that with some rare exceptions, it is impossible to appreciate the'state of the mucous membrane of the large intestine, by means of the faecal discharges, except in very rare cases.* * Dr. Abercrombie, in his valuable work on Abdominal Diseases, arrives at nearly similarconclusions. — Cowan. M 93 PATHOLOGICAL ANATOMY. SMALL INTESTINE. [Part I^ 144. Intestinal ulcerations were often, at least in their origin, ■independent of inflammation. This was evidently the case ■with a great number of those in the small intestine ; they were the result of softened tubercles ; for the development of the latter could not be attributed to inflammation, since so long as they remain unsoftened, the mucous membrane covering them continued healthy. Far from being the cause, the inflamma- tion of the mucous membrane was, as we have already seen (117), subsequent to the presence of the granulations. The same remark is equally applicable to some cases of ulceration of the large intestine. Where softened tubercle could not be considered the cause, it would still be difficult to regard ulceration as simply the effect of inflammation, which does not usually take place in isolated patches on a mucous surface. Of this fact we have we think afforded a proof for the colon, when speaking of the softenino- with redness and thickenino; of its mucous mem- brane, which almost invariably extends to its whole surface. As to the small intestine, we will remark, that while distinct traces of inflammation are ranch less common than in the colon, its ulcerations are still more frequent ; and that where inflammation appeared to be their cause, it had still a peculiar character, since the ulcers are most generally limited to the patches. These reflections are strengthened by what we have said respecting the extreme rareness of ulcerations of the small intestine in all chronic diseases except phthisis; while simple inflammation of the mucous membrane is quite as frequendy observed in one case as the other.* * These remarks arc peculiar to our author, and as they have been, and no doubt will be, contested, we direct the reader's attention to the evidence in their favor, and the mode of reasoning adopted. — Cowan. Chap. 4.] LYMPHATIC GLANDS, TUBERCULOUS. 99 IN PATIENTS WHO DIED OF OTHER CHRONIC DISEASES. 145. With the exception of the tuberculous granulations, we have met, though in different proportions, all the other alterations just described, in cases fatal from a variety of other chronic diseases. Thus out of ninety-two individuals, thirteen offered a greater or less number of ulcerations, confined to one or n)ore portions of the large intestine. But six among these had tubercles in the lungs, and were consequently phthisical ; reducing the number of cases with ulcerations to seven out of eighty-six. Of these seven, four were examples of dysentery and in nearly all the ulcerations were of small extent, and slightly varying in character from those we have just described. Softening, with or without redness or thickening of the mucous membrane, was observed in one third of the cases, that isj much less frequently than in phthisis. CHAPTER IV. LYMPHATIC GLANDS. 146. These were frequently tuberculous, sometimes more or less red and increased in volume, very rarely with any other kind of alteration. The relative frequency of their tubercu- lisation was as follows : the mesenteric, meso-cœcal, meso- colic, cervical, lumbar and axillary glands. We do not enu- merate the bronchial glands, for although we examined them with equal care, we have most frequently omitted to note the results. We think, however, that we may venture to affirm, on 100 PATHOLOGICAL ANATOMY. GLANDS J [Pai't 1, the strength of later observations, that they are not oftener tuberculous than those of the mesentery. ARTICLE I MESENTERIC GLANDS. 147. Out of one hundred and two cases, where they were carefully examined, they were tuberculated in twenty- three. Thus modified, their volume was increased. In the majority of instances the transformation was not general ; it was only partial (Obs. 9, 15, 16, 31). In others, only minute points, either in the centre or circumference of the gland, could be detected. These points were interspersed through a structure usually red, and less consistent than nat- ural ; in general the altered glands were aggregated in dis- tinct groups. All the mesenteric glands were not equally affected. Those nearest the caecum were most frequently modified ; and in the twenty-three cases we are now examining, we have only once seen the affection universal — (Obs. 23). The transformation of each individual gland was here complete ; no trace of its primitive structure remaining. There was evidently not only production of a new tissue, but transformation of one structure into another ; unless we would rather admit that the glandular tissue was removed in part at least by absorption.* 148. We have only once found, in the centre of an incom- * The transformation of healthy into morbid structure cannot we think he satisfactorily demonstrated by a single example. In physiology the gradual formation of our tissues follows certain laws, and has certain limits — but morbid deposit seems always something more — something added, and not merely a modification of what previously existed. If we might cite our #^ Chap. 4.] MESENTERIC, TUBERCULOUS. 101 pletely tuberculated mesenteric gland, a small portion of the grey semi-transparent substance. In all other cases, the gra- nulation was yellowish, opaque, and really tuberculous from the first moment it could be observed. This mode of devel- opment of the tuberculous matter differs from what Laennec ^considers to be the case in the lungs. 149. The mesenteric glands, when tuberculated, presented 10 other organic alteration. We have only once remarked, ^conjoined with tuberculous matter, a shining; firm, granulous substance, very analogous to encephaloid matter — (Obs. 4).* 150. The mesenteric tubercles were very rarely softened ; result no doubt depending on their being recent. This is [t least probable, for, in the majority of cases, the development of tuberculous matter in the mesenteric glands seems gradual, ^and is almost always partial j it is consequently recent at the own observations, we would say that, nowhere is this more evident than in the lymphatic glands, which often combine the e,reat advantage of pre- senting an identical alteration in all its various stages ; and from a careful inspection of cases where this facility was afforded, the tuberculous matter seemed always a simple deposit, and by its gradual increase, to have caused the ultimate absorption of the glandular structure. — Cowan. **Thc co-existence oil different morbid alterations is a subject of considera- ble pathological importance. Pathologists are well aware that tumors, wherever situated in the body, are almost invariably of the same description, and knowing the nature of one, they do not hesitate to predict that of the others. There is a remarkable case cited by Andral (Anat. Path. vol. i. p. 420), showing the great analogy of cancerous and tuberculous matter. Trousseau {Arch- Gen. de Med., 1823) has found, though very rarely, these two morbid productions together, as well as cancer and melanosis. We have already seen that extreme emaciation characterises both the cancerous and tubercular diathesis, and this unity of effect under such different circumstan- ces, with respect to the pulmonary oigans, induces us to suppose that loss of flesh in phthisis may not be a consequence of the condition of the lungs. — CoWAN. 102 PATHOLOGICAL ANATOMY. GLANDS ; [Part I, period of the individual's death, and the softening only takes place when the transformation is complete. 151. But what is the cause of this alteration ? We have remarked (147) that the mesenteric glands when tuberculous were increased in volume : when they only presented some '"^ tuberculous points, they were more or less of a bright red and often slightly softened. But this slight excess of volume was. not always accompanied with this change of color and consis- / tence ; so that in some instances inflammation appears to have f influenced the development of tuberculous matter, while in"' j others, and in not so large a number of cases, it is true, no -' such influence can be traced. - M -^ Whatever may be the immediate cause of these tubercles, '"". let us now inquire whether they invariably depend on an in- flammatory state of the corresponding mucous membrane ? J In every instance, when the mesenteric glands were tubercu- j lous, we have found ulcerations of the small intestine, and these ulcerations had not taken place without primary or secondary inflammation of the mucous membrane ; they were also them- selves a perpetual source of irritation. When the mesentery was only partially tuberculated, it was so in the cajcal portion, or the part which corresponds to the most usual seat of large ulcerations. Tliese facts seem to point out a close connexion between tubercles in the mesentery, the mucous membrane, and ulcerations of the small intestine 5 but in more than one- half of the cases, the ulcerations were small, and when ex- tensive, and consequently chronic, no increase of tuberculous matter was observed. The only example of complete tuber- culous transformation of a// the mesenteric glands was that of a young man, whose affection was still recent, who had expe- rienced but very sliglit diarrliœa, and in whom we found the mucous membrane of the small intestine perfectly healthy, both / Chap. 4.] MESENTERIC, TUBERCULOUS. 103 as regards color, consistence, and thickness. — (Obs. 23.) The only appreciable alteration, and doubtless it is not a very im- portant one with regard to the object we have in view, was a round ulceration of a line in diameter, with pale flat edges, situated near the caecum. We must therefore conclude, that if the inflammation of the lymphatic glands, that of the mucous membrane, and the ulcerations of the small intestine, ought to be viewed as the occasional cause of mesenteric tubercles, there are other cases where no such dependence exists. It may perhaps be said in reply to this, that tubercu- lous affections are essentially chronic, and probably, that of the mesentery existed anteriorly to the origin of the principal disease, and that during this interval the inflammation of the raucous membrane might have disappeared. But this is only opposing an hypothesis to a fact, and taking for granted as an invariable law, what really is not so ; for, tuberculous matter is capable of very rapid development, as we shall hereafter prove, when speaking of the progress of phthisis. We may remark in anticipation, that we have never met mesenteric tubercles except in phthisical cases ; we cannot therefore suppose them to have preceded the principal affection; partic- ularly as no well marked indications of irritation of the mucous membrane of the small intestine were at any time ob- served.* 152. The duration of phthisis had no influence on the de- velopment of the modiflcation we are now considering. It was equally frequent in cases where the disease was recent, * The mode of reasoning to which our author resorts is rather novel in medicine, and indeed till very lately would have been impossible. The reader will observe how it wholly rests on numerical facts, and to what sat- isfactory conclusions it would often lead, and what useless conjectures would be avoided, were accurately analysed facts at our disposal. — Cowan. 104 PATHOLOGICAL ANATOMY. GLANDS; [Parti, (from six weeks to five months,) as when it was protracted from one to ten years. 153. When the glands were not tuberculous, they were quite often greatly increased in volume, and of a variably in- tense red color. This may lead us to conclude, that when the tuberculous matter was coincident with inflammation, it had been preceded by the latter. 154. We have not detected any symptom which could be attributed to the alteration before us. In the instance already cited, where the whole of the mesenteric glands were tuber- culated, the patient never complained of pain around the um- bilicus. Pressure properly applied discovered no tumor. However, if in cases of phthisis, we detected a tumor in the region of the mesentery, it might, we think, be regarded as tubercidous, for in no example of this description have we observed any other. ARTICLE II. MESO-CiECAL, MESO-COLtC, AND LUMBAR GLANDS. 155. The raeso-csecal glands were rather less frequently tuberculated tlian those of the mesentery, but oftener than those of the right lumbar meso-colon. They were enlarged like tlie mesenteric glands, seldom entirely transformed into tuberculous matter, and were more or less red in points where this transformation did not extend. Five times out of sixty the lumbar glands have been tuber- culated. In three cases their transformation was complete ; they were about the size of a walnut, indurated, and nowhere softened in the least degree. In one of these cases the mu- Chap. 4.] MESO-C^C AL, CERVICAL, AXILLARY, &,C. 105 COUS membrane of the small intestine and colon was perfectly healthy, and the state of the glands could not be explained by any lesion of the abdominal viscera. The patient was a female of seventy years old. In not one of the cases now under consideration, have we seen the grey semù-transparent matter combined with the tu- berculous ; the development of the latter therefore follows the same course as in the mesenteric glands. We have only once found the right lumbar meso-colic glands tuberculated. ARTICLE III. CERVICAL, AXILLARY, AND BRONCHIAL GLANDS. 156. The cervical glands were more or less tuberculous in one-tenth of our cases, eight times out of eighty ; and, like the mesenteric glands, larger than natural, and of a variably in- tense red color in the parts which had not undergone tuber- culisation (Obs. 9, 18, 35, 47). In four of these cases, the mucous membrane of the trachea was of a more or less florid red color. In one instance it even presented some small ulcerations. In the others, it was healthy ; so that, in not one of the examples presenting those vast ulcerations we have described (Obs. 15, 43), were the cervical glands tubercu- lated ; and here, as in many cases of mesenteric tubercles, tu- berculous transformation must be viewed as depending on some other cause than the inflammation of the corresponding mucous membrane. In a single instance (Obs. 9), the cervical glands, converted into tuberculous matter, were the cause of pain, and this pa- N 106 PATHOLOGICAL ANATOMY. GLANDS. [Parti, tient also furnished the only example we possess of tubercles in the axillary glands, and the same pain was also complained of in the latter as in the neck. 157. When the bronchial glands were tuberculous, they were usually of increased volume, and of a grey and blackish color. They were very rarely tinged with red, or with an onion-peel color. IN PATIENTS WHO DIED OF OTHER CHRONIC DISEASES. 158. The morbid change we are examining seems peculiar to phthisis. In ninety-eight cases, fatal from a variety of chronic diseases, as dysentery, &£C. &;c. we have not met a single instance of tuberculated lymphatic glands. A consid- erable number, however, among them, were examples of in- flammation and sometimes ulceration, he. of the intestinal mucous membrane; an additional motive for believing that the inflammation of mucous membranes is not either the only cause, or even the most important element of tuberculous transformation.* * M. Broussais says, he has often found them, (tuberculated glands) inde- pendently of any tubei'culous affection of the lungs, both in adults and in- fants. Vide Exam. Med. vo\. i. p. 344. To judge of the value of this assertion, we i-efer the reader to what our author has stated in page 19, of his reply to M. B.'s criticisms. M. L. fully confirms the accuracy of the opinion, that after tlie age of fifteen, tuberculated glands never exist without tubercles in the lungs, by the additional experience of eight years. — Cowan. Chap. 5.] LIVER ; fatty state. 107 CHAPTER V. BILIARY APPARATUS. ARTICLE I, LIVER. 159. The fatty transformation of the liver was the most fre- quent, and at the same time the most remarkable alteration of this organ, it existed in one-third of the cases (forty out of one hundred and twenty). In this condition the liver was pale, almost always of a light brownish yellow color, spotted with red, externally and internally. It retained its natural form ; but its volume was nearly always augmented, and at times double its usual dimensions. This increase was almost invariably at the expense of the right lobe. The liver then overlapped a large portion of the anterior surface of the stomach, occupied the epi- gastrium, extended the breadth of two or three fingers below the false ribs, and reached the iliac crest and the spleen, which was also occasionally covered. We once saw it situated in the centre of the abdomen, and about two inches from the pubes. 160. Its consistence (with the exception of cases where the alteration was but slightly pronounced) was greatly dimin- ished; it easily yielded to traction, and was sometimes much softened. In very advanced cases, the scalpel and hands were greasedas by ordinary fat substances. When the morbid 108 PATHOLOGICAL ANATOMT. LIVER; [Parti, change was much less evident, we ascertained its exist- ence by placing a thin section of the liver on a sheet of paper; and exposing it to the flame of a candle : a very slight heat melted a small quantity of the fat, saturated the paper, and thus demonstrated its presence. The lesion con- stantly occupied the whole of the liver.* 161. The causes of the fatty transformation of the liver appear to us equally obscure as those of other organic diseases. Without therefore attempting any explanation, we will point out the principal circumstances with which it is accompanied. One of the most obvious is, that this lesion is almost con- fined to cases of phthisis ;f so that it may, to a certain point, be considered as depending on this affection. Out of two hun- dred and thirty cases, nearly equally divided between acute and chronic diseases, we have only met nine examples of fatty liver, and among these nine, seven relate to patients who presented a certain number of pulmonary tubercles. By adding these nine cases to the forty already mentioned, we have forty-nine * The fact of any particular morbid alteration, invariably occupying the totality of the organ affected, is interesting, and, combined with the gene- ral characters of inflammation when attacking parenchymatous organs, viz. that of being usually bounded to one side of the body, if the organ is double, and almost invariably (perhaps always) to a greater or less portion of or- gans, which are single, we may, I think, justly entertain a doubt as to its inflammatory origin. This observation is applicable to that state of the kid- ney, so accurately described by Dr. Bright. Other reasons we think might also be adduced in favor of the idea that it does not arise from inflammation. — Cowan. f Compare this with the 150th proposition of M. Broussais : — " Chronic gastro-enteritis is the cattse of hepatic engorgements, and of those yellow fatty enlargements of the liver, which we sometimes find in the bodies of those who die even of phthisis .'" — Andral has arrived at the same results as M. Louis. — Cowan. Chap. 5.] FATTY STATE CAUSES. 109 examples of this condition of the liver (and these include all we have collected during three years), out of which forty- seven were cases of phthisis. There are assuredly few phe- nomena of whose mutual dependence there is no doubt, in confirmation of which facts are more unanimous. Sex is another cause which favors the fatty degeneration of the liver ; for, out of the forty-nine cases above mentioned, ten only relate to men, — leaving the proportion between them and female patients, nearly as one to four. It is true that phthisis was rather more frequent among the latter, in the ratio of sixty-six to fifty-seven ; but this difference cannot sen- sibly affect our calculation, or the accuracy of our assertion. The strength or weakness of the constitution exercised no influence in producing the alteration in question. Age was equally without effect. Among the forty phthisical cases re- ferred to, eighteen were from twenty to thirty, thirteen from thirty to forty, five from forty to fifty, three from fifty to sixty, and one from sixty to seventy ; a proportion almost coinciding with the frequency of phthisis in the different periods of hfe. We are also unable to enumerate among the number of causes, which favor the development of this fatty state of the liver, the diseases of the duodenum ; since, in the first place, these were rare, and equally so in cases where the liver pre- sented the fatty transformation, as in those where it was per- fectly healthy (102.) 162. This morbid alteration may take place very rapidly. We have seen it in instances where phthisis had passed through all its stages in fifty days (Obs. 36.) The variations in the duration of the disease have not sen- sibly modified the proportion. The results were similar in cases where phthisis had lasted only some months, or had been protracted during several years. no PATHOLOGICAL ANATOMY. — LIVER ; [Part I> 163. If, however, we admit that this peculiar condition of the liver niay be acute or chronic, our conclusion can only be founded on the dependence existing between this lesion and phthisis itself; for we have no means of diagnosis in our power at any period of its duration. We have in vain attempted to assign to it any class of symptoms ; none such presented them- selves. There was no pain complained of in the right hypo- chondrium ; pressure on the liver, when extending below the edges of the false ribs, was equally without effect ; and if it caused pain in the epigastrium, when occupied by the liver, this might be attributed to the state of the gastric mucous membrane. We have only once seen the color of the skin affected ; this was in the case of a female patient, aged 30 (Obs. 30), in whom phthisis was both very obscure and slow in its progress. She had lived in England some years, and about the middle period of the disease, had experienced some shooting pricking pains in the right hypochondrium, and other symptoms which induced a suspicion of disease of the liver. She was treated with purgatives and calomel. The color of the skin became gradually changed, and when we saw the pa- tient, it presented a very pale yellow tint, except on the face, where it inclined more to a brown and was less equally distrib- uted. The sclerotics retained their natural white color ; and this fact, as we shall hereafter see, ought necessarily to throw a doubt over the presumed cause of the color of the skin. In this absence of all characteristic symptoms, there is only one circumstance which might lead us to suspect the patholo- gical condition of the liver ; viz. its increased volume, which exists frequently and almost exclusively in phthisis in such cases. 1C4. In every case where the adipous degeneration existed, the liver presented no other organic lesions. The latter, in- Chap. 5.] CYSTS, FRIABILITY, EMPHYSEMA. Ill deed, were at all times very rare. Thus we have only twice remarked tuberculous matter in this organ (Obs. 9). In two individuals, from eighteen to nineteen years old, this organ offered internally numerous small cysts, from one to three lines in diameter, of slight consistence, barely allowing them to be separated from the surrounding tissue. Their parietes were about the twenty-fifth part of an inch thick, and enclosed a greenish pulpy substance. We have only encountered these cysts in the liver and in cases of phthisis. In another instance (a woman aged twenty-nine), the middle lobe was destroyed and replaced by an irregularly rounded fibrous cyst, nearly double in volume the lobe to which it corres- ponded, and of the 25th of an inch, or often less, in thickness. This cyst, of a yellowish white, contained a colorless rather tur- bid fluid, of moderate density, in which floated about one hun- dred minute rounded bodies, varying from the size of hemp-seed to that of a small cherry. They were formed by a thin mem- brane, enclosing a limpid fluid. The parietes of the cyst itself were composed of a white opaque membrane, of the consis- tence of coagulated albumen, from half a line to three quarters of a line thick, very slightly adherent, smooth and polished like a serous membrane on its outer surface, and of a dull ap- pearance internally. Here also there were five elongated ele- vations, from an inch to an inch and a half of surface, and from one to two lines thick, rough, nodulated, and presenting the aspect of the concrete albumen on the surface of a poached egg. The parenchyma surrounding the cyst was healthy. The consistence of the liver was very variable, sometimes soft, at other times firmer than natural, often combining indu- ration with brittleness, but in no instance giving rise to any characteristic symptoms. One of the patients, whose history we have given (Obs. 7), presented a solitary example of an 112 PATHOLOGICAL ANATOMY. BILE. [Part I, emphysematous liver ; it was lighter than the lungs, and rather -less than its natural volume. ARTICLE II. BILE AND GALL BLADDER. 165. In one-third of the cases where liver was adipous, the bile in the gall bladder was very dark colored, of a viscid trea- cle-like consistence, in a medium state, as it were between a solid and fluid. In another third, it was still very thick, but less so than what we have just described. In the last division, its color and consistence were natural, and in general it was less abundant according as it was more viscid.* However, the thickened state of the bile, in which it as- sumes very much the appearance of treacle, is not confined to this particular modification of the liver. We find it in other conditions of this organ, though proportionably it is much less frequent. Thus, in three phthisical patients, where the liver was healthy, the bile presented this peculiar consistence. We have observed the same fact in patients who died from other chronic diseases, and whose liver was healthy. In five out of seventy, the bile had a semi-solid consistence similar to that of treacle. 166. No relation could be traced between the state of the bile and that of the stomach. Its consistence was very con- * The healthy state of tlie secretion, in a large proportion of the cases, and its similarity with that observed in other instances where the hepatic parenchyma appeared sound while the secretion itself varied are additional arguments in support of the opinion we have advanced in a previous note, that the peculiar modification in question is not depending on inflammation. — Cowan. Chap. 5.] GALL-BLADDKR ; CONSISTENCE, &;C. 113 siderable under the most varied conditions of the latter ; when the mucous membrane of the stomach was softened, thinned, inflamed, or perfectly healthy ; when patients had partially preserved their appetite to the last, or when anorexia was com- plete long before death ;* both when vomiting had been fre- quent, and when it was altogether absent. In no instance have we detected any appreciable change in the bile of the ductus choledocus. 167. The parietes of the gall-bladder were seldom mor- bidly affected. Twice we have seen them more or less thick- ened from infiltration, and twice from another cause. In one of these last (Obs. 49), adhesions were formed between the fundus of the gall-bladder and the abdominal parietes, and in the corresponding point its mucous membrane was destroyed to the extent of about an inch. Similar, though less consider- able, loss of substance existed near the neck. Elsewhere the membrane was about a quarter of a line thick, and presented in miniature the columnated appearance sometimes seen in the urinary bladder. The submucous cellular tissue was thickened, and the portions corresponding to the ulcerations easily torn. The gall-bladder contained about two hundred calculi, varying in volume from that of a pea to a millet-seed. Two years before her death the patient had experienced acute pains in the corresponding region of the abdomen, and during eleven months had had several attacks of jaundice. In three women, of the respective ages of thirty, thirty-four and sixty, * In the original are the words " bien avant le terme total." They seem to have escaped the notice of the translator. I presume there is a verbal error in the original, and that " total" should be "fatal" and, therefore, I have translated them as above. — H. I. B. 114 PATHOLOGICAL ANATOMY. SPLEEN, [Part I, a considerable number of calculi were found immersed in a large quantity of bile, without any alteration of the parietes of the gall-bladder. No symptom indicated their presence, and deatb took place at different periods of the year, spring, sum- mer and autumn. IN PATIENTS WHO DIED OF OTHER CHRONIC DISEASES. 16S. In cases fatal from various chronic affections, princi- pally of the liver (perhaps chronic hepatitis), we have also found biliary calculi, with thickening and ulceration of the coats of the gall-bladder. These alterations were even a little more frequent in these diseases than in phthisis. The biliary calculi were not constantly accompanied by ulcerations, but we have never observed the latter when the former were not pres- ent in larger or smaller quantities. Calculi were also generally present when the mucous membrane was simply thickened. CHAPTER VI. SPLEEN. 169. If our ignorance of the functions of the spleen renders the study of its morbid changes less interesting than that of those of other organs, their number and frequency are at least calcu- lated to excite the zeal of observers ; and, on this account, we cannot but enumerate the results of our examination. The alterations observed, referred in general to its consistence and volume, or the development of accidental tissues. Chap. 6,] tuberculous; size. 115 170. The latter were two in number : one, the tuberculous, which existed in one fourteenth of the cases ; viz., seven times out of ninety instances, which were carefully examined (Obs. 6, 7, 9). The tubercles were very numerous, varying in volume between a hemp-seed and that of a filbert in one case. They were in all, with one exception, more or less round, yellowish, opaque, of a dull appearance, in allrespects similar to those in the lungs. They were not encysted, and the immediately surrounding tissue was healthy. In two patients, where they were the most numerous, various other parts of the body were affected, as the mesentery, neck, axilla, and even the brain (Obs. 9).* We have never observed the grey, semi-transparent matter conjointly with tubercles ; so that here again they appear to be tuberculous from the com- mencement. In the seventh observation the tuberculous matter had not its usually rounded appearance, and in other respects presented slight variations from what was observed in the others. The individual was a man, aged thirty-seven, whose disease had lasted five months, and in whom the spleen presented rather an increased volume ; it was partially ad- hering to the diaphragm, and wholly covered by a false, cartilaginous membrane, about a half a line thick. Beneath it, on the outer surface of the spleen, was a dull yellow-colored tissue, not evidently organised, very firm and resisting, very * The result of our own observations, from a residence of eight months in the Hôpital des Enfans Malades, at Paris, would lead us to suspect that the proportional frequency of tubercles in the different organs varied much in the infant and adult. The brain especially presented them much more frequently ; and when this was the case, with very few exceptions, we found tubercles in the spleen. Exact knowledge of the changes in the seat and characters of disease in different periods of life is an interesting and important subject for future researches. — Cowan. 116 PATHOLOGICAL ANATOMY. SPLEEN. [Parti, similar to chamois leather ; it had a lenticular conformation, four inches and a half in diameter, being thin at the edges, and about one inch thick in the centre. 171. The other description of morbid structure we have only met once ; it consisted of rounded, yellowish, shining, elastic, moist granulations, very different from tubercle, and irregularly interspersed through the parenchyma of a softened and enlarged spleen. 172. The volume of this organ was very variable ; much smaller than natural in fifteen individuals, while it was twice, three, four, or more times its usual size in sixteen others. We have endeavored to discover whether there was any relation between this increased volume and intermittent or continued fevers experienced by the patient at a period more or less anterior to death, and we arrived at a negative result. In the majority of individuals who had had intermittent or severe continued fever, this organ was very small ; we have only twice found it voluminous after the former, and once after the latter. 173. Its consistence was as variable as its size. In ten cases it was much firmer than usual, and in all, with one ex- ception, the ivhole of the parenchyma was equally affected. Increased density was most frequently connected with increas- ed volume. This was also sometimes combined with great friability. In eight out of ninety cases, the softening was equal to or even greater than that in typhus fever. IN PATIENTS WHO DIED OF OTHER ACUTE OR CHRONIC DISEASES. 174. To determine whether any peculiar influence could be ascribed to phthisis in the production of these various changes, they have been compared with analogous states in cases fatal from various acute and chronic diseases. In the Chap. 7.] URINARY organs; tubercles; cysts. 117 latter the increase of volume was in the same proportion as in phthisis, while its diminution was at once more considerable and more ^frequent. Out of one hundred and sixty cases where we are not including examples of typhus, in fifty the spleen was small. Among these, the decrease was very con- siderable in twenty-one instances, fatal from pneumonia, or some affection of the heart ; a result seemingly pointing out that the dimensions of the spleen are independent of embar- rassed cir'iulatlon. Softening was more frequent after acute than after chronic diseases ; very nearly coinciding with the proportions observed in phthisis. In none of these examples have we seen the spleen tuberculated. CHAPTER VII. URINARY ORGANS. 175. They very seldom offered any remarkable changes. We have frequently attentively examined the renal cap- sules, and the only alteration observed was, in two instances, a small quantity of unsoftened, tuberculous matter. We have never seen the latter in these organs in cases of chronic dis- ease, except in those of phthisis. 176. The Tcidneys, in three fourths of the examples, were perfectly sound, as to their consistence, color, and vol- ume. Sixteen times only out of ninety we have found them rather redder than natural. Three times their consistence was considerably increased. In four cases, small cysts were de- 118 PATHOLOGICAL ANATOMY. URINARY ORGANS ; [Part I, veloped (Obs. 19). In three they presented a certain quan- tity of tuberculous matter, and in one of these the alterations extended into the ureter. The great rarity of similar facts induces us to give the history of the instance to which we have alluded. FIFTH OBSERVATION. A BARBER, set. 24, of a scrofulous and delicate habit, born ol healthy parents, at the age of twelve years sprained the right foot. After the persistence of acute pains during two years, they ceased, recurring at distant intervals. Some fistulae, formed round the tibio-tarsal articulation, discharged during four years before we saw him, almost constantly, a certain quantity of pus. He had continued his business, and often walked considerable distances without inconvenience. He had coughed and expectorated a year and seven months, and was admitted into the hospital of La Charité, February 16th, 1822. At the commencement of the cough, some very acute pains in right side of the chest compelled the application of a large num- ber of leeches to the spot. There had been no haemoptysis, and the dyspnoea had existed very little more than six months. For more than a year the appetite had sensibly diminished, and during the last four months had altogether ceased ; the thirst was urgent and diarrhoea frequent. The patient did not re- collect having had perspirations ; he had complained of rigors the last fifteen days. On the 17th of February, extreme emaciation ; no head- ache, or pains in the limbs or loins ; intellectual faculties, clear ; speaking hurried ; voice, without huskiness ; breathing, rapid ; cough, rather frequent, and occasionally in paroxysms ; Chap. 7.] tubercles; cysts. 119 expectoration, scanty, greenish-colored and opaque ; percus- sion, every where clear; resonance of voice and pectoriloquy between the scapulœ, and under the right axilla. Skin, dry ; temperature increased towards the evening ; no perspiration or rigors the preceding night ; pulse, moderately frequent. Tongue, clean and natural on edges ; thirst, urgent ; very little appetite ; epigastrium, not painful ; occasional nausea after cough ; four liquid stools ; colic pains with flatus. In the succeeding days, some increase of the diarrhoea, but no sensible change in the other symptoms. There was a slight deafness from the 12th to the 15th of May, when death took place, preceded by delirium, the last twenty-four hours. Opening of the cor'pse thirty-six hours after death. Exterior. — Nothing worth noticing. (The brain was removed for anatomical purposes). Thorax. — Adhesions of the upper and posterior parts of both lungs to costal pleurae. A small, tuberculous excavation existed in the summit of the left lung, which offered in the rest of its extent, numerous grey, semi-transparent granulations, surrounded by healthy lung. By making a vertical section from the summit to the base, numerous rounded openings were seen, formed by the more or less thickened and uniform- ly dilated bronchia, their dilatation extending nearly to the surface of the lung. The same state of things existed in the right lung, where the excavation in the summit was small, the granulations in still greater number, and the bronchial dilata- tion more considerable than in the left ; heart, of moderate volume. Abdomen. — Mucous membrane of stomach red around the cardiac orifice ; some ulcerations in small intestine ; others of large dimensions in the cascum. The colon and other viscera, 120 PATHOLOGICAL ANATOMY. URINARY ORGANS ; [Part 1, with the exception of the right kidney, were heahhy. This -kidney presented its natural volume and situation ; it was of a light yellow color, nodulated in its upper third, and had noth- ing remarkable below. The corresponding ureter was hard to the touch, about four lines in diameter, diminishing both in size and density as it approached the bladder. The renal parenchyma was destroyed in the upper third, and replaced by a yellowish, opaque substance, in every respect tubercu- lous, lying on a false membrane of a similar nature. The latter was prolonged inferiorly, lining the pelvis and ureter, to the parietes of which it was firmly adherent. Consistent on its adherent, it became gradually soft and friable towards its free surface ; it was from half a line to a line in thickness, and firmer in the ureter than elsewhere.* 176. Most unaccountably we omitted to examine the blad- der ; we are, therefore, ignorant whether this tuberculous membrane was prolonged into its cavity. And although this does not appear probable, from the fact that the consistence and thickness of the ureter diminished on approaching the bladder, we shall refrain from any conjecture on the subject. 177. Of the two other cases, one was a young man, aged 18, of pretty strong constitution, generally in good health, not liable to colds, and who died of phthisis after an illness of seven months. Among other morbid alterations, we observed nu- merous ulcerations in both intestines, some tuberculous granu- lations, and atasnia in the portionof jejunum joining the ileum ; " Laennec mentions an instance where the ui'eters were " so much dilated as to receive the thumb, and their internal coat converted into an adhesive layer of tuberculous matter." These examples pre- sent an interesting variety in the mode of tubercular deposition. — Cowan. Chap. T.] TUBERCLES ; inflammation ; cause. 121 a great number of tubercles in the mesentery ; the two kidneys redder than natural ; and in the summit of the right was an oval tubercle, not encysted, about an inch in its greatest diameter, of a lemon yellow color and of good consistence. The other example was also a young man, of weak consti- tution, who died of phthisis five months from its beginning. The intestinal mucous membrane was perfectly healthy in con- sistence, color and thickness. No tubercles in the mesentery ; they were, however, numerous on each side of the lumbar vertebrae, around the upper margin of the pelvis and in the neck. One of the cones in the summit of the right kidney was converted into tuberculous matter, a little softened at the centre. The adjoining cone offered here and there a small quantity of the same substance. The intervening tissue was healthy. 178. In both these last instances we have carefully exam- ined the state of the mucous membrane of the bladder and ureters, and have found it free from alteration. We cannot, therefore, attribute the development of the tuberculous matter in the kidney to inflammation of this membrane. And, in the previous observation, how can we suppose the false membrane lining the pelvis and ureter, to have been the product of in- flamed lymphatic vessels, which by many medical men are considered the source of tubercles ? 179. The bladder, more or less contracted or distended, never presented any morbid alteration. We have even scarcely observed slight injection of its mucous membrane. IN PATIENTS WHO DIED OF OTHER DISEASES. 180. In nearly two hundred fatal cases of other diseases, we have carefully inspected the kidneys, without ever finding p 122 PATHOLOGICAL ANATOMY. GENITAL ORGANS ; [Part I the slightest trace of tuberculous matter. The other changes were the same with those occurring in phthisis. With two exceptions we have also constantly seen the mucous mem- brane of the bladder free from all alterations in these subjects. CHAPTER VIII GENITAL ORGANS. A RT I C L E I . MALE GENITAL ORGANS. 181. In the small number of instances in which we have examined the penis of phthisical patients, we have observed nothing worth remarking. But out of forty cases where the prostate, vesiculae séminales and vasa deferentia were scrupu- lously examined, three presented a greater or less quantity of tuberculous matter in the prostate ; and in one of these (the subject of the following observation), it occupied the prostate, vesiculse séminales and vasa deferentia. SIXTH OBSERVATION. A German tailor, aet. 24, of rather weak constitution, but little subject to illness, having a fair skin, light hair, regular shape and spare habit, was admitted into the hospital of La Chap. 8.] TUBERCLES IN THE PROSTATE, &;C. 123 Charité, October 27th, 1824. He had been ill fifteen days, and was attacked in the commencement of his illness, while in perfect health, and without any apparent cause, with a mod- erately copious haemoptysis, which, in spite of being twice bled, repose and abstinence, has since continued. A cough began at the same time, since which he has experienced a sense of heat and copious night perspirations ; the appetite had diminished, and thirst much increased. No burning sensation or pain in chest. 28th. Surface of body, including lips and tongue, pale ; pros- tration ; breathing, rather quick ; cough, rather frequent ; a por- tion of the spitting vessel was occupied by blood, more or less frothy, fluid and blackish ; percussion of chest, clear ; respira- tion, distinct, rather weaker under the clavicles than else- where ; pulse, weak, slightly accelerated, at ninety ; heat of surface, natural ; thirst, rather urgent ; appetite, much dimin- ished ; abdomen, not painful ; stools, rare. (Venesection of | viij. ; common emulsion for drink ; mus- tard foot-baths). The haemoptysis ceased entirely on the 30th, and did not again return. During the three following months, that is, until the 5th of February, 1825, the day of his death, the cough was usually very violent during the night; expectoration, copious, consisting at first of a clear fluid, but at the end of November, and during the following month, this was associated with sputa of an opaque and at times nummulated appearance. These were of greyish color, semi-vitrified, as it were, and scanty during the whole of January. On the 2d of December, respiration under the clavicles was coarse, but without any râle. This character was still more evident on the 9th of January, and in the an- terior and inferior half of the left side, and every where pos- 124 PATHOLOGICAL ANATOMY. GENITAL ORGANS ; [Part I, teriorly, the respiratory murmur was mingled with a quite fine crepitation ; the percussion there remained constantly clear. On the 25th, there was very great dulness of sound about three inches under the left clavicle, and in the same region well marked pectoriloquy. From the middle of January the dyspnœa was considerable. No pains were complained of in the larynx or in the region of the trachea ; the voice became changed only eight days before death. Slight acceleration of the pulse during the months of No- vember and December, which afterwards increased, and from the 15th to the 20th of January it varied from ninety-five to one hundred and ten. The heat increased proportionably ; constant night sweats, which were in general limited to the upper part of the body ; there were also some irregular rigors during the last month. Very shortly after the entrance of the patient into the hospital his appetite increased, and he took more food, so that by the end of November and the following month, he ate a fourth or half of the usual house allowance. Stools rare, bowels open- ed by eneraata of flaxseed tea, during the first two months ; the evacuations then became frequent and fluid. No colic, nausea or vomiting ; thirst always urgent. After the diarrhoea commenced the debility rapidly increas- ed ; and during the last twenty days the patient was confined to his bed. There was slight delirium a few hours before death, coming on at four, p. m. A blister was applied to the left arm from the beginning of December, and from the same time frictions of the bydrio- date of potash every morning in each axilla were employed to within a few days of death. Chap. 8.] TUBERCLES IN THE PROSTATE, StC. 125 Opening of the corpse forty Jiours after death. Exterior. — Almost extreme emaciation without œdema. Head. — Very trifling infiltration beneath the arachnoid ; some white, opaque, miliary granulations attached to this membrane along the longitudinal fissure ; a spoonful of limpid fluid in the left lateral ventricle ; rather less in the right ; two more in the lower occipital fossae. Immediately below the pons varolii and in the substance of the medulla oblongata, there was a tubercle, about the dimensions of a middle-sized pea, neither encysted nor softened, and round which the medullary substance was healthy. The remainder of the cerebral mass was sound. Neck. —The epiglottis had nothing unnatural about it. There was a deep, round ulceration, one line and a half in di- ameter, at the junction of the vocal cords. Lower portion of tracheal mucous membrane slightly reddened, but of natural thickness and consistence. Thorax. — From four to five ounces of clear fluid in each of the pleurée. A white, narrow band extended from the costal pleura to the summit of the left lung, where it terminated in a point corresponding to a tuberculous excavation. The whole of the upper lobe was indurated, and offered numerous yellow spots at its surface, and two small cavities in its summit ; every where else there was an almost infinite number of irreg- ularly shaped tubercles, varying in size from that of a pea to a hazel-nut, frequently confluent, and occasionally softened or incompletely excavated. They were less numerous in the lower lobe, where none of them were softened. Nearly all were surrounded with hepatized pulmonary tissue. The inferior lobe of the right lung was slightly engorged, but presented no tubercles. The latter were also less numerous 126 PATHOLOGICAL ANATOMY. GENITAL ORGANS ; [Pai't I, in the upper lobe of this lung than in that of the left ; none -of them were softened. In neither lung could we detect the grey,' serai-transparent matter. The broncliia were of a uni- form pink tint. Heart, small and healthy ; aorta, natural. Abdomen. — The stomach contained a large quantity of green bile and a little thick tenacious mucus. Its lining mem- brane was of a yellow color, and much softened in a small portion of the great cul-de-sac. In an elongated surface of from five to six square inches along the great curvature, it was mamillated, of a greyish red, more than half a line thick, and evidently raised above the surrounding parts. Elsewhere it was sound. The condition of the raucous membrane of the small intestine, in its upper third, was healthy ; it presented some transverse ulcerations in the middle third, and in the lower portion, some longitudinal and elliptical ulcerations, similar in shape to the patches in which they were situated. The transverse ulcerations did not encircle the intestine ; they were from an inch to an inch and a half wide in their centre, gradually narrowing at either extremity. The corresponding mucous membrane was completely removed, and the ulcerated surface very uneven, owing to the thickened and partially destroyed submucous layer. Their edges were prominent, of a reddish and yellowish tint, in consequence of the presence of numerous softened tubercles in the substance of the submucous tissue. Externally the portion of intestine corresponding to the ulcerations, was more or less greyish or violet-colored, pre- senting inequalities caused by tuberculous granulations situated between the peritoneal and muscular tissues. The longitudi- nal ulcerations were not complete ; that is, the mucous mem- brane was only partially destroyed. Their surfaces were uneven, like those of the previous patches, both from this cause and in consequence of a number of strips formed by Chap. 8.] TUBERCLES IN THE PROSTATE, &;C. 127 the mucous membrane. The intervening mucous mem- brane was healthy. It was pale, thickened, and of the con- sistence of mucus, throughout the whole of large intestine. The caecum and right lumbar colon offered five small, ir- regular, tuberculated ulcerations, leaving the muscular coat exposed. The mesenteric glands were increased in vol- ume, and almost wholly tuberculous; this was also the case with many of the mesocaecal and also of the right mesocolic glands. Liver, pale and slightly adipous ; the bile of the gall-bladder very thick and very dark-colored. The spleen contained ten or twelve tuberculous granulations of the size of a green pea, and its tissue was redder than natural. Kidneys and bladder, healthy. The prostate presented its usual volume, and was almost entirely converted into tuberculous matter, which was not softened. The vesiculas séminales were rather voluminous^ indurated, and filled with very firm, tuberculous substance, divided into masses by the natural cellular intersections of the part. These intersections were indurated, greyish-colored, more than half a line thick, and resembling the external cov- ering of the vesiculae. From their junction, and for about three inches farther, the vasa deferentia were about two lines in diameter, and offered the resistance of a tense cord. At the end of this distance they decreased ; their parietes were twice their usual thickness, opaque, like those of the vesiculœ and their cavity, filled, in the space indicated with firm, un- softened, tuberculous matter. Beyond this all was natural.* * These rare examples of tuberculous deposition on mucous mem- branes are^remarkable, we think, from the surface on which it took place, and not from any peculiarity in the mode of its formation. The structure of the parts enabled us here to see the mechanism, as it were, of morbid pro- ducts, which we are inclined to believe is similar to what takes place in all 128 PATHOLOGICAL ANATOMY. GENITAL ORGANS ; [Part I, 128. Without fixing our attention upon every point of this observation worthy of interest, we will observe that the form and internal anatomical arrangement of the vesiculce séminales were not destroyed ; that there was no transformation of tissue, but a simple development of tuberculous matter ; that this development was the product of a morbid secretion in the vesiculae and vasa deferentia, such as took place in the ureter, which we have described in the preceding chapter. We would remark, likewise, that these facts are very analo- gous to the cases of tuberculous peritonitis we shall shortly describe, and that they are contrary to the opinion of those who consider tubercles as the products of the inflammation of the lymphatic vessels (178). 183. Another circumstance merits to be remarked ; viz. that the tuberculous matter, elsewhere deposited than in the lungs, as in the spinal marrow, layers of the mesentery, spleen, prostate, &;c., was every where at the same stage of develop- ment, not yet softened ; which seems to indicate the existence of a common cause acting at once on all these points. IN PATIENTS WHO DIED OF OTHER ACUTE AND CHRONIC DISEASES. After other acute and chronic diseases, we have never ob- served tubercles in the prostate, vesiculae, séminales, or vasa deferentia. our tissues ; viz. production of something not previously existing, gradually destroying the natural structure, but not resulting from its transformation. — CowAW. — See Carswell on Tubercle. Illustrations of Pathological Anat- omy. London. — H. I. B. Cîiap. 9.] VAGINA, UTERUS, OVARIES/ 129 ARTICLE II. FEMALE GENITAL ORGANS. 184. With the exception of their size, they were almost always natural. The color of the vagina was either white, pink, or livid, and this nearly in the same proportion as in cases fatal from various other diseases ; it did not seem to depend upon the more or less embarrassed state of the circu- lation. In no instance have the parietes of the vagina pre- sented any organic lesion. 185. The uterus was generally diminished in volume. As in other diseases, we have often observed some soft, small, pale-colored polypi in the cavity of the body or neck. Occa- sionally fibrous bodies of inconsiderable volume were devel- oped in the wall of the uterus, at a variable distance from its peritoneal covering. In one case, we found the most super- ficial layers of the internal surface of the fundus and neck, for about a line in depth, transformed into tuberculous matter (Obs. 32), and immediately beneath this, surrounded by healthy, structure, some yellowish miliary granulations of the same nature. In this patient the menstruation had continued regular to within three months of her death ; we may, there- fore, presume that the development of the tuberculous matter took place subsequently to that period. We have twice observed a small quantity of the same sub- stance in the ovaries. These frequently presented serous cysts usually of small volume, and in nearly the same propor- tion as after other chronic diseases. 130 PATHOLOGICAL ANATOMY. PERITONEUM ; [Part I, IN PATIENTS WHO DIED OF OTHER CHRONIC DISEASES. 1S6. We have found tuberculous matter in the uterine parietes only in cases of phthisis ; while the other alterations were nearly equally frequent in this and in other chronic affections. CHAPTER IX PERITONEUM. 187. There were many examples of serous effusion into the peritoneum. We have observed it (varying from one to eight quarts) twenty-two times, that is, in one fifth of the cases. The men were equally affected as the women ; and it v/as not more frequent where the liver was adipous and the mesentery tuberculous than when these alterations were not present. 188. Besides the effusion, we found occasionally a yellow- ish, soft, false membrane, and a certain quantity of thick pus, inodorous, such as exists in acute abscesses (Obs. 4, 16, 31). This double alteration was present in four cases, and could only be the result of an acute peritonitis ; and the symptoms observed during life proved that the inflammation was devel- oped a few days, or more frequently only twenty-four hours before death. The fourth and sixteenth observations confirm the truth of this assertion. In another instance (Obs. 31), peritonitis ap- peared to have come on likewise during the last twenty-four Chap. 9.] MEMBRANES AND ADHESIONS. 131 hours. We did not observe the symptoms, but feel entitled to attribute to it the extreme restlessness experienced by the patient the evening preceding death, and which was remarked by the attendants in the ward. These few facts show that the peritoneum, like the other organs, is susceptible of acute inflammation in the last periods of phthisis, and that the symptoms of it are very often similar to those which it excites under very different circumstances. 189. Old cellular and partial adhesions were present in three cases; in a fourth they were universal (Obs. 14), result- ing from a chronic peritonitis experienced by the patient two years and a half before death. 190. In another instance (Obs. 48), we have seen on the surface of the peritoneum, covering the great omentum, nume- rous semi-transparent, miliary granulations, as if lying embed- ded in an incompletely opaque false membrane, and they were raised with it. We have also found between the layers of false membrane, covering the intestines and the anterior pa- rietesofthe abdomen, patches of tuberculous matter of various dimensions (Obs. 32). Lastly, in a very remarkable instance which we shall now relate, we have seen the same matter de- veloped in the omentum and mesocolon. SEVENTH OBSERVATION. A BONNET maker, aet. 27, of a weak constitution, a month in Paris, was admitted into the hospital of La Charité, April 7th, 1824, and stated that he had been ill five weeks. His illness commenced after a severe wetting, while upon his journey, and was marked by cough, expectoration, rigors, and 132 PATHOLOGICAL ANATOMY. PERITONEUM ; [Part I, partial diminution of appetite. These symptoms persisted ; the thirst became considerable and anorexia complete. The shiverings returned from the slightest cause ; the cough had much increased the last eight days, and he had since been sensible of dyspnœa. Weakness was present from the com- mencement, and soon accompanied with swelling of the legs. The patient had not, however, kept his bed ; he took a little exercise everyday, and had not felt any pain in the abdomen. On the 8th of April, face, pale ; slight oedema round the ankles ; considerable loss of strength ; the sputa were greenish or yellowish, partially opaque, mingled with others of a greyish color, semi-transparent, and as if vitrified ; cough, rare ; con- siderable oppression ; speaks hurriedly ; a mucous râle pos- teriorly and principally in the left side, from the summit to the base of the lung ; percussion, clear ; pulse, somewhat ac- celerated ; heat, moderate ; tongue, dry, rather red : mouth, clammy ; thirst, urgent ; anorexia ; abdomen, tense, elevated, every where rather clear on percussion and not painful ; how- ever, at moments the patient complained of slight uneasiness. Bowels costive. (Decoction of the triticum repens with oxymel and nitre ; two enemas of parietaria ; gum potion ; two rice creams ; broth three tim.es daily.) The same symptoms continued with variable intensity until death, which took place on the 29th of August. Their in- crease was gradual, almost unperceived ; the cough, generally very feeble ; expectoration, never abundant, and not varying in its characters from what we have already described. On some days the patient neither coughed nor expectorated. During the last three months the lower two thirds of the right side of chest were completely dull ; the respiratory murmur, very distant and obscure in the same part ; there was an oc- Chap. 9.] TUBERCULOUS MEMBRANES ; ADHESIONS. 133 casional crackling sound under the corresponding clavicle. To the left the respiration was a little weaker in the latter region than in the lower portion of the same side, occasionally min- gled with a mucous râle, and now and then with a slight indistinct crepitation. For the first fifteen days the pulse was rather accelerated ; it afterwards became calm, and again more frequent towards the fatal termination ; it was always weak and regular. The increased temperature varied with the state of the circulation, and ceased when the pulse became natural in frequency. It was seldom observed at night, and perspirations were still more rare. The tongue was almost constantly red and dry during the whole of these four months ; a small ulceration near its point and on the right side was observed during the last few days. The thirst diminished with the decrease of febrile movement, and re-appeared, though slightly, with its augmentation. After some days of abstinence the appetite returned, and the desire for food afterwards was urgent, but some rice creams (crèmes de riz) and a little milk were alone permitted. Nau- sea, rare ; no vomitings. Abdomen, rnore or less voluminous, with occasional uneasiness. No colic pains at any time. Diarrhœa came on at the end of May, persisted in the begin- ning of June, then ceased, returned at different intervals, and was very copious during the last twenty days. The countenance lost speedily the slight color which it had and became pale and slightly yellow. The patient felt wearied by the duration of his illness, without, however, suf- fering much disquietude ; he spoke only of the increased size of the abdomen, which incommoded him, and which he ascribed to flatulence. Rapid emaciation, very gradual de- crease of strength, so that to the last day he perambulated the 134 PATHOLOGICAL ANATOMY. PERITONEUM ; [Part I, wards of the hospital. The tendency to sleep increased with the weakness. On the 29th of August, at nine, p. m., he rose for the purpose of placing himself on a night-stool, and had scarcely done so, when he fell back against the wall. He was lifted into bed, and in a quarter of an hour afterwards again rose, was assisted in lying down by the nurse, and at half past nine expired without a struggle. The treatment consisted in the use of demulcents, slight diuretics, and weak astringents. Opening of the corpse thirty-four hours after death. Exterior. — Universal emphysema, especially of the neck and lateral parts of trunk, accompanied with bullae, contain- ing a violet-colored fluid. The arms, though crepitating on pressure, were very small, so extreme was the ema- ciation. Head. — Two small spoonsful of clear fluid on the upper portion of the arachnoid ; a larger quantity in the occipital fossas. Very slight sub-arachnoidean infiltration. Brain, rather soft ; consistence of septum lucidum and inferior surface of fornix almost pulpy. About a spoonful of serum in each lateral ventricle. Neck. — Epiglottis and larynx, healthy. Mucous mem- brane of the trachea, of a livid pink color, of natural thickness and consistence. Chest. — Left lung, without any adhesions, of a dirty grey color, interrupted by whitish spots, corresponding to masses of grey and tuberculous matter, which were larger and more nu- merous in the upper than in the lower lobe. There was no ex- cavation, and the surrounding parenchyma was healthy. The right lung presented the same lesion, and its two lower thirds were covered by a false membrane, united to one lining the Chap. 9.] TUBERCULOUS OMENTUM. 1.35 costal pleura, by means of filaments, enclosing in their inter- stices about ten ounces of clear serous fluid. The bronchia were thin and of a yellowish red tint. The heart was of usual dimensions, containing a small quantity of pale, frothy blood. Its parietes were flaccid ; both ventricles thinner than natu- ral ; the left was only three lines thick. They were so supple that at first sight the muscular fibres seemed separated one from another by a certain quantity of air, but this was not really the fact. Abdomen. — Its anterior parietes adhered to the subjacent viscera, by means of cellular filaments of various lengths. The omentum covered the greater part of the small intestine, forming a mass from twelve to fifteen lines thick, uneven, alternately yellow and blueish in color, composed of the tuber- culous and purplish-grey, semi-transparent matter. The former occupied four fifths of the mass, and was no where softened. The mesocolon and mesorectum presented the same alteration, but were only half as thick as the omentum. The greater number of the mesenteric glands were tuber- culous. The liver adhered to the diaphragm by means of a false membrane easily separated. It was of a deep yellowish- brown color, of very moderate volume, exceedingly soft, and its specific gravity so inconsiderable, that it floated in water like a healthy lung. Internally, there was an infinite num- ber of cavities, varying in size, from a hemp-seed to that of a pea, and rather empty than full. The bile in the gall-bladder, clear and scanty. The spleen, rather larger than usual. Its peritoneal covering detached in its inferior half, formed a sack containing at least two ounces of a blackish fluid. Its tissue was quite soft and similar in color to the fiuid just mention- ed. Kidneys, natural. Stomach, partially covered by a false membrane. Although the organ was remoyed with the great- 136 PATHOLOGICAL ANATOMY. PERITONEUM, [Part I, est possible care, it offered, to the left of the cardiac orifice, a circular perforation with pale and thin edges. But from the absence of effusion, we ought to conclude that the perforation was the result of slight mechanical force, and did not exist during life. Internally two very different appearances were present. Near the pylorus, and extending to some distance, the mucous membrane was greyish, mamillated, of good con- sistence, and in twenty points more or less near, incompletely destroyed over a surface of two lines ; elsewhere it was of a nearly white or light brown color, and extremely soft and thin ; the corresponding layers were easily torn. The mu- cous membrane of the small intestine every where pale and soft like mucus ; that of the colon rather less so. No ulcer- ations in either intestine. 191. This observation is interesting on several accounts. With regard to the tuberculous matter, it presents a solitary example, in our own experience, of its equal development in parts which were examined in the lungs, mesentery^ omen- tum, &;c. Sic, while in all our other observations, it was always further advanced in the lungs than any where else. The thoracic and abdominal symptoms were in harmony with the morbid condition of the organs. The union of a certain quantity of the bluish-grey and semi- transparent matter with the tubercular in the omentum, is an additional argument in favor of their mutual connexion. 192. In many cases of sudden death, after acute diseases, (n)ore especially the eruptive), we have seen subcutaneous emphysema universal, but rarely so considerable as in the present instance. It is the only example we have met among chronic affections ; and we have never before observed it in the hepatic parenchyma. The volume of the liver rather less Chap. 9.] TUBERCULOUS OMENTUM. 137 than natural, appears much more remarkable than the emphy- sema. For, supposing the latter to have taken place either a short time after or before death, the liver must have previous- ly been extremely small ; and, as we possess no example of a liver so diminutive as this supposition would infer, we are almost forced to conclude that the emphysema was gradually developed long before death, in consequence of some peculiar but unknown alteration of the parenchyma. 193. The flaccidity, the elasticity, the inconsiderable thick- ness of the left ventricle of the heart, form also a singular combination of circumstances, and to a certain point assimilate the state of this organ with that of the liver. We have never found the substance of the spleen more completely softened, and it is the first time we have observed its peritoneal cover- ing partially detached. The morbid alteration of the mucous membrane of the stomach, small intestine and colon could scarcely be more considerable; yet notwithstanding such universal and severe disease, the patient complained of no pain, was almost without fever, and death was still unex- pected. 194. In the two preceding chapters we have seen the tuberculous matter deposited on the surface of mucous mem- branes, in the ureters, vesiculse séminales, and vasa deferentiaj that is, developed by means of secretion or exhalation. A similar process no doubt took place in the present case in the great omentum, and also where masses of tuberculous matter were found between the layers of false membrane which lined the cavity of the abdomen. It is even probable that these are not rare examples, and that exhalation is one of the most frequent means employed by nature for the production of tuberculous matter. We are the more inclined to believe s 138 PATHOLOGICAL ANATOMY. PERITONEUM. [Part 1, this, since exhalation is also a source of other morbid pro- ductions equally fatal, as, for instance, that of cancer de- veloped on the free surface of the peritoneum. IN PATIENTS WHO DIED OP OTHER CHRONIC DISEASES. 195. After various other chronic diseases, we have seen several cases of serous effusion into the peritoneal cavity. Excluding diseases of the heart, in which this is so frequent, we have found it sixteen times out of seventy-seven cases ; nearly therefore in the same proportion as in phthisis. Acute peritonitis, coming on shortly before death was present in four cases, three of them cancerous affections of the uterus, one a case of dysentery. But in no one of these seventy-seven cases* have we met either tuberculous peritonitis, or grey, semi-transparent granu- lations on the peritoneum, or in layers of false membrane on its surface. These results concur with the preceding facts in pointing out the analogy between the tuberculous and the grey, semi-transparent matter, both of which appear confined to phthisis. * Up to the present moment M. Louis has not found a single exception to this law. Vide Examen, de l'Examen, page 24. — Cowan. Chap. 10.] BRAIN AND ITS MEMBRANES. 139 CHAPTER X. BRAIN AND ITS MEMBRANES. 196. Though in phthisis, the cerebral functions are undis- turbed, and in general continue so to the last moment of exist- ence, we have, however, in the majority of cases, found some alteration in the brain, or in the parts connected with it. We shall successively describe them. 197. In patients advanced in age, the dura mater was more or less adherent to the saggittal suture and its vicinity ; it frequently presented near the longitudinal sinus, or at a con- siderable distance from the same part, lacerations from two to four lines in length. These gave passage to some round, white, opaque, or semi-transparent bodies, of uniform struc- ture, about a line more or less in diameter, and two, three, four, or sometimes more in number ; at the edge of the lacerations, the dura mater was divided into two laminae for a small space. Occasionally the internal layer of the skull was thinned or de- stroyed in the corresponding point to the extent of one or two lines. These bodies were more or less adherent to the aper- tures in the dura mater, and less frequently present in young subjects than in patients more advanced in age. 198. They were attached to the upper surface of the arach- noid covering the brain, and seldom to the layer lining the dura mater ; they were almost always present, whether the latter membrane was or was not perforated. They were never farther than two inches from the median line, and in- creased in number as they approached it. Their volume varied 140 PATHOLOGICAL ANATOMY. BRAIN; [Part I, from that of a millet-seed to a green pea. They were either in groups, forming more or less rounded or irregular looking patches, or disseminated, closely attached to the arachnoid, which was always thickened and opaque in the corresponding points. This fact and the occasional absence of the pretended glands of Pacchioni, induce us to consider them as morbid productions. We shall hereafter mention them under the name of " arachnoidean granulations." 199. In some other instances the arachnoid was thick, opaque, and free from granulations. In two cases this double lesion occupied the whole of its upper surface. In two others we found fragments of a yellowish and extremely soft false mem- brane. This was evidently very recent, and proves that the arachnoid, like other serous membranes, is liable to acute in- flammation during the last days of life, when emaciation and weakness are extreme. 200. Five times out of ninety-nine cases, there was in the upper part of the arachnoid a little limpid or reddish serosity, from three to five small sponsful (Obs. 7, 12, 16, 22, 28). Much more frequently, and in about one half of the examples, we found in the inferior occipital fossae one or two spoonsful of the same fluid ; and whenever we have opened the spinal canal there was a still larger quantity. 201. In three fourths of the cases, beneath the upper por- tion of the arachnoid, there was a more or less considerable serous infiltration, which we shall call subarachnoid infiltration. When very partial, it generally occupied the posterior half of the region we have mentioned. If more abundant, it existed every where, both in the interstices, and on the surface of the cerebral convolutions, and when very considerable, it tvas three quarters of a line thick over the latter. The thicker it Chap. 10.] EFFUSION INTO VENTRICLES. 141 was the more easily the arachnoid and pia mater could be detached. 202. In twelve cases, or about one eighth, we found the pia mater more or less red, thick and injected. In six of these the injection extended to the medullary substance of the brain. 203. Serous effusion into the lateral ventricles was equally frequent with the arachnoidean infiltration (204), and in gen- eral proportionate to it. The quantity varied from one to five spoonsful in each ventricle. The serous fluid was generally limpid, and we have never found it turbid except in three subjects, and in no one did we detect any alteration in the structure of the arachnoid, or of the corresponding cerebral substance. We may also observe, that the effusion was ex- tremely slight in cases of sudden death, favoring the supposi- tion that in the majority of instances it was principally pro- duced during the last struggle. Except in one of the cases in which the fluid was turbid, we have not observed any characteristic symptoms. 204. We have seen three times, in the septum lucidum, about a spoonful and a half of limpid, serous fluid, and in these cases the subarachnoidean infiltration, and the effiasion of fluid into the lateral ventricles were proportionably considera- ble, and had attained the limits we have mentioned above. The parietes of the septum were firmer than usual, and the arachnoid lining them seemed thickened. 205. The cerebral substance presented various alterations. Fourteen times out of ahundred and one, it was more or less injected. In five it was much softer than natural, and in one it presented the consistence of the brain of a new-born infant. In a sixth case the softening was bounded to the left hemi- sphere. In these different examples the duration of phthisis 142 PATHOLOGICAL ANATOMY. BRAIN ; [Parti, varied from seven months to five years. We have six times observed the pulpy softening either of the fornix, septum lucidùm, or the corpora striata (Obs. 2, 7, 15, 25, 26), and, with the exception of the latter, without any change in the color of the softened tissue. IN PATIENTS WHO DIED OF OTHER DISEASES. 206. These different modifications of the brain and its membranes were not pecuhar to phthisis. We have encoun- tered them after a variety of other diseases. The granula- tions of the arachnoid and lacerations of the dura mater were nearly equally frequent as in phthisis. In one hundred and fifteen cases, excluding apoplexies, softening of the brain, and typhus, there were sixteen examples of a slight clear or turbid serous effusion over the upper portion of the arachnoid. This effusion was rather more frequent after chronic than acute dis- eases. Nine times out of an equal number of cases, we have remarked a more or less extensive thickening and opacity of the superior portion of the arachnoid. Four times there were some fragments of thin, soft, and yellowish false membranes- The subarachnoidean infiltration was present in two fifths of the cases, and quite as much in quantity in fatal and prolonged acute affections, as in those more essentially chronic, as in cancer, for example. The pia mater was more or less thick- ened, red and injected fourteen times ; an almost similar pro- portion to that of phthisis, but much less frequently so than in cerebral diseases or typhus, in the proportion of two to seven. In these various circumstances the brain was more or less injected; effusion into the lateral ventricles was very fre- quent ; we have remarked it ninety-two times, in different degrees, within the limits mentioned for phthisis, and it was Chap. 10.] HYDATIDS AND TUBERCLES. 143 almost always proportionate to the subarachnoidean infiltration. In cases of sudden death the quantity of effused fluid was hardly equivalent to two or three cofFee-cup spoonsful, which fact seems to confirm what we have previously stated in relation to the period at which this effusion seems to take place in the majority of instances (203). In fifteen cases the consistence of the brain was remarkably diminished, although less so than in those instances of phthisis already mentioned. Two only were acute cases ; and as the number of the latter, compared with chronic diseases, was as forty-five to seventy, we may conclude that softening of the cerebral substance is chiefly confined to protracted cases. Lastly, we have observed six examples of partial and almost pulpy softening of the brain, all subsequent to chronic affections. Thus whether the softening of the brain was either general and slight in amount, or partial and pulpy, it was almost ex- clusively confined to chronic cases, from which coincidence we may suspect that both these species of softening are some- times analogous in their nature. The morbid changes observed in the brain, and parts con- nected with it, are then equally common after phthisis and other chronic affections. Many of them frequently existed after prolonged acute diseases ; only varying in their relative proportion. 207. The only lesions we have remarked exclusively in the brain of phthisical patients, are hydatids and tubercles. We do not consider hydatids as peculiar to phthisis, but from what has been hitherto observed, we are inclined to be- lieve that this is the fact with regard to tubercles. We have already met one example of tubercles in the medulla oblongata (Obs. 6) ; we will relate a similar one relative to 144 PATHOLOGICAL ANATOMY. BRAIN ; [Part I, the brain and cerebellum, after having first detailed the only case of hydatids in the brain we have observed.* * It may be remarked here, that our author relates no instance of hydatids in the lungs, and can merely infer their connexion with tubercles from their occasional co-existence+ together. The fact is not without interest, as indicating a state of constitution favorable to both these productions, and strengthening the idea that there is nothing specific in phthisis, but that it depends on a generally deteriorated state of health. The opinions of Dr. Baron, in his work on Tuberculous Affections, and of M. Dupuy in his Traité de l'affection Tuberculeuse, that hydatids and tubercles are identi- cal, are too irreconcilable with facts to merit discussion. They are very frequently associated together in the pig, which has probably been the source of the idea of their being modifications of each other. Andral has only met them four or five times in six thousand cases. — Clinique Med. vol. iii. page 393, — Vide also Precis. d'Jlnatomie Pathol., page 408. — Laennec, page 298, note by Translator ; also page 373, Op. Cit. — Cowajv. t 1 did not mean to point out on any occasion a change of translation which I had made, but on the present one I find it necessary to deviate from this rule, because in his version the translator has, in my opinion, misinter- preted our author, and has added the note which, were I to publish it with- out comment, would still farther lead to error. The following is the original French of the paragraph 207. " Les seules altérations que nous ayons ob- servées exclusivement dans le cerveau des phthisiques, sont des hydatides et des tubercles. Nous ne considérons pas les hydatides comme une lésion propre à la phthisic, mais ce qui a été dit jusqu'ici, doit porter â croire que ce caractère appartient aux tubercules. Nous avons déjà vu un example de cette lesion dans la moelle allongée (Obs. 6)," &c. Dr. Cowan translates the passage thus. " The only lesions we have remarked exclusively in the brain of phthisical patients are hydatids and tubercles. We shall not con- sider hydatids as peculiar to phthisis, but from what has hitherto been ob- served we are inclined to believe them intimately connected with tubercles. We have already met with an example in the spinal marrow (Obs. 6)," &,c Now if the reader will compare the original with Dr. Cowan's translation, he will perceive that not only has the translator given a wrong meaning to the passage, but in so doing has attributed to Louis an opinion which the words of the original by no means authorise. Louis says nothing about the intimate connexion of tubercles and hydatids. Andral, in five cases of hy- datids, found in one alone tubercles connected with thein. — Clin. Med. vol. iii. page 403. — H. I. B. Chap. 10.] HYDATIDS AND TUBERCLES. 145 EIGHTH OBSERVATION. A STONE-CUTTER, Eet. 54, of Spare habit, sober, industrious and seldom ill, had been subject for more than three years to sore throats, which lasted from twenty-four to thirty-six hours ; for a still longer period he had been liable to slight diarrhoea, coming on every month, continuing a day or two, and not ac- companied with colic. Six months before entering the hos- pital, he was suddenly seized, without any apparent cause or previous cough, with hœmatemesis, to the extent, he said, of two quarts ; and some days after he passed a large quantity by stool. He had kept his bed several days afterwards, and during three months could not continue his occupations. Cough and expectoration had commenced with the hae- morrhage or shortly afterwards ; rigors, succeeded by heat and perspirations, had come on during the last two months, and since the same period the respiration had been very laborious. The appetite had diminished ; meat was disliked from the commencement ; thirst, always very moderate ; no pains in the chest or diarrhœa. On the 26th of November, 1822, the day after his admis- sion, weakness, not extreme ; no headache ; intelligence, active ; respiration, easy, with little heaving of the chest ; imperfectly defined pectoriloquy between the vertebral col- umn and the supra spinous fossa ; respiration, coarse and loud in the same region, elsewhere, natural ; cough, not frequent ; expectoration nummulated, surrounded by a viscous transpar- ent fluid ; some shooting pains in the lateral parts of the chest ; voice, rough and discordant, as it had been during the last T 146 PATHOLOGICAL ANATOMY. BRAIN; [Parti, month. Sensation of rawness in the larynx during cough or deglutition. Temperature, natural ; pulse, calm, regular, un- der seventy. Tongue and appetite, natural 3 little thirst ; de- glutition, difficult, although the pharynx and amygdalas were perfectly healthy ; the whole of the abdomen sluggish ; had one stool of moderate consistence the preceding evening. (Decoction of lich. island; pectoral infusion for drink; gum potion ; a fourth of house allowance. Four ounces of wine.) The following month, slight general improvement ; he felt better and was free from rigors ; aphonia, occasionally com- plete. The appetite increased, and he had his food doubled. From the 24th of December to the 31st of January, the day preceding his death, his intellectual faculties remained unaffected, he slept little, had no headache, but became very gradually weaker. The degree of aphonia was variable ; there was a constant pain immediately above the thyroid cartilage, with sense of heat, especially at night ; swallowing the saliva caused pain ; natural state of pharynx and amygdalae ; increase of cough and dys- pnoea during the first ten days of January ; these diminished after the 15th, when the expectoration became more opaque. At the same time there was a somewhat acute pain corres- ponding to the left mamma, without distinct alteration of the clearness of percussion in the same region. Under the left clavicle, to the extent of five inches, there were tracheal res- piration and gurgling râle ; this was equally the case posteri- orly in the corresponding point, though over a less extent of surface. On the right side there was a mucous râle. The pulse continued slow ; the rigors returned during the evening, followed by heat and perspirations. From the 26th to the 28th of December, violent colic pains, Chap. 10.] HYDATIDS AND TUBERCLES. 147 succeeded by copious diarrhosa, lasting from the 2d to the 10th of January ; entirely ceasing from the 16th to 17th, and after- wards reduced to two or three stools in the four and twenty hours. Tongue, constantly natural ; epigastric region, free from pain ] diminution of appetite from the commencement of diarrhœa. 31st. Sudden increase of debility; face, very palej he complained of a very unpleasant feeling of weakness in the epigastrium ; on percussion, under left clavicle for three inches, perfect flatness ; sputa, greenish and greyish, with a slight pink tinge on edges, and of the consistence of pea-soup. Pulse, calm and regular ', there was slight delirium during the night, and death took place at three, a. m. Food was given proportionately to the appetite and state of the alimentary canal . At the commencement of the diarrhoea, rice water, sweetened with quince syrup, was prescribed ; afterwards, the diascordium, with a grain of opium, in eight ounces of infusion of cachou, as soon as it became consider- able. Opening of the corpse twenty-nine hours after death. Exterior. — Nothing remarkable. Head. — Strong adhesions of the dura mater to the sagittal suture. No infiltration beneath the arachnoid. On the upper part and sides of the brain, beneath the pia mater, there were observed about twenty small vesicles, elevated about a line or a hne and a half above the level of the convolutions, while the rest of their substance was imbedded in the cerebrum, which was perfectly healthy immediately around them. Their form was rounded, and they were of different dimensions. Three among them equalled in size a common hazel-nut ; they 148 PATHOLOGICAL ANATOMY. BRAIN; [Parti, ■were smooth exteriorly, and each had a pedicle, from which a \Yhitish and opaque membrane, only partially covering the hydatid, seemed to radiate. The latter was formed by a soft, thin membrane, containing a fluid which gave a cloudy ap- pearance to water. The other hydatids had the same struc- ture, but were a little larger, more opaque, and their surfaces were more or less rough, giving them somewhat the aspect of a mulberry. Brain, much injected ; lateral ventricles, pons varolii and cerebellum, natural. Neck. — Total destruction of the mucous membrane on the laryngeal surface of the epiglottis ; the edges of the ulceration ratherthick, indurated and whitish; the bottom, rugged and pink colored. Two small, superficial ulcerations above the supe- rior vocal cords, of which the left was almost entirely destroy- ed ; the circumference of the ulcer was greyish, and indurated like lard. Mucous membrane of the trachea, red and shghtly thickened inferiorly ; that of the bronchia still redder ; both were free from ulceration. Chest. — On the left side, rather less than a quart of dirty red-colored fluid, enclosed by a false membrane, which covered the lung ; diaphragmatic and costal pleurae of a florid red inter- nally, and about half a line thick. At the summit of the upper lobe was a large excavation, lined by a semi-cartilaginous false membrane, reposing either on healthy pulmonary tissue, tuber- cles, or small melanotic masses. In the rest of its extent, it pre- sented a number of small and generally incompletely emptied cavities. The lower lobe contained numerous grey granula- tions, without tubercles or excavations. On the right side, (with the exception of the effusion and false membrane, which did not exist), the state of the lung was very similar to, though less extensively disorganized, than the left. Heart, sound ; the aorta, below cœliac trunk, presented numerous cartilaginous Chap. 10.] HYDATIDS AND TUBERCLES. 149 and osseous patches. The femoral arteries presented circular and rather parallel osseous bands, slightly prominent internally. Abdomen. — Gastric mucous membrane of alight pink color in some points, a little softened in the great cul-de-sac, but every where of natural thickness. To the left of the cardiac orifice there was an ulceration of half an inch in diameter, with irregular, slanting edges, lined by the uneven and thick- ened submucous tissue. The mucous membrane of the duo- denum, slightly greyish, with no other lesion. That of the small intestine was natural, with the exception of two small ulcerations, offering some semi-transparent miliary tubercles at their surface. In the large intestine it was soft as mucus, and in many points of a violet red. In the rectum there were ten small, submucous abscesses, of the size of a pea, and eight ulcerations of similar dimensions. The spleen was softened. The other viscera of the abdomen were healthy. 208. Hydatids of the brain are extremely rare ; so much so, that at the period of our taking the last observation, M. Chomel had not met a single example. They were never entirely enveloped by the cerebral substance. They pro- truded under the pia mater, in which, no doubt, they origi- nated. The healthy condition of the cerebral substance im- mediately in contact with them seems to indicate the slowness of their increase, and the total absence of all cerebral symp- toms is also in favor of this idea. The patient did not experience the slightest cephalalgia. With the exception of hydatids, all the other alterations, however numerous, gave rise to corresponding symptoms. The aphonia was caused by the ulcerations in the larynx. The pain beneath the thyroid cartilage and the dysphagia, (the pharynx and tonsils being perfectly healthy,) pointed 150 PATHOLOGICAL ANATOMY. BRAIN; [Parti, out, as we shall see (289), or at least gave reason to suspect, the ulceration of the epiglottis. The attack of pleuritis was accompanied with a pretty acute pain in the left side of chest. Pains equally acute came on with the diarrhoea, which, though only present eighteen days, had produced the pulpy softening, and perhaps complete disorganization of the mucous membrane of the colon ! In the midst of all these disorders, and at the commencement of two severe inflammations, which run their course rapidly, viz., pleuritis and enteritis, it is worthy of remark, that the pulse continued calm, and the temperature was not elevated ! How numerous are similar facts, which prove that it is especially to the investigation of local symptoms that the physician ought to direct his attention, in order to make a correct diagnosis ! Let us also remark, that the disease commenced by a copi- ous haemorrhage preceding the cough and expectoration. Not- withstanding the assertions of the patient of his having vomited the blood, and although intestinal haemorrhage succeeded in a few days, it is scarcely possible to doubt that both were de- pending upon the lungs ; first, because haemoptysis is fre- quently the precursory symptom of phthisis ; and it is some- times so abundant, that patients both affirm and believe that blood has been vomited, although this has not been the fact ; secondly, because the state of the stomach was not such as causes haematemesis ; and because every thing else is in favor of the idea, that during the haemorrhage, and long after, this viscus was healthy. Lastly, because the biuod voided by stool could very easily have proceeded from the lungs, some having passed into the stomach by deglutition. Chap. 10.] TUBERCULOUS MASSES IN IT. 151 NINTH OBSERVATION. S09. A YOUNG girl, set. 19, with active intellect and reten- tive memory, born of healthy parents, but herself of a feeble constitution, combining the lymphatic with the sanguineous temperament, and not subject to colds, entered the hospital of La Charité, October 1st, 1822. Her illness, dating seven months, had commenced by rigors, dyspnoea, loss of appetite, thirst, and a pulsating pain in the epigastric region. During five months, the rigors occurred daily without interruption, but were afterwards less regular. The epigastric pain was almost constant ; loss of appetite more or less complete ; thirst, variable in intensity ; neither nausea nor vomiting. The dyspnœa had gradually increased ; but cough and expectora- tion had only existed the last three weeJcs ; and, twelve days before entering the hospital, she had been attacked with a slight hsemoptysis. The catamenia had been suppressed two months before her present illness, and had not since reap- peared; at each menstrual period she was attacked with a headache, much more violent than usual at those periods. Bowels had been always regular, and emaciation had com- menced with the first symptoms. Oct. 1st. Intelligence, perfect ; no headache ; respiration, rather accelerated ; coughs little ; sputa, flocculent ; percus- sion, every where sonorous ; imperfect pectoriloquy between the shoulders ; no thoracic pains ; pulse, one hundred ; ap- petite, moderate ; slight thirst ; tongue, rather red ; cervical glands, enlarged and painful ; a tumor in umbilical region, rather to the right, without tenderness, of the size of an ordi- nary apple ; no pain in the epigastrium ; bowels, constipated. 152 PATHOLOGICAL ANATOMY. BRAIN ; [Part I, (Fifteen leeches to labia ; gum potion j pectoral infusion and soups). On the following days the appetite was much increased, and a fresh application of leeches was prescribed, on account of some streaks of blood in expectoration. 10th. Patient complained of acute pains in the right axilla, where the glands were much enlarged. Drowsiness ; face, injected and turgid. 20th to 25th. Intense headache ; face, more flushed than usual ; sudden flashes of heat more frequent, and more incon- venient. 25th. Twelve leeches to labia without any relief; no sen- sible change in cough or expectoration ; distinct pectoriloquy between the shoulders ; respiration, tracheal under clavicles j the abdominal tumor seemed increased. Nov. 4th. For the first time some liquid stools, and for the last three days nocturnal perspirations ; tumor in abdomen, painful. (V. S. ad g viij). From this date to the 26th of December, the day of her death, the face was of a deep red color, which afterwards changed to a livid tint. Much drowsiness at times, and at other moments inability to sleep ; headache, nearly constant. The debility rapidly increased, and the patient was wholly confined to her bed. The sputa, occasionally viscous and spumous, became opaque and streaked with blood, twenty-four hours before death. Dyspnœa, more and more urgent. Dec. 1st. Complained of burning sensation in the course of the trachea, which sensation was experienced often after- wards. The rigors, which had returned almost daily since her entering the hospital, persisted. Copious perspirations during Chap. 10.] TUBERCULOUS MASSES IN IT. 153 sleep, which did not yield to successively increasing doses of acetate of lead. The diarrhœa, with occasional colics, continued. Com- plete anorexia from the 1st of December ; no nausea, vomit- ing, or distinct epigastric pains. Thirst, at last, very urgent ; and on the 23d, the tongue, which had been whitish or slight- ly red for some time previously, assumed a dull red color, and was covered by a number of small, white, opaque, almost miliary spots. From the commencement of the diarrhoea, the patient was treated by rice water, sweetened with quince syrup. Small doses of syrup of poppies were prescribed for the restlessness, but with little success. The food consisted of some rice creams, and occasionally broth. Opening of the corpse thirty-three hours after death. ExTERioK. — Integuments mottled; extreme emaciation. Head. — At the posterior part of the right hemisphere, the arachnoid was adherent to the dura mater, in a point cor- responding to a nodulated tumor, developed near the surface of the brain, and about the size of a common nut. It was of a dull greenish-yellow color, firm, in every respect tuberculous, and not encysted. Round it the cerebral substance was healthy. Between the upper surface and lateral ventricle of the same hemisphere, five siniilar tubercles existed. On the left side there were four, and one of them occupied the posterior and inferior part of the opticus thalamus. At the base of the posterior lobe of the same side, a portion of the cerebral structure was transformed into tuberculous matter, under the form of a layer four lines thick, and an inch and a half in extent. It was partially adherent to the dura mater, u 154 PATHOLOGICAL ANATOMY. BRAIN ; [Part I, which lies above the cerebellum, the corresponding layer of which had undergone the same alteration. Lastly, at the inferior part of the left hemisphere of the cerebellum, a non- encysted tubercle, about the size of a nut, extended to the spinal marrow, and even to a small degree, into its substance. Neck. — - The cervical glands were very voluminous, com- pletely transformed into crude tuberculous matter; larynx and epiglottis, natural ; mucous membrane of the trachea, intense- ly red, especially posteriorly. Chest. — A mass of indurated, tuberculous, lymphatic glands, about the size of a goose's egg, in right axilla. Uni- versal cellular adhesions of both lungs. An extensive an- fractuous cavity in the summit of the left lung, containing a small quantity of red fluid, and traversed by numerous bands or intersections of grey substance. The parietes were formed by a semi-cartilaginous false membrane, lying upon tubercles and the grey, semi-transparent matter. The remainder of the upper lobe was almost entirely transformed into the grey or tuberculous matter, and into small excavations, between which the pulmonary parenchyma was of a deep red color. Pretty numerous crude tubercles in the inferior lobe. Similar lesions in the right lung, but less extensive ; two softened tubercles protruded on the surface. Bronchia, of a bright red color, communicating freely with the excavations. Heart, rather small, but healthy ; aorta, natural. Abdomen. — About a quart of limpid serum in the perito- neal cavity. The liver, rather larger than usual, presented twelve small cysts, two to three lines in diameter, and filled by a greenish, pulpy substance ; their parietes were very thin, greyish, and easily torn. Parenchyma, healthy ; bile in gall- bladder, black and thick like treacle. Mucous membrane of the stomach, red, mamillated, and of good consistence on the Chap. 10.] TUBERCULOUS MASSES IN IT. 155 anterior surface, to the extent of three inches ; it was pale elsewhere, and very soft in different portions of the great cul- de-sac. There were in the duodenum ten small ulcerations, from a line to a line and a half in diameter. Others similar to these were dispersed through the whole length of the small intestine, either occupying the patches, or situated in their intervals. Their edges were rather prominent, and the bot- tom lined by the thickened submucous layer. The mucous membrane of the large intestine was red in the ascending colon, which also offered two small, superficial ulcerations ; elsewhere it was pale, and throughout as soft as mucus. The mesenteric glands were voluminous, red, and in part tuber- culous. The tumor, felt in the umbilical region, was situated above the pancreas, equal in size to the shut hand, formed by the re-union of a large number of tuberculated, lymphatic glands, connected inferjorly with the lumbar glands, which were similarly affected. Not one was softened. The spleen, of ordinary dimensions, contained numerous round tubercles, varying from the size of hemp-seed to that of a small nut. The other viscera of the abdomen were healthy. 210. The most striking fact in this observation is not the development of tubercles in the brain and cerebellum, but their simultaneous existence in a variety of other organs, as the lungs, neck, right axilla, mesentery, loins and spleen ; and, more especially, their equal development every where, with the exception of the lungs. We do not see how any explanation of these facts can be attempted, unless we admit the action of one and the same cause upon all these organs at the same time. For if the ulcerations of the small intestine were the only cause of the conversion of the mesenteric glands into tubercles, how do we 156 PATHOLOGICAL ANATOMY. BRAIN. [Part 1, explain those of the brain, axilla, or spleen ? How do we ao- count for the similar state of the tuberculous matter, every where unsoftened, if the causes of its production were differ- ent, and the time of its deposition not identical ? Under no hypothesis can the state of the small intestine explain the tuberculous transformation of the glands situated above the pancreas, since the tumor existed previous to the entrance of patient into the hospital, long before the commencement of the diarrhœa, and, consequently, at a period when the raucous membrane of the small intestine was still healthy. And let not this be considered mere conjecture, for the inconsiderable size and structure of the ulcerations of the small intestine are sufficient proofs that they were recent. Let us also remark that the tuberculous matter was more ad- vanced in the lungs than elsewhere, which, in this instance, as well as in others, favors the idea that, with respect to tubercles, the whole economy is, as it were, in subjection to the lungs. 211. The fewness of the symptoms caused by the tuber- cles in the brain is also worthy of attention. The increase of headache at the menstrual period, and the sudden flushings of the face, can scarcely be ascribed to the presence of tubercles in tlie brain, since the pain complained of in the cervical glands might have been their cause, or at least have had some influence upon their production. If "we reflect also, that the intellectual faculties and the voluntary movements were never affectefl, the symptoms we have mentioned, if depending on the brain, were at least very insignificant. It will at the same time be granted, that if tubercles and hydatids can be devel- oped in so latent a manner in the brain, the same may take place in the lungs ; and we ought not to feel surprised that phthisis may remain concealed, as it were, during a variable period of time. This proposition, which we shall hereafter Chap. 10.] SUMMARY ; secondary affections. 157 strengthen by numerous examples, is realized in the case be- fore us, for from the moment of the entrance of the patient into the hospital, pectoriloquy could be detected, while the cough had only existed a few days ! Most probably there were pulmonary tubercles from the commencement, that is, as soon as the dyspnoea and fever were manifested, for the most im- portant chronic alteration of the viscera, viz. that of the lungs, can alone explain the first symptoms. SUMMARY. 212. It is sufSciently obvious, from what has preceded, that the pulmonary organs were not the only ones whose func- tions were impeded, but that others were the seat of exten- sive morbid alterations sufficient alone to produce death ; and that almost all contributed to hasten the final catastrophe. Their rapid survey will give a clearer idea of the whole. Tubercles and pulmonary excavations were in one tenth of the cases connected either with recent inflammation of a por- tion of one or both lungs, of the pleurœ, or with the effusion of a notable quantity of limpid fluid into the thoracic cavity. The trachea presented ulcerations, often of very great size, in rather less than one third of our observations. Its mucous membrane was merely reddened, sometimes slightly softened, or thickened in one fifth. The larynx was ulcerated in rather more than one fifth, and the epiglottis in a nearly similar proportion. The pericardium contained a marked quantity of very clear fluid in one tenth of the cases, and presented traces of chronic 158 PATHOLOGICAL ANATOMY. SUMMARY ; [Part 1, or recent inflammation in many others. The heart was rather frequently softened ; the aorta, red in the majority of young patients, and its structure more or less modified after the age of forty. In one twelfth of the patients the stomach was very much dilated, and situated lower down than natural. Its mucous membrane was red, sometimes mamillated, a little softened, and thickened anteriorly, nearly in the same proportion. In one fifth it was more or less extensively softened and thinned. We found it in the same proportion very red, softened, and some- times thickened in the great cul-de-sac ; it was ulcerated, of a more or less greyish tint, and mamillated in many others, &;c. ; so that it was only healthy in one fifth of our examples. In the small intestine there were ulcerations, varying in number and extent, in five sixths of the patients. They were nearly as frequent in the large intestine, of which the mucous membrane, often red, and in one half of the cases thickened, was either throughout its whole extent, or only over a part, of the consistence of mucus, so that we have only seen it per- fectly healthy three times. The tuberculization of lymphatic glands was less frequent in the neck, loins, mesocolon, and axilla than in the mesen- tery, where it existed in various degrees, in one fourth of the cases. The liver had become adipous in one third of the examples. The parietes of the gall-bladder were occasionally thickened and ulcerated, and when this was the case, as also under some other circumstances, it contained calculi. The spleen was softened, and under or above its natural volume in a great number of instances. It was tuberculated in one sixth. Chap. 10.] SECONDARY AFFECTIONS. 159 The last alteration was nearly equally frequent in the kid- neys, where we sometimes discovered cysts. In many individuals the prostate was tuberculated ; in one of these there was an example of tubercular exhalation in the interior of the vesiculse séminales and vasa deferentia. We have once seen the internal surface of the uterus converted into tuberculous matter. From one to six quarts of clear serous effusion in the abdo- men existed in one fourth, and a small quintity of pus, "or some false membrane in the pelvis in four others. We have seen several cases of tubercular peritonitis. In one the great omentum and mesocolon presented a mixture of grey, bluish, semi-transparent and tuberculous substance. The cerebral arachnoid was often partially thickened, pre- senting more or less numerous granulations in its upper por- tion, especially near the falx. In two cases it was lined by a yellowish and soft false membrane. The tissue uniting it to the pia mater was infihrated, and the ventricles distended by a very appreciable quantity of serum in three fourths of our examples. The same fluid was found in the occipital fossae, but less frequently and not so abundantly. In one seventh the brain was injected ; in one twentieth its consistence was gen- erally diminished, and in one instance to a remarkable extent. Its partial and pulpy softening was observed in the same pro- portion. All the serous membranes, the arachnoid, pericardium, pleurae and peritoneum, were thus very frequently the seat of effusion ; and it was in the lateral ventricles of the brain that this was most generally observed, at least when copious. The same membranes were also liable to acute inflamma- tion, coming on towards the close of life, and this was most frequently the case with the pleurae. 160 PATHOLOGICAL ANATOlViy. SUMMARY; [Parti, la some instances, many of the morbid states just glanced at, as the softening and thinning of the gastric mucous mem- brane and the ulcerations of the intestines, were sufficient of themselves to have caused death, independently of the lungs. However combined with them, there were other lesions. The seventh observation furnishes a case in which all the viscera, with the exception of the kidneys, were more or less ex- tensively affected. The period to which the commencement of these different alterations could be referred, was very variable. Pneumonia, pleuritis, softening and redness of the great cul-de-sac of the stomach, pulpy softening of the colon, peritonitis, arachnitis, partial and pulpy softening of the brain originated a few days previous to death. The greater part were the result of in- flammation, plainly proving that weakness, so far from being an obstacle, is, on the contrary, favorable to inflammatory action. The other alterations dated much further back, sometimes to the commencement of phthisis, as, for instance, softening with diminished thickness of the mucous membrane of the stomach ; and in some cases, the large intestinal ulcerations (Obs. 4). These various morbid changes presented a two-fold char- acter ; some were peculiar to phthisis, others were not so ; but were present in different degrees, after a variety of other chronic affections. Among the first class may be enumerated ulcerations of the larynx, and more especially of the trachea and epiglottis ; ulcerations of both intestines (principally of the small) ; the adipous state of the liver : so that by seeing an ulceration in either of the organs mentioned. Sec, we could be able to assert, independently of all farther investigation, that the patient had died of phthisis. Chap. 10.] SECONDARY AFFECTIONS. l6l These ulcerations, wherever they were situated, in their mode of production presented many points of resemblance. When the mucous membrane was destroyed, the submucous layer gradually thickened and became uneven ; after a time it ulcerated, and then the muscular coat in its turn began to thicken : this was, like the former, subsequently destroyed (though its total destruction was extremely rare) ; so that in proportion as one of the coats of the intestine became ulcer- ated, the succeeding one thickened, and by thus opposing greater resistance to its destruction, protracted the fatal termi- nation. The last morbid alteration was peculiar to phthisis, viz., tubercles, wherever they might be found. We have never ob- served them in a single instance in any organ, without their existence in the lungs ; so that their presence in these last viscera seems a necessary condition for their development in other parts. Another fact which strengthens the idea of this dependence is, that with one single exception, we have always seen the tuberculous matter more advanced in the lungs than elsewhere, and when tubercles existed at the same time in different parts of the body, they were at the same degree of development; and it would be difficult to conceive of this uni- formity, in parts so distant one from another, so various in struc- ture, unless we admit the influence of one and the same cause, acting simultaneously on a great number of organs ; thus making tuberculous deposition quite independent of those occasional causes we are apt to suppose active in certain cases. As our object, however, is not to support one opinion more than another, we will remark, that we have found one excep- tion to the law we have established. It was in a case of typhus. w 162 PATHOLOGICAL ANATOMY. SUMMAKT, No tubercles existed in the lungs, and yet there was a small quantity of tuberculous matter in the mesenteric glands.* * See Appendix A by the Translator for some valuable remarks upon the development of tubercles. — H. I. B^ SECOND PART SYMPTOMS. PART II. SYMPTOMS. 213. In this division of our work, we shall successively describe the symptoms of phthisis, and those attending its different complications, the variations it presents in its pro- gress, when acute or latent ; the circumstances attending the perforation of the pulmonary parenchyma and sudden deaths ; after which, we shall examine the causes which are generally considered as influencing the development of tubercles in the lungs ; and, finally, we shall briefly speak of the treatment. CHAPTER I. SYMPTOMS OF PHTHISIS. 214. From what has already been said, it will be seen how rare it was to find a case of phthisis in which the morbid altera- tions were confined to the lungs ; and it might be thought almost impossible, judging from the one hundred and twenty-three observations we have collected, to give the history of the dis- ease in a state of simplicity. But let us remark, that it would not be right to view many of the lesions we have described in the light of complications ; as, for instance, the ulcerations of the trachea, larynx and epiglottis, of the small and large in- 166 SYMPTOMS. GENERAL DESCRIPTION; [Part II, testine. and the adipous transformation of the hver ; for these alterations being pecuHar to phthisis must be regarded as a part' of the disease itself. We may also observe that pleurisies, pneumonias, &ic. fee, coming on in the last periods of the affection, do not interfere with its simplicity. We have thus greater latitude for forming our conclusions than might at first be anticipated ; and we are enabled to found a general de- scription of the disease upon a large number of facts. To adopt some method in the description of the symptoms, we shall follow the example of Laennec, and divide phthisis into two principal stages ; the one anterior, and the other subsequent to the softening and evacuation of the tubercu- lous matter of the bronchia. 215. First Stage. — In the majority of instances the cause of the disease was unknown. One third of the patients ascribed the first symptoms to alternations of heat and cold, to which their avocations exposed them ; to draughts of air ; to immersion of the feet in cold water ; to drinking cold water when perspiring ; but the greater number of those who referred their disease to draughts of air or alternations of heat and cold to which they were exposed by their profession, were far from being confident or positive as to the accuracy of their statements ; it was simple conjecture on their part. A very few referred, with considerable precision, the first symptoms of having taken cold, to twenty-four, thirty-six, or forty-eight hours after the apphcation of the cause to which they attributed it. 216. Whether an apparent cause did or did not exist, the affection generally commenced with a slight cough, at first ex- citing no attention, but it was regarded as a simple cold, \\o which many of them were subject. The cough was usually accompanied with clear expectoration, like frothy saliva, or (as existed in one tenth of the cases) it continued^free from all Chap. l.J FIRST STAGE. 167 secretions during many months. In some cases it came on in paroxysms, and made rapid progress. After a certain time, the sputa were less clear, slightly greenish, and a little opaque. They completely changed their characters in the second pe- riod. In some instances, the first symptoms were preceded by a more or less copious haemoptysis, or this latter symptom commenced at the same time with the rest. The breathing was not at first sensibly affected, and by some patients dys- pnoea was only complained of at a somewhat advanced period of the disease. Very frequently there were variably acute pains between the shoulders and in the sides of the thorax, some time after the commencement. If, in this stage of the complaint, we ausculted the patient, the respiratory murmur was not sensibly changed ; at least this was commonly the case, especially when there were only grey granulations. In other cases, the respiration was feeble under one of the clavicles ; or in the same regions, and in a very limited space, there was a slight mucous and sonorous râle, with rather less clearness on percussion than on the opposite side. 217. To these local symptoms were added various derange- ments of different functions. Occasionally, from the com- mencement, there were alternations of temperature, and night perspirations ; but most frequently these came on at a more advanced period, and generally in the second stage of the dis- ease. With very few exceptions, the appetite was at first unaffected, but afterwards gradually diminished. If the cough was violent, it sometimes caused vomiting after food ; and when this only was the cause, the sickness was of short dura- tion. Very few had diarrhoea. The strength diminished more or less rapidly, and emaciation was soon associated with the other symptoms, though at first its progress was very gradual. 168 SYMPTOMS. GENERAL DESCRIPTION ; [Part II, 218. Second Stage. — The cough was now usually more frequent and more inconvenient, especially during the night. The sputa assumed a greenish color, were striated by yellow opaque lines, free from air, and presented a peculiar appear- ance, being of a rounded shape, and as if torn on the edges. Occasionally, from the influence of regimen and demulcents, some of these characters disappeared, but sooner or later again returned. Towards the close of life, they frequently resembled pea-soup with a greenish or greyish tinge. Last- ly, they were often mingled with expectoration, similar to what is observed in the first stage ; haemoptysis was pretty frequent, but in general not copious ;* the dyspnoea was in pro- portion to the progress of the disease ; the pains in the thorax were often more acute than previously ; sometimes there were very urgent pleuritic symptoms, demanding active treatment. The patients usually lay with the head low, and the decubitus varied ; however, in some cases it was exclusively on the side opposite to the large excavations. By auscultation, more or less evident pectoriloquy, gurgling râle or tracheal respira- tion, could be detected in one or various points, corresponding to the summit of the lungs, and in one third of the cases per- cussion was dull under one clavicle, and quite frequently to a considerable extent. It was also in this stage of the complaint that the symptoms peculiar to ulcerations of the epiglottis, larynx, and the different lesions of the mucous membrane of the stomach, developed themselves. 219. In the greater number of instances, the fever was con- tinuous with occasional exacerbations. These occurred in the evening, with rigors, heat, and perspiration. The thirst was * " In this state of tbt disease haemoptysis to any extent is very uncom- mon." — Laennee, page 348. — Cowan. Chap. 1.] SECOND STAGE. 169 urgent, except when the progress of the disease was very- slow. The appetite, which was in general variable, diminish- ed as debility increased, or even in some examples the ano- rexia was complete, though the mucous membrane of the stomach was healthy, or only presented traces of recent and unimportant lesions. In a small number of cases the alvine evacuations continued regular until the last. Many experi- enced diarrhœa twenty or thirty days only before death ; but in the majority it commenced very much earlier. The ema- ciation made rapid progress, and unless some unexpected acci- dent intervened, as, for example, perforation of the substance of the lungs, death took place in the last stage of marasmus, without any disturbance of the intellectual faculties. 220. The duration of each stage was very variable, and proportionate to that of the disease itself, the limits of which are shown in the follov/ins table : — Duration of Number of Duration of Nu mber of Disease. Deaths. Disease. Deaths. 24 Days, . 1 11 Months, 2 35 Days, . . 2 12 Months, , 5 50 Days, 1 12 Months and a half, 2 52 Days, . . 1 13 Months and a half. 1 81 Days, 1 14 Months, 3 3 Months, , ^ 2 14 Months and a half. 1 3 Months and a half, 3 15 Months, 5 4 Months, . 2 17 Months, . 2 4 Months and a half, 2 18 Months, 1 5 Months, . 9 19 Months, . 1 5 Months and a half, 2 20 Months, 1 6 Months, . 7 2 Years, 8 6 Months and a half. 1 2 Years and a half, 2 7 Months, . 8 3 Years, 4 7 Months and a half, 5 4 Years, 6 8 Months, . 4 5 Years, 2 9 Months, , 7 10 Years, 1 9 Months and a half. 1 12 Years, 2 10 Months, , 3 14 Years, 1 10 Months and a half. 1 20 Years, 1 Total, 63 Total, 51 170 SYMPTOMS. GENERAL DESCRIPTION ; [Part D, That is to say, out of one biindred and fourteen cases, the duration of which has been determined as accurately as pos- sible, rather more than two tenths have died from the first to the sixth month of the disease ; four tenths from the sixth to the twelfth month ; rather less than a fourth from the first to the second year ; and less than one fifth from the second to the twentieth. 221. We have endeavored to discover whether age had any influence on the more or less rapid progress of the affec- tion ; and we have never found this to be the case, unless, perhaps, in some instances of very acute phthisis. 222. On the other hand, the influence of sex appears cer- tain ; for if the proportion of deaths in male and female phthis- ical patients in whom the disease had lasted more than a year, was equal, it was as thirty to forty-two, when death occurred during the course of the first year. Perhaps this difference niay be explained by considering that the adipous state of the liver, and the softening with diminished consistence of the gastric mucous membrane were much more frequent in women than in men (89, 161), and that these lesions must necessarily have accelerated the fatal catastrophe. 223. As to the mortality from phthisis compared with other diseases, it was nearly as one to two ; for out of three ])un- dred and fifty-eight fatal cases in the v^ards of M. Chomel, during three years and a half, one hundred and twenty-three were phthisical ; the remaining two hundred and thirty-five included a variety of other diseases. And if to this number of phthisical subjects, we add those who, dying of some other disease, had tubercles or tuberculous cavities in the lungs (viz. 40), we find that out of three hundred and fifty-eight cases, one hundred and sixty-three, or nearly half, presented pulmonary tubercles in the lungs, and were really consumptive ! This Chap. 1.] MORTALITY OP PHTHISIS; COUGH; SPUTA. 171 proportion is immense ; it does not, however, include a com- parison with all those cases which are necessarily fatal, in the actual state of our knowledge. Let us now successively study the symptoms we have enumerated. 224. Cough. — It varied much. Some patients only coughed towards the close of life (Obs. 31, 32), although cavities had existed for some time. Others, and they were not numerous, coughed very little, or even after a certain time, not at all, until the disease approached its termination, although there seemed to be a tuberculous affection from the beginning (Obs. 30). The greater part complained of a troublesome cough, especially at night, forcing them to resort to opium to obtain sleep, which did not always succeed. This cough sometimes came on in paroxysms, caused a good deal of dyspnœa, frequently vomiting, and an oppressive sen- sation in the epigastrium. In general the violence and fre- quency of the cough were in proportion to the more or less rapid progress of the disease. 225. Expectoration. — The passage from the first stage to the second was, as we have already observed, indicated by a remarkable change in the aspect and form of the sputa. From being white, mucous and spumous, they became green- ish, opaque, deprived of air, and streaked with more or less numerous, dull, yellow lines, which made them sometimes seem composed of many colors. Auscultation of the summit of the lungs detected resonance of the voice, pectoriloquy, or a very strong respiratory murmur, as if tracheal, often mingled with a gurgling, or sometimes with a dry râle. We occasion- ally found among the sputa fragments of a white, opaque substance, resembling (as Bayle has remarked) boiled rice ; but this was rare, and in the majority of instances the striated sputa were alone present. 172 SYMPTOMS. — SPUTA, [Part II, After some time the striated appearance and the occasional fragments of white substance ceased to be observed. The ex- pectoration became uniform in composition, and separated into rounded, distinct masses, with their edges as if torn and floc- culent. These masses were heavy and more or less consistent ; they did not sink always, but floated sometimes on the surface of a clear liquid, which was expectorated with them. After presenting some time a greenish-yellow tinge, they assumed a greyish, dirty appearance, very analogous to what we find in old tuberculous excavations ; this took place towards the close of life, from fifteen to twenty, or, most frequently, only a few days preceding death. They then diminished in consistence, spreading out on the sides of the spitting box, resembling the pulp of boiled peas, and were occasionally streaked with blood or surrounded by a pink areola. This latter color would no doubt have been observed more frequently, if the patients had continued to expectorate during the last twenty-four hours, for we generally found, after death, the bronchial mucosities more or less tinged with blood. 226. The union of all these characters is sufficient, without other examination, almost certainly to indicate tuberculous excavation in the lungs. We lay stress upon all, for green, opaque, homogeneous sputa exist in chronic and sometimes also in acute catarrh ; but they are not then striated, and do not contain those white particles we have described, and are not usually in distinct masses as in phthisis. The rounded, num- mulated form (pelotonnée) of the sputa is certainly one of their most valuable peculiarities with regard to diagnosis, and in two very remarkable examples (Obs. 30, 33), both to M. Chomel and ourselves, it was the first indication of a tubercular affection. It is, however, right to mention, that a few days before death, we have in two instances seen the sputa thus nutn- Chap. 1.] IMPORTANT FOB THE DIAGNOSIS. 173 mulated and opaque, although no tubercles, tuberculous exca- vations, or dilated bronchia existed in the lungs. 227. The expectoration we have described, with the ex- ception of three cases, was constantly present. In these in- stances it always continued mucous, spumous, whitish or slightly yellow, or even greyish, semi-transparent, as if vitrified, without ever presenting that separation into distinct masses, which we have shown to be so important. In the majority of instances, the greenish, opaque, striated sputa, were associated with a mucous, spumous and more or less viscous expectoration, retaining the characters observed in the first stage ; or, instead of this, they floated in a clear, thin fluid, like saliva. Sometimes they were dry, as it were. 228. The quantity of the expectorated matter varied at diflerent periods of the affection. In the commencement, if the progress was rapid, it was sometimes very abundant, from ten to twenty ounces in the four and twenty hours. In the second stage it was less copious, unless indeed the expectora- tion of the first period was prolonged in conjunction with that of the second. When this was not the case, it very frequent- ly happened, that the bottom of the spitting vessel was scarcely- covered, and we have never seen it completely filled. A smallnumberof patients only expectorated a few isolated sputa in the twenty-four hours. In two instances, during some days, all expectoration ceased. A third (a fatal case of croup in a woman,* who had large tubercular excavations in the * Vide sixth observation in Mémoire sur le Croup, considéré chez. V Adulte; Recherches sur diverses Maladies, page 203. — Louis. — This memoir contains nine examples of this affection, nearly all occurring during the course of other diseases ; two in phthisis ; three in t3'phu3 ; one in chronic pleurisy ; one in gastro-enteritis ; two in gastritis. The progress of the disease was not affected by the complications. The symptoms were 174 SYMPTOMS. — sputa; [Part II, iungs, and ^vhose illness dated nine months at the time we observed her), never expectorated at any period of the dis- ease ; and the care we took to ascertain the correctness of this fact assures us of its truth. After continuing for some time greenish and opaque, &ic., from the influence of repose, regimen and demulcents, they were more or less modified ; they were less opaque, occa- sionally vitrified in appearance, retaining or losing their rounded form, and after some time resuming their former aspect. 229. During the first stage, when the expectoration is mu- cous and spumous, the gurgling and pectoriloquy are absent, and, consequently, there is no excavation; the sputa, therefore, could only come from the bronchia. At a more advanced period, they were at once the product of bronchial secretion, and of the contents of the tuberculous excavations. Of this we have proofs in the change in their physical characters from the moment that pectoriloquy and gurgling announced the softening of tubercles, and their communication with the air tubes ; and more especially in the resemblance of the yel- lowish streaks we have described, with the liquefied, tubercu- lous matter, such as we find it in recent excavations. Still later in the disease the same double origin is evident, if we recollect that we frequently find in the bronchia communicating with the sore throat, heat, redness of the pharynx, &c. with dysphagia. Then pain in larynx and trachea, gradually increased alteration of the voice, with dys- pnœa, anxiety, but very rarely with paroxysms of suffocation. The forma- tion of the false membrane was always from above downwards, sometimes commencing in the nasal fossae. The duration varied from six to eight days; only one recovered. The absence of suffocating paroxysms and the forma- tion of the false membrane from above downwards, seem principally to dis- tinguish it from the same affection in children. — Cowajv. Chap. 1.] MODIFIED BY THE STATE OF THE BRONCHIA. 175 excavations, a substance precisely analogous to the contents of the latter ; that towards the close of life this substance is not sensibly different from the expectoration ; that the differences so frequently observed in the results of auscultation before and after expectoration suppose some change of proportion in the fluids contained in cavities ; and, moreover, that it is impossible for bronchia to communicate freely with excavations, and not receive by the impulses of the cough, a certain portion of their contents ; and, lastly, that the situation of many of these open- ings at the inferior part of the excavation shows that simple gravitation is often sufficient to produce the same effect. These reflections are strengthened by the pathological state of the bronchia in a great number of cases. We have, in fact, seen (36), that when they were intensely red and much thick- ened, it was not in the neighborhood of masses of grey or tuberculous matter, but in that of the large excavations ; a fact which cannot be easily explained, unless we admit the passage of the contents of these excavations into the bronchia. 230. From the above statements, we think it more than probable, that the violent inflammation of the bronchial mu- cous membrane, at this stage of the disease, considerably modifies the expectoration ; that at a certain period, the opaque, greenish and greyish sputa are equally the product of bronchial secretion as of the cavernous parietes ; and that little or no difference exists between the matter furnished by the one or the other.* * It would be easy to multiply opinions and experiments relative to the expectoration in phthisis ; we think, however, that Aretasus is right in regarding them rather as objects of historical research than applicable to practical utility.! — Cowan. 1 1 cannot agree with the translator, for it appears to me that it is neces- sary to study the peculiarities of the expectoration as much as those of any other secretion, or the state of any function in the body. Aretaeus knew 176 SYMPTOMS. — Hemoptysis; [Part II, 231. Hcemoytysis. — It was present in two thirds of the cases, fifty-seven times out of eigljty-seven. By copious hcemoptysis, we understand the expectoration (in a few minutes, a quarter of an hour, half an hour, or an hour), of several ounces of more or less liquid, spumous blood, occasionally dark colored and coagulated, and sometimes ac- companied with contractions of the diaphragm, which induce patients to suppose they have vomited the blood. Haemop- tysis is inconsiderable when a few mouthfuls of frothy blood are rendered either pure or mingled with the expectoration. This may be repeated for several months successively. Both kinds seemed equally frequent. Out of fifty-seven patients, the haemoptysis was copious in twenty-five. 232. Copious or otherwise, it sometimes preceded both the cough and expectoration. This was the case with twelve of our patients, and in eight out of these the hcernorrhage was copious. The quantity was more frequently abundant (in the proportion of nine to seven), in the course of, or at the com- mencement of the first stage of the complaint. Bloody ex- pectoration was rare towards the termination, when the patient was very weak. We have only observed it at this period in four cases, twice copious, and twice in small quantity. 233. Are we, however, to consider the haemoptysis, espe- cially when copious, which precedes cough and expectoration, as the precursor of tubercles, or simply as a symptom which reveals their presence ? For nearly three years we have con- stantly questioned every patient under our care, and who was attacked with any other disease than phthisis, if they had ever nothing of various means which we now possess of verifying our results ; he, therefore, ought not to he quoted upon this question. But an unanswerable argument upon the necessity of minute attention to sputa will be found in the last four lines of paragraph 226. — H. I. B. Chap. 1.] IS IT A SYMPTOM OR CAUSE OF PHTHISIS? 177 spit blood, and we have invariably received answers in the nega- tive, except when external violence had been received on the chest, or when the catamenia had been suddenly suppressed. Patients subject to bronchitis during many years, and whose breathing was usually free, had never had haemoptysis. On the other hand, we have seen some individuals with tubercles in the lungs, who had never experienced any direct symptom announcing their presence ; so that nothing seems to be less surprising than that pulmonary tubercles should give rise, at a certain period of their existence, to a single symptom, and in particular to expectoration of blood ; we therefore think that haemoptysis (with the exceptions already mentioned), when- ever it occurs, renders the presence of tubercles in the lungs infinitely probable. We limit our conclusion to probability, for many well-attested facts appear fortunate exceptions.* Analogy, moreover, is in favor of what we advance. For, when haemorrhage occurs in any internal organ, it is almost constantly a symptom of more or less considerable alteration of structure. Let us add also, that when haemoptysis pre- ceded the other symptoms of tubercles, it was occasionally followed by dyspnoea ; it came on suddenly (Obs. 32, &;c.), usually when the patient appeared in perfect health, without * Pulmonary apoplexy has been considered both by Laennec and others, as a frequent cause of hcemoptysis. M. Louis, from the consideration of facts, thinks the coincidence rare ; he has very frequently found this lesion when no haemoptysis had taken place. Hypertrophy of the left ventricle would naturally be thought peculiarly predisposing to hœmoptysis, yet out of twenty-seven cases of this description in not one was it experienced, while in six of them the pulmonary artery and its ramifications were evidently enlarged. (Vide £a:a?nen. page 38). There is often a wide difference between facts and our explanation of facts. — Cowan. 178 SYMPTOMS. — HiEMOPTYSis ; [Part II, previous phenomena, or any apparent cause ; and it is not un- natural to suppose that the then concealed cause was identical with what subsequently reproduced the symptom. But we shall confine ourselves to these iew reflections, which are indulged in rather to excite examination, than to supply facts. 234. Sex had an evident influence on the occurrence of haemoptysis. It was more frequent in women than in men, in the proportion of three to two. Thus, out of forty-two women who were carefully questioned on this point thirty-six had expectorated blood ; but out of thirty-eight men, it was so with only twenty-one. 235. The proportion of haemoptysis in different ages was not the same in both sexes. One third of the female patients, between the ages of nineteen and forty, had not experienced it ; while, from forty to sixty-five, it was only absent in one seventh ; an inverse proportion to what ought to have existed, if, according to the opinion of some physicians, haemoptysis may be considered in some cases as a supplement to dimin- ished or suppressed catamenial discharge.* In men, on the contrary, the proportion was exactly similar, either before or after the age of forty ; so that out of twelve cases above this period, six had expectorated blood ; and out of twenty-six below forty, fourteen. Should the small number of the facts we have analyzed be deemed insufficient to establish satisfac- torily a relation between the age and the frequency of haemop- * It would appear to us that the age from forty to sixty-five was most liable to menstrual disturbance ; which, if not usually so violent as at an earlier age, is at least more general. Perhaps this view of the subject is supported by what the author says farther on, that the majority of the cases of hajmoptysis were among robust constitutions. — Cowan. Chap. 1.] EFFECT OP SEX AND AGE UPON IT. 179 tysis in either sex, it will at least serve to fix the attention of observers, and stimulate them to farther investigations. 236. The age seemed without evident influence on the quantity of blood expectorated ; and the frequency of its recurrence seemed to depend on the duration of the disease. 237. We have also endeavored to decide whether there ex- isted any connexion between haemoptysis, and the strength or weakness of the general constitution. Out of forty-eight cases, haemoptysis occurred in an equal number of feeble and strong constitutions, though among the women there was a predominance of robust constitutions. 238. In some instances, copious haemoptysis only occurred once ; it was seldom repeated three, four, or a greater num- ber of times. The following observation, while an example of this description, will also furnish an instance of the very rare fact of the symptoms of typhus fever coming on during the last stage of marasmus, and after very copious evacuations of blood. TENTH OBSERVx\TION. A YOUNG man, aet. 18, well made, tall, with black hair, impetuous temper and moderate corpulency was admitted into the hospital of La Charité, November 26th, 1821. Born of healthy parents, and subject to dyspnœa from his infancy, he was seized in the end of October, while in perfect health, and without any appreciable cause, with a copious haemoptysis. The expectoration of blood had since con- tinued, though in diminished quantity, until the last few days. Cough had commenced with the haemoptysis, was accompa- 180 SYMPTOMS. HaiMOPTYSIS î [Paît II, nied with some expectoration, and caused little inconvenience. No pain in chest, heat nor rigors. Some sensibility to a low temperature. The patient had refused every kind of treat- ment, continued his usual food and occupations, and decided very reluctantly to enter the hospital. 27th. Expression, rather lively ; general strength, only slightly diminished ; breathing, little accelerated ; cough, rare, and excited by lying on his back ; expectoration, viscous, yellowish and spumous ; some of the sputa of a bright red. Cannot lie easily on left side ; percussion, rather duller under left clavicle than under the right. Respiratory murmur, oc- casionally absent in som.e parts, and on the lateral parts of the left side we heard with the stethoscope a sound very similar to that caused by a bubble of air when agitated with water in a moderately sized tube. Pulse, calm, rather full ; tempera- ture, natural ; tongue, clean ; appetite, good ; no thirst ; ab- domen, yielding, not painful. Slight diarrhœa the last two days. (V. S. § viiij. ; barley water with gum syrup ; gum po- tion ; a pint of milk ; one fourth of bread allowance.) No evident change the next day. 29th. Very soon after the visit, he was attacked with a copious haemoptysis, esti- mated at § vj. Blood, dark-colored or frothy, and bright red. Respiration, as before. Auscultatory phenomena, as before. (V. S. g viij. ; blister to the left arm ; barley water ; muci- laginous mixture and soups). 30th. Fresh haemoptysis, accompanied with sense of drag- ging at epigastrium ; no increase of cough ; no sense of heat in chest, and no previous rigors. Up to the 8th of December, he merely expectorated a few sputa tinged with blood ; but on the morning of the same day, Chap. 1.] FREQUENCY. 181 while perfectly quiet, was seized with an haemoptysis more copious than the first ; respiration, weaker posteriorly on the left side than on the right. (V. S. ad Sxij). The next day, slight soreness of throat, with difficult deglu- tition ; thirst, not urgent ; bowels, regular ; heat of surface, every where natural ; pulse, accelerated ; sputa, white ; face, emaciated, and of a dull white aspect. From the 9th to the 15th, three copious hsemoptyses took place, which were treated by two bleedings and a large blister between the shoulders. On the 16th, sputa moderately thick, yellowish, and imperfectly divided into distinct portions (pelotonnés). During the following fifteen days, they pre- sented nearly the same appearance ; breathing was more oppressed ; the cough increased in violence ; heat of surface, slightly elevated ; night perspirations ; the appetite improved ; the food was gradually augmented ; and on 28th, the patient took daily a quart of milk with four ounces of bread, and some- times rather more. Jan. 2d. Considerable dyspnœa; cough, much more when lying on the left side than on right ; no râle could be heard an- teriorly on auscultation ; pulse, jerking and pretty frequent ; the lively expression had given way to that of weariness ; he had scarcely left his bed for^some days ; considerable ema- ciation. (Two rice creams). From the 2d to the 8th. No appreciable change, unless in the respiratory murmur, which became very coarse under the left clavicle. 9th. The tongue, which had been natural, then assumed a bright red color. 10th. Almost complete deafness. 11th. This symptom increased ; the patient was continually groaning ; pulse, rather full and tumultuous. 182 SYMPTOMS. — HEMOPTYSIS ; [Part II, ^V. S. § viij, ; barley emulsion for drink). 12th. Tongue, dry and blackish; thirst, intense; heat of skin, rather pungent ; pulse, less full and less tumultuous than yesterday ; gurgling under left clavicle and sibilant râle under the right. (V. S. I viij). The blood was covered with a pretty thick buff. The day after, three stools were passed. In the night of 13th to 14th, almost constant delirium. On the morning of the 14th, face, pale, air of prostration ; deaf- ness continues; heat of skin, dry and pungent; breathing, noisy with crepitating râle on the left side ; cough, frequent ; sputa, scanty ; tongue, dry and encrusted. (Infusion of violets ; gum potion). 15th. At visit, a little less dulness of eye ; pulse, as be- fore, rather full ; in other respects as yesterday. The follow- ing night he was delirious. On the morning of the 16th, face, unequally flushed ; intelligence, good ; tongue, dry ; temper- ature, elevated ; cough, rather less frequent ; gurgling was heard under left clavicle ; the patient frequently uncovered his chest. The same symptoms persisted until death, which took place on the 18th, at two, p. m. Opening of the corpse forty-two hours after death. Exterior. — Emaciation, almost extreme. Head. — Brain, firm, not injected ; two small spoonfuls of serum in the lateral ventricles and in the inferior occipital fossae. (The larynx was not examined). Chest. — Some adhesions at the summit of the lungs. The right lung crepitated and some of the upper portions of Chap. 1.] TREQUENCT. 183 it were slightly congested, and presented throughout their whole extent, numerous grey, semi-transparent granulations, of the size of hemp seeds. In the left lung, the upper lobe was completely converted into tuberculous excavations, con- taining a muddy, greyish, faetid substance. These were sep- arated from each other by intersections of a grey, semi-trans- parent matter of half a line or more in thickness. The lower lobe was similarly but much less extensively affected. The septa dividing the excavations were thicker, and the pulmonary structure here and there still permeable to the air. Heart, of natural volume ; parietes of left ventricle thinner than usual ; aorta, healthy. Abdomen. — The gastric mucous membrane was pale throughout and covered by thick mucus ; that of the small intestine was healthy, with the exception of some red, oval spots in the neighborhood of the csecum. Faeces were firm ; spleen, larger and more consistent than natural ; the liver and other viscera of the abdomen, healthy. 239. This observation is very remarkable in many respects, particularly as regards the haemoptysis. The alarming repetition of this haemorrhage might by some be attributed to the rapid progress of the disease ; but this influence cannot be admitted, since its progress has been much more rapid in other cases (Obs. 33,) where no haemoptysis was observed ; and also be- cause, in every example we have analyzed, the recurrence of the haemorrhage was in direct proportion to the duration of the affection. Venesection was here carried as far as the strength of the patient would permit, but without the slightest success. The haemoptysis frequently appeared the day after venesection, as if the patient, instead of being bled, had been guilty of some excess. 184 SYMPTOMS. — HEMOPTYSIS. [Part II, 240. As to the question of causes, it is proper to remark, that the haemorrhage came on suddenly, without any evident reason, without previous symptoms or cough, and in the midst of apparent heaUh ; it could not therefore be considered the ef- fect of bronchitis, which did not exist, but must necessarily be attributed to the existence of tubercles, of which it was the first indication. If this be admitted, it follows that the tubercles were independent of all bronchial inflammation, and were here the cause and not the effect of bronchitis. We shall again insist upon this very important consideration, remarking only that, in the instance we are now analyzing, the opinion we have expressed is confirmed by the results both of ausculta- tion and percussion. We have, in fact, seen that when the patient first entered the hospital percussion was less clear under the left clavicle than under the opposite one ; and this indicated an alteration already too considerable to be ascribed to the inflammation of the bronchial mucous membrane, which, whatever opinion we may adopt, was necessarily recent. 241. We shall not insist on the fact of typhus fever coming on towards the close of the patient's life and after very copious venesection, particularly since cases of this description are so rare, that we have not met a second example, and as our ob- servation in this respect is not sufficiently exact to draw any legitimate conclusions. The mucous membranes were not properly examined ; we have mentioned the universal pale- ness of that lining the stomach, but we have said nothing as to its consistence or thickness ; and although it is rare to find it softened or in any way affected when its paleness is gen- eral, yet the fact is not impossible, and the contrary has not been stated. The red patches, mentioned in the small in- testine, were, perhaps, the same as those which thicken and Chap. 1.] CAN TYPHUS OCCUR IN PHTHISIS ? 185 ulcerate in the progress of typhus fever, but this cannot be determined from so brief a description. We cannot, there- fore, afhrm that the symptoms depended, or did not depend on one lesion or another, nor can we expect for an observation so incomplete that confidence which it does not merit. It can- not be too often repeated, that the, science of medicine is faulty in its foundation ; facts, that is, facts properly and completely observed, are deficient in the great majority oj instances. 242. In some rare examples haemoptysis seems to have been produced by a paroxysm of coughing. It almost always occurred without any assignable cause, and was seldom ac- companied either with a sense of heat or pains in the chest, or with any more febrile excitement than during the days which had preceded. 243. Dyspnoea. — It was generally very slight, not com- plained of by the patients and seldom even noticed unless after exercise. Its progress followed that of the principal affection, and it was seldom extreme ; we have never met with more than three cases, where the patient was compelled to lie with the head much elevated, or to retain a sitting pos- ture. After death, we found nothing to explain this anom- aly ;* the heart was healthy, its orifices unaffected ; there was no effusion into the cavity of the pleurae. 244. In a certain number of cases, dyspnoea was only sen- sible one or several months after the origin of the cough. Most frequently it commenced with it : it even sometimes existed * At the time Louis wrote this, he had examined carefully but very few cases of emphysema of the lungs. Iq the cases he has stated this affection may have existed. — H. I. B. Z 186 SYMPTOMS. — DYSPNŒA ; [Part llj anteriorly (in about one tenth of the cases), and when this ■occurred, it was often coincident with haemoptysis, which had also "preceded the other symptoms. Under these circum- stances, the dyspnoea and hcemoptysis were probably not symptoms preceding tubercles in the lungs, but the first indi- cations of their existence. Perhaps this was equally the case when no haemoptysis was present ; but that it was so is far from being demonstrated, for many patients had their breath- ing more or less affected from infmcy, and it was impossible to date the origin of phthisis from so remote a period ; for out of these examples, which formed one ninth of the whole, as great a number had attained the age of fifty, as among those whose dyspnœa had coincided with the first symptoms of the disease. 245. The oppression was referred to the central part of the chest, whatever differences might exist in the state of the two lungs. There were only three exceptions to this fact, and in these the uneasy sensation seemed confined to the side prin- cipally affected. 246. Pain is not, we well know, the most troublesome symptom in phthisis ; many were altogether exempt, or only spoke of it when their attention was directed to the sub- ject. A few complained spontaneously ; and it is no doubt owing to this absence of pain, and frequently its insignifi- cance and rarity, conjoined with the insensible progress of the symptoms, that patients are so completely deceived as to their real situation. Without mentioning the pleuritic symptoms, which compelled some of them to ask advice, the greater number had experienced pains either between the shoulders, or on the lateral parts of the thorax. These last were present in one third of the examples, and were sometimes rather in- tense and of variable duration. They came on at very differ- Chap. 1.] PAIN, ITS CAUSES ARE PLEURISY, StC. 187 ent periods of the disease, sometimes two or three months before death, when the cough and expectoration had lasted one, two, or more years ; at other times (and these were cases where phthisis had gone through all its stages in five or six months), they were present very shortly after the appearance of the first symptoms ; they sometimes persisted only a few days, in others one or many months ; occasionally they were sufficiently intense to incommode the patient, but not to compel him to remain in bed. 247. Most frequently there was a direct correspondence of the pains with the adhesions, mostly cellular, of the lungs and pleuree, and very often with the number and size of the excavations. And as these two lesions were almost always combined and proportionate to each other, it would be difficult to assign any cause for the pains, if we were not aware that tubercles are developed in other organs without pain, and as those we are now considering are very similar to pleuritic pains, increasing like them by inspiration and cough, of an acute and lancinating character, they are no doubt the conse- quence of chronic inflammation. We have, in a small num- ber of instances, been able to convince ourselves in a more direct and positive manner, that this was actually the cause of the pains experienced by phthisical patients. It was in those cases where the lungs presented on one side large excavations with very slight adhesions, on the other, universal adhesions and no excavations, and when the pain had been confined to the side where the adhesions were greatest. As, however, we sometimes see that tuberculated glands in the neck and axilla (Obs. 9), become the cause of pain, it is un- doubtedly possible that, under certain circumstances, this may be the case with tubercles in the lungs. It is, in fact, what we have remarked in the only example of encysted tubercles, 188 SYMPTOMS. — PAINS IN CHEST. [Part II, which we have collected (Obs. 31). This patient had expe- - rienced, during the last fifteen days of her life, pains between the shoulders, and no adhesions existed between the lungs and pleurae. This was also the fact in some instances of acute phthisis, where more or less intense pains were felt in the lat- eral parts of the chest, and no trace of pleurisy was discoverable after death (Obs. 35, 36). It is then possible that, in some examples, the pains in the chest may be owing both to the development of tubercles and the adhesions which follow. 248. Twenty-two patients assurred us that they had never felt any pain in the thorax, and in the majority of these ad- hesions were limited to the summit of the lungs, while the excavations were equally extensive and numerous, as in those cases in which acute pains had existed. This confirms what we have said, as to the most frequent cause of pains in the chest in phthisis. We can, indeed, easily conceive how adhesions limited to the upper part of the pleurae should not cause in- convenience, the corresponding portion of the thorax being the least moveable, and pleuritic pains appearing to be acute, in consequence merely of the elevation of the ribs and of the expansion of the pulmonary parenchyma. 249. Besides, if, as we have remarked in the first part of this work (42), the inflammation of the pleurae and the conse- quent adhesions are often depending on the influence of tuber- cles, we can understand why pains are present in such variable periods of the disease, since tubercles themselves are progres- sively developed. 250. To sum up our remarks, we find that thoracic pains corresponded with the adhesions of the lungs to the pleurae, and not willi the dimensions or number of the excavations. They appeared to result from adhesions formed by chronic inflammation of the })leurac, and when these were confined to Chap. 1.] fever; time of its occurrence. 189 the summit of the lungs, no pains were experienced, although the excavations were considerable. We may add that age, which seemed without influence on the progress of phthisis, had a very sensible effect on the duration of pain. 251. Fever. — The majority of patients having fever when admitted into the hospital, we have endeavored to fix the period of its commencement with precision, and in this we think we have succeeded, whenever we have been able to de- termine the time at which the rigors, or the alternations of heat and cold commenced, especially when these were accom- panied from the first with thirst or palpitations. Taking this epoch for our guide, the fever had commenced with the earliest symptoms of phthisis, and accompanied them through their whole course in rather more than one fifth of the examples, or in twenty -one out of ninety-five cases which were complete as to the particular we are now considering. Five among these were examples of acute phthisis (Obs. 33, &ic). Among the remainder the disease had lasted from five months to three years, including several examples of simple phthisis (Obs. 27, 29). In nineteen other cases the fever had commenced in the first half of the disease, in those cases where the affec- tion, with more or less complication, had passed through its different gradations in a period varying from three months to five years. In about three fifths, the febrile state was present in the second stage of the disease, occasionally only a short time before the fatal termination ; in every instance, the mor- bid condition of the lungs was associated with alterations in a greater or less number of organs. 252. Since fever frequently commenced in the first stage of the complaint, or even from its very beginning, that is, when the lungs were still the only organs affected, we must conclude 190 SYMPTOMS. — fever; [Part II, that its principal and often only source was the more or less extensive alteration in the respiratory organs. 353. Except in cases of very acute or very chronic phthisis, it was impossible to appreciate the circumstances which thus accelerated or retarded the presence of the febrile state ; and to occupy ourselves with the investigation of this, as well as of the variations in innumerable other symptoms, would in our opinion be endeavoring to discover the cause of differences in tastes, physiognomy, and the great varieties of em-hon-point in individuals who are in perfect health. We must know how to content ourselves with the knowledge of the principal facts, and not seek to explain every variation they may present.* * In the minds of many fever and inflammation are inseparable, but a Trariety of considerations render this view of the subject untenable. We shall take advantage of the author's remarks in his Examen, page 36, to make the reader acquainted with the evidence of facts on this point. There is no acute affection vi^hich is not preceded for a few hours or days by more or less intense febrile movement, and during this period no local symptoms, to which it can be attributed, can be observed. M. Louis has remarked this fact in five twelfths of those attacked by erysipelas of the face ; in one half of the cases of measles ; in a still greater number of pneumonias (com- ing on in healthy individuals) ; in one fourth of the examples of cynanclie tonsillaris, and invariably preceding small-pox in the adult. Not a single symptom could be detected capable of revealing an alteration of any of the organs presiding over our different functions. That they were modified was evident; but no one could ascribe that modification to inflammation. On what it depended we are at present ignorant. But we are justified in saying that it is not inflammatory. The development of febrile movement in the early stages of phthisis, when the lungs are the only organs affected, is, therefore, no proof of inflammation, and we must admit that the foj-mer may exist without any appreciable local lesion. Is there not a great analogy between this precursory febrile movement, terminating in eruptions or some local inflammation, and what in other circumstances continues, without producing any particular affection, and which we call continued fever .' Are wc more justified in considering the Chap. 1.] RIGORS. 191 254. Although rigors were among the most frequent symp- toms of fever, they were not constant, being absent in one sixth part, — sixteen times out of ninety-five. The patients whose cases are excepted, complained only of great sensi- bility to cold, declared they never had any shiverings before coming to the hospital, and had been exempt from them during their residence there. This fact is not more singular than the not unfrequent absence of the same symptom in cases of phlegmonous suppuration. In the greater number of instances, the rigors came on every evening, and seldom at any other period. While in general occurring only once, in some cases they were irregularly- repeated several times in the day ; but we have never ob- served two distinct rigors which, in the opinion of some authors, daily recur at a fixed hour. 255. Occasionally, the rigors which took place daily, at a latter of an inflammatory nature than the former ? Though perhaps continued fever is never wholly unaccompanied by some local disease, yet may not this be a very secondary cause of the continuance of the fever ? The fact, that in eruptive diseases the fever is arrested by the local disease it tends to estab- lish, is remarkable, and confirmative of the foregoing observations. Inter- mittent fevers, irritative fevers, all admit of the same reflections. The wfant of proportion between the local disease and the febrile disturbance, so fre- quently observed in erysipelas, pneumonia, &c., is another argument for their independence of each other, or rather for the possibility of fever ex- isting without inflammation.! — Cowan. t I find great difficulty in understanding the meaning of the translator in the last paragraph. Does he intend by the term " continued fever" to refer to the typhoid affection .' If so, he either thinks the typlius of London differ- ent from that of Paris, or he has little confidence in the results to which Louis arrived when studying the typhoid disease in Paris. For the eluci- dation of this subject, the reader may refer to Louis on Fever, and particu- larly observe what he says in pages 195, 196 and 381 of vol, I. — H. I. B. 192 SYMPTOMS. — fever; [Part II, particular hour, were sufficiently inconvenient to require treat- ment for their suppression. This was sometimes successful, and at others we merely lessened their duration or intensity. The temperature, however, remained always elevated in these cases, and after the rigors had been suspended during a varia- ble period of time, they returned with the same violence as before the administration of the febrifuge. It is also easy to foresee that the state in which the stomach of phthisical pa- tients usually is, forbids the indiscriminate use of the sulphate of quinine. 256. The shiverings were generally followed by heat and perspiration. We say generally, for perspiration was absent in one tenth of those who had chills ; and on the other hand, they sometimes existed without the rigors : this was princi- pally during the night, when the patient was asleep. The perspirations were so copious and inconvenient in some in- stances, that sleep was dreaded. They did not appear to depend on the state of the other organs, and generally coin- cided with the diarrhœa, which was frequently very abundant when the perspiration was so copious as to oblige the patient to change of clothing once or several times during a night. We have in vain multiplied our questions, in order to discover whether any dependence existed between these phenomena, and whether they were supplementary of each other; we have never succeeded in afibrding ourselves proofs of the balancing (balancement) of our functions insisted upon by some authors. We have distinctly observed, in the course of perspirations more or less copious, that the diarrhœa diminished during two or three days ; but it soon returned with its previous violence, proving that its variation was a simple coincidence, and not a consequence of the state of the cutaneous perspiration. 257. It may, perhaps, be urged that if the " balancement" Chap. 1.] SUDAMINA. 193 alluded to is not real in cases of phthisis, it is not less certainly the fact in other diseases. But we have equally failed to dis- cover it in fevers, rheumatism, and in general whenever one of the two symptoms came on during the existence of the other; their mutual influence and dependence were never evi- dent ; so that we think ourselves justified in saying that when the contrary appears to be the case, it is probably purely accidental and exceptional. This fact is not, perhaps, without importance, since the majority of medical men regard the *' balancement" of our functions as a fact on which they found their practice. ^58. The sudamîna, so frequent after the perspirations in continued fever, are much rarer, ceteris paribus, in the course of any other disease. We have occasionally seen them in phthisis, but never so numerous as in typhus fever, in which the elevation of the epidermis is sometimes so general, that by very slight friction it might be entirely removed from nearly the whole surface of the body. 259. Let us remark, that these copious perspirations indi- cated disorder in the functions of the skin, as remarkable by its intensity as duration ; that this disorder, whether sympa- thetic or otherwise, was not the less positive, and existed without any sensible change of structure in the organ itself; and that thus a function may be more or less modified during a long period of time, while the organ on which it depends offers no appreciable change of structure. We may also observe, that while facts are wanting to prove distinctly that diarrhœa may exist without appreciable lesion of the intestinal mucous, membrane, we may presume this to be the case, from the analogy existing between diarrhoea and more or less profuse perspiration. Of this we cannot be positive, for in our opinion, A 2 194 SYMPTOMS. THIRST AND APPETITE. [Part II, analogy is only useful to point out fresh subjects for investi- gation, to lead us to the discovery of facts, but never to supply them ; were it otherwise, we might conclude that a thing really existed because it was possible, which is absurd. Lastly, for those who consider inflammation as the only cause of func- tional derangement, it would be difficult to imagine this phenomenon in any degree the cause of the perspirations of phthisical patients, whose skin remains pale and relaxed in the midst of these immense evacuations. 260. The thirst presented, like the other symptoms, very remarkable variations ; absent in one fourth of the cases, it was more or less intense in the rea)ainder ; it preserved no con- stant relation with the state of the stomach, intestinal canal,* or with the diarrhoea ; it was much more frequently propor- tionate to the fever, commencing almost constantly with it, accompanying its progress, and increasing during the evening and night exacerbations. In a few instances the thirst had been preceded by the fever. 261 . Appetite. — When speaking of the gastric symptoms, we shall see tlie numerous variations in the appetite, for * In the majority of cases where thirst was absent, the mucous membrane of the stomach was natural, and diarrhœa had only been present in the last period of the disease, sometimes thirty, forty, and fifty days before death ; twice only, it had existed, with some short intermissions, nine months or two years. In .patients, whose thirst was more or less urgent, the gastric mucous membrane was nearly healthy, or only presented recent alterations, in rather more than one half of the examples ; diarrhœa was nearly always present, but preceded by the thirst, sometimes twenty or more months, in two fifths of the cases. In other patients the thirst commenced with or succeeded the diarrhœa, when even the latter had been violent (Obs. 4). Thirst was extremely ui-gcnt in two individuals whose gastro-intestinal mucous membrane was Itealthy, and who had never had diarrhœa. — Louis. Chap. I.] DIARRHŒA. 195 the dependence of this on the state of the gastric mucous membrane was too evident to admit of separate description. 262. JDiarrhœa was so frequent, that we feel justified in considering it rather as a symptom than a comphcation, and shall consequently not defer its consideration. Out of one hundred and twelve patients, five only had no diarrhœa. It presented numerous gradations of intensity and duration. In one eighth of the patients it commenced with phthisis, per- sisting until death, having lasted from five to twelve months. In some of those who died after an illness of four or five years, it was almost constant during this long period of time. In the majority of cases, it commenced in the second stage of the affection ; in others, towards the very close of the disease ; so that we could consider it under two principal points of view, viz., when it occurred towards the close of life, or when it dated from a period considerably anterior to death.* 26-3. Diarrhœa towards the close of life. — We place in this class all those cases where the diarrhœa commenced from twenty to five days before death. They formed one fourth part of the whole. In some tliis symptom was accompanied with slightly increased heat of the skin, unusual rigors, and variably intense colic pains. Most frequently nothing similar was ob- served. The stools were usually infrequent. When we have examined the evacuations, they were yellowish, pultaceous, consisting of very clear fluid, free from blood or mucus, in which fragments of a variably consistent substance floated. The smell was not very offensive. With only one exception, the mucous membrane of both intestines was the seat of some alteration. In one half of the * The following analysis only refers to ninety-five cases, where the mu- cous membrane of both intestines was carefully examined, — Louis. 196 SYMPTOMS. -^DIARRHŒA, &C. [Part II, individuals there were ulcerations in the small intestine or colon, sometimes in both ; but, with one exception for the former, and two for the latter, they were small and kw in number. In four fifths the mucous membrane of the large intestine was soft as mucus, and almost invariably more or less red. 264. There was an exact correspondence between the symptoms and the alterations to which they might be attri- buted. For, if the diarrhoea had only preceded death by a few days, this seemed to be equally the case with the ulcerations and softening of the mucous membrane of the colon. In fact, the ulcerations were small, the cellular tissue lining them very thin ; and, from their natural tendency to increase, and that of the cellular layer to thicken, we might certainly consider them as very recent. With regard to the softening, with or without redness of the mucous membrane of the large intestine, we will observe, that it was equally intense in cases fatal in two or three weeks from a simple attack of dysentery ; most ordinarily it was evidently the result of inflanmiation, which, in its commencement, had in many cases been attended with slight febrile movement, liquid stools and colic pains ; and where the pains and fever were absent, the origin of the alter- ation must coincide with that of the diarrhœa, unless we admit that colitis was always latent, which is impossible. Every consideration, then, seems to favor the conclusion, that the small ulcerations and the softening we have described, with the inflammation on which they most usually depended, were very recent at the period of death. If we cannot imagine that so important an alteration as the pulpy softening of the mucous membrane of the large intes- tine could be constantly latent, we may however conceive the possibility of its being so, and in fact we have collected three Chap. 1.] DIARRHŒA OF LONG DURATION. 197 observations where this was actually the case. In one of these, the softening was conjoined with a tolerably intense red color of the mucous membrane. There had been no complaint of pain in the abdomen. The diarrhœa was less copious in individuals in whom ulceration alone existed, than where softening was present : — a result easy to be foreseen, from the difference in the real im- portance of the two alterations. 265. The diarrhœa of long duration presented two prin- cipal modifications : it was either continued or remittent. '^QQ. The duration of the latter varied from fifteen months to forty-eight days. The remissions were variable, from eight to ten, fifteen, or twenty days; the stools were generally scanty ; colic pains rare. Fifteen of our patients were examples of this. In ten, the small intestine was ulcerated ; in six, this was the case with the colon, and, with the exception of two instances, for both intestines, the ulcers were small. The mucous mem- brane of the colon was exceedingly soft in ten others, and in three of these red and thickened ; so that this series of pa- tients offered nearly the same alterations, both as to intensity and extent, as those of the preceding series, in whom the diarrhœa commenced, as it were, only a few days before death. It seems natural, from this alone, to suppose that the lesions observed after death were very secondary in the pro- duction of the diarrhœa ; that they originated in the second series as they did in the first, that is, towards the close of life ; and that previously to this period the diarrhœa resulted from a simple alteration of secretion, which we have already remarked, appeared to be the case with the perspirations. 267. Chronic and continued diarrhœa lasted from one to twelve months, sometimes even longer. It was more or less violent, and generally accompanied with colic. In one in- 198 SYMPTOMS. CONTINUED DIARRHŒA. [Part II, Stance, where it was prolonged five months (Obs. 4), there were not less than from twelve to fifteen stools, often copious, during the day. Out of forty-one patients, affected in this way, thirty-five had ulcerations in the small, and thirty-one in the large intestine. Twelve times the ulcerations of the small intestine occupied its whole length. They were of consider- able size, and about an inch in diameter in thirteen patients, whether they were universally or only partially distributed. There were nineteen examples of extensive ulceration of the large intestine, and thirty of softening of its mucous membrane. The latter was red in seventeen of these. Thus, after long continued diarrhoea, we found extensive and numerous ulcera- tions; that is, morbid alterations similar to what we find when diarrhoea has been chronic but with occasional intermissions, though in the former case the ulcerations were much more intense, and evidently of longer duration. 268. Large ulcerations existed in both intestines, in six patients in whom the diarrhœa had been copious and contin- ued during two, three, five, and eleven months. In others, they were only considerable in the small intestine or colon. If in the small, the diarrhœa was not the less chronic and con- tinuous ; an evident proof that it cannot be considered as ex- clusively resulting from alterations in the large intestine. We must, however, admit that the latter was its principal source in phthisis, for the mucous membrane of the colon was much more frequently softened and inflamed than that of the small intestine. What, however, renders it still more improbable that the affections of the colon are the only cause of diarrhœa, is, that in continued fever, where this symptom is very seldom wanting, the chief and often only alteration of the alimentary canal is in the small intestine. 269. To be able to predict with sonje certainty the exist- Chap. 1.] EMACIATION. 199 ence of large and numerous ulcerations, it is not only requisite that the diarrhœa should have been chronic and continuous, but that the stools should have been frequent ; for, in many instances where this last condition was wanting, although the diarrhœa had continued many years uninterruptedly, the ulcer- ations were very inconsiderable.* But we have never met with an example where the diarrhœa was chronic, continuous, and when at the same time the stools were numerous, without large intestinal ulcerations. The certainty of the diagnosis would be still farther increased by the inspection of the evac- uations. For, in accordance with what we have remarked in the former part of this work (143), their color was greatly changed, and their odor similar to that of animal substances some time in maceration, when the ulcerations were extensive and numerous. 270. If those in the rectum were small they exerted no in- fluence on the diarrhœa. If they were extensive, and partic- ularly if situated close to the anus, the dejections were extremely frequent, mucous, accompanied with tenesmus, sometimes streaked with blood, and generally involuntary. The loss of strength and flesh was also proportionate to the number and frequency of the stools in all the cases. 271. Emaciation was present in one half of the cases from the commencement of the first symptoms, whether the pro- gress towards the fatal termination was rapid or slow, varying for example from five months to three years. In a very few instances it coincided with the first appearance of the diarrhœa or loss of appetite, although the gastric mucous membrane was often perfectly sound, or its alterations still recent at the mo- * These facts confirm what we have already said, viz. that vitiated secre- tions are probably in many instances a cause of diarrhœa. — Louis. 200 SYMPTOMS. — EMACIATION. [Part II, nient of death. In one third, it seemed to originate with the fever ; its origin, therefore, in the majority of cases, could not be attributed either to the fever, diarrhoea, loss of appetite, or to a morbid state of the gastric mucous membrane ; we are then obliged to ascribe it to the more or less extensive altera- tion of the pulmonary parenchyma interfering with the nutri- tive function. The diarrhœa once established, the emaciation proceeded rapidly. The state of the gastric mucous mem- brane exerted also an active influence, and unless some accident to the brain or lungs, a perforation of them, for ex- ample, shortened the patient's life, the marasmus became extreme. Loss of flesh can furnish to the physician very useful indi- cations as to the diagnosis in cases of latent phthisis ; that is, when the patients, without experiencing any local symptoms, are harassed by continued fever of some duration, and accom- panied with dyspnœa and emaciation. Under these circum- stances it is rare that the seat of the disorder is not in the lungs, and the affection tuberculous. It is an additional reason for having recourse to all the means in our power for discover- ing the exact state of the lungs in such cases. 272. Emaciation was evident in almost all the tissues. The adipous ultimately disappeared almost entirely ; the skin itself became thinner ; the muscles were not less diminished in vol- ume. We have already spoken of the state of the heart ; but the change was much more evident in the muscles of volition ; among these, the flat muscles, the temporals, and those covering the parietes of the chest, he. were in the majority of individuals not one third of their natural thickness. The muscular layer of the stomach also appeared thinner. The uterus was evidently in several instances smaller than natural, &:c. Chap. 2.] DIAGNOSIS. FIRST PERIOD. 201 273. The face had no particular expression. In patients whose complexion was habitually florid, it became gradually pale. In some îev^ instances its color increased, which ap- peared owing to peculiar circumstances (Obs. 55). The cheeks were not red in the intervals of febrile exacerbation, and the slight blush which they then assumed was similar to what we see in the course of other chronic affections under similar circumstances. The remainder of the body shared in the paleness of the face. Very rarely there was slight oedema round the ankles, and still more rarely throughout the whole of the lower ex- tremities (Obs. 3). Sometimes one hand and the fore-arm were slightly infiltrated, which announced a serous effusion in one side of the chest. But none of these symptoms were peculiar to phthisis, and were not more frequent in its course than in that of other chronic diseases. CHAPTER II DIAGNOSIS. Auscultation and percussion are the means by which we may arrive at the diagnosis of phthisis. But as the results of auscultation and percussion differ at the different periods of the disease, we shall, for the sake of the diagnosis as well as for the history of the progress of the affection, separately consider the results obtained at two periods, one previous to, and the other succeeding the formation of tubercular excavations. B 2 202 SYMPTOMS. — DIAGNOSIS, FIRST PERIOD; [Part 11^ 274. First period. — The diagnosis in this period, as in that corresponding to it in other chronic diseases, is often un- certain ; but we beUeve that by a careful examination of the facts, we may frequently acquire a very high degree of pro- bability. We will glance at some of the principal circum- stances. In the greater number, the cough came on without any evident cause, and frequently one or several months elapse without expectoration. This absence of any obvious cause, and this dryness of the cough are of themselves very remark- able, differing from what occurs in simple bronchitis. Whether the expectoration be present from the commence- ment, or only from a more advanced period of the disease, it at first is clear, frothy, white, and forms a fluid very analo- gous to saliva, and it retains these characters for a longer or shorter time, which is not the case in simple pulmonary catarrh. So, likewise, thoracic pains, when present in the latter affection, are rarely felt except in the middle of the sternum, while in phthisis they are not only frequent, but are situated in the sides of the chest and between the shoulders, also with other characters to distinguish them from those in bronchitis. Conjoined with the preceding symptoms, pains, such as we have described, seem to us strongly indicative of tubercles in the lungs. On the other hand, out of twelve hundred patients, not in- cluding cases of amennorrhœa, or persons suffering from ex- ternal violence upon the chest, not one, with the exception of phthisical patients, had experienced hcemopiysis ; so that the occurrence of this symptom during this period, preceded or followed by thoracic pains, cough and expectoration havin»- the characters we have described, renders the presence of Chap. 2.] AUSCULTATION AND PERCUSSION. 203 tubercles in the lungs almost certain. And as the combina- tion of these symptoms is rather frequent, we see how it is possible in many instances to diagnosticate phthisis at a very early period. 275. There is also very often in a limited space less sound on percussion under one of the clavicles than under the other ; and as tubercles are almost invariably developed from the summit to the base of the lungs, this fact, if well determined, greatly increases the certainty of our diagnosis. The respiratory murmur is also rather weaker in the point corresponding to the dulness on percussion than in any other portion of the chest ;* * It may be here useful to mention another result of auscultation, on which the attention of medical men has only been lately fixed, and which was first signalized by Dr. Jackson, of Boston, in the wards of M. Louis, who has twice amply confirmed its value as an additional aid in diagnosis. We refer to the study of the expiration. In health this is scarcely and sometimes not at all sensible, and never seems to occupy the seat of inspira- tion, but is evidently at a distance from the surface in the larger bronchia, and very feeble. But when the density of the lung is increased, the ex- piration becomes gradually more and more distinct and superficial, till it resembles a second inspiration, and frequently is alone heard ; without accurate comparative examination, it might easily be, and no doubt often has been mistaken, for the inspiratory murmur. What renders this sign pecu- liarly valuable is, that the change in the expiration precedes that of the inspiration, and consequently the modification is principally applicable to the early periods of the disease, when correct diagnosis is so important. 1 have frequently seen M. Louis, from this symptom alone, decide on the ex- istence of induration of the lung, when it could neither be detected by per- cussion or modified inspiration. Dr. Jackson has also proposed a plessimeter ot India-rubber, which, from its yielding no sound of its own, and protecting the patient from the pain which the use of the finger or a hard substance often occasions, possesses decided advantages. M. Louis agrees fully in its utility and efficiency ; the piece employed should be about a quarter of an inch thick and an inch square. t — Cowan. t This subject is doubtless a very interesting one to any individual who is desirous of an early diagnosis in phthisis. I think, however, that the exist- 204 SYMPTOMS. — DIAGNOSIS, FIRST PERIOD ; [Part II, a mucous, sonorous, or crepitating râle is occasionally heard, which is either confined to this region, or extends a very short distance beyond it, and is of a different character ; so that the alterations in the respiration and clearness of sound on percussion, like the development of tubercles, take place from the summit to the base of the chest, and are confirmative of the diagnosis founded on the previous symptoms. 276. When we, therefore, meet in the same individual the dry cough which has existed a variable space of time, and in many instances has come on without apparent cause, accom- panied with clear, mucilaginous kinds of expectoration, pains in the sides of the chest or in the back, haemoptysisat the com- mencement or during the progress of the cough, dulness of sound under one or both clavicles, diminution or any other alteration of the respiratory murmur in the same point, while the remainder of the lungs is healthy, we may be certain of the presence of unsoftened tubercles. The dyspnoea, the loss of appetite, the emaciation, the sensibility to cold, and often the chills, &c., which are present in this first period, assist our diagnosis, but could not, independently of the preceding symp- toms, confirm it. ence of a prolonged expiration at the apex of the lungs, as a sign of the ex- istence of tubercles, is not yet perfectly demonstrated. I would i-emark at this time, that I have often found at the same time that the expiration be- gins to become longer the inspiration shortens, both in phthisis and pneu- monia. How far shortening of the inspiration may be of use in diagnosis, I cannot as yet say, as my means of examination have been limited since I first noticed the fact. Meanwhile I leave it to others having larger opportunities to investigate it, but I would suggest the necessity of always analyzing the respiration so far as to describe the inspiration and expiration, and to mark their respective durations, and the peculiar râles heard during each. — H. I. B. Chap. 2.] AUSCULTATION AND PERCUSSION. 205 277. Many of our observations (Obs. 10, 35, Stc), and annong others the following, are illustrative of what we advance. TENTH OBSERVATION. (Bis.) A BOOK-BINDER, sBt. 16, tall, habitually thin, entered the hospital of La Charité, March 23d, 1825. Hair, black j skin, fresh colored ; he was not subject to sickness of any kind, or cold. He dated his present illness fifteen days ; he had ex- perienced at the commencement, without any apparent cause, great lassitude, with violent rigors, and a cough accompanied by a small quantity of clear expectoration. These symptoms had continued ; pains in the precordial region were excited by cough, and on the eighth day he expectorated a little blood. Bowels, costive ; thirst, not urgent ; very little appetite. The general weakness had much increased. March 25th. Expression, rather animated, a little less how- ever than usual ; considerable debility ; he had walked with difficulty to the hospital. Cough, usually dry, rarely ac- companied with a clear, mucous, spumous expectoration ; it no longer excited pain in the precordial region. Per- cussion of left part of chest, natural, but rather dull for two inches under the right clavicle, where there was a slight crepitating râle. Respiration, rather confused pos- teriorly in the corresponding point, but elsewhere natural. No oppression ; but he cannot repeat many words without drawing his breath. Pulse, one hundred and six, regular ; heat of skin, natural in the morning, elevated towards noon, and accompanied vi^ith perspiration at night. Tongue, S06 SYMPTOMS. DIAGNOSIS, FIRST PERIOD; [Part II, very moist, natural on edges, a little yellowish in the centre ; Tery little appetite ; thirst, moderate ; abdomen, not painful ; three liquid stools without pain the previous evening. The patient is quite tranquil, and attitude in bed is natural. (Infusion of violets ; gum potion ; V. S. § viij. ; diet.) Thedisease continued to progress, and up to the 31st of May, the day of his death, the following is the result of our observations. He coughed very little during the first month, but rather more frequently afterwards ; the expectoration was of no marked character, and so scanty that it was generally dried up in the spitting vessel. There were occasionally pains in the leftor right side of the chest, lasting for a short time. During the latter half of May, the breathing was always somewhat oppressed. On the i^9th of March there was con- siderable resonance of voice under the right clavicle. On the 8th of April the respiration in the same region was almost tracheal, both anteriorly and posteriorly, and accompanied by a gurgling, which became a coarse crepitation two inches be- low the clavicle ; this râle extended to a very short distance. On the left part of chest the respiration appeared natural, except superiorly and posteriorly, where there was an occa- sional crackling sound. On the 13th, great resonance of voice under both clavicles. On the 28th, pectoriloquy was evident in every direction round the summit of the right lung; it was doubtful on the left apex. No other evident change in the results of auscultation, which was performed many times, oc- curred before death. From the 29th of March, percussion under the right clavi- cle became gradually duller, and extended over a larger space. The heat of the skin was considerable in the evening ; night perspirations almost daily, and not preceded by rigors. On the 25th, pulse, ninety-five ; it increased shortly afterwards, Chap. 2.] AUSCULTATION AND PERCUSSION. 207 and never again fell below one hundred; and from the 15th of May it was one hundred and twenty. Very little thirst ; appetite, always feeble. The food con- sisted of some rice creams, with sometimes an e^v. Bilious vomitings took place on the 11th and 12th of May, and did not occur afterwards; the epigastrium was never painful; stools, scanty and rather fluid. May 26th. Œdematous state of left cheek, hand and fore- arm ; this gradually increased until death. On the morning of the 30th, the countenance was slightly changed ; there was an expression of terror, without doubt to be attributed to the extreme dyspnoea which then existed. Death took place at three o'clock the next day, preceded by very slight delirium. Opening of the corpse twenty-nine hours after death. Exterior. — Slight œdema of the lower extremities, also of the fore-arm, and face on the left side ; limbs, flaccid. The head was not examined. Neck. — Mucous membrane of epiglottis, of a pale pink color, without other alteration. A superficial ulceration at the convergence of the vocal cords. Trachea, of a bright red color throughout, with numerous small oval ulcerations, of about a line in breadth, as if portions of the membrane had been artifi- cially removed ; the latter was elsewhere of natural consist- ence and thickness. Chest. — Some long and thick adhesions at the summit of both lungs, especially that of the right. About a pint of clear serum in each pleura. The whole of the upper right lobe was of considerable density, presenting at its summit tuberculous excavations communicating whh the bronchia, and none of them were larger than a small nut. Their parietes were not lined by false membrane, but formed by a semi- 208 SYMPTOMS. — DIAGNOSIS, FIRST PERIOD; [Part II, opaque substance, homogeneous, of a greyish and greenish aspect, tolerably firm, not granulated, and yielding by pressure a similarly colored fluid, which was turbid. This induration, which existed in the whole upper lobe, presented various small excavations, and numerous irregularly defined tubercles. These last existed, without excavations, in the upper part of the lower lobe, the base of which was slightly congested, and contained some semi-transparent granulations. Similar, but less extensive lesions in the left lung. Bronchia of right lung redder than those of the left ; they were slightly ulcer- ated. Heart, of good size, and aorta healthy. Abdomen. — A quart and a half of limpid, rust-colored serum in the peritoneal cavity. Œsophagus, healthy, except for about an inch at its cardiac extremity, where it was much thinned and easily torn ; internally it had a bluish tint, and its thin mucous membrane was wanting over a space of half an inch. The stomach, which was rather voluminous, and con- taining a small quantity of turbid fluid, had over its upper portion and great cul-de-sac a bluish tint, like that of the lower part of the œsophagus, in a continuous surface about equal to the palm of the hand ; the same color reached to within two inches of the pylorus in bands, three or four lines wide, and as many inches long. The corresponding mucous membrane was ex- tremely thin, and soft as mucus, rather viscous and semi-trans- parent, here and there it was destroyed. In the intervals of the colored portion it was a little softened, but of naturaJtint. Duodenum, sound. The mucous membrane of the small in- testine was of its natural color and consistence, slightly soften- ed, and presented in its last two thirds about forty small ulcera- tions, from two to three lines in surface, and almost all upon the patches. Their lining and their circumference, for the space of two lines, were greyish and formed by the submucous layer, Chap. 2.] AUSCULTATION AND PERCUSSION. 209 slightly thickened. The mucous membrane of the large in- testine was in contact with some puliaceous, yellowish fseces. It was every where softened, and especially so in the caecum, where it was not more consistent than mucus ; it offered nu- merous ulcerations, from half an inch in surface and upwards, both in the caecum, ascending and transverse colon. Their edges were prominent, their bottom blackish, and formed by the slightly thickened submucous layer. Opposite to the ileo-csecal valve there was a greyish patch, partially ulcerated, in which was rather a large number of tuberculous granula- tions, imbedded, as it were, in the submucous membrane. This last was more or less thickened throughout the whole course of the intestine. Many of the mesenteric glands nearly equally scattered through the mesentery were rough, in- creased in volume, reddish colored, and in part composed of crude, tuberculous matter. The other organs of the abdo- men were healthy. The bile of the gall-bladder, darkish colored and very viscous. This observation is one of those which speaks most strongly in favor of auscultation and percussion. At our first examina- tion of the patient, on the seventeenth day of the disease, he might have been considered laboring under simple catarrh. But the absence of all apparent causes, and the slight haemop- tysis which had occurred on the eighth day, having induced us carefully to examine the chest, we found that the respira- tory murmur below the right clavicle was feeble and mingled with a crepitating râle confined to this region; that the percus- sion was also duller there than elsewhere ; and from these symp- toms we did not hesitate to consider the patient as phthisical, although his general health, and the short time which had elapsed from the commencement of the affection appeared c 2 210 sîwpTows. — DIAGNOSIS, SECOND PERIOD; [Part II, little favorable to such a diagnosis. It v^'as, however, soon con- finned by tlie progress of the symptoms, the resonance of the voice and pectoriloquy under the right clavicle ; and, if we recol- lect the mode of tubercular development, it will be granted that our diagnosis was not less easy than rational. However, not to distract the attention from the principal object of this chap- ter, we shall content ourselves with remarking, that the softened state and diminished thickness, with partial destruction of the gastric mucous membrane were latent; that bilious vomiting only occurred during two days, which of itself was insufficient to characterize the lesion which existed ; the same remark may be made as to that of the lower portion of the œsophagus. 278. Second period of Phthisis. — The sputa, which be- come somewhat thick towards the close of the first stage, are greenish, and marked with whitish lines on their surface, at the commencement of the second. They have not yet any definite form, but they soon become thicker, rounded, and often rag- ged (lacérés) in their circumference, characters which are pecu- liar to phthisis (226). Thoracic pains begin, or if previously existing, are sometimes more intense, and are of equal impor- tance. Hssmoptysis is pretty frequent, and is not accom- panied by any peculiar circumstance ; so that among the local symptoms, the sputa alone differ in the two periods of the disease. 279. The results of percussion in this period are not less decisive than in the other. In fact, we have seen that in one third of the cases, the upper lobe of one or the other lung was entirely converted into tubercles, grey substance, and into excavations successively smaller from the summit to the base. When this was the case the corresponding part of the chest was dull on percussion, while it was clear every where else. This state of things, of itself, and without other investigation, vi^ould Chap. 2.] PECULIAR (PELOTONES) SPUTA, &,C. 21 I almost be sufficient to characterise phthisis. By means of this alone in subjects who were but slightly emaciated, and in whom the aflection had gone on slowly, we have been able many times to recognise the existence of tubercles without any interrogatory, or examination of the sputa, and, more- over, the autopsy has verified the truth of our diagnosis. 280. At the same time that the sputa become striated with yellowish hues and denser, the respiratory murmur is strong, coarse, or even tracheal under the clavicles, in the part cor- responding to that in whicli are found after death the largest excavations. To this is frequently conjoined either a crepita- ting râle (resembling the sound produced by bending dry basket-work, or a very dry piece of sole leather), or the true gurgling. The voice soon becomes resonant, and this is shortly replaced by pectoriloquy. The space in which these different changes take place is at first limited, but it daily in- creases ; and in some instances, where the whole of the upper lobe is converted into numerous excavations, the respiration is coarse, and more or less tracheal throughout its whole extent. The gurgling and other râles are also present, but their char- acters, as well as those of the tracheal respiration, diminish as we recede from the clavicle, thus coinciding with the succes- sive development of tubercles, and of their evacuation when softened. The pectoriloquy becomes daily more distinct, without, however, existing throughout the whole of that part of the thorax which corresponds to the upper lobe. 281. These shades of difference in the characters of the râles and tracheal respiration, which take place from the sum- mit to the base of the lungs, are most important for the accu- racy of our diagnosis. They must fix our attention not less than the local symptoms we have described ; for, although pectoriloquy and tracheal respiration prove the existence of 2 SYMPTOMS. DIAGNOSIS, SECOND PERIOD J [Part IV, an excavation, they do not indicate its nature ; and if we at once concluded, from the mere existence of these symptoms, that the case was phthisis, we should, at least occasionally, be led into error, as the following observation will prove. ELEVENTH OBSERVATION. A DAY laborer, set. 59, of middle height, feeble constitution, had been subject to shortness of breath from childhood, which had considerably increased the last ten years, during which he had been laboring under bronchitis. This last was less intense during the summer, was very troublesome in the winter, and then accompanied by emaciation. For the last six months, gradual diminution of both cough and appetite ; but, one month before entering the hospital, the anorexia had been complete, the cough had become more troublesome, and the debility more considerable ; he had entirely ceased his occupations. He had never complained of pains in chest, and never had had haemoptysis. November 30th, 1824, the day after his admission, face, pale ; lower extremities, slightly infiltrated ; walks slowly, and with difHculty ; cough, moderate ; expectoration, opaque, greenish, not striated ; respiration, almost perfectly tracheal, and with a coarse, crepitating râle under right clavicle, and posteriorly in the corresponding point ; great resonance of voice and indistinct pectoriloquy in the same regions; chest, every where sonorous on percussion ; pulse, very little quicker than natural , tongue, clean on edges, brown in the centre ; thirst urgent ; anorexia ; abdomen, voluminous, and obscure fluctuation could be detected. Diarrhoea and night sweats the last fifteen days. Chap. 2.] DILATATION OF THE BRONCHIA. 213 (Infusion of rice and the trilicum repens for drink ; dias- cordium ; frictions with the tincture of digitahs ; two rice creams). Up to the 19th of November, when death took place, he gradually became weaker ; the dyspnoea increased, and for the last six days the expectoration resembled a greenish- colored pea soup; no change in auscultation on the right side. On the 7th, a mucous râle, mingled with a gurgling sound, was heard under the left clavicle ; posteriorly and superiorly the respiratory murmur was very strong, as well as the reso- nance of the voice ; there was a loud sonorous râle throughout the whole chest during the last four days ; the pulse became very frequent. Complete anorexia ; nausea, succeeded by vomitings, with a dry tongue. On the 10th, copious diarrhœa came on, and from fifteen to twenty stools were passed daily until death. Drowsiness was almost constant the last four days, and he ex- pired at seven, p. m. Opening of the corpse thirty-seven hours after death. Exterior. — Slight œdema of the lower extremities. Head. — Close adherence of dura mater to sagittal suture, slight sub-arachnoidean infiltration ; cortical substance, rather pink ; the medullary was slightly injected and of good con- sistence ; a spoonful of clear fluid in each lateral ventricle ; rather less in the inferior occipital fossae. Neck. — Epiglottis and larynx, natural ; mucous mem- brane of the trachea, red throughout, especially inferiorly, otherwise perfectly healthy. Chest. — Numerous cellular adhesions over the whole of both lungs. The summit of the right lung, to the extent of two inches, seemed formed by numerous cysts, varying in ■214 SYMPTOMS. DIAGNOSIS, SECOND PERIOD; [Part II, size from that of a pea to a large nut. These apparent cysts were formed by dilated bronchia, containing a reddish mucous fluid, or a yellowish opaque substance of variable consistence. They were closely compacted together, and formed by a thin mucous membrane, resembling that of the colon, rather red, resisting, and continuous with that of the bronchia, which ap- peared natural in every other part of their extent. Some of them had a kind of valves to them. The same lesion existed in the summit of the left lung, but occupied but an inch and a half merely, and the dilatation of the bronchia was less consid- erable. There were neither tubercles nor tuberculous matter in any portion of the lungs. The right was slightly congested, but not so supple as the right, and with the exception of the dilatation described, healthy ; the heart was small ; the aorta presented throughout its whole length some prominent yellow- ish spots. Abdomen. — About three quarts of clear serous fluid in the abdominal cavity ; stomach, small; the mucous membrane, of a greyish color near the pylorus ; punctated with red spots every where else ; in some points it was thin and extremely soft, except in its greyish part, so that it was capable of being detached in fragments, from one to two lines long only ; small intestine, contracted, of twice its usual thickness and very short ; its lining membrane as soft as mucus; that of the colon was a little thickened throughout, extremely softened in the sigmoid flexure, and every where rather less firm than natural ; the liver adhered to the diaphragm ; structure, healthy ; gall-bladder, not larger than a filbert ; it contained two blackish, soft, nodu- lated concretions, enveloped in mucus ; its parietes exceeded half a line in thickness, principally in consequence of the thick- ened state of the mucous membrane ; the submucous layer, was much indurated ; cystic duct, natural. Chap. 2.] DILATATION OF THE BRONCHIA. 215 282. When we first saw the patient, we consideredhim laboring under some organic abdominal affection and an ex- tremely chronic phthisis, which liad only caused very limited disorganization. The clearness of percussion under the clavi- cles at first inspired us with doubts; but auscultation indicating the existence of an excavation in the same point, we could not avoid supposing it the result of suppurated tubercles; a sup- position apparently confirmed by the cough, dyspnoea, expec- toration, and more especially by the part of the chest in which the excavation was situated. We were mistaken in our con- jectures, and perhaps should be again so, were a similar fact to be presented to us.* However, let us remark, that there were neither haemoptysis, pains in the chest, nor striated ex- pectoration ; from all which we may conclude, that the exist- ence OÎ pectoriloquy in a very limited space, in an individual affected with chronic bronchitis, and when the expectoration is opaque, greenish, purulent, and rounded, is not sufficient to determine the existence of tubercles ; to do this with certainty, either haemoptysis, pains in the chest, or dicninished sound on percussion round the excavation, must be present at the same time with those just mentioned. * James Jackson, Jr., in a letter to his father, dated January 25th, 1833, mentions the case "of a young girl with whom we made acquaintance last year at La Pitié. She then entered Louis's wards in March; cough, ex- cessive ; oppression ; respiration, at last up to sixty-six in a minute; exces- sive subcrepitous rale, the longest and most numerous 1 ever heard, over the whole right lung behind, and all this of recent origin. Louis doubted be- tween bronchitis and acute phthisis. Tbe actual symptoms could not be explained by either, but the excessive dyspnœa led him to hold the last in suspicion." The cholera came, and the patient passed from the ward. At the date of the letter she came again, ill with the small-pox. She died, and a very great dilatation of the bronchia was found, with some gangre- nous spots in the substance of the lungs. See Jackson's Memoir, page 167. — H. LB. 216 sr.MPTOMs. — DIAGNOSIS, SECOND PERIOD. [Part II, 283. No doubt similar facts are rare ; and indeed years may elapse without encountering a second ; but we must not, on that account, neglect it, since it is a striking proof of the difficulty of diagnosis in circumstances apparently the most favorable, and of the importance of some local symptoms, especially of percussion. It was in fact more than probable, as we at first suspected, that a tuberculous affection of ten years duration would have terminated in some induration of the lung, and produced corresponding results from percussion.* 284. Pectoriloquy did not always exist opposite excavations, even when there was free communication with the larger bron- chia, and they were of considerable size. Occasionally also the resonance of the voice was not very distinct, but usually, at the same time, there were gurgling and tracheal respiration ; so that when these two symptoms are present, particularly if beneath the clavicles, where great tuberculous cavities are found, they are equivalent in value to' pectoriloquy, and like it show the existence of a cavity. 285. To the preceding symptoms were conjoined in some cases metallic tinkling. This peculiar sound, which we have heard in three instances (Obs. 1), announces, as M. Laennee has said, a large tuberculous excavation, filled with air and fluid, and communicating with the bronchia. It also exists after perforation of the lung by the emptying of a softened tubercle into the pleural cavity (424, Stc) ; but the distinc- tion between these two cases is easy ; for, when the sound occurs in a tuberculous excavation, it is associated with pec- toriloquy and tracheal respiration, both of which are absent * Wc are aware of the truth of M. Laennec's observation, that induration round tuberculous cavities does not always prevent the chest from being sonorous ; but for this to be the case the excavation must be very extensive (Obs, 1,28). — Louis. Chap. 3.] PNEUMONIA AND PLEURISY, &;c. 217 when this is not the case. We shall not insist on the geiieral symptoms, which are never sufficient for the diagnosis of local disease, but we shall observe that those which indicate ulcer- ations of the epiglottis and larynx* are not without value; since, from our researches in the first part of this work (60), these lesions appear peculiar to phthisis.f CHAPTER III. PNEUMONIA AND PLEURISY OCCURRING SHORTLY BEFORE DEATH. 286. When pneumonia was very limited, no symptom in- dicated its existence ; but when more extensive, five eighths of the patients complained of pain in one side of the chest, three, four, or five days before death : at the same time the respiratory murmur was weak, mingled with a fine crepitation, and percussion was more or less dull in the corresponding point. The expectoration became sometimes viscous, without, however, presenting any other of the characters presented by * Mr. Bedingfield remarks, in his valuable Compendium of Medical Practice, that every case of ulcerated larynx and trachea which had fallen under his observation terminated fatally; and, with the exception of two instances, depending upon syphilis, Di-. Armstrong was equally unsuccess- ful. These results are confirmative of the author's conclusion as to the dépendance of this lesion on the tubercles in the lungs. — Cowan. t For some remarks in relation to diagnosis, see Translator's Appendix, B. — H. I. B. D 2 218 SYMPTOMS. PNEUMONIA AND PLEUKISY, &£C. [Part II, pneumonia when it occuis in subjects not weakened by pre- vious disease. When under other circumstances, these symp- toms are, however, sufficient to define the nature of the com- plication, and the time of its invasion ; they also prove that pneumonia may happen in phthisical patients when emaciation is extreme, and that the existence of complications with great debility is not an insuperable obstacle to the diagnosis of ac- cidental intercurrent diseases. 237. Pleurisy, developed under the same circumstances, also gives rise to symptoms by which it may be detected in the majority of the cases. Seven out of eleven patients were examples of this complication, and they had all experienced exacerbation of the dyspnœa, acute pains in one side of the thorax, three, nine, eleven, or seventeen days before death. In three among these there was an increase of heat and thirst, and the pulse was accelerated. Œgophony was present in two, and would no doubt have been more frequently de- tected, had complete examination been possible. In cases of extreme weakness, the necessary exertion to effect this might not be free from danger. The symptoms, however, were suffi- ciently marked to enable us to form a diagnosis, and to prove that the affection existed only a few days before death. 2S8. If pneumonia, coming on in the last period of phthisis, is rapid in its progress and accelerates the fatal termination? this is not the case in an earlier stage of the complaint, for then the patients are enabled to continue their avocations, the debility and emaciation having made but little progress. Pneumonia is then, in fact, almost invariably curable, though associated with tuberculous excavations.* We cannot arrive at the same conclusion for pleurisy, when coming on in- the * M. Andral makes the same remark. — Louis. Chap. 4.] ULCERATION OF THE EPIGLOTTIS. 219 course of phthisis ; for, with one exception, we have never seen it entirely cured, not even when occurring before tuber- culous softening had taken place. The symptoms might often he palliated , the effusion in part dissipated, but it was never wholly absorbed, and after a variable period of time, the pa- tients died, having in addition to the tubercles in the lungs, false membranes and effusion in one or both sides of the chest. CHAPTER IV. SYMPTOMS OF ULCERATIONS OF THE EPIGLOTTIS, LARYNX, AND TRACHEA. ARTICLE I. SYMPTOMS OF ULCERATIONS OF THE EPIGLOTTIS. 289. Out of eighteen patients in whom we have observed this alteration, in six there were no ulcerations either of the larynx or trachea. Four among them complained of a varia- bly intense pain in the upper part of the thyroid cartilage, or between this and the os hyoïdes. The pain was compared to that of a raw sore, to prickings, or to a sense of burning. It was present a month, two months, or only a few days before death. In three instances there was dysphagia, although no alteration existed in the pharynx or tonsils ; liquids were some- times returned by the nose. Out of twelve other patients who had ulcerations in the epiglottis, larynx and trachea, in 220 sYMPTOBis. — EPIGLOTTIS ; [Part II, four, deglutition was difficult, and pain was complained of in the same region. Only one among them, during a certain time, rejected liquids by the nose. 290. Thus the sympton)s of ulceration of the epiglottis become evident from a detail of the facts, viz., a fixed pain in the upper portion of or immediately above the thyroid carti- lage, with some difficulty in swallowing and the return of liquids by the nose, while the pharynx and tonsils remain healthy. These symptoms are confirmed by what we observe in ulcerations of the larynx, for in this case there is neither return of liquids by the nose nor difficulty in deglutition, so long as the pharynx and epiglottis are not affected. Perhaps in the absence of the symptoms peculiar to ulceration of the larynx, a fixed pain at tlie upper part of the thyroid cartilage would sufficiently indicate those of the epiglottis. At least this would appear to be the case from the following observa- tion, where pain was almost the only symptom observed. TWELFTH OBSERVATION. A TAILOR, set. 40, of a weak constitution, born of parents who died at an advanced age, entered the hospital of La Charité, October l8th, 1824. He had never been seriously ill, and was not liable to colds ; said his present indisposition had lasted fifteen months, and that he had coughed from the commencement ; had not expectorated during the first two months, after which the expectoration was more or less abund- ant and soon accompanied with dyspnoea. Some acute pains were felt in one side of the chest, three months subsequently to the first symptoms ; they continued fifteen days, recurring Chap. 4.] ULCERATIONS. 221 afterwards at two different periods, but of a little shorter dura- tion. For the last fortnight there had been slight soreness of throat, hoarseness and dysphagia ; had had occasional perspi- rations, but no rigors ; the appetite had gradually diminished. The diarrhoea had been almost constant the last six months, with occasional colic ; it was less violent after the first two months. The emaciation and weakness dated from the com- mencement of the expectoration. He had relinquished his occupations for six months, and been confined to the bed the last two. October 19th. Face, pale and thin ; pain and pricking sen- sation at the upper part of the thyroid cartilage ; sense of dry- ness in the same region ; slight difficulty in deglutition, though the pharynx and amygdala were natural ; no peculiar feeling in the course of the trachea ; cough, pretty frequent ; expec- toration, not copious nor quite opaque ; slight dulness of sound under both clavicles, particularly under the right, w'here it occu- pied almost the whole of the space corresponding to the upper lobe. Tracheal respiration and resonance of the voice, with- out pectoriloquy, under both clavicles, but more evident under the right than left. Pulse, ninety ; great sensibility to cold. Appetite, much diminished; little thirst; epigastrium, not painful ; six liquid stools with very slight pain the last twenty- four hours. (Infusion of rice with quince syrup ; diascordium with gr. j. of opium three times a day). On the following days the expectoration became opaque and of a dirty color, the pain of the throat continued almost in the same degree, and the appetite quite failed. November 7th. Considerable increase of diarrhœa ; tongue, natural ; pain in the thyroid cartilage as before ; deglutition of saliva, very difficult ; no alteration of voice ; no uneasiness 222 SYMPTOMS. — EPIGLOTTIS ; [Part II, in the course of the trachea complained of; slight acceleration of the pulse. No change took place the two following days. On-the 10th of November, at five, a. m., loss of consciousness, and at the visit we found him lying on the right side, the pupils much contracted, the eyelids half closed, breatliing accelerated, pulse slow, all the niovements extremely feeble, and excited only by the changes in his position made by another person, and complete insensibility. No change occurred be- fore death, which took place at twelve, m. Opening of the corpse twenty-tivo hours after death. Exterior. — Extreme emaciation. Nothing else remark- able. Head. — Three small spoonsful of reddish, slightly turbid fluid on the upper surface of the arachnoid. Some spots of blood on the inner surface of the dura mater, easily removed, and not adherent by false membranes. A tolerable consistent infiltration beneath the arachnoid. Haifa spoonful of fluid in each lateral ventricle, rather more in the inferior occipital fossae. Brain, slightly softened and injected. Neck. — Œdema of the glottis, of a line and a half thick near the arytsenoid cartilages, much less elsewhere. Mucous membrane of the epiglottis, more or less red, presenting some ulcerations on its lingual surface ; it was of the same color, with an unusually shining appearance, and also accompanied with ulcerations on its laryngeal surface. The fibro-cartilage was denuded at the bottom of one of these, and superiorly on the right side it was completely destroyed to the extent of two lines. Larynx, natural ; mucous membrane of the trachea, red inferiorly. TnoRAX. — The left lung presented some cellular adhe- sions superiorly and posteriorly. The right was universally Chap. 4.] ULCERATIONS. 223 adherent, and at its upper portion the false membrane was semi-cartilaginous ; in other parts it was moderately dense cellular membrane. In the summit of the upper lobe there was a vast anfractuous excavation, as large as the patient's closed hand. It was almost filled by a red and turbid fluid, traversed by thin, cord-like prolongations, and partially lined by fragments of a soft false membrane. Its parietes were scarcely two lines thick posteriorly ; they were thicker anteriorly, and were formed by a dark greyish substance, more or less firm, and in many points semi-transparent. The re- mainder of the lobe was dense, converted into the grey, semi- transparent matter, into tubercles, or into partially filled cavi- ties. There were also in the upper part of the two other lobes some unsoftened tubercles, and the grey, semi-transpa- rent substance. The same lesions existed in the left lung, but were less extensive. The. contents of the right bronchia were red and analogous to those of the large excavation. The mucous membrane was redder at the summit than at the base of the lung. The heart was small ; the aorta presented throughout its whole extent numerous yellow-colored patches. Abdomen. — Two quarts of clear serosity in the peritoneal cavity. Stomach, contracted, enclosing a large quantity of very viscid mucus. Its lining membrane formed numerous folds, was every where rather red, and of normal consistence and thickness. The small intestine was extremely contracted, allowing the entérotome* to pass with difficulty, and contain- ed much grey-colored mucus. Its mucous niembrane was sound, with the exception of some small tuberculous granula- tions, ulcerated or entire, which existed in the lower fourth, * A peculiarly formed pair of scissors for opening the alimentaiy canal. H. I. B. 224 SYMPTOMS. — epiglottis; [Part II, either on the glandular patches or in their intervals. The large intestine was filled with a turbid, greyish-colored, offen- sive fluid. From the cascal valve downwards, its muscular coat was denuded for a foot and a half, with the exception of a belt of sound mucous membrane of about an inch in breadth, corresponding to which the parietes of the intestine were healthy. Thus denuded, it was greyish-colored, firm, about a line thick, with here and there fragments of raucous mem- brane and cellular tissue on the point of being detached. Lower down there were four ulcerations of an inch and a half in diameter, where the exposed muscular layer was half aline thick. The mucous membrane was very pale and exceed- ingly soft in the sigmoid flexure and rectum. The right meso- colic glands were rounded, of the size of a large pea, greyish- colored, shining, opaque, but not tuberculated ; those of the mesentery were natural ; liver, of ordinary volume, firmer than usual ; gall-bladder, greatly distended by a clear reddish colored bile. The other viscera were healthy. 291. We shall not extend our reflections on this observa- tion, where so marked a correspondence existed between the symptoms and the morbid changes observed after death. The ulcerations of the epiglottis exactly coincided with the spot where the patient complained of pain, and also explained the slight difficulty in swallowing. The tracheal respiration and the resonance of the voice were in proportion to the extent of the excavations. The absence of sonorousness on percussion announced the presence of much grey and tuberculous matter in the part. The lesions of the large intestine could scarcely be more extensive after long and copious diarrhœa. Lastly, if the gastric mucous membrane was perfectly sound, with the exception of being slightly red, (the effect probably of some Chap. 4.] ULCERATIONS AND DESTRUCTION. 225 recent lesion), the patient had never had either nausea, vomit- ing, or epigastric pains. Let us observe that this is the only instance in phthisical patients, where we have found ulcerations on the lingual sur- face of the epiglottis, and where the lymphatic glands of one of the mesocolons were transformed into cancerous matter. We have already made the same remark in relation to the mesenteric glands (Obs. 4). 292. The following case is an example o^ the complete destruction of the epiglottis, and confirms what has been said respecting the peculiar symptoms attending the ulcerations of this organ. THIRTEENTPI OBSERVATION. A GARDENER, Set. 33, tall, of a lymphatic and sanguineous temperament, of a strong constitution and very well made, en- tered the hospital of La Charité, September 6th, 1824. Five years previously he was attacked with pneumonia, and after convalescence his breathing was not at all affected ; long be- fore this he was subject to hoarseness coming on in the winter ; he said that he had been now ill a year, and had ceased his oc- cupations six weeks. At the commencement, he was attacked with cough, irregular rigors, and expectorated a fluid like frothy saliva. The cough had since continued; the expecto- ration had become rather less clear and more copious the last four months ; he had been always very sensible to cold, a slight decrease of temperature occasioning shiverings ; for six months night perspirations had been constant, witii increased heat of surface. The voice had become affected during the E 2 226 SYMPTOMS. — EPIGLOTTIS ; [Pait lly last three months, and the upper part of the larynx was the seat of more or less acute pain ; liquids were returned by the nose during the last five weeks. Diminution of appetite from the first ; of late the digestion had becocne languid, and there was occasional vomiting with the cough. No uneasy sensa- tion in the epigastrium, no pain of side, no hemoptysis ; grad- ual emaciation the last three months. September 7th. Face, rather pale ; weakness, not extreme y sleep, interrupted by cough ; hoarseness, with great inequality and discordance of voice. A constant lancinating pain be- tween the thyroid cartilage and os hyoides, accompanied with sense of heat and dryness ; the pain was increased by cough,, by speaking, by flexion of neck forwards, and by deglutition ; the latter was frequently difficult, and provoked the rejection of liquids through the nose. Cough, frequent ; dyspnœa, urgent during the night; some scanty, opaque, yellowish and and o-reenish sputa floating on the surface of a copious, clear fluid, or sunk at the bottom. Percussion, on both sides an- teriorly, clear ; pressure under the left clavicle was painful, and the exj)iration tracheal ', under the right the respiratory murmur was rather stronger than natural ; there was great resonance of voice and bronchial respiration between the clavi- cles. Pulse, moderately accelerated ; heat, natural ; tongue and pharynx presented no alteration ; epigastrium, not painful. In the evening the patient passed one stool of good consist- ence, and only complained of the pain in his throat. (Looch ; gum mixture ; two rice creams). Some slight amendment the following days, and on the 17th he was only sensible of the pain in the neck when cough- ing, speaking, or swallowing ; nothing remarkable in the ex- pectoration ; respiration was tracheal, and there was pectoril- oquy under the right clavicle, and posteriorly in the corres- Chap. 4.] ULCERATIONS AND DESTRUCTION. 227 ponding point; little appetite; stools, liquid or pulpy, and not numerous. October 4th. Increase of pain, constant ; deglutition, espe- cially of solids, very difficult ; liquids did not return by the nose ; increased appetite ; this state continued for some days, and the other symptoms increased. On the 12th, liquids alone could be swallowed; the pharynx and tonsils were, as before, unaffected ; the expectoration presented the same characters, and seemed occasionally to be detached immediately from the larynx ; no change in auscultation ; pulse, rather quick ; night perspirations, copious ; alvine evacuations, daily, of natural consistence. (Twelve leeches to neck). The pain persisted ; some slight decrease of the burning sensation in the larynx ; aphonia, constant ; the expectora- tion was thick and greenish ; diarrhœa came on and contin- ued uninterruptedly from the 15th to the 31st, when death took place. The appetite had suddenly ceased, the epigas- trium had become painful on pressure, and pulsating pains were complained of in the same region ; the tongue was always natural. Opening of the corpse tiventy-nine hours after death. Exterior. — Emaciation, almost extreme. Head. — The dura mater presented on both sides some lacerations through which the arachnoidean granulations were apparent ; pia mater, injected, easily torn ; cerebral substance, normal. There was a spoonful of clear fluid in each of the lateral ventricles. Neck. — The base of the tongue and lower part of the pharynx presented many small, and, in general, scattered ulcer- ations, but they were numerous, and clustered together in one 228 SYMPTOMS. — epiglottis; [Part 11, point only. The epiglottis, the lateral ligaments and superior vocal cords were completely destroyed ; the lower were only partially so. Nearly the whole of the surface, where this de- struction took place, was more or less red, indurated and of an uneven aspect ; the arytaenoid cartilages were sound, with their articular surface exposed. The mucous membrane of the trachea was of a light pink tinge, but its color and consist- ence were healthy. Thorax. — On opening the chest the lungs did not col- lapse, and the pulmonary vescicles were generally dilated ; the right lung was every where adherent ; the left, which was entirely free, presented on its upper lobe a kind of wrinkled surface, corresponding to a small, very indurated mass of grey, semi-transparent substance, situated about half an inch be- neath the pleura, and giving off some small prolongations of the same nature. Near it was a middle sized tuberculous ex- cavation, lined by a false membrane, and some fragments of iiepatized lung. There were also numerous grey, semi-transpa- rent granulations, diminishing both in number and volume from above downwards. The right lung offered in its upper lobe a pretty large excavation, communicating with one in the lower lobe. Both contained a red, thick, opaque fluid, and were lined by a firm, grey-colored, serai-transparent false membrane. There were also numerous softened tubercles and grey granu- lations in the upper lobe; these last were likewise numerous in the lower; heart and aorta, natural. Abdomen. — Stomach, voluminous ; its mucous membrane rather red in the great cul-de-sac, grey-colored and mamillated in the rest of its extent with the exception of a limited por- tion of the posterior surface near the small curve ; it was rather firmer than natural in the part corresponding to the grey color; the last twelve patches of the small intestine pre- Chap. 4.] ULCERATIONS AND DESTRUCTION. 229 sented some ulcerations, and a few semi-cartilaginous granu- lations. The remainder of the lining membrane was healthy ; that of the large intestine was thick and softened, but might still be detached in fragments of one or two lines in length ; it was not ulcerated. The liver was voluminous and soft ; the bile of the gall-bladder, a little thicker than natural ; spleen, small, and easily broken down ; no other alteration. 293. Jn this, as in the preceding observation, there were pains in the upper part of the thyroid cartilage, or between it and the OS hyoides, with difficult deglutition. But both of the symptoms in the present instance were much more intense, absorbed the attention of the patient, and corresponded to the extensive nature of the alteration. The pain was constant, lancinating, accompanied with a sense of heat, increased by all the movements of the neck, and especially by swallowing, which became daily more difficult ; for a long time a part of the liquid he had to swallow was returned by the nose. The deglutition of solid food was always more difficult than that of fluids, and quite impossible during the last fifteen days. The destruction of the epiglottis and superior vocal cords was com- plete, while it was only partial in the inferior. The dis- organization appears, therefore, to have proceeded from above downwards. The afiection of the epiglottis was no doubt in the commencement without complication ; aud probably the pain and dysphagia were at first exclusively depending upon it ; the latter probably had never any other source. 294. The progress of the symptoms was slow and constant ; and as we do not know whether the epiglottis is more neces- sary for the deglutition of solids than fluids,* we cannot decide * M. Magendie relates two cases of complete destruction of the epiglottis, where deglutition was not at all impeded. He thinks that, when dysphagia 230 SYMFTOMS. — EPIGLOTTIS ; [Part 11, wliether its entire destruction took place during the last fifteen days only, or at a much earlier period. The patient had never labored under venereal disease ; and from what we have before stated, especially in the summary of the first part of this volume, the tendency to ulceration in phthisis appears so great as to render it unnecessary for us to seek for any other cause in the present case. 295. The following observation is another very remarkable example of the symptoms we are considering. FOURTEENTH OBSERVATION. A MANUFACTURER of artificial flowers, set. 18, of a rather delicate constitution, entered the hospital of La Charité, December 23d, 1824. For the last seventeen months, he was convalescent from what he said was called ascites, but which had been treated in the commencement by the appli- cation of seventy-five leeches to the abdomen. He had been confined to his bed a year, without having ever experienced abdominal pains, fever, or even marked loss of appetite ; his strength returned very slowly, and he had not yet completely regained his flesh. Five months before entering the hospital, he was attacked with slight haemoptysis during five successive days, which was succeeded, after an interval of seven weeks, by cough, expectoration, and difficulty of breathing, and soon is present, it is to be'attributcd cither to caries of the arytœnoid cartilages, or to ulcerations of the edges of the glottis preventing this opening from being accurately closed at the moment of deglutition. Vide Précis élémen- taire de Physiologie, page 67. Third edition. — Cowan. Chap. 4.] ULCERATIONS AND DESTRUCTION. 231 after by perspirations every night ; no loss of appetite ; stools^, regular; he had ceased his usual occupations seven days be- fore we saw him. December 24th. General paleness of surface ; great de- bility with but slight emaciation ; breathing a little oppressed; cough, infrequent ; expectoration, clear, and rather viscous ; percussion, every where good, except for about two inches under the left clavicle, where the sound was rather dull ; in the same region the respiration was loud, with sonorous râle, and accompanied with slight pain; a similar râle, though more feeble, existed under the right clavicle ; we could no where detect tracheal respiration, pectoriloquy or resonance of the voice ; the pulse was somewhat accelerated ;, heat of skin, moderate ; perspirations copious and universal during the night, not preceded by rigors ; tongue, pale and whitish ; ap- petite rather less than when in health ; thirst, natural ; stools, regular. (Pectoral infusion ; gum potion ; one fourth of full house allowance). January 1st. An acute pain complained of to the left of the OS hyoides, with an intense burning sensation, which was in- creased by cough, external pressure and deglutition ; the latter was accomplished with difficulty, although the tonsils and pharynx were natural ; the next day the dysphagia was increased, and liquids were partially ejected by the nose. From this time until death, a period of three months and a half, these symptom.s continued with only slight variations; the patient could only drink by mouthfuls, and even then some drops of the fluid were returned by the nose ; the swallowing of solids or liquids seemed equally painful, and the increased suffering caused by the attempt absorbed the patient's atten- tion ; he seldom complained of any thing else. Leeches 232 SYMPTOMS. — EPIGLOTTIS ; [Part II, were twice applied to the neck (on the 9th and 11th of Jan- uary) without any success ; a blister applied some days after- wards over the part where pain was complained of, proved equally inefficacious. The voice became slightly altered on the 5th of January ; on the 25th, the aphonia was complete and continued so until death. During the last month the pain in the os hyoides ex- tended to the inferior portion of the larynx. There was generally considerable oppression, and for the last two months the breathing was hurried. From the 9th of Jan- uary there were some nummulated or ragged sputa, surrounded by a fluid rather clear, and tolei-ably abundant ; on the same day, the dulness of sound occupied a greater extent, and was more evident under the left clavicle than at the time of the entrance of the patient into the hospital ; there was some crackling in the same region, and below this the respiratory murmur was very indistinct ; the respiration was tracheal un- der the right clavicle, and the air seemed to enter the stetho- scope when the patient spoke. February 13th. This two-fold phenomenon existed under both clavicles ; the respiration was feeble, and on percussion the sound under the left clavicle was rather dull. Towards the end of February there were some striated sputa. On the 4th of April many of them were of a pale pink color. On the 5th, when the patient was alone in the garden, a slight hcemoptysis occurred, which ceased very soon. January 9th. Pulse, eighty-five; on the ITth, it was one hundred. It was subsequently either faster or slower. Dur- ing the last two months the heat of the surfiice was increased, the perspirations were universal and copious, without previous rigors. The tongue was occasionally whitish, but never red ; appe- Chap. 4.] ULCERATION AND DESTRUCTION. 233 tite, generally good ; digestion, easy ; the patient was very ill-humored when put upon a strict diet; diarrhoea came on about the middle of January, was almost constant, and the stools were frequent towards the end of February and in the beginning of March ; some nausea occasionally from cough. The loss of strength was rapid ; yet, eight days before death, the patient was able to go alone into the garden. He seldom appeared anxious about his condition. On the evening of the 11th of April, there was a marked change of expression ; the respiration was more embarrassed ; and soon afterwards there was loss of consciousness, which continued until five o'clock the next morning, when he ex- pired. The pectoral infusion had been replaced by rice water after the diarrhœa had commenced; diascordium, either with or without opium, was soon added to it, and the patient took it without repugnance ; and while the stools continued frequent ; his food was limited to some rice creams; at other times he had a fourth or one eighth of the usual house allowance. Opening of the corpse twenty-seven hours after death. Exterior. — Extreme emaciation. Nothing else remark- able. Head. — Slight sub-arachnoidean infiltration ; a few mil- iary granulations, adherent to the arachnoid, near the median fissure ; a spoonful of fluid in each lateral ventricle ; brain, moderately firm ; cortical substance, of a light violet color, especially towards the base. Neck. — The epiglottis was narrower than natural, and about one line thick near its circumference ; the mucous mem- brane lining its inferior surface was destroyed ; the subjacent F 2 234 SYMPTOMS. — EPIGLOTTIS 5 [Part 11, cellular layer thickened, and of a light pink color ; the upper vocal cords deeply ulcerated, the lower only superficially; the arytaenoid cartilages, perfectly sound and denuded at their base. For one inch below the vocal cords, the lining mem- brane of the trachea was of a pale reddish brown color, a little thickened, and perforated by numerous small ulcerations. Near the bifurcation it was redder, and presented on the fleshy portion two ulcerations, from one to three lines in diameter. Thorax. — The lungs were every where adherent at their summit, by means of a false semi-cartilaginous membrane, from a line to a line and a half thick, and over the remainder of their surface by a more or less dense cellular tissue. There was a very rugged excavation in the summit of the left lung, as laro^e as a goose's eva, extending to the interlobular fissure, and containing a red, thick and turbid fluid ; remnants of tuberculous matter were attached to its inner surface, which was not invested with a false membrane. Its sides were thin posteriorly, and almost entirely formed by the semi-cartilagi- nous false membrane we have already described, while anteri- orly they were thick and indurated, being composed of a large quantity of grey and blackish substance, more or less semi- transparent, which was interspersed with a great many tuber- cles and tuberculous excavations, and occupied almost entirely the remainder of the lobe. At the upper part of the inferior lobe there was a small anfractuous excavation, containing a similar fluid to the preceding, and some grey and yellow- colored granulations. Analogous lesions, but less extensive, existed on the right side. The bronchial mucous membrane was of a bright red, and in the left lung offered some ulcera- tions. Heart and aorta, natural. Abdomen. — Short and dense adhesions, but easily broken, between the anterior parietes, omentum, and intestines. Stom- Chap. 4.] ULCERATIONS AND DESTRUCTION. 235 ach, of moderate dimensions ; mucous membrane, red and soft- ened in a part of the great cul-de-sac, of a greyish color near the pylorus, white, mamillated, and of a good consistence every where else. Near the great curvature, and within two inches of the pylorus, there was an ulceration of six lines in diameter, the edges of which were everted and formed by the softened and red mucous membrane, while the bottom consisted of the cellular layer, whicli was uneven and twice its usual thickness. Duodenum, natural. Small intestine contained a large quan- tity of mucus in its superior portions, and a turbid, greyish fluid in the lower ; there were numerous ulcerations through- out its whole length, but which were largest in the middle portion. The most considerable were from half an inch to an inch in surface ; the majority were from two to three lines in diameter, situated upon the patches, dark-colored, and with flat edges, except when raised by tubercular granulations. The submucous layer was slightly thickened, and in their in- tervals the raucous membrane was softened. Ulcerations existed in different portions of the great intestine, the largest of which were about two inches in surface, situated in the course of the caecum and ascending colon. Their structure was similar to what we have described in the small intestine, with the exception of some small grey granulations in their centre, and the absence of tubercles in their circumference. Near the anus there were numerous ulcerations, about the size of a a shilling, or rather larger. No change in the mesenteric or mesocolic glands ; liver, rather soft, of variable color, from a yellowish red to a deep red ; bile, natural ; spleen w^as seven inches long by five in breadth, and very firm ; its substance was of a red violet color, of an adipous and shining aspect, and distinctly exhibiting only some vascular orifices, with a kw 236 SYMPTOMS. — EPIGLOTTIS. [Part II, white attenuated filaments. The other viscera of the abdo- men, healthy. 296. The symptoms pointed out as pecuhar to ulcerations of the epiglottis, viz., the pain above the thyroid cartilage, the difficulties of swallowing, the return of liquids by the nose were here remarkably prominent, and enabled us to recognize the nature of the affection soon after their appearance. Du- ring three months and a half they persisted with very slight variations, and, as in the preceding example, almost entirely engrossed the patient's attention. The change of voice was soon associated with the earlier symptoms, so that the affec- tion of the epiglottis and that of the larynx seem to have origi- nated nearly at the same time. 297. In regard to the diagnosis of the pulmonary affection, we may observe, that at the period of the patient's admission into the hospital, the cough only dated three months ; there was nothing characteristic in the expectoration ; there was neither resonance of the voice nor pectoriloquy ; the emaciation was inconsiderable ; in short, the general symptoms were in- sufficient to indicate the disease. There was, however, a dull sound under one of the clavicles, or in that region where tuber- cles are first deposited ; two months anteriorly to the cough he had had haemoptysis, and from these two facts we did not hesitate to consider him attacked with phthisis. 298. The everted state of the edges of the ulceration in the stomach must not escape notice ; it is the only instance of the kind we have met. In analogous cases the mucous membrane was, as we have already seen, distinctly ulcerated, and preserved round the edges its natural connexion with the subjacent layci-. The patient had been attacked, two years and a half before Chap. 4.] LARYNX, ULCERATIONS ; CHANGE OF VOICE. 237 his death, with a disease which he designated as abdominal dropsy ; but the universal adhesions of the peritoneum proved it to be peritonitis, and the history of the treatment is in favor of this opinion. ARTICLE II. SYMPTOMS OF ULCERATED LARYNX. 299. These vary according to the part affected and the extent and depth of the ulcerations. Out of five patients in whom they were confined to the junction of the vocal cords, only one had the voice affected, and this from the six- tieth to the twentieth day preceding death ; the aphonia after- wards became complete, and there were occasional pains in the larynx. Four others complained of slight dryness and heat in the throat a few weeks before the fatal termination. In nine cases where the ulcerations were small and super- ficial, situated in the ventricles, between the arytaenoid carti- lages, or the inferior chordae vocales, there were hoarseness with more or less alteration of the voice, sense of heat and prick- ings in the larynx, and subsequently more or less complete aphonia. These symptoms were slightly pronounced, and except the hoarseness they did not exist in two of the pa- tients. In three this symptom commenced eight days, and in the others six or eight months before death. The duration of the pain was equally variable. Complete aphonia existed only in two. In the eight cases where the ulcerations of the larynx were deep, and the vocal cords more or less completely destroyed, similar but much more urgent symptoms were observed. They commenced from one to five months before death. The 238 SYMPTOMS. — LARYNX. [Part II J hoarseness preceded the pain one or more weeks, and occa- sionally several months. The aphonia was present twenty or thirty days, two months, and sometimes at a still earlier pe- riod before the fatal termination. The pain (and we are only speaking of cases where there was no ulceration of the epiglottis) was occasionally very acute, pungent, lancinating, and accompanied with a sense of heat. One of the patients compared it to the sensation of a raw surface, and the pres- ence of some streaks of blood rather frequently in the ex- pectoration confirmed the comparison. The pain was exas- perated by cough and speaking, varied in intensity, and was sometimes absent for a few days. The cough in this class of patients had also a peculiar character; it was discordant (déchirée) or wheezing ; the deglutition was easy, unless there was some affection of the epiglottis. 300. Thus, whatever modifications existed in the ulcera- tions of the larynx, the symptoms were always of the same nature ; but they varied much in intensity and duration. Hoarseness was present in four fifths of the cases. Pain was frequently absent when the ulcerations were superficial, but if these were deep it was continued. The same remark applies to the aphonia : we may, therefore, consider as symptoms of superficial ulcerations of the larynx, the existence of a slight pain of some continuance in this region, conjoined with a greater or less alteration of the voice ; while, on the other hand, the presence of an acute, continued, and often violent pain, followed by a loss of voice during one or more months, indicated the existence of deep ulcerations.* * We have not thought it necessary to detail any individual facts, as the ajccuiacy of our description may be deduced from those which are scattered throughout the work. — Louis. Chap. 4.] TRACHEA ; ulcerations. 239 ARTICLE III. SYMPTOMS OF ULCERATED TRACHEA, 301. However numerous these ulcerations might be, they seldom gave rise to any symptom. Only one patient, m whom the mucous membrane of the trachea was destroyed over the whole of its muscular portion, complained a long while before death of a sensation of some obstruction existing just above and posterior to the sternum, which was soon fol- lowed by a slight sense of heat. Some individuals complained of pain in the larynx, although this was not ulcerated, and in the trachea the largest ulcerations were situated near the bifur- cation, with only some very diminutive ones superiorly. In one case there were paroxysms of dyspnoea for several successive days ; they ceased quickly after the application of a blister to the neck. In other instances, when even the disorganization was considerable, the patients lay with the head low, and were not liable to greater dyspnoea than when no such ulcera- tion existed.* The expectoration presented no peculiar char- acters ; so that the only symptoms we can attribute to the morbid alteration we are considering are those which were experienced by the subject of the following observation, viz., a sense of obstruction, with a slight heat behind the upper portion of the sternum. * Paroxysms of dyspnœa have been generally enumerated among the symptoms of ulcerated trachea. — Louis. 240 SYMPTOMS. TRACHEA, ULCERATIONS; [Part II, FIFTEENTH OBSERVATION. 302. A GIRL, get. 23, of a lymphatic and sanguineous temperament, large proportions, robust, not liable to colds, and never having had a serious illness, had for the last six months labored under the majority of the symptoms of phthisis. The expectoration and dyspnœa had commenced with the cough ; night perspirations had existed for some time ; there had been occasional diarrhœa, but no loss of appetite. Ema- ciation, however, had been evident from the very commence- ment of the cold. She had had no haemoptysis or pain in the chest, when, without any evident cause, she was suddenly atacked with violent shiverings, succeeded by heat, pain in the right side, and extreme dyspnœa. These symptoms con- tinued, and on the eleventh day from their commencement, she was admitted into the hospital of La Charité, December 9th, 1822. 10th. Expression, animated ; frontal headache ; lassitude in the limbs and loins ; pain between the thyroid cartilage and OS hyoides ; deglutition, difficult ; slight hoarseness ; a constant acute pain in the right side of the chest, augmented by cough and pressure, with evidently increased local tempera- ture. There was extreme dyspnœa ; she lay with her head much elevated. Coarse-like bronchial respiration under the clavicles, tracheal posteriorly and laterally, in the lower half of the right side, where there were œgophony and dull sound on percussion. Cougii, fi-equent, discordant, accompanied with a milky looking and slightly aerated expectoration, mingled with some opaque masses, thick, and streaked with white lines ; pulse, one hundred, quick, pretty full ; heat of skin, Chap. 4.] OPPRESSION behind sternum, &ic. 241 moderate ; tongue, rather red on edges, whitish in the centre ; sensation of dryness with shght redness in the pharynx ; thirst, moderate ; anorexia ; occasional nausea with cough ; consti- pation. (V. S. § xij. ; decoction of triticum repens with nitre ; gum potion ; two emolHent enemas). The bleeding was repeated on the two following days, and twenty leeches were applied to the side without success. On the 13th, a blister five inches square was ordered, and on the 14th, the intensity of nearly all the symptoms was dimin- ished ; the pulse was less accelerated ; the pains in the neck and the alteration of the voice persisted. The improvement continued on the following days ; on the 3d of January no segophony could be detected. There was evident pectoriloquy between the scapula and vertebral column on the right side ; its existence on the left was doubtful. Du- ring the night she had two paroxysms of dyspnoea. A few days afterwards the segophony was again heard. February 28th. Percussion, perfectly flat under the right clavicle; ab- sence of respiratory murmur there ; considerable dyspnœa, and the patient lay with the head raised. These symptoms continued until death, which took place on the 21st of March. The pulse was more or less accelerated ; heat of skin, varia- ble, greatest in the evening and at night. Some irregular rigors almost every day, with night perspirations, which were frequently accompanied with sudamina. The fixed pain between the thyroid cartilage and os hyoides was constant, though varying in intensity ; the voice was always modified, and aphonia existed the last twenty days. The pharynx was slightly red but not swelled ; the deglutition was at first difficult, then easy, and again difficult during the G 2 242 SYMPTOMS. TRACHEA, ULCERATIONS; [Part 11 , last few weeks. To these symptoms another was added on the 10th of January. She complained of having experienced for some hours a sense of obstruction behind and immediately above the sternum, exciting occasional efforts to swallow ; there was no sense of pricking or heat in the same region ; the pain in the throat had ceased. This state of things con- tinued during several weeks, and on the 7th of February and following days, an acute pain was felt in the course of the trachea during respiration. At the same period, some cere- bral symptoms announced a fresh complication. On the 11th of February, there were giddiness, headache, and for some minutes loss of consciousness. No paralysis succeeded, but the headache persisted, and on the next day the vertigo returned. 28th. A sensation similar to that resulting from a violent bruise on the right side of the face. On the 2d of March, the mouth was drawn to the left, the right arm very feeble ; no affection of the right leg. The feebleness soon after extended to the whole of the right side, and the superior and inferior extremities were successively affected by pain, numbness, and loss of temperature. Some uncomfortable prickings in the right eye, followed by a sense of heat ; the pupil of the same side, which was at first the larger of the two, became very small. On the 8th, while- laughing with her companions, she was seized with loss of consciousness for some minutes. No sensible increase of cerebral symptoms on the following day. 16th. Considerable prostration ; paralysis of the right side, almost complete ; tongue, deviated to the same side. 19th. Loss of speech, but she indicated her wants by gestures ; delirium during the night and restlessness on the 20th. This continued the following night. 21st. Alternate rigidity and spasmodic movements in the right arm, and at moments slight stiffness in the left. This continued until four o'clock Chap. 4.] OPPRESSION behind sternum, &c. 243 in the evening, when rattling respiration came on, and death took place at midnight. The appetite, at first good, soon almost entirely ceased. During part of February, there were pains in the epigastrium and right iliac fossa. Some nausea at considerable intervals. Afterwards the desire for attending to the necessities of nature rarely came on, and when it did it was slight. February 7th. Tongue, rather red, and covered with numerous apthous patches, which were easily removed, and were again secreted in the beginning of March. 12th. Tongue, natural ; some nausea and bilious vomitings ; the diarrhœa was almost con- stantly present, but slight, with occasional colic and tenesmus. Emollient drinks, Sydenham's white decoction or rice water, and mustard pediluvia were prescribed according to the symp- toms. Leeches were applied to the labia at the commence- ment of the cerebral symptoms. Opening of the corpse thirty-five hours after death. Exterior. — Considerable, but not extreme emaciation. Nothing else remarkable. Head. — Bones of skull, very thick. Beneath the arach- noid, covering the upper and middle portion of the left hemi- sphere, over an extent of four square inches, was a membranous, yellow, concrete substance, about a line in thickness, appar- ently developed in the pia mater. The cerebral substance was a little soft, but not injected. There was a spoonful of serum in each lateral ventricle. The inferior half of the sep- tum lucidum was softened, pulpy, and its fragments floated in the fluid of the ventricles. Neck. — The mucous membrane of the laryngeal surface of the epiglottis was entirely destroyed. Superficial ulceration of the upper vocal cord of the right side ; that on the left side 244 SYMPTOMS. — TRACHEA, ULCERATIONS; [Part II, was almost annihilated ; the lower was less extensively affected. The lining membrane of the muscular portion of the trachea was- destroyed ; the muscular fibres were denuded, and more or less thickened in nearly their whole extent. Ten of the cartilaginous rings were exposed, as if the mucous membrane had been artificially removed. The remaining part was soft- ened, and of a light pink color. Thorax. — Right lung, adherent at its summit by a thick membranous band ; lower down it was covered by a false membrane, about one line thick, with an undulated surface, continued over the diaphragmatic and costal pleurae, and en- closing two quarts of limpid fluid. In the upper lobe there were two cavities nearly empty, about the size of a nut, commu- nicating with the bronchia, and numerous softened tubercles. The two other lobes presented a great many grey granulations. The left lung offered several inequalities at its surface, which were caused by tubercles ; there were some excavations at its summit, rather smaller than those on the right side ; the lower lobe was only slightly engorged. Five or six ounces of red- dish-colored fluid in the pericardium ; the heart was extremely soft, of moderate volume, and of a deep livid color; aorta, healthy. Abdomen. — Liver, fatty and voluminous; bile in gall- bladder, rather thick, and of a brownish color ; lining mem- brane of stomach, covered with some thick and tenacious mu- cus, alternately red and softened in the great cul-de-sac ; healthy within three inches of the pylorus, thin and mamillated elsewhere ; duodenum, natural ; numerous pale, yellowish miliary granulations under the mucous membrane of the small intestine, in the upper four feet ; farther down their number diminished, and they ceased altogether in the lower third ; middle-sized ulcerations throughout the whole intestine, inter- Chap. 4.] OPPRESSION behind sternum, &;c. 245 spersed with tubercular granulations, and separated by inter- vals of from three to eight inches ; their bottom was blackish, and the mucous membrane a little detached and thickened on the edges in the greater number. The last ulceration, which included the ileo-csecal valve, and the whole circumference of the intestine was by far the most extensive. The correspond- ing muscular coat was thickened and denuded. There were several ulcerations in the large intestine, where the lining membrane was pale and soft as mucus ; these ceased within three inches of the anus. The lowest encircled the gut, and was about four lines wide. All the mesenteric glands were enlarged and changed into tuberculous matter which was not softened ; some of the mesocolic were in the same state. The remaining viscera were healthy. 303. Notwithstanding the number of the various alterations which have been described, each gave rise to its peculiar symp- toms. Phthisis presented its own ; those of pleurisy were dis- tinctly marked. The same may be said of the morbid state of the brain and its membranes. The ulcerations of the epi- glottis were pointed out by the situation of the pain, above and on a level with the upper part of the thyroid cartilage ; those of the larynx by the change of the voice, and subse- quent aphonia. Lastly, the obstruction complained of by the patient behind the upper portion of the sternum, and the pain in the course of the trachea during inspiration, justified the sus- picion of some more or less considerable alteration. We shall presently find that this last symptom existed also in cases where the mucous membrane of the trachea was merely red and slightly thickened ; an additional reason for regarding it of importance in the diagnosis of the lesion we are now con- sidering. The dyspnœa was urgent ; but the state of the 246 SYMPTOMS. TRACHEA, ULCERATIONS ; [Part II, lung and pleurae of the right side sufficiently explain its ex- istence, SO that we need not attribute it to the ulceration of the trachea ; besides, it coincided with the attack of pleurisy, which came on when probably the affection of the trachea did not exist. The anorexia, nausea, pain in the epigastrium, were in unison with the condition of the gastric mucous membrane. The diarrhoea, though not copious, had persisted, almost un- interruptedly, nine months ; and we found the intestinal ulcerations, without being very large, by no means small, and very numerous, especially in the small intestine. The tenes- mus complained of by the patient, though not urgent, indi- cated some alteration of the mucous membrane of the rectum ; and we have accordingly seen it the seat of ulcerations, one of which was remarkable for its annular form. It is possible then, in some instances, as we have before remarked, to recognise the greater number of the complica- tions which arise in the course of chronic diseases, even when general debility is considerable. In the following observation, the affection of the trachea was still more pronounced than in the one which precedes, without, however, giving rise to any appreciable symptoms. SIXTEENTH OBSERVATION. 304. A TAILOR, a3t. 24, of a weak constitution, not liable to colds, received in 1814 a kick from a horse in the region of the pubes. A tumor of a very chronic nature succeeded, opened spontaneously, and gave rise to a fistula, which for nine years was alternately closed or discharging. He was Chap. 4.] CAUSING NO symptoms. 247 admitted into the hospital of La Charité, February 16th, 1824, having experienced the last five weeks pains in the upper part of the thighs, which rendered walking difficult. For nine months he had coughed and expectorated, and he had had, at times, slight haemoptysis. During the last two months, the expec- toration had been difficult, and the sputa seemed to lodge in the larynx, where there was a sensation of dryness. Diar- rhœa had been rather copious for more than two months, after which the appetite had almost disappeared. 17th. Face, pale ; mind, active ; great debility, and almost extreme emaciation ; pains in the upper part of the thighs in- creased by any attempt to walk, which the patient found it almost impossible to do. The fistula, which was situated just above the symphisis pubis, discharged a small quantity of very thin pus. Little cough ; expectoration, scanty, greenish, opaque, mingled with a certain quantity of limpid mucus ; not much dyspnœa ; percussion, every where clear ; no pectoril- oquy or tracheal respiration ; a slight mucous râle was heard^ but confined to the upper part of the chest ; voice, natural ; no pain in the larynx or trachea ; pulse, rather quick ; heat, moderate ; rigors, rare ; perspirations, copious ; mouth, clam- my ; tongue, rather red on edges; anorexia, almost complete ; little thirst ; abdomen, yielding and without pain ; six liquid stools. From this period up to the 25th of April, when death took, place, no uneasy sensation was felt in the neck. He only complained of a slight soreness of the th'roat a few days before the fatal termination. The pharynx was always natural, and no change was observed in the voice. The expectoration continued as before. On the 6th of March, percussion was clearer posteriorly on the right side than on the left; there was also slight resonance of voice under the right clavicle, and 248 SYMPTOMS. TRACHEA, ULCERATIONS J [Part 11, mucous râle under the left. 2-2d. Percussion in the latter region, completely dull ; the respiration there was tracheal, with imperfect pectoriloquy. The patient was constantly lying on his back. The perspirations continued, notwithstanding the use of the acetate of lead in gradually increased doses ; pulse, more or less accelerated ; rigors, present almost every evening. The appetite rapidly increased, the patient eating the half of the usual house allowance of bread and vegetables in the beginning of March ; this was the case to the last. Up to the 19th of April the diarrhœa was inconsiderable, but it then suddenly, and without apparent cause, became copious. On the following evening he was seized with ex- tremely acute pains in the abdomen, followed by prolonged rigors and frequent nausea. 21st. Much less pain ; belly, tympanitic : tongue, red ; slight alteration of expression. 22d. Pain had ceased ; abdomen, sunk ; stools, numerous, with extreme weakness ; and on the 25th death took place, after an hour's struggle, at ten, a. m. Diascordium, julep and opium were principally prescribed. Opening of the corpse twenty-two hours after death. Exterior. — The rami of the pubes were denuded of their periosteum, and had the aspect of a substance which has been eaten by ants, and were surrounded by a thin, greyish and rather fœtid pus ; the attachment of the muscles to the descending ramus was destroyed ; those forming the boundaries of the abscess were greyish and greenish, covered by a detritus of the same color and softened. The abscess extended as low down as the middle of both thighs. Head. — Two small spoonsful of fluid over the upper por- tion of the arachnoid ; slight sub-arachnoidean infiltration j Chap. 4.] CAUSING NO SYMPTOMS. 249 pia mater, slightly injected ; brain, healthy ; a spoonful of serum in each lateral ventricle. Neck. — Three superficial ulcerations on the laryngeal surface of the epiglottis ; the intervening mucous membrane, healthy ; a small ulceration at the junction of the cordae vocales ; lining membrane of the trachea, pale and ulcerated ; the ulcerations increased in number and size from above down- wards. Many of the cartilaginous rings were denuded; in some there were small, lenticular excavations ; twelve were in some parts much thinned ; three were completely destroyed for about a line. The muscular fibres corresponding to the soft- ened portions were exposed and nearly destroyed, where three of the ulcerations existed. Chest. — Universal adhesions of both lungs. The upper lobe of the left lung was indurated, impermeable to the air, with the exception of a very thin, superficial layer ; it pre- sented a middle-sized excavation in its summit, partially in- vested by a red, firm, false membrane, lying on some grey, semi- transparent substance, interspersed with tubercles. The cavity contained a turbid, thick and greyish fluid, and communicated with the bronchia, which were here redder and more thick- ened than elsewhere. The remainder of the lobe offered some small excavations, and was almost entirely transformed into the grey matter, which was thickly sprinkled with tuber- cular granulations. Lower lobe, healthy. The same altera- tions existed on the right side, but were less extensive. There were some small superficial ulcerations in the left bronchia ; heart, a third less than usual ; aorta, natural. Abdomen. — Half a quart of turbid inodorous fluid in the abdominal cavity ; no communication with the abscess behind the pubis ; slight adhesions between some of the con- H 2 250 SYMPTOMS. TRACHEA, ULCERATIONS ; [Part II, volutions of the small intestines by means of a soft, yellow- colored false membrane, which also covered the bladder and rectum. The subjacent peritoneum was of a bright red ; liver, small and healthy ; bile, rather abundant, viscid, and green colored. The stomach contained a small quantity of yellow fluid, was voluminous, and its mucous membrane pale, and of a perfectly natural firmness and thickness. At the origin of the small intestine there were numerous opaque, submucous miliary granulations, and throughout its whole length ulcera- tions increasing in size and number from above downwards. If small, they were usually partially concealed by the valvules conniventes; when larger, they occupied the glandular patches, of which some were destroyed, whilst others presented small ulcerations, more or less approximated, with some slightly softened tubercles. The muscular tunic was not denuded, except where it corresponded to some large ulcerations, and then only partially. In the caecum and transverse colon, there were two very extensive ulcerations. They encircled the intestine, and were at least three inches long, presenting a greyish rugged surface, formed by the submucous cellular layer, about half a line thick, while the corresponding muscu- lar layer was twice its usual thickness. Between these two large ulcerations there were six smaller ones. The descend- ing colon and rectum were occupied by others, tolerably nu- merous, narrow, semi-circular and dark colored. The mucous membrane was red and of a moderate consistence in this last part. Mesenteric glands, voluminous, red, and partly tuber- culated. This was the case with those of the mesocaBcum and mesocolon, corresponding to the ulcerations. The other viscera of the abdomen were healthy. 305. In this, as in the preceding instance, there were ulcer- Chap. 4. CAUSING NO symptoms. 251 ations of the epiglottis, larynx and trachea. They were slight in the first two, but in the last they were extensive, deep, and accompanied with partial destruction of the fibro-carti- lages ; but none of these lesions were indicated by the symp- toms. It was in vain that we attempted by questions to dis- cover the existence of any symptoms which could be referred to ulceration of the trachea. We arrived at negative resuhs alone, and our failure cannot be attributed to a deficiency of intelligence in the patient, whose memory was good and mind active, nor to his extreme weakness. In proof of the accuracy of this last assertion, we would refer to our observations of croup in the adult,* where weakness was almost constantly present, but in which cases a more or less severe pain in the trachea was invariably complained of. Among others, we remember the case of a woman who died from phthisis, and who was attacked v/itb croup when the emaciation was at its maximum, and who complained of heat and pain in the course of the trachea from the very commencement of the symptoms of the afi:ection. it is probable, in the present instance, that the absence of symptoms was owing to the extremely slow progress of the disease. 306. Although we are unable to determine the exact period v/hen the morbid state of the trachea commenced, we thhik, however, it must have been of considerable duration. Of this we have in some measure a proof in the solution of continuity of many of the fibro-cartilages, and in the almost total destruc- tion of the muscular membrane of the trachea in difiTerent points, for these disorders must have required some time for their development. It may also be remarked, that this is the * Mémoire sur le Croup considéré chez l'Adulte. — Vide Recherches Ana- tomico Pathologiques sur diverses Maladies. 8vo. Paris. 1826. — Louis. 252 SYMPTOMS. — TRACHEA. [Part 11, first instance where we have seen the complete destruction of portions of the fibro-cartilages, and where the destruction of the muscular layer was so considerable. 307. Let us also remark, that the bronchia were only ulcer- ated on the side corresponding to the large excavation, but they were redder and thicker there than elsewhere ; and thus we have confirmed what we have advanced on the probable cause of ulceration in the air passages, and the influence of the expectorated matter on their inflammatory appearance (53). 308. The inconsiderable diarrhœa until within a few days of death, notwithstanding the number and size of the intestinal ulcerations, must not be overlooked. This great disproportion between the symptoms and lesion is not common, and may perhaps be attributed to the fact of the submucous layer in the ulcerated portions not being, as it usually is, destroyed ; indeed, this is the only example of large ulcerations we have seen, where the thickened muscular tissue was not more or less extensively denuded. 309. When inflammation of the lining membrane oj the trachea (characterized conmionly by a bright red color, sometimes conjoined with a slight thickening or softening), existed without ulcerations, in some instances the patients, complained of a more or less acute pain, accompanied with sense of heat in the neck; this was observed in three out of seventeen. Five others suffered, during some time, from pains of the throat and larynx, although no morbid change could be detected in these parts. 310. If we compare the symptoms complained of in the first three cases with those we have observed in croup, where heat and pain were almost constantly present, we feel justified Chap. 5.] STOMACH. 253 in regarding them, whenever they occur in the course of phthisis, as indications of inflammation of the mucous mem- brane of the trachea. Perhaps we may also refer to the same cause the existence of pain referred to the larynx or fauces, when the deglutition and voice are not affected ; for pain in the throat, accompanying inflammation of the mucous mem- brane of the trachea, is perfectly analogous to what is felt in the glans penis from calculus in the bladder. 311. Hoarseness was sometimes present when there was neither ulceration nor inflammation of the laryngeal mucous membrane, but it was then transitory, occurred at different periods of the disease, and was not accompanied by pain in the throat. In conclusion then, we find that in the majority of cases ulcerations of the larynx gave rise to their peculiar symptoms: — that those of the epiglottis, if not extensive, were usually latent : — that those of the trachea were only once character- ized by special symptoms : — that simple inflammation of the mucous membrane of the trachea frequently excited heat and pain, the latter being sometimes referred to the throat or larynx. CHAPTER V. SYMPTOMS OF THE VARIOUS ALTERATIONS OF THE GASTRIC MUCOUS MEMBRANE. 312. At different periods of phthisis, the patients experi- enced symptoms of variable intensity referrible to the stomach. As these varied with the lesions of the mucous membrane, we shall describe them under corresponding articles. 254 SYMPTOMS. — STOMACH ; [Part II, ARTICLE I. SyMPTOMS OF SOFTENING WITH DIMINISHED THICKNESS OF THE MUCOUS MEMBRANE OF THE STOMACH.* 313. At a variable period (seldom at the commencement of phthisis), most frequently tvA'O, four, five, six, or more months preceding the fatal termination, the patients who were attacked by the morbid alteration we are considering, lost their appetite, and soon after experienced pains in the epigastrium, which were often very acute. Some days, or even months subsequently, they had nausea, then vomiting, or these last two symptoms commenced, and were succeeded, after one or more weeks, by pain. It was rare to see all these symptoms manifest themselves at the same time. In many instances they were intense from the beginning ; in others, their devel- opment was gradual ; most frequently they became more and more insupportable, and continued with variable remissions until death. 314. These symptoms were present in almost all the cases, but differed in intensity. In sixteen cases out of nineteen there was nausea with epigastric pain, and in fifteen, vomiting. In three there were no very distinct gastric symptoms, notwith- standing the serious nature and extent of the alterations of the mucous membrane (Obs. 10 (bis), 26). In some, the pain, nausea and vomiting were preceded during one, two, or three years by disordered digestion. 315. The pain was pungent, lancinating, and occasionally ** For greater detail we refer the reader to our Recherches Pathologiques, already cited, First Memoir. — Louis. Chap. 5.] SOFTENING, &C., OF MUCOUS MEMBRANE. 255 accompanied with heat ; it produced, in some instances, the feehng of a bar stretching across the epigastrium ; in others it could not be compared to any thing. It was usually contin- ued and progressive in intensity. It was, however, at times intermittent, ceasing altogether a few days before death. When very acute, it engrossed the patient's attention, and no questions foreign to the point were answered willingly, so that unless we had carefully examined all the functions, the exist- ence of phthisis might for a time have been overlooked. The acuteness of the pain was the more remarkable, since we ob- served it in instances where general debility was considerable, and the complications numerous. The slightest pressure upon the epigastrium was insupportable, and liquids of moderate temperature appeared as if iced. Who can believe after this that the mucous membrane of the stomach is very insensible, or that it shows its sufferings in a very different manner from that of other organs? The pain was not sensibly alleviated by opium ; it was sometimes diminished for several successive days by Seltzer water.* It was in one instance calmed momen- tarily, a short time after it commenced, by a cordial draught (Obs. 31). 316. The vomitings were almost always bilious, commonly rare at the beginning, but increasing in frequency as the disease proceeded. 317. Light food was in some cases digested by some with- out much difficulty, while others could only venture to eat at a particular hour, generally in the morning (Obs. 32). The appetite occasionally improved for one or more weeks, though the mucous membrane was seriously and extensively affected * Seltz on the lower Rhine. The water contains, — Carbonic acid 213 parts ; carb. sod. 5 ; carb. magnes. 6 ; carb. of lime 78 ; mur. sod. 13, in 8,94D parts of water, — Cowan. 256 SYMPTOMS. — STOMACH ; [Part II, (Obs. 39). But sooner or later, in the majority of instances, no kind of food could be supported, and even pure water was rejected ; so that the dread of vomiting made the patients resist the cravings of thirst. 318. Among the symptoms therefore indicating the soft- ened condition and diminished consistence of the gastric mu- cous membrane, anorexia, nausea, vomitings, and epigastric pains may be enumerated. They afford us a proof that the lesions of the stomach, in common with those of the other organs, are characterized by pain and disordered functions. 319. When the symptoms we have described have been constantly present for some time, say three or four weeks, we may regard as certain the existence of a thinned and softened mucous membrane. Daily experience convinces us of the truth of this assertion. 320. Many of the observations scattered through the course of this volume (Obs. 31, 32, 39, Sic), may be cited in sup- port of what we advance, but the following appears more than usually applicable. SEVENTEENTH OBSERVATION. A WOMAN, set. 35, mother of several children, of a weak con- stitution, and not liable to colds, entered the hospital of La Charité, July 13th, 1824 ; she had been confined ten months before, and had suffered mucli in the left knee the last six ; it presented all the rational symptoms of a white swelling. She was in the surgical ward, and had two moxas applied, which were followed by cessation of the pain and diminished volume of the joint, which subsequently became ankylosed. On the Chap. 5.] SOFTENING, k-C, OF MUCOUS MEMBRANE. 257 5th of November she was transferred into the wards of M. Chomel, and in addition to the preceding details, we learned that on the 1st of August, after a great mental disturbance, she was seized with alternate rigors and flush- ings, cough, epigastric pains, nausea, ^and occasional vom- iting ; that at the same time there had been slight aug- mentation of thirst and loss of appetite. These symptoms, which had since persisted, were soon associated with increased heat of surface coming on in the evenings, night perspirations, and occasional rigors. The expectoration had only been pres- ent since October. Shortly after, acute pains were felt in the right side of the chest, and after a week's duration yielded almost immediately to the application of a blister to the parts. The stools were fluid and frequent during the last three days ; emaciation dated from the period of her last con6nement. November 5th, Expression, rather animated ; great general debility, the patient could hardly turn herself in bed ; thirst, moderate ; anorexia, almost complete ; tongue, natural ; pain in epigastrium, which was sensible to the slightest pressure ; fre- quent nausea, principally during the night and after the cough, sometimes followed by bilious eructations ; abdomen, slightly painful ; evacuations, liquid with previous colic ; cough, most troublesome in the night, and less frequent during the day ; expectoration, white, spumous, floating on a large quantity of clear fluid; respiration, rather accelerated; percussion, less clear on the lateral, posterior and lower half of the right side than on that of the other ; respiratory murmur stronger under the right clavicle with occasional crepitation ; pulse, one hundred and fifteen, small and weak ; temperature, moderate during the day, elevated at night ; rigors in the evening with night perspirations ; oppression referred by the patient to the epigas- trium, which was the seat of much anxiety and uneasiness. I 2 25S SYMPTOMS. — STOMACH ; [Part II, (Solution of gum syrup ; rice water with lemon juice ; a grain of opium with gum potion). The gastric symptoms continued, and became daily more intense. From the 8th to the 21st of November, two days before death, bilious vomitings occurred frequently in the four- and-twenty hours, either accompanying the cough, or in the intervals ; extreme uneasiness and anxiety ; sense of suffoca- tion, with very acute pains in the epigastrium ; the slightest pressure there insupportable. Distaste for all food ; the weakest broth caused a feeling of oppressive weight in the stomach. She afterwards vomited every thing ; drank extremely small quantities at once, and liquids at the ordinary temperature ap- peared cold, like ice. The tongue was natural, or rather pale, to the 18th ; it then became red, hot, smarting, and covered by white apthous patches, which were frequently renewed. They extended to the lips, inside of the cheeks, and to the soft palate ; at first appearing under the form of small spots, like grains of starch, gradually increasing, and by their union covering the surface. The stools were fluid, but not frequent until the 18th they then became suddenly very numerous, and during the last three days were passed involuntarily, and were almost constant. At the same time there were pains over the whole abdomen, and especially in the right iliac fossa. The cough remained stationary ; expectoration, scanty and spumous; percussion did not vary. 19th. Tracheal respira- tion under the right clavicle, but no pectoriloquy ; pulse, small, weak and rapid, except during the last four days, when it fell from one hundred and forty to one hundred. Great sensibility to cold. The patient was constantly changing her position in bed, laboring under the greatest general uneasiness and anxiety, so that at times she could hardly tell where she Chap. 5.] SOFTENING, Sic, of mucous membrane. 259 was suffering. No delirium was observed before death, which took place November 23d, at six, a. m. Opening of the corpse twenty-six hours after death. Exterior. — Extreme emaciation. Nothing else remark- able. Head. — Slight sub-arachnoidean infiltration; brain, healthy ; two small spoonsful of fluid in the right lateral ventricle ; rather less in the left ; no other alteration. Neck. — Epiglottis, larynx and trachea, healthy. Chest. — Left lung, without adhesions, presenting at the middle portion of the upper lobe a greyish-colored and whitish mass, about the size of a small hen's egg, composed of an infi- nite number of tubercular granulations, separated here and there by a reddish and slightly granulated tissue. There were also in other parts grey granulations, some of which were immediately beneath the pleura, and made it prominent. Right lung, universally adherent by means of a double false membrane, the folds of which were firmly connected together. This was thicker inferiorly than it was above, and the greater part was transformed into tuberculous matter. There were numerous yellow and grey granulations under the pul- monary pleura, and especially where it lined the interlobular fissures, the edges of which, to the depth of about a line, were converted into the grey and semi-transparent substance. At the summit of the upper lobe there was a middle sized exca- vation, containing a small quantity of pus, communicating with the bronchia, but not lined by a distinct false membrane. The pulmonary parenchyma was rather firmer in its immediate neighborhood than elsewhere. The bronchia were of a bright red color about the excavation only. Heart, small, healthy, of a firm texture ; aorta, natural. 260 SYMPTOMS. STOMACH ; [Pai't II, Abdomen. — Stomach, of moderate volume, containing a small quantity of turbid bile ; the superior half of its raucous membrane, to within three inches of the pylorus, was of an unequal yellow tinge, and with the exception of some small spots, soft as mucus ; in fact, with the back of the scalpel it could be scraped off like viscid mucus. The softened part was much thinner than natural. Near the cardiac orifice, and in the small curvature, where the softening'and diminished con- sistence were least evident, the mucous membrane offered four reddish elevations, firmer than itself, about a line thick and rather less in breadth. No peculiarity observable in the ves- sels which were under the softened membrane. The lining membrane of the small intestine was of a pale-pink hue, and of normal thickness and consistence. Some small ulcerations occupied the last glandular patches. The large intestine con- tained a little thin, turbid, reddish fluid. Its mucous membrane was of a violet red color, minutely mamillated, slightly thick- ened, and not firmer than mucus. In the ascending and trans- verse colon there vi^ere three ulcerations, of a line and a half in diameter, with denudation of the corresponding muscular coat. There were also some smaller ones in the middle of the rec- tum, close together, and lined by the submucous layer; this was opaque, and every where three times its natural thickness. The liver was rather voluminous, pale, adipous, and extending below the ribs. Bile of the gall-bladder, moderately thick, in color like the juice of preserved prunes. Spleen, of ordi- nary dimensions, partially invested by a thick false membrane, containing much tuberculous matter ; it presented internally about sixty granulations of the same nature, surrounded by the healthy parenchyma. The mesocaecum and small omen- tum offered on their surface some small tuberculous patches. The other viscera were healthy. Chap. 5.] SOFTENING, &LC. OF MUCOUS MEMBRANE. 261 321. This observation is interesting in many respects. In the first place, the simple recital of the facts proves that the affection of the lungs and that of the stomach commenced simultaneously, which is by no means usual ; and while in the majority of cases in which this complication exists, death is most frequently to be attributed to the lungs, it was in this instance caused rather by the state of the stomach, than by any other lesion. From the great preponderance of the gastric symptoms, it would have been easy in this case, as we have al- ready stated, to have overlooked the presence of phthisis. The patient's attention was wholly directed to the stomach, and it was necessary to force her, by repeated questions, to speak of the state of her chest. The progress of the softening was not very rapid, and yet we never saw such intense anxiety and uneasiness, or so energetic an expression of suffering. The succession of the symptoms is particularly worthy of attention ; their little intensity at first when the lesion of the mucous membrane was inconsiderable, and their uninterrupted pro- gress afterwards. In the beginning we find slight epigastric pains, nausea, and vomiting excited by cough ; the nausea is then permanent ; the vomiting occurs in the intervals of the cough, consists of bile, and daily increases in frequency and copiousness; there is a gradual augmentation of pain ; in short, the symptoms are always proportionate to the morbid changes taking place. 322. The diarrhoea, so suddenly violent towards the close of hfe, is also a very remarkable fact. It was accompanied by acute pains throughout the abdomen, and indicated without doubt the commencement of one of those severe cases of en- teritis so frequently developed in the last stage of phthisis (264), and which so rapidly produce the softening of the mu- cous membrane of the large intestine. Let us also remark, 262 SYMPTOMS. — STOMACH ; [Part II, that this softening corresponded to a considerable thickening of the submucous layer, which retained its whiteness, although we cannot but consider its increased thickness as the result of acute inflammation (135). 323. The state of the lung and pleura of the right side merit attention. The former, on account of the excavation in the upper lobe, which offered the very rare example of a tuberculous cavity of a certain size, immediately surrounded by almost healthy parenchyma, or which was but a little harden- ed ; the pleura, on account of the false membrane on its sur- face, and its tubercular transformation ; a fact we have never observed except when tubercles existed in the lungs. 324. The pleurisy which gave rise to the membranous exudation came on only a month before death, that is, when there were already tubercles in the summit of both lungs, and more especially of the right ; we cannot, therefore, attribute their development to this inflammation. We cannot, like- wise, suppose the pleurisy to have been the cause of the tubercles situated immediately under the pleura, since these were equally present on the left side, where the lung was free from all adhesions, and the pleura natural. 325. Lastly, the tuberculous matter developed in the false membranes covering the right pleura and spleen, in the sub- stance of the latter, and on the peritoneal surface, was every where unsoftened, in the same stage of development; this seems to require, as we have already remarked (210), the presence of one and the same cause simultaneously acting upon different organs. Chap. 5.] INFLAMMATION OF ITS ANTERIOR FACE. 263 ARTICLE IT. SYMPTOMS OF INFLAMMATION OF THE MUCOUS MEMBRANE OF THE ANTERIOR FACE OF THE STOMACH. 326. The eight individuals in whom we have observed this morbid condition experienced during a variable space of time, anorexia, pains, heat in the epigastrium, occasional nausea ; some few had vomitings. Only one was exempt from pain, and in this instance phthisis had lasted five years, and the ap- petite had ceased com.pletely a few days only before death. 323. These symptoms of an affection of the mucous mem- brane of the stomach were not all present at the same time. Anorexia most frequently was first observed, and this was after a time accompanied by pain in the epigastrium. Pressure in this region increased this pain, and there was often a burning sensation, with more or less long and complete remissions, and a feeling of suffocation was caused by the lightest food. Nausea was the last in its appearance, very variable in frequency and duration, and sometimes solicited by the cough. Vomiting only occurred in two instances, in one of these the ejected matter was bilious, in the other white and insipid. In every instance there was fulness in the epigastric region, produced by the hver descending below the ribs; a fact which has more than once made us suspect that the gastric symptoms were caused by inflammation of the anterior surface of the stomach. 328. The symptoms were of shorter duration than when the membrane was thinned and softened ; they were gene- rally present froraone to three months. The progress of the 264 SYMPTOMS. — STOMACH ; [Part II, affection was chronic, though the pain and other morbid phe- nomena were occasionally very urgent. The following is one of the most interesting examples that we have collected. EIGHTEENTH OBSERVATION. An unmarried female, set. 26, of a strong constitution, of nervous temperament, and who had suffered constantly from colds during the last five years, entered the hospital of La Charité, January 20th, 1823. During the first two years and a half, none of her symptoms had been urgent. After this, there was an increase of cough and expectoration, and for five months a constant spitting of blood, notwithstanding repeated bleedings and the application of leeches. There was some slight improvement in the general symptoms the two following years ; she almost completely regained her strength and flesh ; the catamenia, which had been suppressed during eighteen months, returned at their usual intervals ; in short, she suffer- ed from nothing but a slight cough and some dyspnoea, when in November, 1822, after dancing, she was attacked during the night with violent rigors, followed by heat and perspira- tion, accompanied with pains in the right side of the chest, and increased cough and dyspnœa. From that moment, the shiverings returned every evening, the pain persisted, and on the sixth day she was attacked by an haemoptysis, which con- tinued, though gradually diminishing in intensity up to the period of the patient's admission into the hospital. January 9th. Oppressive headache ; considerable debility ; dyspnoea with shooting pains between the shoulders ; cough, frequent at night ; expectoration, greenish, streaked with Chap. 5.] INFLAMMATION OF ANTERIOR FACE, hc. 265 blood, scanty ; this was mingled with a clear, frothy, and more copious fluid ; a mucous râle posteriorly on the r'ght side; every where else, r spiration was healthy; no reso- nance of voice nor pectoriloquy ; tongue, mtural ; thirst, urgent; anorexia; nausea from cough ; epigastrium, sensible to pressure ; constipation. (Pectoral ptisan ; pectoral mixture with ammonia ; two small rice creams). January 22d. Sputa nummulated (pelotonnés), united by a clear mucus, without any trace of blood ; the patient com- plained of acute pain in the right side ; leeches were applied with decided relief. On the next day pains in the epigas- trium, with nausea in the intervals of the cough. From this period until death, which took place on the 17th of May, the following symptoms were observed. On the 27th of January, there was a fresh pain in the right shoulder, near which a crepitous rale mingled with a gurgling could be heard. On the 29th, the pain had increased, the respiration was much more embarrassed, the cough frequent, and the expectoration clear with thick spots of florid blood ; a fine crepitation was heard over the whole of the right side of the chest. Pulse, very rapid, small and weak. Eight ounces of blood were taken with prompt relief February 5th. Another attack of pain, slight crepitation under the right mamma ; this also readily yielded to an application of leeches. Subsequently the pain, dyspnoea and crepitation, with occa- sional yellowish and rather viscous sputa, were renewed from time to time, and combated by the same means, varied according to the strength of the patient. On the 5th of May, there was evident pectoriloquy between the scapula and spinal column on both sides, with dulness on percussion under the right clavicle, where there v/as some fine crepitation. On the J 2 266 SYMPTOMS. — GASTRIC ; [Part II, 11th, there was slight haemoptysis, and the expectoration assumed a dirty grey color, which it retained to the last. The anorexia and nausea continued some days, after which the ap- petite improved, so that she ate one fourth of the full allow- ance, with only a slight feeling of oppression after every meal. In the commencement of JVJarch, the anorexia, with sharp pains in the epigastrium, returned. On the 15th and 16th, there was almost constant nausea, with small bilious vomitings and sense of heat in the epigastric region. The loss of appe- tite continued, the nausea gradually ceased, leaving headache, general lassitude, and some bilious vomitings. During the month of April the same symptoms were observed ; the epi- gastric pains were very severe, and the vomiting of bile oc- curred at intervals. On the second of May, increased anxiety and uneasiness, with tenderness of the abdomen ; constant epigastric pain, increased by the slightest pressure, cough or movement of the body. The tongue, which had hitherto been natural in color, be- came very red, and covered with small, whitish, membranous patches, easily removed. These appeared and disappeared several times, and the pain in the region of the stomach after a slight diminution returned with great intensity a few days before death. Diarrhœa came on during the last fortnight ; the pulse was constantly accelerated ; the heat of the skin increased towards the evening, with frequent night perspira- tions ; the rigors were much more rare. Opening of the corpse twenty-six hours after death. Exterior. — Extreme emaciation. Nothing else remark- able. Head. — Adhesion between the arachnoid and dura mater, near the longitudinal fissure and in other points near it, by means Chap. 5.] LIVER INFLUENCES THIS INFLAMMATION. 267 of some white, opaque granulations attached to the arachnoid, which was more or less thickened and opaque in the corres- ponding portions ; the sub-arachnoidean infiltration, rather copious ; cerebral substance, softer than natural ; three spoons- ful of fluid in the left lateral ventricle, rather less in the right ; half a spoonful of similar fluid in the ventricle of the septum lucidum, which was itself firm and resisting. Neck. — Left cervical glands, voluminous, tuberculated, but not softened ; similar state of the bronchial glands ; larynx and epiglottis, natural; trachea, of a pale pink color, without ulceration. Thorax. — Some slight cellular adhesions at the summit of both lungs. Externally there were whitish and slightly pink-colored elevations formed by the tuberculous matter. In the upper lobe of the right lung there were two cavities com- municating with the bronchia, and a certain number of tuber- cles surrounded by the firm, granulated, hepatized lung, im- permeable to the air, of a red color anteriorly, and a yellowish grey posteriorly. In the lower lobe there were only a few tuberculous granulations. In the upper part of the left lung there were some small excavations, and some semi-opaque, grey granulations, surrounded by a grey, semi-transparent substance into which this lobe was almost entirely changed. The lower contained only a small number of granulations, and was slightly congested at its base. There were four ounces of serosity in the pericardium ; the heart was small but healthy ; the aorta and pulmonary artery, sound. Abdomen. -—The liver extended four inches below the false ribs, was enlarged, adipous, of a tawny color, spotted with red, and of moderate density. The gall-bladder contain- ed a dense black, stringy bile ; the stomach descended below the crest of the ilium, was voluminous, much elongated, and 268 SYMPTOMS. — GASTRIC ; [Pavt II, partially overlapped by the liver; its lining membrane was covered by a thick viscous mucus, much more abundant over its anterior surface than elsewhere. In the former part it was of a bright red, evidently'thickened and rather softened ; in the remainder of its surface it was of a pale red, and was of a healthy consistence and thickness. Duodenum, healthy. The mu- cous membrane of the small intestine was slightly greyish colored and easily torn, with here and there vascular aborisations, and presented seven small dark ulcerations, generally distributed, of two lines in diameter, with wide intervals between them. The lining membrane of the large intestine was greyish or blackish, and every where softened, with twelve small ulcera- tions ill the ascending colon, and three in the rectum imme- diately above the sphincter ani ; the mucous membrane was slightly detached on their edges, and the corresponding sub- mucous layer greyish-colored and a little thickened. The mesenteric glands were healthy, but around the biliary vessels there were numerous tuberculated lymphatic glands. Spleen, small, with four tubercles, of the size of a small nut, in the middle of healthy texture. 329. Let us reflect a moment on the facts of this observa- tion. The volume of the stomach was very considerable, it extended low down, and was partly covered by the liver ; the mucous membrane lining the anterior surface was of a bright red color, thickened, and a little softened, most evi- dently inflamed ; the inflammation was almost limited to the portion overlapped by the liver, which renders the influence of this organ on its development very probable. The ano- rexia, epigastric pain, nausea and bilious vomitings were in unison with the gastric lesion, and from the urgency of the former, we might have anticipated the more serious alteration Chap. 5.] LIVER INFLUENCES THIS INFLAMMATION. 269 of softening with diminished tliickness. Though chronic in their progress, the symptoms daily acqulied greater intensity. Thus this lorm of gastritis, which prevailed in seven eighths of our cases, gave rise to characteristic symptoms, only varying from the mere acut form by being less urgent, and by the ab- sence of vomiting in most cases. This fact confirms what we have advanced in the preceding article ; namely, that the stomach, in common with the other organs, reveals its morbid alterations by pain and the greater or less disturbance of its functions. We shall shortly specially consider the state of the tongue, but we may here remark, that in the last two instances it re- tained its natural appearance ; that it was even pale up to the moment when it was covered with an apthous exudation, a period long subsequent to the invasion of the gastritis. 330. The development of tuberculous matter in the lym- phatic glands is worthy of notice. The mucous membrane of the trachea was of a very pale pink color, less so than what we usually observe after a variety of other diseases ; it was neither softened nor thickened ; it might have been considered perfectly healthy, and consequently we have no reason to attri- bute to it the state of the cervical glands. It will, however, perhaps be thought, that the state of the glands surrounding the biliary vessels, might be explained by the inflammation of the gastric mucous membrane. To this we would reply, that if some of the lymphatics of the stomach traverse the glands in question, it can only be after passing through those situated on the small curvature, and if the inflammation of the mucous membrane was not sufficient to transform these latter into tuberculous matter, we cannot suppose it capable of affecting the more distant. Let us add also, that we have only seen the tubercular transformation of the glands surrounding the 2T0 SYMPTOMS. — GASTRIC ; [Part II. biliary ducts, three times, and tliat we have never seen the same alteration in the glands occupying the small or great curve of the stomach, although a somewhat chronic inflammation of the gastric raucous membrane was very frequent. 331. We shall be very brief on the morbid alterations in the lungs, only remarking, that the frequent recurrence of in- flammation on the right side confirms what we have advanced (286) relative to the harmlessness of pneumonia in phthisis, and that tubercles may be regarded, in this respect, as foreign bodies, the influence of which is almost always less injurious that of internal causes. ARTICLE III. SYMPTOMS OBSERVED WHEN THE MUCOUS MEMBRANE OF THE STOMACH IS RED AND SOFTENED IN THE GREAT CUL-DE-SAC. 332. Whether this state of the lining membrane was alone present or accompanied with small ulcerations, or a niamil- lated state of the mucous membrane, we could seldom detect any symptom which might be considered characteristic. There had, in some cases, been diminished appetite long be- fore death, but this, with some exceptions, seemed to coin- cide with the progress of the principal affection, and was also present when the gastric mucous membrane was sound. In the majority of cases there was only complete anorexia from ten to twenty days before death. In two instances, or one ninth, towards the close of life, there were nausea and epigas- tric pains. This absence of symptoms attending an alteration which is usually very serious, and which presents the char- acteristics of acute gastritis, has made us suppose that in the majority of cases it came on very shortly before death. Chap. 5.] SOFTENING AND REDNESS OF CUL-DE-SAC. 271 333. The following is one of the two cases we have men- tioned, in which the gastric symptoms had the longest dura- tion and greatest intensity. NINETEENTH OBSERVATION. An unmarried woman, set. 48, tall, of a strong constitution, and not having menstruated the last ten years, entered the hospital September 22d, 1822. She said she had been ill nine months, was never subject to cold, and had not had pneu- monia ; at the commencement, cough, expectoration, dyspnœa and night sweats ; these symptoms persisted, gradually in- creased, and the perspirations had become copious. During' the fifth month she was attacked with haemoptysis, which lasted two days, with pain in the right side ; the latter has since continued, though less soon after it commenced ; she is obliged to lie on the left side. Rigors were rare ; diminution of appetite since the invasion of cough, and for four months the patient has only taken a small quantity of boiled meat with bread ; thirst, urgent ; emaciation from the first. . September 3d. General headache ; subject the last six months to giddiness on assuming the vertical position ; nose and lips livid ; lies with the head raised ; respiration, rather thoracic and accelerated ; cough, moderately frequent ; sputa, scanty, clear, spumous, or greenish, and with white streaks. On the right side, anteriorly, and especially exteriorly to the mamma, the chest was dull on percussion ; there was no pain, but almost every where gurgling and very coarse crepitation. Under the clavicle there were tracheal respiration and indis- tinct pectoriloquy. On the left, nothing peculiar, either by 272 SYMPTOMS. — GASTRIC ; [Part 11, auscultation or percussion. Pulse, frequent, unequal, irregu- lar, and sometimes intermittent ; the action of the heart was "sensible in every part of chest, and accompanied with pretty strong impulse in the precordial region, especially under the sternum; mouth, clammy, with bitter taste; thirst, urgent ; anorexia ; tongue, rather red in the centre ; pain in the epigas- trium for some hours ; nausea, rather frequent immediately after, and in the intervals of cough ; bowels, costive ; ab- domen, rather tympanitic. (Compound decoction of inula with nitre ; gum potion, with thirty drops of tinct. digitalis ; twelve leeches to the anus). From this moment until the first of October (day of her death), continuance of the same symptoms ; the anorexia, nausea, epigastric pains were more or less urgent ; no vomit- ting. A small quantity of soup did not appear to increase the uneasiness ; the tongue continued red in the centre ; there was slight diarrhœa, with some pains in the right side, in the direction of the colon. The pulse was less irregular twenty- four hours after the api)lication of the leeches, but afterwards its Irregularity daily increased. The lower extremities be- came infiltrated ; perspirations were copious, with occasional rigors. No sensible change of expectoration. The dyspnœa rapidly increased, at times requiring a sitting posture; the pain under the right mamma continued more or less acute to the last ; death took place after an agony of some hours. Opening of the corpse twenty-eight hours after death. ExTERiou. — Slight infiltration of the lower extremities. Redness of the ride side of the face where the head rested. Head. — Some nearly fluid sub-arachnoidean infiltration. Chap. 5.] SOFTENING AND REDNESS OF CUL-DE-SAC. 273 A spoonful of serum in each lateral ventricle; the rest of the brain was entirely healthy. Thokax. — Dense adhesions at the summit and base of the right lung, by means of a firm, thick, membranous effusion. Between these points, the false membrane formed a kind of sack, traversed by filaments enclosing in their intervals a small quantity of clear reddish fluid. A large rugged excavation occupied the summit of the right lung, lined by a double false membrane ; its firmest layer was in contact with the pulmon- ary structure, which was either healthy, or more or less severely altered; a communication existed between this cavity, the bronchia and numerous small cavities. The lower lobe was congested. No adhesion of the left lung ; it contained a few crude tubercles, and a small quantity of the grey, semi- transparent matter in its upper lobe. The heart and pericar- dium were invested by an undulated false membrane of toler- able consistence, a line or more in thickness, thinner upon the auricles than upon the ventricles, and bathed by a small quan- tity of clear reddish fluid. Parietes of the left ventricle rather thicker than natural ; those of the auricles were, on the con- trary, thinner than usual. Lining membrane of the aorta and its branches of a bright red color, without any change of thick- ness or consistence. Abdomen. — Two quarts of clear fluid in the peritoneal cavity ; stomach, voluminous; lining membrane, thick, very soft, of a violet red in the large extremity ; of a greyish color, mamillated, and of increased thickness and consistence in the remainder of its extent. The mucous membrane of the small intestine was of twice its usual thickness in the upper three fifths ; color and consistence, every where normal ; there were three very small ulcerations near the ileo-caecal valve. That of the large intestine was much softened throughout its K 2 274 SYMPTOMS. — GASTRIC ; [Part II, whole length ; of a pale pink color in the descending colon and rectum, with numerous small ulcerations, diminishing in number from above downwards. Mesenteric glands, healthy ; liver, voluminous, congested, of a greyish-yellow color, spotted with bright red ; bile in the gall-bladder, thin and light color- ed. Left kidney, of twice its usual volume ; the right, at least four times as large as common, with an uneven lobulated surface, almost wholly consisting of a membranous sac, filled by a clear, dark-colored fluid like urine, and intercepted by a transverse septum, pierced in its centre. There were no traces of the renal structure except on the convex edge, where there was a layer from two to three lines thick. On the neck of the uterus there was a soft vesicular polypus, of the form and size of the uvula; the other viscera appeared healthy. 334. The lining membrane of the stomach was here the seat of two very distinct alterations ; the one, consisting of redness, thickening and softening of the portion covering the large extremity, was recent ; the other (the mamillated state) was the result of a chronic affection. To the latter we might be inclined to attribute the anorexia which was present at the early part of the disease ; but we shall soon find (340) that we have no satisfactory reasons for doing so. As to the epi- gastric pains and nausea, which were experienced about a month before death, they may be compared with what we have observed in the cases of the preceding sections, and evidently indicate a more recent affection than the mamillated state, which, in fact, has never presented to us the same symp- toms ; they must, therefore, be referred to the inflammation of the mucous membrane of the great cul-de-sac. 335. It is very remarkable, moreover, that notwithstanding the co-existence of so many serious lesions, the one we are Chap. 5.] FROM ULCERS OF THE MUCOUS MEMBRANE. 275 now considering gave rise to very distinct symptoms, doubtless nearly as they would have been in a case of simple gastritis, and that the same remark will equally apply to the pleurisy, phthisis, and pericarditis. The fever at the commencement may be ascribed to the development of the pulmonary tuber- cles, for all complications were absent until some time after- wards ; and, moreover, we shall relate cases of simple phthisis (Obs. 27, 28, 29), in which fever came on at the same period, and with greater intensity. A RT I C L E I V . SYMPTOMS OF SIMPLE ULCERATION OF THE GASTRIC MUCOUS MEM- BRANE. 336. Of this condition, as we have already said (96), we have only met two examples. In one, where a single ulcer- ation of about two inches in surface existed (Obs. 38), the patient experienced during the last three months of life a pain in the epigastrium, increased after meals ; during the same period there was diminished appetite, with slow and painful digestions ; the other instance we shall now detail. TWENTIETH OBSERVATION. A GIRL, set. 19, of a nervous temperament, and weak and delicate constitution, naturally thin, not having menstruated, and subject to shortness of breath from her infancy, was ad- mitted into the hospital of La Charité, February 24th, 1824. She had been ill three years. Her illness had commenced 276 SYMPTOMS. — GASTRIC ; [Part II, with a violent hasmoptysis, recurring two days afterwards, and treated by bleeding. This haemorrhage subsequently reap- peared every two or three months, more frequently during the winter than summer ; the last attack was about a month be- fore entrance. It was always accompanied with efforts of vomiting, and the patient believed that the blood came from the stomach. Cough and expectoration commenced with the haemoptysis, and had since continued ; her habitual dyspnœa was much aggravated, and she had been annoyed occasion- ally by pains in her chest. Nausea and vomiting, often ac- companied the paroxysms of cough, and diarrhœa with colic, lasting a few days or weeks, had not been infrequent from the beginning ; the appetite had always been pretty good. Dur- ing the year before entrance she was very subject to rigors, and for fifteen days she had had heat in the evenings, and night perspirations ; no thirst. The patient had continued to grow taller, and assured me that she had lost but little flesh. February 25th. Face and the rest of the surface of the body, pale ; little appetite ; tongue, a little whitish ; epigastri- um, not painful ; stools, not painful, but rare ; breathing, rather accelerated ; slight oppression ; cough, often dry, most trouble- some at night; it sometimes caused nausea and vomiting. Sputa, thick, greenish, scanty, lying in a limpid fluid like saliva. Percussion of the chest, every where clear. For about four inches under the right clavicle there was a coarse and copious crepitation ; and in the corresponding point pos- teriorly, there were tracheal respiration and imperfect pecto- riloquy ; on the left side this was quite distinct. Pulse, rather quick ; heat, moderate. (Infusion of violets ; to sit over the vapor of hot water ; six leeches to labia; a fourth of house allowance). The progress of the disease was slow, but constant. Chap. 5.] FROM ULCERS OF THE MUCOUS MEMBRANE. 277 From the beginning of March the appetite greatly diminish- ed ; there was a sense of weight in the epigastrium after food, with almost constant nausea and vomitings, either after or in the intervals of the cough. A small quantity of bile was sometimes mingled with the contents of the stomach ; the mouth was clammy, and had a bitter taste during the whole of this month ; the tongue was whitish in the centre, and a little red on the edges. In April, the symptoms were more urgent; the mildest drinks caused oppression in the epigas- trium, and were sometimes vomited ; very rarely pure bile was ejected ; nausea was constant ; appetite, almost gone ; expression depressed ; temper, irritable, with frequent anx- iety ; the thirst became very urgent, without any change in the appearance of the tongue ; she never complained of epi- gastric pains. The same symptoms continued until death, which occurred on the I2th of May. The stools became soft towards the end of March ; they were fluid at the beginning of April, and preserved the same character, though never numerous, three or four a day to the last ; they were accompanied with very little colic pain. The dyspnœa rapidly increased ; the cough was always more urgent during the day than at night. From April the sputa were nummulated, with a ragged, flocculent appearance, and after the 1st of May, greenish, flat and purulent. On per- cussion the chest was very dull anteriorly and on the left, to- wards the end of April. From the 18th of March, under both clavicles and in the corresponding region posteriorly, there were tracheal respiration and pectoriloquy. Under the right clavi- cle, occupying a considerable extent, there was a very coarse crepitation, with occasional gurgling. At the end of April, this double râle was evident on the left side, first anteriorly, then posteriorly, through almost the whole extent of the 278 SYMPTOMS. — GASTRIC ; [Part II, chest ; this continued until death. There were from time to time pains in the left shoulder, right side of the chest, or in the iarynx. Heat of surface, much elevated ; copious night sweats ; rigors rare, and from the end of April the pulse was rapid. There was a variably intense but constant headache ; and from the 20th to the 30th of April she complained of contin- ual tendency to drowsiness. These symptoms disappeared spontaneously. Slight delirium during the last twenty-four hours ; gradual loss of strength ; and she was wholly con- fined to her bed after the middle of April. On the 18th of March nine leeches were applied to the labia ; a gum potion, with a grain of opium, was almost constantly prescribed ; the diarrhœa, when severe, was treated by the white decoction and diascordium ; the food was limited to some rice creams, and for the last six weeks scarcely any thing was taken. Opening of the corpse thirty hours after death. Exterior. — Extreme emaciation ; no œdema. Head. — A very small quantity of fluid in the lateral ven- tricles ; brain and membranes, perfectly healthy. Neck. — Larynx and epiglottis, natural ; mucous mem- brane of trachea, of a rather bright red color inferiorly, of good consistence. Thorax. — Summit of the right lung, adherent ; theleft per- fectly free ; both lungs voluminous, of a light pink color, be- coming deeper posteriorly. The upper lobe of the left lung was indurated, with some yellow-colored elevations on its sur- face, corresponding to small tuberculous excavations, separated by a very thin layer from the pleura ; the whole lobe was converted into half filled tuberculous cavities, separated by the grey semi-transparent matter, or the red, granulated, hep- atized lung. At the summit there was a middle-sized exca- Chap. 5.] FROM ULCERS OF THE MUCOUS MEMBRANE. 279 vation, communicating with numerous, very much dilated bronchial ramifications. The lower lobe was slightly con- gested, easily torn, and interspersed with tubercles. In the summit of the right lung there was an excavation four times as large as that of the left ; the remainder of the lobe pre- sented a mixture of grey matter, tubercles, and healthy struc- ture. The bronchia were red and not thickened ; the bron- chial glands voluminous, but not tuberculated ; heart and aorta, natural. Abdomen. — Stomach, rather smaller than usual, containing a little yellowish fluid. Its lining membrane was white, smooth, and near the pylorus covered with a thick mucus. With the exception of this region, and a small portion of the great cul-de-sac, it presented from seventy to eighty ulcera- tions, from one to two lines in diameter. Its destruction in the corresponding points was not always complete ; it was sometimes only thinned, so that the thinning was in bands of two or three lines wide. In the intervals it was pale, and of normal thickness and consistence. The mucous membrane of the small intestine was healthy. That of the caecum was red, much softened and thickened here and there. In the colon it was only rather softer than natural. No alteration of the mesenteric and mesocolic glands. The liver was pale, rather soft, of usual dimensions ; uterus, one inch wide, and five lines only thick ; the other viscera were healthy. 337. In the majority of cases where the mucous membrane of the stomach is ulcerated, it is more or less thickened or mamillated in the intervals, but in this example no such alter- ation was observed ; the ulcerations seemed artificially pro- duced, and had they not been present we might have said the membrane was quite healthy. At the same time the gastric 280 SYMPTOMS. — GASTRIC ; [Part II, symptoms were rather severe, and there could be no doubt of a more or less serious lesion of the mucous membrane ; there was no epigastric pain, but nausea and vomiting were present long before death, continued to the last, and notwithstanding its slow progress, the affection was always plainly marked. 338. The healthy condition of the mucous membrane of the small intestine must not escape attention ; that of the colon was only slightly softened, while the diarrhœa had per- sisted several months. It is probable that, under these cir- cumstances, it depended for a time on a change of secretion jnot caused by inflammation. 339. When the only lesion of the gastric mucous membrane was the mamillated state, we have not been able to detect any symptoms by which it might be recognised. In some cases the appetite was diminished from the commencement ; in others from the middle of the disease ; and more rarely it continued good to the last. A small number presented, at considerable intervals, nausea and vomitings ; in only one in- stance were epigastric pains complained of. In three others this region was rather sensible to pressure ; but this slight sen- sibility of the epigastrium is often present in acute catarrh, when the cough is frequent and the stomach healthy ; it might therefore in this instance have been caused by the cough, and on that account cannot be relied on as a symptom. 340. We have compared the above symptoms with those experienced by patients whose gastric mucous membrane pre- sented no alteration, either as to color, consistence, or thick- ness, and no difference was observable. In both the anorexia had commenced at very variable periods ; some of the latter had also nausea and vomiting at distant intervals. The loss of appetite in cases where the mucous membrane Chap. 5.] SUMMARY. 281 of the stomach was healthy proves that anorexia, even when protracted, is not sufficient to determine the presence of gas- tritis ; when not accompanied with pain, nausea and vomitings, it aids little in the diagnosis, and is another proof (259), that a function may be for a long time deranged, without any ap- preciable alteration of structure in the organ which discharges it. Besides, if the mamillated state of the mucous membrane be the result, as we believe it is, of very chronic inflammation, we can perceive the difficulty of recognizing its symptoms in a disease in which the functions of the stomach are deranged even when its mucous membrane is perfectly healthy. This would not, perhaps, be the case were there no co-existing complication ; at least we may presume so, from what occur- red in the twenty-second observation. 341. When the gastric mucous membrane was more or less red in its ivhoh extent, without any alteration of thickness or consistence, we have observed distinct symptoms (as epi- gastric pains or nausea) a few days only before death ; symp- toms which indicated recent inflammation, and this was verified by the nature of the appearances after death. 342. From what has preceded, we may conclude that the greater number of the morbid conditions of the stomach is characterised by peculiar symptoms. When it was thinned and softened, loss of appetite, nausea, bilious vomitings, epi- gastric pains were almost constantly present, and generally some time before death. When the inflammation was con- fined to the anterior surface of the stomach, the symptoms were much less urgent, commonly less numerous, and of shorter duration ; the loss of appetite was more or less con- siderable ; there were nausea and epigastric pains, though not 282 SYMPTOMS. — GASTRIC J [Part II, violent, and in one fourth of the cases, vomiting. The same symptoms were observed when the ulcerations were large, or when they were small and numerous. When the inflamma- tion was confined to the mucous membrane of the great cul- de-sac there were no vomitings ; nausea and epigastric pains were seldom observed ; this frequent absence of symptoms made us conclude that this inflammation came on towards the close of the disease, and perhaps, in some cases, like pneu- monia and pleurisy, in the last twenty-four or forty-eight hours. Finally, no symptom positively indicated the mamillated state of the mucous membrane, and when it was universally red without any change of thickness, or consistence, a part of the patients experienced nausea and epigastric pains two or three days before death. This simple statement of facts points out, we think, very clearly in what light we ought to regard vomitings which oc- cur in the progress of phthisis, vomitings which have hitherto been classed among the symptoms of the disease. When they have been preceded during a certain time by more or less anorexia, and accompanied with epigastric pains, they are generally indicative of a very serious alteration of the mucous membrane of the stomach ; and this union of symptoms is what we most generally observed. Vomitings can be much less frequently attributed to the cough ; and in these cases- there is no epigastric pain, the appetite is good, the digestion easy, and they occur generally at the commencement of the disease ; but when resulting from organic alteration they are almost invariably confined to a more or less advanced period of the affection. But here, as in a thousand other circumstances, there are facts which defy the sagacity of the observer, and seem excep»- tions to the most general laws. One of our patients, for in- Ghap. 5.] SUMMARY. 2S3 stance, presented during the last month of life, pains in the epi- gastrium, nausea and vomitings, either during the cough or in its intervals, although the gastric mucous membrane was perfectly ^healthy. 343. To conclude our remarks on the state of this mem- brane in cases of phthisis, we shall relate two facts, one of which seems an instance of chronic gastritis, with an ulcera- tion, as if cicatrized ; the other an example of complete de- struction of the muscular tunic in one spot, while the corres- ponding mucous and submucous layers were unaiîected. TWENTY-FIRST OBSERVATION. A SHOEMAKER, ffit. 34, of middle height, rather delicate constitution, addicted to onanism from an early age, entered the hospital of La Charité, July 12th, 1S24. He had en- joyed habitually good health ; had never been seriously ill ; was not liable to colds. He dated his present illness a year and a half ago, had ceased his occupation five months, and attributed his indisposition to great grief at the loss of his sav- ings. He was first attacked by slight diarrhœa, accompanied with almost complete anorexia. These symptoms continued without variation during eleven months, with only slight epi- gastric pains occasionally, but without fever, nausea or vomit- ings. After this period he was seized, without evident cause, in the middle of the night, with a copious hemoptysis, which returned on the two following days, and seemed at length to yield to strongly acidulated drinks. At the same time there were cough, expectoration and dyspnœa, with vomitings after the cough ; after that period the diarrhoea ceased ; soon after 284 SYMPTOMS. — gastric; [Part II, the appetite returned, and during the last four months there were night perspirations, rarely preceded by rigors. He had never, experienced pains in the chest. July 13th. General paleness of surface ; great debility ; pain in the limbs ; varia- ble state of thirst ; tongue, natural ; no tenderness in the epi- gastrium ; daily stools, of natural firmness. Pulse, small and weak, slightly accelerated ; heat, moderate, with evening ex- acerbation ; night sweats. Respiration, loud and almost cav- ernous round the summit of the left lung, natural and free from râle every where else ; speaks hurriedly ; slight dyspnœa ; sputa, greenish, in small irregular masses, and scanty. Con- siderable emaciation. (Decoction of lichen; gum potion; julep; one fourth of house allowance). Up to the 8th of August there was neither nausea nor vomiting; the appetite improved and the digestion was easy ; the skin was always rather hot in the evening with occasional perspirations during the night ; diminution of dyspnœa, but great debility. The patient having quitted the hospital at this period, on the following day there were great increase of cough, renewal of the vomiting and loss of appetite. This compelled him to re-enter, and from the 10th of August to the 2d of November, the following is the result of our observatious : — Cessation of vomitings and no subsequent recurrence ; the appetite con- tinued depressed during some days, but soon after was as good as in the report of August 8th; after the invasion of diarrhœa on the 2d of October it diminished, and continued inconsider- able to the last. There w^as no epigastric suffering, and the looseness, which was at first violent, with great prostration and rapid pulse, quickly diminished. The tongue was almost always a little red, and rather livid ; the heat of surface in- Chap. 5.] CHRONIC GASTRITIS WITH ULCERATION. 285 creased in the evening and during the night ; very rarely there vi^ere perspirations and rigors. Sept. 2-2d. Percussion under the left clavicle, very dull ; this gradually extended, and in the middle of October there vi^as every where loss of sound anteriorly on the same side. The respiration under both clavicles was tracheal, and was soon followed by gurgling. There was sudden increase of the prostration on the 1st of November, and on the 2d, at five, p. m., the patient expired. During a few days rice water was prescribed, and afterwards the infusion of violets. During the last month he only took a little soup and some rice creams. Opening of the corpse forty hours after death. Exterior. — Extreme emaciation. Nothing else remark- able. Head. — Slight sub-arachnoidean infiltration ; a spoonful of fluid in each lateral ventricle, rather less at the base of the skull ; brain, soft and injected. Neck. — Epiglottis, natural. Larynx, pale, with two superficial ulcerations, one at the union of the vocal cords and the other on the left inferior one. Tracheal mucous mem- brane rather red, with numerous ulcerations of a line in diam- eter, without any thickening of the membrane either around them, or in their intervals. Some similar ulcerations in the left bronchia. Thorax. — Slight adhesions at the summit of both lungs. The upper lobe of the left lung presented two large excava- tions, lined by a greyish, semi-cartilaginous, somewhat opaque membrane, filled with a greenish matter, analogous to what existed in the bronchia ; the remainder of the lobe was con- verted into a greyish, semi-transparent substance, containing 286 SYMPTOMS. — gastric; [Part II, numerous half-filled small excavations, many of which were only separated from the pleura by an extremely thin layer. In the summit of the lower lobe there was a small quantity of grey, semi-transparent matter, interspersed with tubercles. In the right lung the lesions were of a similar description, but less extensive. Heart, healthy ; numerous semi-cartilaginous spots in the interior of the aorta. Abdomen. — Stomach, of moderate volume, rather con- tracted at the centre. Its mucous membrane of a tawny color in the cul-de-sac, more or less greyish elsewhere ; this last tint was interrupted by some whitish-colored spots, from one to two lines in diameter, where the membrane was evi- dently thinned. One of these, of a very light grey, oval, seven lines long and five wide, situated posteriorly near the small curvature, and half way between the cardia and pylorus. The mucous membrane seemed insensibly to terminate at its circumference, after having gradually decreased in thickness over an inch and a half of surface. This termination was the more indistinct on account of the color of the mucous mem- brane being similar to that of the spot we have described, which was itself formed by the submucous layer ; so that after having removed all the mucous membrane the stomach was white with the exception of this spot. The latter was also circumscribed by a thin flattened ring, about one line in breadth, formed by the firm adhesion of the submucous layer to the subjacent muscular tunic. The consistence of the mucous membrane, where thinned, was rather diminished. The muscular coat presented no alteration. The lining mem- brane of the small intestine was of normal consistence and thickness, and offered numerous narrow, transverse ulcerations in the three upper fourths, and in the lower portion pretty numerous yellowish granulations, of a tuberculous appearance, Chap. 5.j CHRONIC GASTRITIS WITH ULCERATION. 287 of the size of a pea or smaller, and ulcerated at their summit. There were numerous ulcerations in the large intestine, from one to two inches in surface ; smaller in the rectum than else- where. The greater number was rough, from the promi- nence of the denuded fibres of the muscular coat, which were a half a line thick ; around them the mucous membrane was red and thickened ; in other parts this last was healthy. The raesocolic glands, about the size of a pea, were tuberculated and firm; those of the mesentery were unaltered. There was only one kidney; it was situated to the right, nearly twice the usual volume, with two fissures, one anterior, the other at its internal edge, and two small pelves, which termi- nated after a short distance in a single ureter. 344. The loss of appetite experienced by the patient eleven months before the accession of cough, when, as far as we can judge, no tuberculous affection of the lungs existed, is no doubt to be ascribed to a chronic inflammation of the mucous mem- brane of the stomach, of which the diminished consistence and partial destruction were the consequence. In general, when a certain portion of this membrane is destroyed, the adjacent parts are natural, or at least offer neither increase nor diminution of thickness ; the lining submucous layer presents no change of color, but is occasionally a little thickened or partially destroy- ed, as we have already seen in the thirty-eighth observation ; it also does not form any elevated boundary around the mucous membrane. Does not the difference between these characters and those of the ulcerations just described prove, when con- nected with the history of the symptoms, that there had been a very chronic gastritis, with ulceration of the mucous mem- brane which had undergone a partial cicatrization ? It may perhaps be argued, that were this the case, the mucous mem- 288 sïMPTOMS. — GASTRIC ; [Part II, brane would have reached beyond the indurated and circum- scribed boundary ; we can only say that, in the few examples we possess of distinct cicatrization in the small intestine, the mucous membrane never extended beyond the circumference of the ulceration. TWENTY-SECOND OBSERVATION. 345. A WOMAN, set. 49, a gold wire drawer, of a weak con- stitution, seldom liable to colds, entered the hospital of La Charité, July 13th, 1824. She had been ill a year, and had ceased her business five weeks. At the commencement, general uneasiness, sense of debility, partial loss of appetite, and emaciation. In the fifth month, cough, expectoration and dyspnœa (which afterwards were continued) were con- joined with the previous symptoms ; during the last month complete loss of appetite and diarrhoea. In the fourth month pains and pricking sensations in the right side of the chest, which have been more or less urgent ever since. No haemop- tysis, night perspirations, or epigastric pains, and she was very rarely sensible of rigors. July 14th. Considerable debility ; extreme emaciation j some oedema of the lower part of the legs. Tongue, a little red at the point ; mouth, clammy, and with occasional bitter taste ; thirst, variable; very little appetite ; marked resistance to the hand in the epigastric region and below the right false ribs, for a space of three inches ; no pain in the correspond- ing parts ; epigastric pulsation the last few days ; one liquid stool and slight tension in the hypogastric region. Cough, frequent in the morning, with some greenish and opaque Chap. 5.] DESTRUCTION OF THE MUSCULAR COAT. 289 sputa ; on the right side and anteriorly there was dulness on percussion; ahnost the same was observed in the correspond- ing point posteriorly. Respiration, tracheal under the right clavicle with gurgling and pectoriloquy over a considerable extent ; the decubitus on the right side provoked cough and increased the dyspnoea. Pulse, rather full and quick. (Rice water with quince syrup ; gum potion ; three rice creams). The anorexia continued, the diarrhoea increased, became copious, and then entirely ceased after the beginning of Au- gust. There were neither nausea, vomiting, nor epigastric pains. The hypogastrium was the seat of a very trouble- some sensation of weight, principally felt after food, which sometimes consisted of an egg and a small quantity of bread j there was slight tympanitis. The stools became very fre- quent and offensive the last four days, and at nine, a. m., of the 17th of August, the patient expired. During the thirty-three days on which we observed this patient, the state of tlie tongue was very variable ; its color, though usually natural, was at times more or less red, without any accompanying change in the functions of the stomach and intestines. The heat of the skin was elevated in the evening ; there were no perspirations, and the results of the examination of the chest were nearly the same as at the first. Diascor- diura, with a grain of opium, was prescribed when the diar- rhœa was urgent. Opening of the corpse tiventy-three hours after death. Exterior. — Extreme emaciation. Head. — A small spoonful of fluid on the upper surface of M 2 290 SYMPTOMS. GASTRIC J [P^rt II, the arachnoid ; some slight emphysema between this mem- brane and the pia mater, without infiUration. A spoonful of fluid in each lateral ventricle ; the lower half of the brain was less firm than the upper. The tuber annulare and the spinal marrow were still more softened. Three spoonsful of sUghtly frothy fluid in the lower portion of the vertebral canal. Neck. — Epiglottis, larynx and trachea, healthy. Thorax. — Left lung, without adhesions; its upper lobe was much nodulated with many granulations, crude, or softened tubercles, placed very superficially ; these were nu- merous internally also ; very few existed in the lower lobe. The right lung was universally adherent to the costal pleura, by means of a semi-cartilaginous false membrane. At the summit of the upper lobe there was a vast anfractuous exca- vation, lined by a very dense, greyish false membrane, half a line thick, inclosing a greenish substance streaked with blood, and intersected by some short interrupted bands. In the remainder of its extent the upper lobe was indurated and transformed superiorly into a dark, homogeneous, greyish, hard and slightly elastic substance, more or less semi-trans- parent inferiorly ; it was crossed by irregular semi-cartilagi- nous bands, and contained either softened tubercles or small excavations. The bronchia were thickened, more dilated and redder in the right upper lobe than in the left. The heart was small but healthy ; there were numerous yellowish patches throughout the whole aorta. Abdomen. — The peritoneal cavity contained a quart and a half of reddish fluid. The liver descended four inches below the ribs, extending as far as the iliac crest ; its structure was firm and. brittle. The gall-bladder contained a very dark-colored viscous fluid. The stomach was small and closely adherent by part of its posterior surfiice to the pancreas, the tissue of Chap. 5.] DESTRUCTION OF THE MUSCULAR COAT. 291 which was much indurated ; the mucous membrane presented a greyish pink tinge ; it was every where mamillated and rather thickened, with diminished consistence in the large curvature, and covered with a copious and viscous mucus. Near the small curvature, between the cardiac and pyloric orifices, and in the portion adhering to the pancreas, there was a slight depression, about the size of a dollar, round which the mucous membrane was a little corrugated. In the de- pressed portion it was very thin and brittle, but not mamil- lated ; the corresponding cellular layer was healthy ; the mus- cular membrane was destroyed and replaced by a white, semi- cartilaginous tissue, about a quarter of a line thick, in which the fleshy fibres terminated. These were m.ore than half a line thick at the point of junction, for a space of four lines, but were not otherwise modified ; the submucous layer was indurated and thickened to the same extent. The small in- testine contained a greyish, thin, tenacious substance, with a faint odor; its lining membrane was a little softened, present- ing throughout, numerous small ulcerations, many of which were in the centre of the glandular patches. Similar ulcer- ations existed through the whole of the large intestine as far as the anus ; they were lined by the slightly thickened sub- mucous tissue. In their intervals the membrane was as soft as mucus, and twice its usual thickness ; it was every where in contact with a greyish and reddish liquid. The mes- enteric and mesocolic glands, rather voluminous, but healthy. Spleen, small, of a texture as firm as that of the liver. Uri- nary apparatus, natural. 346. The state of the gastric mucous membrane, which was grey and mamillated throughout its whole extent, thinned in one point, while it was somewhat thickened elsewhere, and the 292 SYMPTOMS. — GASTRIC. [Part II, decrease of appetite long anterior to the invasion of phthisis, render this observation very analogous to the preceding, and prove. the existence of a chronic gastritis long before the ap- pearance of phthisis, and for some time without complication. In this respect the fact is one of great interest, as it shows what as yet we have only ventured to intimate, that the mam- illated state of the mucous membrane of the stomach is the result of a chronic affection, characterized by very obscure symptoms. Hitherto we have never observed this condition isolated from more or less numerous complications, and since in these cases the gastric symptoms closely resembled those we observe when the stomach is healthy (339, 340), it was impossible to know to what they might be referred. The ob- servation before us proves, more evidently, that the symptoms are exceedingly obscure, and doubtless confined in the ma- jority of instances to a greater or less diminution of appetite with difficult digestion. We do not say this is always the case, for we have had examples in which this condition of the membrane was combined with redness, and in these cases there were occasional nausea and epigastric pains (90, 326). The partial transformation of the muscular coat into a semi- cartilaginous substance is equally worthy of our attention. Without conjecturing when this might have taken place, or the exact cause which produced it, we shall only remark that we have lately met with a very analogous fact ; but instead of the semi-cartilaginous transformation, the muscular tunic was here converted into a fibrous tissue about half a line thick. The corresponding cellular layer was more or less thickened. Chap. 5.] TONGUE, ITS COLOR. 293 ARTICLE V, STATE OF THE TONGUE. 347. It is proper, after having studied the symptoms which correspond to the different conditions of the gastric mucous membrane, to investigate whether there is not some dépend- ance between these conditions and the state of the tongue. The following is the result of our inquiry : — Out of nineteen cases with softening and diminished thickness of the mucous membrane of the stomach, in nine the tongue, which was al- ways moist, never presented at any period of the affection distinct redness ; and out of ten others it was red at the point and edges in four, during fifteen or twenty days ; while in the remaining six this v^'as the case for a very limited period, only two or three days. 348. In eight examples where the inflammation was con- fined to the anterior part of the gastric mucous membrane, in half the tongue was red, in the rest it was pale. In one the redness was very transitory. 349. When the inflammation occupied the totality, or a portion of the great cul-de-sac of the stomach (in w^iich case, as we have remarked, it probably dated but a few days before death), the tongue was natural in ten instances; while in seven others it was more or less red on the edges, either very shortly before the fatal termination, or during a few days only, at some earlier period. 350. In patients where the mucous membrane was evidently mamillated; the tongue was more or less red during a varia- ble space of time in eight out of nineteen ; in the remain- 294 SYMPTOMS. — tongue; [Part U, der it was natural. In six out of fourteen other examples, where the gastric mucous membrane presented a variety of morbid alterations, the tongue was redder than natural for one or more weeks. 351. Lastly, where the mucous membrane was healthy, both as to color, consistence and thickness, the tongue was more or less red in ten out of nineteen ; and in one of these the redness persisted during the whole course of the disease, and was more intense than in any of the preceding instances ; the tongue also at one period became dry, as we occasionally see it in continued fever. The observation is sufficiently in- teresting to be detailed. TWENTY-THIRD OBSERVATION. A WHEELWRIGHT, agt. 25, of a tolerably strong constitu- tion, had been ill three weeks when he was admitted into the hospital of La Charité ; he said that seven months previously he had been attacked with continued fever, which lasted five weeks, but had not been accompanied with diarrhoea; his convalescence was rapid and complete ; his digestion had been easy and regular, and his appetite excellent up to the period of his present illness. During the first eight days of this last affection he had complained of uneasiness, loss of ap- petite, thirst, slight cough and inaptitude for exertion ; this was followed by increased heat without rigors, night perspira- tions, intense thirst, complete anorexia, increased cough, pains under the sternum, throbbing in the ears on assuming the ver- tical position, and confinement to his bed. Leeches were applied to the epigastrium (where no pain had been ex- Chap. 5.] ITS REDNESS. 295 perienced), without the shghtest rehef to any of the symp- toms. On the 3d of August, 1824, the day after his admission, his state was the following : — Face, rather animated ; he complains much of weakness ; tongue, dry, shining, of a bright red on the edges, yellowish, moist and villous in the middle ; urgent thirst, anorexia, bitter taste in the mouth, no pain in the epi- gastrium ; the whole of abdomen is insensible to strong pres- sure ; constipation. Pulse, seventy-five, active, full ; heat, elevated ; breathing, not accelerated ; no râle in any part of the chest ; the cough causes pain under the sternum ; expec- toration, scanty, spumous ; position in bed, natural ; slight general uneasiness. (Lemonade ; an emollient enema, and diet). On the following days the tongue was moist, clean, and intensely red ; there were one or two liquid stools in the twenty-four hours ; the anorexia continued, and the lemonade appearing to produce some uneasiness in the epigastrium, it was changed for a solution of simple oxymel ; pulse, slower than at first. 11th. No change in the state of the tongue or di- gestive tube; the solution of oxymel was not supported better than the lemonade ; the patient vomited a little bile. His only complaint was of the chest, at the posterior part of which on the right side, there was a slight sonorous râle. (Solution of gum syrup). Until the 8th of September, when death took place, the thirst was more or less urgent, anorexia constant, no pain in the epigastrium ; some bile was vomited on the 22d, 29th, and 30th of August. The tongue presented some variations. On the 16th it was of a deep red color and rather dry ; on the 28th it offered the same aspect with the addition of some small white apthous patches round the edges ; it was unusu- 296 SYMPTOMS. — TONGUE ; [Part II, ally red on the 1st of September, perfectly clean and smart- ing. This redness daily increased, and on the 5th was asso- ciated with dryness and augmented thickness, which continued to the last. The stools became rare ; during the last eight days there were some diarrhoea and tympanitis. August 16th. Increased oppression. 21st. The pain in the chest, cough, and dyspnoea continued stationary ; the respiratory murm.ur was weaker anteriorly on the left side than on the right; ex- pectoration, scanty, rather greenish and opaque ; this contin- ued to the last. The pulse, which was almost natural on the 23d of August, was eighty-five on the 28th ; there was pro- portionate increase of temperature, which afterwards continued. From the 28th of August, rapid increase of weakness and emaciation, and soon the patient was unable to leave his bed. He expired with very little pain and no delirium, and almost without any rattling respiration, at four, p. m. The solution of gum syrup was continued with emollient enemas. On the 16th of August and 3d of September, leeches were applied to the anus without any advantage. Opening of the cor'pse sixteen hours after death. Exterior. — Extreme emaciation. Head. — Slight sub-arachnoidean infiltration; medullary substance of the brain, rather vascular; a spoonful of serous fluid in each lateral ventricle, and also at the base of the skull. Neck. — Epiglottis, larynx and trachea, natural. Chest. — Cellular adhesions over the greater part of the lungs. The upper lobes contained numerous softened tuber- cles, especially those of the right, and anteriorly rather than posteriorly ; in other parts they were not softened. The sub- Chap. 5.] USE IN PROGNOSIS. 297 stance of the lung surrounding them seemed every where heahhy, and there were no grey, semi-transparent granula- tions. Bronchia, thin, and of a pale pink color ; heart and aorta, natural. Abdomen. — Stomach, small, with numerous valvular folds internally. Lining membrane, velvet-like, pale, not in the least injected, and every where of normal thickness and con- sistence. The same paleness and healthy state of the mucous membrane existed throughout the whole of the small intes- tine, with the exception of a small, very pale ulceration, one line in diameter, and about twelve inches from the caecum. The lining membrane of the large intestine w'as white, of nat- ural thickness and consistence, except in the last tv/o feet, where it was of a livid red, softened, and had numerous small ulcerations, at the centre of which there were small coagula of very dark colored blood. The mesentery consisted of an irregular flattened mass, of about an inch thick and at least thirty inches in superficies, formed by the union of completely tuberculated mesenteric glands, not softened, and about as large as a chestnut. Many of the lumbar glands had partially undergone the same transformation. The pancreas was harder and whiter than natural ; the other viscera of the abdomen were healthy. 352. The absence of epigastric pain in this case in which the progress of the symptoms had been tolerably rapid, and the intellectual faculties had remained unaflected, and in which only a slight vomiting of bile occurred, made us relinquish the idea of gastritis, and having merely some suspicions in re- gard to the state of the lungs, we were unable to form any rigorous conclusion as to the nature of the disease ; but the gradual emaciation, the redness and dryness of the tongue, N 2 298 SYMPTOMS. — tongue; [Part II, the continuation and increase of the same symptoms made us believe that the disease was, and would shortly prove to be, fatal in its nature. As in many other instances, the condition of the tongue was useful for our prognosis, and we think that its value as a symptom is almost wholly confined to this indi- cation. At least, after the facts we have related, it must ap- pear evident that there is no real relation between the state of the tongue and that of the stomach ; for if it is sometimes red in gastritis, it is still more frequently pale ; and, on the other hand,, it is sometimes dry, hard, and intensely red, when the gastric mucous membrane is healthy. These facts, indeed, ought not to excite surprise, as they sim- ply prove that the tongue is no exception to the general laws of the system, which would be the case, did it either constantly or solely indicate the condition of the gastric mucous mem- brane. In fact, whenever there is febrile movement, the whole system more or less participates ; the appetite ceases ; the skin becomes hot, moist, and frequently colored ; the secretions are modified ; the urine is red, scalding, &ic. Why should the tongue remain unaffected by these changes ? Why should it not become more or less red, dry, moist, clean, oe coated ?* * Perhaps there never was an opinion in medicine more generally adopt- ed than that the state of the tongue was indicative of that of the stomach 5 and yet when brought to the test of accurate observation its fallacy is at once detected, and the inaccuracy of experience demonstrated. The results of our author are not peculiar to himself, though perhaps the evidence he adduces is as yet the most incontestable. Dr. Stokes, in his second lecture during the session of 1832 — 3, says, " the tongue is only useful as an index of the general state of the system, and not of the stomach." Dr. Piorry, in an interesting memoir on this subject, (Vide Collection de Mémoires sur la Physiologie, la Pathologie et le Diagnostic, par M- Piorry. Paris, 1831), concludes, — First, That the redness of the tongue depends on the volume Chap. 5.] ALBUMINOUS EXUDATION UPON IT. 299 From the first examination, the anorexia was complete ; and this becomes more remarkable, from the fact that not only was the gastric lining membrane healthy, but there was scarcely any febrile excitement present ; this proves that loss of appetite may exist without fever, or any sensible alteration of the mucous membrane of the stomach. 353. With the exception of a very small ulceration, the mucous membrane of the small intestine was healthy, while the whole of the mesentery was transformed into tuberculous matter. Are we not compelled to admit that this transforma- tion was quite independent of inflammation of the intestinal mucous membrane, as we have already shown (151) ? 354. In some instances the tongue was the seat of an albu- minous exudation, which deserves more attention than mere redness. This exudation was developed towards the close of the disease, four, eight, ten, and even sixty days before death ; it sometimes presented the form of patches from two to three and rapidity of the circulation. Secondly, That in many instances it is no indication either of gastritis or gastro-enteritis. Thirdly, That redness of the tongue frequently accompanies thoracic disease. Fourthly, That the limited appearance of the redness is owing to the unequal distribution of the deposit on its surface; remove this, and it becomes general. Fifthly, That the evaporation of the saliva and the secreted fluids on the surface of the tongue is the principal cause of its dryness. Sixthly, That this dryness is rather depending on the state of the thorax than of the digestive tube. Seventhly, That the deposits on the tongue and teeth in cases of fever, are the result of the desiccation of the saliva, which is itself modified by the state of the sys- tem generally. We refer the reader to M. Louis's work on the Jlffection Typhoïde, (vol. ii. pag« 64, Paris ; Translation, page 55), for additional evidence on this subject. The author's conclusions exactly coincide with those he has ad- vanced in the present volume. — Cowan. 300 SYMPTOMS. — TONGUE ; [Part II, lines in surface, which occasionally by their union completely covered the tongue ; at others, it assumed the form of small ■ points like starch, more or less thickly scattered, and in their intervals the substance of the lung was denuded. The exu- dation was easily removed, was about a quarter of a line thick, and generally re-appeared several times before death. In the majority of instances it was simultaneously present on the tongue, lips, cheeks, gums, and occasionally on the palate. Almost invariably there were pricking sensations in the tongue, heat and redness ; the mucous membrane was, how- ever, in some cases, very pale immediately beneath the exu- dation. 355. The redness, heat, prickings with the albuminous nature of the secretion,* distinctly show an inflammation of the mucous membrane of the tongue. We have, however, just remarked, that it was occasionally pale beneath the patches and in their intervals, and this is difficult to be reconciled with inflammation in an organ so vascular as the tongue. Is it a fact that the albuminous false membranes are not always dependant on inflammatory action, and that they may be re- garded under certain circumstances, as resulting from an alter- ation in secretion not produced by inflammation ? This ques- tion it is very difficult satisfactorily to answer, but after the fact we have stated, the inquiry is natural. The investigation of causes seldom leads us to any useful result, and as the ana- tomical characters of inflammation are frequently obscure, it is, we think, right to note scrupulously every thing that may relate to it. 356. It is, however, quite impossible to doubt, that the ex- * See the Inaugural Dissertation ot M. Blache. Pans, 1824. — Lox7is. Chap. 5.] ALBUMINOUS EXUDATION UPON IT. 301 udation in question is, in the immense majority of cases, the product of inflammation, and it thus forms an additional fact to what we have said on the frequency of inflammation to- wards the close of chronic diseases.* 357. The state of the tongue we have been'describing is not connected with the condition of the gastric mucous membrane any more than simple redness is. We have observed it in one eighth of our cases ; three times when there were softening and diminished thickness of the lining membrane of the stomach ; ' four times when the inflammation was limited to its anterior surface ; three times when it was perfectly healthy ; and twice among the remainder. f * See the Summary of the first part of this work. — I.oiris, t M. Louis has found this exudation equally frequent towards the close of acute as well as of chronic diseases. It has generally been classed among the fatal symptoms, but M. Louis has seen it almost as often in cases which recovered, as under the opposite circumstances. Its indications seem rather those of general weakness, than of any particular termination. — Cowan. 302 SYMPTOMS. GENITAL FUNCTIONS ; [Part II, CHAPTER VI. FUNCTIONS OF THE GENITAL ORGANS. ARTICLE I. GEINERATIVE FUNCTIONS IN MEN. 358. We have frequently interrogated phthisical patients in regard to their desire for sexual intercourse, and in every instance this desire has appeared to have declined with the increase of general weakness and other symptoms, almost ex- actly as is the case with individuals laboring under any other affection. It is, however, possible that at the very commence- ment of the tuberculous affection, when there is little diminu- tion of strength, though sufficient to prevent the patients con- tinuing their usual occupations, that there should be a more evident inclination to sexual pleasures than when in perfect health ; but this is easily accounted for by the effect of idle- ness upon the mind, which is then much more under the influence of every impression. It would indeed be very sin- gular, when all other functions are deteriorated, that the gen- erative should assume unwonted activity ; this is an additional reason for us not to admit so commonly received an opinion, without undeniable proof.* * M. Louis has since continued his investigations on the state of the genital organs in phthisis, and has in no instance discovered any evidence of their increased activity. Vide Examen, page 45. — Cowan. Chap. 6.] SEXUAL DESIRES ; MENSTRUATION. 303 ARTICLE II. GENERATIVE FUNCTIONS IN WOMEN. 359. The catamenia were almost invariably suppressed sooner or later in phthisis. Once only they continued until death, but were irregular, scanty, and during the last three months recurred every ten days. This patient was ill nine months and a half, and during the whole time did not expec- torate ; after death we found numerous excavations in the lungs ; the uterus was small and healthy. In other instances the menses, previous to their total suppression, were more or less irregular, either in quantity, or in their periods of recur- rence ; and, with the exception of diminished volume, the uterus was always perfectly healthy. This fact is again in favor of what we have more than once insisted on (259, 340), that functional derangement does not necessarily suppose any appreciable organic alteration.* * As the uterine functions are usually depeudant more on the general state of the system than on that of the uterus itself, their irregularity in a disease like phthisis must be regarded as an indication of some general con- dition of the constitution, and not of any local disease of the uterus. Men- struation is not a necessary, but an accidental function 3 and when inter- rupted by disease, the organ which discharges it may remain indefinitely free from organic lesions, as is actually the case both before and after the menstrual period. The same mode of reasoning may, we think, be applied to- the skin, which, as the author has remarked, may be the seat of profuse perspirations for an indefinite period, without presenting any appreciable change of structure. The secretions on the surface of the skin are doubtless intimately dependant on the state of the circulation, respiration, temperature, &c., and we think that in many cases they are to be regarded as purely phys- ical efl'ects of simple exudation, either from an engorged state of the capilla- 304 SYMPTOMS. GENITAL FUNCTIONS ; [Part 11, 360. When the duration of phthisis was less than one year, the average period of the catamenial suppression was about the middle of its progress. When the affection was prolonged from one to three years, the suppression occurred during the last third. But, to have a just idea of the value of this symp- tom, it is necessary to state the limits of its variations. Thus, in a young woman in whom the disease lasted three years, the catamenia ceased at the end of the thirteenth month > while another individual of the same age, and in whom the duration of the disease was similar, continued to menstruate to within two months of the fatal termination. When the progress of phthisis was chronic, we could not detect any cause on which the catamenial suppression de- pended ; but when the duration of phthisis was less than twelve months, in the majority of instances the suppression coincided with the invasion of fever ; that is, corresponded to the period when the influence of the principal affection upon the functions of the various organs became more evident and real. ries, diminished tone of the solids, or increased fluidity in the blood. Neither of these examples is, we think, of much weight in favor of the opinion they are intended to support, and ought not to invalidate the generally received opinion, that long continued functional derangement implies organic disease. Let it be recollected that pi-olonf!,ed functional disorder is never confined to a simple increase or decrease of what is natural, but is invariably attended by a change in quality as well as quantity. The latter is necessarily de- pendant on adventitious circumstances, and is often no criterion of the state of the organ itself; the former may occasionally be so, but is much more frequently to be traced to organic alteration. The relation between the secretion of an organ and its organic structur-e, would be an interesting and difficult subject of inquiry. There can be no doubt that important changes in the former may take place when no organic lesions can be detected. — Cowan. Chap. C] PREGNANCY. 305 361. The menstruation having in some instances persisted, with little variation, till within a month before death, we can easily understand how pregnancy can take place, and go through its usual periods in the course of phthisis ; of this we have observed two examples. The most remarkable instance is that of a woman who died when in the last stage of emaciation, after having, twenty days previously, given birth to a robust child. Her lungs pre- sented numerous excavations. 362. We have not been able to decide whether pregnancy is capable of retarding the progress of phthisis; it is indeed evident that numerous facts are required, and several years of observations in a lying-in hospital, before we can have any positive information on the subject. We may, however, ob- serve that perhaps there have been some error and confusion among those who have hitherto admitted such an influence. It is indeed possible, that many of the sym.ptoms of phthisis, may be less prominent during pregnancy, while the progress of the disease is really unaffected. On the other hand, it is not impossible that after labor the progress of phthisis may be more rapid than at any previous period, and this difference before and after confinement, may, to a certain extent, have given rise to the impression. Is it probable, however, that pregnancy, itself a cause of dyspnœa, should procrastinate the duration of phthisis, in which dyspnoea is always a more or less troublesome symptom whenever the patient uses any exertion ? o 2 306 SYMPTOMS. — cerebral; [Part llj CHAPTER VII CEREBRAL SYMPTOMS. 363. In nearly every case the intellectual faculties were undisturbed until death took place. In the instances where we have found partial and pulpy softening of the brain, with traces of inflammation of the lining membrane of the lateral ventricles or the subjacent tissue, the cerebral symptoms short- ly before death were very remarkable. They were absent in three out of six cases, in which there was pulpy softening ; we have observed them in one case of arachnitis, which we shall now detail. TWENTY-FOURTH OBSERVATION. A PORTER, set. 44, was admitted into La Charité, May 6th, 1824. He had been a prisoner in England for fifteen years, four of which were spent in the hulks ; he had coughed and expectorated the last twenty years ; he was attacked with haemoptysis for the first time in January of the present year, but he had been liable to oppression in his breathing for six years, with universal swelling of the whole body during winter, which lasted about six weeks. The appetite had not failed till v/ithin the last month, when he began to make use of Leroy's remedy, (medicine de Leroy ), of which he took two spoons- ful a day. Having used this fifteen days it produced a violent Chap. 7.] ARACHNITIS. 307 diarrhœa, which he was unable to restrain, and for its relief he entered the hospital. Face, with a slight yellow tinge ; no headache ; cough, rare ; very little oppression; expectoration, rather copious, greenish, not striated, slightly frothy ; no pain in the chest, nor had he ever experienced any ; percussion, every where clear, except under the right clavicle and for some distance from above downwards ; tracheal respiration in the same region and pos- teriorly between the shoulders ; pectoriloquy at the right only ; a very coarse râle, diminishing from the summit to the base, was was heard in both lungs ; considerable hoarseness, with altera- tion of the voice the last two months ; no pain in the larynx ; pulse, sixty-four ; heat, natural ; tongue, moist, rather red on the edges ; mouth, clammy ; no appetite ; pain in the epi- gastrium immediately below the xyphoid cartilage, both from pressure and cough ; the remainder of the abdomen, yielding, and not painful ; two liquid stools the previous evening. On the next day considerable diarrhoea ; from eight to ten stools ; the patient spent most of his time near the stove. On the 22d, almost constant drowsiness ; intelligence did not seem much confused, but patient said he had lost his senses ; no complaint of pain. In the night of the 22d, some involuntary stools ; the pa- tient did not reply to questions, but tried to get up, saying he was going home, and in the attempt he fell upon the floor. At seven in the morning the expression was stupid, eyes fixed, pupils contracted ; almost constant spasmodic movements of the masseter muscles, and of those of the right arm ; stiffness of the left arm and leg, with expression of pain whenever the slight- est attempt was made to move them ; the patient was not quite unconscious, since he attempted to protrude the tongue when 308 SYMPTOMS. — CEREBRAL ; [Part II, asked to do so ; pulse, one hundred and fourteen ; no change in the respiration. (Sinapisms). At eight, A. M., he made an effort to speak, and uttered a few unintelHgible words ; the arms and neck were stiff, resist- ing any attempt to move them. The same sym])toms con- tinued during the day ; the breathing became ratthng in the night, and on the next day (24th), at eleven, a. m., he expired. Opening of the corpse twenty-two hours after death. Exterior. — Nothing remarkable. Head. — Lacerations of the dura mater, giving passage to some granulations springing from the arachnoid, covering the brain, which was opaque and thickened in the corresponding points. Two thin bony layers, nine lines large, were embedded in the dura mater lying over the left hemisphere, near the falx. Great distention of the cerebral veins, with sub-arachnoidean infiltration. Brain itself, pale, not injected, of normal consist- ence. The right lateral ventricle contained about two spoonsful and a half of turbid fluid, the left rather less ; the plexus cho- roïdes were rather opaque, and contained vesicles ; there were three spoonsful of clear serosity in the lower occipital fossae. Neck. — Larynx and epiglottis, natural ; lining membrane of the trachea, rather red above the bifurcation, elsewhere of normal color, thickness and consistence. Thorax. — Some cellular adhesions at the summit of the left lung; two linear osseous concretions in the upper lobe; slight engorgement at the centre of both lobes. Dense ad- hesions over the upper part of the right lung, by means of a false, semi-cartilaginous membrane, more or less thick. The summit was occupied by a rather large excavation ; lower down there was a very small anfractuous cavity, where numer- Chap. 7.] ARACHNITIS. 309 ous semi-cartilaginous lines terminated, of a bluish color, en- closing a greyish-blackish matter, formed by the combination of the melanotic and grey, semi-transparent substance ; this cavity was red, like the bronchia that opened into it. The remainder of the upper lobe was indurated and transformed into a grey substance, interspersed with minute tuberculous excavations. Some granulations of the same nature existed in the lower lobe, which was partially engorged, and presented at its superior portion a pretty large excavation, lined by a false membrane, and containing a thin, red fluid. The bronchia communicating with the cavities were more or less red and thickened ; the others were thin, and of a light pink color. The heart was rounded at the apex, rather larger than usual, on account of the increased size of the left ventricle, the pa- rietes of which were six lines thick ; aorta, healthy. Abdomen. — Stomach, of ordinary dimensions; its lining membrane, of a bluish grey color, except in the small curva- ture, where for about one inch and a lialf, it was of a pale pink tint ; thickness and consistence every where natural, ex- cept a very limited portion in the great curvature, which was softened and easily torn ; there was over its whole sui-face a layer of thick, tenacious mucus. The mucous membrane of the small intestine was sprinkled with numerous black, minute points ; in other respects healthy. That of the large intestine was soft as mucus, pale in the upper half, a little red in the lower, without ulcerations, and in contact with a turbid, grey- ish-pink substance. The mesentery and other viscera of the abdomen were healthy. 364. Although in our description of the lateral ventricles, we have neglected to describe the state of the lining mem- brane, yet the nature of the contents seems to me sufficiently 310 SYMPTOMS. — cerebral; [Part II, to justify the idea that it was inflamed ; the fever also and the cerebral symptoms can scarcely be referred to any other lesion. The latter were in fact those of arachnitis ; and we ought to remark that the weakness of the patient seemed to be no obstacle to their development. It is true that a very important symptom, viz., headache, was absent ; (at least the patient never complained of pain in his head) ; but this might be owing to the rapid progress of the disease, which was fatal in forty-eight hours ; its different periods were confounded together, and delirium with slight drowsiness, were the first indications of its existence. We have already seen that the progress of inflammations occurring towards the close of chronic diseases, or when debility is far advanced, is rapid ; and of this the present observation furnishes an additional proof. It is also remarkable that the alteration of the arach- noid was limited to the portion of this membrane lining the lateral ventricles, which, in the opinion of those authors who have most successfully studied this disease (Messrs. Parent and Martinet), is extremely rare.* 365. As to the origin of the tuberculous affection of the lungs, it was probably coincident with that of the cough ; but of this we cannot be positive. What appears certain is, that the progress of the disease was extremely slow. This is prov- ed both by the mildness of the symptoms and the undimin- ished strength, until the appetite began to fail. 366. The following observation is an example of partial softening of the brain, with inflammation of a small portion of the sub-arachnoidean tissue. * Andral. in his Clin. Med., vol. iv. page 65, relates five cases of this de- scription, only three of which are distinctly inflammatory. Out of eighty- nine cases of arachnitis (vide pages 201, 203), in eleven the a/Iëclion vs^as confined to the ventricles. — Cowan. Chap. 7.] SOFTENING or THE BRAIN ; SUB-ARACHNITIS. 311 TWENTY-FIFTH OBSERVATION. A butcher's man, set. 38, short, but stoutly made, with black hair, and brown skin, and of a strong constitution, had been ill eight months when he entered the hospital of La Charité, September Ist, 1822. Usually in good health, he had not been liable to cold or sore throat ; he attributed his present illness to a violent blow he had received on his chest shortly before the appearance of the first symptoms. At the com- mencement there was cough, with somewhat copious expec- toration, and alternation of heat and cold ; these symptoms continued, but after two months the rigors almost ceased ; he had only perspired the last fifteen days. The cough was gen- erally violent, and the voice had been affected after the second month. At this period also he was attacked with a pretty copious haemoptysis ; this was afterwards renewed, but small in quantity, and at distant intervals. The appetite gradually diminished, and for the last three days the stools had been liquid, which he attributed to having eaten a large quantity of grapes. His strength failed, and for three months he had ceased his usual occupations, though he had never been con- fined to his bed. September 2d. No headache ; cough, not frequent ; sputa, greenish, opaque, most of them floating in a clear fluid ; voice, rough ; percussion of the chest, clear on both sides ; a crepitating râle with obscure respiration under the right clavicle, without pectoriloquy. Pulse, calm ; heat, natural ; tongue, clean ; little appetite ; deglutition, easy ; stools, liquid, not numerous. No pain either in the throat, larynx or abdomen. 312 ssMPTOMs. — CEREBRAL ; [Part 11, (Rice water ; gum potion ; a quarter of the house allow- ance). But little change occurred on the following days. 28th. Still no headach or pains in the limbs ; percussion under right clavicle dull, whh very obscure respiration, and more copious crepitation than before. Considerable resonance of the voice in the corresponding point posteriorly ; the anorexia and loose- ness had increased ; there was a bad taste in the mouth, and pain in the epigastrium ; this pain had lasted three days, and on the previous evening the patient had vomited a little bile. He complained of a twisting sensation in the hypogastrium, and the abdomen was tympanitic. (Rice water sweetened with quince syrup ; diascordium ; gum potion; five cups of soup). From this moment the debility rapidly increased, and the patient no longer left his bed ; he often complained to his companions of constant headache, and frequently supported his head with his hands. In the night of the 9th of October, there were alternations of stupor and delirium ; persistence of the same symptoms the next day and following night. On the 11th, at the hour of visit, he did not answer, or re- plied very indistinctly to questions ; his eyes were usually fixed, and at moments there was a smile on his lips ; the res- piration was slightly accelerated ; pulse, calm, at sixty-six. The delirium continued, and the increased agitation compelled the use of a straight waistcoat. The next day, his expression was nearly natural ; intelligence had returned, and he went alone, without falling or stumbling, to the night-stool. During the night, constant delirium but no agitation. 13th. The same state ; heat, elevated ; pulse, frequent. The patient did not speak. 14th. He again rose to go to the night-stool, but at the visit he appeared quite Chap. 7.] SOFTENING OF THE BRAIN ; SUB-ARACHNITIS. 313 exhausted, though in answer to questions he said he was quite well. During the day he showed by signs that he understood what was said to him but was unable to speak. 15tli. Expres- sion rather animated; eyes, half closed ; lay with the knees elevated ; made us understand that he did not suffer pain. 16th. Retained the [same position in bed as he had the pre- ceding evening; he seemed perfectly conscious, followed our movements with his eyes, and at nine, a. m., expired. O'pening of the corpse iwenty-tivo hours after death. Exterior. — Extreme emaciation. Head, — Dura mater as if lacerated, giving passage to the arachnoidean granulations ; marked distention of the superior veins on the right side ; very little on the left. Three spoons- ful of serum in the left lateral ventricle, much less in the right ; septum lucidum softened, pulpy, of natural color. Similar state of the posterior crura of the fornix ; corpus cal- losum less consistent than the other portions of the brain, but it was by no means so soft as the septum. The rest of the encephalon was firmer than usual, and very slightly injected. Between the arachnoid and pia mater, anterior to and at the sides of the optic nerves, there was a layer of concrete pus, about three lines thick and an inch wide. Neck. — A superficial ulceration on the inferior surface of the epiglottis ; larynx, natural ; two inches lower down, and on the fleshy potion of the trachea, there was an ulceration about the size of a half dollar, with thickening of the corres- ponding submucous tissue ; in other respects the mucous mem- brane was healthy. Thorax. — Weak cellular adhesions over the summit of the left lung, which presented a moderate quantity of tuber- p 2 314 SYMPTOMS. — cerebral; [Part II, cles, and of grey, semi-transparent granulations, diminishing in size and number from above downwards ; its lower lobe was firm, granulated, of a variable red color, and everywhere hep- atized. The right lung adhered to the costal pleura through- out, and very firmly at Its apex ; it offered in its upper lobe a vast tuberculous excavation communicating with the bronchia and with other smaller cavities ; all of these contained a great quantity of sanious matter ; they were lined by two false mem- branes, one of which was soft and yellowish, the other very firm, greyish, semi-cartilaginous, lying either on the healthy lung, the grey, semi-transparent matter or tubercles. In the re- mainder of the same lobe there were numerous softened tuber- cles, or some more or less excavated ; its lower lobe was of a deep red color and carnified. Heart and aorta, natural. Abdomen. — Stomach, rather contracted ; its lining mem- brane covered with a good deal of mucus ; it was pale, with a punctated injection in the great cul-de-sac ; its consistence and thickness were rather less than natural. There were a few small ulcerations, and four submucous abscesses, about the size of a pea, in the lower six feet of the small intestine; in other respects the mucous membrane was healthy. That of the caecum and colon was much softened, with some small ulcerations in the right colon. Mesenteric glands, increased in volume with no other alteration. The remaining viscera were healthy. 367. The softened state of the septum lucidum and fornix, with the inflammation of the sub-arachnoidean tissue between the optic nerves, renders the analysis of the cerebral symp- toms difficult and necessarily throws doubt upon any classifica- tion we may make. We may, however, remark, that there were neither pains, rigidity, nor paralysis of the limbs, and, con- Chap. 7.] SOFTENING OF THE BRAIN; SUB-ARACHNITIS. 315 sequently, but very incomplete indications of softening. The headache and agitation may be equally referred to the one alter- ation as to the other, so that it is impossible to decide whether they were owing to these two species of lesions, or to one of them only. The general characters of the symptoms, how- ever, were rather those of meningitis than those of partial softening of the brain. Without insisting farther on this subject, which is not im- portant for our immediate purpose, let us observe that there was hepatization of the left lung, and that its inflammation, as is so frequently the case when complicated with a cerebral affection, gave rise to no symptom ; that the ulcerations of the trachea and epiglottis were also latent ; and what is still less frequently the case, that there had been hoarseness v/ith alter- ation of the voice for more than six months, while the state of the larynx was healthy. 368. We shall conclude this chapter with a rapid summary of an observation already published,* which is an example of partial softening of the brain unaccompanied by any other alteration. TWENTY-SIXTH OBSERVATION. A WATCHMAKER, ffit. 19, of dclicate health and very nerv- ous temperament, entered the hospital of La Charité, Oc- tober 29th, 1823. He had coughed and expectorated the * Mémoire sur le Ramollissement avec Amincissement de la Membrane Muqueuse de V Estomac. Vide Mémoires sur diverses maladies, page 31. — Louis. 316 SYMPTOMS. CEREBRAL J [Part 11, last four months, was extremely emaciated, and presented all the symptoms of phthisis ; he complained of a dull headache, with, pains in the limbs and loins, vigilium, and extreme de- bility. His intellect, naturally good, was unaffected, and his expression was without any peculiarity save the emaciation. Nothing remarkable occurred on the two following days, but on the 2d of November there was a great general prostration of strength ; he did not reply to questions, although he indi- cated by signs that he comprehended them. He could not support himself in the upright posture. Tiie same night there were delirium and constant talking. 3d. At ten, a. m., his eyes were fixed ; expression, dull ; limbs, on both sides very feeble, almost incapable of any movement ; he understood when spoken to, but replied with the greatest difficulty and unwillingness, so that it was only after repeated questions that he said that he had a pain in his head. During the day the state of the stupor was complete, without convulsive move- ments. On the next day, 4th, spasmodic contractions of the limbs, principally those of the right side ; pupils, dilated, especially that of the left eye ; head, turned to the left ; total loss of consciousness with an expression of vacancy. The pulse, which was ninety-four in the evening, was now one hundred and fourteen ; frequent moaning during respiration. These symptoms continued until the evening, when he expired at eight o'clock. Opening of the corpse thirty-six hours after death. Head. — Lacerations of the dura mater traversed by gran- ulations attached to the arachnoid, which was thickened and opaque in the corresponding points. Cerebral veins, rather distended, with some injection of the pia mater; the right hemisphere, firm and with numerous red points ; the left, Chap. 7.] SOFTENING OF THE BRAIN ; SUB-ARACHNITIS. 317 less injected, rather soft ; septum lucidum, of a pulpy consist- ence ; a similar state of the fornix, particularly of the left pillar, without any change of color ; two spoonsful of serous fluid in the left ventricle, rather less in the right ; in the former the lining membrane was thickened. Two spoonsful of serous fluid also in the inferior occipital fossœ. Thorax. — Some tubei'culous excavations in the summit of the left lung, the anterior part of which, for the space of two inches, almost wholly consisted of tubercles and the grey, semi-transparent matter. Abdomen. — Mucous membrane of the stomach, softened and thinned over a considerable extent. Some ulcerations in the small intestine. Very considerable softening of the mu- cous membrane of the colon. 369. The softening of the septum lucidum and fornix were very similar to what existed in the preceding observation ; the effusion into the ventricles coincided in its quantity with the difference in the degree of softening existing on one side and the other, which makes us consider it as an effect, and not a complication. Besides, the symptoms were here very dis- tinct, viz., headache, delirium, pain, spasmodic contraction of the limbs, and lastly, dilated pupils. We were unable to de- cide whether there was any paralysis of the extremities, but it is very probable that there was some, and that It came on soon after that of the retina, which was marked by the dilata- tion of the pupils. The extreme debihty of the patient when the affection commenced, and its subsequent rapid progress with the intense nature of the symptoms, are all very remark- able. 370. We have elsewhere detailed (Obs. 15), the history of a partial softening of the cerebral substance, preceded by the 318 SYMPTOMS. LATENT PHTHISIS, IST KIND ; [Part II, inflammation of the sub-arachnoidean tissue on the upper por- tion of the brain, and which had come on thirty days before death. Although not intense, the symptoms corresponding to both of these lesions were very distinct. 371. We would remark, in terminating this division of our subject, that we have observed partial softening of the brain quite as frequently after other chronic affections ; that we have never seen apoplexy come on at the close of diseases of long duration ; that this fact makes an additional distinction be- tween softening of the brain and apoplexy ; and it points out a fresh analogy between haemorrhage of the brain and that of other organs, which so seldom occurs, in any of them, when the debility is extreme. CHAPTER VIII. OF THE VARIETIES WHICH PHTHISIS PRESENTS IN ITS PROGRESS. 372. In the general description of phthisis, we have seen that its first symptoms are cough, expectoration, dyspnoea, and sometimes haemoptysis ; that sputa do not always com- mence with the cough ; that the dyspnoea is equally irregu- lar as to the time of its appearance ; this is also true in regard to the fever and the succeeding symptoms. These slight differences, however, in the order and duration of the morbid phenomena, do not interfere with the regular progress of the disease ; they do not, if we may so express ourselves, alter its physiognomy ; but there are instances where its characters are so completely modified that its recognition is impossible before Chag. 8.] MAY BE SUSPECTED TO EXIST. 319 its progress is considerable ; it is, in fact, latent^ for a longer or shorter period. At other tinnes it assumes the form and pro- gress of acute diseases ; its different periods seem confounded together, and the diagnosis is not less obscure than in the previous case. We shall successively study these two varie- ties of phthisis, adducing facts to establish their existence. . ARTICLE 1, LATENT PHTHISIS. TWENTY-SEVENTH OBSERVATION. 373. A WOMAN, aet. 32, with active intelligence and good memory, of middle stature and pretty strong constitution, was admitted into the hospital of La Charité, November 9th, 1822. She was not liable to colds, had been ill three years, but considerably worse the last two months and a half. Her illness had commenced with rigors, followed by heat and per- spiration, and until the last three months they had been re- peated daily at about one o'clock. The appetite had dimin- ished from the beginning ; the thirst had become urgent, and there was slight emaciation. No other symptoms were ob- served during the first year. At the commencement of the second she began to cough and expectorate clear sputa, which during the last three months have become opaque and num- raulated. She had kept her bed nine weeks, and had had slight diarrhœa the last four, before entering the hospital. November 10th. Mind and senses, perfect; extreme ema- * Some speculative objections have been made to the use of the term latent, when applied to plithisis. It is evident that our author employs it merely to indicate the obscurity of the symptoms. — Cowaw. 320 SYMPTOMS. LATENT PHTHISIS, 1 ST KIND ; [Part II, elation ; breathing, rather accelerated ; cough, not frequent ; sputa, nummulated, of a dirty pink color, and soon losing their shape. Percussion, dull under the clavicles, particularly under the left, and over a considerable space ; tracheal respi- ration and evident pectoriloquy in the same points ; this was also the case in the corresponding parts posteriorly. Pulse, small, weak, regular, frequent ; heat, natural during the day, elevated at night ; perspirations confined to the head and chest ; tongue, natural ; mouth, clammy ; thirst, not urgent ; no appetite ; deglutition, difficult ; she had experienced a sense of heat and dryness of the throat the last two months ; abdomen, a little sensible to pressure ; the previous evening three mucous stools. Great debility. (Decoction of rice with quince syrup ; three cups of in- fusion of catechu with the same syrup ; gum potion ; two rice creams.) No evident change took place on the following days, and on the 18th of the same month, after an agony of some hours, she expired. Opening of the corpse forty-eight hours after death. Exterior. — Nothing remarkable. Head. — Arachnoid, thickened and rather opaque for about two inches near the longitudinal fissure, with partial adhesions to the dura mater ; some slight sub-arachnoidean infiltration ; two small spoonsful of fluid in each lateral ventricle ; that in the right was turbid. Neck. — The epiglottis, larynx and trachea were not ex- amined. Thorax. — Strong cellular adhesions over the summit of the right lung ; the left, perfectly free. In both lungs the upper lobe was very easily broken, and presented numerous Chap. 8.] MAT BE SUSPECTED TO EXIST. 321 small excavations, communicating with each other, and lined by a false membrane ; their intervals consisted of grey, semi- transparent granulations, and small portions of hepatized lung. The lower lobes were healthy. Heart, of natural volume ; sides of the left ventricle, rather thin, those of the right, evi- dently thickened ; both were of tolerable consistence ; the aorta was of a rose tint here and there, without other alter- ation. Abdomen. —■ Stomach, of natural volume ; lining mem- brane, pale, without lividity, and of normal thickness and consistence ; duodenum, healthy. In the lower half of the small intestine there were some granulations of a tuberculous nature ; many of them vœre slightly ulcerated ; over others, which were not softened, the mucous membrane was healthy. That of the large intestine was a little softened near the cae- cum, where it presented ten small ulcerations, from one to two lines in diameter, without tubercles ; no other altera- tion. The mesentery and other viscera of the abdomen were healthy. 374. The history of this disease presents tv^70 very distinct periods. In the first, there was febrile movement, without cough ; in the second, the fever was accompanied with cough and expectoration. Was phthisis present in the first, or did it originate only in the second ? If the examination after death had revealed a chronic and serious alteration of some organ besides the lung, we might attribute to it the symptoms of the first period ; but the lungs were here the only organs seriously affected, and we must, consequently, refer the symptoms of both periods to them, more especially as the character of the febrile movement was identical in both ; and since the fever B 2 322 SYMPTOMS. LATENT PHTHISIS, IST KIND; [Part II, was not preceded by bronchitis, the present observation will allow us to draw the double conclusion, that tubercles may be developed in the lungs independently of bronchitis, and that they may remain latent for a considerable period, that is, with- out exciting either cough or expectoration. 375. Another fact also increases the interest of this obser- vation, we refer to the gradual diminution of appetite during three years, although the gastric mucous membrane presented no perceptible alteration. This is a striking illustration of the fact to which we have frequently alluded, that a lesion of a function may be prolonged during a considerable time, without the presence of any appreciable organic change ; that loss of appetite is not enough to characterise gastritis ; that fever, and by this we mean a quick pulse, ^increased heat, &c., is of itself, vi'hatever may be its cause, capable of producing the same result. Lastly, this observation is one of those very rare instances in which the development of tubercles is confined to the supe- rior pulmonary lobes. TWENTY-EIGHTH OBSERVATION. 376. A BELLOWS mender, ast. 44, born of parents who lived to an advanced age, of a moderately strong constitution, with a fair skin, black hair, and usually enjoying good health, was admitted into the hospital of La Charité, March 24th, 1824. His appetite was never very great ; his habits were very temperate, and he said that he had been ill the last nine Chap. 8.] MAY BE SUSPECTED TO EXIST. 323 months. At the commencement he was seized with rigors, followed by heat and perspiration, thirst, anorexia, &£c. ; dur- ing the first fortnight the fever confined him to his bed, after which it diminished, though it never was completely absent, as he was always liable to increased heat and occasional rigors ; the thirst abated ; the appetite improved, though it was never quite restored ; he engaged again in his business, and contin- ued in a doubtful state of health for four months, during which time there was no cough. After this period, the fever con- tinued, the rigors returned daily, general weakness increased, and he was obliged to relinquish his occupation, and lie a con- siderable part of the day on his bed. In the last six weeks the anorexia was complete, and shortly afterwards it was ac- companied with a slight cough, so that when the patient en- tered this had been present about a month only. Our inquiries were particularly directed to the accuracy of this fact, and the patient invariably persisted in declaring that he never had any cough previous to this period. For some months he had been subject to hoarseness and oppression, had rapidly lost his flesh, experienced occasional pains between the shoulders, and during the last three years had been attacked with ten copious haemoptyses, one of which occurred only a few days previous to his entering the hospital. March 25th. Expression, natural; sleep, much interrupted by cough ; sputa, yellow, greenish, not nummulated, but con- tained in a limpid, copious fluid ; percussion of the thorax, clear ; a crepitating râle over nearly all the chest, decreasing in force fiom above downwards; tracheal respiration, with distinct pectoriloquy between the shoulders ; and on the right side, when the patient spoke, there was a specious of metallic tinkling ; pulse regular, very slightly accelerated, weak ; tongue, moist and clean, pale on the edges, spotted with red in the 324 SYMPTOMS. — LATENT PHTHISIS ; 1 ST KIND; [Part U, centre ; mouth, clammy ; thirst, moderate ; very little appe- tite ; breath, faetid ; constipation the last two days ; abdomen, every where yielding and free from pain. April 1st. State of the patient, nearly the same ; he com- plained of constipation and extreme weakness ; the metallic tinkling, more evident than before ; anteriorly on the right side there was a crepitating râle mingled with a gurgling sound ; percussion, dull under the left clavicle ; sense of op- pression in the epigastrium. 2d. Uneasiness and anxiety, with increased dyspnœa. These symptoms gradually in- creased, and the patient expired the following morning, at five o'clock. Opening of the corpse twenty-seven hours after death. Exterior. — Nothing worth noting. Head. — Rather considerable sub-arachnoidean infiltration; some granulations near the longitudinal fissure, adhering to the dura mater ; pia mater, slightly injected ; brain, firm and healthy ; two spoonsful of serum in the lateral ventricles. Neck. — Epiglottis, larynx and trachea, natural. Chest. — Lungs, every where adherent to the costal pleu- ra ; superiorly the adhesions consisted of a very dense false membrane, a line thick, and lower down, of cellular prolonga- tions. The summit of the left lung presented a vast, rugged excavation, traversed by bands, and lined by a false, semi- cartilaginous membrane, lying upon more or less serious- ly diseased lung. The upper lobe was indurated, of a greyish color over two thirds of its extent, from its anterior edge ; it had a granulated appearance internally ; it was, in fact, hepatized and easily broken down ; it contained numer- ous tubercles and some grey, semi-transparent matter; the Chap. 8.] MAY BE SUSPECTED TO EXIST. 325 lower lobe was rather red, with pretty numerous tubercles and granulations. A similar excavation existed at the summit of the right lung, but still larger ; the remainder of the upper lobe consisted of tubercles and grey granulations. The bronchia communicating with the two large cavities were very red and much thickened ; the others were thin and of a pale pink color. Heart and aorta, natural. Abdomen. — Stomach, of moderate volume, containing a good deal of thick and tenacious mucus. The lining mem- brane was rather red round the cardiac orifice, greyish along the large curvature, white in other parts ; it was a little softened in the great cul-de-sac, of normal consistence and thickness elsewhere. That of the small intestine presented some varia- bly red spots, and in the lower half five small ulcerations, many of which contained tuberculous granulations in their centres. There were three large ulcerations in the caecum ; the mucous membrane of the colon was here and there of a light red, without any other alteration ; the fœces were of a bright yellow color, of normal form and consistence. Mesen- teric glands, rather voluminous, of natural color and firmness. Liver, pale ; bile in the gall-bladder, dark colored and thick, like treacle. The other abdominal viscera were healthy. 377. Between this and the foregoing observation there is an almost complete analogy both as regards the simplicity of the disease and the progress of the symptoms. The febrile move- ment preceded the cough, which indeed only existed the last six weeks, and after death the lungs were the only organs in which a serious and chronic lesion was present. We cannot, therefore, attribute the previous febrile movement either to the cough, or to the morbid condition of any other viscus, and we are forced to the conclusion that tubercles existed Ions: an- 326 SYMPTOMS. LATENT PHTHISIS, 1 ST KIND ; [Part II, terior to the cough, and were not dependant on bronchitis. This induction is still more natural and necessary in this last observation than in the preceding, for in this the cough only dated six weeks, while the tuberculous excavations were very large, and we have already seen (19), and shall again verify the fact farther on, when speaking of acute phthisis, that sim- ilar excavations are not produced in six weeks, or in two months, that they necessarily suppose the duration of the dis- ease to have been from four to five months. 378. In both cases it is clear that tubercles existed in the lungs during a longer or shorter space of time, without deter- mining cough ; that they gave rise, while in this latent state, to febrile symptoms more or less intense, to anorexia, emacia- tion, and more or less complete loss of strength. In cases where these are the only symptoms, are we able to decide upon their cause ? This was not impossible in the case before us ; for two years before the invasion of the febrile symptoms, the patient had had several hœmoptyses, and we have said (233), that this fact, if not certain, is at least an infinitely probable indication of pulmonary tubercles. Supposing for a moment that we had seen the patient soon after the com- mencement of the fever, we ought then, by means of the pre- vious history, to have suspected the existence of tubercles in the lungs, and perhaps at this period auscultation would have removed every doubt. We ought, therefore, never to neglect this method of investigation, whenever febrile symptoms are present without any evident cause, more especially if these have been preceded by one or more hœmoptyses.* * I cannot forbear attempting to impress upon the mind of the reader the importance of this paragrapli, though I have no recorded facts to support it. But I remember perfectly the case of a female who entered Louis's wards Chap. 8.] MAY BE SUSPECTED TO EXIST. 327 379. Among the stcondaiy phenomena meriting attention, we may recall the metallic tinkling, which, according to Laen- nec, announces a vast excavation partly filled with air and fluid, which was the case in the instance before us. We ought also to remember the state of the gastric mucous membrane, which was almost perfectly healthy, although the digestive functions had been deranged for a long time. However, the absence of nausea and vomiting did not lead us to expect any serious alteration. Lastly, the bronchia were healthy with the exception of those communicating with the excavations, proving, as we have already remarked (36), that the thickening and altera- tion of their mucous membrane, result from the constant action of the contents of the excavations. TWENTY-NINTH OBSERVATION. 380. A SEMPSTRESS, Bst. 22, born of healthy parents, not liable to cold, usually in good health, and with considerable embonpoint, was admitted into the hospital of La Charité September 9th, 1824. She had been subject to shortness of breath from her infancy, and her present illness had com- menced two years and a half before her entrance into the hos- pital. During the first seven months she had constant fever, with intense febrile excitement and some dyspnœa. The case was a very difficult one, and very rigid examinations were made in order to discover some local disease. The respiration was indistinct, but presented nothing peculiar at first. After a time an expiration came on, first in one lung and afterwards in the other, but before this commenced, the fever made one of us (Jackson) decide that it was a case of acute phthisis. — H. I. B. 328 SYMPTOMS. — LATENT PHTHISIS, Istkind; [Part II, with daily paroxysms of cold and heat at four, p. m. These gradually ceased without any treatment having been tried. While they continued, the patient was confined to her bed, ate very little, having almost completely lost her appetite from the commencement ; the emaciation was rapid. She afterwards partially recovered her strength and flesh ; her usual dyspnœa considerably increased, and during the three months which preceded her entrance into the hospital, that is, from the moment she began to cough and expectorate, it be- came extreme. Previously to this period she had neither coughed nor expectorated, and on this point, the patient, whose intelligence was developed and memory good, never varied her statement. The appetite was always much dimin- ished, almost absent. The diarrhœa, constant, sometimes copious during the last eight months, and accompanied with colic pains. The debility daily augmented, and for five months before we saw her, she had been confined to her bed. The rigors, followed by heat and perspiration, had re-appeared the last five weeks ; there had been no hagmoptysis. September 10th. Face, pale ; extreme weakness ; intel- lectual faculties, perfect ; great emaciation ; considerable dys- pnœa ; speaks hurriedly ; cough, principally violent in the morning ; expectoration, greenish, scanty, semi-opaque. Tra- cheal respiration with distinct pectoriloquy and dulness of sound to an extent of five inches under the left clavicle ; the same symptoms posteriorly in the corresponding point ; on the right the respiration seemed natural ; pulse, weak and accel- erated ; heat, rather elevated ; tongue, rather pale ; very little appetite; the liver extended three inches below the ribs; no pains in the epigastrium ; three stools with colic the last twenty-four hours. Chap. 8.] MAY BE SUSPECTED TO EXIST. 329 (White decoction ; solution of gum syrup ; julep ; rice and an egg for food). 12th. She complained for the first time of pains in the up- per part of the larynx. 18th. Continuation of the pains, which were only felt on attempting to swallow ; appetite, rather improved ; coughs little ; no rigors. 20th. Increased cough and dyspnoea, with frequent stools and copious perspi- rations. (Gum potion with a grain of opium). The diarrhœa rapidly diminished ; the cough was occasion- ally violent ; some nausea and even vomitings of a clear fluid mingled with mucus ; total loss of appetite ; no alteration of voice. 30th. The pains in the neck had ceased ; she complained of headache and general lassitude: the tongue, lips, and in- terior of the cheeks, were covered by a large number of white thin patches, beneath which the mucous membrane was rather redder than natural ; she experienced no pricking sensations in the tongue, and the membranous patches disappeared the next day. The deglutition became very difficult ; the expectoration ceased ; the pulse fell to ninety the last two days, and on the 4th of October, at ten, a. m., she expired, having preserved her consciousness, and having experienced much mental anxiety at the idea of dying. Opening of the corpse tioenty-iwo hours after death. Exterior. — Nothing remarkable. Head. — Four small spoonsful of fluid on the upper por- tion of the arachnoid ; slight sub-arachnoidean infiltration • some injection of the pia mater ; cortical substance, of a pink color; the medullary presented few red points. A spoonful s 2 330 SYMPTOMS. • — LATENT PHTHISIS, IST KIND ; [Part II, of clear fluid in each lateral ventricle; two more in the in- ferior occipital fossae. Neck. — Mucous membrane of the pharynx, pale, thick- ened, and on it there were numerous small ulcerations, from one to two lines in diameter ; that of the epiglottis was de- stroyed over half of its lower surface. Nothing worth noting in the larynx and trachea. Thoeax. — The left lung adhered intimately to the costal pleura; the upper lobe was invested by a false semi-cartilagi- nous membrane, from a line to a line and half thick, which was continuous anteriorly and internally with another less thick, which partially covered the upper lobe on the right side. In the summit of the left lung there was a vast excavation with very thin parietes anteriorly, bounded inferiorly by a thin rugged septum, dividing it from another cavity seated in the posterior edge of the lower lobe. The remainder of the upper lobe was transformed into a greyish matter, opaque, not granulated, and which was traversed by a great number of white firm bands, which seemed at first view continuous with the semi- cartilaginous covering which has been described. In the midst of these there was rather a large number of small tuberculous cavities. The cavity of the lower lobe was of moderate size, it contained a thick liquid of a livid red color, and it was trav- ersed as was that of the upper lobe, by a great number of bands of grey semi-transparent matter. In the remainder of the lower lobe there were considerable masses of grey semi-transparent matter, interspered with the numerous whitish yellow granulations. The intervening tissue was healthy. At the summit of the right lung there were some small exca- vations, and every where numerous granulations or masses of grey, semi-transparent matter, similar to those in the left lung; many among them were an inch wide by three inches long, Chap. 8.] MAY BE SUSPECTED TO EXIST. 331 and were spotted with white, opaque, miliary points ; two-fifths of the lung were permeable to the air. Bronchia, rather red and slightly thickened near the excavations ; elsewhere they were healthy. Having injected the pulmonary artery, we found ramifications in the healthy parts, very few, and only in some of the grey, semi-transparent masses. There were none in the grey, opaque substance occupying the upper lobe of the left lung, which substance, to all appearance, was the result of chronic inflammation (16). Several of the bands traversing the excavations were supplied by some very small arterial ramifications. Heart, small ; parietes, thin, but firm ; aorta, healthy, narrow. Abdomen. — Stomach, elongated, nearly covered by the liver ; its mucous membrane was of a bright red, rather soft- ened anteriorly, normal every where else. Some minute ulcerations in the lower sixth of the small intestine, and in their intervals numerous white, opaque, semi-cartilaginous granulations, increasing in size and number towards the caecum ; in the rest of its extent the mucous membrane was healthy, with the exception of some red spots. Eight irreg- ular ulcerations, from an inch to an inch and a half in surface, in the caecum, ascending and transverse colon. The corres- ponding mucous membrane was destroyed, and the cellu- lar layer rough and thickened. In the intermediate spaces and in the remainder of its extent, tlie mucous membrane was a little softened, of twice its usual thickness, and in some points of a violet color. Mesenteric glands, small and healthy. The liver descended an inch and a half below the ribs, was of a tawny color spotted with red, with numerous pale points ; it was not distinctly adipous. The bile of the gall-bladder, dark colored, and of the consistence of treacle. Spleen, rather voluminous and softened ; the other viscera, healthy. 332 SYMPTOMS. LATENT PHTHISIS, ISTKIND. [Part II, 381. Our reflections on the previous observations are equally applicable to this last. When we first saw the pa- tient the cough had only been present two months, and al- ready large excavations existed in the left lung. It had, therefore, been preceded by tubercles, which cannot, at least in this instance, be considered a result of bronchitis. The condition of the gastric naucous membrane indicated a recent alteration ; the intestinal ulcerations were dependant upon, and consecutive to phthisis. It is then to the lungs alone that we can attribute the intense febrile phenomena experi- enced by the patient during the first six months of her pro- tracted illness ; for no one, doubtless, will believe the fever to have been a simple ague, which does not diminish the strength and appetite, so as to force the patient to remain in bed. Some, however, may still consider our conclusions precipi- tate; but let them remember that this patient was very intelli- gent, her memory good, that she was questioned with the greatest care, that all the organs were carefully examined after death ; and they will 1 think admit, that if the facts are rigorously correct, our conclusions are legitimate. While we ought always to avoid deducing consequences from doubtful facts, let no such hesitation exist about those which are well ascertained, especially when no complications are present to render their interpretation difficult. 382. We have said that the redness, combined with slight softening of the membrane lining the anterior surface of the stomach, was a recent alteration } and our opinion is confirmed by the inconsiderable epigastric pains and nausea which came on after the entrance of the patient into the hospital ; so that in this instance, as in the first two observations of this chapter, the previous anorexia, experienced by the patient some time before death, was not dependant on any appreciable alteration Chap. 8.] 2d ; impossible to recognise it early. 333 of the mucous membrane, but on the general phenomena, perhaps the febrile affection, by which the stomach is influ- enced in common with other organs. Relatively to the distribution of the pulmonary artery, we refer the reader to what we have said in the first part of this work (11), and shall merely observe, that the left lung was almost wholly converted into excavations, and the grey and opaque, or semi-transparent substance ; that on the right side there were barely two fifths of the lung permeable to the air, and that the respiratory function was almost entirely confined to this diminished surface. 383. The following observation is another example of latent phthisis, the progress of which was so chronic and obscure that it was not recognised durino; life. THIRTIETH OBSERVATION. A WOMAN, set. 31, of a delicate constitution, great sensibility, and subject to shortness of breath from her infancy, complained of being liable to frequent indispositions for several years past. She said she was not subject to cold ; but, in referring to the first symptoms of deranged health, we discovered that for seven years she had expectorated a little every morning, and that during the first eighteen months of this period she had had a constant cough. This was never inconvenient, and ceased spontane- ously after a long voyage and a residence of three months on the sea side, although her habits of life were not different from what they had been previously. She did not recollect to have since taken cold, but the cough was excited momentarily by fog- gy weather and strong scents. During the last three years her 334 SYMPTOMS. LATENT PHTHISIS, 2d KIND; [Part II, usual dyspnœa had ratlier increased. At the commencement of this period her digestion became languid, and now and then she suffered from a sense of weight and prickings in the right hypochondrium ; the skin assumed a yellowish tint, and an or- ganic affection of the liver was supposed to exist; for four or five months she was treated by calomel and purgatives ; her diet was much restricted, although her appetite was but slightly di- minished. This treatment did not relieve her. Afterwards the digestive functions became more deranged ; the appetite de- creased, and the catamenia were suspended at diflerent intervals for three or four months, and had been wholly suppressed for the seven months preceding her admission into La Charité, January 2d, J 823. She had been subject to sore throats and palpitations ; the thirst was occasionally urgent the last three years ; she had never had hcemoptysis. January 2d. Yellowish tinge over the whole surface ; con- junctivas, natural ; brownish spots on face ; considerable de- bility ; lassitude in the limbs ; prickings in the legs, back, and sides of the chest ; speech, rather hurried; no dyspnœa when quiet, but it is brought on by the least exertion ; no cough nor expectoration ; percussion, every where clear ; respiratory mur- mur, natural, except under the right shoulder-blade, where it was stronger than in the corresponding point on the left side. Pulse, rather quick ; heat moderate ; tongue, clean, moist, of a pale pink color ; appetite, diminished ; no thirst ; digestion, easy, especially of animal food ; epigastrium, resisting, as from some flat surface underneath; hypochondria, yielding; stools, rare ; urine copious and without pain. The patient complain- ed only of weakness and pain at the back of the neck. (Infusion of sapon. offic. for drink ; extract of gentian 3j., twice a day ; quarter of the house allowance). She remained nine months in the hospital, where she died on Chap. 8.] IMPOSSIBLE TO RECOGNISE IT EARLY. 335 the 2Sth of September. During this period we examined her every ten days, more frequently during the last month, and the following was the result : — At the end of February there was a slight cough, although then and until September the patient assured us that she did not cough ; the breathing was quick- ened by the slightest movement, but from the absence of cough leading us to suppose this to be owing to general weak- ness, we paid but little attention to it. During the last fif- teen days of September the cough became much more f-equent, and u>e then heard it for the first time. On the 2-^d, there were some nummulated sputa, which made us suspect phthisis, but auscultation, imperfectly employed the same day, gave no satisfactory information. The pulse v^^as always small and weak, and was but slightly accelerated until after the first six months. In general there was slight increase of heat in the evening, and during the last month only, occasional rigors with night perspirations, occupying the neck and chest. The ap- petite was variable ; during the first seven months she ate a fourth or an eighth of the house allowance ; after this there was complete anorexia. Digestion was almost always dif- ficult, but rather less so during part of the fourth and fifth months, when boluses of ox-gall were prescribed ; there was some nausea during the last forty days. At the com- mencement and during the course of this last period, she complained of pains in the neck and of difficult deglutition, particularly just when the food was entering the stomach. The thirst was always rather urgent in the evening. From the fifth month the liver descended below the ribs, and she was sensible to the presence of a weight falling to the right or left as she changed her position in bed. The tongue was constantly the seat of heat and unpleasant pricking sensations, and retained its natural color until the end of 336 SYMPTOMS. LATENT PHTHISIS, 2d KIND J [Part 11, August. It was afterwards covered with white, rounded, vari- ably thick patches, which lasted one or two days, re-appeared after irregular intervals. At first no change took place in the color of the tongue ; it subsequently becan-je red. A similar exudation took place on the roof of the mouth and inner sur- face of the cheeks and lips. Colic pains were frequent, sometimes very acute, and dur- ing the last six months there was occasional diarrhœa. The yellow state of the skin persisted, and towards the middle of July the brown spots on the face, which were light-colored and small when we first observed the patient, became darker, and gradually extended over the whole face, like a mask. Œdema of the lower part of the legs, during the last six months. The debility progressed slowly, and the patient was confined to her bed the last fifteen days only. Opening of the corpse thirty-four hours after death. Exterior. — Extreme emaciation ; slight œdema of the lower part of the legs. Head. — Some arachnoidean granulations in the course of the longitudinal sinus ; the brain was yellowish on the surface, of firm consistence ; the remainder of the encephalon was healthy. Neck. — Base of the tongue, rather red, and covered with a false pultaceous membrane ; larynx and epiglottis, natural ; the trachea was filled by a white frothy fluid ; its mucous membrane was healthy. Thorax. — Left lung, free ; slight adhesions of the right upper lobe, corresponding to a large tuberculous excavation, lined by a thin false membrane, almost wholly in contact with healthy lung. Numerous small excavations communicated with it, which were surrounded by slightly infiltrated or indu- Chap. 8.] IMPOSSIBLE TO RECOGNISE IT EARLY. 337 rated pulmonary tissue ; the two lower thirds of this lung were engorged, and of a pale red color, in the left lung the engorgement was less considerable, but at the summit there were numerous small excavations, containing the remnants of tuberculous matter. On both sides, the bronchia communi- cating with the excavations, were of an extremely pale pink color, and very thin ; elsewhere, they were pale ; in all, the mucous membrane was of normal consistence and thickness. There were about six ounces of serous fluid in the left, pleura. Heart, of moderate volume ; lining membrane of left ven- tricle and aorta of a bright red ; this color extended to the middle arterial tunic, which was not otherwise affected. Abdomen. — The mucous membrane of the œsophagus was pale, and everywhere covered by a soft pultaceous membrane, which seemed simply in contact with it. The stomach was small ; its lining membrane and that of the small intestine were everywhere normal, as regards color, consistence, and thick- ness ; that of the colon was greyish, and soft as mucus in its two lower thirds ; mesenteric glands natural. The liver, though not increased in volume, descended below the ribs an inch and a half; it was of a deep yellow color, like gamboge, fatty, and of moderate consistence. The bile of gall bladder was of a dirty reddish color, and thick ; the kidneys were pale and a little enlarged ; the other viscera of the abdomen were healthy. 384. The latent character of the disease is here so evi- dent, that long reflections on our part would be wholly super- fluous. During the nine months that the patient remained in the hospital, she may almost be said, with the exception of the last fifteen days, to have had no cough ; and surely no one T 2 338 SYMPTOMS. LATENT PHTHISIS. 2d KIND ; [Part II, can doubt that the excavations in the lungs existed anteriorly to this period. The only difficulty we can have, is to know when the disease originated. If, on inspection after death, the lungs had been the only organs profoundly affected, we might refer the origin of phthisis to the period at which the derangement in the patient's health commenced ; but the liver was diseased, and probably had been so for some time, and as it had been supposed by some for a long time to be the sole organ affected, one might attribute to it the greater number of the general symptoms which were present sev- eral years before death. If, however, we reflect that three years anterior to any alteration in the color of the skin, the patient was attacked with a chronic pulmonary catarrh, not intense certainly, but constant during eighteen months, that after its disappearance the cough was easily renewed by the slightest cause, such as odors, fogs, &,c. ; that the alteration of the liver is one almost peculiar to (161), and depending on phthisis, and, consequently, subsequent to the existence of the latter; we shall be induced to believe that the presence of tubercles in the lungs must be referred to the period of the chronic bronchitis ; and to their influence must be ascribed the uneasiness, and other symptoms experienced by the pa- tient from this moment until death. It would, indeed, be im- possible to have any correct idea of the very gradual progress of the debility, and the general mildness of the symptoms, if the cause to which we refer them had not acted very slowly, and the tubercular development had not been extremely chronic. 385. We have taken for granted that the change in the color of the skin depended upon the liver ; but the condition of the conjunctiva) may render this doubtful ; and our doubts may be strengthened by the Aict, tliat in no instance of the Chap. 8.] CICATRIZATION OF CAVITIES. 339 fatty degeneration of the liver, have we observed an analogous modification of the color of the skin. We must, however, re- member, that the patient had experienced pricking and a sense of weight in the right hypochondrium, symptoms which were not present in the cases where the same morbid lesion was observed. The œsophagus was lined by a false membrane, similar to that we have remarked on the tongue and inside of the mouth ; during a month the oesophageal deglutition was more or less difficult, and there had been j)ains in the neck. Now, since the trachea was healthy, we are inclined to refer both symptoms to an inflammation of the lining membrane of the oesophagus, which produced the exudation just spoken of. This opinion appears highly probable, although we have fre- quently observed a similar exudation to the one in question, without these accompanying symptoms. 386. Let us also remark that, notwithstanding the frequent variations, the diminutions, and finally the total loss of appe- tite, the gastric mucous membrane was perfectly healthy. The structure of the excavations also merits our attention. The largest was invested by a false membrane, lying upon almost healthy pulmonary tissue ; this fact is rare, and it is only in analogous instances, when the number of tubercles is small, that we can conceive the cure of phthisis to take place, by the union of the sides of the cavity. Lastly, with the ex- ception of a pale pink tinge near the cavities, the communica- ting bronchia were healthy, which fact, as well as the history of the symptoms, is contrary to the idea of chronic bronchitis being the cause of tubercles. 340 SYMPTOMS. LATENT PHTHISIS, 2d KIND ; [Part II, THIRTY-FIRST OBSERVATION. 387. A YOUNG woman, set.- 21, of delicate health and great sensibility, had quitted, two months previously, the haber- dashery business, to enter a religious establishment. She was well formed, with moderate embonpoint, and said she had been ill six weeks before entering the hospital of La Charité, September 24th, 1822 ; she attributed her illness to the coarse nature of her food. The menstrual discharge com- menced at the age of fifteen, returned every fifteen days dur- ing the first three years, after which it was less frequent, but always irregular, and accompanied with severe pains, princi- pally in the loins. From the first there was some leucorrhœa, and frequently epigastric pains ; these had much increased the last six weeks, so that she could not support any thing upon the abdomen, and they were exasperated by coarse vegeta- bles, as beans ; they became very acute at night, but were moderated during an hour by a cordial mixture, which pro- duced a burning sensation in the epigastrium. To these symptoms nausea was soon added ; there was almost complete loss of appetite, with frequent colics, occasional diarrhoea, and during three weeks, daily rigors, followed by heat and perspiration ; there had been no cough, and no sensible in- crease of her dyspnœa, which she had had from childhood. September 25th. Face, pale ; muscular system, firm ; slight loss of flesh ; sleep, interrupted ; she seldom complained of headache ; great debility ; breathing, rather oppressed, which is referred to the epigastrium ; no cough nor expectoration ; pulse, very slightly accelerated ; heat, natural ; tongue, rather Chap. 8.] IMPOSSIBLE TO RECOGNISE IT EARLY. 341 moist, whitish ; bad taste in the mouth, which is clammy ; loss of appetite ; no thirst; complains of pain below the xyphoid cartilage, without any increased local heat ; another pain is felt around the umbilicus, with slight increased volume of the abdomen ; bowels, constipated for some days. (Solution of oxymel for drink ; emoUient enema ; two half rice creams). The patient not liking the oxymel, an infusion of succory was substituted ; this was equally disagreeable, and weak tea with milk was preferred. October 4th. Some slight pains in the throat ; respiration, laborious, at times panting, very variable. In the upper part of the right lung, posteriorly, there was indistinct pectoriloquy; this was also sometimes heard opposite the inferior angle of the scapula ; the voice seemed to come in jerks ; in other respects the respiration seemed natural ; there was no cough, or pain in the chest ; there were some heat and frequency of the pulse in the evening, with persistence of the epigastric pain. 9th. Slight cough ; tracheal respiration and distinct pectoriloquy between the scapulae, more extensively heard at the right than the left side. We were very particular in our inquiries as to the state of the respiration, previous to the pa- tient's entering the hospital ; and the only answer she return- ed was, that she was attacked with a cold every winter, lasting from one to two months, and that she had not coughed once for the last twelve months. Until tlie 17th of November, when death took place, no evident change occurred in the state of the chest ; the sputa were scanty, sometimes frothy and mucous, at others, com- pletely opaque and flocculent ; the cough was usually trouble- some at night, and accompanied by occasional paroxysms of dyspnoea. During the last three weeks the pulse became 342 SYMPTOMS. LATENT PHTHISIS, 2d KIND ; [Part II, more frequent, with increased heat in the evening ; no perspi- rations or rigors. The epigastric pains were only momentarily mitigated by a warm bath ; they afterwards became very acute, and were usually accompanied by increased local temperature ; they ceased two days before death. From the 20th of October she was attacked with bilious vomitings, recurring several times during the day, and increasing in frequency to the last. The patient could not bear the same drink more than three days in succession, and at length became disgusted with every thing. The tongue, towards the close, became dry ; there were occasional colics and diarrhœa. Great agitation during the last night, but no delirium or loss of consciousness. Opening of the corpse twenty-seven hours after death. Exterior. — Considerable emaciation ; the right cheek, on which the patient lay during life, was of a livid color. Head. — Slight sub-arachnoidean infiltration ; the brain, and parts connected with it, perfectly healthy. Chest. — Some clear serous fluid in the pleurae; lungs, free, soft, crepitating, healthy at their base, indurated at their summit, where we found a great number of encysted tubercles. Some were excavated or only softened ; the majority were still crude ; the cysts were easily separated from the pulmonary tissue, and in their intervals or lower down there were numer- ous grey granulations, yellowish at their centres. The bron- chia were thin and of a deep red. The heart was small and of a bright red color. Abdomen. — Some reddish colored serum in the lumbar regions ; about five ounces of healthy looking pus in the pelvis. The omentum was closely adherent to the small in- testine, as were also some of the convolutions among them- Chap. 8.] ENCYSTED tu:bercles. 343 selves, in points corresponding to ulcerations. Numerous miliary granulations on the peritoneal surface of the small in- testine, most of which were semi-transparent ; some were slightly opaque in the centre, and all were situated on the adherent surface of the peritoneum. The mucous membrane of the stomach was red in the great cul-de-sac, over an extent of two inches ; healthy in the vicinity of the pylorus and ante- riorly ; soft as mucus in the remainder of its extent. There were numerous ulcerations throughout the whole of the small intestine, situated transversely, and with intervals of from two to six inches ; many of them encircled the gut. The inter- vening membrane was healthy ; in the ulcerated points it was destroyed, and the submucous layer was thin and of a greyish color ; and in some points the muscular tunic was exposed, thickened, and its fibres sometimes separated by tuberculous granulations. The transverse and right lumbar colon present- ed two radiated ulcerations of the size of a dollar or larger, and similar in their structure to those of the small intestine ; be- tween these there was a much smaller ulceration, lined by the peritoneum. The mucous membrane was pale and much soft- ened in the transverse colon. Mesenteric glands, more or less tuberculous, and the portion of the gland not yet trans- formed was of a somewhat bright red color. The liver was voluminous, pale, yellow, spotted with red, easily torn, and adipous ; the gall-bladder, rather small, and contained bile of the color and consistence of treacle ; the other viscera of the abdomen were healthy. 388. The fact of pectoriloquy having been observed before the cough is an evident proof of the latent nature of the dis- ease. But to what period ought we to refer the origin of the tubercles ? The solution of this question appears to us impos- 344 SYMPTOMS. LATENT PHTHISIS, 2d KIND ; [Part II, sible. For if we go back to a period anterior to the six weeks preceding the entrance of the patient into the hospital, that is, farther back than the period considered by herself as the commencement of her illness, we cannot lay greater stress upon the last cold than upon the one preceding, for, during the interval her health was good. However, the size, num- ber and structure of the ulcerations of the small intestine seemed to indicate that the pulmonary tubercles, on which they depended, existed anteriorly to the apparent origin of the disease. 389. At the time we collected this observation we had not specially directed our attention to the softening with diminish- ed consistence of the gastric mucous membrane, and we have only here noted its extreme softening. It is, however, proba- ble that both alterations existed, the patient having presented in an intense degree, and during a considerable space of time, the symptoms which characterize this double lesion, viz., ano- rexia, epigastric pains, nausea, disgust for every kind of drink, and lastly bilious vomitings. The purulent effusion in the pelvis, was the result of an acute and recent peritonitis, occurring doubtless during the last twenty-four hours ; at least we are inclined to this conclusion, because when we last saw the patient no symptoms of perito- nitis existed, and during the night on which she died she ex- perienced unusual agitation without any cerebral derange- ment ; also, because at the close of other chronic diseases we have remarked the same agitation, occurring at the same period, and only under similar circumstances. We, however, regard this mode of viewing the subject as conjecture merely, and have only employed it to show that diseases, when near their termination, are not without interest for the observer. Chap. 8.] ENCYSTED TUBERCLES. 345 THIRTY-SECOND OBSERVATION. 390. A COOK, aet. 24, of a weak and delicate constitution, middle stature, and having been much subject to leucorrhœa both before and subsequently to the first appearance of the cat- amenial discharge, had been ill six weeks when she was admit- ted to the hospital of La Charité. At the commencement, she had experienced colics, and pains of a very indeterminate nature; these pains, which were acute and unaccompanied by fever during the first weeks, afterwards diminished ; fever then succeeded, and she was frequently liable in the evening to rigors, followed by heat and perspiration. From the first the appetite was diminished, and soon ceased altogether, the patient only taking a small quantity of food in the morning, having remarked that in the evening it was always the cause of increased abdominal pain. Some purgative medicine, dur- ing the first fifteen days, produced slight diarihœa ; there were scarcely any increase of thirst, and no cough. The cat- amenia had returned at their usual period on the 16th of the last month. On the 15th of July, 1824, the day after her admission, the face was pale ; there was slight general debility ; percussion of chest, clear ; respiration, every where natural ; no cough or expectoration; she had however experienced nineteen months previously, after a protracted cold, an hsemoptysis, wliich con- tinued more or less during six weeks ; the cold returned in the following winter ; in the interval and ever since there had been some difficulty of breathing, but no cough. The skin was a httle hot, and the pulse very slightly accelerated ; the u 2 346 SYMPTOMS. LATENT PHTHISIS, 2d KIND ; [Part 11^ patient had had some rigors the previous evening. The tongue was large, rather moist, of a whitish brown coU)r ; the mouth, clammy with bitter taste ; no thirst ; warm drinks excited dis- gust ; cold drinks produced coHc ; abdomen, rather tense and sensible to pressure throughout ; epigastrium, painful ; suffer- ings increased by all movements and during the febrile exa- cerbation in the evening ; occasional colics ; two stools, daily. (Solution of gum syrup ; emollient enema ; emollient fomen- tations ; hipbath; two soups). From this moment up to the 26th of August, the day of her death, there was no cough, with the exception of the last ten days ; she then attributed it to throwing off the bed clothes during the night, because she felt too warm ; it ex- cited little attention, and on account of her weak state, auscul- tation was not practised. There was always more or less heat in the evening, sometimes preceded by rigors, and constantly followed by perspiration. Towards the end, the pulse became very rapid, small and weak. July 17th. The patient vomited some mouthfuls of bile ; this was soon repeated with increased frequency and copious- ness; it occurred almost daily until death, amounting sometimes to several pints of a greenish, yellow-colored bile. The epigas- tric pains were very violent, accompanied with heat, and were always increased shortly before vomiting ; from the middle of August they were only sensible at that period. The abdo- men increased in volume, was often hot and painful ; the diar- rhœa was moderate and remittent ; the appetite, which was usually depressed or absent, occasionally revived, when the patient relished a little soup and a fresh egg, without after- wards vomiting. The debility rapidly increased. On the 26th of August, during the visit, the patient was sensible of her approaching dissolution, and pointed out to us Chap. 8.] ENCYSTED TUBERCLES. 347 some lenticular bluish spots, wiiich had just appeared on the chest and hands. She expired at three, p. m., the same day. Opening of the corpse eighteen hours after death. Exterior. — Extreme emaciation ; flaccidity of the limbs ; persistence of the lenticular spots observed during life ; no vibices. Head. — The upper half of the brain, firmer than the lower ; two small spoonsful of serous fluid in the lateral ven- tricles. The tuber annulare and cerebellum, rather soft. Neck. — Epiglottis, larynx and trachea, natural. Thorax. — Right lung, every where closely adhering to the costal pleura ; the upper lobe contained innumerable mil- iary, grey, semi-transparent granulations, more or less opaque in their centre ; there were none in the lower lobe. The left lung presented loose cellular adhesions, with every vi'here grey, semi-transparent granulations, and at its summit a mid- dle-sized tuberculous excavation, lined by a semi-cartilaginous membrane, applied either on healthy lung or granulations, and covered by a soft albuminous exudation. The bronchia were healthy ; heart, rather small ; aorta, natural. Abdomen. — The viscera and abdominal parietes were lined over nearly the whole extent by a false greyish mem- brane, either immediately in contact with itself, or with a dull white, yellowish, friable substance, arranged in patches, which were larger and more numerous in the small pelvis than any where else ; in a word, tuberculous matter in- terposed between its layers. This was most abundant in the pelvis. The stomach, of moderate volume, contained some bilious fluid. The principal portion of the great cul-de-sac was of a pearl white, and in the corresponding point the mu- cous membrane was extremely thin, and of the consistence of 348 SYMPTOMS. LATENT PHTHISIS, 2d KIND ; [Part II, mucus ; a similar alteration existed near the pylorus, over a surface of about four inches ; between these two softened por- tions there were bands from three to four lines wide in the same state, while the intervening membrane was healthy. That of the small intestine offered some inconsiderable ulcer- ations, and was every where extremely softened. There were two ulcerations of three lines in diameter, with a much less softened state of the lining membrane in the large intes- tine ; some redness in the rectum. The liver was rather redder than natural, and easily broken down. The bile of the gall- bladder was of a brown color, and moderately dense. The interior of the uterus and the upper half of its neck were of a dull yellowish white, with an uneven surface ; this was caused by the transformation of the superficial layer into very firm tuberculous matter, of about a line in thickness ; beneath this were numerous miliary granulations of the same nature ; the remaining portion of the parietes was free from alteration. 391. The analogy between this last observation and the preceding is most striking, whatever may be the point of view from which we judge of them. Both individuals were nearly of the same age, similar constitutions, and equally liable to pro- tracted bronchial affections and gastric symptoms ; very little cough existed in either case towards the termination of the dis- ease, and after death analogous lesions were found in the lungs and mucous membrane of the stomach. The tubercu- lous affection in this last instance, as in the preceding one, had also evidently preceded the cough ; and on account of the haemoptysis which had occurred eighteen months before the entrance of the patient into the hospital, and the slight dys- pnœa which had existed from that time, we may consider the Chap. 8.] SUMMARY. 349 tubercular development to have commenced at the same period. The state of the uterus and of the peritoneal cavity is not without interest. A false membrane invested the anterior abdo- minal parietes and viscera, enclosing between its layers a dull yellow substance, in patches of various dimensions. This might be regarded by some as solidified pus ; but if we reflect that it presented the characters of tuberculous matter, — that we have never found a similar deposition, except in cases of phthisis, - — that its occurrence on the surface of a false membrane is not more difficult to conceive of than on the lining membrane of the ureters, vas deferentia or vesiculae sém- inales (Obs. 5. 6), we cannot, I think, suppose it other than tuberculous matter. With regard to the tuberculous trans- formation of the inner surface of the uterus, it must have taken place rather rapidly, since no derangement of the uterine functions existed previous to the patient's admission into the hospital (183). 392. The tuberculous matter was also at the same stage of development in every organ, which seems to point out the influence of a general cause acting upon many parts at the same time, and favors what we have advanced as to the nature of the deposition between the layers of the false membrane. 393. The six observations we have just detailed are not the only examples we have collected ; two of those, included in another division of our work, might be added to the number. One (Obs. 4) refers to a man who died after a violent diar- rhœa of five months duration, having coughed only during the last six weeks, and in whose lungs we found numerous tuber- cles and excavations, with very extensive intestinal ulcerations. The organic alterations were such that it was impossible not 350 SYMPTOMS. — LATENT PHTHISIS ; [Part II, to suppose that tubercles were in the lungs anterior to the couQ^h ; and since the diarrhoea was probably caused by the commencement of intestinal ulcerations (which we have shown are a consequence of phthisis), we must admit the origin of the pulmonary tubercles to have dated from the same period. The other instance (Obs. 9) was that of a girl, aged nineteen, who had been ill seven months, but who had coughed only a few weeks before entering the hospital ; pectoriloquy was then distinct ; the sputa were isolated and flocculent, which facts, combined with other reasons, proved the existence of tuber- cles anterior to the cough. 394. Out of one hundred and twenty-three cases of phthisis, eight (or one fifteenth), were examples of pulmo- nary tubercles which were latent, or in other words, which preceded the cough, during a period varying from six months to two years. This proportion, although considerable, is doubt- less much less than it really is, if the haemoptysis, which so often precedes the cough and expectoration, is the effect, and not a precursory symptom of tubercles- In fact, haemoptysis had appeared before the other symptoms in seven of the cases cited as specimens of what we have termed " regular phthisis." The eight cases of latent phthisis may be naturally divided into two classes : in one, the tubercles existed a more or less long period before exciting cough or expectoration, or even any important general symptoms (Obs. 4, 30, 31, 32) ; in the other, they gave rise to intense general symptoms, as fever, emaciation, anorexia, &ic., before they excited cough or expectoration (Obs. 9, 27, 28, 29). The indistinctness of the symptoms in the first division diverted the attention from precisely ascertaining the condition of the lungs; but in the other instances, from the impossibility of referring the symp- toms to any particular organ, and the known frequency of Chap. 8.] SUMMARY. 351 phthisis, the presence of tubercles ought to have been sus- pected ; we should have examined every local symptonti, such as pain in the side or between the shoulders, haemopty- sis, &.C., and especially should we have endeavored to ascer- tain the exact state of the pulmonary organs by means of auscultation and percussion. Had this been done, it is indeed probable that phthisis would have been recognised in all the cases of the second series long before the presence of cough and expectoration. We are then strongly called upon to have recourse to these means in analogous cases, and in general whenever there is emaciation, and it is doubtful what the diagnosis is. 395. The fact that tubercles may exist in the lungs without at once giving rise to those peculiar symptoms which, sooner or later, are almost invariably observed, must not be considered extraordinary, since this may be the case in all diseases, in- flammations of parenchymatous organs, of serous membranes, sometimes even in those whose course is acute, as softening of the brain, &c. &£C. But what really is remarkable, was the violence of the general symptoms, the functional derange- ment of organs which presented no appreciable organic alter- ation, while the only viscus really affected seemed functionally healthy. It is, in fact, in the examples of simple and latent phthisis (Obs. 27, 28, 29), that the febrile symptoms have been most prominent, and the disorder of the digestive func- tions most protracted. This fact confirms what we have pre- viously stated (252), that in the majority of instances the fever in phthisical cases is dependant on tubercles in the lungs, and not on the consecutive morbid changes, such as intestinal ulcerations, &;c., Sic. 396. In the present state of our knowledge, it seems im- possible to determine, or even to offer any conjecture on the 352 SYMPTOMS. — AccTE PHTHISIS; [Part II, nature of the causes which thus mask the presence of pul- monary tubercles. We cannot attribute it to deficient sensi- bility by which the lungs become insensible to the presence of tubercles, since six eighths of the cases were females, and in one half of these, anteriorly to the cough, the febrile symp- toms were very intense, and a general reaction marks as much susceptibility in the system as the development of local symptoms does. The presence of complications equally fails of offering any explanation, for in the majority of instances they did not exist. We shall again refer to these facts, when considering the causes of tubercles in the lungs. ARTICLE II. ACUTE PHTHISIS. The observations which we have as yet detailed demon- strate the extreme variations in the duration of phthisis. We have seen it go through all its stages in periods varying from three months to tiventy years (Obs. 10, 24) ; in the following examples its progress has been still more rapidly fatal than in any which have preceded. THIRTY-THIRD OBSERVATION. 397. A GIRL, set. 18, of a tolerably strong constitution, with brown hair, firm, muscular system, with moderate em- bonpoint, entered the hospital of La Charité, April 29th, Chap, 8.] RAPIDLY FATAL. 353 1822. She had been little subject to cold, usually in good health, and dated her present illness only fifteen days. At the commencement, she was attacked by rigors with shiver- ings, followed by heat and perspiration ; the rigors were re- peatedly renewed ; the heat increased and the thirst became urgent ; there were occasional nausea, and more rarely some mouthfuls of bile rejected ; complete loss of appetite and fre- quent constipation ; the debility had progressed with the other symptoms ; lastly, on the tejiih day from the commencement there were slight cough and expectoration ; the catamenia, present from the age of fifteen, had been absent the last three months ; the patient had not kept her bed. April 30th. Expression, animated ; dull headache ; general lassitude ; respiration, thoracic and accelerated (forty-four) ; cough, frequent ; sputa, semi-opaque, rather greenish, mingled with bubbles of air ; pains in the middle of the sternum and under the left clavicle ; sonorous râle on both sides of the chest; pulse, one hundred and three, neither full nor hard ; heat intense ; night sweats ; tongue, red on the edges, whitish in the centre ; mouth, dry, clammy, and with a bitter taste ; thirst, urgent ; anorexia ; one liquid stool during the night. (Twelve leeches to the labia ; acidulated infusion of vio- lets for drink ; solution of gum syrup ; two emollient ene- mata). May 1st. Increased uneasiness ; pain in the right side of the chest ; expectoration, copious, greenish, a little striated with yellow lines ; auscultation as before. (A poultice to the painful part). May 2d. No remarkable change ; sweat in the night ; some diarrhoea and sudamina. (Blister to the chest). w 2 354 srMPTOMS. — acute phthisis ; [Part II, From this period to the 19th of May, the day of her death, the progress of the disease was rapid and regular ; the respi- ration, thoracic, frequent, varying from forty-nine to even sixty times in a minute ; cough, very violent, especially during the night ; the expectoration Avas more or less copious, mucous, frothy, or wholly opaque, greenish, without air, and streaked with yellow hues ; percussion of the chest, frequently repeated, was clear ; over the right side there was much mucous râle on 7th. On the 10th, the respiratory murmur was not so distinct on this side as on the left, and a little crepitation was heard about the mamma. On the 18th, at each inspiration, there was a kind of liquid crackling over nearly all the front of the chest, with a httle crepitation on the left side. The pulse gradually quickened on the 16th, (one hundred and sixty-four) ; heat, much elevated and dry; constant night sweats until the 12th ; anorexia continued ; thirst, very urgent, the patient drinking five or six quarts of fluid in the four and twenty hours ; some nausea, with bilious vomitings and epigastric pains the last seven days, and during the whole time there was slight diar- rhoea. The uneasiness increased ; the face was pale and express- ed surprise ; appearance, much fallen on the 16th. During the night of the 1 8th there was slight delirium, with embar- rassed utterance ; the patient cried out for assistance to be relieved of the sufferings in her chest. Death took place at three, a. m., on the 19th. The blister ceased to suppurate some days before death. She continued the same drinks ; emollient enemata were fre- quently ordered ; and during the last week, on account of the dry state of the skin, M. Chomel prescribed some warm baths. Chap. 8.] RAPIDLY FATAL. 355 Opening of the corpse twenty-four hours after death. Exterior. — Extreme muscular rigidity ; considerable emaciation. Head. — Slight snb-arachnoidean infiltration ; the brain was healthy. Thorax. — The left lung offered some adhesions posteri- orly ; the upper lobe contained numerous grey, semi-trans- parent granulations, and small tuberculous masses in a crude state, surrounded by slightly engorged pulmonary tissue ; the engorgement was more considerable in the base of the lower lobe, which contained few granulations ; the right lung, uni- versally adherent, was transformed at its base into a mass of tuberculous matter of a pale rose tint, to the extent of two inches in height and two in breadth, occupying nearly the whole circumference of this part of the lung ; it was perfo- rated by a kind of anfractuous canal, enclosing a small quan- tity of a thick, dark-colored fluid. Elsewhere the lung pre- sented numerous grey, semi-transparent granulations, and small softened masses of tuberculous matter ; its tissue was slightly engorged. Abdomen. — The gastric mucous membrane was covered by a viscid mucus nenr the pylorus, and had some irregular redness in the great cul-de-sac ; the small intestine, colon, and other abdominal viscera were healthy. 398. In this observation the interval between health and disease was short ; the cessation of one, and the commence- ment of the other were well marked ; the duration of the dis- ease was thirty-five days, that of the cough twenty-five only. The violence of the symptoms is as remarka le as the rapid progress of the affection. At first, very intense febrile move- 356 SYMPTOMS. — ACUTE PHTHISIS ; [Pait II, ment, associated after ten days with cough, expectoration and dyspnœa ; the latter rapidly increased ; on the sixth day of the cough the breathing was forty-seven, and it was still more accelerated on the succeeding days ; the temperature was much elevated, and the pulse very frequent ; all pointed out an acute affection of the lungs. The percussion of the chest, however, was clear, the results of auscultation nearly negative, not favoring the idea of bronchitis, and only giving reason to suspect, towards the close of the patient's life, the first degree of pneumonia, which gave no explanation of the preceding, or even the actual symptoms. Under these circumstances, was it possible to recognise the nature of the disease ? 399. We might no doubt have employed auscultation with greater care, and have studied the effects of the voice in every part of the chest; but supposing this to have been done, could we have formed our diagnosis ? We think not. In fact, if we had detected resonance of the voice in the lower part of the right side, to have ascribed it to an excavation, would have been to have formed a conclusion in opposition to the general law* of the developtnent of tuberculous matter, viz., from the summit to the base of the lungs ; so that every thing seemed combined to falsify diagnosis, both from the situation of the lesion and the violence of the symptoms. f The absence of the symptoms of pleurisy or pneumonia,, connected with the appearance of the sputa, made M. Chomel for a moment to suspect the existence of phthisis ; but so many circumstances were opposed to the idea, that he ceased * Out of one hundred and twenty-three cases, this is the only example of tuberculous matter developed from the base to the summit of the lungs. — Louis. t Vide note on page 326. — H. 1. 13. Chap. 8.] DIFFICULT OF RECOGNITION. 357 to entertain it. The fact, however, ought not to be forgotten ; it increases the value of the expectoration as a diagnostic sign, and shows how useful it is to observe minutely its char- acters. 400. It is also very remarkable that, notwithstanding the extreme rapidity of the tuberculous development, there were scarcely any traces of inflammation in the surrounding tissues, more particularly in the right lung. The digestive organs were too incompletely described to allow us to extend our remarks on the gastric symptoms. Nevertheless, we would remark that the vomiting of bile con- nected with the dark stripes of the mucous membrane of the stomach might lead us to suspect that there was a somewhat serious pathological state of this organ ; but of what use are suspicions when we need authentic facts ? 401. In the following observation, the tuberculous affection was not the immediate cause of death, but in its commence- ment it was equally violent with the preceding, and this in- duces us to give it a place here. THIRTY- FOURTH OBSERVATION. A TEACHER of the piano, aet. 46, of middle height, strong constitution, with a large chest and moderate embonpoint, was admitted into the hospital of La Charité, October 6th, 1823 ; he had been ill three weeks. This affection had com- menced without any evident cause, after having partaken of a moderate repast, with rigors, soon followed by heat, which last had continued from that time. After the first four-and-twenty hours the breathing became oppressed ; the dyspnœa continu- 358 SYMPTOMS. — ACUTE PHTHISIS ; [Part 11, ally increased, and there was occasional cough. During the last eight days the thirst was very urgent with loss of appe- tite ; no unpleasant feeling at the epigastrium ; no nausea, vomiting or diarrhœa. October 7th. Expression of uneasiness combined with in- difference ; answers questions slowly ; headache ; movements of the thorax, limited and frequent ; great oppression ; cough, rare, some mucous and frothy expectoration ; respiration, weak, without râle, under the right clavicle, natural every where else ; heat of the skin, moderate ; pulse, eighty ; tongue, yellowish in the centre, natural on the edges ; ano- rexia ; little thirst ; sense of heat with dryness in the phar- ynx ; deglutition, easy ; no epigastric pain ; constipation. (Infusion of violets with gum syrup ; gum potion with oxyrael ; emollient injection). The sputa becoming slightly viscous, he was bled the next day to § X. 9th. Expectoration, rather easier ; dyspnœa, as before ; no change in percussion or auscultation ; tongue, rather red on the edges ; painful sense of heat and dryness in the pharynx, which, as well as the tonsils, was of a bright red; deglutition, difficult; thirst, moderate; heat, considera- ble ; pulse, one hundred and four. Blood of the preceding evening, covered by a slight greyish layer, about a line thick. (Pectoral infusion with oxymel ; gum potion with § ss. of the oxymel of squills ; blister five inches square to the anterior part of the chest). The next day the heat of the surface was diminished ; pulse, rather less frequent. 11th. Sputa, rather viscous, white, spumous ; respiration, as on tlie 9th. No crepitation could be detected, and percussion was every where clear ; pulse, rather weak, ninety-six ; pharynx and tonsils as before; Chap. 8.] DEATH FROM PNEUMONIA. 359 the uneasiness increased ; the movements became difficult and uncertain ; two liquid stools. (Demulcent gargle). 12th. Pulse, less frequent ; expression of prostration ; speaks slowly ; the uvula was infiltrated ; be still complained of the heat and dryness in the pharynx and along the neck. No change on the following day. 14th. A kind of bellows sound (bruit de soufflet) was heard over a great part of the chest; expectoration, viscous, white or greyish ; pulse, very quick; tongue, hard, dry, and cracked. Heat of the pharynx, the same ; its redness and that of the uvula rather less ; in- creased anxiety, with general redness of the face. Some deliri- um in the night, and the next morning, at ten, a. m. he expired. There were daily two liquid stools ; profuse perspirations of the head during the night ; the abdomen was never painful. Opening of the corpse twenty-two hours after death. Exterior. — Nothing worth notice, save that the muscular system was well developed. Head. — Considerable sub-arachnoidean infiltration ; the upper cerebral veins were distended ; pia mater, moderately injected ; brain, very firm, and firmly injected ; a spoonful of clear fluid in each lateral ventricle. Neck. — Amygdalae, healthy ; uvula, a little thickened ; partial destruction of the epiglottis on the left side, for the space of two lines long, rather less broad ; mucous membrane of the larynx, natural ; that of the trachea, of a bright red in- feriorly, and of good consistence. Thorax. — Lungs, voluminous, dark colored ; the left was free, the right, partially adherent. Their tissue was red, and granulated over the greater part of their extent, easily broken 360 SYMPTOMS. — ACUTE PHTHISIS ; [Part II, down, especially that of the right ; it was firmer at the sum- mit than at the base, and yielded when pressed a dark colored fluid, which was mingled with a little air inferiorly ;^tbere were numerous grey, semi-transparent granulations, which diminished in size from above downwards. They were opaque and yellowish in their centre, and above they were of the size of a hemp seed, below as large as a millet seed, the latter of which were wholly semi-transparent The bronchia were thin ; their mucous membrane, healthy, with the exception of a slight livid tint, such as we frequently find in patients whose respiration had been difficult for some time before death. Heart, rather soft ; the aorta presented some yellowish patches. Abdomen. — Round ulcerations of about a line in diam- eter through the whole length of the oesophagus ; the corres-- ponding mucous membrane was destroyed. Stomach, volumi- nous ; lining membrane, of an orange-red color, rather softened in one half of the great cul-de-sac, and thinned in some por- tions of the same region ; it was elsewhere uneven, mamillated, greyish, and presented some indentations, from one to two inches long by a line wide, where the membrane had only one fourth the thickness it possessed in the mamillated portion. Duodenum, rather red, without other alteration. Small in- testine healthy, with the exception of one submucous abscess, about the size of a pea ; the lining membrane of the large intestine was equally healthy, except in being slightly red in spots ; the liver was soft and of a tawny color ; spleen, rather large. The other viscera were natural. 402. Whatever may have been the day on which the pneumonia commenced, the patient evidently died in conse- quence of it, and not of phthisis ; but we think that at one period tubercles were alone present in the lungs, that they Chap. 8.] DEATH FROM PNEUMONIA. 361 were the cause of the first febrile symptoms, and that their development was acute ; and the pneumonia may perhaps be considered the result of their rapid formation. In fact, from the 7th to the 11th inclusively, that is, until the fourth day before death, the respiratory m.urmur was natural on the left side of the chest, rather feeble on the right, and nowhere was there acrep- itous or other râle. Had there existed at this period some central portion of the lung attacked with pneumonia, the respi- ration on the surface would have been rather increased than diminished. Besides, an inflammation of so limited a descrip- tion would not explain the violence of the symptoms or the in- tensity of the dyspnœa ; percussion was universally clear on the day after the entrance of the patient, and on the 11th of October ; the hepatization was every where at the same de- gree of development, and seemed to have taken place simulta- neously in every part of the lung. For all these reasons, we cannot suppose pneumonia to have originated earlier than the fourth day preceding death ; therefore the fever, dyspnoea, and cough, anterior to this period, were owing to the very rapid development of tubercles. This really formidable commence- ment, and its resemblance to what occurred in the preceding observation, induce us to conclude that if the pneumonia had not been rapidly fatal, the tuberculous affection itself would have been so. It cannot be supposed that when the fever and dyspnœa commenced, tubercles had already been in the lungs for a time ; for before the appearance of the pulmonic symptoms the patient was in perfect health, and it is difficult to imagine such numerous granulations to be present without some derangement of the pulmonary functions ; so that every thing indicates that the tubercular affection was here extemely rapid. x2 362 SYMPTOMS. — ACUTE PHTHISIS ; [Part II, 403. The inflammatory condition of the larynx and the ulcerations of the œsophagus doubtless increased the patient's anxiety and uneasiness, and it is to the latter of these lesions that we refer the inconvenient sensation complained of in the neck. 404. We have hitherto considered the mamillated state of the gastric mucous membrane, when combined with a greyish color (94), as the result of chronic inflammation ; this con- dition was very prominent in the instance before us, and yet thirty days before death the patient's health seemed excellent. Is this alteration compatible witli a somewhat healthy state of the digestive functions, or is it sometimes capable of being rapidly produced ? 405. Among the examples of acute phthisis we shall in- clude the following observations, in which, however, the pro- gress of the disease was rather less violent and rapid than in the preceding cases. THIRTY-FIFTH OBSERVATION. A TAILOR, set. 19, of middle stature and moderately strong constitution, entered the hospital of La Charité, May 4th, 1824. He had been subject to colds during a few previous winters, had never been seriously indisposed, and dated his present illness twenty days, having ceased his occupation the last four. At the commencement, cough, clear expectoration, sensibility to cold ; anorexia ; constipation ; these symptoms continued, increased in intensity diiring the last eleven days, and were associated with pains in the left side of the chest, principally near the shoulder, with headache andlassitude. Chap. 8.] FATAL IN FIFTY DAYS. 363 On the fifteenth day there were diarrhœa and complete loss of appetite. Patient took no nourishment afterwards. May 5th. Face, hot, red, animated ; eyes, brilliant, lively ; headache ; lying on back, though he can lie in any position ; oppression, moderate, little cough ; expectoration, like frothy saliva. On the left side there was pain under the edge of the false ribs, and percussion was dull in the lower half of the same side of the chest, and anteriorly under the clavicle ; gurgling very distinct in the latter region, and opposite the shoulder there was incomplete segophony. On the right side auscul- tation and percussion gave only negative results. Pulse, ninety, moderately full ; tongue, moist, natural on edges, with a yellowish-grey coat in the centre ; mouth, clammy ; thirst, urgent ; no appetite ; epigastrium and hypogastrium, sensible to pressure ; three liquid stools. (Infusion of violets ; gum potion ; V. S. | x.) 6th. Same symptoms ; the blood drawn on the day pre- vious, had a coagulum without bufl' or cup. The same symptoms continued constantly and almost uni- formly increased up to the 4th of June, when death took place. The dyspnœa was urgent and breathing very rapid dur- ing the last eight days only. Towards the middle of May the patient referred all her dyspnœa to the left side of the chest. Cough, sometimes violent, but usually moderate ; the expec- toration was somewhat copious, clear, frothy, whitish, some- what spotted with blood on the 1st day of June, and soon it became greenish, but not striated towards the last. May 14th. Percussion, perfectly flat on the left side below the mamma and over the two inferior thirds of the chest posteri- orly ; the œgophony heard about the shoulder changed to a simple resonance of the voice, which soon extended lower down; the gurgling continued with occasional cracklings. 364 SYMPTOMS. — ACUTE phthisis; [Part II, 26th. Tracheal respiration under the left clavicle, without pectoriloquy. 28th. Slight crepitation anteriorly on the same side. Pulse, always accelerated, generally not less than one hundred, but it was nriuch quicker the last eight days. Heat, elevated ; rather copious night perspirations, but rarely chills. The tongue retained its first appearance ; thirst, urgent, pro- portionate to the febrile symptoms ; no appetite ; epigastrium, rather painful the first six days ; afterwards not so. From the 22d to the 24th of May, some clear vomitings, without bitter- ness. Two or three liquid stools daily, rarely with colic pains. The debility rapidly increased, and the pain in the side hav- ing been once overcome, the patient complained of nothing save that he did not recover his strength. He was not anxious about his condition except during the last few days of life. At this time he lay constantly on the right side ; his debihty pre- vented the exploration of the chest after the 28th of May, be- fore which the respiration was natural. During the last week the patient's face was constantly of a deep red color, and sometimes it was of a crimson hue. Some deafness and delirium the day preceding death. June 4th. During the visit the intelligence was clear; thirst, most urgent ; and whilst su jSfering extreme dyspnœa ; he drunk rapidly and without assistance ; perspiration, very copious ; and at eleven, a. m., he expired. He continued the use of the drinks first prescribed. Some thin broth was occasionally taken ; he was bled a second time on the 10th of May ; and twelve leeches were applied to the anus, with a blister to the left side of the chest on the same day, without any apparent relief. On the 31st the dyspnœa, heat of the skin, and frequency of the pulse induced a repeti- tion of the bleeding, which produced only a momentary relief. Chap. 8.] FATAL IN FIFTY DAYS. 365 Opening of the corpse twenty hours after death. Exterior. — Considerable emaciation. Considerable thin- ning and almost total destruction of the skin in the middle of the blister on the chest. Head. — Brain, firm, rather injected; a spoonful of serous fluid in each lateral ventricle, and a spoonful and a half in the occipital fossae. In other respects the encephalon was healthy. Neck. — Cervical glands, red, voluminous and firm ; some of them contained miliary tubercles. Laryngeal surface of the epiglottis, slightly ulcerated, with a pufiy state of the sub- mucous tissue ; larynx, natural ; mucous membrane of the trachea, of a bright red, especially at its lower part, of normal thickness and consistence, with some small ulcerations which seemed as if made with an instrument. Thorax. — The left lung filled exactly the cavity of the pleura ; it adhered to the diaphragm by means of a false mem- brane ; it was merely lying upon the pleura over the rest of its extent, and was firm and resisting every where except for the space of about an inch and a half at its anterior edge. At its summit there was a half emptied cavity about the size of a nut, with numerous tubercles, and some isolated, hepatized portions of lung ; the remainder of the whole lung was almost entirely converted into crude tuberculous matter, disposed in masses of variable dimensions, between which there was scarcely a tenth of the parenchyma permeable to the air. The pleura resting immediately upon the tuberculous matter could be easily separated from it. The right lung was free, with nu- merous tubercles at its summit, many of which were softened or half excavated ; they were confined to this portion of the lung ; the thin edges of the upper and middle lobe were hep- 366 SYMPTOMS. — ACUTE PHTHISIS ; [Part 11, atized to a considerable extent. The left ventricle of the heart rather enlarged ; aorta, natural. Abdomen. — Stomach, of moderate volume; its mucous membrane, red and softened in the great cul-de-sac, and be- low, over a space of four or five square inches, it was pearl- colored, thin, and as soft as mucus ; in the same portion the submucous vessels were very evident ; in the rest of its extent it was mamillated, more or less red, of normal consistence, and one twenty-fifth of an inch thick. In the small intestine, near the cascum, there were some semi-cartilaginous granulations, some of which were ulcerated ; also some small ulcerations, from one to two lines in diameter, with flattened edges, and seven others about an inch in surface ; all situated upon the patches. Where these ulcers existed, the corresponding sub- mucous tissue was denuded, uneven, thickened, and here and there destroyed ; elsewhere the mucous membrane was healthy. That of the caecum and ascending colon was soft ; the large intestine was every where else natural. The mesenteric glands, corresponding to the ulcerations were voluminous, more or less red, and spotted with numerous miliary tuber- cles ; liver, healthy ; bile, dark colored, thick ; spleen, volu- minous and softened ; the other viscera were natural. 406. Up to the period of the invasion of the cough and fever, there was no functional derangement, so that we must refer the commencement of phthisis in this instance to that date ; it was fatal in fifty days. It is true, the lungs were not the only organs affected ; but if we reflect that the left was almost entirely transformed into tuberculous matter, and that the right also contained a certain quantity, it will be allowed that if death could have been accelerated by any compli- cations, they must have existed but a very short time before Chap. 8.] FATAL IN FIFTY DAYS. 367 death ; so that we may regard it as the effect of the tubercu- lous affection of the lungs. 407. It is not so easy to point out the relative influence of the principal affection, and of its complications in the produc- tion of the febrile phenomena. Auscultation, indeed, proved that the inflammation of the substance of the lung occurred only towards the close of life, and thus its influence upon the general symptoms was not exerted except a short time before death ; but we cannot affirm that the inflammation of the gas- tric mucous membrane did not commence at the same time with the cough, although we think it probable that it did not date more than four days previous to the patient's admission into the hospital. At this period, in fact, the anorexia be- came complete, and the epigastric pains were not present until some days afterwards. This, however, may appear doubtful, so that the observation before us is not a distinct example of the general symptoms which accompany acute phthisis. 408. When we first saw the patient there was slight aego- phony opposite the left shoulder; beneath this, percussion was perfectly flat, and there was no resonance of the voice, which made us suppose there was an effusion circumscribed by adhe- sions. But after death we found neither fluid, nor false mem- branes, nor adhesions ; it is, therefore, impossible to give any explanation of the asgophony, unless we admit of circumscribed effusions without false membranes, or a cause for aegophony very different from effusion. 409. However this may be, the absence of aegophony be- low the shoulder on the twentieth day of the affection, in a point where percussion was dull, and where we found the lung transformed into tuberculous matter, proves that this transfor- mation already existed at that time ; we can, therefore, scarce- ly doubt that the tuberculous matter was developed almost at 368 SYMPTOMS. — ACUTE PHTHISIS ; [Part II, once throughout the whole of the left lung ; a very rare cir- cumstance, and one which may be considered as peculiar to acute phthisis. 410. Around the softened and thinned portion, the gastric mucous membrane was red, thick, and mamillated. If this last condition depends, as we have every reason to believe it does, on inflammation, the other most probably had the same origin. Let us also remark, that the ulceration of the epiglottis gave rise to no symptom ; though we frequently asked the patient if he felt pain in this region, a negative answer was always returned. THIRTY-SIXTH OBSERVATION. 411. A WASHERWOMAN, 8et. 23, of a pretty strong con- stitution, born of healthy parents, not liable to colds, entered the hospital November 11th, 1821. The catamenia had been suppressed dnring the eleven previous months, and with the exception of some unpleasant sensations, which returned from time to time, and a slight debility, her health was never disturbed. She said that she had been ill fifteen days. Her affection had commenced by great oppression, and after eight days, an acute pain came on in the left side of the chest, with cough, expectoration, great heat, especially at night, anorexia and thirst ; these symptoms were preceded during some days by diarrhœa. November 12th. Acute pain in the left side of the chest, increased by cough, inspiration and decubitus on the same side ; cough, frequent, often dry ; expectoration, frothy, whitish ; pulse, rather quick ; heat, increased at night ; tongue, Chap. 8.] FATAL IN FORTY-EIGHT DAYS. 369 moist, greyish in the centre ; thirst ; anorexia ; three liquid stools without colic. (Infusion of violets with oxymel ; gum potion ; twelve leeches to the labia ; poultice to the chest.) Shortly after the application of the leeches, the pain of the chest diminished and completely ceased ; the patient could lie on either side. 14th. The skin was less hot; the expectoration mucous, yellowish and rather viscid ; the cough was very severe in the evening ; it was the same the next day ; the pain in the side did not return, and there was a little appetite. 16th. Ex- pression, less animated than usual; expectoration, more liquid. 17th. Respiration, not hurried ; pulse, a liitle accelerated ; skin, mildly warm, nearly natural ; night sweats ; four liquid stools. (V.S. §x.) From the 17th to the 24th the febrile excitement was very slight ; the pulse was nearly calm ; the cough, less frequent ; sputa, rare, thin ; daily perspirations ; diarrhœa less than usual ; appetite, increased ; the food was increased gradually to a quarter of the house allowance, and the patient complain- ed merely of being unable to recover her strength. In the night of 26th she vomited her drink, and in the morning complained of a bitter taste in her mouth ; the appe- tite became less ; the epigastrium was not painful ; the pulse was accelerated ; there was slight heat of the skin. (Food diminished.) The same symptoms continued the following days, and during the night of the 1st of December, after a copious per- spiration, she was attacked with a violent rigor, much cough and dyspnoea, followed by a deep pain under the sternum. In the morning the sputa were white and spumous ; the face livid, with great general depression. Y 2 370 SYMPTOMS. — ACUTE phthisis; [Part II, (Blister to the sternum.) These symptoms continued to increase up to the 15th of December, when death took place. 7th. Mucous râle with a kind of gurgling, was heard under the left clavicle. 11th. Same results from auscultation, with percussion flat in the same points. The voice suddenly became extinct, and contin- ued so to the last; no annoying sensations in the larynx. The pain under the sternum was felt sometimes during the cough. 4th. Sputa, greyish, rounded and opaque ; they retained these characters until death ; diarrhœa during the last ten days. The patient said nothing, complained of nothing, and usually lay on the left side, apparently absorbed by the feelings of oppression. Opening of the corpse forty hours after death. Exterior. — Moderate emaciation ; brain, not exam- ined. Neck. — Larynx, natural ; lining membrane of the trachea and bronchia, of a somewhat bright red color. Thorax. — Right lung, free, without tubercles, and engorg- ed at its base. The left presented some cellular adhesions at its summit, was free elsewhere, and there was no trace of false membranes. The upper lobe was almost entirely composed of tuberculous matter, every where softened almost uniformly, and contained three cavities, which were incompletely emptied ; the tuberculous matter was divided into numerous masses, be- tween which there was a certain quantity of the grey, semi- transparent matter. The lower lobe presented a small num- ber of tubercles, and was engorged at its base. Heart, of a proper size ; its parietes were a little thicker than usual ; aorta, healthy. Abdomen. — The stomach was not more voluminous than Chap. 8.] FATAL IN FOKTY-EIGHT DAYS. 371 the colon ; its mucous membrane was pale. There were twelve ulcerations, from one to two lines in diameter, in the small intestine. Liver, voluminous, fatty, and of a tawny color; the kidneys were of a livid red; uterus, normal; the ovaries of usual volume, but containing a small quantity of tuberculous matter. 412. Let us rapidly examine the principal circumstances of this observation. The catamenia had been suppressed ten months, during which time there had been slight uneasiness at the usual periods, but neither fever, emaciation, oppression, nor cough ; in a word, no symptoms which could be referred to an affection of the lungs. We cannot, therefore, date the origin of the tubercles farther back than the invasion of the dyspnoea, so that the affection lasted forty-eight days, and was probably the only cause of death ; for notwithstanding the incomplete description of the gastric mucous membrane, yet from its paleness, the absence of nausea, vomiting and epigas- tric pains, we may regard it as healthy. The prompt termi- nation of the disease is rather remarkable, since there were no tubercles in the right lung, and those in the left were almost entirely confined to the upper lobe of the left lung. 413. But the principal peculiarity in this observation is its remittent character. In fact, after some days of oppression, the patient is attacked with fever, cough, expectoration, and acute pain in the left side of the chest ; these symptoms con- tinue with more or less intensity, eight or ten days, and then yield partially to the application of leeches to the labia ; at least the pain ceased and the other symptonjs diminished ; and after a general bleeding of ten ounces, the fever almost completely disappeared ; the cough diminished ; the expectoration became less copious, and the digestive functions improved. This 372 SYMPTOMS. — ACUTE PHTHISIS ,' [Part II, amendment lasted eleven days, and during the night of the 1st of December, the patient was seized with rigor, oppression, and anxiety ; the cough was frequent, and death unexpectedly took place on the thirteenth day of this last cKacerbation. Could not one say that the disease remained for some time stationary ? It is, however, probable, that it constantly progressed, and that the violence of the last attack was principally owing to the sudden softening of a certain number of tubercles, and their evacuation into the bronchia. It is certain, at least, thai the expectoration underwent a decided alteration from the moment the symptoms became formidable. 414. The pain felt in the left side at the commencement renders this observation analogous to the preceding, and shows that when tuberculous matter is rapidly developed, it can oc- casion more or less suffering. In neither case were there any traces of recent pleurisy. However, it is possible that as the tuberculous matter was developed immediately under the pleura, the pain might still be owing to this membrane. 415. In the four observations we have just detailed, the commencement of the disease was more or less violent, and death took place from thirty to fifty days, in the midst of more or less local and general symptoms. There was no haemop- tysis ; cough and expectoration sometimes preceded the dys- pnœa, which last fact approximates these cases to those in which phthisis is much less rapid in its course, and is latent during a certain period, giving rise only to general phenomena. 416. But the number of our observations is too limited to justify any general description of acute phthisis, or to allow us accurately to d^ilineate the diagnostic signs of its first stage. We think, however, the disease ought to be dreaded, in those cases where dyspnoea, cough, expectoration, fever, with Chap. S.] SUMMARY. 373 sometimes pain of the chest and very hurried respiration come on suddenly and without evident cause ; and where these symptoms persist and increase, notwithstanding the treatment we oppose to them, while the characteristic signs of pneu- monia, pleurisy, and severe suffocating bronchitis, are wanting. Our diagnosis may be assisted by the careful practice of aus- cultation and percussion. Should we find percussion obscure exclusively under the clavicle, and the respiratory murmur feeble, or in any way altered, when symptoms such as we have described are present, we may consider the existence of unsoftened tubercles as certain. But notwithstanding this combination of symptoms and the positive results of ausculta- tion and percussion, doubts might still be entertained as to the nature of the disease in the first stage, if, as was the case in the thirty-fifth observation, the tuberculous matter should be simul- taneously developed throughout the whole extent of one lung. For, under these circumstances, the dulness of sound at the inferior and posterior part of the chest might favor the idea of pneumonia, although in front the dulness of sound should be limited to a small space in the subclavicular region. The change in the expectoration at the commencement of the second period, the strong and tracheal respiration where it was previously obscure, and the resonance of the voice would soon remove all doubts. 417. In the thirty-third, thirty-fifth and thirty -sixth obser- vations there were tuberculous excavations in the summit of the lungs ; but they were small, incompletely excavated, and without false membsanes ; which proves, as we have already remarked, that these membranes only exist when the progress of phthisis is much less acute. 418. Notwithstanding its rapid development, secondary disorders were present, and similar to those we have described 374 SYMPTOMS. — ACUTE PHTHISIS ; [Part 11, in cases where the duration of the disease was more chronic* Thus, we observed ulcerations of the mucous membrane of the epiglottis and trachea (Obs. 34, 35), of the oesophagus (Obs. 34), and of the small intestine. In one case (Obs. 35), the mucous membrane of the stomach was softened and thinned ; in another the liver had undergone the fatty transformation (Obs. 36) ; and in another the cervical and mesenteric glands contained a small quantity of tuberculous matter (Obs. 35). 419. Three of the patients were very young, eighteen, nineteen and twenty years of age ; a fourth, in whom we found only grey, semi-transparent granulations, was in his forty-sixth year ; the acute form was therefore not confined to young per- sons, and perhaps additional facts will demonstrate its existence at all periods of life. 420. We shall terminate this article by the following ob- servation, which we should have mentioned first, were it not deficient in many of its anatomical details. THIRTY-SEVENTH OBSERVATION. An UNMARRIED woman, confincd seventeen days since, of a pretty strong constitution, and usually enjoying good health, entered the hospital of La Charité, July 13th, 1822. Dur- ing her pregnancy lier health had been excellent, and for six days after her delivery her general state was very satisfactory. She was then suddenly and without any evident cause attack- ed with violent cough, accompanied with expectoration, dys- *This result is remarkable. — Cowan. Chap. 8.] FATAL IN THIRTY DAYS. 375 pnœa, fever, anorexia, and intense thirst. The lochia were suppressed and some abdominal pains succeeded. Ten leeches were applied to the epigastrium at the commencement ; and she was bled without evident relief; these symptoms continued to increase, and there was occasionally nausea. On the 14th of July, the left side of the chest became painful, and on the 15th her symptoms were the following — Some headache, occasional buzzing in the ears ; face, pale ; great debility ; the patient required assistance for every thing; expression, wandering, but her answers were just; memory, faithful ; decubitus, elevated ; respiration, thoracic, forty-three in the minute ; the pain in the lateral and inferior part of the left side, less acute than on the preceding evening; cough, rather frequent ; percussion, every where clear ; pulse, one hundred and forty ; heat of the skin, not very great ; no perspiration ; tongue, moist, rather pale ; thirst urgent ; ano- rexia ; abdomen, yielding ; pain in the umbilical region ; eight to ten liquid stools in twenty-four hours . (Infusion of violets; gum potion; blister to the anterior part of the chest.) From this period to the 1st of August, the day of her death, we observed the following : — Considerable oppression ; respiration, frequent (fifty in a minute on the 23d of July) ; cough, moderate ; expectoration, a little brownish, not viscous, on the 19th ; it was viscous, red, or greenish, and with yellow streaks on the 23d ; this continued with little variation to the last. 17th. Respiration, natural on the right side, feeble on the left ; obscure anteriorly on the 18th and 19th; and on the last day associated with a slight, dry, sonorous râle. On the 23d, gurgling was heard ; on the 30th, the respiration under the clavicle was tracheal. Pulse, irregular for a short time on the 16lh ; it was small and one hundred and thirteen 376 SYMPTOMS. — ACUTE PHTHISIS ; [Part II, on the 26th, continuing as frequent to the last ; heat, always elevated ; the tongue, constantly pale and moist ; it was at first yellowish in the centre, but a few days after entrance it became clean, and of almost natural color ; no appetite ; thirst, rather urgent; the left lumbar region more or less painful ; stools, rare; except the last ten days, when there was slight diarrhoea. Dur- ing the same period the abdomen was rather tympanitic. The patient appeared very uneasy, not speaking except to answer questions. On the 23d she said she had no pain ; from the 22d to the 25th there was some numbness in the right arm On the 26th, she complained of an acute pain in the shoulder of the same side if she made the slightest movement ; the movements of the right leg were also difficult and painful. On the 20th, it became oedematous and more painful ; the patient seemed to apprehend her danger, and thought herself dying of consumption. 31st. Expression, rather more ani- mated than usual ; she died at four, a. m., the following morning. Opening of the corpse twenty-seven hours after death. Exterior. — Emaciation not very considerable ; slight œdema of the lower extremities without vibices. Head. — Sub-arachnoidean infiltration much more consid- erable to the left than to the right ; brain, lateral ventricles, &;c., natural. Thorax. — A pint of serous fluid in the right pleura ; the lung of the same side was a little engorged, but free from tubercles ; the left lung was every where covered by a false membrane, forming adhesions to the costal pleura, much less dense at the base than at the summit of the lung. Between these two ex- tremes the layers were separated, and enclosed about a quart and a half of thick pus ; the lung was soft and rather heavier Chap. 8.J FATAL IN THIRTY DAYS. 377 than the right, containing numerous small abscesses communi- cating with each other, but not, as far as we could detect, with the bronchia. They were about the size of a filbert, separated by a variably thick layer of sound lung, and filled with thick pus, slightly greyish in the centre, and very thick at its circumference. Elsewhere there was no trace of either tuberculous, grey, or semi-transparent matter. The bronchia were thin and of a pale pink tinge. Heart, flaccid ; right ven- tricle rather larger than the left, with the parietes only one line thick; the aorta, of a bright red color, which gradually faded in the large ramifications ; crural veins filled with coag- ulated blood. Abdomen. — A pint of fluid in the pelvis; liver, of mod- erate volume, tawny, and rather adipous ; spleen, twice its usual size, of a dull red color and much softened ; gastric mu- cous membrane, red and softened in a portion of the great cul-de-sac, elsewhere healthy ; mucous membrane of the small intestine, natural ; that of the large intestine, of a bright red and very soft ; uterus, augmented in volume and softened ; its internal surface was of a brown red color, in contact with a sanguineous fluid ; it presented a reticulated appearance ; in one portion, which was prominent, and which doubtless cor- responded to the attachment of the placenta, it was easily removed, and formed a layer of about a line thick. The vaginal parietes were red, and on the left side presented a perforation of half an inch in diameter, opening into an abscess lying on the iliac bone. 421. When the patient was admitted into the hospital, there was no evident emaciation ; her muscular system was well developed ; in short, every thing indicated a recent affec- tion ; our reiterated questions as to the state of her health z 2 378 SYMPTOMS. — ACUTE PHTHISIS. [Part II, during pregnancy, were always answered by her saying, she was perfectly well, and that the cough and the other symp- toms had come on six days after lying-in ; so that we must admit that the left lung underwent the alteration we have described in the space of one month. 422. The condition of the lung has been incompletely noted ; we have omitted to indicate the structure of the small abscesses, and it may be questioned whether they were not the result of some other affection than the tuberculous. If dilatation of the bronchia (and we think we have only to choose between this lesion and tuberculous excavations) was the cause of the appearance, the disease must certainly have been chronic, the communications of the principal bronchial divisions easy to be established, and the contents of the cavities thin. But in this case the disease was recent, and we could not discover any communication with the bronchia, and they were dense exteriorly, all which characters are not unusual in a tuberculous affection. Although the communication be- tween the cavities and bronchia was not demonstrable after death, the cavernous râle which existed during life seems to have indicated its existence ; we must also recollect the adi- pous state of the liver, which we have seen is almost confined to phthisis (161). We may then regard this observation as an example of acute phthisis, passing through its different stages in thirty days. It is remarkable that out of five cases of this affection, in two it was limited to one side of the chest. 423. We shall offer no remarks on the majority of the complications which were present, only recalling the pains and weakness of the right side of the body, when some bloody sub-arachnoidean infihration, more at the right side than at the left, was the only encephalic alteration. Is there any connexion between this lesion, and especially the unequal dis- tribution of the fluid and the symptoms? Chap. 9.] PERFORATION OF THE LUNG. 379 CHAPTER IX. SYMPTOMS OF PERFORATION OF THE LUNG BY A SOFTENED TUBERCLE DISCHARGING ITSELF INTO THE PLEURAL CAVITY. 424. This species of perforation pointed out by Laennec, presents itself under two principal divisions ; in one, a com- munication is established between the pleural cavity and the bronchia in the other, this is not the case. In both, the mo- ment of perforation is marked by very serious and character- istic symptoms which, when well marked, render our diag- nosis, if not certain, at least extremely probable. We shall prove this assertion in the following observations.* THIRTY-EIGHTH OBSERVATION. A MAN, set. 36, of small stature and impetuous character, was admitted into the hospital of La Charité, September 16th, \822. He had quitted a few days before the prison of Poissy, where he had been confined five months, having con- tracted soon after his arrival a cold, which had made continual * The first four observations of this chapter have been already published in our researches on various diseases ; subsequent experience having only confirmed the results contained in our first work. We have, as it were, changed them in no respect, except that we have introduced some points in detail which were suppressed in the observations, and we have given them the form adopted throughout this work. — Louis. 380 SYMPTOMS. PERFORATION OF THE LUNG ; [Part II, progress. Emaciation had commenced with the cough, and during two months he experienced daily rigors, epigastric pains, with fluid and frequent stools. Three days before en- tering the hospital, he was attacked suddenly, after having vomited on account of being exposed to the fumes of burning charcoal, with a violent pain in the left side, accompanied with dyspnœa, and great anxiety ; after twenty-four hours the violence of the symptoms somewhat abated. On the third day from their invasion, the patient, who resided about three hun- dred paces from the hospital, came there on foot having occu- pied an hour and a half in so doing. The next day the pain and anxiety being still considerable, twenty leeches were applied to the chest. Two days afterwards (19[h), face was pale, fatigu- ed ; his breathing thoracic and frequent, with orthopnoea ; acute pain ; percussion unusually clear over the whole of left side, more clear than on the right, and no respiration could be heard there, either in inspiration or expiration, nor any metallic tink- ling ; the intercostal spaces were prominent and wide ; cough rare, some nummulated sputa ; pulse, one hundred and twenty ; action of heart scarcely audible in the precordial region ; mouth, clammy ; thirst, urgent ; very little appetite ; sense of weight in the epigastrium after food ; pain on pressure in the same region, which has been the case for the last two months. (V. S. § X. ; infusion of violets; with gum syrup; gum potion ; julep.) 20th. Symptoms nearly the same ; fresh application of leeches to the left side, which was three quarters of an inch larger than the right ; the next day a blister was applied. 25th. Pulse, down to ninety-two ; the dyspnœa variable, sometimes very urgent ; decubitus, as before ; left side still increases without any change in auscultation and percus- sion. Chap 9.] DYSPNŒA ; pain ; percussion clear. 381 There was but a slight change in the symptoms during the following days. The patient dishking examination, ausculta tion was not again practised until the 5th of October. In the upper fourth of the left lung, there was then a confused mur- mur, and opposite the inferior angle of the scapula, when the patient spoke, there was metallic tinkling. In the same point, and lower down, the sound on percussion was dull ; anteriorly it was clearer tlian natural, but here there was no metallic tinkling ; the pain had ceased ; the left arm was œdematous. On the 7th, the metallic tinkling was heard five inches below the axilla, and nearly every where on the same side of the chest posteriorly, On the 8th, it was evident immediately under the axilla. On the 13th, it was heard in the same region and on a level with the mamma ; inferiorly, percussion was perfectly flat. On the 20th, percussion was very clear between the clavicle and mamma ; the metallic tinkling was no where heard. Cough, not very frequent; expectoration, scanty. On the 21st it was sanious, and resembled what is often found in tuberculous excavations. The patient remain- ed constantly in the sitting posture. The appetite was ex- ceedingly variable ; epigastrium, always painful on pressure, and the lightest food, soup, &c. caused a sense of weight in the same region ; stools, more or less frequent ; little perspi- ration ; daily increase of weakness. The infiltration of the left arm continued until death. 8th. Erysipelas in the elbow joint, which went through its usual stages as if no complica- tion existed. 18th. Some slight redness and swelling of thighs; the next day these symptoms were increased. 21st. Great alteration of the expression, and he expired at three, p. M., on the thirty-third day from the origin of the symptoms which indicated perforation. 382 SYMPTOMS. PERFORATION OF THE LUNG; [Pai't II, Opening of the corpse seventeen hours after death. Exterior. — Considerable infiltration of the lower ex- tremities, especially on the left side, where the inguinal glands were redder and more voluminous than on the right. On the left arm, where the erysipelas had occurred, the skin was still rather red, about a line thick, and lying on a layer of concrete pus, more than half an inch in depth, which was deposited in the midst of infiltrated serum. Head. — Moderate infiltration beneath the arachnoid ; three small spoonsful of serum in the lateral ventricles. Neck. — A superficial ulceration, one inch in length and half an inch wide, on the lower part of the muscular portion of the trachea. Thorax. — On the left side there were nearly four quarts of greenish-colored pus, free from odor, surmounted by a small quantity of air. The lung presented some cellular adhesions at its summit, and was invested elsewhere by a false mem- brane, which lined the diaphragmatic and costal pleural. The lung was flattened against the vertebral column, about two inches and a half in its thickest portion, presenting posteriorly, opposite the angle of the third rib, a rounded opening, four lines in diameter, the termination of a canal of the same dimen- sions, which, after an inch and a half, was continuous with one of the large bronchia. This canal was lined by a membrane which reposed either on tuberculous granulations or healthy lung, and evidently resulted from a larger cavity, successively narrowed by the compression of the air and pus. There were some small, incompletely excavated cavities in the summit of the same lung, with numerous grey, semi-transparent granula- tions. The right lung presented superiorly a depression cor- responding to a semi-cartilaginous mass, enveloped by a black Chap. 9.] dyspnœa; sudden pain, &c. 383 and dry substance with some softened tubercles. The mu- cous membrane of the bronchia was of a bright red. Some ounces of serum in the pericardium. Heart and aorta, nat- ural. Abdomen. — Stomach, somewhat distended by fluid; its lining membrane was exceedingly soft in the great cul-de-sac, where it presented some red spots, and in the lower portion of the sanie region, over a surface of two inches, it was de- stroyed, and the cellular layer was gone in some points. Else- where the consistence and thickness were normal. In the last quarter of the small intestine there were three large annular ulcerations, with numerous very small ones in their intervals, and tuberculous granulations, some of which were ulcerated at their summit. The mucous membrane of the large intestine was everywhere softened, and presented some ulcerations in the ascending colon. The liver and pancreas were natural ; the spleen vvas very soft and voluminous. THIRTY-NINTH OBSERVATION. 425. A SEMPSTRESS, set. 45, of a pretty strong constitution, although constantly subject to difficult digestion, had been ill fifteen days when she was admitted into La Charité, June 4th, 1824. Her illness had commenced with cough, expec- toration, and a pretty copious hagmoptysis, which lasted eight days, and had since been frequendy repeated, especially dur- ing the last four months. From the same period the dyspnœa had become considerable ; she had frequent pains in the sides of the chest ; almost constant rigors and perspirations ; she had lost her flesh and appetite, and vomited nearly every 384 SYMPTOMS. PERFORATION OF THK MJNG ; [Part II, thing she took. For three months, epigastric pains, frequent colics, with mucous and bloody stools were associated with the preceding symptoms. She had not kept her bed nor ceased her occupation. 9th. Some emaciation ; skin, rather yellow ; headache ; pains in the limbs ; expectoration, frothy, white or greenish, semi-opaque. Under the left clavicle, where the pains had been almost constant for three months, percussion was perfectly flat ; the respiration was tracheal, and pectoriloquy very distinct over three inches of surface ; below this there was some cavernous râle. On the right side the respiration seemed natural. Appetite, feeble ; tongue, moist, and of a good color ; cold drinks insupportable ; epigas- trium very sensible to pressure, offering a resistance to the hand, which extended along the right false ribs. (Decoction of polygala, with quince syrup ; julep ; three rice creams.) On the following days there was rather copious diarrhoea, and from the 18th to the 20th, constant nausea, with complete anorexia. A gum potion with syrup of poppies was prescrib- ed, and after three days the symptoms abated, the appetite returned, and she was soon able to eat one fourth of the house allowance, with only a slight sense of weight in the epigas- trium ; about the same results obtained from percussion and auscultation. July 20th, at eleven, a. m., when free from suffering, she was attacked with jjain near the inferior angle of the scapula, which was at first moderate, then suddenly very violent, with dyspnœa, anxiety, continual cough, and orthopnœa. These symptoms did not abate during the night, and the pain frequently seemed to extend from the back over the v.'hole of the chest, as far as the umbilicus, again returning to the back. In the morning the respiration was extremely difficult, the- Chap. 9.] DYSPNOEA ; sudden pain, &;c. 385 racic, and fifty-two in the minute ; the patient said she was suffocating, and that no posture was easy ; the face was altered without, however, having an expression of intense suffering ; the pain in the back was acute, and the shghtest percussion on the right side of the chest was insupportable; the per- cussion was much clearer on the right than the left side, even when attempted at the most sonorous part of the former ; respiratory murmur, absent there, except posteriorly and supe- riorly ; no metallic tinkling ; pulse, regular, extremely small and weak, a hundred and twenty-eight ; constant palpitations. All these symptoms persisted ; the anxiety increased ; there was no change in auscultation, and after intense suffer- ing, sometimes interrupted by a transitory stupor, she expired on the 23d, at twelve, m,, three days after the commencement of the pain. Opening of the corpse twenty-eight hours after death. Exterior. — Considerable emaciation. Nothing else re- markable. Head. — Some arachnoidean granulations on both sides of the longitudinal fissure ; pretty thick sub-arachnoidean infil- tration ; cortical substance of the brain, rather pink. Neck. — Larynx and trachea, natural. Thorax. • — An incision made into the right side of the chest gave vent, with some noise, to an inodorous gas ; the pleu- ra, which lined the dorsal region, was covered by a soft false membrane, in contact with four ounces of turbid fluid. The lung occupied rather less than one third of the thoracic cavity, and adhered for about three inches to the surrounding parts, by means of a false, semi-cartilaginous membrane, half a line thick. Immediately below this adhesion posteriorly, there A 3 386 SYMPTOMS. PERFORATION OF THE LUNG ; [Part 11, was a rounded opening, three lines in diameter, communica- ting with a sm-all cavit}-, lined by a very thin false mem- brane resting upon healthy pulmonary tissue. This small cavity did not conimnnicate either with the bronchia, nor with a very large excavation just above it, which was in- vested by a double false membrane, the inner layer of which was soft, the other semi-cartilaginous. In the three lower fourths of this lung there were only some grey, semi- transparent granulations. The left lung adhered to the costal pleura in its upper half, and presented at its summit a large excavation, communicating with the bronchia, and also with numerous small cavities ; in the two upper thirds there were numerous grey granulations, surrounded by a yellowish, moist, semi-transparent substance, firm, homogeneous, and entirely deprived of air ; the remainder of the organ was red and hep- atized. The bronchia were of a bright red color. Two ounces of serum in the pericardium ; heart sound. Abdomen. — The liver, voluminous, uneven, deeply grooved at the right of the suspensory ligament, rather red, especially in the right lobe ; it covered the stomach, and extended nearly to the umbilicus. The stomach was contracted ; its internal surface was nearly every where covered by mucus, presenting near the cardia a white space about four inches in surface, where the lining membrane was extremely thin, pale, and soft as mu- cus ; whilst the surrounding portion was mamlUated, pink- colored and thickened to the right ; very thin and of a bright red to the left. Near the pylorus were numerous red bands, one inch long by three lines wide, where the mucous mem- brane was thin and depressed. In the small intestine this membrane was red and injected, but of normal thickness and consistence ; in the colon it was red, softened, and with small ulcerations. Chap. 9.] ACUTE DYSPNŒA ; ANXIETY, &c. 387 FORTIETH OBSERVATION. 426. A woMANj, aet. 32, tall and strong, entered the hos- pital of La Charité, Sept. 11th, 1823. She had constant- ly coughed and expectorated the last eleven months, with frequent haemoptysis and pains between the shoulders ; rigors, followed by heat and perspiration, with epigastric pains, were present fvon the commencement. Her breathing had been affected for a long time. The day after admission the expression was animated ; headache ; speaks hurriedly, with occasional aphonia ; atti- tude, easy ; respiration, natural, except on the right side pos- teriorly and superiorly, where it was rather tracheal ; some dyspnœa ; expectoration, greenish; no pectoriloquy; pulse, rather quick ; heat elevated ; tongue, clean and moist ; appe- tite, depressed : pain on pressure in the epigastrium ; consti- pation. (Infusion of Iceland moss ; pectoral ptisan ; gum potion with syrup of poppies; emollient enema ; one eighth of the house allowance.) From that time to the 20th of December, when she ex- pired, the following is the result of our observations : — In the beginning of October the patient complained of great heat between the shoulders ; there was resonance of the voice and traclieal respiration in the same point and under both clavi- cles, especially the right ; percussion, every where clear; ex- pectoration, puriform. December 4th. Doubtful pectoriloquy between the shoul- ders and under the left clavicle ; gurgling in the same point, over a space of six inches. In the night of the 19th, some 388 SYMPTOMS. PERFORATION OF THE LUNG ; [Part 11, acute pains were felt in the back ; in the morning these had diminished, without any evident increase of dyspnœa. The following night she was attacked by a violent and sudden pain along the vertebral column, accompanied with dyspnoea and anxiety. The next morning the patient was in the sitting posture, spoke only of her pain and difficulty of breathing, and assured us of the suddenness of the attack ; the countenance was altered, and percussion was clearer to the left, posteriorly and laterally, than on the right side. Over the same extent, instead of the respiratory murmur, there was only a mucous râle, which appeared to traverse an empty space before arriv- ing at the ear ; there was no metallic tinkling ; and on the patient's lying down and rapidly rising, no peculiar sound was heard ; the breathing was very frequent, with great agitation ; she expired at ten o'clock the same evening, after intense suffering. The heat was constantly elevated, and the night perspirations copious. These were unsuccessfully treated during two months, by the aqueous infusion of bark, in doses of from eight to ten ounces a day. In the beginning of October the appetite w^as feeble ; there was a bitter taste in the mouth ; the tongue was whitish ; there were occasional vomitings during the paroxysms of the cough ; these were present with a still greater anorexia and a natural state of the tongue, on the 4th of December. On the 10th, the thirst was more urgent ; all drinks produced a sense of weight in the epigastrium ; during several days there was con- siderable diarrhœa. The emaciation was rather rapid, and on the 4th of December the left arm was œdematous. Opening of the corpse thirty-four hours after death. Exterior. — Considerable oedema of the left arm. Noth- ing else remarkable. Chap. 9.] ACUTE DYSPNŒA J ANXIETY, SlC. 389 Head. — Three small spoonfuls of serum in the lateral ventricles. The remainder of the encepalon, healthy. Neck. — Trachea and larynx, natural. Thorax. — Only a small quantity of gas escaped from the left side, which contained about three quarts of a sanguinolent fluid, without any fragments of albumen. A soft membrane, ofa deep red color, and one quarter of a line thick, every where invested the lung and thoracic parietes. The summit of the lung, for two inches and a half, was intimately adherent to the neighboring parts; and almost immediately beneath this adhesion posteriorly there was a rounded opening, about the size ofa pea, communicating with a vast excavation, contain- ing a very small quantity of a greyish fluid, similar to what was in contact with the diaphragm. This cavity communicated with the bronchia. The upper five sixths of the lung were transformed into an indurated, greyish, semi-transparent sub- stance, interspersed with numerous tubercles and small exca- vations ; these communicated with each other, and in some points were separated by a very thin layer only from the tho- racic cavity ; the lower sixth of the lung was crepitating ; the bronchia were of a pale pink color. There were some exca- vations in the summit of the right lung, and at its base some crude tubercles ; heart, one third less than its usual volume ; aorta, every where ofa bright red. Abdomen. — Stomach, larger than usual ; lining membrane of a pale rose color in some parts ; mamillated anteriorly and in a portion of the great cul-de-sac ; in the same points it pre- sented some ulcerations, from two to six lines in diameter ; in the rest of hs extent it was of normal consistence and thick- ness. In the small intestine there was much mucus, but its membrane was pale and firm, and in the lower fifth some ellip- tical patches were ulcerated ; the mucous membrane of the 390 SYMPTOMS. PERFORATION OF THE LUNG ; [Part II, large intestine was pale ; the ulcerations diminished in fre- quency on approaching the rectum, where only one existed. The liver was soft, easily torn ; the bile rather fluid, and not high colored ; spleen, a little softened ; cortical substance of the kidneys much redder and moister than usual ; pancreas, indurated ; uterus, healthy. FORTY-FIRST OBSERVATION. 427. A WOMAN, ast. 26, of a feeble constitution and ex- treme sensibility, entered La Charité, November, 15th, 1823 ; she had lost her flesh the last two years, which she ascribed to mental anxiety. Though little liable to taking cold, she had constantly coughed and expectorated during the last five months, and during the first fifteen days of the pulmonary affection, was sensible of fever, with headache, much oppression, and the expectoration was occasionally bloody ; the symptoms were subsequently much milder. During the last six weeks her appetite had almost ceased, and she had frequent colic, also rigors, followed by heat and night perspirations. Nov. 16th. Expression, rather animated ; considerable weakness, with marked emaciation ; voice, feeble, husky, the last two months ; cough, frequent ; expectoration, greenish, imperfectly nummulated ; respiratory murmur, weaker in the upper half of the left side than in the right, in the correspond- ing part; elsewhere, the respiration was natural, and no reso- nance of voice nor pectoriloquy could be detected ; heat, mod- erate ; pulse, one hundred ; and the preceding evening her usual rigors, followed by heat, had returned at eleven, p. m. Tongue, rather red on the edges, villous and yellowish in the Chap. 9.] ACUTE PAIN ; faintness ; dyspnœa, &ic. 391 centre ; appetite, diminished ; epigastrium, yielding ; the right lumbar region resisting, without evident tumor ; stools, regular. (Pectoral ptisan ; infusion of Iceland moss ; one fourth of the house allowance.) The febrile paroxysms incommoding the patient, the sul- phate of quinine was employed ; but on account of the un- easiness, vertigo, epigastric pains, &;c., which followed its administration, it was suppressed on the 27th. The rigor had ceased, though the heat returned at the usual hour. December 4th. Tracheal respiration under the left clavicle ; constipation ; almost complete anorexia ; return of the rigors. On the following days the cough provoked nausea, and the constipation was succeeded by copious diarrhosa. In the night of the 1st of January, she experienced sudden- ly a sensation in the left side of the chest, similar to what would have been caused by the circulation of a gas from be- low upwards in this same part; the breathing at the same time became very difficult ; there was a tendency to fainting, and almost immediately afterwards a very acute pain behind the left mamma. In the morning this pain continued; it was deeply situated ; the breathing was much more hurried, and the patient was obliged to lie on the right side; much general uneasiness ; the sensation of the presence of gaseous fluid no longer existed. On the left side the chest resounded like a drum ; no respiiation nor metallic tinkling could be heard ; the aphonia was complete ; face pale ; lips discolored, and the patient was threatened with syncope if she attempted to sit up ; pulse, feeble, small, one hundred and sixteen. The state of the respiration having been accurately ob- served up to the 16th of January, the result of our observa- tions was the followinii : — 4th. Under the left axilla some 392 SYMPTOMS. — PERFORATION OF THE LUNG ; [Part IT, very weak respiration, with slight mucous râle under the clav- icle of the sanae side. 5th. xMetallic tinkling two inches below the clavicle when the patient spoke. 7th and following days, it extended more over the chest, and was caused by inspira- tion as well as speaking. The pain becoming more acute, leeches were applied on the evening of the iOth. The next day the dyspnœa was increased, breathing very hurried, pain diminished, metallic tinkling, as for some days past, heard over the three lower fourths of the chest, which last gave a very clear sound on percussion, whilst there was no respiratory sound there ; no change up to the 16th. On the 17th, the dyspnœa was much increased ; percussion of left side was still clear. She expired on the 18th, without suffering, a few minutes after saying to M. Chomel that she needed sleep. From the commencement of the pneumo-thorax, the decu- bitus was constantly on the right side ; the aphonia occasion- ally disappeared ; the cough was not generally very frequent; the expectoration, greenish, nummulated ; pulse, small, weak, and frequent; there was little mental depression, and hope of recovery was present to the last. There was no appetite ; alternately constipation and diarrhœa ; some mucous vomit- ings for a (ew days after the perforation. Opening of the corpse twenty-three hours after death. Exterior. — Nothing remarkable ; considerable emacia- tion. (Brain and larynx could not be examined.) Thorax. — Percussion of the left side, clear only anteri- orly ; it contained rather more than one hundred cubic inches of a gas, which proved to be carbonic acid ; the remainder of the thoracic cavity on this side, that is, about three fourths, contained a turbid, greenish fluid. The right lung" was scarcely twice as large as the closed hand ; it was adherent at its sum- Chap, 9.] ACUTE pain; faintness ; dyspnœa, he. 393 mit for about two inches, and immediately below this adhe- sion, posteriorly, there was a rounded opening of two lines and a half in diameter, with thin edges, and communicating with a cavity, about the size of an ordinary apple ; it was an- fractuous, and lined by tuberculous fragments lying on a thin false membrane, pierced in several points by the orifices of the bronchia. Below the perforation there were numerous yel- lowish patches, corresponding to softened tubercles, on the point of emptying themselves into the pleural cavity ; the re- mainder of the lung was soft, not containing air, but some tubercles, which diminished in number towards the base. The pleura was every where invested by a thin false membrane, firm superiorly ; and in contact with the diaphragm, there was a greenish substance, of a gelatinous consistence, enough to have filled an ordinary tumbler. The right lung presented some adhesions, with a small excavation and tubercles in its upper lobe. Heart, small ; aorta, healthy. Abdomen. — The stomach contained a moderate quantity of viscous and yellowish mucus ; the lining membrane was of a tawny color, nearly every where mamillated, of good con- sistence, and partially destroyed over a surface of two lines in length on the small curvature ; that of the small intestine pre- sented in its lower half numerous small ulcerations ; it was of a bright red color, and a little softened near the ceecum, for the space of two feet. The lining membrane ^of the large intestine was throughout as soft as mucus, red and ulcerated in the ascending colon, with a light pink tint over the other parts of it ; the liver extended for a breadth of three fingers beyond the ribs, was rather voluminous, of a dull yellow color spotted with red, of moderate consistence and rather adipous. Bile of the gall-bladder, pale and thin ; the other viscera of the abdomen were natural. B 3 894 SYMPTOMS. PERFORATION OF THE LUNG ; [Part 11, FORTY-SECOND OBSERVATION. 428. A PORTER, set. 26, short, well made, with red hair and well developed muscular system, was admitted into the hospital November, 8th, 1824 ; he had been employed in the service of the army from his twelfth to his twenty-fourth year; had enjoyed good health, and dated his present illness eight months ; he had coughed and expectorated during the same period, and attributed his cold to the bad condition of the office where he pursued his occupation. The cough had greatly increased, came on in paroxysms, and during the last five months the expectoration had become opaque ; in the fourth month, during fifteen days, he had experienced acute pains in the back, and these had been felt in the left side of the chest for the last fortnight ; at the commencement there was no fever, but for three months there had been increased heat in the evenings, with constant copious perspirations every night. The appetite had not diminished, but the last two months it had been rather more urgent than usual ; bowels, regular. The emaciation was evident three months from the commencement of the first symptoms, and from the same peri- od the patient had ceased his occupations. November 9th. Great weakness ; little emaciation ; a slight intermitting pain in the left side of the chest ; moderate dys- pnoea ; cough, frequent and in paroxysms during the night ; expectoration, scanty, greenish, opaque, imperfectly nummu- lated ; respiratory murmur, confused, with mucous râle and some dulness of sound under the right clavicle, with resonance of the voice post! riorly in the corresponding point ; on the left side the respiration was weak posteriorly. Pulse, slightly Chap. 9.] DYSPNŒA ; acute pain, &c. 395 accelerated; heat and copious perspiration lastnijrht; appe- tite, good ; tongue, clean ; abdomen, not painful ; stools, rare ; patient calm. (Infusion of Iceland moss ; gum potion with a grain of opium in the evening; a quarter of the house allowance.) 20th. Immediately under the right cla^icle it seemed as if a small pufFof air entered the stethoscope when the patient spoke. On the morning of the 28th, the sputa presented some streaks of blood, and in the evening there was an expec- toration of about twelve ounces of blood. This continued more or less until the 8th of December, and seemed to di- minish after the use of a gum potion, which contained a drachm of powdered ratanhy root, and it disappeared com- pletely on^ the third day ; three bleedings from | x. to § xij. each, with demulcent drinks, had been previously tried with- out success. During the first four days of the haemoptysis, there was a crepitating râle on the left side, every where pos- teriorly, and in the lower half anteriorly. 9th. Respiratory murmur, nearly natural on the left side ; sputa, white, greenish and nummulated ; thirst, moderate; pulse, calm ; the appetite, which for a time diminished, re- turned ; there was no diarrhœa ; dyspnoea increased ; the cough continued strong during the night. There was little change up to the 30th ; the cough usually excited pain in the left side. 5th. Pectoriloquy evident under the right clavicle, with slight crepitation in the lower half of the same side ; it was nearly universal on the left, and on the 28th it was con- fined to this side. 31st. The patient complained of increased suffering during the cough in the leftside. In the evening the pain became suddenly very acute, with considerable dyspnœa ; the next day the difficulty of breathing and anxiety were ex- treme. January 2d. At seven, a. m., the patient was quite 396 SYMPTOMS. PERFORATION OF THE LUNG ; [Part II, conscious, and clearly remembered what had occurred since the invasion of the pain, but already his sight had become confused ; the face was bathed in perspiration ; the dyspnœa was extreme, breathing very rapid; percussion of chest much clearer ante- riorly on the left side than on the right. In the same region no respiratory murmur nor metalhc tinkling could be heard ; suffocation seemed imminent, and two hours afterwards she expired. The same day, the expectoration was greyish, of a disagreeable aspect, like viscid size. There were some pains in the region of the larynx. From the 15th of December the heat during the evening was considerable ; perspirations, copious during the night, without rigors ; no chills ; thirst, moderate ; the appetite gradually diminished and then entirely disappeared^ diar- rhœa present during the last five days only. Opening of the corpse iiventy-three hours after death, ExTEKioR. — Muscles, thick, firm, well colored ; emacia- tion, only commencing. Head. — A small spoonful of serum in each lateral ven- tricle ; a spoonful at the base of the skull ; no other altera- tion. Neck. — Epiglottis and larynx, natural ; lining membrane of the trachea, red, of normal consistence and thickness, pre- senting immediately above the bronchial bifurcation two small irregular ulcerations, from one third to a fifth of an inch in surface, with a thickened state of the submucous layer in the corresponding point. Thorax. — An inodor<:fUs gas escaped, with ome noise, through a small incision made into the left side of the chest. There was a space of from two to three inches between^ the lung and parietes of the thorax, augmenting from above Chap. 9.] DYSPNŒA ; acute pain, &tc. 397 downwards; the lung was fixed by four whitish, thin, firm bands, uniting the puhnonary and costal pleuraî. Its base, and the corresponding portion of the diaphragm were lined by a soft false membrane, with a reticulated appearance, thick, and in contact with about twelve ounces of a pretty clear reddish fluid. Its upper lobe was enveloped by another false membrane, half a line thick, and semi-carlilaginous ; and at its lower portion there was a rounded yellow patch, a line in diameter, corres- ponding to a softened tubercle, which had been partially dis- charged into the pleural cavity. The opening was in part closed by a small quantity of tuberculous matter, and the cavity lined by a thin, soft, light colored false membrane ; there was no communication with the bronchia. Towards the central part of the same lobe there were three excavations, similar to the one we have described, surrounded by healthy lung, and in the summit two other smaller ones, as large as hazel nuts, surrounded by indurated, greyish tissue where the red and thickened bronchia terminated. The lower lobe was slightly engorged, and contained some semi-transparent gran- ulations. The right lung adhered every where to the costal pleura by dense cellular membrane ; its summit was indurated for the space of three inches, and presented four excavations, about the size of a cherry filled with greenish pus, and sur- rounded by a firm greyish structure ; this was intersected by numerous while, semi-cartilaginous or cellular septa, irregular- ly distributed and exuding, when pressed, a very small quan- tity of greyish fluid. The communicating bronchia were of a bright red, and their mucous membrane thickened. The lower lobe was a little engorged, contained two or three tuber- cles, and some isolated portions of hepatized lung, of the size ' of a ruit. The bronchial glands were grey and voluminous, not tuberculated. Heart and aorta, healthy. 398 srMPTOMs. — perforation of the lung ; [Part II, Abdomen. — ■ Stoinacli, twice as large as u.?ual, reaching a little below the umbilicus, and containing a large quantity of viscous mucus ; its lining membrane was of a dark red color posteriorly, rather soft anteriorly, where its color was natural. The elliptical patches of the small intestine were ulcerated in the lower sixth ; on them., likewise, there were numerous tuberculous granulations, the softening of which seemed to have been the source of the ulcerations ; no other alteration of the mucous membrane. In the ascending colon there were six small greyish ulcerations ; the corresponding cellular tissue, rather thickened, and here and there destroyed : between these ulcerations there were others still smaller. Throughout the whole of the large intestine the lining membrane was a little softened and thickened. The mesenteric glands were reddish and voluminous, not tuberculated. Spleen, pale, and nearly twice its usual volume ; the other viscera, healthy. FORTY-THIUD OBSERVATION. 429. A CABINET maker, set. 42, short, of a feeble constitution, but usually enjoying good health, and little subjectt o cold, said that hischesthad never been affected before the commencement of his present illness. He had been ill five months, having re- linquished his occupations the last two, without however being confined to his bed. He was attacked, without any evident cause, by a rather violent cough, with clear expectoration. In the beginning of the fourth month this was combined with dyspnoea and acute pains in the right side, requiring the appli- cation of leeches and a blister. The expectoration had be- come very thick the last three weeks, and for ten days the Chsp. 9.] DYSPNŒA ; ACUTE PAIN, hc. 399 cough had much increased ; the thirst was urgent, the heat at night augmented, with copious perspirations. The appetite had diminished from the first, and for twenty days had ceased ahogether ; considerable emaciation the last two months ; he has never had rigors, haemoptysis or diarrhœa. January 4th, 1S25 (the day after his admission), the face was pale, with marked emaciation and debility ; cough, rare ; dyspnoea, moderate ; decubitus, variable ; sputa, greenish, opaque, not striated ; percussion, less clear on the right side than the left, especially in the lower half posteriorly and later- ally, where it was completely flat ; respiratory murmur, weak, mingled with a mucous râle nearly every where on the same side ; tracheal respiration and pectoriloquy at the summit of the right lung ; it was less distinct on the left side between the shoulder and vertebral column. Voice, almost extinct the last two months; no pain, or dryness, or heat, in the region of the larynx or trachea. Pulse, small, weak, acceler-- ated ; tongue, moist, whitish in the centre ; mouth, clammy, with bitter taste; anorexia; no thirst; epigastrium, sensible to pressure ; occasional nausea from cough ; three natural stools without colic the preceding evening. Patient is calm, and utters no complaint. There was no sensible change on the following days ; the larynx and trachea were never painful and they were always insensible to external pressure. 10th. He complained of slight pain in the right side of the chest. On the 13th, during the night, he was attacked suddenly with a very acute pain in the left side, accompanied with great uneasi- ness and dyspnœa. In the morning the face was pale, and the expression altered ; the pain was rather less acute, with con- siderable dyspnoea ; decubitus, not very elevated ; percussion, very clear over the whole of the left side. We omitted to perform auscultation until after the visit, when the leeches 400 SYMPTOMS. — PERFORATION OF THE LUNG; [Part II, having been applied directly upon the painful spot, we were unable to finish our examination. He died the same day, at four, p. M., retaining perfect consciousness to the last. Opening of the corpse forti/ hours after death. Exterior. — Considerable emaciation. Nothing else re- markable. Head. — A small spoonful of fluid in the lateral ventricles ; no other alteration. Neck. — Epiglottis, natural. Numerous superficial ulcer- ations on the vocal cords, and for about three lines below them. Trachea, every where of a bright red ; its mucous membrane was entirely destroyed over its fleshy portion, with numerous small, rounded, superficial ulcerations, from one to two lines in diameter, in the rest of its extent ; these existed also in the bronchia, being situated between the rings. The submucous tissue corresponding to the large ulceration in the trachea Vv'as generally thickened ; in some points it was de- stroyed, which caused the part to be very uneven. Bronchial glands, large and greyish, with some tuberculous deposit; cervical glands, healthy. Thorax. — Percussion of the left side, very clear anteri- orly ; the cavity was partly occupied by the lung (which ad- hered by its summit for about three inches), and by a quart of dirty-colored serum, containing numerous yellow albuminous fragments. A very soft false membrane invested the lower lobe, at the upper part of which was an opening of two lines in diameter, communicating with an excavation, about the size of a nut, lined by the remains of tuberculous matter, with- out any false membrane, and communicating with the bronchia. This lobe contained numerous grey, semi-transparent granula- tions ; the summit of the upper lobe was indurated, with a Chap. 9.] ACUTE pain; dtspnœa, he. 401 large quantity of grey and blackish matter, in the centre of which there was a tubercle about the size of a common nut ; elsewhere there was very little greyish matter, but some irreg- ularly dispersed tubercles. The right lung adhered to the cos- tal pleura by means of a firm false membrane two lines thick inferiorly ; the upper lobe was almost entirely converted into a grey, shining, elastic substance, surrounding numerous dull white granulations ; it presented at its summit two excava- tions, about the size of a nut, filled with a turbid, reddish fluid and scattered tuberculous fragments, but no false mem- brane ; the inferior lobe contained a similar cavity, with some grey granulations and engorged portions. Heart, healthy j some irregularly distributed redness in the aorta. Abdomen. — The gastric lining membrane presented a pink tint in the great cul-de-sac, where it was extremely soft- ened in some spots ; it was perfectly healthy near the py- lorus, rather softened elsewhere, and partially ulcerated in some points of its lower half. In the middle third of the small intestine there were numerous transversal ulcerations, three of which encircled the gut ; lower down the elliptical patches were nearly all ulcerated,"^ with destruction of the corresponding raucous membrane ; the submucous tissue was rough, thickened, presenting numerous small excavations in the same points ; elsewhere the mucous membrane was healthy. In the ascending colon there was one large ulceration, with numerous smaller ones in the rectum and caecum, and in its appendix. The lining membrane was softened in the lower half of the large intestine ; the other abdominal viscera were healthy. 430. U we now glance over the preceding observations, we c 3 402 SYMPTOMS. — • PERFORATION OF THE LUNG ; [Part II, find that at a variably advanced period of phthisis, the patients experienced, sudclenJy, m one side of the chest, a violent pain usually with extreme dyspnœa and intense anxiety, which were succeeded by all the general symptoms of acute pleurisy ; that these symptoms persisted unabated or with slight remis- sions to the last, death following their appearance in twenty- four hours to thirty-eight days (Obs. 38, 40) ; that after death there was found a variable quantity of air, pus, or bloody-col- ored fluid in the side of the chest where the pain had been felt, and also a perforation of the lung from the opening of a tuberculous excavation into the pleural cavity. 431. The connexion of the symptoms with the state of the kings after death is so striking, that the simple exposition of the facts is sufficient to show their mutual dépendance. The pain is caused by the passage of the tuberculous matter into the pleurae, while the dyspnoea and anxiety are the effects of the more or less rapid effusion at first of air, and afterwards of a variably composed fluid -, so that whenever, in case of phthisis, a violent pain in one side of the chest shall come on suddenly, accompanied with dyspnoea, anxiety, and all the general symptoms of acute pleurisy, we may conclude that perforation of the lung has taken place in the manner we have described. At least, it was by these symptoms that we diag- nosticated with M. Chomel the accident in question, in the examples we have just detailed. 432. These symptoms are besides so rational, that we might almost have anticipated their presence à priori; and from the analogy existing between the perforation of the small intestine and that of the lungs, they might still more easily have been foreseen. There is, in fact, in both cases at the instant of per- foration, an effusion of irritating fluid on a serous membrane ; and, as sudden pain with all the symptoms of intense inflam- Chap. 9.] SUDDEN DYSPNŒA AND ANXIETY. 403 mation occurs in one case, we might naturally expect to find them in the other. But if this sudden pain in a certain part of the abdomen, accompanied by the symptoms of intense peritonitis, is sufficient for the diagnosis of perforation of the intestine, it is natural to suppose that the case would be the same in perforation of the lung, and that a pain equally sud- den and severe in one of the sides of thechest, connected with extreme dyspnoea and with the other symptoms of pleurisy, would be sufficient, especially in a phthisical patient, to prove its existence. 433. Sudden dyspnœa and anxiety, independently of pain, may also lead us to suspect the presence of perforation. Of this the following observation is a proof. FORTY-FOURTH OBSERVATION. A WOMAN, œt. 24, of a rather delicate constitution, was ad- mitted into the hospital of La Charité, September 28th, 1824. She was subject to shortness of breath from her in- fancy, was little liable to colds, and then only for a few days ; had never had pneumonia, and had now been ill three months and a half Without any appreciable cause, she was attacked at first with cough and white expectoration, which gradually be- came opaque and greenish ; rigors, at first frequent and irregular, afterwards rarer j there had been increase of her habitual dys- pnœa, night perspirations, and, since the third month, increas- ed heat in the evening ; appetite, a little diminished ; vomiting often occasioned by cough ; from the first, emaciation was evi- dent ; no diarrhoea. September 29th. Face, rather pale ; considerable debility ; 404 SYMPTOMS. PERFORATION OF THE LUNG ; [Part II, moderate emaciation ; sleep, often interrupted ; pain in the left shoulder from the commencement, worse during the night than during the day, that is, when the accesses of cough were the most severe ; sputa, greenish, opaque, not striated, surrounded by a very frothy mucus ; percussion, nowhere very clear ; reso- nance of the voice and tracheal respiration under the left clav- icle; pulse, rather quick ; tongue, whitish, and had not a very thick coat ; bitter taste in the mouth ; appetite, pretty good ; digestion, easy ; abdomen, yielding, without pain ; occasional colic the last six weeks ; dejections, infrequent.) (Decoction of Iceland moss ; gum potion ; two cups of milk ; a quarter of the house allowance.) From this period until death, which took place on the 1st of January, the cough was always very troublesome, espe- cially during the night, when the patient was sometimes oblio-ed to retain the sitting posture to relieve the dyspnoea. The pains in the shoulder did not increase ; from Nov. 25th to the 28th they were very acute in the left side, without any increase of the dyspnoea. At this period, percussion was clear under the left clavicle, and we heard indistinct pectoril- oquy both here and in the corresponding point posteriorly ; lower down the respiration was coarse, mingled with a large, dry, crepitating râle. December 24th. Distinct pectoriloquy and a gurgling were heard where the crepitation had existed previously ; difficulty of breathing as before ; decubitus hori- zontal. 26th. The dyspnoea became, suddenly, very intense, without having been preceded or followed by pain in the chest. On the morning of the 2Tth, it was still urgent ; the decubitus was elevated ; the heat considerable ; pulse, rapid; face, injected ; expression, animated ; speech, hurried ; great anxiety; percussion of leftside infinitely clearer than the right ; the respiration in this part was confused and distant, and after Chap. 9.] SUDDEN DYSPNŒA AND ANXIETY. 405 every respiratory movement there was a sound similar to what we produce by blowing into an empty bottle. The abstraction of five ounces of blood produced only a momentary relief. The next day the dyspnœa and anxiety were increased ; she said she should die of suffocation ; no change in auscultation or percussion during the following days, and the patient expired during the night of the Slst, after experiencing every grada- tion of suffocation, but without pain in the left side of the chest. The sputa assumed rapidly the nummulated form, were without smell, although after the 26th of December, the patient's breath was very faetid. It had an odor similar to that which arises from animal matter which has been macerated for some time. From the commencement of the extreme dyspnœa the heat had continued elevated, rigors rare, night perspiration variable. The appetite gradu- ally diminished, and from the 1st of December entirely dis- appeared ; the vomiting, which consisted of food and mucus, yielded about the middle of November, after the use of Seltzer water. For some days the epigastrium was slightly painful ; the thirst was never urgent. Diarrhœa came on in October ; during the first twenty days it was scanty and intermittent, afterwards constant and copious ; faeces, yellow, soft, without blood or mucus. The patient's spirits were pretty good to the last ; she dreaded death, and constantly referred to the sub- ject. She always took the julep in the evening, with a grain of opium in the gum potion during the day; her drink con- sisted of rice water and the white decoction with canella ; the food was diminished with occurrence of the diarrhoea and decreased appetite. Opening of the corpse thirty-tivo hours after death. Exterior. — Considerable emaciation. 406 SYMPTOMS. PERFORATION OF THE LUNG ; [PaVt II, Head. — Some miliary aracbnoidean granulations in groups, adherent to the dura mater ; brain, very firm ; cortical sub- stance extremely pale ; two small spoonfuls of fluid in each latéral ventricle, rather less in the inferior occipital fossae ; en- cephalon, otherwise healthy. Neck. — Larynx and epiglottis, natural ; trachea, of rather a deep red, with two small ulcerations. Thorax. — Left lung, adherent over its upper three fifths by means of a very dense false membrane ; it was elsewhere free, and invested with a reddish soft membrane, prolonged over the diaphragm and ribs, from which it was separated by a space which was partly occupied by a reddish, turbid fluid, which was similar, except in density, to what we find in tuber- cular excavations. Immediately below the adhesions there was an opening of five lines in diameter in the lower lobe, communicating with a cavity which extended upwards into the interlobular fissure. The excavation was lined by yellow- ish tuberculous fragments, traversed by numerous bands of about a line thick, composed of a very dark, greyish, semi- transparent substance, in which no vascular ramifications could be traced : several small excavations communicated with the one described ; a very small portion of the lobe was permea- ble to tJie air ; at the summit of the upper lobe there was a similar and still larger excavation ; the remainder of the lobe presented numerous small cavities communicating together, with a blackish-grey substance in their intervals, so that it was nearly wholly incapable of respiration. The right lung offer- ed inferiorly some adhesions, and in its upper lobe numerous softened tuberculous masses, the largest of which were in the centre ; these were less numerous in the lower lobe, which was engorged in many points, and firm without hepatization in the remainder of its extent. The bronchia were rather red Chap. 9.] METALLIC TINKLING, &1C. 407 on both lungs, aud extensively communicated with the exca- vations ; the bronchial glands were greyish, voluminous, not tuberculated. Heart, rather small ; aorta, healthy. Abdomen. — A quart of clear fluid in the peritoneal cavity. The stomach contained much viscid inucus ; and in the centre of the great cul-de-sac, for as large a space as the palm of the hand, the submucous vessels were much distended, and the lining membrane soft as mucus over one half of this surface ; it was elsewhere healthy. The elliptical patches in the lower fifth of the sm.all intestine were thicker than natural, nearly all more or less ulcerated ; these ulcers were somewhat rough, owinff to the thickeninc; and ulcerations of the submucous tis- sue ; in the intervals there were numerous yellowish granula- tions, many of which were ulcerated ; the mucous membrane in the other portions was healthy. Some small ulcerations in the caecum ; lining membrane of the large intestine, pale, every where thicker than natural ; rather softened in the ascending colon, and elsewhere not firmer than mucus ; sub- mucous layer, white, opaque, and three times as thick as usual in the same parts. Mesenteric glands, red and voluminous, not tuberculated ; the mesocolic, small and healthy ; liver, fatty ; bile in the gall-hladder, natural ; spleen, twice its usual volume ; the other viscera were healthy. 434. Notwithstanding the absence of pain, we did not hesi- tate about the existence of perforation of the lungs, when the patient told us of the sudden invasion of the dyspnœa and anxiety. However, the diagnosis here, as in the preceding cases, was assisted and comfirmed by auscultation and percus- sion ; for on percussion of the suffering side shortly after the commencement of the oppression, pain [was there any pain ?] and anxiety, there was a very clear sound produced, as we 408 SYMPTOMS. — -- PERFORATION OF THE LUNG ; [Part II) already know, and this sound was clearer than that produced by percussion of the opposite side. The ear, when applied to the most sonorous part, was unable to detect any respiration, or at least it was heard as if from a distance, for a short time only, very seldom, and in a very confused manner. This twofold phenomenon indicates, as Laennec has stated, the pres- ence of a certain quantity of air between the costal pleura and the lungs, and as pneumo-thoraxis one of the immediate effects of perforation of the latter, we must necessarily be induced to believe that the pneumo-thorax was the result of it in the pres- ent case. But one readily conceives that in the absence of the symptoms we have mentioned, the pneumo-thorax would have been much less valuable relative to the point we are ex- amining, since it may arise froin other causes than perforation of the lungs. 435. Sooner or later a certain quantity of pus or purulent fluid was conjoined to the presence of a gas, and when this was the case the metallic tinkling was produced by the inspi- ration, expiration, or speaking. This, however, depended on the communication of the pleural cavity with the bronchia (as in Obs. 38, 40, &,c.) ; in those cases auscultation in show- ing that metallic tinkling exists, and percussion announcing the presence of a certain quantity of air in the cavity of the pleura proved, independently of other symptoms, that perforation had existed. But, as the reader may have observed, this combina- tion of circumstances does not always take place (Obs. 39), for sometimes tuberculous cavities, when opened into the pleura, do not communicate with the bronchia, and then there is no metallic tinkling. This may also be the case when the effusion of air is not accompanied by a fluid, or when the latter is too scanty. Auscultation cannot, therefore, detect perforation in any case until some time after its occurrence ; and in those Chap. 9.] METALLIC TïNIILING, StC. 409 instances where no con:intiunication with the pleural cavity ex- ists, the diagnosis depends entirely on the other symptoms. 436. The quantity of fluid necessary for the production of the metallic tinkling, does not seem to he very considerable, since we have heard it (Obs. 41), when percussion detected no dulness of sound. On the other hand, a large accumu- lation of fluid did not appear to interfere with its presence (Obs. 3S). 437. The seven preceding observations, including another which we have thought it unnecessary to detail, are the only examples we have met with ; and in all, the rational symp- toms, independently of auscultation and percussion, were suffi- cient for the diagnosis of the lesion. This seems, however, not to be always the case ; for in the three examples related by Laennec, in his important work on auscultation (Obs. 31, 39, 41), these symptoms do not appear to have been present. When this is the case, nothing would lead us to detect its ex- istence, and if the discovery were made it would be by acci- dent, as it were, by auscultation and percussion, and this could happen only when there is a communication existing with the bronchia, for then alone is there metallic tinkling. 438. Percussion and auscultation would also be the only means of diagnosis we should have of perforation of the lung, if the symptoms were but slightly marked, since they would indicate a pneurao-thorax, of which perforation of the lung is incomparably the most frequent cause. 439. There were some variations in the pain important to be noticed. Acute, inobservations thirty-eight, thirty-nine, forty, and forty-two, it was much less urgent in the others, though from its suddenness, the accompanying dyspnoea, or the mod- ification in the physical condition of the chest, it did not cease D 3 410 SYMPTOMS. PERFORATION OF THE LUNO ; [Part II, to be important for the diagnosis. We have, in fact, seen in observation forty-one, that at the moment the pain came on, and a short time before, the patient thought she perceived the circulation of a gas in the left side of the chest ; a sensation which continued some time, and which was doubtless produced by the passage of the air into the corresponding cavity. In- stead of being surprised at the slight variations in the pain, we ought rather to wonder they were not more considerable ; it was equally acute in observations thirty-nine and forty-two, as in the others, and in both these instances it was caused by the passage of the contents of a very small excavation into the pleural cavity, which did not communicate with the bronchia, whilst in the others the excavation was considerable, and com- municated with the bronchia. Lastly, the pain was absent in one case (Obs. 44), in which the perforation was large, the cavity extensive, and the quantity of the effused irritating matter doubtless very great. 440. The dyspnœa and anxiety, except in observation forty-one, were very urgent, and in this exceptional case, the slightest movement produced a tendency to syncope. This example was also interesting, an account of the decubitus on the right side with the head low, while the majority of the other'patients retained the sitting posture. 441. It is also worth observing, that notwithstanding so great and sudden an obstacle to the circulation, the face was generally of its natural paleness ; a fact, however, which must not be regarded as extraordinary, since we frequently observe patients exceedingly pale when the dyspnœa is extreme ; as for instance, in great dilatation of the heart, and even in some cases where the right and left cavities communicate. 442. The time elaj)sing from the moment of perforation to the fatal termination, must also be noticed. Death, in fact Chap. 9.] PLACE PERFORATED. 411 took place in sixteen, twenty-four, thirty-six, and seventy-two hours, six, twenty, and thirty-six days, from the origin of the first symptoms ; the cause of these differences it is not easy to explain. We may in vain seek it in the relative strength of the patients ; for the female who was the subject of obser- vation thirty-nine, and who died after seventy-two hours, was apparently as strong as the patient of the thirty-eighth obser- vation, who survived thirty-six days. We cannot refer it either to the difference in treatment, the latter having remain- ed during the three days following the perforation, in his own house, suffering acute pain, without any remedies being ap- plied. The variations in the size of the excavations, or the quantity of the fluid which escaped into the pleural cavity, also fail to afford any assistance in the inquiry, but rather in- crease our difficulty, for where patients died from thirty-six to seventy-two hours after the accident, the cavity was very small, not communicating with the bronchia, and necessarily dis- charging only a small quantity of matter into the pleura. We insist on these details, because it is important that the phy- sician should be aware, that in certain complications, mortal in their nature, the fatal termination may take place some hours or some weeks after their invasion, without his being able to anticipate or explain these differences. 443. In five of our cases the perforation occurred at the same point, viz., opposite the angle of the third or fourth ribs. This fact is interesting, both from its correspondence with the seat of the pain in the commencement, and because it is doubt- less dependant upon the progressive development of tuber- cles from above downwards. We must also recollect that out of the eight cases, seven were on the left side, where we have already seen that the tuberculous affection was rather more fre- quent and farther advanced than on the right. We have only 412 SYJiîPTOMS. PERFORATION OF THE LUNG ; [Part II, found a single perforation in the same lung ; but in many cases (Obs. 41), tbere were numerous yellow and white spots, corresponding to softened tubercles ; these were only sepa- rated from the pleura by an extremely thin layer, and they seemed on the point of opening into the pleural cavity. If we consider the frequency of this disposition, we may be sur- prised that perforation is not more common ; this is doubtless to be attributed to the adhesions which almost invariably take place. For the summit of the lung, where the sides of the excavations are often solely formed by the false semi-cartilagi- nous membrane, this is evident; occasionally also the tuber- culous matter is immediately in contact with the ribs, and in some cases, traverses the intercostal muscles. In these ex- amples had there been no adhesions, it would have escaped into the pleural cavity. 444. We must also notice the rapidity with which the effu- sion of turbid or sanguineous fluid may occasionally be formed. It was considerable in observation forty, where death took place in twenty-four hours after the perforation, although per- cussion during the first twelve hours was clear over the whole side of the chest. In this case then the effusion took place in less than twelve hours. In observation forty-one, in which the serous effusion did not occur, at least in any considera- ble quantity, until a long time after the perforation, the pro- gress was equally rapid. These facts are, however, strictly in accordance with what we observe in simple pleurisy, and more especially in the cure of hydrocele by injection, when a considerable effusion of purulent fluid is formed in the tunica vaginalis in a few hours. 445. In cases where death occurred twenty -four hours after the perforation, there was also a soft false membrane, Chap. 9.] QUANTITY OF THS EFFUSION, &tC. 413 probably organized, every where investing the lung and pleura. 446. We shall pass over many other circumstances in these observations calculated to arrest our attention, only remarking that the quantity of fluid in the cerebral ventricles, as in the cases of sudden death, was very small ; that notwithstanding the sudden obstacle to the circulation, prolonged in some cases during several days, the mucous membranes were not redder than where the circulation was much less impeded ; this seems to prove that, to produce congestion of the mesenteric vessels and mucous membrane, the impediment to the circulation must have existed a long time. Lastly, we will observe, that not- withstanding the intelligence and the sensibility of the patient, who was the subject of observation forty-three, and the numer- ous questions relative to the state of the trachea, we detected no symptom calculated to make us suspect the presence of the immense ulceration discovered after death. 447. The cases detailed in this chapter are relative to indi- viduals in whom phthisis had existed from six to sixteen months, and whose ages varied from twenty-four to forty -five years. Additional observations will determine whether per- foration of the lung takes place in very chronic cases, and in old people ; for as yet the number of facts is much too incon- siderable to justify any conclusions on the subject. 414 SYMPTOMS. — SUDDEN DEATHS ; [Part II, CHAPTER X. SUDDEN DEATHS. 448. We have already seen how many causes, foreign to the existence of tubercles in the lungs, accelerate the fatal termination in cases of phthisis ; but there are instances where death occurs still more suddenly and unexpectedly. Sometime the appearances after death seem to offer some explanation, while in others the most rigorous inspection of all the organs is not attended with any satisfactory results. The following observations are proofs of both these asser- tions. ARTICLE I. UNEXPECTED DEATHS, WHICH MAY BE EXPLAINED MORE OR LESS PLAUSIBLY BY THE STATE OF THE ORGANS AFTER DEATH. FORTY-FIFTH OBSERVATION. 449. A GOLDSMITH, 33t. 22, short, obliged to leave a mili- tary life on account of his feeble constitution, four years ill, was admitted into the hospital of La Charité, April 10th, 1823. His illness had commenced with a slight cough and expectora- tion ; these had since continued, and for the last seven months had been very troublesome, since which they had been associa- ted with dyspnœa, daily rigors and night perspirations. During Chap. 10.] EXPLICABLE BY THE STATE OF ORGANS. 415 the last three days of March he had experienced a rather acute pain in the left side of the chest, with increased dys- pnoea. For the last year his appetite had diminished, and there had been frequent uneasiness, with sense of oppression in the epigastrium ; his strength had much diminished ; no diarrhoea nor haemoptysis. 11th. Face, natural; slight ema- ciation ; slight epigastric oppression. Cough, frequent during the night ; sputa, greenish, opaque, ragged, and surrounded by a limpid fluid. Percussion, very obscure at the superior and external portion of the right part of the chest, clear every where else; respiratory murmur natural on the left; tracheal un- der the right clavicle, with a rather fine crepitation towards the centre of the same side, both anteriorly and posteriorly. Pulse, regular, not frequent ; tongue, moist, villous in the centre natural on the edges ; very little appetite ; stools, rare ; ab- domen, not painful. The patient complained of nothing but slight epigastric uneasiness. (Decoction of Iceland moss ; julep ; one eighth of the house allowance.) 21st. The dulness of sound in the right side occupied a larger space ; appetite, improved ; the patient was able to take a quarter of the house allowance without oppression at the epigastrium ; stools, regular ; no perspirations. (Blister to the right side of the chest.) On the following days, some pain in the throat ; no appe- tite ; increased heat ; and on the 26th we remarked a slight eruption of red spots, not elevated, extending over the whole body ; desquamation in some points ; the pain of the throat had ceased for two days ; the tonsils and pharynx were nat- ural ; pulse, fuller and quicker than usual, with some increase of dyspnœa ; the anorexia persisted, and the cough excited occasional nausea. 27th. No trace of eruption ; pulse, full, 416 srMPTOMs. — SUDDEN DEATHS ; [Part II, one hundred; respiration, accelerated. The patient com- plained of a pain near the edge of the left ribs, which he had felt three days ; percussion of the same side of the chest was every where clear, and respiration natural ; on the right side no change since the last report. Expectoration, as before ; tongue, natural ; one moderately firm stool. The next day, 28th, the breathing not appearing more affected than usual, we did not examine the patient. In the evening he was sit- ting up in the bed at the time supper was being distributed, and asked for food ; a few minutes afterwards he expired without any struggling, his companions having perceived he was not quite so well as usual half an hour only previously. Opening of the corpse tioeniy hours after death. Exterior. — Muscular system well developed ; slight emaciation ; some vibices, in the extremities chiefly. Head. — Numerous lacerations of the dura mater, giving passage to the arachnoidean granulations ; cerebral veins, dis- tended with blood ; considerable injection of the brain and cerebellum. Three small spoonsful of serum in the lateral ventricles. Neck. — Larynx, natural. For an inch and a half below the cordae vocales, the lining membrane of the trachea was red and thickened ; below this it was healthy, then again of a bright red, two inches above the bifurcation ; this redness ex- tended into the bronchia, especially on the right side. Thorax. — The right lung was adherent to the costal pleura, inferiorly by means of cellular prolongations, and supe- riorly by a false semi-cartilaginous membrane, from one to three lines thick, and which, by being prolonged over the interlobular pleura, constituted the greater proportion of the sides of a vast excavation, occupying the summit of the upper Chap. 10.] EXPLICABLE BY THE STATE OF ORGANS. 417 lobe, and communicating with smaller cavities. The struc- ture of the membrane was not uniform ; one part was of a pearly color, like cartilage ; another was yellowish, like the intervertebral ligaments ; here and there were some portions of grey, semi-transparent matter. The lower lobe was slightly engorged, and contained numerous grey granulations. The left lung was every where adherent, voluminous, firmer infe- riorly than superiorly, where there were some half emptied excavations, and grey, semi-transparent granulations. In the two lower thirds its tissue was of a bluish grey color, and the surface formed by an incision, rather granulated ; pressure forced out a certain quantity of greyish turbid fluid, almost without air. Heart, rather voluminous, but healthy. Abdomen. — The stomach contained a moderate quantity of turbid fluid ; its mucous membrane presented some dark look- ing stripes, was a little softened in the great cul-de-sac, and healthy in the remainder of its extent ; duodenum, natural ; many elliptical patches of the small intestine, red and more or less ulcerated ; the large intestine contained much mucus, with very little fœcal matter, and presented in the ascending colon some small ulcerations, with tuberculous granulations in the centre of the greater number ; the mucous membrane was thickened and detached around their edges, but every where else natural. Many of the mesenteric glands were rather red and voluminous ; the other viscera of the abdomen were healthy. 450. The right lung and a great proportion of the left were incapable of respiration ; the left lung was hepatized, and the rapidity with which this had taken place explains the patient's sudden and unforeseen death. Thirty -six hours before death, E 3 418 SYMPTOMS. — SUDDEN DEATH ; [Part 11, the left side was every where clear on percussion, and the res- piration seemed natural ; so that, in this period of time, the whole, or least the greater part of this lung, had passed from a state of health to the second degree of inflammation, a fact by no means extraordinary, since we have observed it several times under other circumstances. It may be conjectured, from the existence of the pain experienced by the patient four days before death, that there was then some nucleus of in- flammation in the substance of the lung, and that this was the case, is rather probable ; but this supposition does not inter- fere with the conclusion, that the greater part of the hepatiza- tion had taken place in a very short time ; perhaps in twenty- four hours. But how do we reconcile the existence of such feeble symptoms with so rapid an alteration of an important organ ? How explain the sudden and unforeseen approach of death ? We confess our incompetency to give any satisfactory answer to these questions. 451. Among other interesting circumstances attending this observation, we must mention the peculiar and compound nature of the membrane investing the summit of the right lung, and the almost healthy state of the gastric mucous mem- brane, although the derangement of the digestive functions long preceded the patient's death. FORTY-SIXTH OBSERVATION. 452. A SERVANT, aet. 32, and ill sixteen months, entered La Cliarité, April 15th, 1822. He was short, diminutive, and very subject to colds both before and subsequently to a pleurisy, which attacked him at the age of twenty-five years ; Chap. 10.] EXPLICABLE BY THE STATE OF ORGANS. 419 he attributed his present disease to repeated exposure to cold in a journey during the winter of 1820 and 1821. Since that period he had coughed, and was Hable to some dyspnoea ; ex- pectoration did not commence until seven months after the cough began, at the end of which period the emaciation also commenced, and about three months afterwards night perspira- tions came on and had continued regularly ; finally, during the last three weeks there had been diarrhœa and sore throat ; he hadnever had haemoptysis. April 16th. Expression, nearly natural ; cough, infrequent during the day, troublesome at night ; expectoration, greenish, opaque, not striated ; percussion of the chest, every where clear ; considerable resonance of the voice under the clavi- cles ; indistinct pectoriloquy between the vertebral column and right scapula ; voice, husky, nearly as it had been the last two months ; no pain in the region of the larynx ; pulse, frequent, full ; heat, moderate ; no rigors the last eight days ; anorexia; throat, painful; free edge of the velum and pha- rynx, red ; deglutition, easy ; no pain in the epigastrium ; four liquid stools the last twenty-four hours. (Decoction of Iceland moss ; gum potion ; quarter of the house allowance.) 26th. Aphonia, sense of heat and prickings in the larynx ; velum and pharynx as before'; deglutition, difficult ; three liquid stools ; copious perspiration. (Twelve leeches to the anus ; blister to the neck ; infusion of violets with gum syrup ; gum potion.) May 10th. Aphonia continues; pains in the larynx less acute ; liquids occasionally returned by the nose ; no pain in neck ; under the right clavicle and in the corresponding point posteriorly, a coarse dry râle, and whenever the patient spoke the air seemed to enter the stethoscope ; some of the sputa 420 SYMPTOMS. — SUDDEN DEATH ; [Part 11, were rust-colored ; the pulse was only slightly accelerated ; heat, moderate ; tongue, natural ; very little appetite ; abdo- men, not painful ; slight diarrhoea. On the two following days no sensible change took place, nor was there any on the 13th ; on the same day, two hours after the visit, the patient was found dead. A gum potion, with syrup of poppies, and three rice creams had been prescribed in the morning. Opening of the corpse twenty-three hours after death. Exterior. — Nothing remarkable. Head. — A little serous fluid in the upper part of the arachnoid ; a spoonful in each lateral ventricle ; slight injec- tion of the cerebral substance. Neck. — The edges of the glottis were infiltrated, rather more on the right side than the left, in the latter of which they were a line and a half thick ; the lining membrane of the larynx was pale and not altered. Immediately below the cordae vocales, were two ulcerations of three lines in diameter ; and two inches above the bifurcation of the trachea, on the fleshy portion there was another ulceration of four lines wide, by eight in length ; the intervening mucous membrane was healthy. Thorax. — Cellular adhesions over the whole of the right lung ; a very large excavation at its summit, lined by a double false membrane, of which the laiernal layer lay either on healthy pulmonary tissue, or on white, yellowish, or grey granulations, which were numerous in the remainder of the lung. The summit of the left lung was partially adherent, and contained some small excavations. In the remainder of its extent there were three zones formed of grey, semi-transparent matter, about an inch thick, and separated by layers of pul- Chap. 10.] EXPLICABLE BY THE STATE OF ORGANS. 421 monary tissue of nearly the same dimensions, and slightly en- gorged. This grey substance was interspersed with numerous whitish or yellowish miliary granulations. Heart and aorta, healthy. Abdomen. — Lining membrane of the stomach of a slight violet color in the great cul-de-sac ; in other parts healthy. That of the small intestine presented some brownish-red spots, and in the lower fifth numerous ulcerations, generally extend- ing to the muscular layer. The mucous membrane of the large intestine was red in the descending colon, with three moderately sized ulcerations in the right and transverse colon. Liver, rather engorged with blood ; the other viscera of the abdomen were healthy. 453. If we glance over the state of the principal viscera we have described, we see in the brain an effusion of serum into the lateral ventricles, much less considerable than in many cases where no peculiar circumstances attended death, so that it cannot here be considered a cause of the fatal ter- mination ; the state of the lungs did not prevent their continu- ing respiration for a considerable time. We may make the same remark as to the abdominal viscera, so that nothing in the condition of these organs explains the cause of death. The state of the glottis remains to be examined. It will, perhaps, be thought that the oedema was not sufficient to produce suffo- cation, and in proof of this opinion it may be said that we have not mentioned any paroxysms of dyspnœa which characterize this lesion. To this we will reply by the relation of a fact which we observed some months previously ; it refers to a young man attacked with typhus fever, and who died from violent suffocation, accompanied with a wheezing inspira- tion ; these symptoms came on only two hours before death 422 SYMPTOMS. — SUDDEN DEATH ; [Part II, and we afterwards found the œdema of the glottis, and of the same extent as in the case before us. It is possible then that in the two hours elapsing between the visit and the pa- tient's death, something very analogous had taken place in the present instance ; that this really was the case, cannot how- ever be ascertained. Not insisting longer on a doubtful supposition, we will ob- serve that we have collected two other observations of œdema of the glottis in phthisical patients, less marked than in the present case, and from the frequency of the ulcerations of the epiglottis and larynx, it is singular that our examples are not more numerous. Œdema, however, is not usually attendant on ulcerations in the intestines, stomach, &;c. of phthisical patients, which seems to indicate that the cause of the ulceration is entire- ly local, and that it does not influence the surrounding tissues. The deposition of the grey matter, in the form of zones in the left lung, is a rare anatomical fact. ARTICLE II. SUDDEN DEATHS WHICH ARE NOT ACCOUNTED FOR BY THE POST- MORTEM APPEARANCES. FORTY-SEVENTH OBSERVATION. 454. A SEMPSTRESS, ast. 23, of a pretty strong constitu- tion, and usually enjoying good health, not liable to colds, and having never been seriously ill, entered the hospital of La Charité, June, 23d, 1823. She had coughed uninterruptedly the last five months ; and during the first two had not expec- torated ; dyspnoea had come on at the same time ; there had Chap. 10.] INEXPLICABLE BY THE STATE OF ORGANS. 423 been no hfemoptysis, pains in the chest, nor rigors, though from the first she had been very sensible to cold ; and for the last two months had had night perspiration. For the same period her appetite had been much diminished, and every thing but soup caused uneasiness in the epigastrium ; there had been some diarrhœa and rapid emaciation. 24th. Ex- pression, rather lively ; inconsiderable debility ; cough, fre- quent at night ; sputa, greenish, opaque, ragged, immersed in saliva and clear mucus ; some dyspnœa ; dull sound on per- cussion ; gurgling and tracheal respiration under the left clavi- cle ; evident pectoriloquy in the corresponding point posteri- orly. Pulse, rather quick ; night perspirations ; tongue, villous, whitish ; bitter taste in the mouth ; very little appetite; abdomen, yielding, without pain ; three liquid stools, with scalding. July 3d. Pectoriloquy on both sides between the shoul- ders ; complexion, florid ; expression, animated ; pulse, ac- celerated, small, and feeble ; perspirations and digestive functions as before. 5th. The patient walked in the garden, and was in excellent spirits. The next day, at four, p. m., after returning to her bed from the night stool, she died sud- denly, to the great surprise of her companions, with whom she had just been conversing. Opening of the corpse thirty-seven hours after death. Exterior. — Considerable emaciation, with numerous vibices over the whole surface. Head. — Very slight sub-arachnoidean infiltration; brain, rather spotted with blood ; three small spoonsful of clear serum in the lateral ventricles, and an equal quantity in the lower occipital fossoe. Neck. — Larynx, natural ; lower part of the trachea of a 424 SYMPTOMS. — SUDDEN DEATH ; [Part II, bright red ; numerous tuberculated cervical glands on the left side. Chest. — Cellular adhesions over the summit of the lungs ; some excavations in the same regions, rather larger on the left than on the right side, lined by a thick and firm false mem- brane, surrounded by grey, semi-transparent matter, inter- spersed with yellowish tubercles, forming an indurated portion in the summit of each lung, about two inches and a half in height. There were elsewhere numerous grey, semi-trans- parent granulations. The bronchia were dilated without be- ing thickened in the upper half of the left lung; the lymphatic glands around their principal divisions, and the trachea were somewhat tuberculated. Heart, rather soft, and contained no blood ; aorta, every where red. Abdomen. — Stomach, of moderate volume, and free from bile ; mucous membrane, of a livid color about the cardia and over a considerable portion of the great cul-de-sac, where it was also a little softened ; elsewhere it was healthy. The mucous membrane of that part of the small intestine which rested in the pelvis was red, butof normal consistence and thickness with- out ulceration ; near the CEecum some crude tuberculous gran- ulations, about the size of hemp seeds. Jn the large intestine the lining membrane was slightly softened and tliickened, with some ulcerations in the transverse colon. Liver, red and a little engorged in the right lobe ; bile of the gall-bladder somewhat viscous, of a mahogany color ; the other viscera of the abdomen were healthy. 455. The affection of the lungs was undoubtedly consider- able ; but they were still in the greater part of their extent capable of respiration, and some minutes before death the res- piration went on regularly. Between this moment and that Chap. 10.] INEXPLICABLE BY THE STATE OF ORGANS. 42 in which death suddenly took place, no appreciable change occurred in the organs. They cannot then explain the cause of death. Can we compare the viscera to the muscles of locomotion, aud think that in certain instances they suddenly become incapable of continuing their functions from a sense of fatigue ? 456. The morbid alterations of the other viscera were too inconsiderable to arrest our attention. The aorta was red, but we are as yet ignorant of the real value of this sign, and be- fore explaining any phenomenon by it, we must learn its value. FORTY-EIGHTH OBSERVATION. A WOMAN, aet. 60, entered the hospital of La Charité, July 14th, 1823, of a strong constitution, usually enjoying excellent health, seldom subject to colds, and now ill the last seven months. During the first six weeks she experienced general uneasiness, with sense of weakness, and considerable diminution of appetite; after this she had cough with expec- toration ; during the three last months dyspnœa, pain in the right side of the chest, and universal flushings, which much incommoded her ; these symptoms continued, with some slight improvement in the appetite ; there had been no haemoptysis, diarrhœa, colic or rigors. 15th. Face, pale, thin ; considera- ble general weakness ; sleep, tranquil ; sense of oppression referred to the epigastric region ; little cough ; sputa, ragged, greenish, opaque ; sound, dull, with tracheal respiration and pectoriloquy under the right clavicle, and posteriorly in the corresponding point; doubtful pectoriloquy on the left side; elsewhere the respiratory murmur was rather loud, and accom- F 3 426 SYMPTOMS. — SUDDEN DEATH; [Part II, panied with a sonorous râle ; occasional pain in the right side ; pulse; rapid ; tongue, clean and moist, rather red ; little ap- petite ; no pain in any part of the abdomen, except we em- ployed strong pressure; bowels, regular: some ardor urinae. (Decoction of Iceland moss ; gum potion ; a quarter of the house allowance ; a cup of the common wine.) On the following days some increase of the appetite ; no rigors nor diarrhoea ; the patient spent much of her time in walking. 25th. She did not appear worse than usual; she walked out during the day. In the evening the face became rather hvid, but she slept tranquilly ; at midnight she awoke, complained of suffocation, and at one, a. m., was found dead. For the last two days she had complained of nausea and dis- gust for food. Opening of the corpse thirty hours after death. Exterior. — Slight oedema of the whole of the right lower extremity ; some vibices in the same region ; crural veins pre- sented no obstruction. Head. — The dura mater was ossified for about a square inch in surface, near the posterior portion of the falx ; considerable infiltration of the sub-arachnoidean tissue ; the choroid plexus was converted into vesicles containing a serous fluid, of which none existed in the cavity of the ventricles ; cerebral sub- stance, slightly injected. Neck. — Larynx, trachea and epiglottis, natural. Thorax. — The upper half of the right lung was adherent to the costal pleura ; a large excavation communicating with several smaller ones, occupied the summit ; they were all sur- rounded by the grey, semi-transparent substance which was interspersed with nuiDcrous tubercles ; no part of this portion of the lung was healthy. The remainder offered numerous Chap. 10.] INEXPLICABLE BY THE STATE OF ORGANS. 427 grey, yellowish granulations, and was slightly engorged. Of the left lung there were some inconsiderable adhesions, with tuberculous excavations in its apex ; the base was also slightly engorged. Heart, small and healthy ; aorta, large, with nu- merous yellow patches on its surface, and also embedded in its parietes. Abdomen. — A great number of miliary, semi-transparent granulations, developed in a very thin, cellular false membrane covering the small intestine and mesentery. Stomach, rather contracted; lining membrane red and softened over half the great cul-de-sac, greyish colored and healthy elsewhere. Some middle-sized ulcerations in the lower five feet of the small intestine, presenting some tuberculous granulations on their surface, with here and there denudation of the muscular coat ; every where else the mucous membrane was normal. That of the large intestine was softened in its right colon, healthy in the rest of its extent, except immediately above the anus, where there were three small ulcerations. Mesenteric glands, natural ; liver, small, red, and easily broken down ; twelve small calculi with pointed surfaces, and some very dark bile in the gall-bladder. Spleen, much softened, of usual volume, easily reduced to a reticulated texture , kidneys, red ; mucous membrane of the bladder,' injected. A small fibrous body, embedded in the uterus, which was of a pale pink color. 457. The cause of the sudden death is not more appar- ent in this than in the preceding instance, and the same reflec- tions are in a great measure applicable to both. One of the lungs was still permeable to air throughout its greater part; the lesion of the stomach was slight, and of moderate extent ; the ulcers of the small intestine were slight ; the mucous membrane of the colon had only a limited softening. 428 SYMPTOMS. SUDDEN DEATH INEXPLICABLE ; [Part II, The morbid alterations \^ere, in fact, much less extensive than in many cases when the approach of death was slow, and pre- ceded by a long struggle. We di not speak of the slight con- gestion of the lungs, the kidneys, liver, intestine, and of the mucous membrane of the bladder ; for these lesions were pro- bably the effect and not the cause of the kind of death of which we are now speaking, and may to a certain extent be compared to the vibices found on the skin. We shall not, moreover, stop to mention farther the redness and slight de- gree of softening of a part of the mucous membrane of the stomach, which is probably a recent lesion, and which corres- ponded perhaps to the disgust for food experienced by the patient two days before death, and which was too slight in degree to be of much importance in the explanation of the death of the patient. 458. We have, in a former part of this work (Obs. 7), related a case in which death was equally sudden, and in which all the viscera were extensively modified. In this case we are surprised that life should have been so prolonged, and that death should have taken place without its usual pro- dromes. In a fourth example, similar to the preceding, and relating to a woman, aged thirty-six, the progress of the dis- ease was rapid, and death occurred at a moment when the greater portion of the lungs was permeable to the air, the alterations in the stomach and small intestine inconsiderable, the brain healthy, and the emaciation more advanced than in the cases we have just related. It is remarkable, in fact, that in none of these last patients was the emaciation very con- siderable. We must also point out two peculiarities, comiàion to nearly all the observations in question, and not present in cases of phthisis when the approach of death has been gradual, viz., Chap. 10.] SOFTENING OF THE BRAIN. 429 the^ecchynioses and the moderate efFusion of fluid into the lateral ventricles. These two appearances are also present in other instances of sudden death, when it occurs during conva- lescencej or under other circumstances, without any important alteration of the viscera (203). 459. We shall terminate our remarks on cases of sudden death by relating two analogous observations, in which there was a remarkable softening of the whole cerebral substance. FORTY-NINTH OBSERVATION. An old-clothes-seller, œt. 54, of a lymphatic and sanguine- ous temperament, subject to difficulty of breathing from his infancy, and to cough and expectoration the last two years,' was admitted into La Charité, April 9th, I823. From the commencement of the latter period he had experienced pains between the shoulders, also in the epigastrium and under the false ribs; with these jaundice was associated eight or nine times during the first eleven months ; it had not since reappeared, and he had only experienced occasional epigastric pains, and with these his appetite had diminished. He also stated that anterior to the cough and expectoration, he had been liable for thirty years to apoplectic seizures, characterised by sudden loss of strength in the limbs, flushings of the face and vertigo, all of which rapidly disappeared. He had never lost his con- sciousness, and these attacks, which in the beginning had been rare, had gradually become more frequent, returning every two or three weeks, and followed during the six months pre- ceding the cough by weakness and numbness in one or the 430 SYMPTOMS. SUDDEN DEATH INEXPLICABLE ; [Pai't II, Other side of the body, during half an hour or an houi-, after which they entirely disappeared. 10th. Face, pale and thin ; no headach ; no pains in the limbs ; speaks rather hurriedly ; breathing, accelerated ; cough, rare ; sputa, flat, green and opaque ; on the left side anteriorly, percussion was very obscure : there was a dry râle with coarse crepitation, but no pectoriloquy ; on the right side, respiration seemed natural. Pulse, small and weak, eighty-four; rigors for the last three weeks, returning regularly at ten, a. m., followed by heat and perspiration, but they had not occurred the day before his entrance into the hospital. Tongue, moist, not red ; mouth, rather clammy ; scarcely any appetite ; no thirst ; abdomen, not painful ; no diarrhœa. (Rice water ; gum syrup ; blister to the left side of the chest ; three rice creams ; two soups.) In the following days, no evident change either in the state of the circulation or respiration ; some heat in the evenings, without previous rigors or consecutive perspirations; slight diarrhoea. 19th, in the morning, the patient experienced an uneasiness for which he could not account ; the following night there was slight delirium. 20th. During the visit, con- siderable stupor ; intellect, nearly gone ; pupils, much con- tracted ; utterance, embarrassed ; motions of both sides free ; tongue, moist, not deviated ; pulse, one hundred and thirty ; respiration, very slow. These symptoms persisted until ten, p. M., when he expired. Opening of the corpse thirty-four hours after death. Exterior. — Nothing remarkable. Head. — Several lacerations of the dura mater giving pass- age to granulations springing from its laminse. Slight infiltra- tion of the sub-arachnoidean tissue ; brain, pale, moist, and of Chap. 10.] SOFTENING OF THE BRAIN. 431 about the consistence of that of the foetus of six or eight months ; there was a spoonful and a half of clear fluid in each lateral ventricle, and a much smaller quantity in the lower occipital fossae. The tuber annulare and the cerebellum were nearly as soft as the cerebrum. Neck. — Larynx, natural ; mucous membrane of the trachea, of a vivid red over its fleshy portion. Chest. — Dense adhesions over the summit of the right lung, by means of a semi-cartilaginous false membrane, from one to two lines thick. A vast excavation in the same region surrounded by tubercles and the grey, semi-transparent sub- stance, which almost entirely occupied the remainder of the upper lobe. In the intervals between the larger masses of grey matter there was a homogeneous firm substance, very much resembling the jelly from veal, and presenting in de- tached points a slightly granulated appearance. The lower lobe contained a few tubercles and was slightly engorged. There were some adhesions over the summit of the left lung, the upper lobe of which, except that it did not contain any ex- cavations, was rather hard, and was otherwise affected as the right was. In the left lung the bronchia of the upper lobe were very red and thickened ; they were thin and of a pink colorin the right lung. Abdomen. — When removing the anterior parietes of the abdomen, we lacerated the gall-bladder, which was closely ad- hering to them. It extended an inch and a half below the false ribs, and contained two hundred calculi, varying in size from a pea to that of a millet seed ; its lining membrane was destroy- ed over an inch square corresponding to the adhesion, as also over a smaller space near the neck. These ulcerations seem- ed as if produced by some instrument. The mucous mem- brane was elsewhere firm, about half a hne thick, and seemed 432 SYMPTOMS. — SUDDEN DEATH INEXPLICABLE ; [Part II, formed by innumerable intersecting fibres, giving it in minia- ture the appearance of tlie urinary bladder, when the muscular coat is somewhat thickened ; the submucous layer was thick- ened, and that forming the bottom of the ulcerations very brittle. The cystic duct was very narrow near its junction with the hepatic, and contained several calculi. The ductus choledocus was healthy. Liver, spleen, pancreas and kidneys were natural. Some tuberculous granulations in the renal capsules. Mucous membrane of the stomach, of a pinkish- grey tint, nearly every where maraillated, being thicker in these portions than elsewhere ; near the pylorus it was destroyed over a very small surface. Some of the ellip- tical patches of the small intestine were ulcerated. Lining membrane of the colon thick and softened, with numerous small ulcerations becoming rarer from above downwards. Mesenteric glands, healthy. 460. Here, as in the two preceding observations, the cause of the sudden death remains unexplained. We shall not attempt to attribute it to the softened condition of the brain, for we are quite ignorant what degree of firmness is necessary for the support of life ; we may, however, observe that we cannot pay too much attention to all alterations in the consistence of our organs. The researches of MM. Rostan and Lallemand have thrown much light on the partial softenings of the brain ; it remains to be shown when a general softening of this organ, always easily recognised by those accustomed to pathological researches, may be regarded as a morbid condition ; it is for the purpose of assisting in the solution of this question that we detail the following observation, which is also an example of latent tubercles. 461. The condition of the brain was not the only remarka- Chap. 10.] SOFTENING OF THE BRAIN. 433 ble circumstance in the fact before us ; the extensive mamil- lated state of the gastric mucous membrane, its thickening, over the same part, and loss of substance near the pylorus, are not without interest if we compare them with the symp- toms present during the two years preceding death ; that is, pains in the epigastrium and diminished appetite. These are indeed the symptoms of chronic gastritis, and may in common with the mamillated state, have resulted from it, though the presence of other complications render our conclusions less positive. Let us also notice the relation existing between the biliary calculi, the thickened and ulcerated state of the gall- bladder, the pains under the short ribs, and lastly, the jaun- dice, which occurred several times in the course of the same year. FIFTIETH OBSERVATION. 462. A COOK, set. 48, of middle stature, moderate embou' point, great sensibility, had always enjoyed good health pre- vious to her present illness. The catamenia, which first appeared in her eighteenth year, were suppressed at the age of thirty ; their usual period was every six weeks, they were always scanty, and only of some hours duration. Three years before her admission into the hospital she suffered much men- tal anxiety from being unjustly deprived of her savings, and was suddenly seized with loss of sensation and of motion, but her intellectual faculties were not affected. Wishing to die, she refused all treatment, and continued in this condition about two months. She was then attacked by pains in the limbs, g3 434 SYMPTOMS. — SUDDEN DEATH INEXPLICABLE J [Part II, and soon afterwards by some convulsive movements in the hands and feet. The progress of the disease was very gradual, and eight months elapsed before the patient could resume her oc- cupations. She continued in good health during the succeed- ing six months, when she was attacked, without evident cause, by erysipelas in the left leg. An empiric made her anxious about the consequences of this affection, and immediately the mucous secretion of the nasal fossae and a leucorrhcea, to which she had been liable from childhoood, were suppressed ; a spitting of blood, also, which had occurred frequently from the same period, came on both morning and evening, and was attributed by the patient to the unhealthy state of her gums. At the same time an epistaxis, to which she was frequently liable, ceased. She experienced a sense of weight in the frontal sinuses, and lost her smell and taste ; the appetite was not affected. The suppressed evacuations did not return, and the patient never recovered her usual good spirits. Three weeks before her admission into the hospital she was seized with violent headache, accompanied with heat and thirst, which co nfinedher to her bed five days. There were no other symptoms ; she was not liable to colds, and did not cough. Feb. 16th, 1822. The day after her admission into La Char- ité, the intellectual faculties were unaffected ; there was slight headache ; complete loss of both taste and smell ; the nose enlarged at its base and laterally. This was attributed to the habit, since she had ceased blowing her nose with a handker- chief, of extracting the dried mucus with her fingers ; little general debility. Tongue, natural ; thirst, rather urgent ; little appetite ; stools, natural ; pulse, calm ; heat moderate ; respiration, easy ; no evident emaciation. (Decoction of dulcamara ; occasional sulphur baths ; blister to the arn) ; one eighth of the house allowance.) Chap. 10.] SOFTENING OF THE BRAIN. 435 The headache disappeared, but returned slightly on the 20th of February, after exposure to a cold wind. 22d. It had much diminished ; the appetite was improved and thirst gone. 23d. Nothing remarkable. 24th. At ten, p. m., she complained of a sense of heat, general uneasiness, and a feeling of swell- ing and fulness in the face. Two hours afterwards she ex- pired. Opening of the corpse thirty-two hours after death. Exterior. — Some ecchymoses on the surface of the skin ; great rigidity of limbs. Head. — Brain, extremely pale, very soft throughout its whole extent, like that of a new-born child ; the olfactory nerves were natural ; mucous membrane of the nasal fossae, healthy ; that of the frontal and maxillary sinuses was a line and a half thick, infiltrated, serai-transparent, firm, and in color like the pulp of a baked apple ; there was no dried mu- cus in these parts. Neck. — Glottis, epiglottis and larynx, natural. Thorax. — Some adhesions over the summit of the left lung ; five crude tubercles, about the size of a small walnut in the summit, surrounded by a little grey, semi-transparent sub- stance, and enclosing four nuclei, of a bony earthy structure j the posterior portion of both lungs was slightly engorged; bronchia, pale and thin. Abdomen. — Convex surface of the liver, very uneven, in- tersected by variously directed depressions, which gave it the aspect of the cerebral convolutions ; the structure of the organ was healthy, and rather congested, especially in the large lobe. The gastric mucous membrane was of a bluish-grey color, with here and there a pink tinge ; that of the small intestine, natu- 436 SYMPTOMS. SUDDEN DEATH INEXPLICABLE ; [Part 11, ral ; the kidneys were much congested ; spleen, firm, volumi- nous, pale ; the other viscera were healthy. 463. Without any desire to assign any cause for the sudden death of this patient, we would remark that the state of the brain in this observation is very analogous with that in the prece- ding, as are also the cerebral symptoms. Both patients were of nearly the same age (forty-eight and fifty-four), and at a period of life when the brain is naturally very consistent, while in these instances, although the patients died suddenly, it was not firmer than that of a new-born infant. This great deviation from the normal state appears to us an evident mor- bid condition, and this opinion is confirmed by the symptoms, vi'hich'could not have been caused by any thing except the brain. In the one case we had vertigo, flushings of the face, sudden weakness of the limbs, of short duration, and frequent- ly recurring during a period of thirty years ; these attacks became more frequent the last six months, and were asso- ciated with numbness of the extremities, which lasted half an hour, and then entirely ceased ; the intellectual faculties were never affected. In the other case there was complete paraly- sis of motion and sensation three years before death ; this continued unabated two months, gradually disappearing at the end of eight months, and, as in the preceding case, the intel- lectual faculties remained undisturbed. In both, the cerebral symptoms had ceased two years before death. If the symp- toms are not exactly similar, they are at least very analo- gous ; and the greatest softening of the brain occurred in the case in which the symptoms had been most intense ; so that we must necessarily suppose some dépendance between the state of the brain and the symptoms observed. If, how- ever, this should not be fully admitted, the facts may excite Chap. IL] CAUSES of phthisis. 437 further investigation on the part of observers, and this is our chief object. We shall not enlarge on the sudden suppression of the nasal and buccal secretions, &c., but we would remark that the tuber- cles in the left lung were latent, and had not excited cough ; that the patient was not liable to bronchitis, that the bronchia were healthy, and, consequently, nothing can justify the sup- position that the tubercles resulted from their chronic inflam- mation. As~was the case in the majority of the instances of sudden death, there were vibices on the extremities. CHAPTER XI. CAUSES OF PHTHISIS, 464. A KNOWLEDGE of the causes of disease is without doubt of the highest importance in medicine; for, if not al- ways available for treatment, it often enables us to adopt pro- phylactic measures ; and this consideration alone explains the interest attending the study of the causes of phthisis, and the great attention their investigation has received. Unfor- tunately, as is the case in many other circumstances, asser- tion is much easier than proof, and the detection of error than the discovery of truth, so that little really satisfactory has as yet been effected. Our own observations have not demon- strated the cause of tubercles in the lungs, but they have brought us to conclusions opposed to the doctrine of irritation, and on this account we think it useful to expose the results of our investigations. 438 CAUSES ; [Part II, 465. We shall successively examine the influence of sex, pneumonia, pleurisy, bronchitis, &tc,, on the production of phthisis. INFLUENCE OF SEX. 466. We have already said that the one hundred and twenty-three observations of phthisis were collected during rather more than three years, in wards containing forty-eight beds, equally divided between men and women. Sixty-six of these cases belonged to the latter, fifty-seven to the men, which seems to indicate the greater liability of women to phthisis. This now is strengthened by another fact. In an equal num- ber of patients of both sexes who have died from other chronic affections, we have found tubercles in the lungs twenty-five times in women, and only fifteen times in men ; that is, by joining these two results, the proportion of phthisical cases in men and women, was as seventy to ninety-two ; a differ- ence very considerable in favor of the weaker sex.* INFLUENCE OF PNEUMONIA AND PLEURISY. 467. In eighty cases of phthisis, where we have carefully endeavored to learn the diseases existing anteriorly to the tubercular affection, three had pneumonia four years before death, and from that time the cough and expectoration had con- tinued ; four had the same disease three, six, and fifteen years previous to the appearance of the first symptoms of phthisis, without having incurred greater liability to colds during the * See Translator's Appendix, C. — H. I. B. Chap. IL] INFLUENCE OF PNEUMONIA AND PLEURISY. 439 same period, or having been subject to dyspnœa. All were of a feeble constitution and of the lymphatic tempera- ment; that is, they presented those characters which phy- sicians have classed among the principal predisposing causes of phthisis. These observations mutually destroy one another in reference to the point now under consideration, and, there- fore, all that we can deduce from them is, that pneumonia exerts no influence in the development of phthisis. 468. It will doubtless be said, that this conclusion is falsi- fied by a great number of facts, particularly by the observa- tions of M. Broussais. Without disputing the accuracy of these facts, we cannot help thinking that we ought not to deduce from them what has been heretofore deduced. Acute and chronic pneumonia and pleurisy are very common in the army ; M. Broussais, who has examined a number of cases fatal from both of these diseases, has found in many of thenn tubercles in the lungs, and has hence considered pleurisy and pneumonia as their cause. To render this conclusion rigorous, tables of mortality were necessary for the pur- pose of ascertaining whether the lungs under these circum- stances were more frequently tuberculated than in individuals of the same age, dying in the civil hospitals, in a time of peace. Without this confirmative evidence, the proposition of M. Broussais is wholly conjectural, since instead of dépen- dance, there may have been a simple coincidence merely be- tween two diseases in other respects so different ; this is ren- dered still more probable from the consideration, that the period of life when tubercles are most frequent (fi-om twenty to thirty) (481), was precisely that in which M. Broussais so often observed pneumonia and pleurisy. These observations are not only incapable of proving pneumonia to be a cause of tubercles, but the history of the disease itself rather favors a 440 CAUSES ; [Part II, contrary supposition. It is, in fact, (Bayle) most usually de- veloped from the base to the summit of the lungs, while the reverse is the case for tubercles ; pneumonia seldom attacks both sides of the chest, while phthisis almost invariably occu- pies both lungs. Phthisis is more frequent in women than men ; the inverse holds good for pneumonia. Out of seventy- five patients attacked by the latter disease, whose histories we have collected during the last three years, twenty-three only were women : eighteen died, — fifteen men and three women. 469. The same reflections are equally applicable to pleu- risy. We have found it more frequently in men than women ; it was generally confined to one side of the chest, and if we have often discovered tuberculous granulations in the lungs in fatal cases of chronic pleurisy, they were equally numerous on the sides of the chest where the pleurisy did not exist, as on the other. 470. These facts are evidently much opposed to the doc- trine of irritation. We are, however, far from asserting that pneumonia can exercise no influence in tubercular develop- ment, for who can prescribe bounds to what is possible ? But this influence appears as yet but mere conjecture, and we think it can only be demonstrated by means of the tables of mortality already alluded to, by which the diseases of indi- viduals who had died in various circumstances may be con- trasted with each other. However, supposing for a moment that such an influence really does exist, it cannot be very considerable, since among the somewhat numerous facts we have carefully collected, we have found no evidence in its favor.* * See Translator's Appendix, D. — H. I. B. Chap. 11.] INFLUENCE OF BRONCHITIS. 441 INFLUENCE OF BRONCHITIS. 471. This influence does not seem to be demonstrated more fully than that of pneumonia. Out of eighty individuals who distinctly recollected the symptoms they had experienced ante- riorly to the origin of phthisis, only twenty-three were subject to catarrh ; fifty-two, or about two thirds, being rarely affect- ed. What conclusion are we to draw from this ? — that phthisis is equally frequent in individuals liable to bronchitis, as in those where no such liability exists ; it cannot, therefore, be considered as a consequence of the latter, no evident rela- tion existing between them. Another class of facts will lead us to the same conclusion. Women, who are more frequently attacked by phthisis than men, are less subject to bronchitis, or at least to that kind of bronchitis which is sufficiently intense to require treatment. Out of one hundred and forty-nine cases, collected during the last three years, fifty-two only, or about one third, were women. 472. Whether, therefore, we investigate the connexion -which exists between inflammation of the substance of the îung or of the bronchial membrane and phthisis, we arrive at the same conclusion, viz., the sex luhich seems the most ex- posed to phthisis is least frequently attacked by pneumonia or bronchitis ; and this in the proportion of one to three. The opinion then, that pulmonary tubercles are the result of chronic inflammation of the bronchial mucous membrane, pulmonary parenchyma or pleura, on whatever theory it may be supported, is quite unsatisfactory ; the preceding results cannot be set aside, except by a larger series of observations, H 3 442 CAUSES ; [Part II, which shall prove that the proportion we have established resulted from a purely accidental combination of facts. 473. But if, contrary to all probability, our observations should be thought not sufficiently numerous to establish the relative proportion of phthisis in men and women, our con- clusions would not on that account be invalidated, since the relative frequency of phthisis, compared with that of pneu- monia or bronchitis in either sex, would still remain unaf- fected. 474. If, however, by a series of well observed facts, it should appear that these two affections really exercise an in- fluence in the production of phthisis, it would still be undecid- ed whether they were a necessary cause, and whether phthisis depended upon their presence ; our observations on acute phthisis seem distinctly to prove the contrary. The first is relative to a young woman who was not subject to colds (Obs, 33), had never had pneumonia and was in perfect health up to the moment when she was attacked with fever, which was soon followed by cough and expectoration ; she died on the thirty-fifth day of her illness, and twenty-fifth from the com- mencement of the cough ; after death we found a large mass of tuberculous matter at the base of one of the lungs, softened and partially excavated, with grey granulations, he. he. These morbid productions were certainly not the result of bronchial inflammation ; to support the contrary idea, we must prove that bronchitis of twenty-four hours duration could have produc- ed tuberculous deposit, he. But we respect the reader too much to suppose him supporting such an opinion, or other equally improbable suppositions, and shall consider the fact of phthisis being developed independently of all inflammation, as satisfactorily as possible demonstrated in the instance be- fore us. Chap. 11.] INFLUENCE OF BRONCHITIS. 443 475. The other observations of acute phthisis are equally- decisive ; we shall mention particularly the thirty-fourth, that of a man, usually enjoying good health, suddenly seized, without any evident cause, with fever, then cough, and who died on the thirtieth day from the commencement of the symptoms. The lungs were filled by an immense number of grey, semi-transparent granulations, the bronchial mucous membrane being perfectly healthy, with the exception of a slight livid tint, doubtless produced by simple congestion to- wards the close of life, and which is frequently observed in cases of sudden death. We would also recall the thirty-fifth observation, relative to a young man, aged nineteen, in per- fect health until attacked, without any assignable cause, by fever and cough, and in whom there was sufficient tuberculous matter developed in the lungs on the twentieth day, to render the percussion of the chest dull. We might also cite obser- vations thirty-six and thirty-seven, and especially the tenth (bis), in which there was dulness of sound under the right clavicle on the seventeenth day, although in this instance, the fatal termination was not equally rapid. Out of one hundred and twenty-three cases, therefore, six or one twentieth of the whole were direct illustrations of the production of phthisis, independently of all inflammatory action, either in the sub- stance of the lung or in the bronchial mucous membrane. 476. The same fact may also be deduced from our exam- ples of latent phthisis. Three among them (Obs. 27, 28, 29), were instances of simple phthisis ; the cough and expec- toration had been preceded, during six or twelve months, by a continued fever with slight remissions ; and from the absence of all cotTi plications, this fever could only be the result of the presence of tubercles, which were here not produced by either pneumonia or bronchitis. Observation fourth is also in support 444 . CAUSES ; [Part II, of this assertion, for here the cough and expectoration came on after four months of violent diarrhœa, and only preceded death six weeks. The size and structure of the excavations were evident proofs of the presence of the tuberculous matter ante- rior to the cough, which was here an effect, not a cause. 477. Not only then is the influence of pneumonia, pleurisy, and bronchitis in the development of phthisis not demon- strated, but our observations induce us to suppose its existence imaginary, or at least restricted within very narrow limits ; from what has preceded, we think that we have proved, that in one twelfth part of our cases, pulmonary tubercles were devel- oped independently of all inflammation, either of the substance of the lung, pleurae, or bronchia. We must, however, acknowledge, that the slow progress of phthisis in the greater number of instances, and the striking similarity of its symptoms to those of simple bronchitis in the first stage, and the inflammatory state of a part of the bronchia so frequently present in cases of phthisis, offer an easy ex- planation of why inflammation, and more especially that of the bronchial membrane, should have been regarded as a cause of tubercles ; we think, however, that in the majority of cases this opinion is no longer tenable. 478. There is also a circumstance not less certain than those on which we have hitherto insisted, and which might indeed be substituted in their stead, viz. (36) that the bronchia are in general healthy in the vicinity of either un- softened tubercles, or masses of grey, semi-transparent matter (Obs. 29, he.) ; that the redness and thickening of those which communicate with tuberculous excavations, seem the result of the constant passage of the contents of the latter, and that in cases fatal from some other affection, but with crude tubercles, or grey granulations in the lungs (Obs. 50), the Chap. IL] INFLUENCE OF DRESS. 445 bronchia are almost constantly healthy, both as to color and thickness. Facts of this description are not uncommon ; we have lately encountered several, and it is only necessary to have met a single example, to feel convinced that in many instances, inflammation and tubercles in the lungs are inde- pendent of each other.* INFLUENCE OF DRESS. 479. The influence of dress, and especially of stays, on the production of phthisis, is also perhaps a mere assertion. Sev- eral of the women we examined were liable to shortness of breath before they became consumptive ; but this was equally the case with the men ; so that if we should admit a connexion between this peculiarity in dress and phthisis, it would not be correct, even if they have been worn from a very early period of life, to attribute phthisis to stays. Besides, the majority of our female patients had been educated in the country, were habituated to rustic occupations, and had only been accus- tomed to stays after their residence in Paris, when their growth was established, or in other words, when stays could not have exerted any considerable influence on the dimensions of the chest. Supposing, however, this influence to have existed, its demonstration would be exceedingly difHcult, for it would be necessary to compare a great number of women together, some of whom had worn stays from a very early period, the others only after the full growth of their bodies, to be enabled to decide if phthisis was more frequent in one class than in the other. The influence of stays in phthisis, and in general of those causes which interfere with the devel- * See Translator's Appendix, E. — H. I. B, 446 CAUSES ; [Part lï, opraent of the frame, is still more problematical, from the fact that tubercles are nearly equally frequent in individuals of a strong as in those of a feeble constitution.* HEREDITARY INPLUENCE.f 480. One tenth of our patients were children of parents, one or both of whom appeared, as far as we could judge, to * " The deposition of the peculiar matter of tubercle in any of the tissued or organs of the body, is only the result of previous changes in the general system, cognizable, as we have endeavored to show by the physical con- dition of the patient, and by a disordered state of various functions ; a con- dition of the body quite distinct from mere debihly, and therefore inexplicable on the idea of a difference of force or tone of the system, and which, though very generally accompanied with a feeble organization, is not inconsistent with too great development and inordinate action of particular parts, and even with considerable physical power of the system." — Article on tuber- cular Phthisis. — Cycl. Pract. Med. page 325. § — Ccwan. t There can be but little doubt that as a general principle, children born from healthy parents are more robust than those in opposite circumstances, and on this account are less predisposed to disease. The evidence hitherto adducedin favor of the hereditary nature of phthisis, amounts to little more than the announcement of this fact, and while we cannot help admitting, in the children of consumptive parents, a predisposition, there is no reason to suppose that in the majority of instances, prophylactic treatment would not be attended with success. The fact of tubercles being found in the foetus, only proves that phthisis is one of the many diseases which may bet developed before birth, and we have no reason to believe that it may not arise from any cachexia in the parent which interferes withs the proper nutrition of the child, as well as from the tuberculous. In general terms it may be stated that children are hereditarily predisposed to phthisis in proportion as their general health is enfeebled, whatever may be the cause, and that attention to this fact is of more practical importance to the physi- cian, than the knowledge of whether tuberculous disease did or did not exist on the part of parents. — Cowajv. § Sec Translator's Appendix, F. — H. I. B. Chap. 11.] HEREDITARY INFLUENCE; AGE. 447 have died of phthisis ; but as the disease could have been transmitted or spontaneously developed, and since we are ignorant of the cause of death in their brothers and sisters, it follows that we have not collected any fact in favor of the hereditary nature of phthisis. We do not wish to imply that this hereditary influence is doubtful, for too many examples seem to justify an opposite opinion ; and probably also the proportion we have mentioned of individuals born from con- sumptive patients, is too small, from the difficulty which in hospitals attends the investigation ; but we believe, that to determine the question satisfactorily, tables of mortality would be necessary, comparing an equal number of persons born of phthisical parents with those in an opposite condition. INFLUENCE OF AGE. 481. Of this there is no doubt; the number of deaths from phthisis, is more considerable from twenty to forty, than from forty to sixty, although the absolute mortality is less in the first than in the second period. This fact has already been proved by Bayle, and our own observations are confirmative of his with some slight variations.* Phthisis is distributed in the different ages as follows : — Between the ages of according to our notes according to Baylo's 15 and 20, 11 died ; 10 died. 20 " 30, 39 " 23 " 30 " 40, 33 " 23 " 40 " 50, 23 *' 21 «' 50 " 60, 12 " 15 " 60 " 70, 5 « 8 « * Seo Tianalator's Appendix, G. — H. I. B. 448 TREATMENT ; [Part II, CHAPTER XII. TREATMENT. 482. It was simple, and varied according to the indica- tions. These were founded on the state of the functions, and the different comphcations occurring in the progress of the principal disease, 483. Upon the arrival of the patient, if there was very little or no fever, no thoracic complication, (as pleurisy, pneu- monia, haemoptysis, &ic.), and if the digestive functions were not deranged, we prescribed, whatever might have been the stage of the disease, the decoction of Iceland moss, a gum potion, and frequently small doses of syrup of poppies to allay the cough and procure sleep. One fourth or an eighth of the usual house allowance was given in proportion to the appetite ; the food was afterwards either increased or diminished, as cir- cumstances pointed out. 484. When fever was present without local inflammatory symptoms, as was the case in the second stage, we ordered infusion of the pectoral flowers, a gum potion, some broth, with two rice creams daily. Under this regimen the violence of the fever abated, and there was general improvement in all the functions ; the thirst was less urgent; the appetite in- creased_^; the breathing became less oppressive, and the expec- toration more easy ; the food was always regulated by the state of the patient and his appetite ; vegetables and frequently milk were allowed. This amelioration was more or less perma- nent, but after a certain time some complication invariably supervened, requiring a change in the treatment. Chap. 12.] TREATMENT. 449 485. If the patients entered the hospital soon after the commencement of the disease, and if the symptoms were more or less acute, the infusion of violets, a simple gam potion, diet, and usually venesection in proportion to the strength, were prescribed. Leeches were also applied to the labia when the catarnenia were suppressed or irregular, but only when the disease was not chronic in its progress, and when fever was present. Bleeding, either local or general, under these cir- cumstances, exerted little or no influence over the disease. 486. When the cough was very troublesome during the night, we prescribed at first an ounce or half an ounce of syrup of poppies in the evening, and if this did not succeed, we ordered a gum potion with doses of opium, gradually increased, from one to three grains. In some cases in which this remedy was used without success, the acetate of morphia and extract of belladona were successively tried without any additional success. In four cases where opium, under every form, had failed, it was given during the day in doses of from one to two grains, without any diminution of the cough ; in three of these it was suppressed because it occasioned pains in the throat. These pains were pungent, with a sense of dryness and slight hoarseness coming on half an hour, an hour, or even sooner, after the pill was swallowed ; the deglutition was also difficult, though there was no redness of the pharynx or amygdalae. These symptoms returned whenever belladonna was taken, and persisted from two to three hours. 487. Pleuritic pains, at whatever period they occurred, when urgent, required particular attention. If present in the earlier periods of the disease, and accompanied with fever, venesection was prescribed and repeated if necessary, accord- ing to the strength of the patient and violence of the symp- I 3 450 TREATMENT. [Part II, toms ; leeches were then applied and afterwards a blister. Under this treatment the symptoms abated, but did not wholly disappear ; the effusion was not completely absorbed, and the pains occasionally returned. At a more advanced period, when the emaciation and debility were considerable, some leeches or a small blister were the only remedies re- sorted to. Pneumonic symptoms were treated precisely in the same way, and, as we have already remarked, with success. 488. Venesection was also employed in cases of copious haemoptysis; but although carried to great extent in three instances (Obs. 16, 42), it failed to arrest the hsemorrhage, for it came on after the venesection, in the midst of the most perfect calmness of the patient, just as if the individual had committed some error in diet. In one case (Obs. 10), a large blister was applied between the shoulders, without any evident success; in another (Obs. 42), the haemorrhage was not arrested until after the administration of a gum potion, with half a drachm of the powder of ratanhy root. On the first day that this was used the haemoptysis was much diminished, and on the third ceased altogether. If the haemoptysis was slight, or if the expectoration only presented a red tint, and the debihty very considerable, we confined ourselves to demulcent drinks, hand and foot baths, enemata and diet. In some cases, under these circumstances, a very small bleeding was practised with evident success, the red color of the sputa dis- appearing very soon after the vein was opened. 489. In six cases in which the dyspnœa was considerable and there was no disease of the heart, or acute affection of the lungs, blisters were applied over the sternum, with relief in two cases. When the same application was made to the arm, the patient never appeared benefited in any way, whether Chap. 12.] TREATMENT. 451 it was made before or after entrance into the hospital. In four examples of acute phthisis, blisters were also applied to the chest after venesection, without any decrease of the op- pression, fever, or cough ; so that bleeding and derivatives have failed in the majority of those cases we have observed. 490. In three of the instances where the alteration of the voice and pains in the larynx indicated ulcerations in this region, leeches were twice applied to the neck and were suc- ceeded by a blister, without any success. This treatment was opposed to the ulcerations of the trachea (usually indeed giving rise to no symptoms), but from their frequency, as well as those of the epiglottis and larynx, the application of medicated vapors at a certain period of the disease, would perhaps be advantageous. 491. The sulphate of quinine was given in some cases where the rigors were very troublesome and regular in their recurrence ; they diminished or disappeared entirely after the use of the febrifuge, but the heat persisted, and the rigors also returned when the remedy was abandoned. In one case (Obs. 41), its suppression was necessitated by the oppression at the epigastrium, &:c., which it occasioned. 492 In six cases the acetate of lead was employed to check the perspirations, in doses gradually increased to twelve or fifteen grains daily, but in only one case with success. In one instance it was replaced by the infusion of bark or pepper- mint, without any advantage, 493. The stomach often gave indications for treatment. When it was the seat of acute pains, accompanied by heat, and the emaciation and debility were not extreme, leeches were applied to the epigastrium, which diminished the pains for a short period, but they returned with nausea and vomiting of bile. When there was great general weakness, emollient drinks 452 TREATMENT. [Part II, and external applications were the only remedies entiployed ; a solution of gum or tartaric syrup, if the thirst was urgent ; but all drinks soon inspired disgust, producing a sense of weight and difficult digestion in the epigastrium. The Seltzer water diluted relieved the vomiting for some days, but soon lost its effect. Opium neither diminished the pain nor vomiting, which arose, as we have seen in the great majority of instances, from the softening and thinning of the gastric mucous mem- brane. 494. When the diarrliœa was slight, the food was simply diminished, and rice water with gum syrup prescribed. If more urgent, the quince syrup was substituted. Under this treat- ment it sometimes remained stationary, or was even suspend- ed, but usually it increased, and then, if possible, the white decoction and the diascordium, either with or without opium, were ordered, but in general unsuccessfully. Twenty-five patients were submitted to this treatment, from twelve to forty-eight days before death. They may be naturally ranged into three classes ; in some there were ulcerations in one or both of the intestines, generally with a considerable softening of the mucous membrane of the colon, which was often red and thickened ; in others the ulcerations were considerable, and the softening of the lining membrane of the large intestine near- ly as in the first class ; in a third class, the mucous membrane was simply softened, without redness or ulceration. In the first, including fifteen cases, the diarrhoea was diminished in three after the administration of the diascordium, and continu- ed so till death ; in one of these instances the soilening was inconsiderable. In the second division, a similar result was obtained in two out of eight individuals, in one of whom there was only a large ulceration in the cœcum. Lastly, in one patient of the third class, where the diarrhœa was Chap. 12.] TREATMENT. 453 very copious before taking the diascordium, it was much diminished from the moment this medicine was prescribed, and continued so during the forty days preceding death ; so that out of twenty-five cases, six only appeared to have been benefited by the diascordium ; we must also add that in three instances in which the mucous membrane of the colon was ulcerated, softened, or thickened, the diarrhœa was in- creased by the diascordium. The decoction of catechu was employed with the same in- tention, in doses of four to eight ounces. Sixteen patients took it ; in five of these the debility was too great and death too near to appreciate the action of medicine. The eleven others began its use from two to three v/eeks before death, and five appeared benefited. In one of these, however, the suppres- sion of the diarrhoea was immediately succeeded by uneasi- ness, anxiety, thirst, heat in the throat, &,c., which were worse to the patient than the diarrhoea. After death, we found evident traces of recent inflammation of the mucous membrane of the stomach and trachea, which might easily in this instance, as in many others, have been spontaneous, and not the result of the remedy employed ; there were also numerous intestinal ulcerations with softening of the mucous membrane of the colon. These last lesions were equally present in the other cases. Ratanhia root was also tried in the same circumstances in one case without success. Lastly, opium, in doses of one or two grains a day, was prescribed in five cases, but the diarrhoea diminished in only one instance. Thus diascordium, catechu, opium appeared equal in their effects upon the diarrhoea of the advanced stage of phthisis ; and from the difference which exists in the action of catechu and opium, we may suspect that the success we have men- tioned is rather apparent than real. 454 TREATMENT. [Part II. We'may observe, while on this subject, that towards the close of chronic diseases, and particularly of phthisis, it would perhaps be preferable to avoid any stimulating plan in the treatment of diarrhoea ; for, from the facts we have related in the first part of this volume, diarrhœa, in the majority of in- stances, is dependant upon an inflammatory state of the mu- cous membrane of the large intestine, which is soon followed by disorganization ; and as this membrane is the principal source of the diarrhœa, our remedies should be chiefly applied to its surface. Let us add, always on the testimony of facts, that the last period of chronic disease is favorable to every kind of inflammation, a fact which should constantly be remembered, whatever class of symptoms may be predomi- nant ; also, that the gastric mucous membrane is then fre- quently affected, an additional reason to employ, in general at least, mild internal remedies.* * See Translator's Appendix, H. — H. I. B. APPENDIX. TRANSLATOR'S APPENDIX. [It is proper to state that the different sections of this Appendix are to be found in various parts of the English translation, and all of them except the first, A, are printed in the same type as the original. It is true that the portions thus added are included in parentheses, and the translator's name is attached to them, but when several pages are thus introduced, it is difficult for the reader to keep carefully in mind whether he is reading Louis's de- ductions or some remarks by the translator. Wishing that the original work should be studied without any extraneous matter to divide the attention, I de- termined to place all Dr. Cowan's additions in the present form. They con- tain some very valuable data, though I fear he has quoted at times from some " closet therapeutic" writings, as he calls them, or^ in other words, he has cited the works of some who have not always been influenced by the same philosophical spirit which guided Louis in his investigations. — H. I. B.] A. Origin and development of Phthisis. We have no intention of supplying what the author has omitted, by detailing the numerous opinions which have been entertained on the origin and mode of development of tubercles. We refer those who are desirous of pursuing the subject, to Dr. Forbes's Translation of Laennec ; Bayle (Recherches sur la Phthisic Pulmonaire) ; Andral [Precis. Anat. Pathol..^ and his Clinique Médicale) ; Broussais (Inflam- mations Chroniques, vol. i.) ; Cruveilhier (Med. Prat. Eclairée par J 3 458 translator's appendix. VJJnat. Pathol.); Lombard (Essai sur les Tuhercles) ] Magendie Jownal de Physiologie, vol. i.) ; Trousseau and Leblanc (Archives Gen. de Med., 1S28) ; and in our own country to the writings of Drs. Alison, Stokes, Baron, Williams, Carswell, Clark, Spittall, Rogers, &.c. The inquiry has elicited more talent and ingenuity than any positive and practical results : we would therefore warn the student from at- taching too much importance to the subject, and recommend him to receive all opinions and hypotheses with great reserve and caution. Let him remember, that since tubercles are found in every organ of the body, all opinions relative to their formation, which are depend- ing on the peculiar structure of the lungs, are necessarily capable of only partial application, while analogy would lead us to suppose that an identical morbid production, so generally distributed, would origi- nate in some tissue common to all our organs. The form and rapidity of tuberculous deposition are undoubtedly subject to great variations ; these difierences are most sensible in a comparative view of tubercles in the lungs and those in other organs, though in many cases of acute phthisis the formation of pulmonary tubercles seems free from any peculiarities ; and, on the other hand, the previous modifications to their complete development, which are in general only to be traced in the lungs, are occasionally present in other organs ; these facts may explain many variations in the progress of phthisis, and show how very opposite opinions may be equally true, in particular circumstances, while they are all false in any general application. As the relative frequency of tubercles in our different organs is a very important question in the history of phthisis, we shall compare our author's results with those of other observers, remarking that they are not to be regarded as definitive, but merely as incentives to further investigations. Laennec, in his section, " Organic Changes which usually attend phthisis" (page 28fi), while he agrees in most points with M. Louis, has not reduced his observations to the numeri- cal form, and has evidently allowed the condition of the pulmonary organs almost wholly to engross his attention. Andral principally differs from M. Louis in having found rather more frequently tuber- cles in various organs when none existed in the lungs ; he also thinks them more frequent in the pleural and peritoneal false membranes, ORIGIN AND DEVELOPMENT OF PHTHISIS. 459 testicles and bones. M. Lombard, in his Essai sur les Tubercles, in 100 adult plithisicai patients, found tubercles in the intestines 26 times ; in the mesenteric glands, 19 ; bronchial glands, 9 ; cervical, 7 ; spleen, 6 ; lumbar glands and the sub-peritoneal cellular tissue, 4 ; axillary glands and anterior mediastinum, 3 ; subarachnoidean cellular tissue, spinal marrow, false membranes of the pleurse and peritoneum, intercostal muscles and ovaries, 2 each ; gall-bladder, liver, posterior mediastinum, pleura, vertebrse, omentum, uterus, pros- tate, bladder, cerebrum and cerebellum, medulla oblongata, kidneys, and vesiculfe séminales, 1 each. The same observer, in 100 cases of phthisis in infants, gives the following proportions : — Bronchial glands, 87 ; lungs, 73 (30 times in only one lung, 13 in the left, 17 in the right) ; mesenteric glands, 31 ; spleen, 25 ; kidneys, 11 ; intestines, 9 ; brain, 9 ; cervical glands 7^ meningœal membranes, 6 ; pancreas^ gastro-hepatic glands, cel- lular tissue lining the peritoneum, 5 ; spleen 4 or 25 (this organ is twice mentioned, with two widely different numbers, — the result had better be considered negative) ; inguinal glands, 3 ; cellular tis- sue lining the pleurœ, 2 ; lumbar glands, bladder, omentum, gall- bladder and false membranes covering tlie pleura, ] each. Though these figures may not be, and probably are not, rigorously exact, yet the variations in the frequency of tubercles in the different organs in the adult and infant are most striking and too considerable to depend on any accidental inaccuracies. The more frequent occurrence of tubercles in the bronchial glands than in the lungs, (Andral has observed this fact in the adult, but very rarely, — Vide Clinique Médicale, Maladies de Poitrine), in the mesenteric glands than in the intestines, and the inverse proportion in the lungs and in the cervical glands, is remarkable and rather difficult to explain by the doctrine of irritation of the mucous mem- branes. The preponderance of tubercles in the brain, and meninges in infants is also striking, and coincides with general observation. M. Lombard seems to have omitted altogether the pharynx, larynx and trachea. We may then conclude that in children the distribution of tuber- cles differs widely from that in adults, that they exist in a greater number of organs at once, and are not so invariably present in the 460 translator's appendix. lungs. We are disposed to think that the latter fact is not satisfac- torily established, either for infants or adults, and that the value of M. Louis's observations on this point (which only present one excep- tion in 350 examples) is not yet impaired, for we must remember that MM. Andral and Lombard, not considering the grey, semi-trans- parent granulations to be a modification of tubercles, they no doubt have omitted to mention them in their calculation, and this may be the cause of the non-accordance of their results with those of M. Louis. Tubercles are not peculiar to man, they are very frequently found in horses, and appear in these animals to be more frequent in the fibro-cellular tissue of the nasal fossae, than in the lungs. — (Vide M. Dupuy, De V Affection Tuberculeuse, &fc., 8vo. J 817. Paris). They are rare in the intestines, M. Dupuy only finding them twice out of seventy-two cases. The same observer has found them in the pig 5 and here they are in general associated with the cysticercus. In monkeys, various rodentia, and in cows they frequently abound ; and in all occupy a variety of organs. — (Vide Andral, Precis, de Anatomie Pathologique, page 431, vol. i.) In the twenty-second number of the Annales d'Hygiène Publique, there is a letter from M. Huzard, on the liability of cows, confined in the stables of Paris, to consumption. The author simply establishes the fact, that they are very liable to the disease, but has not analyzed the various influences to which they are exposed, in a way calculated to admit of any positive and satisfactory inductions. B. Diagnosis of Phthisis. We have already directed the reader's attention to the study of the expiration, as an additional means of detecting an alteration in the density of the lung, and insisted upon its importance as peculiarly applicable to the earlier periods of tubercular deposition. The differ- ence in the seat of simple bronchitis and of that which is complicated DIAGNOSIS OF PHTHISIS. 461 with pulmonary tubercles, is a fact not less remarkable than impor- tant in aiding our diagnosis of phthisis, and has never yet received that attention which, judging from the evidence of M. Louis, it un- doubtedly deserves. He has invariably found that the sibilant, mucous and submucous râles, resulting from simple catarrh, originate in the loioer part of the chest, while bronchitis complicated with pul- monary tubercles, is always situated in the tipper lobes. Simple bron- chitis usually attacks both sides of the chest, while the rhonchus from tubercles is at first almost constantly confined to the upper lobe of one side. In the eruptive diseases, continued fever and emphysema, the seat of the bronchial inflammation is constantly in the lower lobe ; and during the last three years, out of more than 140 cases, M.Louis has not met with a single example in contradiction of the above state- ment. When bronchitis is universal, of course these distinctions are not available, unless we have been enabled to follow its gradual pro- gress. Of the immense importance of this law, there can only be one opinion ; and in many instances attention to the seat of bronchitis would dissipate much doubt and anxiety, and early indicate the real nature of an affection which, without the knowledge of this fact, would frequently be confounded with simple catarrh, and thus frus- trate the hopes both of the patient and practitioner. There are some rare instances of chronic bronchitis with dilatation of the bronchia in the upper lobes (Obs. II), which might easily, judging simply from some local symptoms, such as pectoriloquy and gargouillement, be mistaken for tuberculous excavations. Under these circumstances we must carefully inquire into the history of the case, the duration of the symptoms, their being limited to one side of the chest, the absence of fever, and the preceding characters of the bronchial affections to which the patient has been liable. The pres- ence also of haemoptysis, pains, and especially the condition of the digestive tube, would perhaps always enable us to arrive at some satis- factory distinguishing characters between these two affections. Per- cussion also would assist, for around chronic tuberculous excavations» more or less sensible induration of the lung would have occurred ; and this is not usually the case for dilated bronchia. In those in- stances where the size of the tubercular cavity renders percussion clear, notwithstanding the partial induration, it would be scarcely 462 translator's appendix. possible to confound the acoustic phenomena with those arising from dilated bronchia. "• Tho situation and character of pneumonia may also aid our diag. nosis of tubercles. In the great majority of cases amono- young sub- jects it is seated in the loiver lobe, and is usually confined to one side of the chest ; while in persons above fifty M. Louis has found that the uppe7' lobe is more frequently affected. An attack of double pneu- monia in the upper lobes is a very probable indication of tubercles. These remarks are not applicable to the pneumonia which so often occurs towards the close of life ; it then not unfrequently occupies both sides of the chest. It may be worth observing", that in measles the expectoration is often nummulated and flocculent, as in the second stage of phthisis. We may also again advert to the fact, that the existence of chronic peritonitis is sufficient to justify the diagnosis of pulmonary tubercles though no general symptoms may have directed our attention to the iungs. In the chapters on latent and acute phthisis, the reader will be enabled to appreciate some of those numerous difficulties which often interfere with the diagnosis of phthisis, and at the same time be convinced how variable are the symptoms, and incalculable the progress of this affection. The absence of cough and of expectoration at a time when tubercular cavities are present in the lung, the vio- lence of the general symptoms while the lesion of the pulmonary organs is barely to be detected by the most careful examination, are facts never to be lost sight of, and highly calculated to prevent hasty conclusions respecting the presence or absence of a disease, which, •while rarely or ever destitute of some local characteristics, is often so protean in its general manifestations. The student's attention is too apt to be directed to the signs of phthisis in its advanced stage, such as pectoriloquy and purulent expectoration, &c. &c. ; but these prom- inent symptoms are certainly of secondary interest to those numerous and earlier indications gathered from an accurate history of the case, from a correct investigation of the succession of the symptoms, and from the knowledge of their individual value. The appreciation of the nicer shades of auscultation and percussion can only be acquired by long and persevering practice ; but the affirmative and negative value of the evidence which this means of examination affords, will DIAGNOSIS OF PHTHISIS. 463 amply repay the time and trouble expended in obtaining the neces- sary skill for its acquirement. It is far more practically useful to detect the first indications of tubercular deposition, than accurately to describe the varying and curious acoustic phenomena resulting from an excavation in the lungs; far more useful to be able rightly to interpret the value of the white frothy expectoration, than to mul- tiply experiments for the purpose of discovering the presence of pus. Let it be remembered that there is no one symptom which constitutes a disease, nor any one phenomenon which is invariably present ; our diagnosis to be correct, must be deduced from all the symptoms which are submitted to our notice, and their just estimation, founded upon an accurate knowledge of the pathology of the affection. The habit of mingling the description of all the accessory symp- toms with those which are the fundamental signs, has been most injurious to the progress of diagnosis, and in the indiscriminate enu- meration of every possible variation which may be noticed in the progress and symptoms of any disease when associated with indi- vidual peculiarities, the essential and leading features are too apt to be overlooked, and no definite or satisfactory information conveyed to the mind. The uncertainty almost constantly attending the just appreciation of particular symptoms, which we well know may depend on very different and opposite causes, gives great additional value to every increase of our facilities for the physical examination of our organs. The results which this method of investigation affords, are not exposed to the same liability to error, and though frequently in- capable of affording any elucidation as to the nature or seat of par- ticular diseases, they always possess a negative value of no small importance to the practitioner, both as to prognosis and treat- ment. Let the student also recollect that he cannot be too mi- nute in his inquiries: — accurate diagnosis is founded upon minutiae, and it is only by multiplying our points of recognition, that we can trace with any certainty the ever-varying features of disease. We at the same time improve our own sagacity, and acquire that perspi- cuity in description by which our observations become available to others ; the mind no longer rests satisfied with some shadowy and uncertain conclusions, but by patient and minute investigation seeks to combine and rationalize the often complicated materials from which 464 translator's appendix. remedial indications are to emanate. The want of correct diagnosis has been peculiarly evident on the subject of phthisis, and has ren- dered useless a vast mass of information on the therapeutics of this disease, because in many cases the existence of the disease itself may be questioned. At no period of medicine has diagnosis been so generally or successfully studied as at present, but at the same time we feel that it is far from being cultivated so extensively as it deserves, and we sincerely trust that the younger branches of the profession will make it still more an object of special study and devotion. c. Influence op Sex in the production of Phthisis. M. Benoiston de Chateauneuf, in a very interesting memoir to which we have more particularly referred in the notes to this chapter, says, that out of 1554 deaths from phthisis, 745 were men, 809 women. In the Statistical Tables of Paris, published under the auspices of M. Chabrol (Vide Journ. des Progrés des Sciences et des Inst. Médicales, t. ii. 1830), we find that out of 9542 cases of phthisis, 5582 were women, 3960 men. M. Lepelletier found that the number of phthisi- cal females admitted into the hospitals of Paris, were in relation to males as 5 to 3. Dr. Papavoine, in his Inaugural Essay on Tuber- cles, mentions that out of 532 girls from the age of 2 years to 15, ex- amined at the hôpital des Enfans Malades, 308, or two thirds, were tuberculous ; while out of 388 boys, 210, or about a similar propor- tion, presented the same morbid peculiarity. Dr. Darwall, in his summary of cases at the Birmingham dispensary (Vide Midland Med. and Surg. Reporter, No. 3, Feb. 1829), gives 8G cases of tubercular consumption, 48 of which were women, 38 men. To this evidence we might add the opinions of a variety of authors, both ancient and modern, in favor of the greater liability of women to this disease, but we shall confine ourselves to numerical results, and we think the INFLUENCE OF SEX IN THE PKODUCTION OF PHTHISIS. 465 Striking accordance of the above sufficient to establish the fact in question. It may be objected that they were not all cases of phthisis ; probably not, but since the majority of fatal pulmonary cases are phthisical, and as the relative frequency of pleurisy and pneumonia in either sex is the inverse of that of phthisis, this objection tends to strengthen rather than invalidate the results. The proportions given by Dr. Papavoine respecting children, in whom sex seems to have no influence, are rather confirmative than contradictory, for at this period of life the peculiarities of either sex are not developed, and their habits, among children of the lower classes at least, do not essen- tially vary. If dress, professions, and sedentary occupations are the causes of phthisis in the adult, we might have expected à priori, that the relative frequency of the disease would only be apparent Avhen these causes become active. It must not be forgotten that these results are principally derived from the Statistical Tables of Paris, and are not in unison with those obtained in New York, Sweden, &c. (Vide Cyclop. Pract. Med., part xxii. page 309). They cannot, there- fore,, be regarded as more than a highly probable approximation to the truth, founded upon the greater comparative accuracy of the de- tails, and their being collected at a time when the knowledge of the diagnosis of phthisis and post-mortem examinations gave a previously unknown value to all researches upon this subject. To arrive, how- ever, at positive conclusions, it would be necessary, as Dr. Clarke says, to know the relative number of the sexes alive in each place, their relative deaths from other diseases, and their relative ad- missions into the hospitals referred to. The habits and occupations of the sexes, the district being manufacturing or otherwise, would no doubt produce many local modifications in the results. K 3 466 TRANSLATOR s APPENDIX. D. Influence of Pneumonia in the production OF Phthisis. M. Lombard, in a valuable memoir on the respective prevalence of pneumonia in either side of the chest (Vide Jlrch. Gen. de Med., Jan. 1831), says that in 968 cases collected by Andral, Chomel and him- self, 195 had pneumonia in both lungs, 260 in the left lung, 413 in the right. This is strong additional evidence in favor of M. Louis's results ; it is to be regretted that in 195 cases of double pneumonia, the presence or absence of tubercular complication is not mentioned* The same author has investigated the influence of age on pneu- monia. His researches are founded on 206 children from the age of 1 day to J 8 months, on 118 from 18 months to 14 years, and on 1284 persons of ages varying from 15 to 83. He infers that pneu- monia forms three seventeenths of all the organic derangements found in infants who have died during the first eight days ; two ninths during the second week ; three tenths during the third week ; two ninths between the sixth week and end of the eighth; one tenth only between the second and sixth month. In the second year it amounts to one third ; from the second year to the sixth, one fourth to one fifth ; from the eighth to the eleventh, one fourth to one sixth ; from the fourteenth to the nineteenth only one thirty-seventh ; from the nineteenth to the twenty-seventh, one ninth ; from the twenty- seventh to the forty -seventh, one fifteenth; from the forty-seventh to the eighty fifth, one fourteenth; above this, one eighth. The reader is requested to compare these results with similar researches in phthisis, and he will find them corroborate the author's opinion, as to tlie independence of pneumonia and tubercles ; indeed we think that an impartial view of all the preceding facts renders this con- clusion inevitable. It may not be uninteresting to oppose the testi- mony of facta to the propositions (163 — 171) of M. Broussais. Baylo, Laennec, Andral, Lombard, all agree in regarding pneumonia as a very secondary cause of phthisis. INFLUENCE OF BHONCHÏTIS IN PRODUCING PHTHISIS. 467 E. Influence of Bronchitis in the production OF Phthisis. This section (478) and the authors reasoning are particularly worthy of serious attention, and highly calculated to shake our faith in some of apparently the best substantiated medical facts. Perhaps in the history of phthisis no one opinion was more universally admitted, than that bronchitis was amongst the most frequent and active causes of pulmonary tubercles ; this cannot however be any longer supported and its accuracy is rendered still more problematical by what has been advanced in the notes on " Diagnosis," as to the situation of simple bronchitis at the hase of the lungs. Chronic inflammation of the bronchial mucous membrane does not appear more influential. In eleven cases of dilated bronchia, where the general symptoms of phthisis had not been present, and the duration of the affection was from two to six years, the raucous membrane was intensely red, thickened and granulated, while tubercles existed only in three, and were neither numerous nor softened. It is not intended to deny that bronchitis may and does occasionally hasten the development of tubercles (acting like all other causes which tend to weaken the sum total of health), but that it has no direct specific influence. Indeed we may perhaps conclude, that any source of intense and prolonged febrile movement may be indirectly the cause of tubercles. Out of forty-six cases of continued fever (affection typhoide) observed by M. Louis, m four there were some tubercles or grey, semi-transparent granulations in the summit of the lungs, and in these instances death took place from the twenty-fifth to the forty-sixth day of the disease. No tubercles were found in those Avho died at an earlier period. — (Vide An. d'Hyg. Pub., No. 11, page 55.) Simple increased circulation, when not inflammatory, cannot be regarded as a cause of tubercles. M. Louis has collected forty-four fatal cases of diseases of the heart; nineteen were hypertropliy of 468 translator's appendix. the right auricle, twenty-nine hypertrophy of the right ventricle. In six of the latter the pulmonary artery was enlarged and thickened, thus proving the increased impetus of the circulation: — in all there were only two examples of pulmonary tubercles, while in fifty cases of cancer this complication existed in eleven instances. To conclude this irresistible mass of evidence, in forty cases of emphysema of the lungs, accompanied with chronic bronchitis of several years duration, only four presented tubercles in the lungs;, and in one alone were they numerous. — (Vide Examen, page 78.) F. Influence of Dress in the production of Phthisis. We cannot coincide with the author's reasoning in this paragraph (479). The fact of stays only being worn after the chest was fully devel- oped does not in the least weaken the evidence of their being a cause of phthisis, for the respiratory and digestive functions may be equally impeded by any obstructions to the movements of the thorax as by those which influence its development. The change of habits also in the individuals mentioned, from a country life to a residence in Paris, renders all calculations on the influence of dress valueless. From the evidence brought forward at the end of this chapter (G), rela- tive to certain professions, it may be fairly argued, in the absence of any positive evidence on the influence of particular articles of dress, which, as the author says, it would be very difficult to obtain, that what- ever interferes with the free action of the lungs, either by any habit- ual posture of the body, or mechanical obstruction, may be considered as powerfully predisposing to pulmonary tubercles. In delicate children particularly, the effect of any mode of dress by which mus- cular action is impeded cannot but be most prejudicial, and if not terminating in phthisis, is undoubtedly the most fruitful source of spinal deformity. INFLUENCE OF AGE. 469 G. Influence of various causes in the pro- BUCTioN OF Phthisis. These results (481), are confirmed by those of Dr. Darwall; in forty-eight female cases of phthisis, the numbers were as follows : — Deaths. 9 16 16 6 1 In the Statistical Tables of Paris already referred to (C), founded on 9542 examples of phthisis, we find ages arranged according to the relative frequency of tubercles. Age. 15 to 20 20 to 30 30 to 40 40 to 50 55 20 to 30 SO to 40 10 to 20 40 to 50 50 to 60 Age. to 10 60 to 70 70 to 80 80 to 90 90 to 100 This table strengthens the preceding with regard to the adult age ; for the earlier periods of life, the materials are less copious and from many circumstances less likely to be correct. Of this Ave may judge by comparing the recent researches of Drs. Lombard and Papavoine, made at the Hôpital des Enfans Malades. The former has found tubercles in one eighth of the children who die between their first and second years ; in two sevenths between the second and third years ; in four sevenths, between the third and fourth ; in three fourths, between the fourth and fifth years. From this last period until puberty, tubercles are more frequent than anteriorly to the fourth year, but less so than between the ages of four and five. These results 470 TRANSLATOR S APPENDIX. are very similar to those of Dr. Papavoine ; this pathologist has found that from the fourth to the fourteenth year the number of tuberculous children is greater than that of those who are not so ; that tubercles are most frequent betAveen the fourth and seventh years ; that they again become numerous from the twelfth to the thirteenth year ; that be' tween the fourteanth and fifteenth years the same proportions exist as between the third and fourth. These data are founded on the post- mortems of 920 children (388 boys — 532 girls), from the age of two years to fifteen. Out of these 538, or nearly three fifths, presented tubercles. — (Vide Journ. des Prog, des Se. Médicales, t. ii. 1830 : and Revue Med., June, 1830). The above details all coincide in placing the maximum of tubercles in the adult, between the ages of twenty and forty. The great frequency of tubercles in children as implied by the researches of Drs. Lombard, Papavoine and others, is a fact of considerable interest, and is not consonant with what has hitherto been the general opinion. This no doubt may be attributed prin- cipally to our pathology being now founded on post-mortem exami- nations, and not on mere symptomatology ; also to the modifications which age produces in the symptoms of tubercles, to their different distribution in children, and their frequent manifestation by abdomi- nal rather than thoracic symptoms. The question of the influence of age is an important one, and is still depending on future investiga- tions for its complete elucidation. We refer the reader to the able summary of Dr. Clarke (Vide Cyclop, of Pract. Med. part xxii. page 307), for more extended details on this interesting subject. The causes of phtliisis have never received that attention which they really deserve, more especially since the result of their influ- ence is a morbid condition of the system, for the removal of which, medicine has hitherto been almost inert. Under tliese circumstances prevention is evidently a more important investigation than cure, and the active agents of tubercular disease merit our most serious and attentive research. There is one prevailing error which has attended the majority of investigations on the etiology of this and other dis- eases, which, in the appreciation of the succeeding remarks, must not be forgotten. Every possible influence has been occasionally associated with an affection so frequent in its occurrence, and the INFLUENCE OF VARIOUS CIRCUMSTANCES. 471 long list of causes often contains an indiscriminate enumsKation of every agent capable of modifying the health, without any definition of its relative activity, or any attempt to distinguish between M'hat essentially predisposes to disease and what simply hastens its devel- opment after the predisposition has been formed. Without attention to this the causes of disease can never be classified, for in proportion as the health is debilitated and constitutional peculiarities abound, do we multiply the number and activity of those influences which re- act upon the frame, and thus each individual adds a new cause to our list, until novelty is almost impossible, and prophylactic treatment would require another Avorld for its employment. In attempting, therefore, to investigate the causes of consumption, those influ- ences are alone examined which appear capable, by a more or less prolonged application, of producing tubercular deposition in a. healthy individual. In accordance with these views, we shall now make the reader acquainted with some recent extensive researches on this most important subject. It will be necessary almost entirely to confine our remarks to the conclusions admitted by all, or by the majority of those on whose in- quiries we can rely, for each author having adopted a different plan in the arrangement of his details, and arrived at different results with regard to many individual facts, it would require a volume rather than a note to enter at length into those considerations by which these differences might either be explained, or attributed to the peculiar and à priori views of the nature and causes of phthisis, which have occasionally influenced the writers. Our principal sources of infor- mation are three. 1st. A memoir, by M. Benoiston de Chateauneuf, on the relations of consumption to trades and professions generally, published in the Annales d'Hyg. Puhl. for July, 1831. It is founded upon the inspec- tion of the registers of four of the principal hospitals of Paris, inclu- ding a period of five or ten years, as the individuals belonging to particular professions were numerous or otherwise, determining the proportion which the deaths from phthisis in each trade bear to the total admissions of persons of that trade. The number of professions (principally among the operative classes), is 42, and the sum total of admissions 43,000 (26,045 men and 16,955 women). Out of these 472 translator's appendix. 1554 have died from thoracic affections, (745 men, 809 women), or ahout one thirty-fifth for the former and one twenty-first for the latter. The reader will at once perceive that this mode of deciding the question can never be completely satisfactory, for the determi- nation of the comparative mortality of phthisis in any particular pro- fession requires a knowledge of the number of deaths in that pro- fession from diseases in general. We might, without this information, discover that phthisis was more or less frequent in certain circum- stances, but the peculiar tendency to its production rather than other diseases, can only be resolved by the comparison to which we have alluded. This has been foreseen in the memoir of Dr. Lombard, of Geneva, published in the same periodical for January, 1834 ; though even here the results are far less positive than would be desirable, on account of the total number of persons engaged in each trade not having been mentioned. This talented and indefatigable pathologist founds his inductions on a still larger and in some respects a more valuable collection of facts. He divides them into five series. First, 1495 deaths from phthisis, collected by himself in the different hos- pitals of Paris, and contrasted with a table oï general mortality in the same professions, published by M. Villermé, but taken in another year. Secondly, 676 cases in the general hospital of Hamburg, arranged and contrasted as above. Thirdly, 572 phthisical cases in a hospital of Vienna. Fourthly, the memoir of M. Benoiston de Chateauneuf. Fifthly, 88v!9 deaths collected from the registers of Geneva, of which 1003 were from phthisis ; giving an average of 114 deaths out of every 1000 deaths from diseases in general. This last division is the most valuable, since it presents materials for the comparison we have already referred to. Dr. Lombard's researches are therefore founded on a total of 4300 deaths from phthisis, and 54,572 individuals, exercising 220 different occupations. The third source to which we would particularly refer is the inter- esting volume of Mr. Thackrah, on The effects of Arts, Trades and Professions, Sfc, on Health and Longevity, 2d edition, London, 1832. This we believe is the only work of the kind published in England, and the reader will find in it much valuable information, and discover many proofs of the author's talent and research. The extent of in- quiry which it embraces necessarily precludes those accurate numeri- INFLUENCE OF DUST. 473 cal details which are indispensable for arriving at rigorous conclu- sions. Phthisis has also, from the nature of the work, been only considered as one of many other diseases to which our manufacturing and other classes are liable, and the author's pathological views with regard to the nature and causes of this disease, have insensibly bias- ed his researches and modified his conclusions. He says, page 98, "No agents excite tubercular development more than irritation of the bronchial membrane. Much, I conceive, depends on the size and Jigure of the particles Avhich enter the air-tube. The dust from the roads produces no apparent mischief, while the mason's chippings from the stone occasion serious and often fatal injury to the lungs." (As if no other and moi-e important considerations did not influence this result.) " The dust from old iron, which is thrown off so copiously as to deposit a thick brown layer on the dress of the dealers of this article , produces 710 inconvenience, while the less apparent detach- ment of particles from the file, is decidedly baneful to the workers in iron. It is then the forjn rather than the material, the spiculiE, the angular, or pointed figure of the particles detached, which we con- ceive the chief cause of the injury. The bronchial membrane is mechanically irritated or wounded ; and fi'om the daily repetition of this injury, the lungs at length become seriously diseased, and a vast majority die consumptive!" With these impressions upon the mind, much misconception as to the really active causes of phthisis will continue to prevail, and many useless preventive measures be adopted. No really conclusive re- searches can be made under the influence of such preconceived, and we believe erroneous opinions. There are other materials, of which we shall avail ourselves in the course of these remarks ; they will be mentioned under the particular divisions to which they are applicable. We shall now examine the evidence adduced on some of the most important influences resulting from different occupations. Influence of Dust in the production of Phthisis. No opinion has been more prevalent, than that those who are ex- posed to the inhalation of the dust of vegetable, mineral, or animal substances, are peculiarly liable to phthisis, and on the supposition that consumption was essentially a disease of the lungs, and in the L 3 4'4 translator's appendix. great majority of instances the result of bronchial inflammation, no conclusion --.vas more natural or more probable. The reader cannot, Tve think, have impartially examined the evidence on the influence of bronchitis, acute or chronic, in the production of phthisis, and reflected on the general deposition of tuberculous matter which takes place in this disease, with many other circumstances attending its progress and invasion, and retain his probably previous opinion as to the influence of bronchial inflammation on pulmonary tubercles. Once remove from the mind the impression of a necessary connexion between bronchitis and tubercles, and we feel persuaded that the ex- amination of the evidence brought forward on the subject of dust, will terminate in the conviction that this agent exerts at most but a very secondary and unimportant influence in the production of phthisis, compared with other causes to Avhich we shall have occasion to refer. The question is far more than one of speculative interest, as it has already given rise to the exercise of great talent and in- genuity, in inventing means for the removal of an evil which by many has been regarded as the most fatal to which the manufacturing classes are liable. (Would that it were!) It is evident that a comparison of the mortality from consumption in a list of dusty occupations, such as those of bakers, charcoal-men, grain-market porters, thread-makers, cotton-spinners and rag-pickers (and we might have fixed on any other list) is utterly incapable of deciding the predisposing influence of dust in the'production of the disease. The other influences attend- ing these occupations, which are admitted to be still more powerfully predisposing to phthisis, reduce the common element of dust to a mere cypher in the account. Some, working in the open air ; others, in close-heated rooms ; some actively employed, while others are confined to a sedentary occupation, &c. &c., at once show how necessarily insecure all our results must be from such varying and complicated materials. As another general principle it may be ad- vanced, that in a change of particles a change of employment is included, and precisely as dust is evolved from hard substances, and IS more or ]ess fine in its texture, the occupation of the workman is sedentary, his posture confined, and muscular exercise limited to the upper extremities. Now these last causes are admitted by all as most strongly predisposing to phthisis (proved by their estimation in INFLUENCE OF DUST. 475 occupations where dust is not included), and we would ask why their influence should be diminished by the presence of another apparent cause, more consonant, it is true, with our preconceived ideas as to the natui'e of the disease, but which is not present in those occupa- tions where the average mortality from phthisis is the highest ? No evi- dence is more universally cited on this subject than that of Dr. Knight, of Sheffield (Vide JYorth of England Med. and Surg. Journal, August and November, 1830). It does indeed incontestably prove that the occupation of grinding steel instruments, unusually tends to shorten life and induce phthisis. Dust, — dust is the explanation; but we think the evidence brought forward in its support tends to an opposite conclusion. -We find, in fact, that the grinders, previous to the com- mencement of the last century, were not an unhealthy set of men ; at this time they carried on their trade in the country; worked in large open rooms ; -practised other deparimenls, as hafting and forging, and were often months with only four or five hours work daily- They now pursue their profession in close rooms, work sixteen hours a day, and are wholly confined to grinding. The usual posture is with the shoulders elevated, the elbows resting on the knees, and the body inclined forwards. It is an interesting though painful observation, that the most dissipated workmen live the longest ! (That influence must be fatal indeed which makes vice a means of lengthening life !) The same observer states, that out of 250 workmen employed in polishing steel, ]54 had chest afi'ections; while in an equal number of workmen pursuing other occupations in conjunction with polishing, 56 only were affected. There was not an example of a polisher of forks reaching his thirty-sixth year. Magnets, wire masks, currents of air and moisture, have been successively tried for the purpose, of arrest- ing the metallic particles, but the mortality has not been diiimiishcd. It is impossible not to be convinced that the influence of dust has here been sadly overrated, and blinded observers to the employment of means calculated to counteract the real sources of the evil in ques- tion. M. Parent Duchatelet, in an interesting memoir on the effects of tobacco on the workmen (Vide ^n. d^Hyg. Pub,, April, 1829), found- ed on an accurate examination of 4518 individuals employed in the different manufactories of France, and who are exposed to the inhal- ation of irritating vegetable particles, found that they wore not at- 476 translator's appendix. all pe'.n'iar^y l'/^ hie to chest affections, and that their general health depended on the quality of the food and the number of hours they were employed. It will be seen also, in the work of Mr. Thackrah, that chillren, comparatively, do not suffer in dusty occupatio. s ; this he attributes to the greater force of the pabulum vitEe, and their less liabiliti/ to tubercular development. Facts prove the latter opinion to be incorrect; the difference is therefore depending on some other cause. The results also of MM. Benoiston and Lombard, ('•^nïz.vi.andxi.), on the relative influence of mineral, vegetable and animal particles are exactly the inverse of each other:* the former making animal parti- cles the most prejudicial, and mineral the least ; thelatter giving a very large proportion in favor of the mineral particles (177 per 1000 deaths) over the animal. Let the reader compare these heterogeneous profes- sions, which are congregated together for the purpose of arriving at these results, and he will at least admit that if true in the abstract, they are far from being demonstrated. It is also but fair to notice that M. Benoiston, while he finds the proportion of deaths from phthisis rather more considerable in occupations involving an air charged with animal particles, yet the average mortality of all the different professions where the influence of dust is present, is not greater than the general average for occupations not exposed to this additional inconvenience. From the researches of Drs. Young, Leblanc and Alison, it would appear that stone-masons are peculiarly liable to phthisis. It must however, be recollected, that compara- tively few post-mortem examinations have been made for the purpose of determining this question, and that the appearances mentioned by Dr. Alison in his valuable paper, are rather those of inflammation than tubercle. Were the existence of tubercular disease ascertained, the influence of dust in its production is still undecided. The hard nature of the material, the partial exercise of the body, exposure to varieties of temperature, habits of intemperance, &-c., probably exert a more powerful influence. We find, in fact, (Vide Benoiston, page 27), that oui of 887 quarry-men, 551 stone-cutters, and GO marble-workers, the proportion of phthisis was less than the general average. In a department of France (Meusnes) celebrated for the * From data obtaineil in the cities of Paria and Geneva. — H. I. B. INFLUENCE OF MOISTURE. 477 fabrication of mill-stnnes, in a period of seventeen years no increase of mortality from phthisis, conipared with other departments where this occupation was not genera], could be detected. M. Thackrah also found no liability to phthisis (which could be attributed to their employment) in plasterers, turners, lime-workers and whitewashers. Let us terminate these remarks by citing the conclusion to which Dr. Lombard arrives by a review of the lohole of his facts (CG), viz., that the influences which modify the system in general, such as a sedentary life, &c. &c., are more active in the production of phthisis than those acting lor.ally upon the lungs, as dust, vapors, &c. ; and if we reflect that the latter agents are never present independently of the former, their real activity as causes of pulmonary tubercles is at best but problematical. Our conclusions are in some degree opposed to the opinion of Dr. Clarke, in his admirable essay already referred to, but that distinguished observer admits that " in almost every in- stance the sufferers are exposed to causes (independently of dust) fully adequate to the production of the tuberculous cachexia.'* We refer the reader to the original memoirs for full information j our object in these remarks is to remove that settled conviction so generally prevalent, as to the influence of a local cause on the pro- duction of phthisis. We again say, that the nature of the disease is a powerful à priori argument against the influence of dust of any description, and that the direction hitherto given to our opinions and preventive measures has tended to distract our attention from the observation of more important and active causes. We are now, let it be remembered, solely considering the inhalation of dust in refer- ence to phthisis. Its presence can never be beneficial, and its action on the bronchial and digestive mucous membrane is no doubt often, and probably always more or less injurious. It is not, therefore, our wish to discourage the use of any means by which the inconvenience may be diminished, but to prove that its immediate action upon the pulmonary organs has hitherto been greatly exaggerated. Influence of Moisture. The evidence on this subject is perhaps more uniform and satisfac- tory than on any other, and tends strongly to expose the fallacy of 478 tkanslator's appendix. theoretical opinion. Tanners, dyers, wool-scourers, brewers, washer- women, and many other occupations in which the upper or lower ex- tremities are exposed to wet, and the air charged with aqueous vapors, present fewer cases of consumption than almost any others. The testimony of Mr. Thackrah and Dr. Lombard on this subject is unanimous, and M. Benoiston is only in contradiction with regard to the washerwomen of Paris, who, as Dr. Lombard observes, pursue their occupation under peculiar circumstances, and on that account offer no criterion for the same employment in other countries. Brick- makers (Thackrah) who work half naked and with their bare feet in puddle all day, are not more liable to thoracic affections than men whose occupations is under cover, and dry. Longevity is common. M. Parent Duchatelet, states (^nn. (THyg. July, 1830), that " débar- deurs" of Paris, or those who are employed in removing the wood for fuel from the river, where it is floated down in rafts, and who spend the greater part of the day nearly all the year round, with their legs im- mersed in the water, are less liable to chest affections than the majority of workmen, and their general health is remarkably good. These re- searches are founded on the personal examination of 670 men, who are constantly pursuing this occupation. This strikingly coincides with the very general opinion that consumption is rare in marshy districts. A general practitioner at Swineshead in Lincolnshire, has seen only two cases in sixteen years. Dr. Harrison of Horncastle, in the same county (Vide Med. and Phys. Journ., t. viii. page 225. 1802), confidently asserts that consumption is less frequent in the marshy districts, than in other parts of his neighborhood. Cases occurring in a dry situation were checked by a removal to one sur- rounded by fens. The ingenious and accurate Dr. Wells (Vide ŒVans. Soc. Med. Chir. vol. iii. page 471. Lend. 1812,) brings for- ward a variety of observations on this subject. He attempts to prove that the causes of intermittents induce a state of constitution which is a protection from consumption, and says that in countries where one prevails the other is always absent, or at least much less preva- lent. He recommends children, predisposed to consumption, to be sent to schools in fenny districts, or to universities in Holland. Mor- ton, Raulin, Rush, Southey, and others, decidedly recommend a dry climate, but their advice seems principally founded on theoretical A DRY AND HOT ATMOSPHERE. 479 views. Compared with the statistical results to Avhich we have alluded, the evidence of Dr. Wells and others is not without consid- erable interest, and numerical details from the marshy districts of England would be highly desirable. The effect of moisture on con- sumption may also be indirectly inferred, by considering the influ- ence of opposite conditions, viz., A Dry and Hot Atmosphere. Dr. Lombard, (Jinn. Jan. 1834), in 244 deaths among persons ex- posed to this influence, as enamellers, file makers, smelters and founders,* finds the average of phthisis more than double that of the preceding class. The first was 53 per 1000, the last 127. He also thinks that in certain occupations, as in those of watchmakers, jew- ellers, and goldsmiths, the mortality from phthisis may in part be attributed to the hot and dry atmosphere to Avhich they are exposed. Mr. Thackrah, on the other hand, from the observation of sugar re- finers, men employed in the dryhouses of cloth, in singeing cloth, stuff pressers, calenderers, glass workers, stovers, iron founders, many of whom are constantly exposed to sudden changes of temper- ature, did not find any peculiar predisposition to pectoral affections, nor any prevalence of those complaints so commonly attributed to this cause. It will be recollected that workmen in these depart- ments are generally subject to great muscular exercise and almost constant activity of the cutaneous functions. Animal Emanations. There is but one opinion on this subject, viz., that individuals ex- posed to their influence are less liable than others to consumption. Butchers, tanners, leather dressers, candle makers, nurses, soap boilers, knackers, or those engaged in killing and cutting up dead horses (Vide Lond. Med. and Phys. Journ., vol. vi.), men employed in the dissecting rooms, in exhumations, catgut makers (Labarraque), * Out of forty-seven deaths not one was from phthisis, which Dr. Lombard thinks may be attributed to the moisture which their occupation requires. 480 translator's appendix. nightmen, are mentioned without any exception, as enjoying a high standard of health and freedom from pulmonary complaints. Vegetable Emanations. Those who work in the open air as agriculturists, gardeners, florists, and who are liable to emanations from living plants, are decidedly among the most healthy. The occupation of crushing rape and mus- tard seed appears peculiarly beneficial, (I'hackrah, page 58). Starch makers, bakers, &c., who are exposed to the effects of vegetable fermentation do not appear affected, and from the interesting re- searches of M. Parent du Chatelet and M. Girodet in Ann. (THyg. Pui., March, 1832, on the maceration of flax, it is probable that many of our generally received opinions respecting the influence of vege- table decomposition on health are erroneous. Mineral Emanations. The evidence relative to mercurial vapors is very contradictory, and insufficient to determine their real influence in the production of phthisis. At Geneva, phthisis among gilders is rare ; at Paris it ap- pears frequent. The effects of lead, antimony, &c., while they act powerfully on the nervous and digestive systems do not appear to predispose to phthisis. The tendency of metallic fumes to produce scorbutic symptoms and that of mercury to maintain an alkalescent state of the fluids, would both militate theoretically against their favor- ing tubercular deposition. Influence of Impure Air. Dr. Lombard, by a comparison of all the professions carried on in the open air or in workshops, found the proportion of deaths from phthisis double among the latter, and this proportion increased as the apartments were close, narrow, and imperfectly ventilated. Other facts, however, prove that an impure atmosphere, when not associated with other deleterious influences, cannot be regarded as peculiarly predisposing to phthisis. In No. 107 of the Edin. Med. and Surg. Journal there is an interesting paper by Mr. Watson, surgeon of Wanlockhead, a mining district. After an experience of fifteen INFLUENCE OF AN ACTIVE LIFE IN THE OPEN AIR. 481 years, he concludes that miners are not more liable to phthisis than others. He gives an account of 74 men, working during four or five months, for sixteen hours daily, in a mine where a candle burned with difficulty. Not one was attacked with any pulmonary affection. The average mortality among the miners was less than among the other inhabitants. In Annales d'Hyg. Pub., Oct. .1829, M. Parent Duchatelet gives a tabular view of the health of 32 workmen em- ployed in cleansing tlie sewers of Paris. Their ages varied between seventeen and fifty-five, and they had pursued the occupation from six months to fifteen years. Not one became phthisical, or presented any chest affection. Colliers do not appear liable to phthisis, and though many species of mining interfere with the general health, con- sumption does not seem to prevail. Dr. Forbes, in his notes to Laennec, says, that the great majority of miners in Cornwall are de- stroyed by chronic bronchitis. If consumption is rare under these circumstances, it would be a striking confirmation of M. Louis's opinions on the distinct nature of bronchitis and tubercles. Influence of an Active Life in the Open Air. On this point it may be sufficient to state that all occupations in- volving these two conditions are admitted by every observer, to present a much smaller proportion of individuals attacked by phthisis than any others : husbandmen, butchers, carters, coachmen, sailors, coopers, quarrymen, &c., may be cited. Influence of a Sedentary Life, with a confined posture of the 'Body. Of all the causes which seem directly active in the production of phthisis, this appears the most general and influential ; it must never be lost sight of when estimating the predisposing tendency of par- ticular professions. However variable the situation of the individual in every other respect, wherever these two conditions are present, phthisis may be said to prevail, and its prevalence, according to Dr. Lombard, (Ann. (THyg., Jan. 1834, page 33,) is in proportion to the M 3 482 translator's appendix, more or less muscular exercise certain sedentary occupations require. As a general rule also, sedentary employments are more fatal among women than men. Tailors, shoe-binders, shoemakers, milliners, lace-makers, printers, engravers, jewellers, watchmakers, clerks, &c. &c., may be more particularly regarded as the victims of phthisis ; and in our manufactories, there is no doubt that a far greater number of consumptive patients is produced by the want of exercise and a contined posture of the body, than by those special and in general local influences to which the disease has been so often erroneously attributed. It will be at once seen to what an extensive portion of our population, both in the middle and lower classes, these remarks are applicable, and consequently the immense importance of being aware of the fatal tendency of an influence, which has been often over- looked or regarded as secondary to other causes which perhaps may now be considered as comparatively inert. The increased mortality among females arises not only from their being principally exposed to the influences we are considering, but from their great privations on account of their diminished wages, &c., and other bodily derange- ments peculiarto the sex. The number of hours the workmen are employed, the time allotted for their meals, and the quality of their food, no doubt powerfully modify the results, but we have no positive information by which we may define the extent of these influences. There is one conclusion in Dr. Lombard's memoir, which may per- haps be illustrative of the influence of food, viz., that the poorer classes are twice as liable to phthisis as those in easy circumstances. It is founded upon comparing the number of professions which are above or below the general average in either division, and since sedentary habits and a confined posture of the body are more or less common to all, this great difference in the frequency of phthisis, may in part at least be attributed to food. There does not appear to be any foundation for the opinion that occupations requiring OToZeni e.rerase of the upper exlremities, (as those of backsmiths, sawyers, locksmitlis, &-c.), predispose to phthisis. Exercise of the Vocal Organs. M. Benoiston was only able to collect 24 examples of occupations in- volving this condition, and among these there was no peculiar tendency NFLUENC ES WHICH PREDISPOSE TO PHTHISIS. 483 to phthisis (Ann. d^Hyg.^Jiûy, J831.) Dr. Lombard fully confirms this result. Out of 254 deaths, including schoolmasters, preachers, profes- sors, barristers, musicians and officers, the mortality from phthisis was only 75 per 1000 deaths, while we have already stated that the gen- eral average from all professions indiscriminately was 114. The exercise therefore of the vocal organs is beneficial rather than in- jurious. The reader must not forget that we are considering the activity of different influences in the development of tubercles, not their effects on individuals who are already tuberculous ; and although, for the sake of brevity, we have often resorted to the simple form of assertion, the preceding remarks are based upon a very large series of observations, collected by different observers, and are not to be confounded with the innumerable vague and indefinite surmises which we find scattered through the various monographs onphthisis_ The necessity for examining a large mass of facts, and reuniting a variety of professions in which the influence of some common con- dition may be traced, must be apparent to all. An infinitude of ac- cessory causes may interfere with accurate conclusions, when bounding our examination to particular occupations ; but the errors to which our details are always more or less liable, are corrected by a greater extent and variety of materials. It is to the partial obser- vation of particular facts that we may attribute the contradictory nature of the evidence on the causes of consumption. In concluding our remarks upon the influence of professions on phthisis, we will briefly enumerate those general causes which may be regarded as injurious or preservative. Influences which predispose to Phthisis. 1st. A sedentary life, more especially when associated with a con- fined posture of the body. 2d. Bad quality or insufficent quantity of food. 3d. The impure air of workshops, 4th. A dry and hot atmos- phere, with a variety of mineral and vegetable emanations ; the effects of which, however, independently of those influences already stated, are far from being proved. 5th, The action of different kinds of dust, the activity of which, like the preceding, is in all probability very much less than has been hitherto supposed. 484 translator's appendix. Preservative Influences. 1st. Muscular exercise in the open air. 2d. An air charged with animal emanations. 3d. Moisture. 4th. Exercise of the vocal organs. 5th. Nutritive food. The essential practical deduction from the foregoing details is, that continued sedentary employment, a confined posture of the body, and the want of air, exercise, and wholesome food, are the immensely pre- ponderating causes of phthisis ; and that other influences acting locally on the lungs, and which have always been regarded as most deleterious, are supported with comparative impunity, when disasso- ciated from those we have first enumerated. There are few evils which cannot at least be mitigated, if not avoided, where we have accurate ideas of the causes which produce them ; and the means to be adopted for diminishing the victims to consumption, are at once indicated by the inspection of the fore- going details. It is evident that the attention of observers has been too much directed to what may be considered rather as accidental, and, in many cases, unimportant accompaniments, than to the really active and efficient causes of phthisis. The registers of mortality prove that our prophylactic measures have hitherto failed ; the sub- ject therefore demands renewed investigation, and its vast impor- tance entitles it to our most serious attention. The infinite sub- division of labor which the increasing and artificial wants of society involves, is daily multiplying the sources of phthisis, and without adopting some effectual preventive measures, this fatal scourge upon the manufacturing and commercial prosperity of England, will annu- ally extend its baneful influence. Tn what those preventive meas- ures must consist to be really effectual, we shall briefly point out in our remarks on treatment. Influence of Climate. On no subject has more been written or less satisfactory informa- tion been obtained ; the ideas of a changeable climate and phthisis seem almost inseparable, and more particularly with respect to INFLUENCE OF CLIMATE. 485 England, consumption has been regarded as one of those necessary indiû-enous evils, to which, as a nation, we are inevitably doomed. If however, we reflect that no climate is exempt from phthisis, that in the northern and torrid zones it is far less general than in the more temperate regions of the globe ; tliat in the same climate its relative prevalence among particular classes of individuals is immensely dif- ferent ; that in countries where this disease is unusually frequent, those who are least exposed to its influence, are precisely those most ex- posed to the vicissitudes of the climate ; we cannot but confess that the importance of the latter in the production of phthisis has been much exaggerated and far too exclusively considered. Its action on the human frame must be admitted to be extremely complex ; the ultimate result, as Dr. Copland says, arising chiefly from the com- bined operation of heat, light, electricity, atmospheric pressure, the various emanations arising from the soil, and the productions, vege- table and animal, constituting the food of man. Independently of these numerous considerations, the grand and, in our opinion, most important influence of civilization renders the appreciation of climate peculiarly difficult; and the simple inspection of mankind in different countries, forces us to admit, that the most vaiiabh climates, not- withstanding the disadvantages imputed to them, are the most favorable to the advancement of the various bodily and mental powers. Countries thus circumstanced are rather benefited than injured by this state of the weather and seasons, as is illus- trated in the robust frames, mental activity, and the longevity of their inhabitants. The physical and moral condition of the British Isles, Denmark, Sweden, and the more continental districts of West- ern Europe, demonstrate this fact. In no country are the animals finer than in England, or the inhabitants, viewed as a community, more robust, and if under these circumstances, a disease of the nature and character of phthisis is found to prevail, and its frequency can be traced to particular classes of individuals, evidently exposed to influences which are in no wise depending on the climate of the countrj'' they inhabit, its prevalence must necessarily be ascribed to other causes, aud not attributed to what has been too easily admitted as a powerful agent in tubercular disease. The reader must not paiatake the spirit of our remarks, or suppose that we are denying the 486 translator's appendix. influence of a changeable climate on delicate predisposed constitu- tions ; nor are we ignorant of the fact that the sudden change from a hot to a'cold climate is frequently followed by pulmonary consump- tion, but we are simply examining the natural tendency of a particular climate, abstractedly considered, to induce tubercular disease in those habitually submitted to its influence ; and after perusing the works of Clarke, Young, Laennec, Mosely, Beddoes, Wells, Southey, and Fothergill, we have not been able to collect any conclusive evidence upon the subject. All calculations where the occupations, food, habits, &c., of the inhabitants are not duly considered, may be regarded as negative ; for, having once demonstrated that the maxi- nnum of liability to phthisis in a country like England, is found among those least in contact with the variations of its climate, the influence of the latter must be regarded as secondary to the action of causes, without the previous agency of which it would have been compara- tively if not wholly inert. We are unable to favor the reader with any positive evidence on the relative frequency of phthisis on the sea coast or inland; numerous details and exact appreciation of the changes in food, occupation, &c., which one or the other involves, would be necessary for the solution of this important question. The most contradictory opinions have been entertained, and in the pres- ent state of our knowledge we prefer avowing our ignorance, to the expression of an opinion which can have little else for its support than theoretical assumption. The observation by Dr. Rush, that phthisis is unknown among the Indians of North America and very uncommon among the colonists in the first stage of civilization, is most interesting, and highly confirmatory of the preceding remarks ; we are much inclined to believe that were the influence of climate un- connected with all other causes, the activity of which is incontestable, in the present state of our evidence it would not admit of demonstra- tion, and that in England the prevalence of phthisis is owing to the requirements of fashion and commerce, rather than the consequence of our much calumniated climate. Contagion of PhtJiisis. This question is decided in the afiirmative by the majority of authors, [from Aristotle down to modern times ; we have not, how- CONTAGION OF PHTHISIS. 487 ever, been able to collect the slightest satisfactory evidence in favor of the conclusion, but have waded through a mass of incomplete and often absurd facts, which are rather painful illustrations of the credu- lity of many of the most distinguished ornaments of their profession, than data to regulate the decision of any philosophical inquirer. The difficulty of determining the contagious nature of a disease so preva- lent as phthisis, is very great, and the number of facts necessary for its substantiation would be considerable. Without attempting to offer any decision upon the subject, we may remark, that the pathol- ogy of the disease, its progress and causes, Avhen compared with what we know relative to diseases whose contagion is not doubtful, all tend to favor the idea that consumption is not contagious. In the memoir of Dr. Lombard (page fi6), attendants on the sick, in hospitals and elsewhere, are invariably classed in the lists of Geneva, Vienna, and Hamburgh, as amongst those who are least exposed to phthisis. This fact is not easily reconciled with the idea of con- tagion. The negative evidence also of Beddoes, Young, Russel and Portal, is more decisive than any which has been adduced on the opposite side. Wherever doubt exists, the judicious practitioner will of course studiously avoid all unnecessary exposure; but there are quite sufficient reasons, independently of any idea of contagion, to render the prevention of the attendance of delicate, predisposed individuals on consumptive or other patients, both prudent and de- sirable. Dr. W. Philip, in his valuable little work on the employment of minute doses of mercury, page 57, insists strongly on the influence of neglected bilious complaints in the production of phthisis ; stating, that according to his experience more than half of the cases of pul- monary consumption are of this nature, and might with certainty be prevented by removing the cause of irritation, before the nerves, which convey the effects of the irritation to the lungs, had essentially in- fluenced the state of their vessels. The general pathology of the disease renders it highly probable that derangement in the digestive functions is a primary and frequent cause of phthisis, as indeed is every influence which interferes with any of the important functions of the body, though from the almost invariably morbid state of the alimentary canal in conjunction with pulmonary tubercles, the occa- 488 translator's appendix. siona] predominance of gastric over thoracic symptoms, and more particularly the special character of the alterations observed in the liver and digestive tube, and their dépendance on the state of the pulmonary organs, it is to be presumed, that the direct influence of bilious complaints on consumption has been overrated, and that the secondary effects of tubercles in the lungs have been often regarded as the causes of those pulmonary symptoms, which are frequently so latent in their character and tardy in their manifestation. It has been generally supposed that the seasons exerted a powerful influence on the mortality from this disease, and the Hippocratic opinion of the fatal influence of autumn has generally prevailed. The only numerical details we have been able to collect are in the memoir of M. Benoiston (^n7i. (THijg. July, 1831, p. 19). Out of 12,668 deaths from phthisis, occurring at Milan, Paris, and in the surround- ing country, the proportion in the different seasons was as follows : — Autumn, 3001 Winter, 3109 1 ^^_> 12,668 Spring, 3482, Summer, 3076 These results are almost negative ; the question is still undecided, and it is more than probable that the result in each country will vary with the local peculiarities of the climate. We do not intend occupying the reader's attention by the enumera- tion of the long lists of supposed causes of phthisis, believing that it is far better to be ignorant of the cause of a disease, and to avow this ignorance, than to refer it slightly and without proof to the action of influences which in no wise contribute to its production. In the latter instance we are wandering in the dark, exciting unnecessary fears, and giving useless if not dangerous advice ; while by with- holding our decision, we remain as it were on the defensive, and retain that state of mind which is favorable to the research and dis- covery of truth. Opinions have too often acquired solidity by repe- tition, rather than by the addition of any positive evidence adduced in their support; and it is so much easier to cite the authority of names than that of facts, and to coincide in the opinions of others rather than tett their validity, that it is not difficult to trace the inroads of TREATI^IENT OF PHTHISIS. 489 those errors and absurdities by which medicine is so obscured and re- tarded. No branch of investigation has more extensively suffered from the tendency to which we are alluding, than that of the causes of disease. Prejudice, superstition, and system have principally labored in their creation, and it is the difficult task of the modern inquirer, to extract truth from the crude and amorphous materials amassed by these powerful but deceptive agents. The importance, however, of the inquiry is immense, and if pursued with no other in- tention than the discovery of truth, will not only increase the sum of our knowledge, but exert a beneficial influence on mankind at large. H. Treatment of Phthisis. " C'est c\ l'hygiène qu'il faut demander la cure des affections invétérées, et surtout, de celles qui comme la phthisie pulmonaire sont liées au plan même de l'organization et à la manière dont les fonctions sont modifiées par les agents dont nous sommes journellement influencés." — Broussais' Phleg. Chron. vol. ii. page 253. In the following observations it is not our intention to lay down any precise and definite rules for the treatment of consumption, but to direct the reader's attention to some general conclusions relative to the nature of the disease, founded on a review of its pathology ; to enumerate some of the more prominent preservative and curative indications resulting from a knowledge of its causes ; and to give a brief outline of the principal remedies which have been successively proposed, leaving to the judgment of the practitioner their selection, and to maturer experience the determination of those infinite combi- nations on which their successful application depends. Pathology would indeed be an arid and thankless science, did it only lay bare the disorganization of our frame, and were it not asso- ciated with the hope, nay, certainty, of ultimately rationalizing the N 3 490 translator's appendix. employment of our therapeutical agents. Its legitimate object is the cure of disease, and though perhaps never conducting us to the dis- covery of specifics, it must necessarily tend to define those conditions against which our remedies are directed, and shield us from that painful and injurious uncertainty, invariably attending our ignorance of the seat and nature of disease. Exactly in proportion as patho- logical knowledge has advanced, simplicity of treatment has pre- vailed. The complicated formulas of a dim, superstitious and fanci- ful physiology, are rapidly yielding to the more simple indications of positive knowledge, and at the present moment, perhaps there is no surer criterion of our deficient information as to the real nature of any particular affection, than the variety and complex character of the means which are proposed for its cure. The most incurable dis- eases abound most in specifics, and on the substratum of our igno- rance, prescriptions accumulate with empirical rapidity. ISo disease more strongly illustrates the truth of these remarks than phthisis. It has constantly been the victim of pharmacopseial experiment, while in recent researches we can alone discover any accurate ideas as to its nature and seat. From an impartial review of the numerous details scattered through the course of this volume, we feel justified in concluding. That phthisis, though generally commencing in the lungs, cannot be regarded merely as a local disease of these organs, but depends on some constitutional tendency resulting from the impression of causes which especially react upon the general health, and the more or less prolonged influence of which terminates in the formation of tubercles. That while certain constitutions from hereditary or other causes, are peculiarly liable to this termination, yet that none are exempt or incapable of becoming tuberculous, and from the nature of the causes, the universalily of the disease, and the variety of organs in which tubercular deposit takes place, it cannot be regarded as a specific, but as an almost physiological and necessary consequence of the more or less prolonged application of influences, which interfere with tlie normal discharge of the nutritive functions of the body. Tiial no age is exempt from tubercular formation. That in children tubercles in general occupy a greater number of TREATMENT OF PHTHISIS. 491 organs than in the adult, and are not, as is the case after the age of fifteen, invariably first deposited in the lungs. That a predisposition to phthisis may exist an indefinite period of time, but under these circumstances the action of almost any influ- ence interfering with the general health, may give rise to tubercular development. That tubercles may remain latent in the lungs, and with the ex- ception of those instances in which they are rapidly developed, fre- quently do not in their crude state, and even occasionally when softened (vide cases of latent phthisis), give rise to characteristic constitutional symptoms. That the number of organs affected, and the extent of tubercular deposition in the lungs, may be regarded as in general proportionate to the predisposition previously existing, but that in many cases of acute phthisis, the lungs may be extensively tuberculated as well as the other organs, while in many subacute and long protracted cases, the portion of the pulmonary tissue which is affected, and the amount of tubercular deposition generally, may he inconsiderable. That tuberculous matter may be at once secreted in the form to which the term " tubercle" is usually applied, but that in the lungs especially, and occasionally in the other organs, some previous modi- fications of structure occur, which may be regarded as preliminary steps to the formation of tubercles, and depending on the same dia- thesis. That no incontestable evidence exists to prove the absorption of tubercles in the lungs ; but the presence of cretaceous deposit, and the history of many individual cases, render the fact highly pro- bable. That tubercular excavations are capable of cure independently of all medical aid. That the softening of tubercles in the lungs is usually accompa- nied with both local and generally inflammatory symptoms, and that the progress and duration of the disease are subject to incalculable variations, depending on constitutional peculiarities and the condition of the other organs. That the lesions of the digestive tube are the most frequent and important afler those of the lungs. 492 translator's appendix. That the number and extent of the secondary lesions are propor- tionate to the violence and duration of the febrile excitement, and that several of these morbid alterations are equally characteristic of phthisis with the more prominent organic modifications of the pul- monary organs. Lastly, we believe in common with Dr. Clarke, and many other pathologists, that the real cause of tubercles is a morbid condition of the general system, hereditary in some, and in others induced by a series of functional derangements, ultimately affecting the whole animal economy. It would be easy to enumerate other pathological peculiarities of phthisis, but many of them have already been insisted upon in the course of the Avork, and our object at the present moment is sim- ply to justify the grand therapeutical deduction, that in tlie cure of consumption our principal reliance must be placed upon general rather than /ocaZ measures; to the latter attention has hitherto been far too exclusively directed. We have already remarked, that the nature of the really active causes of phthisis strikingly confirms the conclusions we have drawn from the examination of its pathology, and we shall now briefly ad- vert to some of those practical inferences which result from their consideration. Among the most fatal and generally active causes of phthisis in our manufacturing and other classes, are sedentary occupations and a confined posture of the body. It needs no arguments to show how they are to be counteracted. The workman, whose employment ex- poses him to these injurious influences, should take regular and daily exercise in the open air, be restricted in the number of hours he is employed, and never be allowed exclusively to follow any one occu- pation which experience has now shown will almost inevitably shorten his life and terminate in phthisis. He should alternately pursue other departments of his trade, requiring very opposite conditions for the muscular system ; and if in some few instances his manual dexterity may be impaired, his life at least would be prolonged and his general usefulness and activity increased. However imperative and multi- plied may be the wants of civilized society, we cannot be justified in supplying them at such an immense expense of human life, and TREATMENT OF PHTHISIS. 493 still less in not systematically enforcing regulations, -which, if not obviating the evil, would undoubtedly materially lessen the amount of its influence. In all our manufactories where children are employed, gymnasia should be erected, and some short intermissions from their con- fined and sedentary postures be devoted to active and Avholesome exercises. Baths should be provided, by which not only cleanliness might be promoted, but the important functions of the skin invigo- rated ; and let it never be forgotten that charity does not only consist in furnishing an asylum in which the wretched victim of our artificial wants may expire, or in procuring the assistance of medicine by which some temporary relief to his sufferings may be afforded, but in surrounding him with our care when in health, and in the exhibi- tion of our solicitude to prevent those evils, to which he is now, too often inevitably doomed. The importance and extent of our manufacturing classes are such, that all inquiries calculated to elucidate those causes which injuri- ously affect their general health, address themselves to our most serious attention, and we think sufficient evidence has been brought forward to prove that those measures which have hitherto been put in force for diminishing their liability to phthisis, can never be at- tended with success while the far more fatal evils of a sedentary life and confined posture of the body are continued. These remarks are equally applicable to a variety of other trades and professions, and it is only necessary for the practitioner to be aware of the fact, to be ena- bled at once to seize the indications, and adapt his preservative mea- sures to the peculiarities of individual circumstances. From what has preceded, we may deduce the injurious tendency of every thing which can interfere with the free action of the lungs, such as various articles of dress, the acquirements of certain accom- plishments, protracted hours of study, and the absence of all free and unconstrained exercise in the open air. To these may be added late hours, stimulating food, and a variety of other details, by which gentility is purchased at the expense of health, and a state of con- stitution formed which becomes the prey to the first accidental influ- ence to which it may be exposed. The greater liability of women to phthisis is an almost necessary 494 translator's appendix. consequence of the truth of the preceding remarks, and should in- crease our solicitude, more especially where any predisposition exists, early to enforce our preservative measures. From the evidence which has been adduced relative to the effects of moisture, the utility of aqueous vapors whenever the workman is exposed to a dry and heated atmosphere, may be fairly deduced, and on similar grounds the selection of a moist climate in preference to one of an opposite description, would be justified. The same consid- eration Avould also point out the superiority of a residence on the sea coast ; always supposing that other important considerations, such as temperature, exposure, &,c., have not been overlooked. The influence of impure air, while evidently less than has been generally supposed, is still very sensible under particular circum- stances, and points out the advantages of strict attention to ventila- tions, the necessity of lofty and capacious workshops, and the avoid- ance of crowding too many into the same apartment. Another and most important deduction is the benefit that would result from a sufficiently early change of occupation in those cases (and they form the great majority), where freedom from labor, and removal to a warm climate are impossible, and where death is inevi- table if the injurious employment is continued. Those occupations where the individuals are exposed to more or less muscular exertion, particularly in the open air, to animal emanations and moisture, as for instance, gardeners, ploughmen, butchers, coachmen, tanners, excisemen, bookbinders, dyers, grooms, &c., might be advantageously substituted, and would constitute one of our principal resources in the treatment of phthisis among the lower classes. We again say that to be effectual, it is against those influences, the direct tendency of which is to induce that state of the constitu- tion which precedes the development of tubercles, that our prophy- lactic treatment must be directed ; they are to be viewed as the essential causes of phthisis, the real sources of the activity of those secondary agents to whose influence too exclusive attention has been given. " Consumption may be regarded," says the warm and philanthropic Beddoes, " as a vast pit-fall situated on the high road of life, which we have not sense enough of our common interest to agree to fill up, or fence round," and it will still gape for its victims TREATMENT OF PHTHISIS. 495 until our preservative measures are guided by more accurate knowl- edge of the causes and nature of the disease. "There is certainly no subject," says Dr. Clarke, " connected with health, which possesses greater claims to the attention of the inhabitants of this country, than that which relates to the causes and nature of that class of diseases of which consumption is one of the most frequent and most fatal forms. Until we arrive at a knowledge of the state of the system, which leads to the formation of tubercles, and of the circumstances which induce this state, we cannot hope to establish rules for the prevention of consumption upon any sound principles." We have already expressed our conviction of the inefficiency of our curative measures in the great majority of instances q/ïer pulmonary tubercles are formed ; prophylactic treatment is therefore unusually important, and we do not hesitate to say, in the prevention of a disease like phthisis, would be unusually successful. In what it ought to consist, the patliology and causes of the disease at once point out, while its selection must be guided by the individual peculiarities of the case. In proportion as predisposition exists, more particularly when asso- ciated with the peculiar liability of sex, the greater the necessity for an early and systematic employment of all those means by which the general health may be supported and improved. They consist in arr, exercise, food, clothing, change of climate and of occupation, the use of baths, and attention to the functions of the skin and bowels gener- ally, with the avoidance of all those habits and influences which tend in any way to counteract the object we have in view, viz., increasing the tone and vigor of the constitution. While in the vast majority of instances our preservative treatment can only be partially enforced, yet there are few cases in which much good might not be effected when fully aware of its power, and we feel it impossible to insist too strongly upon the immense importance of adopting means for the prevenlionof phthisis, believing that in the present state of our knowledge, they are alone capable of materially lessening the fatal ravages of this scourge of civilized man, and of England in particular. We shall now take a brief survey of those means which have been recommended by the majority of authors after pulmonary tubercles are formed; enumerating them individually, and extending their application to the dififerent periods of the disease, leaving the appre- 496 translator's appendix. ciation of their relative value and clioice of combination to the judg- ment of the reader. Our object at the present moment is the accu- mulation of materials for treatment, not their adaptation to any peculiar views we may ourselves entertain. The earlier period of phthisis is usually characterised by a dry cough, clear expectoration, pains in the chest, haemoptysis, slight hectic, increased sensibility to cold, more or less emaciation, and some modification of the respiratory murmur and percussion in the upper portion of the chest. It is in this stage of the disease that we have the almost unvarying testimony of authors, from Hippocrates downwards , in favor of a milk and a vegetable diet ; and if we con- sider the tendency to and in general presence of febrile excitement, with the frequency of gastro-intestinal derangement in this affection, the advantages connected with such a diet, as a general principle, can scarcely be contested. There are, however, many cases (more particularly when the scrophulous constitution predominates), where animal food and moderate quantities of malt liquor and wine might be advantageously substituted ; but these are exceptional cases, and do not negative the united testimony of the most judicious and practical of our writers, in favor of a milk and vegetable diet. M. Broussais (Vide Phleg. Chron., vol. ii. page 361), adduces some striking evi- dence in favor of the advantages resulting from limiting the patient to two pints of milk, with from two to eight ounces of bread daily, during six weeks or two months. In the examples mentioned, the symptoms were acute, recent, occurring in adults, and giving every reason to suspect (local symptoms are not mentioned) tubercular deposition. In all, the result was most satisfactory. Ass's and goat's milk may be tried, should cow's disagree ; the latter, however, may in most cases be rendered digestible by boiling, — mixing it with small quantities of flour, lime water, soda water, mineralwate fs (Hoffman), distilled aromatic water (Broussais), «Sz-c. Should it still disagree, we may try light broths, animal jellies, gelatinous food in general ; various preparations of rice and flour, eggs, buttermilk ; oysters have been also highly recommended, and may occasion- ally vary the diet of phthisical patients. No distinct rules can be laid down; our object is to furnish the patient, at the least possible expense of his organs, studiously avoiding every thing which stimu- TREATMENT OF PHTHISIS. 497 lates the circulation and induces that state of the system which would be favorable to tubercular softening. It is evident that in particular circumstances both these indications may be fulfilled by a diet of a very opposite description, and little more can be said, than that in proportion as the symptoms are acute, and the constitution plethoric and irritable, must the diet be mild and scanty. In the more ad- vanced stages of the disease the condition of the digestive organs must be our principal criterion for the quality and quantity of in- gesta. Attention to clothing is very important. It should be warm in proportion to the debility of the patient, and the temperature to which he is exposed. Flannel, and Avhere this excites too great irritation, leather should be worn next the skin. The feet should be warmly and securely defended, and females should never expose their arms and chest to the air, or vary the warmth of their dress at particular hours of the day. Too much clothing must be equally avoided, par- ticularly where there is much tendency to perspiration, and at night it may in general be advisable to substitute calico for flannel as re- commended by Dr. Barlow. Exercise in the open air should be regarded as one of the most essential curative measures, and must not be relinquished, as is too often the case, from the dread of taking cold ; our best security against this complication consists in regular and habitual contact with the atmospheric changes around us. By proper clothing, and avoid- ing extremes of temperature, incipient cases of phthisis may be ad- vantageously exposed to the open air. All violent exertion, whatever tends to accelerate the circulation, and excessive fatigue, should be avoided. On few subjects could such multiplied evidence be adduced, as on the benefit resulting from horse exercise in phthisis. The prac- tical Sydenham placed his chief reliance upon it, and recommends journeys of some months undertaken in this way. The patient, he says, should almost live on horseback, and attention to this injunc- tion, he thinks of greater importance than rules of diet. Dr. Rush is equally convinced of the efficacy of horse exercise, and mentions his having cured several who were laboring under the symptoms of con- firmed phthisis, by advising them to become postmen. Russel, Mar- o 3 498 translator's appendix. ryat, Morgagni, Mosely, Beddoes, and more recently Drs. Graves and Stokes, all agree in its occasional eflBcacy, when sufficiently per- severed in. Stoll has remarked that it is injurious, and Dr. Dickson has advised its discontinuance when hectic symptoms are present. Without doubt like all other remedies, it requires discrimination ; in the more advanced stages of the disease, and indeed, whenever great weakness and emaciation are present, it would probably be injurious, and may then be advantageously replaced by carriage exercise, which is fre- quently the only plan in our power to adopt. The patient, says Dr. Graves, should be at least from four to five hours a day in the open air. Van-Swieten was in the habit of recommending his patients to turn coachmen. On the efficacy oî swinging- there is some contradictory evidence, but from the testimony of Dr. Currie, who tried it in his own case and that of Dr. Carmichael Smyth, who wrote expressly on this sub- ject, with the more casual remarks of Themison, Desault and Southey, we may safely conclude that where it agrees it may be occasionally useful. It has a decided tendency to increase the circulation in the extremities and surface generally, and perhaps to lower the pulse, though this is contested ; with children who are naturally fond of the exercise, it would be more peculiarly applicable. Tvavelling may be safely recommended under certain circum- stances ; its influence upon the mind, the choice of climate which it affiards, the habitual exposure to the air, are amongst some of its ad- vantages. It is in the early stages of the disease only, and more especially where the symptoms are chronic, that benefit may be ex- pected. The circumstances of the patient must admit of every comfort, and minute attention paid to other means by which the gen- eral health may be improved. Tliere is nothing specific in its influ- ence, and unless enjoined with due regard to the condition of the patient, will frequently only hasten the disease. In those cases where the symptoms are more acute, the constitu- tion irritable, the mucous membranes relaxed, the cutaneous func- tions impeded, and there is much tendency to hsemorrhage, sea voyages have been almost universally recommended in preference to travelling. In connection with the voluminous evidence we possess ID favor of vomiting in the early stages of phthisis, the influence of TREATMENT OF PHTHISIS. 499 moisture, the advantages of an equable temperature, the benefit of being much in the open air, the purity of the atmosphere, the robust state of health among those accustomed to a sea life, there is every reason to suppose, that when judiciously recommended, sea voyages are among our most powerful means of arresting incipient cases of consumption, and merit still greater confidence in the removal of that state of constitution which predisposes to tubercular deposition. Sailing or cruising for some time would probably be more advisable than a long voyage, particularly if the patient has derived benefit from the sickness ; and in those cases where change of climate is recommended and much improvement has taken place during the voyage, it would be better to repeat the latter, than hazard the doubt- ful benefit of a residence on land. The Atlantic is considered on the whole as a much more favorable climate than the Mediterranean, though this fact is not satisfactorily decided, and during the winter^ perhaps voyages between Madeira and the West Indies would be among the most favorable. We are inclined, however, to think that voyages round our own coasts, and repeated at short intervals, would at least in incipient cases, be equally useful, and might certainly be tried by a far greater number of invalids. We can do little more than submit the subject to the practitioner's attention, referring him to the works of Reid, Fothergill, Gilchrist, Clarke, &c., for more detailed information. The real influence of climate on consumption is beginning to be far more correctly appreciated, and greater discrimination shown in the selection of those cases where change of climate is recommend- ed. It has been too often considered as a last resource, rather than a means the efficacy of which depended on its early application ; and in the immense majority of cases which annually leave England for the advantages of a warmer temperature, all favorable results are not only impossible on account of the advanced stage of the disease, but the progress of the affection is frequently hastened. When ulcera- tion has taken place, and the general symptoms indicate a fatal ter- mination, removal to a hot climate may be regarded as decidedly injurious, experience having proved that under tliese circumstances the progress of phthisis is more rapid. It is in the incipient stage of the complaint, where the scrophulous diathesis prevails, where the 500 translator's appendix. progress of the disease is chronic, and the general symptoms not prodominant, that the beneficial effects of climate may be expected. The action of a warm climate on the healthy frame, in exciting the functions of the skin and liver and diminishing those of the lungs, explains some of the advantages to be expected in pulmonary affec- tions. The benefit of exercise in the open air also points out that our selection should be guided by other than thermometrical consid- erations, and while a mountainous country like Madeira includes the facility of easy change of temperature by change of elevation, yet where horse or carriage exercise is important, a more level and ex- tensive country is preferable. A mild and moist climate ought to be preferred, and there are many situations on the south and western coasts of England, which may be resorted to with advantage. It has been thought that change of climate to be effectual ought to be com- plete, and Avith this view the East or West Indies, South Carolina, Florida, the Northern States of South America, and more particularly Egypt, have been proposed. We can offer no decided opinion upon the subject ; there is every probability that in some cases such a change would be beneficial, but the liability to other diseases must not be forgotten, and an accurate appreciation of the health and con- stitutional peculiarities of the patient is more peculiarly necessary. In very chronic cases there can be little doubt that life may be some- times prolonged several years by residence in an equable mild climate. As a general principle, it may be safely admitted, that the change from a variable temperature to one of an opposite description, when not involving any serious diminution of the patient's comforts, is always advantageous ; and where circumstances render removal impossible, confinement to apartments of which the heat is regulated and the purity of the air as much as possible preserved during the more rigorous weather of this climate, may be judiciously recom- mended, and indeed is often our only resource. It must, however, be recollected that this mode of treatment, being unfavorable to im- provement of the general health, should only be enforced when ex- posure to the air is constantly attended with increase of the symptoms. It is principally adapted to very delicate persons, especially females, to those advanced in life, and to the latter stages of the disease. We must refer the reader to Dr. Clarke's elaborate work ; it is impossible TKEATMENT OF PHTHISIS. 501 at the present moment to do more than direct his attention to the subject. Much difference of opinion exists on the relative advantages attending a residence on the coast or inland for consumptive patients. It is not in our power to answer the question. It would be easy to prove how imperfectly the subject has been studied, but we are in- clined to think, from a review of the causes of phthisis, that when due attention is paid to temperature, exposure, and other local con- siderations, that the sea coast on the whole is preferable. Emetics. — Though frequently prescribed to fulfil temporary indi- cations, they may with great propriety be classed among the reme- dies employed in the general treatment of phthisis. It would be easy to extend this article to considerable length, by the simple enumeration of the names of those who have written in favor of the use of emetics in a variety of diseases, and as Dr. Young says, it is remarkable that a very great majority of the cures of consumption related by different authors, have either been performed by emetics, or by decidedly nauseating remedies. Their systematic employment has been more particularly recommended by Drs. Morton, Parr, T. Robinson, Marryat and Reid. The latter, especially, has brought forward a variety of valuable evidence in favor of the practice. Many subsequent authors have repeated the treatment he proposed, and confirmed his encomiums on the benefits of vomiting in phthisis. It is evident to the most casual observer, that the effects of vomiting are general, and not confined to the stomach. The mechanical pressure upon the abdominal and thoracic viscera, the influence upon the arte- rial and venous circulations, the effects upon the nervous system, and the subsequent diaphoresis, all point out that the action of vomit- ing is general and complicated ; and, associated with the benefits resulting from sea voyages, swimming, &c., there is every reason to believe that the use of emetics in incipient cases of phthisis is satis- factorily demonstrated. The presence of gastritis, inflammatory or congestive head symptoms, hernia, pregnancy, &c., of course contra- indicate their use. From what we know of the effects of protracted sea sickness, and the history of cases Avhere emetics have been con- tinued several months, there is no reason to suppose that their con- 502 translator's appendix. tinued employment is either necessarily or generally injurious to the stomach. The tartar emetic, ipecacuanha, sulphate of zinc, and sulphate of copper, either singly or combined, have been usually employed. When a simple tonic and derivative effect is desired, the sulphate of zinc alone, or in solution with alum, as Dr. Mosely recom- mends, should be preferred, (sul. zin., ^nj.; alum, 3J.; aq. Oj.), but in proportion as we wish to allay febrile symptoms, the tartar emetic and ipecacuanha, in conjunction or singly, are most effectual. Violent and continued vomiting must be avoided ; the smallest doses, as a general rule, are best. And we must particularly guard against exciting diarrhœa. The morning has generally been considered the best time for their administration, though when rigors come on at any particular period of the day, the well known action of an emetic in the cold stage of intermittent fever, would render their trial at this period advisable. When repeated at night they have allayed the hectic symptoms, and promnted sleep. Their administration re- qtiires discrimination, and they should only be persisted in when their effects are evidently favorable. Dr. Marryat in his "Thera- peutics," prescribes one grain of tartar emetic with three of ipecac- uanha, to be taken two or three times a week in the morning, fasting. Mr. Adair (Vide Med. Comm. vol. xviii., page 473. 1791), orders a grain of the sulphate of copper, with a drop of sulphuric acid, in half an ounce of water, to be preceded by a pint of warm water, and re- peated three alternate evenings, and afterwards daily, every morning. Dr. Senter (Trans. Coll. Phys. vol. i. Philad. 1793), gives a dry vomit of from seven to ten grains of sulphate of copper and ipecacu- anha, to be taken fasting every second or third morning. Dr. Reid found that five grains of ipecacuanha were sufficient to begin with. The preparations of emetine might be tried, particularly with chil- dren. We shall conclude our remarks on emetics by observing that their therapeutical employment in phthisis, and their influence on the health generally, are considerations of great interest and im- portance.* * We are gratilied to find that our conclusions on the importance of emetics are confirmed by Dr. Clarke in his admirable section on this subject TREATMENT OF PHTHISIS. 503 It may, we think, be safely advanced as a general principle in the treatment of disease, and more particularly of constitutional disease, that our measures should be principally directed to those organs and tissues of the body which are least liable to be involved in the natural progress of the affection, and, consequently, in the treatment of phthisis, we should not attempt its cure by acting on the digestive mucous membranes, but on the cutaneous and urinary organs which are so seldom organically affected. The use of baths in a variety of forms with dry or moist and stimu- lating frictions on the skin, are almost invariably included in the treatment prescribed by different authors. The mutual influence of the pulmonary and cutaneous functions is sufficiently established, and the importance of the latter too evident to need illustration. Dn Armstrong, in his valuable essay on consumption (page 213), says, "If we go more minutely into this subject, we shall find that many diseases of the skin are incompatible with those of the lungs ; hence in Great Britain, those persons afflicted with cutaneous eruptions, ar& the least exposed to pulmonary consumption : but let that disease be incautiously cured, and they often fall victims to suppuration in the lungs, as I well know from personal observation." " I have seen,^ says the same author, "coughs of a phthisical tendency disappear on the coming out of a spontaneous eruption of the skin ; and I have seen a similar effect from pimples artificially induced on the surface by irritating ungent ; the connexion between phthisis and the skin (Vide Cycl. Pract. Med. Part xxiii. page 342.) That distinguished writer coinciding with Dr. Carswell's ingenious views relative to the cause of the peculiar locality of tubercular deposition in the lungs and elsewhere (Vide Article " Tubercle") says, " we can easily conceive how the repeated ac- tion of emetics may prevent the deposition, or at least the accumulation of tuberculous matter in the bronchial ramifications and air-cells, and thus pre- vent the localization of the disease, and give time for the correction of the constitutional disorder. In this manner, it is not improbable that a judi- cious use of emetics may prove a powerful means of preventing the déposi- tion of tuberculous matter in the lungs." The same author refers to the powerful and recent evidence of Dr. Giovanni de Vittis, in favor of the use of emetics in phthisis and chronic catarrh. Vide Annali Universali di Jkledicina. December, 1832. — Cowa.n. 504 translator's appendix. appears to me a subject of vast importance in a practical and patho- logical point of view." In the treatise of the late Dr. Kentish on the employment of baths, there are some striking cases of severe pulmonary affections success- fully treated by the common vapor or sulphur-vapor bath. In one example of apparent phtliisis the latter was taken every other day during four months with ultimate success and gradual increase of the general strength. To be effectual, baths must be persevered in, and much care taken by the use of diluents, friction and exercise, to avoid their injurious effects. The temperature should be regulated, and the stimulating nature of the bath adapted to the peculiarities of the patient's constitution. In scrophulous and chronic cases, much ben- efit may be expected from this mode of treatment, and in opposite circumstances their judicious employment will at least prove a valua- ble palliative remedy. The hot air bath, proposed in 1819, by Dr. Gower, and since modified, is powerfully diaphoretic and a convenient application. Counter irritatioji in the treatment of phthisis has the testimony of almost every ancient and modern author in its favor. The theory of its action is far less important than the inquiry, if experience has satisfactorily demonstrated its utility ; all we can say is, that there are few subjects in therapeutics on which so little discordance of opinion has existed. Every gradation of irritation from simple rube- faction to the actual cautery has been recommended, and evidence in favor of all has been adduced. The revulsive treatment so much insisted upon by the ancients, seems reviving in modern practice. In its application to phthisis we may admit, as a general rule, that it should be avoided when much febrile excitement is present, or at least be deferred until this has been subdued. It should be propor- tionably deep and permanent in its character as the disease is chronic and the lymphatic temperament predominates, and wlienever it pro- duces great general irritation, pain, loss of sleep, &c., its mode of ap- plication should be varied, or if this is insufficient, it must be wholly relinquished. With attention to these general principles, it may be regarded as eminently useful in all chronic thoracic affections ; when supported by the patient, it should never be omitted in the treatment of phthisis, though in all acute cases it must follow the use of anti- TREATMENT OF PHTHISIS, 505 phlogistic measures. A variety of stimulating lotions, containing vinegar, alcohol and ammonia, have been proposed by Drs. Scuda- more, Hall, and others, and perhaps may be always safely recom- mended with some slight modifications as to temperature. They inci-ease the circulation on the surface of the chest, and render the skin less easily affected by atmospheric changes. They are gene- rally advised to be used in the morning, and repeated once or twice during the day. Dr. Hall recommends the more powerful and per- manent action of a pad steeped in alcohol. Blisters, either frequently repeated or caused to suppurate, are among the most general means resorted to for counter irritation. They may perhaps be regarded as best adapted for incipient threatening cases, and for the treatment of those incidental complications so frequently occurring during the progress of the principal affection. They may also be occasionally conjoined with the use of setons, issues, tartar emetic ointment, or other means by which a suppurative process is established. As our object in the employment of blisters in phthisis is local irritation, and the avoidance of any general re-action always desirable, Dr. Thomp- son (Vide Mat. Med. t. ii., page 548) says, this may be effected by moistening the skin with water, and passing a piece of nitrate of silver lightly over it, so as to include the whole of the moistened surface. The action is rapid, effectual, and purely local. Dr. Thompson strongly recommends it where much febrile excitement and constitu- tional irritability are to be dreaded. Intense pain and slough result from an excess of the nitrate of silver. Dr. Scudamore, with the same intention, speaks highly of a saturated infusion of cantharides in strong acetic acid, applied to the skin by means of a camel's hair brush. p The tartar emetic ointment, or a strong solution of this salt (Thomp- son) applied hot to the previously frictioned skin, either alone, or in severe cases, conjointly with setons or issues under the clavicles, or between the shoulders, may be regarded as the least painful, and most effectual means of counter irritation. Croton oil, ammonia, and a variety of irritating liniments may be occasionally useful ; the ac- tion of the former is mild and easily supported. In proportion as humoral pathology prevailed, our derivative meas- p 3 506 translator's appendix. ures receded from the disease they were intended to remove; at present, however, it is generally admitted, that it is better to apply our remedies as near as possible to the affected organ, and the sub- clavicular regions are considered the best points for establishing per- manent counter irritation. Dr. Graves invariably places two setons beneath the clavicle in all incipient cases, and advises their employ- ment at the age of puberty, whenever phthisis may be apprehended. It may perhaps be useful to let old wounds occasionally heal and form new ones, for it is probable they become less effectual after the constitution is habituated to their presence. Bleeding. — " Super onmia vero venesectione, eaque satis tempes- tive, frequenter, et copiosé adhibitâ, ut malicentus, et tabidus fuerit ËBger," says Morton, and perhaps there are few diseases in which bleeding has been more generally prescribed, or more frequently repeated. The buffy appearance of the blood so usual in phthisis, has been erroneously considered as a justifying indication for the use of the lancet; in the present state of our knowledge this symptom alone is quite insufficient, since we well know that mercury, preg- nancy, exercise, &c., are capable of producing this peculiar condition of the circulating fluid. It has, we think, been 'demonstrated in the course of this volume, that phthisis, in its origin or causes, is not an inflammatory disease ; and, that in all its subsequent stages, inflam- mation is usually the result of tubercular deposition, or in those cases where it precedes the latter, an accidental complication which has- tens its development. These are not to be regarded as theoretical views, but the ultimate expression of numerous and analysed facts ; on their reception or rejection, will the practitioner's reliance on the efficacy of bleeding, as part of the general treatment of phthisis, ma- terially depend. It must not be supposed that antiphlogistics are to be excluded from tha therapeutics of consumption ; if inflammation is not a cause, it is a very frequent complication, and adopting means for its prevention and removal, forms a leading indication in the treatment of this affection. To protect the individual and the affected organ from the influence of all those agents, internal and ex- ternal, which tend to create an inordinate degree of excitement, or favor the development of active congestion, may be regarded as one of the most important practical rulca. It is tlic opinion which regards TREATMENT OF PHTHISIS. 507 inflammation as the source of all the evil, and considers the removal of it as the only, or principal means of preventing the progress of the disease that we are now combatting. After reflecting on the pathology of phthisis, its nature, its causes, and the general character of the remedies Avhich have been most successful in its cure or palliation, and after having compared the conflicting evidence of a variety of authors on the subject, we think that bleeding should be regulated by precisely the same principles in consumption, as in any other disease, and ought never to be prac- tised without the presence of those indications which guide us in the employment of venesection in general. The practitioner should never forget the chronic nature of the disease, the impossibility of curing it rapidly, the subsequent debility, and the importance of be- ing governed in the abstraction of blood, by the state of the digestive organs. It is more particularly in the early stages, when the heat, pulse, cough, and dyspnoea indicate inflammatory action, that bleed- ing will be useful, and may occasionally be repeated with advantage. Small revulsive bleedings of a few ounces will often aflTord relief to the thoracic and hectic symptoms. The application of leeches under the clavicles has been recently recommended in the early stages of the complaint ; of tlieir real eflicacy we are unable to speak with certainty ; we have seen them tried by M. Louis without any evident success. Local bleeding in the form of cupping is also frequently indicated against the intercurrent inflammatory complica- tions. Were we to choose between the indiscriminate use of the lancet or its rejection in phthisis, we believe the latter would be less prejudicial. Stahl, Dover, Van-Swieten, Watt, and Stoll, are among the most strenuous advocates of general and repeated bleedings. They are objected to by Marryat, Heberden, Reid and others. Mercurials. — In the supposed analogy between phthisis and scro- phula, and in the doctrines of hepatic and syphilitic consumptions, we may trace the reason of the frequent employment of mercury. It has been more particularly recommended for the cure of phthisis by Drs. Rush, Stev/art and Physic, who have strongly advocated the tonic treatment in conjunction with salivation. Mr. Watt, in his cases of diabetes and consumption, published in 1808, also advises 508 translator's appendix. salivation after the. singular preliminary treatment of repeated bleed- ino-s to induce febrile re-action ; his avowed object was to modify the blood. By the majority of authors its use has been confined to particular indications occurring in the earlier stages of the disease, to scrophulous habits, to cases of mesenteric affection, hepatic ob- structions, and its action as a mild purgative. The greater number of modern authors regard its habitual administration in phthisis as decidedly injurious. From what we know of its general action upon the frame, the irritable state of the nervous system which it induces, the increased susceptibility to external influences, the febrile excite- ment, and the necessary interruption to other indications, there seems no reason to call in question the propriety of this opinion as a gen- eral rule ; and if in the use of mercurials we include the production of its ordinary constitutional effects, there is still greater reason to erase it from the list of therapeutics for phthisis. We are, however, inclined to believe that its good and bad effects have been greatly exaggerated, the former being frequently founded on erroneous diag- nosis, the latter on its abuse. There can be no doubt that in scrophulous phlegmatic habits, and in various derangements of the digestive tube, that it forms one of our most valuable remedies, and the researches of Dr. W. Philip on the employment of small doses of mercury, exhibit the action of this agent in a new light, and prove that we have hitherto been ignorant of the means by which its real efficacy in chronic diseases may be obtained, and its injurious effects avoided. The evidence relative to the influence of mercurial vapors is too contradictory to allow of any positive conclusion, and the arguments against the use of mercury, founded upon the experiments of Dr. Clayton, in 1694, Dr. Saunders, in 1793, and more recently those of M. Cruveilhier, consisting of the injection of mercury into the veins of dogs, and the apparent production of tubercles in the lungs, can- not be admitted as of any value, since there is no doubt that in all these instances the mercury was simply deposited in the pulmonary tissue, where it produced suppuration like any other foreign body. The expressed juice or extract of taraxacum has been favorably mentioned as an alterative in tuberculous constitutions, by Hufe- TREATMENT OF PHTHISIS. 509 land, Zimmermann, Kaemp, and its utility is acknowledged by mod- ern practitioners. The sarsaparilla, the muriate of lime and of baryta, and more especially the mineral waters, are also deserving of increased at- tention. Digitalis. — Since its diuretic powers were so successfully demon- strated by Dr. Withering, in 1785, digitalis has been alternately extolled as a cure, or condemned as injurious' in the treatment of phthisis. Reid thinks it a stimulant ; Saunders, a tonic ; Dr. Hamil- ton, a direct sedative ; Kinglake, a narcotic stimulant ; Magennis, that it acts by extinction of morbid action ; Beddoes, that its efficacy in consumption is equal to that of bark in intermittents, &c. &c. ; from all these satisfactory conclusions, the reader may infer that it really has some active properties, and that its action varies with the circum- stances under which it is administered. It is now very rationally almost entirely rejected as a cure for consumption, and merits only to be regarded as one of the many means occasionally useful in this disease, and which may sometimes assist the operation of more im- portant measures. It seems principally adapted to phlegmatic habits, after depletion, and especially where there is any anasarcous ten- dency. The state of the digestive tube must be previously ascer- tained, and from its effects accumulating it requires to be very closely watched. Prussic Acid. — This has quite as little claims to be regarded as a specific for phthisis as the former. Its action is more undoubtedly sedative, and it may be often prescribed with advantage against the cough, particularly in the early stages, when the system is irritable and any spasmodic symptoms are present. It may be considered as more adapted to hectic than digitalis, and often tends to allay sick- ness, epigastric pain, and pyrosis. Dr. Thompson speaks highly of its use in laryngeal affections, and in phthisis it may be regarded as a useful and palliative remedy. The discovery of any means by which a sedative influence might be procured, and the cough moderated, without any injurious secon- dary effects resulting, would be a valuable addition to the thera- peutics of phthisis. Dr. RoUo recommended the hepatized or hydro- sulphuret of ammonia, on a theory of its chemical action. It has 510 translator's appendix. since been mentioned by Dr. Armstrong, and more recently by Dr. Newton, in the second number of the Dublin Medical Journal. The latter gentleman, in conjunction with Dr. Marsh, found that it lower- ed the pulse, increased the appetite, promoted the urinary secretion, and acted powerfully on the skin. These properties give it claims to the practitioner's attention as a palliative remedy for phthisis, and we hope some judicious trial of its real efficacy will be made. The dose mentioned is, three drops three times a day, in a tumbler of water. We may gradually increase this quantity to thirty or forty drops. Nausea, headache, and vertigo result from an overdose. From what we know of the action of alkalies upon the system, their solvent power, and general adaptation to febrile symptoms, at least in the earlier stages of disease, there is every inducement to continue our investigations on the subject, and we think their appli- cation to phthisis, on these and other grounds, well worth the prac- titioner's attention. We have no facts to bring forward, and shall therefore refer the reader to Dr. Burrows' s very interesting and tal- ented lectures, published in the Medical Gazette, page 711. 1834. Iodine has not, we think, received the attention it deserves as a remedy in phthisis. Its well known action in scrophula, goitre, visceral engorgements (particularly those of the liver), demonstrate its powerful influence upon the absorbent system ; and the evidence of Drs. Baron, Gairdner and others, on its employment in consump- tion, amply justify its continual trial in this disease. It is almost unnecessary to remark, that so active a remedy requires great care and discrimination, but from the statements of M. Zinck, of Lausanne, (Vide Journal Complémentaire, April and May, 1824), it is probable that its injurious effects have been exaggerated. Its association with soda in the blood makes Dr. Burrows suppose it possesses a solvent power. Scrophulous phlegmatic habits, the absence of febrile ex- citement, and a healthy state of the digestive tube are the most favor- able conditions for its administration. Its influence upon the stomach may be avoided, by prescribing it in the form of inhalation to which we shall presently refer. Its diuretic and emmenagogue powers give it additional claims to our notice. Some objections to its em- ployment in phthisis have been advanced by Laennec, MM. Laennec and Récamier (Vide Revue Med., June, 1825) ; they only prove what TREATMENT OF PHTHISIS, 511 our knowledge of the drug would at once indicate to every judicious practitioner, that it is not universally applicable.* Bark. — This has also enjoyed the reputation of possessing specific properties in the cure of phthisis. The opinion has been principally supported by Morton, De Metternich and Sedillot, while by other authors it has only been prescribed to answer particular indications. Mead advises it before, and Heberden after ulceration has taken place ; Dickson limits it to hsemoptysis ; Fothergill to the latter stages of the disease ; and Bayle seems to regard it solely as an anti- periodic. A variety of evidence is in short adduced in favor ot equally variable opinions ; we may therefore conclude that bark must be prescribed on the same general principles which indicate its em- ployment in other chronic diseases, and that it has no claims to the character of a specific for phthisis. The combination of bark and steel, bark and sulphur, as advised by Drs. Trotter and Sims in scrO' phulous cases, seems to have been very successful. The partiality displayed by authors to particular remedies renders the opinion of any single individual of comparatively little impor- tance, but by comparing the treatment pursued by numerous prac- titioners under similar circumstances, we can occasionally discover some point on which they are more or less unanimous, and thus in- crease the probabilities in favor of the efficacy of any particular rem- edy. One of the most popular, as applicable to phthisis and chest affections generally, is sulphur. Its virtues are highly extolled by Galen, Sylvius, Willis, Lieutand, Sydenham, Stahl, Hoffman, and many others, and from its special and powerful action on the cuta- neous surface, its internal use, in a disease like phthisis, has perhaps been too much neglected. As a remedy for costiveness in this * In a recent work by Dr. Morton, of Philadelphia, entitled Elustrations of Pulmonary Consumption, Sfc, the efficacy of iodine in phthisis is sup- ported upon an extensive practical observation of its effects. He prescribes the iodine in the form of a solution containing three grains of iodine, and six grains of hydryodate of potash in an ounce of distilled water, from three to fiye drops of which are 'given every morning, noon and night. We have not ourselves seen the work, but quote from Dr. Clarke's notice respecting it. — Cowan . 512 TRANSLATOR s APPENDIX. affection, it is worthy of notice, and might perhaps be advantageously employed against profuse perspirations. Its forming a constituent portion of the nervous system, and its general absorption when taken internally, proved by its presence in the perspiration, &c., are suffi- cient reasons to make us suppose that it may at least be occasionally useful. Its most effectual exhibition is probably in the form of min- eral waters. Of the utility of its external application, there can be no doubt, and in the form of inhalation it is far from being inert. A variety of other remedies, such as myrrh, iron, preparations of lead, &c., have been favorably mentioned in connexion Avith con- sumption, but since they have not been regarded as peculiarly ap- plicable to this disease, we think it quite unnecessary to refer to them. We shall now make a few remarks on the local remedies which have been proposed, and direct the reader's attention to the method of fumigation or inhalation. The application of medicated vapors to thoracic affections, may be traced back as far as the writing of Galen, who speaks highly of the vapors from experiment. These were also recommended by Rhazes (an Arabian physician), and Bennet, who prescribed them in conjunction with some of the balsamic remedies. The latter writer especially, has insisted upon the use of fumigation, invented an apparatus for their administration, and was also in the habit of employing the vapors from a variety of infused herbs. Dr. Pearson and others have spoken of the utility of aether, and the former prescribed the inhalation of narcotic vapors, arising from the macera- tion of 9j., 5j., of the leaves of hyoscyamus in ^j. of asther. Dr. Mead, who does not appear himself to have pursued the treatment, thinks the fumigations, as described by Bennet, were too much neg- lected. It will be easily gathered from these slight references, that the methods proposed by more recent authors, have no other claims to novelty than the use of agents with which our predecessors were un- acquainted. Their real value is not, however, on this account diminished, and after an examination of the works of Gannel,* Mur- * Two Memoirs on the Inhalations of Chlorine, &c. Translated by W. H. Potter, M. R. I. 8vo. London, 1830. — Cowan. TREATMENT OF PHTHISIS. 513 ray,* Scudamore.-f- and Cottereau,| we do not hesitate to say, that the evidence in favor of the palliative effects of chlorine and iodine in phthisis, is amply sufficient to encourage others in the application of these remedies. The cases related by M. Cottereau are by far the most satisfactory ; we would refer to the first, also published by Gan- nal, and to the twelfth, as particularly striking and decisive as to the existence of pulmonary tubercles. Sir C. Scudamore insists strongly on the power of iodine in facilitating expectoration, diminishing cough, and promoting sleep and appetite. Dr. Thompson, in his Mat. Med., speaks very favorably of the palliative action of chlorine in phthisis. All his trials were upon advanced cases ; though not ultimately successful, it invariably gave relief, and, as he expresses himself, may be said to have scattered flowers on the borders of the grave. It is but fair to state, that Dr. Stokes of Dublin, M. A. Laen- nec, of Nantes, M. Joulmouche, of Rennes, and M. M. Flandin and Mi-quel, of Paris, have administered chlorine inhalations without success, and occasionally have found them injurious. The utility of these and other vapors of the narcotic class, as particularly recom- mended by Dr. Scudamore in chronic bronchitis and various other affections included under the general term asthma, is more satisfac- torily demonstrated, and may tend to point out those cases of con- sumption where peculiar benefit may be expected from their employ- ment. Whatever may be the result with regard to their sanative influence in this disease, they may be considered as forming valuable adjuncts to the therapeutics of thoracic affections. How far their beneficial effects are depending on their local action, it is rather diffi- cult to determine ; but from the absorbing power of the bronchial membrane, and the active nature of the agents employed, it is more than probable, that much may be ascribed to their general influence, * Inhalation of Iodine, Sfc, J. Murray, M. D. London, 1829. t Inhalation in Pulmonary Consumption, fyc. By Sir C. Scudamore, M. D., F. R. S. 8vo. London. X Mémoire by Cottereau. — Arch. Gen. de .Med. November, 1830. — R 3 514 - translator's appendix. which has the advantage of being produced without injury to the gastric mucous membrane. The vapors of boilmg tar have been highly extolled by Dr. Crich- ton and others. The experience of Dr. Forbes leads to a less favor- able conclusi.m ; but Dr. Morton, in the work already alluded to, says, that among the various substances which he has tried, there is no one which he has prescribed with equal success to tar. In chronic catarrh he knows of no plan of treatment that can vie with this. (Vide Op. C{<, page 511.) Sulphurous fumes have also been recommended, as well as diffusing a variety of vapors in the apart- ment of the patient ; on their beneficial or injurious effects we are unable to speak. We cannot close these remarks, without insisting upon the neces- sity of strict attention to accuracy of diagnosis and clear discrimina- tion of the peculiar circumstances under which our remedies are applied. Without this our facts cannot be available to others, and from want of attention to these important data, by far the greater portion of the details to Avhich we have alluded, is utterly incapable of leading to any positive results. The difficulty of the inquiry is immense, and much caution must be shown in arriving at general conclusions ; on the other hand, the hopelessness of the disease, the inefficiency of every known treatment, fully justify experiments in search of a new remedy, and it is not irrational to suppose that so great a desideratum may be found in a class of substances which, while they exert a general influence upon the health, are capable of being directly applied to the diseased organ. After thus expressing our convictions, we leave the subject to the judgment of the reader and to the decision of future investigation ; we shall now briefly advert to the pneumatic method. This is evi- dently but a varied application of the preceding, and includes the inspiration of oxygen, hydrogen, and other gases. Fouicroy (in the Annales de Chimie, No. 4. Paris 1790), gives the result of the inspi- ration of oxygen in twenty cases ; in all it was prejudicial, hastening the progress of the disease, and increasing the febrile symptoms. Beddoes tried the effect upon himself; it occasioned true hectic, emaciation, dry cough and dyspnœa. Increased excitement is also TREATMENT OF PHTHISIS. 515 the effect on animals, and neither theoretically nor practically is there any inducement to renew our experiments. The use of hydrogen, carburetted hydrogen and carbonic acid, has been attended with much greater success. Beddoes relates some cases which were greatly relieved by breathing a mixture of hydrogen and common air. In another instance, mentioned by Dr. Crowther, the employment of the carburetted hydrogen in the proportion of 1 part to 24 of air, was also useful. Dr. Percival, in his Essays, 1774, found the inspiration of carbonic acid in thirty cases, palliate the febrile symptoms. This result is confirmed by the investigations of Drs. Withering and Hulme. Dr. Home, of Edinburgh, says that carbonic acid is useful in allaying fever, and an impure atmosphere is recommended by Darwin against hectic. It is also probable that the favorable effects Avhich appear sometimes to have resulted from a residence in cow-houses, may in part be ascribed to the same cause. Connecting with these details the fact that miners seem little liable to phthisis, and recollecting the opinion of Dr. Wells and others, in favor of marshy places in consumptive cases, there is sufficient evi- dence to justify some confidence in the palliative efficacy of these gases. The subject is deserving of attention, and will be viewed with additional interest, when we reflect on those symptoms which indicate an active state of the respiratory functions in phthisis, viz., increased heat, florid color of the skin and mucous membranes, and compare them with the physical condition of the lungs. The ab- sence of constant dyspnoea and the complete oxygenation of the blood are remarkable physiological facts in many examples of this affection. Is it depending on the circulation of oxygen in the venous as well as the arterial blood, on account of the diminished production of carbonic acid, arising ft-om impeded nutrition.' Treatment of the more prominent Symptoms of Phthisis. Under this division we shall include hœmoptysis, hectic perspira- tions, cough and diarrhoea. Hœmoplysis. — The diagnostic value and importance of this symp- tom have already been fully insisted upon. We can scarcely be said to possess any curative means against lisemoptysis ; they arc ratiier preservative and palliative. No precise rules for their administration 516 translator's appendix. can be laid down ; the constitution of the patient, the stage of the disease, and the more immediate cause of the hsemoi'rhage, when such can be traced, require numerous modifications in the treatment. We must also recollect that it is very seldom fatal in its immediate effects, and would in general cease, independently of treatment; we must therefore be backward in attributing too much efficacy to par- ticular remedies. The means most generally prescribed under these circumstances, consist in i-est in the horizontal posture, cool air, cold applications to the chest and scrotum, or between the shoulders, with warmth to the extremities, bleeding, nauseants, purgatives, sedatives and astringents. It is important to remember that we are treating a symptom only, and not a disease ; this must regu- late the activity of our measures, and prevent our indiscriminately resorting to powerful antiphlogistics ; though from the experience of Dr. Cheyne and others, there is every reason to suppose, that when symptoms of pulmonary congestion and increased circulation are present, small and repeated bleedings are among our most effectual remedies. In the majority of cases, rest, with cool air, sponging the chest with vinegar and water, the application of warmth to the ex- tremities and saline laxatives, will be sufficient. When the symp- toms persist, nauseants, with sedatives, such as digitalis and Prussic acid may be tried. The former especially have been highly spoken of by Aasheim, Piso, Baglivi, Murray, and more recently by Dr. Graves of Dublin, who also corroborates the opinion of the preceding authors on the utility of small doses of ipecacuanha in this and other hsemorrhages. Dr. Graves prescribes two grains every quarter of an hour until some improvement is observed, and afterwards every half hour until the flow of blood ceases. He precedes the ipecacu- anha by a purgative injection and a saline purge. This treatment he has almost invariably found successful. Dr. Cheyne thinks that in all cases where inflammatory symptoms are present, a com- bination of antimony and nitre, frequently repeated, is one of the most efficient remedies. Emetics have been strongly advised by Robinson, Marryat, Reid, Stoll, Dr. Parr and others, and from state- ments of these writers, there can be no doubt that the danger to be apprehended from their use has been greatly exaggerated. The action of vomiting on the pulmonary circulation is not so easily de- TREATMENT OF PHTHISIS. 517 termined. The venous congestion of the head and upper extremi- ties, and the probable repetition of this state in the lower, from the contraction of the abdominal parietes, combined with the diminished action of the heart and the subsequent rapid diaphoresis, lead us to conclude that it is not attended with danger in hsemorrhage of the lungs. The effects of sea sickness and the relief which vomiting affords to dyspnœa, arising from a congested state of the heart and lungs, are not compatible with the idea of any increase of blood in those organs. Perhaps since the principal advantages of nauseants and emetics arise from their action on the heart, and their tendency to equalize the circulation, the former should generally be pre- ferred. A tea-spoonful of common salt, swallowed dry or dissolved in water, has been successful in the hands of Le Meza, Rush and others, and from its being easily procured, is worth remembering. Dr. Carmichael Smyth speaks highly of the efficacy of the extract of hyoscyamus. Opium is not admissible until after depletion. Sul- phuric acid, vinegar, acetate of lead, ratanhia and other astringents, may be occasionally useful. Cold water and small pieces of ice taken internally are valuable adjuncts in acute and incipient cases. Liga- tures to the limbs are too painful to be applied, unless the quantity of blood renders the danger imminent. Dry cupping has been re- cently recommended, particularly where depletory measures are con- tra-indicated, and in the more advanced stages in these and other circumstances it may be advantageously employed. In the treatment of hajmoptysis the state of the liver and bowels should be particularly attended to. Hectic Fever. — This is evidently not confined to the latter stage of the disease, neither does it depend, as M. Broussais has argued, on the absorption of pus from tubercular abscesses, nor does it always correspond to the extent of pulmonary disorganization. The fact, that secondary alterations are proportionate in number and impor- tance to the violence and duration of febrile movement, points out the necessity of diminishing, as much as possible, vascular excite- ment ; never forgetting the natural tendency of the disease, and avoiding the use of means calculated to hasten the development of 518 translator's appendix. those secondary symptoms, which so powerfully influence the pro- gress and accelerate the termination of phthisis. In the treatment of hectic we should rather confide in attention to general measures, such as diet, clothing, early rising, ventilation, tepid sponging, warm bath, &c., than in the administration of medi- cine. Tn acute and incipient cases more active means may occasion- ally be advisable, and here it is that small bleedings have been prin- cipally of service. Small doses of tartarized antimony and saline med- icines may be successfully employed under the same circumstances. Since hectic fever has been regarded as an attendant upon rather than essential to the disease, specific remedies have diminished both in number and value, and against]a symptom associated with such a variable state of the general health, means of the most opposite de- scription may be occasionally successful. Poterius was in the habit of prescribing a preparation which was long regarded as a valuable anti-hectic. It consisted of one part of tin, one of metallic antimony, deflagrated with six of nitre. Other Avriters seem to have found it useful. Reid advises a powder containing fifteen grains of nitre and one of tartar emetic. Sydenham speaks highly of an infusion of two drachms of rhubarb in a quart of mild beer or other liquid for chil- dren, when the febrile symptoms are not intense. Vinegar and water was much praised by Galen as the best refrigerant, and if we recol- lect its astringent properties, perhaps its employment in phthisis has been too much neglected. M. Orban (Vide Thompson's Mat. Med., p. 35), both at Tunis and in France, used it extensively in consumption, and says that its effects were always beneficial when it produced a costive state of the bowels. The quantity taken daily was seven ounces diluted with forty-nine ounces of rain water. Small doses of alum and sulphate of iron were prescribed at the same time. Dr. Roberts (Medical Transactions of the Coll. Phys., vol. v.) strongly advocates the use of vinegar for checking the hectic and morning sweats, restraining hasmoptysis, and producing costiveness. Dr. Thompson speaks favorably of its palliative influence, and occasion^ ally prescribed it with the infusion of columba or carscarilla. Its ex- ternal use has already been mentioned, and we think its internal deserving of further trial. Different combinations of the sedatives and narcotics are often available. It is in those cases where the TERATMENT OF PHTHISIS. 519 hectic symptoms are urgent, that the pneumatic method promises to be of service. Perspirations. — These are usually classed among the symptoms of hectic, though in phthisis they are doubtless in part supplementary to the pulmonary functions. The general means enumerated in the preceding section must form the basis of our treatment. When these are not successful, the use of sulphur deserves attention, and in cases where the sweating is partial, nitre and opium, as recom- mended by Bennett and Hoffman, may be tried. When febrile symp- toms are present, sudorifics may be successfully employed in check- ing perspirations. Adair and others have advocated the use of emetics on the same grounds, Morton advises waking the patient just before the perspirations come on, Percival recommends the external application of the decoction of bark ; this is also mentioned by Broussais, The sulphuric acid is one of the most effectual means ; the vegetable acids and the acetate of lead internally or in lotions may also be tried. Our object is rather to moderate than altogether to prevent perspirations, which may be considered, when not extreme, as beneficial. Exact ideas of how far the skin may be supplementary to the lungs are still wanting. Diarrhœa. — This can be no longer regarded as a simple attendant upon the hectic fever, but in the great majority of instances is de- pending on local inflammation, which is sooner or later followed by ulceration. The knowledge of this fact will at once regulate the treatment of diarrhœa in phthisis, more particularly in the early stages of the disease, and demonstrates the injurious tendency of the pur- ging system too frequently resorted to, as well as the necessity of avoiding the use of either medicine or food which unnecessarily stimulates the digestive mucous membrane. We have seen how rapidly the disease progresses when abdominal symptoms are con- joined with the thoracic ; the state of the alimentary canal, and its liability to inflammation, should, therefore, we repeat, be constantly kept in view in the treatment of phthisis. Our best preserva- tive and curative measures consist in warm clothing ; mild tempera- ture ; great attention to the skin ; bland nutritious diet ; the use of only mild purgatives when necessary ; or what is still preferable, eiiemata ; also the hip bath, and local blood-letting when symptoms 520 translator's appendix. of inflammation are present. To these means we may add mucila- ginous drinks small doses of rhubarb, hydrargyrum cum cretà, ipe- cacuanha, Dover's powder, chalk mixture, white decoction, and other slightly astringent drinks, as lime water and milk, or infusion of pomegranate and milk. In severe and more advanced cases Dr. Stokes speaks highly of the effect of a large blister on the abdomen. Dr. Graves thinks a grain of the nitrate of silver, given three or four times a day, is one of the best remedies. When arresting the discharge is important, the turpen- tines and balsams, given as enemata, with opium may be resorted to. The sulphate of copper and acetate of lead, with opium, have been occasionally successful. Strychnia, a combination of cusparia, nitric acid and laudanum, and with discximation, diffusible stimulants, have proved advantageous in particular circumstances. It is only by a knowledge of the pathology of diarrhœa in phthisis, that our reme- dies can be rationally or successfully applied. Cough. — Tranquillizing the cough is an important indication. By interrupting sleep and accelerating the circulation, it exerts a power- ful influence over the general comfort and health of the patient. Before tubercular softening has taken place, and communication established with the bronchia, the expectoration remaining white and frothy, coughing cannot be regarded as a salutary effort, but the result of pulmonary irritation, and should be treated accordingly. At a later period it is evidently necessary to avoid suffocation, but even then its frequency and violence may be advantageously moderated. In addition to those general measures to which we have so often re- ferred, the cough may be calmed by mucilaginous mixtures, decoction of Iceland moss, small doses of hyoscyamus, Prussic acid, digitalis, the different preparations of opium, aether, the inhalation of emollient and narcotic vapors, breathing the gases advised in the pneumatic method, and occasionally by the use of small doses of tonics, or the employment of antiphlogistics, as the general state of the patient may indicate. In the more advanced stages, when bronchitis and ulcera- tion are present, we must be guided in our treatment by the intensity of the febrile symptoms. It is at this period that the trial of chlorine and iodine inhalations have been particularly recommended, though in many cases their use during the first stage of the disease ought TREATMENT OF PHTHISIS. 521 not to be neglected. The activity of these agents may be moderated by combining them with different narcotics. Sulphur, turpentine, copaiba, are often serviceable in chronic cases. Emetics and nau- seants are valuable, but as well as expectorants in general, must not be prescribed without attention to the state of the gastric mucous membrane. Sinapisms to the chest with pediluvia often relieve urgent symptoms, and Avhen suffocation is threatened from bronchial obstruction, these means with emetics and diffusible stimuli are our principal resources. There are many other incidental indications which we have pur- posely omitted. Our object in this rapid sketch was to present to the mind of the younger portion of our readers, an outline of the more prominent pathological features of consumption ; to expose some of those general principles of treatment which may fairly be deduced from our present knowledge of its causes and morbid altera- tions, and to direct his attention to those remedial measures which have been advised either for its palliation or cure, by numerous and judicious practitioners ; not attempting to define their modus operandi, or subjecting them to the ordeal of any pathological theory. In the course of our inquiries we have often been discouraged by the abun- dance and contradictory nature of the materials presented to our notice ; while, at the same time we have felt surprised at the ease with which closet therapeutics may be invented, and those ad libi- tum pathological combinations conjured up, for the removal of which our remedies are so conveniently and accurately adjusted. It would not have been difficult to have minutely detailed a multitude of pre- cise and definite regulations for the treatment of phthisis, and per- haps to have impressed the minds of some with a favorable idea of our superior curative acumen ; but we have studiously endeavored to avoid the inducements which empiiical reputation in medicine holds out, convinced that there are few obstacles more fatal to the progress of science and improvement, than those preposterous pretensions which quackery so uublushingly propagates, at the expense of all honorable feeling and to the detriment of the health of a too easily deluded population. Notwithstanding all that has been written and done upon the sub- s 3 522 translator's appendix. ject of consumption, we are still totally unacquainted with anything like a satisfactory method of cure, and it is only Avhen the upright spirit of inquiry which has characterized our author's researches, shall have equally pervaded the minds of those who are continuing the investigation, that any decided increase to our present knowledge, or rather the removal of our present ignorance, may be expected. To be strictly honest in medicine requires unusual probity and devo- tion ; our efforts must not be undertaken with the eager hope of dis- covery, but with the conviction that at best we can only furnish our item to the now accumulating mass of accurate observation, from which medicine as a science shall hereafter be eliminated. In looking back on what has yet been accomplished, and comparing it with what remains to be done, we can ot avoid the impression that we are now executing the labor by which future generations are to pro- fit; but with the present means of observation in our power, and the facilities for recording and communicating the results of our inquiries what may we not anticipate from the united exertions of minds alive to the advantages to be gained by systematic research, and called into action " under circumstances different from any which have yet existed in the world, and over an extent of territory far surpassing that which has hitherto produced the whole harvest of human in- tellect." AMERICAN EDITOR'S APPENDIX Section I. — Prescriptions. For various prescriptions the reader is referred to sections 1 of Vols. I, and II, of the Translation of Louis on Fever. The following are not mentioned in the work alluded to. 1. Looch, page 226, line 27. There are several preparations un- der the general name of Looch. They are composed of several articles mixed with sugar and syrups. The Looch Blanc, which is probably referred to in the present work, is made as follows, — R Sweet Almonds No. xij. Bitter do. " ij. Water § iv. White Sugar § i. Gum Tragacanth grs. xv. Orange Flower Water 5 U- Mix in a mortar after having made a paste of the almonds by rub- bing them with sugar and water. — Fot. 2. Pectoral Mixture, page 265, line 7. I find in the Formulary of Edwards and Vavasseur two pectoral potions, but whether either of them is the one referred to by Louis, it is imposible for me to decide. The active principle of both is the Hydrocyanic Acid. 524 AMERICAN editor's APPENDIX. 3. Pectoral Ptisan, page 265, line 7. R Malv. Flor. Althœse " Tussilag. " Papav. Rh. " ââ part, equal. M. Take 3i. or 3ij. of this mixture and infuse for twenty minutes in boiling water Ibij. Then strain and add Marsh Mallow Syrup ibs.ij. — FoT AND Ntsten's Dictionary. 4. Syrup of Five Roots, page 30, line 5. K: Rad. Asparagi Off. Rad. Rusci Aculeat. ââ § v. Aq. fcvii. Boil to one half. R; Apii graveolent. Aneth. Fœniculi. Apii Petroselin. ââ § v. Aq. calid . Ibij- Infuse and mix the two liquids and add Ibvi. of sugar. To be used in potions of Sij- to §j. to sweeten drinks. — Edwards and Vav- ASS£UR. Section II. — Peculiar Terms. Mamelonné. This word was translated mamelonated in the work on Fever, but throughout this one the term mammillated has been retained. It is a correct English word, and, therefore, is more prop- erly used than the word I introduced. The only objection to it in my own mind is, that it seems to convey something more than the French expression does. Crèmes de riz. These words in the other work are translated rice fritters. Dr. Cowan's Translation is undoubtedly the better one of the two. He uses the term rice-creams. Pelotonnée. This word it is very important that the reader should understand correctly. I have used the word nummulated, not be- PECULIAR TERMS. 525 cause I conceive it to be the best, but because Dr. Cowan used it at first. I say at first, for Dr, Cowan has not thought it necessary to translate it always so. In this edition the word nummulated is always used, whereby I mean to express that condition of the expectoration in which the sputa are greenish, flat, distinct, sometimes ragged, and are floating in a thin fluid. Verge tures. Dr. Cowan translates by the word vibices. This is diflFerent from the expression made use of in the work on Fever. Perhaps it is better. Vide Louis on Fever, Vol. I, page 339. REPORT [In the edition which I have of the work (Paris, 1825), the following Report is introduced by the publishers, from the hope that it would be inter- esting to the reader ; for the same reason I introduce it here, though Dr. Cowan omits it.] Report made to the Royal Academy of Medicine upon a Manuscript entitled, — Anatomico -Pathological Researches upon Phthisis. By M. Louis. You have commissioned MM. Bourdois, Royer-Collard and myself to present a Report to you upon a Manuscript by M. Louis, entitled Anatomico-Pathological Researches upon Phthisis. This subject has been so thoroughly treated by Bayle, that any succeeding writer upon it must almost unavoidably be exposed to an unfavorable preju- dice ; but this prejudice is soon overcome, when we are acquainted with the circumstances which induced M. Louis to write upon this subject, and with the results to which his observations have led him. At an age when physicians in general cease their attendance at hospitals, and forego the collecting of cases in order to devote themselves exclusively to practice, M. Louis quitted practice to de- vote himself entirely to the study of facts. He has collected, from the month of October, 1821 to the present time, Avith extreme care the history of all the patients who have been admitted into the wards St. John and St, Joseph of the hospital of La Charité. The number of these patients is 1960, of whom 358 died. Of the last, 123 died from phthisis, and 40 others, who were carried off by different dis- 528 academy's report. eases, had tubercles in the lungs. This lesion, then, existed in nearly a half of those who died, and was in the third of them the principal, if not the only, cause of death. The comparison of so great a number of facts, which he had at first collected for his own instruction only, has presented M. Louis with results of such impor- tance, that he has thought it to be his duty to offer them to the Academy. This work is divided into two parts ; the first is devoted to the examination of the anatomical lesions, observed in the lungs and in other organs ; the second, to the exposition of the symptoms which are connected with each of these lesions. The author has added some considerations with regard to the general history of phthisis, its causes and duration ; and from the observations which he has col- lected, and which form the basis of his work, he has selected fifty, which he has reported in confirmation of the results which he pre- sents. It is only of tubercular phthisis that he treats ; he thinks, with M. Laennec, that the granulations of Bayle are only commencing tuber- cles, and that cancer, ulceration, melanosis and calculi of the lungs ought to be referred to other orders of diseases. First Part. — The anatomical lesions observed in the lungs have been so well described by Bayle and Laennec, that the author has limited himself to a very concise description, in which, however, we find many remarks peculiar to himself. He has observed, for ex- ample, that tubercles not only particularly affect the apex of the lungs, as has been said, but also, when they invade their different lobes, that those of the apex are more numerous and larger, and that they become soft at a period when those of the base are still hard. He thus establishes the fact, that the differences with regard to the number, size, and the more or less advanced state of the tubercles apply more exactly to the superior lobe compared with the inferior, than to the apex compared with the base. He has often found the superior lobe entirely disorganised, and, at the same height the cor- responding parts of the superior lobe still permeable to the air and containing a few tubercles only. These remarks are followed by two very curious cases, one in wliicli a large excavation was filled b}?^ a fibrinous clot, and another in which a fragment of the pulmonary academy's report. 529 substance, perfectly sound to appearance, was inclosed in a cavity without adhering on any side to its parietes. The air passages have presented M. Louis with lesions, which have been but imperfectly described by Bayle. This physician found a lesion of the larynx in 17 cases only of 100 ; ulcer- ations of the trachea are still more rare according to him, and he does not even make known the proportion of cases in which he met with them ; he says nothing of those of the epiglottis. Of 102 patients, M. Louis found the epiglottis ulcerated in 18, the larynx in 23, and the trachea in 31. In many cases he has seen the ulcerations of the trachea occupying the whole muscular portion, and in one case many of the cartilaginous rings completely destroyed in a part of their extent by the progress of the ulcer. As to the mucous membrane of the bronchia, it did not frequently present any alteration in the neighborhood of crude tubercles, whilst it was al- most always thickened and of a red color in the neighborhood of cavities, and especially of those which were very large, and which we naturally consider of long standing. From this circumstance he concludes that inflammation of the mucous membrane of the bronchia being posterior to the softening of the tubercles, cannot be considered as their cause, but much rather the effect of the irritation from the matter poured into the bronchia from the cavities. The situation of the ulcerations of the trachea, which are more numerous and larger at its back part, and that of the ulcerations of the epi- glottis, which almost exclusively occupy the laryngeal surface, in- duce us to believe, according to M. Louis, that the irritation of these parts by the contact of the sputa, is one of the causes which produce them. In a tenth of the patients the pulmonary parenchyma was the seat of an acute inflammation, which supervened a short time before death. The adhesions of the pleura, which are so common in patients with phthisis, have especially engaged the attention of the author. He has found the lungs perfectly free from them in one case only. He has generally observed a kind of proportion between the adhesions and the internal disorder; when the adhesions were weak and of small extent, the examination of the lungs presented very small cavi- t3 530 academy's report. ties ; but when these adhesions were strong and of great extent, the eavities were ahiiost always very large. It has been for a long time observed that tubercles are often de- veloped in many organs at the same time, and that in the phthisical especially, we frequently meet with them in other parts at the same time that we find them in the lungs. Bayle proved the presence of tubercular matter in the intestines ; but no one has hitherto pre- sented the numerical results contained in the work of M. Louis. He has recognised the presence of tubercles or of tuberculous matter» in the small intestine, in nearly a third of the patients ; in the large intestine, in a ninth ; in the mesenteric glands, in a fourth ; in the cervical glands, in a tenth ; in the lumbar glands, in a twelfth j in the prostate, in a thirteenth ; in the spleen, in a fourteenth ; in the ovaries, in a twentieth ; in the kidneys, in a fortieth ; in the uterus, in the brain, in the cerebellum, )in one patient only. in the medulla oblongata, in the ureters, These researches, made with the greatest care, have led M. Louis to a very important result. Not one of the 358 subjects, whom he examined after death, presented tubercles in any organ, who did not also have thorn in the lungs. The tuberculous con- cretions, which are formed in the chronic inflammations of serous membranes, are not even an exception. In all the cases of this de- scription which presented themselves to M. Louis, the attentive ex- amination of the lungs has led him to the discovery of tubercles in these organs. In a single individual, who died from a severe fever, and whose lungs appeared sound, the mesenteric glands contained some tuberculous grains. Will this observation, which has been made with regard to 350 patients over fifteen years of age, apply to infants ? This question can be answered only by numeroua post- mortem examinations. academy's report. 531 The anatomical study of organs, which are not the special seat of phthisis, has supplied M. Louis with many other interesting facts. The heart was not increased in size except in three cases, and this increase occurred in the left ventricle. In the few cases in which an alteration in the thickness of the heart presented itself, it was almost always on the left side. These facts point out the true value of the theories of some authors, Avho consider the tuberculous hard- ening of the lungs as one of the most active causes of diseases of the heart in general, and particularly of the right cavities. In the major- ity of phthisical patients, M. Louis found the heart diminished in the same proportion as the other viscera. The aorta, when measured for comparison, and through its whole length, in patients who died from phthisis and from other affections, was found more contracted in those who died from phthisis than in those who died from acute affections, but less so than in those who died from cancerous affec- tions. In a fourth of the cases, the aorta presented a remarkable redness on its internal face, but without any change in the consistence and thickness of its membranes. Neither these lesions nor those of the pharynx, oesophagus and stomach, which follow, were observed by Bayie. Ulcerations of the œsophagus and pharynx occurred twice only. The œsophagus also presented in three cases a thinning with a soft- ening of its membranes at its cardiac extremity. Ulcerations of the pharynx and oesophagus were not met with in any individuals who died from other chronic diseases ; they are were observed only in those who have died from phthisis and from typhus fever. In 9 cases of 96 in which the stomach was carefully examined, M. Louis found it twice or three times its usual size ; the great curvature descended as far as the crest of the ilium. The same change in the size and situation of the stomach was only twice ob- served in patients who died from other diseases. However remarka- ble this phenomenon is, the structure of the stomach presents lesions of much more importance, and which have already been pointed out by the author in his Memoir upon the softening and thinning of the Mucous Membrane of the Stomach. A careful examination of this membrane in 96 cases of phthisis, offered in 77 of them remarkable lesions, such as softening with thinning, redness with thickening, a 532 academy's report. mamillated aspect, &c. ; in two cases, it presented two ulcerations without change in its structure or color. A comparative examination of the same membrane in about the same number of fatal cases of other chronic diseases presented alterations in one half of them only, end these alterations were of less extent ; the softening with thin- nino', which was observed in 19 cases out of 96 of phthisis, was found only six times in 94 cases of other chronic diseases. Thus, lesions of the stomach are much more frequent and severe in phthisis than in other affections. The duodenum presented some ulcerations in three cases, and an increased size of its mucous crypts in a certain number of instances. The study of the anatomical lesions, which are frequently seated in the small intestines, has fixed the attention of M. Louis upon the elliptical patches which are formed by the agglomeration of the mu- cous crypts, spoken of by some anatomists, though the importance they deserve has not generally been attached to them. M. Louis has observed that these patches, which exist in a sound state, and which are situated opposite the mesentery, participate but very slightly in the lesions of the surrounding mucous membrane, and are often the seat of lesions in which this membrane takes no part. These patches are the most usual seat of ulcerations, both in phthisis and in severe fevers. M. Louis has found these ulcerations in five sixths of the cases of phthisis, which induces him to believe that he has examined these organs with more care than even the scrupulous Bayle, who did not discover lesions of the intestines but in two thirds of his cases. The development of these ulcers also presented this remarkable circumstance, namely, when they were confined to the mucous membrane, the cellular was very thick, and when this was destroyed by them, the muscular coat was equally thickened ; ao that at the same time that one of the membranes was undergoing ulceration, the other was acquiring a greater thickness, and was thus retarding the perforation of the intestine. The mucous membrane» moreover, is sometimes reddened ; it is seldom softened and thick- ened. Ulcerations were not so frequently found in the large intestine as in the small, but they were larger. M. Louis has many times ob- served the caecum and ascending colon ulcerated throughout. The academy's report. 533 softening of the mucous membrane occurred more frequently than in the small intestine, namely, in three fourths of the cases. The tuberculous degeneration of the lymphatic glands of the mes- entery was observed, as we have stated, in a fourth of the cases, in all of which there were ulcers in the intestines ; but the tubercles were far from being in proportion to the number and size of the ulcers. In one case in particular, in which all the mesenteric glands were tuberculous, there was throughout the intestinal tube only one very small ulcer of a line in diameter, occupying the small intestine the mucous membrane being in other respects perfectly sound throughout. In many cases in which the intestines were ulcerated, there was not a single mesenteric gland tuberculous. The author has not found a more constant relation between the presence of ulcers in the trachea and of tubercles in the cervical glands. He therefore concludes that the tuberculous degeneration of the lymphatic glands ought to be referred to some other causes than the inflammation or ulceration of the neighboring membranes. The falty state of the liver, observed by Bayle, though he did not rigorously determine its frequency, is one of the most remarkable lesions that occur in phthisis ; it seems, we may say, peculiar to this affection. M. Louis has proved its existence in two thirds of his cases of phthisis, whilst he has not met with it but twice in 220 pa- tients who died from other diseases. He has also ascertained its greater frequency in women than in men, in the proportion of nine to two. The duodenum was sound in most cases. This fact is of no little importance at present when it is maintained, that diseases of the glandular organs are always consecutive of those of the neighs boring membranes. The spleen was frequently altered in consistence and size in this disease, as it is in many others. The tuberculous degeneration, as we have seen, has been many times observed in it, as well as in the liver, the kidneys, the ureters, the prostate, the vesiculse séminales, the ovaries and the uterus. The ^cnfonewm presented some traces of recent inflammation in four cases. In another, there were some semi-transparent miliary granulations. In one case, the two folds of this membrane, the epi- ploon and mesentery, were formed of a tuberculous and of a grey, 534 ACADEMY s REPORT. semi-transparent substance, imperfectly mixed together, and had be- come more than an inch thick. The brain also presented some remarkable lesions. The lateral ven- tricles contained from one to three spoonfuls of serous fluid in three fourths of the cases, and the sub-arachnoidean membrane at the upper part of the brain was infiltrated. In five cases the brain was softened throughout ; in five others the softening was partial, pulpy, and limited to the centre. The collection of small granulations, often found at the summit of the brain, upon the sides of the longitudinal sinus, and considered by some anatomists to be of a glandular nature, ought to be regarded, according to M. Louis, as morbid productions. He sup- ports this opinion, first, upon their entire absence in many cases ; secondly, upon the inequality which they present in their develop- ment, when they do exist, and upon the alteration which is con- stantly found in the arachnoid in their vicinity, for it is thickened and opaque. The first part of M. Louis's work concludes with a discussion of the question, Avhich of the different lesions ought to be regarded as peculiar to phthisis, and which as accidental. He refers to the first class the adhesions of the lungs, or at least those of the apex in many cases, the ulcers of the air passages and of the alimentary canal, the fatty degeneration of the liver, and the tuberculous affec- tion, wherever it may be observed ; to the second class, pneumonia, acute pleurisy, the softening of the mucous membrane of the stomach and intestines, peritonitis, arachnitis and softening of the brain. Second Part. — The author, after a concise description of phthisis, always in conformity with the facts which he has collected, examines particularly some of its principal symptoms, and establishes, accord- ing to his observations, their frequency, the period of their appear- ance, and some other circumstances, which authors heretofore have imperfectly described. Hœmoptysis, with which he commences this part, occurred in two thirds of the cases ; in a fifth it appeared before the cough and ex- pectoration. No one, who was not affected with phthisis, out of i960 patients whose cases have been observed by the author, had had haemoptysis, with the exception of some individuals in whom it oc- curred in consequence of external violence, such as a contusion of academy's report. 535 the chest, or a fall, and with the exception of a few females who had it in consequence of the suppression of the catamenia. The author, therefore, concludes that with these exceptions, a copious haemop- tysis renders the existence of tubercles in the lung's very probable. Your committee are of opinion that this most melancholy conclusion is happily weakened by many other facts. However, htemoptysis is observed more frequently in women than in men, in the proportion of three to two. The pains of the chest, experienced in phthisis, may be referred to pulmonary tubercles, or to adhesions of the pleura ; and as these two lesions are almost always found in conjunction, it is difficult to determine on the examination of the corpse which has produced the pain. The acute sensibility of the pleura, and the well established absence of pain in a large number of cases of external or internal tubercles favor the belief, that this pain is seated in the external membrane of the lungs, rather than in the parenchyma. This, how- ever, is not always the fact ; a woman, whose case is reported in this work, experienced, during the fifteen days immediately preceding her death, some pain between the shoulders, and the examination of the corpse presented only some encysted tubercles without any ad- hesions, and, besides, all the patients, in whom the adhesions were limited to the apex of the lungs, did not complain of pain in the chest. The examination of the _/e&rz7e attack, which comes on in all cases of phthisis, at its second period, presented the following results. Chills occurred in five sixths of the patients ; sweats in nine tenths. The opinion advanced by old authors, and repeated by all the moderns that sweats alternate with diarrhoea, is contrary to the facts observed by M. Louis, not only in phthisis, but also in other diseases. The author has indeed sometimes seen the diarrhoea diminished for two or three days when the sweats appeared, but it soon resumed its former intensity, though they lost none of theirs. In relation to these copious and prolonged sweats, M. Louis makes the very natural remark, that a function may be for a long time seriously altered, though the struc- ture of the organ, which performs it, present no appreciable change. Diarrhœa occurred in all the patients, with the exception of 1 out of 37. When it preceded death but a short time, from five to twenty days, for example, we usually found in the intestines but very small 536 academy's report. ulcers, and the mucous membrane was softened, often red and thick- ened. When the diarrhœa was of long standing and had been con- stant, there were almost always large and numerous ulcers in one or the -Other intestine, and sometimes in both. The diarrhœa was no less violent when the ulcers principally occupied the small intestine, than when they were of a greater size in the large intestine. This observation is not unimportant at present, when some theoretical physicians make the colon the exclusive seat of diarrhoea. The symptoms of softening of the stomach, of perforation of the lung, and of its effect, pneumo-thorax (seven cases of which are re- ported by the author), and of ulceration of the epiglottis, the larynx and trachea are particularly examined. We shall not occupy you with the symptoms of softening of the stomach and of perforation of the lung, on which subjects M. Louis has already presented to you two special Memoirs ; we shall speak of the other lesions only. The patients, in whom the epiglottis was ulcerated, experienced a fixed pain on a level with the top of the thyroid cartilage or above it, and a difficulty of deglutition, which was sometimes so great as to cause the rejection of liquids by the nose. A local pain of greater or less acuteness, and a complete loss of voice for one or more months were the only signs of ulceration of the larynx. Ulcers of the trachea, however large, did not usually produce any particular symptom. Lesions of the stomach gave rise to some symptoms which have led and can lead in future to their recognition during life. A want of appetite, pain of the epigastrium, and even nausea with vomiting of bile have distinguished these lesions. As to vomit- ing, which all physicians have considered as excited exclusively by the cough, M. Louis thinks that it may arise from this cause, espe- cially at the commencement of the disease ; but he has observed that then patients have some appetite ; they do not feel pain at the epi- gastrium, and can digest their food with facility. By the aid of these signs he can distinguish with certainty sympathetic vomiting from that which is produced by the lesion of the mucous membrane of the stomach. As the stomach is very often diseased in phthisis, and as phthisis is one of the most common diseases, it was at once easy and inter- esting to know what relation existed between the state of the tongue ACADEMY s REPORT. 537 during life and that of the stomach after death, and to test the value of the assertions which are daily made on this subject. The stomach appeared sound in 19 cases out of 97, in which it was examined with extreme attention ; in 77 it presented various lesions. In 9 out of 19 in whom it was sound, the tongue had been during life more or less red. In one of these latter cases the redness and dryness of the tongue were extremely marked, and continue dfr m the patient's admission into the hospital until death, which took place thirty-two days after, and the stomach was found perfectly healthy in every re- spect. Of the 77 other cases in which the stomach presented either a simple softening with thinning of the mucous membrane, or a more or less extensive redness, either mamillated or not, &c., the tongue was red during life in 35 only, and in 5 of these but very slightly so. The result, therefore, is that redness has been observed about tlie same number of times in individuals in whom the stomach was healthy, and in those in whom it presented some serious lesion. The diagnosis of phthisis is easy at an advanced period ; every one knows how uncertain it is during the first stage, and sometimes fora very long interval. M. Louis has particularly directed his attention to determining, by the comparison of the facts that have come under his observation, the signs by the aid of which we can at first suspect, and afterwards recognise this disease. A dry cough, which continues for many months, a shortness of breath easily brought on by walking or speaking, pains of greater or less acuteness in the back or in the sides of the chest, a remarkable diminution of flesh and strength ought to create strong suspicions of the existence of tubercles in the lungs ; if one or more htemoptyses occur, it is almost a certainty that the patient is phthisical. Percussion and auscultation are then very suitable for removing our doubts; if the sound of the chest be dull below one of the clavicles to a small extent, if the respiratory murmur there be more feeble and accompanied by some râles, these two phenomena occurring at this point only, where tubercles generally first develop themselves, their existence can no longer be doubted. M. Louis under this head, relates the case of a patient, in whom, by means of these signs, the disease was recognised seventeen dayg after the appearance of the first symptoms. u 3 53S ACADEMY s REPORT. The diagnosis is usually easy in the second period, when cavi- ties take the place of tubercles ; pectoriloquy furnishes a never- failing sig-n. It is important, however, to remember that the partial dilatation of some of the bronchia may produce this phenomenon, and that in order to form a sound judgment we ought to connect with this sign every one that can confirm it. An interesting case is reported in support of this wise precept. In other articles of his work, M. Louis presents some interesting views relative to the duration of the disease, the circumstances under which we most commonly meet with it, the sudden deaths, which are not very rare in phthisis, and which the examination of the corpse does not always explain. He has remarked with respect to its dura- tion, that there died in the first year a greater proportion of women than of men. He has found an explanation of this difference in the very unequal frequency, in the two sexes, of some secondary lesions, such as the fatty degeneration of the liver, and the softening of the mucous membrane of the stomach, which he has met with much more frequently in women than in men. Two articles are devoted to latent and acute phthisis. Five cases catne under the observation of M. Louis, in which there were not more than fifty days between the appearance of the first symptoms and the death of the patients. In one of these cases, death occurred even on the twenty-fourth day. Lastly, in a concluding chapter, M. Louis has examined Avith the facts before liim, the question of the nature of tubercles, a question so often and so uselessly discussed by reasoning and inference, and he has been led to the conclusion, that the tuberculous degeneration of the lungs is something diflTerent from inflammation, or from the effect of inflammation. We shall here limit this analysis, in which we have presented to you only the principal results which the author has deduced from his observations. We think that the Academy, whose special object it is to give a useful direction to the labors of physicians, cannot aflTord too much encouragement to those whose number is always too small, who, instead of abandoning themselves with the m.ajority to theoretical discussions, devote their lives to the collection of observations at the academy's report. 539 bedside of the sick, and search after death for traces of the disorders which preceded and produced it, and from a comparison of these facts deduce rigorous conclusions. (Signed,) BOURDOIS, ROYER-COLLARD, CHOMEL, the Reporter. Read and approved at the session of the Section of Medicine, July 12thj 1825. ADELON, Secretary of the Section. A true copy, PARISET, Perpetual Secretary. INDEX. [The numerals denote the Observations, the figures the page, the capital letters the sections of the Translator's Appendix.] A. Age, Its influence upon phthisis, 447, G. Aorta. Frequently red internally, 52 ; almost always in young subjects^ 52 ; its organic lesions common after the age of thirty-five years ; its size less in phthisis, but particularly in cancerous affections than in acute dis- eases, 53 ; the cause of its redness and of its organic lesions, 55. Apoplexy. Not found after acute diseases, which fact distinguishes it from softening of the brain. Arachnitis. Comes on sometimes towards the last periods of phthisis, 140 ; ventricular arachnitis, its symptoms, 307, xsiv ; sub-arachnoidean effusion complicated with partial softening, 311, xxv. Arachnoid. Is the source at times of opaque granulations, morbid pro- ductions near the longitudinal fissure, 139, 140 ; contains sometimes serous fluid in its superior cavity, and the membrane situated under it is frequently infiltrated, 140. B. Bands. Found in tuberculous excavations, their structure, 14, 330, xxix. Belladonna. Employed without success in cough ; its effects, 449. Bile. Oftener black and thick in patients who died of phthisis, than in those who died of other diseases, and when the liver is fatty than under any other circumstances, 112. Bladder. Almost perfectly healthy in phthisical patients, 121. Blood-letting. Its inefficacy in many cases of hsemoptysis, x, xlii. 542 INDEX. Brain. Is sometimes injected in phthisical patients, 141 ; wholly soft- ened, 141, xlix, 1, or partially so, 141, 142 ; its partial and general softening are found almost exclusively after chronic diseases, 143 ; sometimes the seat of tubercles, 143, ix ; or of hydatids, 143, 144, xxviii. Bronchia. Cannot be found in tuberculous cavities, nor where tubercles exist, nor in the grey, semi-transparent substance, 35 ; state of their mucous membrane near the cavities and crude tubercles ; their ulcerations, 36, sxix, 1. c. Capsules, Renal. Contained tuberculous matter in two cases, 117. Catechu. Employed in diarrhœa ; its effects, 453. Causes of Pulmonary Tubercles. Result to which we are led by obser- vation, 437 ; influence of sex, 438, C ; that of pleurisy and pneumonia not proved, 438 to 440, D ; but supposing that this influence really exists, what means must we use in order to make it evident .'' 440 ; influence of catarrh not better demonstrated, 441, E; many observations of acute and of latent phthisis prove directly that tubercles in the lungs are not the effect of in- flammation, 441, 442, 443 ; the condition of the bronchia confirms all these facts, 444, H ; influence of corsets is perhaps imaginary, 445 ; what is neces- sary to be done in oi-der definitely to determine the hereditary nature of phthisis, and to define the exact limits of this fact, 447 ; influence of age, ib. G ; of various causes, G. Cavities. Tuberculous ; the period at which they are entirely empty ; their structure when old or recent, 13, 14 ; communicate with the bron- chia, 14 ; sometimes traversed by bands, 14 ; they presuppose the destruc- tion of a portion of the pulmonary tissue, 14, 15 3 dimensions, 15, i ; char- acter of the fluid contents, 21, 22 ; may be filled with organized fibrine, 25, ii, or contain a fragment of healthy lung, 27, iii ; only one may be formed in a lung, and In this there may be no other traces of tubercles 31, iii ; how we may prove such a cavity to be tuberculous, 33. Chills. Do not occur in a certain number of patients, 191 ; hour at which they usually return, 191, 192 ; effect of cinchona upon them when regular in their recurrence, 192. Complications. Do not prevent the symptoms of the different lesions from manifesting themselves, 245, xv3 149, viii ; 224, xii ; 274, xix. Cough. Variable in phthisis, both in force and time of commencement, 171 ; returns at times in hard spells, ib. : opium and belladonna employed for it unsuccessfully, 449, H. Cysts. Of a peculiar character developed in the liver. 111, 154, ix ; fibrous cysts containing hydatids in the liver. 111. D. Diagnosis. When it is probable, 201 ; or certain in the first stage of phthisis, 202 to 204, x bis. ; is easy in the second stage and depends then in INDEX. 543 a great measure upon the existence of pectoriloquy, 210, 211 ; importance of percussion at this period ; it alone is sufficient for the diagnosis, 210 ; how pectoriloquy may he insufficient to indicate the existence of a tuberculous cavity, 211, xi ; Trans, note, 203. Diarrhœa. Commences at different epochs, 19-5 ; the intestinal ulcera- tions are small when it commences late in the disease, 196 ; they are small when it has been long and intermittent, 198; it seems at times to be merely an altered secretion, 197, 280, xx. Diascordium. Given in diarrhœa ; its effects, 452. Duodenum. Ordinarily healthy ; rarely ulcerated ; its crypts are not oftener enlarged when the liver is fatty, than when it is healthy, 72. Duration of phthisis generally, 169, 170; in men and in won)en, 170. Dura Mater. Is often divided at its upper part, which divisions give passage to arachnoidean granulations, 139. Dyspnœn. Its degree ; its commencement in phthisis, 185 ; exists some- times from childhood, 185, 186 ; point of the chest to which it is usually referred, 186. E. Emaciation. Its commencement, 199 ; in some cases its progress is very rapid ; inferences to be drawn from it ; attacks all the tissues of the body, 200. Emphysema. Of the external cellular membrane rare in chronic dis- eases, 134, vii ; emphysema of the liver still more rare, 136, 137, vii. Epiglottis. Is frequently ulcerated in phthisical patients ; the propor- tion, 46 ; these ulcerations exist most frequently on the laryngeal face, 47 ; and are more .*"requent in men than in women ; they are peculiar to phthisi- cal patients, 48 ; their symptoms, 219, xii, xiv ; is sometimes entirely de- stroyed, 225, xiii. Epiploon. Contains at times tuberculous or semi-transparent matter, 135, vii} its mode of development, 137. Fibre- cartilages of the Trachea. At times solution of their continuity in cases of deep ulceration of the trachea, 249, 251, xvi. Fever. Origin and duration very variable ; circumstances which cause its varieties, 189 ; its cause, 189, 190 ; symptoms of continued fever in a patient in the last stages of phthisis and in extreme debility, 184, 185, x. Fever, Continued. Scat of the ulcers of the intestine in these cases, 77. Functions. May be deranged for a long time without any sensible alter- ation in the organs which perform them, for example, digestion, 280, 281, .322; exhalation from the skin, 193. 544 INDEX. G. Gall- Bladder. Its parietes are sometimes thick and ulcerated, 113, 114. Gastritis. Anorexia, even when it lasts a long time, is not sufficient to prove its existence ; frequent in phthisical patients. Vide Stomach. Genital Functions. Is it prohable that the inclination for venery is in- creased in phthisical patients, 302. Gestation. May go on regularly in phthisis, 305 j has it a real influence upon the cause of phthisis, 305, Glands. When tuberculous they are enlarged, 99 ; do not become tuberculous except in phthisical patients, 106 ; axillary glands become tuberculous, painful, 105, 154, ix ; cervical glands tuberculous in a tenth part of phthisical patients ; cause of this lesion, 105; lumbar glands some- times completely changed into tuberculous matter, 104; mesenteric often tuberculous, what proportion, 100 ; part of the mesentery where they are most frequently thus diseased, 100; rarely softened, 101; causes of this transformation, 102, 103 ; sometimes red and swollen in phthisical patients without being tuberculous, 104; consequence of this fact, 104; in patients who have died of other chronic diseases, 106. Granulations. Grey, semi-transparent of the lungs follow the same course that tubercles do, and change more or less rapidly into tuberculous matter, 5 ; they are the commencement of it, 5 ; their arrangement, the îength of time they occupy before becoming as large as peas, and the^part of the pulmonary texture in which they occur, 6. Gurgling. Frequently heard over cavities at the summit of the lungs, 211 5 indication of this when combined with tracheal respiration, 215, 216. H. , Hœgophony. Causes, 367, xxxv. Heart. Generally small, rarely enlarged in phthisis ; smaller still in cancerous affections, 50, 51, 52 ; sometimes softened, 50 ; the dimensions of the left ventricle vary much more frequently than those of the right ; in- frequency of organic lesions of the heart, 51. HcBmoptysis. Severe or slight; its frequency; period at which it occurs, 176, 178, X ; when it precedes cough and expectoration, is it a forerunner of tubercles, or a proof of their existence, 176, 177 ; its cause at the different periods, 177, 178, 1S4, x ; influence of sex, 178; age, 178 ; constitution, 179 ; upon its frequency. Examjiie of severe haemoptysis occurring sev- eral times, 180, 183, x, 395, xlii ; its treatment, 450, G. Hydatids. Developed in a fibrous cyst, which destroyed a lobe of the liver, 111 ; very rarely found in the brain, 145 to 149, viii. Icterus. Occurred several times during one year in a case in which there was disease of the gall-bladder, 429, xlix. INDEX. 545 Inflammation. Very common in the later periods of phthisis and of other chronic diseases, 160, 301 ; dehiUty predisposes to it, 160. Intestine, Small. Ils mucous membrane when in a healthy state ; its structure ; number of elliptical patches observed in it, 74, 77 ; their dis- eases, 78; its mucous membrane sometimes softened, thickened and red, proportion, 79 ; tuberculous or semi-transparent granulations frequent in them, 79, 80 ; still more frequent are ulcerations, 81 ; seat, size, form, color, structure of the ulcers, 82, 83; muscular membrane sometimes thickened, is at times destroyed over them, 83, 84, iv ; cause of the ulcerations, 93 ; con- dition of the small intestine after other chronic diseases, 90. Intestine, Large. Its mucous membrane often red, .softened and thick- ened, proportion, 91, 92 ; cause of this softening, 93, 94 ; period at which it occurs, 94 ; submucous cellular membrane frequently thickened and white when the mucous is softened ; cause of this thickening, 93 ; its ulcer- ations a little less frequent than those of the small intestine, 95 ; their di- mensions, 87, 95, iv, 224, xii ; their frequency in the different parts of the intestine, 95; their form, color and structure, 95,96; causes, 98 ; tubercu- lous granulations are much more frequent there than in the small intestine, 94; they are never found in subjects who have died of other chronic affec- tions than phthisis, 99 ; condition of the large intestine in consequence of these affections, lb. K Kidneys. Sometimes in phthisical patients have cysts and tubercles in them, 117, 118, v. L. Larynx. Frequency of ulcers in it, their situation and extent, 46 ; symp- toms, 237 ; peculiar to phthisis, 48. Lesions peculiar to -phthisical subjects. Lesions which are common to them with those who die of other chronic diseases ; their origin, general causes, 159 to 162. Liver, Often fatty in phthisical patients, especially in women, in what proportion, 107 ; fatty change may come on very rapidly, 109 ; no peculiar symptom marks it, 110. Liver sometimes has cysts of a peculiar character in it. 111 ; its left lobe may be destroyed by a fibrous cyst containing hy- datids, 111; its consistence is very variable. 111, 112; it is sometimes affected with a very marked emphysema, 112, 135, vii. Lungs. Do the wrinkled depressions, found sometimes at the apex, cor- respond to fixed lesions ? 35 ; their apex is at times enveloped with a kind of semi-cartilaginous covering, which is thick in a case of a very large cav- ity, 15 w 3 546 INDEX. M. Membranes. Muscular membrane of the stomach transformed over a small space to a semi-cartilaginous substance, 291, xxii. Membranes, Serous. All of them are more or less subject to an effusion of serous fluid in phthisical patients, 159. Menstruation. Sometimes continues to the very last periods of phthisis, 303; most common period of its suppression, 304 j causes which retard or accelerate it, 304, 305. Mesentery. Wholly tuberculous, 297, xxiii. See Glands. Mesocolon, Mesorectum. Tuberculous and semitransparent substance in lamina, 135, vii. o. Œdema of the Glottis. Rare in phthisical subjects who have ulcera- tions in the larynx, 48 ; what that indicates, 421, 422, xlvi. Œdema of the Legs. Rare in phthisical patients, 201 ; example of one of those cases of œdema which had been very considerable ; obstruction of the crural veins with layers of fibrine, thickening of their parietes, 30. Œsophagus. Rarely ulcerated in phthisis, 57 ; often deprived of its epidermis ; its parietes sometimes thinned and softened near the cardia, 58 j remnants of a kind of membrane upon its surface, 57, 337, 339, xxx ; symp- toms which depend upon it, 335, 339. Opium. Inefficacious in cases of pains from thinning and softening of the mucous membrane of the stomach, 255 ; administered likewise without effect in diarrhœa, during the last days of life of phthisical patients, 453. P. Pains of the chest in Phthisis. Degree, frequency, situation, 186, 187 j. cause, 187, 188 ; cases in which they do not exist, 188 ; when the disease goes on rapidly, 368, 372. Pectoriloquy. Time of ^occurrence, 1G8 ; must be accompanied with other signs in order for it to indicate certainly the existence of phthisis, 212, xi. 215. Percussion. Importance for the diagnosis of phthisis in its first and sec- ond periods, 210. Vide Perforation. Perforation of the lungs in Phthisis. Its varieties, 379 5 perforation not communicating with the bronchia, 383, xxxix, 394, xhi ; side of the chest most usually affected by it ; part of the lungs where it occurs, 411 ; number of perforations in the same subject; reason why they are not more frequent, 412; age of the patients, 413 ; symptoms of , 402 5 may be suspected à^norir 402; pain may be absent and yet the diagnosis may not be impossible, 403, xliv ; how the rational symptoms are confirmed by auscultation and perçus- INDEX. 547 cussion, 407, 408; do the rational symptoms always take place? use of aus- cultation and percussion when they are slight, 409 ; duration of life after perforation, 410. Peritoneum. Frequently the seat of an effusion of serous fluid in phthis- ical patients, 130 ; miliary granulations on its surface, their nature, 131. Tuberculous patches between the folds of a false membrane effused upon all the free surface, 131, 345, xxxiij old adhesions, 131 ; its condition in con- sequence of chronic diseases different from phthisis, 138. Peritonitis, Acute. Occurs sometimes during the last days of life, 131. Pia mater. Sometimes injected more or less in phthisical patients as after other chronic diseases, 141, 142. Pharynx. Rarely ulcerated in phthisis, 57, 227, xiii ; condition after other chronic diseases, 58. Phthisis. What it consists of, 3 ; two periods, first before, second after the softening and evacuation , of the tuberculous matter, general descrip- tion, 165 to 171 ; duration in 114 persons, 169 3 course more rapid in women than in men, 170 ; why so : proportion between it and other diseases which prove mortal either from their nature or by accident, 170. Phthisis, Acute. Example, death on 35th day, 368, xxxvi; can we re- cognise it ? Example of a remittent acute case, 368, xxxvi ; its diagnosis in the first period in which there is much doubt, 372 ; produces the same sec- ondary disorders that chronic cases do, 373 ; are all ages liable to it? 374. Phthisis, Latent. Cases of one latent a year, six months, &c., xxvii, xxviii, &c. The facts belonging to tMs species of phthisis are naturally divided into two classes, 350 ; diagnosis, 350, 351 ; phthisis latent like all other diseases over those which are acute, 351 ; are any causes to be as- signed for this latent state of phthisis ? 351, 352. PleurcB. Adhesions much more frequent than in other chronic diseases, 39 J cause and nature of these adhesions, 40, 41 ; effusion of serous fluid frequent into their cavity, 41 ; false membrane covering the right pleura in a great measure tuberculous, 258, 262. xvii. Pregnancy. Capable of retarding consumption ? 305. Prostate. Sometimes tuberculous in phthisis, 122 and vi, 127. Pulmonary Artery. Its arrangement in the lungs of phthisical patients, 8, 331, xxix. Pneumonia, Acute. Generally curable in phthisis, 218 ; frequent at the end of phthisis and other chronic affections, 37, 3S ; symptoms, 217; period of its commencement, 217. Pneumonia, Chronic. Anatomical characteristics ; exists sometimes at the summit of the lungs in phthisical patients, 11. R. Rectum. Ulcerations, 96 ; symptoms of them, 199. Respiration, Tracheal. Heard over cavities, 168. 548 INDEX. S. Seltzer Water. Momentary relief from it of the pains caused by the softening and thinning of the mucous membrane of the stomach, 255. Semi-transparent grey substance. Frequent in the lungs in phthisis, 7 5 changes into tubercles, 7} sometimes found in other parts, 135, vii} rarely vessels in it, 8, 331, xxixj sometimes arranged in zones, 420, xlvi. Spleen. Sometimes tuberculous in phthisis, 115 ; in one case had in it an accidental tissue of another nature, 116 ; sometimes very small ; variable consistence, 116; size independent of the circulation, 116; sometimes cov- ered with a tuberculous false membrane, 260, xvii ; its lesions in conse- quence of other diseases, 116. Sputa. Chai'actei-s and differences in the first and second periods of phthisis, 172, 173; their appearance during the last days of life, 173; their quantity, 173; influence of regimen upon their appearance, 174; their two- fold source in the second period of phthisis, 174. Stomach. In many cases very large, and had its position altered oftener in phthisical patients than in those who died of other chronic diseases, 59; mucous membrane was frequently and more seriously diseased in phthisis than in other affections ; tables proving this assertion, 70, 71 ; thinning and softening of the mucous membrane of the stomach, 60; different aspects of this lesion, 61, 62; its causes; proportion of its occurrence in men and women, 63; symptoms of it, their origin, progress and duration, 254 ; rarely fail to occur, 256; when marked they are superior to all the rest, 257, xvii; inflammation of the mucous membrane of the anterior face, 64; proportion of cases in which this is met with, 64 ; influence of the hver upon it, 65 ; symptoms, 263; why suspect its liuiited nature, 263, xviii; redness and softening of the mucous membrane limited to the great cul-de-sac, 65 ; pro- portion of cases in which this lesion is met with, 65 ; its nature, the period of its development, 66 ; its symptoms, 270 ; observed rarely, 270, xix ; sim- pie ulcerations of the mucous membrane, 68 ; syuiptoms, 275, xx ; mamil- lated state, greyish color of mucous membrane, nature of this lesion, 68; has no well marked symptoms in phthisical patients, 279; digestive func- tions not commonly altered when the mucous membrane is well, 280, 281 ; Other lesions of this membrane ; universal redness without change of struc- ture, 2S1 ; large nipple like processes ; pus under the mucous membrane ; imperfect cicatrization, 70, xxi ; muscular membrane changed into semi- cartilaginous substance, 268, xxii. Sudamina. Not common in perspirations of phthisis, 193. Sudden death. Sometimes accounted for in phthiais by the state of the organs after death, 414. xlv, xlvi ; at other times impossible, xlvii, xlviii; occurred in two persons in whom the brain was throughout very much soft- ened, 429, xlix, 1. Smi:uts. Fi-equent in phthisis, 192; not inversely as (he diarrhœa, 192; cause of them in phthisical patients, 193. INDEX. 549 T. Thickening. Very important to be noted in all cases, 93. Thirst. In how many cases absent 5 symptoms and lesions with which it coincides, 194. Tiiikling, Metallic. Heard sometimes over large cavities, 216, 217, i, xxviii ; mode of distinguishing this from the tinkling which occurs in per- foration of the pulmonary texture, 216 5 condition of the tinkling in this last case, 409. Tongue. Color in different states of the mucous membrane, 293, 294 ; cases in which it remained more or less deeply red, and afterwards became dry while the mucous membrane of the stomach was perfectly healthy 295, xxiii ; its importance in pathology, 2 8 ; membranous exudation on it, surface nearly equally frequent in all conditions of the stomach 5 cause and nature of this exudation, 299, 300. Trachea. Ulcers very frequent and occupy at times all the fleshy por- tion, 43, 44 ; their cause, 44, 45 ; their symptoms, 239, 240, xv. Treatment. When no fever, and when more or less severe, 448 ; when phthisis is somewhat acute, 449 j cough not very bad, 449 ; symptoms of pleurisy, 449 ; pneumonia, 450 ; severe haemoptysis, 450 ; ulcers of the larynx ; copious perspiration, pains at the epigastrium and vomiting, 451 5 severe diarrhœa, 452, G. Tuber .annulare. Tuberculous, vi, 125. Tubercles. Their qualities, laws of development, 4, 5 ; exist almost al- ways in both lungs, 6, 10 5 so ten at various epochs gradually, from the apex to the. base, rarely all at once, 12, 13 5 not entirely emptied before the third month from their commencement, 13; same degree of development out of the lungs every where 3 what this circumstance proves, 155, 156, vi, ix, 262, xvii, 256; peculiar to phthisis 161. Tubercles, Encysted, 342, xxxi. u. Ulcerations of the Stomach, Epiglottis, fyc. Sfc. (Vide these words) ; what they have in common, 161. Uterus. Tuberculous, 129, xxxii ; size and condition in those who die of other diseases, 130 ; inflamed alter delivery, xxxvii. Vasa Deferentia. Tuberculous, 122, vi; causes of this lesion, 128. Ventricles of the Brain. Frequent serous eifusion towards the end of chronic diseases, 141, 142. VesiculcB Séminales. Tuberculous, 122, 128, vi ; cause of this lesion, 128. 550 INDEX. Vomiting. Depends sometimes on the cough merely ; ordinarily on the bad condition of the mucous membrane of the stomach ; mode of distinguish- ing these two cases, 281 to 283. w. Women. More liable to phthisis than men, and to grave affections of the mucous membrane of the stomach, 63, 65 ; to the fatty stale of the fiver, 109 ; less exposed to ulcers of the epiglottis, larynx and trachea, 47 ; greater mortality among them than among men during the first year of phthisis, 170, COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special arrange- ment with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE C28(t14l)MI00