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The hissing sound was considered by Läennec to be occasioned by a local contraction of the smaller bronchia, from thickening of their inner membrane. The other sounds are probably owing to the presence of a minute quantity of thin and viscid mucus obstructing, more or less completely, the smaller bronchial tubes. When the hissing sound is once fairly established, it usually persists for some hours: the clicking, chirping, and unctuous sounds are, however, not at all of a permanent character; for they often appear, disappear, and reappear in the short space of a few minutes, especially after a fit of coughing. Should the râle sibilant occupy the greater part of both lungs, the danger would be imminent from the small quantity of oxygen which could arrive at the air-cells to arterialize the blood.
"The râle muqueux is, in bronchitis, produced by the passage of air through mucus accumulated in the bronchial tubes. It is only heard when the secretion, which was at first suppressed, is again re-established. This râle, like the two former, is subject to great variation; it may be exceedingly feeble and audible only from time to time, or it may be so loud that it can be heard with distinctness many feet from the bed in which a patient is lying. It is then called "gargouillement."
"If the mucous rattle be only heard at a few points of the chest, and the sound be feeble, it portends a favourable issue; if, on the contrary, the gargouillement' supervene, it indicates the greatest danger.
"External Causes.-The word cold,' employed to express this disease, would seem to signify that it always arose from cold. That cold is an occasional excitant cannot, for a moment, be doubted; but it would lead us to very erroneous notions to suppose that catarrh invariably, or even most frequently, derived its origin from this source: for, were this the case, the disease, common as it is, would certainly become far more common. If I were asked whether sudden changes from heat to cold, or from cold to heat, were the general exciting causes of cartarrh, I should say no; otherwise men employed in gas-manufactories, glass-houses, and typefounderies, &c., would be the very persons most subject to the disease: there seems, however, very little evidence to prove that this is the fact. Again, the inhabitants of Newfoundland and of some other countries, for example, where in certain seasons the range of the thermometer varies in the course of twenty-four hours from 40° to 50° Fahr., would never be free from catarrh; while the truth is, the inhabitants of these parts do not suffer more from cartarrhal affections than the natives of regions apparently more favourably located. Once more, how often are the citizens of farfamed London obliged to fly, in the course of a few seconds, from the torrid to the frigid zone; or, in other words, to leave a drawing-room, heated to nearly 70° Fahr., to occupy a bed-room cooled down, perhaps, to a temperature some way below the freezing point! As this frequently happens during severe frosts without injurious effects, we are compelled to look for other external causes, the chief of which are moisture with cold, miasm, noxious gases, and impalpable powders."
The second branch of our doctor's treatise is upon the direct or positive diseases of the lungs; and he thus describes one of the
most common disorders that occurs in temperate and cold climates, viz., Peripneumony, or inflammation of the lungs :
"Anatomical Characters. 1st Stage, or Stage of Engorgement.-The lung is, externally, of a livid or violet hue; internally, it is of a deep red colour; it is increased in weight and density; it crepitates when handled, but less so than healthy lungs; if divided with the scalpel, a sero-sanguineous, frothy fluid escapes in abundance; the cellular, or spongy texture of the lungs, is still visible, except where it may have passed into the second stage.
"2nd Stage, or Hepatization Rouge.-In this stage, the lung is still further increased in weight and density, having a strong resemblance to liver; it no longer crepitates on pressure; its colour externally is less livid and violet than in the first stage. If cut into, the interior presents a mottled appearance. In some parts it is of a deep red colour; in others violet, or of various intermediate shades; the whole being interspersed with white and black spots, the former being caused by the divided extremities of the bronchial tubes, the latter by black pulmonary matter. On tearing a portion of hepatized lung, a granular texture is discoverable, but there is no exudation of sero-sanguineous fluid, although a reddishcoloured fluid can be scraped off with the scalpel. The portion of lung surrounding the hepatized part is sometimes in an emphysematous state. Dr. Skoda, alluding to this last condition, says, 'Das letztere geschieht insbesonders haüfig an den Rändern der Lappen.'
3rd Stage: Hepatization Grise.-The lung presents the same characters, as to weight and density, in this as in the former stage. It is now of a pale yellow, or straw colour, and its granular appearance is more conspicuous. On incising it, a yellowish opaque fluid may be collected on the knife. When the hepatization rouge is passing into the hepatization grise, yellow points of purulent matter are first seen; these gradually coalesce, and at last produce the appearance just described.
"4th Stage: Abscess of the Lung.-This is an exceedingly rare termination of peripneumony-so rare, indeed, that I have as yet never seen an instance of it, either in hospital, dispensary, or private practice, during a period of fifteen years. The late Dr. Thomas Davies, alluding to its extreme rarity, remarked that he had not met with a single specimen ' after twelve years' habitude in post-mortem examinations.' That Läennec firmly believed an abscess of the lung to be an exceedingly infrequent termination of inflammation, can be perceived from the following passage extracted from his work :- One of the best proofs (says he) which I can give of the rarity of abscess of the lungs is derived from this fact, that, notwithstanding the zeal with which morbid anatomy has been cultivated in France during the last twenty-years, I know of only two well-authenticated instances of this affection besides those above mentioned.' He refers to several cases which occurred in 1823, during the prevalence of a peculiar medical constitution.
"When inflammation of the lung terminates in abscess, the abscess is seldom large and solitary, but, on the contrary, small collections of pus are usually met with in various parts of the lung. The parietes of these
abscesses are formed of pulmonary tissue, filled with purulent infiltration, and in a state of soft detritus, or disorganization.
"Duration of Peripneumony.-The duration of the different stages of this disease depends in a great measure on the age, temperament, and mode of life of the patient, and on the nature of the epidemic, if one prevail. The first stage may last only a few hours before signs of hepatization become manifest, or it may prove fatal without running into the second stage. In general, the stage of engorgement persists from twelve hours to two or three days; that of hepatization rouge from one to three or four days; and that of hepatization grise from two days to a week."
Pulmonary consumption is stated to have carried off prematurely "no fewer than one-fourth of the inhabitants of Europe." Ah! what an appalling army. We ourselves have seen, and been bosomly connected with the victims of this fell instrument of the Almighty's wisdom, in thinning the ranks of human kind. How ghastly in one sense; but how preparative in another! To our extract, and then to a sentiment:
"Anatomical Characters.-The anatomical characters of tubercular deposit may be considered with advantage under two divisions,-1. Isolated tubercular matter; 2. Infiltrated tubercular matter.
"Isolated Tubercular Matter.-There are three varieties of isolated tubercular matter; viz. 1. Common tubercle; 2. Tubercular granulations; 3. Encysted tubercle.
"Variety 1. Common Tubercle: First Stage.-When a portion of lung, in the immediate vicinity of a large opaque tubercle, is minutely examined, it will frequently be found studded with exceedingly small bodies, having a gelatinous appearance and pearly lustre. Their colour is greyish, with a tinge of red; their form is roundish, or somewhat angular; and they adhere by minute filaments to the adjacent parts. They may be seated in the air-cells, or cellular tissue separating these. When incised, not a trace of blood-vessels is discoverable, and they seem perfectly homogeneous.
"Second Stage.-Tubercles in this stage are characterised by granules, almost colourless, or of a greyish hue, roundish form, and semi-transparent; their hardness is considerable, approaching that of cartilage; and they adhere, with great firmness, to the adjacent pulmonary tissue; their size is pretty accurately represented by seeds of millet, and they have therefore been termed 'miliary tubercles.' They may be few in number, or both lungs may be completely studded with them.
Third Stage. In this stage, the tubercles become enlarged by deposits on their external surface, and they frequently coalesce, and form irregular masses of very variable size. While these changes are going on, a small yellow speck is seen, generally near the centre of each tubercle, but sometimes at the circumference; this gradually spreads, and finally involves the whole tubercle. Tubercles in this stage are called 'crude.'
"Fourth Stage: Period of Softening.-At whatever part of a tubercle the yellow spot first made its appearance-whether at the centre or cir
cumference-that part is the first softened. The softening progressively, extends through the whole substance of the tubercle.
"The degenerated or softened matter, appears under two forms; sometimes (especially in scrofulous habits) it is soft and pliable, of a cheesy consistence, mixed with a small quantity of a straw-coloured semi-transparent fluid, occasionally tinged with red; at other times it closely resembles thick pus; it is of a yellow colour, and inodorous.
"The softened tubercular matter finally bursts into the neighbouring bronchial tubes, becomes evacuated, and leaves a true tubercular excavation. This excavation is frequently crossed by bands of pulmonary substance crowded with tubercles still in the crude state, and also by bloodvessels of considerable size, but never by bronchial tubes; the blood-vessels are, however, generally forced to the sides of the excavation, and not completely obliterated.
"If an excavation exist, destitute of these intersections, it is termed an 'unilocular tubercular excavation;' if only one band cross the cavity dividing it into two parts, the excavation is then called 'bilocular tubercular excavation;' and, lastly, if the cavity be intersected by many bands, it receives the name of multilocular tubercular excavation.'
"Variety 2. Tubercular Granulations.--This variety of tubercles, which is extremely rare, was first accurately described by Bayle. Tubercular granulations generally exist in countless numbers; they are about the size of millet seeds, of a round or ovoid figure, and extremely uniform in their appearance; they are either colourless, or of a grey hue, and transparent; occasionally they form masses of considerable size, but never coalesce, for on incising a mass each granule is found separated from those adjacent by cellular substance either perfectly healthy, or only slightly congested. In the centre of each granule is usually to be seen a dark-coloured spot, which disappears as the granule enlarges. Jaundice, according to Läennec, stains the granules yellow, and gangrene imparts to them a brownish or dirty brown colour.
"Tubercular granulations, and the other varieties of tubercle, like the common tubercle, have their periods of crudity and softening; sometimes, however, they destroy life before the latter period arrives.
"Variety 3. Encysted Tubercle.-This variety of tubercle is still more rare than tubercular granulations, so rare indeed, that the generality of physicians pass through life without meeting with a single specimen of it. Louis, the most indefatigable morbid anatomist who ever lived, never met with but one instance during the course of his dissections, which extended through a period of many years; and Läennec confesses to have seen but four or five cases.
"The cysts which contain the tubercles are of a semi-cartilaginous texture. On the inside they are smooth, polished, and rugous, and adhere but slightly to the enclosed tubercular matter; externally they are firmly attached to the pulmonary tissue in which they are imbedded.
"2. Infiltrated Tubercular Matter.-Tuberculous infiltration sometimes exists without the development of tubercles, but this is exceedingly rare : in general it is found encircling tuberculous cavities. This, like the common tubercle, has its four stages, viz. the first, or gelatiniform; the second, in
which the tuberculous matter becomes almost as firm as cartilage: the third, or crude stage; and the fourth, or period of softening. When the tuberculous infiltration is examined during the second stage, it is seen in masses of very variable size, dense, humid, homogeneous, and of a greyish colour, with some degree of transparency, not a trace of organization being discoverable. As the third period approaches, minute yellow spots are recognised; these spots gradually augment, till the whole mass be converted into yellow tuberculous matter, which finally softens, and is evacuated.
"Whether tubercular matter appear under the form of isolated tubercular matter, or infiltrated tubercular matter, its various stages may exist at the same time; thus, in the same lung, one crop may appear softened, another crude, and finally, another gelatinous."
Consumption, the direst of discases in one sense, the most merciful in another, deserves to be contrasted in a spirit of Christian philosophy, which is neither difficult of being conceived, nor to be felt as more than theoretical,-as immediately practical. To be sure, its steps if generally slow are sure; and then it is so deceptive, not merely by its insinuating progress, but by the fascination which it throws around the soul, that it may be regarded as a special enemy. Still, if one will comprise within the circuit of his observations and emotions the passages, the offices, the opportunities which decay begets and presents, he cannot as a mortal being, with an hereafter before him, but pronounce the most insidious of diseases as a harbinger of good tidings, a messenger of love. Just think of the numbers that note the condition of the patient who may be mellowing into holiness, and preaching by his looks and his gradual decline, if not by his affecting speech, the best and most impressive of all lessons! Or, if he still pertinaciously cling to a false and flattering hope, it is seldom that this does not call forth serious reflection and discourse on the part of those around him. Very probably some devout person frequently visits the dying man, and an entire family are hearers of the prayers and aspirations which sickness suggests; and therefore it becomes far better to dwell in, or to repair to the house of mourning than the house of mirth and thoughtlessness. In a word, is not consumption the most interesting of all the mortal ailments, of all those troubles which are destined to end in death,-the most interesting because the most instructive? There may be cause for welcoming the fallacy under which the patient labours until he is on the very threshold of the grave; for he may nevertheless be ripe for heaven. But the more frequent duty of relatives and bosom friends is to guide his mind to the scene that must sooner or later terminate his earthly existence; and the earlier this direction is attempted, requiring as it must ever do delicacy and judgment, the less bitter will be the portion that is thrown into the cup of life, and the more salutary the results. There is a great mistake often committed on the part of friends