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Societa' Italiana di Biochimica e Biologia Molecolare
In collaborazione con:
Dipartimento di Scienze Biochimiche "A. Rossi Fanelli"
Istituto Pasteur - Fondazione Cenci Bolognetti
Sapienza Universita' di Roma
being a translation of
AUENBRUGGER'S ORIGINAL TREATISE
INVENTUM NOVUM EX PERCUSSIONE THORACIS HUMANI, UT SIGNO ABSTRUSOS INTERNI PECTORIS MORBOS DETEGENDI.
Translation by John Forbes, London, 1824.
The Author Preface.
I here present the Reader with a new sign which I have discovered for detecting diseases of the chest. This consists in the Percussion of the human thorax, whereby, according to the character of the particular sounds thence elicited, an opinion Is formed of the internal state of that cavity. In making public my discoveries respecting this matter, I have been actuated neither by an itch for writing, nor a fondness for speculation, but by the desire of submitting to my brethren the fruits of seven yearobservation and reflexion. In doing so, I have not been unconscious of the dangers I must encounter; since it has always been the fate of those who have illustrated or improved the arts and sciences by their discoveries, to be beset by envy, malice, hatred, detraction and calumny.
This the common lot, I have chosen to undergo; but with the determination of refusing to every one who is actuated by such motives as these, all explanation of my doctrines. What I have written I have proved again and again, by the testimony of my own senses, and amid laborious and tedious exertions; - still guarding, on all occasions, against the seductive influence of self-love.
And here, lest any one should imagine that this new sign has been thoroughly investigated, even as far as regards the diseases noticed in my Treatise, I think it necessary candidly to confess, that there [page 3] still remain many defects to be remedied - and which I expect will be remedied - by careful observation and experience. Perhaps, also, the same observation and experience may lead to the discovery of other truths, in these or other diseases, of like value in the diagnosis, prognosis and cure of thoracic affections. Owing to this acknowledged imperfection, it will be seen, that, in my difficulties, I have had recource to the Commentaries of the most illustrious Baron Van Swieten, as containing every thing which can be desired by the faithful observer of the nature; by which means I have not only avoided the vice of tedious and prolix writing, but have, at the same time, possessed myself of the firmest basis whereon to raise, most securely and creditably, the rudiments of my discovery. In submitting this to the public, I doubt not that I shall be considered, by a those who can justly appreciate medical science, as having thereby rendered a grateful service to our art, - inasmuch as it must be allowed to throw no small degree of light upon the obscurer diseases of the chest, of which a more perfect knowledge has hitherto been much wanted. In drawing up my little work I have omitted many things that were doubtful, and not sufficiently digested; to the due perfection of which it will be my endeavour henceforth to apply myself. To conclude, I have not been ambitious of ornament in my mode or style of writing, being contented if I shall be understood.
December 31, 1760. [page 4]
Of the natural sound of the Chest, and its character in different parts.
I. The thorax of a healthy person sounds, when struck.
Scholium. I deem it unnecessary to give in this place, any description of the thorax, I think it sufficient to say, that by this term I mean that cavity bounded above by the neck and clavicles, and below by the diaphragm: in the sound state, the viscera it contains are fitted for or their respective uses.
II. The sound thus elicited (I.) from the healthy chest, resembles the stifled sound of a drum covered with a thick woollen cloth or other envelope.
III. This sound is perceptible on different parts of the chest in the following manner:
1. On the right side anteriorly it is observed from the clavicle to the sixth true rib; laterally, from the axilla to the seventh rib; and posteriorly from the scapula to the second and third false ribs.
2. The left side yields this sound from the clavicle to the fourth true rib, anteriorly; and on the back [page 5] and laterally, in the same extent as the other side: over the space occupied by the heart the sound loses part of its usual clearness, and becomes dull.
3. The whole sternum yields as distinct a sound as the sides of the chest, except in the cardiac region where it is somewhat duller.
4. The same sound is perceptible over that part of the spinal column which contributes to form the chest.
Scholium. The sound is more distinct in the lean, and proportionably duller in the robust; in very fat persons it is almost lost. The most sonorous region is from the clavicle to the fourth rib anteriorly; lower down, the mammae and pectoral muscles deaden the sound. Sometimes, owing to the presence of muscle, the sound is dull beneath the axilla. In the scapular regions on the back, owing to the obstacle afforded by the bones and thick muscles there, it is also less distinct. Sometimes, but rarely, it exists over the third false rib - owing, I conceive, to a very unwonted length of the thoracic cavity.
Of the method of Percussion.
IV. The thorax ought to be struck, slowly and gently, with the points of the fingers, brought close together and at the same time extended.
Scholium. Robust and fat subjects require a stronger percussion; such, indeed, as to elicit a degree of sound equal to that produced, by a slight percussion, in a lean subject. [page 6]
V. During percussion the shirt is to be drawn tight over the chest, or the hand of the operator covered with a glove made of unpolished leather.
Scholium. If the naked chest is struck by the naked hand, the contact of the polished surfaces produces a kind of noise which alters or obscures the natural character of the sound.
VI. During the application of percussion the patient is first to go on breathing in the natural manner, and then is to hold his breath after a full inspiration. The difference of sound during inspiration, expiration, and the retention of the breath, is important in fixing our diagnosis.
VII. While undergoing percussion on the fore parts of the chest, the patient is to hold his head erect, and the shoulders are to be thrown back; in order that the chest may protrude, and the skin and muscles be drawn tight over it: a clear sound is thus obtained.
VIII. While we are striking the lateral parts of the chest, the patient is to hold his arms across his head; as, thereby, the thoracic parietes are made more tense, and a clearer sound obtained.
IX. When operating on the back, you are to cause the patient to bend forwards, and draw his shoulders towards the anterior parts of the chest, so as [page 7] to render the dorsal region rounded; and for the same reasons, as stated in VIII.
Scholium. Any healthy person may make experience of percussion in his own person or that of other sound subjects; and will thus be convinced, from the variety of the sounds obtained, that this sign is not to be despised in forming a diagnosis.
Of the preternatural or morbid sound of the Chest, and its general import.
X. And Scholium. To be able justly to appreciate the value of the various sounds elicited from the chest in cases of disease, it is necessary to have learned by experience on many subjects, the modifications of sound, general or partial, produced by the habit of body, natural conformation as to the scapulae, mammae, the heart, the capacity of the thorax, the degree of fleshiness, fatness &c. &c. inasmuch as these various circumstances modify the sound very considerably.
XI. If, then, a distinct sound, equal on both sides, and commensurate to the degree of percussion, is not obtained from the sonorous regions above mentioned, a morbid condition of some of the parts within the chest is indicated,
Scholium. On this truth a general rule is founded, and from this certain predictions can be deduced, as will be shown in order. For I have learned from [page 8] much experience that diseases of the worst description may exist within the chest, unmarked by any symptoms, and undiscoverabie by any other means than percussion alone.
A clear and equal sound elicited from both sides of the chest indicates that the air cells of the lungs are free, and uncompressed either by a solid or liquid body. (Exceptions to this rule will be mentioned in their place.)
XII. and XIII. If a sonorous part of the chest, struck with the same intensity, yields a sound duller than natural, disease exists in that part.
XIV. If a sonorous region of the chest appears, on percussion, entireiy destitute of the natural sound, - that is, if it yields only a sound like that of a fleshy limb when struck, disease exists in that region.
Scholium. The nature of the indications above pointed out, will be understood by any one who attends to the difference of sound elicited by percussion of the chest, and of the thigh, in his own person.
XV. The superficial extent of this unnatural sound (XIV.) in a sonorous region, is commensurate with the extent of the morbid affection.
XVI. If a place, naturally sonorous, and now sounding only as a piece of flesh when struck, still retains [page 9] the same sound (on percussion) when the breath is held after a deep inspiration, - we are to conclude that the disease extends deep into the cavity of the chest.
XVII. If the same results (XVI.) are obtained both before and behind, on points precisely opposite, we are to conclude that the disease occupies the whole diameter of the chest.
Scholium. These varying results depend on the greater or less diminution of the volume of air usually contained in the thorax (lungs); and the cause which occasions this diminution, whether solid or liquid, produces analogous results to those obtained by striking a cask, for example, in different degrees of emptiness or fulness: the diminution of sound being proportioned to the diminution of the volume of air contained in it.
Of the diseases in general In which the morbid sound of the Chest is observed.
XVIII. The preternatural or morbid sound occurs in acute and chronic diseases; it always accompanies a copious effusion of fluid in the thoracic cavity.
Scholium. It must be admitted that whatever diminishes the volume of air within the chest, diminishes the natural sound of that cavity; but we know from the nature, the causes, and the effects, of acute and chronic diseases of the chest, that [page 10] such a result is possible in these cases; and the fact is finally demonstrated by examinations after death. The effect of effused fluids in producing the morbid sound, is at once proved by the injection of water into the thorax of a dead body; in which case it will be found that the sound elicited by percussion, will be obscure over the portion of the cavity occupied by the injected liquid.
Of Acute diseases in which the chest yields the morbid sound.
XIX. The morbid sound which is observed in acute diseases, occurs during their progress, or at their termination.
Scholium. This consideration ought to lead all medical men to use percussion in acute diseases; as they will thereby be enabled to form a more correct judgment, which in such cases is always a matter of difficulty. It has often occured to me to see cases of acute diseases, apparently over, and imposing on the physician under the mask of intermittent or remittent fevers, and which have eventually ended in a fatal vomica or fatal scirrhus of the lungs.
XX. The preternatural sound which is perceived during the course of acute diseases of the chest, occurs most frequently in inflammatory affections.
Scholium. The reason of this observation (XX.) will be obvious to any one acquainted with the [page 11] nature of inflammation. The preternatural sound may also be observed sometimes in epidemic exanthematous diseases, previously to the eruption; - as was the case in the petechial epidemic of 1757, 1758, 1759, and in the miliary epidemic of the present year (1760). In the latter instance, I observed that the preternatural sound, when once present, continued to the termination of the eruption.
XXI. The morbid Sound which occurs towards the termination of acute diseases, is observed, when the excretion of morbid matter is not adequate to the severity of the affection.
XXII. The morbid sound occuring in inflammatory diseases is commoniy observable on the fourth day; it rarely precedes, but often follows this period.
Scholium. This sign occurs rarely on the third, and very often on the fourth, fifth, and seventh day - but never later. It is observed in those inflammatory affections of the pleura or lungs, or both, which are accompanied by a humid cough; but not in those attended by a dry cough, - such (e.g.) as the dry pleurisy, and inflammation of the mediastinum, pericardium, and heart. At least in these latter affections, the sound is not observed, until such time as they verge towards a fatal termination, or have degenerated into obvious abscesses or vomicae.
XXIII. The morbid sound increases, from the time of its appearance, according to the nature, severity, and [page 12] duration of the disease; it diminishes proportionably to the nature, duration, and copiousness of the excretions.
Scholium. The progressive augmentation of the preternatural sound depends on the gradual deposition of the morbific matter, which I have often found in such quantity as to occupy the inferior two-thirds of the affected side.
XXIV. The disease in which the preternatural sound is once present, either proves fatal [on a decretory day, reckoning from its origin]; passes off with due excretion; or terminates in other affections.
XXV. The following corollaries are the result of my observation of inflammatory diseases of the chest, studied under the sign of morbid resonance:
1. The duller the sound, and the more nearly approaching that of a fleshy limb stricken, the more severe is the disease.
2. The more extensive the space over which the morbid sounds is perceived, the more certain is the danger from the disease.
3. The disease is more dangerous on the left than on the right side.
4. The existence of the morbid sound on the superior and anterior part of the chest (i.e. from the clavicle to the fourth rib) indicates less danger, than on the inferior parts of the chest.
5. The want of the natural sound behind, indicates more danger than it does on the anterior and superior part of the chest. [page 13]
6. The total destitution of sound over one whole side, is generally (passim) a fatal sign.
7. The absence of sound along the course of the sternum is a fatal sign.
8. The entire absence of the natural sound over a large space in the region of the hearth, is a fatal sign.
Scholium. I have sometimes observed that the fatal prognostics given in the corollaries 6 and 7, were not verified when the matter made its way outwards, or abscesses formed in parts less essential to life. And this natural process has been often happily imitated by the antients, by cauterising or otherwise incising, the affected parts.
Of Chronic Diseases in which the preternatural sound is observed.
XXVI. The preternatural sound observed in chronic diseases is owing either to - (1.) some hidden condition of the organs, which disorders them with a slow progress and finally destroys them; or exists (2.) when certain obvious causes have induced a slow disorganization of the same.
Scholium. These are the general sources of chronic diseases of the chest; and from whichever of the two classes of causes these arise; the morbid sound will equally and always be present.
XXVII. The diseases of the first class are, 1. those which depend on hereditary predisposition; 2. those which [page 14] arise from affections of the mind, particularly ungratified desires, the principal of which is Nostalgia; 3. those which affect certain artisans, naturally possessing weak lungs.
Scholium. 1. The influence of an hereditary taint in producing diseases we know by experience, though we cannot explain it. - See Van Swiet.
2. Mental affections, we find, produce quite opposite effects, while acting as causes of pectoral diseases. Of these affections of the mind I have observed none more powerful in rendening obscure the natural resonance of the chest, than the destruction of cherished hopes. And as among this class of diseases, Nostalgia (commonly called heimwehe - home ail) occupies the first place, I shall here give a short history of it.
When young men, not yet arrived at their full growth, are forcibiy impressed into the military service, and thereby at once lose all hope of returning safe and sound to their beloved home and country, they become sad, siient, listless, solitary, musing and full of sighs and moans, and finally quite regardless of, and indifferent to, all the cares and duties of life. From this state of mental disorder nothing can rouse them, - neither argument, nor promises, nor the dread of punishment; and the body gradually pines and wastes away, under the pressure of ungratified desires, and with the preternatural sound of one side of the chest. This is the disease Nostalgia. I have examined the bodies of many youths who have fallen victims to it, and have uniformly found the lungs firmly united to the pleura, and the lobes on that side where the obscure sound had existed, callous, [page 15] indurated, and more or less purulent. Some years ago, this disease was very common, but is now rarely met with, since the wise arrangement has been adopted of limiting the period to military service to a certain number of years only.
3. The various arts and occupations of life have their peculiar diseases, in like manner as the ages, temperaments, and sexes have theirs. This truth is exemplified in the case of the man of letters, the husbandman, the workers in metals, painters, &c. &c. Our particular business, however, at present, is with those arts which dispose to diseases of the chest indicated by the sound so often described. Thus I have remarked that Tailors, Millers, &c. who are forced to inhale, during their labours, a fine dust, become phthisical; while shoemakers, weavers, &c. from the forced position or application of their weak chests, during their various occupations, become asthmatical, with scirrhous lungs, &c.
I may here state a fact which I have frequently proved by dissection, but which I cannot well account for - it is this: in the above mentioned class of cases it is extremely rare to find both lungs affected at the same time; and, when this happens, one lung is always more diseased than the other.
XXVIII. The diseases mentioned (in XXVI. 2.) arise either from (1.) a vitiated condition of the fluids, gradually produced; or (2.) from acute affections imperfectly cured.
Scholium. 1. The vitiation of the humours arises from ingesta which cannot be assimilated, the effect [page 16] of which in producing chronic diseases is well known.
2. An acute disease is said to be imperfectly cured when some morbid affection still remains after it, in some part of the body. This morbid condition will be observed either in the site of the primary disease, or, at least, in that portion of the chest, which yields the morbid sound; - namely, the pleura, or lungs, or both these together, or the mediastinum or pericardium. When the primary inflammatory disease is succeeded by a collection of pus in the chest, the affection is readily recognized; but if the secondary affection is a scirrhus of the lung, how often and how grievously are medical men thereby deceived! Often have I met with cases of fancied convalescence from acute fevers, in which there was hardly any cough or dyspnoea, or indeed any other sign of disease (as appeared to the attendants) but a trifling degree of irregular fever. In these cases, however, on percussion the preternatural sound was found over one whole side of the chest, and the final result was death, preceded either by dropsy or extreme emaciation; the real seat of the disease remaining, perhaps, unknown to the very last!
XXIX. For the above reasons, it may be received as a general rule in chronic diseases, that when, together with the indication stated XXVI., there are emaciation and debility, - the case is desperate.
Scholium. This result is inevitable whensoever the disease doos not yield to medicine. In such [page 17] cases we may always conclude, that the lung of the side which yields the preternatural sound, is either compressed by some foreign body, is indurated by disease, or destroyed by some morbid acrimony developed within its own structure.
Of the preternatural sound of the chest which results from copious extravasation of the fluids contained in the vessels of that cavity.
XXX. The fluids contained in the vessel of the chest are: 1. Chyle; 2. Blood; 3. Serum and Lymph.
Scholium. I must candidly admit that I have never seen a case of extravasated chyle. I however believe the thing possible, although I am well aware that the thoracic duct runs outside the pleura: the same causes that produce erosion and perforation of the thoracic parietes, may produce this.
XXXI. The extravasation of these fluids (XXX.) may arise from the following causes: 1. rupture of the conaining vessels; 2. too great tenuity of the contained fluids; 3. nonabsorption of the same &c. &c.
Scholium. 1. Under this head come wounds, con- tusions, &c.
2. Extravasations from internal causes arise from rupture of relaxed and debilitated vessels, during a state of plethora and overactivity of the circulation.
3. A third class of causes are obstructions originating in a bad habit of body. [page 18]
XXXII. When from these causes the fluids mentioned are poured out in considerable quantity, the preternatural sound will exist over the space occupied by them.
Scholium. The correctness of this statement is evinced by the experiment mentioned at the end of the scholium of XVII.
According to the plan former proposed (XI.) I shall now proceed to notice those affections of the chest which are not indicated by percussion.
Of those affections of the chest which are not indicated by percussion.
XXXIII. Certain diseases attended by a violent cough, and thereby creating a suspicion that the lungs are certainly implicated, are nevertheless truly diseases of the abdomen, and affect the pulmonary organs merely sympathetically.
Scholium. Under this head are ranged the gastric and convulsive coughs of infants, pregnant women, and such other persons as have their abdominal viscera oppressed by the lentor of autumnal agues, or a superfluity of phlegm.
XXXIV. Violent coughs dyspnoeas, asthmas and consumptions, are also occasionally observed, which originate in some incomprehensihle irritability of the nerves of the chest. [page 19]
Affections of this sort rarely give rise to the preternatural sound: from the absence of this, however, and the presence of a copious watery urine, their existence may be pretty confidently presumed.
Scholium. Under this head are ranged the coughs, dyspnoeas, and asthmas so common in hysterical and hypochondriacal affections; the nervous consumption and asthma of old persons; and, perhaps we may add the polypous concretions found near the heart in young subjects.
XXXV. A slight engorgement of the lung, a scirrhus of small extent, a small vomica, and a trifling extravasation, are not detected by percussion, - unless, sometimes, by the decreased resonance of the affected part.
Scholium. These affections are not dangerous until they reach a size when they become more readily discoverable by means of percussion.
XXXVI. There is another class of diseases of the lungs [undiscoverable by percussion] in which the distinguishing symptoms are a very severe cough, with expectoration of fatty, chalky, gypseous and stony matters.
Scholium. These cases are known by the nature of the expectoration. I have frequently observed a cough of this kind (but without the peculiar expectoration) succeeding miliary fevers improperly treated. [page 20]
Of the appearances on dissection, in cases where the preternatural sound of the chest had been observed.
XXXVII. These are the following:
1. Scirrhus of the lungs;
2. The conversion of this into an ichorous vomica;
3. A purulent vomica (simple or ruptured) in the pleura, lungs, mediastinum or pericardium.
5. Dropsy of the chest, in one or both cavities;
6. Dropsy of the pericardium;
7. Extensive extravasation of blood in the cavity of the pleura or pericardium;
8. Aneurism of the heart.
Scholium. I will now proceed to notice diseases in order, premising, occasionally, some account of the general symptoms.
Of scirrhus of the lungs, and its symptoms.
XXXVIII. By scirrhus of the lungs I mean the degeneration of the natural spongy substance of the organ into an indolent fleshy mass.
Scholium. A portion of sound lung swims in water, but this carniform degeneration sinks. There is often observed a vast difference in the character of these scirrhi, in respect of hardness, colour and component parts. Thus, in inflammatory diseases of the [page 21] chest proving fatal on the fifth, seventh, or ninth day, the lung is very often found so completely gorged with blood, as to resemble liver in every respect, both as to colour and consistence. One appearance deserves to be noticed: the lung is frequently invested with a purulent adventitious membrane, in those instances wherein the fatal peripneumony has succeeded an acute pleurisy. In chronic diseases of the lungs the appearances are extremely various. Frequently they are interspersed and as it were marbled with a fatty kind of matter; frequently along with the fleshy appearance, they have the consistence of cartilage; and very often they are found indurated by means of a thickened and black blood. These varieties, doubtless, depend on varieties of the morbific matter.
XXXIX. The presence of scirrhus of the lungs, in its primary unsoftened condition, may be suspected from the following signs:
Together with the diminution or entire loss of the natural sound over the affected part, there is an infrequent cough without any expectoration, or with only a scanty excretion of viscid and crude sputa. During a state of quiescence there is nothing to be observed much amiss, either in the condition of the pulse or respiration; but upon any considerable bodily motion, or after speaking for some time, these persons become speedily exhausted, anxious, and breathless, and complain of a sense of dryness and roughness in the throat. At the same time the pulse, which had previously been of moderate frequency, becomes quick and unequal; the respiration [page 22] and speech are broken and interrupted by sighs; the temporal, sublingual, and jugular veins of the affected side, are more than usually distended; while it will be observed that this side of the chest is less moveable than the other, during inspiration. Meanwhile the natural and animal functions continue to be well performed; and the patient can lie on either side indifferently.
All the above symptoms are more severe in proportion as the scirrhus is more extensive.
Of Vomicae in general.
XL. When an humour, sound or morbid, is deposited from the circulating mass in a solid form, and (together with the extreme vessels) is afterwards, by means of the vital powers softened and converted into matter, and contained in a sort of capsule, I term this collection of matter a Vomica.
Scholium. This notion applies to every vomica, whether produced by a vice of the solids or fluids, as is clear from the history of obstruction and inflammation.
XLI. I have observed two kinds of Vomica - the Ichorous and Purulent. The former occupies the lungs only; the latter, both the lungs and other thoracic viscera. They are both either close, or communicating with the Trachaea.
Scholium. By the term Ichorous Vomica, I mean a sac containing a thin fluid frequently [page 23] of a reddish yellow colour, frequently of a reddish brown, often of a colour between these, different from pus, and arising from the destruction of a scirrhus lung. By Purulent Vomica, I understand an encysted abscess of the chest, resulting from the conversion of an inflamed spot into a white, thick, glutinous, fatty matter. When these communicate with the Bronchia and discharge any of their contents by expectoration, they are called open; otherwise, close or shut.
XLII. 1. Ichorous Vomica. If a scirrhus of the lung, recognized by its proper signs (XXXIX.) is converted into matter, it presents the following symptoms: The patient begins to languish and waste away insensibIy (although the usual quantity of food is taken), with a quick, contracted, and unequal pulse. The respiration, even during a state of quietude is unnaturally anxious and frequent; and is remarkabiy interrupted by sighing. The forehead, during the more severe attacks, is sometimes covered with a cold sweat. The eyes are dim; the veins of the cheeks and lips are livid, and the tongue, especially on the affected side, is of a leaden hue. At the same time there is neither pain nor thirst. The diseased side, however, is observed to be less mobile than natural, and the degree of immobility is proportioned to the bulk of the vomica into which the scirrhus has been resolved. The cough is infrequent, interrupted, and dry; or the expectoration, if any, is dirty or blackish (coenosum aut fuscum). [page 24]
When things have got to this height, the appetite begins to fail, and at length is entirely lost; and whatever is eaten oniy produces an increase of anxiety during the process of digestion: this process, however, takes place without any hectic flushing, which always accompanies the purulent vomica.
In some cases, when there is a dissolution of the central parts of the scirrhus, the abdomen and hypochondres sink in; in a very few instances, the same parts are slightly swollen, and with an indistinct feeling of fluctuation. The urine rarely presents any deviation from the natural state; sometimes, however, it is red, and with a sediment (if any exists) of a cinnabar colour. The stools are of natural character, except under the influence of medicine. The extremities, even when of a livid colour, are never hotter than natural, until a few days before death; the affected side is, moreover, observed to swell, and the hand and foot in the first place. The patient now suffers from frequent sinkings and faintings; and from having hitherto been able to lie easily on either side, he is able to remain on the affected side only.
2. Close Purulent Vomica. The following are the symptoms of this affection: While the abdominal organs still continue to perform their functions well, there is often present a very troublesome, frequent, dry cough, so severe as to irritate the fauces, to render the voice hoarse, and often to excite vomiting. At this time are observed frequent irregular chills, foiiowed by heat, and strong flushing of the cheeks and lips, particularly of the affected side. A degree of lassitude is experienced, [page 25] more remarkable after a full meal; and at the same time, there is perceived a degree of quickness and straitness of the respiration, sufficient to excite suspicion of some morbid affection of the chest. The pulse is also found to be contracted, frequent somewhat hard and unequal during the period of digestion; and even at other times it is never in a perfectly natural state, - more especially, under the influence of bodily motion, laughing, or speaking.
If at this time the Vomica has reached a size to be detected by percussion, the following additional signs exist: The patient is not nourished by the food taken, partly because it is, in a greater or less degree, rejected by vomiting, and partly on account of the imperfect assimilation of what is retained. As the disease increases, the whole process of respiration is at length carried on by one lung; an incessant state of anxiety prevails, and the patient remains fixed on the diseased side, through dread of impending suffocation if he turn on the other. The face, hands, feet, and the affected side are oedematous; while the opposite part of the body, from deficient assimiiation, hectic heat, and nocturnal perspirations, is extenuated. The urine now becomes scanty, red, turbid, with a copious branny sediment, and soon putrefies; and the scene is finally closed with short and asthmatic breathlessness, lividity of the cheeks, lips, and nails, &c.
3. Purulent Vomica communicating with the Trachea. When a Vomica of considerable size, discoverable by percussion, bursts into the Trachea, or rather Bronchia, by a large opening, it produces instant suffocation; if, by a small aperture, [page 26] it is recognized by the following marks: By means of a violent cough, pus is expectorated, which is, in different cases, white, yellow, saffron, green, brown, bloody; which sinks in water, and, when thrown on hot coals, emits a stinking nidorous smell. If at this time, while the patient is coughing and spitting, the palm of the hand be placed over the site of the vomica, i. e. over the place where its existence had been detected by percussion, - the noise of fluid within the chest will be sufficiently manifest. This kind of expectoration will cease for some days, with relief to the patient; but it speedily returns, and is a preceded, for four and twenty hours, by an increase of the febrile state. During this state of things, and before the return of the expectoration, if percussion is applied over the site of the vomica a sound exactly like that from a fleshy limb is obtained; but if this is delayed until the evacuation of the accumulated pus, then there is perceived a distinct, though obtuse sound. The slow fever which invariably accompanies this condition, is encreased after eating, and is still higher during the night; and at these times, the forehead, neck, and chest, are covered with perspiration. With the increase of these symptoms, and the continuation of the purulent expectoration, the breath becomes tainted, insomuch as to be extremely disagreeable both to the patient and the attendants. The thirst continues great, but the appetite is lost, even for the greatest deiicacies, which, however sparingly taken, produce, in place of refreshment, langour and anxiety. (The case is very different with them whose sputa are inodorous, the appetite in many being [page 27] even great.) The urine is uniformly frothy, grows speedily putrid, and deposits a viscid, tenacious, white sediment. The patient now daily grows more emaciated: the bones almost pierce the skin, - the hair falls off, - the nails become curved, - the legs swell; at length a colliquative diarrhaea supervening first lessens, and then suppresses the expectoration, and the sufferer finally dies suddenly, on the third day after that on which he began to remain obstinately fixed on his back, with his legs drawn under him.
XLIII. Empyema. When a vomica (XXXVII.), ascertained by percussion, discharges its contents into the cavity of the pleura, and upon the diaphragm, Empyema is produced.
Scholium. I premise this definition to prevent the affection now in question from being confounded with a vomica that has discharged its contents into the trachaea.
XLIV. If a large vomica, whose superficial and central extent is supposed to have been recognized by the marks pointed out (Obs. Third. XV., XVI., XVII.), shall have burst as above mentioned (XLIII.), it may be recognized by the following signs:
The patient who had usually lain on the affected side, starts up with a sudden pain (as if neariy suffocated), and begs to be held in the erect posture.
If percussion is now applied it will be found that the natural sound, which had been nearly lost in the site of the vomica, has in some deree been restored in that place; while it is more or less [page 28] destroyed (according to the quantity of pus effused) over the posterior and inferior parts of the chest.
There is now a very frequent cough, which is either dry, or with a scanty, frothy and noisy expectoration. The respiration becomes very laborious, with frequent faintings, and a cold sweat bedews the forehead and throat; the cheeks and lips are of an ominous red, while the nails grow livid, the pupils dilate, and death (which follows in a few hours the rupture of a large vomica) is finally preceded by dimness of sight, &c.
A small vomica, ruptured in the same manner, produces the same symptoms, and is equally fatal. This issue, however, is of later occurrence, and is preceded by the marks of pleuro-peripneumony.
Of Dropsy of the Chest.
XLV. When water is collected in the cavity of the chest, between the pleura (costalis) and the lungs, the disease is called dropsy of the chest; and this is said to be of two kinds, namely, according as the fluid occupies one, or both sides.
Scholium. This is ascertained by percussion in the living subject; and is demonstrated by anatomical examination after death. The general symptoms of this disease are chiefly the following:
1. Difficult and laborious respiration;
2. A cough at intervals, which is dry, or only attended by sputa of a thin watery nature, or occas ionaI somewhat viscid; [page 29]
3. A pulse contracted, somewhat hard, frequent unequal, and often intermitting;
4. A sense of breathlessness and suffocation on the slightest motion;
5. An incipient dislike of warm food;
6. Perpetual anxiety about the scrobiculus cordis;
7. Great pressure on the chest, and distension of the stomach during the period of digestion;
8. A murmuring noise about the hypochondres, and frequent eructation of flatus, with momentary relief;
9. Scarcely any thirst;
10. Urine very scanty, and rarely made, red, with a lateritious sediment;
11. Swelling of the abdomen, more especially in the Epigastrium, and particularly in that point on which the incumbent water gravitates;
12. A sublivid swelling of the extremities, especially of the feet, which are moreover cold to the touch;
13. Oedematous tumescence of the inferior palpebrae
14. A pallid, or, according to the nature of the affection, a sublivid discoloration of the cheeks, lips, and tongue;
15. Inability to lie down; anxious distressing nights, with heaviness, yet frequently sleepless.
All these symptoms vary in a wonderful manner according to the disease.
First Kind. - Dropsy of one side of the Chest. Beside the general signs of this disease above enumerated, the affected side, if completeiy filled with water, is enfeebled (effoeminatum), and [page 30] appears less moveable during inspiration. In this case, also, the affected side yields no where the natural sound on percussion. If the chest is only half-filled, a louder sound will be obtained over the parts to which the fluid does not extend; and, in this case, the resonance will be found to vary acording to the position of the patient, and the consequent level which the liquid attains. The Hypochondre of the affected side is also unusually tumid, and more resisting to pressure than the rest of the abdomen. The palpebra, hand, and foot of the affected side are slightly oedematous. It is a remarkable fact, that the reclining posture (decubitus declivis) is easily borne when the chest is entirely full; while the contrary is the case, when there remains space for the fluctuation of the water.
Second Kind. - Dropsy of both sides of the Chest. If fluid is contained in both sides of the chest, the following specific signs, in addition to the general symptoms, exist: The natural sound is destroyed over the space occupied by the water in either side. The patients uniformly become asthmatic; and resemble, in many respects, those labouring under Ascites, ony that the former have their inferior palpebrae and hands swollen. They cannot lie in an horizontal posture, and are equaliy threatened with suffocation on whichever side they turn; on which account, they are forced to remain sitting, day and night, to prevent the pressure of the fluid from being felt on the upper parts of the chest (which would be the case on lying down), in the same degree on which it now gravitates on the abdomen. The effect of this state of things might lead to the suspicion of Ascites, [page 31] only that we find, on examining the patient in the erect position, that the hypochondriac regions are more swollen than the inferior parts, which is not the case in Ascites.
All these subjects die as if from peripneumony, that is to say, - the pulse fails, the whole body, except the chest and head, grows cold, the cheeks and extremities become livid, the respiration is at first laborious, then interrupted, and finally ceases altogether.
XLVI. Dropsy of the Pericardium. When the liquor pericardii is morbidiy encreased, so as to be capable of disturbing the natural action of the heart, the disease is called Dropsy of the Pericardium: of this there are two species, as the fiuid is purulent or serous.
Scholium. The fluid naturally present in the pericardium accumulates in still greater quantity in those who suffer a long protracted mortal agony, as we find on examination after their death. But it is not to this accumulation, originating in the relaxation of death, but to that produced by obstruction during life, that I apply the term dropsy. I have ventured to divide the affection into two species, because I have often witnessed both of them. In the first variety, the heart is rough, and as it were shagged, with a coating of the purulent matter; while in the latter, the organ is only of a paler colour than natural. Many may be of opinion that the purulent dropsy would be better classed under the head of Empyema; but I shall never quarrel about words, when there are appearances to instruct us. [page 32]
Signs of Hydropericardium. Almost all the symptoms which have already been enumerated as accompanying dropsy of the chest generally accompany this species also: in addition to these, however, I have observed the following specific signs of the dropsy of the pericardium:
The sound in the cardiac region, which I have already stated (III. 2. 3.) to be naturaily more obscure than in the other parts of the chest; is now as completely deadened as if the percussion were applied to a fleshy limb. A swelling is perceived in the praecordia, which can readily be distinguished, by its superior resistance, from the stomach distended by flatus.
The patients fall asleep, while sitting, the body being inclined forwards; but they soon are roused by the unconscious dropping of the head. On this account, they complain to all around them of the distressing propensity to sleep which they experience. At the same time they suffer from faintings (accompanied by a pulse frequently unequal in respect both of its rythm and volume), and, indeed continue to undergo to the end of their wretched life, and in every position of body, the greatest distress. A few days before death, in many cases, the neck is swollen, and the eyes become extremely red, as if from crying. This state of things is sometimes terminated suddenly by a stroke of apoplexy, or more slowly by leipothymia.
The same signs are furnished by percussion in the purulent, as in the proper dropsy of the pericardium; but in the former, the other symptoms are precisely the same as those which exist in the close [page 33] purulent vomica. In the purulent dropsy, the fluid commonly resembles turbid whey, - the thicker portions of it (quod purulentum est) being found adhering to the heart like fringes.
Of the symptoms of a copious extravasation of Blood.
XLVII. The causes of a large extravasation of blood into the cavity of the chest have been noticed in the Scholium of XXXI. The foliowing are the symptoms of this affection.
Scholium. There is incessant and indiscribable anxiety and oppression at the praecordia and on the chest, while there is constant jactitation of the body, and complete intolerance of the horizontal posture. Percussion elicits none of the natural sound over the space occupied by the extravasated blood. In all cases the pulse is extremely contracted, frequent, and irregular in every way. The respiration is extremely laborious, with a frequent cough, and broken by profound sighing. All the veins become flaccid, and the eyes are at first red but ultimately pale. Cold sweats &c. follow, and the patient dies stertorous.
These are the symptoms when the blood flows into the cavity of the pleura without any accompanying lesion of the lungs: when these are wounded, there is also bloody expectoration, and a passage of air to and from the wound in the parietes of the chest. [page 34]
Aneurism of the Heart.
XLVIII. When the heart becomes so much distended by blood, accumulated in its auricles and ventricles, as to be unequal to propel forward its contents, it frequently becomes thereby enormously dilated. This dilatation has been called Aneurism of the Heart.
Scholium. We frequently observe this state of the heart on dissection, (1.) in sudden and extensive peripneumonies of both lobes at the same time, and (2.) in those fatal inflammatory diseases which are noticed towards the end of the Scholium on XXII.
The pathognomonic sign of this affection is the complete fleshy sound on percussion existing over a considerable space in the region of the heart. Whenever this sound is perceptible in the acute peripneumony it is a sign that the patient will not survive twenty-four hours: in fact, he is already at the last gasp, and is speedily carried off as in apoplexy, unconscious of his fate.
In the second class of inflammations, the sign is equally fatal, but is attended by different symptoms. In this case, the patients suffer dreadfull anxiety, and by the constant jactitation of their limbs, are perpetually uncovering themselves. Older persons, indeed bear more tranquilly their sufferings; but the younger are pertinaciously restless and violent, struggling and talking, attempting to get out of bed, demanding their clothes, and endeavouring to [page 35] walk or go about their usual occupations. Meanwhile the eyes become dull, the cheeks livid, and the nails and extremities are tinged with a leaden hue, and death is ushered in by cold sweats, and the gradual extinction of the pulse and respiration.
Cedant haec miseris in solatium, veris autem medicinae cultoribus in incrementum artis: Quod opto!