In the other form, a direct communication exists between the bronchial tube and the sac of the empyema. They are both efforts of nature to get rid of the purulent collection and effect a spontaneous cure, but as the means adopted are so widely different, an equally opposite train of symptoms, may naturally be expected to attend these processes, and such we find to be the case.

In the examples detailed by Dr. Greene, and in those which I have given, the expectoration was thrown up in small quantities at each paroxysm of coughing, and though it amounted to a considerable quantity during the twenty-four hours, yet what followed each paroxysm of coughing never occasioned any distress to the patient, or alarm to his attendants, and was excreted gradually and regularly, without producing any violent or distressing symptom to the patient; and the removal of the empyema, as shown by diminution in the extent of the dulness and return of respiratory murmur in the affected side, was equally gradual and progressive. But, in the second class of cases, where a direct communication has been established, we have, in addition to the rapid development of the physical signs denoting the accident (such as the sudden removal of the dulness, with metallic phenomena of the voice and cough, and a tympanitic sound over the portion of the chest previously dull), a violent and sudden paroxysm of coughing, usually accompanied with expectoration of a large quantity of pus, so great as in almost every instance to produce the most alarming symptoms of suffocation, and not unfrequently even death from this cause.* This is followed by relief for a time, but a second and third accumulation of the matter takes place, which is again got rid of in the same way; and on each occasion the patient's life is in imminent danger from asphyxia.

I have now seen three instances of empyema terminating in

* See Hodgkin's Lectures on the Morbid Anatomy of the Serous and Mucous Membranes.

this manner, and the particulars of a fourth have been communicated to me; and though a pretty frequent, it is by no means a very desirable mode of cure.

In my first case, the expectoration, though copious, purulent and foetid, was never thrown up in the manner indicative of a direct communication with the pleural cavity, nor was any such communication discovered at the post mortem examination, neither was there evidence of bronchial inflammation, and, as before stated, the tubercles being hard and crude, could not have supplied the pus so abundantly expectorated; the conviction, therefore, is forced on us, that, in this particular instance, we have a direct confirmation of the doctrines advanced by the ancient physicians, and more recently enforced by Drs. Hutton and Greene; and were evidence wanting, it is supplied by the occurrence of the uncontrollable diarrhoea, which, resisting every kind of treatment, received a decided check on the purulent expectoration being established; and it is also remarkable, that the inspection of the intestines afforded no explanation for the occurrence of this latter formidable symptom. Heretofore, the efforts of nature in this woman were unavailing, and, as an additional one, she endeavoured to procure the evacuation of the fluid by an external opening; but the shattered and broken down constitution of the patient was unable to bear up against processes so slow and wasting, and she fell a victim to the disease in spite of the great exertions made by nature for her recovery. The post mortem examination showed that the layers of lymph, lining the opposed surfaces of the pleura, were exceedingly thin; and this will account for a circumstance in which this case differed from the two which follow it, viz., that after the evacuation of the fluid of the empyema, the sound, from being dull, immediately became clear. Many treatises on auscultation assert that after the removal of the effusion, the sound becomes clear. This is not strictly true; for if the layers of lymph be unusually dense, the sound will still remain somewhat dull, and Dr. Stokes has shown that in empyema of long standing, the ribs become hypertro

phied-thus constituting another cause for dulness. In our case, the clearness of sound was explained by the small quantity of lymph found lining the sac of the abscess.

The mode by which the matter works its way externally has not been sufficiently investigated. In some instances an abscess forms in the integuments, which opens both inwardly into the pleura, and externally through the integuments. But in other cases, there is no such abscess, and the process commences on the inner surface of the costal pleura. Thus Dr. Hodgkin* thinks, "that in some cases, the process resembles one which more frequently occurs in the peritoneum ; viz., that when a considerable quantity of the inorganizable product of inflammation is collected, ulcerative absorption takes place in that part of the serous membrane with which it is in contact, and that, by a communication of the same process, the external opening is effected." In our case, the lymph was uniformly diffused, and in no part was it collected in any considerable quantity; and, as far as one instance goes, it confirms the observation of Laennec, who considers that it is by means of gangrene and ulceration of the pleura, that the fluid works its way outwards, and that destruction of the periosteum and caries of the ribs, are frequent accompaniments of the lesion.†

METHOD OF DIAGNOSIS IN EMPYEMA WITH COPIOUS PURULENT

EXPECTORATION.

It may be useful to investigate the grounds of diagnosis in cases like those detailed by Dr. Greene and myself, which presented some of the symptoms of pulmonary abscess and bronchitis; for it is evident, that without clear and distinct views on this subject, no useful conclusion can be arrived at, and our prognosis must be devoid of anything like certainty, or even probability.

Op. cit. vol. i. p. 113.

† See Forbes's Translation of Laennec on Diseases of the Chest, 4th Ed.

P.

406.

66

In the first case detailed by Dr. Greene, except the abundant purulent expectoration, no sign of pulmonary abscess or fistulous communication with a bronchial tube could be discovered." In his second, the symptoms likely to lead to an erroneous diagnosis, were the following:-" On applying the stethoscope under the spinous process of the scapula, and towards the root of the lung, a loud gurgling sound was heard; the resonance of the voice, also, was so loud and clear in this situation, as to amount to imperfect pectoriloquy, while percussion yielded a very dull sound. All these phenomena were the more striking, as contrasted with the voice and respiration on the opposite side. These signs, combined with the profuse, purulent expectoration, led me to suspect that the pleuritic effusion might be complicated with some structural disease of the lung-probably with a pneumonic abscess."* In his third case, we find no symptoms which could lead us to suppose the existence of a pulmonary abscess, except the copious purulent expectoration. The lung of the unaffected side yielded a clear sound in every situation, and the respiratory murmur was in every part puerile, and free from rale.

So that we have now six cases of empyema, in all of which copious purulentexpectoration formed a prominent symptom; in four of them there were no physical signs whatever to account for this phenomenon, not even those of bronchitis.† In one, we are told, a loud gurgling sound was heard towards the root of the lung; but it is not mentioned whether this sound was persistent, or, if remov

* Dublin Medical Journal, vol. xvii. p. 275.

+ I am not ignorant of the fact, that in some rare cases of phthisis, the constitutional symptoms may continue for a long time, before the slightest trace of the physical phenomena of the disease become manifest, owing, most probably, to the morbid processes being confined to the central parts of the lung. I have now seen many such cases, and have observed in some of them a peculiarly fætid odour from the breath after coughing, and from the expectoration. The diagnosis in these obscure cases rests upon the want of correspondence between the presence of all the symptoms of phthisis, and the total absence of the physical phenomena. We are not, however, in such cases, left long in doubt, for very soon the lesion becomes discoverable by auscultation and percussion.

able by a paroxysm of coughing; there were also "imperfect pectoriloquy," and " a very dull sound." "Gurgling," "imperfect pectoriloquy," "and a very dull sound," are then the only physical signs likely to mislead the physician; and in the present state of the science, and possessed as we are of the facts disclosed in Dr. Greene's paper, we do not anticipate much difficulty on these points. The gurgling was but a larger degree of the rale noticed in my second case, and would probably have been completely removed, or at least greatly modified, by coughing, followed by expectoration. The presence or absence of the “imperfect pectoriloquy," by itself, must be considered of no value whatever as a sign to be relied on, either for or against the existence of pulmonary abscess in any part of the lung, and, above all other situations, of least value at the root of the organ, for here there is naturally an increased resonance of the voice, which some term bronchophony, and others may, with as much reason, call imperfect pectoriloquy. The dulness of sound was caused either by the deposition of thick layers of lymph, the result of the previous pleuritic inflammation, or by a still existing effusion in the part-a condition by no means irreconcileable with the fact, that gurgling was heard over the seat of this dulness, for Andral distinctly states that an effusion of fluid between the lungs and the ribs does not prevent our hearing sounds generated in the bronchial tubes.*

The history of this case, the situation (the root of the lung) in which the phenomena occurred, and the paucity and valueless nature of the signs, could hardly mislead any one at the present time, particularly when we bear in mind that pneumonic abscess

* "When the bronchi are full of mucus, the interposition of a liquid between the lungs and the ribs does not prevent the different rales from being heard, to which the accumulation of this mucus may give rise. This remark is not devoid of importance, for the existence of these rales may incline one to think, that the lung is in immediate contact with the ribs, and consequently may occasion the disease to be mistaken.”—Clinique Medicale, by Spillan, p. 603.