PRODUCTS, ADVENTITIOUS. 



109 



matter. Such cavities generally communicate 

 with others, and always with bronchial tubes. 



Cavities vary in size from that of a nut to 

 very nearly that of the lung itself; the edges of 

 the lobes being rendered continuous by pleural 

 false membrane, and the pulmonary texture 

 destroyed from base to apex. They form first 

 at the apex, and more readily at its posterior 

 than at its anterior aspect, and very rarely 

 advance pari passu in both lungs. When of 

 recent origin they contain pus and softened 

 tubercle, with or without foetor, in the dif- 

 ferent conditions already described. When of 

 old date, on the contrary, they contain a dirty, 

 thin, greenish fluid, with grumous particles 

 suspended in it, and stained, or (as is most 

 common) not stained, with blood. In rare 

 instances fibrinous coagula, firm and adhe- 

 rent*, which may even be the seat of vascu- 

 larizationf, are found within them ; and still 

 more rarely portions of pulmonary substance, 

 either gangrenous \ or free from such change. 

 Vegetable productions of low type are often 

 to be found amid the contents or upon the 

 walls of cavities of a certain age. 



The course and event of cavities are points 

 of extreme interest. 



1 . Their most common course by far is to in- 

 crease in size, through communications formed 

 with softening tubercle on their confines. 



2. They become stationary, the tuberculizing 

 process having ceased in their neighbourhood. 

 The double membrane lining them acquires 

 more and more perfectly the characters and 

 properties of the structures forming the inner 

 wall of fistulae ; and they cease to exercise de- 

 leterious influence of any serious kind. The 

 cure of phthisis is sometimes, according to 

 Laennec, accomplished in this manner; but it 

 is obviously necessary for the cure of the dis- 

 ease, not only that the cavity should itself 

 become innocuous in the manner described, 

 but that tuberculization should cease in the 

 rest of the lung that the rest of the lung 

 should be healthy. Now we regret to be forced 

 to state that during a search of several years 

 carried on under peculiarly favourable circum- 

 stances, we have failed to discover a single ex- 

 ample of this fortunate coincidence ; nor do we 

 believe (while to deny its possibility would be 

 rash) that evidence has ever yet been furnished 

 of its actual occurrence.^ 



* Univ. Coll. Museum. 



f Louis. 



j Some time since a patient of ours expectorated 

 a fetid mass, about the size of a large pea, present- 

 ing under the microscope, and even to the naked 

 eye, the characters of pulmonary tissue. This is the 

 only instance of the kind that has ever occurred 

 to us. 



M. Louis relates a case (Op. cit. Transl. p. 19, 

 case 3) in which a solitary excavation lined with 

 pseudo-membrane of recent origin, existed at the 

 apex of one lung in the midst of healthy tissue ; 

 and considers it presumable that, if the patient had 

 survived a short while longer, the membrane in 

 question would have assumed the fistulous charac- 

 ters we have above described : under these circum- 

 stances a cure of phthisis would have been accom- 

 plished. But in the first place it was not accom- 

 plished ; in the second it appears extremely doubtful 



3. That tuberculous cavities are capable of 

 cicatrizing, and that they actually do cicatrize 

 with very considerable frequency, was taught 

 by Laennec, and has since his time been almost 

 universally accepted as matter of established 

 doctrine. We must nevertheless affirm that we 

 have ourselves in vain sought for a single spe- 

 cimen of cicatrized tuberculous cavity; nor can 

 we avoid deliberately questioning the fact of 

 such cicatrization ever occurring. 



The shape of fistulous cavities, the smooth- 

 ness and polish of their internal surface, the 

 fact that atmospheric pressure must act con- 

 stantly on that surface, and, in fine, their struc- 

 tural analogy to fistulas in other parts of the 

 body, form so many a priori arguments against 

 the possibility of cicatrization. Laennec saw 

 their force ; but certain observed facts led him 

 to disregard them, and admit the reality of 

 partial and complete adhesion of the apposed 

 walls of cavities. These facts are as follow. 



(a.) In the latero-posterior part of the upper 

 lobe of a particular lung appeared a deep de- 

 pression, containing a material solid arid resist- 

 ing. From the centre of this depression a 

 white opaque lamina, about half a line thick, 

 and of cartilaginous consistence, extended in- 

 wards, divided into two parts, and then re- 

 united, thus forming a small cavity, which was 

 filled with a yellowish-white, opaque, friable 

 substance, much drier than common tubercu- 

 lous matter. Here was (according to the as- 

 sumption) a partially closed pulmonary cavity ; 

 and, be it observed, Laennec never saw more 

 than one such case. 



(/8.) In the upper part, especially, of the 

 upper lobes, Laennec frequently saw bands or 

 nodules composed of condensed cellular or 

 " fibro-cartilaginous " tissue, with a depres- 

 sion on the superjacent pleural surface, of 

 variable depth, puckered, firm, and uneven, 

 and with adhesion of the pleura at the corre- 

 sponding point; the converging bronchial tubes 

 being somewhat dilated in the vicinity, and 

 obliterated in the exact site, of those bands 

 or nodules. Further, these bands or nodules 

 were always situated at the depth of half a 

 line, a line, or two lines at furthest, from the 

 surface of the lung; and were or were not 

 distinctly continuous with substances of simi- 

 lar nature on the surface of the pulmonary 

 pleura. Here were the assumed evidences of 

 complete closure of cavities, the puckering 

 and thickening on the pulmonary surface 

 showed that cicatrization had occurred un- 

 derneath, but did not (as Laennec was often 

 erroneously said to have maintained) in any 

 measure constitute the actual substance of 

 cicatrices. 



But it may be objected to this doctrine : 

 that the superficial puckering is often seen, 

 where subjacent cellular bands or nodules 

 cannot be discovered ; that it frequently 



(for reasons which M. Louis has anticipated, but not, 

 as we think, satisfactorily set aside) that the exca- 

 vation was of tuberculous rather than of purulent 

 origin ; and in the third the eventual assumption of 

 the fistulous characters, in this particular case, is 

 matter of hypothesis. 



