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vious essay; but since then I have met with an instance in which the pulsatile crepitation was detected at another portion of the thorax. A private patient, who called on me one morning from the north of England, complained of symptoms which indicated the presence of phthisis. He was a tall, thin, anæmic young man, who had been much confined in an office, at the desk. He had suffered slightly from hæmoptysis, had nightsweats, and was losing flesh and strength. The right lung, at the apex, rendered unmistakable evidence of tubercular deposition in an early stage. On the left side there were, here and there, bronchial cooings; and the posterior part of this lung had been the seat of sharp pleuritic pains. On placing the stethoscope to the left of the vertebral column, and very low downat the base, in fact, of the left lung at its posterior and inner margin-I caught a pulsatile crepitation, much finer than that which had been observed in the preceding cases, but unquestionably governed by the same influences. When a long expiration was made, the crepitation was lost; when a long inspiration was made, it reappeared. This might have indicated nothing more than crepitation from tubercle; but the sound happened only in conjunction with the action of the heart, being coincident with the systole, synchronous with the pulse, and as perfect in its occurrence as the pulse itself. It was obviously connected, therefore, with aortic pulsation.
Analysing the auscultatory symptom thus described, we are led to trace it to a point connecting it with the acts both of respiration and of circulation. It is produced only in the precincts of a pulsating structure, such as the heart or a large artery; and it is obviously brought out by the action of the pulsating organ. In so far, then, it is a circulatory sound. But, again, it is not capable of being elicited except in the chest, nor there unless the lungs be distended with air; the air in the lungs may be held in the statical condition, but it must be present. Hence the sound is strictly compounded of two acts; one, inspiratory or predisposing; another, pulsatory and exciting. · The cases in which the sound is met with are all of a kind in which there are signs of thoracic disease. In two of the cases cited, there were extensive cardiac lesions; in one there was mitral murmur, and evidence of enlargement of the whole heart: in the other, the physical indications pointed out the existence of mitral and aortic disease, also with great enlargement. In the remaining cases, the circulatory apparatus was apparently healthy. In all the cases there was marked pulmonic disease, which offered one analogous fact throughout, viz., unmistakable signs of pre-existent pleurisy; two of the patients had also been sufferers from long standing bronchial disorder and emphysema; the other two gave evidence of tubercle.
CAUSE AND CAUSATION OF PULSATILE PULMONIC
CREPITATION. The study of these facts of diagnosis, taken in connection with the character of the pulsatile crepitation itself, led me early to the cause of the sound. It occurred
to me in the case of Mrs. K., that a portion of the left lung, at the point where it partially envelopes the left side of the heart, had been drawn downwards by pleuritic adhesion, and bound to the thoracic wall immediatelyoverthe heart; that the piece of lung thus placed was subjected to the impulse of the heart during systole; and that, when the lung was inflated on inspiration, the sudden compression, produced by the impulse, elicited the crepitation by forcible expulsion of air from the air-vesicles. I explained this view to Dr. Snow, who concurred with me entirely. In the succeeding two cases the same explanation presented itself; in the last case a like exposition was suggested, except that in this example the aorta, instead of the heart, was the pulsating body. Let me now show how far this diagnosis was proved correct.
Post mortem Facts. The first two cases above recorded ended fatally, and both, curiously enough, exactly six weeks after the occurrence of the pulsatile crepitation. I look upon this circumstance, of course, only as coincidental. The first patient died slowly, from exhaustion. The second died while he was sitting up in bed, laughing at some passing event.
The post mortem examination, in the first case, revealed no disease of the segments of the mitral valve itself; but in the left ventricle, immediately below the valve, and to the left side, there was firmly attached to the endocardial membrane a rounded concretion, the base of which was of the size of a shilling, and the projection of which into the ventricle extended for at least half an inch. The concretion was partly organised. The heart was hypertrophied. The pericardium was adherent to the lung, and over the base of the left ventricle, to the left side, in the exact position over which the pulsatile crepitation had been heard during life, there extended a corner or tongue of lung. This structure, bound down to the pericardium by the under surface, was attached to the thoracic wall above by a band of adhesion an inch broad, which was inserted, almost like a fine tendon, into the thoracic wall close to the sternum. This band pulled the lung quite over the heart in an oblique direction. On its under surface the piece of lung was compressed into a concavity, into which the rounded surface of the heart fitted ; the appearance of the lung indicated that the structure had been subjected to compression at this overlapping point. The parts as thus presented were shown at the Medical Society of London in 1854.
In the second case, extensive disease was found on the left side of the heart. The segments of the mitral valve were thickened and indurated; on the aortic valves were atheromatous deposits; and there was an extension of atheroma into the aorta. The heart was unusually large from dilatation, with parietal hypertrophy.
At the base of the heart externally there was the same condition as was observed in the preceding example, except that there was no adhesion of the lung to the pericardium ; but a piece of the left lung, at its lower anterior margin, two inches in length and
tongue-shaped, was dragged obliquely from above downwards over the heart by a membranous band. The band was firmly attached to the sternum by its extreme end. The portion of lung passing over the heart was compressed on the under surface into a concavity, and its structure was condensed. The centre of the compressed spot corresponded above with the centre of the ring which I had marked on the thorax externally by the iodine line.
To make the fact of causation more evident still, I performed, in this inspection, the following experiment. I placed a piece of tubing in the trachea, the lungs and heart being still in situ, and made my assistant inflate the lungs with air, whilst I, seizing the extreme point of the tongue of lung, extended it in the line in which it had been bound; then, when the whole lung was full of air, I forcibly compressed the tongue of lung between the fingers and thumb of my free hand, and, holding the stethoscope between the back of the compressing hand and my ear, I elicited, with each compression of the hand, the same sound precisely as I had heard during the life of the patient.
OBSERVATIONS BY DR. WOILLEZ. At the time when I first described the case of Mrs. K., in 1854, the sound which is here designated as “pulsatile pulmonic crepitation" had not, I believe, been noticed by any other observer; and, indeed, the same remark applies to the paper published in the Medical Times and Gazette in February, 1860. But I