with numerous granules and crystals of cholesterin. At other times the whole has been converted into a solid calcareous mass, frequently round, at others having numerous prolongations and irregularities, which accurately fit the surface and bronchi with which they are in contact. These cretaceous and calcareous concretions may remain an indefinite time in the parenchymatous substance of the lungs, or they may be evacuated through the bronchi with the sputa. The cyst which incloses them then forms a dense linear cicatrix.

Such appear to be the usual modes in which tubercular ulcers heal. They occur in exactly the same manner as abscesses in other parenchymatous tissues, the result of simple exudation; and that the process in both is identical, is proved by the frequency with which in the latter calcareous deposits also take place.

If, then, the further deposition of tubercle could be arrested, there seems no reason why cavities in the lung should not heal with the same frequency as ulcerations or abscesses in other internal organs. Indeed, the careful dissections of morbid anatomists have recently shown that this arrestment, instead of being a rare or occasional occurrence, really happens with extreme frequency.

In 1845, I made a series of observations with reference to the cretaceous masses and puckerings so frequently observed at the apices of the lungs in persons advanced in life. The conclusion arrived at was, that the spontaneous arrestment of tubercle in its early stage occurred in the proportion of from one-fourth to onethird of all the individuals who die after the age of forty. The observations of Rogée' and Boudet,' made at the Salpetrière and Bicêtre Hospitals, in Paris, amongst individuals generally above the age of seventy, showed the proportion in such persons to be respectively one-half and four-fifths.

The wood-cut on the next page represents a characteristic specimen of these cretaceous and calcareous concretions in the apex of a lung, accompanied with puckerings and increased deposition of carbonaceous black pigment. It will be observed also that the pulmonary tissue, besides being indurated and contracted, is also somewhat emphysematous.

That such appearances are really evidences of arrested tubercles, is established by the following facts:—

1. A form of indurated and circumscribed tubercle is frequently

1 Archives Générales de Médecine, vol. v. 1839.

2 Comptes Rendus, tome 6me. 1843.

met with, gritty to the feel, which, on being dried, closely resembles cretaceous concretions.

2. These concretions are found exactly in the same situations as tubercle. Thus they are more common in the apex, and in both lungs. They frequently occur in the bronchial, mesenteric, and other lymphatic glands, and in the psoas muscle, or other textures which have been the seat of tubercular depositions or scrofulous abscesses.

3. When a lung is the seat of tubercular infiltration throughout,

Section of the summit of the right lung in Elliot's case, p. 41, exhibiting the cretaceous masses, more or less loaded with and surrounded by carbonaceous deposit. Many air-vesicles are enlarged, constituting incipient emphysema. The preparation now in my possession exhibits a characteristic specimen of the mode in which a considerable amount of tubercular exudation is arrested by calcareous degeneration. Natural size.

whilst recent tubercle occupies the inferior portion, and older tubercle, and perhaps caverns, the superior, the cretaceous and calcareous concretions will be found at the apex.

4. A comparison of the opposite lungs will frequently show, that whilst on one side there is firm encysted tubercle, partly transformed into cretaceous matter, on the other the transformation is perfect, and has occasionally even passed into a calcareous substance of stony hardness.

5. The seat of cicatrices admits of the same exceptions as the seat of tubercles. In a few cases, I have found the puckering and

cicatrix in the inferior lobe only; and have met with three where the inferior lobe was throughout densely infiltrated with tubercle, whilst the superior was only slightly affected.

It has indeed been argued that, occasionally, these cretaceous masses may be the result of a simple exudation, or of what Dr. Gairdner has called bronchial abscess in the lung. When they are found isolated in the middle or base of the organ, such certainly may be the case, and consequently the fifth argument may be affected. But this is rare, and can scarcely make any alteration in the vast proportion of those concretions and puckerings which are undoubtedly the result of abortive tubercles. With these facts before us, and with the knowledge that there is nothing in the nature of tubercle itself which is opposed to the arguments derived from anatomy, the frequent spontaneous arrest of this form of exudation may now be considered established.

Since these observations, however, have become known, it has been stated that after all, practically speaking, phthisis pulmonalis does not mean the existence of a few isolated tubercles scattered through the lung, and that what is really meant, is that advanced stage in which the lung is affected with ulceration, and in which the bodily powers are so lowered that perfect recovery seldom or never takes place. But here again, a careful examination of the records of medicine will show that many even of these advanced cases have recovered. Laennec, Andral, Cruveilhier, Kingston, Pressat, Rogée, Boudet, and others, have published cases where all the functional symptoms and physical signs of the disease, even in its most advanced stage, were present, and yet where the individual survived many years, ultimately died of some other disorder, and on dissection, cicatrices and concretions have been found in the lungs.

M. Louis, however, observes: "I have not, in a single instance, discovered, in the midst of healthy pulmonary tissue, cavities communicating with the bronchi, and lined, like old existing tuberculous excavations, with a false membrane of slightly grayish colour, and opaque semi-cartilaginous appearance." Now, considering the large number of observations made by so distinguished a pathologist and physician, the inference to be derived from this statement, as well as from the whole tenor of his remarks on the cicatrization of tubercular cavities, is that, without absolutely denying their rare occurrence, they are of little practical importance. It is a matter of

1 Sydenham Society's Translation, p. 24.

very great moment, therefore, to show, not only that tubercles may be arrested at an early period of their development, and when they are limited in extent, but that cavities of large size may be completely healed, and leave, even in the midst of healthy lung, unequivocal traces of their tubercular origin. On this point the following case must, I think, convince the most skeptical:—

CASE I.-Advanced Phthisis; Restoration to Health; Death many years afterwards from Delirium Tremens; on Dissection, a Cicatrix, three inches long, in the Apex of Right Lung, and Cretaceous Concretions, with Puckering at the summit of Left Lung. John Keith, æt. 50, a teacher of languages, was admitted into the Royal Infirmary, February 8, 1844, in a state of coma, and died an

hour afterwards. On examination, the membranes of the brain, at the base, were unusually congested, and covered with a considerable exudation of recently coagulated lymph, here and there mingled with bloody extravasation. The apex of the right lung presented a remarkable cicatrix, consisting of dense white fibrous tissue, varying in breadth from one-fourth to three-fourths of an inch, and measuring about three inches in length (Fig. 18). The pleural surface in its neighbourhood was considerably puckered. On making a section through the lung, parallel with the external cicatrix, the substance immediately below presented linear indurations, of a black colour,

The section of the same portion of lung seen from within, the apex having been left entire to show the deep puckerings which covered its surface. The line of the healed cavity is densely loaded with black carbonaceous deposit, in which are seen five cretaceous concretions, three of them encysted. This preparation, now in my possession, is, perhaps, a unique specimen, proving the healing, by cicatrization, of an enormous tubercular excavation in the lung. Natural size.