lectures"
ON THE
THEORY AND PRACTICE
PHYSIC.
BY JOHN BELL, M.D.,
Member of the American Med. Association, and of the Med. Soc. of the State of Pennsylvania ,
Fellow of the College of Pliysiciansof Philadelphia;
Member of the American Philosophical Society, and of the Georgofili Society of Florence, etc., etc.
AND
BY WILLIAM STOKES, M.D.,
"/
Lecturer at the Medical School, Park Street, Dublin; Physician
to the Meath Hospital, etc., etc.
FOURTH EDITION, REVISED AND ENLARGED.
IN TWO VOLUMES.
VOL. II.
PHILADELPHIA:
ED. BARRINGTON AND GEO. I). HASWELL.
1848.
[Entered, according to Act of Congress, in the year 1848, by Barrington and
Haswell, in the Clerk's office of the District Court for the Eastern District of Penn-
sylvania.]
WPj
CONTENTS OF VOL. II.
DISEASES OF THE RESPIRATORY APPARATUS.
LECTURE LXXXIV.
DR. BELL.
More satisfactory diagnosis of Thoracic Diseases in late years — Auscultation
and Percussion—Auscultation properly includes percussion—Its application to diag-
nosis—Laennec the father of auscultation—The physical laws from which it is de-
duced—Chief sounds elicited by the pulmonary apparatus: I. During respiration:
II. By the voice: III. By coughing : IV. Those of an adventitious kind.—The first
class, or the Respiratory, subdivided into two orders, the simple and the compound—
The simple includes the respiratory or vesicular sound or murmur, also called puerile
respiration, the bronchial and tubal or blowing, the cavernous and the amphoric—Origin
and diagnostic value of these sounds—The compound sounds, or rhonchi, are moist and
dry—of the moist are the mucous or moist bronchial, cavernous, sub-mucous and humid
with continuous bubbles—These explained—Cr.pitant or moist crepitant, sub-crepitant,
or rhonchus redux, cavernous—Pulmonary crumpling sounds—The dry rhonchi are
classed under the head of sibilant and sonorous—Explanation of these terms—II. Vo-
cal Auscultation gives natural and morbid bronchophony, also cegophony, pectoriloquy
and amphoric resonance—III. Sounds in Coughing—The bronchial, cavernous and
amorphic, and metallic tinkling—IV. Adventitious Sound—These are friction sounds,
viz: the grazing, friction proper and grating—Table of morbid phenomena of respira-
tion coexisting with inspiration and expiration—Sounds of the heart and vascular
murmurs modified by the 9tate of the Iung3—Theories of M. Beau and Dr. Skoda—M.
Beau's views of resonance explained—Objections—Dr. Skoda's views of consonance
applied to vocal sounds—His division of the sounds in respiration—Stethoscope, and
manner of conducting auscultation . ■ . • . .25
LECTURE LXXXV.
DR. BELL.
Physical Diagnosis of Pulmonary Diseases (Continued).—Percussion—Denned—
Avenbrugger its discoverer for diagnosis in thoracic diseases—Corvisart—Piorry—
Two varieties, immediate and mediate—Mode of using immediate percussion—Divi-
sions of mediate percussion—Plexirneter—Substitution for it of a finger or fingers
—Chief percussing agents, a hammer and the fingers—Directions for mediate percus-
sion—Percussion of the chest—Different regions in which it is practised—Postures of
the patient and physician in percussing the different thoracic surfaces—What found
on percussion—A verifying of different states of the lungs and pleural cavity—Diffe-
rent sounds in different regions of the chest—Two chief divisions of sound on percus-
sion of the chest, viz., increased sonorousness and diminished sonorousness or dulness—
Auscultatory percussion—Autophonia—Succussion—Inspection—Measurements—In-
struments for—Two sides of the chest seldom quite symmetrical—Comparison—Value
of comparison—Application of, to diseases of the chest—Sources of physical diagnosis
—Improved diagnosis not always immediately productive of improved therapeu-
tics .......... 39
LECTURE LXXXVI.
DR. BELL.
Diseases of the Respiratory Apparatus—Extensive operation of the causes of these
diseases and large number of persons exposed to them—Chief causes; atmospherical
vicissitudes and neglect of hygiene—Community of causes affecting the several parts
iv
CONTENTS.
of the air-passages, and community of organic function and morbid action of the mu-
cous membrane lining these passages—Inferences from the study of the diseases 01
one part applicable to those of the other parts—Division of the diseases of respiration
into three heads : those of the air-passages; of the parenchyma of the lungs; ana
of the pleura or serous envelope.—Coryza—Its synonyms—Divisions—simple and
ulcerative—Varieties of the simple; acute and chronic—Acute coryza—■Anatomical
characters—Symptoms—Local for the most pari, sometimes general superadded—-Ex-
tension of inflammation to adjoining parts of the mucous system—Coryza in infants
—its dangers —Consecutive coryza —Progress —Diagnosis — Prognosis—Causes—
Treatment— Modifications in acute coryza.—Oz^na, the ulcerative species of coryza—
Fetor not a distinctive feature—Anatomical characters—Symptoms—Progress—Diag-
nosis—Distinction between ozeena and polypus—Inspection and exploration—Etiology
—Cases—Treatment—Local and general . . • • • .47
LECTURE LXXXVII.
DR. BELL.
Laryngitis, or Cynanche Laryngea—Its varieties—Erythematic Laryngitis—General
mildness of the disease and simplicity of its treatment—Catarrhal Laryngitis—Chiefly
dangerous in infants—Its treatment—Acute Edematous or Sub-mucous Laryngitis—A
most formidable disease—Its symptoms—Respiration and deglutition both affected ;
and afterwards the cerebral functions—Duration—Edema of the glottis not a separata
disease—Two varieties of acute laryngitis established by Cruveilhier—Is not of fre-
quent occurrence—Treatment actively and speedily antiphlogistic—Venesection—
General Washington's case—Leeches to the throat, or cups to the nucha—Blisters—
Tartar emetic with small doses of opium—Calomel and opium—Early recourse to
laryngotomy—Mortality from acute laryngitis . . . . .53
LECTURE LXXXVIII.
DR. BELL.
Laryngitis Membranacea—Croup—Anatomical peculiarity characteristic of the dis-
ease; lymphatic exudation in a membranous form in laryngeal inflammation—Phlo-
gosis extends to trachea and bronchiae; sometimes to the lungs—The chief seat of
croup is in the larynx—Proof from dissections and the leading symptoms—Character
of the breathing and the voice in croup—Dyspnoea evincing affection of the lungs at
the same time—Causes—referable to locality, states of atmosphere, and age of the pa-
tient—Seasons in which it prevails—Mortality from croup in New York, Philadel-
phia, and Boston—Epidemic croup—Age at which croup is most common—Propor-
tion of the sexes—Symptoms—Precursory or common, and imminent and special—
First and second stages — Duration—Mortality — Varieties of croup — Spasmodic
croup—Dr. Ley's theory—Diagnosis—Difference between primary and secondary
or consecutive croup—Membranous exudation from air-passages forms in some other
diseases—Treatment—Intentions of cure—First remedy, an emetic—Tartar emetic to
be preferred—Venesection—The warm bath—Leeching or cupping—Calomel with
tartar emetic—In approaching collapse, perseverance in the use of calomel and stimu-
lating and anti-spasmodic expectorants; blisters, epithems, etc. . . 62
LECTURE LXXXIX.
DR. BELL.
Therapeutical Action of Tartar Emetic and of Calomel in Croup—Practitioners
who have employed calomel—Venesection—its advocates—Leeching—Expectorants;
those of the antiphlogistic kind to be first used—Tartar emetic and opium ; calomel
and opium—Squills—The alkalies—Polygala senega; its alleged powers and true
value—Diaphoresis; is sometimes critical; when useful, and how procured—Tartar
emetic, as a diaphoretic, to be given in the smallest doses—Warm pediluvia and
counter-irritants to the lower extremities—Vapour-bath—Warm bath not to be con-
founded with the hot bath—The arm-bath—Antispasmodics ; the bestanti-spasmodics,
venesection, tartar emetic, calomel, and the warm bath ; opium, and afterwards assa-
fcetida, camphor, &c.—Topical remedies; blisters—when and where to be applied__
Stimulating liniments—Cauterization of the fauces and pharynx—Tracheotomy.__La-
ryngismus Stridulus; not identical with spasmodic croup as often met with__De-
scription of L. stridulus—With affection of the glottis are associated spasms in other
parts—Causes of the disease; the children most liable to it—Treatment; commonly
mild—mixed, hygienic, and medical—Prevention . . . .80
CONTENTS.
V
LECTURE XC. .
DR. BELL.
Chronic Laryngitis—Its synonyms—Idiopathic and symptomatic—Morbid Anatomy—
Applicableness of the title, laryngeal phthisis.—Large proportion of ulcerations in
the epiglottis, larynx, and trachea, in phthisical subjects—Symptoms: sensations,
voice, aphonia, cough, breathing—Different species of chronic laryngitis,—a know-
ledge of, necessary for prognosis and treatment—Examination of the fauces and
pharynx—To determine the state of the lungs : auscultation, percussion, and expecto-
rated matter—Duration of the disease—Causes: age, sex, prior disease, vocal strain,—
Peculiar exposure of clergymen, — atmospherical vicissitudes, habits — Complica-
tions . . . • . . . . . .96
LECTURE XCI.
DR. BELL.
Treatment of Chronic Laryngitis—Rest of the vocal apparatus—antiphlogistics—
counter-irritants,—narcotics, mercurials, iodine, sarsaparilla, balsam of copaiva, blue
mass and syrup ofsarsaparilla, sulphurous waters—Topical remedies; inhalation of
simple and stimulating vapours; caustic to the parts—The author's own experience—
Attention to anginose complication—Syphilitic chronic laryngitis ; mercurials, sarsa-
parilla; iodine—Tracheotomy, when proper—Change of climate—attention to the
digestive organs—Prophylaxis—Clergymen,—rules for their guidance—Uniform tem-
perature of air—Jeffray's Respirator ...... 104
LECTURE XCII.
DR. BELL.
Bronchitis—Its complications with other diseases—Catarrh, a prelude to more serious
disease—Importance of early attention to it—Outlines of the treatment of catarrh—
The dry method of Dr. Williams—Bronchitis.—its divisions—Asthenic variety—The
kind showing itself in young children, ox capillary bronchitis—Duration of acute bron-
chitis—Symptoms,—appearance of the sputa—Physical signs — Percussion, indi-
rectly useful—Touch, giving a sen3e of vibration—Auscultation—Modifications of
sound, produced by inflamed and obstructed bronchiae—Morbid Anatomy—Causes 114
LECTURE XCIII.
DR. BELL.
Treatment of Acute Bronchitis—Venesection not to be pushed far—Purgatives—
Emetics, of doubtful value in acute bronchitis—Tartar emetic, as a counter-stimu-
lant—Rules for its use—Immediate effects various—Case—The warm bath—pedilu-
vium—Blisters and other counter-irritants to the chest—Calomel in bronchilis com-
plicated with abdominal disease; to which are added opium and ipecacuanha—Second
stage of bronchitis, with symptoms of debility—Stimulating expectorants useful ; car-
bonate of ammonia, wine whey, senega, acetate of ammonia—Calomel and a few cups,
with stimulants, for congestion of a part of the lung—Diaphoresis without diaphore-
tics—Diuretics as antiphlogistics sometimes useful.—Secondary or Symptomatic
Bronchitis—Complication of bronchitis with various diseases, especially eruptive
fevers—Treatment by local depletion, counter-irritants, and moderate stimulation—Dr.
Copland's plan of external cutaneous revulsion—Emetics—Bronchitis succeeding
laryngitis—Active depletion in—Outlines of treatment—Complications of acute bron-
cliitis—Bronchitis with remittent fever, in the typhoid stage—Cooling remedies
useful—Depletion and stimulation sometimes necessary at one time—Inhalation of
watery vapour—Change of posture—Quinia and laudanum, for excessive bronchial
secretion—Dr. Graves's practice—Sugar of lead .... 123
LECTURE XCIV.
DR. BELL.
Chronic Bronchitis—Description of—Expectorated matter—pus with hectic fever—
Difficulty of diagnosis of chronic bronchitis with purulent expectoration—Morbid Ana-
tomy—Ulcerations of bronchia? are rare—Causes,—primary irritation of the lungs,—
and secondary in other diseases—Bronchitis after gastric irritation—Stomachic cough
—Its diagnosis—Bronchitis with intestinal irritation,—with other morbid states,—
gout, syphilis, &c.—Treatment, modified by cause—Venesection not often required—
Local bloodletting preferable—Purgatives—Antimonials—Calomel or blue mass, with
VI
CONTENTS.
ipecacuanha and hyosciamus—Colchicum and digitalis—Iodide of potassium—Ionics
with the balsams—Compound syrup of sarsaparilla with iodine or iodide of iron
Counter-irritants to the chest—Inhalation of various vapours—Modification of treat-
ment in complicnted chronic bronchitis—Visits to mineral springs—Change of air and
climate—Prevention of chronic bronchitis . "2
LECTURE XCV.
DR. BELL.
Effects of Bronchitis—Nan-owing of the Bronchia—Causes—Symptoms—Obliteration
of the Bronchice—Dilatation of the Bronchia—Organic changes in the tubes and air-
cells—Thickening, the first change—Duration and Progress—Symptoms—Difficulty of
inspiration—Obliteration of the hronchiae with shrunken pulmonary tissue—Dilatation
of the bronchia? may occur very early in life—Prior diseases—Symptoms analogous
often to those of phthisis pnlmonalis—Diagnosis between these two diseases—Its
great difficulty—Causes—Treatment,—nearly the same as for chronic bronchitis—
Ulcers of the Bronchice.—Dilatation of the Air-cells—Pulmonary or Vesicular
Emphysema—Dilatation and rupture of the air-cells—Symptoms equivocal—Disease
often begins in early life,—Constitutes a variety of asthma.—Influenza—Epidemic
Catarrh—Epidemic Bronchitis—Closely resembles common bronchitis—Exhibits
the same features, complications, and alterations—Seasons for its appearance—Is met
with at all seasons—Its reputed terrestrial origin—Supposed to depend on a particular
poison—Objections to this view—Treatment—Regulated by the same principles and
consisting of the same remedies as'common bronchitis of the season . . 145
LECTURE XCVI.
DR. BELL.
Bronchial Congestion—Dry Catarrh—This with pulmonary emphysema constitutes
mainly asthma—Treatment—Mild aperients, alteratives—The alkalies—Regulation
of diet.—Asthma—Its proximate cause—Remote and exciting ones in general—Varie-
ties compounded of the nervous and congestive—Symptoms—Designation by the term
spasmodic unnecessary—True asthma always implies spasm—Organic seat and ana-
tomical lesions seldom ascertained—Causes enumerated—Treatment—To vary with
the complications of other diseases with asthma—Bloodletting sometimes necessary__
Emetics—Mild laxatives with narcotics—Remedies during the paroxysm—Stramo-
nium extract the best—Counter-irritants—To prevent a return—Tonics, change of
air, and bathing, and use of sulphurous waters—Grinder's Asthma . . 158
LECTURE XCVII.
DR. BELL.
Pertussis : Hooping-cough—Its double connexion—with the respiratory and with the
nervous system—Analogous to asthma—Symptoms—Duration—-Two periods__the pre-
cursory or catarrhal and the convulsive or hooping—Value of auscultation during the
interval—Causes—Contagion the commonly recognised exciting cause__Predisposi-
tion by early life—in girls more than boys—Complications—Bronchitis the most fre-
quent—Morbid anatomy,—not clearly defined—Nervous origin probable—Diagnosis-
Treatment—To be useful should be early and decided—Antiphlogistics followed by
narcotics and anti-spasmodics—Counter-irritants to spine—Change of air__Vaccina-
tion—Attention during the paroxysm.—Summer Catarrh—Summer Bronchitis-
Is not different from bronchitis of other seasons, except in its more strict periodicity
—Outlines of treatment—Probable prophylaxis . . . ig^
LECTURE XCVIII.
DR. BELL.
Hemoptysis—May be called bloody secretion—Is idiopathic or secondary; the last
variety most common—Active and passive—Structural changes—Causes,__'ao-e inhe-
rited predisposition, certain employments, atmospheric exposures, plethora comnres"
sion of the chest—Tubercular diathesis and disease the most frequent cause__Next
to this diseases of the heart—Hemoptysis often vicarious—Apoplectic congestion of
the lungs, an effect from a common cause—Explanation of its origin—Sifrnvtoms—
Quantity of blood discharged, variable—The physical signs few—Progress—Dias-nos '
noteasy—Prognosis—Treatment—Indications, to arrest the discharge and to prevent its
return—Venesection to be freely used at first—Attention to posture__First remedi
CONTENTS.
VU
simple—Cold sponging of the neck and chest—Risk of reaction, unless suitable deple-
tion is practised—Leeches to remote parts,—vulva or anus—Active purging—Pecu-
liarities sometimes following the use of leeches—Sugar of lead—Tartar emetic—Blue
mass with laxatives—Astringents—Narcotics and chalybeates . . . 176
LECTURE XCIX.
DR. BELL. 4
Pneumonia—Transition slight from vesical bronchitis to pneumonia—Definition—
Varieties—Symptoms—Chief diagnostic marks of pneumonia—Stages of Pneumonia—
Measured by auscultation—Minute crepitation in the first stage—Condition of the
lungs in the first stage, or that of engorgement—Microscopical characters—Second
stage, or that of hepatization—State of the lungs in—Microscopical characters—
Changes of position of individual lobes—Third stage, or that of suppuration—Products
of deposit in the pulmonary cells—Change of respiratory sounds in the second stage
of pneumonia—Morbid anatomy—Appearances of the lungs in the three stages of
pneumonia—Inflamed bronchia? with pneumonia—Appearances in catarrhal pneumo-
nia,—in hypostatic or senile pneumonia,—in circumscribed pneumonia—Gangrene
of the lungs—Local symptoms resumed—Percussion—Cough—Appearance of the
sputa—Their microscopical characters—Different states of the expectoration—Colour
of the sputa—Dyspnoea—Pain—Decubitus—General symptoms—Febrile phenomena
—frequent pulse and respiration, and disordered digestion—State of the skin—Pun-
gent heat of the surface—Urine—Disorder of the liver,—jaundice—Delirium, when
occurring—The blood in pneumonia,—exhibits the characters of hyperinosis 188
LECTURE C.
DR. BELL.
Pneumonia (Continued)—Symptoms of Infantile Pneumonia—Difficulty of diagnosis in this
disease—It always follows capillary bronchitis—Is catarrhal pneumonia—Peculiari-
ties of respiration in the young patient—Physical signs—Bronchial respiration the
most important—> Expectoration — Percussion — Anatomical characters—Symptoms
and diseases precursory of pneumonia—Commonly the disease attacks suddenly—Is
preceded sometimes by intermittent fever and cholera, measles, rheumatism and gout
—follows surgical operations—Progress of sthenic pneumonia—Sudden sinking—■
Case—Prognosis and Termination—Critical evacuations and critical days—Age modi-
fies results—The old and young most apt to sink under pneumonia—Part of the lung
most liable to inflammation—Which side most affected—Complication with other dis-
eases increases danger—Causes—External and internal—Climates and countries in
which pneumonia prevails most—Is a common disease in southern Europe—Winter
and first spring months the chief seasons for pneumonia—Immediate or exciting
cause—Particular employments less apt to cause the disease than is supposed—Inter-
nal causes—Liability of the disease to return in the same person—Tuberculous phthi-
sis—ige—Young children most liable—Sex—Men much more liable than women—
Treatment—Great mortality in pneumonia—Contradictory reports of different modes of
treatment ..... ... 200
LECTURE CI.
DR. BELL.
Treatment of Pneumonia—Superiority of venesection over all other remedies—Extent
of its use and frequency of repetition—Not to be deterred by the fear of interfering with
critical evacuations—Circumstances which modify bloodletting—Original strength of
constitution ; complication of pneumonia with other diseases—Bloodletting in the pneu-
monia of infants—Purgatives—Tartar emetic—Laennec's and Louis's advocacy of—
Mode and rule for using it in infantile subjects—Calomel—Revulsives and counter-
irritants—Drinks ........ 210
LECTURE CII
DR. BELL,
Treatment of Pneumonia (Concluded)—Opium and other narcotics—Depression to be
met by stimulants and mild tonics—Treatment of complications—Bilious pneumonia
—Tartar emetic in their case—Regimen and drinks in pneumonia—Convalescence—
Cautions requisite in—Typhoid Pneumonia—Its epidemic prevalence—Predisposing
causes—Symptoms—Treatment—Depletion less used, and stimulants more freely—Com-
plications to be attended to—Chronic Pneumonia—Physical signs of—Caution against
much depletion in—Edema of the Lungs—A secondary disease—Symptoms and treat-
ment . ....... 217
VUl CONTENTS.
LECTURE CIII.
DR. BELL.
Phthisis Pulmonalis—Difference between phthisis and the phlegmasia? of the respi-
ratory apparatus—Universality and continued prevalence of phthisis—Fearful mor-
tality from the disease—Appearance of tuberculous lungs—Tubercle, its distinguish-
ing anatomical trait.—Natural History of Tubercle—Its Origin and Growth De-
rived from the blood—Deposited in the pulmonary cells and parenchyma—Envelopes
the tissues, which preserve their normal character—Tubercles take the form of the
tissues in which they are imbedded—They do not grow, in the physiological sense—
Different appearances of pulmonary tubercles—Grey and yellow—Grey tubercles the
most common—Miliary granulations the supposed primary form of tubercle—Changes
in grey tubercle from slight causes—Appearance and characters of yellow tubercle—
Frequent coexistence of the grey and yellow varieties—Grey semi-transparent granu-
lations—Originate at an advanced period of phthisis—Grey semi-transparent matter
does not always appear under the form of granulations—Mode of distribution of tuber-
cle in the lunjjs—Miliary tubercles,—aggregated tubercles,—tuberculous infiltration—
Structure and Elementary Composition of Tubercle—Resemblance between the genera-
tion of tubercle and the formation of normal tissue—Dr. Wright's description—Vo-
gel's additional remarks—Constant elements of tubercle,—molecular granules, adhe-
sive hyaline mass, and peculiar tubercle-cells—Chemical composition—Seats of Tuber-
cle—Upper lobes of the lungs most affected—Stages of or Changes in Tubercle—Of
crudity, of softening or elimination and of ulceration or cavity—Maturation preceding
softening—Vomica—Successive changes of tubercle described . . . 230
LECTURE CIV.
DR. BELL.
Phthisis Pulmonalis (continued)—Organic relations of pulmonary tubercles to contiguous
and surrounding parts — Their vascular relations — Changes in the lungs caused by
tubercles—Bronchitis, pneumonia, pleurisy, and pneumothorax—Pleurisy and pneu-
monia intercurrent diseases — Frequency of pleuritic adhesions — Perforation of the
pleura—The bronchia? greatly suffer in phthisis—Also, the following organs and tis-
sues:—The arynx and trachea, the bronchial glands, the bloodvessels, the spleen,
the digestive canal, the mesenteric glands, the lymphatic glands, cellular and serous
tissues, the Jiver, the brain and its meninges—The larynx and trachea, the bronchial
glands, the small and large intestines, and the liver, the organs most affected in pul-
monary tuberculosis—The blood in phthisis ..... 242
LECTURE CV.
DR. BELL.
Causes of Phthisis Pulmonalis—External Causes—Climate—Difference of mortality
in different countries—Consumption, a common disease in the Mediterranean climates,
—also in the West Indies, and in the islands of the Indian Ocean—Consumption varies
in its rates of mortality in different periods—Cold and moisture—They act chiefly
by impeding the cutaneous functions—Experiments and observations by M. Four-
cault—Close and impure air a common cause—Deleterious influence of confinement
in close and impure air—Effects of dust given out in certain trades—Deficient or im-
proper food—Habits of intemperance dispose to phthisis—Internal causes of con-
sumption—Age—Sex—Hereditary predisposition—Conformation of the chest__In-
fluence of inflammation of the respiratory organs—Tubercle may be formed without
inflammation ...... 247
LECTURE CVI.
DR. BELL.
Phthisis Pulmonalis (continued)—Duration and Termination—Symptomatology__Symp-
toms proper to the lungs, and symptoms depending on associated disease of other
organs—Two periods of phthisis—Symptoms of the first period—Symptoms of the
second period—Varieties of phthisis—Acute and latent phthisis—Cases—Symptoms of
phthisis considered separately—Cough—Sputa : their microscopical appearances__He-
moptysis—Dyspnoea—Pain—Fever—Thirst—Gastric symptoms—Slate of the tongue
—Diarrhoea—Chronic peritonitis—Symptoms in ulceration of the epiglottis, larynx, and
trachea—Pneumonia—Pleurisy—Genital functions—Cerebral disorders—__Tubercu-
lar meningitis—its symptoms and progress—State of the senses—Emaciation__Per-
foration of the parenchyma of the lung by bursting of tubercle—Acute and chronic
phthisis—Acute inflammatory tubercle without suppuration—Bronchitic, pneumonic
and hemoptysical varieties . . . , . . .261
CONTENTS.
ix
LECTURE CVII.
DR. BELL.
Symptomatology of Phthisis (continued)—Symptoms not clear in some cases of acute
nor in latent phthisis—Proportion of cases of latent tubercle—Cause of latency not
known.—Diagnosis—Two periods—General symptoms in first period—Order of phy-
sical signs—Points to be ascertained before physical examination—Percussion—Aus-
cultation—Menstruation—Contraction of the chest—Diagnosis in second period.—
Prognosis—Almost always unfavourable—Alleged proofs of cure of consumption—
Rogee's observations—Louis's commentaries—Boudet's confirmatory experience 271
LECTURE CVIII.
DR. BELL.
Treatment of Phthisis Pulmonalis—Discouraging view of the subject—Systematic
divisions of treatment, into prophylactic, palliative, and curative—Prophylactic treat-
ment—To be begun early in life—Attention paid to the health of the mother, or the
nurse who may replace her—The child to take abundant nutriment, and moderate but
not violent exercise in the open air—The warm, and then the tepid bath—Cheerful
emotions encouraged, but yet suitable "restraint practised—Moderate exercise of the
intellect—Watchfulness at the epoch of puberty—Various exercises, including gym-
nastics ; tepid or cool bath; skin protected by flannel ; food nourishing; milk, eggs,
and meat—For weak appetite, bitter infusions, and for anemia, preparations of iron—
Health still delicate, travel is beneficial—Attention to ventilation in the sleeping
apartment—Tone to be imparted to all the organs, and equability of functions pre-
served—Palliative treatment—Complication of phlegmasia? of the thoracic organs and
disorder of the digestive apparatus to be removed—Antiphlogistics succeeded by tonics
—Different ideas of palliative and curative treatment—The practitioner to make hi.^
choice—Circumstances determining him—Different forms of phthisis—Localized bron-
chitic variety; its treatment—Hemoptysis; its treatment—Pneumonia; its treatment—
Recuperative measures—Depletion not always necessary—Diarrhoea, remedies in—
Perspiration andnight sweats—Additional hygienic measures—Exercise on horseback
travel ; change of scene—Benefits from change of climate overrated—Climate of East
Florida—Alleged efficacy of residence in marshy countries disproved—Summary of
curative treatment—Reported remedies against tubercle—Counter-irritation—Condi-
tions for its use—Opening of a tuberculous cavity by perforation of the walls of the
thorax .......... 284
LECTURE CIX.
DR. BELL.
Tuberculosis of the Bronchial Glands—Bronchial Glandular Phthisis—Morton's
account of this disease, as Phthisis Scrophulosa—Studied only of late years—Different
forms of—Changes in the tubercular glands—Effects of pressure of the bronchial
glands on other parts—the great vessels, trachea and bronchiae, the lungs, nerves, and
oesophagus—Communication between the bronchial glands and the lungs—Union of
glandular and pulmonary tubercles—Symptoms—chiefly from compression—Dropsy—
Hemorrhage—Alteration of the voice—Auscultation—Diagnosis—Prognosis—Causes
—Age—Complication with pulmonary tubercle—The disease properly scrofulo-tuber-
cular—Treatment—Curative and palliative—Prophylaxis.—Gangrene of thk Lungs
—Almost always a secondary disease—Is most common in children, and attacks men
more than women—Anatomical lesions—Different forms of the disease—Change of
pulmonary texture by—Cavities—Stages—Concomitant lesions in the lungs and other
organs—Symptoms and Diagnosis—not very distinct—Causes—Associated with pulmo-
nary apoplexy—The insane most liable to the disease—Treatment—regarding it as a
disease of the blood—To correct putrescence and keep up the tone of the system 299
LECTURE CX.
DR. BELL.
Melanosis or Melanoma—Its generic character—Its division into true and spurious—
Its seats—True pulmonary melanosis—Histological elements of melanotic tumours—
Causes—Deficient elimination of carbon—Concomitance between black infiltration and
reparation of pulmonary tubercle—M. Guillot's observations on carbonaceous deposits
in the lungs—Aged persons its chief subjects—The black colouring matter is carbon—
Spurious melanosis attributed to the inhalation of carbonaceous matters—Exposure
in coal mines—Dr. Makellar's observations—Dr. Graham's analysis of carbonaceous
X
CONTENTS.
deposit—This deposit common without any special exposure—Symptoms At r&
slight, afterwards cough, expectoration, sometimes dark or black sputa, hemop ysis
in the last period of the disease, weak circulation, loss of appetite, diarrhoea, colliqua-
tive sweats, slow pulse, dyspnoea, vertigo and syncope—General diagnosis—Post-mor-
tem appearances—Black deposit at first, in the walls of the pulmonary vesicles—Oblite-
ration of the minute vessels and the vesicles—Conversion of affected part of lung into
a peculiar tough elastic tissue—Sometimes general infiltration of the lung with black
matter—Cavities—Heart flabby and soft—Misapplication of the term black phthisis
—Subjects of melanosis, not tuberculous—Treatment—Reparation of Tubercle in con-
nexion with black deposits in the Lung*—Hasse's and Goillot's descriptions and conclu-
sions.—Cancer of the Lungs—Cancer a malignant heterologous tumour—Its analo-
gies to tubercle—Is more organised—Resemblance in the manner of softening—Ef-
fects of cancer on the system—Cancer of the lung, a rare disease—Is primary or se-
condary—The last most common—Primary carcinoma, mainly in one lung, and by
infiltration—Secondary variety, as isolated tumours—Bones and testicles, the most
frequent origin of secondary pulmonary cancer—Pleura sometimes affected—Symp-
toms and Signs—Dr. Stokes's summary of .... 309
LECTURE CXI.
DR. BELL.
Pleurisy—Pleuritis—Its forms and complications—Chief symptoms—Fever, pain, diffi-
cult breathing, hard and frequent pulse, and decubitus on the back—Even the chief
symptoms not always present; and they may be present without pleurisy—Structure of
the pleura—Anatomical lesions—Change in the pleurr itself,—in its secretion ; imme-
diate effects of this latter—Quality and changes of secreted matters—False membranes
—their characters—Tubercles and cancerous bodies—Change in the secretion and
state of the lung by the effusion—Causes—Identical almost with those of pneumonia—
Cleghorn's description of bilious pleurisy—Physical signs ■•—altered conformation of
the thorax, dulness on percussion,—resonance of voice in auscultation—cegophony
—friction sounds—Diminished vibration of the parietes of the thorax—General symp-
toms—Fever, state of pulse, buffy and cupped blood—Progress, duration, and termina-
tion of pleurisy—Varieties—Complications—Prognosis , 319
LECTURE CXII.
DR. BELL.
Treatment of Pleurisy—Bloodletting, by venesection, the first and chief remedy—In
feeble habits and in advanced stages, cupping or leeching—Cupping followed by saline
purgatives—Tartar emetic—Opium in full doses after venesection—Blister to the side
—Purging most useful in complicated and epidemic pleurisies—Diuretics; nitre, digi-
talis, colchicnm—Calomel with nitre and a little opium—Treatment of children.—Ty-
phoid Pleurisy.—Puerperal Pleurisy.—Chronic Pleurisy—Not always resulting
from the acute form—Symptoms and physical signs—Dilatation of the side—Diagnosis
—Absorption going on—Contraction of the chest—Treatment—Calomel—Iodine—Hy-
gienic measures.—Pleurodynia—Its symptoms—Diagnosis between it and pleurisy
—Treatment.—Pneumothorax—Causes, symptoms, and treatment.—Hydrothorax,
—Its causes, symptoms and treatment ...... 328
DISEASES OF THE HEART.
LECTURE CXIII.
DR. BELL.
Diseases of the Heart—Position and structure of the heart—its valvular mechanism
—Beat or impulse of the heart; when felt—Percussion—Various tones according to
the part of the chest struck—Auscultation—Two sounds of the heart: the first caused
by the systole of its ventricles ; the second by the resistance and sudden tightenina of
the semi-lunar or sigmoid valves—Different organic affections of the heart—Functional
disorders—Simple carditis, a rare disease—Sequences of—Softenino-—varieties and
causes of—Diagnosis not easy—Treatment, similar to that of pericarditis__Perfora-
tive ulceration and rupture—Recorded cases of and complications with__Aneurism ven-
tricular—Thurman's summary of—Its precise seat and complications—Aneurismoi the
auricles ........ 345
CONTENTS. xi
LECTURE CXIV.
DR. BELL.
Hypertrophy of the Heart—Divisions of hypertrophy—General view of disease of the
heart's cavities—Average dimensions of a healthy heart—Anatomical characters and
volume of a hypertrophous heart—Change of form—Excitingcauses—Different forms
and complications of hypertrophy—Connexion between hypertrophy and cerebral dis-
ease, particularly apoplexy—Ossification of the cerebral arteries—Capillary conges-
tion of the mucous membranes and liver—Disease of the kidneys in hypertrophy of
the heart—Palpitation—Impulse heard, through the stethoscope—Hypertrophy with
dilatation—Sounds of the heart and state of the pulse in hypertrophy—Arterial pulse ;
its cause and characters ; modifications by hypertrophy—Causes commonly affecting
the pulse—Signs of hypertrophy of the right ventricle—Treatment of hypertrophy—
Abstraction of blood, short of producing anemia—Moderate and frequent abstractions
to be preferred—Purgatives and diuretics—Tonics and narcotics—Perseverance in
treatment of hypertrophy all-important ...... 355
LECTURE CXV.
DR. BELL.
Dilatation of the Heart—A consecutive disease—Two forms — Simple dilatation
without thickening—Dilatation with attenuated walls—Signs and diagnosis of dilata-
tion—Treatment, by moderate tonics.—Diseases of the valves and orifices of the
Heart—Their connexion with hypertrophy—Large proportion on the left side—Pro-
portionate size of healthy valves—Induration, ossifications, excrescence, and vegeta-
tions of the valves—Atrophy or inadequacy of the heart's valves—Endocarditis the
most frequent cause of valvular disease—Gout, a cause—General symptoms and effects
of an alarming nature—Diagnosis—Well-defined peculiarities of pulse—Prognosis—
Physical signs—Murmurs—Their varieties—Venous or continuous murmur—Venous
pulse—its cause—Purring tremour or thrill—Table of the different murmurs 368
LECTURE CXVL
DR. BELL.
Pericarditis—Connexion between diseases of the membranes of the heart and rheuma-
tism—Divisions—Anatomical appearances—Injection and redness, in patches, of the
pericardium—Loss of its smoothness and polish—Milk spots or patches—not always
evidence of inflammation—After plastic exudations, the pericardium is pale and rough
and after repeated attacks is thickened—Effusion of serum, containing plastic matter
—Gelatinous exudation, peculiarly organised—Pus after renewed inflammation—Pseu-
do-plastic matter—Hemorrhagic effusion—Effusion of pus—Mixture of organisable
and inorganisable matters—Tubercular formations—Muscular substance of the heart,
as if macerated and wasted—Dilatation with hypertrophy of the left ventricle—Cavi-
ties of the heart containing blood of different appearances—Valves thickened—Com-
plications with pleurisy and pneumonia and with peritonitis— Engorgement of the liver
—Kidneys affected wtih granular disease—Effusion of serum in the ventricles of the
brain—Serous infiltration of the cellular tissue—Symptoms—Dulness on percussion ;
arching or elevation of the cardiac region—Friction of the opposite false membranes
of the pericardium against each other—Altered sounds and impulse of the heart—
Pain of this organ—Palpitations and irregular circulation—Physical symptoms, the
most characteristic-—Progress and Termination—Pericarditis varies in its intensity and
duration—Stages of the disease—Chronic lesions in those who survive—Adhesions
of the pericardium do not shorten life—Symptoms of adhesion—Diagnosis—Inferred
from the collection of symptoms previously detailed—Latent pericarditis—Prognosis
—Favourable termination in a majority of cases—Rheumatic cases furnish most cures
—Those from Bright's disease less favourable—Cure by natural process—Causes—
Exciting ones not well ascertained—Pericarditis is a consecutive disease—Most com-
mon in rheumatism—Next, in frequency, in Bright's disease—Ultimate cause—altera-
tion of the blood—Results of experience of different writers—Age has its influence—
Males more liable than females—Pleurisy a frequent concomitant; so, also, is pneu-
monia— Treatment—Antiphlogistic, with modifications—Under what circumstances
venesection useful—Local depletion—Auxiliary reducing means—Tartar emetic and
colchicum; incases of abdominal complication, calomel and other purgatives—Opium
—Calomel as an alterative—Ptyalism often recommended—Its real value—Iodide of
potassium especially useful in cases of complication with Bright's disease — Iodide
of iron—Counter-irritation by pustulation and vesication of cardiac region—Great
attention to the state of the skin required in the prophylaxis of pericarditis 377
Xll
CONTENTS.
LECTURE CXVII.
DR. BELL.
Diseases of the Heart (continued).—Endocarditis—By whom described—Its origin in
rheumatism—Symptoms—Not always clear—Diagnosis—A frequent, concomitant ot
imUlUIUOIl LI)B Sdllie 111 an mc ouwivico---xiuniiuua waguio---k'"""----
e itself—In acute cases and more advanced stage,
antiphlogistics required—Calomel and laxatives—Early and free use of astringents and
stimulating applications to the eye—The lecturer's own experience — Precautions in
examining the eye . ..... 617
VOL. II.—2
XV111
CONTENTS.
LECTURE CXL.
DR. BELL. .
Diseases of the Eye (continued)—b. Purulent Ophthalmia of Adults—Egyptian Uptiinai-
mia—Shows itself at any time alter infancy—First and main seat, the conjunctival
lining ofthe eyelids—Subsequent extension to the anterior part of the eye, including
cornea and iris—Upper eyelid suffers most—The disease most noticed by military
surgeons—May prevail epidemically—shows itself in schools and asylums—Symptoms
—Disease divided into three stages—In the first stage, the symptoms analogous to
those of catarrhal ophthalmia—The second stage brings the purulent discharge, with
redness, puffiness, and elevation of the conjunctiva—In the third stage, the proper
tunics of the eye are affected—Tendency of the second stage to become chronic—Pro-
fuseness of the discharge—Pain great—Remissions periodical—Symptoms in com-
mon with those of the ophthalmia of new-born infants—Variety in the symptoms—
Disease sometimes milder, and confined to the upper eyelid—Appearances characteristic
of this disease in adults—granular eruption with phlyctenule—Chronic the first form
of the disease—The acute ingrafted on it—Early appearances on the conjunctival
surface—Effects of purulent conjunctivitis on the tunics of the eye and the eyelids—
—General symptoms, in the beginning slight; in the advanced stage, are of a febrile
nature—Diagnosis—Prognosis unfavourable—Causes—Opinions divided respecting a
contagious origin—Positive testimony in favour of contagion—Purulent ophthalmia
has originated in persons not exposed to the disease in others—States of the weather
—Crowded barracks—Close air on board ship—Treatment—In the first stage, anti-
phlogistic to a certain extent—Early use of nitrate of silver and analogous remedies
—Moderate exercise in the open air—In the second stage, decidedly antiphlogistic—
Excision of a part of the conjunctiva—In lymphatic habits and in secondary attacks,
and in a civic population, a less energetic and a mixed treatment, including tonic re-
medies, the best—Topical applications, from the first, and the cold douche—Stimu-
lating remedies to the eye even before the inflammation is gone—Granular conjunctiva
—A constant occurrence in chronic purulent ophthalmia—Its appearances and conse-
quences—Affection of the cornea—Treatment—Combination of general with topical re-
medies—Vascularity and opacity ofthe cornea, common results of granular conjunctiva
—Gonorrhoeal Ophthalmia —A consequence of gonorrhrea or of inoculation with gonor-
rhoea! matter—Theories to explain its attack—Three forms of gonorrhoeal inflammation
—Chief and most violent—Symptoms and immediate effects—Diagnosis—Prognosis—
Treatment—Fearful rapidity ofthe disease—Antiphlogistics ; cauterization, and exci-
sion and incision ofthe conjunctiva—Mild gonorrhoeal ophthalmia—Gonorrhoeal inflam-
mation ofthe external tunics and iris—Its analogy to rheumatic ophthalmia—Simul-
taneous occurrence of rheumatism with gonorrhoea and gonorrhoeal ophthalmia 626
LECTURE CXLI.
DR. BELL.
Diseases of the Eye (continued).—Sclerotitis—Is rheumatic—Symptoms—Redness of
a pink hue, and particulardirection,—vessels running in straight lines—cornea dim, a id
receiving vessels from the sclerotica—Diagnosis—Causes—The same as of rheumatism
in other organs—Continuation of disease of the cornea and iris—Treatment—At first, in
milder cases, purgatives and Dover's powder—In the fully formed stage, venesection,
cupping, and leeching—calomel and opium—tartar emetic and nitre with opium—Calo-
mel where the disease is merely suspended—colchicum with salines—iodide of potas-
sium—Counter-irritants—Lotions and ointments to allay pain—When the inflammation
has subsided, bark or sulphate of qninia—For chronic sclerotitis, rely on regimen, occa-
sional cupping, laxatives, and quinine.—Corneitis—Structure ofthe cornea—Is sus-
ceptible of inflammation—acute or chronic,—primary or secondary—Symptoms__Con-
comitant affection ofthe iris—Scrofulous corneitis, occurs in young persons__Corneitis
is an obstinate disease—Treatment—Antiphlogistic, with reserve and restrictions__
Local applications not of much service—Summary of treatment when disorganization
is threatened—Phlyctenular or scrofulous corneitis—Changes in the cornea consequent
on its inflammation—Vascularity—ulceration—chalky appearances—opacity__leucoma or
albugo—Treatment of opaque cornea.—Iritis—Structure of the iris—Iritis is either pri-
mary or secondary—Symptoms and pvgress—The most characteristic symptoms,—a
change in the appearance and colour ofthe iris, and a red band round the cornea—In-
flammation begins at the pupilary border—Changes of figure of the pupil__Sichel's
opinions—Changes and effect-; from iritis—Constitutional disturbance__Causes the
same as of ophthalmia in general—Particular ones, or those of diathesis__rheumatic
gouty, scrofulous ; and of prior disease, as syphilis—Question of mercury, as a cause
—Treatment—Antiphlogistics and mercury—Iodide of potassium in sub-acute and
CONTENTS.
XIX
chronic iritis—Treatment in these stages—Use of belladonna and stramonium—Va-
rieties of iritis—General indications of treatment.—Choroiditis—Vascularity of the
choroid coat—Few external symptoms—Functional disorders—Case of the lecturer's
— Treatment—In the main, antiphlogistic—but with early recourse to tonics.—Reti-
nitis—Difficulty of distinguishing it from choroiditis—Causes—Case—Amaurosis—
Its diversified causes—Practical inferences to guide us in the treatment of amaurosis.
—Scrofulous Ophthalmia—One of the mixed forms of ophthalmia—&/mpfo77W—Is
most common in children—Its organic features—Physiognomy of those affected with
the disease—Organic changes—Implications of the tarsi and Meibomian glands—
Treatment—Change of habitation—Moderate depletion and laxatives—Tonics—sul-
phate of quinia and iodide of iron—Narcotics—Regulation of the diet—Clothing—
Change of air—Collyria—pencilling the eyelids with solutions of nitrate of silver and
of iodine—General plan of treatment—Disorganising inflammation of the cornea—
Extract of belladonna—Erysipelatous ophthalmia—Symptoms and treatment—Pustular
ophthalmia—Symptoms and treatment—Variolous ophthalmia—Time of its appearance—
Treatment—Catarrho-rheumatic ophthalmia—Symptoms and treatment referable to those
of catarrhal and of rheumatic ophthalmia.—Ophthalmia Tarsi—Its two varieties,
catarrhal and scrofulous—Symptoms of catarrhal ophthalmia tarsi—Chronic form, or
lippitudo—Entropium—Ectropium—Causes— Treatment — Scrofulous ophthalmia tarsi—
has features in common with the catarrhal—Its scrofulous ones, hordeola, vesicles,
or pustules and ulcers—Psorophthalmia—a wrong term—This variety may be con-
nected with favus difpersusot impetigo figurata—Tylosis—Madarosis—Treatment of scro-
fulous ophthalmia tarsi . ....... 637
DISEASES OF NUTRITION —CACHEXLE.
LECTURE CXLII.
DR. BELL.
Difficulty of Classification of Diseases, termed Cachexia?—Cullen's and Cop-
land's definition—Dr. Williams's explanation of morbid deposits.—Scrofula—Its
multiplied relations and associations—Anatomical and histological characters—Resem-
blance of the scrofulous to typhous deposit—State of the blood—Scrofulous pus—
Identity of scrofulous and tubercular diseases-*-Symptoms and p-ogress—Cullen's de-
finition; its incompleteness—Countenance—Swelling of lymphatic glands, cellular
tissue, and joints—tumid abdomen—Irritation of the ocular, nasal, and pharyngeal
mucous membrane—Swelling and other changes of the tonsils; cough; ulcerations
of the tongue; disorder of the digestive mucous membrane—The sc.rotu\o\i*fades—In
a more advanced stage, inflammation and ulceration of the lymphatic glands of neck—
Discharge of pus and cheese-like product of tubercle—Abscess of cellular tissue—
Similar cacoplastic deposits in serous membranes, and in the pancreas, liver, mesen-
teric glands and urinary and genital organs—The bones, especially the extremities of
long bones and the vertebra? affected—Curvature of the spine and distortion of the
thorax—Scrofulous disorders of the skin, eye, and ear—Irregularity in nervous and
muscular systems—Brain and senses sometimes very susceptible—Sometimes great
vivacity—sometimes dulness—Intellect sometimes precocious, sometimes deficient—
Irritative fever—Complicated with uterine disorders, hysteria and epilepsy—Special
pathology of scrofula—deterioration of blood and deposit of granular pus and tubercle
—Causes—Inherited predisposition the chief cause—Scrofula preserving its character-
istic features in all countries and climates—Transmission by descent more general
than supposed—Affinity between tubercle and scrofula—Acquired diseases of parents
—Causes of scrofula in their children—syphilis; excessive venery; paralysis; in-
sanity— Hereditariness does not pass over one generation to appear in another—Cause
not unit—Difference in the age of the parents—Effects of French conscription—
Crowded lodgings—impure air—defective nutriment—Examples—Scrofula prevails
in the negro population—Morbid states—as the exanthemata—exciting causes of
Bcrofula . . . . . . . . . . 654
LECTURE CXLIII.
DR. BELL.
Scrofula (Continued)—Treatment—Indications of cure—Elements of disease presented
by Dr. Williams—Importance of prophylaxis—Knowledge of causes suggests means of
prevention—Outlines of prophylaxis and cure—Necessity of perseverance and of time
(or a cure—Proper notions respecting the tonic treatment—Purgatives to precede iron
and iodine—Fresh air, wholesome food, and exercise, necessary conditions for curing
scrofula—Use and effects of iodinic preparations—Small doses with large dilution to
be preferred—No necessity for the large doses used by some physicians—Iodide of
XX
CONTENTS.
iron—Mr. Phillips's success with—Most convenient form—Iodide of zinc—Hy ro-
chlorate of lime—Lime-water—Arsenic, to be kept back until other remedies are
tried—Alternate use of iodide of potassium and carbonate of iron, or the potassio-tar-
trateof iron—Bromine—Bromides of potassium and of iron—Ointment of bromide ot
potassium—Cod-liver oil—Preparations of walnut leaves—Mercury ; when admissible
—When narcotics are proper—These combined with mercury or iodine Most com-
mon forms or varieties of scrofula—Tabes mesenterica—Alleged connexion with ente-
ritis—Outlines of treatment—White swellings—Modified treatment—Tuberculous objec-
tions ofthe skin—General indications of cure, including hygienical measures 663
LECTURE CXLIV.
DR. BELL.
Syphilis—Lues Venerea—Its divisions into local or primary, and constitutional or se-
condary syphilis—Two varieties ofthe local form—First, or gonorrhcea, not properly
a syphilitic disease—Already treated of.—Local or Primary Syphilis—Symptoms;
chancres or sore of genitals; characters of Hnnterian chancre; not diagnostic of
syphilis ; appearance of sore varying with the tissue affected—Not different degrees
of poisoning and corresponding sores—Alleged connexion between different primary
sores and secondary eruption—True test of a venereal sore; inoculation propagating
the like—A certain period of maturity for the poison to be transmissible; four or five
days—Mistakes in diagnosis of sorejs on the genital organs and of those on other
organs—Poison sometimes transmitted by the medium of a person who does not
receive the contagion—Bubo, secondary to chancre and to other sores on the penis, and
other causes—Inoculation, test of venereal bubo—Treatment of Primary Syphilis—Pro-
phylaxis to prevent disease at all, and next to prevent progress after first symptoms—
Destruction of chancre necessary, or its conversion into a common sore—Remedies—
General treatment; rest and antiphlogistic regimen ; chancre persisting, the treatment
required—Phagedenic ulcers—Mercurial dressings not required—Mercurial treatment
of primary syphilis compared with non-mercurial—Safely and greater expedition of
the latter — Mercury useful at times — Salivation unnecessary—Treatment of bubo—
French practice successful before suppuration : Ricord's directions after suppuration
674
LECTURE CXLV.
DR. BELL.
Syphilis (Continued).—Secondary or Constitutional Syphilis—When syphilis is consti-
tutional—Progress ofthe d isease in its successive stages—Hunter's description—His first
and second stages correspond with Ricord's secondary and tertiary forms—Proportion of
cases in which secondary symptoms occur—The less proportion the sooner the primary
disease is cured—Modes of transmission of secondary syphilis—Generally not commu-
nicable—Secondary symptoms in new-born children—Occasional suspension of symp-
toms—Difficulty of diagnosis of secondary syphilis—Varieties of venereal eruptions—
Description of—Sore throat—Treatment of Secondary Syphilis—Attention to coexisting
acute diseases—These to be cured first—Derangements of function to be removed—
Treatment, varying with the constitution, habits, and other diseases of the patient—
Remedies in first stage or secondary form of constitutional syphilis—Mercurials use-
ful ; and still more iodine—Donovan's solution—Syphilitic ulcerations—Their appear-
ance and treatment—Vegetations—Treatment of.—Tertiary Syphilis—Symptoms
appear late—Order of parts affected—Not transmitted hereditarily—Secondary symp-
toms often disappear when hereditary without treatment—Tertiary symptoms may
then seem to be primary—In tertiary symptoms, or the second stage of Hunter, the
iodide of potassium the chief remedy—Attention to the symptoms of phloaosis ; •
these to be met by appropriate measures—Cyanuret of mercury ; its advantages over
the bichloride—General treatment and cautions . . . . 683
FEVERS.
LECTURE CXLV1.
DR. STOKES.
—General considerations on—Erroneous modes of investigation—Importance of
the labours of French pathologists—Complication of fever with local disease__Pri-
mary and secondary fevers—Relation of, to local changes—tendency to spontaneous
termination—Principles of treatment—Errors of Brown and Broussais—Researches
of MM. Gaspard and Magendie—Their pathological conclusions—Importance of the
knowledge of secondary lesions—Effect in preventing crisis—Treatment__Humoralism
and solidism ....... . qqq
CONTENTS.
xxi
LECTURE CXLVII.
DR. STOKES.
Intermittent Fever—Definition and character of—Phenomena ofthe paroxysm—Cold
stage—Internal congestions—Pathology of—Hot stage—Ague not a simple fever—
Affections of various viscera—Theory of Broussais—Effects of bark, quinine, &c.—
Modus operandi of ....... . 698
LECTURE CXLVIII.
DR. BELL.
Alleged Causes of Intermittent Fever—Miasm or malaria, an imaginary cause—
Periodical fever prevails under most opposite conditions for the evolution of malaria—
More attention due to sensible states of the atmosphere—Slight differences in locality
modify climate—Phenomena of dew—Exposure of the labourers in the Campagna di
Roma—Disadvantage of the miasmatic hypothesis on the score of prophylaxis—Avoid-
ance of extremes of known states of the atmosphere—The miasmatic hypothesis con-
futed by Folchi in Rome and Dr. Pritchett in Western Africa—Geological Causes—Dr.
Robert Jackson, Dr. Heyne—Causes pertaining to the individual and to changes in his or-
gans—Age—Inhni in utero may have ague—Vitiation of the blood—Consecutive and an
effect, not cause—Poisoning ofthe cerebro-spinal axis—Schultz's opinions—Disorder
nnd enlargement ofthe spleen : the chief cause of intermittent fever, as alleged by M.
Piorry—His propositions—Objections to—M. Piorry believes that intermittents may
occur without exposure to miasm—Liver a frequent sufferer in periodical fevers—
Dropsy an effect ofthe fever—So also of hyperemia, congestion, and phlogosis ofthe
mucous membranes—Associated engorgement and induration ofthe mamma? in inter-
mittent fever—Phlegmasia? of the respiratory passages and of the pleura and lungs
are frequent complications—Periodicity, common in all the disturbances of the nervous
system—Essays on by the lecturer— Type of periodical fevers—Relative proportions of
quotidian and tertian types—Contradictory estimates—Quartan of comparatively rare
occurrence—Marsh miasm supposed to be less the cause of the quotidian than of the
tertian and quartan types—Tendency ofthe fever to return at septan periods—Time of
recurrence—Each type has a tendency to recur at a particular hour, and in cases of
relapse to appear at the same hour ...... 706
LECTURE CXLIX.
DR. BELL.
Treatment of Intermittent Fever—Remedies in the cold stage—A mild emetic—
Warm drinks—Warm applications to the extremities and over the epigastrium—Inter-
nal stimulants generally injurious—Laudanum or Dover's powder often does good—
Bloodletting—Lecturer's experience and cases—Pressure on the extremities—Reme-
dies in the hot stage—Stimulants given in the cold stage increase morbid reaction in
the hot—Venesection on certain conditions—In common, cool air and drinks and affu-
sion of cold water—cold enemata—laudanum—Treatment in the apyrexia, or interval
between the paroxysms—The Lecturer's confidence in Peruvian bark and the sulphate
of quinia—His large clinical experience with these substances—Good effects of cin-
chonic preparations in enlarged spleen, with intermittent fever—Various formulae of
the bark and sulphate of quinia—Dose ofthe bark—Advantages ofthe salts of quinia
—Dose of—Experience in India, Algeria, and in Florida—Time of administration of
the anti-periodic—Salts of quinia not active until they enter the circulation—Medium
period in which to give the sulphate—Best means of introducing it into the system—
Failing hy the stomach, we have recourse to its use by enemata and by endermic
medication or through the skin—Also, to the mucous surface of the mouth and throat—
Modified treatment in complications of gastro-enleritis and of broncho-pulmonary irri-
tation and phlogosis—Danger of perseverance in tonics—Want of success from the use
of mercury—Success attending venesection —Local bloodletting—Indications for its
use from the spinal pathology of intermittent fever—Counter-irritation to the spine—
Bloodletting alone, or mercury alone, or the cold bath alone, not to be relied on with-
out bark ami its equivalent tonics—Exclusive reliance on bark or arsenic not justifiable
— Abstinence sometimes brings a cure—Call for nutritive tonics and iron—Cold bath-
ing— Indications for its use—Cold enemata—Several remedies besides the bark and
Milphate of quinia in intermittent fever—All the tonics and astringents and bitters em-
ployed on occasions— Peruvian bark or sulphate of quinia, the febrigum magnum—
Other salts of quinia, and the triple ones with metallic combinations—Valerianate of
quinia-lisalleged advantages—Arseniate ofquinia—Citrate of iron and quinine—Ferro
cyanate of quinine—Combination of sulphate of quinia and carbonate or sulphate of
iron—Iodides of quinia and of cinchona—Arsenic, or arsenious acid—its physiolo.—Exanthemata—Their general character—Close
relation to diseases of the gastro-pulmonary mucous surfaces—Erythema—Its chief
features, causes, and treatment—Seven varieties of acute erythema described—
Chronic erythema.—Erysipelas—Its synonyms—General features—Varieties—Cuta-
neous, phlegmonous, or sub-cutaneous, and the diffuse cellular inflammation—Anatom-
ical changes—Lesion of internal organs—The blood—Prognosis—Causes and Treatment
—Venesection or leeching; vomiting and purging; antimony, colchicum ; topical
applications—Warmth and moisture—cold—blisters; lunar caustic; unguents—
iodine—Erysipelas Neonatorum—Its danger and mortality—Collateral relations of
erysipelas, the most important—Diffuse inflammations of the serous and mucous
membranes—Connexion between erysipelas and puerperal fever or puerperal peritonitis
—Reasons for believing in the identity of the two disorders—Sameness of diffuse in-
flammation ofthe peritoneum and erysipelas in both sexes—Erysipelas passing from
theskin to and through the entire digestive canal—Diffuse inflammation of the mucous
surfaces—Epidemic erysipelas in the United States—Black Tongue—Chief features
ofthe disease, involving both skin and mucous membranes—Outlines of treatment—
Connexion of this epidemic with puerperal peritonitis—Great mortality of this last
during the epidemic.—Roseola—its varieties—Symptoms and treatment . 858
LECTURE CLXII.
DR. BELL.
Exanthemata (Continued)—Different classifications of eruptive fevers—Small-pox in-
cluded under this designation—Symptoms of the Exanthemata—Skin in a state of con-
gestion—A similar state of the mucous membranes—Entire sentient surface in a state
of irritation—Reaction in the brain and spinal marrow—Difference between the in-
flammation of the cutaneous and that of the mucous membrane—Exanihemata pro-
perly diseases of the cutaneo-mucons system—Precursory symptoms—Sometimes
high fever with little or no eruption—Diagnosis—Difficult in the period of invasion
and until the eruption is fairly established—Primary eruption—maculae and papula?
—not diagnostic—Visceral complications in all—Eruption an effect of internal dis-
ease—Careful study ofthe symptoms—Period of Incubation—Complications—With the
several exanthemata, are associated inflammation of particular organs—Anatomical
changes—Congestive inflammation ofthe dermis—Exudation of fluid—Morbid altera-
tions of the mucous and serous membranes—Mortality—Very great—Tables__Treat-
ment—General outlines.—Measles—Symptoms—Precursory, those of catarrh—Date of
eruption—Its appearance—Diarrhoea—Period of danger from inflammation of the lungs
—Varieties—Complications and Sequelae— Measles varies in intensity at different seasons
—Pneumonic the most frequent complications—Entero-coiiiis—Gangrene of the lips
and lungs—Meningitis—Delirium, coma and convulsions—Simultaneous appearance
of measles and small-pox in the same person —Also epidemically—Chronic diarrhoea
a troublesome complication—Phthisis readily developed by measles—Typhoid stale
—Morbid Anatomy—The skin and mucous membranes chiefly affected__Lungs fre-
quent sufferers—Causes— Contagion—Alleged communicableness by the blood and
tears—Modern introduction into Europe and America—Rhazes—Doubtful results of
CONTENTS.
xxvii
inoculation—Treatment—Simple—In the mild variety of measles—When the lungs are
implicated—Antiphlogistic remedies required—Venesection—Measures required when
the eruption retrocedes—The cooling regimen in small-pox and measles firstclearly laid
down by Rhazes—Long anterior to Sydenham—Outlines ofthe method of Rhazes 871
LECTURE CLXIII.
DR. BELL.
Exanthemata (Continued).—Scarlatina—Scarlet Fever—Its characteristics—Causes—
Varieties—Symptoms—of Scarlatina Simplex—of Scarlatina Anginosa—of Scarlatina
Maligna—of Scarlatina sine Exanthemate—Diagnosis between scarlet fever and measles
—Difficulty of distinguishing congestive scarlatina from cholera and typhous fever
—Prognosis—Morbid Anatomy—Sanguineous congestions of the brain, spleen, and
plates of Peyer—Also, inflammation of the fauces and air-passages—In some cases,
no lesion is visible—Exfoliation of the mucous membrane of the urinary organs
—Epithelial scales in the urine—Complications and Sequela—Inflammations of the
different viscera—Simultaneous appearance of scarlet fever with other exanthe-
mata—Rheumatism—Diphtheritis—French measles—Anasarca a frequent and trou-
blesome sequela of scarlatina—Primary cause, the suspended functions of the skin
—The dropsy sometimes attacks suddenly and with violence,—sometimes comes
on slowly—Albumen and blood found in the urine—Often, the albumen is want-
ing—Edema of the lungs—comes on suddenly—Is in the interlobular cellular tis-
sue—Edema of the glottis—Pericarditis—owing to disease of the kidney in scar-
latina—Suppuration of the ear—Purulent effusions into the joints—Abscesses in
the soft parts—Malignant affection of the throat—Treatment—Fluctuation of opinion
respecting the value of depletion—Changes in the character of the disease—The lec-
turer's practice and experience—The cooling regimen, a mild emetic, cold affusion—
Mild salines with tartar emetic—Phlogistic symptoms met by venesection or leeches—
Cold drinks—For restlessness and wakefulness, Dover's powder—Probable cause of
death in eruptive fevers—Loss of vitality or of functional action ofthe skin—Simul-
taneous disease of pulmonary mucous membrane — Poisoning of the system—Oppres-
sion and violence of symptoms not explicable by inflammation—Malignant, a typhoid
state—Principles of practice, same as in congestive fever—Treatment of particular
cases—the anginose, the cerebral—Cold affusion—sometimes tepid bathing—Stimu-
lants—spirits of turpentine and carbonate of ammonia, camphor mixture, capsicum—
Anasarca, treatment of—Prophylaxis ...... 885
LECTURE CLXIV.
DR. BELL.
Exanthemata (Continued).—Variola—Small-Pox—Variolous eruption—Varicella—
Variola, or small-pox proper—The lecturer's experience in epidemic small-pox—Va-
riola an acute, contagious, inflammatory disease—Varieties—Periods—Evidences of
its very contagious character—Morbid Anatomy—Symptoms and Progress—Secondary
fever—Coincident Exanthemata—Inoculated Small-Pox— Prognosis of Variola—Treatment
—Cdoling regimen and antiphlogistics moderately used—Associated inflammation
to be treated with depletion—Secondary fever, modified treatment in—Danger from
sequela? of small-pox—Skin peculiarly liable to morbid impressions—Ectrotic or
aborting method in variola—Prophylaxis.—Vaccinia or Cow-Pox—History—Its origin
and alleged identity with variola—Protection by Vaccination—Inferences by Drs.
Mitchell and Bell in favour of vaccination—Re-vaccination—Age for Vaccination—
Stages of vaccine pustule—Selection of matter—Its insertion, or application—Retro-
Vaccination—Number of incisions—Causes modifying development of vaccine pustule
—Anatomy of the Vaccine Pustule—Vaccine cicatrix—Small-pox after Vaccination—Va-
rioloid—Its origin, symptoms, and comparative frequency — Occurrence not propor-
tionate to the period after vaccination ...... 898
LECTURE CLXV.
DR. BELL.
Rheumatism—Rheumatic Fever—Fever anterior to the local inflammation—Rather a
diathesis disposing readily lo inflammation and fever—Rheumatic diathesis met with
in the vigour of life—Division of rheumatism into acute and chronic—Distinction be-
tween the two—Seat and Complications of Acute Rheumatism—Two chief seats, articu-
lar and muscular—Extent of parts affected—Metastasis to internal organs; some-
times these first attacked—Practical inference—Community of causes of external and
internal rheumatic inflammation—Complication of chorea with rheumatism—Com-
munity of cause in a morbid state of the blood—Cerebral affections—Puerperal rheu-
matism — Syphilitic rheumatism—Acute articular rheumatism, acute arthritis—Symp-
XXV111
CONTENTS.
toms and Progi-ess—Constitutional disturbance great—Transfers of disease—-Sta e
the blood—of the urine—Diagnosis between rheumatism and goat—Anatomical ctianges
—Causes—Vicissitudes of weather—The chief predisposing cause, excess of nutrition
and hematosis—Sudden and violent strain, long marches—Special predisposition—
Other causes—Males more liable than females—Influence of age—Treatment t ree
and repeated venesection—Must not expect to remove at once the rheumatic lever-
Local bloodletting, at the part affected and at the spine ; purgatives; tartar emetic; col-
chicum; the two combined ; their great depressing power; opium in large doses;
nitre in large quantities; mercury, its true remedial value and time of use ; warm
bath; tonics; sulphate of quinia with opium—Other varieties of rheumatism ; endo-
carditis; pericarditis— Capsular rheumatism—its affinity to gout; preference for the
knee—Treatment—Nodosities ofthe joints — Membranous, fibrous, or aponeurotic
rheumatism—Treatment; iodide of potassium—Muscular rheumatism, is less acute
than articular—Parts of the muscular system affected—Rheumatic diaphragmitis the
worst—Treatment . . . . • • • .913
LECTURE CLXVI.
DR. BELL.
Chronic Rheumatism—Ideas to be attached to the term chronic; its relation to acute
—Division of chronic rheumatism—Morbid anatomy—Symptoms—Causes—Treatment
—Length of time for cure—Entire renovation of the system necessary—Classes of
subjects of chronic rheumatism—Symptoms—Diagnosis between chronic rheumatism
and chronic gout—Remedies,sometimes analogous to those in the acute; occasionally
bloodletting; always free purging; Dover's powder; diaphoretics; colchicum;
iodide of potassium ; sulphate of quinia, sometimes with purgatives preceded by
blue mass or colchicum. Mixed varieties of chronic rheumatism ; blue mass with
hyosciamus, &c.; bathing after various fashions ; embrocations and liniments ; ban-
daging; acupuncturation ; warm and hot bathing ; sea-bathing; hygienic treatment,
preventive and curative—Rheumatic paralysis—Electricity in . . . 927
LECTURE CLXV1I.
DR. BELL.
Gout—Podagra, &c.—Reasons for regarding gout as a febrile disease—Its affinity to
rheumatism—The general or constitutional disturbance precedes the local lesion—
Gouty Diathesis—Wherein predisposition to gout consists—External habit or physi-
ognomy—Temperament—Modes of living—Excessive repletion and indolence the
chief predisponents—Gout a disease of the rich, or of those easy in life who eat much
and work little—The poor drunkard and the rich bibber—Exception in cases of certain
menials of the wealthy, and labourers who drink malt liquorto excess—Vexation and
strong mental emotions in general—Danger to the man of letters from free indulgence
of the appetite—Inherited predisposition—Its real force—Age and sex considered—
Paroxysm of gout—Warning or premonition—Disorder of the digestive organs the
chief predisposing and often exciting cause—What is the special exciting cause acting
on a plethoric habit—Excess of lithic acid in the blood—Proofs derived from chemis-
try and physiology, and from the pathology of analogous diseases—Important infer-
ence—Treatment—In acute gout, the remedies antiphlogistic—Sometimes venesec-
tion, always purgatives—Colchicum with the alkalies and magnesia—Modus operandi
of colchicum—Diet extremely simple in acute gout—Convalescence not to be hurried
by tonics—Bathing, general and local, and frictions—Treatment of a second paroxysm
analogous to that ofthe first—Change in appearance of the articular inflammation—
Tendency to attack the great toe—Suppuration rare—Topical remedies of small value
—Cold of doubtful propriety, if not dangerous ..... 938
LECTURE CLXVIII.
DR. BELL.
Chronic Gout—Its analogy to dyspepsia—Treatment analogous—Case in which direct
depletion was required—Chronic gout is seen in females—Analogy to rheumatism__
Local treatment of service—Chronic gout more harassing and continued than the
acute—Chalky concretions—Sediments in the urine—Irregular Gout; its sub-varieties
—Admission of atonic or misplaced gout hypothetical—Comparisons of diathesis and
diseases—Restriction of term gout to articular inflammation with constitutional dis-
order—Prophylaxis—Conditions for prevention—Hygienic and therapeutical means__
Necessity of restricted and regulated diet—The appropriate drink—Exercise and
fresh air—Perseverance in prophylaxis . . 94g
LECTURES
ON THE
THEORY AND PRACTICE OF PHYSIC.
LECTURE LXXXIV.
DR. BELL.
DISEASES OF THE RESPIRATORY APPARATUS.
More satisfactory diagnosis of Thoracic Diseases in late years — Auscultation
and Percussion—Auscultation properly includes percussion—Its application to diag-
nosis—Laennec the father of auscultation—The physical laws from which it is de-
duced—Chief sounds elicited by the pulmonary apparatus : I. During respiration :
II. By the voice: 111. By coughing : IV. Those of an adventitious kind.—The first
class, or the Respiratory, subdivided into two orders, the simple and the compound—
The simple includes the respiratory or vesicular sound or murmur, also called puerile
respiration, the bronchial and tubal or blowing, the cavernous and the amphoric—Orierin
and diagnostic value of these sounds—The compound sounds, or rhonchi, are moist and
dry—ofthe moist are the mucous or moist bronchial, cavernous, sub-mucous and humid
with continuous bubbles—These explained—Crepitant or moist crepitant, sub-crepitant
or rhonchus redux, cavernous—Pulmonary crumpling sounds—The dry rhonchi are
classed under the head of sibilant and sonorous—Explanation of these terms—[I. Vo-
cal Auscultation gives natural and morbid bronchophony, also ozgophony, pectoriloquy
and amphoric resonance—III. Sounds in Coughing—The bronchial, cavernous and
amorphic, and metallic tinkling—IV. Adventitious Sound—These are friction sounds,
viz: the grazing, friction proper and grating—Table of morbid phenomena of respira-
tion coexisting with inspiration and expiration—Sounds of the he.ut and vascular
murmurs modified by the state of the lungs—Theories of M. Beau and Dr. Skoda—M.
Beau's views of resonance explained—Objections—Dr. Skoda's views of consonance
applied to vocal sounds—His division of the sounds in respiration—Stethoscope, and
manner of conducting auscultation-
Within the last quarter of a century the investigation of diseases of the
organs contained in the thoracic cavity has been conducted on a much
more certain basis than formerly; and some well-ascertained physical
laws are now applied to guide us to a diagnosis, the general accuracy of
which is in most satisfactory contrast with the vague generalities before
prevailing on this subject. The means for reaching these favourable
results, or physical diagnosis, are by Auscultation and Percussion,
terms of which the etymology, like most of those of a scientific character,
conveys a more imperfect notion of the range of subjects than they are
actually intended to cover.
Auscultation, literally the art of listening, now indicates a particular
method of investigating the state of certain organs, by the different sounds
given out when the ear is applied on or over them, or heard when the
VOL. n.—3
26
AUSCULTATION AND PERCUSSION.
adjoining cutaneous surface is struck by the fingers or by instruments. 10
this latter mode of investigation the term percussion is applied. Ausculta-
tion enlightens us only on the physical states and changes of the organs,
leaving to other modes of investigation the ascertaining of vital pheno-
mena. But, as no physical change can take place in a living tissue or
organ without a modification, at the same time, of its vitality, ausculta-
tory results, deduced from a comparison of the healthy and morbid states
of an organ, become an evidence of pathological changes, and even ofthe
successive steps of these changes—from the first slightest lesion to com-
plete disorganization.
Auscultation is applied primarily and mainly to the acquiring of a diag-
nosis of the diseases of the thoracic viscera, and also, but with less
certainty of detail, of those of the abdominal viscera, pregnancy, frac-
tures, injuries of the brain, and sometimes penetrating wounds of the
chest and abdomen. In its application to the study of thoracic diseases
it is termed pulmonary or cardiac, according as the sounds heard are
elicited from the lungs or from the heart.
Laennec, the first to reduce the scattered facts to a system, and who must
really be regarded as the father of auscultation, based his observations on
a well-known principle in acoustics ; viz., that air in passing through and
impinging on tubes of various diameters with varying force, will give rise
to particular sounds. He taught and, with few exceptions, his contempo-
raries and successors have accredited the opinion, that the sounds heard
in respiration, on applying the ear to the chest, are the results ofthe fric-
tion of the air against the walls or sides of the trachea, bronchiae, and pul-
monary vesicles, and, in the case of morbid changes, of dilated tubes and
cavernous excavations. Modifications of these sounds will be caused by
the interruption to the free passage of air through the canals by mucus or
pus adherent to the sides or when detached and partly filling the cavities,
or by bubbles of air engaged in mucus, &c. The distinctness and clearness
as well as quality of the sounds conveyed to the ear, when it is directly
applied to the chest (immediate auscultation) or indirectly by a stethoscope
(mediate auscultation), will vary with the nature and amount of the tis-
sues and morbid products interposed between the pulmonary tubes inter-
nally and the skin externally. Hence, when the tissue of the lungs is
more compact than usual, as in hepatization, or is infiltrated with fluid, or
when fluid is contained in the pleural cavity, the sounds from the tubes
will of course be different from those given out when the pulmonary tis-
sues and its envelopes are in a normal condition. Some farther modifi-
cations, as respects force and distinctness, may be expected from the
greater or less thickness of the walls of the thorax, and the relative pro-
portion of muscle and adeps between the ribs and skin ; but they are of
less moment than the obstructions to the conveyance of sound internal to
the thoracic parietes.
In the details of auscultation applied to the diagnosis of pulmonary
diseases, I cannot be expected to engage in this place ; and must refer
you, if you are not already in possession of one or other of them to
the manuals on the subject by Drs. Gerhard and Walshe,- MM. Barth
and Roger, Dr. Hughes, &c, or to my Introductory Chapter to Dr.
Stokes's Treatise on Diseases of the Chest, 2d Edition, recently pub-
lished, and the excellent Lectures of Dr. Williams. You will find that I
have indulged in some critical remarks on the want of harmony, as
MODIFICATIONS OF RESPIRATORY SOUNDS.
27
respects terminology and the meaning attached to the same terms, among
some of the most esteemed writers on the subject of pulmonary auscul-
tation. In the main, however, there is sufficient accordance of opinion
among a large majority of these to entitle their statements to confidence,
so far at least as to induce you to make your own observations and thus
to verify antecedent experience. The most that I can now attempt is to
mention briefly the chief sounds elicited by the pulmonary apparatus, and
which are heard by applying the ear on the chest or to one end of the
stethoscope, the other resting on the chest. These sounds are of four
kinds. I. Those given out during the process of respiration. II. Those
furnished by the voice in speaking. III. Those during coughing. IV.
Those of an adventitious kind or friction sounds.
I. The sounds of respiration have been divided into two classes. 1.
Simple sounds or murmurs. 2. Compound sounds or rattles. The first
are caused, with various modifications, by the simple blowing of air; the
second by the admixture of air and liquid together.
The first of the simple sounds or murmurs in respiration, and character-
istic of the normal state, is the respiratory, as it was termed by Laennec,
or the vesicular by Andral, a term now more generally adopted. It is
that of a soft and gentle, or, as it has otherwise been described, a mellow,
continuous, gradually developed, breezy murmur, unattended with a sen-
sation either of dryness or humidity. You are to understand, in reference
to this word vesicular, that it is meant to designate the seat but not the
character ofthe sound ; not one which conveys the notion of a successive
dilatation of separate vesicles, or, as it is sometimes called, pure and
vesicular. This sound is chiefly inspiratory ; the expiratory is not only
much weaker but is of less duration. A precise estimate ofthe degree of
difference between the two has been made by M. Fournet, who fixes on
10 : 2 as the ratio of their comparative intensity and duration in the healthy
state. MM. Barth and Roger say 3 to 1. These two murmurs follow
each other so closely, however, that they may, practically speaking, be
said to be continuous.
The vesicular sound is more distinct in thin than in fat or muscular,
and in very young than in old subjects. In young persons, whose respira-
tion is naturally frequent, the sound is more loud and slightly blowing,
constituting what has been called puerile respiration, or puerile vesicular
murmur. It is heard best at the anterior and lateral parts, and in the
lower two-thirds ofthe posterior part ofthe thorax.
In some instances, this puerile sound has a pathological signification,
as when it is partial or only heard over particular portions of lung, and
then in exaggerated strength to make up for the deficiencies of other
parts. Hence the propriety of the term supplemental affixed to it, on
these occasions, by M. Andral.
Bronchial, or Tubal and Blowing, is the next modification of respira-
tory sound : M. Louis terms it, an approach to the bellows sound, heard
in the space between the vertebral edge of the scapula and the dorsal
spine, at the level of the origin of the bronchia. This blowing respira-
tion, which exists, also, though in a less degree, towards the sub-spinal
fossae, is more marked on the right than on the left; a difference accounted
for by the greater calibre of the right than the left bronchia. It resembles
the sound produced by blowing through the hand, rounded into the form
of a tube, or through a stethoscope. This bronchial is also called tracheal
28
PULMONARY AUSCULTATION.
or tubal murmur or sound. It is both normal and morbid. It diners from
the vesicular, not only in the degree but in the quality of sound ; it is
louder, harsher, and rougher ; and has this additional peculiarity, that
the intensity and duration of the respiratory sound are increased to such
an extent, as to equal, in these respects, the inspiratory. M. Fournet
points out the error, occasionally committed, of mistaking the pharyngeal,
buccal, and nasal murmurs, for bronchial respiration produced in the
regions to which the ear or stethoscope is applied. The correction is
made by causing the patient to change the form of the openings of those
parts during the auscultation, and to vary the degree ofthe rapidity with
which the air enters them.
Closely allied to bronchial respiration, and by M. Andral described as
one of its varieties, is the blowing or puffing respiration, which gives a
sensation as if the air was drawn during inspiration from the observer's
ear or from the surface of the chest, and puffed back with equal force
during expiration.
Still of the same order and alliance of sounds is the cavernous, tersely
described by Laennec as the sound produced by inspiration and expira-
tion in an excavation formed in the substance of the lungs, whether it be
from the softening of a tubercle, from gangrene, or from abscess. It re-
sembles that made by breathing strongly into the two hands disposed so as
to form a cavity. It requires a practised ear to distinguish between the
cavernous sound and bronchial or tracheal respiration.
A modification of the cavernous respiration is described by Laennec
under the title of veiled puff. Very analogous to the cavernous is the
amphoric resonance, or amphoric respiration. M. Louis describes it, as
arising from air entering a large cavity through a narrow opening.
I have now mentioned the chief simple sounds or murmurs which are
either the vesicular or modifications of this latter ; and which are sup-
posed to depend on a current of air impinging, with more or less force,
on tubes (larynx, trachea and bronchia?), or their minute subdivisions into
cells, or on the sides of morbid cavities, as of dilated bronchia?, pulmonary
abscess, and softened tubercle (vomica). Next, I have to speak with
equal brevity of the other division of sounds.
Compound Sounds or Rallies (relies, rhonchi). These sounds may be
said to supersede the respiratory murmurs : they are caused by the partial
obstruction to the passage of air through the bronchial tubes, or to its
introduction into their terminal vesicles, owing to a narrowing of these
cavities, or its admixture with liquid of some kind. Of this class there
are two primary qualities of sound—the humid or moist, and the dry rhon-
chi. The last is merely a comparative term to establish a kind of con-
trast with the rhonchi more evidently moist. Many divisions or varieties
of these rhonchi have been detailed by different auscultators, which I
shall not now repeat; but shall restrict myself to the following, as suffi-
cient for practical purposes :—1. The mucous rhonchus or moist bronchial
rhonchus or rattle, the large crepitating rale of Laennec. The death
rattle, as it is called, conveys a good though exaggerated idea of this
sound : it evidently depends on the passage of air through tubes con-
taining a fluid which gives rise to a bubbling, compared to that produced
by blowing through a pipe into soapy water. The sound of bubbling is
generally interspersed with some whistling, chirping, or hissing notes.
This mucous rhonchus is one of the signs, as summed up by Louis •
COMPOUND RESPIRATORY SOUNDS.
29
" first of pulmonary catarrh ; it then exists on both sides, and progres-
sively descends; secondly, of phthisis when the tubercle becomes soft;
it then occurs at the apex of the lungs, under the clavicle ; thirdly, of
gangrene ; fourthly, of dilatation of the bronchia ; fifthly, of abscess of the
lung. It is generally circumscribed and confined to one side. When
alone, therefore, it cannot form a pathognomonic sign." In unnatural
enlargement of the bronchial tubes, the bubbling of air through them is of
the coarsest kind ; it is quite gurgling, and if the liquid be scanty, has a
hollow character entitling it to be called cavernous rhonchus.
A roughness added to the ordinary respiratory murmur or more regu-
lar but weaker sound of bubbling, constitutes the sub-mucous rhonchus of
some writers. It may result from a slight degree of bronchitis, but acquires
its chief importance by its being permanently present when bronchial
inflammation is constantly kept up by the irritation of adjacent tubercles
in an incipient state.
Under the title of humid rhonchus with continuous bubbles, M. Fournet
describes a morbid sound, which, he states, existed in twenty-three sub-
jects, the only ones carefully examined, affected with sanguineous conges-
tion of the lungs.
2. Crepitant rhonchus or moist crepitant rhonchus has been compared
to the sound produced by salt when thrown on live coals, or by pressing
a thin layer of healthy lung between the fingers ; or by dry parchment or
silk stuff rubbed between the fingers ; also to the sound of tearing a piece
of sarcenet, and hence, according to Chomel, who adduces this compa-
rison, it is often called the sarcenet sound. Dr. Williams, with more
approach to reality, compares the crepitation in question to the sound
which can be produced by rubbing slowly and firmly between the finger
and thumb a lock of hair near one's ear. Dr. Corrigan remarks, on such
comparisons, that they are bad, as they lead us away from the manner of
the production ofthe sound.
This sound, called also humid vesicular, is exactly that of small bub-
bles breaking through fluid, and, it is thus produced in the diseases in
which it is heard—in pneumonia and oedema of the lung. Crepitant rhon-
chus is chiefly, but not exclusively, met with in pneumonia, of which it
is represented, however, as diagnostic. Besides in oedema it is heard in
apoplexy of the lungs, and occasionally in pulmonary catarrh and bron-
chitis. It is small, clear, and, most usually, it is accompanied by vesicu-
lar murmur. M. Louis makes a remark of some importance on this
rhonchus, viz., that it is heard over the whole chest of some healthy per-
sons at the moment of a first forcible inspiration, after which it disappears.
3. Sub-crepitant rhonchus, or by some (Laennec and Chomel) called
rhonchus redux, rale de retour, produces a sensation similar to that heard
on applying the ear near the surface of a liquid slightly effervescing, or
blowing with a pipe into soap-suds. It has been subdivided into the
sub-crepitant, the liquid, and the continuous. Dr. Corrigan, on the other
hand, does not believe sub-crepitant rhonchus to be a division available
in practice or recognised by the ear; while M. Louis thinks that it can-
not be mistaken. It is met with in pulmonary catarrh, or bronchitis in its
most acute and intense form ; and in this case it is confined chiefly to the
posterior and inferior part of the chest, or is heard in both sides at once :
or if it extends to the upper it always begins below. At the summit of one
or both lungs, it indicates local tubercular bronchitis, or tubercles in a state
of softening.
30
PULMONARY AUSCULTATION.
Cavernous Rhonchus—Gurgling.—Consists of a limited number of bub-
bles of large size, distinctly projected, having a peculiarly hollow metallic
sound, coexisting commonly with inspiration and expiration, but occasion-
ally ceasing to be produced for a time—with or without cavernous respi-
ration. It commonly arises from a cavity in the lung, or from a largely-
dilated bronchial tube. M. Fournet mentions a pulmonary crumpling
sound, resembling the new leather-creak of pericarditis, and conveying to
the ear the impression ofthe crumpling of a tissue pressed against a hard
resisting substance. It was detected by him in the first stage of phthisis,
in one-eighth of the cases ; also in one case of encephaloid tumour of
the mediastinum, and in another of non-tuberculous cavity of the summit
ofthe lung.
Of the dry rhonchi we have the sibilant and sonorous, included under
the head of the dry bronchial. The sibilant resembles a slight and pro-
longed whistle, as if through the teeth; and is either grave or acute, dull or
clear : it is capable of masking the respiratory sound. The sibilant rhon-
chus generally occurs in tubes narrowed by swelling of their mucous or
sub-mucous coats; and hence, but in limited extent, is met with in
pulmonary catarrh, or in the early stages of acute bronchitis ; and, also,
in asthma or pulmonary emphysema. In typhoid affections it occurs in
three-fifths of the cases, generally about the eighth day, and over the
whole of the chest.
The sonorous rhonchus is a grave, and sometimes an extremely loud
sound ; at one time resembling snoring ; at another the sound of a
bassoon ; and very frequently it is the cooing of a turtle-dove. It is
most commonly met with at the beginning of pulmonary catarrh.
We are very properly told by Dr. Williams that, as any of these rhon-
chi may be produced in only one tube and yet make a great deal of
noise, it is not to be supposed that they are important in proportion to the
noise they make. It is rather when they are very permanent, or when
several of them are heard at once in different parts of the lungs, that they
announce disorder, which may be serious either from its permanency or
its extent.
II. Sounds furnished by the voice in speaking; or Auscultatory Vocal
Phenomena. I now come to the second division, or auscultation of the
voice. That a vibration is communicated to the parietes of the chest
during the act of speaking is evident to another person whose hand is
placed on this cavity at the time ; but still more so if the ear be applied
through the intervention of the stethoscope. The phenomenon thus
heard is called vocal resonance, and is modified according as the stetho-
scope is applied over the larynx, trachea, or bronchia. It is then called
natural laryngophony, tracheophony, and bronchophony. The voice at
this time is transmitted from the larynx and trachea with a startling force
and loudness.
Natural bronchophony, which, though loud, is considerably less intense
than the vocal resonance of the air tube before its bifurcation, is heard at
the upper part of the sternum on the middle line, and with less force
towards the edges of this bone ; behind, in the middle line, over the
division of the trachea; and, on either side, between the spines of the
scapula?. In proportion as the bronchial tubes ramify and are buried as
it were, in the spongy pulmonary tissue, the sound originating in the
vibrations of the glottis becomes deadened or dull; or it is merely an ob-
AUSCULTATORY VOCAL PHENOMENA.
31
scure and diffused buzzing, a kind of vibration or fremitus, which may,
as before remarked, be felt by the hand placed on the chest.
As there is no absolute standard of vocal resonance by which to measure
deviations, we cannot say what should be considered a sign of disease, on
our applying the ear or stethoscope to any part of the chest. But as there
is, generally, symmetry in the two sides, and as the resonance is equal,
except under the clavicles and on each side the spine between the spines
ofthe scapula, in which it is somewhat stronger on the right, any very
notable difference between the two sides may be considered as morbid.
If, for example, under one clavicle the voice resounds loudly, while it is
scarcely heard under the other, we may be sure that there is some physical
difference between the two sides which does not exist naturally. This
leads us to inquire what are the circumstances which give rise to changes
in the natural voice.
1. Morbid bronchophony occurs in the same morbid states of the lung or
tube under which morbid bronchial respiration is evolved. The condi-
tion for the more ready and complete transmission of sound in the tubes,
whether by vibrations of air in breathing, or of the walls of the tubes in
speech, are the same, viz.:—increased induration and solidification of the
tissue interposed between the tubes and the thoracic parietes. The two
kinds of signs are then associated, and whenever one is heard we are
pretty sure to find the other. They are met with in red or grey hepatiza-
tion of the lung, in pneumonia, in pleuritic effusions, and in indurations
ofthe pulmonary tissue, as in tubercles and dilated bronchia.
2. (Egophony is another ofthe modifications of vocal resonance in cer-
tain morbid states ofthe lungs. It sounds to the ear like the bleating of
a goat, and hence the origin of this term, introduced by Laennec. The
voice is rendered thus broken and tremulous by its transmission through
a liquid effused between the pulmonary pleura and the costal pleura, and
which is thrown by a vocal resonance ofthe lung into a state of irregular
vibration.
When most strongly marked, cegophony is distinctly metallic, jarring
and muffled, is synchronous with the articulation of each word, or follows
it immediately, like a shrill echo of natural resonance, conveying the idea
of a distant origin. It does not appear to traverse the stethoscope, but rather
to flutter tremulously about the applied end. CEgophony may be regarded
as a favourable sign in pleurisy, as it indicates but a moderate degree of
effusion; but we cannot regard it as pathognomonic of this state. It is heard,
generally, on one side in the lower half of the sub-spinal scapular space,
but may change its position on the different portions of the body.
3. Pectoriloquy—cavernous voice—is a still greater degree of vocal reso-
nance, in which not only the voice but speech reaches the ear from a
cavity formed in the lungs, as if the patient spoke directly in the ear of
the auscultator. The cavity must be of some size, and communicate
directly with the bronchia?. This takes place in phthisis, gangrene of
the lung, and abscess, and in considerable dilatation of the bronchial
tubes. Curgling is often heard at the same time with pectoriloquy, and
adds to its diagnostic value.
4. .l/iiphoric Resonance or Metallic Tinkling designates that peculiarity
of transmitted sound in speaking, which conveys the idea of its being
produced in a hollow space of a large size, and it is hence called amphoric
—like the humming produced by speaking across the mouth of a large pit-
32
PULMONARY AUSCULTATION.
cher, three-fourths empty. It coincides usually with amphoric respiration.
It may be produced in the cavity left by a large vomica or abscess, or
by several of these coming together; but its more common seat is the sac
of the pleura, into which air has entered through a fistulous opening in the
lung.
I must not conclude this division of our subject without apprising you,
that the best auscultators ofthe day are far from attaching the same im-
portance to these different vocal resonances, in a diagnostic point of view,
that Laennec did, or from believing that they can be as readily distinguished
as he supposed.
III. Auscultatory Tussive Signs, or Resonance of the Cough.—In our
endeavours to ascertain the sounds elicited by coughing, we pursue the
same steps as in the case of the resonance of the voice in speaking ; and
hence the divisions of the cough, in pulmonary disease, into bronchial,
cavernous, and amphoric, corresponding, in fact, very much with broncho-
phony, pectoriloquy, and amphoric respiration ; the former sounds being
elicited by the act of coughing,—the latter by the voice. In a semeiolo-
gical point of view, the sounds from coughing have less value than those of
the voice, as these latter have less than those of respiration.
Metallic Tinkling, already spoken of in connexion with amphoric
resonance, is less commonly produced in respiration than as a phenomenon
of vocal or tussive resonance. In some instances it is evolved only by
forcible coughing. It is a name given to a quick, sharp, ringing sound,
closely resembling that produced by gently striking a hollow metallic or
glass vessel with a pin. I shall most probably have occasion to speak of
the origin of this sound in a future lecture.
Auscultation of the Larynx is thus described by MM. Barth and
Roger:—" In the healthy condition of the larynx, the respiratory sound
has a hollow and cavernous tone, the vocal resonance is at its maximum,
and the cough gives the sensation of the rapid passage of air through a
hollow space. In the pathological condition, the laryngeal respiratory
murmur is harsher, or more rasping, as, for instance, in acute or chronic
laryngitis, or else it is replaced by a whistling sound, as in spasm or oedema
of the glottis, in stridulous laryngitis, in some cases of foreign bodies in,
arid compression of, the trachea ; or by a sonorous tone, as in the case of
laryngeal ulceration with thickened edges, and obstruction to the passage
ofthe air ; or again, by a snoring sound, as in simple or stridulous laryngitis,
ulcerations, laryngeal vegetations, fyc,—a sound which has frequently a
metallic tone in croup.
" In some circumstances, the ear perceives ^laryngealcavernous rale, as,
for example, when the trachea and larynx are filled with mucus, this rale
may be more circumscribed and confine itself to the presence of the mucus
upon an ulceration, or around a foreign body arrested in the ventricles, &c.
Finally, in some rare cases, we hear a tremulous ox vibrating sound, which
announces the existence of croup with floating false membranes. There
is another sign, that is met with in a great many diseases of the larynx,
that may be established, it is true, by auscultation of the chest, but which
ought to be mentioned here : it is the diminution, or complete obliteration
of the vesicular murmur. This phenomenon accompanies every alteration
which offers an evident obstacle to the introduction of air into the air pas-
sages, whether it obstruct or narrow the diameter of the tubes (as swelling
inflammation, vegetations, accidental products, foreign bodies, &c.) whe-
COEXISTFVCE OF MORBID PHENOMENA OF RESPIRATION 33
ther it compresses them from without (cancerous tumours, cysts, aneu-
risms, &c), or whether, finally, it produces more or less complete occlusion
ofthe superior orifice ofthe air tube (as hypertrophy ofthe tonsils, polypi
of the nasal fossa? falling upon the superior part ofthe larynx, &.c).—Br.
Francis G. Smith''s Translation, pp. 48-50.
IV. Adventitious or Friction Sound.— This sound is produced by the rub-
bing together ofthe two opposing surfaces of the lamina? of the pleura,
when the latter is in a morbid state from having lost its polished smooth-
ness ; and hence the propriety of the title friction sound. It exhibits
three varieties : viz., 1. The grazing sound. 2. Friction sound, properly
so called. 3. Grating sound.
These sounds are always audible in inspiration, but not so in expiration,
unless they be strongly marked : thus the grating variety is not perceived
in the latter movement, while the others manifest themselves in both.
Under all circumstances, they appear first in, and disappear last from
inspiration. It requires great attention to distinguish the rubbing sounds
from similar ones arising from the movement of the clothes of the patient
or the observer. Pleural friction sound consists either of a single, or, more
commonly, of a series of jerking sounds, few in number, manifestly super-
ficial in seat, and varying in harshness, tone and intensity, so that it may
be divided into soft friction or rustling, and hard friction or rasping. It
is audible over a variable, but usually limited, extent of surface ; per-
sistent or intermittent; of variable but commonly more or less consider-
able duration; almost always heard in inspiration, and more intensely-
developed with that movement, but most frequently accompanying both
inspiration and expiration. Friction sound is one of the first signs of pleu-
risy ; but rapidly ceasing with effusion, to return often after absorption,
and especially when false membrane is formed between the two pleural
surfaces. It is met with in interlobular emphysema, according to Laen-
nec ; and it occurs also sometimes in pleuro-pneumonia towards the de-
cline of the disease, and when convalescence has set in.
In illustration of some ofthe important associated phenomena of auscul-
tation, I shall introduce the following table by M. Fournet, for which I
am indebted more immediately to the British and Foreign Medical Review,
vol. ix. :—
Table, showing the mode of coexistence of the Morbid Phenomena of
Respiration with Inspiration and Expiration.
[The order in which the different phenomena are set down in each division, exhibits the
degree to which they relatively acknowledge the law regulating them all.]
A. Morbid Characters coexisting exclusively, or almost exclusively,-with Inspiration.
1. Humid rhonchus with continuous bub-
bles.
2. Primary crepitant rhonchus of pneumo-
nia.
3. Mucous rhonchus of third stage of pneu-
monia.
4. Grazing pleuritic sound.
5. Pulmonary crumpling sound.
6. Dry crackling rhonchus.
7. Sub-cropitant rhonchus of oedema.
VOL. II.—4
8. Sub-crepitant rhonchus of capillary bron-
chitis.
9. Rhonchus crepitans redux of pneumo-
nia.
x.b. The first three sounds coexist
exclusively with inspiration ; the others
sometimes occur in expiration also, but
exceptionally only. The frequency of these
exceptions increases from .No. 4, down*
wards.
34
PULMONARY AUSCULTATION.
B. J forbid Characters Coexisting with both movements.
Humid cavernous rhonchus
Dry cavernous rhonchus.
C Bronchial }
Dry < Tracheal > rhonchi.
C. &c* j
Cavernous rhonchus.
Grating pleuritic sound.
Friction pleuritic sound.
Augmentations of intensity.
Diminutions of intensity.
Augmentations of duration.
Diminutions of duration.
11. Amphoric character.
C Cavernous character-
l*' 2 Veiled puff.
13. Bronchial character.
14. Metallic tinkling and echo.*
15. Blowing character.
16. Kinging character.
17. Clear ditto.
18. Mucous rhonchus.
19. Humid crackling ditto.
20. Dry, hard, rough, laborious character.
21. Humid character.
C Morbid Characters coexisting chief y -with Inspiration.
1. Diminution of duration and intensity.
2. Complete cessation.
3. Humid character.
4. Dry character.
5. All varieties of friction sound.
6. Pulmonary crumpling sound.
7. Dry crackling rhonchus.
8. Sub-crepitant rhonchus of oedema.
9. Sub-crepitant ditto of capillary bronchitis.
10. Rhonchus crepitus redux.
11. Humid crackling rhonchus.
12. Bucco-pharyngeal rhonchi.
13. Cavernulous rhonchus.
14. Gurgling ditto.
15. Humid, bronchial, tracheal, laryngeal
rhonchi.
16. Dry acute-toned bronchial, cavernous,
tracheal, laryngeal rhonchi.
D. Morbid Characters coexisting chiefly -with Expiration.
1. Augmentation of intensity and duration.
2. Metallic tinkling and echo.
3. Clear character.
4. Ringing ditto.
5. Blowing ditto.
6. Bronchial character.
7. Cavernous ditto.
8. Amphoric ditto.
9. Dry grave-toned bronchial, cavernous,
tracheal, laryngeal rhonchi.
E. Morbid Characters coexisting first -with Inspiration, and then extending to Expiration.
1. Pleuritic friction sounds.
2. Dry and humid crackling rhonchi.
3. Hard, rough, dry, laborious character.
4. Humid character.
5. Crepitant rhonchi, primary and redux.
F. Morbid Characters coexisting first -with Expiration, and then extending to Inspiration.
1. Clear character.
2. Ringing ditto.
3. Blowing ditto.
4. Bronchial character.
5. Cavernous ditto.
Sounds ofthe Heart and Vascular Murmurs have a diagnostic value in
pulmonary auscultation, as when we find them propagated to a greater
extent, or with more force in certain directions than in health, without
the heart or the vessels being the seat of the disease. The positive in-
tensity of the heart's sounds is unaltered, but its relative intensity,
as discovered in different parts of the thoracic surface, is changed!
In the latter case, we infer, if the cardiac sound be more intense than
* In some cases of hydropneumothjprax with perforation, observes M. Fournet " the
metallic tinkling of Laennec is not to be discovered ; but, instead, the amorphic character
of the respiration seems to reverberate in a sort of vague diffused echo, which rinas like
the voice under an archway ; this phenomenon may he called resonnance metallique ■ it
often accompanies the voice and cough." The English reader will here recognise the
precise description, almost the very words, of Dr. Williams, in reference to the pheno-
menon of tinkling echo. "
THEORIES OF AUSCULTATION.
35
common, that the lung or pleura has undergone some change, rendering
them unusually good conductors of sound. Or there may be rarefaction
in certain limits, so that the sounds of the heart's beats shall be less dis-
tinctly heard than common.
Theories of M. Beau and of Dr. Skoda on Auscultation.—1 have for-
borne from introducing any conflicting theoretical views and explanations
which assume a different basis from that laid down by Laennec and, gene-
rally, by his contemporaries and immediate successors up to the present
time. But, brief as is my present sketch, it ought to include, for your
information, a notice of certain positions advanced by some other writers
and observers, who claim for them, also, the enforcement of physical laws
and of experimental observation. The chief of this class of auscultators
are M. Beau, of Paris, and Dr. Skoda, of Vienna.
M. Beau advanced his new thccry of the sounds heard in respiration
in the Archives Generates de Medecine, in 1834, and in a series of papers
in the same journal for 1840 he enlarged and enforced his views with
additional illustrations and arguments. His cardinal proposition is, that
the sounds heard during respiration are elicited by the same means as
those formed by the voice in coughing, viz.:—primarily at the glottis and
upper apertures by vibrations at these parts, and secondarily by the tra-
cheo-bronchial tubes and ramifications receiving and transmitting these
vibrations, which finally pass through the pulmonary parenchyma, and
envelopes to the walls of the chest, and thence to the ear resting on
thin last. The movements of the air in them has little to do in either
case with the sounds heard externally. If, in common respiration,
a person snores, to use a familiar example, the sound thus made at
the nostrils, and more particularly at the velum palati and pharynx,
resounds through the bronchia? and vesicles, and is heard by the ear
applied to the chest. This fact, which I have myself noticed, seems to
be not a little confirmatory of M. Beau's theory of resonance, as the noise
made in the mouth and fauces at this time is not accompanied by any
corresponding deviation from the usual respiratory movements, by which
the air might be introduced into the bronchia? and vesicles with more
force than ordinary. The chief sounds made resonant in the bronchia? are
the glottic, according to M. Beau's explanation.
Dr. Spittal, of Edinburgh, after having become cognisant of the views
of M. Beau, advanced in 1834, instituted several experiments, which,
together with accompanying reflections, he has recorded in the Edinb.
Med. and Surg. Journ. (1839). Dr. Spittal's results are fully confirmatory
of the theory of the French writer.
M. Beau enumerates the orifices or openings of the respiratory pas-
sages, capable of causing vibrations in the air which traverses them and
of producing the superior sound, which afterwards becomes resonant and
audible in its several varieties, according to the part ofthe laryngo-bron-
chial tube and ramifications over which the ear is applied. These orifices
are five in number, viz.—1. The lips ; 2. The nostrils ; 3. Isthmus of the
pharynx; 4. Orifice of the glottis ; 5. Opening of the larynx. The orifice
of primary, and indeed paramount importance, among all these, is the
glottis; it is the glottic sound " reverberated in the air tubes and pulmo-
nary vesicles that gives rise to all the various sounds of respiration de-
scribed by auscultators. It is a double sound, at one moment inspiratory,
at another expiratory."
36
PULMONARY AUSCULTATION.
You will find a tolerably full synopsis of M. Beau's papers in my Intro-
duction and Appendix to Dr. Stokes's Treatise on the Chest. In this
same work I have also introduced, from the Edinb. Med. and Surg. Jour.
(1841), an outline of Dr. Skoda's theory of auscultation. 1 ought to add,
that MM. Barth and Roger (Practical Treatise on Auscultation—Trans-
lated by Dr. Newbigger, with an Appendix by Dr. Lawson), deny the
accuracy of M. Beau's opinions. I give you the conclusion of their argu-
ment:—
" In summing up this long discussion, which the elaborate exposition
into which M. Beau has entered has in some degree rendered necessary,
let us call to mind the chief propositions which invalidate his theory:
1. The guttural sound is heard the more distinctly the nearer we examine
to the seat of its production, while the vesicular murmur is equally well
heard in every point, where there is a sufficient mass of pulmonary tissue.
2. The guttural sound may be strong, and yet the vesicular murmur ab-
sent ; and, on the other hand, the vesicular murmur may be pure, clear,
and distinct, without the perceptible existence of any noise at the back of
the mouth. 3. An observer, who has had a little practice, can recognise
the production of the guttural sound, at a distance, while the respiratory
murmur takes place immediately under his ear. 4. When a given point
of the chest is explored, the two sounds may be distinguished from each
other, although they exist simultaneously."
Dr. Skoda explains the different degrees of strength ofthe voice in the
chest, and perceptible to the ear applied to it by the law of consonance.
When one body gives the same vibrations with another, or when it pro-
duces the same note, or its vibrations form an aliquot part of the note, it is
said to be consonant with this other body. The note of a Jew's-harp is
scarcely perceptible when it is struck in the air, and it is heard much
more distinctly when played in the mouth. Thus the air in the mouth
must increase the sound of the Jew's-harp ; i. e., must consonate with it.
It sometimes happens that the voice is heard more strongly at the tho-
rax than at the larynx, which itself is sufficient to show that its strength
is increased by means of consonance within the chest. As it is certain
that the air in the pharynx, mouth, and nostrils, consonates with the
sound formed in the larynx, there can be no doubt, Dr. Skoda thinks,
that the air in the trachea and bronchia? may also be thrown into conso-
nant vibrations with the sounds formed at the larynx. Hence it is the
air in the chest and not the parenchyma of the lungs which consonates
with the voice at the larynx, as the latter seems ill adapted for conso-
nating, being neither stiff nor sufficiently dense. The strength of the
consonance depends upon the size and form ofthe spaee in which the air
is confined, and upon the properties of the walls which bound the space.
It appears that the consonating sound of the inclosed air will be strono-er
the more perfectly the walls reflect the sounds which spread through the
air. For air to consolidate, it must be confined within a circumscribed
space. A space surrounded by solid walls produces the greatest conso-
nance, while in a linen tent the sound is but little increased.
The deductions drawn from these physical principles will serve to ex-
plain the consonance of the voice in the chest. The air in the trachea
and bronchia? consonates with the voice as far as their walls resemble
those of the larynx ; and an increase of consonance of the air in the rami-
fying bronchia? ofthe lungs is procured either by their walls being carti-
USE OF THE STETHOSCOPE.
37
laginous or becoming thicker, or by the surrounding tissue of the lungs
becoming devoid of air. Provided, therefore, that there is no interruption
of continuity between the air in the bronchia? and that in the larynx, the
walls of the latter, thus thickened and firmer, reflect the sound more
strongly than the membranous walls of the bronchia? and their vesical
terminations.
It does not follow, according to Dr. Skoda's views, that hepatised lung
should transmit sound more readily, or indeed quite as readily, as the
healthy parenchyma, provided the lining of the cavities including the
bronchia? be sufficiently firm and resisting to cause the air to consonate in
them. The vibrations in the walls of the larynx and the bronchia? are
not, he thinks, transmitted along them from the glottis, in vocal move-
ments ; but they are received from the air in its state of consonance and
are in force and number proportionate to those of the air. They may
afterwards spread through a layer of fluid or of muscle several inches
thick, even to the parietes of the thorax ; and the sounds produced
by consonance on the bronchia? will be perceptible at the walls of the
chest.
But while differing from the school of Laennec as to the mechanism of
the transmission of vocal sounds through the chest, Dr. Skoda describes
nearly as his immediate predecessors, and most of his contemporaries,
have done, the morbid states of the respiratory organ which give rise to
an increased resonance of the voice.
The Austrian professor divides the varieties of respiratory sounds as
follows—1. Vesicular respiration. 2. Bronchial. 3. Indeterminate. 4.
Amphoric and metallic. The Rattles or rhonchi are divided by him into
1, the vesicular; 2, the consonant; 3, the crackling or dry crepitating
with large bubbles ; 4, indeterminate ; 5, rattles with amphoric echo.
I shall conclude by a few directions for the use of the stethoscope what
I had proposed to say in auscultation proper. The best shape for a stetho-
scope (from !tt»9oc, the breast, and , I examine), is that of a perfo-
rated cylinder, hollowed at the chest end into a conical cavity, and the
other end made flat, or slightly concave, to fit the ear ; in some cases, as
when we want to explore small spots of the chest, to ascertain for exam-
ple the extent of resonance, and whether it is produced in a small cavity,
or merely transmitted by consolidated lung from several bronchial tubes
distributed over some extent of surface, we use the instrument somewhat
modified. Its conical cavity is filled up by a conical perforated plug,
which re-converts the instrument into a simple perforated cylinder, and
circumscribes its power. The stopper is also used when we want to shut
out the sound of respiration in listening to the sound of the heart or
arteries.
The stethoscope serves—1. To conduct sound by its solid walls. 2. To
conduct and concentrate sound by its closed column of air (resonance).
3. To transfer sounds from its column of air to its solid walls, or the con-
verse, when circumstances impede their transmission by one of these ways.
4. To diminish this power of transfer, and contract the field of hearing
when small spots are to be explored.
Sometimes a flexible tube, like a common ear trumpet, is used for a
stethoscope, and answers well, like that made of brass wire coiled and suit-
ably covered, the invention of Dr. J. L. Ludlow. It has the advantage
from its flexibility of being applied more conveniently, both for the pa-
tient and the physician, than the straight, rigid tube of wood.
38
PULMONARY AUSCULTATION.
The instrument should be applied in close contact with the chest, at
one end, and with the ear at the other. Continued attention is required
by beginners to prevent the least tilting of the trumpet end, that next the
chest, by which air is interposed and the thoracic sound lost or greatly
weakened.
For the manner of conducting auscultation, we cannot give directions
more clearly and succinctly than by using the language of M. Louis, on
the occasion, as follows :—
" The person to be examined should lie on his back, or sit, according
as we wish to auscult the anterior or the posterior part of the chest; he
must lean neither to the right nor the left; his shoulders must be in the
same plane, and his symmetrical muscles in the same state of relaxation
or tension as the position of the patient.
" The contraction, tension, and relaxation ofthe muscles, have a marked
influence on the results of auscultation, and when the corresponding points
of the thorax are examined in comparison wTith each other, as we must
always do if we want to draw rigorous inferences, we might imagine dif-
ferences that did not exist, merely from the bad attitude of the patient.
" The auscultator, too, must select a convenient position, as Laennec
recommends, and take care that the respiratory sounds are not intercepted
by thick clothes, and particularly that the patient does not retain any
which might produce a fallacious sound, as, for instance, silk coverings.
He must also find out which is his best ear, as experience shows that
almost every observer has one ear finer than the other. All these precau-
tions, which at first sight may seem over-punctilious, are absolutely neces-
sary to prevent our falling into gross errors.
" In opposition to Laennec, it is now allowed that the naked ear per-
ceives sounds as well as when aided by the stethoscope ; and, indeed, it
often happens that it distinguishes shades of sound which had escaped it
when assisted by this instrument. The cases in which we ought to pre-
fer mediate auscultation are very rare, and it is often necessary to have
recourse to immediate auscultation to determine with clearness what would
otherwise be obscure.
" The patient and the observer being properly placed, auscultation, to
be successfully practised, requires another condition, namely, the ear, if
unaided,is to be exactly applied to the chest; if the stethoscope is used,
the whole of its circumference is to be applied to the parietes of the tho-
rax, so that if the patient is so wasted that the intercostal spaces leave a
cavity under the stethoscope, it must be filled up by compresses placed
upon the thorax."
VARIETIES OF PERCUSSION.
39
LECTURE LXXXV.
DR. BELL.
Physical Diagnosis of Pulmonary Diseases (Continued).—Percussion—Defined—
Avenbrugger its discoverer for diagnosis in thoracic diseases—Corvisart—Piorry—
Two varieties, immediate and mediate—Mode of using immediate percussion—Divi-
sions of mediate percussion—Plexirneler—Substitution for it of a finger or fingers
—Chief percussing agents, a hammer and the fingers—Directions for mediate percus-
sion— Percussion of the chest—Different regions in which it is practised—Postures of
the patient and physician in percussing the different thoracic surfaces—What found
on percussion—A verifying of different states ofthe lungs and pleural cavity—Diffe-
rent sounds in different regions ofthe chest—Two chief divisions of sound on percus-
sion of the chest, viz., increased sonorousness and diminished sonorousness or dulness—
Auscultatory percussion—Autophonia—Snccussion—Inspection—Measurements—In-
struments for—Two sides of the chest seldom quite symmetrical—Comparison—Value
of comparison—Application of, to diseases of the chest—Sources of physical diagnosis
—Improved diagnosis not always immediately productive of improved therapeutics.
Percussion.—I shall continue a description ofthe methods of physical diag-
nosis of diseases of the lungs, by some remarks on percussion. This term is
applied to the act of striking the external surface of any of the great cavi-
ties,but more particularly the chest,for purposes of diagnosis. M. Piorry de-
fines it to be, a method of exploration, by which impulse, imparted to an or-
gan or the walls of a cavity, gives rise to a sound and a degree of resistance
fitted to enable us to judge of the physical state of the part to be explored.
This is obviously a kind of auscultation ; the sounds listened to being artifi-
cially made by the observer instead of being the result of vital actions in
the interior of the organ. But percussion is something more than mere aus-
cultation, since it impresses the sense of touch also; and hence every per-
cussion gives rise to two distinct sensations, which the examiner or ope-
rator ought to analyse. They are, the sensation of touch and that of hear-
ing ; the former of which not being appreciated by the observers near,
prevents them from distinguishing degrees of sound, of which he who per-
cusses is readily sensible.
We are indebted to Avenbrugger of Vienna for the discovery of per-
cussion as a means of diagnosis ; but it was not until after the lapse of
some years, and when Corvisart became the translator of the German
work, and applied the method to detecting diseases of the heart, that it
attracted any notice. At the present time we are indebted to M. Piorry
more than to any other writer for the extension and precision of view
and of practical detail in percussion. Favourable mention may, also, be
made of M. Mailliot, his pupil and commentator, who, in his Traite
Pratique de Percussion, has presented with adequate clearness the promi-
nent particulars ofthe subject.
There are two varieties of percussion ; direct or immediate, and mediate.
Immediate percussion consists in striking directly with the fingers or hand
on the skin over the part to be explored. Mediate percussion consists in
striking the part by the intervention of another body. Avenbrugger and
Corvisart practised direct percussion. The former used the four fingers
of his right hand closely united on a level with each other ; the ball of
the thumb being placed firmly against the articulation of the second pha-
40
PERCUSSION OF THE CHEST.
lanx ofthe index finger, so as to support and give firmness to the fingers.
The points ofthe fingers are then to be brought down perpendicularly on
the surface with a sharp and quick stroke, which is found to produce a
sound varying in properties with the condition of the subjacent parts.
Avenbrugger recommended that the patient's chest should be covered
with a thin dress, or that the operator should wear a glove, so as to pre-
vent the sort of click resulting from the contact of the naked hand and
skin. Corvisart struck the chest with his open hand, in order, as he
alleged, to be able to appreciate the extent of the portion of the thorax
which did not resound, and to determine more accurately the nature of
the obstacle.
Mediate percussion consists in striking the parts to be examined by the
intervention of another body. Some, and they include the larger number
of English and American physicians, make use of one or more fingers of
the left hand resting on the chest, while they strike with those of the
right. Others, and chiefly the French physicians, have recourse to some
foreign body, usually of a solid nature, interposed between the chest and
the percussing fingers, to receive the first impulse of the latter. The body
interposed is called a pleximeter (from 7rhe%uc percussion, and i«im», a
measure). Hence we have digital mediate percussion, and pleximetral
mediate percussion.
The pleximeter used by M. Piorry is a thin circular plate of ivory,
about an inch and a half in diameter, provided with two prominences,
slightly hollowed and filed on their outsides, to allow of their being held
with the fingers and thus secure the better the application of the instru-
ment on the skin of the part to be explored. Of the various modifications
of this pleximeter and the new ones proposed from time to time, the left
index finger and aflat piece of India rubber are to be preferred. The plexi-
meter, of whatever nature it may be, should rest in close apposition with
the surface, so as almost, to use the words of M. Piorry, to make one
body with the part that it covers. For this reason it appears advisable to
apply the palmar rather than the dorsal surface of the finger to the chest,
when this takes the place of a regular pleximeter.
There are varieties of percussing agents ; the chief ones are the fingers
and some modification of a hammer. Preference should be given to the
former, of which, generally, the index and median are the ones used.
They should have their ends brought exactly to the same level, and be
supported by the thumb with its'ball laid firmly upon the outer surface of
the former, between the articulations of its second and third phalanx. The
fingers employed in percussion should strike at the same moment, as if
constituting one body, on the pleximeter or its digital substitute, and they
should strike perpendicularly on the part examined. Care must be taken
not to let the nails strike, as the noise which would thus be made must
interfere with or drown the sound elicited from the organ beneath the
body struck. All necklaces, breastpins, &c, should be removed from the
patient, as their resistance is apt to interfere with the sounds proper to
percussion.
In proceeding to Percussion of the Chest, we should be aware of the
different regions in which it is practised. Laennec and Piorry have
divided the chest into twelve regions, on which examinations by percus-
sion may be performed, with a view of ascertaining the physical con-
ditions of the lungs. These are, 1. Sternal; 2. Supra-clavicular- 3.
DIFFERENT REGIONS OF THE CHEST EXAMINED. 41
Clavicular; 4. Sub-clavicular; 5. Mammary; 6. Vertical; 7. Sub-
scapular; 8. Supra-spinal; 9. Spinal; 10. Sub-spinal; 11. Sub-scapu-
lar; 12. Axillary.
1. The sternal region is bounded by the limits of the sternum, which
lie between the articulations with the clavicles and the cartilages of the
ribs. 2. The clavicle and the cleido-mastoidean and trapezius muscles
express the bounds of the supra-clavicular region. 3. The clavicular
region will include all the portion of lung covered by the clavicles. 4.
The sub-clavicular region is limited by the sternum, the anterior border
ofthe axilla, the clavicle, and the fourth rib. 5. The mammary region
begins at this point to terminate at the eighth rib. 6. The vertebral
region will include the extent ofthe twelve dorsal vertebra?, and the ribs
attached to them as far as the angles which they form. 7. The sub-
scapular region will embrace the whole extent of the posterior portion of
the thorax, comprised between the limits of the lung and the superior
border of the scapula. 8, 9, 10. The limits of the supra-spinal, spinal,
and sub-spinal regions are indicated with sufficient clearness by the rela-
tions which these bear to the scapula, so as to render any farther descrip-
tion unnecessary. 11. The whole space comprised between the vertebral
column, the posterior border of the axilla, the inferior angle ofthe scapula,
and the tenth, eleventh, and twelfth ribs, will constitute the sub-scapular
region. 12. The axillary region extends from the top ofthe axilla to the
eighth or ninth rib.
The physician should be at his ease, whether sitting or standing, in
order to make the exploration with more effect. The degree of force of
percussion will be regulated by the thickness of the tissues interposed
between the pleximeter and the lungs, and, also, the intention of the ex-
aminer, as, for example, whether the means to ascertain the state of the
superficial portion ofthe lungs, or their density at greater depths. Per-
cussion should be practised in preference on the ribs, but not to a neglect
ofthe intercostal spaces, if it is only for the purposes of comparison.
In percussing the front part of the chest, if the patient be seated the
physician should also sit; if the former be in bed, he should stand. The
shoulders should be thrown back by elevating the arms, so as to protrude
the chest, and give a relative degree of tension to the skin and muscles.
Percussion of the chest, made with equal force on both sides, will give
rise to the same degree of sound from the apex of the lungs to the fourth
rib ; but below this latter different results may be expected, and a modi-
fied process is to be adopted. The mamma?, particularly in the female,
prevent a continuance of the percussion downwrards, and afterwards the
heart on the left side and the liver lower down on the right give different
qualities of sound.
In examining the posterior part of the thorax, the patient should be
directed to sit on a stool without a back, or on the outer angle of a chair,
and with the head inclined forwards and arms crossed on the breast. Per-
cussion is then to be made, by pressing with some degree of firmness either
the pleximeter or the fingers ofthe left hand on the muscles covering the
scapula and the vertebral sulci; and striking with various degrees of force,
in different points down to the regions where the pulmonary tissue ends,
behind the liver and spleen.
For percussion on the sides of the thorax, the patient should lie on the
side opposite that to be examined, with the arm raised, but not to such a
42
PERCUSSION OF THE CHEST.
degree as to give tension to the pectoralis major, latissimus dorsi and teres
major muscles ; and thereby prevent their separation and the application
of the pleximeter or finger directly below the axilla.
You may perhaps ask, before proceeding to practise it, what ought we
to find in percussion of the chest ? The answer is ready. You will have
vibrations giving rise to sounds, varying in intensity and clearness accord-
ing as you strike over the lungs in health or in disease, that is, according
as they are hollow and distended, or partially obstructed and compact; or,
according as they are encroached on by solid organs, such as the heart or
liver, or are covered with effused fluid. Considering the simplicity of the
principle—the production of sonorous vibrations by percussion—and its
application to common every-day use, as when we strike a wall with a
hammer to ascertain what part is brick and what wood, or, suspecting
fraud, to discover concealed cavities in walls, by the difference in the
sound emitted according to the density ofthe body or part struck ; or in
the familiar example of striking on an empty, a half-filled, and an entirely
full cask—it is a matter of surprise that this principle was not earlier ap-
plied to investigate the physical state ofthe different regions ofthe thora-
cic cavity and the different states of the same region, so as to ascertain
when the contained lung is healthy and when it is diseased.
With this preliminary notice of the general nature of percussion, we are
prepared to learn the difference of sounds in the different regions of the
chest. The sound is clear above the clavicles, somewhat clearer behind
these bones, and still more a little below them. The resonance is greatest
over about the third rib; but becomes less distinct in the mammary region,
and null in a great part of the precordial region. It disappears on a level
with the seventh or eighth rib, to be replaced on the right by the dulness
ofthe liver, and on the left by the sonorousness ofthe stomach.
On each side, the chest sounds clearly over all the parts which corre-
spond with the lungs.
Behind, there is little sound above the scapula, less again on the supra
and intra-spinal fossa? ; but towards the lower angle of the scapula the
sound becomes clearer,—to be gradually succeeded by that of a less dis-
tinct nature, until we have the complete dulness of the hepatic and splenic
regions. On each side of the spine there is considerable resonance.
Age and sex cause modifications in the sound ofthe chest on percussion.
The lungs are at their maximum density in adult age, and minimum in
old age ; and hence, while the chest of children sounds more clearly than
that of adults, it is exceeded in this respect by that of old people. The
greater fulness and extension of the mamma? in a well-formed female
interferes with percussion of the anterior part of the chest; and hence this
does not furnish quite so full data for diagnosis as in the case of an indi-
vidual of the other sex. The individual differences are very great. In
some persons whose chest is very muscular, there is a want of clearness;
and in others, cushioned as it were in fat, dulness prevails.
The diagnostic value ofthe two chief divisions of the states of sound ;
that of increase and that of diminution or of dulness is easily inferred.
We find that the first or increased sonorousness is met with in all cases in
which the pulmonary tissue is lighter ; and the latter, on the contrary,
whenever the density of the lung is increased.
Examples of increased clearness of sound, on percussing the chest, are
found, 1, in dilatation of the bronchia?, whatever may be the cause (chronic
AVENBRUGGER'S APHORISMS — AUTOPHONIA. 43
mucous catarrh, pituitous catarrh, dry catarrh, &c); 2, in dilatation of the
air cells or vesicles (the emphysema, properly so called, of Laennec); 3,
in infiltration of air into the cellular tissue connecting the pulmonary vesi-
cles (the emphysema of systematic writers); 4, in infiltration of air into
the cellular tissue beneath the pleura (subpleural emphysema). To this
enumeration we might add, as causes exaggerating the clear sound heard
on striking the thoracic parietes, the excavations following phthisis, hepa-
tization, gangrene, and pulmonary apoplexy.
Diminished clearness of sound, approaching more or less to dulness, is
met with in congestion, inflammation, gangrene, and oedema ofthe lungs,
and in pulmonary apoplexy and tubercles ; it being understood that these
diseases have not reached that stage in which cavities are formed in, and
at the expense of, the parenchyma ofthe lungs.
A few aphorisms of Avenbrugger, as we find them quoted by M. Mail-
liot, may be quite appropriately introduced in this place.
1. So soon as a portion of the chest, usually sonorous, suddenly loses
its natural sound in this respect, and gives out that as if striking on leather,
disease is concealed in the part which emits this quality of sound.
2. If the chest, percussed on a spot, commonly sonorous, gives out the
leather sound, we may be sure that disease is coextensive with the limits
ofthe new sound.
3. If the chest, when struck on a particular region which is generally
sonorous, emits the leather sound, the patient should be directed to make
a full inspiration and to hold his breath. If, while the air is thus retained,
the leathery sound be still heard, we augur a great depth of the disease
in the cavity of the chest.
4. If the chest, on being percussed at its anterior part while the inspired
air is retained, gives out a sound of striking on leather, then percuss the
region behind and directly opposite ; and if it emits at this spot, which is
usually sonorous, the leathery sound, we may infer that the disease per-
vades the entire thorax.
Modified auscultation, to consist of listening with the stethoscope applied
to the chest while the latter is percussed, has been recommended. It is
alleged that, by this means, the sound elicited by percussion is conveyed
to the ear with a force and distinctness superior to that which occurs in the
common method; but there is the inconvenience of loudness superseding
the particular quality of sound really caused by the state of the parts be-
neath. We have, it is true, the testimony of Drs. Cammann and Clark
(J\"ew York Med. and Surg. Journ., vol. iv.) in its favour, who assure
us that they were able, by the difference in the sound elicited, when the
instrument was over the heart, on its margin, or external to this area, to
measure that organ in all but its antero-posterior diameter, under most,
perhaps all, circumstances of health and disease, with hardly less exact-
ness than they would be able to do if the organ were exposed before them.
Like success attended trials to define the outlines ofthe liver. But, after
all, these are negative results, and do not prove the propriety of the
method for detecting real and actual respiratory phenomena. Dr.
Walshe, in his work already referred to (The Physical Diagnosis of Dis-
eases ofthe Lungs), speaks in very disparaging terms of this modified
auscultation.
Autophonia is another modification of auscultation, which consists in
the observer listening to his own voice while his ear is applied to the chest
44
INSPECTION—MEASUREMENT.
of the patient. The voice is represented to vary in character with the
state of the contained viscera. This mode, originating with iM. laupin,
is represented by M. Hourraan to be a useful auxiliary in the investiga-
tion of the pulmonary diseases of children. . -tit
Succussion is the oldest practised fashion of auscultation, as it dates
from Hippocrates. It detects the presence of air and fluid in a cavity,
and hence is a useful aid to the diagnosis of pneumothorax, and of a
tuberculous cavity in the lungs containing pus and air. It is performed
by imparting a sudden and somewhat violent motion to the patient, as when
he is jolted on horseback or suddenly gets up and sits down on a hard
seat, or by another person shaking him, and then applying the ear sud-
denly to the chest, a sound of fluctuation is heard, if there be the mixture
of fluid and air as just described, in a cavity. Sometimes the slightest
agitation of the body, as from coughing, sneezing, turning quickly, walk-
ing up stairs, will elicit the sound. The formal method of practising suc-
cussion consists, while the patient is seated on a chair or bed, to take
him by the shoulders and shake him with some force ; the operator ceas-
ing suddenly from the succussion and listening to the sound of fluctuation.
Inspection is another means of physical diagnosis by which we detect a
difference in the size ofthe two sides ofthe body, and particularly ofthe
chest. WThat thus strikes the eye is more confirmed in a certain manner
by measurement.
* For the purpose of measuring the chest we may use the graduated tape
coiled in a metallic box by a spiral spring. Dr. Stokes prefers a pair
of broad steel callipers, the free extremities of which terminate each in a
wooden ball. By either of these instruments we measure, first from the
projection of a vertebra round the side of the thorax to a line marked
with ink, to the middle of the sternum, and thence round on the other
side to the vertebral spine whence we set out. In this way any differ-
ence between the circumference ofthe two sides will be ascertained. In-
equality in this respect is not, however, always a sign of disease, for, on
the contrary, a symmetrical conformation ofthe chest is rare. According
to the observations of M. Woillez the right and left segments were found
equal in twenty-seven only of a hundred and thirty-three subjects. The
right side was more expanded than the left in ninety-seven, and the left
than the right in nine individuals.
" The morbid conditions discovered by circular measurement are, in-
crease or diminution of bulk of either side as compared with the other;
and defective expansion during the act of inspiration. Deficiency of ex-
pansion, confined as it usually is to one side of the chest, is best ascer-
tained by comparing the width of the two sides at the end of expiration
and of inspiration ; little or no difference will be found to exist in the for-
mer, but a very marked excess on the sound side at the latter period, under
the supposed conditions of deficient expansion." (Walshe,op. cit.)
Measurement, by showing a retraction of the side following atrophy of
the lung, is a most important part of diagnosis in the early stage of phthisis.
In empyema, on the other hand, we detect a notable dilatation of the
affected side.
In connexion with the subject of physical diagnosis and as illustrative
of the manner in which it is turned to the best account for practical purposes,
the mode of investigating the thoracic diseases by comparison, so ably set
forth by Dr. Stokes, is worthy of your careful study. I cannot do more
SOURCES OF PHYSICAL DIAGNOSIS. 45
than indicate the chief traits here, but would recommend you to follow
it out in its various bearings in the pages of this distinguished teacher's
work (Treatise on Diseases of the Chest), already referred to at different
times.
The symmetrical conformation of the thorax favours greatly the study
of the diseases of its contained viscera by comparison ; just as we judge
of the extent of tumefaction or degree of deformity of a limb, by com-
paring it with its fellow, in addition to a study of the direct symptoms of
the disease. To take some of the examples adduced by Dr. Stokes:—
Feebleness of respiration occurs in many diseases of the lungs, and in
phthisis particularly we often meet with feeble vesicular murmur under
one ofthe clavicles. Now, if we were to restrict our examination to this
side, we might be led to error by this symptom, for extended auscultation
on the other side might show that there is naturally in this person feeble
respiration over the whole chest. An opposite state may occur, as in a
case of a loud vesicular respiration approaching to puerile. This is com-
mon when some other portion ofthe lung has been disorganised or other-
wise suspended in its respiratory function ; but it may be universal, and
it then ceases to have a special diagnostic value. To be available as a
symptom, we must discover it in one portion of the lung coexisting with
feebleness of respiration in another portion.
So also in the phenomena of the voice. Greatly increased resonance
would induce suspicion of solidified lung, if we did not, on examining
the corresponding region on the other side, find that there also is bron-
chophony presented, and that both lungs exhibited this phenomenon habit-
ually in this case. It is only where the resonance is loud and distinct in
one lung, and either wanting or much less intense in the corresponding
portion of the opposite one, that it becomes a symptom of decided value.
" Independent of the importance," says Dr. Stokes, " of the principle
of comparison, its practice, in all ca^es, is of the greatest utility, by leading
to the discovery of lesions which would otherwise escape us. I remember
being called to see a patient, who had received an injury ofthe side, and
who was labouring under fever, cough, expectoration, and dyspnoea.
His attendants had examined him repeatedly with the stethoscope, and
discovered nothing but bronchitis. I had him stripped, and found the
phenomena of empyema and pneumothorax in the lower part ofthe right
lung; his attendants had examined the upper part of the chest carefully,
but had neglected the lower, and th*is the true nature of the disease had
escaped them."
I believe that I cannot conclude these remarks and directions respecting
physical diagnosis in a more appropriate manner than by enumerating,
after Dr. Stokes, its sources, viz. :—
" 1st. Signs purely acoustic, including the results of percussion and of
auscultation, mediate and immediate. It may be observed here, that of
all the signs these are of the most universal application ; there being no
disease of the lung or heart in which they do not occur.
" 2d. Signs derived from the alterations of shape and volume of the
thorax. This source of diagnosis is capable of application to many,
though by no means to all the diseases of the lungs, heart, and great ves-
sels. Changes of shape and volume imply either the existence of acute
diseases, in which the products of the disease have rapidly accumulated,
or, which is the more frequent case, of diseases which have a great
46
SOURCES OF PHYSICAL DIAGNOSIS.
degree of chronicity. Under the first head we may reckon rapid liquid
effusions into the pleura or pericardium, the result of inflammation, and
recent pneumothorax, from fistula. Under the second, we have chronic
liquid and aeriform effusions, hypertrophy and atrophy of the lung, both
the result of chronic disease, and aneurismal or other organic tumours.
" 3d. Signs referable to the sense of touch : these we find to occur in a
considerable number of thoracic diseases ; as, for instance, in bronchitis,
with effusion ; in the dry pleurisy and pericarditis ; in various diseases of
the heart and great vessels; in abscesses of the lung, communicating with
the bronchial tubes ; in certain cases of liquid effusions into the serous
cavities ; and in hepatization ofthe lung.
" 4th. Signs derived from the inspection of the motions of the thorax
during respiration: these occur in cases of local or general impermeability
of one lung, and in cases where the motions of respiration are otherwise
impeded or altered.
" 5th. Signs derived from the inspection of the thorax, with reference to
the action ofthe heart and great vessels.
" 6th. Signs derived from the existence of an external collateral circula-
tion, as indicative of the existence of obstruction of the great internal
venous trunks, such as the cava and innominata?.
"7th. Signs derived from the observation of the displacement of the
thoracic or abdominal viscera: of these, some may be appreciable by the
senses of sight and touch merely, while others must be ascertained prin-
cipally by that of hearing. The displacement ofthe heart (perceptible to
the eye and touch), and the protrusion of the liver into the abdominal
cavity, are examples of the first division ; while the displacements and
compression of the lung, from liquid or aeriform effusions into the serous
sacs, furnish examples ofthe second.
"Now it is never to be forgotten, that although in these various classes
we have a vast number of well-marked and essentially differing physical
phenomena, there is not one of them which, taken singly, can be considered
as a pathognomonic sign. Nay, we might go farther, and declare that no
possible combination of them can be considered absolutely pathognomonic.
By some of them, taken singly, or by various possible combinations, we
may, indeed, ascertain the existence of certain mechanical conditions of
the intra-thoracic viscera—as, for instance, permeability or impermeability;
increase or diminution ofthe quantity of air; the existence of cavities of
various sizes and with various commanications ; the roughened state of a
serous membrane ; or the displacement of particular organs: but if we
seek to determine by physical signs alone the cause of all or any of these
phenomena, we shall find it to be difficult or impossible. It is only, as
we have said before, by the connexion of the accurately ascertained
physical signs with the previous history and actual symptoms of the case,
that a correct diagnosis can ever be arrived at."
If, after a survey of our whole position, and the bearings of physical
diagnosis on therapeutics, you should ask whether the domain of the latter
has been enlarged by a better diagnosis, and whether we have gained
either a new remedy or a better plan of treatment generally in phthisis
for example, I am unable to reply in a direct manner to the whole ques-
tion. Physical diagnosis has not certainly revealed or suggested any new
remedy or new plan of treatment generally. It has not advanced our
therapeutical boundaries; but within the old limits it has given a better
DISEASES OF THE RESPIRATORY APPARATUS. 47
insight into and a better appreciation of the value of remedies, and a better
understanding of the time and the precise indications for their use, by
indicating, as it were, the very spot or point of disease to be acted on,
and the changes of tissue to be completed before recuperation of function
can be brought about.
LECTURE LXXXVI.
DR. BELL.
Diseases of the Respiratory Apparatus—Extensive operation nf the causes of these
diseases and large number of persons exposed to them—Chief causes ; atmospherical
vicissitudes and°neglect of hygiene—Community of causes affecting the several parts
ofthe air-passagesfand community of organic function and morbid action ofthe mu-
cous membrane lining these passages—Inferences from the study of the diseases of
one part applicable to those of the other parts—Division of the diseases of respiration
into three heads: those of the air-passages; of the parenchyma of the lungs; and
of the pleura or serous envelope.—Coryza—Its synonyms—Divisions—Simple and
ulcerative—Varieties of the simple; acute and chronic—Acute coryza—Anatomical
characters—Symptoms—Local for the most part, sometimes general superadded—Ex-
tension of inflammation to adjoining parts of the mucous system—Coryza in infants
—its dangers —Consecutive coryza —Progress—Diagnosis — Prognosis—Causes—
Treatment—Modifications in acute coryza.—Ozsna, thejulcerative species of coryza—
Fetor not a distinctive feature—Anatomical characters—Symptoms—Progress—Diag-
nosis—Distinction between ozaena and polypus—Inspection and exploration—Etiology
—Cases—Treatment—Local and general.
I now take up for investigation that large and important class of diseases
depending on structural changes and derangements of function of the
respiratory apparatus, or rather ofthe pulmonary organs, which constitute
the greater and necessary part of this apparatus, the remaining portion of
which is, you know, made up of the bony and muscular case. In the
zones called temperate, which include the largest portion of the civilised
world, the causes for the production of these diseases are continually at
work, and the effects are told in a fearful mortality, the rate of which is
hardly changed, except by the increase arising out of epidemic influences
and aggravations. The people inhabiting the temperate or middle lati-
tudes are exposed to great atmospherical vicissitudes, in which cold and
moisture are predominant; and against which the majority of them are
imperfectly protected, by proper habitation and clothing. Poverty pre-
cludes the masses from the regular and methodical enjoyment of these
means, and ip-uorance and inattention debar those in better circumstances
from their judicious use and application. It is easy to see, when one looks
around on the deplorable neglect of both public and private hygiene, how
imperfect and scant are the resources of medicine. The former brings
with it a train of constantly operating and wide-spread causes of disease,
affecting the multitude ; the latter can only reach a few individuals. In
prevention alone consists the safeguard ofthe many ; its agencies are evi-
dent, and the conditions for their effectual operation easily traced. Pre-
vention has strength and health, and the supports of both on its side ; cure,
on the other hand, supposes, of necessity, prior infirmity and deterioration,
and such rapidly changing conditions in the body to be acted on as to
puzzle calculation, and often to defy the most patient, conscientious, and
48 DISEASES OF THE RESPIRATORY APPARATUS.
learned efforts to solve the problem which it offers. But these are topics
which involve too many considerations of both proof and postulate to
allow of our even sketching them at this time,—and I shall pass on to an
examination in detail, of the diseases ofthe organs of respiration, being
the effects ofthe wide-spread cause, to which I, just now, adverted.
Experience proves what general anatomy and physiology had, d, priori,
indicated,—that the morbid agency of atmospherical vicissitudes is often
manifested in quick succession, if not simultaneously, in all the air-pas-
sages, from their beginning at the nostrils to the termination at the bron-
chial cells. Rarely indeed is one portion seriously affected without the re-
mainder suffering to some extent, either in its organic properties or func-
tional exercise. Still, however, is each region, in virtue of the modification
of mucous tissue with which it is lined, and of nervous supply for particular
function, the seat of morbid changes which require separate consideration.
The whole extent of the mucous membrane ofthe air-passages has one
common stimulus, that of atmospheric air, evinces a community of func-
tion in its secretion of mucus, and of morbid action in its exudation of
plastic lymph or pseudo-membrane. Hence it is no strained inference to
admit, that the lesions of structure and other deviations from the normal
state, which we are able, with considerable accuracy, to measure in the
uppermost division of the air-passages, represent very fairly those which
occur in the lower and less accessible divisions ;—even if an improved
system of diagnosis did not allow us to measure these lesions and devia-
tions at their true value. Irritation and inflammation of the mucous mem-
brane of the nasal fossa?, picture forth, in their leading phenomena of
organic life, irritation and inflammation of the laryngeal mucous mem-
brane,—as these last do of the tracheal and bronchial. A careful study
of the phlogosis of one, cannot, on this account, fail to aid us very con-
siderably in acquiring a knowledge of the others.
But, although the chief functional activity of the respiratory apparatus
is manifested in and through the mucous membrane ofthe air-passages;
as, for example, the sense of smell in that of the nasal fossa?; vocalization
in that of the larynx, the changes completing hematosis in that of the
bronchia?, yet to these is superadded a large parenchymatous structure, in
lung proper, and its investing membrane or pleura. A tolerably natural
division of these diseases is deducible from this anatomical arrangement.
Accordingly, I shall speak of the diseases of the air-passages first, then
those of the parenchyma, and, lastly, those of the serous investment or
pleura.
Coryza.—I begin with a notice of inflammation ofthe mucous membrane
investing the nasal fossa?. The name of coryza has been given from the
earliest times down to the present, to this form of disease. Its syno-
nyms are " cold in the head," " blenorrhinia," and " rhinitis." The
last or rhinitis, with a show of philological precision, in its being derived
from Ptv, nose, is as little applicable as the others ; for, why should rhi-
nitis be appropriated to inflammation of the lining or mucous membrane
of the nose, and not designate, as well, inflammation of the investing or
cutaneous membrane ?
Coryza has been divided into two kinds, the simple or benign and the
ulcerative ;—and the first again into the acute and the chronic varieties.
The anatomical characters of the inflamed nasal membrane, opportu-
nities for the examination of which have only been furnished in very
SYMPTOMS OF CORYZA.
49
young subjects, are, in the acute state, redness, injection and often a vio-
let hue of the part, which is, also, somewhat swelled an.I thickened, and
more easily torn than in health. Pseudo-membranous exudations have
been noticed by Billard and others. In chronic coryza the nasal mem-
brane has more density than before ; it is rough, rugous or with raamrai-
lated elevations on its surface; and so thickened that the nasal canal may
be not only greatly obstructed, but even entirely closed. It is of a pearl
or sometimes slate colour.
Symptoms.—Coryza is ushered in with a troublesome feeling of dryness
and fulness of the nasal fossa?, a stuffing of the nose, together with pru-
ritus, which provokes to frequent sneezing. To these soon succeeds a
flow of transparent mucus or serum, of a saline taste, which reddens
and scalds the skin at the lower side of the nostrils, and the upper lip.
The inflammation extending to the frontal sinuses, gives rise to pain at
the root ofthe nose, and along the supra-orbitar region, in fine, to frontal
cephalgia, which is aggravated by the least motion of the body, and
which is sometimes so annoying as to interfere with any exercise of the
intellect. Less commonly the inflammation extends to the lachrymal pas-
sages and the conjunctiva, which latter is injected, and there is accom-
panying flow of tears and intolerance of light. In another direction the
Eustachian tube and the inner ear may be affected, and there then ensue
a sense of fulness, occasional pain in the ear, and diminished sense of
hearing. Should the maxillary sinus be inflamed, the patient complains
of pain in the corresponding cheek with some degree of tension of the
jaw, and even aching ofthe teeth implanted in it. The sense of smell is
rendered quite obtuse, and for a time even lost; and that of taste has,
also, lost much of its delicacy. All the symptoms enumerated are some-
times restricted entirely to one side, in which alone are felt the unplea-
sant sensations, and from which alone flows the increased and morbid
secretion.
Although coryza, for the most part, manifests itself by local symptoms,
yet, sometimes, it is accompanied by a febrile disturbance,—irregular
chills, dry and hot skin, accelerated pulse, want of appetite and general
languor. This state is more apt to show itself, if coryza be the precursor,
as it often is, of bronchitis and pulmonary catarrh,—a continuation or
extension this ofthe primary phlogosis, which, although not mentioned in
the preceding description, is, by far, the most important. It is this com-
plication which the ancient writers characterized by the term gravedo.
Thus Celsus, nares claudit, vocem obtundit, tussim siccum movet.
At the expiration of two or three days, the first symptoms abate ; the
nasal secretion becomes more consistent, and of a white, then of an opaque
yellowish, or greenish colour, which exhales a spermatic odour. In
some instances it is quite fetid. The mucus thus formed is easily de-
tached, dries rapidly, and is converted into crusts, which obstruct the pas-
sage of air through the nasal passages, and give rise to a nasal sound in
speaking, which sometimes is evident from the beginning of the disease,
owing to the swelling of the mucous membrane.
In infantile subjects coryza is a much more serious disease than it is
in adults : as, owing to the narrowness, naturally, of the nasal passages,
these last are more easily obstructed by thickened mucus ; and, hence,
great difficulty, not to say impossibility, of breathing, when the child is
at the breast. Between the calls of hunger, if they are yielded to, and
VOL. n.—5
50 DISEASES OF THE RESPIRATORY APPARATUS.
the danger of asphyxia, the little sufferer falls into a state of prostration and
marasmus, unless means be taken to feed it with the spoon. In a child
predisposed to spasm of the glottis or laryngismus stridulus, the impedi-
ment to respiration from coryza, and when the little being is at the breast,
will give rise to a paroxysm with convulsions.
In consecutive coryza, after diphtheritic stomatitis and angina, the dis-
charge from the nostrils consists of a fetid sero-sanguinolent matter, ac-
companied by the expulsion of false membranes.
The progress of coryza is rapid ; rarely does it extend beyond a week;
or, if it is protracted, "it will generally be found that this is by successive
renewals of the disease, rather than by uninterrupted prolongation of the
original attack. Sometimes it assumes an evidently periodical type, and
requires quinine for its removal.
Chronic coryza, whether idiopathic or following the acute variety, sel-
dom gives rise to pain, but rather a feeling of discomfort in the nose and
of weight at the root of the organ. The secretion is always increased,
and is of a thick consistence, opaque, greyish, yellowish or greenish, and
inodorous. In some cases, however, the smell is insupportably fetid,
even when there is no ulceration of the mucous surface. Persons affected
with chronic coryza rarely have a clear voice, and they are seldom able
to speak or sing long without their being much fatigued.
The diagnosis of coryza is easy. In very young children, the suffoca-
tion caused by sucking may proceed from some organic defect in the
mouth, the tongue, or the nasal fossa?, as well as in the nipples of the
mother; but in such cases, independently of the results obtained by direct
inspection of the parts, the difficulty from such malformations must have
existed from birth ; whereas if the difficulty depended on coryza, we have
means of ascertaining that the child sucked freely before the attack of this
disease.
Chronic coryza may be mistaken for polypus of the nose ; but in the
case ofthe latter, the stuffing ofthe nose is not constant, but only occurs
in damp weather, and is not accompanied with a discharge. Besides,
inspection of the nasal fossa? will generally lead to a discovery of the
polypus.
The prognosis of coryza presents no gravity, except in the case of a
newly-born infant, or one at the breast.
The causes of coryza must be frequently operative, as inflammation of
the pituitary membrane takes place more readily than that of the other
portions of the mucous system. Although the disease is common at all
ages, it is most frequent in the period of childhood and among lymphatic
subjects. It is sometimes epidemic after sudden changes of weather and
at the beginning of cold seasons. Often it has been obviously due to
residence in damp localities, to the suppression of perspiration ofthe feet,
to being exposed bare-headed, the use of tobacco, &c.
Treatment.—Acute coryza is, for the most part, left to run its course.
If there be febrile excitation and headache, it is desirable that the patient
should take an active cathartic, such as salts and the infusion of senna, or
the compound powder of jalap ; and afterwards diluents, and pursue a
restricted regimen, resort to warm pediluvia, and live in air of a me-
dium temperature. For the troublesome and sometimes persistent frontal
headache and sharp pain in the frontal sinuses, which are met with more
particularly in seasons of epidemic catarrh, I know of no remedy so good
SYMPTOMS OF OZjENA.
51
as the application of a few leeches just inside the nostrils, or to the first
narrowing of the passage. I have myself found the greatest relief, and
have at different times conferred the same benefit on my patients, by this
means. A revulsion is sometimes exerted with good effect on the pha-
rynx and fauces, by the use of stimulating lozenges, such as of oil of
cubebs, slowly dissolved in the back part of the mouth. A speedy termi-
nation has been put to the disease, by what is called the aborting treat-
ment. It consists in touching as much of the nasal membrane as can be
reached with a sponge dipped in a solution of nitrate of silver, of the
strength often grains to the ounce.
In the case of a newly-born infant suffering from coryza, and occlusion
of the nares in consequence, it must suspend for a while its sucking, and
be fed with its mother's milk administered by teaspoonfuls.
Chronic coryza will demand a more sustained treatment, chiefly of an
alterative kind, after premising some laxative medicines. With this view,
the blue pill, compound syrup of sarsaparilla, and iodide of potassium, will
be given to advantage. Stimulating fumigations, or inhalations through
the nose of pungent vapours, are serviceable in some cases ; while topical
applications, such as nitrate of silver, or mercurial preparations directly to
the part, are preferred by some. A blister to the nucha has been found to
answer a good purpose. Masticatory substances have also been pre-
scribed.
Ozjena.—The ulcerative species of coryza, on which I propose to offer
a few remarks, is usually designated by the term ozcena. Some have
thought that fetor of the nares and of the discharge from them constitutes
a distinctive character of this disease ; but in this they are mistaken, for,
in some cases of common coryza, and of polypoid tumours and excres-
cences, the discharges are also fetid.
Anatomical Characters. — The nasal fossa?, in ulcerative coryza, have
their mucous lining thickened, swelled, mammilated, lacerable, and coated
with a fetid pus. The membrane is also destroyed in many spots with
ulcerations, which vary in their seat, number, extent and aspect: more
commonly, according to Boyer, they are met with at the anterior portion
of the septum, at the point of union of the bone and cartilage ; but they
are also seen at the root of the nose, on the mucous membrane which
covers the nasal bones and the vomer. In number they are few; there
being often only one ulcer, and, at most, two or three, but they are of large
size. Some are superficial, others deep and extend to the bone, which is cari-
ous, and softened or necrosed. A puriform sanguinolent mucus and brown
or blackish crust obstruct the nasal fossee, which exhale an extremely
fetid odour. In more aggravated cases—happily of rare occurrence—the
destruction of parts may extend to the loss of the bones of the nose, of
the septum, the vomer; and finally of the nose itself, either in part or
entirely.
Symptoms.—The beginning of oza?na is gradual, and scarcely marked
by any noticeable symptom ; or, at the most, more than would be met
with in chronic coryza. The patient, after a while, has his nose habitu-
ally stuffed ; he blows out a thick, yellowish, greenish and purulent mu-
cus, in large quantity ; and experiences an uneasiness, but without pain,
in the nasal fossa?. These latter are obstructed with adherent crusts or
scabs, which most patients pick off with their finger-nails, and produce,
in consequence, a bloody oozing mixed with the other secretion. By this
52 DISEASES OF THE RESPIRATORY APPARATUS.
means, the irritation of the membrane is kept up and the cure retarded.
In the more aggravated cases, the fluid which escapes from the nares is
ichorous and fetid, and the air which traverses these passages during ex-
piration is itself impregnated with this fetor,* which has been compared to
different offensive and stinking bodies that need not be specified here.
When the ulceration extends to the bones and cartilages of the nose, this
oro-an is swelled and deformed, and assumes a violet-red colour: it exhi-
bits, also, edema, on pressing the integuments with the finger ; and by this
latter means we detect, also, crepitation.
The progress of ulcerative coryza is always slow : although, at times, it
undergoes exacerbations which give it the appearance of an acute disease.
Having little tendency to get well spontaneously, oza?na is almost always
tedious in its course and of indefinite duration. However much it may
interfere with the comfort and social pleasures of the patient, it does not
shorten life, and if death occurs to one thus afflicted, it is owing to com-
plication of another disease.
The diagnosis is not easily made between common chronic and ulcera-
tive coryza ; and hence the necessity of a careful inspection of the parts,
as recommended and practised by M. J. J. Cazenave, of Bordeaux. The
patient being placed in a good light, opposite a window, and the head
thrown back, so as to expose the cavity of the nasal passages as much as
possible, the physician will introduce a probe curved at one end, in
hook fashion, as far up the nasal fossa? as he can ; he will then gradually
withdraw it, while making various movements of rotation so that the end
of the hook part shall impinge against the pituitary membrane. If this
latter be clear of ulcerations, the end of the probe will glide easily over
it; but if, on the other hand, there should be solutions of continuity, the
instrument will be caught in them and retained by the raised borders of
the ulcers. This exploration should be made first and most carefully
along the septum at the part near the root of the nose, as that on
which ulceration most frequently occurs. The distinction between oza?na
and polypi or other tumours and morbid growth is easily determined by
careful inspection and exploration ; and that between the disease under
notice and glanders is ascertained by a review of all the symptoms which,
in the latter terrible disease, soon cease to be local, and when once they
become general, assume unmistakable appearances.
Something may be inferred from the amount and odour of the discharge
as to whether the ulcer be simple and benign, or fetid and in a measure
malignant.
With the etiology of oza?na we are imperfectly acquainted : it is rare,
except from traumatic cause in childhood ; and is met with chiefly in the
period of youth and adult age. Sometimes it would seem to be heredi-
tary. The predisposition apparently is laid in a lymphatic temperament
and scrofulous diathesis; at least such are the constitutional characteris-
tics of those who, under my own observation, have been sufferers from
this disease. Of the two last whom I have been called upon to treat one
a male, in advanced life, the other, a female, of middle age, both had
small-pox in early life, and both were, for a term of years on the list of
dyspeptics. In the case of the female, a single lady, the ulceration de-
stroyed a portion of the cartilaginous septum, leaving quite a large opening
between the nares. I mention these two cases of individuals whose cha-
racters are well known to me as irreproachable in every particular in
order to invalidate the too hasty assumption of some writers that 'the
DIVISION OF DISEASES OF PULMONARY ORGANS. 53
disease is chiefly of syphilitic origin, especially where the bones and car-
tilages are implicated. That oza?na has, however, such an origin, in
certain cases, is undoubted. In others, it can be traced to the lesions
left by the extirpation of polypi.
Treatment.—This will consist of local applications and of constitutional
remedies. The first are mainly detersive and stimulating, and sometimes
astringent; the latter ought to vary with the condition of the patient, in
respect to his labouring under other diseases, such as syphilis, scrofula,
or anemia. If symptoms of nasal irritation be present, manifested by
heat, tension, and the frequent formation of dry crusts or scabs, a few
leeches to the inside of the nostrils in the manner already recommended
for simple acute coryza, will be found serviceable, and constitute a good
introduction to other remedies. For a while, simple emollient washes
may be required, and revulsives by laxative medicines ; but after this, an
alterative course, consisting of mercury, with sarsaparilla and diaphoretics,
or of iodine, with the like adjuvants, should be adopted, according to the
particular circumstances of the case. I have known salivation to remove
oza?na at once ; but as this is a harsh and uncertain remedy, we should
content ourselves with the use of blue mass and narcotics, followed by or
alternating with tonics. Preferable to all is the use of iodine in the
form of combination of the iodide of potassium, and, also, in union with
iron, as in the iodide of iron. From both of these preparations I have
derived the best effects ; they were the internal remedies chiefly relied on
in the case ofthe lady before adverted to, which ended in entire removal
of the disease. The solution of the iodide of mercury, and arsenic, or
Donovan's solution, has been given with success ; so also has the solution
of arsenic with potassa (Fowler's solution).
Of the topical remedies, the list is a long one ; the chief are solutions
ofthe chlorides of lime and of soda, ofthe acetate of lead, corrosive sub-
limate, nitrate of silver, and alum, also, creosote, carried up the nasal
fossa? by injection. Ointments of most of these substances have also been
used to the same parts,—applied by means of a probe or ivory rod, to the
end of which is fastened a small piece of sponge or lint. Mercurial
fumigations have been practised : they ought to be associated with
calomel, or blue mass, or a dilute solution of corrosive sublimate, inter-
nally. The best detergent washes and correctors of fetor, are the solu-
tions ofthe chlorides of lime and soda.
LECTURE LXXXVII.
DR. BELL.
Laryngitis, or Cynanche Laryngea—Its varieties—Erythematic Laryngitis—General
mildness ofthe disease and simplicity of its treatment—Catarrhal Laryngitis—Chiefly
dangerous in infants—Its treatment—Acute Edematous or Sub-mucous Laryngitis—A
most formidable disease—Its symptoms—Respiration and deglutition both affected ;
and afterwards the cerebral functions—Duration—Edema of the glottis not a separate
disease—Two varieties of acute laryngitis established by Cruveilhier—Is not of fre-
quent occurrence—Treatment actively and speedily antiphlogistic—Venesection—
General Washington's case—Leeches to the throat, or cups to the nucha—Blisters—
Tartar emetic with small doses of opium—Calomel and opium—Early recourse to
laryngoiomy—Mortality from acute laryngitis.
I continue the investigation of the diseases of the pulmonary organs by
speaking of the diseases of the larynx, both acute and chronic. These
•
54 DISEASES of the RESPIRATORY apparatus.
again, may be inflammatory or nervous ; and, if the former, may be accom-
panied by an erythema or a tumefaction of the mucous membrane of the
part, or by the secretion of mucus or of pus, or the formation of false mem-
branes.
Simple erythematic laryngitis is the mildest of all the forms^ of
inflammations of this organ. Its causes are external and internal. Ihe
former are sudden variations of temperature ; breathing air in which
irritating molecules are suspended; throwing open the neck, which had
been habitually covered, to a cold air. Of the internal causes we find
enumerated fatigue of the larynx in protracted and loud singing and
speaking. Sometimes it supervenes on the diseases of other organs, and
by simple continuity of tissue, as we see in inflammation of the pharynx
or of the bronchia?, or sympathy as in gastro-enteritis. It is sympathetic,
as in measles, in which the same inflammatory congestion is present in
the conjunctiva and bronchise. It also shows itself in small-pox and in
erysipelas.
Erythematic laryngitis is sometimes preceded by a feeling of general
discomfort; sometimes by fever: and again it makes its attack suddenly,
and manifests itself by a pain in the larynx, which may be slight, or of a
more acute nature, augmented when the patient speaks or coughs, or
when the larynx is pressed on. The voice loses its force, is changed in
character, and hoarse. Deglutition is painful, and the cough is harassing
by its frequency and dryness. After a while some mucus tinged with
blood, aq,d more frequently opaque, is excreted. When the inflammation
is slight, it is not accompanied by any notable symptom ; but when it is
intense, the innervation may be so profoundly disturbed as to mask the
evidences of the local disease. This last is an occurrence common in nearly
all the anginose affections, and should be borne in mind by the physician
when he is called upon for his prognosis. The patient when questioned
will often reply that he feels no pain : he is disinclined to speak, and
dozes much.
The treatment ofthe milder cases of this form of laryngitis is very sim-
ple ; consisting in tepid mucilaginous drinks, and a mild purge, followed by
warm pediluvium. But if the inflammation be more acute, blood should
be drawn from the arm ; and if relief does not soon follow, leeches must
be applied to each side of the larynx, from opposite the os hyoideus to the
lower end of the thyroid cartilage. There will be risk of the inflammatory
afflux being increased, unless the leeches are in sufficient number to act
decidedly on the injected mucous membrane, by the abstraction from its
minute and capillary vessels, of a sufficient quantity of blood. Mild counter-
irritation will follow, if necessary, and a mercurial purge. Sometimes,
though rarely, this disease may be converted into bronchitis, or into another
kind of laryngitis, or become chronic and give rise to laryngeal phthisis :
hence, though it is never to be neglected, it demands more especial atten-
tion in those who have had laryngitis before in any form, or who are
predisposed to phthisis. The expression—* it is only a slight cold or
a sore throat,' is a foolish, and has been often a destructive remark by
lulling suspicion of danger, and preventing the requisite remedial means
from being adopted.
Catarrhal laryngitis, little different from the preceding, is caused
more directly by atmospherical changes, sometimes of an epidemic nature
ACUTE EDEMATOUS OR SUB-MUCOUS LARYNGITIS. 55
and by suppressed perspiration. Its treatment is the same as that of the
erythematic variety, with the difference that more benefit is obtained by
the administration of an emetic. This remedy is the more necessary in
the catarrhal laryngitis of infants, who are unable to throw off the accu-
mulated mucosities in the windpipe, and are in imminent danger of suffo-
cation in consequence. Here is an instance of the importance of removing
an effect which may be more perilous than the cause, or inflammation of
the mucous membrane itself. Derivation by purgatives is also advisable
in this case; and if the principle be admitted we should select those
which most excite to increased secretion the mucous follicles of the
intestinal canal. Calomel, therefore, with aloes or rhubarb, will be prefer-
able to the saline purgatives, which often cause excessive watery discharges
without their exerting a good effect on the laryngeal disease. The common
cough mixtures are of very doubtful efficacy in laryngitis, since they con-
tribute to increase the secretion of mucus without a corresponding
augmentation of ability to throw it off. Free expectoration, by which the
bronchia? are cleared, will not suffice for the laryngeal tube without addi-
tional efforts of a voluntary nature, which children cannot make, or rather
will not, because they do not understand the necessity and use of the
measure. Counter-irritation, by stimulating liniment rubbed on the neck,
or even a small blister over the part, is at times called for, in cases of
continued and excessive secretion of mucus in the larynx.
Acute Edematous or Sub-mucous Laryngitis.—A formidable variety
of laryngitis is that called edematous, which should be regarded as an aggra-
vated degree of the erythematic. Edematous ought not in propriety to
designate this more violent stage of inflammation of the larynx—the effu-
sion in the sub-mucous cellular tissue being only an effect ofthe inflam-
mation. Acute laryngitis in this degree is one ofthe most alarming and
intractable diseases we are called upon to combat. It is more frequent in
adults than in children. Sometimes it begins with the symptoms of
cynanche tonsillaris. Soon, however, its diagnosis is rendered evident by
difficult and even laborious inspiration, accompanied with stridor and hiss-
ing sounds, whilst the expiration is free ; pain and feeling of constriction at
the larynx, greatly increased by pressure on the thyroid cartilage, flushed
face, lustrous eye, great thirst, full and frequent pulse. The cough is very
troublesome, harsh and more stridulous than in croup, and accompanied
by constant and involuntary hawking, as if to clear the passage by expecto-
ration. In the aged the expectoration is often copious, and evidently from
the larynx ; but it fails to give relief. The voice, at first acute and
piping, gradually becomes thick, then hoarse and whispering, and at last
is completely suppressed. There is sometimes great difficulty in swallow-
ing owing to the epiglottis ceasing to perform its valvular office ; whence
it happens that when the patient begins to drink, a portion of the fluid
escapes into the larynx, and produces a fit of coughing, which seems to
threaten instant suffocation. The pain from ineffectual trials to drink pro-
duces in some a real hydrophobia ; the sight of a fluid recalling so vividly
former sufferings. The patient complains of a feeling, as if of a foreign
body in the larynx ; and a similar obstruction in the oesophagus. An
examination of the fauces shows them, in most instances, to be inflamed,
and very often, by pressing the tongue as much as possible downwards
and forwards, the epiglottis can be seen erect, thickened, and of a deep-
red colour.
56 DISEASES OF THE RESPIRATORY APPARATUS.
With the increase of edema, laborious respiration, and an inadequate
supply of air affect the appearance of the patient, as manifested in his pal-
lid countenance, anxious expression, livid lips, protruding ^nd watery
eyes ; pulse quick, feeble, and irregular ; surface ofthe body cold, lhe
patient is restless and apprehensive ; he seldom sleeps for many minutes
at a time : when he begins to doze, he starts up in a state of the utmost
agitation gasping for breath, every muscle being brought into action which
can assist respiration, now become a convulsive struggle. He is quite
enfeebled, becomes delirious, drowsy, at last comatose, the circulation
being more and more languid ; and he dies on the fourth or fifth day of
the disease, or even earlier. Instances, says Dr. Cheyne (Cyclopaedia of
Practical Medicine), have come to our knowledge, in which the disease
has terminated fatally within twelve hours (one of Dr. Armstrong's pa-
tients died in eight hours and another in seven); and, therefore, continues
Dr. C, if a person dies suddenly in the night, who had complained on
the foregoing day of sore throat, laryngitis may be suspected as the cause
of death. I have myself seen such. Contrasted with these are other
cases in which the disease has lasted three or four weeks.
The anatomical changes are inconsiderable ; sometimes only amounting
to a redness ofthe mucous membrane of the larynx, which, in some in-
stances, is also easily torn and thickened. In the latter case, there will
be a diminished diameter ofthe laryngeal canal,—a result that may ensue,
also, from serous or purulent infiltration in the sub-mucous cellular tissue.
Finally, on occasions, we meet with inflammation and enlargement ofthe
mucous follicles, or even superficial ulcerations ; and, more rarely, pus-
tules analogous to those found in small-pox.
When the disease has been restricted to the upper part of the larynx, the
immediate cause of death is shown in the opening of the glottis being almost
entirely closed by the thickeningand swellingof thearyteno-epiglottic mucous
folds. Bayle, to whom we owe the most accurate account of edema ofthe
glottis or super-glotteal laryngitis, has shown how these folds are so disposed
that every impulse coming from the pharynx, such as the air inspired, turns
them backwards into the opening of the glottis, which they obstruct in a
greater or less degree, whilst every impulse coming from the trachea throws
them outwards, and enlarges the opening. In other words, the glottis is
blocked up during inspiration, and more or less open in expiration. In-
cision of these folds exhibits a thickening and increased density of the cel-
lular tissue, from which, with difficulty, the infiltrated serum is exhaled. If
the inflammation has been rapid, plastic lymph is found instead of se-
rum, at the rimce glottidis. The vocal cords are sometimes the seat of
lesions. Frequently there are traces of inflammation of the pharynx and
tonsils.
Cruveilhier (Dictionnaire de Medecine et de Chirurgie Pratiques) makes
a division of laryngitis into super-glotteal and sufr-glotteal. The former
coincides more with that form just described, and depends on the anato-
mical lesions in the mucous folds which extend from the epiglottis to the
arytenoid cartilages (aryteno-epiglotteal ligaments), and which become by
inflammation so enlarged and tumid as to be felt by the finger on exami-
nation. The epiglottis itself is sometimes the chief seat of the lesions
observed. The sub-glotteal variety consists also in an inflammation of
the cellular tissue, but of that portion below the rima, and extending to
ACUTE EDEMATOUS OR SUB-MUCOUS LARYNGITIS. 57
the cricoid cartilage, which is sometimes necrosed. The symptoms are
the same as those of the first variety, except that they are somewhat less
violent; as, owing to the greater density of the cellular tissue below the
folds of the glottis, there is less infiltration than when these latter are in-
flamed. Hence, also, the disease is not so speedily fatal in the sub-glot-
teal variety, which we should, therefore, regard as that with which those
persons are affected, who, as has been already stated, have lived for
weeks under an attack of acute edematous laryngitis.
The causes of acute laryngitis are not very obvious. Sometimes they
are atmospherical vicissitudes. At times the disease supervenes on con-
valescence from fevers, and, again, on chronic laryngitis. It has been
observed in connexion with erysipelas, and especially the epidemic variety.
The more distinctly edematous cases are seldom primary. M. Valleix
says that out of 37 cases there were only two of this kind.
By some an edema of the glottis has been regarded as a different dis-
ease from that now under consideration ; but without good cause. The
term is misleading: it ought to be oedema rimse glottidis. The only dif-
ference between this and the acute sub-mucous laryngitis just described,
is in the extent to which the cellular tissue is inflamed.
Happily this formidable disease is not of frequent occurrence. I have
already said that it is confined almost entirely to adults ; there being very
few cases on record in which it has attacked children, or persons under
the age of twenty. Authors describe, among the accompanying pheno-
mena, in some cases, swelling of the integuments which surround the
larynx, especially on the forepart of the neck. I have had one case of
this kind under charge, in which the tumefaction was so rapid that it
could hardly be exaggeration to say that its progress was almost visible.
The subject was a child between two and three years of age. Venesec-
tion and purging seemed to have little effect in controlling the disease,
which was obviously arrested, however, by leeches applied to the neck.
Calomel was given at the same time ; and it seemed to be useful in
completing the cure.
Treatment.—But I am anticipating what is to be said on the treatment
of acute edematous laryngitis. The weight of experience is in favour of
free bloodletting, which, to be serviceable, must be early resorted to. At
the same time, it must be admitted that we cannot hope by this means to
remove the edema and the consequent obstruction to respiration, which
constitutes so much of the character as well as gives danger to the dis-
ease. But if the physician should be fortunate enough to be present at its
inception, and aware of its symptoms, he may, by the use of the lancet,
arrest the inflammatory action which causes the edema ; or, if the first
critical period have passed, the farther swelling may still be prevented
and absorption facilitated by this means. It is not often that a French
writer can be quoted, whose directions, of a therapeutical character, so
nearly correspond with our practice, on this side of the Atlantic, as those
of M. Andral (Cours de Pathologie Interne). He says: In this dreaded
malady we act promptly and energetically. The first indication to be ful-
filled is, to detract blood largely by venesection, which will be quickly
followed by a vomit or a purge. Leeches are to be applied round the
neck in large numbers; in a short time the intestinal canal is again to be
acted on, and sinapisms are to be applied to the lower extremities : in a
word, we should adopt a treatment eminently perturbating.
5S
DISEASES OF THE RESPIRATORY APPARATUS.
On this main outline of practice I shall offer some remarks. The use
ofthe lancet will be more serviceable in a case in which the patient is
yet in the prime and vigour of life, than when he is farther advanced and
his constitution impaired. It promises more, also, if the complexion is
good, that is, if it indicate arterialization ofthe blood ; as when the face
is flushed, and even turgid, and the eyes bloodshot. But when the face and
lips, especially the latter, become livid, the expression anxious, and the
eyes protruded and watery, we can no longer hope for a removal of the
swelling and stricture ofthe glottis by general bloodletting, which has the
disadvantage at this time of weakening the action of the heart and of the
respiratory muscles, and thus of disabling the patient from bearing up yet
awhile against the depressing influence of the disease. But even in this
latter stage it may be justifiable to open a vein, and to watch whether any
relief follows the discharge of blood, an effect manifested by a somewhat
less laboured inspiration, and an amended colour ofthe face and lips. If
such a change take place, wTe shall be encouraged to let the blood flow
until the main indication be fulfilled. Otherwise we promptly close the
orifice, and prevent further loss ofthe circulating fluid. When we have
them at our disposal, leeches applied in the manner already advised exert
a more evidently controlling influence over the inflammation ofthe laryn-
geal membrane than venesection. Both in the case of the child before
mentioned and in that of an adult, a married female, about thirty years of
age, patients of mine, leeching arrested the disease, after copious vene-
section had failed to do so. But, in both, the amount of blood drawn in
this way was large. From the adult nearly twenty ounces were taken,
under my own eye, after venesection had been used to procure a smaller
quantity in the early part ofthe day. Tartar emetic was also freely ad-
ministered, both as an emetic and counter-stimulus. Dr. Francis of New
York, about nineteen years ago, was attacked with acute laryngitis, for
which he was bled to the extent of a hundred and fifty-two ounces in six
days: and three or four days after, as he was still thought to be in a pre-
carious state, he was bled again. (See a paper on Laryngitis by Dr. Beck,
in his Journal, No. 12.) Dr. Cheyne (op. cit.) gives a still more marked
case ofthe value of venesection, because the general appearance and the
habits of the patient would not seem to bear such extreme treatment. It
was of a young woman, who earned a pittance by gathering cockles on
the strand at ebb tide, and afterwards by hawking them through the streets
of Dublin. This person presented herself, July 13th, 1813, on the second
day of laryngitis, pale, scarcely able to articulate or swallow, the effort
producing a convulsion, as when a crumb enters the windpipe ; the voice
sounded as if she was throttled, inspiration being slower than natural, and
sibilous. The successful treatment consisted in bleeding her at noon, ad
deliquium, which, by the way, says Dr. Cheyne, had nearly proved fatal.
The venesection was repeated twice in the course of the evening. On
the following day respiration was rendered difficult by the least exertion.
Hitherto she was unable to swallow. She was again bled, and a purga-
tive enema and blister were prescribed. Next day she began to expec-
torate yellow mucus, and could swallow fluids. On the 16th of July
convalescence was begun.
Of the inefficacy of bloodletting on other occasions, a remarkable
instance was presented in the practice of Dr. Armstrong. The loss of one
hundred and sixty ounces of blood within six hours gave temporary respite
ACUTE EDEMATOUS OR SUB-MUCOUS LARYNGITIS. 59
to the difficulty of breathing, but yet it was so far from arresting the inflam-
mation that death took place within twenty-four hours. The first accu-
rately reported case of acute laryngitis, and one which will ever have
deserved historical importance attached to it, was that which proved fatal
to Washington. " The disease," says Drs. Craik and Dick, his physicians,
" commenced with a violent ague, accompanied with some pain in the
upper and forepart ofthe throat, a sense of stricture in the same part, a
cough, and a difficult rather than painful deglutition, which were soon
succeeded by fever, and a quick and laborious respiration." The general
had himself bled in the night of Friday, 10th Dec, 1799, that of his
seizure, to the amount of twelve or fourteen ounces. On the following
morning " were employed two pretty copious bleedings, a blister was ap-
plied to the part affected, two moderate doses of calomel were given, and
an injection was administered, which operated on the lower intestines, but
all without any perceptible advantage, the respiration becoming still more
difficult and distressing. Upon the arrival of the first of the consulting
physicians, at half-past three in the afternoon, it was agreed, as there were
yet no signs of accumulation in the bronchial vessels of the lungs, to try
the result of another bleeding, when about thirty-two ounces of blood were
drawn without the smallest apparent alleviation of the disease. Vapours
of vinegar and water wrere frequently inhaled ; ten grains of calomel wTere
given,'succeeded by repeated doses of emetic tartar, amounting in all to
five or six grains, with no other effect than a copious discharge from the
bowels. The powers of life seemed now manifestly yielding to the force
of the disorder ; blisters were applied to the extremities, together with a
cataplasm of bran and vinegar to the throat. Speaking, which was painful
from the beginning, now became almost impracticable ; respiration grew
more and more contracted and imperfect, till half-after eleven, on Satur-
day night, when, retaining the full possession of his intellect, he expired
without a struggle."
Harsh strictures were made, at the time, by English writers on the treat-
ment of the illustrious patient by his physicians ; particularly on the score
of such large sanguineous evacuations. The disease was, in fact, at that
time unknown—at least as laryngitis; and it was not until the year 1806,
according to Dr. Cheyne (op. cit.), that a case was duly recorded as such.
Dr. Monro, who was called into consultation, announced, as his opinion,
that the symptoms arose from inflammation and thickening of the wind-
pipe ; and afterwards recommended, in case suffocation should be immi-
nent, to perforate the larynx between the thyroid and cricoid cartilages.
Laryngotomy was performed, but only after stertorous respiration had
come on, and the countenance was changed from the purple of imperfect
respiration to cadaveric paleness: the patient died two hours afterwards.
The most approved method of treatment recommended at this day will
be found to vary little in its general features from that pursued in the
case of General Washington. One very important means was not used
by his physicians—the application of leeches. Objections have been
made, on valid grounds, to vomiting the patient, whose epiglottis, in this
disease, remains stiffened and erect, and of course leaves the glottis open
to the introduction into the larynx of fluids ejected from the stomach, or,
at any rate, to the irritation of the rimao glottidis in their passage from the
oesophagus into the mouth. But whilst we deprecate vomiting, we are
not forbidden the use, in relatively large doses, of tartar emetic, which,
60 DISEASES OF THE RESPIRATORY APPARATUS.
in this form of laryngitis, as well as in croup, is tolerated to a great
extent. By toleration, I mean its not causing either vomiting or purging;
at the same time that it tends to abate arterial action. The medicine
may be administered in quarter and half-grain doses every hour, or even
half-hour, according to the intensity ofthe disease. A very minute trac-
tion of opium combined with it will enable the stomach to retain it more
readily, without diminishing its sedative or contra-stimulant effects.
If we are deprived of the use of leeches, cups to the nucha should be
applied, after venesection, so as to detract as much blood as can possibly
be spared from the laryngeal region. The two means of bloodletting may
even be had recourse to in very severe cases almost conjointly, or in
quick succession. Tartar emetic failing to produce the desired reducing
effect on the system without vomiting, or even after its beneficial but in-
complete sedative operation, calomel, conjoined with minute doses of
opium, should be given every hour, or at most every two hours. If want
of confidence be felt in the tartar emetic alone, or fears entertained that it
must necessarily vomit, the medicine may be advantageously combined
with calomel and opium, and continued until relief be procured. After
venesection and leeching, a blister over the upper part of the sternum
may be of service, or preferably on the nucha ; and, if there be much, as
often there is, spasm of the glottis and larynx, it may be dressed with
morphia or belladonna ointment. For the relief of this symptom, while
we are removing its cause—inflammation—assafcetida mixture, with a
few drops, in each dose, ofthe tincture of belladonna, will be of service.
Gentle frictions with the belladonna tincture or liniment over the larynx
and trachea will contribute to the same end. Derivatives, by the warm
bath, warm pediluvia, saline diaphoretics and sinapisms, ought not to be
omitted.
Mr. Crampton and others recommend the application of leeches to the
inflamed palate and tonsils : the objection is not in any danger of subse-
quent inconvenience, but in the difficulty of the operation. The leech
must be directed to the required spot by its being inclosed in a tube, the
introduction and application of which is itself not a little irritating at any
time ; but in laryngitis must be productive of great distress. Remember-
ing, also, the temporary tumefaction of the part to which leeches have
been applied, we reasonably fear even a slight increase of this condition
ofthe glottis, although it would be of short duration. Incisions or scari-
fications of the edematous glottean borders, with a long and narrow bis-
toury, covered with linen or muslin, to within two or three lines of the
point, have been practised by Lisfranc; while Legroux recommends lace-
ration of the membrane, to be performed with the end of the nail of the
index finger, cut obliquely in each side for the purpose. The difficulties
of either of these operations are manifest enough.
In the more distinctly marked erysipelatous laryngitis, in which the
serous effusion at the rima glottidis occurs so rapidly as of itself to en-
danger life, less active but not less prompt measures are called for. The
subjects of this variety of the disease are, for the most part, inmates of
hospitals in which erysipelas prevails, and amongst such of them as are
peculiarly liable to erysipelas, viz., the convalescent from continued fever,
or from eruptive fevers, and those labouring under secondary syphilitic
ulcers. Less call will exist here for the use of the lancet; and in its place
we employ leeches, emetics, and bring on copious diaphoresis by the warm
ACUTE EDEMATOUS OR SUB-MUCOUS LARYNGITIS. 61
and vapour bath. Mr. Busk, at a meeting ofthe Royal Medical and Chi-
rurgical Society, at which Dr. Budd read a paper advocating the erysipe-
latous character of edematous laryngitis, related two cases in proof of the
success of a mode of treatment described by him. It consisted in making
a great number of minute punctures on the back ofthe tongue, the uvula,
and the pharynx, with a sharp-pointed bistoury. The operation was re-
peated every half-hour for two or three hours ; it was productive of a great
discharge of serum, and the relief was sudden and decided. The parts,
after the puncture, should be gargled with warm water.
On one point in the treatment of acute edematous laryngitis, there is
unanimity of opinion. It is, to have recourse to laryngotomy so soon as
symptoms of suffocation are exhibited, and the remedies which have been
employed do not exert a marked ameliorating effect. The designation
by Dr. Baillie of the period of thirty hours of treatment, by bleeding and
opiates, without relief, after which bronchotomy should be performed, is
entirely too arbitrary. Dr. Cheyne very properly remarks, that " thirty
hours may be too long to wait, or it may be too short. If the circum-
stances ofthe patient, especially the condition ofthe circulating fluid, be
such as to contraindicate bleeding, and to show that asphyxia is imminent,
it may be improper to put off the operation for thirty minutes. If the
complexion is good, if asphyxia is not threatened, the operation may be
delayed for thirty days." Seldom, indeed, has the operation been per-
formed soon enough to afford well-grounded expectations of relief; for,
as Mr. Ryland justly observes (Diseases and Injuries of the Larynx and
Irachea), when the disease has continued some time, the lungs become
gorged with venous blood, serum is effused into their reticular texture,
and emphysema is likewise induced in them. The brain suffers, probably
from the nature ofthe blood circulated through its vessels, and gradually
loses its functions. The consequence is, such an exhaustion of the vital
powers that reaction and recovery cannot take place even when the respi-
ration is rendered free by means of laryngotomy.
But whilst stress is laid upon an early recourse to the operation, we
must still not deprive the patient of the chance of recovery by omitting it
even in the last and apparently hopeless stage. Mr. Goodeve relates the
case of a patient of his who was quite insensible when the operation was
performed ; no pulse could be found at the wrist ; his face was suffused
with blood,"and his lips livid; and it was hard to say whether he breathed
or not, and yet he recovered. The spot to be selected for laryngotomy is
the triangular space between the thyroid and cricoid cartilages, over the
crico-thyroid membrane. An incision of an inch in length is made through
the integuments along the central line of the neck, just over the crico-
thyroid space ; the edges of the wound are then separated, and the in-
cision is continued down to the membrane, which, upon being exposed,
may either be punctured with a trocar or divided in a transverse direction
with the scalpel. If the disease, for the relief of which the operation has
been done, requires that the artificial opening be maintained for some
time, it will be necessary to introduce a canula through the wound, and
confine it there by bandages, as the irritation produced by it will cause
strong expulsive efforts on the part ofthe patient ; but if the disease is of
a temporary nature, it will suffice to cut away a portion of the crico-
thyroid membrane. Laryngotomy is more suited to adult males than to any-
other class of persons, because the larynx in them is lower in the neck, and
62 DISEASES OF THE RESPIRATORY APPARATUS.
its dimensions larger, and consequently the crico-thyroid space more am-
ple. The canula has been worn bv different persons for a length ol^ time
without inconvenience ; the periods varying from six months to ntteen
years. . . , ,
The mortality is great in acute laryngitis. Of twenty-eight cases col-
lected by Mr. Ryland, eighteen proved fatal ; and even this is under the
average, in his opinion.
Edema of the larynx, which I have described in its acute stage, does,
however, occasionally present itself in a sub-acute, if not chronic form, as
part of general dropsy; or it supervenes gradually on phlogosis of another
organ, with but little premonition of its approach. It constitutes the serous
infiltration of Bayle. It is not less dangerous in this than in the acute
form. Hydragogue cathartics and diuretics, among which digitalis must
not be forgotten, and vesication of the forepart of the neck, will be the
chief remedies. It is in the chronic form that we may anticipate most
from laryngotomy.
LECTURE LXXXVIII.
DR. BELL.
Laryngitis Membranacea—Croup—Anatomical peculiarity characteristic of the dis-
ease; lymphatic exudation in,a membranous form in laryngeal inflammation—Phlo-
gosis extends to trachea and bronchia;; sometimes to the lungs—The chief seat of
croup is in the larynx—Proof from dissections and the leading symptoms—Character
ofthe breathing and the voice in croup—Dyspnoea evincing affection of the lungs at
the same time—Causes—referable to locality, states of atmosphere, and age of the pa-
tient—Seasons In which it prevails—Mortality from croup in New York, Philadel-
phia, and Boston—Epidemic croup—A^e at which croup is most common—Propor-
tion of the sexes—Symptoms—Precursory or common and imminent and special—
First and second stages — Duration—Mortality — Varieties of croup—Spasmodic
croup—Dr. Ley's theory—Diagnosis—Difference between primary and secondary
or consecutive croup—Membranous exudation from air-passages forms in some other
diseases—Treatment—Intentions of cure—First remedy, an emetic—Tartar emetic to
be preferred—Venesection—The warm bath—Leeching or cupping—Calomel with
tartar emetic—In appr aching collapse, perseverance in the use ot calomel and stimu-
lating and anti-spasrnodic expectorants ; blisters, epithems, etc.
Laryngitis Membranacea—Croup.—Croup has received a variety of
names: Laryngitis Pseudo-m,embranosa, Cynanche Trachcdis, C. Laryn-
gea, C. Stridula, Angina Palyposa, Suffocalio Stridula, Morbus Strangu-
lators ; Bronchitis, by Young ; and Empresma Bronchilemmitis, by Good.
The attempt to designate this disease by a symptom, whether of a sound
in breathing, or of a sense of imminent suffocation, must be misleading,
because not exclusively belonging to it ; and a term which implies its
primary fixation in any other part than in the larynx is erroneous. Croup
is now adopted, both by continental as well as English writers, and is a
title which cannot mislead by its connexion with any hypothesis of cause
or nature. In the United States the disease is known, among the people
commonly by the term Hives.
Morbid [Anatomy.— The anatomical peculiarity which distinguishes
croup from other varieties of laryngitis, is the production, primarily in the
larynx, of a false membrane. This production is secreted from the mu-
LARYNGITIS MEMBRANACEA—CROUP.
63
cous or lining membrane ofthe larynx ; it consists of albumen with a pro-
portion of phosphate of lime and carbonate of soda ; and occasionally
fibrin. It is corrugated and hardened by diluted sulphuric, nitric, and
hydrochloric acids; and, on the other hand, rendered softer and diffluent
by concentrated acetic acid, liquid ammonia, alkaline solutions and a
strong solution of the nitrate of potassa. A microscopic examination
shows it to be about a line thick and of a slight consistence : it is com-
posed almost entirely of ordinary pus-globules, mixed with inflammation,
corpuscles, and a species of cell double the size of.the pus-globule, but
otherwise similar to it. "Regarding this false membrane or lymphatic
exudation as a product of inflammation, we should naturally expect to see
the surface from which it is given out evince this morbid state. Accord-
ingly, the mucous membrane itself is often found to be rough, red, and
thickened ; but at other times one is not a little surprised to find it un-
changed in these particulars. It is no forced supposition, however, that
the inflammation may be so far relieved by this pseudo-membranous secre-
tion that there would be diminished redness, which, as in many other
cases of greatly increased vascularity during life, disappear entirely by
death. The same explanation will apply to those cases in which there is
neither false membrane nor increased redness observable after death,
although there had been unequivocal symptoms of croup before this ter-
mination. Even when we speak of this new product as the anatomi-
cal character of croup, we must at the same time admit that it is not
always present: it should rather be regarded as one of the chief proofs
of an inflammation of the mucous membrane of the larynx, which may
still be checked early ; and thus the lymph will not be given out with
sufficient freedom to form the membrane. Sometimes, in place of this
latter lining entirely the cavity of the larynx, we find patches and shreds
and at times merely thickened mucus.
But, farther observation shows, that the morbid action, in croup, is not
long confined to, although it commonly begins at, the mucous membrane
of the larynx. The trachea and bronchise are soon implicated, and to
such a degree as to be lined with this membranous exudation now con-
tinuous with that of the larynx ; and the bronchise are filled with a tena-
cious mucus. Evidences of inflammation may generally be discovered
over the whole of the mucous membrane of the lungs : their cavity is
always full of fluid ; the interstitial cells are sometimes filled with serum.
Nay, we have known, says Dr. Cheyne (Cyctopcedia of Practical Medi-
cine), parts ofthe lung hepatised, and inflammation to extend not merely
to the parenchyma but to the serous membrane, in consequence of which
we have seen fluid effused into the cavity of the pleura. In many dis-
sections the lungs have a solid feel, do not recede when the thorax is
opened, and cannot be compressed. Some have divided croup into varie-
ties according to the extent of the region of the mucous surface affected ;
hence we have laryngeal, laryngeo-tracheal and laryngeo-bronchial. We
may not be able, nor is it very desirable for practical purposes, to desig-
nate in advance these varieties; but it is exceedingly important that we
should be fully aware of the coincidence of tracheitis and of bronchitis,
and at times even of pneumonia with croup, or the laryngitis of children.
For the most part, the first lesions are felt and seen in the mucous mem-
brane of the fauces and larynx, and subsequently extend to the tracheo-
bronchial portion. It has been affirmed as a general fact, that exudatory
64 DISEASES OF THE RESPIRATORY APPARATUS.
inflammation appears, in the respiratory passages, to spread, invariably,
from above downwards, never in the opposite direction ; so that when
commencing in the bronchise, it can only descend to the pulmonary cells,
never mount to the larynx. (Haase—final. Descrip. of the Organs of
Circulation and Respiration.) If this be true we cannot admit the inverse
course as indicated by Dr. Stokes, who supposes that the irritation may,
at times, begin at the bronchial terminations, as manifested by cough, and
then violently fix itself in the larynx. Dr. Stokes, in treating of the pri-
mary inflammatory croup of children, lays down, as one of the most
important considerations, the complication with inflammation in the remain-
ing portions of the respiratory apparatus. In a considerable number of
cases, he assures us, that the laryngitis is preceded by some inflammatory
affection of the lung, which continues during its progress, but which is
overlooked in consequence of the prominence of the croupy symptoms.
" I have little doubt," continues this author, " that many children that
die with symptoms of croup are carried off as much by disease of the
lungs as by that of the larynx and trachea ; for I have seen many in-
stances in which, during life, the stethoscope indicated unequivocally the
existence of intense bronchitis or pneumonia, and have invariably found
that the diagnosis was confirmed by dissection." We cannot doubt the cor-
rectness of the opinion of a frequent conjunction of croup with bronchitis
and pneumonia. In the few fatal cases of the disease, or at least of a pul-
monary disease beginning with croup, which I have seen, this conjunction
or complication was unequivocal ; the patient having recovered from the
laryngitis, but sank under the pulmonary lesion. But it would be gene-
ralising too much were we to say, that in the majority of cases of croup,
in its first stage, and in its first attack, pneumonia existed either antece-
dently to laryngitis, or even came on contemporaneously with the latter.
The absence of the diagnostic signs, and the prompt and entire relief
afforded, in many instances, by the very first remedy, an emetic, forbid
such a supposition to the extent advocated by Dr. Stokes. In reasoning on
the order in which the pulmonary complications show themselves, we can-
not be unmindful ofthe effects ofthe mechanical impediments to respiration
by the encroachment on the calibre ofthe larynx and the almost occluded
glottis. The breathing must be laboured and hurried, the blood is imper-
fectly changed in the lungs ; there is effusion of serum in their paren-
chyma, and accumulated mucus in the bronchial cells. The frequent
complication of lobular pneumonia with croup has also been pointed out
by MM. Rilliet and Barthez (op. cit., p. 1, p. 321).
Laryngeal se%t of Croup.—I have already stated the seat of the inflam-
mation of croup to be the mucous membrane which lines the air-passages,
and in a more particular manner, the larynx and the trachea. The membra-
nous exudation varies in thickness, consistence, and extent of surface over
which it is spread : it is more commonly found in the larynx and upper
third of the trachea than in any other situation (Ryland). Bretonneau
gives three instances in which the false membrane extended from the
epiglottis, without breach of continuity, to the extremities of the bronchial
ramifications. In reply to the remark of Laennec, that this false mem-
brane is generally found in the larynx, but that it very rarely extends
above the glottis, we may cite the experience of Dr. Thomas Davis who
in his published lectures, remarks, that of six preparations then upon the
table before him, nearly every one presents the false membrane also in
LARYNGITIS MEMBRANACEA—CROUP.
65
the inner surface of the epiglottis. We must even go farther, and ad nit
that, in a great many cases, especially those in which croup proper has
been preceded by fever and anginose symptoms, a lymphatic exudation
forms on the tonsils and pharynx. M. Guersent estimates at nineteen out
of twenty the number of cases of croup in the child originating in this
way. This proportion is doubtless too large to represent croup in gene-
ral. In twenty-six fatal cases of croup in the Children's Hospital at
Paris, between 1S34 and 1839, there were but thirteen with inflammation
other than of the air-passages ; in nine there was an accompanying mem-
branous exudation ofthe tonsils, pharynx, and isthmus ofthe fauces.
As many English writers, and most of our own, persist in calling croup
tracheitis, or cynanche trachealis, and one ofthe former even takes credit
to his countrymen for having established beyond doubt its treacheal seat, I
shall adduce additional, I would call it conclusive evidence, in favour of
the disease being more especially laryngeal than tracheal. Desruelles, in
his Traite Theorique et Pratique du Croup, d?apres les Principles de la
Doctrines Physiologique, 2ine ed., Paris, 1824, quotes or refers to the fol-
lowing writers respecting the seat of croup :—It is probable, says Vieus-
seux, that croup, which is suddenly fatal, is that in which the larynx is
the part first affected. Royer Collard holds the same opinion. Bard has
seen a whitish coat on the fauces, epiglottis inflamed, and covered with
mucosities extending to the larynx. MM. Beauchene, Sedillot, Carron
d'Annecy, Leveque Lasource, Lechevrel, Latour, Valentin, Dejaer, Mer-
cier, Carus, Regnaud de Lorrnes, have published cases in the Journal
General de Medecine, in which a lesion of the larynx was manifest.
Albers, after an inspection of the cadaveric phenomena, believes that most
frequently inflammation arises in the larynx and upper part ofthe trachea.
Boisseau (Diction. Abrege des Scien. Med.) says, the larynx is always
affected in croup ; it is also the only part. The bronchise are frequently
intact, and are never alone inflamed. The trachea is never affected
without the larynx being in a similar condition. Simple croup, in the
opinion of Desruelles himself, has its seat in the mucous membrane
of the larynx ; but the false membrane is often thicker in the trachea,
and the traces of inflammation greater in it. From these appearances,
Dr. Jackson, of the University of Pennsylvania (American Journal
of the Medical Sciences, vol. iv.), has drawn an inference that the exu-
dation begins lower down, as in the bronchial ramifications, and, a -
cending to the trachea, ultimately reaches the larynx ; an opinion coinci-
dent with that of Dr. Stokes, already detailed. In two fatal cases, the
symptoms of which and the post-mortem appearances are described by
Dr. Jacks,on, the membrane was continuous from the superior margin of
the glottis down and into the bronchise, or the lung-'. It became thicker
in its progress downwards. The mucous membrane of the larynx, tra-
chea, and bronchise, beneath this lining, was highly injected with blood
and inflamed ; presenting an appearance rather rougher than common.
Blaud (JYouvelles Recherches sur la Laryngeo-Tracheite—Connue sous le
nom de Croup) details twelve fatal cases, in all of which there was a
membranous exudation lining the upper part ofthe air-passages ; and in
almost every case, when regions are specified, the larynx is shown to be
affected, and thence mostly down to the middle of the trachea: in one
instance the false membrane is stated to have extended from the trachea
to the bronchise and their ramifications. In the case of a child three years
vol. n.—6
66 DISEASES of the RESPIRATORY apparatus.
old, which terminated in six hours, false membrane formed, and was
found after death in the whole of the larynx and greater part of the
trachea, adherent and coming off in strips. Sometimes, even in primitive
croup, the pharyn.v is partially lined with a membranous exudation, con-
tinuous with that in the larynx.
The character ofthe voice and breathing in croup, which arises from a
spasmodic contraction of the constrictor muscles ofthe larynx, is further
evidence of its laryngeal seat. The glottis can be voluntarily narrowed
by some persons, so as to produce or imitate the sonorous hissing of
croupal breathing. Croupal voice depends on two causes ; viz., the
spasm of the constrictor muscles of the larynx, and an alteration of the
mucous membrane lining the vocal cords, by inflammation. Hoarseness,
or a raucous voice, depends oh the vocal cords in croup becoming softer
and relaxed, by which the air is prevented from causing the complete
vibrations in health. The thicker the covering of the mucous membrane,
that is, the greater the inflammation, the hoarser will be the voice; and
the hoarser the voice, the more serious the affection of the glottis and
larynx. This state may extend to aphonia itself, which is temporarily
relieved by expectoration. A grave or bass voice indicates a serious
affection of the larynx and its vocal cords. An acute tone of voice is
generally the result of a spasm of the laryngeal muscles and of the smaller
opening ofthe glottis.
We cannot understand, nor give any adequate explanation, of spas-
modic croup, or of the fits of threatened suffocation in common croup,
unless we admit the laryngeal seat of the disease. The irritating cause
is in the mucous membrane of the glottis and larynx : by a reflex-motor
action, the irritation of the membrane, transmitted to the brain, causes a
return of innervation on the muscles of the glottis and larynx, and they
are contracted with more or less violence. The cerebral excitement is
kept up in these cases, and often augmented, 1, by the external air which
is not in relation with the morbid sensibility of the inflamed organ ; 2,
by the duration of the inflammation itself; 3, by the various products of
inflammatory secretion, which, like so many foreign bodies, irritate the
air-passages. Hoarseness or an equivalent condition of voice may be
the fixed one in croup ; but the modifications depending on spasm of the
laryngeal muscles must be considerable. The spasm may be continued,
remittent, or intermittent; varieties which may exist in laryngitis with
false membrane from the glottis down to the bronchise. A suspension of
the more violent symptoms may take place, and the disease seem so far
to be intermittent; but it is the spasm of the muscles, not the secretion
ofthe exuded membrane and croup proper, which intermits. Inflamma-
tion of the membrane, like any other of the phlegmasia?, is liable to
exacerbation ; but this latter does not always correspond with spasm or
fits of laborious breathing and imminent suffocation. The spasm of the
glottis is most common at night; and hence a mucous irritant, hardly a
source of complaint during the day, may, without any, or with very slight
increment, be a source of imminent suffocation at night, owing to the
greater susceptibility of the nerves and muscles at this time. Death
rarely results from the occlusion of the glottis, by the thickenino- of the
mucous membrane or the superposition of false membrane on this latter •
but it may by the spasmodic action of the muscles. Even where the
false membrane is formed and adherent, the breathing is sometimes free
just before death.
CAUSES OF LARYNGITIS MEMBRANACEA—CROUP. 67
But, although the characteristic symptoms of croup depend on organic
lesion ofthe larynx, we cannot render an account of all the phenomena
of the disease if we overlook its tracheo-bronchial and even pulmonary
complications. Of these I have already spoken. The dyspnoea gives a
tolerably good measure of their presence and intensity. Hence, when we
see the lips of a livid or violet colour, the face tumefied, the eyes promi-
nent and shining, headache, somnolency, comatose stupor or convulsions, a
peculiaVanxiety, hurried.breathing, and throwing the head back, we recog-
nise symptoms of impeded pulmonary circulation and decarbonization of
the blood, and feel ourselves more urgently called upon to remove this
state of things, whether the laryngeal symptoms proper be urgent or not.
Causes.—The circumstances under which croup most readily and gene-
rally appears, are in reference to locality, states of atmosphere, and age.
As regards locality, we find that large bodies of water, running or stag-
nant, fresh or salt, predispose to the disease. A damp and cold atmo-
sphere has a similar tendency ; although we must consider cold as rela-
tive. An easterly wind with rain, and a reduction of the thermometer
by a few degrees even in July, will bring on an attack in a child not suit-
ably protected from these influences.
The influence of locality in the production of croup is manifested very
clearly at Warsaw, particularly in the spring season, at the time of the
breaking up of the ice in the Vistula ; in the circumstance ofthe disease
being worse on the banks of the river and lower part ofthe city than in
the upper. It is comparatively rare among the children who live in the
upper stories, or on the first stage. The children ofthe poor who reside
on ground floors are the greatest sufferers. But, contrary to what we
would suppose, croup is little seen at Venice, bedded in the sea ; and it is
more frequent in Florence, bordering almost on the Appenines, than at
Leghorn, on a paludal soil, on the sea-coast.
Winter and spring are spoken of as the seasons in which it most fre-
quently makes its attacks ; but the line of separation between exposure
and immunity from croup is not always designated by the almanac. In
New York the months exhibited mortality, during a period of sixteen
years, in the following order: October, November, January, March, De-
cember, February, April, May, September, July, August, and June.
Croup is represented to be more frequent when epidemic catarrh or influ-
enza prevails ; but the fact is only of occasional occurrence, for in some
influenza seasons which I have witnessed I have not found soch a coinci-
dence. In Boston, on the other hand, the disease would seem to increase
at a faster rate than that ofthe population, the deaths, from 1811 to 1820,
were 43 ; from 1821 to 1830, 245 ; and from 1831 to 1839, 376 ; being
in these periods respectively 5 ; 15-9 and 21*3 per 1000 deaths from other
diseases.
Croup has prevailed at times epidemically, although we may suspect
that some of the accounts of its appearance in this way are really those of
its aggravated endemical occurrence. Vieusseux of Geneva, in his Me-
moire sur le Croup ou Angine Tracheale, relates that croup has been ob-
served to be epidemic in different parts of France. Between 1772 and
1783 it occurred twenty times in Geneva ; from 1776 to 1784, four times
in Tarascon ; from 1771 to 1783, four times in Etampes; and from 1780
to 1784, four times in Beziers. It is not unlikely, as the inquiries of M.
Bretonneau have satisfied him, that these visitations, or some of them at
68 DISEASES OF THE RESPIRATORY APPARATUS.
least, were of secondary croup or angina diphtherite, already described.
Valentin (Recherches Historique et Pratiques sur la Croup, Pans, 1^12,,
who lived for some time and travelled extensively in the United States,
and is known to some of our old physicians, speaks of the epidemic returns
of croup at Cremona, in Italy, in 1747 and 1748 ; at Frankfort on the
Main in 1758 ; in Sweden four different times ; at Franconia in 1775 ;
also in Warsaw in 1780; at Altona, Tubingen, and Stuttgard, in 1807,
and Vienna in 1808. He also mentions the disease having appeared in
this way in Portsmouth, Virginia, in 1805.
Dr. Valentin gives some statistics of croup in this country, forty years
ago, which are not without interest as forming data for comparison with
its mortality at this time. Thus, in the city of New York the deaths from
croup in 1804 were 75, in 1805, 70, and in 1806 they were 106. The
population of that city at the time was estimated at 70,000 inhabitants.
If we compare these returns with the mortality in 1838, which was 182,
and in 1839, which was 141, and bear in mind the increase of population,
we shall draw the inference that croup prevails less extensively now than
formerly in Ne"w York. The average number of deaths annually from
croup, for a period of 16 years, from 1819 to 1834, was 140 ; or 1 death
from croup for 37-3 of other diseases. In Philadelphia, in 1807 the deaths
were, in all, 2045, of which 54 were from croup ; in 1808 the annual
mortality from all diseases was 2271, and from croup 53. On referring
to the mortuary returns for 1838, I find the deaths from croup in this city
were 101, and in 1839 but 83; leading to the same conclusion as that
just drawn respecting New York.
As respects age, croup may occur at any time between the second or
third month after birth and puberty. The younger children are when
weaned, the more liable they are to the disease. Out of 350 cases pre-
sented in a tabular form by M. Andral (op. cit.), 21 took place between
birth and eleven months after this epoch ; 61 between a twelvemonth and
two years of age ; 45 between two and three years ; 54 between three and
four years ; 42 between four and five ; 39 between five and six ; 29 be-
tween six and seven ; 3 between seven and eight. From the period be-
tween eight and twenty years of age, there were but 27 cases ; and between
twenty-six and thirty, none. At thirty and at thirty-four years of age there
were, respectively, four: and one was reported at seventy years of age.
Some will deny that it was genuine primary croup which assailed these
persons in adult life. In the Philadelphia return for 1839, the only
one before me, all the deaths were under ten years of age, viz., 19 in the
first year from birth, 18 in the second year, 33 between two and five years,
and 13 between five and ten years. In New York, of 88 males, I omitted
to notice the femalt-s, 63 died under a twelvemonth ; 25 between one and
two years of age; and 43 between two and five years. The narrower o-bttis
of a child than of an individual who has reached puberty is adduced as a
probably predisposing cause of the croup in early life. The difference
says Dr. Cheyne, between the glottis of a child of three years and that of
one at twelve is scarcely perceptible, whereas at puberty the aperture of
the glottis is quickly enlarged, in the male in the proportion of 10 to 5
and in the female of 7 to 5 ; the bronchise at the same time enlarging and
the voice undergoing a corresponding change. Respecting the relative
liability ofthe two sexes, it would seem that this disease is much more
frequent in males than females. Of 252 cases treated by Goelis, 144 were
SYMPTOMS OF LARYNGITIS MEMBRANACEA —CROUP. 69
boys and 108 girls ; J urine gives the proportion as 72 boys to 47 girls in
119 cases. The return in the New York Bill of Mortality for 1839, already
mentioned, gives 88 males for 53 females ; in Philadelphia, on the other
hand, for the same year, the proportion was reversed, the deaths of boys
being 38, and of girls 45.
The habit of body most liable to croup is fulness of cellular and adipose
tissue, and a strumous diathesis.
Symptoms.—The symptoms of croup are precursory, or those common
to catarrh and other affections of the larynx and bronchise, and imminent
or special. Among the first are hoarseness, cough, and modification ofthe
common voice, with some febrile irritation. These may exist a day or
two before the others are apparent; or they may only show themselves a
few hours before the more alarming and distinctive manifestations of the
disease. Indeed, if we are to credit even formal professional accounts,
we should be led to believe that sometimes croup shows itself at once, in
all its intensity and danger, without any prodrome. But a more careful
inquiry would have satisfied the narrator that the child, said to be thus
suddenly and unexpectedly attacked, had previously some of the symp-
toms first mentioned, to which may be added, in certain cases, gastric de-
rangement owing to the eating of some indigestible substance. Hoarse-
ness has a signification in children more distinctive than in adults ; since
it seldom precedes common catarrh in the former, as it so commonly does
in the latter; and hence, if accompanied with a rough cough, hoarseness
should at once excite the attention of the parent, and induce a call on the
physician.
The approach of an attack of croup, which takes place almost always
in the evening, and generally at an advanced hour, or towards midnight,
is often indicated, after a day of unusual exposure to the weather or get-
ting the feet wet, by variable spirits, greater readiness than usual to
laugh or to cry, a little flushing, and occasionally coughing ; the sound
of the cough being rough, like that which attends the catarrhal stage of
the measles. More generally, however, the patient, after a period of
sleep, gives a very unusual cough, which it is not easy to describe in
words, but which is readily recognised by a person who has once heard
it. Comparisons of the cough in croup have been made to the coughing
through a brazen trumpet, to the crow of a cock, and to the low sharp
barking of a dog, or, better still, to the noise made by a dog or a cat
which has swallowed something the wrong way, as it is called, and makes
half-efforts at vomiting. A repetition, for a few times, of this cough,
rouses the patient, who now evinces a new symptom in the altered sound
of his voice, which is puling or whining, and as if the throat was swelled.
The cough is succeeded by a sonorous inspiration, not unlike the kink in
pertussis ; the breathing, hitherto inaudible and natural, now becomes
audible and a little slower than common, as if the breath were forced
through a narrower tube ; and this is more remarkable as the disease ad-
vances. The ringing followed by crowing inspiration ; the breathing as
if the air were drawn into the lungs by a piston ; the flushed face ; the
tearful and bloodshot eye ; quick, hard, and incompressible pulse ; hot,
dry skin ; thirst, and high-coloured urine ;—form a combination of symp-
toms which indicate the complete establishment of the disease. The sen-
sation of pain about the trachea is manifested in young children by a fre-
quent application of the hand to the throat. The patient exhibits great
70 DISEASES OF THE RESPIRATORY APPARATUS.
anxiety and restlessness, and frequent desire to change from place to place;
he is thirsty, and drinks, and in many cases without difficulty, although,
by some writers, difficult deglutition is mentioned among the diagnostic
signs of the disease. At each inspiration the tumid larynx descends
rapidly towards the sternum, whilst the epigastrium is drawn upwards
and inwards. Such are the symptoms which indicate the first, confirmed,
or inflammatory stage of croup, and which, violent as they are, sometimes
subside about midnight, even without medical treatment ; to return, per-
haps, in the course of the following evening. But in general, unless the
disease be treated with promptitude and judgment, the second stage, cha-
racterized by a new order of symptoms, comes on the following day and
terminates fatally.
This second stage is called the purulent, the suppurative, or the suffo-
cative. It may commence from the second to the seventh day, or, in the
suddenly fatal, it may succeed the first stage in a few hours. This period
is characterized by the absence of any remission, and the increased se-
verity of all the symptoms, particularly the acceleration and diminished
power of the pulse and of respiration. The cough, from being loud and
sonorous, becomes husky and suffocating; it resembles the cough which
attends tracheal phthisis, antl cannot be heard at any distance from the
bed ; the voice is whispering; the respiration wheezing; the countenance
pale ; lips livid ; the skin motley ; the eyes languid ; the pupils are di-
lated ; the iris with less colour than natural : a symptom, this last, which
attends the advanced stage of diseases of the lungs ; and mentioned by
Dr. Cheyne, with a remark that it has been, he thinks, overlooked. The
tongue is loaded and has purplish edges ; thirst considerable ; skin much
less hot, and the stools dark and fetid ; the surface ofthe body is covered
with a cold, viscid perspiration ; the feet and hands swelled. In this
the second stage, or that of suppuration, the breathing may be often re-
marked as most free in positions which are generally least favourable to
easy breathing, as, for example, when the head is low and thrown back.
There is seldom recovery from this stage last described. Sometimes tem-
porary relief is obtained by the expectoration of a portion of the albumi-
nous, membranous, and muco-puriform matters obstructing the larynx and
trachea. When the excretion is free, recovery may take place, but slowly;
but when it is scanty, or if the inflammation has extended downwards,
through the bronchise, as it usually does when thus severe, the issue is
commonly fatal. In this case, the patient tosses about in great distress ;
he seizes on objects around him, and grasps them convulsively for a mo-
ment ; he throws his head back, seizes his throat as if to remove an
obstacle to respiration, makes forcible efforts to expand the lungs ; and,
after a longer or shorter time of distress, seldom above twenty hours, he
expires, sometimes with signs of convulsive suffocation, but as frequently
with continued increase of the foregoing symptoms, exhaustion of the
vital energies, and a state of lethargy. The stethoscope generally
furnishes information in this period of the extension of disease to the
larger bronchise. This extreme state of disease seldom lasts more than
twenty-four hours: it corresponds with the stage of collapse of some
writers.
Duration.—Croup, when fatal, at an average, occupies a period of four
days: it has destroyed life in twelve hours. Sometimes, however the
second stage is prolonged for two or three weeks, and the patient, ex'pec-
MORTALITY OF LARYNGITIS MEMBRANACEA —CROUP. 71
torating freely, emerges slowly from that which had seemed to be an
utterly hopeless condition. Along with puriform fluid, of which the sputa
chiefly consists, there is sometimes expectorated a white, soft, tubular
matter, like macaroni stewed in milk, which is called the membrane of
croup. We can hardly admit the chronic character of true croup, laryn-
gitis membranacea. That the patient, relieved from the inflammation and
its consequent morbid productions in the larynx, should suffer for many
days, perhaps weeks, from the extension and persistence of a sub-acute
disease of the bronchise and lungs, we can well understand. I have seen
cases of this nature myself; and believe them to be of more ready occur-
rence, and, I may add, more frequently mortal in children of a strumous
habit.
Mortality. — The mortality from croup has varied at different periods,
and is rated very differently by writers in different coun'ries. M. Andral
estimates the recoveries to the deaths to be barely 1 in 10 ; adding, that in
a small village in France (near Treste-sous-Jouarre), during a period of
epidemic croup, in 1825, of sixty children attacked the entire number
perished with the disease. It is encouraging to know that the treatment
is more successful now, or, at any rate, the relative mortality is less than
it was at the beginning of the present century. M. Double (Traile du
Croup) has taken the pains to prepare a table exhibiting the results of the
practice of fifty-eight writers who have published their experience in this
disease, from which it appears that the number of cures is rather more
than a third part of the whole. The authors being ranged in chronological
order, we can make at once two classes, twenty-nine in each ; and show
that, whilst nearly four-fifths died of croup of those who had been attacked
and who had been attended by the first class, not quite one-half of the
entire number attended by the second, or more modern class, fell victims
to the disease. In the spring of L760, that of its first appearance in the
county of Lancaster, England, Mr. Fell, a surgeon, who announces this
fact, adds that, during the season, six children labouring under croup were
committed to his care, to all of whom it proved fatal. But even at the
present day our professional vanity is rebuked at the great mortality from
croup in different parts of Europe. In a capital like Paris, where all the
knowledge and resources of medicine would, we might suppose, be brought
to bear for the cure of disease in every form, the American student will
be not a little surprised at the results of hospital practice, in croup, as
exhibited, in the prize essay on the subject by M. Boudet (Archiv. Gen.
de Medecine, Fev. et Avril, 1842). Thus, of twenty-six cases of croup,
received into the Children's Hospital, in Paris, for a period of six years,
or from 1834 to 1839, the deaths were twenty-two in number. In the
last year (1839), and in the two following years, croup was epidemic in
Paris ; the deaths from this disease having been in 1838, '39, and '40,
respectively, 187, 286, and 326. In the Children's Hospital, in 1340,
the deaths were 23, and the recoveries but 2 ; in 1840, during the first
six months the deaths were 12, being the entire number of all the cases
received in the hospital. This terrible mortality might reasonably be attri-
buted to the deteriorated constitution of the poor children brought to the
hospital, did we not read in M. Boudet's essay that a physician, whom
he names (M. Loyseau), living in Montmatre, near to Paris, lost twelve
out of fourteen cases, which he was called upon to attend at the houses of
his patients. I have not the requisite data on which to express an opinion
72 DISEASES OF THE RESPIRATORY APPARATUS.
ofthe proportionate mortality of croup in the United States ; but, adding
my own experience to that of my professional friends, I should say, that
it is not nearly so great as that given in any of the preceding statements
of European authors, particularly the continental ones. Cases of croup
are of very frequent occurrence with us — the deaths, compared to the
number attacked, are few.
Varieties and Complications.—Before I speak ofthe treatment of croup,
it will be necessary to say something of its varieties and complications;
for, on a clear understanding of these points will depend very much our
selection of appropriate remedies. Laryngeal croup is distinguished by
the symptoms already mentioned, and more especially great aggravation
ofthe disorders in voice, speech, and breathing, with more or less feeling
of strangulation and pain in the larynx. In the tracheal croup, in which,
although the larynx is not free by any means from disease, the trachea is
chiefly affected, there is a dry, shrill, or sonorous cough, and a sharp
lancinating pain in the course of the trachea, sometimes with slight tume-
faction. The patient speaks in an undertone ; but there is little hoarseness,
and the voice and speech are not lost, or at least not so much affected as
when the disease is seated partly or chiefly in the larynx. The cough,
as the disease advances, although frequent and severe, has not the dis-
tressing sense of suffocation which accompanies the laryngeal variety.
The fits of coughing are often followed by vomiting, or the rejection of
membranous shreds, with a thick, glairy, and sometimes sanguinolent or
purulent mucus. Generally the excretion of the substance is productive
of much relief, which is increased after each discharge, unless the inflam-
mation has extended down the ramification of the bronchise ; and then the
respiration continues to be extremely difficult, and the disease assumes
all the characters of an acute bronchitis, and frequently terminates unfa-
vourably. Cases of this description seldom run their course so rapidly as
those do which chiefly affect the larynx. All the symptoms evince less
severity, especially when treated early ; and it sometimes continues twelve
or fifteen days, but usually from five to nine.
Croup with predominance of bronchial inflammation. This variety
corresponds with the Cynanche Traxhea/is Humida of Rush, and the
Mucous Croup of some still more recent authors. I follow the specifica-
tions of its character as laid down by Dr. Copland (op. cit.). It is not
infrequent in young children of the lymphatic temperament, who are fat
and flabby, with a white soft skin. It is often met with soon after the
period of weaning, and in those who are brought up without the breast.
It commences with coryza and the other symptoms of catarrh, and often
with a little fever. After these have been present for some time, the
child is attacked in the evening, or during the night, by a sudden hoarse-
ness, and a suffocating, dry sonorous, or shrill cough, with a sibilous
inspiration. The countenance is pale and covered with perspiration, and
the lips are violet. Several slight fits succeed to this first attack ; the
voice remaining hoarse and low, the respiration sibilous and slightly diffi-
cult ; but a remission usually takes place in the morning. In the following
evening there is a return of the croupal cough in a slighter depree.
Sometimes the invasion is more gradual; the remissions but slio-ht or
hardly evident, and the accession of expectoration much earlier • the
disease approaching nearer, as respects its seat and character, to acute
bronchitis. After the first, second, or third day, the cough is no longer
VARIETIES OF LARYNGITIS MEMBRANACEA— CROUP. 73
dry, its fits become shorter; it is sometimes accompanied with a mucous
rattle, and begins to terminate in the expectoration of a thick, glairy
mucus. The disease now assumes many of the features of, or passes into,
bronchitis. It is the bastard or false croup of M. Guersent, more properly
the laryngeo-bronchial variety of M. Duges, and milder in its character than
the first, which 1 have described at length.
Spasmodic Croup.—Thus far, there can be no doubt about the inflam-
matory nature of croup, whether it be simply laryngeal, laryngeo-tracheal,
or laryngeo-bronchial. The difference is simply in the degree and diffu-
sion of inflammation along the mucous membrane ofthe air-passages, and
the treatment in all must be of the same kind. But another variety with
more distinctive peculiarities is alleged to be common in children, and
every now and then to be seen in adults ; it is called laryngismus stridu-
lus or spasmodic croup, and is represented to be dependent on a temporary
affection of the nerves, by which the muscles of the larynx are thrown
into spasmodic action, and thus diminish so rapidly and greatly this canal
as to cause feelings of imminent suffocation, and on occasions death itself.
This variety of croup occurs chiefly in weak, irritable children of a nervous
temperament, and liable to worms. A quite different view of the cause
of this affection was presented a few years ago in a work on the subject
by the late Dr. Ley. He attributes it to a suspended or imperfect func-
tion of the branch of the eighth pair of nerves which is distributed to the
larynx, caused, as he supposes, by the pressure of the enlarged cervical
and bronchial glands. Children of a strumous and scrofulous habit are
the greatest sufferers. Dentition is an exciting cause, by the swelling
and inflammation of the glands to which it gives rise. The distressing
symptom of crowing and prolonged inspiration is not, Dr. Ley thinks,
owing to a spasmodic closure of the glottis, but rather to an inability of
this part to enlarge to its normal size, owing to the want of innervation
from the diseased glandulce concatenates. From the same cause, the trans-
verse fibres, behind and connecting the rings of the trachea, losing their
contractile power, the sputa accumulate ; hence the " prodigious rattling
in the upper part ofthe asper arteria, resembling the sound which attends
when there is phlegm that cannot be got up, scarce sensible when they are
awake, but very great when they are asleep, described by Dr. Molloy ;
' that kind of noise which an increased secretion ofthe mucus on the air-
passages would produce,' noticed by Dr. North." The approximation of
the sides of the glottis, thus produced, Dr. Ley argues, is owing to de-
fective power of the opening muscles, and may be either complete or
partial. If complete, the child may be carried off by convulsions or by
asphyxia without convulsions. More commonly, however, the glottis,
becoming gradually, but partially open, air rushes through the still con-
tracted aperture, producing the sonorous inspiration so characteristic of
this disease, and this commonly announces the partial recovery of the
child.
The pathological views of Dr. Ley would lead to a prophylaxis which
consists mainly in removing both the enlargement of the obstructing glands,
and in giving tone to nutrition, so as to prevent their becoming subse-
quently diseased. But whilst admitting the propriety of this course, so
far as it goes, we cannot give our adhesion to the pathology on which it
is founded. Croup is too readily as well as promptly curable, and yields
too frequently to a removal of specific irritation, such as dentition, indi-
74 DISEASES OF THE RESPIRATORY APPARATUS.
gestion, &c, for us to suppose that it could depend on a cause so deci-
dedly and fixedly organic as that advanced by Dr. Ley.
In reference to spasmodic croup, in general, there is no sufficient diag-
nosis to enable us to distinguish it from common inflammatory croup.
Cases of pure and unmixed spasmodic croup are rarely met with in prac-
tice ; the intermediate states between it and the inflammatory variety being
more constantly observed. It is worthy of notice, also, that, in the un-
doubted inflammatory and membranous variety of croup, the obstruction
of the larynx, or the laryngeo-tracheal canal, by new formations, is not
sufficient to prevent the access of air to the lungs,—but that a great part
ofthe phenomena and consequences ofthe disease are to be attributed to
spasm of the larynx and trachea. This, however, it has been justly re-
marked, is spasm caused by inflammation, for which no antiphlogistic
will be equal to venesection. Its nature may be understood from my
preceding remarks on the laryngeal seat of croup. Dr. Copland says,
that he has scarcely ever seen a well-defined case of spasmodic croup un-
connected with dentition ; or one terminate fatally without the concurrence
of convulsions in its advanced stages, or towards its termination ; and it
has very commonly presented evidences of cerebral congestion. Dissec-
tion has revealed, in some cases, albuminous concretions, sometimes ex-
tensive, but more frequently consisting of small isolated patches in the
larynx ; sometimes an adhesive glairy fluid, with vascular spots in the
epiglottis and in the larynx. The congestion of the brain, particularly
about its base and the medulla oblongata, and ofthe lungs, cavities of the
heart and large vessels, which are also found, are most probably consecu-
tive changes. Still it must be conceded that there is a variety of croup
of primary origin meriting the name of spasmodic. It may be induced by
a preceding attack of the inflammatory ; it appears to be most common in
strumous and scrofulous habits. To a sudden invasion of croup, following
and apparently caused by indigestible substances, such as nuts, apples,
&c, and which is promptly removed by their expulsion, the title of spas-
modic would seem to be applicable enough. In using it, I could wish
that we had a terminology which would serve to designate croup thus
occurring in children, and sometimes, though but very rarely, it is true,
in adults, in which there is a temporary congestion of the mucous mem-
brane ofthe larynx, and, often, trachea, and thickening of the vocal cords,
constituting a morbid change very analogous to that which takes place in
the bronchial ramifications in nervous or dry asthma. The suddenness
ofthe attack, its frequently gastric origin, and immediate removal, some-
times by an emetic, sometimes by a common anti-spasmodic, or opium, or
other narcotic, are farther points of resemblance between this nervous or
spasmodic croup, and nervous or dry asthma. With both of these may-
be associated not only congestion, but actual inflammation of the mucous
membrane,—that of the larynx in croup, that of the bronchise in asthma,—
and both with very slight modification of symptoms may require decided
antiphlogistic remedies, antecedent to, and sometimes in place of those
ofthe anti-spasmodic, opiate, and narcotic class just referred to.
In our diagnosis it is very important that we should not confound pri-
mary and idiopathic croup, either inflammatory or spasmodic with second-
ary and symptomatic croup, in which the false membrane or puriform
exudation is consecutive to an extension of that which lines the fauces
and pharynx. The latter state is found in angina maligna, or diphtheriie
VARIETIES OF LARYNGITIS MEMBRANACEA — CROUP. 75
by which latter term of late years it has been called by Bretonneau, and
others after him, and under which it has engaged our attention. We are
the more required to study this complication, as, unfortunately, some of
the French writers, including even Laennec, have thought that it repre-
sented true croup, which, on this account, they have spoken of as not only
epidemic but contagious. Such confusion in pathology must, of course,
greatly obscure the treatment; and physicians, by an erroneous refine-
ment, would be tempted to a practice in true croup that must be unfortu-
nate and destructive, since it would recognise typhoid complications,
which only exist with the membranous angina and secondary croup. The
contrasted features of the two diseases are so well exhibited by Dr. Stokes
(op. cit.), that I shall give them entire:—
PH1MAUT CllOUr. SECONDARY CROUP.
Jingina Maligna vel Membranacea.—Diph-
therite.
1. The air-passages primarily engaged. 1. The laryngeal affection secondary to
disease ofthe pharynx and mouth.
2. The fever symptomatic of the local dis- 2. The local disease arising in the course
ea>e' of another affection, which u generally accom-
panied hy fever.
3. The fever inflammatory. 3 The fever typhoid.
4. ISecessity for antiphlogistic treatment, 4. Incapable of bearing antiphlogistic treat-
and the frequent success of such treatment. ment; necessity for the tonic, revulsive and
stimulating modes.
5. I he disease spasmodic and in certain 5. The disease constantly epidemic and
situations endemic, but never contagious. contagious
6. A disease principally of childhood. 6. Adults commonly affected.
7. I he exudation of lymph spreading to 7. The exudation spreading to the glottis
the glottis, from below upwards. from above downwards.
8. The pharynx healthy. 8. The pharynx diseased.
9. Dysphagia either absent or very slight. 9. Dysphagia common and severe.
10 Catarrhal symptoms often precursory 10. Laryngeal symptoms supervening with-
to the laryngeal. out lhe pre.eXJstence of catarrh
11. Complications with acute pulmonary 11. Complications with such changes iare.
inflammation common. [Gastric complications common.]
12. Absence of any characteristic odour of 12. Breath often characteristically fetid.
the breath.
In the accuracy of one of the features (7) of true or primary croup, I
must, however, express my disbelief. I need not go over the "aigument
again, nor repeat the proofs of the downward extension of the lymphatic
exudation from the glottis and larynx to the trachea, and thence to the
bronchiae; but I will just add one familiarfact to the proofs already presented,
viz., alterations of the voice, of course glotteal disorders, preceding the'
other symptoms ofthe disease.
The occurrence of secondary croup, or of angina membranacea, with
extension to the air-passages, is frequent in times of real epidemic croup-
of which proof is furnished in the late epidemic at Paris, before referred
to. The prevalence of exanthematous diseases, and great tendency to
mortification of tissues, particularly gangrenous tonsillitis, was also appa-
rent to all, and is so described by M. Boudet (op. cit.). This writer
speaks of epidemic croup having been contagious, but without specifying
the form of the disease which manifested this property.
In many instances of the malignant sore throat, the exudation thrown
out rom the inflamed surface forms a pellicle coextensive with the spread
of the morbid process from the fauces to the pharynx and air-passages.
76 DISEASES OF THE RESPIRATORY APPARATUS.
In some cases, ulceration and slight apparent sloughing occur in the cen-
tral parts and those first affected, whilst the surrounding surface »"« »e
parts subsequently diseased, become covered by a soft and easily lacerated
exudation. The complication with croup of various stages of angina or
sore throat—malignant or epidemic—whether commencing m the pharynx,
or in the fauces and extending to the pharynx, is not uncommon, tire-
tonneau describes a remarkable epidemic affection of this nature, which
he called scorbutic angina, or angina maligna. In eighteen cases ot which
he gives the dissections, the air-passages were affected. In five, the dis-
ease occurred in children, aged from eight months to seven years, and in
all of them the exudation was first formed in the pharynx. In one case,
it descended into the minute bronchise. The remaining thirteen cases
proved fatal by the air-passages having been attacked ; and in one case
the laryngeo-bronchial membrane seemed to be alone affected.
The lymphatic exudation is sometimes formed in the course of other
diseases, as typhous fever, gastro-enteritis, chronic pleurisy, &c. In some
cases, the morbid action originates in the tonsils, and extends to the ad-
joining parts. In the croup epidemic in Buckinghamshire, in 1792, de-
scribed by Rumsey, the croupal symptoms were stated to have been co-
eval with inflammation of the tonsils, uvula and velum pendulum palati;
and large films of a white substance were formed on the tonsils. Croup
may also be complicated with thrush ; and with all the exanthematous
fevers,—measles, small-pox, and malignant scarlatina.
Treatment. — The intentions of cure of croup are properly defined by
Dr. Copland to be,— 1st, to diminish inflammatory and febrile action,
when present ; and to prevent, in these cases, the formation of a false
membrane, or the accumulation of albuminous matters in the air-passages;
2d, when the time for attempting this has passed, or when it cannot be
attained, to procure the discharge of these matters ; 3d, to subdue spas-
modic symptoms as soon as they appear; and, 4th, to support the powers
of life in the latter stages, so as to prevent the recurrence of spasm, and
to enable the system to throw oil' the matters exuded in the larynx and
trachea.
Called up in the night to see a child who, after having gone to sleep in
the evening, is at this time suffering from well-marked croup, the physi-
cian ascertains the antecedent and collateral circumstances, in regard par-
ticularly to prior attacks, their duration and treatment, and the general
habit and morbid predisposition of the patient, and then prescribes an
antimonial emetic. He may find that, before his arrival, either ipecacu-
anha or antimonial wine, or the compound honey or syrup of squills, had
been administered. If already nausen has ensued by means of some one
of these, and the system shows a readily excitable impression to their
action, it will, sometimes, be enough to continue the article in perhaps
larger doses than had been given before his arrival. But if no ameliora-
tion has been produced, he should at once proceed to administer a solu-
tion of tartar emetic in a dose of from a quarter to a third of a grain, to
be repeated every ten or fifteen minutes, until either emesis and the accom-
panying relaxation are brought about, or the medicine fails to vomit at all,
or to abate materially the violence of the symptoms. In reference to the
dose and frequency of its repetition and the entire quantity of tartar emetic
to be given at this time, we must remember, that the greater the phlogosis
in general, but more particularly of the thoracic viscera, the greater will
TREATMENT OF LARYNGITIS MEMBRANACEA — CROUP- 77
be the toleration by the system of the medicine ; or, less equivocally ex-
pressed, the longer will be the time before its ordinary effects are mani-
fested. Commonly, between one and two hours will be the interval in
which the salutary operation of the tartar emetic may be expected If,
after two hours' administration ofthe medicine in full doses, it fails even
to nauseate, recourse must be had, not toother enutics, but to means cal-
culated both to abate the now evidently violent disease, and to renew the
susceptibility of the system to tartar emetic. The remedy next in order,
and the one indicated by the symptoms and our knowledge of the patho-
logy ofthe disease, is bloodletting. If a vein in the arm can be found it
should be opened—if there be failure in this respect, we may sometimes
procure blood near the ankle-joint or the instep, both feet being immersed
during the time ofthe flow of blood in warm water. You frequently will
be recommended to open the jugular vein, on account of its being super-
ficial. The operation is simple, but not quite so easy as you might be led
to suppose ; and the appearance of the thing is revolting to the mother
and others present. But, as essentials ought never to be sacrificed to
appearances or prejudices, if we cannot open a vein elsewhere, we must
not hesitate to draw blood from the jugular, even although there be some-
times difficulty, which I have not myself experienced, in stopping the
flow. A diminished pulse, paleness overspreading the face, and a feeling
of sickness, nausea, and even vomiting, are frequent effects ofthe detrac-
tion of blood, and evidences, in this case, of its having been carried to a
suitable extent. Often, after venesection, free vomiting will be caused
by the tartar emetic which had been given before the operation, without
any such effect then resulting. The quantity of blood drawn will vary
with the intensity of the symptoms and the habits ofthe patient. I often
direct four ounces to be taken from the arm of a child between a year and
two years old.
Associated with the two remedies already mentioned, viz., tartar emetic
and the lancet, is the warm bath ; and hence it is proper that the physician,
immediately on his arrival, should ask to have warm water in readiness in
case of need.
Failing to produce the desired impression with the tartar emetic, and
either fearing to draw blood from a vein on account of the prior state and
diseases of the patient, or unable to perform the operation, owing to the
vein being imbedded in adipose and cellular tissue, it is proper, if a regu-
lar bathing-tub is not at hand, to have a large wash-tub three parts filled
with water of the temperature of 96°, in which the child should be im-
mersed up to its neck. If the vessel is not deep enough for this purpose,
a blanket must be drawn over its back, so as to cover the shoulders and
leave the head alone free. The period of immersion will vary from one
hour to two or three hours, according to the effect produced by the bath,
and the other remedy or remedies which may be had recourse to conjointly
with it. The system which, before immersion, was intractable to the tartar
emetic, will after a time evince its renewed susceptibility by nausea and
free vomiting. It may be, also, that the attack is so violent and the danger
imminent, as to require recourse to the appropriate remedies in quick suc-
cession : so that immersion in the warm bath shall accompany the admin-
istration of the emetic tartar, and whilst the patient is yet subjected to the
trial of this treatment, blood will be drawn from the arm or jugular vein.
It rarely happens that a decided and salutary impression is not produced
78 DISEASES OF THE RESPIRATORY APPARATUS.
by these three agents in the cure of croup. I have found vomiting and
the warm bath adequate to produce a complete solution of the paroxysm
in cases in which, but for the fatness ofthe children and consequent diffi-
culty of finding a vein, I should like to have bled. The free perspiration
begun in the bath is kept up the remainder of the night, by having the
patient enveloped in blankets and administering minute doses of tartar
emetic and a little sweet spirits of nitre, with a drop or two of laudanum
each time. In a city, when the indication is urgent for the abstraction of
blood, we can obtain the desired end by the use of leeches applied to the
upper part of the sternum, or directly above the clavicle, on each side of
the trachea. The same object is attained also by cupping between the
shoulders, or on the nape of the neck. The quantity to be thus abstracted
is a little more than an ounce and a half for every year that the child has
completed ; but this recommendation need not be literally followed out.
In the few more severe cases, in which the course of the disease is still
unchecked by vomiting, bloodletting, and the warm bath ; or in which
after partial relief there is a renewal ofthe symptoms, we direct leeches to
the throat. I have treated successfully by leeches and an emetic a case of
croup in a child six weeks old. If we are not called on until the suppu-
rative stage is begun, and the distressing symptoms undergo scarcely any
remission, we must endeavour to act on the mucous surface, and procure a
detachment of the false membrane, by combining with tartar emetic calo-
mel in full doses ; and if the bowels have been already freely acted on,
we add a little opium.
Impressed, as we should be, with a belief in the diffusive operation of
mercury, and of its more especial action on the mucous membranes, we
cannot hesitate to have early recourse to it in those cases of croup which
do not yield promptly to tartar emetic or the lancet, as well as in those
which evince complications of bronchitis or of gastro-hepatic disorder.
To Dr. Benjamin Rush are we indebted for the free use of this valuable
remedy in croup. Dr. Hamilton, on the other side of the Atlantic, soon
adopted the practice, which he carried to a still greater extent than our
Philadelphia professor. As the ultimate effects of mercury, when given
in large quantities, are to attenuate the blood by destroying its fibrin and
colouring matter, and to produce a cachectic state of system utterly incom-
patible with the existence of adhesive inflammation, we have additional
indications for its use in croup. It may be given in doses of one to three
grains, combined with a sixth of a grain of tartar emetic, every two hours,
until its effects are evinced on the bowels by increased and green alvine
discharges. Afterwards, especially if the skin have lost its febrile heat
and the excitement generally be diminished, a minute portion of opium
may be added to the articles already mentioned ; the more readily, too, if
at intervals there is an aggravation of the distress in breathing by an ap-
parent spasm of the glottis. The calomel once begun to be administered,
its use should be persisted in until its desired effects are obtained ■ care
being taken to adapt other remedies, which may be employed at the same
time, to the varying states ofthe general system. Thus, if there be a suf-
fused blush ofthe face, turgid jugular vein, strongly throbbing carotids,
with a heaving of the chest, we may venture, even though venesection
has been freely used, to apply leeches in the manner advised already, and
sinapisms to the extremities. Evidences of depression ofthe vital powers,
in a paleness ofthe face, coldness ofthe skin, and smaller pulse, will on
TREATMENT OF LARYNGITIS MEMBRANACEA — CROUP. 79
the other hand, require abstinence from the tartar emetic and recourse to
the hot-bath, frictions ofthe surface, and warm infusion ofthe root ofthe
polygala senega, with oxymel of squills and even the addition of a little
carbonate of ammonia. During all this time, the calomel should be regularly
administered until the breathing is free and equable and the expectoration
loose and abundant.
In the suppurative stage, or that of approaching collapse, we should
stimulate the cutaneous surface by sinapisms to the extremities, volatile or
turpentine liniments and epithems to the chest, or by a blister between the
shoulders. More stimulating expectorants, consisting of the fetid gums,
as assafcetida or ammoniacum, mixed with squills and ammonia, are also
to be administered by the mouth, and enemata given, both to evacuate
the bowels and to produce derivation from the seat of disease. A warm
hip-bath will contribute to the same end. The inhalation of watery or other
vapours, never easy to be done by adult patients, is still less so in the case
of children : when it can be accomplished it is no doubt of considerable
service.
The treatment of croup with bronchitis, or of croup followed by bron-
chitis, is nearly the same as for this latter disease. Cups to the chest, or
between the shoulders, succeeded by blisters ; and calomel with very mi-
nute doses of opium, and tolerably free purging, are leading means of
cure at this time.
Having thus sketched the outlines of the treatment of croup ofthe severer
kind, I must add a remark, that, in a majority of cases of this disease, an
antimonial emetic will suffice to give immediate relief, and a purge in a few
hours afterwards to complete the cure. In spasmodic croup, or in that
kind supervening suddenly on catching cold, or on indigestible matters in
the stomach, even if it should be inflammatory, these remedies will
generally suffice, on the day following the attack. Febrile irritation
and unusual fulness of face and cough still remaining, we ought either to
bleed or to give full doses of calomel until the mucous membranes of the
air-passages are relieved. This is done both by the direct removal of their
congestion and inflammation, and indirectly by the full action of the medi-
cine on the gastro-hepatic apparatus. It ought to be laid down as an in-
variable rule, that a purgative is to be given in the morning following an
attack of croup of the preceding evening, if we would greatly diminish the
probability of a fresh attack the second night. A croupy cough, without
much fever or symptom of laryngeo-bronchial irritation, may often, in deli-
cate subjects, be treated with anti-spasraodics, to which a little ipecacu-
anha or squills has been added. I have relieved entirely an adult from an
attack of croup by the extract of stramonium and blue mass given in pill;
although during a prior one I deemed it necessary to bleed, leech, and
vomit her freely, and afterwards to give calomel in large doses.
Before speaking of local treatment in croup, and the probable utility of
bronchotomy,—laryngotomy and tracheotomy,—let me bespeak youratten-
tion to some remarks on the curative powers of tartar emetic and of calo-
mel, and, likewise, of some other remedies in croup. The first two are
not, I think, regarded in all their therapeutical bearings as they ought to
be. But I shall postpone these subjects to another lecture.
80
DISEASE^ OF THE RESPIRATORY APPARATUS.
LECTURE LXXX1X.
DR. BELL.
Therapeutical Action op Tartar Kmetic and of Calomel in Croup—Practitioners
who have employed calomel—Venesection—its advocates—Leeching—Expectorants;
those of the antiphlogistic kind to he first used—Tartar pmetie and opium ; '-alomel
and opium—Squills—The alkalies—Polyuala senega ; its alleged powers and true
value—Diaphoresis; is sometimes critical; when useful, and how procured—Tartar
emetic, as a diaphoretic, to be given in the smallest doses—Warm pediluvia and
counter-irritants to the lower extremities—Vapour-bath—Warm bath not to he con-
founded with the hot bath—The arm-bath—Antispasmodics ; the best anti-spasmodics,
venesection, tartar emetic, calomel, and the warm bath ; opium, and afterwards assa-
foetida, camphor, &c.—Topical remedies; blisters—when and where to be applied—
Stimulating liniments—Cauterization ofthe fauces and pharynx—Tracheotomy.—La-
ryngismi's Stridulus ; not identical with spasmodic ctoup as often met with—De-
scription of L. stridulus—With affection of the glottis are associated spasms in other
parts—Causes of the disease; the children most liable to it—Treatment; commonly
mi I'd—mixed, hygienic, and medical—Prevention.
Not infrequently Ihe relief from an attack of croup will be as permanent
as it was speedy, by means of vomiting and its accompanying effects ; and
no other remedy after an emetic will be required for the solution of the
paroxysm. I would lay stress on the words ' accompanying effects,' which
I have just used ; for it seems to me that they are overlooked by not a few
practitioners, who think that the simple act of vomiting is itself the prime
and sole means of detaching and expelling the morbid accumulations in
the air-passages ; and that the chief mischief from the disease consists in
the mechanical obstruction of these passages. With such persons the
selection of an emetic is a matter of comparative indifference, provided
they can cause their patients to vomit. But a very slight retrospect of the
pathology of croup must convince us> that, from the outset, our remedies
should be selected with reference to their power of abating morbid arterial
and secretory action, not only in the larynx and trachea but in all the
bronchial ramifications ; and, also, of causing sedation of the vessels of the
lungs proper as well as those ofthe brain. The effects produced by an
emetic should harmonise with, and in degree be a substitute for, those
caused by the next remedy, to which, if the paroxysm persists, we must
immediately have recourse. This next remedy is venesection.
Now, we know of no emetic substance which is comparable in
these respects with tartar emetic. It diminishes the excitement of the
heart and arteries, is a sedative also to the capillary tissue, checks morbid
secretion, itself dependent on capillary excitement, and allays spasm-
effects these manifested after vomiting, but which often precede this latter
and are independent of it. The mere act of vomiting is an evidence,
rather than a cause, of relaxation : it will serve to eject mucosities and
albuminous shreds and membranous exudations from the larynx and
trachea; but there must have been'an antecedent state of diminished ex-
citement and turgescence of the mucous membrane and its withdrawal
from the adherent plastic lymph, before this latter can be readily detached
and new formations prevented. It is true that certain substances by a
peculiar irritation of the gastric nerves, will call the muscular parietes of
the stomach and the diaphragm and abdominal muscles into combined
TREATMENT OF LARYNGITIS MEMBRANACEA — CROUP. 81
action, and give rise to vomiting: but their effect is confined merely to
evacuating the contents of the organ; and if their do>e have been large,
they cause continued straining efforts to vomit, with, at the same time,
little or no increased secretion from the tracheo-bronchial vessels and
mucous follicles ; but rather an accumulation or temporary congestion of
the thoracic and cranial cavities. Such emetics as these, sulphate of cop-
per, for instance, may produce continued expulsive motions; but their
sedative effect on the mucous membrane of the air-passages being slight,
or none at all, they fail to arrest its morbid secretion, or to produce a
separation of that which is already formed. The notion, that the mere
act of vomiting will separate, to any notable extent, adherent false mem-
brane, or that the mere scraping off of membrane and glairy mucus will
give much relief to a croupy patient, the mucous tissue of whose larynx
and trachea is inflamed, is too purely mechanical.
Our object, then, being to abate and speedily remove the morbid ex-
citement manifested by abnormal secretion, and the turgescence and in-
jection of the mucous membrane of the air-passages, and particularly of
the upper portion, we shall have recourse at once to the agent best calcu-
lated to attain this end. Some writers recommend us to use, in the
precursory or forming stage of croup, ipecacuanha wine, or syrup of
squills, and to reserve the tartar emetic for the inflammatory stage. Dr.
Cheyne, who advises an emetic in the inflammatory stage, but without
specifying the substance to be used, lays great stress on the peculiar
advantages to be derived from the administration of tartar emetic in the
suppurative stage. Having myself seen so repeatedly the failure of
attempts to arrest the forming stage of croup by the domestic prescriptions
of ipecacuanha wine, or even by the compound syrup of squills, I uniformly
prescribe at once a solution in water of tartar emetic, proportioning the
dose to the exigency of the case, that is, to the probable duration and
degree of inflammation. By this means, the disease is either at once pre-
vented from maturing, or we acquire a measure of its violence and an
index to a speedy recourse to the lancet. In a majority of cases of even
distinctly formed croup, tartar emetic will be found adequate to stop the
paroxysm, by removing the peculiar cough, restoring the voice to its
natural tone, and giving ease to the respiration ; while, at the same
time, it procures the discharge of mucus, and, it may be, of albuminous
shreds and portions of false membrane. The little patient in a state of
languor hardly unpleasant, induced by the operation of the tartar emetic
in the manner already described, now goes to sleep; and the anxious
mother is in a great measure relieved from her solicitude for the remainder
ofthe night.
Not only in the incipient stage, but in the milder forms of actual croup,
are other substances preferred by some practitioners to tartar emetic ; on
account of the prostrating effects of the latter. Were our diagnosis so
certain that we could ascertain positively the precise degree and duration
of the changes in the mucous membrane, from its first increase of natural
secretion to the exudation of plastic lymph, and the congestion and
thickening of the membrane itself, a graduation of medicines at this time
might be attempted ; but as this is not in our power, and as we know that,
from the first coming on of hoarseness and cough, precursory of croup, there is
a tendency to increase of excitement and phlogosis of the passages, the safe
practice seems to me to be that which shall prevent these probable and
VOL. n.—7
82 DISEASES OF THE RESPIRATORY APPARATUS.
often dangerous and fatal results, even though it be at the expense of
momentary strength, and with the tax of temporary prostration. I Deheve,
therefore, that the early use of tartar emetic is not only the safer but the
milder practice, as it will most probably prevent unpleasant consequences,
and save the necessitv of recourse to harsher and complex measures which
would be called for", if medicines of less power had been used in the
beginning of the disease. I have met with but one case in which alarming
prostration was caused by a persistence in full doses of tartar emetic, after
the violence ofthe paroxysm of croup had been subdued by the medicine.
The mother mistook my direction, to give the solution conditionally, that
is, if the symptoms returned after my departure, for a positive injunction ;
and the result was a sinking of the vital powers, and deliquium of my
patient; from which state, however, I soon succeeded in restoring her by
active frictions, sinapism to the epigastrium, and laudanum and ammonia
internally. It wTill often be proper, if, after free emesis, there be much
straining to vomit without corresponding discharge, to give a drop or
two of laudanum to the little patient, and to allow it to sleep, for which it
will be sufficiently prone, for a while.
You must by this time be fully aware of the therapeutical basis on
which I rest my use of tartar emetic in croup, as wTell as in so many other
of the phlegmasia?. It is not merely as an emetic, but as a contra-stimulant
or sedative, and opposed to inflammatory action irrespective of its procuring
evacuations, that I habitually use this medicine. Its utility in this way
is beginning to be perceived by some of the practitioners of Great
Britain, one of whom, Dr. Wilson, of Kelso, relates his successful use of
tartar emetic in croup ; he having cured ten out of twelve cases. He
gave, after leeches had been applied to the larynx, followed by warm
poultices frequently renewed, the antimonial salt, in doses of one-fourth
to one-third of a grain, at first every hour, until a decided impression was
made, and afterwards every two hours, till the patient was considered in
safety. The toleration of the medicine did not extend so far as that it
did not vomit at first quite freely ; but it had no action on the bowels,
which required castor oil or some other laxative to obviate costiveness.
For children, Dr. Wilson properly directs from half a minim to a minim
of laudanum in addition to the tartar emetic.
With these opinions, and the ground on which they rest respecting the
operation of tartar emetic, you may readily suppose that I put no faith in
blue vitriol (sulphate of copper). Its astringency following emesis is not
a property which we want at this time.
It is not a little vexatious to find writers of established and deserved
reputation take such limited views of the effects of calomel in various
diseases. One will tell us, that unless it purges it will do little good ;
another assures us, that its administration will be useless in this stage of
croup, because time is not allowed for it to touch the mouth. This last
notion, that we cannot procure the full revolutionising and alterative
effects of mercurial preparations in general, unless the salivary glands are
inflamed and incipient ptyalism caused, is rank empiricism, and has com-
pletely blinded us to their therapeutical operation. Calomel which we
may speak of as in a great measure representing the other preparations of
mercury, when taken into the stomach acts very speedily on the mucous
membrane of this organ and ofthe small intestines ; and, in a short time
on the liver and pancreas, which, by means of their excretory ducts are
TREATMENT OF LARYNGITIS MEMBRANACEA — CROUP. 83
placed in close and continuous relation with the intestinal mucous surface.
Soon the large intestines are affected, and increased defecation is the conse-
quence. But the operation of the medicine, even in purgative doses, is
not confined to the gastro-intestinal canal and its subsidiary glands : it is
extended to all the other mucous surfaces—the respiratory in one direc-
tion and the genito-urinary and its secretory apparatus in another ; and is
followed by increased expectoration and diuresis, together with an abate-
ment of prior irritation which may have prevailed in one or other of these
divisions. Calomel acts in a more especial manner on all portions ofthe
mucous system, and through it on their glandular appendages; and
hence its use is more immediately applicable to irritations and inflamma-
tions of the mucous membranes and their glands than to other forms of
disease. Most mischievous has proved the notion that the general
system is not affected by mercury, and notably calomel unless and until
ptyalism is produced. Under the influence of this error, immense
quantities ofthe medicine are introduced into the stomach, with the effect
often of a great depression of the vital powers, and particularly of the
functions of the nervous system, cold skin, excessive inertia, &c. ; the pre-
scribing physician all the while waiting for the action of the calomel. In
this way the patient may be actually destroyed by mercury, without any
suspicion being entertained of the fact by the expectants for salivation.
Delafontaines, Inspector-General of Military Hospitals at Warsaw,
speaks of calomel, as the first and the most efficacious of all the remedies
employed in croup. He regards it, he says, as a specific, at least as cer-
tain against croup as against syphilis. Albers and Olbers recommended
and used calomel; sometimes alone, after venesection, sometimes alter-
nating it with kermes mineral and musk. Frank, at Wilna, relies on
calomel, after venesection, general and local. Autenrieth used it to act
on the stomach and bowels as a revulsive, and to prevent the formation of
a false membrane. Copious and fetid alvine discharges were followed in
a surprising manner by a removal of the affections of the larynx. The
use of calomel and enemata made up the chief treatment of Autenrieth,
in croup. Dr. James Hamilton, the younger, gave a grain of calomel
every hour to children within the year, and two grains and a half for
those two years old, until relief was obtained ; then he gradually dimi-
nished the dose. Commonly evacuations upwards and downwards
resulted. A child, five months old, took thirty-two grains of calomel in
twenty-four hours, and another took eighty-four grains in seventy-two
hours. Let me add, however, that two children were lost by the weak-
ness which resulted from continuing the calomel after the symptoms of the
croup had subsided. Drs. Kuhn, Redman, and Rush, gave calomel
in large doses. Dr. Rush gave six grains two or three times a-day.
Dr. Physick gave thirty grains one day to the child three months old which
was bled three times in the day. Bond first recommended it. Bayley
used it. Bard also praised it, as augmenting the secretions and rendering
them more fluid, and thus diminished or prevented the secretion and ad-
hesion of the membrane.
On our chief remedy in croup, bloodletting, some remarks will appro-
priately find a place at this time. Venesection was first recommended by
Ghisi, who was also among the first (in 1737) to describe the disease ;
then by Home, Crawford, Michaelis, Ferriar, and Cheyne. Balfour,
Bayle, Middleton, and Cheyne, opened the jugular. Vieusseux (of
S4 DISEASES OF THE RESPIRATORY APPARATUS.
Geneva) recommends, in the case of a child three years old, that vene-
section to the extent of six or eight ounces be practised, and then that
leeches be applied to the neck, to be repeated if necessary. Michaelis
recommends large bleeding; he has taken seventeen ounces of blood
at once from a child six years old. But large and small are relative
terms : the large bleeding is that which produces a decided impression
at the time, by lowering the pulse, causing paleness, relaxation, and
approaching syncope. This is the kind required in croup. Dr. Rush
preferred frequent to copious bloodletting ; he has taken altogether'twelve
ounces, in three different times, in one day. Dr. Physick has bled a
child three months old three times in one day. Both these children re-
covered. Muller advocated and practised venesection. Dr. Dick, of
Alexandria, carried it ad deliquium : thirty cures in a winter attest the
value of his practice. Dr. Stearns, of New York, on the other hand, tells
us that, of fifty cases of croup which he has treated without bloodletting,
he lost but two, and in these there were complications. He does not
think that venesection ought to be used in simple croup, because he does
not believe the disease to be inflammatory. My own experience leads
me to believe that in the majority of cases of croup the lancet may be dis-
pensed with, if tartar emetic be early used and persisted in, until an ade-
quate impression is produced ; but if this remedy fails to arrest the pro-
gress of the disease, and to remove the urgent symptoms, no time should
be lost in having recourse to the lancet, or analogous means of sanguine-
ous depletion. Arteriotomy has been practised by Drs. Olbers and
Duntze of Bremen.
Local bloodletting by leeches is a common and favourite method with
a great many practitioners. It is that preferred by the French, who direct
the leeches to be applied to the neck, or between the ears. Some have
pretended to specify the number which should be put on at a time, but,
as in the case of venesection, the bleeding must be relative to the violence
of the attack and robustness of frame of the little patient; and, also, to
the vigour and quality of the leech. Michaelis recommended eight or
twelve; Reil of Halle, ten to twelve ; and he allowed the blood to flow
afterwards until fainting was induced. This, generally speaking, in the
first stage of the disease, is the proper practice. It is that followed and re-
commended by, among others, Mr. Robins (Lond. Med. Gaz., 1840). He
applies " a dozen or more leeches, as the case may require, to the upper
part of the sternum, so as to produce a state of syncope, as soon as possible,
and then to check any excess of bleeding by the application ofthe nitrate
of silver." Whenever the bleeding from leech-bites continues after the
desired full effect is produced, measures ought to be taken at once for
stopping it; and in order to prevent a repetition of sinister results, such as
death itself, from the continued hemorrhage from leech-bites, the physician
should give special injunction on this score ; first that the nurse or mother
look, at short intervals, to ascertain whether the bleeding still continues:
and then that she apply the prescribed means for arresting it; failing in
which he himself is to be sent for. Mr. Yate, in commenting on Mr.
Robins's practice just quoted, thinks that six or eight leeches are enough
to put on any child under four years old ; and after that age we may readily
have recourse to the lancet. In drawing any deductions from the remarks
of European writers respecting the number of leeches which they recom-
mend, we must bear in mind that one European is nearly equal to
TREATMENT OF LARYNGITIS MEMBRANACEA — CROUP. 85
three American leeches. At Geneva (Switzerland), where croup is so
common, one of the fundamental parts of the treatment of this disease is
leeching. M. Odier speaks of it as the most sure and expeditious means
of curing croup. It is so well known, as he informed Dr. Valentin, whose
work furnishes me with these comparative therapeutics in croup, that
most of those persons who pass the summer in the country with their
children provide themselves with leeches, in order that they may be able
to apply them themselves, at once, in case of need ; " and I know," con-
tinues M. Odier, " that several cases of croup have been cured in this
way before the arrival of a physician." The very tender age at which
we can draw blood by means of leeches is in favour of the practice. In
the case of a child but a few weeks old, who was severely attacked with
croup, and to whom I gave ipecacuanha, and even tartar emetic, without
either vomiting or relief following, I directed leeches to the forepart of
the neck, with the effect of almost immediate ease and speedy cure. My
own belief was coincident with that ofthe parents, that but for the timely
application of the leeches the infant would not have lived, even if it had
survived the night.
Expectorants.—While we recognise as one of the chief indications of
croup, the procuring a solution of the inflammation of the mucous mem-
brane of the air-passages, and a detachment of albuminous exudation
which may have been formed on it, we cannot, as an inference, admit
with equal readiness the propriety of giving expectorants, without a rigid
inquiry into their mode of action. Emetics are expectorants and of the
best class ; because they depress the system, while they encourage secre-
tion from the laryngeo-bronchial apparatus. But, although we cannot
continue for any length of time to vomit our patient, we can direct those
medicines which make a near approach, in their sensible effects, to the
emetic class, and in this way render them instrumental both in keeping
down excitement and favouring expectoration, which last is not so much
a cause or means of reducing congestion and inflammatory excitement of
the air-passages and lungs, as an evidence and an effect of such reduction.
Coincident with this view will be the administration of small doses of
tartar emetic, combined with very minute doses of opium, or of calomel
with the same addition ; or of tartar emetic, calomel, and opium. These
remedies will come in as adjuvant to the lancet and purgatives. When
direct repletion has been carried sufficiently far, we may substitute
squills, in the form of syrup, for tartar emetic, unless the excitement runs
high ; and direct at the same time polygala senega in syrup, or what is
preferable, in the form of sweetened decoction, with nitre—letting one or
both of these be given alternately with calomel and opium. As more
nicety is demanded at this time in the use of opium than of any other
medicine, it will be well, whilst administering regularly the other articles
mentioned, to direct it conditionally, according to the state of the bowels,
and the restlessness, agitation, and wakefulness of the patient, and to
leave word with the nurse or attendant either to add a drop or two of
laudanum in every second dose of the other medicines ; or to mix with
the latter a definite proportion at these times of a syrup of laudanum or of
acetate of morphia, prepared for the occasion. Together with squills, the
most approved expectorants in croup, under the supposition that we have
reduced the general excitement as much as in our power, without pro-
ducing a too great and alarming prostration of the system of our patient,
are ammoniacum, senega, and the carbonates of the alkalies, to which
86 DISEASES OF THE RESPIRATORY APPARATUS.
some add, but not, as it seems to me, on sufficient grounds, camphor. Of
these the alkalies are best calculated to diminish the plasticity of the
blood ; and hence they are entitled to be used in a state of arterial excite-
ment and phlogosis, in which some other medicines ofthe class would be
improper. We direct, according to the degree of excitement, either the
carbonates of potassa and soda, or the carbonate of ammonia. The last is
commonly reserved for states of great and commonly alarming depression ;
but much more good would be procured from its earlier and freer use in
this as well as in many other of the diseases of the respiratory apparatus.
Both it and its congeners, the fixed alkalies, ought to be steadily given at
short intervals, with diluent drinks at the same time. Palloni gave sub-
carbonate of potassa with assafcetida.
In the United States the polygala senega acquired for a time great vogue,
as of itself commonly competent to the cure of croup. Dr. Archer, the
father, and afterwards his two sons, Drs. Thomas and John Archer, of
Maryland, most contributed to confer this reputation on the senega. It
was the subject of the inaugural essay of the latter, when taking his degree
at the University of Pennsylvania. To the outlines of treatment of croup
laid down by Dr. John Archer, few of us at this time will make objections.
He recommends, in the first period ofthe. disease, venesection, mercurial
purges and diaphoretics, chiefly tartar emetic. He has no reliance on blis-
ters. After this comes his favourite senega, which ought, he thinks, never to
fail, if the false membrane is not entirely formed ; and when it is formed,
the medicine will cause its expulsion, by the irritation of the throat and
the cough which ensues. The decoction, which he prefers, is made by
boiling half an ounce of the root in eight ounces of water down to four
ounces. Of this a teaspoonful is to be given every hour or half-hour, ac-
cording to the augury from the symptoms. It stimulates, we are told, the
throat, and acts as an emetico-cathartic ; but it has cured without exciting
vomiting. In the second period, calomel is advantageously given at the
same time with the senega. Now that the charm of novelty and the fer-
vour of admiration in consequence have subsided, we are better able to
estimate the senega at its real worth ; and while we admit that it is a good
adjuvant to other remedies, we must also add that it is one on which, alone,
we cannot place much reliance. The emetised polygala senega of Dr.
Bouriot may be enlisted more frequently in our service in the treatment
ofthe first stage and more violent forms of croup. It is made by adding
to Archer's formula an ounce of the syrup of violets and two grains of tar-
tar emetic. Of this compound Dr. B. gives atablespoonful every quarter
of an hour, in order to procure four or five ejections from the stomach ;
and then a te'aspoonful every hour or two as an expectorant. Gradually,
in proportion as the laryngeal and pulmonary oppression is relieved, the
interval for giving the mixture may be increased. Among the means oc-
casionally employed to promote expectoration is the inhalation of the va-
pour of water, or.of vinegar and water. In one case, the child, a patient of
Mr. Coigne, of Courbevoie, expectorated a membranous sac, two inches
and a quarter in size, after having eagerly snatched up a vessel holding
pure vinegar for the purpose of fumigation, and swallowed four or five
mouthfuls. The child was immediately seized with violent cough threw
up a false membrane, and was cured.
Diaphoresis is occasionally critical in croup. At least I have seen a
patient, whom I kept for upwards of an hour in a warm bath, where I ad-
ministered to it tartar emetic so as to excite vomiting, on its being after-
TREATMENT OF LARYNGITIS MEMBRANACEA — CROUP. 87
wards wrapped up in a blanket, remain for several hours in a copious
sweat, during which time the breathing became more and more easy. In
the morning the patient awoke quite free from oppression, and only suf-
fering from a little fever and cough, which were removed by a purgative.
In a somewhat more advanced period ofthe disease, after venesection and
analogous antiphlogistic remedies, the coming on of diaphoresis is accom-
panied often by a relaxation of the laryngeal mucous membrane, freer
breathing, and occasional excretion of tough mucus or muco-purulent
matter. When the skin is of unequal temperature, the pulse frequent and
contracted, and the breathing hurried, we may give with advantage saline
sudorifics—the acetate or citrate of potassa, or of ammonia—in conjunction
with minute quantities of tartar emetic or ipecacuanha wine, and a few
drops of laudanum. The doses of tartar emetic should be decreased in
the order of the following series of its therapeutical effects ; from an emetic
to a contra-stimulant or sedative, then expectorant, and finally diaphoretic.
It is a great mistake to suppose, as is, however, so commonly taught, that
its property of causing sweat is manifested by or bears any proportion what-
ever to the nausea it produces. Never are the diaphoretic effects of this
medicine so satisfactorily exhibited as when the patient makes no com-
plaint of sickness, nausea, or pain, nor experiences any sensation at the
stomach or other organ. The full effects of sudorifics will be not a little
increased by warm and stimulating pediluvia, or, in their stead, warm
flannel wrapped round the feet, and friction of these parts with a warm
hand. It was early remarked in the history of croup, by Ghisi of Cremona,
that patients were cured by an abundant sweat towards the end of the
disease. Dr. Wallenbourg informed Dr. Valentin, that in parts of Russia
the Jewish women ran with their children in their arms, when the latter
are seized and almost suffocated with croup, to vapour-baths, and remain
there until a copious perspiration is induced. Returning home, they cover
them up carefully. Some, he adds, are cured by this means, and slight
remedies in addition.
One ofthe best aids to other remedies, and itself one of our best dia-
phoretics, is the warm bath. But in directing it, you must not fall into
the careless, it may even be called blundering fashion, so common among
otherwise well-informed physicians, of confounding the warm with the
hot bath. You will read of objections to the former, which are only ap-
plicable to the latter, such as its unduly exciting the patient, determining
blood to the neck and head, and flushing the cheek ; and, in fine, inducing
efforts the very reverse of those which we most wish for at this time.
Direct the warm bath ofthe temperature I have mentioned in my last lec-
ture, and you will find that your patient will be soothed and comforted,
and inclined to go to sleep, in a warm, diffused, and febrifuge sweat.
Dr. Grahl, of Hamburg, adduces cases in proof of the signal efficacy of
arm-baths in croup. They are indicated, he thinks, at the commencement
of the stage of exudation. He recommends that the arms of the patient
be placed in a vessel sufficiently deep to admit them to a hand's breacfth
above the elbow-joint, ami filled with water as hot as can be borne. A
cloth should now be thrown over the head of the patient, which, falling
down round the edges of the bath, retains the vapour; and this the patient
should be allowed to respire for a quarter of an hour at a time, repeating
it at short intervals. The first application usually induces some degree
of moisture in the Schneiderian membrane, and diminishes the dyspnoea.
88 DISEASES OF THE RESPIRATORY APPARATUS.
With its repetition the cough usually loses its hoarse tone, and the patient
expectorates exuded lymph. Dr. Grahl admits, however, that when the
symptoms are extremely urgent, calomel in large doses should be given,
and adds a recommendation of much more doubtful propriety, that a bus-
ter be applied to the throat.
Antispasmodics.—Witnesses to the spasm of the glottis and larynx in
croup, which often threatens suffocation and at any rate interferes with the
full expansion of the lungs and circulation through them, you will be na-
turally very desirous of removing it. With this view you may perhaps
be induced to have recourse to anti-spasmodics. These medicines, in the
common acceptation of the term in Materia Medica, are not, however,
those on which you can rely in the early stage of croup. The best anti-
spasmodics in the phlegmasia?, experience will soon prove to you, are
venesection, tartar emetic, calomel, and the warm bath. After this opium
is entitled to a preference, alone, or what is better, combined with the
tartar emetic and calomel. In proportion as the inflammation subsides,
recourse will be had to the recognised anti-spasmodics, such as assafcetida,
castor oil,camphor, and, I may add, extract of conium,and at this time digi-
talis, which sometimes serve very well to allay this irritability of the glotto-
laryngeal muscles, by which they contract with spasmodic frequency and
force under a slight irritation of the lining mucous membrane. They are
used by friction, enemata, and inhalation, as well as by the stomach.
Underwood gives high praise to assafcetida, both by the mouth and per
anum, in which he is joined by Millar, Cheyne, Thomson, and others.
Olbers and Albers place great reliance on camphor, and still more on
musk. The practice of Dr. Rush was the simplest and best, viz., to pre-
scribe a few drops of laudanum towards the decline ofthe disease. I would
not go so far as Gregory and others, in recommending full doses of opium
or laudanum after venesection and vomiting, in croup ; but I well know
that after these operations, and when we are giving tartar emetic and
calomel as antiphlogistics, or, as I prefer terming it, counter-stimulants,
if we join a minute dose of an opiate to these medicines, as already recom-
mended, we shall do more to mitigate and remove spasm and oppression
than by any ofthe more common anti-spasmodics, at the same time that
we carry out, undisturbed, the indications of cure.
Of topical remedies, blisters are the chief ones and those in most common
use. The application of a blister ought always to«be withheld until a re-
duction of phlogosis has been obtained by emetics, antimony, and bleeding.
The remedy is best adapted to the second stage, after the skin becomes
cool and damp, and the pulse has lost its resistance and fulness. It will
often cause a salutary cutaneous reaction, and aid the operation of tartar
emetic and opium, or calomel and opium, in bringing on diaphoresis.
Opinions are not uniform, as to the precise spot where a blister should be
applied. The most common practice is, to place it on the forepart of the
neck, over the larynx and trachea ; but there is no special advantage can
be promised for its use in this way, to compensate for the probably increased
afflux to the mucous membrane ; to say nothing of the pain and continued
irritation at every movement of the head and neck which are felt until the
vesicated surface is healed. We are deprived also of the privilege if it
should be thought desirable, of afterwards putting leeches on this part the
call for which may come up at different periods of the disease, even after
we have begun to use blisters and other counter-irritants. The three best
LARYNGISMUS STRIDULUS.
89
spots for the application of blisters in croup, are the nucha, on the upper
part ofthe sternum and between the shoulders. Vieusseux regards them,
after venesection, as the chief means of cure,—an opinion certainly, which
greatly overrates their value. In bronchial complications, good may be
expected of them ; but in order to be fully efficient, they ought to be kept
in a state of suppurative discharge, by the repeated application of blister-
ing or other irritating ointments to the vesicated surface. M. Valleix
recommends a magistral blister in acute laryngitis, which might be usefully
applied in the proper stage of croup. It is made as follows :—Take of
powdered cantharides and wheat flour, each equal parts, and of vinegar
enough to make a soft paste, which is to be applied to the skin.
Stimulating liniments, such as sweet oil and aqua ammonia, oil of tur-
pentine and tincture of cantharides, and acetic ether, rubbed over the
larynx and trachea at short intervals, so as to keep up a permanent redness
and injection of the cutaneous capillaries, have been had recourse to at
different times with reputed benefit. Ammoniacal cerate, made of simple
cerate, ^j., mixed up with carbonate of ammonia, gj., has been applied
every four hours in quantities of ^ij., on the forepart and sides of the neck,
which are then to be covered with a bag of hot ashes. The skin is soon
studded with little pustules, which cause itching and a pricking pain for
two or three days, after which the cuticle is separated and falls off. Dr.
Copland speaks very highly of oil of turpentine sprinkled on a fold of flan-
nel just wrung out of hot water, and then applied around the neck and
throat.
I may, in this place, as it is classed among the topical remedies, men-
tion cauterization ofthe fauces and pharynx, by rubbing these parts over
quickly with lunar caustic. The alleged effects of this process are to
arrest, if it be done early, the spread and formation of pseudo-membrane
in the air-passages, and at once to relieve the breathing an^l cough. In
primary and common croup, while we do not forget cauterization, we
should be aware that it must not divert our attention from the more active
and heroic measures which I have thought it my duty so fully and point-
edly to recommend to you.
Tracheotomy has been recommended as the last resource in croup.
Apart from the reasons, t\ priori, which would either forbid recourse to
it, or show its nullity, we have, unfortunately, general experience adverse
to its success. The different state of the mucous membrane of the larynx
and trachea, owing to the lymphatic exudation on its surface in the ad-
vanced and last stage, from that in edematous laryngitis of adults, inde-
pendently of the complications or congestions of the lungs, common to
both, forbid us to hope for the same benefit from the operation in croup
that has followed it in the latter disease. Still, we have the favourable
experience of MM. Bretonneau and Trousseau, who have performed it
ninety-eight times. Of 140 cases of croup in which it has been performed
of late years by different French surgeons, 25 per cent, have terminated in
recovery. M. Haine (Ann. de la Soc. de Med. d'Anvers) states that he
has performed tracheotomy in croup in sixty cases, and eighteen times
with success.
Very different views of the subject of treatment of croup have been
advanced by M. Guersent. This gentleman regards the surgical part as
by far the most important, and alleges that the medical treatment is of very
limited value, not acting directly on the disease, and being rarely crowned
90
DISEASES OF THE RESPIRATORY APPARATUS.
with success. Surgical means are those, M. Guersent contends, on which
we must chiefly depend. But he does not wish to be understood as mean-
ing merely tracheotomy, but also local applications to the fauces, in speak-
ing of surgical means. The local applications are liquid or solid : dilute
muriatic acid and solution of alum, &c, but preferably strong solution of
nitrate of silver, come under the first head ; and among the latter, pow-
dered alum or nitrate of silver. I cannot give you any commentary on these
strange opinions, as forcible as by repeating, after M. G., the outlines
of a case in which the surgical means seem to have had a fair trial from
the very outset of the disease, but with a most disastrous result. He was
called, he tells us, to see a child who had, the preceding night, been sleep-
less, restless, and slightly feverish ; there was no cough, nothing to call atten-
tion to the pharynx. M. G. inspected the throat, however, as he made it a
rule always to do, and perceived some white patches on the tonsils, which
he immediately cauterized ; but, notwithstanding, croup of the severest
kind set in, and tracheotomy had ultimately to be performed, but with-
out success. Nothing is said of the medical treatment, and we are left to
infer that M. Guersent, consistently with his opinion heretofore advanced,
either made no trial of it, or rested his hopes mainly on his surgical means.
Laryngismus Stridulus—Angina Stridulosa—False Croup—Thymic
Asthma— Spasm of the Glottis. — I have already expressed my doubts
whether laryngismus stridulus be properly identical with spasmodic croup.
The latter mostly exhibits all the distinctly marked symptoms of the in-
flammatory variety, with the addition of increased difficulty of breathing
and sense of imminent suffocation ; the spasm being an incident in the
train of inflammatory symptoms. In the laryngismus stridulus, on the
other hand, the attacks will come and go, will return frequently, and, on
occasions, without any sinister result, although in general a first attack
should excite watchfulness on the part of the mother or nurse, and induce
her to give early notice to the physician of a repetition of the disease.
The period in which laryngismus stridulus is manifested, is still more
restricted than that of croup ; rarely exceeding three years from birth.
Dr. Kerr (Ed. Med. and Sur. Journ., 1838) has known the symptoms of
the latter to appear as early as eight days after birth. I have had the
treatment of a case in which there is good reason for believing that the
first attack was on the second day after birth, when life was almost extinct
after symptoms of spasm and suffocation. Dr. Kerr agrees with Drs. Ley
and Marsh in the opinion, held also by Kopp, that the children who are
most liable are those of a very full and large habit of body, and who
exhibit marks of the strumous diathesis, or have sprung from scrofulous
parents ; but he also adds, and my own experience is confirmatory ofthe
fact, that he has seen it in thinner habits, and in whom no scrofula could
be suspected.
Symptoms.—Laryngismus Stridulus is characterized by attacks of spasm
of the chest and severe fits of suffocation. The breathing suddenly stops,
or rather there is an extremely slight, piping, imperfect inspiration, forced,
as it were, through the contracted glottis. The respiratory sound has
some resemblance to the crowing inspiration of hooping-cough but is
much smaller and more acute ; it is still more like the singultic attempts
at inspiration made during the hysteric paroxysm. In some cases but
rarely, there may be five or six piping or whistling inspirations, and 'then
a few deeper and stronger, alternating with expirations so slight as scarcely
CAUSES OF LARYNGISMUS STRIDULUS.
91
to be perceived. In extreme cases the respiration stops entirely, and the
face becomes quite livid ; the small inspiratory pipe then takes place,
either in the beginning of the paroxysm or at its termination, it being quite
suppressed by the strength of the attack. This symptom is pathogno-
monic of the disease. In addition to the affection of the glottis, when
it has occurred with such intensity and frequency as to excite attention
and alarm, there are commonly other symptoms associated. The chief of
these are exhibited in the thumbs being turned into the palms, and the
hands more or less clenched, and when opened by force immediately
returning to their former position. The feet are turned inwards and
downwards, and the backs of the hands and feet are swelled. These
symptoms are most distinct when the crowings are numerous, or, as just
remarked, when convulsions are threatened : at other periods they are
seldom present. The disease frequently terminates by convulsions ; and
more rarely it is ushered in by them. Other parts ofthe muscular system
are affected, as when the child is unable to stand or walk erect, or to
swallow liquids, except when given in small quantities. In severe cases,
the child does not void urine as frequently as in health, and the quantity
of the secretion is diminished. In a few cases, continues Dr. Kerr, the
buttocks or groins become tender, and exude watery lymph ; and in per-
haps every case ofthe disease, the buttocks, even when well covered, are
as cool as if newly washed.
It is not correct to speak of the paroxysm being ushered in by fever,
croupy cough, and sneezing, as often there are no such preludes and
accompaniments. The disease has been confounded with spasmodic croup;
but it differs from this latter in the following particulars. I give them as
laid down by Mr. Meade (Lancet, p. 411, 1846): " 1. Spasm of the glottis
is almost exclusively met with in young infants from the time of birth up
to twelve or eighteen months of age. Spasmodic croup, on the contrary,
is extremely rare in infants under a twelvemonth old. 2. In spasm of the
glottis, there is neither coryza nor any febrile disturbance, while spasmo-
dic laryngitis is always preceded and accompanied by some catarrhal
symptoms and slight feverishness. 3. The first attack of spasm of the
glottis may come on either in the night or day, and a child has been
known to have more than twenty fits in the course of the same day ;
spasmodic croup, however, always attacks for the first time at night; and
the child will never have more than five or six paroxysms of difficult
breathing during the whole attack. 4. In spasm of the glottis, there is
no cough, and during each fit there are seldom more than one or two
stridulous inspirations ; while in spasmodic croup there is always a hoarse
cough, and the difficult and noisy breathing continues for some time.
5. In spasm ofthe glottis, convulsions generally come on after the disease
has continued for some time, and also ' carpo-pedal contractions.' Con-
vulsions are very rare, on the contrary, in spasmodic croup, and the con-
traction of the limbs has never (that I am aware of) been observed.
6. Spasm of the glottis is almost always a chronic disease, while spasmo-
dic croup is essentially acute."
In chronic hydrocephalus, as remarked by Mr. Meade, infants, some-
times, on being awakened from sleep, or when they have been crying,
become suddenly stiff, blue in the face, remain for a minute without
respiring, and then draw in their breath with a shrill noise. This is a
real spasm of the larynx, and it only differs from the one which is the sub-
92 DISEASES OF THE RESPIRATORY APPARATUS.
ject of notice at this time in its being a symptomatic in place of an idio-
pathic disease.
Causes.—Mental emotion, such as any vexation, is apt to bring on a
paroxysm. Frequently the child is awakened out of sleep by one. A
current of cold air will produce the same effect. Indigestion is a frequent
exciting cause. In one case the use of milk invariably brought on an
attack. In another, the irritating organic cause seemed to me to be in the
rectum. Straining with some tenesmus would always bring on the disease.
In some days from twenty to thirty attacks of crowing will occur. During
some weeks the crowings will be numerous, and during other weeks there
may be very few. During an attack, the sufferings appear to be occa-
sioned wholly by the want of air, and are not infrequently so great that
the child becomes somewhat livid. Instances have occurred of a paroxysm
of crowing terminating life by the glottis remaining so long shut as to
occasion suffocation ; but in general danger proceeds from the occurrence
of convulsions. These are to be expected whenever the crowings become
numerous. Sometimes they are succeeded by insensibility, and at other
times the child becomes sensible as soon as the fit is over. In general,
when the disease is approaching a fatal termination, the epileptic fits be-
come more numerous, and the child dies, apparently, rather from the effects
of convulsions than from any affection of the glottis. Boys are repre-
sented to be much more liable to the disease than girls.
Dr. Kerr thinks that laryngismus stridulus is almost always a conse-
quence of cold : occasionally, indeed, it commences in summer, but only
when the weather is cold, and especially if the child resides in a cold or
damp house. Dr. Kopp, who has written fully on the disease, which he
also terms thymic asthma, states, that all diseases ofthe respiratory organs
predispose to it,—such as catarrh, bronchitis, croup, measles ; but yet, in a
case in which the attack was brought on by intestinal irritation, no spasm
occurred during a violent and somewhat tedious attack of bronchitis.
Teething also predisposes to it. Autopsic examinations have not revealed
any deviation from health in the larynx or trachea. If convulsions have
occurred, the morbid appearances in the brain are similar to those pro-
duced by convulsions unaccompanied with laryngismus (Dublin Journ.
Med. Science, 1838). In a subject examined by Mr. Meade, the mucous
membrane of the larynx, trachea and bronchia? were perfectly natural in
appearance and structure.
This disease, is obviously the same in its essential features as that de-
scribed by Dr. Underwood, under the head of Inward Fits, and by
Dr. Clarke as " A Peculiar Species of Convulsion in Children," whose
account of it is introduced in a note by Dr. Hall, pp. 111-12, to the last
(American) edition of Underwood. It also closely resembles, if it is not
identical with, the thymic asthma, a detailed description and pathology of
which are furnished by Dr. Montgomery (Dub/in Joum., 1836). °Mr.
Hood had previously (Edinb. Med. and Surg. Journ., vol. iii., 1827)
pointed out, after numerous dissections, the enlarged thymus gland
as the cause of this disease. Taking into consideration all the phe-
nomena, we must go farther in our explanation of its organic cause
than Dr. Ley, who supposes a paralysis of the glottis to be induced by
pressure of swelled glands on the recurrent nerves, and of Dr. Marsh
who suggests that the seat of the disease may be at the orio-in of the
pneumogastric nerve. The real cause is, a lesion which will give rise
TREATMENT OF LARYNGISMUS STRIDULUS.
93
not only to the affection of the glottis, but also to the convulsions, and
occasionally paralysis ofthe muscles ofthe limbs as well as those of degluti-
tion. This must necessarily be in the cerebro-spinal axis, or more particu-
larly at the medulla oblongata. It is sufficient for the production ofthe dis-
ease, at least the glottic symptoms and convulsions, that irritation be trans-
mitted from any organ to the base ofthe brain and to the medulla spinalis,
to be by these reflected through the motor nerves on the muscles of the
larynx, and of the voluntary muscles generally. The chief condition,
therefore, or predisposition, consists in a morbid excitability, by which the
brain and medulla spinalis respond too readily and violently to the irritation
of any sensitive part,—whether cutaneous, gastro-pulmonary, or parenchy-
matous. The explanation furnished by Drs. Montgomery and Kopp, of the
disease they describe being caused by pressure of the thymus gland on the
nerves, is too partial; the disease has come on from other causes. Mr. Simon
(Physiol. Essay on the Thymus Gland) regards the enlargement of this
body as the effect, and not the cause ofthe comatose breathing.
Dr. Griffin (Dublin Journ. of Med. Science, 1838) thus sums up the
essential facts connected with this disease, at the conclusion of an elabo-
rate critical inquiry on the subject: " 1. By the concurrent testimony of
almost all who have noticed the affection, it occurs for the most part, if
not wholly, in strumous habits. 2. It is frequently found in connexion
with enlarged glands in the neck, and perhaps in the thorax. 3. It is
frequently found in connexion with eruptions on the face, ears, or scalp.
4. It frequently terminates in convulsions, and is sometimes, though very
rarely, ushered in by them. I believe it may be said, that nearly half
the fatal cases on record terminated in convulsions. 5. It is met with in
families in which children are subject to head affections or convulsions,
but have also the strumous disposition. 6. It is sometimes met with in
connexion with an apoplectic or comatose state from the commencement,
as in cases of crowing apoplexy which I have described. 7. In a great
proportion of the cases which terminated fatally, there was not the least
symptom of head affection through their whole course, if we do not look
upon the occasional fits of breathlessness and crowing as indicative of it;
and the children were as well, apparently, a few moments before death,
as they were previous to the first attack of the disease, or as any children
could be. 8. The complaint is sometimes, but rarely, attended by cough
and permanent difficulty of respiration. 9. Perhaps it may be said that
from one-third to half of all the cases of which we have any account ter-
minated in death." This last conclusion will serve to indicate the charac-
ter of the prognosis in laryngismus stridulus.
Treatment.—That of the paroxysm would seem to be first in order from
the nature and danger of the symptoms ; but the duration ofthe fit is so
short, that it is over before the physician can arrive on the spot. On the
mother or nurse, then, will devolve the first measures in the emergency.
The little patient should be raised and placed in a sitting posture, or with
the body inclining slightly forwards, so as to allow the respiratory mus-
cles their full power; then he must be slapped on the back, cold water
thrown on his face, and ammonia held to the nostrils. By these means
the respiratory organs are powerfully stimulated ; and crying, sneezing,
or some other strong expiration is produced, so that the glottis opens, and
the fit is terminated. Other remedies, and they are the same with those
adopted in inflammatory croup, or where there is any doubt in the diag-
94 DISEASES OF THE RESPIRATORY APPARATUS.
nosis, will then be had recourse to, viz., an emetic and the warm bath.
These failing, and life becoming rapidly or being, in fact, extinct, arti-
ficial inflation of the lungs has been recommended, or laryngotomy
practised, as the speediest method of accomplishing this purpose.
When the attacks of crowing are severe and numerous, or the one attack
is prolonged, the lower bowels should be emptied by an enema and some
purgative medicine, such as calomel and rhubarb, or turpentine and cas-
tor oil administered by the mouth. Both constipation and diarrhoea occur,
and may even alternate in the same subject in this disease ; the latter,
however, will, I suspect, be found more an attendant on the former and
apparently opposite state than is imagined ; for when diarrhoea is present,
the first part of every stool is hard and dry, and the last nearly as liquid
as water; and if laxative medicine is given, the stools are more natural,
that is, less tenacious and less watery. The looseness, in fact, here as we
every now and then see it in adult subjects, is the effect of irritation ofthe
rectum by hardened feces higher up. Commonly the rule is a good one, to
procure two stools daily for a child affected with laryngismus, or threat-
ened with it, and to avoid carrying the purging any farther; hence, if
diarrhoea should follow, a purgative, or some magnesia or oil, with a drop
or two of laudanum, may be given. Laudanum or its like given with
other views, such as for allaying irritation or of procuring sleep, will
generally fail. In illustration of the direct action on the larynx of mor-
bid impressions or irritants in the stomach, I may state that I have car-
ried off at once all the symptoms of spasmodic croup by an emetic, which
discharged from the stomach an apple that had been eaten and very imper-
fectly masticated a few hours before.
Some of the German practitioners (Kopp, Kirsh, &c.) recommend a
more active course, to diminish and prevent, as they allege, the recur-
rence of all undue congestion and nervous excitement in the heart and
lungs, by low diet, large and frequent bloodlettings (every four or eight
days), blisters and issues on the chest, constant powerful purgatives, &c,
also, to lessen the size of the thymus, by anti-scrofulous resolving medi-
cines, such as mercury, iodine, &c. I will not deny the utility of this
course of treatment in some cases; but they must be comparatively rare,
and can only occur in robust subjects. In a large majority of cases, the
main indication of cure will consist in the methodical and persevering
employment of the means calculated to give tone to the nervous system,
after having allayed its morbid sensibility and removed the obvious
causes of irritation. To meet this view, you will see that the bowels are
kept regular, that the gums be frequently lanced, if they be at all inflamed
or even swelled ; that narcotics, in combination with tonics, and espe-
cially chalybeates, be administered at the same time, and, abo've all, that
the patient procure pure air and light nutritive food.
Convulsions occurring during the course of the disease will inquire a
somewhat more active treatment than that which has just been sketched*
not so much, however, with a view to cure the convulsive paroxysm^
which would for the most part subside of itself, but to remove the morbid
condition of the parts, and notably the brain, irritation in which would
endanger a return of the convulsion. In milder cases, five or six leeches
applied on each side of the trachea will suffice : in more severe cases the
external jugular should be opened with a lancet, if we cannot have recourse
to venesection in the arm, for the causes already mentioned. Relief has
PROPHYLAXIS OF LARYNGISMUS STRIDULUS.
95
been procured by inhaling ether from a sponge saturated with this fluid.
Attention should be paid to the state of the bowels, and means used for
their being promptly evacuated if constipation have existed.
A troublesome attendant on this disease is free and almost continued,
and consequently exhausting, perspiration, by which the chances of fresh
attacks are increased on exposure to any little inequality of temperature,
and especially to humid cold. The curative measures in such a ctse will
be, frequent changes of clothing; sponging the skin every morning with
tepid, and after a while cold salt water, and careful rubbing it after-
wards with a moderately coarse towel ; carrying the child out of doors,
or if this is not advisable, having the apartments better ventilated and
cooler, if they were too warm before.
One of the best means of restoration is a change of air, even from one
part to another of the same city; but if the child can be taken into the
country, or to the sea-shore, its prospect of recovery will be greatly in-
creased.
Prophylaxis.—A knowledge of the predisposing and exciting causes of
laryngismus stridulus will guide us in the modification or abatement ofthe
former and removal of the latter. Of these, cold has been already mentioned
as the chief one. A uniform temperature of the skin should, therefore, be
maintained by suitable clothing, made not after the absurd requirements of
fashion, but so as to protect the chest and shoulders effectually against
currents of air, and the sudden transitions from a hot to a cold room, or
damp entry, or the outer door. The upper garment should be of a wool-
len stuff or cloth, in winter, and made to fit up to the neck. A neglect
of this rule by weak-minded and ignorant mothers, who are more afraid of
the ridicule of their visiters at their children being dressed unfashionably,
than of the imminent danger, and even prospect of death itself, of these
same children, as pictured forth to them by their observant and conscien-
• tious physician, has produced incalculable mischief. That the feet should
be well protected by thick shoes and warm stockings, is a point which is
less contested. The notion that children, particularly those of the city,
can be made hardy by partial exposure of their persons and irregular
exercise in the open air, is as absurd in physiology as it is cruel and de-
structive in fact. Often a change of habitation, from a damp and well-
ventilated one to another that is dry and airy, will prevent the recurrence
of laryngismus.
A predisposition most commonly met with, and necessary to be obvi-
ated if not entirely removed, is that of a strumous habit and scrofulous
diathesis, sometimes associated with full and plump-bodied and well-com-
plexioned children, and sometimes with pale, thin, and sallow ones. In
both, the lymphatic glands are in a state of either unnatural development
or of irritability ; and in both digestion is more or less impaired. To the
restoration of this function by the alternate administration of aperients and
mild tonics, and the use of plain nutritive food, the attention of the phy-
sician will be, therefore, directed. The tepid bath, frictions of the skin,
exercise in the open air, and a residence for a season in the country, will
materially contribute to healthy nutrition and an abatement of the scrofu-
lous diathesis. With this particular view, the iodide of potassium and the
iodide of iron will be usefully prescribed ; and an ointment of the former
should be rubbed on the enlarged glands ofthe neck.
The irritation from dentition will be diminished by occasional, and in-
96 DISEASES OF THE RESPIRATORY APPARATUS.
deed in some cases of the present disease, by frequent cutting of the
gum down to the tooth, so that the lancet shall grate on it. Disorders
ofthe scalp, which we are told to treat with great delicacy and caution
in children, ought not, however, under the influence of this, on occasions,
proper timidity, to be allowed to remain a source of irritation to the child,
and one of the exciting causes of laryngismus. They can best be
managed at the time when the child is under the regular operation of
purgative medicines ; and it will be found that their removal will contri-
bute not a little to the comfort ofthe patient.
See, on the subject of thymic asthma, and morbid states of the thymus
gland, the interesting papers by Drs. Roberts and Lee, of New York, in
the American Journul ofthe Medical Sciences.
LECTURE XC.
DR. BELL.
Chronic Laryngitis—Its synonyms—Idiopathic and symptomatic—Morbid Jnalomy—
Applicableness of the title, laryngeal phthisis.—Large proportion of ulcerations in
the epiglottis, larynx, and trachea, in phthisical subjects—Symptoms .- sensations,
voice, aphonia, cough, breathing—Different species of chronic laryngitis,—a know-
ledge of, necessary for prognosis and treatment—Examination of the fauces and
pharynx—To determine the state of the lungs: auscultation, percussion, and expecto-
rated matter—Duration of the disease—Causes: age, sex, prior disease, vocal strain,—
Peculiar exposure of clergymen,—atmospherical vicissitudes, habits—Complications.
The disease which is the subject ofthe present lecture has been variously
named. In addition to its technical designation of Chronic Laryngitis ;
Laryngeal Phthisis ; Laryngitis with Secretion of Pus ; it has re- '
ceived the popular ones of Clergyman''s Sore Throat; Throat Consump-
tion, &c.
Chronic laryngitis may be the consequence of primary acute laryn-
gitis and idiopathic; or it will show itself after a very brief, and by no
means violent stage of acute phlogosis of the organ, and be combined
with and a symptom of chronic affections of other parts, particularly of
pulmonary tubercles, and occasionally of secondary syphilis. The symp-
tomatic is by far the most frequent variety.
Morbid Anatomy.—The effects of chronic irritation of the larynx vary
from a slight vascularity and thickening ofthe mucous membrane to changes
so extensive as completely to alter and destroy the natural appearance of the
canal. The successive changes in the laryngeal mucous membrane may be,
redness ; thickening or diminished consistence ; softening, partial or gene-
ral ; sometimes vegetations or excrescences of a considerable size. Pus
may be met with on its surface ; and often M. Andral has seen false mem-
branes which, by their firm consistence and shape, perfectly resemble some
of the numerous varieties of the false membrane in croup. The inner
surface of the epiglottis has been covered and incrusted, as it were with
a layer continuous from the larynx. The greater breadth of the larynx
and rimceglottidis in the adult than in the child, explains why the forma-
tion of false membranes is so much less alarming in the former than the
latter. Participating in these alterations, the mucous follicles may become
chronic laryngitis.
97
enlarged and thickened, and secrete more abundantly than common.
They are often raised into small rounded spots, of a dull white or yellow-
ish colour, and then they have been erroneously called tubercles. Ulcera-
tions are met with, which, according as they are above or below the
vocal cords, will cause impaired voice or complete aphonia: they have
been chiefly met with in the epiglottis, the aryteno-epiglottidean ligaments,
the vocal cords, and the base ofthe ventricles ; and they may become so
extensive as to give rise to fistulas. The number of ulcerations is gene-
rally in the inverse ratio of their size. They often extend to other tis-
sues, and when they do, the thyro-arytenoid ligaments are the chief
sufferers. The sub-mucous cellular tissue may be thickened, and
appear under the form of scirrhous cords, or be distended with effused
serum. In this tissue have been found purulent collections and tubercles
in every stage of development.
The muscles of the larynx are, at times, reduced in size ; softened, or
even entirely removed ; and again they are in a state of hypertrophy.
The disease being protracted, the cartilages become affected ; the epiglottis
may be thickened, ulcerated, carious, even completely destroyed. The
thyroid cartilage is less frequently changed ; the cricoid is sometimes
hypertrophied and carious; the arytenoid may be destroyed; and, on the
other hand, all the cartilages may be ossified. In general, the ulceration
begins in the mucous membrane, and extends to the cartilages. Serous-
cysts and even calculous concretions have been found in the ventricles of
the larynx.—(M. Andral, Cours de Pathologie Interne.)
The propriety of the term laryngeal phthisis is supposed to rest on the
occurrence of the symptoms of consumption and its fatal termination, in
consequence of organic changes which take place in the larynx. That
such cases have been met with is not denied ; but the number is very
small. In a great majority of those persons who have sunk under disease
whilst attacked with chronic laryngitis, there has been found to coexist
tubercles of the lungs. Sometimes these last follow, but more frequently
precede the laryngeal affection. The upper portion of the air-passages
chiefly suffers, from ulceration in phthisis. Of one hundred and two con-
sumptive patients noted by Louis, the trachea was found to be ulcerated
in thirty-one, the larynx in twenty-two, and the epiglottis in eighteen.
In the whole of his researches up to the time of making this record, he
met with only seven cases of ulceration of the bronchise. Hastings gives,
it is true, a larger proportion ; the mucous membrane of this part having
been, according to him, ulcerated in all those (leather-dressers of Worces-
ter) who died of chronic bronchitis. Andral tells us (Clinique Medicate),
that of the whole number of cases of phthisis which have come under his
observation, in three-fourths of them there were ulcerations ofthe mucous
membrane of the larynx. It will be the more correct opinion to regard
these ulcerations as symptomatic of tuberculous disease.
Even though chronic laryngitis without complication should seldom be
productive of consumption, the designation phthisis laryngea will still be
applicable to those cases of tubercular pulmonary consumption in which
the disease is aggravated, the symptoms in a degree characterized, and its
march accelerated by the laryngeal affection.
The symptoms of chronic laryngitis are local and general. The local
are derived from the feeling of the part, the voice, cough, expectoration,
state of the respiration, and deglutition. The general symptoms are often
VOL. n.—8
98 DISEASES OF THE RESPIRATORY APPARATUS.
slight, and are only manifested towards the last stage, or occasionally at
the onset ofthe disease.
The uneasy sensations are chiefly confined to the larynx, and in it
they are commonly in one spot only ; as at the upper and lateral part, for
example, of thyroid cartilage. Sometimes there is a simple, pricking
pain ; at the other times no complaint is made whatever, even when the
larynx is the seat of extensive ulcerations. There is usually a tickling
which excites cough,—sometimes a feeling as if an extraneous substance
were lodged in the larynx ; and again of erosion and burning, and even a
lancinating pain. This pain is aggravated by coughing, speaking, and
swallowing; especially if the ulcerations are above the ventricles of the
larynx, and also by inspiring cold air, and by pressure on the organ.
But by far the larger number of persons with chronic and sub-acute
disease ofthe larynx complain most of suffering, and that in some cases
acutely when they swallow. So continued and decided is this symptom,
that, in one case, my patient called on me, for the first time, to have an
obstacle removed from his throat,—retained pieces of fish-bone, as he
thought. To re-assure him, I introduced once or twice a piece of sponge,
tied on whalebone, into the upper part of the oesophagus. His real dis-
ease, violent sub-acute laryngitis with bronchitis, accompanied by a full,
hard, and rather frequent pulse, was removed by repeated venesection,
leeching the throat, cups on the chest, and free purging. The subject in
this case was young, of a full habit, robust frame, and a full liver.
Though not of an angelic nature, he was one of the choir in a church;
and his singing talent no doubt had been often put in requisition in the
social circle.
Difficulty is sometimes experienced in swallowing, and a part of the
food or drink is returned through the nose, at the same time the patient
coughs violently and is in danger of suffocation. These symptoms are
generally attributed to loss of substance of the epiglottis, or excessive
rigidity through inflammation, by which it ceases to cover the larynx
during deglutition. In the disease before us, there are cases in which the
patients were able to swallow, although the epiglottis was far from cover-
ing the glotteal aperture ; and again deglutition was almost impossible,
although the epiglottis was entire ; but the tongue was enormously tume-,
fied, as was the epiglottis, which was erect and stiff at the same time.
The voice is almost always altered in its tone, and this change is one of
the earliest symptoms of the disease. At first it is merely weak ; but more
frequently hoarse, and sometimes entirely extinct. The hoarseness may be
continual ; and at other times it comes on only when the larynx is fatigued,
or the patient is exposed to a temperature which differs much from that
in which he habitually lives. If the individual suffer from severe hunger,
the hoarseness is much increased, but disappears after a meal. Immedi-
ately before menstruation, as well as after venereal indulgences, the hoarse-
ness becomes greater. Dividing the duration of the disease into three
periods, it will be found that, during the first the hoarseness is intermittent,
during the second it becomes continued, and may so remain to the end
though more frequently complete aphonia supervenes during the second
stage. Inequality of the voice is a common symptom in chronic laryngitis ;
more, indeed, than is suspected by the patient himself. When the larynx
is diseased, the volume of the emitted sound is lessened ; and, in general
the emission of air is proportioned to the intensity of the voice. Hence
SYMPTOMS OF CHRONIC LARYNGITIS.
99
discordant and unequal intonation is avoided. But the voice becomes
discordant and squeaking in those who attempt to give it the full develop-
ment which it possessed before. This has been observed in several sing-
ers and pleaders, and in clergymen who persist in the performance of their
clerical duties when their voice has lost its accustomed pitch.
Aphonia may be intermittent or continued. In the former case the voice
is lost at night, while in the morning, or after a meal, it is merely hoarse.
Continued aphonia is a bad symptom. That which comes on suddenly is
an acute form of disease of the larynx, and continues when the disease has
passed into the chronic form, is not nearly so alarming as that which advan-
ces progressively. That which succeeds mucous or catarrhal hoarseness
is not so bad as that which follows the stridulous; which last is believed
to depend on ulcerations or vegetations in the larynx. Alone aphonia is
not of such bad import. I have known it to last some weeks in one of my
patients who was subsequently restored to full health.
The cough is a constant accompaniment to chronic laryngitis, which can-
not always be said of disease of the lower parts of the respiratory apparatus.
It is hoarse, and even croupal, when there is tumefaction of the mucous
membrane ; and generally dry, or at most partially relieved by puriform
mucus and sputa mixed with blood. Sometimes pure blood is expectora-
ted ; at other times false membrane is expelled once daily for some months,
and a more than usually copious discharge has been followed by convales-
cence and restoration to health. Mixed with purulent or sanguinolent
mucus, are occasionally seen the remains of carious cartilages of the larynx.
The sputa, especially in the morning, on waking, are of a yellowish-white
colour and sometimes in small lumps or pellets. In those affected with
aphonia or stridulous hoarseness the cough is very peculiar: it has been
called eructation by MM. Trousseau and Belloc—the latest and most careful
describers of the disease. The frequency of the cough is not, however, a
measure of the state of the larynx; nor is it nearly so unfavourable a
symptom as hoarseness and the change in the volume of the voice. Some
persons in whom there was found great lesion of this part have hardly
coughed at all ; whilst others have been teased with an incessant cough,
in whom both the lungs and the larynx were sound.
The breathing is not much affected in the milder forms and early stage
of chronic laryngitis; that is, when there is no diminution ofthe common
diameter ofthe glottis. After the second stage ofthe disease is reached,
anhelation is marked and goes on increasing until death takes place. This
anhelation may proceed from two causes ; muscular debility, the result of
general weakness, or narrowness of the orifice of the larynx. In the latter
case it takes the following course : at first the patient feels himself liable
to what he calls fits of asthma, which most frequently come on at night;
at a later period the severity of the paroxysm is increased, and the oppres-
sion is permanent. The patient cannot breathe in his bed, unless supported
with pillows, and then the inspiration is habitually sibilant, and the expi-
ration loud and prolonged. Paroxysms of true orthopnoea soon supervene,
during which there are extreme anxiety and threatened suffocation ; and,
generally, in fifteen or twenty days from this time the patient dies suffo-
cated. These nocturnal fits of asthma in chronic laryngitis are not always
of such bad import. I have found them sometimes readily relieved by
tincture of belladonna and carbonate of potassa or liquor potassx, in a
sufficient quantity of fluid, with sugar or syrup. Of this mixture, a single
100 DISEASES OF THE RESPIRATORY APPARATUS.
dose at early bed-time will suffice to ward off the paroxysm. W hen there
is anemia at the same time, a mild chalybeate in the morning more effectu-
ally prevents a return ofthe nocturnal fit.
When the ulcerations are situated at the superior orifice of the larynx,
deglutition is impeded, giving rise to some uneasiness and cough ; but in
cases in which the epiglottis is in part inflamed or removed by ulceration,
there is much dysphagia with a return through the nostrils of the drinks
taken in by the mouth, and a fixed pain in the superior portion of, or im-
mediately above, the thyroid cartilage. Still, as if to prevent positive
conclusions respecting the effects of evident organic lesions, we learn,
from Magendie, that there have been cases in which, notwithstanding the
complete destruction of the epiglottis, deglutition was performed without
abnormal symptoms.
In some cases of chronic laryngitis, pressure on the larynx by grasping
it between the finger and thumb produces a crepitation, which is alleged
to be caused by caries ofthe cartilages, and by some it has been regarded
as a pathognomonic sign of phthisis laryngea. But renewed experiments
show that this occurs when the organ is perfectly sound.
Expectoration in simple laryngeal phthisis does not furnish very positive
signs. It is commonly purely mucus, transparent, and not very tenacious ;
but when there is ulceration, the sputa, without losing these characters, are
often mixed with little puriform masses and streaks of blood, and are
brought up with slight effort, as if to clear the throat. In the morning, on
first awaking, the patient coughs up sputa of a yellowish-white colour and
in little pellet-like masses, but without any particular characters.
It is important to be aware of the different symptoms in the different
species of chronic laryngitis or laryngeal phthisis. The progress of syphi-
litic is not the same as that of simple laryngeal phthisis. The latter gene-
rally originates in the larynx and trachea ; whereas, the former usually
spreads from the pharynx and nasal fossae. It is, we are told, of great
practical importance to attend to this, because experience shows that the
larynx is usually affected in the same manner with the throat. Thus,
where an erythematous syphilitic affection is observed in the throat, the
affection ofthe larynx will not be of an ulcerous nature ; on the contrary,
where the pharynx and velum palati and nasal fossae are deeply ulcerated,
we may expect to find the larynx ulcerated or eroded.
In every case of chronic laryngitis we should examine the fauces and
pharynx, in order to see whether, and to what extent, their mucous mem-
brane is affected. Frequently, there are diseases of these parts and diges-
tive disorder associated with that of the larynx, and although we may not
be able to reach this latter by topical remedies, we can exert a salutary
effect on it through applications to the fauces and pharynx. I have, after
careful and repeated examination, detected in this way ulceration at the
lower part of the space between the pillars of the palate adjoining the
upper part of the larynx ; on cauterising which, the laryngeal affection
was greatly relieved. Elongation of the uvula is of itself a frequently
exciting cause of cough and of irritation of the glottis, and through this
latter of the whole respiratory apparatus. Its excision is often necessary
for a cure, and at times the operation alone will be found sufficient for
this end. An inspection of the epiglottis is very desirable since the
larynx is seldom severely affected without this part participating in the
disease. Sometimes, by getting the patients to utter loud cries during
SYMPTOMS OF CHRONIC LARYNGITIS.
101
the inspection, the epiglottis, carried forward at each expiration, may be-
come visible. As yet, little benefit has been derived from the use of
speculums invented with a view to our examining the larynx by their
means ; and the trials made to ascertain by the introduction of the finger
the state of the epiglottis and upper part of the larynx, must be regarded
as hazardous, although the practice has been recommended with some
emphasis in cases of s.uspected edematous laryngitis, in order to allow of
our obtaining a satisfactory diagnosis.
Believing the title of laryngeal phthisis to be sufficiently comprehensive,
both to express consumption which may result from simple chronic laryn-
gitis, as well as that which has its origin in pulmonary tubercles, and to
which the disease of the larynx furnishes some of the chief characteristic
symptoms, I do not see the necessity of using the terms tubercular laryn-
geal phthisis. It is sufficient for us to be aware of the fact, that with
organic lesions of the larynx of a chronic nature there is commonly com-
plicated a tuberculous state of the lungs, which is, after a time, converted
into true phthisis. In forming, therefore, our diagnosis and prognosis of
diseases ofthe larynx, an examination ofthe state ofthe lungs can never
be omitted. On this point, the advice of Dr. Stokes should be regularly
and fully acted on.—(A Treatise on the Diagnosis and Treatment of Dis-
eases of the Chest. Part I.)
" The first step in the investigation will be to examine accurately into
the history ofthe case ; and in particular to determine whether the laryn-
geal affection was primary or supervened on an already existing state of
the lung. We must examine what were the first symptoms, and whether
they were referable to the larynx or lung. We must inquire into the
past and present state of the fauces, and also whether a syphilitic taint
exists. Now, should it be found that the first symptoms were those of a
laryngeal character, that the voice had been altered from the outset ofthe
disease, or that a syphilitic taint did really exist, we have a good proba-
bility, not that the lungs at the time of examination are free, but that the
first morbid action was exerted on the larynx. But if, on the other hand,
we find that, previous to the occurrence of any hoarseness, or stridor, or
dysphagia, there has been cough without the laryngeal character—particu-
larly if it was at first dry, and afterwards followed by expectoration—if
hectic has existed, although the expectoration continued mucous; if there
have been hemoptysis, pain in the chest or shoulders; and lastly, if the
patient was emaciated previously to the setting in of the laryngeal symp-
toms—we may be almost certain that the tubercle exists, and that the
case, so commonly called laryngeal, is in reality pulmonary phthisis; and
if it appears that the patient is of a strumous habit, or has already lost
brothers or sisters by tubercle, we may form our diagnosis with a melan-
choly certainty, even though, at the time, we can detect no certain phy-
sical sign of pulmonary tubercle."
It follows, from these premises, that we must have recourse, in our
diagnosis, to the stethoscope, the nature and abundance of the expecto-
ration, and the rapidity of the consumption. But, as Dr. Stokes has
stated in the work just quoted, the sounds which would be conveyed to
the ear through the stethoscope, and constitute the phenomena of respira-
tion, are greatly obscured or masked by the state ofthe larynx, when this
part is the seat ofthe disease—a difficulty also mentioned by MM. Trous-
seau and Belloc. Fortunately, percussion serves us here instead of aus-
102 DISEASES OF THE RESPIRATORY APPARATUS.
cultation, and enables us to determine which lung, and of the diseased
one which part is affected. " Under any circumstances," says Dr. Stokes,
" the localised dulness points out that there is something more than laryn-
geal disease ; and we know from experience that that something more is,
in the great majority of cases, tuberclization of the lung." This present,
the disease of the larynx runs its course with greater rapidity.
Between laryngitis and tracheitis, either simpleas such or associated
with phthisis, it is difficult to distinguish. In the former we may expect
dysphagia, and the voice to be more affected—in its being muffled, hoarse,
or wanting—than in the latter. Among the terminations of laryngeal
phthisis, one of the most severe is swelling of the margins of the glottis.
The primitive laryngeal angina (acute edematous laryngitis), of which this
is an accompaniment and a symptom, has been already described with
requisite fulness ; its inflammatory nature is contended for by the French
writers just named. The consecutive is occasioned by organic lesion of
the larynx and its connexions, and may be either inflammatory or active,
or non-inflammatory and passive.
In duration, chronic laryngitis will vary from a few months to many
years. For us to augur a favourable termination, the disease should have
made but little progress. When it has advanced considerably, and the
system is weakened by dyspnoea, cough, prolonged abstinence, or maras-
mus, there is little hope of saving the patient. But as there are on record
accounts of several patients in whom the disease had made great progress
but who were nevertheless cured, it shows the propriety, and indeed duty,
of persevering in our endeavours to save the patient, so long as there is
the slightest shadow of hope.
The causes of chronic laryngitis are not always appreciable. Sometimes
the disease originates under the influence of atmospherical changes. In
such cases we find persons contract a slightly acute laryngitis, which soon
passes into a chronic state and never leaves them. The inspiration of
irritating particles or gases which escape in various manufacturing pro-
cesses ; a prolonged mercurial course ; typhoid fevers, and debilitating
causes in general; exanthemata ; foreign bodies in the larynx, occasion-
ally give rise to it. Of the internal causes, unmeasured and protracted
exercise ofthe voice is one ofthe most frequent and evident ; as we see
in the cases of preachers, pleaders at the bar, and other public speakers,
and in actors and singers. But even here, obvious as is the exciting
cause, we find often so little proportion between its action and the occur-
rence of the disease, that we must look to other collateral causes, and
perhaps still more to the predisposition of the parties affected, as in a
tuberculous and scrofulous constitution. We are, as yet, wanting in the
requisite statistical data for a proper knowledge of the proportions of the
members of different professions and callings affected with the disease.
So far as medical observation and popular belief guide us in forming an
opinion, clergymen are most liable to it. In their case, then, our inves-
tigation should be directed to an inquiry into—1, the temperament which
we may suppose would be most frequently met with in those whose early
bias is to serious and religious reflections ; 2, the bodily constitution and
collegiate habits of students for the ministry ; 3, the kind of labour and
exposure, either voluntarily entered into by, or exacted from, these
young men, after they have assumed the office and responsibilities of the
ministry. It will be found, I believe, on a review of the facts under
CAUSES OF CHRONIC LARYNGITIS.
103
these several heads, that a youth of a nervous temperament and feeble
constitution is exposed, while at college or when pursuing his theological
studies elsewhere, to the enfeebling influences of deficient exercise ; con-
finement in illy-ventilated halls and dormitories; study beyond measure
and at late hours in the night; anxiety of mind, both as respects his pre-
paration for the solemn part which he is destined to perform, and his
worldly success ; aud habits of sensual indulgence, such as the use of
tobacco and other means of enfeebling the nervous system. It is easy to
see how badly such a person is prepared for the unremitting toil to which,
partly from duty, partly from sectarian rivalry, and in no small degree
also from the urgent and often unreasonable calls, exactions, in fact, by
the inconsiderately zealous of his congregation, he is subjected, so soon
as he accepts a call to a church. Preaching often on Sunday, and not
seldom during the week, in close churches, and in the evening too, and
in a pitch of voice beyond his natural one, would of itself bring on laryn-
geal disease in a person already feeble and unable to exercise any organ
much without inducing phlogosis and its consequences. But when to this
cause we add exposure to frequent and sudden transitions from a dry and
hot to a moist and cold air, as when leaving his own home to visit the
sick, and, still more, to attend and officiate bareheaded at funerals, in the
midst sometimes of a storm of wind and rain, or of snow ; and when he
passes from a crowded church, in which he has been perspiring, to the
open and chilling air of a cold night, we cease to wonder that the preacher
should suffer from diseases of the lungs and air-passages, and especially
of that part, the larynx, which has been enfeebled by prolonged and
violent exercise, and is, in consequence, peculiarly predisposed to
disease.
Belonging to predisposition are general debility from deficient ex-
ercise, depraved digestion and nutrition, excess in venereal indulgences,
including masturbation and the depressing passions. The local predis-
position may be found in a want of moderate exercise of the voice in the
intervals between the formal and professional exercise and extraordinary
strain on it; also, in continued irritation of dry hot air by a person habitu-
ally breathing such. Tobacco is a predisposing cause, both of general
and local debility ; and a disturber of the functions of the lungs, stomach,
larynx, and pharynx, by its perverting the secretions of the mucous
membrane lining these organs, and by at first exciting and afterwards
depressing their nervous power. Whatever tends to attract fluids in excess
to the larynx, and to derange the circulation in its mucous membrane, as
well as indirectly to weaken its muscles, which are those of the voice, by
enfeebling innervation, must of course contribute to a morbid state ofthe
organ. The use of tobacco may bring on all these derangements of func-
tion. But one would suppose, from the obstinate perseverance in this
filthy and eminently anti-social practice, that it placed the chance all on
the side of health, rather than of that of disease and of a complication of
unpleasant sensations more annoying to the sufferer than positive pain.
The apparent exemption from deleterious effects in a few persons of a
robust and phlegmatic habit of body, is no argument against the general
rule. The same deceptive reasoning has been attempted to show the
innocuousness of free spirituous and vinous potations in general. But
how small the number of exempts out of the legions of those whose health
and comfort and respectability have been ruined, and their lives abbre-
104 DISEASES OF THE RESPIRATORY APPARATUS.
viated by such practices. Well have these privileged exempts been
called the Devil's decoys—seducers ofthe thoughtless crowd to their un-
doing. The use of ardent spirits is, particularly in conjunction with
exposure to vicissitudes of weather, a powerful cause of this disease.
Age and sex exert a great influence over the development of chronic
laryngitis. Almost all the patients whose cases are recorded by different
writers, were between twenty and fifty years of age ; the most of them
between thirty and thirty-five. It appears from the observations of Louis
and Serres, that among individuals of the tubercular diathesis at least, the
organic alterations in the larynx and trachea are twice as numerous among
men as among women. Women are less subject to alterations of the
organs of voice than men ; arid children, whose constitution is very ana-
logous to that of women, participate in this immunity, attributable, also,
and more especially to the relative infrequency of phthisis at this tender
Complications.—Mention has been made already of irritation and phlo-
gosis of the fauces and pharynx being associated with similar stages of
the larynx. The disease of the latter is commonly in these cases, whether
syphilitic or otherwise, consecutive to that of the former. In some cases
of chronic gastritis, there is morbid redness and aphthae of the fauces and
pharynx, which extend, by continuous sympathy, to the glottis and upper
part ofthe larynx, and give rise to alteration in the voice, cough, expec-
toration of purulent mucus, &c. A restoration ofthe healthy state ofthe
stomach, if accomplished in an early period of the disease, will bring
about a removal of the laryngeal symptoms. In small-pox, we have fre-
quent instances of this extension of inflammation from the fauces and
pharynx to the air-passages, and the consequent changes in the voice and
respiration, already described among the symptoms of chronic laryngitis;
with this difference, that in the secondary laryngitis from small-pox, the
disease runs its course with a rapidity which brings it within the stage of
acute disease. A slight irritation of any part of even the buccal mucous
surface, by establishing an afflux towards the throat, will develop chronic
laryngitis ; as, for example, a caries of one or more of the teeth. A cele-
brated singer, Mme. Mainville Fodor, the syren of the Italian opera, who
enraptured the inhabitants of Paris in my time of study there, is said to
have lost her voice in this way.
LECTURE XCI.
DR. BELL.
Treatment or Chronic Laryngitis—Rest of the vocal apparatus—antiphlogistic*—
counter-irritants,—narcotics, mercurials, iodine, sarsaparilla, balsam of copatva blue
mass and syrup of sarsaparilla, sulphurous waters—Topical remedies; inhalation of
simple and stimulating vapours; caustic to the parts—The author's own experience-
Attention to anginose complication—Syphilitic chronic laryngitis; mercurials sarsa-
parilla; iodine—Tracheotomy, when proper—Change of climate—attention'to the
digestive organs—Prophylaxis—Clergymen,—rules for their guidance—Uniform tem-
perature of air—Jeffray's Respirator.
The treatment of chronic laryngitis will vary with its stage and the pre-
dominance of certain symptoms. In the first stage of the disease marked
TREATMENT OF CHRONIC LARYNGITIS.
105
by slight hoarseness, a feeling of heat and dryness in the throat, and im-
perfect expectoration or hawking of muco-serous matter, the remedies will
be the same as for common catarrh. But if the inflammation does not
readily yield to the simpler means, including abstinence from all kinds of
excitement, and if the hoarseness is increased, and accompanied by aphonia
and the characteristic cough before described, more energetic and system-
atized measures are required. The first condition for restoration to health
is entire rest of the vocal apparatus, as far at least as speaking above a
whisper. Provided there be no effort made by the patient to render what
he utters more distinct, speaking in a whisper is not attended with any
evil, in the opinion of Drs. Trousseau and Belloc ; but even this in con-
versation with a stranger, when an effort at a certain pitch is made, is
sometimes more fatiguing to the patient than his speaking aloud. The
indulgence of whispering is the more allowable, when we reflect on the
extreme difficulty of keeping the patient silent for several months in suc-
cession. First among the class of antiphlogistic remedies, applicable to the
more decidedly inflammatory or incipient stage of the disease, is blood-
letting. The authors just named prefer greatly venesection to leeches,
unless these are freely used. But if the disease have made progress, or
the patient be enfeebled, leeches are to be preferred ; in which case they
should be applied on each side of the larynx and trachea, inside the sterno-
mastoid muscles. The feeling of relief expressed by the patient after their
use is often very great. Cups to the nape of the neck I have seen to be
of marked benefit ; although perhaps not equal to the other method of
drawing blood. If there is reason to believe that the disease has arisen
from suppression ofthe menstrual or hemorrhoidal discharge, or is greatly
aggravated by such suppression, leeches ought to be applied, in the for-
mer case to the thighs or the vulva, and in the latter to the anus. Emol-
lients internally may soothe irritation without exerting any material influ-
ence over the disease ; but their external use, in the form of warm poultices
to the neck, will be injurious by increasing the afflux of fluids to the throat.
Coinciding with bloodletting, and a useful substitute for this latter, is tartar
emetic, given at first to vomit, and afterwards with a view to its contra-
stimulating effects, in such doses, three or four times a-day, as the stomach
will tolerate. In cases of sustained inflammation, the vinous tincture of
colchicum may be combined with the antimony, and occasionally, when
the bowels are to be acted on, with Epsom salts.
After the disease has been of some duration, revellents or counter-irritants
will be found to be among the most efficacious of our remedies. They
are deemed more beneficial than bloodletting by MM. Trousseau and
Belloc. Blisters are advantageous, but only when kept long discharging.
They ought to be applied to the nucha, because when placed in front they
create too much pain and irritation, especially in men with thick beards.
Scions and the potential cautery, applied to the anterior part of the neck,
opposite the crico-thyroid space, are, also, very useful. In milder forms
of the disease, the eruption produced by rubbing a liniment, composed of
croton oil two drachms to an ounce of olive oil, at first twice, daily, will
have a good effect. Next to this, and on the rising scale of activity, are
the tartar emetic and the ammoniacal ointments rubbed, as in the former
case, over the front and sides ofthe larynx and trachea, until an eruption
is brought out by the former, and a rubefaction or slight vesication by the
latter. The antimonial frictions should be continued even after the pus-
106 DISEASES OF THE RESPIRATORY APPARATUS.
tules first appear, and until they are confluent, and then renewed when
the scab begins to fall ; and so on at intervals of perhaps twice a-month,
while the disease lasts, or as long as there is any evidence of relief being
obtained by the practice. I have used iodine ointment with beneficial
results.. The writers already quoted direct, as part of a plan of counter-
irritation, and we may suppose in cases in which the frictions just specified
have not been employed, a small piece of caustic potash, to be applied
once a-week on either side ofthe larynx and trachea. In this way five or
six cauterised spots are made to suppurate at the same time without the
necessity of inserting peas to keep them open. Less confidence is to be
placed in revulsives when applied at a distance from the diseased organ,
unless in the case of suppressed discharge, as of sweat from the feet, he-
morrhoids, &c.
JVarcotics are often of great use in assuaging the pain and cough in
chronic laryngitis. Belladonna, stramonium, and hyosciamus, have been
severally recommended ; the two former, in the shape of diluted or semi-
fluid extracts, by friction to the anterior part of the neck. The salts of
morphia, introduced by the endermic method, are, also, a valuable adju-
vant to other measures. M. Cruveilhier, with a similar intention, directs
the patient to smoke the leaves of stramonium, or of belladonna which had
been boiled in a watery solution of opium, and afterwards dried. By
calming the cough, and allaying and removing pain, these narcotic reme-
dies abstract causes of irritation and of flux to the larynx, and contribute
to the cure. The use of the extract of stramonium in a two-grain pill
twice or thrice a-day, will have a more uniform effect, as I have ascer-
tained by repeated prescription of this remedy in asthma complicated with
laryngeal affection.
A mercurial course, that is, the action of mercury on the mucous secre-
tors and capillary system—but always short of ptyalism—even in cases not
syphilitic, I have found to be of manifest and permanent benefit, particu-
larly in persons of a sanguine temperament and a rather full habit of body
or of active nutrition. In scrofulous subjects we must use mercury with
more reserve, if at all; and where tubercular irritation is obvious the me-
dicine should be carefully abstained from. In these cases, a decoction of
senega with nitre ; iodine—either a solution of the iodide of potassium
three to five grains twice a-day, or Lugol's solution—iodine in water, in
which the iodide has been previously dissolved, are applicable. In
various chronic affections of the trachea and bronchial mucous membrane,
as well as in the present disease, I have used the iodine with much benefit;
and especially I have had occasion to be pleased with its effects, when it
has been combined with the compound syrup of sarsaparilla. In cases in
which the secretion is copious and muco-purulent, the balsam of copaiba
has done good ; combined with sarsaparilla syrup, I prescribed the balsam
on one occasion in what would be called tracheal phthisis, but in which
the bronchiae also were affected. The symptoms—consisting of expecto-
ration, more than a quart in twenty-four hours, and accompanied by hectic,
night sweats and a rapid pulse—disappeared under a treatment of which
this last combination was a leading part. The iodine had also been used
in the manner already mentioned.
When mercury is thought to be proper in chronic laryngitis the pre-
ferable preparation is the blue mass, in doses of five grains every night
with about the same quantity of extract of hyosciamus, made up into pills!
TREATMENT OF CHRONIC LARYNGITIS.
107
In the morning, if the bowels are not free, and the digestive apparatus is
disordered, some mild saline, or rhubarb and magnesia, will be used.
This latter difficulty obviated, and a regular and defined course deter-
mined on, the blue mass and hyosciamus are to be administered every
night, and the syrup of sarsaparilla in the morning. The doses of this
latter will be from half an ounce to two ounces, according as it is found
to agree with the stomach and bowels, by not oppressing the former nor
purging the latter. I do not recommend this treatment as at all of a
specific nature, as far as regards this or any other disease, whatever may
be thought of its action on particular tissues. In the morbid secretions
which accompany chronic inflammations of the mucous tissue, and in
ulcerations of this tissue, in the respiratory, digestive, urinary, and genital
organs, I do not hesitate to regard the blue mass, iodine, and the syrup
of sarsaparilla, and occasionally the balsam of copaiba, as medicines of
undoubted efficacy ; so far at least as I can be influenced by my own ex-
perience, which in this particular entitles me to speak with some confi-
dence. Sulphurous mineral waters, though of secondary importance, are
useful adjuvants to the mercurial and iodine course, especially in recent
cases of the disease.
But without the aid of topical means, the best-devised general remedies
are insufficient for the cure of chronic laryngitis, as they are of ulcerations
and puriform discharges of the throat, nose, eyes, vagina, rectum, &c.
These means are laid down by MM. Trousseau and Belloc, as either emol-
lient, detergent, or irritating ; so as in the latter case sometimes to destroy
the morbid surface itself. " They are either pulverulent, liquid, gaseous, in
vapour, or salts." These gentlemen think that they have ascertained " a
method of bringing medications in form of vapour, powder, or liquid, in
contact with the mucous membrane of the larynx, without interrupting
respiration."
Most frequently the vapour of water was employed, either simple, or
charged with emollient, balsamic, or aromatic substances. Sometimes
the vapours were dry, as the smoke of tar, raisins, hyosciamus, tobacco,'
poppy, &c. The moist vapours have also been charged with chlorine,
iodine, hydro-sulphuric acid, and different essential oils, and applied with
some effect to the mucous membrane of the air-passages; as shown by
the experience of MM. Bertin, Gannal, Cottereau, Richard, Sir C. Scuda-
more, and Dr. Murray, most of which is detailed in my work on Baths and
Mineral Waters. This kind of medication has been taken up by some
physicians lately, as it were a new thing; and it has been made an affair
of newspaper prescription and popularity. If, which I doubt, any physi-
cian gains by such proceedings, the good people at large are certainly
sufferers by their being thus tempted to become their own doctors.
Various kinds of apparatus have been made for the purpose of inhaling
these vapours; but it is admitted, even by some of their inventors, that a
simple teapot is as well adapted as the most complicated machine. MM.
Trousseau and Belloc have also caused patients to inspire fumigations of
cinnabar, sulphurous acid, &c, with various, but not recorded results.
All inhalation, of whatever nature, is, however, liable to the objection
that the substance inhaled is not confined to the larynx, but comes in con-
tact with the mucous membrane of the lungs, which it may irritate. It is im-
possible, moreover, to limit its action, and hence the necessity of restricting
ourselves to the employment of emollient, aromatic, balsamic, and narcotic
108 DISEASES OF THE RESPIRATORY APPARATUS.
vapours, and such as cannot exercise any sinister influence on the lungs.
An objection, or rather a difficulty of more common occurrence, is the
small proportion of these medicated vapours which pass through the glot-
tis at all—closed as this is instinctively when any foreign substance in the
air reaches it.
The liquid medications are much more easily applied, and without risk
of injuring the trachea and bronchiae. Of these, some are irritating;
others simply astringent. The former are, muriatic acid, solutions of
nitrate of silver, corrosive sublimate, sulphate of copper, and sub-nitrate of
mercury, and the caustic solution of iodine as recommended by Lugol.
The solution of the nitrate of silver would seem to be entitled to the
greatest confidence, on account of its rapid action, its relative harmless-
ness, and its known efficacy in so many external ulcerations and other
lesions of tissue. The strength of the solution will vary from a half-drachm
to a drachm in two drachms of water.
Various methods have been devised for applying the caustic to the
larynx. The simplest is the introduction of a small conical paper bent at
its end, and which has been immersed in the solution, into the throat, and
down into the larynx; the mouth of course being kept open during the
time by the crooked handle of a spoon. A piece of whalebone answers
the same purpose, and more conveniently reaches the part affected.
When it is desired to cauterise the pharynx, the base of the tongue, and
the top ofthe larynx at the same time, MM. Trousseau and Belloc take a
piece of whalebone about a sixth of an inch in thickness, and so that it
will not bend too readily : this is heated at an inch or more from one
end, and when softened sufficiently it is bent at an angle of forty-five de-
grees. To the end of this smaller portion a spherical piece of sponge is
fastened, half an inch thick, which is moistened with a solution of nitrate
of silver, and introduced in the following manner. The mouth open, and
the tongue depressed as before, the sponge is passed through the isthmus
ofthe fauces, which gives rise to an effort of deglutition and a consequent
elevation of the larynx, and at this moment the sponge is brought some-
what forward, and from the entrance of the oesophagus it now passes into
the glottis, and by a little pressure against the latter the fluid is squeezed
into the larynx. The cough which is produced at this time favours the
introduction of the caustic. Vomiting is often excited by the operation.
This plan, though not painful, is, according to its proposers, very disa-
greeable : and many patients refuse to submit to it a second time. These
gentlemen have, in such cases, another means of effecting their object.
To a small silver syringe, like that of Anel, a canula, at least five inches
in length, and curved at its free extremity with a very small opening, is
attached. The syringe is filled three-fourths with air, and one-fourth with
a solution of nitrate of silver. The canula is then introduced into the pos-
terior fauces, opposite the larynx ; and the piston being rapidly advanced,
the liquid mixed with the air in the syringe falls in a fine shower on the
superior part ofthe larynx and oesophagus. The patient is seized imme-
diately with a convulsive cough and regurgitation, by which he throws off
all the solution yet uncombined with the tissues. I have used as more
convenient, a piece of sponge sewed carefully to the end of a small-sized
gum-elastic catheter, with a rod in, and the end of which has the required
curve given to it, so as to allow of a ready application to the opening of
the larynx and borders of the epiglottis. The sponge is to be dipped in
TREATMENT OF CHRONIC LARYNGITIS.
109
the solution as just now recommended. The patient is to be made, directly
afterwards, to gargle his throat with water acidulated with muriatic acid,
or salt water, which decomposes any ofthe free solution remaining in the
pharynx.
Another mode of employing caustic solutions mentioned by Dr. Stokes,
is that of Mr. Cusack. A brush of lint, of the requisite size, is sewed on
the end ofthe finger of a glove, which is then drawn on the index finger
of the right hand. The patient should be made to gargle with warm water,
and the lint, being dipped in the solution, can be at once carried to any
part ofthe pharynx, and even to the rima.
It has been appropriately observed by the two French writers from whom
I have so largely borrowed for the pathology and treatment of chronic
laryngitis, that one must have practised these cauterizations, or seen them
performed, to have an idea of their harmlessness and of the little pain
which results. We are very much alarmed at a cautery, for it is exceed-
ingly painful when applied to the skin or mucous opening, though scarcely
felt in the pharynx, larynx, or the neck of the uterus. I know that the
application of a strong solution of nitrate of silver to the.epiglottis and rima
glottidis has been followed by very little pain, and did not prevent the
patient from sitting down to table and eating his meals as usual in half an
hour afterwards. These gentlemen in their valuable work, a good trans-
lation of which has been made by Dr. Warder, of Cincinnati, adduce the
histories of several cases in proof of the superior efficacy of this topical
treatment over any other. It has succeeded after the other means had
been tried in vain.
As discussions have been held in the medical and newspaper press on
the subject of topical applications to the larynx in the treatment of chronic
diseases of this organ, involving a question of priority of practice, which has
been claimed by or for Dr. Horace Green of New York, I shall mention a few
facts relating to my own reading and experience in the matter. Dr. Green's
volume—A Treatise on Diseases of the Air-Passages, &c, appeared in
1846.—My first knowledge of the work of MM. Trousseau and Belloc was
derived from an analytical review of it mine Edinburgh Medical and Sur-
gical Journal for October, 1837. Taking this review as a basis, I wrote
an article headed " Laryngeal Phthisis—Consumption ofthe Throat—
Clergyman's Sore Throat," which was published in ray Eclectic Journal
of Medicine for December, 1837. On that occasion the means of applying
caustic solutions to the larynx were described according to the directions
of Trousseau and Belloc, as given in the Edinburgh Journal and derived
primarily from their work. It is very evident, therefore, that apart from
the knowledge ofthe practice obtainable from the work itself of these gen-
tlemen which was published in Paris in 1837, tolerably full publicity must
have been secured to this knowledge in Great Britain through the Edin-
burgh Journal and in the United States through the Eclectic Journal, before
the expiration of the year 1837. The work itself was translated by Dr. War-
der, of Cincinnati, and published in " Dunglison's American Library," in
the year 1839. So much for the first announcement and subsequent diffu-
sion of the process of the French writers. I have next to add a few words
on the priority of the practice in this country according to the process re-
commended. It would seem, as far as I can learn, that mine was the first
published statement ofthe process recommended by Trousseau and Belloc
having been carried into effect in the treatment of chronic laryngitis. It
110 DISEASES OF THE RESPIRATORY APPARATUS.
was made not formally as a matter of boast but explanatory, in these words,
which occur in Lecture XII. ofthe additions which I made to Dr. Stokes's
Lectures on the practice of Physic, p. 668, and published in 1840. " I
have used, as more convenient a piece of sponge sewed carefully to the
end of a small-sized gum-elastic catheter with the rod in, and the end of
which has the required curve given to it, so as to allow of a ready appli-
cation to the opening of the larynx and borders ofthe epiglottis." My
first trials of the practice were in 1839, and from that time to the present I
have repeated it at intervals and always with benefit.
As regards the extent to which the sponge moistened with caustic can
be carried down into the larynx, this must be a matter of opinion. When
the instrument, as we may call it, is used at all it is carried downwards
and pressed on the glottis : some, with Dr. Green, may insist that it finds
its way into the larynx, others, and the majority, believe that it stops at
the rimae glottidis, and that the fluid alone which is squeezed out of the
sponge passes this part. The difference of opinion by the former does not
constitute any valid claim for discovery.
Of the probable coexistence of angina pharyngea with chronic laryngitis
I have already spoken. Again, I would remind you ofthe importance of
being aware of this conjunction, and, of course, ofthe necessity of exam-
ining carefully the lining of the fauces and pharynx, and of applying to it
appropriate topical remedies ; emollients, if there be inflammation ; caustic
solution, or pencilling it with caustic, if the affection be chronic, and mani-
fest itself either by a relaxed tissue, or by aphthous spots or granular ulce-
rations. The portion ofthe membrane which in these cases more commonly
requires to be treated in this way is that covering the tonsils and the arch
of the palate. For this purpose, we should touch, two or three times
a-wTeek, the part just mentioned with a pencil of nitrate of silver, or a so-
lution ofthe same, or a powder composed of six or eight grains of the salt
to about a drachm of powdered sugar-candy. In the same way we employ
powdered alum. Sub-nitrate of bismuth may be used pure ; calomel with
twelve times its weight of sugar: red precipitate, sulphates of zinc and
copper, with thirty-six times, alum with twice, acetate of lead with seven
times, and nitrate of silver with seventy-two, thirty-six, or even twenty-
four tirries its weight of sugar. The apothecary should be directed to pre-
pare these powders on a porphyry slab, otherwise small crystalline asperi-
ties remain, which act as irritants, and bring on repeated fits of coughing
and the expulsion ofthe powder.
The insufflation is best practised by the patient himself, by means of a
glass tube two lines in diameter and eight or ten inches long. Three or
four grains ofthe powder are to be put into one end of the tube, and the
other is to be introduced as far back into the mouth as possible. After
emptying the lungs by a strong expiration, the patient closes his lips upon
the tube, and then by a quick effort of the diaphragm draws his breath
rapidly. The column of air, in traversing the tube, divides and hurries
along the powder towards the pharynx ; but a part suspended in the air
penetrates the larynx and upper part of the trachea. We are apprised of
its having entered the larynx by fits of coughing, which the patient should
repress as much as possible, so as to preserve the medicine in contact with
the affected tissue. These inspirations will vary in number according to
the sensibility of the larynx and the strength of the powder.
A saturated solution of corrosive sublimate, or of sulphate of zinc or of
copper, will fulfil the same indication as the powders before mentioned.
TREATMENT OF CHRONIC LARYNGITIS.
Ill
When chronic laryngitis has a syphilitic origin, it will be removed by
mercury, and, at times, under circumstances of the most discouraging
nature, as where the patient had been reduced to the last degree of ema-
ciation with hectic fever and night sweats. But let us not forget that this
result is not certain, even in old cases of syphilitic laryngitis ; and that
mercury has in some of these aggravated all the symptoms. In these cir-
cumstances, the ptisan of Feltz has brought about a rapid cicatrization of
the ulcers.—(Cruveilhier, Diction, de Med. et de Chir. Prat.) The ptisan
here referred to is made of a decoction of sarsaparilla, China root, and
other vegetable matters of-less strength, in which sulphuret of antimony
has been previously put, and to which, subsequently, corrosive sublimate
has been added. A neater and more pharmaceutical method is to direct
a solution ofthe mercurial salt in wrater, to which some simple syrup and
a little of Hoffman's anodyne have been added ; and afterwards, in the
course of the day, the compound syrup or a strong decoction of sarsa-
parilla.
In the advanced stages of syphilis, in which the mucous membrane of
the mouth and throat was the seat of extensive ulcerations, I have derived
excellent results from the iodine preparations already mentioned, con-
joined with the syrup of sarsaparilla, in cases, too, in which mercury had
either failed to relieve or had aggravated the disease.
There is, occasionally, an extreme state in this disease short of death,
but which, if pot relieved, ends in dissolution. I refer now to the immi-
nent danger of suffocation in some cases: a present remedy for which is
tracheotomy. But before having recourse to this last trial of our art, we
should have given effect to the following appropriate remarks and sug-
gestions of Dr. Stokes:—
" In some cases spasmodic exacerbations occur so severe as to threaten
the life of the patient. These are more frequently met with in females,
and demand a careful study. The suddenness and violence of attack,
the absence of corresponding fever, and of tumefaction of the epiglottis,
will in general suffice for the diagnosis. I have often seen cases in which
the suffering was so severe, as that, at the instant, performance of tra-
cheotomy was advised, yet in which the breathing was restored to its
ordinary condition by the following simple treatment: the feet were
plunged in warm water, the body enveloped in blankets, and a draught—
consisting of camphor-mixture, ammonia, valerian, ether, and opium—
exhibited, aud repeated according to circumstances. Under this treat-
ment, symptoms will rapidly subside, which, from their character and
continuance, would seem to demand the knife ; and I would advise that,
in all cases, previous to the performance of tracheotomy in chronic laryn-
gitis, the question be carefully investigated, as to whether the urgent
symptoms are the result of spasm or of organic obstruction. Let it never
be forgotten that, even where organic disease and thickening of the larynx
exists, spasm may supervene, and be met by appropriate treatment. We
are not much attached to the doctrine of diseases being necessarily sepa-
rate, but experience tells us that nothing is more common than to see
spasm following organic disease, or organic disease occurring after a
purely nervous lesion.
" In cases showing this liability to spasm, the belladonna or other ano-
dyne plaster may be usefully employed."
Tracheotomy ought not to be performed except when the patient is
112 DISEASES OF THE RESPIRATORY APPARATUS.
threatened with suffocation, and all the promptly available medicinal
means have been had recourse to. These conditions having been com-
plied with, and the operation performed, the physician is freed from the
fear of seeing his patient die of asphyxia, and may proceed to treat the
affection of the larynx in a suitable manner: when the organ is capable
of performing its functions, the canula can be withdrawn, and the wound
allowed to heal. Even should the disease be of such a nature that the
passage of air through the natural canal is afterwards impossible, the
canula may remain for an indefinite period, and the life of the patient be
lengthened. A case is given by MM. Trousseau and Belloc, of an indi-
vidual wearing such an instrument, made of silver, for ten years. They
state their having performed tracheotomy seventy-eight times ; seventy-
three for croup, and five for laryngeal phthisis, with, the loss in one in-
stance only of life during the operation. They give a number of successful
results from tracheotomy.
A more permanent amelioration than from merely medicinal means in
chronic laryngitis, is obtained by a change of climate. With this view,
a residence for a year or more in warmer latitudes, or sometimes during
the winter months only, is recommended to patients with chronic laryn-
gitis as well as to those with chronic bronchitis. Where circumstances
prevent their absenting themselves from home, an artificial climate may
be procured by keeping up a uniform temperature and moisture in the
house ; and the patient confining himself to it during the whole of the
winter. But before having recourse to a change of climate, the patient
should be freed from any inflammation of the air-passages under which
he may be labouring at the time ; for, without suitable precaution on this
score, he will be more likely to be injured than benefited by leaving
home, and exposed to the operation of causes in travelling which tend to
aggravate the inflammation.
Another important consideration is the state of the digestive organs.
There is hardly any morbid association more common than that of irrita-
tion of the bronchial and laryngeo-bronchial membrane with a similar
irritation of the stomach ; especially after the middle period of life. In
cases of this kind, it is well remarked by Sir James Clark : " Upon
tracing the progress of the disease, we shall generally find that the bron-
chial affection, the liability ' to catch cold,' the ' spring cough,' the trou-
blesome morning phlegm, &c, did not occur till the patient had suffered
for some time, often for years, from symptoms of disordered digestive
organs. When this is the case we shall make little progress in the case
of laryngeal and tracheal diseases until we have subdued the irritation of
the digestive organs ; and the hopes of the successful issue of our treat-
ment must, therefore, rest chiefly on the facility with which this yields to
our remedial measures.
This remark may be usefully extended to nearly all chronic diseases
over which the stomach, in its different conditions, displays so great and,
at times, extraordinary an influence, as to induce those who are not pa-
tient and attentive in diagnosis, to attribute the constitutional disturbances
caused by lesions in other organs, and notably in the lungs, heart and
even brain, to gastric origin.
Prophylaxis. — The prophylaxis of chronic laryngitis should consist
in an early attention, on the part of the professional student to all the
agencies counteracting those which bring on the disease. These pre-
PROPHYLAXIS OF CHRONIC LARYNGITTS.
113
ventive measures should be much exercise in the open air, a regular train-
ing of the vocal apparatus by both methodical speech and even song, so
as to accustom the voice to every variety of pitch and intonation ; and
to husband its strength, if it be naturally weak, by acquiring the habit of
distinct and expressive articulation and enunciation. By uniting the two
kinds of gymnastic exercise—that of the muscles-of the body and limbs
generally, and that ofthe muscles ofthe voice—the student will be both
fitted to discharge his subsequent duties and less liable,to catarrhal and
anginose affections. He will enter on the duties of his ministry with some
bodily vigour, and with habits of exercise, which he will feel a pleasure,
as it will be his duty, to continue. When prevented by inclement weather
from taking exercise out of doors, he will have recourse to the use of
dumb-bells and the parallel bars at home. Nor should he omit to keep
his vocal organs in the proper tone during the week, in order that he may,
without fatigue, certainly without injury, task them on Sundays. For
this purpose he will not only read aloud but declaim, and vary his tone
and inflections so as to give himself a wide range of vocal utterance, and
yet retain distinctness and power within this range. Deviation from
healthy digestion, and particularly if associated with uneasiness in any
part of the throat, should be early attended to and corrected ; and a
relaxation of the tissue lining the fauces and pharynx and investing the
soft palate and tonsils, removed by astringents, or even a slight cauteriza-
tion in the manner already described. Among the hardening measures is
the use of the tepid bath, or sponging the surface of the body, and par-
ticularly the surface of the chest, daily, with cold salt and water. The
throat should be well gargled, and, at any rate, the whole neck washed
in the morning with cold water. No ligature, or tight cravat, or stock
should be worn—nothing, in fact, which exerts a compression on the
neck, or invites more blood to the part.
Many ofthe above hints are applicable to the members of the bar and
to all public speakers who would strengthen their physical powers of
utterance, and avoid diseases ofthe vocal apparatus.
x\s any sudden change of temperature of the air which is inhaled is
prejudicial to the invalid suffering under chronic laryngitis, he is recom-
mended, when about to pass out from a warm room into the external air,
to place a silk handkerchief or some kind of network before his mouth
and nostrils. There has lately been made in England an apparatus called
" Jeffray's Respirator," which is preferable to a handkerchief or any simi-
lar contrivance. It consists of a number of layers of delicate wire-net,
secured on each side by morocco leather, and straps or strings so as to
allow of its being tied to the back of the neck, whilst the person breathes
through the wire-net; in doing so, he inhales an air, which, by the time it
has reached his mouth, and certainly his larynx, is of a suitably elevated
temperature. I am acquainted with the case of a lady, who, whilst suf-
fering under catarrh, was kept awake half the night with a troublesome
cough, which was speedily arrested and she allowed to sleep undisturbed,
after she had put on the respirator at her husband's suggestion. Transition
from a cold to a hot air is even still more injurious than the one from
hot to cold ; and hence the respirator should be kent on for a while after
coming in from the outer air.
VOL. n.—9
114 DISEASES OF THE RESPIRATORY APPARATUS.
LECTURE XCII.
DR. BELL.
Bronchitis—Its complications with other diseases—Catarrh, a prelude to more serious
djsease—Importance of early attention to it—Outlines of the treatment of catarrh—
The dry rneth-d cf Dr. Williams—Bronchitis.—its divisions—Asthenic variety—The
kind showing itself in young children, or capillary bronchitis—Duration of acute bron-
chitis—Symptoms,—appearance of the sputa—Physical signs — Percussion, indi-
rectly useful—Touch, "iving a sense of vibration—Auscultation—Modifications of
sound, produced by inflamed and obstructed bronchiae—Morbid Anatomy—Causes.
Bronchitis — Acute Mucous Catarrh — Inflammatory Catarrhal
Fever.—This disease has only been separated from inflammation of the
lungs of late years. We are indebted to Dr. Badham, of Glasgow, for
being the first to perform this service to the profession and to humanity,
and for pointing out its nature and seat, in a small work published by him
on bronchial inflammation. After him, Dr. Hastings, not Naphtha Hast-
ings, has since contributed largely to fix attention on the disease, and to
introduce it formally under the title of bronchitis, by which some writers
used to designate croup. By Sydenham and Cullen it has been de-
scribed under the name of Peripneumonia JVotha. In varying degrees of
intensity, inflammation of the bronchial mucous membrane is met with in
neglected catarrh ; or it comes on primarily after the inhalation of irri-
tating gases or poisons ; or as an occasional and always alarming compli-
cation in remittent and typhous fevers ; in the exanthemata generally, and
more especially in measles and small-pox ; also in gout and rheumatism,
and in hooping-cough, asthma, pneumonia, phthisis pulmonalis, pleurisy,
and carditis. Being in sympathetic relation with all the membranes of
the body, and more particularly with other divisions of mucous membrane,
the bronchial portion is liable to inflammation, not only after laryngitis
and tracheitis, but after gastritis and gastro-enteritis and diseases of the
skin, both acute and chronic. Bronchitis frequently occurs in an epide-
mic form, under the popular title, influenza or grippe. In some situations
it may be said to prevail endemically, as at the Children's Hospital in
Paris. A common cough, catarrh, Or cold on the breast, is a mild form
of bronchitis.
All ages are subject to this disease, which may even be congenital.
Children in our climate are found to be particularly liable to it, and in
some seasons are its chief victims. With us, also, the complication of
bronchitis with hepatic and gastro-intestinal derangement is frequent;
more so, probably, than the union of pneumonia or of pleurisy with dis-
order ofthe liver, designated as bilious pleurisy or pneumonia.
Bronchitis is commonly ushered in with catarrh, the precedent of which
again is frequently coryza, or cold in the head. The first stage consists
in simple irritation of the mucous surface of the eyes and nostrils which
is soon spread to the fauces, and is manifested by an increased secretion
chiefly of a serous fluid ; sneezing, and some soreness of the throat. The
irritation extending to the trachea and bronchiae, there is a tickling cough,
with an expectoration of mixed serum and mucus. At this stage the
isorder sometimes ceases, and the individual is said to have soon got
TREATMENT OF CATARRH.
115
over his cold. But, under other circumstances, there is not simply an
irritation ofthe mucous membrane and glands of the bronchise, but a posi-
tive inflammation of these parts, and a train of associated symptoms which
indicate great distress in the respiratory apparatus, as they do real danger
to the life ofthe patient. Sometimes the affection ofthe bronchia? shows
itself without any prior irritation of the Schneiderian membrane, fauces,
and tonsils ; and this is more apt to be the case in delicate persons, or in
those predisposed to coughs and pulmonary diseases.
A few remarks on catarrh, or a common cold in the breast, as it is
familiarly called, will properly precede a notice of bronchitis in its more
aggravated varieties. If the commonness of a thing were to render men
indifferent to its presence, the people of the East ought not to care for the
plague, nor those ofthe West Indies for the yellow fever ; but still these
diseases are avowedly worthy of study, and serious enough to be avoided
if possible. I will not say that colds are to the inhabitants of our climate
what plague and yellow fever are to those of other countries; but I can
aver confidently that they usher in diseases of greater complexity and
mortality than these latter. The common complications of a cold, viz.,
toothache, earache, headache, weak and watery eyes, sore throat, rheu-
matic pains, indigestion, and renal disorders, are quite numerous and dis-
agreeable enough to entitle it to a very respectful notice, and much more
considerate treatment than it usually receives. If to these annoyances we
add the danger from bronchitis and pneumonia, which often follow in the
train of a neglected cold, and from phthisis pulmonalis, the tubercular
irritation of which is developed by the same cause, we surely have proof
and argument enough for attention not only to the preventive means, but
also to the curative ones, of a disease, whicff, however mild in its incep-
tion, is directly or indirectly productive of such diversified and alarming
results. More particularly should this lesson be impressed on those who,
in consequence of prior attacks of bronchitis or of constitutional tendency
to pulmonary consumption, are in the greatest danger from every fresh
cold. They, at least, can ill afford to make the hazardous experiments of
nursing and sweating themselves one part of the twenty-four hours, and
of exposing and chilling themselves during the remainder, as we every
now and then find persons with catarrh to do.
If time be of value to him who has ' caught a bad cold,' it is the more
incumbent on him to act promptly in the premises, by his submitting at
once and with a good grace to the adoption of suitable measures for his
relief. These will be, quiet in an air of equable and rather warm tempe-
rature, abstinence from animal food and all stimulating drinks whatever,
and in their stead a moderate portion of vegetable matters and simple
demulcents. Under the head of medicine will come a brisk purgative,
mercurial or saline, according either to the prior experience ofthe person
himself, or to the state of his digestion and the activity of his circulation.
If there be indigestion, a foul tongue and turbid urine, let him have a
dose of calomel and jalap, or of calomel and rhubarb ; if his habit be ple-
thoric, he should take salts. After evacuation procured by this means, if
the cough harass and be aggravated by a thin serous secretion from the
trachea and bronchiae, an opium pill of one to two grains, or twenty to
forty drops of laudanum, or Dover's powder in five-grain doses, repeated
two or three times at intervals of four hours, or laudanum with antimonial
wine will come in appropriately enough, and not infrequently relieve all
116 DISEASES OF THE RESPIRATORY APPARATUS.
the troublesome symptoms, including pains in the limbs. The headache
frequently left by the opium is carried off by a dose of magnesia, or eight
or ten grains of carbonate of ammonia, or a teaspoonful of spirits of harts-
horn in water. When the stomach is in a healthy state and the bowels
free, a full dose of opium often cuts short a cold, and will therefore arrest
at once a mild bronchitis. If the cough, however, still continue after the
above remedies have been used, recourse is generally had to various for-
mulas of cough mixtures, the active basis of which is either ipecacuanha
or antimony, and less frequently squills, wTith opium in some form or ano-
ther. My own experience has taught me, that the simpler these formulas
are the better; antimony (tartar emetic) entering in larger proportion, if
there be a tendency to inflammatory action,—ipecacuanha if there be
gastric complication, and opium if the skin be cool or the temperature of
the surface unequal, and the cough be accompanied with thin expectoration,
come on in fits, and be readily excited through the nervous system alone.
I can add, with great confidence also, my own testimony, in confirmation
ofthe favourable opinion of others, to the value of the alkalies in simple
catarrh as well as in the more advanced stages of confirmed bronchitis.
Wine of ipecacuanha, carbonate of potassa and laudanum in suitable
proportions, mixed with simple syrup and water, make a cough mixture,
to which, especially in the cases of catarrh of children, I am not a little
attached. In the more asthenic forms, twenty to thirty drops, for an
adult, of the aromatic spirit of ammonia will be properly substituted for
tbe carbonates of potassa and soda. The physician who has tried the
alkaline remedies will join Dr. Williams in opinion,—that they quiet the
cough and promote expectoration far better than the oxymels and acid
linctus or lozenges, and I would add, than the syrups of squills commonly
in use, and which, however they may appear at the time to " cut the
phlegm," and cleanse the throat, tend to disorder the digestive organs,
and often ultimately increase the cough. Both with a view to keep
up their influence on the secretion from the bronchiae, as well as to their
immediate impression on the glottis and the throat, cough medicines
should be taken frequently ; and during the interval it is well to sheathe
the fauces against irritating secretion, and through continuous sympathy
to operate on the upper portion of the air-passages, by having often, if not
constantly in the mouth, a piece of gum arabic, or by sipping frequently
of thin flaxseed tea, or some analogous demulcent decoction.
In a class of subjects of catarrh, who are said to be of a bilious habit, and
also those who are dyspeptic, opium, and the common cough mixtures
into which antimony and squills enter, are often prejudicial, and increase
the gastric disorder by which the cough is accompanied and not seldom
sustained. For these cases other narcotics are thought to be better
adapted, such as the hyosciamus and conium, &c. ; which certainly less
interfere with the digestive process, and, if combined with rhubarb or the
compound extract of colocynth, or, better than all, the blue mass, will be
found to answer the double indication of modifying beneficially the secre-
tions both of the bronchial and the gastro-intestinal mucous membrane.
The alkalies are useful adjuncts in the intervals between the times of
taking these combinations or the narcotic extracts alone.
There is another plan of treating a cold, by what its author Dr.
Williams, calls drying it up. He first practised it on his own person!
Having observed, on being attacked with one of the colds, to which in
SYMPTOMS OF BRONCHITIS.
117
early life he had been so subject, that taking a quantity of tea or any
other liquid, although very comfortable at the time, was invariablyr fol-
lowed in the course of an hour by an increased 'stuffing in the head,' and
accompanying flow of scalding, irritating humour from the nose and eyes,
he determined to try and prevent such exacerbations "by cutting off the
supplies—by ceasing to drink. For twenty-four hours," continues Dr.
Williams, " I did not take a drop of liquid of any kind ; and to my agree-
able surprise, not only did I escape these occasional aggravations of the
complaint, but the stuffing and discharge began to show evident signs of
abatement, and the handkerchief was in less continual requisition. I per-
severed for twenty-four hours more, and my cold was gone ; there being
only now and then a little gelatinous opaque mucus collected in the nos-
trils and throat, without any stuffing or irritation, just as it takes place at
the end of a cold. What was of still more consequence, no cough fol-
lowed ; the whole catarrhal disease seemed to have been destroyed."
Dr. Williams has been in the habit of acting on this plan of treatment
ever since (some fifteen years ago) under similar circumstances, and has
recommended it to a great many friends and patients with a successful
issue.
The physiological principle on which the dry method acts, is by a
prompt decrease ofthe mass of circulating fluids, and a diminution ofthe
partial plethora of the vessels supplying the morbid secretion from the
affected membrane, which, no longer irritated by its own secretion, is
soon restored to a healthy condition.
On an average, forty-eight hours of abstinence from liquids will be quite
enough to effect a cure. The period may be shortened by exercise and
warm clothing, or lying warm in bed, or by commencing with a purga-
tive, or by any other dry means of increasing the natural secretions.
Bronchitis in its intense and severer forms differs from the milder kind
mainly in the greater extent of the bronchial tubes which the inflammation
occupies. It has on this account been studied under the two heads of
tubular and vesicular. Tubular bronchitis is inflammation of the bronchial
membrane lining the larger and middle-sized tubes, or wherever it lines
tubes properly so called. Vesicular or pulmonic bronchitis is that variety
in which the mucous membrane lining the air-cells of the lungs is in-
flamed. Something, also, will depend on the intensity of the phlogosis,
even on an equal surface. Like all the phlegmasia*, bronchitis exhibits
an acute and a chronic form. The first again is appropriately divided
into the sthenic and the asthenic varieties. Dr. Stokes treats of it under
the head of acute primary and acute secondary bronchitis, a division which
I shall adopt on the present occasion.
Symptoms.—In acute sthenic bronchitis, inflammatory symptoms are
evident from the commencement. After the preliminary stage of simple
coryza and catarrh, with headache and want of appetite, already men-
tioned, or, sometimes, without any notification of this kind, the patient
suffers from pain and feeling of tightness across the sternum, dry hard
cough without expectoration, or with the discharge in this way of gluti-
nous mucus combined with frothy serum, sometimes coloured with blood.
The chills, with which these symptoms are ushered in, soon alternate with
increased heat and dryness of the skin, and are followed by quickened
and somewhat laboured breathing and dyspnoea, and sometimes a dull
pain at the sternum on coughing ; tongue white with red borders ; pulse
118 DISEASES OF THE RESPIRATORY APPARATUS.
quick and full, and at times hard ; pain in the forehead, back and limbs;
constipation, and scanty, high-coloured urine. As the disease advances,
the rough becomes more troublesome, and in its paroxysms causes redness
of the face, watery eyes, and a feeling of pain in the hypochondria
along the false ribs, in the back, and at the lower part of the sternum ;
in fine, in the course of all the attachments of the diaphragm. The cough
is generally excited at each full inspiration ; as, also, by speaking, or the
mere act of drinking, or a simple change of posture ; and it is sometimes
productive of nausea and vomiting. Pain in the course of the trachea
and the bronchiae, as felt under the sternum, and in what is called sore-
ness or the chest, is not a constant symptom. Sometimes it is slight, and
the patient complains of a troublesome heat diffused through the chest and
a tickling in the trachea.
There is an aggravation of the symptoms towards night which is gene-
rally sleepless and disturbed. The common posture is on the back ; but
it is often changed. If there be no relief by expectoration or perspira-
tion, or by prompt remedial measures, bronchitis shows a change of cha-
racter. Feelings of great depression are complained of; the pulse
becomes weak as well as quick ; the brain is disturbed in its functions,
and the muscular strength is much reduced ; the countenance, in place of
being often flushed, becomes anxious and pallid, or partially livid,
according to the quantity of blood in the system ; and pulmonary conges-
tion becomes evident by a slightly diminished resonance on percussion in
the postero-inferior regions of the chest. Ttie secretions are scanty and
vitiated ; the tongue is loaded with a brown fur; the thirst is intense.
Cerebral and abdominal congestions may also occur, and dropsical swell-
ings are no infrequent results. The transition from this stage to death is
soon made, especially in those cases which have been neglected from the
outset. A remarkable feature in the character ofthe worst form of bron-
chitis is, the rapidity with which the collapse and the symptoms of ex-
treme prostration and debility succeed to high fever, and well-marked
local excitement. The whole course of these fatal cases is sometimes
wonderfully rapid, death ensuing within two days from the commence-
ment of the attack. They are commonly confounded with pneumonic in-
flammation, and are scarcely to be distinguished from it during life but by
the physical signs. The severest form of bronchitis is, however, more
formidable and rapid in its course than pneumonia itself.
The asthenic form of bronchitis bears more analogy to broncho-pneumonia
just described than to simple acute or sthenic bronchitis. One of its earliest
and characteristic symptoms is oppression of breathing, and a peculiar
wheezing with spasmodic cough. The pulse is small, quick, or irregular,
and with little or no increase of heat except at night ; the tongue foul and
loaded ; urine scanty ; extremities cold ; headache ; exacerbations of
dyspnoea so severe as to prevent the patient from lying down, and accom-
panied by extinction ofthe voice. The expectoration, at first scanty, be-
comes afterwards very copious and frothy. These are the chief symptoms
of the disease as it occurs in the persons who are most liable to its attacks
viz., the aged and infirm, and those weakened by prior diseases and ex-
cesses. The duration of this form is commonly longer than that of the
other or sthenic, and it has a much greater tendency to pass into the
chronic form. Persons liable to pituitous catarrh, or who have habitually
a cough with copious thin expectoration, generally suffer in this way
when attacked by bronchitis.
CAPILLARY BRONCHITIS.
119
When bronchitis supervenes on pneumonia (vesicular bronchitis), the
smaller divisions of the bronchiae are the parts inflamed. Bronchial
catarrh will sometimes give rise to all the symptoms of suffocating catarrh,
which are regarded as the result of an infiltration of serosity in the pulmo-
nary tissue. In simple lobular pneumonia, the two elements, the bron-
chial and the parenchymatous, are equal and manifested nearly at the
same time. In some cases the cough has a decidedly croupy character,
although the breathing, which is hurried, is not at all stridulous during
the intervals. This state is often associated with slow and laboured den-
tition. Sometimes the bronchial secretions approach nearly to the
membranous form.
The frequency of its occurrence, and the mortality produced by it,
require a somewhat detailed notice of the bronchitis of children. It has
been carefully studied of late years by different French physicians; but
more especially by M. Fauvel, of Paris, and MM. Mahat, Bonamy,
Marce, and Malherbe, physicians to the Hotel Dieu Hospital at Nantes, the
latter of whom have given an excellent description of its epidemic visita-
tions in the years 1840 and 1841. M. Fauvel has designated the disease
by the title of capillary bronchitis, which we may regard as equivalent to
general inflammation of the minute bronchial tubes and their vesical ter-
minations. It is well described by M. Valleix (Guide de Medecin Prac-
ticien, fyc, Tome i.): but I shall follow, just now, the description by M.
Grisolle, derived from the sources indicated above.
Capillary bronchitis follows, almost always, a common bronchitis; and
it is quite unusual for the inflammation to attack at once the smaller bron-
chiae, and to be announced by violent symptoms. When once formed,
capillary bronchitis manifests itself by great oppression ; the breathing,
accompanied often by a hissing, is performed with great difficulty and by
the convulsive and simultaneous contraction of all the respiratory muscles.
The number of respirations in a minute is extraordinarily great; being, in
cases, as many as sixty to eighty even in this time. The cough is trou-
blesome by its frequency and paroxysmal nature, and painful by the
tearing feeling it induces behind the sternum. After repeated efforts, the
patient ejects some glairy and frothy mucus, mixed with white and vis-
cous sputa, which are sometimes tinged with blood. In other cases there
is expectoration of yellowish mucus without bubbles, which is not pro-
ductive of any relief. Percussion gives a clear sound ; and, at times,
even manifests an unusual sonorousness, arising out of the emphysema
caused by the bronchitis. Auscultation reveals sibilant and mucous
rhonchi, but the sibilant rattle is sharper and finer than usual, and is
blended with the mucous; and the respiratory murmur often cannot be
heard.
With so much disturbance of the respiratory functions, the speech is
brief and abrupt; the pulse, always frequent in the disease, acquires an
astonishing frequency at times, ranging from 120 to 160 beats in a
minute. The skin is hot and dry, or bathed in sweat. The whole
appearance of the patient indicates suffering and anxiety. He is seated
in bed, resting on his elbows, and with head inclined forward ; the face
is pale, features altered, and the skin of a mottled appearance ; the lips
and cheeks, for the most part, of a violet hue.
At the end of some days of violent struggle, such as that now depicted,
the system manifests exhaustion ; and the breathing, in consequence, is
120 DISEASES OF THE RESPIRATORY APPARATUS.
less frequent, but not less laborious and painful ; the expectoration is
light; the sub-crepitant rhonchus is less evident ; and mucus accumu-
lates in the air-passages to such a degree as to cause a gurgling noise or
the rattles. The blue tint of the face becomes deeper; and shows itself
in the hands and feet, and sometimes in spots on the body generally ; the
pulse fails to impart any resistance under pressure, while its frequency is
augmented and its regularity lost. The patient becomes more and more
exhausted, falls into somnolency, and gradually sinks into death ; preserv-
ing, however, to the last, all his mental faculties.
When, on the other hand, capillary bronchitis tends towards recovery,
there are diminished frequency of respiration and beats of the pulse ; the
rhonchi are less loud, more diffused, and more numerous, indicating a
more permeable state of the lung; the skin loses gradually its blue
colour; and convalescence has at length begun. The disease may, even
after the subsidence of the more alarming symptoms, exhibit the appear-
ance of simple bronchitis. • Capillary bronchitis seldom terminates in less
than five days, or goes beyond ten, or at the most, fifteen days. Conva-
lescence is tedious, and the disease is liable to relapse.
Acute sthenic bronchitis will vary in its duration from one to two
weeks. In favourable cases the disease declines between the fifth and
eighth days. It then terminates in resolution or in chronic bronchitis.
The appearance of the sputum, if not the chief characteristic of acute
bronchitis, as some regard it, is unquestionably of such importance as to
require our early and continued attention to its successive changes.
Bronchial like pulmonary mucus, in a healthy state, separates into clear
and gelatinous, or else into grey or yellowish flocculi, which remain sus-
pended in water for some time ; but ultimately sink to the bottom. In
the early stage of bronchitis the secretion from the bronchiae is either
wanting, and then the cough is dry and hard, or it is scanty and consists
of a sero-mucous fluid, transparent and viscid. If poured from one
vessel to another, it flows in one mass of extreme tenacity,—drawing
out sometimes like melted glass ; and the degree of viscosity is a tole-
rably accurate measure ofthe degree ofthe existing inflammation. Upon
the surface of the viscid mucus there is usually more or less froth, the
quantity of it depending on the facility or the difficulty with which the
sputa are brought up. These become, as the diseaseadvances,more opaque,
more abundant, and tenacious ; and at the period when the inflammatory
fever ceases, and is either succeeded by an apyrexial state, or by a hectic,
we observe a remarkable change in their character. They are thick, and
have considerable consistence ; or they may pass into the muco-puriform
state, and exhibit masses of a greenish-yellow colour, quite opaque, and,
though somewhat viscid, yet flowing altogether. For valuable specifications
ofthe appearancesand other characters of expectorated matterin bronchitis,
1 would refer to the comprehensive section on this disease by Dr. Stokes,
in his excellent Treatise on the Diagnosis and Treatment of Diseases of
the Chest. I will merely give now his divisions of the secretions from
the bronchial raucous membrane, when in a state of irritation. These
are, 1, transparent mucous secretions; 2, opaque mucous or albuminous
secretions ; this again subdivided into the amorphous, and moulded to
the form of the tubes ; 3, muco-puriform secretions; 4, puriform secre-
tions ; 5, serous secretions.
In very young children the expectoration is either entirely wanting, or
is very slight.
MORBID ANATOMY OF BRONCHITIS.
121
Light is thrown on the pathology of bronchitis by the physical signs.
They are derived, first, from percussion ; second, from the touch ; third,
from auscultation.
As regards percussion, it is admitted, very generally, that it furnishes
no direct sign in the present case ; the sound on striking the chest being
almost always of a natural clearness. A temporary loss of this clearness
may ensue from an excessive secretion of fluid in the bronchial tubes, or
more permanent when tubercles are present at the same time.
The sense of touch guides us in forming a diagnosis in bronchitis, by
the transmission of a distinct vibration when the hand is laid on the tho-
rax. This sensation can be detected both during inspiration and expira-
tion, but is generally more perceptible in the former than in the latter ;
and more in the child and female than the adult male. The vibration is
much more distinct in the middle and inferior than in the upper portions
ofthe lung: it is not met with in simple pleurisy or pneumonia. In pleu-
risy, however, a sensation of rubbing may occur ; but it is that of two
continuous, though roughened surfaces, moving one upon another; whilst
the bronchial vibration gives the perception of air passing in many direc-
tions through an adhesive fluid.
By auscultation we discover in the early stage of acute bronchitis, that
the natural sound of respiration is replaced at times by the puerile, but the
most marked change consists in the formation of the sibilant rhonchus or
wheezing and whistling sounds. They occasionally present a graver tone
like the prolonged note of a violencello, or the cooing of a dove ; and they
indicate that some of the larger bronchiae are the seat of phlogosis. As
the disease advances and the inflammation of the bronchial membrane is
moderated by the secretion of fluid which is at first glairy and mixed with
bubbles of air, we hear a mucous or sub-crepitant rhonchus, chiefly per-
ceptible at the root of the bronchiae over the base of one or other
lung. In capillary bronchitis the sibilant rhonchus is acute and small,
and is mixed up with the sub-crepitant rhonchus. The respiratory sounds,
weak or for a time suppressed in the tissue corresponding to the affected
tubes, are exaggerated in the adjoining ones.
The diagnosis in acute bronchitis is easy enough, if attention be paid to
the sonorousness ofthe chest on percussion, and the rhonchi, at first dry,
then humid, together with the character ofthe cough and expectoration.
The prognosis of this disease depends on the part and extent ofthe
bronchial inflammation. The result in capillary bronchitis is always doubt-
ful, as the disease carries off about a sixth part of the adults and seven-
eighths of the children who become its subjects. The same remark applies
to pseudo-membranous bronchitis. Simple inflammation of the larger
bronchiae, on the other hand, is comparatively a mild disease, which termi-
nates favourably, except in some cases among old persons and children.
Morbid Anatomy.—More frequently the morbid changes in the bronchise
have been found in the bodies of those who have died of other diseases,
during the attack of which they had suffered at the same time from bron-
chitis. In the mild and recent form of this latter, there is found some
redness in a circumscribed portion of the mucous membrane, particularly
at the termination ofthe trachea and the first divisions of the bronchiae ;
but in the terminations of the latter, which are rather serous than mucous,
this appearance is less seldom met with. If the inflammation has been
more intense, the redness extends to a greater number of tubes, and more
122 DISEASES OF THE RESPIRATORY APPARATUS.
so in the smaller ramifications. Often, says M. Andral, the redness is
exactly limited to the bronchiae of one tube, and commonly it is the upper
one which is more peculiarly disposed to inflammation. The fine injection
on which the red colour depends, seems to exist simultaneously both in
the mucous membrane and in the sub-mucous cellular tissue. Sometimes
the redness diminishes progressively from the large bronchiae towards the
small ones; at other times the reverse is met with. Often the redness
presents itself in patches, or zones, constituting, as it were, so many cir-
cumscribed inflammations, between which the mucous membrane is white
and healthy—a state of parts similar to that which is so frequently found
in the intestines. On opening the thorax the lungs do not in general col-
lapse, the escape of air being prevented by the obstructions ofthe bronchiae.
These in most instances contain a quantity of frothy liquid, of the quality
of the matter expectorated before death. Not infrequently it is mixed
with bloody serum ; but as this is not perceived in the matter expectorated
it is probably an exudation from the distended bloodvessels at the moment
after death. Purulent matter mixed with mucus is, also, sometimes ob-
served, and mostly in very acute cases which have proved fatal within
four or five days.
The mucous membrane of the bronchial tubes is soft and granular.
Frequently the changes do not extend beyond the larger ramifications, but
at times they are only seen on the minute terminations, and then the bron-
chitis is said to be capillary. In these cases, on incising the smaller
bronchiae they are found filled with a thick muco-purulent matter, divested
of air-bubbles, which fills up the second and third divisions as far as the
capillary ramifications. Obstruction of the smaller bronchiae, when it is
general, causes necessarily a dilatation of the vesicles (emphysema vesi-
cularis), a lesion which explains why it is, that the lungs, in place of collap-
sing when the thorax is opened, tend on the contrary to expand beyond
their customary limits. Almost always there are spots of interlobular pneu-
monia, a complication more generally met with in children than in adults.
The dilated vesicles contain analogous matters to those found in the bron-
chiae, but they show themselves more in the shape of whitish or yellowish
granulations, which we must take care not to confound with tubercular
granulations, resembling these latter as they do in figure and size. The
bronchial mucous membranes, in common with all the divisions of this tis-
sue in the air-passages, are sometimes lined with false membrane in the
form of white elastic cylinders. These are most apt to occur in the smaller
bronchial tubes. The membranaceous bronchitis often accompanies capil-
lary bronchitis, and is most common in children. In adults a few scattered
branches of small diameter are alone found clogged with white plastic co-
agula down to the still more diminutive twigs, whilst the remainder con-
tain merely the usual fluid, catarrhal secretion.
The blood in acute bronchitis exhibits decided indications of hyperino-
sis. " The buffy coat is scarcely ever absent, the serum is clear,'and the
clot firm and consistent. The fibrin and fat are always more or less
increased, and the haeraato-globulin diminished." The disproportion be-
tween the ratio of fibrin and that ofthe corpuscles, in the increase ofthe
former and diminution of the latter, is not so great in this disease as in
pneumonia and rheumatism.
Causes.—Bronchitis follows sudden exposure to cold and moisture and
the more readily if the application be partial, as by a current of air or'cold
TREATMENT OF ACUTE BRONCHITIS.
123
and wet feet; and the body have been previously over-heated. The disease
is, therefore, one which chiefly makes its appearance in the winter half of the
year; and, on occasions, it assumes an epidemic character, without our being
able, always, to refer this to atmospherical extremes or very marked pe-
culiarities'of weather. Habits of excessive repletion would seem, in
some cases, to predispose to acute bronchial inflammation, as they un-
doubtedly do to bronchial congestion. Of the liability to bronchitis in
the exanthemata, I shall take occasion to speak under the head of
secondary acute bronchitis. The predisposition is increased by prior
attacks ofthe disease. Men are subject to it in much larger numbers than
women.
LECTURE XCIII.
DR. BELL.
Treatment or Acute Bronchitis—Venesection not to be pushed far—Purgatives—
Emetics, of doubtful value in acute bronchitis—Tartar emetic, as a counter-stimu-
lant—Rules for its use—Immediate effects various—Case—The warm bath—pedilu-
vium—Blisters and other counter-irritants to the chest—Calomel in bronchitis com-
plicated with abdominal disease; to which are added opium and ipecacuanha—Second
stage of bronchitis, with symptoms of debility—Stimulating expectorants useful ; car-
bonate of ammonia, wine whey, senega, acetate of ammonia—Calomel and a few cups,
with stimulants, for congestion of a part of the lunsj—Diaphoresis without diaphore-
tics— Diuretics as antiphlogistics sometimes useful.—Secondary or Symptomatic
Bronchitis—Complication of bronchitis with various diseases, especially eruptive
fevers—Treatment by local depletion, counter-irritants, and moderate stimulation—Dr.
Copland's plan of external cutaneous revulsion—Emetics—Bronchitis succeeding
laryngitis—Active depletion in—Outlines of treatment—Complications of acute bron-
chitis— Bronchitis with remittent fever, in the typhoid stage—Cooling remedies
useful—Depletion and stimulation sometimes necessary at one time—Inhalation of
watery vapour—Chancre of posture—Quinia and laudanum, for excessive bronchial
secretion—Dr. Graves's practice—Sugar of lead.
The advantage of the physical signs of bronchitis, is to inform us with
certainty of the first coining on of an inflammatory affection of this cha-
racter. When, with the febrile state before described, whether the func-
tional disorder be permanent or not, we find extensive rhonchi in every
part ofthe chest, especially if they extend to the inferior parts, and there
be little respiratory murmur audible, we should not hesitate to resort at
once to such depletory measures as are admissible in the individual case.
These will consist of bloodletting, by venesection, or by cupping or leech-
ing, and the exhibition of antimonials and mercurials.
In acute bronchitis, both in children over a year old and in adults, if
the pulse be hard and frequent and the respiration deranged in the man-
ner already described, the lancet should be had recourse to at once. The
physician will remember, however, that, in inflammations of the mucous
tissue generally, and the disease under consideration forms no exception
to the remark, he must not expect by bloodletting to make that decided
and permanent impression which he does in phlogosis of the parenchyma
of an organ, or of its serous membrane. Hence, whilst he bleeds so far as
to relieve decidedly the existing oppression, he will not urge it to the pro-
ducing of syncope. His aim must be to bring down the inflammation to
124 DISEASES OF THE RESPIRATORY APPARATUS.
the secreting point, for expectoration, but not to sink the excitement and
depress the strength of the body below this point. There is good reason
to believe, also, that bronchitis will run its course for a definite period,
and therefore, as that for active depletion is likely to be of short#duration,
we should be careful to employ with reserve remedies calculated to reduce
the patient's strength. But, on the other hand, we ought not to be
deterred from venesection or even its repetition by the symptoms of weak-
ness—the sinking as it is called of the patient, which are the effects of
incipient asphyxia, owing to the retarded and in part limited circulation
of blood. The inflammation still persisting, or originally occurring in
persons in advanced life or of a weakened and cachectic habit, and the
pulse exhibiting little hardness, local depletion is entitled to a preference
over venesection ; and that procured by cups is preferable to leeching.
In severe cases, the patient should be cupped over the part which auscul-
tation had proved to be most affected. If no selection be made on this
score, the cups should be placed under the clavicles or between the sca-
pulae. The opinion first clearly pointed out by Broussais, of the greater
advantage from local depletion exercised over the upper than over the
lower parts of the chest, must find confirmation from every observing
practitioner. Even at an advanced stage of the disease, local bloodletting
may be resorted to, if the expectoration have become suppressed and
there is coincident fever and irritation, or increase of dyspnoea not caused
by over-secretion—a point this ascertained by auscultation.
Next to the remedy just mentioned, a free evacuation of the bowels will
often give the greatest relief. There is no disease of the thoracic con-
tents in which free and early purging is so beneficial as in bronchitis. I
have been most sensible of this fact in the epidemic form of the disease,
or in influenza, in which, be it said, also, there is frequently a complica-
tion of gastric and intestinal disorder.
Emetics have been strongly recommended in bronchitis ; and in the
stage in which there is excess of secretion and filling up of the tubes from
this cause, and consequent oppression of breathing, particularly in chil-
dren, they are decidedly efficacious. But in the first and more violently
acute stage, in which there is no secretion, or it is sero-mucous and thin,
tartar emetic in contra-stimulant or sedative doses is entitled to a pre-
ference. This remedy will either follow bloodletting as an adjuvant, or
take its place in cases in which, although the dyspnoea and fever be con-
siderable, we are afraid from other considerations to abstract blood. The
vomiting which follows repeated doses of the tartar emetic is more ser-
viceable, because implying a solution, however temporary, of the disease,
than that which is brought on at once by a large dose. From an eighth to
a fourth of a grain, according to the age of the subject, may be admin-
istered every hour until a decided abatement of the symptoms follows.
M. Girard of Marseilles recommends strongly, after considerable experi-
ence of its efficacy, a succession of emetics of the antimonial salt. This
simple prescription is preferable greatly to common expectorant mixtures,
which often only irritate and tease the stomach, and just serve to increase
the secretion, but without either adequately abating or modifying the in-
flamed condition of the bronchial mucous surface. We have in the
former case, that in which tartar emetic is used, a definite object to be
accomplished by a. modus operandi which we can measure and appreciate;
in the latter we wait for, we know not what, results, and with an ex-
TREATMENT OF BRONCHITIS.
125
penditure of time, which, in acute disease, can never be afforded to
doubtful measures or timid expectancy.
The considerations which should guide us in the exhibition of tartar
emetic in bronchitis are well defined by Dr. Stokes, seemingly the more
so to me because they correspond with my own experience, which has been
considerable with this remedy in thoracic affections, ever since my visit to
Italy more than thirty years ago, and acquaintance with the then new Italian
medical doctrine of counter-stimulus. Even now, after so much has been
written on the subject, I may refer you to my paper, one of the first in order
of time, on Counter-stimulus, in Dr. Chapman's Medical and Physical Jour-
nal, vol. iii. The more robust the patient, the more acute the disease, the
more bloodletting has been indicated, the better it has been borne, the
more inflammatory the blood, the earlier the peiiod at which the disease
has been met by treatment, and last, though not least, the more simple
and uncomplicated the affection, particularly with abdominal diseases,
the greater will be the certainty of tartar emetic exerting that singularly
sanative action which has justly obtained for it the name of heroic. On
the other hand, where the disease has occurred in a debilitated constitu-
tion, where the pulse has not been strong, nor the skin very hot, where
the, teeth are coated with sordes, and the tongue red or dry and chapped,
where the abdomen is swelled, and tender in the epigastric and ileo-
ccecal region, where there have been diarrhoea or vomiting, and pain in
the abdomen ; in such a case or cases, the tartar emetic will either not
be borne at all, or, if retained on the stomach, will exert comparatively
little influence on the pulmonary disease, and too often increase the gas-
tric symptoms.
Laennec recommends an aromatic and opiate to be combined with the
antimony, as in the following solution :—
B. Tart, antim., gr. vj.
Aq. cinnam., ^vj.
Tinct. opii acet,, gtt. xij. M.
Of this solution half an ounce, a tablespoonful, is to be given every hour
or second hour, so that, if possible, the whole of the six grains may be
consumed in the course of twenty-four hours. For many years I was in
the habit of giving the tartar emetic simply in combination with cream of
tartar, either in the form of powder or solution as recommended by Rasori,
with the occasional addition, as circumstances seemed to warrant, of opium
■or laudanum. Of late years, however, I have prescribed the medicine in
question with camphor-mixture, and a little laudanum.
The immediate effects ofthe antimonial practice are various. In a few
cases, particularly where the stomach had been foul, free vomiting is pro-
duced, and, less seldom, purging: but after repeating the remedy two or
three times, it fails either to vomit or purge until the morbid excitement
is reduced, and then the toleration by the system of the medicine having
ceased, nausea, vomiting, and prostration are produced, and would be
perilously increased by its continuance. In a majority of cases, however,
in which there is decided phlogosis of any of the thoracic viscera, tartar
emetic barely causes nausea, and then chiefly when the patient moves.
In evidence of the tolerance by the system of full and repeated doses
of tartar emetic, I would refer to the case of a person labouring under
bronchitis complicated with pneumonia, which was attended by the late
126 DISEASES OF THE RESPIRATORY APPARATUS.
Dr. Otto of this city and myself about ten years ago. The patient be-
came delirious, and would not take any medicine which was prescribed
for him. Both on account, therefore, of its relative want of taste, and of
its being adapted to the stage, which was the second one of the disease,
we prescribed tartar emetic dissolved in some simple drink, slightly sweet-
ened. The dose ofthe medicine was increased from half a grain to two
grains every two hours, so that in one twenty-four hours more than twenty
grains were taken. This practice was continued for four or five days,
gradually reducing the dose of tartar emetic, and with the best effects ;
the delirium was removed, the expectoration became loose and free, the
matter being thick and opaque, and the pulse was abated of its great fre-
quency. In some instances so little apparent effect is produced, so far as
regards its action on the stomach, bowels, skin, and kidneys, that the
remedy might be considered inert, were it not for the disappearance of
the symptoms and signs of pulmonary disease. Dr. Stokes relates his
having frequently seen patients who were using from six to ten grains of
tartar emetic daily, yet who had a good appetite for their food. An
advantage is attributed by this gentleman to the use of tartar emetic,
even when it fails to bring about the restoration of the disease. It is
this ; stimulants and tonics will have now a better effect after we desist
from the use of the medicine in question. This advantage occurs in all
cases in which depletion has been freely and timely practised. Stimula-
ting remedies, which, even in the second stage of this disease, have only
increased the indirect debility caused by continued and unchecked excite-
ment, will now kindly restore the feeble powers of life and re-animate the
exhausted functions.
After the employment of the tartar emetic or in conjunction with it,
the hot bath will frequently be of decided benefit, but it should be con-
fined to the lower limbs, or the lower portion of the body at most. In
this way a salutary derivative effect may be obtained. The heat of the
water when this half-bath is used should be from 98° to 102° ; and the
time of immersion about ten minutes.
The period of inflammatory excitement having passed, and the respira-
tory distress, with the diffused rhonchus still continuing, counter-irritants
should be had recourse to. A blister is to be applied so as to cover the
anterior part of the chest; or, that which is preferred by some prac-
titioners, tartar emetic is to be rubbed on until a free eruption is induced. To
insure its prompt action, the chest should be first well rubbed with a brush
or piece of coarse flannel ; or the skin may be still farther excited by apply-
ing a warm hand wetted with camphorated spirits, or by the short appli-
cation of a mustard poultice. The tartar emetic should then be immedi-
ately rubbed in, either in the form of a warm saturated solution, or an oint-
ment composed of one part of tartar emetic to two of spermaceti ointment.
With these precautions, adds Dr. Williams, who gives this formula, we
shall rarely fail to excite a full pustular inflammation in as short a time as
that required for the rising of a blister, with far less irritation to the sys-
tem, and with decided relief to the pectoral symptoms. Partial as I am
to the use of tartar emetic in this way in many diseases, I still prefer a
blister in the one now under consideration : the counter-irritation pro-
duced by it, in the capillary injection and inflammation, and in the effu-
sion of serum on the cutis, is more complete than that caused by tartar
emetic ; and the subsequent pain is, judging from my own feelings, cer-
TREATMENT OF BRONCHITIS.
127
tainly less than that from the latter. A blister should not be allowed to
remain on a child for more than three or four hours, or until its action
has been distinctly felt by the patient. It is then to be taken off, and the
part dressed ; after which vesication takes place. It is advisable, also,
as recommended by Bretonneau, to cover the blister with a leaf of fine
paper, or gauze muslin. An emollient poultice, applied after the vene-
section is induced, I have often found to be of great service.
In the cases in which disease of the abdominal viscera is complicated
with bronchitis, and in subjects not robust and easily depressed by reme-
dies, and in whom there is more evidence of congestion than of excite-
ment of the circulation, calomel combined with ipecacuanha will be pre-
ferred to the tartar emetic. I have, every now and then, seen ipecacuanha,
in small doses particularly, to have rather an irritating effect than other-
wise in inflammatory affections, and certainly, except in coughs of gastric
origin, it has no beneficial one that I have witnessed. Hence, if the com-
bination just mentioned does not soon relieve the bronchial distress, or
apparently increases it, we must not give up the calomel, but administer
it alone, or with very minute doses of Dover's powder, in which the
opium is the active ingredient. In more than one epidemic bronchitis
among children, I have found, in common with others of my professional
brethren, calomel to be a remedy of the greatest efficacy, when given with
a freedom too which at other times would be hazardous. Should the
bowels be irritable, a few grains of prepared chalk may be usefully added
to the calomel.
The plan of treatment now laid down will often suffice to arrest bron-
chitis, and bring it to a satisfactory termination. But if it fails to do
so, the disease passes into a second stage, which I will not qualify with
the epithet of collapse, as some writers have done. It is one in which
general debility predominates, whilst the morbid local action is still going
on. The skin is cold, it may be clammy ; the pulse small and frequent, or
soft and compressible ; tongue foul and moist; renal secretion small;
whilst the accumulation of mucus in the bronchia? is increasing, with evi-
dently less power of throwing it off by expectoration. An emetic will
often give relief at this time: it should be of ipecacuanha, since our object
is merely to evacuate, by a moderate effort, the bronchia?, without de-
pressing the general system. For this reason, in asthenic bronchitis, as a
general rule, ipecacuanha is preferable to tartar emetic for a vomit. It is
now that the class of expectorants, which in the first stage would have
been for the most part mischievous, may be advantageously enlisted in
the treatment; those of the stimulating class being preferred. At this
time, also, the alkalies may be had recourse to, united with some stimu-
lant. Carbonate of ammonia, assafoetida-mixture, answer admirably, and
enable the child or the old person to throw off the mucus with compara-
tive ease. Aiding to the same end, a teaspoonful of wine whey now and
then for a child, and in proportionately large doses for an adult, should
be tried ; its continuance to be regulated, of course, by the pulse and the
state of the skin. So long as the first is weak and the latter cold, we may
persevere with good effect. Preferable still to the remedies just mentioned,
in the minds of many practitioners, is a decoction ofthe polygala senega,
with the addition ofthe liquor ammonia? acetatis, or the carbonate of am-
monia. If, apart from the symptoms of general debility and difficult ex-
pectoration, we find evidence of congestion or inflammatory engorgement
128 DISEASES OF THE RESPIRATORY APPARATUS.
of a portion of a lung, the use of calomel in minute doses may still be con-
tinued, during the period in which stimulants are administered. Even a
scarifying cup or two over the diseased portion is sometimes admissible.
Of diaphoresis I have said nothing, believing that remedies specially-
given with a view to produce it will either be misplaced by their charac-
ter or by their interference with others already mentioned. Tepid drinks,
moderately warm bed-clothes, an equable air of the chamber, and the
occasional use of the warm semicupium or half-bath, will generally keep
up a moist state of the skin, whilst they contribute to give effect to the
more active plan of treatment already indicated.
I would dismiss diuretics in as summary a manner as diaphoretics, if
the former could only be administered with sole reference to their action
on the kidneys, and not in harmony with the state of the circulation, in
bronchitis. But there are certain remedies, such as nitre, digitalis, and
colchicum, which are both sedative and diuretic, and all of which have
been recommended in the disease under notice, especially with a view to
prevent effusion. Without pretending to specify the precise time when
they ought to be had recourse to, we can very well infer, fro n a knowledge
of their general effects on the animal economy, that they will prove most
useful in the early stage of the disease : they assist to keep down febrile
excitement, and relieve the inflammation of the bronchia?, by means of
derivation through the kidneys. When given with a view to their anti-
phlogistic operation, tartar emetic is combined with one or other of them.
If you prescribe such a combination, you should be aware that it is one of
the most active in the materia medica, and you will be required in conse-
quence to watch vigilantly the first evidences of sedative operation, and
either to desist from the medicine, or to diminish the dose, or prolong its
administration, before prostration is induced, which, as in certain cases in
children and in old persons, cannot be supported nor always readily reco-
vered from.
Secondary or Symptomatic Acute Bronchitis. — Our treatment of
various diseases will be readily modified by the extent to which bronchitis
is associated with them, either as a primary symptom or one of secondary
occurrence. In measles, the chief danger, both in the first or acute stage,
as well as after the disappearance of the eruption, is from bronchitis, the
degree of intensity of which will guide us very much in the use of the
lancet or analogous depletory agents. We must be prepared, however,
at the same time, to see a complication, in the case of eruptive fevers
generally, of asthenia with inflammation, which will prevent our carrying
out, in all its simplicity, the antiphlogistic treatment. More especially is
this caution requisite in bronchitis with scarlatina. Now and then the
complication is increased by the addition of cerebral disease. In such
cases our reliance will be on local depletion, at the same time that we
husband the strength ofthe general system, and even administer camphor
and ammonia in alternation with calomel and ipecacuanha, and apply revul-
sives to the skin. These in scarlatina will be the warm and hot bath
sinapisms to the extremities, friction of the chest and limbs with cam-
phorated and terebinthinate liniments. Vesication is not safe in this ex-
anthema. Bronchitis is a frequent secondary occurrence in small-pox.
During the epidemic visitation of this disease in L823 and 1824 I often
found my patients, more especially those in the hospital, sink under bron-
chitis and pleuro-pneumony after the eruptive febrile stage had been gone
BRONCHITIS WITH REMITTENT FEVER.
129
through, and the desquamation of the skin nearly completed. In some
instances the bronchial disease was coeval with the pustular eruption,
which appeared on the trachea and its ramifications at the same time with
that on the skin ; in others there was reason to believe that the inflamma-
tion of the bronchia? was secondary, and consequent on the morbid im-
pression of cold on an exquisitely sensitive skin not yet furnished with a
new epidermis.
In the regular secondary bronchitis of small-pox and scarlet fever, ac-
companied with accumulated mucus in the bronchia?, which oppresses,
respiration and interferes with the decarbonization of the blood, emetics
should be had recourse to. In some extreme cases of depression and
stuffing up of the bronchia?, Dr. Copland recommends the following pro-
cess, which, he says, he has employed with marked benefit. It consists
in applying, over the epigastrium and lower part of the chest, a flannel
wrung out of hot water and immediately afterwards soaked in spirits of
turpentine, and allowing it to remain on until severe burning heat of the
skin is produced by it. Internally, camphor and ammonia, together with
a hot decoction of the polygala senega, should be used at the same time.
Small doses of ol. terebinth, also might be given by the mouth, or in
alternation with the remedies last mentioned.
As a general rule, emetics are useful in those cases of bronchitis, com-
plicated with scarlet fever, measles, and small-pox, in which a state ana-
logous to diphtheritis is apt to occur. If sore throat and dysphagia be
complained of, purgatives in full doses ought to be administered.
Bronchitis succeeding to acute laryngitis or tracheitis requires full and
active depletion, in the manner already pointed out when speaking of
laryngitis.
Complications of Acute Bronchitis.—It is quite common for remittent
fever, especially the autumnal, to be ushered in with, among other symp-
toms, a slight bronchitis, which, as the fever advances, may either disap-
pear, or, a no unusual thing, be augmented, and thus complicate not a
little this disease. In addition to the other phenomena of fever, we find
the patient exhibits lividity of countenance, cough, hurried breathing, and
expectoration. If, at the beginning, under the impression that, as we
have to deal with both inflammatory irritation, perhaps positive inflamma-
tion in the chest, and a similar state in the abdomen, as in gastro-enteritis,
or gastro-hepatitis, we bleed freely, we shall give the patient the best
chance in our power, by abating the febrile disturbances and concomitant
phlegmasia? and by keeping up the susceptibility of the system to other
remedies, of whatever class they may be. But if, dissatisfied at the bron-
chial irritation still remaining, and the abdomen still continuing tender,
with a show of gastro-enteritis, we bleed again, we do wrong ; the more
so, too, if we bleed largely, and with the expectation that we can strangle,
as it were, the disease. We can do no such thing, but we may greatly
and dangerously weaken the patient. It must be our aim now to ascer-
tain the hold which the associated bronchitis still has on the system, and
having done this, to try and remove it by local depletion and purgatives,
provided these latter be not contra-indicated by the state of the stomach
at the time. The febrile symptoms in some instances predominate in the
respiratory, in others in the digestive system ; and we can, not unfre-
quently, observe a remarkable alternation of this predominance between
the thoracic and the abdominal viscera. More commonly, if there be
VOL. II.—10 J
130 DISEASES OF THE RESPIRATORY APPARATUS.
disease ofthe respiratory mucous surface, there is an associated disease of
• that of the gastrointestinal: the reverse does not prevail with the same
frequency. But as it is not my intention here to discuss the pathology
and treatment of remittent fever, except in connexion with bronchitis, I
shall pass on to another and more advanced stage of the fever, in which
it has assumed a typhoid form. We are now pr%etty well assured that the
morbid condition of the mucous surface of the gums and tongue, by which
they become incrusted with sordes and dark matter, prevails lower down,
and has even extended to the bronchia?, so as obviously to interfere with
the regularity and completeness of respiration. The blood is not changed
as completely as it ought to be in its passage from the pulmonary artery
to the pulmonary vein, owing to the inspired air not being able to reach
it through the secreted coat of mucus which covers the bronchial mucous
membrane. What shall we do at this juncture, when probably the brain
is disordered at the same time, either in consequence of inflammation of
its arachnoid membrane, or of the flow into it of carbonated blood,
which has not been purified in the lungs before it reached the left side of
the heart ? If this collection of symptoms, of which the stomach and intes-
tines furnish a full share, but which I do not now enumerate, have fol-
lowed or been originally associated with bronchitis, we can have the less
difficulty in framing our treatment, with a view to its probable persistence
at this time, even though we should not make our diagnosis clearer by
percussion and auscultation. The brain, the pulmonary apparatus, and the
abdominal viscera, are now all suffering, perhaps more or less phlogosed ;
but the organ, the partially suspended function of which is most prejudicial,
is the lungs. It is now no longer a question, however, whether venesec-
tion is to be practised or not. This might have been debated during the
first stage. AH that is left for us is, to discuss the propriety of local de-
pletion. Were we to be influenced by the general symptoms, even this
would seem to be inadmissible ; but morbid anatomy has revealed to us
the condition of the bronchial mucous membrane at this period. It is of a
violet red almost universally, and the bronchia? are filled with mucus.
We attempt, therefore, the relief of this morbid state of the bronchia? by
cupping between the shoulders or on both sides of the chest; and the
depletions are afterwards repeated in different situations, according to the
stethoscopic signs of predominance of disease. The respiration will also
be greatly relieved by the use of terebinthinate and assafcetida enemata.
Following the cups come blisters, which long experience declares should
be between the shoulders rather than in front of the chest; and if this be
difficult, on account of the posture on the back, and extreme prostration,
they should be applied to the sides of the thorax. Contradictory as it
may seem, there are cases in which, while we deplete to relieve the con-
gestive lung, nutritive and diffusible stimulants are called for to keep up
the general strength, unless we are prohibited from using them by exces-
sive tenderness of the stomach, morbid heat of the epio-astrium and a
dry, red, and shining tongue, and compelled to be spectators, waiting
and watching anxiously for every fair indication to act. One of these
indications is to apply a few leeches over the epigastrium.
WTiilst we attend to the state ofthe skin and endeavour to preserve it
of an equable warmth, by directing flannel to be worn, and thus to promote
insensible perspiration, we are not, I think, precluded from the admission
of cool as well as fresh air into the apartment ofthe patient. I have known
TREATMENT OF SECONDARY ACUTE BRONCHITIS. 13]
patients to be tossing about from side to side, complaining of a sense of
heat and oppression at the chest, and unable to sleep, who, on the intro-
duction of fresh and cool air into the room by the opening of a window,
became composed, and soon fell into a tranquil and refreshing slumber.
The inflamed state of the bronchia?, the impediment to the access of air to
them, and the consequent imperfect hematosis, would all seem to indicate
the advantage ofthe freest supply of air to the lungs, at the very time that
we envelop the skin in warm clothing.
Dr. Armstrong was fully impressed with, perhaps even somewhat exag-
gerated, the dangers from the bronchitis in typhous fever, or, as he called
it, special bronchitis. While in the primary and common form of the
disease, the danger is chiefly from the quantity of mucus secreted exceeding
that which is expectorated, our apprehensions are excited in the secondary
form by the quality, of the secretion. It is, in this latter, more sticky, like
varnish smeared over the bronchial lining, so as far more effectually to
exclude the air from contact with the blood, than is the case with the
less sticky but more copious secretion in common bronchitis. And all
those fevers, continues Dr. A. (Lectures on the Morbid Anatomy and Treat-
ment of Diseases), which are called typhous, typhoid, putrid, low, or ma-
lignant fevers, owe their characters to this special bronchitis..
If, without too much fatiguing the patient, he could be made to inhale
the simple vapour of water, alternately with one of the more stimulating
gases, as chlorine, largely diluted of course, the effect would probably be
useful towards a solution of this varnish and adherent mucus ; and produce
a not ill-timed excitement ofthe bronchial vessels so as to enable them to
throw out a modified and more fluid secretion.
Change of posture is desirable in this variety of secondary bronchitis,
as it is in every form of congestion of the lungs. The patient should be
turned on one or other side, or at least made to incline in that direction, by
being propped with soft pads or air-cushions to his back. A decided predo-
minance of disease in either lung will be an indication of the necessity of
his lying or being turned on the side of the one opposite to that affected.
In the very last stage of this bronchitis with typhoid fever, when hope
is on the point of forsaking us, the patient lying on his back nearly insen-
sible, the mucus having choked up the bronchia?, with its rattle in his
throat, temporary, but immediate, and even sometimes, though more rarely,
permanent relief has been procured by an emetic, to be repeated at inter-
vals, if a renewal ofthe symptoms calls for it.
Dr. Graves has recommended a new, and, in his hands, successful means
of arresting the excessive bronchial secretion, the continuance of which to
this extent is always harassing to the patient, and often hazards his life.
This gentleman proposed the employment of a combination of quinine ten
grains, and of laudanum twenty drops, in the form of enema. He gives
the details of three cases in which the patients were moribund, but in
whom life was clearly saved by this treatment. Justice to the author re-
quires that we should give his own ideas as to the discernment to be exer-
cised by the practitioner in the selection of cases for the administration of
the above remedies. " An accumulation of mucous secretions in the air-
passages," remarks Dr. Graves, " producing the rattles, forms the closing
scene of almost all diseases however different in their nature. To exhibit
remedies for this would be ridiculous : it is only when this accumulation
is the direct consequence of actual disease attacking the air-passages them-
132 DISEASES OF THE RESPIRATORY APPARATUS.
selves, that we can hope for its removal. In such cases, we must try
everything that experience has proved to be even occasionally useful, and
must carefully watch the effect of each new medicine ; for it must not be
concealed, that very different results are obtained from the same remedies
under circumstances apparently similar. The injection of sulphate of qui-
nine and laudanum possesses, as appears from the cases I have detailed,
very great powers, and for that very reason must be used with circumspec-
tion ; for if exhibited at an improper period of the disease, or in cases
where expectoration is at all scanty and difficult, it may produce danger-
ous consequences."
Sugar of lead has been given under these circumstances of disease with
a very happy effect.
LECTURE XCIV.
DR. BELL.
Chronic Bronchitis—Description of—Expectorated matter—pus with hectic fever—
Difficulty of diagnosis of chronic bronchitis with purulent expectoration—Morbid Ana-
tomy—Ulcerations of bronchise are rare—Causes,—primary irritation of the lungs,—
and secondary in other diseases—Bronchitis after gastric irritation—Stomachic cough
—Its diagnosis—Bronchitis with intestinal irritation,—with other morbid states,—
gout, syphilis, &c.—Treatment, modified by cause—Venesection not often required—
Local bloodletting preferable— Purgatives—Antimonials—Calomel or blue mass, with
ipecacuanha and hyosciamus—Colchicum and digitalis—Iodide of potassium—Tonics
with the balsams—Compound syrup of sarsaparilla with iodine or iodide of iron—
Counter-irritants to the chest—Inhalation of various vapours—Modification of treat-
ment in co-nplic .ted chronic bronchitis—Visits to mineral springs—Change of air and
climate—Prevention' of chronic bronchitis.
Chronic Bronchitis.— It has been well said, and the remark is one of
great practical value, that chronic bronchitis is not separated by any dis-
tinct line from the acute form ofthe disease. The two pass by insensible
gradations into each other, and are often conjoined, for, although acute
bronchitis frequently exists alone, chronic bronchitis is rarely free from
occasional admixture of acute inflammation supervening on it, in conse-
quence of the exposure of the invalid who is labouring under the for-
mer to the causes which brought on the disease primarily, such as sudden
mutations of temperature, or errors in clothing, &c. If we would be sure
that we have to do with a chronic inflammation, the knowledge must be
acquired by an observation of the symptoms derived from the pathology
of the mucous membrane itself, and not simply from the duration of the
disease. We every now and then see acute bronchitis in which attack
succeeds to attack during many weeks, with a retention, all the time, of its
original character. So long as the expectorated matter remains glairy and
v^cid, uniting in mass and without opacity, the inflammation is acute.
Towards the termination of an attack of this kind the sputa become
opaque and expectorated in distinct masses, which, although consistent,
are not very adhesive or glutinous. Sometimes, instead of being dimin-
ished and more consistent, as when the disease is about to terminate they
remain in this state, or increase and become diffluent and heterogeneous
in quality without sensible increase of fever, and they then indicate
inflammation ofthe chronic kind.
Morbid Anatomy.—When the inflammation has been chronic the bron-
CHRONIC BRONCHITIS.
133
chial mucous membrane generally loses its bright redness, and presents a
livid, purple, or brownish tint. For this change of colour from a deep-
red or rosy hue we are prepared. But we should hardly, apriori, have said,
that there would be cases in which the mucous membrane ofthe air-pas-
sages was white through its whole extent. Both Bayle and Andral, how-
ever, cite such cases ; and I have witnessed such myself in persons dead of
small-pox, in whom, too, the ulcerated spots were distinctly seen extending
from the larynx into the bronchia?, and the intermediate spaces of a white
colour. These appearances were seen in the bodies of persons who had
died in an advanced stage of the disease, after the third week. It should
not, as M. Andral justly remarks, be inferred that inflammation did not
exist, because the membrane is thus found white. Analogous appear-
ances are presented in other inflamed tissues. Thus, serous cavities filled
with pus and lined with false membranes frequently present no change
of colour, no appreciable alteration in their texture. The intestinal mu-
cous membrane, though traversed with numerous ulcerations, often pre-
sents a remarkable paleness, either in the very place where these ulcera-
tions exist, or in their intervals. More than once, in individuals whose
urine was for a long time purulent, the mucous membrane of the calyces
and pelvis of the kidney has been found very white. In these different
affections of mucous tissues an inflammatory process could not be called
in question ; but whether, by reason of its long standing, or in conse-
quence of general debility, the inflammation appears to have left no other
traces in the organ which was the seat of it than a change in its secretion :
thence very often result new therapeutic indications.
The bronchial membrane is seldom softened in bronchitis ; but it is
often thickened, so as to cause an occlusion of some ofthe minute or ter-
minal branches.
Ulcerations of the bronchia? are rare. The frequency of ulcerations de-
creases from above downwards in the different portions of the mucous
membrane ofthe air-passages. Thus, in chronic laryngitis they are com-
mon enough. It is not rare to find a part of the chorda? vocales stripped of
mucous membrane, and the thyro-arytenoid muscles and the cartilages ex-
posed to a greater or less extent, in persons who, affected with simple chronic
bronchitis or pulmonary tubercles, had their voice for a long time hoarse
or entirely destroyed. The remarkable feature in such cases is, that in a
great majority of them, these ulcerations exist only when there is at the
same time inflammation ofthe lower parts of the mucous membrane of the
air-passages. In the trachea, ulcerations become less frequent than in the
larynx ; they are generally small, and are not at all numerous—seldom
extending beyond the mucous tissue proper.
Symptoms.—Chronic bronchitis in its slightest form manifests itself only
by habitual cough and expectoration, which are increased by certain
changes of weather, and generally prevail most in winter and spring. It
is more common in advanced life, and, in fact, very few old persons are
perfectly free from it. In its severe forms it is acccorapanied with dysp-
noea, occasional pain behind the sternum and about the pra?cordia, a
feeling of heat and weight in the chest, and some febrile symptoms, espe-
cially towards evening, palpitation, and disorder of the digestive func-
tions. The cough varies in its character, being sometimes slight, at others
recurring frequently in fits or catches, and is worse, especially at night:
expectoration copious. Sometimes the respiration is not disturbed, un-
134 DISEASES OF THE RESPIRATORY APPARATUS.
less exercise be used : in other cases, the dyspnoea comes on in paroxysms,
resembling asthma. This is more particularly the case when the mucous
membrane is thickened, or the bronchia? obstructed by mucus. 1 he fit
comes on suddenly and goes off equally suddenly.
To this description it may be added, that even with considerable ema-
ciation the appetite is often good, and the digestion regular. Chronic
bronchitis will, if not restrained, end fatally ; but more generally when
this result takes place the disease is complicated with tubercular phthisis,
which on these occasions it would seem to have developed.
The thorax is sonorous as in health ; auscultation reveals rhonchi similar
to those in acute bronchitis, but with a greater predominance of the moist
than in the latter. The appearance of the expectorated matter in chronic
bronchitis is various. Sometimes it is precisely similar to that in the
latter stage of the acute form ; but most commonly it is less glutinous,
more opaque, and nearly puriform. Occasionally, it is of a dirty-greyish
nr greenish hue, from, as Laennec thinks, an admixture of the pulmonary
matter; and in this state it cannot be distinguished from the expectora-
tion of phthisis. In some cases it is real pus, and presents all the varie-
ties that are seen in pus from other sources ; in its being inodorous, as
from a recent wound, or, again, having the strong odour of the contents
of a large abscess, and occasionally approaching the gangrenous fetor.
After a period, this bad smell disappears, but it may return perhaps seve-
ral times in the course of the year. WThen the secretion is obviously of
pus, there are not unfrequently a quick pulse and signs of hectic, and a
tendency ofthe disease to a fatal termination, with night sweats, emacia-
tion, diarrhoea, and all the common symptoms of pulmonary consumption.
The following case, related by M. Andral (Clinique Medicate), is an exam-
ple of this variety of chronic bronchitis, in which also the tracheo-bron-
chial mucous membrane was white.
A locksmith, twenty-seven years of age, entered La Charite Hospital
during the month of December, 1821. For the two years preceding, this
man had been tormented with a constant cough : he had never spit blood.
When we saw him, he was in a state of marasmus: he expectorated
sputa, formed of greenish, round patches, separated from each other, and
floating in an abundant serum ; these sputa were inodorous, and appeared
to the patient to have a saccharine taste. The respiration was a little
short ; he could lie down in all postures ; the chest when percussed re-
sounded equally well in all parts; some mucous rale was heard in dif-
ferent points ; there was no appearance of pectoriloquy ; the pulse was
not frequent in the morning, but became so towards evening ; every night
the patient perspired a little. The digestive functions presented nothing
remarkable.
What diagnosis, continues M. Andral, could be given here? Auscul-
tation informed us, to be sure, that there was no tubercular cavity ; but
the aggregate of the other symptoms seemed to announce, that numerous
tubercles, beginning to soften, existed in the luno-s.
The marasmus and debility increasing, and diarrhoea also supervening:,
together with disturbance of the intellect, the patient died in a half-coma-
tose state.
Post-mortem examination revealed the following particulars :__A sero-
purulent infiltration of the sub-arachnoid cellular tissue of the convexity of
the hemispheres ; lateral ventricles distended with turbid seium. Pulmo-
DIFFICULTY OF DIAGNOSIS IN CHRONIC BRONCHITIS. 135
nary parenchyma sound, but slightly engorged. The internal surface of
the larynx, trachea, and bronchia?, traced as far as their smaller divisions,
presented everywhere great paleness; the mucous membrane (of the air-
passages) exhibited no other appreciable alteration ; white fibrinous con-
cretions distended the right cavities of the heart. The digestive canal,
opened to its entire extent, presented no other lesion but a bright redness,
scattered in patches over the great intestines.
Here we have a case which presented all the rational symptomsof phthisis,
although the lungs were sound, but we had evidences of decided lesion of
the bronchial mucous membrane, which, notwithstanding, was in a state
that would have been declared sound had we been ignorant ofthe patient's
condition before death. This case serves also to apprise us ofthe difficulty
of distinguishing a simple chronic bronchitis from a tubercular degeneres-
cence of the lungs. What, as M. Andral asks, can auscultation tell us in
this»case, except that there are no cavities ? Let us, he continues, draw
from it this conclusion : that so long as the existence of tubercles shall
not be ascertained by the stethoscope, the return to health should not be
deemed impossible, by the cessation of the bronchitis, which occasioned
all the symptoms. It is against such an inflammation of the mucous mem-
brane of the air-passages, that a great number of hygienic and therapeutic
means have often succeeded, which, if directed against real phthisis,
would certainly have failed, or at most would merely have retarded for a
little the progress ofthe evil.
Much stress is sometimes laid, but without reason, on the large quantity
of expectorated matter in a doubtful disease of the pulmonary organs.
The quantity in chronic bronchitis varies from day to day, but it is almost
always greater in the acute disease ; not unfrequently amounting to one
or two pints in the twenty-four hours. It is increased by every attack of
cold ; or rather the mucous secretion is at first less, with more watery dis-
charge ; and then, after a few days, becomes more copious. In some
rare cases it becomes all at once, and usually without obvious cause, so
very abundant and puriform, as to lead to the suspicion of a vomica having
opened into the bronchia? ; a mistake which is more likely to happen on
account of the oppression which usually precedes and accompanies this
state. The oppression, however, is owing merely to a great increase of
the morbid secretion,—which may itself accumulate to such a degree in a
weakened subject .as to cause suffocation and death. A remarkable case
(No. 17) of this nature is given by M. Andral in his work frequently
quoted by me in this lecture. It is headed—Acute bronchial flux produ-
cing death by asphyxia in an individual affected with pneumonia and chronic
bronchitis.
Auscultation, although it cannot apprise us positively of the exact con-
dition ofthe bronchia? in all their morbid changes, is still a valuable ad-
junct towards our obtaining a correct diagnosis in chronic as it was shown
to be in acute bronchitis. The respiration and cough are heard with
various rhonchi—mucous, sonorous, sibilant, and clicking, which are
continually shifting and changing. There is no bronchial or cavernous
respiration, and, it is added by writers commonly, there is no permanent
absence of respiration in a part, no unusual resonance of the voice : and
in spite of the continuance of the copious and puriform respiration, on lis-
tening, day after day, we still find no signs of a cavity, no cavernous
rhonchus, or pectoriloquy. But the assertion, that there is no permanent
136 DISEASES OF THE RESPIRATORY APPARATUS.
absence of respiration in a part, must be received with some qualification,
as we every now and then find a case like that (No. 2) recorded by M.
Andral, headed—Chronic bronchitis—narrowing of the principal branches
of the upper lobe of the right iung ; and almost entire absence of the respi-
ratory murmur in this lobe.
Chronic bronchitis is often a very obstinate, as it is a harassing and
fatal disease, especially to those of weakly frames. Death results either
from the disease itself, or the complications to which it gives rise in the
altered structure ofthe bronchial tubes and ofthe lungs.
Etiology.—The causes of chronic bronchitis are the same with those of
the acute form, except that the secondary chronic, or that supervening on
other diseases, more commonly follows these than appears, like the acute,
either simultaneously with them or soon after their inception. The
habitual inhalation of dust or fine metallic particles, detached in various
processes in the arts, is a cause of a distinct variety of chronic bronchkis.
Stone-cutters, needle-pointers, they who powder and sift the materials
for making china, and leather-dressers, are particularly liable to the dis-
ease. The first and most marked symptom in these cases is dyspnoea,
which may continue, however, for a considerable time without the disease
declaring itself. But in the course of a few months the dyspnoea is in-
creased, and is accompanied by severe cough and a copious expectora-
tion, sometimes mixed with pus and blood. Not unfrequently the cough
brings on a profuse hemoptysis. At this time the constitution generally
suffers much,—the pulse becomes quick; thirst and fever attend; the
tongue is loaded ; and the aggravation of dyspnoea occasions lividity of
the countenance. Unless, continues Dr. Williams, whose description I
am now repeating, these symptoms are relieved by remedies, and a total
abandonment of the unhealthy occupation, they become worse ; the
expectoration increases to a great extent, and becomes more purulent;
hectic with night sweats succeeds ; and the patient dies with most of the
symptoms of tubercular phthisis.
In early life, chronic, which in such cases might be called also secon-
dary bronchitis, occurs after hooping-cough, measles, small-pox, or some
cutaneous eruption.
Farther examples ofthe occurrence of secondary bronchitis are furnished
in the irritation ofthe lung supervening on abdominal disease, and par-
ticularly on irritation of the stomach, constituting what is often called sym-
pathetic or gastric cough. The following are the symptoms, as given by
Broussais in his Phlegmasies Chroniques (translated by Drs. Griffith and
Hays). It comes on with violent shocks, which occur at each inspiration,
but without swelling and lividity of the countenance, as in hooping-cough.
The expectoration will be proportionate to the degree of bronchial irrita-
tion, sometimes it is wanting, at other times present; but the excretion
may be suspended by means calculated to relieve gastritis, and this sus-
pension is favourable to the patient. This secondary or stomachic cough
is no new discovery ; it is associated with either acute or chronic disease
ofthe gastro-intestinal mucous surface ; being in the first case marked by
more violence, and more likely from the existence of fever to become
complicated with pulmonary inflammation. In reference to an accurate
discrimination of this kind of cases from primary chronic bronchitis we
may say that when there is a want of proportion between the physical s'ip-ns
and functional derangement, we are led at once to the correct principle of
DIAGNOSIS OF CHRONIC BRONCHITIS.
137
diagnosis. This is laid down by Dr. Stokes to be—That when distressing
pectoral symptoms exist, the morbid physical signs being either absent, or,
if present, yet revealing an amount of disease too slight to account for the
symptoms, we may make the diagnosis of sympathetic irritation. If a pa-
tient has had fever, cough, and hurried breathing, for three or four days,
and no commensurate signs exist, we may be tolerably sure that there is
no actual or progressive inflammation ; for, if there were, it would have
by that time fully manifested itself.
I the more willingly introduce here the valuable details on this head
furnished by Dr. Stokes, because the diagnosis is of great practical mo-
ment in a complication of maladies, which is, I know, of frequent occur-
rence, and the treatment of which is subject to fluctuations injurious if not
perilous to the patient. Thus, persons labouring under gastritis, or gastro-
enteritis, have been largely bled, and thrown into a typhoid state ; or the
abdominal inflammation has been exasperated by the use of remedies in-
tended to relieve the pulmonary irritation.
In making this diagnosis, the following are the principal points which
must be attended to in order to avoid error:—
First. WThether the symptoms or signs of incipient tubercle are absent.
Second. Whether there is reason to suspect disease of the larynx or
trachea.
Third. Whether the uvula be or be not relaxed.
Fourth. Whether the patient (if a female) be subject to hysteria.
If the result of an investigation is against the existence of any of these
causes, we may safely infer the abdominal origin of the cough ; and it
will not be difficult to decide between gastritis and worms. Thus enlight-
ened, we shall succeed in readily curing protracted gastric cough, which
had proved intractable to general depletion on the one hand, and various
stimulating expectorants on the other, simply by a removal of the gastritis.
For this purpose, leeches to the epigastrium, iced water, and a bland diet,
will often suffice.
The association of bronchial with intestinal irritation, though of less
frequent occurrence than bronchitis with gastritis, merits notice here.
Without considerable attention to the diagnosis, a physician may be so
far deceived as to take, for remittent pulmonary irritation of the lung, a
case of intestinal worms with sympathetic cough and fever. I had, several
years ago, a case of this kind occurring in a young girl about seven years
of age, in which the pulmonary symptoms with remittent fever were well
marked : but the state of the abdomen, the appearance of the tongue, and
the commemorative history, persuaded me that the patient laboured under
worms. By prescribing accordingly, she was entirely relieved after a
week's suffering, during which the cough was frequent and harassing. I
did not avail to the full extent of the signs furnished by auscultation, but
I was not a little influenced in my opinion by the entire remission from
day to day ofthe bronchial irritation.
There are other varieties of chronic bronchitis, also of a secondary na-
ture, but depending on slower constitutional diseases than those mentioned.
It would be more correct language were we to say, that in the progress of
certain chronic diseases the bronchial mucous membrane is sometimes
violently affected, and that this bronchitis is cured by the same class of
remedies which are adapted to and successful in the original disease. I
cannot concur in all the ideas conveyed by the expression, " that the
138 DISEASES OF THE RESPIRATORY APPARATUS.
gouty, scrofulous, syphilitic, and scorbutic contaminations, may, and no
doubt do, produce their specific forms of bronchial inflammation." The
fact of bronchitis preceding, alternating with, or following an attack ofthe
gout, is not, to my mind, evidence ofthe specific or arthritic character of
the former. A more enlarged view and experience of the operation on
the different organic systems of different active medicines, will show that
the cure of a particular affection by a remedy which has been successful
in gout, for example, cannot be received as evidence that the former was
also a modification of gout. This kind of argument was at one time com-
mon ; as, for example, when a cough or a pain in the head was removed
by colchicum, it was forthwith inferred that these disorders were of an
arthritic character. Now, we know, from extended trials with this remedy,
that it is adapted to a great variety of diseases which, in the nosological
catalogue, have no affinity to each other. I have frequently prescribed it
in bronchitis with manifestly good effect, in cases in which no suspicion
of gout could be entertained.
These remarks are not meant to apply to another variety of chronic
bronchitis, or that consequent upon syphilitic irritation. Syphilis, unlike
gout, attacks, in its successive stages, a certain order of parts, viz., the
mucous membranes, skin, fibrous membranes, and bones. That in its
progress the respiratory mucous membranes and the digestive ones should
suffer, is not incompatible with our existing knowledge of its organic seats.
The upper parts ofthe digestive canal, or the palate, tonsils, and pharynx,
are commonly enough assailed by secondary syphilis, as is the larynx or
upper part of the air-passages. Participation of the bronchia? in this mo-
dification of laryngeal disease, or independent syphilitic bronchitis, has
not probably engaged attention so much as it deserves. In this country
happily, a satisfactory reason exists, in our seldom seeing bad and pro-
tracted cases of syphilis out of the hospitals.
The bronchial disease of syphilitic origin is spoken of by Dr. Stokes,
as either an acute or a chronic affection. In the first, he thinks it analo-
gous to the bronchial irritations ofthe exanthemata, of which he has seen
a few interesting examples; whilst in the second, there is a chronic irri-
tation which, when combined with the syphilitic hectic and with perios-
tosis ofthe chest, closely resembles true pulmonary phthisis. In the first
of these cases he has observed that, after a period of time from the first
contamination, the duration of which has not been determined, the patient
falls into a feverish state, and presents the symptoms and signs of an
irritation of the bronchial mucous membrane. These having continued
for a few days, a copious eruption, of a brownish-red colour, makes its
appearance on the skin, and the internal affection either altogether sub-
sides, or becomes singularly lessened. Dr. Byrne, physician to the Lock
Hospital in Dublin, is quoted by Dr. S. as corroborating by his experience
these views. The former gentleman states, that he has in many instances
seen patients who had been formerly diseased, and who had come into
the hospital either on account of new sores or of gonorrhoea, attacked with
intense bronchitis and fever. The attack would come on suddenly and
the distress was so great that bleeding had to be performed the effect of
which was that, soon after, a copious eruption, often combining the liche-
nous and squamous forms, made its appearance with complete relief of
the chest. In some of these patients, on the day before the eruption, the
stethoscopic signs had been those of the most intense mucous irritation;
TREATMENT OF CHRONIC BRONCHITIS.
139
and yet, when the skin disease appeared, the respiration became either
perfectly pure, or only mixed with an occasional rhonchus in the large
tubes. The same gentleman has observed the reverse of this ; as when
a syphilitic eruption has been repressed, the bronchial membrane became
much affected, and the patient suffered from general febrile symptoms.
These phenomena subsided after bleeding and mild diaphoretics, which
had the effect of restoring the cutaneous eruption.
The more chronic form of syphilitic bronchitis with which pneumonia
is sometimes combined has been more fully described by Dr. Graves.
Debility, night sweats, emaciation, nervous irritability, and cough and
broken rest at night, associated with syphilitic disease, such as periostosis,
sore throat, and eruption on the skin, indicate that the patient is labouring
under a syphilitic cachexy affecting the lungs as well as other parts. A
cautious use of mercury in such cases will improve the patient, whose
amended looks are ultimately followed by a removal of lues, the cough,
and pectoral affection at the same time. We cannot, however, be too
careful in our attempts to establish a correct diagnosis before we begin
this mercurial course, remembering, as we must, how prejudicial this
treatment would be in a scrofulous habit with tuberculous predisposition
or incipient irritation of pulmonary tubercles.
Treatment.—The preceding description of the causes of chronic bron-
chitis, which to some may seem to be rather prolix, will serve not a little
to guide us in our views of the proper treatment of this disease. This, it
must be obvious, will vary with the nature of the case, as modified by
cause, duration, and intensity ofthe symptoms. If these latter indicate
that acute has supervened on chronic bronchitis, recourse must be had at
once to the remedies called for, and already specified as applicable to the
former. Commonly, however, venesection is not required in the chronic
form of bronchitis, unless the patient be of a full and robust habit, and
greatly jarred by the cough. Nor is local bloodletting, although a safer
remedy than general in most chronic local maladies, necessarily required,
unless to relieve a temporary but distressing exacerbation or evident con-
gestion. When called for, it is best done by leeches under the clavicles,
or cups between the shoulders. In case of doubt, I consider it the safest
practice to draw blood rather than to abstain. There are cases, of course,
such as of delicate lymphatic women, and puny children of scrofulous
habit, who are frequently subject to bronchitis, whom it would be clearly
improper to bleed. But that other large class, viz., of labouring men in
town and country, who have had abundant nutriment and used spirituous
and malt liquors, and of young persons of both sexes ' who have neglected
their colds,' will be materially benefited by the abstraction of blood in
the manner last prescribed ; or if the means for this are not at hand, by a
small bleeding from the arm. The circulation is thereby equalized by
the abatement, if not removal, ofthe congestion, and the susceptibility to
the other remedies is thus more completely awakened. These are, in the
first place, purgatives, and then antimony or mercury with opium, ac-
cording to the degree of excitement. Chronic bronchitis is so often asso-
ciated, at least in our climate, with gastro-hepatic derangement, and a
torpid or irregular state of the large bowels, that purging may well pre-
cede the alterative and tonic course with which, in conjunction with
counter-irritants, the treatment is usually completed. An emetic in per-
sons of a lymphatic temperament, and whose tongue is white and loaded,
140 DISEASES OF THE RESPIRATORY APPARATUS.
is sometimes serviceable. Calomel and jalap, or calomel followed by the
compound powder of jalap ; pills of the compound extract of colocynth
and calomel, sulphate of magnesia with wine of colchicum, will represent
the purgatives more immediately required. After this, I have been in the
habit commonly of prescribing'the blue mass with hyosciamus or with
ipecacuanha, in pills twice or thrice a-day, according to the trouble which
the cough gives—attention being paid to keep the bowels open, and to
suspend the prescription if there is any evidence of the mouth becoming
touched. I have seldom seen benefit from salivation, or any approach to
it in chronic bronchitis, except in one, and that a somewhat peculiar case,
in which three grains of the blue mass, united to hyosciamus, caused
copious salivation and cured the patient. She had given me notice of
the peculiar liability to the sialagogue operation of mercury. In milder
cases, a single pill of the blue mass, three grains with half a grain or a
grain of ipecacuanha at night, and a teaspoonful of salts in the morning,
will exert a salutary effect in removing the cough, and giving the secre-
tion a healthy character. I am aware that slight ptyalism has been
strongly recommended in chronic bronchitis-; but my own practice, as
here indicated, which I have pursued for the last twenty-five years, is, I
think, preferable. I know no remedy equal to the blue pill, given as an
alterative.
Where the disease is more paroxysmal, the fits of coughing being'vio-
lent, and febrile irritation manifesting itself every evening, calomel and
tartar emetic, one or two grains of the former and a sixth of the latter
three times a-day, with the addition of opium if the bowels are loose or
irritable, will sometimes be required. If relief is not procured in a few-
days by this course, we must substitute for it the use of colchicum and
digitalis, provided that the disease be still accompanied with febrile symp-
toms, and a feeling of tightness of the chest and difficult expectoration.
Camphor will form a convenient and appropriate medium for the adminis-
tration of the colchicum wine, which will be given in doses of half a drachm
to an adult twice a-day; or thirty drops, if combined with tincture of digi-
talis, in a dose of five drops given at the same time. In walking cases,
wine of colchicum seeds, in doses of ten to twenty drops, three times a-
day, with, in the evening, five to ten drops of laudanum, is one of the best
remedies with which I am acquainted. It serves, in addition to its direct
effects on the bronchia?, to relieve these indirectly by keeping the bowels
in a soluble state. After the regulation of the digestive system, our atten-
tion should be directed to the renal secretion, which is at all times not a
little influenced by the function ofthe lungs, as it, in its turn, modifies this
latter. I have found a three-grain pill of the blue mass at night, and a
moderate dose of the vinous tincture of colchicum on the following morn-
ino-, and both repeated for some days, to have a very good effect. Where
we anticipate a salutary operation through thvi kidneys, the iodide of po-
tassium will be serviceable, and should the more readily be enlisted in
the trealment, if the habit ofthe body ofthe patient.be strumous, and he
exhibit any evidence of tubercular predisposition, which would indispose
us from prescribing mercury.
If, in despite of these remedies, the disease still persists, with an ab-
sence of all the remains of acute disease or of febrile irritation, and exhi-
bits a purely chronic character, with profuse perspiration, cool skin, soft
and rather feeble pulse, and a moist or slightly loaded tongue, the treat-
TREATMENT OF CHRONIC BRONCHITIS.
141
ment should be changed to one of a tonic kind, and the use of the bal-
sams. Calumba and cascarilla, with nitric acid or sulphate of quinia, sar-
saparilla, and taraxacum extract, are useful. The balsam of copaiba is
recommended by Dr. Armstrong, in very warm terms, in those cases of
profuse expectoration without much vascular excitement. Other practi-
tioners and writers of authority and experience do not sanction his praises.
Like my friend, Dr. La Roche (North American Med. and Surg. Journ.),
I have found it, in some instances, of marked efficacy. In others it offends
the stomach, and has little or no influence. It is best given with spirits
of nitre and occasionally I add the carbonate of soda, or the carbonate of
potassa. From my own experience, I would recommend, as when I spoke
of their use in chronic laryngitis, the farther addition of compound syrup
of sarsaparilla and a moderate portion, say five grains, of iodide of potas-
sium. In purely asthenic cases, in which there is a languor of the func-
tions of digestion and circulation, the iodide of iron serves a good purpose.
But at the very outset, or at least after bloodletting, if this be thought
advisable, and purging, counter-irritants should be employed in conjunc-
tion with the remedies already indicated. It may happen, in fact, that,
owing to a weakness of stomach and intolerance of almost any kind of in-
ternal medicine, or to the peculiar circumstances in regard to the occupa-
tion of the patient, or tender age as in children, our main reliance must be
on external remedies, or counter-irritation, to the skin. To carry this out
successfully, we may direct friction of the chest with a liniment, contain-
ing with oil various proportions of tartar emetic, tincture of cantharides,
the essential oils, ammonia, acetic acid, or a diluted mineral acid, accord-
ing to the degree of effect desired. This combination will represent the
liniments which quack physicians and medical quacks laud in books and
newspapers as their own discovery, and as endowed with peculiar and
specific powers. A succession of small blisters applied in the French
fashion, or as flying blisters, may be substituted for the liniment. In milder
cases, again, a warming plaster, composed of pitch sprinkledgover with a
little powdered cantharides or even a mercurial plaster will answer.
Auxiliary to other treatment is the inhalation of various vapours, simple
and medicated, and of gases, in chronic bronchitis. Having ascertained
that the larynx and glottis are free from inflammatory irritation, it may be
occasionally worth while to have recourse to the inhalation of balsamic
and stimulating vapours, in cases particularly of a phlegmatic habit, and
in which the bronchial discharge is considerable. Gases, and substances
of a more decidedly irritating nature, are better diffused with watery va-
pour through the air of an apartment, or small closet even used for the
purpose. In this way iodine and also chlorine might be used with bene-
fit; a few grains of the former, or a solution of the chloride of soda or of
lime being placed on a saucer floating on hot water. As relates to all the
kinds of vapour and modes of applying it, the physician will watch if there
be increase of cough or acceleration of pulse in consequence, and regulate
the continuance of the remedy accordingly. I may refer to my remarks
on this subject in a preceding lecture on chronic laryngitis, and to my work
on Baths and Mineral Waters.
A knowledge of the peculiar circumstances under which chronic bron-
chitis has come on, will of course modify our treatment; as where it has
a syphilitic origin, or appears in a gouty diathesis, or is associated with
chronic gastritis. Of this conjunction, I have already spoken in such a
142 DISEASES OF THE RESPIRATORY APPARATUS.
way as to indicate the appropriate remedies. If bronchitis be one of the
sequences of syphilis, we may shape our treatment accordingly, even though
we have not recourse to mercury. In cases in which the habit of the pa-
tient is scrofulous, and the predisposition to pulmonary tubercles obvious,
iodine, and sarsaparilla, and the narcotics, should take the place of mer-
cury. The simple bitters and quinia, or some chalybeate, will advanta-
geously complete the remedial course, part of which should consist ofthe
tepid and warm bath, according to the degree of excitement prevailing at
the time; and if the reaction be considerable the cold shower-bath.
Regimen.—The diet in chronic bronchitis will be regulated very much
by the state ofthe stomach. If this organ is in a state of irritation, or of
actual phlogosis, the food will be of the simplest and blandest kind. On
the other hand, where the tongue is moist, the stomach free from disease
and the bronchia? from congestion, the cough will not forbid a stronger
diet—particularly in old persons, whose powers of digestion may be ha-
bitually good. There are instances in which a moderate repast of solid
food has allayed the cough, which has been aggravated by an empty sto-
mach. In the case of infants, it is desirable that they should be able to
procure at once milk from the breast, either of the mother or a good wet
nurse. Farinaceous and milky food, commonly recommended to adults
in the chronic stage of pectoml affections, is not equally well adapted to
all. There are some whose stomachs are so constituted that they cannot,
without much inconvenience, indicated by weight ofthe epigastrium, foul
and white tongue, and headache, use a milk diet. Others with whom it
agrees and by whom it is readily digested, are with difficulty persuaded
that, in conjunction with farinaceous matters and vegetables, it can furnish
ample nutriment to their frame. Such persons regard milk in the light of
a ptisan, perhaps a panacea, which is to eradicate their disease ; and, at
table, as meant to be an introduction to more substantial and sapid food,
ofthe animal kind. They obey the doctor's injunction, to take milk at
breakfast afid at dinner ; but they do not understand him to mean for t
breakfast and for dinner ;■ and hence they contrive to finish off with coffee,
and hot bread and butter, perhaps cakes also, at the former meal ; and
fish with wine sauce, calves head, and other made dishes, at dinner. I
do not now sketch from fancy, but from sober observation. The inference
to be drawn for our immediate instruction is, that, in every case, the
dietetic directions should be precise and definite, so as to leave nothing
to conjecture and misinterpretation.
By a review of the food taken at the preceding meal, aggravated
cough some hours afterwards will be prevented for the next day. The
origin of an evening paroxysm may often be thus traced. At all times it will
be found that a patient who wishes to pass a tranquil night, must avoid
either a heavy or a late, even though the latter be a light supper. There
are some persons so constituted that the common functional excitement of
digestion will affect the bronchia?, and give rise to a sensation of heat and
altered secretion with cough : they ought, consequently, to have chymosis,
at least, completed before they retire to rest for the night.
Completeness and regularity of the digestion demand our attention in
chronic bronchitis, and hence the function of the lower bowels must be
carefully watched. In fact, from the beginning of the treatment of the
acute form ofthe disease to the termination of the chronic, and during
convalescence, this is one ofthe prime indications of cure and health. If
TREATMENT OF CHRONIC BRONCHITIS.
143
the bowels are tardy in their peristaltic action in this latter period, we en-
deavour to quicken and give tone to them by the combination of purga-
tives and bitters ; one of the best and most convenient of which is aloes
and quinia ; or extract of gentian and rhubarb. Ripe and dried fruit
often answer the double purpose of affording, in conjunction with bread,
a light and wholesome nutriment, and of keeping the bowels in a soluble
state. The cure de raisins, ripe grapes eaten in considerable quantity for
several weeks together with good wheat bread, and nearly the sole diet,
is a popular remedy on the continent of Europe in many disorders. To
the one before us it is well adapted, particularly in patients who labour
under a slight febrile excitement or an irritability which precludes either
tonics or stimulating food.
The more protracted and obstinate cases of bronchial inflammation will
often be either entirely cured or materially relieved by the use of certain
mineral waters—a selection ofthe kind of which will denend vprv mur-h
on the complications 01 me ureases or oiner orgams wim Uiose or me oron-
chia?. If the skin has been long affected, and the irritation has disap-
peared, or the eruption dried up ; if the liver and bowels have been torpid,
the stronger sulphur water will be preferred—such as the White Sulphur
Spring of Virginia. Dr. Graves speaks in high terms of sulphur in chronic
bronchitis. (Graves and Gerhard's Clinical Lectures, 1842.) Mere aci-
dity and irritation ofthe stomach being the accompaniments, the water of
the Sweet Spring will suffice. Cough, with febrile excitement, evening
paroxysms and a greatly accelerated pulse, have been often completely
and speedily removed by a course of the waters of the Salt Sulphur.
Drinking one or other of these waters, the use ofthe tepid or warm-bath,
and inhaling the pure mountain air ofthe region of Virginia in which they
are situated, have restored many invaluls in the advanced stages of bron-
chitis, whose cases were supposed to be of pulmonary consumption. (Bell,
op. cit.)
In mentioning pure mountain air as one of the restorative agents in
chronic bronchitis, I would not be understood to recommend it in all cases.
So far from such a recommendation holding good, there are varieties of
the disease in which a reduced air, such as that of low grounds, and charged
with moisture, is of paramount importance as a curative agent. In the
dry tracheal and bronchial affections, this kind of air is most serviceable ;
and to breathe it habitually invalids resort, as a winter residence, to Pisa
anil Rome in Italy ; or to Norfolk, Savannah, and Augusta, in our own
country. Those patients who are annoyed by copious expectoration, and
whose system is rather torpid than otherwise, will be told to give Naples
and Nice, in the old world, and parts of Florida, in the new, the prefer-
ence. But although different in the hygrometric states of the air, there
must be a general resemblance on the score of temperature among the
chosen locations for the winter residence of the invalid who suffers from
irritation and other diseases of the air-passages. Although cold is most to
be deprecated, yet a very high heat is also injurious. Temporary exposure
to a cold, or to a cold and moist air, or to currents of air should be sedu-
lously avoided. With this view, as well with that of procuring a uniform
temperature and moisture of the air, neither of which can be done in our
houses heated by fires after the common fashion, it has been proposed to
keep the patient, with chronic bronchitis or incipient phthisis pulmonalis,
in apartments warmed by heated air conducted through flues. It is easy,
144 DISEASES OF THE RESPIRATORY APPARATUS.
by having large vessels of water in the hot air-chamber, to preserve the
requisite moisture of the air which is sent up afrer being heated by the
furnace below, into the rooms above. An additional provision for allow-
ing of the escape of the air from the upper part ofthe room is desirable for
the invalid. I am very sure that many persons who are habitual sufferers
from catarrhal affections of various degrees for nearly half the year, might
entirely escape them by having their houses warmed in the manner just
stated. Neither they, nor the more formally recognised and treated inva-
lid, would be precluded from the advantage and enjoyment of exercise in
the open air during the winter months ; only in the case ofthe latter this
should be taken with a nicer selection of sunny days and noontide hours,
and when a southerly wind prevails.
The prevention of chronic bronchitis will consist in giving the requisite
tone to the skin, in the avoidance of great vicissitudes of temperature,
particularly when the body is perspiring freely, and in maintaining a
regular digestion. The skin is rendered much less impressible from sud-
den atmospherical extremes, by sponging the surface daily with salt and
water, and friction for some time afterwards with dry towels. A more
circumscribed ablution even, as by sponging the chest and neck every
morning with vinegar and water, or salt and water, has been found to be
a capital preventive, especially when followed by dry rubbing for some
time. The undue sensibility ofthe cutaneous function, by which, in one
person, bronchitis, in another rheumatism, is brought on, is greatly dimi-
nished by sea-bathing. The precautions and the associated circumstances
to be attended to in visiting the sea-shore with this view have been de-
tailed in my work on Baths and Mineral Waters. At all times the skin
should be guarded by an inner garment, of such a texture that it is at the
same time a bad conductor of caloric and an absorber of the fluid per-
spiration. On this account, flannel or Merino jackets and drawers
should be worn in winter, and domestic muslin or cotton flannel in sum-
mer. There are many individuals whose liability to fluxions of the bron-
chia? or bowels, or to rheumatism, is such that they cannot at any season
dispense with flannel. In all cases, the inner garment ought to be
changed night and morning; and the invalid, before putting it on, should
use the flesh-brush, or some analogous means of active friction of the
skin.
In directing the prophylaxis for the benefit of children, when we see
the fashion of the dress of these little beings, we cannot but deplore the
exceeding blindness of parents to consequences, and the too general indif-
ference of physicians to the physiological law respecting the evolution of
animal heat. They who have less ability to create animal heat, and whose
bodies in consequence are less able than adults to resist the morbid im-
pressions of cold and moisture, are cruelly exposed to attacks of croup
and bronchitis by their breasts and shoulders and the greater part of their
arms being deprived of all covering in-doors, and often not properly pro-
tected when in the open air. But the chief mischief is in the house__
between the different rooms of which there is often as great a contrast in
temperature as between summer and winter. Add to exposure by transi-
tions of this kind, that in entries, and the occasional detention of children
at open doors in the arms of nurses and mothers, during all which time
the skin of the chest in front, and between the upper part of the shoulders
behind, and even of the arm-pits, is acted on by cold and by cold and
NARROWING OF THE BRONCHIA.
145
moisture, and we find a cause, the chief cause, of so many attacks of
croup and bronchitis. We need hardly inquire for the often additional
ones of cold and damp feet and chill by detention in the open air, without
active locomotion.
LECTURE XCV.
DR. BELL.
Effects of Bronchitis.—Narrowing ofthe Bronchiae—Causes—Symptoms—Obliteration
of the Bronchia—Dilatation of the Bronchia;—Organic changes in the tubes and air-
cells—Thickening, the first change—Duration and Progress—Symptoms—Difficulty of
inspiration—Obliteration of the bronchise with shrunken pulmonary tissue—Dilatation
of the bronchiae may occur very early in life—Prior diseases—Symptoms analogous
often to those of phthisis pulmonalis—Diagnosis between these two diseases—Its
great difficulty—Causes—Treatment,—nearly the same as for chronic bronchitis—
Ulcers ofthe Bronchial.—Dilatation of the Air-cells—Pulmonary or Vesicular
Emphysema—Dilatation and ruptur" of the air-cells—Symptoms equivocal—Disease
often begins in early life,—Constitutes a variety of asthma.—Influenza—Epidemic
Catarrh—Epidemic Bronchitis—Closely resembles common bronchitis—Exhibits
the same features, complications, and alterations—Seasons for its appearance—Is met
with at all seasons—Its reputed terrestrial origin—Supposed to depend on a particular
poison—Objections to this view—Treatment—Regulated by the same principles and
consisting ofthe same remedies as common bronchitis ofthe season.
There are other changes in the bronchial tubes resulting from inflammation
than those which occur in the mucous membrane. These are attended
with opposite symptoms in different cases. As chiefly referable to chronic
inflammation ofthe bronchia?, they might have been described under this
latter head, but for the suspension, which some of you may think has been
already too great, by pathological inquiries before I reached the subject
of treatment.
Considered in relation to bronchitis, the organic changes in the tubes
and air-cells are enumerated, by Dr. Stokes, as follows:—
1. Narrowing of the calibre; obliteration.
2. Dilatation of the tubes.
3. Ulceration destructive of the tubes.
4. Enlargement ofthe air-cells.
5. Atrophy ofthe lung.
I shall not follow the author in the details under these specifications
which you will find in his Treatise, but content myself with a brief sum-
mary from various sources.
Narrowing of the Bronchia.—The channel of the air-passages may be
diminished by tumours pressing on them, such as goitre, aneurisms of
the aorta, and enlarged or tuberculated bronchial glands. The most sim-
ple change of structure ofthe bronchial tubes is a mere thickening ofthe
mucous and the sub-mucous membranes, which generally in some degree
accompanies acute inflammation. This is accomplished by an increased
secretion of soft lymph, which, as the inflammation subsides, is eliminated
and expectorated with the mucus of the membrane ; or if it have been
effused in the cellular and parenchymatous tissue, it is after a while ab-
sorbed. But it is otherwise when the inflammation recurs frequently, or
vol. n.— 11
146 DISEASES OF THE RESPIRATORY APPARATUS.
is of long duration ; for it then causes an effusion of a less absorbable
nature, involves the less vital structures, and as the changes induced are
slow, so they are more permanent, because they become identified with
the nutritive or reparative functions of these tissues. There will then be
produced a degree of hypertrophy of some or all of the various tissues
composing the tubes. Nothing, says Dr. Williams, is more common than
to see the air-tubes of persons who have long suffered from bronchitis
presenting an undue development of the longitudinal elastic fibres; whilst
in other cases the outer cellular coat of the larger bronchia? is thick and
indurated, and their cartilages are sometimes partially ossified. Any of
these changes has the effect of rendering the lungs less easily expansible
in respiration ; the first in particular is a common cause of the short breath,
which persons frequently affected with bronchitis generally manifest; and
alihough not often serious in itself, yet it may so abridge the sphere of the
function of respiration as to make its increased exertion on bodily exer-
cise a matter of difficulty and disorder, and to render it illy able to bear
any other attacks of disease, to which the lungs can in general adapt
themselves by supplementary effort. Thus, when one portion of a healthy
lung is attacked with pneumonia, or compressed by pleuritic effusion, its
function is supplied by the increased and quickened movements of the
other portions, which, in their natural state, are equal to this augmented
task ; but if their pliant elasticity be impaired, and their size more fixed
by an increased stiffness, they will also be, in proportion, less available
for additional exertion, and the body will suffer the more from the crippled
state ofthe function.
Symptoms.—The chief symptom of hypertrophy of the longitudinal fibres,
and of increased rigidity ofthe tubes generally, is difficulty of inspiration,
which is short, quick, and performed with an effort, especially on making
any exertion; whilst the expiration is comparatively easy; but both acts
are often accompanied by wheezing sounds, compared to those made by
broken-winded horses, when the trachea is implicated. These depend on
irregularities in the calibre of some ofthe tubes, and frequently on partial
congestions or inflammation, from which tubes thus diseased are rarely
free. The vesicular murmur is impaired, and the expansion ofthe whole
chest is perceptibly limited. These symptoms resemble those of spasmodic
asthma, except that they are permanent, and are not removed ap the latter
may be for an instant on respiration after holding the breath. As the bron-
chial tubes cannot be narrowed without the sound caused by the entrance of
air into them being also changed, there results a peculiar rhonchus or rat-
tle, on auscultation, which, in consequence of its seat and nature, is called
by M. Andral the dry bronchial rattle or rale, the two principal varieties
of which were denominated by Laennec sibilant and sonorous. Thisra/e
is evidently owing to the air in its way to the pulmonary vesicles, traver-
sing tubes which are narrower than those which usually give passage to it.
In its exit from the vesicles, the air again finds the same obstacles to its
free passage, which causes, during expiration, the rales or rhonchi already
mentioned. Sometimes they are only heard during expiration. When
the obstruction is only on one side or ramification of a large bronchia,
the dulness of sound in respiration is confined to that side. There is
usually diminished clearness of sound on percussion.
In reference to obliteration of the bronchite, the following considerations
merit notice. If we follow the bronchial ramifications from their origin to
RYMPT0MS OF DILATATION OF THE BRONCHIA. 147
the pleura, we shall observe an approach to transformation from mucous
to serous membrane, or at least a decided tendency to it, which increases
as we approach their terminations. In the larger tubes we find a vascular
mucous membrane endowed with villosities and glands, but, as we advance
into the substance of the lung, this tissue gradually loses its original cha-
racters, until, at its ultimate point, if it be not completely serous mem-
brane, it closely approaches to it in appearance and function. It has been
remarked by M. Reynaud, that we may expect to see the plastic inflam-
mation the more the affected tissue approaches to the white structure ; and
here is a cause of the greater liability of the minute tubes to obliteration.
In all cases except where the tube was extremely minute, it has been
found, that, just at the commencement of the obliteration a cul-de-sac ex-
isted, beyond which the tube was converted into a solid fibrous cord, fur-
nishing also ramifications which answered to the originally pervious tubes.
As might be expected, those parts of the lung to which the obliterated
tubes extend, have been found to present a shrunken appearance. In the
neighbourhood of the obliterated canals, however, the air-cells were fre-
quently found dilated, while in ether instances the tissue was dense and
impermeable.
Obliteration of the bronchia? has been met with as either a chronic, or an
acute affection. As a chronic disease it will be frequently found in connex-
ion with tubercle. It is, continues Dr. Stokes, an interesting fact, that it
occurs much more frequently in the upper than in the inferior portions of the
lun hydrocyanic is oneP of thos^
doubtful articles on which we can never place reliance for anything like
neVroTsten"6 ^^ °f ^ " «* **«. and in the ^ulsfve
Ofthe anti-spasmodics, so called, assafcetida in American practice has
ntr^rlXtthe ? " «*? I "^ » the f°rm ^~
Uic child aid Itewnfi .mer /te' m d°Se Var>'inS with the age of
ri™*fow?££l Cf°mP amt' fr°T ten dr°^S t0 half a drachm,
withcara^ra&t^ nd ^0f ^ a^ie's to iTt *"*' ^ "
little laudanum is added. *' t0 Wh,ch' 0n oc™sions, a
174 DISEASES OF THE RESPIRATORY APPARATUS.
There is yet one other remedy of admitted power that has been prescribed
with notabfe benefit in the disease before us. I now refer to the arsenite
of potassa (Fowler's solution), which, as an anti-spasmodic and exerting a
powerful influence on the nervous system, may readily be supposed to be
actively remedial in the simple spasmodic form of hooping-cough. I have
seen it very speedily control cases of considerable severity and of long
standing, beginning in adose of two drops twice a-day, gradually increased
to four drops. A safer remedy, although analogous in some important par-
ticulars in its operation, is the sulphate of quinia, from which I have also
derived good effects in the more advanced stage of the disease. In this
second or apyretic period of hooping-cough tincture of cantharides has
been highly lauded by Dr. Graves (A System of Clinical Medicine). He
cites the prior experience, in its favour, of Dr. Thomas Beattyand that of the
father of this gentleman, when used according to the following formula :—
f&. Tinct. Cinchin. Comp. §v.
------CanthariHis,
------Opii Oamphorat. aa. 3ss.
M. Ft. Mistnra.
One drachm of this may be taken in linseed tea or barley-water three
times a-day ; and in persons above five or six years of age, the dose may
be daily increased one-third, until half an ounce is taken three times in
the day. Tincture of cantharides used in this way produces its good
effects, as we learn from the Dublin gentlemen just named, without giving
rise to pulmonary irritation.
Revulsives in the shape of counter-irritants to the skin, and applied more
particularly to the nucha and along the dorsal spine and also to the chest,
have from time immemorial been much used. Of these it will be sufficient
to designate oil of turpentine with certain adjuvants ; also tincture or juice
of garlic, tincture of assafcetida, croton oil, &c. Assiduous friction alone
along the spine, two or three times a-day and persevered in for a consid-
erable period each time, will be of good service. Warm pediluvia and
the warm bath are serviceable in the earlier periods of the disease ; the
tepid and shower-bath in some of the more protracted, but yet simple
cases. Change of air is recognised among the chief agents of an hygienic
nature, as a means of giving speedy and after a little while entire relief to
patients who had been brought to a very low state, and in whom supervened
emaciation and night sweats, by the duration and violence of the disease.
Vaccination has been spoken of in very decided terms as an efficient
means of moderating the violence of pertussis. Of its value in this way I
know little from personal experience, and in looking to others for counsel
I find the evidences of too contradictory a nature to allow of my reaching
a positive conclusion.
During the paroxysm itself, some minute but not unimportant matters of
detail should be enjoined on the patient or attendant of the little invalid.
It ought never to be left alone ; and on the coming on of a fit it should
be made to sit up and allowed a firm support, particularly for its head,
which should rest on the hand of the person who has charge of it at the
moment. Mucus collected in the back part of the mouth and pharynx
should be detached and brought out by the finger or a feather. With the
same view the patient should be induced to take a few mouthfuls of tepid
or even cold drink. Where the paroxysm has been violent and unduly
SUMMER CATARRH, ETC. 175
prolonged, a compress dipped in cold water and applied to the lower part
ofthe sternum has displayed a tranquillising operation.
Summer Catarrh — Summer Bronchitis — Hay Asthma — Hay
Fever.—A troublesome bronchitis attacks some persons uniformly in
summer, and owing to the accidental circumstances of individual suscep-
tibility to being strongly impressed by vegetable odours and exposure to
emanation from hay, the disease has been supposed to be the product of
such exposure, and hence has been called hay fever or hay asthma. But
even were we sure that this vegetable effluvium is not a coincidence
merely with the coming on of the disease from other causes, we could
still only receive it as an occasional cause. Persons living entirely in the
city without exposure to any such effluvium are affected in a similar
manner.
The peculiarity of this disease consists more in the season at which it
makes its attack, and the marked annual periodicity of its visits, even to
a particular day in the month,—with some in June, with others in Au-
gust,—than in any symptom or order of symptoms varying from those of
catarrh or bronchitis. It exhibits in different subjects all the varieties of
these latter. Sometimes it spends its force on the mucous membranes of
the eyes and nose, giving rise to all the unpleasant symptoms of coryza ;
then, again, it exhibits itself, as in the case of a youthful patient of mine,
in the form of catarrhal ophthalmia ; but more commonly it settles on the
tracheo-bronchial mucous membrane, causing the phenomena of bron-
chitis with greater or less oppression in breathing, and at times almost
simulating asthma. But in no one of its modes of manifestation can it
excite suspicion either of any specific cause or of peculiar organic seat or
symptomatology.
One diagnostic feature has been assumed for it by some patients and
their physicians; in the fact, as they believe, that it will run its course
despite of any mode of treatment or attempt at prevention, except in this
latter case entire change of air by travelling be procured. But even this
is not always effectual prophylaxis. The marvel here, as respects per-
sistence of definite duration, is not greater, however, than we often meet
with in cases of common bronchitis when it attacks certain persons, who
will tell you that it is no use for them to take any medicine—their cold
will run its course. The fact I believe to be very problematical in either
common winter and vernal or in summer bronchitis. But, be this as it may,
the inference that the disease should be allowed 1o go on through its entire
period without recourse to therapeutical means is erroneous, and leads to
mischievous results.
All the precautions required in a case of common acute bronchitis to
prevent remoter bad consequences, such as chronic bronchitis, dilated
bronchia?, development of tubercular disease, are equally demanded in
the affection now under notice. In some cases venesection will be re-
quired to relieve bronchial and associated pulmonary congestion, — fol-
lowed by tartrate of antimony and opium. In others cups to the chest, or
leeches to the trachea or under the clavicles, and calomel, will answer
the same purpose. Those oppressed with tenacious mucus will be relieved
by an emetic, and afterwards the use of alkalies with hyosciamus and
ipecacuanha. To the aged and the constitutionally feeble we give early,
after appropriate evacuation, whether by bloodletting or by purging,
tonics, alternating or combined with some of the stimulating gums.
176 DISEASES OF THE RESPIRATORY APPARATUS.
They who may object to a course of medicine, as they term it, will still
receive benefit by some revulsives to the skin, such as croton oil or tartar
emetic. Considering the strictly periodical returns of summer bronchitis,
it would be well worth while to excite cutaneous irritation by these means,
and to keep it up two or three weeks, before the usual time for the coming
on ofthe disease. The use of some ofthe narcotic extracts with sulphate
of quinia or a preparation of iron during this period, by also contributing
to the same end, would be worth a trial, and, consistently with this view
ofthe case, would be a change of regimen so as to produce a modification
of the customary functional actions.
LECTURE XCVII1.
DR. BELL.
Hemoptysis—May be called bloody secretion—Is idiopathic or secondary ; the last
variety most common—Active and passive—Structural changes—Causes,—age, inhe-
rited predisposition, certain employments, atmospheric exposures, plethora, compres-
sion of the chest—Tubercular diathesis and disease the most frequent cause—Next
to this diseases of the heart—Hemoptysis often vicarious—Apoplectic congestion of
the lungs, an effect from a common cause—Explanation of its origin—Symptoms—
Quantity of blood discharged, variable—The physical signs few—Progress—Diagnosis,
not easy—Prognosis—Treatment—Indications, to arrest the discharge and to prevent its
return—Venesection to be freely used at first—Attention to posture—First remedies
simple—Cold sponging of the neck and chest—Risk of reaction, unless suitable deple-
tion is practised—Leeches to remote parts,—vulva or anus—Active purging—Pecu-
liarities sometimes following the use of leeches—Sugar of lead—Tartar emetic—Blue
mass with laxatives—Astringents—Narcotics and chalybeates.
Hemoptysis (from *ip*. blood, and vtvet, to spit)—Broncho-Hemorrhage—
Pneumo-Hemorrhage—Spitting of Blood.—The term hemoptysis is applied
to a discharge of blood, or a hemorrhage from any part of the mucous mem-
brane of the air-passages—larynx, trachea, and bronchia?; although, for
the most part, the last, or the bronchial mucous membrane, is the seat of
the disease.
Appropriately does the consideration of hemoptysis, which is, for the
most part, bronchial hemorrhage, follow that of bronchitis and bronchial
congestion ; the former being in truth but a modification of the latter;
the discharge of blood giving the relief from the inflammatory congestion
ofthe bronchia? in one case which the secretion of mucus and pus affords
in the other. In hemoptysis the secreting point may be said to be trans-
cended, and blood is exhaled from the bronchial mucous membrane.
This disease is either primary or idiopathic, or it is secondary and
symptomatic. An attention to these two distinct varieties will not only
influence our prognosis, but also guide us in the treatment. The first is
often without danger, curable with ease, and when cured will leave the
person attacked in good health, and open to the common chances of lon-
gevity. The second variety, associated as it often is with tubercles ofthe
lungs, is of bad augury ; not so much on account of the disease of the
bronchia?, as because it indicates a certain degree of advance of phthisis
pulmonalis. The bursting of softened tubercles into the bronchia? is often
accompanied with a slight hemorrhage, from the rupture of small vessels,
CAUSES OF HEMOPTYSIS.
177
which soon stops spontaneously. But, on the other hand, a rupture of a
bloodvessel traversing a tuberculous excavation may give rise to losses of
blood of much more gravity, and which may even prove speedily mortal.
It is only in such cases as these that there is any foundation for the once
current pathology of hemoptysis, in making the disease depend on rupture
of vessels. For the most part, it is, as already indicated, a true bloody-
exhalation or hurried secretion from the capillary exhalent and secreting
vessels of the mucous tissue. Another division, into active and passive,
is not without its use, if we understand by those terms the states of the
system generally rather than of the affected organ. The local irrftation
giving rise to hemoptysis may be associated with a sthenic diathesis and
plethora, and in this sense the disease will be active ; or it may be con-
nected with asthenia, and even anemia, and so far passive.-
The structural changes produced by, or rather associated with, and fol-
lowing simple hemoptysis, are not numerous nor well marked. Blood,
more or less fluid, has been found in the bronchia? ; and when coagula are
present, they exhibit, at times, fibrinous concretions in the form of polypi.
The mucous membrane is commonly a little softened and tinged with
blood in its entire substance: but in general its alterations are not different
from those met with in simple bronchitis. Sometimes, even, it is pale,
or at most presents a light rosy tint. A similar state of other mucous
membranes which were the seat of hemorrhages has been observed ; as
those from the intestines, which have been found pale, with slight injec-
tion in some points. We may, as M. Andral suggests, attribute this want
of colour of the mucous membranes, after death from hemorrhage, to the
circumstance of the blood having escaped from the vessels in place of
remaining in them and giving rise to the appearance of congestion and
inflammation. But in hemoptysis dependent on pulmonary apoplexy or
pulmonary hemorrhage ; that is to say, when bronchial hemorrhage has
succeeded to hemorrhagic effusion into the pulmonary tissue, the organic
changes are more evident. Portions, not indeed large, of the substance
of the lungs, are found indurated equally as in the greatest degree of hepa-
tization. The extent of lesion is both small and circumscribed; the pul-
monary tissue around being quite sound and crepitant, and having none
of that appearance of progressive induration which we find in pneumonia.
The indurated portion is of a very dark red, exactly like that of a clot of
venous blood, and quite homogeneous ; disclosing nothing ofthe natural
texture of the part, except the bronchial tubes and the larger bloodvessels.
In hepatized lung after pneumonia, on the other hand, we can perceive,
says Laennec, who draws the contrasted picture which I am now copying,
the dark pulmonary spots, the bloodvessels, and the fine cellular intersec-
tions; all of which give to this morbid state the aspect of certain kinds of
granite. M. Andral's description ofthe appearance of indurated portions
of the lungs in hemoptysis with pulmonary apoplexy is nearly similar to
that of Laennec's, as will be seen by reference to his Clinique Medicate.
The tissue ofthe lung at the indurated portions, says this writer, was very
hard, black, and granular, when cut into ; and there issued out from them
a liquid similar to coagulated venous blood by strong pressure. Around
this altered tissue the lung was pale, crepitous, and engorged with serosity.
In a majority of cases, the exhalation of blood takes place in one lunc
alone. b
The causes of hemoptysis are numerous and diversified. The period
VOL. ii.—13 r
178 DISEASES OF THE RESPIRATORY APPARATUS.
of life which predisposes to it are of youth and adult age, or from 15 and
20 to 30 and 35 years of age. In some rare instances, this disease has been
noticed in infants at the age of three months (Dr. Morris—Transact. Col-
lege of Physicians, Philadelphia). As regards sex, women are more liable
than men, in the proportion, according to Louis, of three to two: their
liability is greatest in the period between 40 and 45 years of age. The
sanguine and nervous temperaments are the most predisposed. Persons
whose parents had suffered from the disease, or were phthisical, or who are
themselves threatened with consumption, are in most dangerfrom hemopty-
sis. This is increased by certain employments, such as of a tailor or shoe-
maker, which require the body to be much and long bent forward. Sudden
variations of temperature, and particularly change to a dry, cold air, are
enumerated among the causes of spitting of blood, which is, on this ac-
count, more frequent in spring and autumn than at other seasons. The
excitement from long exposure to a burning sun has a similar morbid
effect in some instances. Maritime exposures, and particularly those to
the east wind, is a too frequent cause of hemoptysis, and should be care-
fully shunned or abandoned by those who are predisposed to its attacks.
If elevated regions have contributed to produce the disease, we must
attribute the results rather to the cold, and in the case of travellers ascend-
ing high mountains, to the great muscular effort and excessively hurried
respiration in consequence, than to the rarefied atmosphere.
Hemoptysis has supervened on protracted mercurial treatment, the use
of iodine, the inhalation of irritating gases ; also after strong moral emo-
tions, excessive venereal indulgences, and prolonged wakefulness. It
may be caused by general or local plethora ; the latter induced by ardent
spirits, loud and protracted speech, the suppression of an habitual hemor-
rhage, blows on the chest, or compression of this region. Unhappily the
examples of the force and frequency of this last cause are multiplied from
day to day by the terrific practice of corseting, so general among women,
both gentle and simple, beautiful and ugly ; whether they be attendants
on the ball-room or the church, giddy or serious, religious or profane. It
is doubtless owing to this cause that, as M. Andral thinks, consumption is
so frequently met with in the other sex. M. Louis, it is true, does not
join in this latter"opinion.
M. Andral gives the following statement, as the result of his own ob-
servations, in regard to the relative frequency of the several modes of
connexion between hemoptysis and consumption.
Ofthe persons whom he had known to die of that disease, one in six
never spit blood at all. Three in six (or one-half of the whole number)
did not spit blood until the existence of tubercles in the lungs was already
made certain by unequivocal symptoms. In the remaining two-sixths, the
hemoptysis preceded the other symptoms of tubercular disease, and seemed
to mark the period of its commencement.
By this comparative statement you will see how very frequently hemop-
tysis occurs as one of the symptoms connected with tubercular phthisis.
Under this physician's observation it happened in five cases out of six.
In the experience, however, of Louis, the proportion, though very large,
is not quite so great as Andral found it. Among eighty-seven instances
of consumption, there were fifty-seven, or four in every six, in which
hemoptysis had been present.
Next to tubercular disorganization of the lungs, the most frequent source
STATE OF THE LUNGS IN HEMOPTYSIS.
179
of pulmonary hemorrhage is to be found in organic disease of the heart.
It has been stated by Chomel, Bouillaud, and others both in this country
and abroad, that the disease in these cases is most commonly situated in
the right chambers of the heart. But this is certainly a mistake. The
error has arisen from arguing upon erroneous analogies, instead of attend-
ing to matters of fact. However, the statement is just as little supported
by reason as it is by the result of general experience. The only alteration
in the right cavities ofthe heart which we could suppose likely, u priori,
to cause pulmonary congestions, and thereby hemoptysis, would be in-
creased strength and thickening of their muscular parietes—hypertrophy ;
a morbid condition which is comparatively rare on that side ofthe heart,
and which, perhaps, would not suffice for the production of hemoptysis,
even if it did not oftener exist. The direct effect, on the other hand, of
any obstacle to the free passage of the blood in the right chambers of the
heart, would be to gorge the liver, and the system of the vena portce; and
to prevent the lungs from receiving their due proportion of blood. But
any material obstruction existing in the left auricle or ventricle will im-
pede the return of the blood from the lungs, lead to their accumulation
in those organs, give rise to mechanical congestion, and so dispose
strongly to pulmonary hemorrhage.
Hemoptysis is often vicarious of the menses, and recurs under such cir-
cumstances with considerable regularity; discharges of this kind are not
always incompatible with life, since they have been known to take place
for a period of thirty, and even forty years, as in the cases stated by Pinel.
Laennec thinks that suppression of hemorrhoids more frequently gives rise
to pulmonary apoplexy, which is sometimes an immediate and always a
serious though far from a necessary cause of bronchial hemorrhage. Pul-
monary congestion and the hemorrhage under consideration are notunfre-
quently dependent on hypertrophy of the heart, and dilatation also of its
cavities. Illustrative of the pathology of the disease and the real origin of
the apoplectic congestion, the following remarks of Dr. Watson (op. cit.)
are quite appropriate:—
"In truth, the morbid condition ofthe lungs which I am now speaking
of, has been badly named. The application, by Laennec, of the term
apoplexy to the lungs was singularly unfortunate; for it suggests an analogy
between two things, which, though resembling each other in the appear-
ances which they leave behind them in the organ affected, are yet, essen-
tially, unlike. I have shown you, in a previous part of the course, that
cerebral hemorrhage depends almost always upon the giving way of a
bloodvessel, in consequence of the morbid brittleness of its coats; while
what is called pulmonary apoplexy can very seldom indeed be so caused.
The notions which I have been led to form upon this subject differ mate-
rially from those which you will find expressed in the works of almost
every writer on pulmonary apoplexy. The opinions I entertain were stated
several years ago, in some lectures which I was appointed to deliver before
the College of Physicians; and I have constantly been in the habit of
mentioning them to the pupils of the Middlesex Hospital, and to my medi-
cal friends. It is a matter of satisfaction to me to find that they are es-
teemed to be correct by so sound a pathologist as Dr. Carswell, who has
alluded to them in one of his fasciculi on the Elementary Forms of Dis-
ease. Laennec speaks ofthe pulmonary apoplexy, as if it were the cause
of the hemoptysis. But this is surely a very incorrect view of the matter.
180 DISEASES OF THE RESPIRATORY APPARATUS.
The partial engorgement and the hemoptysis, are not mutually connected
with each other as cause and effect, but they are concurrent effects of the
same cause; of that cause which gives rise to the extravasation or exhala-
tion of the blood in the first instance. A part of the blood so extravasated
passes outwards by the trachea and mouth; while a part is forced in the con-
trary direction,into the ultimate divisionsof the bronchi,soas to filland block
up the whole tissue of a single lobule, or of a bunch of contiguous lobules,
and thus arises the circumscribed variety. Andral conceives that the san-
guine effusion takes place in the uliimate air-cells; and he applies to this
form of disease the term pneumo-hemorrhage, to distinguish it from ordi-
nary hemoptysis, which he calls broncho-hemorrhage; and this I believe
to be the true pathology of the uncircumscribed variety. But it seems to
be vastly more probable that, in the other form of the complaint, the seat
of the effusion is in one or more of the larger branches of the air-tubes;
and that the blood, a part of it at least, is driven backwards into certain
of the pulmonary lobules, by the convulsive efforts to respire which the
patient makes when threatened with suffocation by the copious expulsion
of blood, or by a paroxysm of cough and extreme dyspnoea; especially if
the blood is poured out from the membrane while the chest is in the state
of expiration. It is easy to understand how certain portions of the lungs,
without undergoing any actual change of texture, may in this manner be
so choked up and crammed with blood, which afterwards coagulates, so
as to preclude any subsequent admission of air."
" The principal symptom attending the formation of these masses is he-
moptysis; and the principal, though not the only cause, is disease of the
heart. The hemorrhage is often severe and copious in the first, or circum-
scribed form; sometimes slight and scanty, but commonly slow, oozing,
and persistent, in the second or uncircumscribed form. The heart disease
is in its left chambers, and very often consists in contraction ofthe mitral
orifice. No example of pulmonary apoplexy, or of pulmonary hemorrhage,
even apparently dependent upon hypertrophy of the right side of the heart,
has ever fallen under my notice."
By Dr. Graves (op. cit.) another view of hemoptysis is taken, deduced
from known anatomical and physiological peculiarities of circulation and
sanguineous supply in the lungs. He points out the fact ofthe bronchial
mucous membrane receiving its supply of blood from the bronchial arteries,
and the pulmonary vesicles from the pulmonary artery ; and, also, of the
want of direct communication between these two sets of arteries. An in-
direct one, it is true, is established by a system of capillary vessels, but
this does not prevent the separate phenomena being manifested by the bron-
chial arteries on the one part, and the divisions of the pulmonary artery
on the other, in the case of hemoptysis. Thus the hemorrhage from the
bronchial mucous membrane and consequently from the bronchial arteries,
although it may be copious, yet when it is accompanied by cough, heat,
and constriction of the chest and fever, it is generally scanty and is seldom
dangerous. The blood of this variety of hemoptysis is florid and arterial.
The hemorrhage from the branches of the pulmonary artery is attended by
different phenomena: the blood escapes from them in two directions into
air-cells and into the cellular tissue which connects them. That portion
which gets into the air-cells will also get into the bronchial tubes, and may
be spit up, while that portion which gets into the intervesicular cellular
tissue has no such exit: there it must remain and become coagulated and
SYMPTOMS OF HEMOPTYSIS.
181
solidified. To the union of these two last states, viz., spitting of blood
and effusion into the cellular tissue, the term pulmonary apoplexy has been
applied. In this variety or effusion from the pulmonary arterial branches
into the cavities of the air-cells and outside their cavity into the cellular tis-
sue, the blood is black or dark, and if coagulated some time in the air-
cells and bronchial tubes, it will become coagulated and be spit up in
clots. Many ofthe worst cases of spitting of blood are attended with this
symptom ; and hence a difficulty in establishing a diagnosis and in receiv-
ing as correct one of the current signs of hemoptysis, viz , that the blood
spit up is florid and frothy.
The blood effused into the cellular tissue of the lungs soon loses its
serum by absorption, while its crassamentum, retaining its colouring mat-
ter, is solidified. One beneficial effect of this process is to arrest the fur-
ther effusion of blood, which it does by the pressure of the coagulum on
the bleeding air-cells, and thus, by preventing the passage of the blood
from the pulmonary artery to the pulmonary vein, it stops the circulation
entirely, in the diseased part.
Among the curiosities of this disease may be mentioned its originating
sometimes from strong sensations; such as the impression of music, above
all, on phthisical patients. M. Andral relates the case of a young man
who spit blood whenever leeches were applied to his chest. Sometimes
this discharge has come on in consequence of the application of a sinapism
or a blister; means these, in other cases, of arresting the disease. Frank
tells us of a person who could not sleep during the day without a spitting
of blood resulting; and that he saw another who was seized with hemop-
tysis whenever he ate honey, and another again after having eaten aspa-
ragus. In very nervous subjects the disease has been brought on by strong
odours.
In the symptoms of hemoptysis we note considerable variety. These
have been met with in persons who have been attacked, without any
precursory or even associated symptoms, and who enjoyed good health
afterwards, as they had before. Very generally, however, the disease is
ushered in by numerous and marked symptoms. Among these I may men-
tion a feeling of heat and weight, and an inexpressible uneasiness in the
chest, or in some part of that cavity; a saltish taste, or that of blood, in
the mouth. Soon afterwards the extremities and sometimes the whole sur-
face ofthe body are cold, and irregular chills are experienced in the back
and loins; the countenance is changed, the face becoming alternately pale
and flushed: there is a singing in the ears, lustre and injection of the eyes,
headache, and palpitation. The pulse is accelerated, full, hard, and vi-
brating: pain and uneasiness in the limbs are complained of. The labo-
rious breathing is augmented, and the patient feels a kind of bubbling
caused by the passage of air during the movements of inspiration and ex-
piration, and at the bifurcation ofthe bronchia? a sensation of tickling and
pricking. Now comes on expectoration, consisting of mucus streaked
with blood, or of pure blood, or this fluid is ejected by mouthfuls. It is
florid and frothy, unless it has been retained for a time in the bronchial
cells, in which case it is dark, and towards the end of the attack clotted.
Sometimes the quantity and rapidity ofthe discharge are such that one
would describe it as a vomiting of blood. After it has ceased the patient
commonly experiences relief, especially from the oppression, palpitations,
and headache. This absence of disease may be either temporary or per-
182 DISEASES OF THE RESPIRATORY APPARATUS.
manent. Often, at the expiration of a not well-defined period, the same
symptoms of congestion, already enumerated, are manifested, and are fol-
lowed by fresh hemorrhage. In some cases, this kind of paroxysm has
returned five or six times in the course ofthe day ; its intensity diminish-
ing, however, at each repetition. The quantity of blood discharged is
very variable ; some persons only giving out a few drops, others many
ounces, and even some pounds, in the twenty-four hours.
There are hardly any physical signs of bronchial hemorrhage : nothing
peculiar is indicated by percussion ; the chest being perfectly sonorous,
and auscultation only shows a mucous rattle or rhonchus with unequal
bubbles, usually larger than those of catarrh, and formed, one may sup-
pose, of more liquid materials. The rattle is more or less evident accord-
ing to the quantity of blood effused. These remarks apply to simple
bronchial hemorrhage ; but when it is associated with and kept up by
that congested and indurated state of a portion of the lung called pulmo-
nary apoplexy, auscultation makes us acquainted with the true diagnosis.
In this case the stethoscope, according to Laennec, furnishes us with two
principal signs, viz., 1, the absence of the sound over a small, circum-
scribed space ; and, 2, the crepitous rhonchus around this space. This
rhonchus, which here indicates the slight infiltration of blood, already
described, is always found at the commencement of the disease, but it is
frequently wanting in its latter stages. When these signs, and the fact is
of great importance, coexist with pulmonary hemorrhage, we may be
assured that the origin of the discharge is in the pulmonary substance, and
not in the bronchia? simply. If the induration of pulmonary tissue is ex-
cessive, the absence of sound, or at least of sonorousness on percussion
joined with the signs already indicated, leaves no doubt of the nature of
the disease, and prevents its being confounded with any other except peri-
pneumony ; and even then only in cases in which the spitting of blood
is not very considerable.
In the spitting of blood which accompanies tubercles of the lungs, we
can determine the nature of the cause or combination by the physical signs
characteristic of the tuberculous affection, to be hereafter described.
Commonly the hemorrhage in this case is bronchial or simple ; whilst
that connected with pulmonary apoplexy depends more on hypertrophy
and other affections of the heart, and particularly of its right side.
The progress of hemoptysis is not by any means uniform. It has been
already stated that, in some cases, the attack takes place but once, and
with its cessation the person is left in good health. There are individuals,
and particularly of the female sex, who spit a little blood every day for
months and even years. In some it is readily re-produced by the same
causes which brought it on at first; in others it comes on without obvious
cause. Appearing for the most part at irregular intervals, bronchial
hemorrhage is sometimes periodical: in some women it supplies regu-
larly every month the menses. Moseley and other writers relate cases in
which it has corresponded very accurately with lunar epochs, in the male
sex. After the cessation of the active discharge there is cough, and the
mucus expectorated is usually mixed for some days with dark or clotted
blood, which daily diminishes in quantity.
The diagnosis is not always easy, particularly between pneumonia and
hemoptysis, if the latter be dependent on pulmonary apoplexy. In pneu-
monia the sputa are distinct, and, as it were, fused, which is not the case
PROGNOSIS AND TREATMENT OF HEMOPTYSIS. 183
in the other disease. In nasal hemorrhage the blood sometimes passes
into the posterior nares, and thence into the fauces ; and is brought up by
hawking, sometimes accompanied by cough, but the fluid is dark, and
not frothy, like that which comes from the bronchia? : there are no signs
of thoracic disease, and inspection ofthe throat will generally show some
dark clots adherent to the pharynx. If we look at the nares, also, we
shall see, generally, traces of blood ; and if the patient be made to blow
his nose, clots will appear similar to those brought up from the mouth.
In some cases, again, there is a slight hemorrhage from the vessels of the
pharynx, which, calling the bronchia? into sympathetic irritation, may be as-
sociated with cough, and mixed with the expectorated matter thus brought
up, thereby imposing on the physician as if it were a true hemoptysis. This
latter is usually represented as readily distinguishable from hematemesis,
by the cough, dyspnoea, vermilion colour of the blood, and its mixture
with bubbles of air, when the discharge is from the bronchia?; while in
hemorrhage from the stomach there is nausea, oppression at the epigas-
trium, mixture of the blood with aliment, and with bile and mucosities.
It may happen, however, that the patient is seized with vomiting at the
same time that there is bronchial hemorrhage, and then we may expect to
see alimentary matter mixed with the blood ; nor is the colour of this fluid
always so contrasted in the two diseases as is generally represented by
systematic writers. Costiveness and tardy digestion may accompany both
hemoptysis and hematemesis ; but these symptoms are most common in
the latter. The pulse is generally fuller and harder in the bronchial than
in the gastric hemorrhage. The expectorated blood sometimes comes
from the rupture of an aneurism of the aorta, in which case there is little
time allowed for nicety of diagnosis or recourse to remedies, as the case
at once terminates fatally.
Our prognosis in bronchial hemorrhage or hemoptysis will be inferred
from what has been said in preceding parts of this lecture on the varieties
and progress of the disease. M. Andral assures us, that he has ascer-
tained, by autopsic examinations, that more than a fifth of the cases of
hemoptysis are not tuberculous, that is, are not dependent on or associated
with pulmonary tubercles. In addition to the remarks already made on this
point, I may add, that we see individuals in advanced age who in their
youth had spitting of blood ; some of them valetudinarians, others in
robust health. Still, must we not forget the important and melancholy fact,
that in a large majority of cases of bronchial hemorrhage this is preceded
or followed by pulmonary consumption.
The treatment of hemoptysis resolves itself into, 1, the means of arrest-
ing the discharge ; and 2, those of preventing its return. It consists in
diminishing the sanguineous congestion of the lungs, and in relieving the
opprcs^on of these organs, and consequently the turgescence ofthe bron-
chial mucous membrane, by revulsive action on other organs and tissues.
Venesection and sedatives are employed to meet the first indication ; and
purging, sometimes vomiting, tonics, and external counter-irritants to
meet the second. The very first measures enforced must be absolute
silence and rest in a semi-recumbent posture, and to avoid as much as
possible coughing.
Of the remedial effects of bloodletting, M. Andral is disposed to think
more highly than even our own heroic school at home. Those of the
latter, who derive their notions of French practice from a perusal of some
184 DISEASES OF THE RESPIRATORY APPARATUS.
of the older writers and chance passages in English books, will be sur-
prised to learn that the author just named expresses himself in the follow-
ing manner, on this subject, in his Cours de Pathologie: We have recourse
to emissions of blood either to ward off an attack of this disease, or to
arrest it, or to prevent its recurrence. When a patient, continues M.
Andral, exhibits all the symptoms which characterize the imminence of
hemoptysis, as when he is oppressed and pale, and has rigors through his
frame, bleed him at this time and you will prevent the hemorrhage. Bleed,
also, when the hemorrhage is present, and bleed largely if you wish to
obtain satisfactory results. If you use leeches, take especial care that
they be not applied to the chest, but to the anus, especially when you
have to deal with nervous subjects, or with women.
As a general rule we should draw blood at once from a vein, in an
attack of hemoptysis, and in such quantity as to produce a marked im-
pression on the system, which is measured, not only by a reduction of the
pulse, but by a removal of the oppression, heat, and stricture of the chest,
and a feeling of relaxation bordering on syncope. But in doing this we
must not act empirically, and without an understanding of our true posi-
tion, determined by a knowledge of the premises. In incipient hemop-
tysis, and in the first attack, we should bleed more freely than after the
hemorrhage has been considerable, or in a case in which it has been of
repeated occurrence. We ought, also, to be aware, that a simple idiopa-
thic bronchial hemorrhage will sometimes be of itself sufficient to relieve
the congestion, which may have been but temporary, ofthe mucous mem-
brane ; and that if the discharge do not cease spontaneously, it is readily
stopped by means of an easy application to be hereafter mentioned. When,
on the other hand, we are led to believe, from the habit and general ap-
pearance of the patient, and from the physical signs, particularly those
furnished by auscultation formerly detailed, as well as by the excessive
oppression, and sometimes even acute pain of the chest, that the bronchial
is associated with pulmonary hemorrhage or apoplexy, then should we not
lose a moment's time in having recourse to the lancet, and in procuring a
large abstraction of blood. One bloodletting, says Laennec, of twenty-
four ounces on the first or second day, will have more effect in checking
the hemorrhage, than several pounds taken away in the course of a fort-
night. It is even beneficial, in general, continues this able practitioner
and writer, to induce partial syncope by means of the first bleeding. In
cases of this kind, the fear of exhausting the patient's strength is without
foundation, since we know that the most copious venesection falls short of
the loss of blood sustained from pulmonary hemorrhage, in young and
robust subjects, even in the course of a few mkiutes ; while the debilitating
effect of the hemorrhage is infinitely greater than the loss of blood produced
by the lancet. (Forbes's Translation.) This advice does not asluredly
look like tampering with the disease, by trusting its cure to the expectant
method, which some persons still believe to be synonymous with French
medicine.
Simultaneously with recourse to bloodletting should be the employment
of other auxiliary but not unimportant measures. The position of the pa-
tient must be semi-erect, or sitting, if the strength will allow of it ; or, at
any rate, he should be propped up in bed, so as to have the chest and
shoulders raised ; nor must these parts be enveloped in warm bedding and
clothing; but on the contrary they ought to be exposed to a cool air, and
TREATMENT OF HEMOPTYSIS.
185
even the chest sponged with cold water and vinegar. The remedies at
this time, taken internally, may be of a simple and readily obtainable kind ;
such as vinegar, or common table salt, or mouthfuls of cold and even iced
water. My theory of the effects of this refrigerating or sedative practice
is, that the diminished excitement produced on the capillaries and exha-
lents ofthe skin, and the gastric mucous membrane, is participated in by
those ofthe bronchial mucous, which, in consequence, refuse to give pas-
sage to the blood brought by the larger vessels. But, in advising these
remedies, and I think the remark may be extended to the acetate of lead,
erroneously .called an astringent in place of a sedative, we must be prepared
to see after their use a reaction of the capillary tissue, and a renewal of
the discharge, if it have depended on pulmonary congestion, strengthened
by general plethora, and perhaps hypertrophy of one ofthe great cavities
of the heart. The occurrence of a reaction is not so much an argument,
however, against these sedative or refrigerant agents, adjuvants to blood-
letting, as against reliance on their sole use, unless in simple bronchial
hemorrhage. The inference which I wish to draw from these remarks, is,
that the indication to be fulfilled, not only in hemoptysis, but in other he-
morrhages, is to remove the cause ; as it may be supposed to depend either
on increased raolimen, or undue determination to the lungs, and congestion
of the bronchial mucous membrane. Even if we were possessed of certain
means for curing a lesion ofthe vessels which exhale and secrete blood,
their early employment would be of doubtful efficacy at best, and most
probably decidedly injurious. This is a question which ought to be pre-
sented, from the beginning, to the mind of the physician who has taken
charge of a case of hemoptysis, and who maybe debating with himself, or
with a medical friend, the propriety of trying substitutes for venesection,
in order to arrest the hemorrhage. The quantity of blood, and the exal-
tation of vital phenomena, consequent on or associated with its greater
afflux at this time to the lungs, must be diminished. The means are de-
pletion and derivation. Venesection in the arm or in the foot carries out
both of these objects, but more particularly depletion and unloading ofthe
vascular system. After this, derivation is easier; and when the hemor-
rhage originates in the suppression of some other discharge, it is necessary.
Thus, if habitual hemorrhoids have disappeared, or the menses have been
wanting beyond the customary epoch, leeches to the anus, and a brisk
purge of calomel and aloes, or, for more prompt effect, a stimulating enema,
as of oil of turpentine even, are called for. Without giving it the import-
ance which I once did, and which perhaps some of my professional brethren
are still inclined to do, I cannot but think that the removal of hepatic con-
gestion and of obstruction in the portal circle by active purging, as a
revulsive measure, will contribute to relieve the oppression of the lungs in
hemoptysis. Nor can we overlook the direct sympathy noticed before
between the bronchial and gastro-intestinal mucous membranes, and the
benefit received in phlegmasia and congestions ofthe former by a pouring
out of fluids from the latter. If it were necessary to enforce this view by
collateral aid I might refer you to the observations of writers who, like
Stoll, have noticed the connexion between bilious disorders and hemop-
tysis in certain seasons; and the interesting fact, that free purging gave
prompt relief to the latter complication.
In speaking, as I have just done, of the application of leeches, and of
the employment of purgatives, as both of them answering the indication
186 DISEASES OF THE RESPIRATORY APPARATUS.
for derivatives, I do not mean to affirm that they are either identical or
equally beneficial in their operation. Purgatives follow properly and
safely in subjects of both sexes after bloodletting ; leeches chiefly, if not
only, under the circumstances stated, viz., of suppressed hemorrhoids or
menses. Obviously proper as these last would seem to be from analogy,
and a knowledge of their generally beneficial derivative action, they are
not always safe or useful in hemoptysis, certainly not as a substitute for
venesection in the first attack and early period of the disease. Laennec
has noticed the return of the menses and aggravation of menorrhagia during
the application of leeches to the epigastrium. The first of these effects
I have myself seen from this cause. But still farther, general bleedings,
and more particularly those of small extent, have appeared, under the ob-
servation ofthe French writer just quoted, to have a like effect on hemop-
tysis ; and cases of this kind are clearly those in which purgatives should
have a trial. On this remark, Doctor, now Sir James Clark, has the fol-
lowing comment:—" The fact is not generally known, though it is one of
great practical importance. In a plethoric person threatened with apoplexy
ofthe brain or hemoptysis, the application of leeches may, and, I believe,
frequently does, cause the very occurrence of the disease it was intended
to prevent. I have more than once seen slight hemoptysis follow the ap-
plication of leeches round the anus (and have warned patients not to be
alarmed at it), when applied to obviate pulmonary hemorrhage. In one
case a severe attack of hemoptysis took place a few hours after the appli-
cation of the leeches, requiring general bloodletting, &c. A very small
bleeding may, as Laennec observes, produce the same effect; but inde-
pendently ofthe quantity of blood abstracted, there is a sympathetic effect
produced on the extreme vessels by the action ofthe leeches, or the con-
sequent flow of blood from their punctures, which is very desirable and
useful when we wish to promote a sanguine secretion, as the menses ; but
may be injurious when we wish to obviate an effusion of blood from the
extreme vessels: a general bleeding is by far the better practice in the
cases under consideration."
Upon the whole, then, the safer practice is, after venesection, to purge ;
and in so doing selection should be made of those articles which procure
abundant evacuations without straining, the bad effects of which in con-
gestion or retarded circulation of the lungs can be readily imagined. I
have myself found, that common mercurial purgatives, such as calomel
and jalap, calomel followed by the compound powder of jalap, or by rhu-
barb and magnesia, are preferable to the simple saline ; although theory
would indicate the superiority of these latter on the ground of the more
copious fluid discharges and consequent diminution of the bulk of the con-
tained blood ofthe vascular system following their operation.
Hemoptysis with febrile reaction may at once be treated, after venesec-
tion, or where the hemorrhage is but slight and its returns have been fre-
quent, without this preliminary, by sugar of lead. This medicine has ac-
quired great and in many cases deserved reputation in nearly all the forms
of hemorrhage, particularly when administered in conjunction with opium,
as in the following formula:—
R. Plumb, sub-acetat., gr. xij.
Pulv. opii, gr. j.
Sacch. albi, 3ss.
M. ft. pulv. vj.
TREATMENT OF HEMOPTYSIS.
187
Take a powder every two hours, or until the hemorrhage is arrested. In
cases of general plethora and capillary excitement, the opium is not a fit
addition ; but, on the other hand, where the excitement is unequal and
the plethora local, this medicine contributes very much to equalize the
circulation ; and, by causing a certain degree of fulness of the capillary
circulation in all the organs, to take off the strain upon those ofthe lungs.
Care ought to be used that a simple, and in milder cases a sufficient
remedy, in hemoptysis, diluted mineral acid, and especially the sulphuric,
be not administered at the time in which you are prescribing the sugar of
lead. But, on the other hand, it may be prudent, and will rather aid the
refrigerant effects of the salt of lead, to follow the advice of Dr. Thomson,
by directing your patient to drink dilute acetic acid, in order to prevent
any possibility of the conversion of the acetate into the carbonate, in
which last form alone it is specifically injurious to the animal economy.
My own experience enables me to speak with considerable confidence
of the powers of the potassio-tartrate of antimony, or tartar emetic, in
restraining and arresting pulmonary hemorrhage, and that in the most safe
manner, viz., by diminishing the morbid action of the heart, abating the
inflammatory congestion, as well as producing a sedative impression on
the bleeding capillaries themselves. But whether you choose to adopt
my explanation or not, you may be assured ofthe fact. I give the tartar
emetic in simple watery solution, in the dose of an eighth to a fourth of
a grain, every hour or two, according to the urgency ofthe case and the
toleration ofthe medicine by the stomach, without vomiting being brought
on. Even if nausea and retching should ensue, the state of arterial seda-
tion which precedes will prevent any injurious effect, or any increase of
hemorrhage, which, without such prior depression, would be readily
brought on by vomiting. In the weeping hemoptysis, or oozing of blood,
not much in quantity at a time, but persisting with, at the same time,
febrile reaction, yet not enough to justify venesection, I have prescribed
tartar emetic with the best effect. So obvious, indeed, and at the
same time so mild is it in its effects, that my patients have at different
times asked for a renewal of it, when its use had been temporarily sus-
pended.
When hemoptysis assumes a chronic character, and you have symptoms
of bronchial congestion, with small but frequent discharges of blood, and
associated disorder of digestion, you will find the use of the blue pill in
doses of three to five grains, joined to a grain of ipecacuanha, once or
twice a-day, and, if necessary to procure a full alvine discharge, rhubarb
and magnesia, or a small dose of salts on the following day, a good plan
of treatment ;%to be continued until the tongue is clean and the bleeding
cither arrested or reduced to a very small quantity at prolonged periods.
Sometimes a pill, composed of ipecacuanha and soap, taken two or three
times a-day, for some days, will suffice under these circumstances. If
anemia be present, or the patient much reduced by the hemorrhage and
the vascular excitement be inconsiderable, small doses of the oil of tur-
pentine, as ten to twenty drops in some mucilage three times a-day, are
found to restrain and check the discharge. It is in cases of this nature,
and in scrofulous habits, that the hemorrhage becomes passive. In these,
astringents have been prescribed, such as alum, pure tannin, galls, or rha-
tany in moderate doses. By some of the French writers, rhatany in the
form of extract is preferred to all the articles of the astringent class. It is
188 DISEASES OF THE RESPIRATORY APPARATUS.
given in much larger doses than we are accustomed to prescribe it, as, for
example, a drachm, two drachms, and even three drachms—4, 8 or 12
grammes (Grisolle). In cases of incipient tubercle, the administration of
narcotics and some preparation of iron should be tried, under the hope of
postponing for a time, at any rate, the development of symptoms of phthisis.
With this view, also, even more than merely to prevent the recurrence of
hemorrhage, a permanent discharge from the inside ofthe arm by a blister,
or from the chest by means of tartar emetic, may be kept up with good
effect.
All the customary means of giving tone to the general system, without
any special strain upon the lungs, should be had recourse to. Of these
the chief are, plain nutriment, moderate exercise, especially on horse-
back, and alternately with that on foot; the tepid and after a while, if the
reaction be sufficient, the cold bath, by momentary immersion or by
shower; frictions, and great attention to preserving the feet warm and
dry. In a case which came under my care nearly twenty-five years ago,
I directed cloths dipped in cold water to be applied to and wrapped round
the chest, with the effect of speedily arresting the hemorrhage. The pa-
tient himself was much pleased with the remedy. He eventually, as I
learned, sank under phthisis pulmonalis. Late hours and nocturnal
excess of any kind must be avoided by the invalid, who'is fearful of a
return of hemoptysis.
LECTURE XCIX.
DR. BELL.
Pneumonia—Transition slight from vesical bronchitis to pneumonia—Definition—
Varieties—Syniptoms—Chief diagnostic marks of pneumonia—Stages of Pneumonia—
Measured by auscultation—Minute crepitation in the first stage—Condition of the
lungs in the first stage, or that of engorgement—Microscopical characters—Second
stage, or that of hepatization—State of the lungs in—Microscopical characters—
Changes of position of individual lobes—Third stage, or that of suppuration—Products
of deposit in the pulmonary cells—Change of respiratory sounds in the second stage
of pneumonia—Morbid anatomy—Appearances of the lungs in the three stages of
pneumonia—Inflamed bronchiae with pneumonia—Appearances in catarrhal pneumo-
nia,—in hypostatic or senile pneumonia,—in circumscribed pneumonia—Gangrene
of the lungs—Local symptoms resumed—Percussion—Cough—Appearance of the
sputa—'I'heir microscopical characters—Different states of the expectoration—Colour
of the sputa—Dyspnoea—Pain — Decubitus—General symptoms—Febrile phenomena
—frequent pulse and respiration, and disordered digestion—State of the skin—Pun-
gent heat of the surface—Urine—Disorder of the liver,—jaundice—Delirium, when
occurring—The blood in pneumonia,—exhibits the characters of hyperinosis.
Pneumonia—Peripneumony—Pneumonitis—Pulmomtis—Inflammation
of the parenchymatous structure of the lungs.— The passage from the bron-
chial tubes, and more especially their vesical terminations, to the adjoining
tissue external to them or the pulmonary parenchyma, is indeed slight;
and, as Dr. Stokes aptly remarks, he who would call pneumonia a bron-
chitis of the terminal tubes would be hardly guilty of a misnomer. In
fact, between vesicular bronchitis and pneumonia, which is believed by the
best pathologists to consist in inflammation of the pulmonary vesicles, the
difference is but nominal. Even if we suppose different parts to be
VARIETIES AND SYMPTOMS OF PNEUMONIA. 189
affected in the two diseases, how slight is the line of demarcation between
the terminations ofthe bronchia? and the pulmonary cells. The surface is
continuous in both, and in its properties is nearly identical. Rokitansky
(Manual of Morbid Anatomy) thinks that pneumonia, having its seat in
the air-ceils, might be denominated parenchymatous croup.
A comprehensive definition of pneumonia is given by Dr. Williams
(Cyclopaedia of Practical Medicine), viz., Fever, with more or less pain in
some part of the chest; accelerated and somewhat oppressed breathing, cough
with viscid and rusty-coloured expectoration; at flrst the crepitant rhonchus,
afterwards bronchial respiration and bronchophony, with dulness of sound
on percussion in some part of the thorax. He adds : pathologically, pneu-
monia consists essentially in an inflammation ofthe parenchyma ofthe lung,
occasionally but not necessarily extending to the pleura investing them ;
which inflammation, though it usually occasions a certain combination of
general symptoms, is not so essentially connected with these symptoms as
to receive from them an infallibly pathognomonic character.
The chief recognised varieties of pneumonia are the vesicular, the lobu-
lar, and the lobar, according as patches of vesicles alone, or those of an
entire lobule, or an entire lobe or all the lobes of a lung, are the seat of
inflammation.
Inflammation attacking the vesicles, the parenchyma remaining intact,
is vesicular pneumonia. But in what does this differ from vesicular bron-
chitis ? Or, again, the inflammation may attack not only the separate
vesicles, but all the vesicles of a lobule, without the parenchyma being
affected. All parts of the lung may suffer in this way ; but the lesion is
most manifest at the external portions, the root, the inferior lobe, and the
central vesicles. This will constitute lobular pneumonia. Finally, the
entire lobe of a lung and all the lobes of a lung may be seized with inflam-
mation, constituting lobar inflammation. Lobular pneumonia is most com-
mon in children.
Rokitansky makes four varieties of pneumonia ; viz., croupal (ordinary
or plastic pneumonia), typhous, catarrhal, and interstitial; dependent to
some extent on the peculiarities in the state of the blood. Catarrhal
pneumonia, rarely seen in adults, is quite common in children : it is always
lobular, always has a bronchitis of the tubes belonging to the diseased
portion ofthe Jung associated with it, and is a frequent concomitant ofthe
various diseases of childhood, especially of hooping-cough and suffocative
catarrh. Its especial seat is in the superficial lobules, many of which are
often affected, and which become bluish-red, dense, and moderately firm.
The interstitial pneumonia is that usually described as chronic,—some-
times it occurs spontaneously, and spreads from one lobule to another. It
is most frequent at the apices of the lungs. More commonly it is a conse-
cutive affection. There are also hypostatic or senile pneumonia, typhoid
pneumonia, and bilious pneumonia.
Symptoms.—The symptoms of pneumonia are local or general:—1.
Those furnished by the lungs. 2. Those by the other organs or organic
tissues sympathetically and secondarily disordered with the pulmonary.
Under the first head we include cough, expectoration, pain, dyspnoea,
decubitus, and the signs furnished by percussion and auscultation. Before
speaking of these in succession, I may as well at once tell you of the three
received diagnostic marks of pneumonia. They are: 1, the crepitating
sound transmitted when the ear is applied to the chest, or rather to that
190 DISEASES OF THE RESPIRATORY APPARATUS.
part in which is contained the diseased lung ; 2, the rust colour of the
sputa ; 3, the peculiar pungent heat ofthe skin.
I shall begin with what the auscultatory phenomena of pneumonia
offer to us, and connect these with a description of the several stages of
the disease.
Stages of Pneumonia.—The division made by Laennec of pneumonia
into three stages, has been generally adopted by succeeding pathologists.
They are, 1, of engorgement or congestion (engouement); 2, hepatization
and red hepatization or red softening; 3, suppuration or grey hepatization,
or grey softening. I shall describe these several stages in connexion with
the phenomena which they elicit by auscultation.
Auscultation, either by applying the ear to the chest, or by the inter-
vention of a stethoscope, enables us to reach generally an accurate diag-
nosis of pneumonia. The sound heard at this time, if the diseased part
be that chosen to which to apply the ear, yields the crepitating rhonchus
of Laennec, or the fine crepitation, as some others term it. This kind of
crepitation does not, however, entirely replace the respiratory murmur of
health, which is more or less marked on the occasion ; but in proportion
to the intensity of the inflammation is the intensity of the crepitation,
which, after a time, entirely conceals the respiratory murmur. By some
observers (Drs. Gerhard and Rufz), this crepitation is said to be wanting
in children between five and ten years old suffering from pneumonia: by
others (MM. Rilliet and Barthez), it has been distinctly heard. With
the exception of three cases, it has always been blended with bronchial
respiration, in the experience of these last-mentioned writers.
The crepitating rhonchus or the minute crepitation, is characteristic of
the first degree of pneumonia, or that of turgescence and engorgement,—
the second of Dr. Stokes, who believes intense respiratory murmur in the
affected part and fever to be indicative ofthe (his) first stage, and the pre-
cursor of crepitation. In the^rs^ stage the pulmonary vessels are so much
distended that the whole tissue is of different shades of red, and the pul-
monary cells, ordinarily filled with air, become, for the most part, con-
tracted and more solid than before. The blood contained within the
capillaries has, also, undergone a change, both in its physical and other
qualities. The stasis of the blood in the capillaries is attended with a
solution of the colouring matter of the blood-corpuscles, and its blending
with the serous portions of the blood. The walls of these little vessels
are now so far changed as to admit of an exosmosis of their contents, and
the tenacious, rust-coloured, and semi-transparent sputa form in the pul-
monary vesicles, and in the minutest bronchial tubes. Viewed under
the microscope these latter display within an amorphous, or slightly granu-
lated mass, a tolerable quantity of blood discs, a proof that at the outset
of inflammatory stagnation, the smallest vessels undergo partial rupture.
This first stage is designated by the term sanguineous infiltration, (engoue-
ment).—Hasse, op. cit.
The minute crepitant sound of the first stage of pneumonia may undergo
two kinds of change: either it is replaced by the respiratory murmur, indi-
cating a termination of the disease by resolution, or it is lost entirely, no
sound at all being perceived; the morbid phenomena are increased and the
lung becomes hepatized. This is the second stage of Laennec: it is often
reached very rapidly, or after two or three days' disease, more especially
in young and vigorous persons, otherwise prone to plastic exudation. In
STAGES OF PNEUMONIA.
191
rarer instances the first stage is of longer duration, lasting for ten days or
upwards, and then passing, if there be any tendency to the formation of
heterologous products, into a chronic state, or proceeding promptly to the
third and commonly fatal stage.
Hepatized lung is denser and more solid than before ; but it is also
more friable ; more easily crushed and broken. If we take a portion of
hepatized lung, and examine the torn surface with a magnifying glass, the
pulmonary tissue will appear to be composed of a crowd of small, red
granulations, lying close to each other. These are, we may presume, the
air-vesicles clogged up, thickened, and made red by the inflammation.
The colour of hepatized lung will vary much, according to the quantity of
blood left in it; if this be much, it will be red ; if little, pinkish-brown,
or reddish-grey ; if mixed with the black pulmonary matter, a granite-like
aspect. Lung thus diseased does not collapse when the thorax is laid
open : the marks of the ribs are frequently visible on the surface. The
texture ofthe lung at this time is sometimes so soft that a moderate degree
of pressure between the fingers reduces it to a state of pulp. Sometimes
the state of organic change just described is confined to certain limited
portions of the pulmonary lobes, and then it is called lobular pneumonia.
In the stage of hepatization or red softening, gorged capillaries have
thrown out their soft contents (decoloured blood, serum, and fibrin) into
all the interspaces ; and the tissues have lost their distinctive characters,
and become uniformly macerated. The decomposed blood within the pul-
monary cells is now transformed into a coagulated mass (plastic lymph) of
slight consistence. Viewed under the microscope the exudation of genuine
pneumonia reveals a distinctly granulated condition. The effused sub-
stances display a number of blood discs, imbedded in a nearly amorphous,
slightly granulated or striated mass. When some time elapses before the
coagulation of the effused substances takes place, nuclei, which are mixed
with the elementary granules, have become sheathed in spherical cells—
exudation cells. The amorpho-granular mass, after coagulation, is made
up chiefly of exudation cells and pus-globules. In this stage of pneumonia,
granule-cells appear to form in very small number, and often not at all.
The change in position of the individual lobes, in the stage of hepa-
tization, is important in aiding us to trace the progress of pneumonia by
percussion and auscultation. The inferior, which is the lobe the most
frequently affected, is enlarged posteriorly ; its apex being elevated to
above the third rib, whilst in front it is apparently of the breadth of a
couple of fingers only. The middle lobe and the superior half of the
upper lobe occupy almost the whole anterior surface of the thorax, whilst
the inferior and half of the superior lobes cover, in equal proportions, its
lateral surface.
The third stage of Laennec, to which inflammation brings the lungs, is
that of suppuration or grey hepatization. This consists in the conversion
of the semi-solid particles of lymph or blood, which constitutes the solid
or red hepatization, into an opaque, light-yellowish, friable matter, and
finally into a fluid pus. This suppuration is generally diffused in the
form of purulent infiltration; but it is very rare to find it assume the cha-
racter of a distinct abscess. This last is an uncommon termination of
pneumonia. In several hundred dissections of persons dead of this dis-
ease, made by Laennec during a space of more than twenty years, he
only met with five or six collections of pus in the inflamed lung. Once
192 DISEASES OF THE RESPIRATORY APPARATUS.
only did he find a large abscess of that sort. Andral has only once seen
a real abscess of the lung form as a consequence of pneumonia. Phle-
bitic deposits of pus and sometimes tubercular vomica? and cavities, may
have been taken for genuine abscesses ofthe lung.
Suppuration begins at one or several points of a hepatized portion of
lung, nay, each individual air-cell must be considered as a separate sphere
of suppuration, so that the coagulated fibrin partly liquefies, partly changes
into free exudation and pus-corpuscles. The suppuration, for the most
part, spreads very rapidly, without, however, time being allowed for its
taking up so much room as the fibrinous exudation, death commonly
ensuing shortly after the commencement of the third stage. The dirty-
grey appearance of the suppurating portion of lung arises from the admix-
ture ofthe purulent fluid with black pigment. In the course ofthe third
stage, the circulation through the diseased portion of the lung appears to
have been almost wholly interrupted ; at least the smaller twigs of the
pulmonary artery, and sometimes, also, ofthe pulmonary veins, are found
filled with clotted blood, or with fibrinous concretions. (Hasse.)
In this stage it is evident that the sero-sanguineous effusion poured into
the pulmonary cells, and there coagulated, is converted into a mixed fluid,
holding suspended a number of real pus-globules, whereby the utmost
degree of softening is communicated to the tissues.
The deposition of lymph which constitutes hepatization of the lung com-
pletes the obstruction ofthe minute tubes and cells ; hence all crepitation
ceases, and the only sounds that reach the ear are those of the air and
voice in the larger tubes. Instead of the respiration with its prolonged
murmur, there is only a short whiffing, as Dr. Williams expresses it, con-
fined to parts only of the respiratory act, and often ending abruptly with
a click. This bronchial whiffing is not heard in every case, but only
when the hepatization involves considerable bronchial tubes ; and it is
most commonly found in the middle portions of the chest. M. Andral
designates the sound given out at this time, on applying the ear to the
chest, by the term tubal respiration, owing to its resemblance to the
sound which would be produced by blowing into a tube close to the ear
of a listener. It is a variety of bronchial respiration. The voice is modi-
fied at the same time in a peculiar manner, in its passage through the lungs
and parietes of the chest, on reaching the ear of the physician applied to
the latter. The vocal resonance of the tubes is also transmitted by the
condensed lungs to the parietes, as a vibration or fremitus, which may
be distinctly felt by the hand placed on the affected side, and which is
much stronger than that on the healthy one. This affords an easy mode
of distinguishing between a hepatized lung and a pleuritic effusion ; for
the latter when considerable generally abolishes completely the vocal
vibration.
Often we hear in the same patient and at the same time different signs
furnished by auscultation, which announce different stages of pneumonia.
On the healthy side we hear, by auscultation, the normal respiration, of
much more intensity than in health. Sometimes auscultation supplies us
with negative results. This happens when the fluid accumulated in the
bronchia? is in quantity enough to cause so strong a bronchial rhonchus as
to cover all the other sounds. If the inflammation be very limited and
only occupy a part of the base, centre, or root of the lungs, auscultation,
M. Andral thinks, gives no indication to guide us. Auscultation traces
'MORBID ANATOMY OF PNEUMONIA.
193
the morbid changes in the lung through the stages of engorgement to
hepatization. "Can it," says Dr. Watson, "trace it any farther? I
believe not, with any certainty." But, at last, h'e adds,—the structure of
the lung breaks down, and a portion of it is expectorated, and finds its
way into the vacant spot, and gives rise to large gurgling crepitation.
Among the local symptoms should be noticed a diminution in the motion
of the affected side, in proportion as the air fails to get admittance into
the inflamed lung, grey softening or purulent infiltration.
Morbid Anatomy of Pneumonia.—Many of the details under this head
have been anticipated in my remarks on the different stages ofthe disease,
and the anatomical characters of each. These I shall not repeat. Inci-
sion ofthe substance of the inflamed lung in the first stage of pneumonia
is followed by the escape of a somewhat frothy and reddish serum ; the cut
surface itself is deeply red and the pulmonary tissue of the inflamed part
is more friable and is easily torn with the point of the finger. In the second
stage or degree the pulmonary tissue ceases to crepitate, is quite imper-
vious, so heavy as to sink in water, is of a deep-red colour externally and
when cut into presents a like hue or more generally a mottled or marbled
appearance. The fluid which escapes after the incision is red, without
bubbles of air, and less in quantity than that in the first stage. The chief
anatomical character at this time is furnished by an inspection of the cut
surfaces of the inflamed lung, which are studded with red hard granula-
tions, rounded and somewhat flattened, and which are, in fact, pulmonary
vesicles transformed into solid bodies by the thickening of their sides and
filling up of the cavities. This granulated arrangement is still more evi-
dent when the lung is torn. Sometimes it is absent in the case of the
pneumonia of newly born infants and in old persons. The morbid alte-
ration is not confined to the pulmonary vesicles,—it prevails equally in
the intervesicular cellular tissue. Taking into consideration the increased
hardness ofthe lung at this time, it has been proposed to designate the
second stage or degree of pneumonia by the term red induration ; M. An-
dral, likewise, from a review of some of the peculiarities of pulmonary
tissue such as its greater readiness of laceration, thinks that red softening
(ramoUissement rouge) is an applicable title.
In the third stage of pneumonia the lung presents at first the size, hard-
ness, and imperviousness which it had in hepatization, but when complete
the grey or straw colour replaces the red, at first in disseminated spots and
afterwards through the entire organ. When abscesses do form by the union
of several centres of suppuration they rarely communicate with the bron-
chia?. Their seat is mostly under the pleura.
One stage is invariably developed out of another. Thus hepatization
always begins at the centre of a patch in the first stage of inflammation,
and spreads on every side towards the margin ; meanwhile a sound neigh-
bouring patch becomes involved in the first degree, and so on. Purulent
infiltration, in like manner, always commences at the centre of a hepatized
portion. The duration of the respective stages is indefinite ; the third
stage may, however, be attained within five or six days (Hasse).
Both lungs may be inflamed at the same time, and this (double pneu-
monia) is quite common in old persons, and children under six years of
age. But the right, in persons of all ages, is, M. Grisolle assures us, more
frequently attacked than the left, in the proportion of 11 to 5. The dif-
ference is explicable, he thinks, by the difference in volume and capacity
VOL. n.—14
194 DISEASES OF THE RESPIRATORY APPARATUS.
of the two lungs. Pneumonia of the inferior lobe is more frequent than
that of the upper lobe, in the proportion of 4 to 3. The disease is repre-
sented to spread, in its course, from below upwards, from behind forwards,
and from right to left ; but in these respects there will be differences ac-
cording to the form of the disease. Still farther, we learn that, when both
lungs are affected with pneumonia, the inferior lobe of the right lung is
mostly found hepatized, and partially infiltrated with pus, and the upper
lobes, and likewise the inferior lobe of the left lung, in the first stage of
the disease.
Inflamed bronchia?, so common an accompaniment to pneumonia, are,
of course, seen in fatal cases of this latter. The attack is often begun by
bronchitis, which may mask the other disease. Sometimes bronchitis is
consecutive on the pneumonia. Mechanical alteration of the bronchia?,
sometimes noticed in fatal pneumonia, consists in their obliteration, which
always begins in those of a medium calibre. More frequent still are the
cases in which the pleura participates in the inflammation of the lung
proper. This state is recognised, after death, by an injection of varying
distinctness, in albuminous concretions, slightly serous, purulent, or bloody
effusions. Pleuritic effusion is seldom extensive when pneumonia coexists
with the pleurisy.
Rokitansky thus describes the post-mortem appearances after catarrhal
pneumonia : " It is always lobular, always has a bronchitis of the tubes
belonging to the diseased portion of the lung associated with it, and is a
frequent accident ofthe various catarrhal diseases of childhood, especially
of hooping-cough and catarrhus svff'ocativus. Its especial seat is in the
superficial lobules, many of which are often affected, and which become
bluish-red, dense, and moderately firm. The walls of the air-cells are
swollen even to the closure of their cavities, which, when the swelling is
less, contain a watery, mucous, and slightly frothy secretion. There is
no trace of a granular texture discernible. The pulmonary substance
around the diseased lobules being, for the most part, emphysematous, they
appear (when they are situated at the surface) depressed somewhat below
the level and are distinguished by their dark colour." Gradually, during
the disease, the colour changes to a brown-red and eventually to a yellow-
brown. The texture of the lung, from being at first saturated with a turbid
reddish fluid, ultimately assumes the aspect of a pale, yellowish-brown puri-
form one. When a large proportion of pulmonary lobe becomes thus dis-
organised, which is, however, rare, it is found shrivelled, lax, moist, of a
yellow-brown hue, and wholly devoid of air, resembling a wet rag. This
kind of catarrhal pneumonia appears peculiarly calculated, as Hasse ob-
serves, to produce obliteration of the pulmonary texture, with permanent
exclusion of air therefrom, and consequent general dilatation of the seve-
ral branches ofthe bronchia? implicated.
In hypostatic pneumonia which affects aged persons, the morbid changes
are spread over the posterior surface of all the lobes, penetrating thence
to the depths ofthe lung. The most deeply-situated portions of the lung
are here the most intensely inflamed, being found generally in the second,
less frequently and only partially in the third grade or stage. In other
cases the pulmonary tissue is chiefly affected about the roots of the bron-
chia? and bloodvessels. In this senile pneumonia the bronchial mucous
membrane is always much reddened, and the air-passages, from the
trachea to the minutest bronchial ramifications, filled with a turbid, tena-
LOCAL SYMPTOMS OF PNEUMONIA.
195
cious mucus. The pleura is frequently implicated in this variety of pneu-
monia.
Hypostatic pneumonia must not be confounded with that state of the
lungs met with in the persons who die of typhous fever. The pulmonary-
tissue in this latter case is, likewise, of increased gravity, little permea-
ble, and mostly softened ; but careful comparison shows that these changes
are the result of stagnation of, for the most part, diseased blood. The
lung is not so much distended as it is collapsed: and stained of a blue-
black, by imbibition of its fluid blood ; and although the stain cannot be
removed by careful washing, yet the substance of the lung may be, in a
great measure, restored to its natural state, and the tissue will fail to
exhibit any inflammatory product. This stagnation of blood is always
equally diffused along the posterior surface of the lung, whilst the anterior
half is generally observed to be bloodless and dry,—but otherwise per-
fectly sound.
There is a circumscribed pneumonia, virtually lobular, also consequent
upon great surgical operations. It is distinguished by circular patches of
a spherical shape, isolated in the centre of a sound lung, and of the size
of a walnut. They have the appearances of abscesses, but do not contain
fluid matter; their consistence, in fact, being greater than that of portions
of lung in the third degree of inflammation. The adjoining tissue of the
lung is in a state of red or grey hepatization, but beyond this it is per-
fectly healthy, only somewhat moister than usual. Sometimes these puru-
lent deposits are deep-seated, but more frequently seem to be superficial,
and near the pleura.
Gangrene is an unusual result of pulmonary inflammation ; being nearly
as uncommon as the formation of an abscess. It seems, however, as re-
marked by Dr. Williams, to arise pretty generally from the influence of
those noxious gases which directly destroy the vitality ofthe tissue ofthe
lung. The lungs of persons who have died some days after being nearly
asphyxiated in sewers, have been found reduced, in parts, to a dark-brown,
greenish, or livid softening, having a very fetid odour, and being probably
the result of the poisonous influence of the gas on a congested lung.
I now resume a more particular consideration of the local symptoms.
Percussion does not show any change in the sonorousness of the chest, in
the first stage of pneumonia ; and it is until the second or third day that a
dull sound is evident. As the disease disappears the natural sound of the
chest is restored. Percussion cannot be practised when the walls of the
thorax are painful or covered with a vesicated surface, or where there is
deformity of the chest. In practising percussion, do not forget.that the
liver on the right side, and the spleen on the left, will cause a dull sound
on percussion ofthe lower part ofthe thorax.
Cough is present in a very large majority of cases of pneumonia ; but
it exhibits no peculiarity, nor are its violence and frequency proportionate
to the violence of the disease. The expectoration in the beginning of
pneumonia is commonly null, or analogous to that in acute bronchitis.
From the second to the third day it assumes its characteristic appearance :
the sputa become sanguinolent, owing to the intimate mixture of blood
with mucus. Their colour varies with the quantity of blood which they
contain ; and hence they may be yellow, rusty, or of a decided red ; and
they may even pass through all these shades in the same day. Their den-
sity augments as the disease advances ; they become viscous, tenacious,
196 DISEASES OF THE RESPIRATORY APPARATUS.
transparent, and strongly adherent to each other. So decided, at times,
is their gelatiniform consistence, that the vessel containing the sputa may
be completely inverted without their being detached from it. This last
change is seen when the inflammation passes to the second stage, for so
long as it remains in the first, the sputa have not tenacity enough to adhere
to the sides of the vessel.
A new diagnostic feature of the sputa in pneumonia has been announced
by M. Remak. It is, the appearance of fine fibrinous threads of the form
and diameter of the extreme bronchial ramifications. In order to see them
distinctly the sputa are to be poured into and well washed with water.
Under the microscope they are seen to consist of very«delicate fibres laid
lengthwise and inclosing cell-like bodies resembling those of pus. These
fibrous concretions mostly make their appearance from the third to the
seventh day of the disease, but are never seen, according to the author's
observation, in the last stage or that of purulent infiltration. These concre-
tions, considering their coincident appearance with the crepitant rhonchus,
that is to say in the first stage, indicate in M. Remak's opinion a decidedly
favourable result to the case. These observations have been confirmed
by Schonlein.
It is important for you to know that pneumonia of a fatal kind may go
through its course without either cough or the expulsion of any sputa
whatever, or even pain. This latent form, as it has been called, is mainly
met with in lobular pneumonia, which, we may add, is confined almost
entirely to infantile subjects. There are cases, again, in which the sputa
at the beginning ofthe pneumonia may be bloody, but in which they soon
cease to appear at all during the whole course of the disease up to the
period of entire resolution. With the entire absence of expectoration
there must also be an absence of crepitus and of course of the crepitus
redux which Laennec and others speak of as indicating the resolution of
hepatized lung.
A termination of the disease in resolution is indicated by a less height-
ened colour and viscidity of the sputa ; but if, after becoming thinner,
they are again tenacious, they indicate that the pneumonia is paroxysmal.
Sometimes, even although the sputa have lost all their pneumonitic cha-
racters, and exhibit those of the catarrhal state, yet auscultation still ap-
prises us of a crepitation or crepitating rhonchus (rale) of more or less
duration.
A suppression of the expectoration may occur from an exasperation of
the disease ; and also from an excessive viscosity of the sputa, or from
the weakness ofthe patient ; and in these cases the secreted matter may
accumulate in the trachea, and cause death by asphyxia ; or this result
may be brought about by a suppression of the secretion itself.
The expectoration may be also suspended by other diseases complicated
with pneumonia, by purgatives given early in the disease, by excessive
bloodletting or its unseasonable repetition ; and by all the causes which
aggravate pulmonary inflammation. In some cases of fatal pneumonia the
sputa are not suppressed ; but they are smaller in quantity, become changed
in their appearance, and are opaque and mottled with dirty, reddish-grey
streaks, resembling those seen in the last stage of consumption.
When pneumonia terminates by suppuration, the sputa are greyish,
inodorous, and in a measure purulent; even in the red hepatization they
may preserve the same characters ; and, finally, they may lose their vis-
GENERAL SYMPTOMS OF PNEUMONIA.
197
cosity, and resemble a liquid of the consistence of gum-water and of the
colour of liquorice or prune decoction. The termination in gangrene is
manifested by the expectoration of a greenish matter, which yields after a
while a dirty-grey, and exhales an insupportably fetid and characteristic
odour. When pneumonia passes into a chronic state, the sputa are like
those of pulmonary catarrh. All cases of pneumonia are not characterized
by distinct expectoration: some of them slight, some grave, running their
course to a happy or fatal termination ; and yet the sputa merely resem-
ble those of a simple bronchitis. In intercurrent or secondary pneu-.
monia particularly, we must not be surprised at the absence of expecto-
ration.
The colour of the sputa is attributed generally to the blood, in varying
quantity, mixed with them. They are rarely tinged by bile.
The dyspnoea is usually in proportion to the extent and seat of the
inflammation ; although in this respect there are great differences among
different individuals. When the breathing is hurried and laborious, and
the feeling of oppression so great that the patient sits up in his bed, com-
plains of a weight in his chest, has the face of a violet-red, or of a livid
hue, and pants to such a degree that speech is extremely difficult, if not
impossible,—we must augur an unfavourable termination. Dyspnoea may,
it is true, remain after the danger is over ; and in such a case it is owing
either to the imperfect resolution ofthe disease, or to the weakness ofthe
patient.
Pain, according to Andral, is never felt in pneumonia, unless there be
pleuritis coexisting; but Laennec asserts that simple inflammation of the
lung has given rise to pain ; a fact which he had an opportunity of ascer-
taining by dissection of the patient after death. Commonly, the pain is
felt behind the mamma, or a little below or just above and between it and
the clavicle ; or in one or other of the hypochondria. It is increased by
coughing, change of posture, pressure on percussion.
As to the decubitus, it is not correct that the sick always lie on the
affected side: the posture is generally on the back.
Of the other tissues inflamed in conjunction with the pulmonary, in
pneumonia, the pleura is by far the most frequent; pleuritis presenting
itself in 33 out of 35 cases. It is less frequent among old persons and
children. The bronchial glands are also in a morbid state, being swelled,
red and softened in pneumonia. Fibrinous concretions in the cavities of
the heart are also quite common. Softening of the gastro-intestinal mu-
cous membrane occurs in a fourth part of pneumonitic cases.
General Symptoms.—Among these, the most constant is disordered cir-
culation, manifested by a frequent and rather full and sometimes hard pulse,
which becomes small when the inflammation is very violent, but acquires
volume after bloodletting. We are taught to mistrust acute bronchitis, in
the course of which an intense febrile disturbance supervenes, even
although expectoration and auscultation should not furnish any character-
istic signs of pneumonia. A chill is the customary prelude or announce-
ment ofthe inflammation of the lung, and the fever thenceforwards lasts
as long as the disease. A very frequent pulse is a bad sign in pneumonia,
as it indicates intense inflammation. Rarely does the case terminate
favourably when the pulsations exceed 140 in a minute. Coinciding with
this morbid state of the circulation is the frequency ofthe respiratory move-
ments ; and when this correspondence is destroyed by the pulse becoming
198 DISEASES OF THE RESPIRATORY APPARATUS.
slow, and yet the respiration remains much hurried, we have reason to
fear a fatal result; in fact, approaching death. Should the pulse be still
frequent when the other morbid symptoms have in a great measure disap-
peared, there are probably some remains of phlogosis. If intermittent, we
are to attribute it to some disease of the heart. The belief entertained by
the old writers, and still accredited by some of the moderns, that the fever
precedes the pneumonia as its cause, is not correct.
The febrile suffusion of the cheeks is sometimes more manifest on one
side, that, as we read, which corresponds with the side of the affected
lung ; but in this respect there is no uniformity. The redness of one
cheek more than that of the other may depend on the patient's habitually
lying on one side. Disorder of the digestive functions is chiefly manifested
in anorexia and a white and somewhat loaded tongue. There is not much
thirst. The cutaneous exhalation differs in different cases ; the skin is
often dry from the beginning ; at other times bedewed with moisture,
which is converted into a copious sweat. This last symptom, generally
described as either indicative of a milder disease or of an approaching
crisis, I have found not seldom to precede a fatal termination ; and hence,
unless a free and particularly a viscous sweat be associated with favoura-
ble symptoms, indicating an abatement ofthe inflammation, it ought to be
regarded with mistrust. If the skin has remained dry through the whole
of the period of the disease, and towards the decline of the latter it is
covered with sweat, we may regard this as critical and of good augury.
Without attaching to it all the importance which it is thought to merit
by the gentlemen themselves, I shall repeat in their own language what
Drs. Bright and Addison say respecting pungent heat of the surface, as
diagnostic of pneumonia :—
" Of all the symptoms of pneumonia, the most constant and conclusive in
a diagnostic point of view is a pungent heat of the surface ; by this symp-
tom alone the first stage of pneumonia may in most instances be readily
recognised ; by this symptom alone pneumonia has been repeatedly pro-
nounced to exist, before asking a single question, or making the slightest
stethoscopic examination of the chest. The presence of this symptom will
seldom mislead even in the most complicated forms of inflammation within
the chest. It is by no means contended that it is necessarily present at
some period of every case, although that is not probable ; but it may be
safely affirmed, that when inflammation is confined to the chest, however
varied may be the tissues involved in the inflammatory process, provided
this symptom be present, pneumonia may be confidently pronounced to
form a part in nineteen cases out of twenty, and perhaps in a larger pro-
portion. A similar pungent heat ofthe surface is now and then observed
in certain forms of renal dropsy ; more frequently in continued fever, espe-
cially in children ; and still more commonly in the eruptive fevers of the
exanthemata and erysipelas; and as such cases may supervene upon
already existing disease within the chest, the fact ought to be carefully
remembered."—Elements of the Practice of Medicine, pp. 241-2.
The urine is of a deep-red during pneumonia, and deposits a lateritious
sediment at its decline. It must be subject, of course, to considerable
variations, dependent upon the extent of the disease and the degree of
inflammation. When this is severe, the urine is very dark, of high spe-
cific gravity, and frequently sedimentary, especially at critical periods
during the fever. An appreciable amount of albumen is by no means
GENERAL SYMPTOMS OF PNEUMONIA.
199
rare. The urine, for the most part, remains acid during the whole period
of inflammation, and Becquerel found the same to be the case during the
period of convalescence also. The mucus is increased during the febrile
period. Andral's observations show that while in some cases the sedi-
ments are for the most part spontaneous, and composed of amorphous uric
acid, in others, and they the majority, the urine remained clear during
the whole course of the disease ; and in a third class, again, the urine was
alternately clear and turbid or sedimentary. Simon, from whom I now
quote, mentions the occurrence, in a case of pneumonia in Schonlein's
wards, and in two cases of peripneumony, of deposits of ammoniaco-
magnesian phosphate ; he also tells us that precipitate induced by the
addition of acids to the urine gradually crystallized and showed uric acid,
and hence that the turbidity and precipitate were caused by the decompo-
sition of a urate. In one case the urine emitted an odour of hydrosul-
phate of ammonia, and deposited a sediment of uric acid during the dis-
ease. In pneumonia it may be said that, in general, the urea is a little
diminished, the uric acid is increased, the salts are diminished, and the
extractive matters, especially the alcohol extract, are increased. Accord-
ing to Schonlein, the crisis in pneumonia shows itself in the urine by
the secretion becoming sedimentary ; after ten or twelve hours, a crystal-
line micaceous deposit forms, above which the urine becomes clear. But
among the glandular organs, there is no one, the functions of which are
so disordered in this disease as those of the liver. Inflammation of the
right lung is often attended with hepatic irritation, and the flow of bile
is followed by bilious vomiting or stools. In other cases the liver is dif-
ferently affected : the biliary secretion is impeded, and then predominates
what is called the bilious diathesis. This is the bilious pneumonia of
Stoll and other writers, and is a complication quite common in our Middle
and Southern States. The tongue, eyes, and skin, are yellow ; the pa-
tient exhales what has been called a bilious odour, and he is tormented
with cephalalgia in the lower part of the forehead, head, or back of the
eyes. In fine he has complete jaundice.
There is not, often, much disorder of the nervous system in pneumonia.
When delirium occurs, we should regard it as the result of cerebral com-
plication rather than a regular symptom of the disease. It is most apt to
supervene on the sixth day, or from this to the ninth. At times, how-
ever, there is great prostration of force, and from the very outset an
adynamic or typhoid state manifests itself. This is most common in old
persons. To this complication I shall refer under the title of typhoid
pneumonia.
The blood in pneumonia exhibits the characters of hyperinosis more
decidedly in pneumonia than in most other inflammatory diseases ; it also
retains its heat for a longer period. The clot is rather below the ordinary
size, is very consistent and does not break down for a considerable time.
It admits of being sliced, and the sections retain their consistence for some
time. Its surface is covered with a buffy coat, and is more or less cupped.
The serum is of a pale-yellow colour. The quantity of solid constituents
is usually less than in healthy blood. Simon tells us that the maximum
of fibrin in his analyses was 9*15, which is the largest quantity he ever
discovered in inflamed blood. The minimum was 3-4, and the mean of four
analyses was 6-0. Andral and Gavarret found the maximum of fibrin to
be 10-5 ; the minimum 4 ; and the means to fluctuate between 7 and 8.
200 DISEASES OF THE RESPIRATORY APPARATUS.
They never met with more than 10-5 of fibrin in the whole course of their
analyses. The maximum of ha?mato-globulin was, in Simon's experiments,
78, and the minimum 36, which is very far below the amount in healthy
blood. Heller observes that he has often been able to detect biliphcein
in the blood of patients with bilious pneumonia where there have been no
other indications of a disordered state of the hepatic functions.
LECTURE C.
DR. BELL.
Pneumonia (Continued)—Symptoms of Infantile Pneumonia—Difficulty of diagnosis in this
disease__It always follows capillary bronchitis—Is catarrhal pneumonia—Peculiari-
ties of respiration in the young patient—Physical signs—Bronchial respiration the
most important— Expectoration — Percussion — Anatomical characters—Symptoms
and diseases precursory of pneumonia—Commonly the disease attacks suddenly—Is
preceded sometimes by intermittent fever and cholera, measles, rheumatism and gout
__follows surgical operations—Progress of sthenic pneumonia—Sudden sinking-
Case__Prognosis and Termination—(Critical evacuations and critical days—Age modi-
fies results—The old and young most apt to sink under pneumonia—Part of the lung
most liable to inflammation—Which side most affected—Complication with other dis-
eases increases danger—Causes—External and internal—Climates and countries in
which pneumonia prevails most—Is a common disease in southern Europe—Winter
and first spring months the chief seasons for pneumonia—Immediate or exciting
cause__Particular employments less apt to cause the disease than is supposed—Inter-
nal causes—Liability of the disease to return in the same person—Tuberculous phthi-
sis—nge—Young children most liable—Sex:—.Men much more liable than women—
Treatment—Great mortality in pneumonia—Contradictory reports of different modes of
treatment.
Symptoms of Infantile Pneumonia.—The importance but yet difficulty of
diagnosis of pulmonary inflammation in children and the frequency ofthe
disease, will justify my making some additional remarks on this topic.
Acceleration of the pulse and of respiration are important symptoms in
the disease, and influence not a little our prognosis. They may, when
there is no complication of other acute diseases, be taken as a measure of
the intensity and extent of the inflammation. Infantile pneumonia is re-
presented by M. Grisolle to be always consecutive to capillary bronchitis;
and hence it may be regarded as catarrhal pneumonia. The catarrhal
period varies from several days to as many weeks—after this the symp-
toms are all at once exasperated and the disease sets in with violence.
At the outset ofthe disease there are some peculiarities in the mode of
respiration, and, if the child be still fed from the breast, of sucking, men-
tioned by Dr. West (Memoir on Infantile Pneumonia—Brit, and For.
Med. Rev.), which will aid us in forming a correct, and, what is of great
importance, an early diagnosis. If, while a healthy infant is sleeping, the
mouth be gently opened, it will be observed that the tongue is applied to
the roof of the mouth, and that respiration is carried on through the nares.
So soon, however, as the lungs become affected, even when no other
symptom exists than general febrile disturbance, and perhaps the vomiting
above alluded to, the infant will be seen no longer to breathe solely
through his nose, but to lie with his mouth partly open, and drawing in
air through it. This imparts to the tongue its preternatural dryness, and
GENERAL SYMPTOMS OF PNEUMONIA.
201
the same inability to respire comfortably through the nares causes the
child to suck by starts. The infant seizes the breast eagerly, sucks for a
moment with greediness, then suddenly drops the nipple, and, in many
instances, begins to cry. As the disease advances, these peculiarities in
the mode of sucking and respiration often become more striking, but it is
at the onset ofthe disease that it is of especial importance to notice them,
since they afford most valuable indications of its real nature.
As respects the physical signs of infantile pneumonia, it may be said that
the mucous rhonchus is heard in most cases in which catarrh has preceded
the symptoms of pneumonia proper ; but, Dr. West thinks, it should be
looked on as one of the least important of the physical signs of this dis-
ease, since it was present in thirteen only of fifty-one children under five
years of age. It is of importance, however, in the young subject, as the
immediate precursor of bronchial respiration ; while in the adult there is
no such connexion. " The sub-crepitant rhonchus is a sign of far greater
importance than the mucous rhonchus, whether we regard the frequency
of its occurrence or the consequences which follow it. It was heard in
forty-two out of fifty-one cases ; in thirty-one of which it either had not
been preceded by mucous rhonchus, or if it had, that had ceased before
the patients came (says Dr. West) under my notice."
The observation made by M. Guenard is confirmed by Rilliet and
Barthez ; viz., that these sounds readily disappear if the little patients are
kept seated for a short time ; and that their greatest distinctness is when
the child is raised from the bed.
Bronchial respiration, of all the modifications of the respiratory sound,
deserves, in the opinion of Rilliet and Barthez, the most particular atten-
tion. It was present in two-thirds of their cases, and when its existence
was not ascertained, either the disease was very slight, or it had become
impossible to practice auscultation during the last few days of the life of
the patient. Frequently, the bronchial character was only observed during
expiration, the inspiration remaining perfectly natural, or manifesting a
slight rhonchus. This may be regarded as indicative of lobular pneumonia,
the most frequent form of the disease in children. In those from two to
five years old, the bronchial respiration was, in a certain number of cases,
preceded by rhonchi of different kinds. In children of a more advanced
age, it was ushered in by an obscurity of the respiratory sound, and in
this class, more than in the other, it was the first symptom established.
In children from two to five years, it always existed on the posterior part
ofthe thorax, and, most commonly, near the vertebral column; although,
as Dr. West, who makes a similar observation, adds, it is not by any
means invariably confined to this situation.
The expectoration consists of tenacious and whitish sputa. Death comes
on with great agony and often with symptoms of slow asphyxia.
Percussion is of much less value than auscultation in investigating the
presence and characters of infantile pneumonia. Dr. West describes a
difference between the upper and lower part of the chest as appreciable
long before bronchial respiration becomes audible; when bronchial respi-
ration exists, dulness on percussion can always be detected, and even if
it should be necessary to percuss with the utmost gentleness, so as scarcely
to elicit a distinct sound, the finger is yet sensible of the presence of solid
lung beneath.
The anatomical characters of infantile, which is also lobulated pneu-
202 DISEASES OF THE RESPIRATORY APPARATUS.
monia, consists of patches of hepatization disseminated through one or
both lungs.
The precursory symptoms and diseases on the invasion of pneumonia are
various. Sometimes the patient has felt, for a few days preceding, dis-
comfort, fatigue, anorexia, disinclination to motion without either ausculta-
tion or percussion indicating pneumonia. Occasionally, a day, or two or
three days before the attack, a slight fever, like that which precedes va-
riola, scarlatina, measles, &c, accompanies the preceding symptoms.
This is the inflammatory fever which, in the opinion of some writers, al-
ways precedes the local malady. In some cases all the organs are threat-
ened in succession with disease: to-day, the patient complains of gastric
symptoms ; to-morrow, of a tendency to cerebral congestion; subsequently,
to rheumatic pains, until, finally, the pneumonia discloses itself. M. An-
dral has seen pulmonary inflammation preceded by two paroxysms of in-
termittent fever, and during the cold stage of the third a slight cough su-
pervene, pain appear, the sputa of a characteristic nature ; and, in fine,
all the symptoms of pneumonia evinced. Sometimes pneumonia succeeds
bronchitis; the inflammation, at first limited to the large bronchia?, extends
to the smaller ones, and finally to the vesicles. Nothing is more common
than the union of these two diseases; so much so, indeed, that some have
declared that bronchial inflammation exists in every case of pneumonia.
This union is most common in children, especially when lobular pneumonia
is present. Tubercle is a frequent complication. In the greater number of
cases, however, there are no precursory phenomena, and the patient is all
at once seized with a chill, and pain in one or other side. Commonly the
chill precedes the stitch ; at other times the order is reversed; or, again,
there is neither pain nor chill, but cough and fever are the first declaratory
symptoms. When pneumonia supervenes on violent fevers, it is preceded
by great dyspnoea. Occasionally, I may not say unfrequently, in fever,
the pulmonary inflammation is not revealed by any symptdm, and its pre-
sence is only proved by dissection. Broussais records instances of this in
the intermittent fever which attacked the military in the hospital at Bruges:
it is far from uncommon in our intermittent fever in the United States, and
especially in that marked variety of it called of late years the congestive.
I have had occasion when describing the organs affected in epidemic cho-
lera, to mention the congested lung in many fatal cases of that disease.
This state was most evident in the stage of reaction. Disease of the large
intestine is mentioned by MM. Barthez and Rilliet, as a most frequent
complication; as is, also, gangrene ofthe mouth.
In subjects worn down by cancer and other chronic diseases, Laennec
has pointed out the occurrence of pneumonia, which soon ends in coma,
tracheal rattle, and death. The bronchial affection of measles sometimes
passes into pneumonia of the catarrhal form, especially if the eruption is
repressed or disappears suddenly; but in this case the symptoms are com-
monly urgent and sufficiently characteristic. Pneumonia is sometimes pro-
duced in gouty and rheumatic subjects, and this may occur either vicari-
ously, so that the limbs are relieved, or conjointly with these affections.
P. Frank has remarked that, in rheumatic subjects, pneumonia sometimes
terminates without any expectoration, and with a copious discharge of clear
urine, amounting to twelve pounds and upwards. This curious fact is
another evidence of the connexion which subsists between rheumatic and
gouty affections and a diseased state of the fluids ofthe body.
Inflammation of the lungs sometimes succeeds to and complicates acute
GENERAL SYMPTOMS OF PNEUMONIA.
203
rheumatism. The fact is distinctly stated by Dr. Latham (Lectures on
Subjects connected with Clinical Medicine, pp. 86-7, Am. Edit.). Of 136
cases of acute rheumatism, inflammation of the lungs was found in 24 ;
or in the proportion of 1 in 5^. Of 90 cases of rheumatism in which the
heart was inflamed, the lungs were inflamed in 19 ; here the proportion
is more than one in five. The danger from pneumonia in rheumatism
exists chiefly when inflammation ofthe heart, or rather when endocarditis
or pericarditis is conjoined.
Several surgical writers have noticed the occurrence of pneumonia after
amputation and other great surgical operations, and likewise after exten-
sive wounds; and it has been supposed that this disease is frequently the
cause of death in these cases. Of this form I have previously spoken. I
well remember to have heard Dupuytren frequently speak, in his clinical
lectures at the Hotel-Dieu, of this always troublesome and not seldom fatal
sequence of amputations, particularly in scrofulous subjects; and so im-
pressed was he with the necessity of some preventive measures, that he uni-
formly directed a blister to be applied, and a discharge established, com-
monly on the chest or the inside of the arm, before he removed the dis-
eased limb. M. Erichson (Med. Gaz., 1841), by -whom this subject has
been examined in detail, regards pneumonia thus occurring as in close
affinity with typhoid pneumonia.
The progress of sthenic pneumonia is well and tersely described by An-
dral (op. cit.). From the first to the second day ofthe disease, pain, chill,
impeded respiration, cough without expectoration, crepitating rhonchus,
resonance of the chest, and fever, are the observable phenomena, and
those which constitute the first period of the disease. From the second
to the third day the expectoration is distinctive, by its becoming viscous
and variously coloured. The crepitating rhonchus (crepitation) is more
evident, the resonance of the chest is weaker on the side in which the
pneumonia exists ; the pain is less acute than at the beginning, but the
dyspnoea is increased ; the patient lies on his back ; the fever is violent,
skin dry, sometimes moist. If resolution be not effected in the first stage
of the disease, or that of engorgement, and the symptoms be more intense,
the second stage is reached ; and then the laborious breathing is increased,
the speech is tremulous, the tenacity ofthe sputa is augmented, as is also
the dulness of the chest on percussion : crepitation disappears and yields
to bronchophony ; the pulse is strong, frequent, and full, or it is either
really or apparently feeble. At this stage the pneumonia may terminate
suddenly by asphyxia, or its resolution may still be brought about. In
this latter case there is an abatement of the symptoms and approach to
convalescence. If the pneumonia reaches the third stage, the expectoration
in the larger number of cases is watery and brown, and more or less like
plum-juice. Commonly, also, the face becomes pale and cadaverous some
days before death. There are no definite periods for the several stages of
pneumonia to be gone through. Sometimes suppuration takes place at
the fifth day ; and sometimes the lung is only in a state of red hepatiza-
tion by the fifteenth and even the twentieth day. Whatever may be the
degree and kind of pneumonia, it pursues a uniform course with evening
exacerbations.
In some cases, after the subsidence of pain and all the unpleasant symp-
toms of pneumonia, and when the patient is congratulating himself, and
praising his physician for the removal of his disease and the prospect of a
204 DISEASES OF THE RESPIRATORY APPARATUS.
speedy restoration to health, things take a most unexpected turn. The
pulse becomes slow and wTeak, the skin cool, then cold ; sweat oozes
from every pore, but to increase the coldness and weakness. If the pa-
tient is asked how he feels, his reply is,—" quite comfortable ;" his only
complaint is, that he cannot sleep. Uneasy at this new state of things,
the physician, who had probably already allowTed his patient light nutri-
ment, now makes it more stimulating, by substituting animal broths for
sago, arrow-root, or panada, and bread and tea. He directs, also, wine
and water at intervals, and warm applications to the feet, and frictions of
the skin generally. No reaction taking place, and the serous oozing from
the skin still continuing, more like that in epidemic cholera than any
other morbid state, powerful stimuli are prescribed,—such as volatile
alkali, wine whey, hot brandy and water, and opium in small and re-
peated doses internally, and sinapisms and blisters externally ; but all
without avail. The patient becomes weaker and weaker, and finally
expires without pain, and with less pulmonary oppression than is common
with the dying. In this brief sketch I have had in view an actual occur-
rence. It was in the case of a patient of my own who had been bled
twice ; the first time sixteen, the second twelve ounces, for pneumonia
with a severe stitch in the right side. A blister subsequently applied
removed this pain ; calomel and tartar emetic with a little opium were
given ; and in the course of four or five days the patient seemed to be
out of danger; his pulse good., breathing easy, expectoration free, decu-
bitus natural. In this comfortable state, taking light nourishment and
using some mild diaphoretics with opium, he remained two days, after
which the symptoms already described began to appear. The period of
sinking and collapse was of three days' duration, during which nothing
seemed to arrest the progress towards death ; nor indeed to impart even
temporary force to the pulse or warmth to the skin.
With so vivid a recollection of the case, made to me more interesting
by the estimable character of the man who was its subject, I was attracted
by the heading of a paper in the Edinb. Med. and Surg. Journ. (1840),
entitled, " Remarks on Collapse occurring during the Treatment of Acute
Pneumonic Diseases, by Mr. Kerr, of Paisley." This gentleman gives
the outlines of three cases, two of which were fatal, resembling the one
which I have just described. He does not speak of their putting on any
ofthe symptoms of typhoid pleurisy or pneumonia. Mine had nothing of
that character at its onset; but, on the contrary, exhibited all the symp-
toms of well-marked acute inflammation.
The mean duration of pneumonia is from twelve to twenty-five days.
In some cases it terminates in two or three days; in others, has extended
to thirty and even forty days.
Prognosis and Termination.—The prognosis in pneumonia is always
serious, although physicians are not agreed as to the proportionate mor-
tality ; some rating it at one in three, others at only one in twenty ; and
one in fifty, and even sixty cases. Even of the probable result of cases
apparently favourable, as measured by the symptoms, we ought to speak
with caution. Our opinion will be modified by the stage of the disease,
its duration, and the tendency to a crisis by spontaneous evacuation. A
very frequent pulse, as when it is 120, and hurried respiration, are bad
signs; so is an obstinate cough with scanty or difficult expectoration.
The character of the expectoration will guide us materially in prognosis.
PROGNOSIS OF PNEUMONIA.
205
Thus, in simple pneumonia the viscidity and rusty tinge of the sputa are
in exact proportion to the intensity ofthe inflammation, and their increase
in quantity and diminution, or tenacity and colour, are the common at-
tendants on resolution. Dirty or watery-brown sputa and those contain-
ing pus import great danger, inasmuch as they indicate the probable
supervention ofthe third stage, and a gangrenous odour generally implies
a state of great peril. The sudden suppression of expectoration is gene-
rally an unfavourable sign ; for although the disease may be resolved
without any increase of the expectoration, yet this has always a favour-
able influence and contributes greatly to the cure. A dry, harsh state of
the skin attends bad cases complicated with gastric disease, exhibited in
a loaded or parched tongue, great thirst, sickness of stomach, and tender-
ness of the epigastrium. A moderately perspirable skin is the most
favourable state ; profuse perspirations, as I have already stated, some-
times occur in fatal cases. The same has been remarked of diarrhoea,
yet both these discharges occasionally prove critical. A copious deposit
in the urine may be generally viewed as a favourable sign ; and the ob-
servation of Hippocrates seems to be commonly true, that if, after having
been turbid, the urine becomes clear before the fourth day ofthe inflam-
mation, a fatal result may be anticipated. Delirium is generally con-
sidered to be a symptom of great danger; and it is the more so when it
is constant and not merely the temporary effect of the nightly febrile ex-
acerbations; but in hysterical females it is of less importance. Equally
fearful is a comatose or lethargic state, as it shows that the functional dis-
order has greatly encroached on the strength required for the necessary
treatment.
Ofthe evacuations regarded as critical, Laennec believed the lateritious
sediment in the urine to be the most common : Frank and Andral describe
perspiration as more frequent. Dr. Williams, whose summary of opinions
I am now making use of, believes that the two are commonly conjoined;
and there seldom occurs in pneumonia a perspiration that can be called
critical, without, at the same time, a deposit in the urine. A copious ex-
pectoration of a critical character does not occur so often as is described
by Sydenham and Cullen, and, indeed, by the older writers generally.
Andral, confirming the opinions of Hippocrates and other writers, says,
that there are certain days in the duration of the disease in which there is
a great tendency to amelioration. Of ninety-three cases, he found that
twenty-three gave way on the seventh, thirteen on the eleventh, eleven
on the fourteenth, and nine on the twentieth days. The recoveries in the
remaining cases commenced in twelve out of forty-two non-critical days,
as many as eleven being ascribed to the tenth day. Thus the recoveries
on critical days averaged as high as fourteen, while those on non-critical
scarcely exceeded three.
The age of the subject will modify our prognosis. In children the in-
flammation continues for a much longer period in the first stage ; after
some weeks' duration presenting only some hepatized points at the margin
of the lung or in isolated lobules. The same peculiarity has been noted
by Laennec in certain epidemics. On the other hand, there is a remark-
able tendency to pneumonia in old and debilitated subjects to pass rapidly
to the state of purulent infiltration,—even within a period of twenty-four
to thirty-six hours after the inception of the disease. Gangrene, though
it generally portends death, does not necessarily terminate in this way.
206 DISEASES OF THE RESPIRATORY APPARATUS.
A strong constitution and youth have sufficed to triumph over this sinister
state of things. The extent of the inflammation modifies greatly the prog-
nosis. Thus a double pneumonia affecting both lungs at once is frequently
fatal, even in the first stage; and whenever the whole of one lung is in-
volved there is much danger of an unfavourable issue.
The part ofthe lung that is inflamed will not be without its influence
on our prognosis. It has been a question, disputed by different writers,
as to the relative frequency of inflammation ofthe upper or lower portion
of the lung. Andral's statistics on this point are in favour of the predo-
minance ofthe latter. Of 88 cases of pneumonia, in 47 the inflamraation
was of the inferior lobe, and in 30 of the superior lobe, while in 11 the
entire lung was affected. There is, however, a greater risk of fatal result
when the upper lobe is the part inflamed. Dr. Hughes, in 101 cases,
states, as a result of his inquiries, the inflammation to have attacked the
base alone in 62; the entire lung in 12; the posterior part alone in 8; the
apex in 5; the centre alone in 3. The parts were not mentioned in 2, and
various parts in one or both lungs, without specification, in 9. MM. Val-
leix and Vernois assign, in 139 examples, pneumonia of base and summit,
44; base alone, 44; summit alone, 20; disseminated lobular pneumonia,
31.
From the combined observations of Andral, Chomel, and Lombard, Dr.
Forbes has shown, that out of a total of 1131 cases, the right lung was
affected in 562, the left in 333, and in 236 the disease was double; the
general result of which would be, that out of every ten cases, five would
be of the right, three of the left, and two double. This result is probably
near the truth, and corresponds pretty closely with Dr. Stokes's experience;
but, adds this gentleman, it will be found that the double pneumonia is
more frequent than appears from the above statement. It commonly hap-
pens that, notwithstanding a great preponderance of disease in one lung,
a careful physical examination will detect more or less of it in the other,
even though no local pain or distress exist, which could lead to its detec-
tion. Confirmatory of this opinion I place before you the following table:—
Right Lung. Left Lung. Both Lungs. Unascertained.
Andral (210 cases) 121 58 25 6
Chomel (59) 28 15 16
Valleix and Vernois (128) 17 0 111
Berg (335) 201 134
West (37) 37
Hughes (101) 52 29 19 1
" (145) 43 40 60 2
Total (1015) 462 276 268 9
The complication of other diseases with pneumonia increases the dan-
ger ; as in the case of fevers and the exanthemata, and the more formi-
dable is the inflammation in these cases because it is often latent. Pneu-
monia occurring in the course of a phthisical disease is seldom severe in
itself, but it has a tendency to accelerate the development and softening
of the tubercles. This inflammation is more than usually fatal in preg-
nancy and the puerperal state. It is especially dangerous at the extremes
of life, more particularly in weakly infants and in cachectic old people, and
those exhausted by habitual excesses; and the fatality is much greater
among the lower classes than among those well and regularly fed and
clothed.
CAUSES OF PNEUMONIA.
207
Causes.—The causes of pneumonia may be considered under the two
heads,—of those external, and those connected with the individual him-
self. The first include climate, season, and atmospherical exposures in
general. Pneumonia is a rare disease in hot latitudes, but if scarcely
known in the East Indies, it is of occasional occurrence in the West Indies.
In southern Europe it is far from being uncommon ; as we learn that in
the Archipelago and Greece there is one case of pneumonia to thirty-eight
cases of diseases in general. Of the Ionian Islands, Corfu is said to suffer
most from this disease. The gradual substitution of pulmonary for hepa-
tic disease is shown in the English troops returning from India losing the
latter and becoming subject to the former. In Italy pneumonia is quite
common. At Pavia, it appears, from a return made for a period of
three years, that in the first year one-seventh of the cases received into
the hospitals were of pneumonia ; in the second year, the proportion was
a sixth ; and in the third year, a fourth. At Padua, the proportion is
very variable ; being at one time a fifth, at another a sixteenth, then a
twenty-third, and even a fifty-eighth. At Wilna (Russia), the proportion
is one in seven to one in eight. Pneumonia is very common in Rome,—
a fact long ago pointed out by Baglivi; indeed, there is hardly any differ-
ence in this particular between that city and London. There is good
reason to believe that inflammation of the lungs is a prevailing malady
along the whole European coast of the Mediterranean ; in regions and
districts, the climate of which has been long supposed to display a sanative
influence in all chronic and pulmonary diseases, but in a more especial
manner in consumption. I shall point out more formally, hereafter, this
fallacy, when treating of the etiology of phthisis pulmonalis. At Nice,
Genoa, Pisa, and Florence, the disease prevails greatly, and cuts off many
ofthe inhabitants. The neighbourhood of Naples, or around Mount Ve-
suvius, is remarkable for this occurrence. Hence it may be called truly
endemic, especially by those who attribute it to the noxious exhalation
which prevails there. To more recognised climatic influences should we
attribute the endemic character of pneumonia in northern Europe gene-
rally, in which we must include Great Britain.
There is not entire uniformity in the seasons, even in the same latitudes
in which pneumonia is most rife. In general, however, it may be said
that the latter winter and first spring months give the largest number of
cases in northern and middle Europe, and in the United States. In the
West Indies, on the other hand, the maximum of frequency is in summer.
In Paris, the chief months are January and April. Recent statistical returns
in England show, that the greater mortality from pneumonia in persons
under 15 years of age takes place in December.
The immediate and exciting cause of pneumonia is represented to be
sudden transition from a warm to a cold medium while the body is heated,
and especially in a state of perspiration. Facts justify this explanation in
many cases; but in many more, perhaps the majority, it does not apply;
and we are fain to suppose a peculiar predisposition by which certain indi-
viduals under common exposures contract pneumonia. Still, knowing the
seasons and districts in which the disease is most prevalent, we can hardly
refuse believing that a sudden and concentrated application of these atmos-
pherical influences, in'the manner just described, should count largely in
our inquiries into the causation of pneumonia. The epidemic occurrence
ofthe disease is clearly proved, although even here, again, we shall be at
208 DISEASES OF THE RESPIRATORY APPARATUS.
a loss to account for the fact in any known and appreciable limitations and
combinations of states ofthe atmosphere.
The influence of particular employments, in which those engaged are
much exposed to cold and humidity, ha? been greatly overrated, as we
learn from Thackrah, among others. Regularity in other respects, and
particularly avoidance of alcoholic stimulation, renders exposures of this
nature, and even sudden transitions from high to low temperature, com-
paratively innocuous.
That there are internal causes, a special but not a priori recognisable
predisposition, by which pneumonia is readily developed and renews its
attacks in certain persons more than others, we can hardly doubt. Authors
relate cases in which the same person has had the disease repeatedly ; Dr.
Rush mentions twenty-eight times; M. Andral sixteen times in eleven
years ; and M. Dezoten fifteen times. Perhaps the chief predisposing
cause, at any rate the one depending on recognised peculiarity of organi-
zation, is tubercles of the lungs. How many are the cases of tuberculous
consumption in which pneumonia is developed. Often I have seen
it near the close of the disease, rendering its removal in the then exhausted
condition of the patient, who is sinking rapidly into death, a matter of great
difficulty. The influence in this case is, however, reciprocal ; for pneu-
monia, though it does not directly cause, yet it develops the production
of tubercles. Pneumonia may supervene on chronic bronchitis ; and still
more readily and frequently on acute pleurisy. It complicates sometimes
dothinenteritis, as also measles, scarlatina, and small-pox, and follows the
suppression of any of these eruptions ; as indeed it does of less acute ones.
Phlebitis is sometimes associated with it. Chronic inflammation of some
other organ singularly predisposes some individuals to pneumonia. One
ofthe most severe cases ofthe disease which I ever met with, if measured
by the structural changes in the lungs, terminated the life of a lady who
had for years suffered under chronic gastritis with softening of the mucous
membrane of the stomach.
Age has an influence on the etiology of pneumonia. All ages are declared
by M. Andral to be subject to pneumonia. It has been known to attack
the foetus in utero ; and it is quite common in children, rather less in adult
life, and prevalent in old people. Guersent reports the disease to be very
common and fatal among children, and that, of the deaths in the hospital
of sick children at Paris, before the completion of the first dentition, three-
fifths occur fro.m pneumonia which is chiefly latent. The age between one
and five years from birth is declared by MM. Barthez and Rilliet to be a
predisposing cause of pneumonia. Secondary acute pneumonia is much
more frequent at this age.
Sex displays a modifying influence, in the greater readiness of men to
contract pneumonia. Out of ninety-seven cases which occurred in the
wards of La Charite, under the care of M. Chomel, seventy-three were men,
although the number of patients in the hospital wards of either sex was
nearly the same. MM. Rilliet and Barthez tell us that of 245 cases of
pneumonia, 95 were of girls and 150 boys.
Treatment.—If inferences were to be drawn respecting the treatment of
pneumonia from the proportionate number of fatal cases, we should be
greatly at a loss to determine on which side the advantage lies ; both
owing to the fluctuation at different times in the same place, and the dif-
ferent results published by two sets of writers of the same cases. The
great success of M. Laennec, under the tartar-emetic treatment, in his only
TREATMENT OF PNEUMONIA.
209
losing two out of fifty-seven cases, has been often quoted in his and its
favour ; whereas if we are to believe in the critical accuracy of M. Bouil-
laud, the deaths were seven in number, leaving at this rate the mortality
to be rather less than one in eight. In the Charite, in the years 1825 and
1826, the results of M. Laennec's practice were 12 deaths in 30 cases of
pneumonia. M. Chomel very frankly admits, the deaths in his hospital
practice were one in four; but M. Louis goes still farther, and rates it at
one in three. M. Bouillaud, in summing up the results of the practice
which he advocates, early and full bloodletting, reports in 102 cases 12
deaths and 90 cures, which is a mortality of 1 in 8^. M. Lacaze of Mont-
geron, near Paris, has published, in the Journal Hebdomadaire (1834), a
statement of the treatment of 42 cases of pneumonia treated by large bleed-
ings, which shows only one death out ofthe entire number. In the ques-
tion of mortality and of treatment, you must, however, always remember
that, as a general rule, with equal skill, and the same means employed in
out-door practice as those enlisted in hospital service, the results will be
in favour of the first. The class of persons who, in large numbers, are
sent to hospitals, their prior mode of life, poverty, bad feeding, over-work,
or excesses of various kinds, and the deteriorating influence of the air of
a hospital, are all adverse circumstances against the favourable effects
from a remedy or plan of treatment. On this account we cannot implicitly
follow the practice pursued by hospital physicians, nor receive for our
guidance their caution against a full antiphlogistic course of treatment in
inflammatory diseases. The inability of their patients in the hospital to
bear free depletion, ought not to be received as evidence of its inapplica-
bleness to patients of even a similar age and temperament out of doors.
I deem it the more important to introduce these cautionary remarks just
now, believing that they will apply to the opinion of Dr. Stokes respecting
his inculcation of restricted venesection in pneumonia.
It is difficult to explain the results furnished by M. Louis's tables, with
respect to bloodletting in pneumonia. To find that with the exception of
the first few days, it matters little at what period we bleed, is indeed an
unexpected result, and one which is opposed to the experience of all
practical men in this country. It may be observed, however, that M.
Louis has not separated the sthenic from the asthenic or typhoid pneumo-
nia ; and as we know that the lancet has comparatively little efficacy in
the latter form, we must conclude, without impugning the method or ac-
curacy of M. Louis, that its value in sthenic pneumonia is greater than
what appears from these calculations.
In addition, it may be observed, that no mention is made of local bleed-
ings having been employed in connexion with the lancet: had these means
been extensively employed, there would, doubtless, have been stronger
evidence in favour of bloodletting. It is certainly true that we can seldom
cut short a pneumonia by bleeding. In two instances only have I seen
this result, but the common effect of genera] bleeding is to remove or modify
the constitutional symptoms.
In some cases the affection is merely converted from a manifest into a
latent but progressive disease, while in others the lung continues unresolved
and in a passive condition. In such cases, tubercle, chronic induration
and atrophy are commonly the results.
But I reserve for the next lecture a methodical view of the treatment of
pneumonia in its varieties and stages.
VOL. n.—15
210 DISEASES OF THE RESPIRATORY APPARATUS.
LECTURE CI.
DR. BELL.
Treatment of Pneumonia—Superiority of venesection over all other remedies—Extent
of its use and frequency of repetition—Not to be deterred by the fear of interfering with
critical evacuations—Circumstances which modify bloodletting—Original strength of
constitution ; complication of pneumonia with other diseases—Bloodletting in the pneu-
monia of infants—Purgatives—Tartar emetic—Laennec's and Louis's advocacy of—
Mode and rule for using it in infantile subjects—Calomel — Revulsives and counter-
irritants—Drinks.
The treatment of pneumonia will differ according as we have to do with the
simple primary or secondary, and the mixed or typhoid pneumonia. It is
to the first that my remarks will chiefly apply just now. As respects venesec-
tion, too cautiously advised by Dr. Stokes, although I would not go so far as
the late Dr. Gregory of Edinburgh, who was in the habit of saying in his
lectures that, provided he was called early in pneumonia, he would be
contented to dispense with all other aids than those of the lancet and water
gruel, I cannot help regarding it as the chief remedy, itself superior to all
other means, and not to be replaced by any other or by all others. M.
Louis's authority is sometimes invoked against bloodletting in pneumonia,
which he says is neither shortened nor materially influenced by the remedy.
But here is one of the instances of the fallacy of the numeral method.
Without a careful specification of the constitution and habits of the persons
whose cases are numbered by M. Louis, his estimates cannot be intro-
duced to contradict the experience of both ancients and moderns in favour
of free, or we might, as Dr. Watson properly does, say prodigal bloodlet-
ting. The abstraction of blood is productive of immediate and direct re-
lief to the suffering organs, which are now able to resume, in degree, their
functions at once. To be most effective, venesection ought to be prac-
tised at the first invasion of the disease; an advantage which may be
readily procured in private, but very seldom, if ever, in hospital practice.
M. Andral advises free bleeding from a large orifice; but to stop short of
bringing on syncope, to prevent which he advises that the patient be bled
in a recumbent posture. Leeches and cups, which are of service in cases
of pleuritic stitch, ought, as this judicious practitioner recommends, to be
considered as adjuvants, but not a principal remedy nor as substitutes for
the lancet.
If we can bleed early, within the first twelve or twenty-four hours of
the attack, and produce a decided impression just short of syncope by this
remedy, we may then, as so strenuously recommended by Dr. Armstrong,
give at once a full dose of opium, as of two or three grains, with a view
of arresting the further progress of the disease. The efficacy of the opium
will depend entirely on its early administration ; after the first day we can-
not hope for much from it, and when hepatization has begun it will be in-
jurious. How often should the bleeding be repeated ? Dr. Stokes tells
us (Treatise, &c.) not more than twice; M. Andral says from three to five
times ; and that, if the disease is very violent, blood may be abstracted
twice in the same day, once in the morning and once in the evening. Some
have bled fifteen to twenty times in a pneumonia. My own observations
TREATMENT OF PNEUMONIA.
211
would induce me to press the use of the lancet without stint, where there
is pleurisy associated with pneumonia, until the pain is removed and the
breathing comparatively easy. It is hardly worth while to speak of a
bloodletting which does not produce a decided impression: short of this
it seems to aggravate the sufferings of the patient. On one occasion, a
young woman, a dispensary patient, of previously good constitution and
rather full habit, was directed by me to be bled, and she was bled, but
not to the extent which I wished. I prescribed a repetition ofthe opera-
tion on the morning following the first venesection, but the quantity fell
far short of the exigency of the case. In the afternoon (the fifth day of
the disease), when I again visited her, I found her still suffering acutely.
I now opened a vein myself, and let the blood flow until twenty ounces
were abstracted. From that hour she was relieved, and her convalescence
may be said to have begun at the same time.
We must not be restrained from this remedy by a fear of its interfering
with a crisis by expectoration, or urine, if the inflammation be still great
and the symptoms urgent as at first. Bloodletting is best on the first day ;
it is good on the second and the third, and will often save life on the sixth
and. even the eighth day ofthe disease. After expectoration is freely es-
tablished, and the sputa have lost their viscosity and rusty colour, and the
breathing is easier, it would be imprudent, under an idea of accelerating
the cure, to draw blood. Venesection in pneumonia is a remedy of neces-
sity, not of precaution; nor is it one of cumulation, an increase merely of
remedial impression for the removal of the disease. Bloodletting cannot
be as efficacious in the hepatization of pneumonia as it is in the primary
stage of engorgement; but still it often produces excellent effects; even,
as M. Andral assures us, after the grey hepatization in the suppurative
stage. Not that we bleed in this case for the removal or absorption ofthe
pus, but to relieve other parts of the lung in which hepatization still pre-
vails. Mere smallness and frequency of pulse will not deter us from using
the lancet, if the accompanying symptoms indicate oppression rather than
depression or prostration. The pulse in pneumonia, as in most of the
phlegmasia?, often rises and acquires volume after bleeding. Copious
sweat has been regarded by some as a cause for our withholding the use
of the lancet; but I have already told you that often a warm sweat ac-
companies some of the worst and fatal cases ; and hence, that it is not
critical, nor can its suppression be attended with deleterious effects, if this
result follows an abatement of the intense phlogosis which, in some cases,
seems to keep it up. By some physicians the inflammatory buff and cup
ofthe blood drawn are regarded as a necessary appearance to indicate and
justify the repetition of the bloodletting. But on this point there is no uni-
formity; for in some of the worst and inflammatory cases of pneumonia
you will not see any buff on the blood.
Returning from this digression, let me conclude my remarks on the
circumstances requiring and modifying bloodletting in pneumonia. When
delirium is present in the disease, and proceeds from meningitis, we find
additional reason for the use ofthe lancet, followed, if necessary, by cups
or leeches to the temples. In intemperate subjects local depletion from
the head will suffice, followed by tartar emetic and opium, in old per-
sons we are too apt to be deterred from this remedy, under an idea that
they are weak, and their systems will not react under the temporary de-
pression caused by loss of blood. But this is a mistake, if assumed as a
212 DISEASES OF THE RESPIRATORY APPARATUS.
general rule. Original strength or weakness of constitution, prior health
or disease, and the habits of the patient, are qualifying circumstances of
more importance than those of adult or of advanced life. An old man of
seventy, who has been habitually robust, healthy, and temperate, can part
with more blood than a young man of twenty-five, of an anemic orscrofulous
habit, and weakened by excesses of any kind,—in the same disease. I
ordered to be both bled and cupped a female eighty years of age, and of a
thin habit, and apparently fragile constitution, who had pleuro-pneumonia
during the last winter (1843-4). She recovered entirely, and lived four
years afterwards. In the complication of pneumonia with eruptive fevers,
some physicians are afraid to draw blood,—imposed upon by the small,
frequent pulse, and predominance of nervous symptoms, great weakness,
and apparent prostration. This is often the critical epoch, when blood-
letting is most required to save the patient. It will be more necessary in
these cases than in others, to aid in bringing on reaction by moderate
stimuli, with small doses of opium and external warmth and frictions. A
similar remark applies to the supervention ot pneumonia on gout. The
attack is still pneumonia, by whatever terms we may choose to qualify it;
and if it is not removed by active treatment, it will kill the patient. The
complication of pneumonia with typhous and typhoid fevers is a very
common occurrence, and merits prompt attention. Congestion predomi-
nates over inflamraation, and we cannot hope to free the lungs by full
bleedings ; but we may greatly relieve them, and simplify the diagnosis
by small ones either from the arm, or preferably by cups to the chest,—
on the sides, under the clavicle, and between the shoulders. The pre-
sence of the menstrual flux has been supposed to contra-indicate bloodlet-
ting in pneumonia ; but without reason, if the symntoms are violent, and
the case is of such a nature that it would otherwise call at once for vene-
section.
In the pneumonia of children we have at first difficulty in establishing
a correct diagnosis, latent as the disease is so apt to be in this class of
subjects ; and, afterwards, a difficulty in carrying out and adapting our
views of practice, in reference to their peculiar constitution. Bloodlet-
ting is required in primary infantile pneumonia, but not to the extent nor
wTith the same freedom of repetition as in the case of adults. If it does
not materially shorten the disease, it abates the febrile movement and
diminishes the local malady and the probability of complications. Could
we, with Dr. Gerhard (Am. Jour, of Med. Sciences, vol. xv.), in his valu-
able paper on the pneumonia of children, suppose that this disease, in
subjects from two to five years of age, approaches more to sanguineous con-
gestion from mechanical obstacle to the circulation than to inflammation,
we should feel the less inclined to bleed, and would trust more to revulsion
and counter-irritation. But as MM. Rilliet and Barthez pertinently ask (A
Treatise on the Pneumonia of Children— Translated by Dr. Parkman of
Boston): a rapid progress, formidable symptoms of reaction, evident
traces of an inflammation of the lung or its dependencies—are not these
sufficient to characterize an inflammatory affection ? Whatever shade of
pathological opinion on this point we may adopt, the fact is not the less
clear that children do not in general require nor bear very copious ab-
straction of blood. Nutritive life is active in them ; and there is great
mobility both of the circulatory and nervous systems ; but their powers of
reaction are not great. We are restrained, also, by another consideration
TREATMENT OF PNEUMONIA.
213
in the disease before us. It is seldom idiopathic ; but results from other
diseases and ailments, among which, as I have already told you, bron-
chitis is one of the principal. Thus gradual in its approach and compli-
cated with other diseases, the pneumonia of children is not of that open
kind that would justify large and repeated bloodletting. The experi-
ence of MM. Rilliet and Barthez and the recorded testimony of other
writers adduced by them, are unfavourable to the remedy, which, as they
allege, under these circumstances, exerts little or no immediate salutary
impression, and displays no influence in shortening the duration of the
disease. More may be expected from the application of leeches under
the clavicles, or cups on each side ofthe chest, or between the shoulders,
than from venesection ; for unless we produce a stronger effect on the
disease than it is in our power to do by the common expectorants, we
shall almost certainly lose our patients.
Although bloodletting is the chief it must not be regarded as the sole
available remedy in pneumonia. In the beginning of the disease and
towards its decline tolerably active purgatives, into the composition of
which calomel enters, are administered with good effect. In fixed hepa-
tization we cannot promise ourselves much service from them. But next
to bloodletting in pneumonia comes tartar emetic. My own experience,
and I have used this medicine freely for the last twenty-five years, is coin-
cident with that of Dr. Stokes and the French School. I would quote on
this particular point, in terms of decided approbation, the language of
Laennec, who says : " As soon as I recognise the existence of the pneu-
monia, if the patient is in a state to bear venesection, I direct from eight
to sixteen ounces of blood to be taken from the arm. I very rarely repeat
the bleeding except in the case of patients affected with disease of the
heart, or threatened with apoplexy, or some other internal congestion.
More than once I have even effected very rapid cures of intense peripneu-
raony without bleeding at all; but in common I do not think it right to
deprive myself of a means so powerful as venesection, except in cachectic
or debilitated subjects. I regard bloodletting as a means of allaying for
a time the Violence-of inflammatory action and giving time for the tartar
emetic to act." M. Lepelletier, among the numerous pathological facts
contained in his volume, gives, from various sources, the details of
twenty-four cases of pneumonia successfully treated by venesection and
tartarized antimony conjointly, and of twelve failures by the same method ;
of thirteen fortunate ones by tartar emetic, and of two fatal when the
same means were used. (Brit, and For. Rev., vol. i.)
We generally begin, says Dr. Stokes, with the use of from four to six
grains on the first day. The dose is increased by one or two grains daily,
until ten, twelve, or fifteen grains are exhibited in the twenty-four hours.
He has never gone beyond this dose ; but it must be remembered that the
most careful attention was always paid to local treatment.
For the reduction ofthe ordinary inflammations ofthe lung in Ireland,
continues Dr. S., returns show that it is seldom necessary to administer
more than from twenty-five to thirty grains of the remedy given in the
doses above mentioned. In many cases, however, larger quantities have
been employed ; thus, he has often continued the exhibition of the remedy
to the amount of fifty grains, and in one case, where an acute double pneu-
monia was superadded to a chronic bronchitis, one hundred and seventy
grains were used in the quantity of twelve grains daily. The patient's
214 DISEASES OF THE RESPIRATORY APPARATUS.
symptoms and appearance daily improved under its use, and during the
latter period of its exhibition, his appetite and digestive powers were
excellent. In this case, the recovery was perfect and permanent. In
many cases, the first doses produced vomiting, and in some purging; but
the effects generally subsided, after the first twenty-four hours. With re-
spect to the interval of tolerance, he has constantly verified the statements
of Laennec; and there is hardly a more interesting circumstance in medi-
cine than to see a patient take from eight to twelve grains ofthe remedy
daily, without vomiting, purging, or sweating—without any effect, indeed,
save the gradual removal of the pneumonia. This treatment is seldom
followed by abdominal irritation. In one patient, after the use of eight
grains daily for four days, violent vomiting, diarrhoea, and pain in the
abdomen supervened. These symptoms subsided under a sedative treat-
ment, but returned, in two days, with such violence that the lancet had
to be employed. In another case, the usual symptoms of poisoning with
tartar emetic followed the first dose of the medicine ; both these patients
recovered without difficulty.
Believing that adequate justice is not done to the antimonial practice
by our medical brethren generally in the United States, many of whom
are pleased to reject what they call theory, on the strength of some a
priori reasoning of a hypothetical nature of their own, I give insertion
here to the opinions of M. Louis on the subject. This gentleman's skep-
ticism on the remedial value of modes of practice the most esteemed by
others is well known, as, for instance, on the efficacy of bloodletting in
pneumonia ; and henr^e more will be thought of his favourable view of
the utility of tartar emetic in full doses in this disease.
" To sixteen of the individuals who recovered, tartar emetic was admin-
istered, during a period of from four to seven days, in quantities progres-
sively increasing from six to twelve grains in six ounces of the distilled
water of the flowers of the linden-tree (eau distille de tilleul), sweetened
with half an ounce or an ounce of syrup of poppies, and the patients took
these quantities in six or eight doses. Their disease lasted, on an average,
eighteen days—three days longer than that of the individuals not subjected
to this treatment: so that it would appear at the first glance, that the emetic
tartar had a pernicious effect on the course of the disease, instead of having
accelerated its fortunate termination.
" But this influence was pernicious in appearance only. The emetic
tartar was administered, after several bleedings had been performed, on
the eighth day of the affection on an average, because the disease continued
acquiring greater and greater intensity ; and in cases not bled for the first
time till the fifth day, as a mean term : whilst it had been performed on
the third day in the cases in which this medicine was not employed. That
is to say, it was given under the most unfavourable circumstances, and in
severe cases, which explains the long duration of the disease in those who
took it. Let us add, and it is necessary to insist on the importance of this
fact, that the patients, for whom the emetic tartar was prescribed, were
older than those who did not take it, in the proportion, on an average, of
forty-five years to thirty-one : an enormous difference, which shows that
not only had the medicine no pernicious effect on the duration ofthe dis-
ease ; but that in some cases it must have accelerated its course and pre-
vented a fatal termination.
" The last proposition appears, moreover, to be confirmed by the changes
TREATMENT OF PNEUMONIA.
215
which almost immediately followed the exhibition of the emetic tartar.
From the day following that of its first employment, fifteen of the seventeen
persons who took it found themselves a little better, or much better, having
then perceptibly more strength, an improved physiognomy, and the respi-
ration less restrained. Besides, thirteen of them, whose chest emitted a
sound more or less completely dull over a certain space, when the emetic
tartar was first administered, showed from the following day a perceptible
improvement in this respect; percussion of the thorax being already more
sonorous ; and these various ameliorations were permanent, and made ad-
ditional progress daily.
" The increase of strength from the day next ensuing, or that in which
the medicine was administered, is the more remarkable, as its action was
accompanied with frequent purging and vomiting. In sixteen cases out
of seventeen, the alvine evacuations were very numerous, ranging from
eight to fifteen on the first day, one-half less frequent on the second, and
on the third and fourth, not more so than in the ordinary state. The vomi-
tings were less numerous, and of a shorter duration, than the alvine dis-
charges : they did not continue beyond the first day, and were absent
altogether in five instances.
" Three ofthe patients who died took the emetic tartar, and did not
experience any improvement on the day following that of its administra-
tion. One alone of these had not the evacuations mentioned.
" Thus of twenty cases in which the emetic tartar was employed under
unfavourable circumstances, three only were fatal ; which cannot leave a
doubt, as it appears to me, of the utility of this medicine, in large doses,
in the treatment of pneumonia ; and so much the more as these three indi-
viduals were all aged, being sixty or seventy years old."
Laennec has been severely censured for his statement, that the gastro-
enteritis of fever does not contra-indicate the use ofthe tartar emetic. In
this matter he has been scarcely done justice to, for there is every reason
to believe that he makes use of the term gastro-enteritis in the conventional
mode then so prevalent in Paris, and in which gastro-enteritis and fever
were convertible terms. There is no ground for believing that Laennec
would give tartar emetic in acute gastritis ; and his statement is reduci-
ble to this, that the remedy may be employed in the pneumonia of fever ;
and without entering into his reasoning on the subject, we must agree with
him, that the contradictions to the use of this, as of all other medicines,
ought to be founded on experience alone. It is now proved, that the ex-
istence of typhous fever does not contra-indicate the use of tartar emetic,
but that, on the contrary, its exhibition may be followed by the happiest
effects ; the gastro-enteritis of Broussais, then, does not contra-indicate the
use of this remedy.
The rule to guide us in the antimonial practice is thus described by Dr.
Stokes:—The success of the antimonial treatment depends on or is favoured
by, the inflammatory character ofthe fever, the early stage of the disease,
the absence of complication with other diseases, the fact of the patient
having borne bleeding well, and the firmness ofthe coagulum ; the more
the case presents these characters, the greater will be the likelihood of
the tartar emetic acting favourably. But in the typhoid, secondary, and
complicated cases, in those where the powers of life have been previously
injured, where bleeding cannot be used with boldness, and where stimu-
lants are required, the exhibition of the tartar emetic, in full doses, is very
216 DISEASES OF THE RESPIRATORY APPARATUS.
hazardous. The mercurial treatment is to be preferred from its greater
safety, and, in this disease, more than equal efficacy.
It is while the crepitating rale is heard more distinctly, and before a
complete solidification has taken place, that the remedy answers best.
Indeed, in the advanced stages ofthe disease, and where the object is to
remove hepatization, the antimonial is inferior to the mercurial practice ;
but the mere occurrence of hepatization does not contra-indicate the use of
the antimony, if it be in the early stage of the disease, and while the crepi-
tating rale is advancing in other portions of the lung.
In those cases in which the remedy has been borne well, it is not advi-
sable to omit its use suddenly. A severe relapse has followed this prac-
tice ; but by diminishing the dose at the rate of a grain or two daily, these
effects can be avoided. In those cases in which the tartar emetic is not
borne, or its use seems inadmissible, we may generally have recourse to
mercury.
Respecting the value ofthe tartar-emetic treatment in the pneumonia of
children, my own experience coincides with the conclusions of MM. Rilliet
and Barthez, viz., " that the tartar emetic may be employed with success
in the child; that there is no danger in a somewhat elevated dose ; that
the tolerance is generally easily established ; that the gastrointestinal
accidents give little cause of fear; and finally, that this medicament ap-
pears to act more directly upon the pulse and respiration than upon the
hepatization itself." This remedy is likewise of service in secondary pneu-
monia. From a grain to a grain and a half may be taken in the twenty-
four hours. But a remark made by the French writers just named, will
not a little diminish our faith in the therapeutic powers of even the most
approved remedies in this disease. It is, that the first signs of amelioration
appear in nearly all cases at the same period of the disease, from the
seventh to the ninth day, whatever may have been the treatment employed.
As a prompt abater of inflammation calomel is inferior to tartar emetic,
but where congestion is complicated with phlogosis, and especially where
secretion from a mucous membrane is suspended by an inflammatory con-
dition of the latter, calomel is entitled to a preference. This medicine acts
on the gastro-hepatic and gastro-intestinal apparatus, which are liable to
be implicated in pneumonia, and in this way, by revulsion, relieves the
oppressed lungs, at the same time that it facilitates abundant secretion of
sputa and thus unloads the turgid and congested air-cells. Calomel con-
tributes, also, to a more natural action of the skin, which becomes softer
and cooler under its use. We may advantageously combine with it nitrate
of potassa, and, taking care not to offend the stomach, minute doses of
tartar emetic. My own usage is, after an adequately full venesection, to
administer a mercurial purge of calomel and jalap, or ten grains of calomel
followed, after four or five hours, by half an ounce of sulphate of magne-
sia and a drachm of the wine of colchicum seeds. I then, if the lancet is
not again called for, but the pneumonia persists, direct calomel in a dose
of two grains every two hours, to be continued for forty-eight hours, either
alone or in combination with nitre and tartar emetic. But in thus pre-
scribing calomel, I do not desire to see those proofs of extreme constitu-
tional operation which end in ptyalism, short of which its best therapeutical
effects may, in a vast majority of cases, be obtained.
Counter-irritants in the shape of sinapisms to the extremities and hot
pediluvia, are generally and usefully prescribed. As revulsives, leeches
TREATMENT OF PNEUMONIA.
217
to the vulva, or the anus, in cases of suppressed menstruation or of hemor-
rhoids, shortly before the coming on of the pneumonia, are directed in pre-
ference to their application to the chest. Blisters, a favourite remedy with
nearly all writers, are beginning to be regarded with mistrust by some of
the most judicious of our practical men. In the acute and febrile stages
ofthe disease they are not to be relied on; and they irritate, often exces-
sively, the patient, especially if he be of a nervous temperament. When
prescribed, they ought to be either very early, or, a safer practice, towards
the decline ofthe disease. In children we must trust more to counter-ir-
ritation than in adults; and hence, in cases of pneumonia attacking the
former class of subjects, we direct stimulating liniments rubbed on the
skin, irritation of the lower extremities by liniments or sinapisms, the warm
bath and blisters to the chest.
Drinks of the demulcent class are always preferred : but we must study
variety, so that the patient may not have a distaste, or, in fact, a disgust
towards them. We are cautioned against the free use of drinks, in pneu-
monia, as calculated to injure both by filling the bloodvessels and by in-
ducing dyspnoea, owing to distention ofthe stomach.
LECTURE CII.
DR. BELL, a
Treatment of Pneumonia (Concluded)—Opium and other narcotics—Depression to be
met by stimulants and mild tonics—Treatment of complications—Bilious pneumonia
—Tartar emetic in their case—Regimen and drinks in pneumonia—Convalescence—
Cautions requisite in—Typhoid Pneumonia—Its epidemic prevalence—Predisposing
causes—Symptoms—Treatment—Depletion less used, and stimulants more freely—Com-
plications to be attended to—Chronic Pneumonia—Physical signs of—Caution atrainst
much depletion in—Edema of the Lungs—A secondary disease—Symptoms and treat-
ment.
I spokk of opium as a medicine which might be usefully given on the ac-
cession of pneumonia, and especially and mainly after a large bleeding.
This period over, we ought to be very sparing in the use of this medicine,
which may increase the pulmonary congestion, both by its effects on the
circulation and by dangerously weakening the innervation on the respira-
tory muscles, and also by its operation on the lungs themselves through
the par vagum. On the subsidence of the pulmonary inflammation and
of the violent action of the heart, and the coming on often of nervous symp-
toms and wakefulness,—Dover's powder, in doses of three grains every
two or three hours, will be of much service. When calomel is adminis-
tered, this fashion of opiate may be usefully combined with it, even in an
earlier period ofthe disease; and, as already pointed out, the addition of
a few drops of laudanum to the tartar-emetic solution is both admissible
and proper. You will find no contradiction between these admissions in
favour of the occasional use of opium, and the general prohibition pre-
cedingly laid down. Opium alone, after the first day, and in such doses
as to produce its hypnotic effects, is prejudicial; but opium combined with
calomel, or with tartar emetic, or even ipecacuanha, serves both as an ad-
juvant and corrigent, and aids the operation of these medicines without
any inconvenient exhibition of its own more distinctive and peculiar powers.
218 DISEASES OF THE RESPIRATORY APPARATUS.
In cases of doubt, less objection applies to other narcotics, such as hyos-
ciamus; and as a narcotic diuretic which directly soothes, and indirectly
relieves also, by a revulsion on the kidneys, digitalis is entitled to consi-
deration. Calomel and digitalis are most useful, particularly the former,
in the pneumonia of children.
Sometimes sudden depression follows venesection, or comes on in the
process of pneumonia, as I stated at the conclusion of a former lecture.
This requires mild tonics and even stimulants. Of the latter I prefer, as
prompter in its operation, and less hurtful subsequently, carbonate of am-
monia, to which small doses of Dover's powder and wine whey are pro-
perly added. In the cases in which we are forbidden to repeat venesec-
tion, but rely on the calomel, it is no bad practice to give, alternating with
this latter, the carbonate of ammonia; and in some instances, where the
expectoration and urine are scanty, small doses of oil of turpentine. Possi-
bly under these circumstances a trial might be made of tincture of cantha-
rides, as recommended in sthenic pneumonia, by Dr. Mendim, who regards
the medicine, oddly enough it would seem to us, as counter-stimulant.
In the second, verging on the third stage, the iodide of potassium has
been used with manifestly good effects by Dr. Upshur. (Medical Exami-
ner.) He directs it in doses of five grains every two hours, in two ounces
of infusion of hops. Dr. U. believes it to be particularly indicated; 1. In
the pneumonia of anemic persons, in which the disease is characterized by
typhoid symptoms in its early stages. 2. In cases in which inflammatory
action, high at the commencement, has been much reduced by antiphlogis-
tic treatment and the suppurative stage is just beginning. 3. In cases
which are superinduced on long-continued intermittents, that have left the
blood much impoverished.
In our recourse to tonics we shall be chiefly guided by the state of the
stomach and the predominance of gastric debility. Of this class, ealumba
infusion, with a few drops of nitric acid, will be found to meet our wishes
most satisfactorily.
The complication of hepatic disorder, or it may be inflammation of the
liver with pneumonia, ought not to make any difference in the essential
points of practice in the latter disease. Venesection cannot be postponed
nor preferred in favour of emetics and purgatives, nor of mercurials which
do not purge; but these remedies, and especially purgatives, will very
properly follow bloodletting, and contribute not a little towards the cure. In
those cases of bilious pneumonia, or, as these are generally designated with
us, bilious pleurisy, whether there be pneumonia with pleurisy, pleuro-pneu-
monia, or pleurisy alone, preference should be given to calomel over tartar
emetic, after the lancet has been used. We give calomel, at first to act on
the bowels, aiding its operation in this way by saline purgatives, and after-
wards as a direct antiphlogistic; a sedative, in fact, but not as a sialagogue.
The regimen in ordinary pneumonia ought to be strictly antiphlogistic
throughout; and hence a restriction to simple drinks, demulcent and di-
luent. Warm drinks are those generally recommended; but unless there
be some gastric complication forbidding their use, cold ones are not inad-
missible. If the counter-stimulant plan be adopted, the patient should not
be allowed to drink much liquid until toleration of the tartar emetic is es-
tablished.
An exception to the antiphlogistic course in pneumonia is sometimes
met with, in the cases of old and intemperate persons, to whom, in some
TREATMENT OF PNEUMONIA.
219
instances, wine and even spirits have been allowed. The safer practice
will be to give volatile alkali (carbonate of ammonia) in union with opium ;
and if farther stimulus be required to sustain the sinking powers of life,
wine whey in small quantities at short intervals will answer every purpose.
The temperature ofthe room should be attended to, in connexion with
the other parts of the treatment of pneumonia. Hot air and currents of
cold air are alike injurious; an average temperature of 60° F. will be the
best, but this is to be understood of the air for breathing, and not that to
which the skin can be exposed in an uncovered state. I have no doubt
of the good effects of occasionally allowing the patient to breathe cold air,
admitted by opening the windows; provided there be no current blowing
across or over him, and also that his whole body, even his face, with the
exception of his mouth and nostrils, be carefully and warmly covered at
the time.
Posture is of great moment in pneumonia; so that the chest should be
raised above the level ofthe lower part of the body. The best means of
doing this is by a bed-chair with a notched rack, which will allow of its
being raised to any required angle. Muscular exertion of all kinds, in-
cluding that of talking, is injurious, and must, except for the necessary
acts of defecation, &c, be prohibited.
Convalescence.—Remembering the tendency to tuberculous disease of
the lungs in consequence of pneumonia, we must watch with peculiar care
the state of the pulse and the breathing, and ascertain the state of the lungs
by auscultation, so as to be prompt and decided in case of any remains of
crepitation, to keep the patient on a restricted regimen, and even to have
recourse to leeches and cups, if local or partial (lobular) inflammation
remains.
Sometimes convalescence may be retarded by a passive edema of the
lungs, as it is termed by M. Andral, which follows inflammation. Tonics
are useful in this state, the diagnosis of which is not clear, or rather it
must be reached empirically by watching the effects of treatment; tor, as
we learn from the same high authority just named, dyspnoea and the cre-
pitating rhonchus, to which this form of the disease gives rise, are not suf-
ficient to enlighten us.
We are apt to be misled both during the progress of pneumonia and of
many other phlegmasia?, by a persistent fulness and tension, or at least
vibration ofthe pulse, which is due to hypertrophy, or sometimes tempo-
rary irritation of the left ventricle. A persistence in bloodletting and ana-
logous depletion is not called for in such a case, or at any rate after the
symptoms proper to pneumonia have disappeared. I have found tincture
of digitalis in small doses, five drops, or vinous tincture of colchicum,
twenty drops, twice or thrice a-day, with a little sweet spirits of nitre, or
cream of tartar in solution, to bring down the pulse, and at the same time
meet the other exigencies ofthe case, should there be any remains of pul-
monic congestion.
The means for preventing a relapse are the same as those which are
prophylactic against pneumonia. They will consist in a careful protection
ofthe skin by suitably warm and, what is best for this purpose, flannel and
merino inner garments: nor will these be of much avail unless the chest
and the shoulders up to the neck be kept uniformly covered, and the feet
be protected by thick and warm shoes from cold and dampness. The
neglect of a plain principle of hygiene in this respect will explain in a
220 DISEASES OF THE RESPIRATORY APPARATUS.
great degree why women and children are such sufferers from pulmonic
disease. It is bad enough for mothers to be such slaves of absurd fashion
in their own persons, as to expose their shoulders to the cold in the way
in which they commonly do ; but it is positive cruelty, whose only excuse
is gross ignorance, to subject their infants and other children to similar
exposures.
Typhoid Pneumonia.— I have now to offer a few remarks on a
very important modification of pneumonia, the typhoid. Epidemically
prevailing under the names of typhoid pleurisy, bastard peripneumony,
putrid pneumonia, &c, its ravages are great, and even when occur-
ring sporadically, or as an intercurrent, it is not less to be dreaded.
In the United States during the last war with Great Britain, and for
two successive winters after the peace, or from 1813-14 to that of 16-
17, this disease prevailed very extensively, in fact from Canada to Geor-
gia. To me this form of pneumonia possesses a peculiar interest from
its epidemic prevalence in Virginia, when I was a student of medicine,
and also, from the circumstance of my early introduction to clinical me-
dicine taking place, by my services being enlisted for the relief of many
of the numerous sufferers from the disease. The general predisposing
causes were, atmospherical extremes and vicissitudes, especially prolonged
cold and moisture; the occasionally predisposing ones were defective food,
mental anxiety, or derangements and feebleness of the nervous system, by
the prolonged or suddenly increased use of ardent spirits. The aged and
the intemperate, and those much exposed to hardships, were the chief suf-
ferers; although, in other instances, disease, rapidly followed by death,came
on in young subjects of different habits and constitutions. The most
speedily fatal and least manageable complication was that with angina.
Endemically,typhoid pneumonia is met with in low marshy districts, during
the later winter months; cold and moisture seeming to give rise to pulmo-
nary congestion at this season, with the same readiness that heat and mois-
ture did, during the antecedent autumn, to congestions of the spleen. Ac-
cording to the class of subjects, we may expect, in those countries, and
with some slight modifications of temperature, to see bilious pneumonia
and typhoid pneumonia. In towns and situations in which a large num-
ber of people are congregated, with but limited opportunity of inhaling
air, while they are still exposed to its inclemencies, and on whom imper-
fect alimentation and the use of ardent spirits also exert their effects, we
see pneumonia more manifestly of a typhoid character, with gastrointes-
tinal complications, and attacking subjects of different ages thus circum-
stanced.
By whatever name we may designate the disease, we cannot help being
struck with the general sameness of the causes assigned by different wri-
ters, and on reflection, with the mode in which these causes operate, by
enfeebling the nervous and capillary systems and inviting congestions, the
precise location of which will depend on prior weakness and present atmo-
spherical conditions. If we admit the share which the nervous system,
thus deteriorated, performs in the special etiology ofthe disease, we must
go a step farther, and see in its morbid condition a cause for depravation
of the blood, and the introduction of a new element in the pathology of
typhoid pneumonia. It was in reference to the probable part performed
by the blood in the production of this disease that I have elsewhere made
the remark that its history yet remains to be written. It may be that the
TYPHOID PNEUMONIA.
221
same causes which tend to derange thp functions of the nervous system act
also on the composition and quality of the blood, and that the two stand
in the relation of common effects rather than in that of cause and effect.
Be this as it may, we cannot overlook the state of the blood, in studying
the pathology, or in laying down the indications of cure, of typhoid pneu-
monia. Connecting the observations left us by Huxham, ofthe peculiar
appearance and change of the blood in the disease, with the remarks of
M. Andral (Essai de Hematologic Pathologique) on the defibrinization of
this fluid in cas.-s of pyrexia in which there is such a tendency to sangui-
neous congestions, we know enough to authorize a belief that in typhoid
pneumonia the blood has undergone a change of this nature, analogous to
that in scurvy and in splenic congestions.
We cannot say, as Dr. Stokes justly remarks, that there is any specific
typhoid pneumonia ; but we find that, under a variety of depressing cir-
cumstances, conditions of the lungs more or less analogous may be in-
duced, presenting the characters of the disease as given by various
authors. Among these he refers to Huxham on Fevers ; Stoll, De Peri-
pneumonia Vera; also Burserius, who has described an erysipelatous pneu-
monia. In the writings of Good, Williams, Mackintosh, and Andral, the
disease is noticed. Louis merely alludes to the occurrence of hepatiza-
tion in typhous fever, in Recherches sur la Gastro-Entente. In the ear-
liest editions of the Histoire des Phlegmasies, the statements of Broussais,
written before he had formed his theory of fever, may be studied with
great advantage. He recognised the secondary and complicated pneu-
monia of typhus, the latency of the disease, and its slow resolution. P.
Frank has described several varieties ofthe disease ; of these, the nervous
peripneumony seems most like the disease met with here.
This disease is seen more frequently in hospital than private practice—
a fact strongly illustrative of its connexion with the low state of the sys-
tem. Dr. Stokes has observed it in the following cases :—
1st. As a complication with enteritis, or gastro-enteritis.
2d. Complication with true typhus.
3d. Occufring in cases of bad erysipelas.
4th. Supervening in cases ofthe diffuse cellular inflammation.
5th. Complicating the delirium tremens from excess.
6th. As a consequence of phlebitis.
7th. As apparently the sole disease.
Now, although these cases must be considered different as to their origi-
nal nature, yet, with respect to the pneumonia, they have a certain agree-
ment ; for the affection is more or less latent, presents similar physical
signs, requires that the antiphlogistic treatment should be employed with
extreme caution, and in many cases that the free and early use of stimu-
lants should be resorted to. Of the cases above noticed, those complica-
ting typhous fever are most frequently observed.
The terminations of typhoid pneumonia are various: it may rapidly
produce a fatal hepatization ; it may form gangrenous abscess ; or induce
a chronic solidity of the lung, passing into the tubercular condition.
One of the most interesting circumstances to the practical physician is
the extreme slowness of its resolution, as compared with sthenic pneu-
monia. Months may elapse before the respiratory murmur is restored,
and in many cases this is never completely re-established. The fact, that
contraction of the chest has been only met with in these cases, shows the
222 DISEASES OF THE RESPIRATORY APPARATUS.
slowness with which the disease is removed. For farther details on the
pathology of typhoid pneumonia, I refer you to Dr. Stokes's Treatise on
Diseases of the Chest.
I should give you an imperfect view of typhoid pneumonia if I were to
restrict myself to the notices of the disease by European writers alone. Of
its epidemic prevalence in the United States I have already spoken. I
might have added, that its appearance during the periods indicated gave
rise to a number of essays on the subject, the majority of which were writ-
ten in haste and in a spirit of preconceived pathology and therapeutical indi-
cation, nor were they illustrated with the requisite detail of cases or of post-
mortem examinations. But apart from its epidemic visitations, typhoid
pneumonia would seem to exhibit an almost endemic character in particu-
lar portions of our country, and which in addition, also, to its frequent
sporadic recurrence invest it with decided interest in the eyes of the
American practitioner.
Dr. S. H. Dickson, occupying a different field, and witness to the occur-
rence ofthe disease under different circumstances from what English wri-
ters have described, is entitled to be heard with no little consideration in
this matter. This gentleman, who, until recently, was Professor of the
Institutes and Practice of Medicine in the Medical College of South Ca-
rolina, and who is now Professor ofthe Theory and Practice of Medicine
in the University of the City of New York, holds different views from
those generally entertained on the pathology of typhoid pneumonia. He
classes it among the idiopathic fevers, with a remark of " the disease so
widely prevailing at times over the North American continent—its eastern
poition especially." Its being modified by circumstances, is described in
the following terms: " Thus, while it scarcely differed from ordinary
catarrhal fever in some situations, in others it appeared little more than a
violent inflammatory congestion of the lungs—like the lung fever of the
eastern states ; and in others still, the chief symptom was a pulmonary
congestion, little or not at all inflammatory, resembling what has sometimes
received the denomination of pulmonary apoplexy. In some districts it
was ushered in by a chill, long-protracted, extremely distressing, and,
indeed, in many cases fatal, whence it received its common title of cold
plague. At its commencement, so many of the cases presented a cutane-
ous eruption, or the occurrence of petechia?, that the vulgar called it a
spotted fever,and the learned a pestilential typhus, or, as I have said above,
a return ofthe old febris petechialis. It is strange to find how soon in its
progress it lost that feature, even in the very localities where it had been
most marked." (Essays on Pathology and Therapeutics, being the substance
of the Course of lectures delivered by Samuel Henry Dickson, M.D. fyc.)
The disease continues to show itself sporadically, Dr. Dickson observes,
where it has once found footing. " We scarcely pass a winter without meet-
ing with instances of it, especially among our blacks."
Regarding its etiology, the author just cited justly remarks that it has
certainly some relation to the sensible qualities of the atmosphere—as its
dampness and coldness, and that the disease occurs most obviously in
those peculiarly exposed to these agents, especially if the exposure be pro-
tracted. Children seem to enjoy a special exemption. Females are less
liable than males. To the atmospherical causes predisposing to the disease
may be added damp and illy-ventilated dwellings, insufficient food or
clothing; labour beyond the strength and continued fatigue. An important
TREATMENT OF TYPHOID PNEUMONIA.
223
form of typhoid pneumonia is that which occurs in delirium tremens from
excess of stimulants. " The disease, as we learn from Dr. Stokes, com-
monly attacks the left lung, particularly in its lower portion, and yet it is
constantly overlooked. The coexistence of gastritis and of a low peri-
carditis with the disease ofthe lung has been recorded."
The symptoms are those common to pneumonia, with the addition of
great dejection of the spirits, and from the beginnings in many cases, a
degree of delirium which sinks gradually, as the patient grows worse, into
the low muttering characteristic of typhus. As the disease advances the
typhous symptoms become aggravated.
The next most common form of typhoid pneumonia, described by Dr.
Dickson, resembles much, in its onset, the bilious pleurisy of the southern
portion of our country, indicated by " great gastric oppression, frequently
with retchinprand vomitinp-of foul mucous and bilioussecretions. Thecoun-
tenance is flushed, the eye red and watery, there is aching ofthe head, back
and limbs; the pulse is full, but unduly soft and compressible,soon becoming
feeble and losing its volume. This stage of vascular excitement is short ;
muscular prostration soon supervenes, and the circumstances of the patient
become very similar to those described in the first instance." A " peculiar
pulmonary congestion" has constituted the principal symptom, in " several
impressive examples of this disease." But of all complications of typhoid
pneumonia, the most alarming and fatal, as I well remember, were the an-
ginose ones. Popular apprehension in this respect corresponded too
closely with their fatal result.
Auscultation apprises us ofthe crepitant rhonchus, or if the disease is
far advanced, bronchial respiration and bronchophony. In some cases,
however, there is no abnormal sound. The disease is sometimes ushered
in with sudden increase of prostration and an anxious expression of face
and appearance of emaciation. The substances effused in the lungs are
but little plastic and of a dirty-grey colour as if mixed wTith decomposed
blood. The brain, as we learn from Dr. Dickson (op. cit.) is usually more
or less altered in appearance, its vessels filled with dark blood, and effu-
sions of serum, of coagulable lymph, and even of purulent-looking fluid,
are occasionally found upon the surface of the membranes, in the ventri-
cles, and even, it is said, within the cerebral substance. The blood is, as
in typhus, of a particularly blackish hue.
Treatment of Secondary including Typhoid Pneumonia.— Dr. Stokes
enumerates the principal points of difference between the treatment of the
typhoid and that of primary sthenic pneumonia. They are—
" 1st. That general bloodletting is to be used with extreme caution.
" 2d. That the mercurial is in general to be substituted for the antimo-
nial treatment.
" 3d. That counter-irritation may be employed at an earlier period.
" 4th. That the vital forces are to be carefully supported.
"5th. That as gastro-intestinal disease frequently complicates the pneu-
monia, close attention must be paid to the abdominal viscera.
"6th. That stimulants are to be used with greater boldness and at an
earlier period."
A still more extended view of the subject may advantageously be taken,
by our regarding all secondary or intercurrent pneumonias as associated
with states ofthe system in which debility predominates, owing to the ex-
haustion by the other and primary disease or the habits of life which either
224 DISEASES OF THE RESPIRATORY APPARATUS.
predisposed to or excited them into activity. Hence we may expect to
find pneumonia occurring in the progress of small-pox, measles, scarlet
fever, hooping-cou^h, remittent and typhoid fevers, and sometimes also
in cachectic and enfeebled habits of body, under all of which circumstances
the treatment must be modified by these complications. But, and herein
is a source of danger, we must not content ourselves with merely regard-
ing pneumonia, in such cases, as a symptom or condition of organ depen-
dent on the primary disease and removable by the means employed for it.
We have to deal not the less with pneumonia, although its febrile associa-
tions are different from the usual ones, and the sensibility of the patient
so small that the several stages are gone through with hardly any notice
from general symptoms. We are not the less required to direct remedies
especially for the removal of the morbid condition of the lung, although
we must not draw blood with the same freedom, nor give tartar emetic as
liberally, nor restrict our patient to the antiphlogistic regimen, as we do
in simple sthenic or primary pneumonia. I am afraid that some practition-
ers persuade themselves, that the stimulating medicines administered for
the removal of debility and to quicken the action of the sluggish heart and
inert brain, will carry off at the same time the inflammation of the lung.
This kind of medication will do no such thing. All that we can hope for
from it and the exhibition of some nutritive stimulants at the same time,
is to sustain the powers of life generally, and thus give an opportunity for
the inflammation to go through its several stages, with the prospect, often
indeed a faint one, that absorption may be sufficiently active to remove the
deposited blood in the parenchyma, or the expectoration vigorous enough
to allow the patient to throw up the pus that may have been formed.
In this kind of pneumonia, then, we must have recourse to the compound
practice, which, although it may be adverse to the simplicity of systematic
medicine, is really required by the exigencies of the case. It was that
certainly attended, I distinctly remember, with the largest measure of suc-
cess in the epidemic typhoid pneumonia, during its prevalence in northern
Virginia. It consists, after an emetic, in the administration of diffusible
stimulants, at the same time with that of the remedies more particularly
adapted to pneumonia. Thus, while we direct volatile alkali, camphorated
julep, wine w-hey, brandy and water, oil of turpentine, sago with wine
whey, &c, we may often usefully draw a few ounces of blood from the
chest by cups or leeches, give minute doses of tartar emetic with opium,
or its weaker substitute ipecacuanha similarly combined ; or the indica-
tions forbidding the antimony, we have recourse to calomel, at first in such
doses as to act on the bowels, and afterwards as a counter-stimulant, and
sedative alterative. Infusions of polygala senega and of sanguinaria
Canadensis are useful remedies.
Convalescence from this disease is slow, and requires the administration
of mild tonics such as infusion of bark or sulphate of quinia, and great
attention to the rules of hygiene.
More freely than in sthenic pneumonia shall we have recourse to revul-
sion to the skin—to counter-irritants, and among these blisters are entitled
to a favourable consideration : they should be used earlier than in the sthe-
nic or simple variety. Also, to soothe the pain and oppression, fomenta-
tions and bags of hot salt to the chest. Great attention is required at this
time, to the posture of the patient, which should be semi-recumbent, alter-
nating with entire pronation ; or if this cannot be done, he should change
ATELECTASIS.
225
from back to side, and from one side to another. In some cases of second-
ary pneumonia with very hurried pulse and but slow respiration, I have
employed small doses of digitalis with advantage. Cold skin, on the
other hand, is benefited by oil of turpentine mixed with some mucilage.
The ethereal oil of turpentine has been recommended by Dr. Huss of
Stockholm, in the following formula:—K. iEther ol. terebinth., jss. ;
ovor. vitell., j. ; mucilag. ^ij. ; aqua?, ^j. Ft. emulsio. Dose, a tea-
spoonful every hour. Opium in full doses often gives signal relief in those
cases in which the nervous system is much implicated.
Atelectasis.—I revert to the subject of infantile pneumonia in order
to introduce, by some additional remarks on it, a consideration of the
fmtal condition ofthe lungs after birth, and to point out a probable source
of error in writers on inflammation of the lungs in children. It has been
already stated, that the chief characteristic feature of infantile pneu-
monia is its first showing itself in a single lobule, or if in several they are
separate from each other: after a longer period of duration ofthe inflam-
mation, the contiguous lobules, in groups as it were, are affected. Lobular
pneumonia for the most part appears on both sides of the chest at the same
time, and begins at the lower lobe. The lungs are heavier than common,
and do not crepitate. Their surface exhibits, at the diseased parts, a
granite-red hue, arising from a number of reddish patches. Each patch
represents a lobule varying in the extent of congestion, and corresponding
with a partial induration of the pulmonary tissue. To the hand grasping
these deep knots or nodes, the sensation is that of tuberculous granulations.
The engorged lobules are prominent, of varying size, have a smooth ap-
pearance, and considerable density; no longer crepitate: they are infil-
trated with a reddish sanies, are impermeable to air, and sink in wrater.
In their interior they exhibit a roseate colour, studded with red spots.
The impermeability that exists during life may, however, M. Bouchut
asserts, be removed in the dead body by insufflation, by which the ob-
structed cells are distended, resume a roseate hue, and elasticity, with
crepitus characteristic of the organ in its healthy state. In true hepatiza-
tion of the lung, this change by insufflation cannot be supposed to take
place. The very inception, almost, of lobular pneumonia, is evinced
by small, red, miliary points, somewhat hard like ecchymoses, in the midst
of which is a small point of a darker hue than the rest. These ecchy-
moses are so many vesicular pneumonias, by which the congestion of the
entire lobe begins.
Lobular, by extension, is often converted into lobar pneumonia. Tu-
bercular pneumonia is as common in children as simple pneumonia ; and
makes its appearance without premonition, or at least in children appa-
rently in good health. The tubercles in these cases act as irritants, and
induce inflammation of the lungs, which is the fatal disease. Infantile
pneumonia is sometimes complicated with pleurisy, and often with bron-
chitis. Vesicular or catarrhal pneumonia beginning in catarrh occurs con-
jointly with both the lobar and lobular forms ofthe disease. Emphysema
is an extremely frequent accompaniment. In a small number of cases only
is the brain affected. In the greater number of cases of lobular pneumonia
death occurs before the inflamed lobules have passed into the stage of grey
hepatization, or the lobular pneumonia becomes general,and the third stage
consequently presents no peculiarity. On occasions, however, the inflamed
lobules either become infiltrated with pus, and present, on a small scale,
VOL. n.—16
226 DISEASES OF THE RESPIRATORY APPARATUS.
the same appearance as is seen on a large one in ordinary grey hepati-
zation ; or each lobule becomes the seat of a small distinct abscess, with
numbers of which the lung seems riddled.
The prognosis in .infantile pneumonia is unfavourable. Were we to
receive the report of MM. Valleix and Vernois, we should almost abandon
all hope of recovery. These writers indicate 127 deaths in 128 cases.
M. Bouchut's experience, in the Necker hospital, was somewhat more
encouraging ; since out of 55 children attacked with the disease, the re-
coveries were 22, and the deaths 33. Among children of a somewhat
more advanced age, or from two to fifteen years old, the deaths in the
Children's hospital (Hopital des Enfans) were 48 out of 61 cases.
Atelectasis (from arsx*?, imperfect, and onuw, I draw out), or atelectasis
pulmonum as it was called by Jcirg, consists in an imperfect expansion
of the lungs by the first inspirations after birth ; that is in a permanence
of the foetal state, in the lung ofthe newly-born infant. The disease does
not depend on any original defect of formation in the respiratory organs,
but upon restricted functional development at the time of birth.
An entire lung, or even an entire lobe, is seldom found in a state of
atelectasis—but for the most part only single and scattered lobes. The
inferior lobes of both lungs, and the posterior half of the remaining ones,
generally are in a particular manner liable to retain the foetal condition.
The patches of a brown or violet colour on the surface of the lungs, in
intensity proportionate to the want of expansion, always exhibit a deep
depression, the superincumbent pleura remaining perfectly smooth and
polished. A lobe in this condition, so far from being enlarged, as in
common, is, on the contrary, of smaller dimensions than the others, and
almost as collapsed as in the foetus; being, in general, deeply imbedded
within the thorax, and drawn towards the entrance of the bronchia? and
bloodvessels. The general aspect may be likened to dimples created by
emphysema in adult lungs. Crepitation is not produced either by inci-
sion or pressure, unless where a few air-cells here and there happen to
have become expanded. The same delicate reddish froth is never found
here as in the healthy parts of the lung, but merely a small quantity of
serous, slightly sanguineous fluid. The cut surface appears smooth —
uniform — without a vestige of granular elevations. The whole of the
diseased structure is not softened, but rather of a hard character : still with-
out the tenacity ofthe healthy parts. When a piece is cut off and placed
in water it sinks to the bottom of the vessel. It is possible to dilate arti-
ficially or by insufflation the undeveloped parts, if death takes place a day
or two after birth. Where, however, the little patients have survived
for weeks or months, this inflation seldom succeeds, or only imperfectly.
At this juncture, the unexpanded pulmonary cells are for the most part
adherent; a remarkable fact, seeing how long the lungs continue unex-
panded in the foetus, without adhesion ever taking place.
In infants who had died of atelectasis, E. Jorg invariably found the
foramen ovale of the heart unclosed ; a fact confirmed by Hasse, whose
description of the disease I now adopt. The brain was in a congested
state. When death followed shortly after birth, the body had the ap-
pearance of being generally well developed, but was extensively ecchy-
mosed ; the hands and toes were clenched ; and there was foam in front
of the nostrils and of the closed mouth. When, however, the disease
had lasted some time, the body was wasted and the skin loose and
ATELECTASIS.
227
wrinkled. Inflammation of one part of the lung may be contiguous to
another part, atelectatic ; a different state of things from that described
by Jorg, who believed that both the affected or collapsed and the adja-
cent parts are found inflamed, when the disease had been of some dura-
tion.
If we compare the description of the affected lung in infantile pneumo-
nia, the chief features of which I derive from M. Bouchut (Manuel Pra-
tique des Maladies des Nouveaux-Nes et Des Enfans a la Mamelle), writh
that of atelectasis so carefully given by Hasse, and dwell a little on the
account of this latter by Jorg, we can see the difficulty of diagnosis ofthe
two diseases, and understand how they would seem to run into each other
and be confounded together. Thus, if many of the French and some of
the German writers have mistaken atelectasis for infantile pneumonia,
Jorg himself and others have described as phenomena ofthe former what
were really incident to the latter. Hasse himself, in describing what he
believes to be marked differences and contrasts between the two diseases,
indicates, as distinctive of one, certain appearances that some of his con-
temporaries regard in quite another light. Thus, he says that atelectasis
usually affects both lungs,—pneumonia is for the most part confined to one.
Bouchut asserts that lobular pneumonia almost always attacks both lungs.
In inflammation, the diseased portions are preternaturally distended, whilst
in atelectasis they are collapsed, and inferior even to the healthy texture
in volume. But here, again, is a difficulty: Dr. West says, that in both
diseases the dark portions of the lung are depressed beneath the general
level; but in atelectasis the depression is real and owing to the dark por-
tions never having been expanded by the entrance of air: in lobular
pneumonia it is apparent only, being produced by the emphysematous
distention of the surrounding tissues. In inflammation, Hasse observes,
the pulmonary texture is softened, in atelectasis it is hard, and the cut
surface is not granular but smooth. Now we have seen that a certain
degree of hardness under pressure was mentioned as one of the changes
induced by inflammation. Then again, as regards seat: both diseases
most affect the lower portion of the lung. Shall wre attach any import-
ance to the alleged difference of colour in the two diseases? " In atelec-
tasis the colouring of the diseased portions of lung always approaches
more to a violet, their exterior appearing smooth and glistening so as to
contrast with the dull, brown-red surface of inflammation." It must,
however, be remembered, that Bouchut speaks of the smooth appearance
of the inflamed lobule, while he designates the colour to be of a granite-
red, and West describes it as mottled, portions of deep red being inter-
spersed with others having a natural aspect. Here, in colour at least, there
would seem to be contrasted appearances—a ground of diagnosis. Infiltra-
tion of the inflamed lobules with a reddish sanies would seem to be another
point of distinction. Where no complication exists, the anatomical charac-
ters of a first or third stage of pneumonia are not discoverable either on or
near the diseased patch : in short, we have nothing like pneumonia except
the solid, non-crepitant mass, which has been confounded with the second
stage of that disease, namely, with red hepatization. A portion of incised
lung retaining its foetal condition, allows a little thin, dark, apparently natu-
ral blood to escape upon pressure. In the first degree of pneumonia a tolera-
ble quantity of turbid, bloody fluid, mingled with fibrin, and with a few
minute air-vesicles, — in red hepatization, a tenacious dirty-brown red-
228 DISEASES OF THE RESPIRATORY APPARATUS.
dish,—in grey hepatization, a large proportion of greyish-yellow purulent
fluid may be expressed. Finally, and this is an important consideration,
the secondary phenomena attendant upon pneumonia, as inflammation of
the pleura and ofthe bronchial mucous membranes, softening ofthe bron-
chial glands, fibrinous concretions within the heart's cavities, &c, are
wanting in atelectasis. Hasse concludes his summary with this not
encouraging remark : But the peculiar characters of this foetal condition
of the lung are only thus marked during the first few weeks after birth ;
subsequently when, as already stated, ulterior changes take place, it be-
comes extremely difficult to form an exact diagnosis from mere cadaveric
inspection. The embarrassment is greater the younger the child. It is
chiefly with infants under a twelvemonth, that there can be a question
of atelectasis, as has been justly remarked by Dr. Gerhard.
Hasse closes his critical remarks with the following inferences: New-
born infants are prone to an organic affection of the lungs, altogether dis-
tinct from pneumonia, and dependent upon imperfect inspiration after
birth, by many pathologists confounded with pneumonia, and by Rilliet
and Barthez designated as carnification. The greater number of cases of
pulmonary disease occurring at the earliest period of infantile life, and
set down as pneumonia, may be looked upon as cases of atelectasis. The
last assertion is, however, to be taken with some reserve ; inasmuch as,
in. vast lying-in or foundling hospitals, pneumonia is apt to become epi-
demic with new-born infants, and, under these circumstances, to attain a
numerical preponderance over atelectasis.
Although cadaveric phenomena may fail to furnish us with an exact
diagnosis, the vital ones or symptoms will not fail us in the same way.
Febrile disturbance, and this of a paroxysmal character, with headache,
florid redness ofthe tongue and lips, thirst, sudden stopping in the midst
of eating, coming on where previous good health had existed, point to a
state of things in connexion with symptoms of pulmonary disease, which
cannot be referred to a congenital obstruction merely in some point or
points ofthe lung, such as atelectasis.
Chronic Pneumonia.—It may sometimes happen that acute pneumonia
stops short after the effusion of lymph or stage of red hepatization, and
the diseased portion of the lung, after partial absorption, assumes a dense
and indurated character, and a colour varying from a dingy red to brown,
buff, and sometimes grey, the " induration gris" of Andral. This mor-
bid change of texture is almost always in circumscribed spots. A slow
inflammation of the lung, accompanying tubercular formations, to which
the epithet chronic may be applied, is the most frequent form of the dis-
ease. Other heterologous substances, such as medullary fungus, in par-
ticular, enter into the same reciprocity of action with the inflammatory
product as tubercles. Most of the consolidation of lung met with in
phthisis is of this nature. Dr. Gerhard (op. cit.) represents acute pneu-
monia to have a tendency to become chronic in young children.
The symptoms of chronic are similar to acute pneumonia, but of reduced
intensity. The sarae may be said of the physical signs, which are those
of circumscribed consolidation with, of course, obstruction ofthe pulmo-
nary vesicles of the part.
The diseased portions of lung may remain unchanged for a length of
time, producing only some impediment to respiratory function and a slight
paroxysmal fever. But in other cases they become the means and cen-
SYMPTOMS AND TREATMENT OF EDEMA OF THE LUNGS. 229
tres of fresh inflammation, or they may become the seats of ulceration,
and phthisis terminating in death.
The treatment will be modified by the stage and duration of prior dis-
ease, and the constitutional diathesis of the individual. General blood-
letting is not called for, and will, mostly, be mischievous ; but it is differ-
ent, in some cases, with a local detraction of blood by cups or leeches over
the diseased lung, which contributes to check progressive inflammation
and to stimulate the absorbents to remove the lymphatic exudation,— a
result quickened by counter-irritants, calomel, or blue mass with narcotics,
and the iodide of potassium with the syrup and infusion of sarsaparilla.
A regulated regimen and moderate exercise in a pure and mild air are
of course to be enjoined.
Edema of the Lungs—Pulmonary Edema.—A few words will suffice
for a notice of effusion into the pulmonary tissue, which, although it have
its seat there, is, like all hydropic formations, merely symptomatic of other
and often remote organic disease, commonly obstruction to the circulation.
Pulmonary edema results from organic diseases of the heart, lungs, or
liver; it occurs also in eruptive fevers, especially scarlet fever and meas-
les, and in consequence of renal disease, as I have had occasion to men-
tion in its proper place. It shows itself in the aged, in those enfeebled by
prior causes, and in the convalescent.
The symptoms are both remote or displayed in other organs, and direct
or evinced in derangement of pulmonary function. The former are the
direct product ofthe organic causes, and of course various; the latter are
cough, difficult breathing, and thin mucous or serous expectoration.
With these we generally find also edema of the limbs. On percussion,
the chest emits a dull sound, or one less clear than natural. The vesi-
cular murmur is also indistinct, and particularly at the posterior part of
the chest. The physical signs are, indeed, closely analogous to those in
the first stage of pneumonia ; but there is an absence ofthe characteristic
symptoms of these latter, such as fever and even rust expectoration, and
the disease does not advance to other stages.
The treatment will depend of course on the organ affected and the dura-
tion of its disease, the degree of phlogosis, &c. If the heart be the seat,
the remedies will be varied according to the part affected : sometimes
direct depletion, sometimes tonics and diuretics doing most good. When
edema of the lungs follows scarlet fever or measles we are generally con-
tent with the employment of hydragogue cathartics and diuretics ; of the
former the compound powder of jalap or scammony with cream of tartar,
and ofthe latter digitalis alternating with solution of cream of tartar, calo-
mel and squills. When the oppression is considerable, and complaint
made of pain in any part ofthe chest, the application of a few leeches, or
in their stead, of cups, will both relieve and predispose to a more satis-
factory operation of the purgatives and diuretics. Cutaneous revulsives
are also called for. If the patient be bed-ridden, his posture ought to be
frequently changed, in order to prevent passive congestion and increase
of the edema.
230 DISEASES OF THE RESPIRATORY APPARATUS.
LECTURE CIII.
DR. BELL.
Phthisis Pulmonalis—Difference between phthisis and the phlegmasia? of the respi-
ratory apparatus—Universality and continued prevalence of phthisis—Fearful mor-
tality from the disease—Appearance of tuberculous lungs—Tubercle, its distinguish-
ing anatomical trait.—Natural History of Tubercle—Its Origin and Growth—De-
rived from ihe blood—Deposited in the pulmonary cells and parenchyma—Envelopes
the tissues, which preserve their normal character—Tubercles take the form of the
tissues in which they are imbedded—They do not grow, in the physiological sense—
Different appearances of pulmonary tubercles—Grey and yellow—Grey tubercles the
most common—Miliary granulations the supposed primary form of tubercle—Changes
in grey tubercle from slight causes—Appearance and characters of yellow tubercle—
Frequent coexistence of the grey and yellow varieties—Grey semi-transparent granu-
lations—Originate at an advanced period of phthisis—Grey semi-transparent matter
does not always appear under the form of granulations—Mode of distribution of tuber-
cle in thf limns—Miliary tubercles,—aggregated tubercles,— tuberrculous infiltration-
Structure and Elementary Composition of Tubercle—Resemblance between the genera-
tion <>f tubercle and the formation of normal tissue—Dr. Wright's description—Vo-
gel's additional remarks—Constant elements of tubercle,—molecular granules, adhe-
sive hyaline mass, and peculiar tubercle-cells—Chemical composition—Seats of Tuber-
cle—-Upper lobes of the lungs most affected—Stages of or Changes in Tubercle—Of
crudity, of softening or elimination and of ulceration or cavity—Maturation preceding
softening—Vomica—Successive changes of tubercle described.
Phthisis Pulmonalis—Pulmonary Tubercle, or Tubercular Phthisis.
—Phthisis Pulmonalis, or Pulmonary Consumption, is now almost every-
where among medical men understood to designate a disease caused by
the presence and development of tubercles in the lungs, and of tubercles
alone. This proposition, distinctly affirmed by Laennec, has been con-
firmed by MM. Andral and Louis.
Hitherto you have had presented for your notice those diseases of the
respiratory apparatus which are preceded by hyperemia, and consist in
phlogosis, with an increase, in the case of inflammation of the air-passages,
of its natural secretion, mucus, and if this morbid process be not speedily
checked, of the effusion of plastic lymph. The plasma or formative mat-
ter of the blood, that is to say, the blood independently of its corpuscles
or colouring part, furnishes this exudation mainly by its fibrinous portion,
which in its coagulation assumes a stratified arrangement, and gives rise
to the formation of false membranes. But this change implies organiza-
tion and the production of distinct and regularly formed cells. Another
formation from the fibrinous fluid of the hlood plasma, when the inflam-
mation has reached and somewhat transcended the degree of exudation of
coagulable lymph, is pus, which is, also, regularly organised, in its cor-
puscles being for the most part of a cellular nature, with a nucleus, cell-
wall and contents. The successive changes in the pulmonary tissue or
organ, beginning with hyperemia and ending in suppuration, or in milder
cases in resolution, are local, and other and distant organs are only af-
fected by sympathetic irritation : there is nothing formed incompatible
with the subsequent discharge of function ; for the fluid products are either
discharged externally, or are absorbed, or acquire organization, and, as in the
case of false membranes, assimilate themselves to the tissues out of which
PULMONARY CONSUMPTION.
231
they were originally formed. How often do we not find that false mem-
branes have been formed on the pleura, and after having become adherent
to this membrane, and in a degree identified wTith it, have remained for a
series of years without any notable inconvenience to the individual in
whom the change had taken place.
Very different from all this is the state of things in Phthisis Pulmonalis,
the disease of the lungs on which I am now about to address you. In it
the bloodvessels do indeed throw off a portion of their contents, it may
be, also, that this, to a certain extent, is fibrinous ; and it is deposited,
like the mucus and exuded lymph and the pus, on the air-cells and mu-
cous membrane, &c, or at times in the cellular tissue external to this. But
the process, although it may be the product of a slight hyperemia, is not
clearly so ; nor is it the product of a still higher degree of vascular and
nervous excitement, constituting inflammation. The separation of the
blood, at this time, is properly designated by the term infiltration, the
lowest degree of functional action and secretive deposit. The matters
thus separated are mainly albuminous, or, at best, of degraded fibrin.
At first, their appearance is that of disseminated minute points or seeds;
but, after a period, they coalesce into masses of an indeterminate and
amorpho-granular character, which, at the most, have a very imperfect
cellular structure. Their development is by deposit, accretion, and, finally,
softening: the final product, an indeterminate granular detritus, which
remains a foreign body incapable of being assimilated to the tissues or
organs with which it is in contact, or of being removed by absorption, or
thrown off with any of the normal secretions. There has been no true
plasma or formative fluid: but a pseudo-plasma merely, with scarcely
more vital activity than the mother liquid of a solution from which crys-
talline deposits are formed, in accordance with chemical laws. Neither
have there been transmutations of the normal tissues ; but, rather, new
formations, which penetrate amongst the previously existing histological
elements ofthe body.
Unlike the phlegmasia? which are local, pseudo-plasmata arise in va
rious and remote parts of the body, as well as in those contiguous to the
first products, either simultaneously with these or subsequently. The
common termination of these deposits is by softening, which, although it
bears some analogy to suppuration and ulceration, is not, by any means,
an identical process: it is not productive of true pus except in as far as
this latter is furnished by the contiguous organised tissues which have
been inflamed by the presence ofthe deposited matters, or in the attempt
of these latter to escape through the normal tissues. The successive de-
posits and softenings, with the accompanying destruction and ulceration
of adjoining normal tissue, generally end in death. In some rare cases,
indeed, as we shall afterwards see, the deposit, instead of softening, be-
comes converted into an earthy or cretaceous mass, and forms a concretion
which, no longer receiving fresh deposits, is surrounded and isolated by
an organised investment, and ceases to give farther trouble.
In the class of pseudo-plasmata slightly or not all organised, are tuber-
cle, scrofulous deposits, and typhous deposits. Of these, tubercles are
the most frequent and the most important variety of the class. We under-
stand by the term tubercle, a pathological production presenting itself in
different parts of the body, in consequence of a peculiar predisposition or
raorbid diathesis called tuberculosis. But of the many different organs in
which tubercle is met with, the pulmonary are in a pre-eminent degree
232 DISEASES OF THE RESPIRATORY APPARATUS.
its chosen seat and home. It is to this manifestation, or to pulmonary
tuberculosis, that the following observations are meant, with few excep-
tions, to apply :—
The prevailing term, Phthisis (from a>6«
Bronchial . . 70 ... 1*
Mesenteric . . 102 ... 23 = \
Meso-caecal and ) ,, ,.,., , c 4l tl ,, ,,
nT , > " a little Jess frequently than the mesenteric.
Meso-colon ) n J
Lumbar . . .60 ... 5 = JT
Axillary . . ... 1
The cellular tissue sometimes exhibits tubercles. The peritoneum in a
fifth part of the cases has a serous effusion, and occasionally false mem-
branes, pus, and adhesions. Ascites is only met with when there is com-
plication of heart disease with phthisis. Chronic peritonitis, when not
arising from organic disease of some of the abdominal organs or from
traumatic causes, is almost always of a tuberculous character.
The liver is morbidly affected by what is called fatty transformation,
which reaches the entire subslance ofthe organ. M. Louis has met with
this in 40 cases out of 120, or one in every three. The figure ofthe liver
is normal, but its volume is almost always augmented, and especially at
its great lobe. We find on these occasions that the liver covers almost
entirely the anterior surface of the stomach, fills the epigastrium, goes
beyond the false ribs, and reaches as far as the spleen and crista of the
ileum. Its consistence is commonly altered ; it is soft, and tears easily.
This fatty transformation of the liver is confined almost entirely to phthisis
pulmonalis ; and it is found to be much more frequent among women than
* There is a typographical error in the original, either in the number of cases or the
proportional frequency; the context renders it much the more probable if not actually
certain that it is in the former, we therefore give the latter. It is to be observed, with
respect to the state of the bronchial glands (and, indeed, the circumstance must inva-
riably be borne in mind throughout this article), that the researches of M. Louis refer
to the'disease as it exists in subjects aged upwards of 15—younger individuals beinor
excluded from the hospitals in which he observed. Tuberculization of the bronchial
glands is in infancy more frequent even than that of the lungs.—Ed. Brit, and For.
Med. Rev.
CAUSES OF PHTHISIS PULMONALIS.
247
among men. It occurs when the disease is of short as it does when it is
of long duration. Sometimes the liver is the seat also of tubercles, hyda-
tids, cysts, &c. In general, the bile in subjects in whom this fatty trans-
formation ofthe liver has taken place is of a dark colour and pitchy con-
sistence. In one case only has M. Andral met with tuberculous formation
in the gall-bladder and biliary ducts. The pancreas has always been found
healthy. Seldom are the kidneys altered in phthisis. The same remark
applies to the bladder. Tuberculous matter has been secreted in the
mucous surface of the vesicula? seminales and vasa deferentia, but in
phthisical subjects alone. The muscles are generally atrophied in the
phthisical; and the proportion of phosphate of lime in their bones is less.
M. Dupuy has observed that cows affected with pulmonary tubercle se-
creted milk which contained an unusual quantity of this salt. The peri-
toneum is frequently observed to be the seat of serous effusions in phthisis,
and also, but in less degree, of tubercle. False membranes and tubercles
were found at the same time. Analogous changes are met with in chro-
nic pleurisy.
In a majority of cases some anatomical changes in the brain and its
meninges have been discovered in those dead of phthisis; but the only
morbid ones observed exclusively in these parts, in the subjects of this
disease, are hydatids and tubercles. The last are met with on the upper,
never the under surface of the arachnoid, and in the substance of the brain,
particularly in children. The pia mater is found in many cases to be red,
thickened, and injected.
The blood in phthisis exhibits the ordinary characters of inflammatory
blood ; but, in this respect, there are differences during the successive
stages of the disease. MM. Andral and Gavarret observe, that whatever
be the stage at which the blood is analysed, the fibrin seems always on
the increase, and the corpuscles on the decrease ; these changes being
greatest as the tubercles begin to soften, and greatest in the formation of
vomica?. The fibrin, in this last case, rises to 5-5 and sometimes to 5-9 ;
but never attains the height observed in pneumonia. In the very last
stage, however, as the blood becomes impoverished, the fibrin diminishes
in much the same ratio with the other solid constituents, and sometimes
falls under the healthy standard of 2 to 2*5. Generally speaking, it seems
that the amount of fibrin attains its maximum about the period when the
febrile symptoms are regularly established.
LECTURE CV.
DR. BELL.
Cavses of Piithisib Pulmonalis—External Causes—Climate—Difference of mortality
in different countries—Consumption, a common disease in the Mediterranean climates,
—also in the West Indies, and in the islands ofthe Indian Ocean—Consumption varies
in its rates of mortality in different periods—Cold and moisture—They act chiefly
by impeding the cutaneous functions—Experiments and observations by M. Four-
cault—Close and impure air a common cause—Deleterious influence of confinement
in close and impure air—Effects of dust given out in certain trades—Deficient or im-
proper food—Habits of intemperance dispose to phthisis—Internal causes of con-
sumption—A rises gradually to 8.
duration S
First Phasis.
A few small
tubercles scatter-
ed through the
lung.
Skcond
Piiasis.
Infiltration of
crude tuliercles in
groups.
quality, clear, ringing.
L Commencing bronchophony in rare cases.
f Pulmonary crumpling sound.
Dry crackling rhonchus.
Sonorous, sibilant, rhonchi (symptomatic of bronchitis).
Inspiration—intensity = 12, 1-i.
duration = 9, 8.
quality, clear, ringing.
Expiration, intensity? _ ,„
J i .• J- — o, 10.
"S duration 3
quality, blowing, rarely bronchial.
Dryness and roughness of respiratory murmurs are now masked by
change of quality.
Slight bronchophony, frequently.
Slight obscurity of sound on percussion.
Diminished vocal fremitus.
^ Unnaturally distinct transmission of cardiac sounds.
278 DISEASES OF THE RESPIRATORY APPARATUS.
f Humid crackling rhonchus.
Third Phasis Sonorous sibilant rhonchi, as before.
(or of transition Pulmonary crumpling sound disappears.
from first to se- Inspiration — intensity = 15, 18.
cond stage). duration = 7, 6, 5.
quality, blowing, or slightly bronchial.
Expiration, intensity)
, duration S '
"j quality, bronchial.
Strong bronchophony, or imperfect pectoriloquy.
Sound more obscure, or even dull.
Commencing J Vocal and tussive fremitus much diminished.
softening. Diminution of partial movements of ribs corresponding to indurated
mass.
Transverse retraction of corresponding part ofthe chest.
l^ Sub-clavicular flattening.
The normal intensity and duration of the inspiratory sound being re-
presented by 10, the extreme degrees of increase and decrease mark 20
and 0; between the maximum point of elevation and that of total cessa-
tion, all intermediate grades are observed. A remarkable difference in
the mode of production of increase and diminution is, according to M.
Fournet, that the former change never springs directly from any physical
alteration in the pulmonary structure, and is produced, not in diseased
parts, but in circumjacent healthy tissue ; in a word, it announces the
general fact, that a part of the lung supplies, by increased action, the func-
tional incapacity of another, and characterizes supplementary respiration.
On the contrary, the diminution of the murmur is the direct effect of some
physical obstruction to the entry of the air, and represents the intensity
of that obstruction. The importance of this modification, which, in the
great majority of cases, affects both the intensity and duration of the sound,
is apparent from the fact, that there is scarcely an organic disease of the
larynx, trachea, bronchiae, pulmonary tissue, and pleura, which, as well
as certain spasmodic affections, is not productive of it to a greater or less
amount.
In health, the inspiratory sound is uniform and continuous ; this con-
dition constitutes, according to M. Fournet, its normal rhythm.. In cases
of sharp pleurodynia, he states, this rhythm changes ; the murmur be-
comes abrupt, jerking, and divides into several successive and unequal
parts. In incipient pleurisy, in the dry stage, a similar state is, however,
observed; so that this observation throws no new7 light on the diagnosis
of these two complaints. During the alteration of inspiratory rhythm the
expiratory remains unchanged ; a fact easily intelligible.
The expiratory murmur is subject to much greater increase in point of
intensity and duration than the inspiratory: if we credit M. Fournet, the
maximum increase in these respects may be represented by the number
20, that already employed to designate the corresponding condition ofthe
inspiratory sound. Now, as in the normal state, the former and the latter
murmurs are made respectively equal to 2 and 10, it follows that while
inspiration is only capable of acquiring double its healthy duration, expi-
ration may attain ten times the natural proportion. And again, as it is
elsewhere stated, that while the expiration undergoes this enormous rise,
the inspiratory sound may fall to 1, it follows that instead ofthe expiration
being only one-fifth as intense as the inspiration, it may be twenty times
as intense as the latter ; and hence, that it may actually bear one hundred
DIAGNOSIS OF PHTHISIS PULMONALIS.
279
times a higher proportion to the inspiratory murmur than natural. We
are almost persuaded there is exaggeration in this expiratory estimate ;
at least we have never, ourselves, observed a degree of prolongation in
cases of vesicular emphysema (wherein the abnormal extension has to us
appeared to reach its utmost limit) which could be rated at more than
five or six times the natural amount.—(Brit, and For. Med. Rev.)
Augmented expiration may either coexist with a proportional increase
in the inspiratory murmur, or the healthy ratio ofthe two phenomena may
be destroyed by an accompanying fall in the inspiration. The former
condition occurs in puerile or supplementary respiration ; the latter in the
early stage of phthisis, and in emphysema : these are indeed the only
affections in which the disproportion exists to a very large amount, and
hence its special value in their diagnosis.
The resonance of the voice also undergoes modifications by the presence
of a certain number of tubercles in the parenchyma of the lung. The
alteration, at first slight, gradually increases in such a manner that, after
the lapse of a period of variable length, actual bronchophony may be
detected. The vocal resonance varies, however, on the two sides of the
upper part of the chest, just as we find the character of the respiratory
murmur to vary in these regions.
Mensuration ofthe chest, though not noticed by M. Louis, ought to be
included amongst our aids to diagnosis, derived from physical signs. A
tuberculous lung becomes atrophied and shrunken and the chest corre-
spondingly contracted, with a consequent diminution of its antero-posterior
diameter at the summit, and diminution of the transverse diameter, espe-
cially opposite the upper part of the axillary regions. In the earlier stage
there is no visible alteration, except a flattening or slight hollowing under
the clavicle. The qualifying remark of M. Piorry is worthy of notice on
this occasion. He thinks, that the diminished circumference ofthe thoracic
cavity is owing more to an atrophy of the pectoral and scapular muscles than
to a real curtailment of the capacity of the chest at this part.
There are materials for diagnosis furnished indirectly which are far
from being unimportant. Thus, double pleurisy denotes, almost with
certainty, the existence of tuberculous disease. Ofthe same signification
are ulcerations of the larynx ; for, setting aside cases of syphilis, they are
almost exclusively observed in tuberculous subjects. As tubercles are
developed simultaneously in a multitude of organs, and as after the age
of fifteen they are not formed in any organ without their existing in the
lungs, it follows that the moment special symptoms of their presence in an
organ are met with, we may infer the existence of pulmonary tubercles.
Thus, when we see chronic peritonitis or tuberculous meningitis in any
subject, we are sure that the lungs are suffering from tubercles. Pro-
tracted diarrhoea, as from six to ten months or more, accompanied with
emaciation, and persisting in spite of abstinence, opiates, and blue mass,
and blisters to the abdomen, is almost peculiar to phthisical subjects.
1 da gnosis of the Second Period.—The lesions in *the second period of
phthisis are of a more serious character and greater extent than the first,
and in consequence more easily recognisable. We meet with pains and
hemoptysis in both periods: but the sputa, more or less thick and yel-
lowish at the close ofthe first period, become greenish and striated with
whitish lines at the beginning of the second. The sound of the chest
becomes gradually less clear under the clavicles, or one only of them,
280 DISEASES OF THE RESPIRATORY APPARATUS.
until it lapses into absolute dulness. Not unfrequently the extent of
dulness includes the whole upper lobe. It is now that we see a marked
depression or sinking in of the clavicular region of the chest, and dimi-
nution both of the antero-posterior diameter and of the circumference.
Changes in the phenomena of respiration are going on at the same time.
This is not only rough, harsh, and prolonged in expiration, but it becomes
bronchial or perfectly tracheal under the clavicles where the percussion
sound is dull. It is, also, commonly accompanied by crepitant rhonchus,
composed of large bubbles, more or less moist. The resonance of the voice
is much louder than during the first period ; the bronchophony strong and
sometimes very noisy, so much so as to be disagreeable ; and pectoriloquy
accompanied by respiration becomes audible. Independently of tracheal
or cavernous respiration, which exists opposite tuberculous cavities( vomica?),
that modification of respiration, known under the name of amphoric,
together with metallic tinkling, may also be pretty frequently detected.
In children under five years of age, these signs are not met with ; but
in their stead are those of a merely bronchial character; viz., tubu-
lar respiration, mucous rhonchus, bronchophony, and dulness on per-
cussion.
Prognosis.—The question of the prognosis of phthisis soon receives a
melancholy answer. This disease almost invariably terminates fatally,
after a space of time varying from a few weeks to several years. By
some enlightened physicians phthisis is declared to be incurable. Dr.
Chapman, in his published lecture on Phthisis Pulmonalis (op. cit), in
which he had just before been speaking of the alleged curative powers of
mercury, declares:—" Never have I had the good fortune to witness a
single cure of this form of disease or to know of one well authenticated,
though in private practice, and that of the public institutions I have
attended, mercury was employed by myself or others in several hundred
cases." It may still be not without instruction if I place before you a
brief outline of the prominent reasoning and observations to show the
curableness of phthisis.
Laennec states, as the result of personal observation, that cicatrization
or healing of a tubercle has taken place. M. Andral declares that he has
seen several cases of this healing of tubercles ; and adds, that it may take
place in various degrees. The interior of a cavity being completely emp-
tied of pus, its walls are lined by a cellulo-vascular membrane. After a
while this cavity disappears, and we meet with nothing but a simple cel-
lulo-fibrous line at which abut abruptly large bronchiae; or, there maybe a
larger mass of cellulo-fibrous or of calcareous or cartilaginous structure at
which abut the bronchiae. This is commonly the appearance of things at
the apex of the lung, which is shrunk, puckered, and adherent to the
pleura costalis; and which, in its shrinking, leaves between it and the
pleura a space that is afterwards occupied by a cartilaginous tissue of new
formation. Such, says M. Andral, are the changes which take place in
subjects who, after having exhibited all the symptoms of phthisis pulmo-
nalis, have been cured, and afterwards died of some other disease. Dr.
Carswell believes in' the curableness of tuberculous disease, and points to
the indurated matter, like chalk or hard mortar, found in the bronchial
glands, as proofs that the tuberculous growth and transformation going on
in these parts have been arrested. Simultaneous with these is often the
irritation and tuberculous transformation of lymphatic glands in the neck,
CURABLENESS OF PHTHISIS PULMONALIS.
281
in scrofula, which are evidently often arrested, and the patient is left for
a term of years in tolerable health. He has seen children who had tabes
mesenterica entirely recover, and when examined after a lapse of years,
and some of them in an adult state, having died from other diseases, hard,
dry, chalky masses were found in the mesenteric glands. Dr. Williams
mentions the healing, by contraction in size, of tuberculous cavities ; but
he adds, that they are scarcely ever quite empty: they contain more or less
of a pale-coloured, plaster-like matter, which consists chiefly of carbonate
and phosphate of lime, and sometimes contains earthy concretions. The
contraction is evident from the puckering of the pulmonary tissue visible
on the pleural surface near the cavity, and the adjoining vesicles are gene-
rally dilated to fill up the space. The cretaceous matter is probably secre-
ted by the fibrous false membrane (which lined the cavity of the tubercle);
but it may have been originally of the character of tubercle or pus, and
being unable to escape, the animal part has been absorbed, and the earthy
insoluble salts are left behind and accumulate from successive depositions.
In some cases of tuberculous disease we see the patients cough up chalk-
like concretions, which are an evidence of the chronic nature of the dis-
ease, and of the restorative efforts of the parts to oppose farther degenera-
tion.
Dr. Stokes describes phthisis to be curable. MM. Barthez and Rilliet
make a similar assertion. Dr. S. G. Morton, in his valuable " Illustra-
tions of Pulmonary Consumption," distinctly expresses his conviction, not
merely of the cicatrization of open tubercles but of their entire removal by
absorption. But the most extended investigation of the subject is that by
M. Rogee (Sur la Curabilite de la Phthisie Pulmonaire, fyc). His obser-
vations were made in a careful post-mortem examination of more than two
hundred subjects. Of this number there were a hundred old women, up-
wards of sixty years of age. M. Rogee noticed more particularly two
kinds of lesions at the apex of the lungs, which seemed to him of peculiar
interest, viz., cretaceous or calcareous concretions, and cicatrices of the
pulmonary tissue.
The concretions were found by M. Rogee in fifty cases out of a hun-
dred ; their situation corresponding precisely with that of tubercles as com-
monly seen in the lungs, viz., at the summit of the lung thirty-nine times;
equally distributed through the lung six times; in several parts ofthe lung,
but not at the apex, six times. The relative frequency of the concretions
in the two lungs were as follows:—
In both lungs, simultaneously . . 24 times.
In the right lung . . . . . 17 ''
In the left lung.....10 "
51
\ ery frequently when there were concretions in the lung there were also
some in the bronchial glands. In size they were equal to a grain of hemp
or a pea; sometimes equal to a hazel-nut; and, again, often as small as a
millet-seed. They were found in distinctly tuberculous lungs as well as
those otherwise healthy.
M. Rogee does not hesitate to regard these cretaceous and calcareous
concretions as the result of the transformation of tubercles; in fact of tuber-
282 DISEASES OF THE RESPIRATORY APPARATUS.
cles which were healed. An additional argument in favour of his opinion
is adduced by him, in the fact of concretions being sometimes found in
the lymphatic ganglions, which are also occasionally the seat of tubercles.
Cicatrices are next noticed by M. Rogee. He divides them into four
species:—1. Cicatrices with the cavity still preserved. 2. Cicatrices
with cretaceous or calcareous matter filling the cavity. 3. Fibro-cartila-
ginous cicatrices. 4. Cellular cicatrices. He details cases of persons at a
very advanced age, one of a woman eighty-four years old at the time of
her death, in whose right lung were found two caverns perfectly cicatrized;
a third less advanced containing tuberculous matter, which had passed
into the cretaceous form. In the left lung there was a calcareous concre-
tion. In two other cases of women, each seventy-four years of age at the
time of death, cicatrized excavations were found, which had no communi-
cation with the bronchiae. The whole paper of M. Rogee, which is pub-
lished in three consecutive numbers of the Archives Generates de Medi-
cine, 1839, merits an attentive perusal. He certainly must obtain credit
for establishing the position with which he set out, that pulmonary con-
'sumption is curable.
More recently still, M. Boudet has added his experience and observa-
tions to those of M. Rogee, in confirmation ofthe curableness of phthisis.
M. Boudet (Recherches sur la Guerison Naturelle ou Spontanee de la
Phthisie Pufmonaire) indicates five modes of cure, brought about by cor-
responding changes in pulmonary tubercle ; viz., 1, sequestration, by
becoming completely encysted ; 2, induration, of which there are three
varieties; 3, transformation into black pulmonary matter ; 4, absorption;
5, elimination.
M. Boudet tells us, that he has examined successively and without
selection, the respiratory apparatus of 197 persons, whose ages ranged
from two to sixty-three years, and who died in the hospitals of Paris of
different diseases, including some individuals who were cut off by acci-
dent and wounds in the midst of full health. Of these he found in 45
cases, at ages ranging from 2 to 15 years, 33 tuberculous ; and of 135
from 15 to 63 years he detected tuberculosis either of the lungs or bron-
chial glands in 116. These facts, which, as the author truly remarks,
would seem to be almost incredible, are explained by the readiness with
which these morbid products cease to be incompatible with health, owing
to certain changes in their intimate structure.
Not only have the transformations of tubercle been noted by M. Bou-
det on the dead body, but they have also occurred within his knowledge
in the living subject. In less than a year he collected 14 cases, of which
6 were softened tubercle or undoubted excavations. In all ages and in
every stage of the disease, cures, for the most part indeed spontaneous,
have been brought about.
Dr. H. Bennett (Edinb. Med. and Surg. Journ., 1845) gives the result
of his observations in 73 subjects which he examined, from which it appears
that he found cicatrices in 28.
That the concretions and cicatrices in the lungs of the subjects exa-
mined by MM. Rogee and Boudet, and Dr. Bennett, are really proofs of
an arrest of tubercular deposits and of subsequent sanitary change, would
seem to be established by the following considerations adduced by Dr.
Bennett:—
"1. A form of indurated and circumscribed tubercle is frequently met
PROGNOSIS OF PHTHISIS PULMONALIS. 283
with, gritty to the touch, which, when dried, closely resembles cretaceous
concretions.
" 2. The concretions are found exactly in the same site as tubercle ;
they are most common in the apex, in both lungs.
" 3. When a lung is the seat of tubercular infiltration throughout—
recent tubercle occupying the anterior 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.
" 5. The puckerings found without these concretions exactly resemble
those on which the latter exist. Moreover, whilst puckerings with grey
induration may be found in the apex of one lung, a puckering surround-
ing a concretion may be found in the apex ofthe other.
" 6. The seat of cicatrices admits of the same exceptions as the seat
of tubercles. In one case the author found the puckerings in the inferior
lobe only ; he has only met with three cases in which the lower lobe was
densely infiltrated with tubercle, the superior being only slightly affected."
Hasse, who exhibits due caution in admitting novelties of fact or of opi-
nion, begins his observations on this topic by this remark : " Having
duly considered tubercle in its destructive character, we shall next inquire
into the circumstances under which it is rendered inert, and its ravages
repaired by the healing process, even at an advanced period of the dis-
ease." The possibility of tubercles, while in a crude state, being re-
moved by absorption is still a matter of doubt. M. Andral and Dr. Cars-
well are on the affirmative side. The cure of pulmonary tubercle, whe-
ther in the crude or softened state, is more particularly due to shrivel-
ling and calcareous formation. Tubercular cavities heal precisely in the
same manner, whether debarred from the air-passages, or connected with
several larger bronchial canals. Cavities cicatrize in various ways. They
may disappear altogether, or contract only to a limited extent. In the
first case they fill with a cellulo-fibrous substance. In the second the
cavity is not obliterated, but remains open, simply losing the characters
of the original disease. With the advance of the curative process, the
lung and adjoining portions of the bronchial tubes undergo material
changes. The whole ofthe apex, if not the entire upper lobe ofthe lung,
is shrivelled and obliterated, and at the same time the collective bron-
chial tubes, up to their very end, degenerate into white, thread-like rami-
fications. The involved parenchyma of the lung is now converted into
an almost cartilaginous'mass, impervious to air, very scantily supplied
with blood-vessels, and presenting, when cut, a smooth glistening sur:
face. A very remarkable fact is the extraordinary deposition of black
pigment into the lungs, during the healing process. In older persons,
continues Hasse, this melanotic accumulation is so constant and so con-
siderable, that one m,ight now and then entertain a doubt whether it be
the cause of, or the sequel to the cure of phthisis. But, more of this presently.
Such are the differences, in states apparently similar, in the rapidity of
progress and duration of phthisis, that the prognosis to determine even
the probable period of its termination in death is a very difficult thing.
Sometimes the patient rallies from a condition apparently hopeless, ac-
quires strength and even gains flesh ; and congratulates his physician on
284 DISEASES OF THE RESPIRATORY APPARATUS.
the success of his treatment. A few months more, however, and the
scene is changed. All the bad symptoras return with aggravation, diar-
rhoea sets in, and death soon closes the scene and terminates the false
hopes of the patient and friends, while it rebukes the vanity, if he had given
it any license, of the successful physician.
LECTURE CVIII.
DR. BELL.
Treatment of Phthisis Pulmonalis—Discouraging view of the subject—Systematic
divisionsof treatment, into prophylactic, palliative, and curative—Prophylactic treat-
ment—To be begun early in life—Attention paid to the health of the mother, or the
nurse who may replace her—The child to take abundant nutriment, and moderate but
not violent exercise in the open air—The warm, and then the tepid bath—Cheerful
emotions encouraged, but yet suitable restraint practised—Moderate exercise of the
intellect—Watchfulness at the epoch of puberty—Various exercises, including gym-
nastics ; tepid or cool bath; skin protected by flannel ; food nourishing ; milk, eggs,
and meat,—For weak appetite, bitter infusions, and for anemia, preparations of iron—
Health still delicate, travel is beneficial—Attention to ventilation in the sleeping
apartment—Tone to be imparted to all the organs, and equability of functions pre-
served—Palliative treatment—Complication of phlegmasiae of the thoracic organs and
disorder of the digestive apparatus to be removed—Antiphlogistics succeeded by tonics
—Different ideas of palliative and curative treatment—The practitioner to make his
choice—Circumstances determining him—Different forms of phthisis—Localized bron-
chitic variety; its treatment—Hemoptysis; its treatment—Pneumonia; its treatment—
Recuperative measures—Depletion not always necessary—Diarrhoea, remedies in—
Perspiration and night sweats—Additional hygienic measures—Exercise on horseback;
travel ; change of scene—Benefits from change of climate overrated—Climate of East
Florida—Alleged efficacy of residence in marshy countries disproved—Summary of
curative treatment—Reported remedies against tubercle—Counter-irritation—Condi-
tions for its use—Opening of a tuberculous cavity by perforation of the walls of the
thorax.
To the subject of the treatment of phthisis, the intelligent physician, whose
knowledge of the disease rests on a pathological basis, will approach with
a feeling of depression and discouragement. Even though he should admit
that phthisis is curable, yet he cannot say that it is so under any known
course either of hygiene or of therapeutics, much less by the administra-
tion or use of any one article ; nor can he imitate the means, whatever
they may have been, by which the fatal result has been warded off in
some cases, and tuberculization arrested by the conversion of vomicae
into calcareous deposit. •
The systematic division of the treatment is into the prophylactic, the
palliative, and the curative. Of the two first alone we can speak in terms
of any confidence.
Prophylactic Treatment.—This to be of avail ought to be begun in early
life, even from infancy, when, owing to the disease of the parent and the
lymphatic temperament of the child, there exist well-grounded fears of
the development in it of tubercles. The health of the mother during the
period of lactation, or if she is unable to perform this duty, the health of
the nurse, is a matter of the greatest importance. Abundant nutriment
easy of digestion, but to the avoidance of excessive repletion, daily ex-
posure to the outer air when the weather is not damp, wet, or very in-
PROPHYLACTIC TREATMENT OF PHTHISIS PULMONALIS. 285
clement, and regular bathing, first in warm and afterwards in tepid water,
should be the outlines of hygiene for the infant. When old enough to
take exercise freely itself, the child should be encouraged to indulge in
active sports, if possible out of doors, but not to exert an undue strain on
any organ, by excessive running, jumping, or lifting weights beyond its
strength. With advance of years, mental occupation should keep pace
with, but in no instance exclude or materially interfere with a full share
of bodily exercise. The cheerful emotions should be encouraged, and the
depressing ones sedulously prevented, and when they come on, speedily
dispelled. Let not this advice, however, be construed into indulgence
in appetite for every kind of food, or in caprice or passion, or into a with-
holding of wholesome restraints on these propensities. Restraining coun-
sel and firm rule, far from interfering with the cheerfulness and pleasures
of a child, are found to be signally conducive to a prolonged enjoyment
of them, by nurturing a proper and healthful frame of mind.
Parental vanity ought not to prompt the sometimes precocious intellect
of the child to prolonged exercise of its faculties and sedentary life in con-
sequence, by which hematosis and nutrition are retarded and on occasions
perverted, and a greater probability is afforded for the development of scro-
fulous diathesis and subsequently tubercular formations in the brain and
lungs.
The period of puberty approaching, the greatest watchfulness should
be exerted, but not exhibited, to prevent excitement, which grows out
of the new organic developments, from taking a hurtful direction by the
acquirement of bad habits and especially solitary vices, which throw the
system open to various derangements of health and disorders of a serious,
sometimes of an alarming nature, in which we must include phthisis.
Variety of exercise, by alternate walking and riding on horseback, or in
a vehicle of any description, and moderate gymnastics, frictions of the
skin, and the use of tepid or cool bath, as personal experience may indi-
cate, are now to be regularly and systematically practised. The skin is
to be protected from vicissitudes of temperature by a flannel or merino
jacket with long sleeves, and drawers of a lighter texture and material, to
be changed always at night, and for the most part to be left off during this
time and a gauze jacket substituted for the thicker flannel. Abundant
and wholesome food, in which a fair proportion of animal matters enters,
including milk and eggs, should be allowed ; and occasional languor of
the digestive function remedied by the watery infusion of simple bitters ;
or, if there be paleness and anemia, of one of the milder preparations of
iron.
If early delicacy of frame and constitution continue after puberty, travel
and change of climate will be attended with more beneficial consequences
than at a later period, when phthisis has been developed or made marked
progress.
Both during the period of infancy and in the subsequent period of early
life, the sleeping room should be, if possible, of commodious size, well
ventilated, and with, especially in winter, a southern exposure. Of late
more than formerly, since the increasing use of furnaces and flues to warm
houses, open chimney-places are no longer made, or if made are closed
up, so that persons inhabiting a room of this kind during the day, or
sleeping in it at night, are deprived ofthe requisite means for ventilation,
and for the escape of the impure air generated by respiration and cuta-
286 DISEASES OF THE RESPIRATORY APPARATUS.
neous exhalation, &c. If this difficulty be obviated, I regard the intro-
duction of warm and sufficiently moist air, into all parts of a house, as
decidedly sanitary, and a no unimportant part of prophylaxis, as it is of
palliative cure, by its diminishing the risk of contracting catarrhs and
phlegmasia? of the thoracic viscera, and by rendering them more readily
amenable to remedies and less liable to return.
In fine, remembering the greater tendency to, we dare not say uniform
occurrence of tuberculous formation in consequence of a disordered con-
dition and distribution ofthe blood, it should be our constant endeavour,
by prophylaxis, to impart such a degree of tone to all the organs, and
such a rhythmical exercise of the functions, but without stretching them
to the highest manifestation of vigour, as shall be most likely to conduce
to the elaboration of food into good blood, and then the equable distribu-
tion of this blood to all the tissues, so as to insure a healthy deposit of its
fibrin and other elements for the formation and growth of these tissues, and
the organs into the construction of which in various degrees they enter.
Palliative Treatment.—Our knowledge ofthe complications of tubercles,
and the circumstances accompanying their increase and growth, are suffi-
cient to teach us that they often prove sources of irritation, and develop
inflamraation, as pneumonia, for example, and that they often follow, on
the other hand, the occurrence of this and other forms of thoracic inflam-
mation. In either case, the sufferings and danger of the patient are in-
creased by the occurrence and persistence of these phlegmasia?, whether
it be pneumonia, bronchitis, pleurisy, or hemoptysis; and hence the ne-
cessity for our having recourse to measures, which, although they do not
reach the tubercles themselves, will contribute to remove the complica-
tions, and allow of the organs to perform, with but little comparative
difficulty, their appropriate function for a longer period than if treatment
had not been adopted.
Disorder of the digestive functions, sometimes constituting gastro-ente-
ritis, sometimes associated with altered states of the mucous membrane,
including ulcerations, constitutes additional complications, and requires
correction and abatement, without which the life of the patient is abbre-
viated in a degree that the pulmonary tuberculization alone would not
have caused.
I will first state, in a few words, in what the palliative treatment of
phthisis consists, and then offer some explanations and commentaries, in
addition, for the better understanding of the subject. The occurrence of
partial inflammation, pleuro-pneumonia, or bronchitis, is to be met by
small bleeding, preferably by means of leeches or cups ; the digestive ap-
paratus to be kept in a normal state by plain nutritive food, occasional lax-
atives, with vegetable bitters ; and in lymphatic constitutions, iodine, or
the milder preparations of iron : cough will be obviated by small doses of
opium, or preferably, in reference to the nervous and digestive systems,
by hyosciamus, stramonium, or belladonna; and in cases of dry cough
with heat of the chest, by the inhalation of watery vapour, in which some-
times narcotic substances may be usefully suspended. Counter-irritants
may be used where congestion or pain with slight phlogosis is present.
The concurrent opinion of nearly all those who have most earnestly
and carefully directed their attention to the subject, is in favour of anti-
phlogistic remedies, with a view to remove the local inflammation and
abate the number and violence of the constitutional sympathetic actions,
PALLIATIVE TREATMENT OF PHTHISIS PULMONALIS. 287
such as fever. Nor is this view of treatment abandoned even now that
the deterioration and depravation of function growing out of enfeebling
causes is admitted and in a measure understood. But this knowledge
is so far usefully applied, that while we adopt measures to restrain and
remove promptly the accidentally associated inflammation of the part of
the pulmonary apparatus which may happen to be phlogosed, we are still
especially mindful to have recourse, as soon after as possible, and even
in some cases of very feeble constitutions, simultaneously, to means both
hygienical and therapeutical, calculated to supply blood and to invigorate
the general system.
It may be, when inflammation shows itself early in the disease and is
promptly combated and removed, and, afterwards, judiciously devised
sedative remedies are used, while the hygienic treatment already described
under the head of prophylaxis is persevered in, that tubercular growrth
will be arrested, and phthisis remain in a quiescent or latent state for a
length of time, or for a considerable period of a man's life. Hence the
measures which are proper for palliation are those to be used, but with
somewhat more freedom, in the curative treatment. By some writers, Dr.
Stokes, for example, assuming that tubercles actually exist, but without
complications except those of thoracic inflammation, the treatment is de-
scribed as curative ; while the palliative is understood to apply to the
means adopted for abating the violence of the hectic fever, the cough,
expectoration, diarrhoea, and it may be hemoptysis, without any hopes
of arresting the disease, but merely of diminishing the sufferings of the
patient.
They who deny the curableness of phthisis will regard all the alleged
cases of Dr. Stokes and others as merely instances of suspended disease,
and will of course deny the propriety of the term curative at all to its
treatment. Without adopting this extreme view, I am still disposed to
give, as I have already intimated, a large interpretation to the term pal-
liative, in the disease now before us, and to apply it to all parts of the
treatment ofthe phlegmasiae, or to other forms of disease ofthe lungs and
other organs, ensuing on or associated with pulmonary tubercles—restrict-
ing the term curative to that treatment which modifies by removing or
even diminishing the number and development of these tubercles them-
selves. This, I believe, is the light in which the question is viewed by
M. Louis in his Researches.
With this understanding ofthe use ofthe terms palliative and curative,
you will be prepared to receive with profit the following observations by
Dr. Stokes, which are preceded by a running commentary in proof of the
connexion between inflammation on the one side and tubercle on the other.
On being called, says Dr. S., to a case of phthisis, the practitioner has to
satisfy himself respecting—
1st. The absence of the strumous diathesis, or an hereditary disposi-
tion.
2d. The fact of the disease being recent; for, where physical signs of
tubercle exist, the chance of recovery is inversely as the duration of symp-
toms.
3d. The want of proportion between the extent of disease as indicated
by physical signs, and the duration of symptoms. If the extent be slight,
although symptoms have existed.for months, it shows a power of resist-
ance in the economy.
4th. The calmness of the pulse.
288 DISEASES OF THE RESPIRATORY APPARATUS.
5th. The absence, or slight degree of emaciation or hectic.
6th. The healthy state of the digestive system. In all the extremely
chronic cases, the digestive system continues healthy.
7th. The fact ofthe disease having distinctly supervened on a pneumo-
nia or bronchitis.
8th. The occurrence of free expectoration from the first period of the
cough. An important character, as showing an early attempt to relieve
the irritation by secretion.
9th. The healthy state of the larynx. Most important. The combi-
nation of even a small quantity of pulmonary tubercle, in laryngeal dis-
ease, is always fatal.
10th. The disease, as shown by physical signs, being confined to one
lung, and to a small portion of that lung.
11th. The absence ofthe signs of cavities. This requires explanation.
We know that recovery happens after the formation of cavities, but in
most cases their existence implies that of tubercle in great quantity, occu-
pying other portions of the lung.
12th. The absence of puerile respiration in the healthy portions of the
lung. This character is of value, as showing that a small part ofthe lung
is obliterated, and indicating a quiescent state of the other portions.
13th. The absence ofthe signs of atrophy.
It is not meant that a case should present all these characters in order
to justify our hopes and attempts of cure ; any of them are of value. Of
course the more of them present the better ; and, excluding the first
character, they may be all available in any case of phthisis, whether con-
stitutional or not.
Incipient curable phthisis is declared by Dr. Stokes to be met with in
one of four forms, which may be designated as the Localized Bron-
chitic, the Trachea], the Hemoptysical, and the Pneumonic varieties. I
shall give you his advice in his own language as to the management of
the first.
" Localized Bronchitic Variety.—This is shown by the existence of the
signs of bronchial irritation already described. They occur in the upper
portion, are combined with vesicular murmur and with slight dulness.
The pulse is quickened, the cough is generally dry, but the hectic is not
yet confirmed, nor is emaciation decided.
" At this stage the experience of a great number of cases enables me to
say that a cure can be performed. This is the period for exertion on the
part ofthe physician, but that in which precious time is commonly lost.
" There is a local irritation to be subdued ; tubercle may or may not have
formed. In the first case its quantity is so small, that nature often is able
to throw it off; in the second case, it is threatened, and every day, by
promoting irritation, increases the chance of its deposition.
" The patient must be confined to his room, and all exertions of the lung
forbidden. If he be of a robust habit, and the pulse is inflammatory, a
single bleeding from the arm is to be performed ; the bowels must be kept
gently open, and the diet consist of milk, farinaceous substances, and
light vegetables.
" Leeches are to be applied in small numbers, alternately, to the sub-
clavicular and axillary regions of the affected side. This depletion is to
be repeatedly performed, the cupping-glass being occasionally used over
the bites. Under this treatment Xherdle will be commonly removed, the
PALLIATIVE TREATMENT OF PHTHISIS PULMONALIS. 289
vesicular murmur increased in strength, and the dulness diminished, and
all this with corresponding relief to the symptoms. We are now to com-
mence the use of blisters, which are to be continually applied under the
clavicle and over the scapular ridge. Their size should not exceed that
of a dollar, and they must in all cases be covered with silver paper. A
blister is to be applied about every three days. This counter-irritation is
to be persevered in for several weeks, when the blister under the clavicle
may be converted into a superficial issue, by dressing the surface with a
disc of felt, and a combination of mercurial and savin ointments. During
this treatment the cough is to be allayed by mild sedatives. The following
is the formula which Dr. Stokes employs at this stage :—R. Mucilaginis
Arab, vel Tragacanth. £iij. ; Syrup. Limon. ^ss. ; Aq. purse, ^iiss. ; Aq.
Lauro-Cerasi, £ss.—jj.; Acetatis Morphia?, gr. j. This can be perma-
nently used without deranging the stomach.
As soon as the issue is established, the regimen may be improved.
The patient may now commence the friction with the turpentine liniment,
and if necessary, use inhalations ofthe vapour of water impregnated with
narcotic extract. From twelve to fifteen grains of the extract of cicuta
may be employed, at each time of the inhalation. In mild weather
exercise on horseback should be taken, and the invalid, to perfect his
recovery, should remove to a milder climate, and frequently change his
situation.
Such is the treatment of the most common form of incipient consump-
tion. We owe the principle of local depletion to Broussais, and among
the many boons which he has conferred on practical medicine, there is
none greater than this.
Incipient tracheal irritation, regarded by Dr. Stokes as a distinct form
of curable phthisis, can hardly serve to designate a state of things requiring
separate consideration under the present general head. As far as the
trachea alone is implicated, the disease does indeed require, as he judi-
ciously remarks, an active and decided treatment, which will be successful
just in proportion as the tracheal disorder is unconnected with tubercle.
I need not enlarge on the course to be pursued under either supposition,
after the fulness of detail in which I was led when treating of chronic
laryngitis, the affinity of tracheitis to which was stated on that occasion.
Entire rest of the vocal apparatus, leeches to the windpipe, inhalation of
simple vapour, demulcents, narcotic sedatives, and counter-irritants over
the trachea, or between the shoulders, constitute the main outlines of treat-
ment. The mercurial treatment in the sense in which it is recommended
by Dr. Stokes, viz., to affect the gums gently but decidedly,,is of much
more doubtful efficacy.
In the early stage, tartar emetic with sulphate of morphia, in solution
and mixed with sugar, and in the more chronic, the blue mass with some
narcotic extract, will be employed. The first combination, I direct as
follows :—
li. Tart. Antimonii, gr. j.
Mist. Camphor. §ij.
Sulphat. Morphia?, gr. ss.
Syrup Simplex, ^ss.
Dose.—A teaspoonful at intervals of three or four hours, according to
the irritation of the cough.
When the attack of phthisis in its first stage is ushered in with hemop-
vol. 11.—20
290 DISEASES OF THE RESPIRATORY APPARATUS.
tysis, we have recourse to treatment already indicated in its chief outlines
and details in my lectures on hemoptysis or bronchial hemorrhage. I
had then, however, forgotten that Dr. Cheyne was partial in that disease
to tartar emetic, a remedy of which, from personal experience, I spoke
with considerable confidence.
It may be that, in some lymphatic and feeble subjects, the discharge of
blood by hemorrhage from the lungs gives of itself the desired relief to the
previously congested organs, and reduces the system without the call for any
further loss of blood by artificial means. If the hemoptysis ceases spon-
taneously, and there is no great complaint of heat and oppression in the
chest, we may content ourselves with enjoining entire rest and silence,
cool and acidulated drinks, warm pediluvia, and sinapisms to the lower
extremities, with a mild laxative, or laxative enemata. In more violent
cases in which life is threatened by the great loss of blood, and venesec-
tion has been practised without avail, or the subject is scrofulous and
weak, cold may be applied directly to the chest. I have in some cases
had recourse repeatedly to this remedy by means of a sheet half wrung
out of cold water and applied round the thorax ; and with manifest relief
and comfort to the patient. Ice has sometimes been applied to the chest
with similar intention and effect. Emetics, on the strength of the reports
of their success by M. Rufz in Martinique, are recommended as worthy of
trial by M. Louis. If vomiting were to be brought on by the use of tartar
emetic in moderate doses at short intervals, so as to insure decided and
general relaxation, I see little risk from the remedy, and I have known it
to be advantageous. But if vomiting be suddenly induced by a single
dose of tartar emetic, or, still more, by other emetics which stimulate the
stomach more than they depress the general system, bad effects, caused
by the violent straining and imperfect attempt to vomit, will follow, and
in some instances, as in that referred to by Dr. Stokes, death itself.
Pneumonia supervening on tubercle, the pneumonic variety of Dr.
Stokes, demands a treatment nearly identical with that resorted to when
the disease is primary, as regards the remedies used, but not the extent to
which they are carried. Thus, when the inflammation involves the lung to
any extent, or the stage of phthisis and remaining vigour of constitution of
the patient justify it, venesection should be employed, and even repeated if
the circumstances originally calling for its use still continue. In the more
advanced period of phthisis, it will generally be sufficient to draw blood
from the surface over the affected spot, by cups or leeches, and follow
their application by counter-irritants of blisters or tartar-emetic ointment.
I have found it necessary even in the advanced stage of phthisis, when
cavities were formed, both to bleed from the arm and to apply cups to the
chest. In one case, that of a medical student from North Carolina, this
treatment certainly saved his life at the time (the spring season), and gave
opportunity for him to rally so that he was enabled to return home and
take exercise on horseback. He sank, however, as I afterwards learned,
under the original tuberculous disease, some time in the latter part of the
summer.
In all intercurrent irritation and inflammation of the mucous membrane
and parenchyma in phthisis, including, of course, bronchitis, pneumonia,
and hemoptysis, Dr. Stokes and other leading practitioners of the Dublin
School, recommend, in decided terms, the free use of mercury, so that it
shall give rise to ptyalism. The practice has long been common, quite
PALLIATIVE TREATMENT OF PHTHISIS PULMONALIS. 291
too common in the United States, where a salutary dread now happily re-
places in the minds of many physicians the confidence once entertained of
the remedial powers of mercury in phthisis.
If mercury is to be of service, it must be in what are rather vaguely
called scrofulous inflammations ofthe pulmonary organs, in which direct
depletion fails us, and which, if not checked, soon end in or rapidly de-
velop tuberculization. In simple anemia, with scrofula or tubercle, where
nutrition is defective, and mere irritation exists with really feeble functional
action, the use of mercury ought to be deprecated in the most decided
manner. You will find in the London Medical Gazette, 1840, a sensible
though somewhat prolix communication from Dr. Munk, setting forth the
indications for the mercurial practice in phthisis, and the modifications and
subsequent measures of treatment required to give it adequate effect.
Among the means of palliation, and, by the more sanguine, of cure, in
phthisis, issues have been highly extolled and not a little used. Dr.
Stokes lays great stress on this remedy, as indispensable in many cases ;
while M. Louis, on the other hand, has seen no benefit from their use.
My own experience would lead me to coincide in opinion with the latter.
Moxa repeatedly used under the clavicle has also been praised.
I now recur to that part of the advice for the treatment of a phthisical
patient, in which, concurrently with or very soon after the employment of
antiphlogistics and revulsives for the removal of intercurrent affections or
of complications in phthisis, recourse is had to those measures calculated
to furnish blood and keep nutrition up to a point of average activity ; for,
be it remembered, that it is not a plethoric state of the system and exces-
sive quantity of blood that give rise to the disorders calling for depletion
and reduction, but a wrong direction, an afflux of blood to a particular
part, consequent often upon the local irritation of tubercle. Our aim,
therefore, must be to establish the equilibrium as soon and with as little
expenditure of strength as possible. Contributing to this end will be the
use of opiates, or if these disagree, other narcotics alternating with simple
bitters, which latter of themselves display a sedative much more than a
stimulating operation. We shall not unfrequently find that carefully en-
veloping the patient in warm clothes, after hot pediluvia, and giving him
a Dover's powder and some warm diluent, or if there be cough, mucila-
ginous drink, surprisingly abate and even remove violent stitches of the
side and incipient pneumoniae or bronchitic attacks ; the renewal of which
will be prevented by the judicious use of tonic but not stimulating reme-
dies. In pleuritic stitches, which often are transferred from one point of
the chest to another, we must rely on moderate counter-irritation or revul-
sion, by fomentation, simple plasters to the chest, and opiates rather than
bloodletting, which, if at all tried, ought to be by the application of a few
leeches over the pained part.
The food in phthisis should consist of nutrimental substances, in a rela-
tively small compass or quantity, and even in reasonable variety ; that is,
of change from day to day commensurate with the digestive powers, more
than with cravings of appetite of the invalid. When diarrhoea sets in
more simplicity of diet is demanded, and even though we may not admit
that the change in the mucous membrane of the stomach and bowels con-
stitutes gastro-enteritis, yet will the alimentary canal be for the most part
readily and injuriously affected by commixture of food and highly season-
ed or very nutritious articles, and soothed by those of a simpler and
292 DISEASES OF THE RESPIRATORY APPARATUS.
blander nature. By curtailing the quantity of bread and milk taken by
a patient in the morning, and withholding for a few days the animal food
taken at dinner, and substituting in its stead rice and sago, and rice-water
and gum-water for drink, and giving as the only medicines a few grains
of magnesia and a fraction of a grain of ipecacuanha at intervals, I suc-
ceeded in reducing the number of discharges in the twenty-four hours
from ten or twelve to two or three: and this was in a case in which dis-
section revealed immense patches of tubercular ulceration of the end of the
small, and beginning of the large intestines.
In some cases of diarrhoea, I have found the patient to derive ease for a
time from sugar of lead with a little opium; in others lime-water and lau-
danum have afforded most relief. All the remedies recommended for diar-
rhoea may be tried in succession, and each may suspend the symptoms for
a few hours or a day or two, but no one exerts any notably controlling
power over the disease, or materially retards its progress to a fatal termi-
nation.
The irritative or symptomatic fever with extreme frequency of the pulse
in phthisis has been attempted to be combated by particular remedies, among
which digitalis ranks foremost. It seems to have been forgotten that the
morbidly excited heart is here but a symptom, an effect of diseased lungs:
wre may produce a temporary sedation ofthe nervous system and diminish
its sensibility to the pulmonary irritation, but we do so by partial poison-
ing, when we give digitalis and analogous remedies. I have derived more
benefit from minute doses of tartar emetic, or from ipecacuanha wine with
carbonate of potassa.
Perspiration and night sweats, so enfeebling to the patient, and sometimes
more distressing to him than even diarrhoea, are, like this latter, occasion-
ally mitigated in their extremes, and even partially suspended ; but seldom
by any remedies directed against them as a mere symptom. All external
excitement by undue heat or covering, and all are undue that are not re-
quired by the feelings of the patient, should be withheld. Cool and slightly
acidulous drinks are to be directed, and of these latter the one longest and
most extensively used is the aromatic sulphuric acid, or elixir of vitriol,
largely diluted with water, to which some patients like the addition of sugar.
Cold sage tea, extolled by some for its wonderful anti-diaphoretic powers
in these cases, has, within my own experience, failed much oftener than
it has proved serviceable. Better is the cold infusion of bark. Sponging
the skin with vinegar and water, and a strong solution of alum in water,
has also been used with temporary advantage.
In addition to the hygienic measures already described, and in connex-
ion with a proper diet in phthisis, we may allow the patient carbonated
waters, such as the Seltzer; and the condimental addition of vinegar and
oil to simple and tasteless articles of food.
As part of the hygienic course, moderate exercise in the open air, and
preferably on horseback, if it can be obtained, should be taken by the
phthisical patient whenever the weather is not inclement. If adequate in-
ducement could be offered so as agreeably to excite his attention, travel
to some extent will be productive of no little benefit in incipient phthisis,
provided there be no complication of pulmonary phlogosis nor much irri-
tative fever. Change of scene with moderate and sustained exercise, are
the chief causes of the relief which is attributed so generally to change of
climate when this is made. WTith our now better knowledge of the effects
PALLIATIVE TREATMENT OF PHTHISIS PULMONALIS. 293
of climate and locality, and of the fact that in nearly all the regions of
the earth phthisis is met with, and in warm climates to a very great
extent, we can hardly promise our patients any very decided benefit in
distinctly formed phthisis, certainly little or no hopes of cure, by send-
ing them to other and distant lands. That certain states of bronchial
irritation and chronic phlogosis, exceedingly harassing to the patient
and by their persistence calculated to develop into destructive activity
nascent tubercles, will be relieved greatly by change of air, we are not
allowed to doubt; but even in such cases it is easier to state the pro-
position in general terms than to specify the precise conditions of atmos-
phere and climate which are to give it a practical value. For many preg-
nant suggestions on this topic, I must refer you to the two works of Sir
James Clark on Climate and on Pulmonary Consumption. Good hints
will be found also in the more elaborate and statistical production of Dr.
Forry on the Climate of the United States and its Endemic Influences, to
which reference has been made by me in former lectures.
The climate of East Florida has been highly lauded by many invalids,
and more than one professional writer on the subject. Dr. Forry (op. cit.),
in particular, is warm in his eulogies of a region which seems to have be-
come in a sort endeared to him by the very hardships which, as one of the
campaigners in the Indian war, he necessarily encountered. He describes
the peninsula of Florida as " possessing an insular temperature not less
equable and salubrious in winter than that afforded by the south of Europe."
The comparison meant to be advantageous for Florida is not, however, you
will have learned from the facts and tenor of my lecture on the "Causes
of Consumption," over-flattering in fact. If the science of statistics, or,
as it is the fashion of the day to call it, " the numeral method," were ap-
plied to an investigation into the proportion of cases of, I will not say cure
but of real relief and prolongation of life, I am afraid that much of the
good opinion now entertained in favour of the countries bordering on
the Mediterranean would be dispelled. The reputation ofthe West India
Islands for the sanative influence of their climate is very much on the same
deceptive basis—maugre the praises of St. Croix and certain parts of Cuba
sounded by both invalids and physicians. The southern portion of the
island of Cuba, the one as yet hardly spoken of, is that, however, on which
our hopes must rest for a winter residence for the consumptive.
I would not advocate the other view of the subject taken by the late
Dr. Parrish, to "rough it" in nearly all weathers (North Amer. Med. and
Surg. Journ., vol. viii.); disregarding, at any rate, the winter's piercing
cold, or Boreas's rude blast; but I believe that the strongest examples of
suspension of phthisis, perhaps of cure, in its incipient stages, have been
furnished by those who have been most intent on change of air and scene,
by almost continual travel,—now south, then north—one year in the far
east, another roaming west. Next to this extended travel will be that
course better adapted to the pecuniary resources as well as the feelings of
the majority of phthisical invalids. It is to travel for weeks, it may be
months entire, on horseback. Even at their own homes this kind of ex-
ercise can be taken daily; and who has not seen, by a persistence in this
plan, invalids apparently in the last stage of decline battle it out for many
months, sometimes years, with the grim tyrant ?
Notwithstanding the prejudice, for I believe the adverse opinion amounts
to this, against rooms artificially warmed, I should prefer, for myself, to re-
294 DISEASES OF THE RESPIRATORY APPARATUS.
side in a house in which equable temperature and moisture were kept up
during the winter and spring months, with adequate ventilation, with the
privilege of sallying out for a short walk, or preferably still, a ride on horse-
back, whenever a genial sunshine and a southern air would allow of exit
from the house. These, with the comforts of home, the prompt use of re-
medies for removing inflammation or any complication of the disease by
one's own physician, and the solace of friends, will give the invalid advan-
tages which neither Nice, nor Pisa, nor Rome, nor St. Augustine, nor
Cuba, can procure for him.
Connected alike with prophylaxis and the cure of phthisis, is the ques-
tion, renewed lately in France by discussions in the Royal Academy and
in journals, as to how far the air of marshy countries affords protection
from this disease ; or, in the present fashion of formalising,—How far is
there antagonism between consumption and intermittent fever? That
there is no special novelty in the idea, must be evident to those who re-
member, or who have read of the sanguine hopes once entertained of the
cure of the consumptive by a residence in marshy regions. I have,
myself, as far back as 1825, when combating the notion of intermittent
fever being caused by the imaginary agency of malaria, spoken of the
contrasted localities of this fever and of phthisis. " In the same county
of Lincoln, in England, the inhabitants of the fens are sufferers from in-
termittent fevers ; those of the wolds or hills are obnoxious to catarrhs,
pleurisies, and phthisis. If an exchange be made of habitation in these
two cases, there will be an exchange of diseases."
The very conflicting testimony on this subject must prevent our making
any immediate conclusion ; or ought I not rather to say, that the adverse
testimony of many physicians both in France and Italy, resident and
practising in paludal regions, the inhabitants of which are continually
subject to periodical fevers, and yet suffer from phthisis, is sufficient to
destroy the value of the opinion of any decidedly prophylactic virtue in
marsh air, and to nullify the general proposition or law that M. Boudin
has attempted to establish. Cayenne, proverbially subject to periodical
fevers ofthe worst grade, as might readily be anticipated from the nature
of its soil, which is mainly alluvial, and its incumbent atmosphere, has also
phthisis among its diseases. The negroes especially, as we learn from
Campet (Traite des Maladies des Pays Chauds), fall victims to it in
large numbers. How frequently, also, are we able to trace in different
parts of our own country in which intermittent and remittent fevers are
endemic, tubercles developed or brought into activity by the visceral
diseases, congestive and inflammatory, associated with these fevers. Dr.
Dickson (of the New York City University) tells us : "I have personally
witnessed several melancholy instances of this kind."
After all that we have hitherto learned of pulmonary tubercle and of
the attempts made to modify, by either moderating or arresting its de-
velopment, are we prepared to speak of curative treatment of the disease ?
It would be presumptuous to do so at present, and I shall dismiss the
investigation by a summary notice of the measures and means which san-
guine hopes have ventured to designate as curative of phthisis. In doing
so, I shall repeat the language used in another place (Notes in Stokes's
Treatise), and to a certain extent some of the ideas advanced in a prece-
ding part of this lecture.
The elements of disease, as well stated by Dr. Williams (Principles of
CURATIVE TREATMENT OF PHTHISIS PULMONALIS. 295
Medicine, p. 329), chiefly to be kept in view in the treatment of phthisis,
are : " 1, the disordered condition of the blood, and its causes ; 2, the dis-
ordered distribution of the blood, and its causes; 3, the presence of the de-
posit, and its effects and changes." In our efforts to correct or remove the
first of these morbid elements, small progress will be made unless ade-
quate materials, in the shape of wholesome aliment and pure air, are sup-
plied to regenerate healthy blood ; in fact, suitable pains taken to procure
for the invalid healthy digestion and improved respiration. Attention to
the state of these functions with a view to hematosis, implies necessarily
a careful superintendence of all the other organic functions, and especially
of secretion and excretion—from the skin, kidneys, &c, and an equable
warmth and active vitality ofthe external surface, maintained by suitable
clothing, bathing, and friction. These last act hygienically in the same
way as counter-irritants do therapeutically.
Whatever good effects are derivable from a change of climate to the
phthisical patient, depend on the aid which it gives to nutrition, including,
of course, hematosis, more than on any directly sanative, or, as some ima-
gine, balsamic influence of the air on the lungs. This truth is beginning
to be better understood, now when it is discovered, that warm southern
climates are never beneficial unless digestion and healthy nutrition are
maintained ; and hence, also, we can now understand the seeming para-
dox, that some phthisical patients are benefited by a change from a warm
to a cool, even although it be a somewhat inclement, climate. The
general health is often better in the latter, and the patient's chances of
longer life increased, provided local hyperemia, congestions, and inflam-
mations of the lungs be guarded against. To these the patient is more
liable in cold climates ; but, as it has seemed to me, he is, on the other
hand, more exposed to tuberculous disease and irritation of the bowels,
and consequent impediment to nutrition, in warm climates. When we
speak of the latter we mean those in which not only the average tempera-
ture of the year is considerable, but also the temperature of the winter
months, as in the West Indies, is relatively high. In atonic states ofthe
system, and where the appetite is inconsiderable, digestion slow, and nutri-
tion imperfect, I would recommend residence, even during the winter
months, in northern latitudes to that in southern and warm ones,—pro-
vided that all due attention be paid to the clothing of the patient, and a
uniform temperature of the air in-doors through a suite of apartments,
if not the whole house, be kept up'. Precautions of this nature will not
be found incompatible with permission to exercise on foot or in a carriage,
whenever the weather is not very inclement. In this opinion I am
strengthened by the observation of cases, the treatment of which, I have
directed in accordance with it.
Of the different remedies which are believed to act on the blood and
prevent new deposits, and to promote the absorption of those already
made, preparations of iodine have, in late years, enjoyed the most vogue.
The mildest and best is the iodide of potassium, which, as a good altera-
tive, favourable to nutrition and improving the appetite, will be found to
amend the general health, even, and unhappily this occurs in the largest
number of cases, when it fails to remove the tuberculous deposit. It
should be combined with the compound syrup and the decoction of sarsapa-
rilla, or a simple vegetable bitter. More benefit will be derived from its
moderate use when largely diluted with water and continued without inter-
296 DISEASES OF THE RESPIRATORY APPARATUS.
ruption, than when it is given in full doses at certain intervals, as twice or
three times a-day, with a risk of its offending the stomach, or producing
its peculiar disorder of iodism.
From at, priori reasoning, and even a due share of favourable attesta-
tions of its power in scrofulous diseases, the iodide of iron has been used
with a view both to promote the absorption of tubercle and to prevent its
farther deposit. As a useful tonic in debilitated states of the digestive
system and of the body generally, this medicine may be used in many
cases of phthisis with advantage ; but if we believe in its possession of
curative powers we shall be disappointed. M. Louis, who, in the last
edition of his work on consumption, passes in review the latest recom-
mended remedies, gives his experience of this article (the proto-iodide of
iron). He employed it in upwards of sixty cases, occurring either in his
hospital or private practice, and, " to his astonishment, in not a single
case did he observe any amelioration which could be attributed to the
new agent." Still, on the faith of M. Duparquier's positive assertions of
its efficacy, M. Louis thinks that it would be worth while to make a far-
ther trial of the medicine.
Common salt has been subjected, by M. Louis, to the same test, that
of experimental trials, and has proved to be without any value. In no
single case did he observe any appreciable effect produced on the state
of the functions. Some patients could not go on with the chloride for
more than a few days, the greater number took it for a month or upwards.
Carbonate of potassa, rather a favourite medicine with Laennec, has
been used and praised by some of his successors for its resolvent proper-
ties in tubercle ; but more on the grounds of analogy than from direct
evidence in its favour. M. Louis might have attached some importance,
however, to a recommendation from such sources, even though he did not
think it worth while to try this article on the faith of M. Pascal's praises.
Dr. Cless, of Stuttgard, lauds sal ammoniac in large doses ; and M.
Hirzog, of Posen, is equally confident of the powers of chloride of lime.
But the truth is, as well observed by the British and Foreign Medical Re-
view, and we introduce the remark as applicable to many physicians both
in Great Britain and the United States, a great number of the Germans are
in the happiest of all possible conditions for " curing phthisis" readily—
in perfect ignorance of the principles of physical diagnosis they trust to
the local and general symptoms for their guidance, and their acquaintance
even with these is superficial and routine-like,—how often chronic bron-
chitis, simple chronic induration, chronic pleurisy, &c, must be confounded
with phthisis under such circumstances, is sufficiently obvious.
Cod-liver oil has been employed by many practitioners with, as they
inform us, clearly beneficial results ; among others by Dr. Thompson, one
of the physicians of the Hospital for Consumption and Diseases of the
Chest, at Brompton (England). When benefit was derived, it was, he
informs us, generally to be observed within a fortnight.
The emetic treatment, once so highly praised and so often practised,
but which fell properly enough into disuse, has been again revived with
fresh laudations by Dr. Hughes. He gives a preference to the sulphate
of zinc or of ipecacuanha in doses of twelve grains, or a combination of
six grains of ipecacuanha and two grains of sulphate of copper. As a
general rule, the earlier the stage and the more chronic the character of
the disease the greater has been the benefit derived from their operation.
CURATIVE TREATMENT OF PHTHISIS PULMONALIS. 297
The emetic is to be given every second, third, or fourth day, according
to the strength ofthe patient.
There is yet another remedy, and as the last recommended for the cure of
consumption, it is, of course, assumed to be better than all its predecessors.
It is Naphtha, introduced by Dr. Hastings, and alleged by him to have suc-
ceeded in his hands in the treatment of undoubted cases of phthisis. Were
we to adopt the views of this writer, we ought to regard it as a specific in
this disease. The fashion in which he announces his success is itself cal-
culated to beget suspicion, as when he tells us, that—" From the very
first moment I employed naphtha in pulmonary consumption up to the
present time, it has been so successful in my hands, that I have no doubt
it will be found, upon careful and judicious use, to be little less than a
specific in the earlier stages of the disease." This is tolerably strong ;
but the following places the writer in the forward rank of boasting empi-
rics : " Single-handed, if I may be allowed to use the expression, it has
cured pulmonary consumption in almost every case in which it has hitherto
been used, when the disease has been treated at an early stage ; and from
what I have more recently observed, although I do not consider myself
justified at present to publish it, I am most sanguine that even in the lat-
ter stages of the disease a restoration of health may generally be calculated
upon." The dose of naphtha which works such wonders is fifteen drops,
taken thrice daily in a little water! As the disease advances, the dose is
increased to forty or even fifty drops four times a-day. A melancholy
commentary on this credulity is furnished by the fate of a warm partisan
ofthe naphtha treatment, Dr. Hocken, who died, not long since, in Eng-
land, from consumption,—notwithstanding his faith in and use of the medi-
cine. Not many years since, hydrocyanic acid was announced by earnest
and zealous physicians in terms of nearly equal confidence. In some
cases of chronic bronchitis and catarrh in lymphatic subjects, naphtha, as
a stimulating expectorant, is of service.
As might have been foreseen, from a knowledge of the pathology of
phthisis, the favourable representations made by different writers of the
good effects of the inhalations of various gases and vaporized substances
have not been borne out by recorded experience. The cases published
some years ago, by M. Cottereau, in illustration of the curative influence
of inhalations of chlorine in phthisis, have been subjected to analysis by
M. Louis; and the result is, that not a single one of thera proves the effi-
cacy of the pretended specific. This gentleman, notwithstanding the
unfavourable issue of the scrutiny, submitted upwards of fifty phthisical
subjects to the action of chlorine, and " without in a single case obtaining
a successful result." I have sometimes found it give temporary relief
to the patient when oppressed by the accumulation of much muco-purulent
matter in the bronchia?, and sometimes it seemed to aid in the temporary
evacuation of a vomica: but I never found it exert a beneficial influence
over the disease by retarding its course, or materially modifying its cha-
racter. Of the inhalation of iodine I am inclined to think more favour-
ably ; but must confess that I have no case to which I can point as
having had its course suspended by the medicine. The alleged cures
performed both by iodine and chlorine inhalations were doubtless of ex-
hausting chronic bronchitis.
Counter-irritants, useful as prophylactics, are still recommended among
the curative part of the treatment of phthisis. I certainly have seen
298 DISEASES OF THE RESPIRATORY APPARATUS.
relief, amounting almost to a suspension of the most troublesome symp-
toms, including, of course, cough, procured by an eruption with croton oil
and also by pustulation with tartar emetic. More, however, must be
hoped for from the use of these and analogous means in the early than in
the advanced stage of phthisis. Dr. Evans, who was once an assistant to
St. John Long, celebrated not many years ago for his wonderful cures of
consumption, so runs the history, has published some lectures on the
disease. Dr. E., after the death of his principal, took to more honest
courses, and applied himself diligently to the study of diseases and to
their treatment in the usual way. I do not think it necessary to repeat
his pathological novelties regarding phthisis, as I believe them not to be
true,but refer to him just now as a witness of some experience on the merits
of counter-irritation ; for it was in rubbing and making the back sore and
raw, that St. John Long's treatment mainly consisted. Dr. Evans still
thinks that this fashion of medication is entitled to more confidence than it
obtains, provided it be conducted in conformity with the recognised prin-
ciples that should govern us in having recourse to counter-irritation.
These are, to abate the original irritation and to make the secondary
irritation at a part distant from the original. Mere stimulus to the skin
will not do good, even if it be not actually prejudicial. There must be
a greater irritation#on the surface than that which exists internally. Dr.
Evans prefers a liniment composed of vinegar and spirits of turpentine,
croton oil, or the ointment of tartrate of antimony, and he particularly
urges an extensive application of the liniment, which he states was the
secret of the undoubted success in many cases of St. John Long.
More reprehensible by far than the quackery of this individual, or of
any other who has figured on the stage of imposture, is the proposition
gravely made, and in one instance if not more carried into practice, to
lay open, by perforating the walls of the chest, the tuberculous cavity.
Dr. Hastings, of naphtha notoriety, has published a case in which an opera-
tion of this kind was performed. The hoped for result was tobring in apposi-
tion the sides of the tuberculous cavity. A more crude pathology can scarcely
be entertained than this, one implying greater ignorance of pulmonary
tuberculosis as well as of the circumstances under which tubercle is formed
in the different organs of the body. It is not so much a cavity per se as
the continual deposition of tuberculous matter on its walls, and still more
the state of the blood and of the assimilating functions by which the matter
is formed, that keep up phthisis and interfere with recovery. Let this
perpetual supply from the blood and its deposit on the lungs be arrested
by a change of diathesis, and we need not trouble ourselves about exposing
a tuberculous cavity and attempting to aid its closing up. This will be done
by natural processes, in a safer and more satisfactory manner than by any
surgical operation, which can never, even in a well-constituted habit, be
performed without danger. In the present case, paracentesis of the chest
could not be thought of even by its most sanguine advocate unless the
sides of the tuberculous cavity were adherent to the pleura: but we
would ask, who shall insure a positive diagnosis on this point, and say that
the cavity is not in the centre ofthe lungs or covered by some pulmonary
tissue. Then again, if there be more cavities than one, must an opera-
tion be performed for each cavity ?
TUBERCULOSIS OF THE BRONCHIAL GLANDS. 299
LECTURE CIX.
DR. BELL.
Tuberculosis of the Bronchial Glands—Bronchial Glandular Phthisis—Morton's
account of this disease, as Phthisis Scrophulosa—Studied only of late years—Different
forms of—Changes in the tubercular glands—Effects of pressure of the bronchial
glands on other parts—the great vessels, trachea and bronchiae, the lungs, nerves, and
oesophagus—Communication between the bronchial glands and the lungs—Union of
glandular and pulmonary tubercles—Symptoms—chiefly from compression—Dropsy-
Hemorrhage—Alteration of the voice—Auscultation—Diagnosis—Prognosis—Causes
—Age—Complication with pulmonary tubercle—The disease properly scrofulo-tuber-
cular—Treatment—Curative and palliative—Prophylaxis.—Gangrene of the Lungs
—Almost always a secondary disease—Is most common in children, and attacks men
more than women—Anatomical lesions—Different forms of the disease—Change of
pulmonary texture by—Cavities—Stages—Concomitant lesions in the lungs and other
organs—Symptoms and Diagnosis—not very distinct—Causes—Associated with pulmo-
nary apoplexy—The insane most liable to the disease—Treatment—regarding it as a
disease ofthe blood—To correct putrescence and keep up the tone ofthe system.
Tuberculosis of the Bronchial Glands — Bronchial Glandular
Phthisis.—I am induced to deviate from the course pointed out by the
anatomical connexion of parts, and their community of object for the dis-
charge ofthe function of respiration, and to suspend, for a while, inquiry
into the remaining diseases ofthe respiratory apparatus, in order to make
a few remarks on those of the bronchial glands, and more particularly
on that morbid condition of these bodies which consists in tuberculosis. My
reason for this deviation is, that, although these glands serve no direct office
in the respiratory function, yet situated, as they are, on the trachea, and sur-
rounding its first bronchial ramifications, even down into the lungs, and con-
tiguous to some of the great vessels, any morbid change in them, espe-
cially by augmentation of size, produces considerable disorder in the respira-
tion and the circulation. And again, they are so often affected with tubercu-
lous deposit, especially in children, that their disease in this way gives rise
to phenomena analogous to those of pulmonary tuberculosis, even when
not complicated with this latter. This complication is, however, as I
have before told you, quite a common occurrence,
Morton, in the third book of his Phthisiologia, allotted to symptomatic
pulmonary phthisis, describes a scrofulous variety of the disease, the seat
of which he supposes to be in the pulmonary glands. This author in-
dicates clearly the infarction or swelling of the glands juxta Trachccam
atque ejus ramulos; and he finds collateral proof of their scrofulous cha-
racter, at this time, in the occurrence of concomitant glandular tumours in
other parts ofthe body, and, also, of ophthalmia, scabies, and other scro-
tulous affections. He soon, however, in the farther progress of his de-
scription, places under the same category and as constituting a part of
scrofulous phthisis, tubercles of the lungs themselves, which he speaks of
under the form of a cretaceous, steatomatous, and meliceritious nature.
I may mention here, by the way, that Morton, on this occasion, describes
two varieties of this form of phthisis ; chronic and acute. The chronic
is modified by the presence of the cretaceous tubercles, the subjects of
which live, he tells us, though as valetudinarians, from youth to advanced
age. In the acute variety the disease terminates in a very short period.
300 DISEASES OF THE RESPIRATORY APPARATUS.
Stark, to whom we are indebted for the first clear account both of
tubercle and ofthe place and circumstances of its deposit, states that the
lymphatic glands of the chest are of a dark colour, and sometimes contain
a matter like cheese. But it is only of late years that the diseases of the
bronchial glands have attracted much attention, owing, in a great mea-
sure, to their prevailing chiefly in early life, and during a period in which
its diseases were not investigated by the aid of morbid anatomy, and with
a view to an illustration of symptomatology and treatment. Even now
we must look to the writings of French physicians for the chief and most
carefully made observations on the subject; and of these, in a more espe-
cial manner, to the elaborate work of MM. Barthez and Rilliet, so often
referred to and quoted by me in these lectures. It is but just, however,
that I should mention the late Dr. Joseph Parrish, of this city, having
many years ago pointed out, and dwelt with no little emphasis on the
morbid states of these glands as part of evidence of the scrofulous cha-
racter of phthisis.
The chief form of disease of the bronchial glands is tuberculosis, which,
both in itself and associated with tubercle of the bronchiae, merits care-
ful study. Of all the varieties of tuberculous matter infiltration is the
most common in these bodies, although we meet with grey and yellow
granulations, and the miliary tubercle also.
Commonly, the central part of the gland is the first affected, and the
disease extends thence gradually to the circumference ; at other times, the
tuberculous matter is irregularly distributed in different parts ofthe gland.
We may find even grey granulations in the centre ofthe organ, whilst the
periphery is already converted into tubercle : at a later period the entire
gland is affected in its tissue ; and it may acquire the size of a filbert, an
almond, or even of a chestnut. We are not to suppose, however, that all
the glands in the same subject undergo the same enlargement. In some
cases there are only five or six tuberculous glands surrounding the bron-
chiae of one of the lungs ; but in other cases they are much more numer-
ous, run into each other, and form large masses, equal, in some instances,
in volume to a hen's-egg, or even to a large apple. Such enlargements
are only acquired, however, by the glands external to the lungs. The
internal ones, on the other hand, seldom exceed the size of a small hazel-
nut, or of a small almond. We can trace them deep into the lungs on a
level with the third and even fourth divisions of the bronchiae. Most
commonly they adhere to the air-passages in the direction of the length
of these latter; while, at other times, they form a kind of arch, surround-
ing in part the bronchiae, the concavity of which is turned towards these
latter and the convexity towards the lungs. In another direction, they are
situated between the pericardium and the lungs, and along the oesophagus,
in the posterior mediastinum ; and, finally, along the large vessels in the
anterior mediastinum, and thence on the trachea and cervical plexus.
These glands are inclosed in a cyst with very thin walls, to which
tuberculous matter closely adheres. On removing this latter we often see
on the internal surface of the cyst a very delicate vascular arborization;
but in recent tuberculosis this structure is not perceptible. The tubercles
which they contain undergo, at different intervals of time, a softening
analogous to that which is observed in the tubercles of other organs ; and
which begins sometimes in the centre, sometimes in the circumference of
the gland ; and on occasions it may be going on simultaneously in both
DISEASES OF THE BRONCHIAL GLANDS. 301
these directions. Abscess may sometimes simulate tubercle of the glands ;
but the difference is easily detected by a careful inspection of the fluid,
which is homogeneous in the former, but grumous and exhibiting the
remains of tuberculous matter in the latter. Suppuration of the bron-
chial glands is, however, a rare disease.
Once softened, the tuberculous matter generally finds exit by a com-
munication established between thecyst and the adjoining organs,although
in a few cases there is reason to believe that it is absorbed but still incom-
pletely.
The next branch of inquiry connected with tuberculosis of the bronchial
glands is the pressure which they exert on adjoining parts. To be able
to appreciate properly the symptoms from this cause, we ought to be aware
of the two kinds of bronchial glands and their respective distributions.
One of these is external to, the other in the lungs. The latter are quite
numerous and accompany the ramifications of the vessels and the air-
tubes ; increasing in size as we trace them from the minute bronchise and
vascular branches to the roots of the lungs, and the great vessels. Among
the glands external to the lungs, anatomists distinguish, situated on the
sides of the trachea and in the space between its bifurcation, the tracheal,
the bronchial, the cardiac at the base of the heart and in connexion with
the great vessels, and the oesophageal ones situated in the posterior medias-
tinum and the vicinity of the oesophagus. These limits may be passed in
disease, so that the cardiac glands fill the whole anterior mediastinum
and extend from the base of the heart to the sternum, and even sometimes
encroach on the space occupied by the lung. The tracheal and the bron-
chial divisions in their hypertrophied state sometimes form a complete
envelope to the tubes from which they derive their name and which they
entirely surround, in place of their being simply in contact with the sides.
It is easy to foresee, after this view ofthe situation of the glands, that
by their enlargements they would compress important organs, and give
origin to a great variety of symptoms, generally, it is true, of a physiolo-
gical nature, as their occurrence is not maintained by any decided anato-
mical lesion. I shall enumerate the chief organs liable to compression
and consequent derangement of function from this cause.
The Great Vessels.—The superior vena cava, the aorta, the pulmonary
artery and veins, and the vena azygos, may be thus compressed ; and
have their circulatory office much disturbed. M. Tonnelle relates a case
in which the superior cava was completely obstructed. Among the second-
ary lesions produced in this way are hemorrhages and dropsy ; the former
of which has taken place in the arachnoid cavity and the latter manifested
by edema of the face. Compression of the pulmonary vessels gives rise
to pulmonary edema, and indirectly it may cause dangerous hemoptysis.
May we not attribute to this cause some of those alarming and obstinate
hemoptyses in young scrofulous subjects, in whom from early life the bron-
chial glands had acquired an unusual volume and been partially tuber-
culized.
The Trachea and the Bronchia.—These organs are not so often unduly
compressed as the great vessels; although instances are related of the
almost entire obliteration ofthe bronchial tubes by this cause.
The Lungs, from the number of bronchial glands distributed through
them, are liable to suffer from pressure by the enlargement of these latter,
which sometimes assume the appearance of pulmonary tubercles and
thrust aside as it were the lungs.
302 DISEASES OF THE RESPIRATORY APPARATUS.
The Nerves, particularly the pneumogastric and their divisions, are
often compressed. Reference has been made in my lecture on croup, to
the hypothesis of Dr. Ley, that compression of these nerves by enlarged
cervical and bronchial glands gives rise to this disease, or at least to some
of its prominent symptoms.
The (Esophagus has been compressed, but without our having learned
the accompanying disorder, if any, that was manifested.
In farther prosecution of the subject of the effects of changes by the
bronchial glands on adjoining parts, we have to note the communications
between the glandular cyst and the thoracic organs. The chief example
of this morbid connexion is in the bronchia?, which, unable to yield much
to the pressure of enlarged glands, form adhesions to these latter, at first
by loose cellular tissue, which afterwards becomes so dense that it is im-
possible to detach the gland without bringing away a portion of the bron-
chia itself. This intimate union is but the prelude to farther changes, which
end in a softening of the tuberculous gland and a communication between
it and the bronchia through a perforation in the cyst and the sides of the
latter. At times, the accumulation of tuberculous glands is so great around
the bronchia as to form a tuberculous investment of some degree of thick-
ness.
The appearances of the perforations in the bronchia? vary ; some-
times they are well-defined and without any traces of inflammation. At
other times they are deeply injected on both sides, and the borders ofthe
opening are irregular. The cystic investment of the gland, after having
been emptied of its tuberculous matter, through the opening into the bron-
chia, shows in its interior a false membrane, which is not, as some have
alleged, analogous in general appearance and colour to the bronchial mu-
cous membrane, although it must be acknowledged that it is not readily
distinguishable from this latter at the line of junction. There may some-
times be seen, intermediate between the tuberculous gland and the bron-
chia, portions of pulmonary tissue traversed by cavities, the sides of which
are formed by the parenchyma ; the cavities themselves being a medium
of communication between the bronchia and the gland. But when the
bronchial gland is deep in the parenchyma of the lungs, and communi-
cates with the bronchia or causes an ulceration of adjoining tissues, it is
very difficult to determine the nature of the case; and it has doubtless
happened that those tuberculous cysts situated in the interior ofthe organ
have been described as true pulmonary cavities.
Perforation of the vessels is a rare occurrence,—and the same may be
said of that of the oesophagus.
A union of glandular and pulmonary tubercles may take place — at
first when they are in a state of crudity, and afterwards of softening. A
similar junction is formed between the primitive bronchial tuberculosis
and that in the bronchial glands. The coexistence of tuberculosis of the
bronchial glands and of tuberculous meningitis has been noticed.
Symptoms.—It is not easy to give the symptoms of a disease which is
seldom met with alone, or uncomplicated with other lesions, before the
primary ones or those of the bronchial glands have attracted attention.
The enlargement simultaneously of the cervical and axillary glands may
beget suspicion of a glandular tumour in the thorax or about the root
of the lungs. MM. Rilliet and Barthez, after an investigation of this
branch of the subject, recapitulate as follows : Compression by the vena
SYMPTOMS OF DISEASES OF THE BRONCHIAL GLANDS. 303
cava may cause edema of the face, dilatation of the veins of the neck,
violet colour of the face, hemorrhage into the arachnoid cavity. Com-
pression of the pulmonary vessels may give rise to hemoptysis and pul-
monary edema.
When the glands compress the pneumogastric nerves, there may super-
vene alteration in the tone of the voice, kinks, like those in hooping-
cough, and paroxysms of asthma, which are so unusual in a child. The
action of the glands on the lungs and bronchia? is still more remarkable.
By compressing the air-tubes, the glands give origin to the production of
intense, persistent, and sonorous rhonchi, of a peculiar quality. They
also prevent the free circulation of air in the lungs, and thence results
obstruction of the respiratory murmur. This phenomenon may also
depend on edema caused by compression on the pulmonary organs.
But the glands may act not only on the bronchiae by pressure, but, like-
wise, as conductors of sonorous impressions. Hence we have the fol-
lowing phenomena : 1. The lung being quite healthy or nearly so, various
alterations in the respiratory sound may be heard in different parts of the
chest, such as prolonged expiration, bronchial respiration, and all the
sounds which in their normal state are formed in the bronchiae and are not
transmitted to the ear. 2. These symptoms are still more evident if there
exist any pulmonary lesions, the stethoscopic indication of which, in
common of little intensity, may seem to be exaggerated by the presence
of the enlarged glands. 3. The stethoscopic sounds furnished by the
lesion of one lung may be transmitted to the opposite side and produce
the impression that a double lesion exists. 4. The bronchial glands
resting on the vertebral column of one side, whilst they surround the
bronchiae on the other, transmit directly to the ear the sounds both normal
and abnormal, which are evolved in a part of the lung remote from the
thoracic cavity, and thus seem to be exaggerated. 5. These stethoscopic
phenomena are especially perceived at the apex of the lungs behind and
more seldom in front.
All these symptoms, which result from the pressure of enlarged and hard-
ened glands on the vessels, nerves, bronchiae, and lungs, are not always
met with in conjunction, and when they do they may come and go, often
in a curious and incomprehensible manner.
Diagnosis.—This, as may have been inferred from an enumeration of
the symptoms, is not an easy matter. It must be made from a careful
sifting and analysis of the symptoms and an observation of their intermit-
tence. It will be proper, after an investigation of the direct symptoms,
to examine the lymphatic glands as far as they are visible ; and especially
those of the neck, which seem to form beaded lines, passing behind the
clavicle and continued down into the thorax, blending with the bronchial
glands proper.
Tuberculosis of the thoracic glands, including the bronchial proper as
well as others in the chest, may be confounded with hooping-cough,
phthisis, and tumours developed in the mediastinum.
Prognosis.—If the tuberculated bronchial glands were the only disease,
we might indulge in a rather favourable augury. Neither so extensive in
their morbid changes nor exciting secondary inflammations as pulmonary
tubercles do, still we find the tuberculous glands associated with, as pre-
cursor or cause, accidents of an alarming nature, such as hemorrhage, per-
foration of the lungs and oesophagus, pressure on the vessels, nerves, and
bronchiae.
304 DISEASES OF THE RESPIRATORY apparatus.
Causes. — Inflammation of the bronchial glands is not an adequate
explanation ofthe causes of their tuberculosis; nor is bronchitis or pneu-
monia more satisfactory.
Age.—This disease is peculiarly one of early life, and in persons of this
period it is more common than pulmonary tuberculosis. Of its frequent
complication with this latter we may judge from the fact stated by Dr. H.
Green, that in 112 cases of pulmonary tubercle, 100 had tuberculosis ofthe
bronchial glands. Rarely are other organs tuberculous in children without
the bronchial being eminently so. Under puberty there are two periods
in which glandular tuberculosis is most rife : first in very young children ;
and next in those from six to fifteen years old. As respects sex, it has
been observed, that girls under three years of age are less liable to the
disease than boys of the same age ; but that between eleven and fifteen
years the susceptibility is equal. Among the most efficient predisposing
causes should be enumerated the scrofulous diathesis; swelling and ulce-
ration of lymphatic glands of the neck and other parts precede and accom-
pany tubercle ofthe bronchial glands. Dr. Joseph Parrish used to dwell
very emphatically on the connexion between scrofula and tubercle. The
present disease might be well called scrofulo-tubercular.
Treatment.— The same difficulties that embarrass us in the diagnosis
are felt in the treatment of tuberculosis of the bronchial glands. When
occurring in an advanced stage we can have but little hopes of any tho-
roughly curative course ; but we may from analogy, after an observation
ofthe effects of remedies on scrofulous lymphatjc glands which are visi-
ble, infer the activity of suitable treatment in the disease.
The primary indication is, to bring to bear as determinately as possible
a wisely devised prophylaxis, which will be similar in all its leading fea-
tures to that of phthisis or pulmonary tubercle. We cannot recognise,
however, as part of prophylaxis, sanguineous and other depletion, under
a belief that there is inflammation requiring removal by these means. Dr.
Ley's opinion, that diseases of the scalp in children often give rise to
irritation and enlargement of the cervical glands, which are continued
down to the bronchial, and his advice to remove these diseases, merit at-
tention. But when this is attempted, it must be with extreme caution,
and by means of combined hygienic and therapeutical measures, which
happily do not conflict with the preventive, nor subsequently curative
treatment of the diseased bronchial glands, if this be still necessary.
For the removal of tuberculosis, and a change in the glandular deposit so
as to prevent its formation, we must encourage as much as possible the ab-
sorbent function. With this view we rely most on iodine and its prepa-
rations, used externally in the form of ointment, or even tincture, and
internally in the form of solution of the iodide of potassium, or of the iodu-
retted iodide (Lugol's solution), and in cases of greater debility the iodide
of iron. The best ointment for prolonged use is that ofthe simple iodide
of potassium, or its combination with some narcotic extract, as of stramo-
nium or of belladonna. This is to be carefully rubbed along the line of
glands in the neck on both sides down to the clavicle, and in a line with
this bone, both above and below it, thence extending over Ihe sternum,
and also in the space between the scapulae.
Alternating or indeed combined with the iodide, we may prescribe ad-
vantageously some largely diluted, simple saline, such as the sulphate of
magnesia, and chloride of sodium, to be taken by the patient daily and
GANGRENE OF THE LUNGS.
305
continued for a length of time. Bitters and other tonics may be used
conjointly with the iodine treatment.
The palliative treatment will be carried out by the exhibition of reme-
dies adapted to allay particular symptoms. The cough is best relieved
by extract of cicuta and lactucarium ; and these failing, we have recourse
to the other narcotics. Among the articles possessing both tonic and
anodyne properties is the wild cherry-tree bark,—a syrup of which is now
prepared by our apothecaries, both pleasant and efrtcacious. Asthmatic
attacks are to be relieved in a similar manner. The extract or tincture
of belladonna I have found to be most serviceable for this purpose.
Plasters of assafcetida or other fetid gums and liniments rubbed on the
chest, are useful auxiliaries to a more active treatment, and correspond
with the indications at this time.
But while recommending an alterative and tonic course we must not
persist in remedies of this latter class when there is much fever. Under
such circumstances we try soothing medicines, and light vegetables and
milk diluted, for food. The preparations of iodine should be suspended
at this time, and some ofthe milder ones of iron substituted for them.
There yet remain some diseases affecting the lungs to be described, in
completion of the entire circle of those of the respiratory apparatus.
These -are gangrene, melanosis, and cancer; which, although of rare oc-
currence, merit a brief notice at this time.
Gangrene of the Lungs.—This is almost always a secondary disease
and in a majority of cases is coexistent with gangrene of other organs,
evincing what may be termed a gangrenous diathesis. It occurs much
oftener in children than in adults, being consecutive, in the former, on
the exanthemata, and attacks men more than women, in the proportion
of 11 to 4: the insane, also, suffer in this way.
Anatomical Lesions.—Pulmonary gangrene presents itself in two differ-
ent forms, the nucleated or circumscribed, and the diffuse, 1© which M.
Boudet, who has written a valuable memoir on the subject (Archiv. Gen.y
1843), adds a third, the laminated. The circumscribed form presents
itself chiefly in the right lung and in its lower lobe. The pulmonary
tissue, when gangrenous, is softened by conversion into a pulpy detritus of
various colours, from a yellowish or greenish-grey to a deep-green or slate
colour; it exhales a characteristic odour, most fetid and insupportable.
There is no longer any trace of pulmonary vesicles, bronchiae, vessels, or
even of cellular tissue ; but a mere putrescent mass, removable with the
least effort. At first adherent to the adjacent tissue of the lungs, it is gra-
dually detached from this latter, leaving an excavation in it of variable
form and size, and filled either with a gangrenous core or an almost liquid
detritus. The sides of this cavity are soft and tufted, and formed of gan-
grenous or sometimes hepatized pulmonary tissue, interspersed with putrid
shreds: occasionally, though but seldom, there is a white or yellow mem-
brane lining the cavity, of a thick but friable and soft nature ; on occa-
sions, it is traversed by strips of different sizes, composed of the remains
of pulmonary tissue, or of vessels which had escaped the gangrene.
Pulmonary gangrene exhibits itself under three aspects, corresponding
to three different stages—1st. The gangrenous tissue, or slough. 2d.
Liquefaction. 3d. The gangrenous excavation or cavity. The parts
surrounding and contiguous to the mortified tissue are of diversified ap-
vol. n.—21 ^
306 DISEASES OF THE RESPIRATORY APPARATUS.
pearance ; sometimes exhibiting a sanguineo-serous congestion, of a violet
or slate and livid colour; and at other times gorged with black blood, and
as it were apoplectic. More generally it is hepatized or carnified, and
bears marks of a phlegmasia surrounding the gangrenous part. It is very
obvious, after a view of the latter lesions, that if the subjects had survived
a few days longer, this hepatized tissue would have been struck with
gangrene.
I have already mentioned the chief forms under which gangrene ofthe
lungs is met with. The appearances under these divisions are numerous
and diversified ; in there being sometimes only some greenish striae, formed
by a liquid of a gangrenous odour, and situated in the centre of a portion
of lung affected with lobular pneumonia, but without communicating with
the bronchiae ; while, again, in other subjects, we meet with a number of
portions of lung apoplectic or changed by lobular pneumonia, of a deep-
red and almost black colour; in the centre of which are seen small exca-
vations containing a sanious liquid of a reddish-brown colour, or else a
dark detritus of a gangrenous odour. Many of these abscesses commu-
nicate with the bronchiae, which latter are of a livid hue, but are not
mortified. These gangrenous abscesses are disseminated, in different de-
grees of advancement, through a lobe or a lung, or even both lungs, show-
ing that they were a part of several successive gangrenous changes.
We also meet with true gangrenous excavations or cavities, sometimes
single, sometimes numerous, varying in form and capacity, and surrounded
with hepatized lung in the manner before described. In other cases,
again, the gangrene reaches the walls of a tuberculous excavation, and
even involves them in destruction. In yet another variety, the gangre-
nous cavity is near the pleura, through which a perforation is made and a
communication established with the pleural cavity.
MM. Rilliet and Barthez, to whom I am indebted for the preceding
description of the morbid anatomy of pulmonary gangrene in children,
enumerate concomitant lesions in the lungs, and, also, other organs, viz.,
1, in the diseased lung or in that ofthe opposite side, lobular pneumonia
or a splenization to a greater or less extent; 2, when there is pleuritic
effusion the gangrene coincides with the carnification ; 3, edema sur-
rounding the gangrene and sometimes general, with or without pneumo-
nia ; 4, the bronchiae are almost always in a morbid state, either around
the gangrene or at a distance; sometimes inflamed, sometimes dilated;
5, the bronchial glands are often altered ; 6, in nine of sixteen cases, a
lesion of the digestive tube, inflamraation or softening ; 7, conjoint gan-
grene of other organs, in the proportion of ten out of eighteen cases. M.
Boudet gives the number of cases of gangrene in adults as fifteen, of which
eleven exhibited the disease both in the lungs and in other organs ; whilst
of five cases in children, four had pulmonary in addition to other gangrene.
The existence of gangrenous with tuberculous lung has been noted, but
they have no positive relations either of affinity for or antagonism to each
other.
Symptoms and Diagnosis.—The symptoms are far from being very dis-
tinct, and the diagnosis is not easily made out in pulmonary gangrene.
Cough and dyspnoea are sometimes slight, or even entirely wanting. He-
moptysis, so rare a disease in children, is quite common when they are
affected with gangrene of the lung. Fetor of the breath, a characteristic
symptom in the adult, is often wanting in the child ; or if there be
CAUSES AND TREATMENT OF GANGRENE OF THE LUNGS. 307
accompanying gangrene of the mouth, its fetor will mask that of the
breath.
The expectorated matter is often very fetid, exhaling an intolerable
stench. Sometimes the fetor of the breath ceases, even while the disease
is fast tending to death. There is, also, a thoracic gurgling which is a
valuable sign in a subject who never had tubercles, as it indicates a cavity
in the lungs. The pulse is generally very weak; there is great prostration,
and a peculiar expression ofthe face, which is of a dark-violet hue. M.
Boudet speaks of dulness of the chest on percussion, resonance ofthe voice,
raucous rhonchus, and greenish sputa, among the diagnostic signs. Dr.
Gerhard (Clinical Lectures by Graves and Gerhard) describes two kinds
of expectoration met with in gangrene of the lungs. "The most common
is blackish, anil resembles an inky sediment. The other kind, of which
we have an example in the present case, is a greyish, frothy fluid, having
some resemblance to yeast, with a fetid odour, which you may perceive
is like that of putrid oysters. This, though the least common, is the most
favourable variety of sputa. It is generally discharged in very large quan-
tities—amounting, sometimes, to a pint or a quart daily."
The prognosis in pulmonary gangrene, as you will have readily inferred
from the antecedent description, is very unfavourable.
Causes.—In inquiring into the causes of pulmonary gangrene, we must
bear in mind the fact,that it is rarely idiopathic, rarely seizes on a person—
child oradult—who is in full health, and that its supposed antecedent even,
pneumonia, is secondary in the subjects attacked with gangrene. Its occur-
rence after pneumonia or during pneumonia does not prove this latter to
be the cause, and we are therefore obliged to look for more extended and
general influences. More stress should be laid on pulmonary apoplexy or
congestion in this relation. Certain diseases, which powerfully impress
and derange the whole economy, such as the exanthemata and typhoid
fever, predispose to gangrene of the lungs. M. Leuret mentions, as a fact
within his own observation and that of other physicians attached to hos-
pitals for the insane, that instances of this disease are more common among
lunatics than among others. Abscess of the liver, spleen or kidneys open-
ing into the lungs has sometimes given rise to gangrene of these last-men-
tioned organs. If we go back a little farther in the theory of causation ofthe
gangrenous diathesis, we must seek for it in the blood itself, which, as we
learn from the observations of MM. Andral and Gavarret, loses some of
its fibrin in the exanthemata and acquires a more alkaline and dissolved
state, with also a tendency to scorbutic disorders. Just such a change
occurred in the cases recorded by M. Boudet, who informs us that he never
found after death, in any case of children, such diffluent, serous, and non-
coagulable blood as in the subjects who fell victims to an exantheme, a
spontaneous gangrene, or a malignant typhoid fever; and of these diseases,
measles or scarlatina complicated with gangrene furnished him most fre-
quently with these peculiarities ofthe blood. A poisoning similar to that
in the exanthemata is sometimes brought about by the excessive and pro-
longed use of ardent spirits. In all the cases seen by Dr. Stokes, the pa-
tients had been long addicted to these drinks. This gentleman supposes,
but without suggesting in what it consists, that a septic poison is intro-
duced into the system, and gives rise to gangrene ofthe lungs.
Treatment.—^Giving colour of probability to the hypothesis of cause ad-
vanced by Dr. Stokes, there is only one kind of remedies, viz., those calcu-
308 DISEASES OF THE RESPIRATORY APPARATUS.
lated to check putrescence, which he has seen to be of any service. He
advises the use of chlorine, exhibited either in the form of chloride of lime
or soda with opium; and the strength of the patient to be sustained by wine
and nourishing food.
In discussing the treatment of pulmonary gangrene, M. Boudet attaches
small value to the remedies used under the idea that it is the result either
of inflammation or of debility. Regarding it as dependent on a deteriora-
tion or depravation of the blood, he thinks the ratio medendi ought to be
shaped in accordance with this view; and hence the recommendation, first
of suitable prophylaxis, such as keeping children out of the way of the
contagion of exanthemata, and subjecting them early to vaccination, by
which these diseases, if they do make their attack, are, he thinks, rendered
of a less virulent character. If measles or scarlatina should, however,
unhappily appear, then we are required to watch with the greatest care the
progress of the disease; and as soon as we see any serious general symp-
toms,—hemorrhage, or purple spots, for example, or any precursor of gan-
grene of the gums, a disease which frequently precedes or accompanies
pulmonary gangrene, and which is developed under the operation of the
same causes as this latter disease, M. Boudet advises that we should
put the patient on the use of citric or sulphuric lemonade; at the same time
that we direct the use of acid and antiseptic gargles, and friction of the
limbs with an acid and aromatic liquor. He refers to his having, in com-
mon with a great many others, seen scorbutic subjects, reduced to the last
.degree of weakness and cachexia, emaciated, ecchymosed, and without
appetite, who were rapidly cured under the operation of acids, employed
both externally and internally. By the use of similar means in the case
of children, we might, M. Boudet believes, probably succeed in saturating
the excess of alkali in the blood, by which latter cause this fluid loses in
a great measure its property of coagulating; and at the same time, by the
use of analeptics, we might combat efficaciously its tendency to lose fibrin.
Conformably with this view, although M. Boudet does not allude to the
remedy, we might advantageously give, in small but repeated doses at
short intervals, the tincture of chloride of iron, or the etherial tincture of
iron, and the citrate of quinia and iron; while following out the other parts
ofthe treatment recommended by Dr. Stokes. Dr. Durrant (Provin. Med.
and Surg. Journ.) relates of his patient having derived much benefit from
the inhalation of creosote, beginning with one. drop three times a-day, in-
creased to four. Iron and quinine, with the iodide of potassium and dilute
nitric acid, were prescribed at the same time. The case was one of circum-
scribed pneumonia ending in gangrenous abscess.
MELANOSIS.
309
LECTURE CX.
DR. EELL.
Melanosis or Melanoma—Its generic character—Its division into true and spurious—
Its seats—True pulmonary melanosis—Histological elements of melanotic tumours—
Causes—Deficient elimination of carbon—Concomitance between black infiltration and
reparation of pulmonary tubercle—M. Guillot's observations on carbonaceous deposits
in the lungs—Aged persons its chief subjects—The black colouring matter is carbon—
Spurious melanosis attributed to the inhalation of carbonaceous matters—Exposure
in coal mines—Dr. Makellar's observations—Dr. Graham's analysis of carbonaceous
deposit—This deposit common without any special exposure—Symptoms—At first
slight, afterwards cough, expectoration, sometimes dark or black sputa, hemoptysis
in the last period ofthe disease, weak circulation, loss of appetite, diarrhoea, colliqua-
tive sweats, slow pulse, dyspnoea, vertigo and syncope—General diagnosis—Post-mor-
tem appearances—Black deposit at first, in the walls of the pulmonary vesicles—Oblite-
ration ofthe minute vessels and the vesicles—Conversion of affected part of lung into
a peculiar lough elastic tissue—Sometimes general infiltration of the lung with black
matter—Cavities—Heart flabby and soft—Misapplication of the term black phthisis—
—Subjects of melanosis, not tuberculous—Treatment—Reparation of Tubercle in con-
nexion with black deposits in the Lungs—Hasse's and Guillot's descriptions and conclu-
sions.—Cancer of the Lungs—Cancer a malignant heterologous tumour—Its analo-
gies to tubercle—Is more organised—Resemblance in the manner of softening—Ef-
fects of cancer on the system—Cancer of the lung, a rare disease—Is primary or se-
condary—The last most common—IVimary carcinoma, mainly in one lung, and by
infiltration—Secondary variety, as isolated tumours—Bones and testicles, the most
frequpnt origin of secondary pulmonary cancer—Pleura sometimes affected—Symp-
toms and Signs—Dr. Stokes's summary of.
In a natural arrangement, the malignant products or formations—mela-
nosis and cancer or encephaloid growth in the lungs—ought either to pre-
cede or follow tubercle; and that which separates them in my course,
gangrene, ought, if it have any organic affinity, to come after pneumonia.
As it is, however, your attention will be, I hope, but little distracted by
the separation.
Melanosis, or Melanoma as it is called by Dr. Carswell, is divided
into the true and the false or spurious. True melanosis is supposed to
owe its origin to a morbid secretion. Spurious melanosis is attributed to
the introduction of carbonaceous matter from without the body and mainly
by inhalation. Melanosis in its generic character is described to be a
morbid product, presenting a black colour of various degrees of intensity,
somewhat humid and opaque, and possessing the consistence and homo-
geneous aspect of the tissue of the bronchial glands of the adult. The
most frequent seat of true melanosis is the serous tissue, more especially
where this tissue constitutes the cellular element of organs. Here the me-
lanotic matter is formed after the manner of secretion, accumulates in the
cells of which the serous tissue is composed, and gradually acquires the
form of tumours of various sizes. A similar mode of formation of this
matter is observed to take place much more conspicuously in loose cellu-
lar tissue, and particularly on large serous surfaces, such as those of the
pleurae and peritoneum. The next variety observed in the seat and mode
of formation of melanotic matter is that in which it is deposited in the sub-
stance or molecular structure of organs, after the manner of nutrition. And,
lastly, the melanotic matter is found in the blood, contained chiefly in the
various capillaries, and under circumstances which show that it must have
been formed in these vessels.—(Carswell—Illustrations ofthe Elementary
Forms of Disease.)
310 DISEASES OF THE RESPIRATORY APPARATUS.
True melanosis is often met with in the lungs of old persons, either in
the interlobular tissue or on the sides of the vesicles; and in some instances
the black pigment occurs in extraordinary abundance immediately beneath
the pulmonary pleura, where it forms irregular superficial elevations dis-
posed like network. At a less advanced period of formation it may be
seen in a liquid form, infiltrating the pulmonary parenchyma, both in its
healthy and morbid states. It is sometimes in isolated masses or encysted.
This last constitutes the tuberiform variety of melanosis, which includes
both the masses and cysts. M. Andral regards it as a form of chronic
pneumonia.
Melanotic matter, as seen in the lungs, may also be found at the same
time in the liver, spleen, brain, &c. Sometimes melanosis is confounded
with the dark matter of the bronchial glands. These latter, it should be
remembered, are small, contiguous to the bronchise, with smooth surfaces,
and whose interior is seldom of any uniform blackness, nor is the liquid
oozing out of a pitchy character. It scarcely colours the finger rubbed
against it; and in this respect differs from the colour of Indian ink which
melanotic matter leaves on the skin to which it is applied.
The histological elements of melanotic tumours are different in different
cases. In many of these they consist of dark (brown or black) granules; some-
times inclosed in more or less distinct rounded orelongated cells ; but more
generally dispersedin dense irregular masses between cellulartissue; some-
times itisaltered blood pigment,and occasionallyitis composed of granules
of sulphuret of iron. These last are met with in false melanosis. But the
pigment is never the sole constituent of melanotic tumours: it forms, as
Vogel remarks, only a portion of the whole, and is scattered amongst other
histological elements, such as perfectly developed or comparatively amor-
phous fibrous tissue, vessels which, however, are never abundant, and
malignant formations, as tubercle, encephaloid and scirrhus. Melanotic
tumours are, therefore, always compound ; although we may say, that, in
general, true melanosis is non-malignant; and so of its combination with
fibrous tumour. False melanosis is generally injurious from its very
nature, since its occurrence pre-supposes an important decomposition of
the fluids ; but when it remains localized it is of less importance.
In true melanosis the colour is brown, of a bistre tint, blackish, or if
only a little pigment is present, grey. In the false variety depending
upon sulphuret of iron, it is slate-grey, or greenish-black ; in that resulting
from altered blood pigment, it is blue, violet or brownish-black. A
more natural division than that into true and false is the one suggested
by Schelling, into innoxious and malignant; the former purely and essen-
tially local, the latter prone to become constitutional and contaminate every
part of the system.
Causes.—Heusinger has advanced the opinion that black deposits in
different parts ofthe body depend upon a deficient elimination of carbon,
and, in particular, of carbonic acid. He believes that they, to a certain
extent, compensate for such defective process, being especially prone to
form in organs which afford the natural outlets for carbon, although other
organs may be similarly predisposed by disease. In confirmation of this
view is the fact, that black infiltration is the almost unfailing concomitant
of the reparation of pulmonary tubercle, and in a greater or less degree
of senile atrophy of the lungs.
M. Guillot, whose interesting observations on the anatomical relations
CAUSES OF MELANOSIS.
311
of pulmonary tubercle to contiguous parts have been mentioned in a
former lecture, has made some valuable researches on the carbonaceous
deposits which take place in the lungs during life. Having had, as its
physician, charge ofthe great hospital for the insane, at Bicetre, in which
are assembled several thousand old men, he has enjoyed great opportu-
nities for investigating a question of pathology, the subjects for which are
chiefly among the aged. M. Guillot endeavours to prove, and he has
apparently succeeded in the attempt: 1st. That the black colouring matter
ofthe lungs in old persons is carbon ; not carbon (charcoal) produced by
the action of the chemical re-agents employed, but carbon deposited in
its solid state, during life, in the tissues of the respiratory organs. 2d.
That this substance may, by its impeding the circulation and respiration,
cause death in the aged and aggravate the effect of acute or chronic affec-
tions ofthe lungs in this class of persons.
Analysis showed the black deposit to possess all the physical and
chemical characters of charcoal. Only once did M. Guillot meet in the
lungs with a compact mass of carbonaceous substance deposited in layers :
it was black, very hard, broke with a metallic shining fracture, infusible,
burnt on platinum without flame, and gave scarcely any odour when
heated. Carbon is not found in the lungs of children.
Spurious melanosis is attributed, especially by English writers, to the
inhalation of carbonaceous matter by those who inhale smoke from lamps
and other sources of imperfect combustion, and the volatilized coal-dust in
mines.
The physical characters of this form of spurious melanosis: viz., the
uniform black colour of both lungs, the absence of any similar discolora-
tion of any other organ ; the occurrence of the disease in those habitu-
ally exposed to the inhalations of the coal-dust always contained in the
atmosphere of a mine ; and the black matter found in the lungs consisting
essentially of this substance, are, Dr. Carswell observes, circumstances
which demonstrate clearly the origin of the black matter, and its iden-
tity with the carbonaceous powder inhaled with the air in breathing. In
corroboration of this view it was asserted, that the greatest amount of
black infiltration affected the lungs of those who worked in coal-pits, and
it was termed, accordingly, anthracosis.
M. Andral, on the other hand, who does not draw the distinction be-
tween two kinds of melanosis of the lung, adverts to the opinion of its
originating from carbonaceous matter introduced into the bronchia? by
inhalation, and thence into the lungs ; but, he adds, that this disease has
been met with in all conditions of persons and modes of life, m the
country as well as in town, in the houses of the latter as in those of the
former. These remarks must apply to true melanosis.
Valuable additions to our knowledge of the subject of spurious melanosis
have been recently made by Dr. Makellar of Edinburgh, who calls the
disease " Black Phthisis, or Ulceration induced by carbonaceous accu-
mulation in the Lungs, of Coal Miners and other operatives." Not having
this work by me I shall make use of the digested notice of it in the Dublin
Quart. Jour. Med. Science, 1847. The author believes that this variety
of melanosis arises from carbonaceous inhalation in the first instance ; and
that it terminates in marasmus and is accompanied by a singular condition
of the lungs. Not alone, however, or even chiefly," is the carbonaceous
matter furnished by the coal; but rather, he thinks, by the smoke from the
312 DISEASES OF THE RESPIRATORY APPARATUS.
lamps and candles, and above all from the explosion of gunpowder, which
are rendered more deleterious by the want of ventilation in the mines and
the consequent disengagement, without chance of its escape, of carbonic acid
in large quantities. In proof of this view, we learn from Dr. Makellar that
stone mining is more injurious than the raising of coal, by its giving rise
sooner to the symptoms of carbonaceous accumulations and in a more
acute form than the latter. A few years ago a very extensive coal level
was carried through the colliery of Tranent, at which a great number of
young and vigorous men were employed in blasting, every one of whom
expectorated carbon, and all died before the age of thirty-five years.
Dr. Graham has declared his conviction, resulting from experiments
made by hira, for the purpose, that the black powder derived from the
lungs (after analysis) is unquestionably charcoal, and in reference to
another case he describes it as having the appearance of lamp-black. One
patient gave out in black expectoration a quantity of this black powder
or precipitated carbon equal to a drachm and a half daily.
It is very clear from the preceding statements ; 1st. That carbonaceous
deposits in the lungs, pseudo-melanosis, take place in old persons, par-
ticularly, without any known or appreciable origin, in the constitution of
the air which they breathe or in any volatile substances suspended in
it; and 2d. That the lungs of persons, young and in the prime of life,
under certain circumstances of exposure to air constantly contaminated
with carbonaceous substances, as in mines, &c, also exhibit carbonaceous
deposits in greater abundance even and aggravation than is exhibited in
the lungs of old persons. Strong as is the connexion between such
exposure and the occurrence of these deposits, the relation of cause and
effect may still be legitimately doubted, when the alleged effects or iden-
tical anatomical phenomena occur in the absence of the presumed cause,
as in the class of subjects mentioned by M. Guillot and others. It is pos-
sible, that the dark treacle-like expectoration of the miners described by
Dr. Makellar, derived its colour from mixture with the minute dust of
coal, accumulated in the pulmonary cells and minute bronchial termina-
tions ; and that the expectorated matter was not primarily or properly a
dark or black secretion. We need not of necessity, in this view, admit
that the carbonaceous deposit was the direct result of the inhalation of
smoke or volatilized coal-dust and of its passage through the air-cells, but
rather that this kind of exposure predisposed the individual in a greater
degree to the formation of carbon in the state in which it is found in the
lungs of both classes of subjects, the one described by M. Guillot and the
other-by Dr. Makellar.
Symptoms.—The leading features of the disease have been well de-
scribed by Bayle under the name of" Phthisis with Melanosis." They are,
at first and often for a length of time, slight, and consist of cough accom-
panied with a white expectoration, the sputa of which are generally round
and rather opaque, and swim in a large quantity of diffluent pituity. In
some there is no complaint of pain or oppression, but only of their cough
preventing them from sleeping. They gradually, however, become
thinner, and their pulse is usually more frequent than in health. In the
latter period of their life, these patients exhibit an extreme of marasmus,
but appear to be scarcely indisposed, although they often expectorate a
great deal. Some die in a few days after they had been for the first time
considered seriously ill.
POST-MORTEM, APPEARANCES OF MELANOSIS. 313
The subjects ofthe disease coming under M. Guillot's notice were thin,
pale and weak. They had cough, and expectorated for a great length of
time. Some had hemoptysis, but this symptom was most common in the
latter period of their life, when the hemorrhage wasconsiderable. The move-
ments of the chest were slow and barely appreciable, the pulsations of the
heart were feeble, and if febrile reaction even supervened, itwasslightand of
short duration ; the digestive functions became more and more languid, the
appetite was gone and the ingestion of food only produced diarrhoea. The
last craving evinced was for wine or other stimulants. The intellectual
faculties were scarcely disturbed. The character of the cough varied ;
sometimes it was dry, but more generally accompanied with the expecto-
ration of abundant and fluid sputa, amounting to nearly a pint in the
twenty-four hours. They may be mixed with blood, or pure blood may-
be expectorated. When this is the case, the lungs were found to be
loaded with a great quantity of carbonaceous matter. Hemoptysis, which
is the symptom of the approaching end of the patient, is, itself, not pre-
ceded by any appreciable cause or any appreciable symptom. It always
lasts for several days.
Percussion indicates dulness in all parts of the thorax corresponding
with the deposit of carbonaceous matter. These are generally most con-
siderable in the upper lobes of the lungs. On ausculting the chest, bron-
chial respiration is heard both during inspiration and expiration, and this
sign, in its intensity, corresponds with the extent of the deposit. Ca-
vernous rhonchus, and pectoriloquy, are also heard, when there are cavi-
ties communicating with bronchial tubes.
The symptoras ofthe disease, as it attacked the colliers, and described
by Dr. Makellar, are, in the main, similar to those just enumerated. The
cough is at first dry, as in dry bronchitis; but expectoration when estab-
lished is mucous, and sometimes bloody ; the appetite fails, emaciation
and loss of strength result. In the advanced stage of the disease, the
patient has remarkable feebleness, and slowness ofthe action ofthe heart;
the pulse varying from thirty-six to forty-five beats in the minute. There
are occasionally colliquative sweats, and vertigo and syncope close the
scene. The symptoms in this class of patients, different from those pre-
cedingly described, are, frequently, a black expectoration, dyspnoea at an
early period, orthopnoea at a later, the surface of a leaden hue, and dropsical
effusions. These symptoms indicate a greater impediment to the pul-
monary circulation than in the melanosis of old men ; and would seem
to countenance the view which I suggested a little while ago, that the
air-cells and bronchise might be really clogged with carbonaceous matter
taken in by inhalation ; and in this way there would be symptoms of
laboured respiration, and impeded circulation, additional to those that
ensue on the deposit or infiltration in the cellular tissue or on the mem-
branes of carbonaceous matter from the blood, the common melanosis
senilis.
The general diagnosis ofthe disease described by Dr. Makellar, may be
thus stated. The fact of the patient having been exposed to carbona-
ceous inhalations at some former period. The existence of a cachectic
state, with a feeble and slow circulation ; evidences of progressive infil-
tration or consolidation, preceded or accompanied by signs of bronchitis,
with or without the black expectoration.
Post-Mortem Appearances.—The black deposit is made, as M. Guillot
314 DISEASES OF THE RESPIRATORY APPARATUS.
represents, at first in the parietes of the pulmonary vesicles. At a some-
what more advanced period, the increase ofthe black matter causes those
polygonal star-like figures which are perceived on the surface of the
lungs. They are most marked in the upper lobes and along the course of
the large bronchial tubes. By its accumulation, the deposit obliterates the
small vascular extremities of the pulmonary artery and veins ; and sub-
jects, almost at the same time, the pulmonary vesicles to a similar con-
version. The exterior of the lung, generally the superior lobe, is wrinkled,
puckered, and presents here and there inequalities of surface, easily ap-
preciated by the touch. These characteristic appearances are best seen,
by insufflation of the lung. The accumulations of carbonaceous matter
vary in size from that of a hemp-seed to that of a walnut. Some-
times one-third of the lung is thus rendered unfit to fulfil its functions.
The diseased tissue apart from some few Venous arterial branches, or a
few bronchial tubes, forms a kind of tough and hard but slightly elastic
tissue, similar to pasteboard boiled in water loaded with soot. M. Guillot
never met with the black matter, in the encysted form, which melanosis
so often assumes in other regions ofthe body.
The subjects examined by Dr. Makellar exhibited disorganization of
the lung, varying from the* impaction of some bronchial tubes with car-
bon, to an almost universal infiltration with a substance like liquid black-
ing. In some cases, the carbon forms semi-solid matter, encysted in
the lung ; while in others, large cavities are found capable of containing a
pint, and filled with the black liquid. These cavities seem to have been
formed by the coalescence of many smaller ones, and death may result
from their rupture into the trachea. They are traversed, as in great tuber-
cular cavities, by bands of pulmonary structure and vessels. The
pleurse exhibit adhesions, and are frequently the seat of liquid effusion
of a dark colour. The heart is found flabby and soft, and the blood
generally dark and pitchy. Enlargement of the liver is common, and in
one case, Dr. Makellar found the carbonaceous accumulations in the liver
itself. Nothing very remarkable was observed in the cerebro-spinal
system, or the digestive tube.
The misapplication of the term phthisis to the disease is practically
demonstrated by Dr. Makellar himself, who tells us, that pulmonary con-
sumption is rare among the miners with whom he is acquainted, and that
when it does occur, it is principally among the female colliers, who, it is
important that we should know, have never furnished a case of carbona-
ceous deposit. This last exemption is to be explained from the fact, that
women are only employed as carriers, and from their continually returning
to the pit shaft they are enabled to breathe a purer air.
The treatment of spurious melanosis must consist primarily and mainly
in withdrawing the patient from the operation of the causes of the disease.
After this is done, remedies will be directed according to the indications
furnished by the symptoms, preference being given to the means of pro-
moting free pulmonary transpiration and expectoration ; and among these
moderate exercise in a pure air and attention to the state of the skin must
rank among the foremost. The prevalence of a cachectic habit, if not of po-
sitive anemia will suggest the use of chalybeates and analogous remedies.
Reparation of Tubercle in Connexion with Black Deposits in the
Lungs.—I shall conclude this notice of melanosis by the remarks of Hasse
and Guillot, on the reparation of tubercle in connexion with the deposit
REPARATION OF TUBERCLE.
315
of black matter in the lungs. They will serve as a completion of the
evidence, adduced in a former lecture, of the curableness, or at least the
suspension of all the bad symptoms, of phthisis pulmonalis, and an ave-
rage enjoyment of life for a term of years subsequently.
"During the reparation of tubercle the black discoloration is both fre-
quent and conspicuous, and is not limited to any particular period of life.
Andral witnessed it in a girl of 9 years. Black, indurated nodules of irre-
gular outline, from the size of a cherry-stone downwards, are found dis-
tributed through the sound portions of the lung, but chiefly in the upper
lobe of each. They mostly contain a nucleus of curd-like, or moist chalk-
like tubercle ; frequently, however, the mass is perfectly homogeneous,
of cartilaginous hardness, and affords a glistening section. We are jus-
tified by analogy in regarding the above nucleus as the remains of tuber-
cle, thoroughly pervaded with black pigment. Secondly, the apex of
the lung, perhaps the greater portion of the upper lobe, is totally trans-
formed into an almost cartilaginous black mass, in which not a vestige of
pulmonary texture is visible. A few, often dilated, bronchial tubes,
with blind extremities, permeate the adventitious structure,—whilst the
greater number, like vessels, are entirely obliterated. These indurated
spots always firmly adhere to the walls of the chest, and generally con-
tain the heterogeneous remains of tubercular reparation. Thirdly,—either
in the midst of the induration just described, or adjacent to the black
nodule, are to be seen shrivelled, shut cavities, whose walls consist of
black hardened texture, and whose interior is filled with a grey-black,
smeary mass, sometimes interspersed with calcareous granules. Oblite-
rated vessels and bronchi terminate in the vicinity. Fourth, and lastly,
in certain rare cases, shut cavities, lined with a thin, but firm, black
shining membrane, occur at the top ofthe lungs, in which situation slight
traces of long extinct tubercular disease are perceptible. These cavities
contain nothing but air, and are sometimes traversed by strong and very
tight cords, attenuated towards the middle. I do not hesitate to regard
all these changes as resulting from the reparation of tubercular mischief,
because, in most instances of the kind, whether in the lungs or elsewhere,
I have found unequivocal evidence of tubercular disease. This, indeed,
was the only affection which could be deduced from the history of the
case, as adequate to account for all circumstances present. Further, the
black tint displays itself in the bronchial glands, almost under the iden-
tical forms and conditions above assigned. In other organs, on the con-
trary, the reparation of tubercle is associated with incomparably less of
the black degeneration. Hence the black colouring in the lungs would
appear to be intimately connected with the disturbance ofthe respiratory
function during phthisis, and quite independent of the accidental intro-
duction of extraneous matter. It is doubtful whether it is ever the sequel
of a sustained sub-inflammatory condition of the pulmonary texture. At
least there is no good proof that black pigment can be thus produced,
apart from tubercular disease." (Hasse.)
M. Guillot assures us that the number of tuberculous persons who arrive
at old age is much greater than is generally believed. I do not exaggerate,
says M. G., when I state that four-fifths, at the least, of the old men
whose organs I examined after death, present evident incontestable traces
of tubercular disease ofthe lungs, not of recent, but of a former malady.
Sometimes, indeed, the interrogation ofthe patient during life has led me
to conclude that it originated during youth.
316 DISEASES OF THE RESPIRATORY APPARATUS.
It would appear that the deposit of carbonaceous matter which takes
place in the lungs of the aged exercises an important influence over the
arrest of tubercular .growth. Around modified tubercles and around
caverns no longer suppurating, in this class of subjects, M. Guillot has con-
stantly found a more or less considerable deposit of carbonaceous matter.
It is in the centre of masses of this matter that evidences of tubercular dis-
ease should be principally sought. Miliary and semi-transparent granula-
tions are also surrounded and imbedded, as it were, in carbonaceous
deposit, which seems to set a limit to farther tuberculous development or
formation. The pulmonary cicatrices which have attracted so much
attention, are found in the lungs of the aged under the same circum-
stances—that is, surrounded by carbonaceous matter.
An explanation of the influence of carbonaceous deposit in arresting
the progress of tuberculosis is offered by the anatomical researches of M.
Guillot. He found that the abnormal circulation established, after a time,
around tuberculous formations, is in its turn obliterated by the carbon;
so that the tubercles, being cut off from communication with the pul-
monary circulation, normal or abnormal, cease to increase and gradually
assume the characters which have been just described. Hence we can
understand how it is that tubercular persons, thus circumstanced, may
live to a very advanced age, and only present, after death, to the ob-
server, the traces of a disease, the progress of which has been arrested by
nature.
Cancer of the Lungs.—Cancer, like tubercle, belongs to the malig-
nant heterologous tumours or Pseudo-plasmata ; and, like it, occurs be-
tween original elementary parts of the parent-tissue, and occupies, more
or less perfectly, all the interstices. In both, in proportion as the infiltra-
tion becomes complete, the elements of the original tissue are compressed,
and appear to be blended with the deposit into a homogeneous mass, and
are gradually atrophied and disappear. The cytoblastema, or matter giv-
ing rise to organised formations in the shape of cells, in the case of can-
cer as of all other morbid epigeneses, is derived, doubtless, from the
blood, is originally fluid, and is identical with the liquor sanguinis. The
chief elements of carcinomatous tumours were detailed when the subject
of cancer of the uterus was before us; and to that enumeration I now
refer you. It must be borne in mind, however, and I believe the remark
has been made to you before, that the anatomical and histological relations
of carcinomatous tumours exhibit the greatest variety ; and that even in
the sarae tumour different parts present very different characters. They
are distinguished from the pseudo-plasmatic deposits, typhous and scrofu-
lous, and from tubercle by a higher degree of organization, in their not
only showing a more highly developed cellular structure, but frequently,
also, in fibres, vessels, and granulations entering into their composition.
But, still, in addition to the points of resemblance which I stated, a
minute ago, between cancer and tubercle, there is another feature in com-
mon; viz., in their softening, and in the manner of this softening. It
begins in the centre, or in several points of the tumour in cancer, and
proceeds even independently of cell-formations.
The effects of cancer on the system at large vary with the stage of
growth of the tumour. At first they are purely local and of small mo-
ment ; but, in proportion as the adjoining elementary tissues and the organs
are pressed on, inconveniences if not derangements of function are expe-
VARIETIES OF CANCER OF THE LUNG.
317
rienced. When softening takes place the consequences are more serious.
There is excitement analogous to inflammation of the surrounding parts,
and the tumour begins to be painful : an unhealthy suppuration ensues,
the tissues being affected with the ichorous discharge ; the bloodvessels
and lymphatics in the tumour and in its vicinity are destroyed ; and the
veins, unless they had previously been obliterated,often give rise to such
very serious hemorrhages as to threaten lire itself. Still farther, the soft-
ened cancerous matter may enter the veins and lymphatics, and produce
inflammation of these vessels and its consequences. Cancer-cells may,
also, enter into the circulation, and, becoming deposited from the capil-
laries, give rise to secondary cancerous tumours.
Cancer of the lung, the more immediate subject for consideration at this
time, is a rare disease. When it-does occur, males are much more fre-
quently its subjects than females ; tire proportion being, in the 22 cases
collected by Hasse, 17 men and 5 women. The disease is not met with
in childhood. The morbid predisposition is greatest in the prime of life.
Varieties of Cancer.—Of the four varieties of cancer, the encephaloid
or medullary is that which chiefly attacks the lungs. In one case alone
did Hasse meet with the colloid variety. Pulmonary cancer may be
either primary or secondary,— more frequently the latter. But even where
cancer originally and mainly occupies the lungs it is always deeply rooted
in the organism, other parts being simultaneously more or less involved.
This remark applies more particularly to the secondary affection which
is preceded by carcinomatous degeneration, in all its stages, of mcst of
the viscera and entire groups of lymphatic glands. Primary medullary
infiltration usually takes place in one lung only ; the neighbouring lym-
phatic glands participating in the sarae species of degeneration. The
affected lung may be cancerous throughout, or else isolated patches of
healthy pulmonary cells may still be detected. The bronchial tubes dis-
appear gradually in the encephaloid mass ; the bloodvessels are partly-
compressed—partly obliterated—or, in part, charged with adventitious
products. The nerves are not traceable into the growth. The whole
tumour, continues Hasse, presents a uniform lardaceous structure, here
and there pervaded by fibrous texture, and by darkish strise and clots, cor-
responding with the amount of displaced pulmonary substance which may
remain.
Secondary cancer of the lung assumes the form of isolated tumours
rather equally dispersed throughout both lungs—superficially and deeply,
—from the apex to the base. Of the various parts whence the cancer
originates, the bones and testicles are foremost. It has been observed
that cancer, in organs whose veins are tributary to the portal system, does
not appear to spread to the lungs, although it is known to lead very often
to corresponding disease of the liver. Secondary tumours within the
lungs vary much in magnitude ; being found in the same lungs as dimi-
nutive as hemp-seeds, and as large as a man's fist: their average size is
about that of walnuts. Medullary cancer of the lung appears to occupy,
cell for cell, the place of the pulmonary texture, or else, in its progressive
growth, merely to displace the adjacent pulmonary cells. The pleura is
found studded with medullary tumours, the bronchial and mediastinal
glands in the last degree disorganised. Some of these glands often attain
the size of hen's-eggs, and press in various ways upon the lungs, the great
vessels, and particularly the oesophagus. Cancerous disease of the lungs
318 DISEASES OF THE RESPIRATORY APPARATUS.
never coexists, we are told, with pulmonary phthisis. In rare instances,
cancer is confined to the pleural cavity and to the lymphatic glands ofthe
thorax, embarrassing the respiratory function, by pressing against the
lungs or air-tubes.
The symptoms and signs constituting the diagnosis of pulmonary cancer
are set forth with more fulness by Dr. Stokes than by any other writer
with whom I am acquainted, and I shall terminate the present notice of
this disease by repeating his conclusions, viz.:—
u I. That the facility of diagnosis mainly depends on the anatomical
disposition ofthe disease.
" II. That we may divide the cases with a view to diagnosis into those
in which isolated tubercles exist, with the intervening tissues healthy;
those in which simple degeneration occurs without ulceration and with
ulceration ; and those in which a tumour of the mediastinum exists, caus-
ing compression.
"III. That the diagnosis in the first case is difficult, from our being
seldom able to avail ourselves ofthe signs of irritation and ulceration, so
important in ordinary tubercles, and the fact of the equable distribution
ofthe disease preventing comparison.
" IV. That in some cases of isolated cancerous masses, the diagnosis
may be founded on the same general principles as that of acute phthisis.
" V. That in simple cancerous degenerations of the lung, the principal
^physical signs are the gradual diminution of the vesicular murmur, with-
out rale; its ultimate extinction; and the signs of perfect solidification.
" VI. That the evidences of perfect solidification are better found in
this disease than in any other pulmonary affection.
" VII. That this form of the disease may exist, simply, or in combina-
tion with empyema, and may be secondary to cancerous tumours of the
mediastinum.
" VIII. That the sides may be symmetrical in this affection, and that
either dilatation or contraction of the sides may occur.
" IX. That the mediastinum may be displaced, even though the side
be contracted.
" X. That under these circumstances we may have the signs of perfect
solidification, accompanied by imperfect pectoriloquism, and increased
vibration to the hand.
" XL That the mediastinum may be displaced and the liver depressed
without protrusion of the intercostal spaces.
" XII. That the heart may be compressed and dislocated in this form of
disease.—Hughes, Syms, Houston.
" XIII. That the flattening of the upper part of the chest may occur
from degeneration of the upper lobe.—Hughes.
" XIV. That the absence of signs of ulceration is very characteristic of
this disease.
" XV. That we have observed these signs but in a single case, and that
the phenomena, though they might be produced by other diseases caus-
ing the same physical conditions ofthe lung, have never before been met
with.
" That cancerous tumours of the mediastinum generally coexist, with
either degeneration ofthe lung, or isolated tubercles in its substance.
" That they may be solid or fluid.
" That they may coexist with cancerous infiltration of the lung, or the
deposit of cancer in the bronchial tubes.
PLEURISY.
319
" That they are to be recognised more by the signs of the tumour than
by those of disease of the lung.
" That dysphagia, tracheal stridor, feebleness of one pulse, difference
of respiratory murmur, from pressure on the bronchial tube, displacement
of the diaphragm, and dilatation of the heart, may occur in this form of
the disease.
" That a cancerous tumour may exhibit pulsation with or without bel-
lows-murmur, but that pulsation is not always attendant on it.
" That though the previous existence of external cancer may assist in
diagnosis, yet that the disease may be all through internal, or the visceral
precede the external cancer.
" That the feebleness of pulsation connected with the extent of dulness
may assist in distinguishing the disease from aneurism.
" That in the advanced period, as in aneurism, gangrene of a portion
of the lung may supervene.*
" That the following symptoms are important as indicative of this dis-
ease : pain of a continued kind ; a varicose state of the veins in the neck,
thorax, and abdomen ; edema of one extremity ; rapjd formation of ex-
ternal tumours of a cancerous character ; expectoration similar in appear-
ance to currant-jelly ; resistance of symptoms to ordinary treatment.
" That though none of the physical signs of this disease are, separately
considered, peculiar to it, yet that their combinations and modes of succes-
sion are not seen in any other affection of the lung."
Examples of cancer of the larynx are rare. M. Louis relates one case ;
M. Trousseau another. Albers of Bonn records two examples of primary
encephaloid of the larynx.
LECTURE CXI.
DR. BELL.
Pleurisy—Pleuritis—Its forms and complications—Chief symptoms—Fever, pain, diffi-
cult breathing, hard and frequent pulse, and decubitus on the back—Even the chief
symptoms not always present; and they may be present without pleurisy—Structure of
the pleura—Anatomical lesions—Change in the pleura itself,—in its secretion ; imme-
diate effects of this latter—Quality and changes of secreted matters—False membranes
—their characters—Tubercles and cancerous bodies—Change in the secretion and
state of the lung by the effusion—Causes—Identical almost with those of pneumonia—
Cleghorn's description of bilious pleurisy—Physical signs:—altered conformation of
the thorax, dulness on percussion,—resonance of voice in auscultation—cegophony
—friction sounds—Diminished vibration ofthe parietes of the thorax—General symp-
toms—Fever, state of pulse, buffy and cupped blood—Progress, duration, and termina-
tion of pleurisy—Varieties—Complications—Prognosis.
Pleurisy—Pleuritis (tt^v^itk, from TAtyga, the side ; also the membrane
that lines the ribs, the pleura).
* Dr. Stokes adds, in a note : " My friend Mr MacDonnell has shown, that from the
anatomical disposition ofthe nutritive arteries ofthe lung, pressure upon any part ofthe
main bronchus might cause the death of the lung. Of course, the liability in this is
greater in the case of mediastinal tumours than in the simple degeneration. Dr. Greene
has met with this gangrene, from the same physical causes, in aneurism. See the Trans-
actions of the Pathological Society."
320 DISEASES OF THE RESPIRATORY APPARATUS.
Pleurisy signifies inflammation of the serous membrane which lines the
cavity of the chest and invests the contained organs of respiration. The
forms under which pleurisy presents itself are various and important. It
may be acute or chronic; it may affect one side of the chest or both sides;
it may be general, involving the whole of one side ; or partial, only part
of one side ; it may be simple or complicated ; the complications may be
either accidental or essential, and in the latter case, the pleurisy and its
complication stand to each other in the relation of effect and cause. I
shall have, after a while, a few additional remarks to make on the varie-
ties of pleurisy. The disease was for a long time confounded with pneu-
monia, and until the time of Laennec there were no positive diagnostic signs
between the latter and pleurisy.
The chief symptoms of pleurisy are, fever after a chill, although this last
is not uniform, and pain in the side, which is usually acute, pungent, and
lancinating, as if a sharp instrument were driven into the side whenever
the patient inspires. With these are associated difficulty of breathing,
which is quick, short, as if jerking ; dry cough, hard and frequent pulse,
flushed face, and, most generally, decubitus on the back or on the affected
side.
A few remarks will be in place on each of these leading symptoras;
and first on the pain. Commonly, pain exists from the very beginning ofthe
disease, but it is often wandering until after the first or second day, when
it becomes fixed and permanent, and also circumscribed in one spot. Its
seat is on a level with or just below one of the mammse at the part cor-
responding with the lateral attachments of the diaphragm ; and it is thus
fixed even when the inflammation pervades a much greater space, per-
haps the whole of the pleura. Occasionally it is felt in the shoulders; in
the hollow of the axilla, beneath the clavicle ; along the sternum, and
sometimes over the whole of one side of the thorax; or on a line correspond-
ing with the borders of the false ribs, or in either hypochondrium, in the
epigastrium, or even in the lumbar region. In most cases the pain, after
having been very acute during the first period of the disease, diminishes
in violence, becomes obtuse, and may cease entirely, even before the ter-
mination of the disease. Sometimes, after having thus ceased, it returns
with intensity, indicating a renewal ofthe inflammation.
But we may have the symptoms enumerated, and pain, also, which is
one of the most constant features of pleurisy, without this disease being
actually present. Sharp pains of a nervous, and still oftener of a rheu-
matic character, closely imitate those of pleurisy ; and if they happen to
be attended with feverish excitement the resemblance is perfect: even
exalted sensibility of the pleura itself is not by any means a necessary
accompaniment to its inflammation. On the other hand, there are cases
in which there had been scarcely a suspicion of disease in the chest,
and yet acute inflammation and its concomitant, copious effusion, had
been for many days or weeks occupying the pleura. The symptoms of
oppressed breathing, proceeding from the pressure ofthe effusion, will be
distinct only when this latter has accumulated very rapidly. In such cases
of embarrassment we seek to be enlightened, and generally with success,
by the physical signs.
The breathing is commonly hurried in pleurisy. If there is no effusion
this labour of respiration must proceed from the pain being opposed to
the free contraction of the muscles which dilate the thorax. Effusion
PHYSICAL SIGNS OF PLEURISY.
321
being present, the dyspnoea is generally proportionate to the quantity of
the effused fluid. But even to this state of things there are marked ex-
ceptions; some persons, with effusions, as we learn from Andral, not only
talk readily, but are able to walk about and perform journeys without any
inconvenience on the score of respiration. The modifications in the re-
spiratory act will depend mainly on the portion of the pleura inflamed ;
in costo-pulmonarypleuritis,the breathing is chiefly diaphragmatic; while
in inflammation attacking the pleura which lines the diaphragm, the tho-
rax is mainly dilated by the intercostal muscles.
The cough characteristic of pleurisy is short, catching as it were, dry,
or accompanied with a thin mucous expectoration. The cough is not in
this disease, any more than in pneumonia, proportionate in frequency or
force either to the intensity or the extent of the inflammation. Should
the sputa assume more consistence and other different appearances, we
may suspect complication, as of pneumonia and bronchitis, or, a rare case,
the opening ofthe pleuritic effusion into the bronchise.
Nothing very positive can be inferred from the decubitus, which varies
in different cases ; for although in some the patient lying on his back
with a slight inclination to one side, or lying on one side, may lead to a
suspicion of effusion in this side ; yet in a large majority of cases we find,
as M. Andral has observed, that, whether there be effusion or not, the
decubitus is on the back, or on the affected side.
For the most part pleurisy is accompanied by fever. In the first or acute
stage, the skin is hot, and the pulse hard and frequent: indeed a tense
pulse is one of the most characteristic symptoms of the disease. In a
more advanced period, either from an abatement of the inflammation, or
the passage of the disease into a chronic state, the skin loses its heat,
but the pulse retains its frequency with less resistance. Profuse sweating
only comes on when tubercles are developed either in the pleura itself,
or in the false membranes formed on it. When pleurisy becomes deci-
dedly chronic, the pulse loses all its frequency, at the same time that the
breathing becomes free and regular. Not, as M. Andral remarks, that
the disease is cured, for the effusion still exists, as is proved both by per-
cussion and auscultation ; but the circumstances are favourable for a cure;
showing, he adds, that the ancients were in error in supposing that fever
was necessary to the resolution of chronic diseases.
The blood taken from a vein, in pleurisy, is cupped, and almost always
exhibits on cooling a coagulura covered with a thick buffy coat. The
fibrin averaged 5 parts in 1000,, in MM. Andral's and Gavarret's experi-
ments, and 6-1 in M. Becquerel's. The blood-corpuscles and albumen
are considerably diminished. Unless in the case of complication, such as
bilious pleurisy, the digestive organs are not disordered. As happens in
other phlegmasia? of the serous membranes, the secretion of urine is
diminished, and deviates from its natural properties. Nutrition is pro-
foundly affected ; chronic pleurisy with effusion giving rise almost always
to marasmus.
Physical Signs.—First among these, as the sign which more obviously
meets the eye ofthe physician, is the altered conformation of the thorax'.
The side in which effusion has taken place is full and more prominent
than the opposite one ; but as we may be deceived in this particular, by
merely looking at the chest, we ought, in order to prevent mistakes, to
take ihe measure of the two sides, by means of a ribbon, one end of which
vol. ii.—22
322 DISEASES OF THE RESPIRATORY APPARATUS.
is to be held on a spinous process of the dorsal column and the other
brought to the middle line of the sternum, or we use a graduated arc for
the purpose. The enlargement on the diseased side is seldom more than
an inch and a half. The ribs and cartilages preserve their relative posi-
tion, as they would during a very full inspiration ; the intercostal spaces
are increased, protruded beyond the ribs, and allowT of a fluctuation being
felt within. But there may be considerable effusion without external
dilatation,—the space for the fluid in the chest being made at the expense
of the lung, which is excessively compressed and reduced to an embryo
size and character, and as such is impermeable to air.
When, on the other band, the effusion is absorbed, and the lung is pre-
vented by any cause from resuming its former expansion, the side which
was before morbidly dilated is now smaller than natural, and contracted.
Percussion indicates the presence of an effusion, however slight, in the
thoracic cavity, by a diminished resonance on the side diseased. At first
the dulness of sound is heard only at the lower part; but afterwards over
the whole Of the affected side, from the sub-spinous fossa of the scapula
and the clavicle to the base of the thorax. In cases of double effusion
the proper resonance of the chest is diminished or lost on both sides ; and
under such circumstances, as there are no contrasted sounds between the
two sides, especially if the effusion be inconsiderable, percussion may
seem to indicate only a physiological state. When the effusion is circum-
scribed within narrow limits the dulness is only at one spot, and at other
times it is not perceptible at all. It may happen, again, that, owing to
the pain being so acute, percussion cannot be practised.
The signs furnished by auscultation in pleurisy are generally of the
most satisfactory kind, as regards the aid which they give us in forming
our diagnosis. At the outset of the disease, when the pain is still very
acute, but before effusion takes place, we discover, either by the ear
applied to the chest or through the medium of the stethoscope, that the
customary respiratory or vesicular murmur is less than common. This
depends on the patient's instinctively dilating his chest less, and of course
expanding less his lungs also, owing to the violence of the pain. So soon
as effusion takes place, the respiratory murmur is heard less distinctly
on the affected side ; and in proportion as the effusion increases, this
sound becomes more and more feeble, while on the other side it acquires
unusual force. If the effusion is very great, the respiratory sound is lost
entirely in every part of the chest. In most cases, the lung being pro-
truded towards the spinal column, the sound ceases, progressively from
below upwards, both behind and in front* A different direction given to
the lung by the effused fluid, as where it is drawn against the walls ofthe
thorax, will cause an extinction of the sound in front, but allow of its
being still heard, though feebly, behind.
When the effusion which extinguishes the respiratory murmur is con-
siderable, it sometimes happens that no other sound takes its place ; but,
at other times, it is replaced by bronchial respiration.
The resonance of the voice is singularly modified in those persons
whose chests are the seat of pleuritic effusion. The ear applied to the
chest on the diseased side, at this time, is sensible of a quality of voice
which resembles the bleating of a goat, and which, for this reason, has
been called by Laennec oegophony. Often, in place of this bleating, it is
a quivering, thrilling, cracked, and discordant sound, resembling the
SYMPTOMS OF PLEURISY.
323
voice of Punch ; an apt comparison for whoever has heard this distin-
guished character, and whoever has not, and proposes to travel, will hear
it in perfection, on the Mole at Naples. At other times, it seems as if the
voice passed through a tube, or it is muffled, and the articulation of each
word seems to be in a peculiar whisper. In many cases these various
slides of oegophony are only heard at intervals, and are only perceptible
in the enunciation of certain words ; even of a monosyllable, as of we,
which will serve to illustrate the case referred to by Andral, who only
detected this sound when his patient uttered the word oui. OEgophony
is not heard when the effusion is inconsiderable ; and it ceases after the
effusion becomes very great. Sometimes the effusion, though slight, is
diffused so that dulness and tubular sound are heard at first over a great
extent of surface ; and after the subsidence of the fluid to the lower por-
tion ofthe lung, the pressure in the bronchial tubes is such as to prevent
the passage of any sound to the air. There are other sounds discovered
by M. Reynaud and further explained by Dr. Stokes, which indicate a
moderate degree of lymphatic effusion. They are called the friction
sounds, and are represented to be characteristic of dry pleurisy; a division
this, by the way, which some eminent pathologists deny the existence
of. The region for hearing it is between the spine and scapula, or be-
tween this latter and the mamma. Change of posture sometimes causes
a difference in the physical signs by changing the place ofthe effusion.
M. Reynaud points out another easily recognised sign of pleuritic effu-
sion. It is the absence of vibrations of the parietes of the thorax when
the hand is placed on it, during the time in which the patient speaks. In
a case in which pneumonia coexisted with pleuritic effusion, and in which,
generally, the symptoms indicating parenchymatous inflammation are
generally wanting, one of these, crepitation, may be removed by causing
the patient to lie on his face. At this time, also, the oegophony becomes
bronchophony.
We may sum up the leading features of pleurisy, in its different stages,
under the heads of progress, duration, and termination.
Pain, commonly seated beneath one or other of the mammae, preceded
or accompanied by fever, and a dry cough, dyspnoea, fever, and often a
weaker than ordinary respiratory murmur on the side in which there is
pain, are the first symptoms which indicate the invasion of pleurisy. If
no effusion is formed, these disappear at the end of a few days and the
cure is complete. But if an effusion in the pleura is formed, the sound on
percussion is dull and flat ; the respiratory murmur, at first weak, ceases
entirely, or is replaced by a bronchial breathing ; different varieties of
oegophony are heard, and the parietes of the chest on the affected side
present a more or less obvious dilatation. Death may be the result of
this state of things in a short period ; and it is more to be dreaded when
the dyspnoea and fever are great. Diminished effusion and beginning ab-
sorption are indicated by a return of the usual sonorousness and respira-
tory murmur, first at the spine and clavicle, and then extending forwards
and downwards. If there be false membranes, oegophony is sometimes
replaced by friction sounds, ofthe middle and lower part ofthe lungs.
If the leading symptoms of pyrexia and laboured breathing are only
abated in violence, without being removed, the disease is prolonged and
passes into a chronic state ; in which case it may either end in death or
restoration to health. Death is generally preceded by decay and maras-
324 DISEASES OF THE RESPIRATORY APPARATUS.
mus, which are the consequence both of the imperfect hematosis, owing
to the complete inertia of one of the lungs, and of the presence of
inflammation with copious suppuration and the production of accidental
tissues. In other cases death takes place in consequence of the sudden
return of pleurisy in an acute form, which, supervening on the chronic,
proves speedily fatal. Finally, death sometimes occurs as the result of
an opening between the cavity of the pleura and the external air, either
by perforation through the bronchial cells or the walls of the thorax, and
in rare cases through the diaphragm. But even under these alarming cir-
cumstances there may be a favourable issue. Critical discharges, such
as metrorrhagia, copious sweats, or a bronchial flux, sometimes announce
the absorption ofthe effusion.
Anatomical Changes.—Before I speak of the anatomical changes in
pleurisy, it is fitting that 1 should direct your attention to the pleura.
The pleura consists of two layers; one distinctly serous, which is
always bedewed with a serous fluid, lines the cavity of the chest,
and forms the outer covering of its organs. The other is clearly fibrous
in the costal pleura, and, together with that of the pericardium, seems
to be a continuation of the deep-seated cervical fascia. Dr. Stokes has
succeeded, after removing the serous coat and a part of the adherent
sub-cellular tissue investing the lungs, in demonstrating the transparent
though strong fibrous coat beneath. This is in direct apposition with and
invests the whole of both lungs, covers a portion of the great vessels, and
the pericardium seems to be but its continuation, but endowed in that
particular situation with a still greater degree of strength for purposes
sufficiently obvious. The fibrous coat covers the diaphragm, where it is
more opaque, and, in connexion with the pleura, lines the ribs, and,
turning, forms the mediastina, which thus are shown to consist of four
layers—two serous, and two fibrous. Henle's researches lead him to a
belief in the pleura consisting of several layers of super-imposed cellular
tissue barely attached to each other, the inner surface being a thin layer of
epithelium-cells. There are bloodvessels in all the layers, except the
last.
The pleura is susceptible of inflammation of the adhesive kind, which
is accompanied merely by pain ; and by the pouring out of serum, coagula-
ble lymph, pus or blood.
Pleurisy gives rise to textural alterations of the pleura, to alterations in
its secreting function, and to modifications in the condition of the lungs,
such as compression, displacement, changes of volume, of situation, and
connexions.
The pleura, in pleuritis, is sometimes reddened by a delicate injection,
but more commonly this redness is owing to the injection of varying in-
tensity in the sub-serous cellular tissue. In many cases the membrane
itself preserves its transparency, and exhibits no marks of vascular ramifi-
cation. Inflammation of a more intense kind gives rise to a vascular
plexus in the serous membrane, filled with blood, and of more or less
closeness and distinctness; sometimes dotted, at other times striated, or
in laminae, and in sinuous bands ; or, a rare occurrence, the whole
diseased surface is of a uniform red hue. Whatever may be the colour,
or opacity, or transparency of the pleura, it is seldom thickened, soften-
ed, or ulcerated. But the spots originally reddened by repletion of the
vessels present little dull white or yellowish points, which rise above the
MORBID PRODUCTS IN PLEURISY. 325
serous surface, in the shape of flat granules, and ultimately coalesce;
and thus constitute the first rudiment of an adventitious membrane. This
first delicate investment of the free surface of the pleura veils its inflam-
matory redness.
The changes of secretion are more numerous and diversified than all its
other abnormal peculiarities. According as the secreted matter is air, or
chiefly serosity, or purulent fluid, it is called pneumothorax, hydrothorax,
and empyema. As regards quantity, this may vary from an ounce to
several pints. In the latter case, the lung is protruded from its place,
and occupies less room than common ; the diaphragm is pressed down-
wards and causes a prominence outwards of the liver to the right and the
spleen to the left; the ribs are more widely separated than in health, and
the intercostal spaces more prominent ; the skin of this side is also preter-
naturally smooth. The mediastinum is pushed to the side opposite that
of the effusion; and when the effusion takes place in the left side, the
heart may be pushed to the right, and its apex at the same time brought
so near the sternum that its pulsations thenceforward are only heard behind
the bone and in the right side of the thorax. The protrusion of the inter-
costal spaces and diaphragm results from a paralysed state of these expan-
sions—in the opinion of Dr. Stokes. Effusion may take place in a few
hours (Hodgkin—Morbid Anatomy of the Serous Membranes).
The quality of the pleuritic secretion is various ; sometimes colourless,
or of a citron hue, limpid, and transparent; at times, in the midst of this
limpid serosity float some albuminous flocculi; or these are partly dis-
solved in the serosity and impair its transparency. In some cases, the fluid
is turbid, or green, or yellowish-brown, or ash-coloured ; sometimes thick,
and as it were, muddy. In other cases the secretion is truly purulent;
or resembling on occasions half-liquified animal jelly ; and it may even
consist of blood (hemorrhagic pleurisy), which is most apt to occur in the
tubercular form of pleurisy.
These liquid products of secretion from the pleura are alleged to become
concrete in part, and to pass into a solid state; and in this way false
membranes are formed, varying, as regards organization, in their figure,
colour, extent, consistence, and thickness. They are the most common
products of pleural inflammation. The more immediate material for this
membranous formation is an almost transparent yellowish jelly, consisting
almost entirely of the fibrin and the serum of the blood. It is the blood
plasma. It soon acquires an increase of consistence, puts on an albumi-
nous appearance, is diffused in layers, and is gradually organised. Red
points show themselves, few in number at first, but after a while increasing,
and gradually running into lengthened lines or streaks along the surface
of the effused matter. These streaks soon become distinctly vascular,
and the newly-formed vessels inosculate with those of the pleura, from
which indeed they originally diverged. The adhesions thus made are of
very different forms and sizes ; being sometimes merely miliary granula-
tions, separated from each other; at other times large concretions of a
cellular texture uniting the two surfaces of the pleura by various bands.
The thickness of the newly-formed membrane is sometimes no greater
than that ofthe pleura itself; but more commonly it exceeds this latter :
the thickness of the new formation is made, however, of several larainse
resting one upon another. Sometimes these false membranes are formed
after a few days' sickness; and again, not after a period of three weeks
326 DISEASES OF THE RESPIRATORY APPARATUS.
from the invasion ofthe disease. These membranes and their adhesions
are more frequently in a line with the inferior lobes and at the base of
the lung. As a general rule, it may be said, that coagulable or plastic
lymph and early adhesion are most to be expected in young, strong, and
healthy persons ; while curdy and unorganised lymph, or granular deposits
with permanent serous effusions, are met with in the old, the feeble, and
the scrofulous. False membranes may pass into a fibrous, cartilaginous,
or even osseous tissue.
In pleuritic effusions, however, substances are not always met with
which allow of such ready organization ; but they stop short at imperfect co-
agulation, and the disease is apt to assume a chronic character. The con-
tained fluid is slow in being absorbed and is liable to a kind of decora-
position ; and a febrile state passing into hectic supervenes. Sometimes
the plastic matter lies loosely agglutinated to the pleura, like uniformly
honey-combed false membranes or imbricated layers. Purulent forms of
effusion result from high inflammation or from the access of air.
Tubercles are not unfrequently met with in inflamed pleura; in the
midst of the false membrane they are quite numerous, and are evolved
with great rapidity. Twice M. Andral has seen the pleura the seat of
cancerous bodies of considerable size.
The lung, which is displaced and compressed by the effusion, is reduced
sometimes to a very small size ; and when covered with false membranes
we might suppose that it had been entirely destroyed. On occasions, it
is only a fobe that is thus displaced ; and the lung itself has sometimes
been pushed towards the side of the thorax backwards or laterally, in
place of on the vertebral column. It is never found to crepitate unless
the effusion be quite inconsiderable ; it is denser than natural, and sinks
when put in water. We sometimes meet with pleuritic effusion and inflam-
mation of the pulmonary prrenchyma at the same time. The effusion may
either precede or be subsequent to hepatization ofthe lung.
Seat.—Simple pleurisy occurs most frequently on one side only, or is
single ; and rather oftener in the right than the left side. Pleuro-pneu-
monia is also mostly single, but more generally in the left than the right
side. Double pleurisy occurs mostly as a consecutive disease.
The causes of pleurisy are identical for the most part with those of
pneumonia; and particularly those which produce a sudden chill and
stoppage of perspiration, such as atmospherical vicissitudes, cold drinks
in the stomach, or the sudden application of cold to the surface of the
body. Early spring is the chief season for pleurisy. Its subjects are,
preferably, the young and those in the vigour of life. Organic lesions of
the lungs, as pneumonia and tubercles, are frequent causes ofthe disease.
But while pneumonia readily produces pleurisy, this latter is not so apt
to produce pneumonia. A rupture of the pulmonary vesicles which estab-
lishes a communication between the cavity of the pleura and bronchise
sometimes causes partial pleurisy. A particular distemperature of the air
will give rise to epidemic pleurisy, which generally is of a more asthenic
nature than isolated or sporadic cases are.
Varieties.—The two chief kinds of pleurisy are the primary and the se-
condary; the last is the most frequent. The varieties of pleurisy proceed
either from the symptoms or the seat of the disease ; and, sometimes, from
particular causes. There are pleurisies, with, as there are those without
effusion,and unaccompanied by pain,cough, dyspnoea, oraccelerated pulse.
There are others, again, that do not give rise to any dulness of sound,
VARIETIES OF PLEURISY.
327
nor to any modifications of the respiratory murmur or of voice. Some,
most pleurisies, are manifested by characteristic symptoms; some are
latent. When the pleurisy is interlobular, nothing is revealed by either
percussion or auscultation ; although sometimes a collection of pus is
found simulating pneumonic abscess. Dyspnoea may be evident, with
slight pain ; the fever is hectic, and death closes the scene. If the disease
be mediastinic, the sound is dull on striking the sternum. When it is
diaphragmatic the pain is no longer referred to the thorax ; the breathing
is purely costal; there is orthopnoea ; the patient sits up in his bed, or leans
forwards and presses on as if to support his hypochondria ; the dulness is
extreme, and there are hiccup, nausea, and sympathetic vomiting. If the
pleurisy is on the right side there is jaundice, owing to transmitted irrita-
tion ofthe liver. This last form presents a very difficult diagnosis, since
it simulates hepatitis, partial peritonitis in the hepatic region, gastritis,
and, finally, rheumatism ofthe diaphragm. I had occasion, when a stu-
dent in Virginia, to watch a case of this nature, in which, conjoined with
all the symptoms of pleurisy, there were jaundice and irritable stomach.
The subject was a young man, a farmer, of robust and strong constitution,
but somewhat addicted to drinking ardent spirits. He recovered under
an antiphlogistic course,—venesection, purging with calomel and appro-
priate adjuncts, antimonials, and subsequently blisters. It is this asso-
ciated derangement of the digestive system with pleuritis that constitutes
bilious pleurisy. The disease described byCleghorn (Diseases of Minorca)
was most probably of this nature, unless we class it under the head of
bilious pneumonia.
" Those pleurisies began commonly like an ague fit, with shivering and
shaking, flying pains all over the body, bilious vomitings and purgings,
which were soon succeeded by quick breathing, immoderate thirst, inward
heat, headache, and other feverish symptoms. In a few hours the respi-
ration became more difficult and laborious ; the most part of the sick
being seized with stitches in their sides, striking upwards to the clavicle
and shoulder-blade ; obliquely downwards along the cartilages of the
bastard ribs ; or else darting across from the breast-bone to the vertebrae
ofthe back ; so that, they could neither cough nor make a full inspiration
without great pain. Many complained chiefly of a load and oppression
in their breast, as if a millstone had been laid upon it; some of a heavi-
ness and fluttering about the heart, which at one time seemed to glow
with extraordinary heat, at another to be chilled with cold, as if it had
been dipt in ice-water. In a few of the sick those complaints preceded
the fever, in others they did not come on till the day after.
" In the progress of the disease it was not uncommon for the pains to
move about in the thorax from one place to another. Sometimes they
would shift from the breast to the limbs, and of a sudden return to the
bowels; and I have seen cases wherein, after leaving one side, they have
attacked the other unexpectedly, and proved fatal in a very short time.
The left side of the thorax was not near so liable to be affected as the
other; forty-two out of sixty patients who were seized about the same
time having had the disease in the right. But whichsoever side was
affected, the sick lay easiest on the opposite ; though the generality were
obliged to lie upon their backs, or to sit up in bed with their heads erect.
Many were drowsy and inclinable to sleep ; but they raved at intervals,
or were much disturbed with extravagant dreams. Some laughed in their
sleep ; others would awake in a fright, and start out of bed, imagining
328 DISEASES OF THE RESPIRATORY APPARATUS.
that the house was in flames ; and that those about them were endeavour-
ing to push them over a precipice ; to pierce their sides with daggers ; to
bind them down with cords, or iron hoops, and things ofthe like nature."
The most frequent complications with pleurisy are, pneumonia, pericar-
ditis, and pneumothorax ; and, but less seldom, bronchitis and even peri-
tonitis. Laennec describes three varieties of the complications of pneu-
monia with pleurisy. The first is the ordinary one of pneumonia with
slight, dry pleuritis. In the second, inflammation ofthe compressed lung
may occur, producing that variety of hepatization which he has denomi-
nated carnification ; while in a third, severe inflammatory action affects
both the pleura and lung. This, says Dr. Stokes, is by far the rarest case.
In children, pleurisy is complicated with and occurs during hooping-cough
and scarlet fever, and is occasionally met with in typhoid fevers. In the
diseases of this class of subjects, secondary pleurisy is sometimes replaced
by convulsions or other cerebral disorder.
Diagnosis.—Pleurisy can only be confounded with pneumonia, from
which it is distinguished by the absence of rust-coloured sputa, dry crepi-
tated rhonchus, nor does the severity ofthe constitutional symptoms corre-
spond with the extent of dulness on percussion in pleurisy as it does in pneu-
monia. There is not, however, any strictly pathognomonic sign of pleurisy.
Prognosis.—Pleurisy must always be regarded as a serious disease; the
prognosis in which will vary, however, according to the nature and inten-
sity of the causes, the extent of the pleuritic inflammation, and the pre-
sence or absence of effusion. In a subject previously enjoying good health,
the disease almost always terminates favourably. Pleurisy induced by
tuberculous irritation must alwrrtys furnish a bad augury; so does double
pleurisy, even before effusion has taken place. The gravity of the disease
will be heightened by its being seated in the diaphragmatic portion of the
pleura, and, still more, by the extent of the effusion : if double, and of any
extent, it is generally fatal. An effusion of pus is more sinister than one
of serum; but we have no evidence to show that blood effused gives rise
to more alarming symptoms than either of the fluids just mentioned. Tht
persistence ofthe fever and dyspnoea is always bad; nor can we hope for
absorption of the effused fluid until these two symptoms have been abated
or have disappeared. Marasmus and profuse sweats must induce suspi-
cion of tubercles in the inflamed pleura.
LECTURE CXII.
DR. BELL.
Treatment of Pleurisy—Bloodletting, by venesection, the first and chief remedy__Tn
feeble habits and in advanced stages, cupping or leeching—Cupping followed by saline
purgatives—Tartar emetic—Opium in full doses after venesection—Blister to the side
—Purging most useful in complicated and epidemic pleurisies—Diuretics; nitre, digi-
talis, colchicum—Calomel with nitre and a little opium—Treatment of children.__Ty-
phoid Pleurisy.—Puerperal Pleurisy.—Chronic Pleurisy—Not always resulting
from the acute form—Symptoms and physical signs—Dilatation ofthe side—Diagnosis
—Absorption going on—Contraption of the chest—Trwtment—Calomel__Iodine__Hy-
gienic measures.—Pleurodynia—Its symptoms—Diagnosis between it and pleurisy
—Treatment.—Pneumothorax—Causes, symptoms, and treatment.—Hydrothorax,
—Its causes, symptoms and treatment.
Treatment.—Universal experience, I believe I may say, is in favour of
early and large bleeding in sthenic or sporadic pleurisy. The sooner after
TREATMENT OF PLEURISY. 329
the invasion ofthe disease we bleed, and the more copious the depletion,
the greater will be the probability of early convalescence. It would avail
little were I to pretend to specify the quantity of blood to be taken from a
vein on this occasion. You must be regulated by the violence of the symp-
toras, and the relief afforded. The pulse, which is generally frequent,
hard, and resisting, ought to be abated in these particulars, especially in
the quality of hardness or tension, by the abstraction of blood; but the
state of the heart will cause modifications in this respect, and the pulse is
less than the dyspnoea and pain our guide as to the freedom with which we
are to bleed in pleurisy. As a general rule, the blood ought to be allowed
to flow until the patient can make a full inspiration without catch or pain.
The repetition of venesection will be regulated by the renewal of the pain
and dyspnoea, more than by the febrile symptoms. As regards mere fre-
quency of pulse, it is of little moment in the case before us; it can never
alone indicate the propriety of depletion. Indeed, it will rather indicate
a fear of this having been pushed too far. It is desirable that, within the
first twenty-four hours, an abiding impression should be produced on the
inflammation ; and hence, if the first symptoms return in even a few hours
after the bloodletting, you should repeat the operation. As our object is
not simply to weaken the heart's action, but to abstract a considerable
amount of blood, and withdraw in this way the material of vascular excite-
ment and engorgement, the patient need not be invited to sit up; but he
should be bled lying down, so that there will be less probability of the
coming on of syncope to interfere with the free flow of blood.
In weak habits of body, either from original constitution or excesses,
although the phlogosis of the pleura be intense and will, if not checked,
be followed by the changes already described, yet we cannot continue to
abstract the desired amount of blood, without weakening beyond measure
the heart's action and inducing a degree of prostration, which, if it do not
actually endanger the patient's life, would prolong excessively the conva-
lescence. We are fain, in such cases, to accomplish our end by free cup-
ping or leeching over the seat of pain. In general you will not have the
choice in the country, but must be content with cupping. After this is
over, a large warm poultice should be applied and covered with flannel.
Adjuvants to bloodletting are purgatives and diuretics. The former
will consist of salines with antimonials, so as to produce large evacuations,
and thus diminish the quantity of the circulating fluid. Preceding these,
a full dose of calomel will be of service, both as itself an evacuant, but
still more by its revulsive operation on the liver and gastro-intestinal fol-
licles, and its decidedly sedative impression. Its use subsequently will be
under the same belief, and not in reference to what the English writers
persist in regarding its specific, that is, its sialagogue operation, or at any
rate the production of a slight soreness and inflammation of the mucous
membrane ofthe mouth and throat. Tartar emetic as a counter-stimulant
does not stand as high in the estimation of British practitioners in pleurisy
as it does in pneumonia and bronchitis. My own experience leads me to
a different opinion. I have, in some of the milder but yet well-marked
cases of pleurisy, trusted almost entirely to tartar emetic, either mixed
with cream of tartar in powder, or dissolved with it in water. Opium may
be given with more freedom in pleurisy, as it may in phlegmasia of the
serous or sero-fibrous membranes generally, than in those of parenchymas
and mucous membranes, with whose secretory function it is more apt to
330 DISEASES OF THE RESPIRATORY APPARATUS.
interfere unseasonably at this time. A full, or rather a large dose of opium,
two to three grains, may be given at once after a large bleeding, and the
patient be left undisturbed by the administration of any other medicine for
the next twelve hours. The repetition of this medicine will depend on
the intensity of the pain, and the diminished hardness of the pulse. In
the form of Dover's powder, it is often very serviceable.
Pain or stitch in the side still remaining after the subsidence of fever
will be met by leeches to the part; or if full venesection has been previ-
ously practised, a blister. More especially is this remedy useful when ef-
fusion is about to take place : it has been known to arrest this latter, and
in other respects to exert a most salutary effect on the progress of the dis-
ease. The blister should be large, and allowed to remain on only until
the skin be vesicated; with this view about eight hours will commonly
suffice. It is not necessary that the cuticle be raised with serum to any
extent; for if at all separated from the cuticle beneath, it will soon rise
into large serous bags after the application of simple cerate or of basilicon
ointment. Once discharging, this effect ought to be continued ; first by
the dressings just mentioned, or if there be much cutaneous sensibility, by
a large poultice of flaxseed meal, or of bread and milk, between two pieces
of muslin, and afterwards by the occasional application of weak blistering
or tartar-emetic ointment. The latter is preferable, if the disease assume
somewhat of a chronic form.
Purging was thought by many of the older writers to be prejudicial in
pleurisy ; nor was the opinion without foundation, for the necessary inter-
ruption to the respiratory movements during defecation, by the straining at
the time, must operate prejudicially. These objections, however, were
derived chiefly from a belief that diarrhoea or natural purgation, when it
occurred spontaneously, was injurious, and that intestinal evacuation in-
terfered with the crisis by expectoration. In complicated pleurisy, or in
that of an epidemic and, as it will be found generally, of a mixed character,
purgatives with calomel for their basis, are of unquestionable efficacy, and
must often take the place of bloodletting. Diuretics have acquired more re-
putation in the cure of pleurisy than purgatives. The antiphlogistic action
of many of them, apart from the amount of renal secretion, will go far to
explain their superiority in this particular. Nitre may be mentioned as
displaying these two effects in a notable degree. Its operation is made
more efficient by free dilution; in fact, by its being dissolved in the patient's
drink. I have at other times generally added to it tartar emetic, as in the
following prescription:—
R. Nitrat. potass., ^iss.
Potass, tart, antim., gr. j.
Aqua fluvialis, ^iv.
M. ft. solutio, et adde.
Lin. sent, infus., ^xij.
M. Sum. pro haustu.
Of this half of a large teacupful, sweetened, and flavoured with lemon-juice,
if required, will be taken by the patient at intervals of an hour or two
through the day. If the inflammation run high, two or three grains of
tartar emetic may be directed, and the quantity of the nitre increased to
two drachms, or even half an ounce, in the twenty-four hours, suitably
diluted in a mucilaginous vehicle. Mucilage or syrup of gum arabic may
be substituted for the flaxseed tea, in the prescription which I have just
TYPHOID PLEURISY —PUERPERAL PLEURISY. 331
given you, if required by the palate of the patient. It is not uncommon
for vomiting to follow the first dose or two of this mixture, but 1 have seen
no disadvantage from this, although it is deprecated by many writers, and
is made a ground of objection to the contra-stimulant use of tartar emetic
in pleurisy.
Other diuretics of the sedative class will be had recourse to in pleurisy,
more particularly when it assumes the sub-acute or chronic form. Of
these, digitalis and colchicum are entitled to our chief confidence ; the
first in infusion or tincture ; the second in vinous tincture of the seeds.
Laennec speaks highly of the infusion of digitalis. Calomel in small
doses is often one of our best diuretics, and the more so when combined
with squills, and opium enough to make the combination sit well on the
stomach.
The preceding treatment is that which the largest experience has shown
to be more serviceable in the pleurisy of adults whose constitutions have
not been greatly debilitated or perverted by prior diseases and vicious
excesses. In children a less vigorous course is demanded. Some indeed
would persuade us that the expectant method is the best with them : but
this is going to the other extreme. The first indication is the same in
infantile pleurisy as in pneumonia and bronchitis; viz., to abate the
inflammation by bloodletting, and in the class from two to five years of
age it will suffice to apply from ten to twenty leeches over the affected
side at the lower part ofthe chest, allowing the bites to bleed for about
two hours. In children somewhat older the lancet may be had recourse
to, and four to six ounces of blood abstracted. We are not called upon
to follow out the other indications in pleurisy, as in bronchitis and pneu-
monia, by giving expectorants; but restrict ourselves at first to counter-
stimulants and afterwards to the remedies that may be supposed to pro-
mote absorption ofthe effused fluid in the cavity of the pleura. Of these
latter diuretics are entitled to preference, and especially in secondary
pleurisy following the exanthemata, and in which the breathing is greatly
oppressed. We direct at this time squills and digitalis, either in tincture
or, preferably, an infusion with some aromatic in addition. Given alter-
nately with calomel, their operation as a diuretic is rendered more active.
Purging is not recommended by MM. Barthez and Rilliet: nor do they
think well of blisters in the pleurisy of children. They advise, however,
the application of a diachylon plaster over the side with a view of keeping
up a grateful and uniform warmth and protecting the skin against the
access of air.
Typhoid Pleurisy.—Resembling typhoid pneumonia so much in its
causes, general phenomena and the circumstances under which it appears,
as regards the habits and constitutions of the patients, typhoid pleurisy
calls for no amplitude of description, nor minuteness of therapeutical
detail for its treatment, after what has been said on the subject of typhoid
pneumonia.
Puerperal Pleurisy.—There is, however, yet another variety of pleu-
risy of which mention has been seldom made. I refer now7 to the super-
vention of pleuritic disease in puerperal fever. Next to peritonitis and
inflammation ofthe lymphatic vessels of the uterus, pleurisy ranks as the
most frequent complication of organic disease with this fever, but more
particularly with puerperal typhus. M. Cruveilhier (Diction, de Med. et de
Chir. Pract) states, that he has seen puerperal pleurisy occurring both
sporadically and epidemically.
332 DISEASES OF THE RESPIRATORY APPARATUS.
This variety of pleurisy is seldom simple and primitive ; it occurs as a
sequence to peritonitis, though sometimes it precedes this latter. Both
come on usually at the same time, viz., at the epoch of milk fever.
Analogous to the puerperal variety is the pleurisy which attacks some
females just before delivery, and which, M. Cruveilhier asserts, is always
aggravated by this latter process. This is too sweeping a dogma. I had
during the last summer (1844) under my charge a lady whom I visited
in the course of the day, and had freely bled for pleuro-pneumonia, and
whom I was called upon to attend in labour on the following morning. She
had been a patient of mine on two former occasions for pulmonary inflam-
mation of long duration and great violence; but in the present instance
she was soon relieved, nor did labour interpose any difficulty or compli-
cation to the pleuro-pneumonia, or this latter interfere with the progress
of convalescence after delivery.
So much importance did the author whom I have quoted attach to the
occurrence of pleurisy in puerperal women, that at the large Lying-in
Hospital (La Maternite), he percussed all the subjects in whom feverish
movements were protracted beyond the common limits, or in whom there
was any symptom of an unusual character. Increased frequency of
breathing and redness of the face are premonitions of the approach of
pleurisy that ought not to be disregarded. Quite recently (1847), I had
a case of puerperal pleurisy. It set in with great severity on the right
side, fourteen days after delivery. The patient was freely bled from the
arm and cupped on the chest. She soon recovered.
The prognosis of puerperal pleurisy is bad, as few in hospital practice,
of those attacked with it survive. The treatment cannot be arbitrarily
laid down. We shall feel justified, however, when our diagnosis is suf-
ficiently made out, in having recourse to sanguineous depletion, with raore
freedom than in simple puerperal fever. Whether this is to be done by
the lancet, or by cups or leeches, will depend on the strength and habit
of the patient, and the state of the system at the time, as well as the
amount of natural evacuations, such as of the lochia antecedently. The
rest of the treatment will merge itself into that of puerperal fever, in which
tartar emetic and opium should not be forgotten.
Chronic Pleurisy—Empyema.—Too commonly, in place of having
studied the phenomena of chronic inflammation of the pleura, practitioners
and writers restrict their observations to one of its effects, viz., the occur-
rence of purulent effusions filling up the inter-pleural cavity, or sac ofthe
pleura, and constituting the disease termed empyema. This separation
of effect from cause is hardly more rational than would be the study of
abscess as a distinct disease from the inflamraation which ended in abscess
and the formation of pus. Both in diagnosis and treatment, embarrass-
ments grow out of this separation. With a knowledge of the antecedent
symptoms and progress of pleural inflammation, we shall have but little
difficulty in reaching a diagnosis of the dilatation of the chest, displace-
ment of the heart, &c, which present themselves in the advanced stages of
pleurisy, whether it be acute or chronic. So, also, if attention be given to
the inception and early period of the disease, we shall see the symptoms of
phlogosis, and be induced to adopt a treatment which will either arrest the
disease or prepare the system for the remedies commonly prescribed for
fixed effusions of purulent matter or empyema. These remarks ap-
ply with equal force to the termination of inflammation of the pleura,
CHRONIC PLEURISY.
333
in the effusion of a large quantity of serous fluid, constituting hydro-
thorax.
The term chronic is less applicable, in its literal signification, to the mo-
dification of pleurisy than to many other diseases denominated chronic, in
which there is not only duration but a notable difference in the degree
and sometimes nature of the organic lesion. Chronic pleurisy some-
times develops acute symptoms, as e converso acute may prevail with little
or no irritation or notable disturbance of function. In the former we have
effusion and false membranes, displacement and condensation of the
lung—symptoms all of which are met with in the latter. More usually,
it is true, there is less general disturbance with these symptoms in the
chronic than in the acute.
Symptoms.—Chronic pleurisy may come on gradually if not insidiously.
We suspect its existence when there is dry cough, a remittent fever with
evening paroxysm, an habitually frequent pulse, shortness of breath after
any exertion, inability to lie on the healthy side, and emaciation. If with
these symptoms we meet also the physical signs of accumulation, com-
pression and displacement, we may safely allege that we have before us
a case of chronic pleurisy with effusion. In certain instances, Dr. Stokes
remarks, with a view to show the paramount value of physical signs when
most of the symptoms are wanting, that he has repeatedly known persons
with copious effusions to look well, to be free from fever, pain, or any local
distress ; to be equally well on both sides, to have good appetite, which
they could indulge without apparent injury ; and all this when the heart
was pulsating to the right ofthe sternum.
Displacement of the heart occurs at a very early period, when the effu-
sion is on the left side, and long before any protrusion ofthe intercostals
or diaphragm. Among the signs of eccentric displacement we may ex-
pect to meet with dilatation of the side to the extent of from one to two
inches. This sign is more valuable in the left than the right side, as this
last is habitually the more developed of the two. Associated with dila-
tation ofthe side is obliteration of the intercostal spaces and smoothness
of the affected side. The diaphragm is also displaced, and causes, in
consequence, a protrusion and resistance of the upper portion ofthe abdo-
men. If the effusion be in the right side the liver is pushed downwards;
if in the left the spleen is displaced.
The sound on percussion is dull in chronic pleurisy with effusion. But
in this respect we find considerable differences, according to the posture of
the patient, and provided adhesions have not yet been formed. When the
patient turns on his face the postero-inferior portion which had been dull
becomes clearer, and, in few instances, it has been observed that there was
a return of clearness in the lateral portion when the patient turned on the
opposite side, so as to allow the fluid to accumulate along the median line.
Respiratory murmurs are totally suppressed except close to the spine and
under the clavicle, where the sound is harsh, bronchial, or even slightly
blowing. QSgophony is not heard when the effusion is considerable :
the same may be said of every other sound, whether natural or morbid.
On this point, however, there is some discrepancy of opinion : Dr. Jack-
son, of Boston, relates cases in which strong bronchial respiration was heard,
although the chest was full of fluid.
The pleura is deeply iniected in this disease, and false membranes
with sero-purulent fluid abound. The membranes are thicker, but less
334 DISEASES OF THE RESPIRATORY APPARATUS.
plastic and organisable than in the acute variety of pleurisy. The effused
liquid, in place of being of a citron colour, is milky, opaque, or purulent,
and exhales a garlicky, sometimes fetid, odour.
Progress and Duration.—A different series of phenomena, but similar
to those described as occurring in acute pleurisy, are observable when
absorption of the fluid in the pleural cavity begins and is continued. The
respiration, from having been inaudible as high as the scapular region or
even the clavicle, now gives out a feeble murmur at this region, which gra-
dually increases in extent downwards. In proportion as the respiratory or
vesicular murmur is heard at increasing distances from the surface, the
bronchial becomes more circumscribed until it is only sensible at the root
ofthe lungs. The sound on percussion also gradually recovers its custo-
mary clearness, first at the upper, then at the lower part of the chest.
Friction sounds re-appear and continue audible for a length of time. The
dilatation of the chest is removed by degrees, and the semi-circular and
vertical measurements fall to the natural standard ; the distance between
the nipple and median line decreases gradually to the normal extent. The
heart, diaphragm, liver, and other abdominal viscera are restored to their
natural position. The return of a dilated side to its natural circumference
is sometimes exceedingly rapid. Dr. Stokes has known it to lose as
much as an inch and a half in eight days.
If the effusion have been considerable and the chronic pleurisy of longer
duration, the absorption is accompanied by retraction ofthe chest, and the
lateral circumference of this latter is much less than natural. Sometimes
the contraction is confined entirely to the lower part of the chest, and is
unaccompanied by depression of the shoulder. One of the first signs of
absorption, with contraction, is the increased prominence of the inferior
angle of the scapula. In many cases the retraction or depression of the
chest is accompanied by projection and depression of the shoulders, ribs,
and nipple ; the scapula is tilted towards its inferior angle ; there is
lateral curvature of the dorsal spine, with the concavity turned towards
the diseased side ; distortion of the ribs ; intercostal spaces unnaturally
narrow ; diminished motions of expansion and of elevation, especially of
the former, while the latter is affected in the same way as during the period
of effusion with dilatation ; motions of ribs on each other much impaired
(Wralshe, op. cit.). On mensuration we find the semi-circular and the an-
teroposterior measurement diminished.
At times pressure is exerted by the sound side, after absorption,
causing displacements the very reverse of that which obtains when the
effusion was going on with corresponding dilatation of the diseased side.
In this way, after the absorption of an effusion on the right side, the heart
was drawn over to that side, so that its pulsations were felt to the right
and not to the left of the sternum. So, likewise, after the removal of
pleuritic effusion in the left side, the heart was protruded upwards to the
left, so that its pulsations were distinct from the fifth to the third rib near
the axilla.
An anomalous state of things is mentioned by Dr. Stokes to prevail in
some rare cases of empyema. It is, a coincidence of effusion and dilata-
tion with contraction on the same side.
The duration of chronic pleurisy varies from two, three, and four, to
six months, and even to one or two years.
The diseases with which a pleuritic effusion is commonly confounded
PROGNOSIS AND TREATMENT OF CHRONIC PLEURISY. 335
are solid growths on the pleura, tubercle ofthe lung, chronic pneumonia,
and enlargement ofthe liver. The diagnosis must rest on a careful com-
parison of all the symptoms of each disease respectively.
The following symptoms and physical signs are summed up by Dr.
Townsend,—Article " Empyema" (Cyclopaedia of Practical Medicine), as
the most characteristic of empyema, and when they are all combined, may
be considered as quite pathognomonic : difficult respiration, increased
by motion or exertion of any kind, and considerably aggravated by lying
on the sound side ; a sense of fulness and oppression on the chest, amount-
ing in some cases to a sense of suffocation ; enlargement of the diseased
side ; protrusion of the intercostal spaces, with obscure sense of fluctua-
tion and edema ofthe integuments; dulness of sound on percussion, and
absence of the respiratory murmur on the diseased side, which remains
perfectly motionless ; puerile respiration in the opposite lung, accompanied
with violent action of the respiratory muscles ; displacement ofthe heart;
descent of the diaphragm, and consequent protrusion of the abdomen :
to these characteristic marks may be added harassing short cough, small,
rapid pulse, flushed cheeks, and other symptoras of hectic fever.
The prognosis in chronic pleurisy with effusion and subsequent contrac-
tion of the chest is more encouraging than appearances would seem to
justify. In young and previously well-constituted subjects, the chest often
recovers its normal proportions, and respiration and the functions gener-
ally are carried on as well as ever. M. Chomel (Elemens de Pathologie
Generate) states, that in the case of a physician of his acquaintance, in
which chronic pleurisy of the left side with dilatation and subsequent re-
traction had existed, he found on inspection and measuring the circum-
ference and antero-posterior dimensions of the chest, that it had recovered
not only the normal development but was actually fuller than the right.
" Perhaps," he adds, " that it was originally so." This writer relates an
instance of a phthisical girl, in which, consequent to pneumonia, there
was pneumothorax, and afterwards effusion of fluid with dilatation and
subsequent retraction ofthe left side : but in proportion as this increased
the right became more dilated, as if the lung of that side expanded to
compensate for the deficient size and function of the other.
Treatment.—The indications in chronic pleurisy are to remove existing
local irritation or the remains of inflammation in the chest, and to support
the strength of the patient. The extent to which a preference will be
given to the measures for carrying one or other of these indications into
effect, will naturally depend on the presence of fever, some pain, dys-
pnoea, and cough, with quickness and any resistance of pulse, as regards
the former, and general debility and suspended hematosis, as respects the
latter. We must suppose that the time and necessity for venesection are
past; but it may still be proper, in cases, to apply a few leeches or cups
to the diseased side ofthe chest, as much with a view to their derivative
and absorbent effect as to direct depletion. If we find reaction after their
use and still much functional derangement of respiration, we may have
recourse to them with advantage even a second time. Less doubt will
be entertained generally of the propriety of blisters applied in succession
to different parts ofthe affected side.
The bowels are to be early acted on by moderate but not often repeated
purging. Diuretics are of more value, and rank still among the means of
directly reducing irritation. Of these some give the preference to digi-
336 DISEASES OF THE RESPIRATORY APPARATUS.
talis ; others, as Laennec, to certain saline preparations, such as the ace-
tate of potassa and the nitrate of potassa ; the former in doses of half an
ounce to two ounces, the latter of two drachms to half an ounce, and oc-
casionally adding to them muriate (hydrochlorate) of ammonia and some
preparation of squills.
Doctor Stokes is partial to mild mercurials " steadily exhibited till a
slight but decided ptyalism is induced." The use of this remedy, of so
much power, for good or evil, must be governed by the constitution of
the patient: who, if of a sanguineo-lymphatic temperament, will be bene-
fited by it, but if a scrofulous diathesis prevail it should be withheld ; at
any rate, short of its producing ptyalism. I have so often seen the salu-
tary remedial effects of calomel as a diuretic and promoter of absorption
when it is given in small doses, as a grain two or three times a-day, that
I should have little hesitation in giving it in chronic pleurisy,—at the
same time that I would deprecate its sialagogue operation.
Still better adapted to the circumstances of the case, and a safer remedy
in purulent formations, is iodine, and more especially the iodide of potas-
sium, in doses of two or three grains three times a-day ; where the debility
is considerable and the habit cachectic, iodide of iron is well adapted to
the case. Dr. Stokes indicates a preference for Lugol's solution, and re-
commends, at the same time, that from two drachms to half an ounce of
iodine ointment be rubbed every day on the chest. Friction alone, in
conjunction with exercise, is a good means of promoting absorption.
To the full as important as the whole medicinal treatment is a well-re-
gulated hygienic course. In the early period of the disease we enjoin
entire quietness in bed and restriction, for a few weeks, to a diet of farina-
ceous food and vegetables with milk. After a time, as the symptoras of
irritation subside and the pulse becomes tranquil, light animal broth or
even a little meat, is allowable. Restriction to an antiphlogistic regi-
men for some time is laid great stress on by Broussais, and it is justly
remarked by Dr. Townsend, in his article on empyema (Cyclopaedia of
Practical Medicine), that so long as there are recurring paroxysms we
must abstain from the tonic treatment. After absorption of the fluid, the
tonic course, of which the best part is exercise in a pure country air, is
to be more fully carried out. Moderate gymnastics may be regarded as
a useful auxiliary to the main treatment. ' The use of an opiate is strongly
recommended by Dr. Stokes.
In cases of undoubted empyema, or fixed purulent effusions in the pleu-
ral sac, the efforts of nature sometimes effect a cure, by the formation of a
fistulous passage through the lungs, or through the walls of the chest,
by which means an outlet is given for the matter contained within the
pleura. Such a result only occurs, however, when the empyema is circum-
scribed, and the fluid is prevented from occupying the entire cavity. Un-
der such circumstances there may be several outlets, each corresponding
with a distinct compartment of circumscribed empyema. Generally speak-
ing, the escape of air through the bronchiae, or the walls of the chest, as
the case may be, is followed by immediate relief of all the most urgent
symptoms, and in some instances the fistulous passage soon ceases to
discharge, and cicatrizes. Sometimes, the evacuation of matter, in place
of affording any alleviation of the symptoms, seems only to aggravate the
disease and to accelerate its fatal termination.
When no prospect remains ofthe effused fluid being absorbed, and the
TREATMENT OF CHRONIC PLEURISY.
337
oppression from its accumulation is great, an opening may be made into
the chest by instrumental operation, constituting what, in the language of
surgery, is called paracentesis thoracis. " This operation is at all times
easy of execution, productive of little pain to the patient, generally fol-
lowed by immediate relief, and has, in numerous instances, been crowned
with complete success." Unhappily the term successful is too commonly
used by surgeons to designate an operation which has been regularly and
completely performed without the patient immediately sinking under it,
or his dying within a short period afterwards. But, results of this nature
cannot satisfy a conscientious and a reasoning physician, nor do they
satisfy a surgeon who is fully alive to the responsibilities of his position,
and who briggswith him the requisite amount of pathological knowledge,
to enlighten him on the previous condition of the organ or part, as well
as the probable changes, anatomical and direct, or functional and indi-
rect, following the operation. In the present case, it must be borne in
mind, that empyema, as 1 stated in the beginning of my remarks on chro-
nic pleurisy,is a consequenceof pre-existing disease ofthe pleura,and some-
times of the lungs also, and that the effect of the operation is merely to
remove the effused fluid, while the organic or structural alterations still
remain. Even if we were to suppose that morbid action, inflammatory
and secretory, had ceased, the lung, we must be aware, has been so long
compressed by the effused fluid, and tied down by numerous dense and
adherent false membranes, as to have lost its elasticity and power of ex-
pansion. Of this we can assure ourselves by abortive attempts to inflate
the lung of a subject who has died from empyema. A copious purulent
discharge may, also, in some cases, follow the operation and increase the
debility of the patient, who suffers, at the same time, from new inflam-
mation of the suppuratingsurfaces. Decomposition ofthe matter discharged
from the'chest, attributed to the access of atmospheric air, is, also, another
consequence of paracentesis thoracis. Another cause of objection to the
operation was, we may say, rather than is, the difficulty of diagnosis, and
the risk, in consequence, of making an opening into the thorax when in
reality there is no empyema,—a mistake which has actually been made
at different times. This objection no longer applies at the present time,
and the physician is, therefore, left free to choose the period most proper
for the performance of the operation. This is indicated in acute empye-
ma, when the breathing is extremely oppressed, and the effusion goes on
increasing. Still, even here, it is advisable to wait until the symptoms
of inflammation shall disappear, before operating. In chronic empyema,
or rather in empyema from chronic pleurisy of such duration as to show
the inefficacy of the various therapeutical means used to cause absorption,
the operation is particularly indicated.
The probability of success from paracentesis will be in proportion to the
youth and good constitution of the patient, the comparative recency of
the effusion, and the absence of complication with organic diseases ofthe
lungs. Dr. Davies, of London, furnished Dr. Townsend, author of the
article " Empyema" (Cyclopedia of Practical Medicine), with returns of
a number of cases of empyema in which the operation had been success-
ful ; " eight of the patients out of ten having recovered. Of these, five
were under six years of age, one was between eighteen and nineteen, and
two above twenty-live."
I shall not repeat the detailed directions for performing paracentesis tho-
vol. n.—23
338' DISEASES OF THE RESPIRATORY APPARATUS.
racis, as you will find them in all the works on operative or practical sur-
gery,—to some one or other of which you would very naturally feel dis-
posed to refer, before undertaking the operation.
Pleurodynia (from T^g*, rib, and a>JW», pain) — Bastard Pleurisy.—
Pleurodynia, formerly applied to all pains of the chest, is now restricted
to those which affect either the intercostal and other muscles of the thorax
or the thoracic fascia?, and which are believed to be analogous to rheu-
matism, and still more to neuralgia. This affection acquires more signifi-
cance and importance when it constitutes a part of general rheumatic dis-
ease, and may then be converted into real pleural or even pericardiac
inflammation.
Pleurodynia is distinguished by a local pain in some part of, the thoracic
parietes, of an acute and lancinating nature, increased by pressure and
movement either of the trunk or arms, and by coughing or even breathing.
The causes are sudden atmospherical vicissitudes, damp lodgings, expo-
sure to currents of air and cold drinks when the body is perspiring. Some-
times it has resulted from an excessive strain on the respiratory muscles,
as in violent gymnastic exercises, carrying heavy burdens, &c. Men are
more subject to it than women, and adults and old persons than young
ones. Like rheumatism, it assumes at one time an acute, at another a
chronic character — and again, from the rapidity of its onset and sudden
disappearance, we can only compare it to neuralgia.
Diagnosis.—Pleurodynia originating from many of the same causes and
manifesting to a certain extent similar symptoms as pleurisy, we are re-
quired to establish for it a correct diagnosis. In the former affection there
is little or no fever, and the cough is transient; the pain, though pungent,
is increased by pressure and the movements of the trunk and arms. In
pleurisy, on the other hand, there is fever, with a hard, resisting pulse and
dry cough, and often coloration of the face on the side corresponding
with the pleuritic stitch. The physical signs give negative results in
pleurodynia, whereas in pleurisy they are of a positive character, such as
dulness of sound, oegophony, friction sounds, &c. Reference being had
to the neuralgic character of the former disease, we may expect to find
associated with it spinal, or, rather, intercostal nervous irritation. Pres-
sure on the space between two vertebras has been, in cases coming under
my own observation, productive of severe lancinating pain of the chest,
similar to, if not identical with, pleurodynia. On other occasions, pain
felt under the sternum and shooting through the chest arises from gastric
indigestion, as that in the shoulders from disordered liver and disorder
ofthe colon.
The treatment of pleurodynia will be modified by the age and consti-
tutional vigour of the patient. Venesection is in some cases decidedly
beneficial. More frequently leeches will suffice, and they, when used,
ought to be applied, in the instance of females, to the inside of the thighs.
Sinapisms, or hot fomentations and stimulating plasters to the pained part,
the warm and even hot bath and warm pediluvia, are so many means of
counter-irritation or of revulsion, which are often sufficient to remove the
pain. In chlorotic^females, or those of an anemic habit, it will be desira-
ble to establish an afflux of blood and nervous excitement in the uterus,
by the hip-bath, and warm aloetic purgatives, to which after a while we
add some preparations of iron. I have found great and early relief pro-
cured in cases of a neuralgic nature by the application of a few leeches
CAUSES AND SYMPTOMS OF PNEUMOTHORAX. 339
to the tender spot, at one or both of the spino-intercostal spaces. A blis-
ter to the same place has produced the like beneficial results.
Pneumothorax (from intvu*, air, and 6&?i|. the chest)—Air in the
Pleura.—Pneumothorax is one of the varieties of pneumatoses or abnor-
mal collections of gaseous matter. They occur in the tissue ofthe organs,
between the fibres of the cellular tissue, as in the parenchyma of the lungs
and liver, constituting emphysema ; and in the natural cavities of the body,
as in the intestinal canal and the peritoneum, tympanites; in the pleura,
pneumothorax, in the uterus, physometra, &c. They are most common in
the intestinal canal, and comparatively rare in the other cavities.
Pneumothorax may occur in three different ways :—1. It may be the
consequence of partial pleurisy, the effusion in which being absorbed
leaves a void which is sometimes filled with air secreted by the mem-
branes. This kind is quite rare. 2. Pneumothorax of an idiopathic kind
arising from the effusion or secretion of air into the sac of the pleura with-
out perforation, in a manner analogous to the secretion of air from the
peritoneum, constituting tympanites. This is, also, an unusual occur-
rence. 3. The most common kind of pneumothorax is that caused by
some unnatural communication between the pleural sac and the external
air; and this may be by a perforation either of the external parietes or of
the pulmonary pleura. The latter is the kind of pneumothorax usually
spoken of, and constitutes a great majority of the cases met with in prac-
tice. The perforation depends on the progress of ulceration, which is
generally of a tuberculous character, and, but rarely, of gangrenous ab-
scess, through the pleura. There are examples on record of pneumotho-
rax resulting from a communication between the cavity of the pleura and
one of the neighbouring hollow organs containing air, as from rupture of
the oesophagus, cancer of the stomach, abscess of the liver, opening into
the lungs and the pleura, &c. The post-mortem appearances will vary
according to the cause. Most generally, together with gas there is liquid
effusion, pleuritic membranes, and tuberculous cavities. The perforations
are sometimes very small, even imperceptible.
The causes of pneumothorax are detailed by M. Andral. Its idio-
pathic origin is rare. Most commonly (if we except traumatic pneumo-
thorax, or that proceeding from a penetrating wound of the thorax and
costal pleura) the cause is external to the cavity of the pleura, and con-
sists in a pulmonary lesion. Sometimes it is owing to a fistula which opens
a communication between a tuberculous cavity and the pleura ; sometimes
to an abscess, the consequence of pneumonia, opening on the pleura ; to
pulmonary apoplexy destroying the lung and the pleura ; to a cancerous
ulcer of the lungs, or, as M. Andral has twrice seen it, to a simultaneous
rupture of some of the pulmonary vesicles and the pleura. The disease
is most frequent between twenty and thirty years of age.
Symptoms.—These consist in—1. A dyspnoea of greater or less severity,
according to the quantity of gas, and the rapidity with which it is formed.
2. A convexity ofthe thorax ; but this is not a constant symptom. 3. An
unusual sonorousness, on percussion, through the whole extent ofthe dis-
eased side, or only at the upper region, for, lower down, a dull sound
indicates a liquid effusion. 4. The absence of the respiratory sound,
coinciding with the sonorousness. 5. Sometimes an amphoric or caver-
nous respiration. 6. If there be air and liquid effused, a gurgling, at first
not very sensible but augmenting each day, in the inverse proportion of
340 DISEASES OF THE RESPIRATORY APPARATUS.
the amphoric respiration and the sonorousness. 7. A metallic tinkling,
the cause of which is not hitherto known. 8. If there be at the same
time liquid effused, succussion causes a noise of displacement, or a splash
ofthe liquid against the walls of the chest.
The diagnosis is well summed up, in its main features, by Dr. Hough-
ton (Cyclop: of Pract. Med.):—
" 1. The sensation of something giving way in the chest, and of air
entering the pleural cavity. Very variable, but often absent or unnoticed.
" 2. In a phthisical individual the sudden supervention of overwhelm-
ing dyspnoea and pain. Rarely absent, therefore very valuable ; still
more so if succeeding last sign.
u 3. Comparison of auscultation and percussion. Nullity of respira-
tion over one side, together with tympanitic clearness of sound, which
below terminates abruptly in complete dulness. If accurately established,
amounting to positive certainty, but sometimes not easy to establish.
OZgophony rare.
" 4. Fluctuation on succussion. Positive certainly, but should be un-
questionably verified.
" 5. Metallic tinkling. Positive certainly, but should be unquestiona-
bly verified. This metallic tinkling is audible during coughing, speaking,
and sometimes during respiration, or, more correctly expressed, after
these movements." Besides this, adds Dr. Houghton, it is often heard
independently of these, observing a certain periodicity, and finer in its
tone. It coincides or alternates with amphoric respiration. Cough is a
common adjunct. Among the general symptoms are a frequent and small
pulse, hectic fever, emaciation, decubitus on the affected side; and
edema, at first of the thoracic region, and afterwards of the entire peri-
phery of the body.
The duration of pneumothorax may be from a period of a few hours
ending in death, or it may extend to several days, and more than a month,
and even a year or two, to three years.
Its termination may be favourable, and brought about by the absorption
ofthe effused air; but most generally death is the result.
The treatment of pneumothorax promises but little more than merely to
palliate some of the worst symptoms, by the alleviation of pain and making
the respiration somewhat easier. Its first and sudden occurrence, causing,
as it often does, great prostration and irritating cough, may require a full
dose of opium combined with antimony or calomel. Subsequent reaction
with fever will be treated by venesection, if the patient be not much re-
duced by long prior disease ; and in other cases by leeches or cups to the
chest. In fact, as perforation of the pleura and consequent pneumotho-
rax are, in the larger number of cases, additions to a previously existing
disease, such as phthisis, the treatment must necessarily be modified not
a little by the stage of the chief and primary diseases, and the remedies
which have been employed or were in use at the time. Blistering and
other means of counter-irritation will generally be allowable in the emer-
gency.
The immediate indication, where, in consequence of the smallness of
the perforation or its valvular condition, air accumulates in the chest and
becomes a cause of oppressive dyspnoea, is, as Dr. Williams justly ob-
serves, to give vent to the air by puncturing the chest. Temporary relief
has been afforded in several instances by this means ; but before having
TREATMENT OF PNEUMOTHORAX.
341
recourse to it, we should consider whether, as it can give only temporary
relief, the condition of the patient be such as to make this likely to out-
weigh the pain and risk of the operation. These certainly are not great,
but when added to the dubious view in which the friends of the patient
may regard an operation which proves but imperfectly successful, they
are, in many cases, enough to deter us from the responsibility of recommend-
ing it. The circumstances are different when the accident occurs before
the consumptive disease has advanced far, when there is still much flesh
and strength, and the physical signs have shown that there is a consider-
able quantity of sound lung ; or if the effusion should have resulted from
chronic pleurisy. The operation may be repeated if the air accumulate
again. As it is impossible to avoid the continued introduction of air into
the chest, the mode of performing the operation is a matter of much less
consequence than in empyema. It is more desirable to puncture low down
in the chest, to permit the discharge ofthe liquid as well as the air.
The following case, recorded by Dr. Stokes, in his Treatise, &c, will
be to you a good clinical lesson.
Gangrene of the lung, empyema, and pneumothorax—Paracentesis—Gangrenous destruction
of the costal pleura—Passage of the fluid behind the peritoneum.
" A gentleman, aet. 36, generally very healthy, with a large, well-formed
chest, had occasionally complained, for the last few months, of pain in
the chest, at one period very severe ; he had been cupped and blistered,
but without relief; at length hectic symptoms set in with restless nights;
soon after, he felt as if something gave way in his side, and immediately
expectorated a horribly fetid matter. A similar attack occurred in a few
days, with the same fetid discharge, but accompanied by prostration,
lividity of the countenance, and dyspnoea. I saw the patient along with
Dr. Marsh and Mr. Crampton. We found the chest to contain air and
fluid ; and in consultation made the diagnosis of gangrene of the lung,
and advised paracentesis. The operation was performed between the
seventh and eighth ribs, a little below and external to the right mamma ;
the withdrawing of the trochar gave issue to a quantity of fetid air; a
probe was introduced, and met by an elastic resisting substance ; this
was apparently perforated, and about three quarts of dirty, grey-coloured,
fetid fluid given exit to. Great relief followed the operation. The pa-
tient, however, passed a wretched night, with hectic paroxysms ; no dis-
charge occurred from the wound.
" 17th. The trochar and canula were introduced, and a quart of the
same fetid matter came away—patient felt easier; passed a bad night.
" 18th. A pint of fetid matter was taken away; spent a most uneasy
night, with incessant cough and frothy expectoration ; the act of cough-
ing sending the fetid air and matter through the external opening in great
quantities.
" 19th. Much exhausted ; said he felt as if there was a well in his
chest; he was sensible of a constant dropping of fluid ; pulse 120 ; great
weakness ; heat and soreness in the side.
" 20th. Mr. Colles saw him, in consultation with the other attendants.
Anodyne enemata and stimulants were ordered ; he passed a better night,
but had great dysuria ; ordered mucilaginous drinks.
" 21st. Passed a bad night; pulse 144, and weak ; during a fit of cough-
342
DISEASES OF THE RESPIRATORY APPARATUS.
ing, which brought on the usual discharge from the wound, about a cupful
of blood gushed out. . .
" 22d. The introduction of a gum-elastic tube gave exit to no fluid, but
a great quantity escaped while the patient coughed ; the abdomen became
tense and tympanitic, with exacerbation of all the symptoms, and the pa-
tient died in about thirty-six hours.
" Dissection.—Externally the body presented some livid marks at the
right side, and a slight fulness in the right inguinal region and side ofthe
scrotum. The right pleural sac contained above a quart of fetid purulent
fluid ; the lung was of a dark-greenish hue, smeared with a creamy sub-
stance ; its lower and back part destroyed by gangrene, leaving a large
greenish-coloured cavity, the size of the hand. The substance of the
lung near this was easily broken down, and the vessels and bronchial
tubes were seen passing through it; the remainder was gorged with a
frothy, dark sanies ; the whole lung was reduced to half its size; some
adhesions united it to the mediastinum, almost forming a circumscribed
cavity : the costal pleura was in some places highly vascular ; in others,
covered with lymphy secretion ; in some places very tenacious. In one
patch, destroyed by gangrene, the intercostal muscles were laid bare for
the space of several inches, and were in one part sloughy, forming an
opening at the inferior and posterior part, at which place nature had at-
tempted an outlet for the fluid—the latter having made its way into the
cellular tissue, beneath the skin, and between the peritoneum and abdo-
minal muscles, down the side of the abdomen to the scrotum. The gene-
ral cavity ofthe right side was much diminished by the liver having been
displaced upwards by the flatus of the intestines ; the liver was in such
close apposition with the lung, as to be in danger of being wounded by
the trochar ; thus accounting for the fluid not coming off by the canula in
the first instance."
Interlobular Emphysema of the Lungs.—The term pulmonary em-
physema applied to dilatation of the air-cells, though commonly used,
since the time of Laennec, in this sense, is not applicable to the existing
state of things. The affection in which the air is effused into the cellu-
lar texture of the lung, is that alone to which emphysema is applicable.
For the most part it is referable to the rupture of one or more pul-
monary vesicles, owing to some violent exertion in lifting, straining,
shouting, or coughing. Laennec believed the immediate cause to be the
rupture of dilated cells. Interlobular emphysema is, upon the whole, a
disease of rare occurrence and subordinate importance. Hasse declares
that he has never seen it before death, nor detected its traces afterwards,
except in subjects where rapid decomposition had caused the formation
of gases within the cellular tissue of various other organs. There are
cases, however, on record, of sudden death from the coming on of inter-
lobular emphysema after fright or some violent mental emotion. The
extravasated air is chiefly found beneath the pleura and around individual
lobules. In the former situation it is sometimes seen in transparent,
movable vesicles, of various sizes. Between the lobules it forms into
parallel, and more or less narrow strata. By this extravasated air the
pulmonary cells are proportionately compressed, but without causing the
paroxysms of dyspnoea that we meet with in vesicular emphysema.
As we cannot make out a clear diagnosis of interlobular emphysema,
it would be useless to pretend to lay down a plan of treatment.
SYMPTOMS AND DIAGNOSIS OF HYDROTHORAX. 343
Hydrothorax (from «/»§, water, and s»ga|, the chest)—Water in the
Chest.—We may restrict the term to serous effusions in the cavity of the
pleurae. One among the many evidences of an amended pathology de-
duced from morbid anatomy is our better knowledge of the causes and
real character of dropsies of the chest, including both hydrothorax and
hydropericardium. No longer regarded as, in general, a primary disease,
we see in these effusions, as indeed in all those of serous sacs, an effect,
or symptom in fact, either of inflammation of their membranes or of im-
peded circulation. Recognising these two as the chief if not sole causes
of hydrothorax, we see in the first variety, or that from inflammation of
the pleurae, active hydrothorax, while the second variety, which may be
called passive, is caused by interruption to the circulation, either by
organic diseases of the heart or congestion of the lungs, and tumours at
the root of these latter. Sometimes hydrothorax results from diseases of
the kidneys, from a febrile state connected with the exanthemata, par-
ticularly scarlet fever; and from a sudden suppression of cutaneous exha-
lation, implying, on occasions, an alteration in the state of the blood as a
more immediate cause. In some of these cases it may be associated with,
if it do not proceed from, edema of the lungs, increasing greatly the dis-
tress and the danger. In more than two-thirds of bodies, opened for
various purposes,—anatomical and pathological study—from two to three
and four ounces of effused fluid are found in the pleural cavity.
The symptomatology of hydrothorax is so little satisfactory that some of
the best modern writers on the subject assert, that, if we except oppres-
sive dyspnoea, there is really no symptom of the disease. That there
must necessarily be variation in this respect is very evident from a sur-
vey of the organic causes,—as to whether they consist in obstructions to
the regular action and circulatory function of the heart, or in prior in-
flamraation ofthe pleura, or in pulmonary obstruction. Still, it is well to be
aware of the common association of morbid phenomena in these particu-
lars, even if we are not able to reach a very exact diagnosis.
The hurried breathing and panting on mounting the smallest ascent,
the oppression and dyspnoea increased by lying down, the starting during
sleep, so commonly spoken of as symptoms of hydrothorax, are, in fact,
evidences of disease ofthe heart which preceded the effusion, and which
would be manifested even if these latter were not present. The effusion
will, however, no doubt, aggravate the original symptoms, and compli-
cate the case.
One of the earliest symptoms of hydrothorax, whatever may be the
origin of the latter, is edema of the eyelids; but, although the precursor
of swelling of the feet and ankles in the evening, it is often not noticed
until in connexion with the latter. The dyspnoea, at first, may excite but
little attention and cause but little inconvenience ; after awhile, however,
its increase becomes marked, and it goes on until orthopnoea is established,
and the patient cannot sleep except in a chair. The occasional, and, at
times, periodical recurrence of paroxysms, during which the oppression
and anxiety of the patient are extreme, are not well accounted for. Great
disorder ofthe circulation is evinced by the blue and almost livid colour
ofthe lips and cheeks.
The physical diagnosis of hydrothorax is more precise than that derived
from the general symptoms. Succussion can only be of service where
there is a communication between the effusion in the pleural cavity and
344 DISEASES OF THE RESPIRATORY APPARATUS.
the air of the lungs, or where gas is mixed with the effused fluid. Per-
cussion, as may be readily supposed, yields a dull sound over the whole
region corresponding to the effusion. By auscultation we hear, if the
effusion be yet slight, oegophony; but more commonly the information
afforded by the stethoscope is negative. No respiratory sound is heard
except at the root ofthe lungs.
The distinction to be drawn between hydrothorax or simple serous effu-
sion and empyema or purulent effusion, are attained with some show of
accuracy. Thus, we commonly see serous effusions in other parts of the
body, as at the extremities and sometimes under the whole sub-cutaneous
cellular tissue, and also in the lungs, associated with that in the chest:
they, also, in general, precede the latter. In empyema there is, indeed,
not unfrequently, similar effusions in other parts; but they follow at some
intervals the purulent collection. In this latter case the respiratory sound
is good on one side, whereas in hydrothorax it is deficient on both
sides.
The recommendation of Bichat, to make, in doubtful cases of hydrotho-
rax, while the patient is lying on his back, pressure upon the abdomen,
so as to throw the viscera upwards and thus diminish the capacity of the
chest, is worth a trial, as an additional means of diagnosis between the
disease in question and empyema. When pressure is made on the affected
side no result follows ; but if made on the healthy one, the expansion of
the lung is prevented ; and as the latter is the only one left for the perform-
ance of the function of respiration, this is impeded and much distress ensues.
The prognosis of hydrothorax, with our knowledge of its causes, must
be always unfavourable ; nor can we say that at any moment death may
not take place suddenly after a slight additional effort, in which respira-
tion and the action of the heart are more tasked than common.
The treatment of hydrothorax will be regulated very much by a knowl-
edge of its cause. If the effusion have ensued on inflamraation of the
pleura, either simple or combined with pneumonia, our remedies should
be the same as those directed for sub-acute or chronic pleurisy and pneu-
monia. Accordingly, we direct a few cups on the affected side or a blister
to be kept discharging, and calomel with squills and nitre; or, if the bowels
be irritable, opium may be used with good effect, both towards removing
the morbid secretory action and promoting absorption. Hypertrophy of
the heart and a full, hard pulse, and pulmonary congestion depending on
valvular disease of the heart, states of this organ associated with hydro-
thorax, are sometimes to be met by venesection, followed by calomel and
nitre, and digitalis with colchicum. In cases of irregular circulation, with
much oppression and symptoms of venous congestion, digitalis, with the
alkalies and tonics, will constitute the outline of treatment. Active
hydragogue cathartics, which are well represented by the compound pow-
der of jalap, gamboge with cream of tartar, or elaterium, often give great
relief in hydrothorax. When, in an enfeebled or cachectic state, efforts at
spontaneous relief are made by expectoration, this should be encouraged
by the use of polygala senega with carbonate of ammonia. When we have
reason to believe, that hydrothorax is caused by diseased kidneys, mercu-
rial purgatives, the blue mass with some narcotic, and diaphoretics, will
be of most service.
Counter-irritation must constitute a leading part of the treatment of
hydrothorax. Blistering has been already mentioned, but in order to be
POSITION OF THE HEART.
345
efficient the discharge must be kept up by the repeated application of
some vesicatory substance. Setons have been highly recommended with
similar intent.
If hydrothorax were not always symptomatic of a grave, if not incura-
ble disease, we might have more confidence in the operation of paracen-
tesis to evacuate the contained fluid. When the oppression from the
effusion is very great, and comes on suddenly, we have examples enough
to encourage this operation, even though its effects are but temporary.
DISEASES OF THE HEART.
LECTURE CXIII.
DR. BELL.
Diseases of the Heart—Position and structure of the heart—its valvular mechanism
—Beat or impulse ofthe heart; when felt—Percussion—Various tones according to
the part ofthe chest struck—Auscultation—Two sounds ofthe heart: the first caused
by the systole of its ventricles ; the second by the resistance and sudden tightening of
the semi-lunar or sigmoid valves—Different organic affections ofthe heart—Functional
disorders—Simple carditis, a rare disease—Sequences of—Softening—varieties and
causes of—Diagnosis not easy—Treatment, similar to that of pericarditis—Perfora-
tive ulceration and rupture—Recorded cases ofand complications with—Aneurism, ven-
tricular—Thurman's summary of—Its precise seat and complications—Aneurism of the
auricles.
I cannot offer you more than an outline of the subject of the morbid states
and the disorders ofthe heart; and even from attempting this, within the
limits of a few lectures, I feel almost deterred, when I look over the works
of Laennec, Bouillaud, Elliotson, and Hope, the lectures by Drs. C. J. B.
Williams, Corrigan, Latham, Clendinning, Bellingham, the manuals of
Aran and Andry, and the elaborate articles in the different Medical
Dictionaries and medical journals, both French and English, as well as
the contribution of Dr. Joy, in the Library of Practical Medicine. But
a comparatively short period has elapsed since Corvisart, the favourite
physician of Napoleon, was the only, as he was the earliest autho-
rity, entitled to any consideration on the diseases of the heart. After
him came Bertin in France, and Testa in Italy, connecting him with those
who in our own day have done so much to make the pathology of the
heart a part of demonstrative science.
For correct diagnosisofthe diseases ofthe heart,we must be familiar, first
with its position in the chest, in health, and then with its healthy structure.
The heart is placed in the anterior mediastinum, rather to the left of the
mesial bone, and so oblique that the apex points forwards and downwards
to the left, while the base lies back nearer the posterior centre, the spine.
It, therefore, lies, with its point forwards, on the diaphragm, underneath
which are the liver and stomach ; and it is bounded on other sides by the
lung, except a small space of about two inches, where, enveloped in its
coverings, it is in contact with the walls of the chest. Its base is directed
upwards, backwards, and to the right side, looking towards the fifth, sixth,
and seventh dorsal vertebra?, the oesophagus and descending aorta interven-
346
DISEASES OF THE HEART.
ing ; and its apex consequently downwards, forwards and to the left,
answering in the erect posture, and in a medium state of distention, and
the heart in the act of systole, to the fifth intercostal space, that is, in
a middle-aged individual, to a point about two inches below, and one
to the inside of the nipple ; or two and a half from the base of the
xiphoid cartilage. When a person in health lies on the back, the apex is
felt just below the nipple; the fifth rib being slightly heaved up ; and
when on the left side, the apex is felt strongly beating between the fifth
and sixth ribs, an inch or more to the left of the nipple ; and on the right
side, where the impulse ofthe apex cannot be felt, there is a gentle heaving
of the lower part of the sternum. When he lies on the abdomen the apex is
felt to beat over the third and fourth intercostal spaces. About one-third
ofthe heart, consisting principally of the right auricle and the upper and
right side ofthe base ofthe corresponding ventricle, lies behind the ster-
num. The orifice of the pulmonary artery and its valves, and conse-
quently those of the aorta likewise, which lie posteriorly, but nearly in the
same line, are placed immediately behind the upper edge of the sterno-
costal articulation of the left side. A moderately-sized stethoscope, ap-
plied over the origin of the pulmonary artery, will cover also the aortic
orifice and its valves, as well as a very considerable portion, nearly half,
of each ofthe auriculo-ventricular openings. The position ofthe heart is
affected in a sensible degree by gravitation, and consequently by posture.
In structure the heart is known to you to be a compound hollow muscu-
lar organ, consisting of four compartments or cavities lined with serous
membrane and invested by a fibrous capsule, external to which is a serous
membrane, that forms, by reduplication, the pericardium or heart-sac.
The lining membrane of the heart has been named by M. Bouillaud en-
docardium (from «i/ov, within, and **g nearly the
same ; at birth the left is a little thicker ; and with the advance of age
the disparity between the two ventricles increases. Hence, as M. Bizot
very truly remarks, we cannot but see, that, to take the thickness of the
wall ofthe right ventricle as a term of comparison, as has been generally
done, in order to estimate the proportional thickness of the wall of the
left ventricle, is the most defective means possible. The two following
tables give the thickness of the walls of the two ventricles :—
MALES. FEMALES.
Lines. Lines.
Ages. Base. Miildte. Apex. Base. Middle. Apex.
1 to 4 3 2T% I-9-1 9 2-5-16 21 »ft
5 to 9 3£ H 2$ »A *h 2T3u
10 to 15 3* 3$ 2$ 3T30 H 2f
16 to 29 4| 3| H 4f 4T* 3ft
30 to 49 417 ft 1 3II 41 4 327 Tic 3 6 If
50 to 79 4.37 R2 9 ^2 9 50 to 89 5
Medium from 16 to 79 4 6 5 ft J 9 Q 95 °T5J 16 to 89 43 4| m
HYPERTROPHY OF THE HEART. 357
Right Ventricle.
MALES. FEMALES.
Ages. Base. Middle. Apex. Base. Middle. Apex.
1 to 4 9 1% 5 10 h\ 1 f3 2"v"
5 to 9 H 5 '6 5 ly35 1 7 Tl. n.—27
402
DISEASES OF THE HEART.
tionably taken too limited a view of the subject; as experience has fully
proved that it may originate in various causes. According to his own
observation, it may originate in any cause, whether organic or functional,
capable of irritating the heart, or of rendering it morbidly susceptible of
irritation; and as structural disease of the organ has this effect more than
any other cause, it is that on which the malady, in its severer forms, is
most frequently dependent. Dr. Latham adopts Heberden's view of
angina pectoris consisting in "distention," or spasm, as Dr. L. explains
the word. The reasons why Heberden believes the disease to pertain
to spasm are, " 1. It comes suddenly and goes suddenly; 2. It has long
and complete intermission ; 3. Wine and spirituous drinks and opium afford
great relief; 4. It is increased by mental agitation ; 5. It exists for years
without other injury of the health ; 6. At first it is not excited by exercise
in a carriage or on horseback, as is usually the case with scirrhus or inflam-
mation (organic disease) ; 7. The pulse is not quickened in the very parox-
ysm ; 8. The paroxysm attacks some after their first sleep ; a frequent
event in diseases which proceed from spasm." Dr. Latham shortly after-
wards makes the following observations on this point:—
"The natural actions in all muscles, voluntary and involuntary, are un-
accompanied by any conscious sensation whatever. But spasm is always
accompanied with pain. And pain and spasm, wherever they are, disable
the parts which they befall. Colic stops the peristaltic movements of the
bowels. Cramp forbids the hands to handle and the feet to walk. But
the heart is a muscle, and its functions flow from its attributes as a mus-
cle. Now we are in search of something in the heart which, as the con-
comitant of pain, may be disabling to its natural functions, and capable,
according to its degree, of hindering or abolishing them altogether. This
we find in spasm. In its spasm of smaller degree the heart fails to close
freely upon the blood and to impel it freely into the arteries. In its spasm
of greater degree it fails to project it altogether. Herein we discern an
adequate explanation ofthe chief phenomena of angina pectoris. It is a
spasm of the heart."
The treatment of angina pectoris will be conducted according to the
notions entertained of its pathology. The proper course is to take cog-
nisance of all the probable and actual organic lesions which may pre-
cede and so often accompany the disorders of the heart. Preventive
measures will be of most importance ; those directed to an avoidance of
undue repletion, and especially at undue hours, and bodily exertion or
mental excitement. Small bleedings and laxatives and sedatives may be
required in some cases ; active purging and low diet in others ; tonics,
and nourishing but not stimulating food in another class ; and in all the
occasional recourse to if not habitual use of counter-irritants. Laennec,
who is not certainly prone to overrate the power of remedies, assures us
that he has most frequently succeeded in alleviating the distress in angina
by the magnet, so applied as to carry a magnetic current through the
thorax. The alkaloids of the ranunculacecc, such as veratria and aco-
nitine, have proved on occasions quite serviceable in the hands of their
original recommender, Dr. Turnbull. A belladonna plaster over the pre-
cordial region, renewed every week or ten days at farthest, procures
considerable alleviation of the attacks. Nitrate of silver in small doses
has been given with alleged benefit.
The duration of the paroxysm itself is so short as seldom to give time
or the physician to direct or administer remedies. In his absence the
ASTHMA.
403
patient ought to be instructed, to have immediate recourse to diffusible
stimulants, and of these the most active are to be preferred, such as Hoff-
man's ether or sulphuric ether, and spirit of ammonia, or still better, the
aromatic spirit of ammonia. Of one or other of these a teaspoonful should
be taken at once, mixed with water enough to allow it to be swallowed ;
and the dose to be repeated in a few minutes, if the paroxysms do not
cease. Sinapisms to the chest, and warmth and friction to the extremities,
should be applied at the same time. If, on the subsidence of the spasm,
pain persist, recourse must be had to laudanum, of which a drachm will
be given in combination with the ether ; repeating the dose in a quarter
of an hour should the pain persist. If these remedies are not at hand,
brandy or other ardent spirits, with equal parts of hot water, should be
taken. Happy would it be for mankind, if the use of these liquors were
restricted to cases of sudden and violent spasm, and of depression, calling
for immediate but temporary excitement. For such purposes were they at
first recommended, and within such ought their use to be confined.
When neuralgia of the heart occurs without the other concomitants of
angina pectoris, as it sometimes does when alternating with neuralgia in
other parts of the. body, the treatment will be conducted on the same
principle and by the same remedies as those on which we rely under this
last-mentioned circumstance.
Asthma has been at different times referred to by me, in the preced-
ing lectures, as a result of a diseased state of the bronchial membrane
and of pulmonary engorgement; and it has been formally so described in
connexion with dry catarrh. A frequent cause of asthma commonly un-
noticed by the practitioner, is disease of the heart. Sometimes from this
latter cause blood remains in the lungs in excess, giving rise to asthmatic
oppression ; as is the case when the right ventricle is hypertrophous, or
the left side of the heart obstructed ; or still more, when these two affec-
tions coexist: also when the circulation is merely accelerated, as by pal-
pitation, running, or by slighter efforts in corpulent persons. Sometimes,
blood does not enter the lungs in sufficient quantity ; and this may arise
from the weakness ofthe right ventricle, from an obstruction in its mouth,
or from increased resistance on the part of the lungs ; as, for instance,
during sleep, when the respiratory function is less active.
The variety of asthma arising from diseases of the heart comprises, in
Dr. Hope's opinion, by far the greatest proportion of the most severe and
fatal cases. Asthma from disease of the heart often imitates the charac-
ters ofthe other varieties ; and this perhaps for a very simple reason, that
the lungs are in much the same state as in those varieties. Thus, it is
humid or humoral, when there is permanent engorgement of the lungs,
causing copious sero-mucous effusion into the air-passages, as in cases of
contraction of the mitral valve. It is dry, when the engorgement is only
temporary, as in cases of pure hypertrophy. It is continued, when there
is a permanent obstruction to the circulation; and any of the varieties
may be convulsive, when the heart has sufficient power to palpitate vio-
lently. The worst cases of convulsive asthma from disease of the heart are
those of hypertrophy with dilatation and a valvular or aortic obstruction.
Asthma is, in fact, then, it will have been seen, but a symptom, or a
series of symptoms, for a removal of which we must direct our remedies
at the organic cause ; but on these points I refer you to my lectures ante-
cedently on this subject.
404
DISEASES OF THE BLOODVESSELS.
DISEASES OF THE BLOODVESSELS.
LECTURE CXIX.
DR. BELL.
General considerations.—Diseases of the Arteries—Arteritis—Is a rare disease—The
internal memhrane of an artery slow to be inflamed—Divisions of arteritis—General
arteritis doubtful—Anatomical characters—Redness not a reliable sign—The inflam-
matory and the imbibition redness the same—Other changes of tissue with redness,
to indicate inflammation — Symptoms—Aortitis — Its diagnosis difficult—Secondary
symptoms rare in arteritis—The chief ones constitute spontaneous gangrene—Treatment.
—Stoppage, Closure, and Stricture of Arteries—Great extent to which obstruclion
of the arteries may be tolerated—Collateral circulation—Some effects of stricture or ob-
struction of the arteries—Hypertrophy of the heart from stricture of theaorta; cyanosis
from that of the pulmonary artery—Seat of stricture of the aorta—Rupture of the heart
in consequence.—Formation of Semi-cartilaginous Patches and of Atheromatous
Deposits upon and between ^tE Arterial Membranes—Frequency of these changes
in the latter period of life—Origin and growth of semi-cartihginous patches—Athe-
roma, how deposited—ends in ossification of the arteries—Generated between the
inner and middle coats of the artery—Calcareous deposits constitute the so-called
ossification—Age, as it advances, predisposes to this formation.—Dilatation of the
Arteries—Arteriectasis—Aneurism—Its varieties—Origin—Causes gangrene in
contiguous parts—Males more liable than females to aneurism—Relations between
aneurism and other diseases—Dissecting aneurism,—its two varieties.
I was afraid to promise to speak of the Diseases ofthe Circulatory Appa-
ratus, when I began with those ofthe Heart; not being sure that I should
be able to bring up for your notice, at this time, a consideration of the
Diseases of the Bloodvessels. The want of any methodical arrangement
by defect of a general title will, however, be productive of little or no
inconvenience, now that I have determined to complete a sketch of the
entire circle. Though continuous one with another, and jointly contributing
to the one function, the several parts of the circulatory apparatus are, not-
withstanding, endowed with different anatomical structures, and take on
disease after different fashions,—according as this has its seat in the cen-
trifugal or the centripetal vessels, or in the great central organ itself. Thus,
while inflammation of the endocardium is a common disease, that of the
continuous membrane, lining the arteries, is very rare; but yet, again,
phlogosis of that of the veins is quite frequent,—to say nothing of the in-
termediate capillaries, in which various important phenomena, both phy-
siological and morbid, transpire with but little concurrent vital implica-
tion of either arteries or veins.
It would not comport with the limited space left me to discuss, in any
detail, all the morbid changes in the bloodvessels ; and I shall, therefore,
select those only which bear directly on pathology, in connexion with
medicine, leaving the surgical relations of the subject to those within
whose province they properly come. The point of view the most inter-
esting and most practical under which to study the diseases of the blood-
vessels, is when they suffer from inflammation and its consequences. It
is that in which we will now place ourselves.
Diseases of the Arteries, and first of Arteritis.—By arteritis, we
understand inflammation of an artery, whether the phlogosis affects one
or more of the coats of the vessel. This disease is very rare, and is,
ANATOMICAL CHARACTERS OF ARTERITIS. 405
usually, coincident with, or consecutive upon the inflammation of other
organs; and, most frequently, originates from traumatic causes. An
artery is slow to be affected by even destructive inflammation around it,
as in the cases, for example, in which the principal artery of a limb is
laid bare, to some extent, in the midst of diffused phlegmon, and yet,
itself, remains unharmed, though surrounded by suppuration. Arteritis
is sometimes a sequence of the retrocession of exanthematous diseases, and
sometimes of rheumatic affections. But of the extreme slowness with
which the internal membrane of the artery becomes inflamed, we have
strong proofs in the experiments of MM. Trousseau and Rigot, who found
that neither alcohol (of 36 degrees, sp. grav. 0-835), nor dilute nitric acid,
nor putrefying animal substances, determined any inflammatory reaction
in their internal membrane, such a result being only attainable by acrid
substances, like the tincture of cantharides and of euphorbium, employed
by Sosse. The active vital properties of the artery are in the third or
cellular coat; the intermediate or elastic one possessing a very low de-
gree of vitality. In the cellular, accordingly, inflammation readily occurs
when acted on by either chemical, dynamical, or mechanical influences.
Arteritis has been divided into general arteritis, believed to invade a
large portion, if not the whole ofthe arterial system, and into partial arte-
ritis confined to individual trunks and branches ; secondly, into acute and
chronic. With Hasse, however, one may doubt the existence of a gene-
ral inflammation ofthe arteries, in the sense of the distinction just made,
and as alleged by P. Frank to be frequently met with. The raore proba-
ble supposition is, that the phenomena attributed to this cause depend on
a peculiar, very possibly inflammatory, alteration of the blood, causing
the inner surface ofthe vessel to become tinged, probably, after death.
Anatomical Characters.'—When speaking of the anatomical evidences
of endocarditis, it will be remembered that it is very difficult to draw any
definite conclusion from the mere redness of the endocardium, in favour
of there having been antecedent inflammation. All that was said, on that
occasion, applies with full force to the appearances of the inner coat of the
arteries. The red colour seen on opening the arteries is, for the most
part, a cadaveric imbibition, and varies, in its intensity, from a delicate rose
hue to a scarlet and even claret colour, penetrating through the inner
or serous coat. It is most common in the dependent parts in the proxi-
mity to inflamed organs, and wherever, in fine, the blood most abounds.
Even in parts of the vessels which are empty, the redness occasionally
met with may have been caused by blood which had been carried on-
wards by movements imparted to the body, or by the disengagement of
gas. Inflammatory redness does not, it is now well ascertained, differ from
the redness resulting from cadaveric imbibition. To have any diagnostic
value, it must be accompanied by other changes in the tissues, such as
thickening or brittleness, or a rough or villous appearance of the internal
membrane, which adheres, at the same time, more or less closely to a
fibrinous clot. Coagulation of blood in the vessel is, in fact, one of the
effects resulting from vascular inflammation ; but we must not look for it
with any uniformity. The most certain anatomical sign of phlogosis of
an artery is a pseudo-membranous albuminous exudation on the inner
surface of the vessel, which may even be so great as to obstruct the cali-
bre of the smaller vessels. This exudation may take place, also, between
the coats of the vessel, and particularly in the cellular shealh. It is
406
DISEASES OF THE BLOODVESSELS.
difficult, some writers say impossible to detect the exuded matter in in-
flamed arteries, because it is carried away with the stream of blood ; and
it has been suggested that, carried on to the capillary system it induces
changes in it, or if it get beyond this, it will effect a coagulation of
the blood at some ulterior point. In some cases, changes of this nature
have been observed.
Symptoms.—In arteritis, acute pains are felt along the course of the vessel,
which beats with more than its usual force. If the artery be superficial it
forms a kind of cord, knotted, unequal, tense, resisting, and very painful
on pressure. Usually the inflammation extends in the direction of the
course of the blood, or towards the veins, but to this rule there are con-
siderable exceptions. If the vessel should be obstructed by the albumi-
nous exudation, or by the coagulation of the blood, symptoms of a dif-
ferent nature occur, manifesting an interrupted circulation, numbness,
palsy, coldness, and even gangrene of the parts, supplied by the artery.
These extreme effects are prevented, if collateral circulation be brought
about by anastomosis of the branches, above and below the obstruction,
but even then there is diminished bulk and partial atrophy of the part.
Aortitis we may suppose to be productive of symptoms of an alarm-
ing and formidable character; but the diagnosis is still imperfect. The
inflammation is generally confined to the arch, and to the thoracic and
abdominal portion. Intense heat, as of a raging fire in the chest and ab-
domen, coinciding with a small and weak pulse, or, according to some,
great beating of the aorta, and dull and deep-seated pain in the course
of the vessel, and finally, lipothymia, have been enumerated as symp-
toms of this disease. To these we must add, according to M. Bizot,
the rapid supervention of edema. When we meet with anasarca, uncon-
nected with disease of the heart, the pericardium, and the kidneys, we
may suspect inflammation ofthe aorta, with the production of false mem-
branes, and concretions of blood. To the violent pulsations ofthe aorta,
which M. Bouillaud regards as so significant, small value should be
attached. We meet with these quite frequently in hypochondriacal, and
in hysterical subjects. Dr. Corrigan thought that he could trace angina
pectoris to inflammation of the aorta, but, as we have seen, there is no
fixed organic lesion connected with this disease, to which it can be said
to be related as an effect. It is in aortitis more particularly that we meet
with phlegmonous abscesses, studding the vessel in its length.
Secondary symptoms, which play so decided a part in phlebitis, are very
seldom observed to follow arteritis. The only secondary affection of pro-
portionate frequency in this disease is what has been termed spontaneous
gangrene, long known by the term of senile gangrene, a name now ob-
solete, in consequence of its having been satisfactorily proved that the
malady may affect any age, not excepting childhood. Ossification ofthe
arteries is not the proximate, but rather the accidental, remote cause of
spontaneous gangrene.
Treatment.—Antiphlogistic measures, aided by posture, should be early
employed in arteritis. If there be fewer, free and repeated bloodletting,
and leeches along the course ofthe vessel, are prominent remedies, the
effect of which we should aid by compresses wet with a saturnine solution,
or if this be not well borne, with emollient cataplasms, and inunction
with mercurial ointment. Purgatives and other antiphlogistic remedies
should not be forgotten.
STRICTURE OF THE AORTA.
407
Stoppage, Stricture, and Closure of the Arteries.—In adopting
this heading from Hasse, I shall, also, avail myself ofthe illustrative cases
and remarks which he introduces on the occasion. The extent to which
stoppage ofthe course of blood by the arteries may be borne by the living
organism could never have been anticipated by mere reasoning or ana-
logy. Even the sudden tying of the aorta in a dog does not, necessarily,
cause death. Closure ofthe arteries of the head is, likewise, easily borne,
as is amply attested by surgical experience. Thus, Kuhl tied both ofthe
common carotids within a short period of each other, with the most favour-
able result.
Atheromatous changes, though commonly productive of dilatation,
sometimes, in consequence of excessive deposition of calcareous products
between the walls of an artery, constrict if not close the vessel. Atrophy
of the part involved is a common result. On the other hand, in atrophy
there is coarctation ofthe arteries, as a consequence ; and hence, the arte-
ries of members that have been long palsied or are worn out, diminish in
size. The veins do not, necessarily, undergo a similar change. Even
in the cases in which the obliteration of arteries proceeds from degenera-
tion of their membranes, as in those from a ligature, a collateral circula-
tion is established. An instance of the former has occurred where the
aorta has been impervious, and, also, in another case, the coeliac artery ;
and, again, where both carotids had been closed through ossification.
Hypertrophy of the heart, you have been taught, in a preceding lecture,
sometimes proceeds from narrowness of the aorta at its origin ; and,
quite recently, the influence of congenital narrowness or entire obstruc-
tion of the pulmonary artery in giving rise to cyanosis, has been pointed
out to you.
Stricture or closure of the aorta, apparently from arrest of development,
occurs at the mouth of or somewhat below the duct of Botallus, the coats
ofthe vessel manifesting no signs of disease. The constriction is mostly
confined to one point, like that produced by a ligature, the tube there
contracting to the calibre of a goose or crow quill, and presenting a cir-
cular or irregularly cleft shape. " The heart was, for the most part, hy-
pertrophied and dilated, particularly its left ventricle. In four individuals
death ensued from rupture,—once of the right auricle, once of the right
ventricle, and twice of the dilated ascending aorta. In several instances,
dropsical accumulations were observed for a longer or shorter period be-
fore decease. This kind of stricture or obliteration of the aorta occurred
in individuals of various ages, from that of seven to that of ninety-two
years ; thirteen were males, and four females ; several of whom enjoyed
good health to the last, while others previously suffered from a variety of
ailments of the respiratory and circulatory functions, referable, in a great
measure, to hypertrophy of the heart. Two died of tubercular affection
ot the lungs. In several, the above diseased condition of the aorta was
accidentally discovered during dissection." (Hasse.)
Formation of Semi-cartilaginous Patches and of Atheromatous De-
posits upon and between the Arterial Membranes.—These two morbid
changes are, for the most part, associated with each other. In persons who
have passed the meridian of life, a cadaveric examination is rarely made
without some trace of them being discovered. Semi-cartilaginous patches
occur throughout the whole of the arterial system, on the free surface of-
the internal membrane. They, in all probability, originate from a semi-
408
DISEASES OF THE BLOODVESSELS.
fluid, almost gelatinous substance, of a pale-yellowish or reddish colour,
forming a layer, of greater or less extent, upon the inner surface of the
artery ; this is most abundant in the smaller arteries, scanty in the aorta.
We have, in fact, the means of tracing, though not always in the same
individual, the progressive transition from the gelatinous layer to the semi-
cartilaginous patch, proving, almost beyond a doubt, the development of
the latter from the former. These patches undergo hardly any change in
the sequel, appearing only to acquire thickness. They never ossify, con-
trary to what has been affirmed by Andral and others.
Atheroma is deposited by a different process. This substance originates
between the internal or serous, and the middle or elastic membranes;
sometimes between the fibres of the latter. In its ulterior change it de-
stroys first the middle and then the internal membrane, leading, eventu-
ally, to the so-called ossification of the arteries. The incipient signs of
this morbid process are cognisable in small, more or less sharply defined,
roundish patches, of the same yellowish white colour as the artery, only
of a more decided hue. The mass generated between the internal and
middle coats, softens and increases in quantity, occasioning gibbous pro-
minences on the free surface of the arteries. The morbid product is found
in every degree of consistence, from that of a boiled white of egg to that
of pus,—its appearance being, however, generally that of thick pease por-
ridge. Bizot has often detected it in shining particles, like gold dust,
and Cruveilhier like cholesterin scales of certain gall-ducts. These masses,
examined by Gluge under the microscope, have been recognised to be
congeries of fat-globules. With the progress of softening of the morbid
product there is a softening and liquefaction ofthe middle membrane, and
subsequently, a cracking, and, ultimately, destruction, also, of the internal
membrane, leaving the external tunic, and what may remain of the mid-
dle, to hold and transmit the blood.
The substance deposited between the internal and middle membranes
may, however, undergo, instead of softening, the opposite process, namely,
that termed ossification. It is not uncommon, indeed, for a vessel to ex-
hibit, in different parts, the two processes of softening and ossification.
The latter mostly assumes the form of thin and very brittle layers of a
pale-yellow colour. The internal membrane passes over them unchanged ;
sometimes, however, it disappears, so that the stream of blood comes into
immediate contact with the bony plate. This enlarges at the expense ofthe
middle membrane, whose fibres become compressed,more and more attenu-
ated, dried, and atrophic ; or else soften and waste away, owing to a semi-
fluid atheromatous mass deposited beneath the ossification. The bony
scales, although in general adherent to the arterial membranes, sometimes
crack and tear at the centre, favouring an ulcerous disposition ofthe parts,
and projecting, in their partially loosened state, into the cavity of the
vessels. Valentin has shown, from microscopical examination, that the
so-called ossifications differ essentially from true bony substance. He
terms them calcareous deposits. In rare instances, the atheromatous mass
is reduced by absorption, and the ulcers heal. Atheromatous deposits
occur in the small vessels as well as in the larger : but the several types of
the disease, hitherto described, are found chiefly in the posterior surface
of the aorta, and the ulcers, almost exclusively, in the abdominal aorta.
A remarkable observation has been made by Bizot, viz., ofthe symme-
trical occurrence of arterial disease as an absolute law. Thus, the same
ANEURISM OF THE ARTERIES.
409
morbid changes are wont to develop themselves in the corresponding
arteries of both halves of the body at the same point, and in equal degree
and extent.
Sex does not appear to exert any material influence upon these affec-
tions, except that in females they are developed at a later period of life,
and in a minor degree. Age, on the contrary, exerts a decided effect, in
its advance being proportionate to the increase and frequency ofthe mor-
bid vascular changes here noticed. Although not able to appreciate the
cause of the morbid process, we must regard the organic changes depend-
ing on it, as referable to some constitutional condition of the organism.
As the atheromatous deposit is most frequent in the smaller arteries ofthe
leg, the brain and the heart, we are prepared to see, with the increase of
the disease, an obstruction of the canals, gangrene of the lower extremi-
ties, certain forms of cerebral softening, and atrophy of the substance of
the heart.
Dilatation of the Arteries—Arteriectasis—Aneurism.—The pro-
gressive formation of aneurism may be traced to the morbid changes just
described. If the whole circumference of the canal is involved, the soft-
ened parts will give way here and there, and be again partially consoli-
dated, till the aggregate of these several dilatations constitutes one uniform
aneurism, which becomes cylindrical, provided the artery immediately
above and below the dilated portion resumes its former character, hut fusi-
form where the transition from the diseased to the healthy state is gradual.
In this, a true aneurism, the external membrane is not exposed, and does
not form the only covering of the tumour ; remnants of the middle
and internal membrane being still everywhere present. When these
degenerations are not equably distributed around the whole circuit ofthe
canal, but where softening is almost entirely confined to one side, it is
easy to conceive that such gradual extension may lead to the establish-
ment of an extensive pouch, formerly supposed to consist of all the mem-
branes, the thin pellucid false membrane having been mistaken for the
internal coat. The most frequent and generally recognised form is that of
circumscribed spurious aneurism, in which laceration, or destruction ofthe
internal and middle membranes, is followed by sac-like distention of the
filamentous sheath. Rupture never takes place when the inner mem-
branes are in a healthy state.
The observation of Hodgson, that aneurisms always determine gan-
grene in the external skin, or mucous membranes, with which they hap-
pen to come into contact, is corroborated by general experience. Aneu-
rism when left to itself, in most instances proves fatal by rupture : but,
occasionally, it yields to the curative powers of nature. Males are much
more subject to this disease than females, in the proportion of 56 to 7, out
of 63 cases reported by Hodgson ; and of 171 to 18 according to Bizot.
As respects age we find in 108 cases of aneurisrS, that the first one
occurred between the 10th and the 19th years, and two between the 80th
and 89th. The numbers in the intermediate periods, were 15 between
the 10th and 29th ; 35 between the 30th and 39th ; 31 between the 40th
and 49th ; 14 between the 50th and 59th; 8 between the 60th and
69th ; 2 between the 70th and 79th.
The relation between aneurism and other diseases is important. Roki-
tansky relates, that in 108 cases, tubercle coexisted in five only, and then
it was restricted to a small portion of the lung, and either in a state of
410
DISEASES OF THE BLOODVESSELS.
retrogression, or altogether extinct. Between cancer and aneurism, there
is an affinity. The aneurismal diathesis is never extinguished ; frequently
most of the arteries are assailed in turn ; and when from some cause or
other, one aneurism dwindles away, a new one immediately forms, either
in the same artery, or in a remote one. Frequently too, the aspect ofthe
patient, and the decay of the organism, bear the impress of cancerous
cachexia.
Dissecting aneurism has been examined by Rokitansky under the name
of spontaneous rupture of the aorta. He distinguishes two varieties of these
spontaneous ruptures. The first originating in an affection analogous to
chronic inflammation in the cellular membrane ; separation of the latter
being the first effect; rupture of the internal and middle membranes the
second. In the other variety the cellular coat may be quite sound, but
the internal and middle membranes are necessarily diseased. Here the
morbid process begins with a solution of continuity in the latter membranes,
the parting of the cellular coat through the force of the sanguineous stream
being secondary. The accident of rupture occurred in the several cases
without previous violent exertion or undue excitement of the circulation—
often in bed, on awaking, &c. Great narrowness ofthe aortal calibre, co-
arctation at the origin ofthe arteries given off, and a thinness of the mem-
branes, seem to be the principal predisposing causes. Out of 15 cases, 8
occurred in males, 7 in females.
LECTURE CXX.
DR. BELL.
Aneurism of the Aorta—Double importance of a correct diagnosis of this disease—
External Appearances—Appearance of the veins of the chest and upper extremity-
Want of movement of the thoracic parietes—Increased expansive movement—Ana-
sarca—General symptoms—Dyspnoea, orthopneea, alteration of the voice, cough, pain,
dysphagia, variations in the pulse—The physical signs are dulness over the sternum and
pain on percussion—A bellows sound and sometimes a rasping sound—The common
respiratory murmur is lost—Attitude ofthe patient—Case—Treatment—Antiphlogistic
remedies—Rest and regimen.—Heterologous Formations in the Circulatory Organs
—These hardly ever occur in the arteries; are found in the veins.—Diseases of the
Veins—Phlebitis—Services rendered to medicine by pathological anatomy in the
instance of phlebitis—Readiness of the veins to be inflamed—Phlebitis, local and
general—Anatomical changes—Alteration in the coats of the vein—Formation of pus—
Sequestration of diseased portions of the vein—Is pus formed by secretion from the
vein or by metamorphosis of the blood itself?—The puriform fluid asserted by Gulliver
to consist of liquefied fibrin—Progress and termination—Coagulation of blood by pus—
Polypi cordis—Organic changes in the capillary system—Lobular inflammation and
lobular abscesses—How is the purulent transformation of the orcrans brought about 1—
Causes—Mainly physi^l—Symptoms—Local and general—Local symptoms—changes
in the vein and contiguous parts—General symptoms, those of constitutional disturb-
ance—Period of infection—Its phenomena—Treatment—In first period, antiphlogistic
—In second or that of infection little can be done—Uterine Phlebitis—Its chief features
—Phlegmasia Dolens—Its pathology and treatment.-—Phlebectiasis—Dilatation of
the Veins—Varicose veins—Three varieties—Hereditary predisposition—Ages at
which these chiefly occur—Phlebolithes—Hemorrhoids of the bladder.
Aneurism of the Aorta.—The most interesting, in a medical point of view,
among the aneurismsof the arterial system is that ofthe aorta. The symptoms
and diagnosis of its diseased state are doubly valuable; first, by enabling us to
ANEURISM OF THE AORTA.
411
ascertain the presence of a formidable malady and thus to direct remedial
measures which, though they be of a negative character, may prolong life ;
and secondly, by preventing needless if not hurtful therapeia, under a notion
of the morbid phenomena being the result of an affection of some other
part—the heart, lungs, digestive system, or even brain. One of the fullest
attempts to reach a satisfactory conclusion in this matter is found in the
"Researches on the Symptoms and Diagnosis of the Aorta," byGeorge
Greene, M.D., edited by Dr. Gordon, and published in the Dublin .Quar-
terly Journal of Medical Science for July, 1846—but not completed.
We may mention in advance that the most frequent seat of aneurism of
the aorta is in the thoracic portion and in the aorta ascendens near the arch.
That ofthe abdominal portion is usually near the cceliac branch. It can-
not be denied that many aortic aneurisms though of considerable size remain
latent, as far as symptoms are concerned, until atthe very moment of rup-
ture and sudden extinction of life.
In proceeding to a"review of the symptoms, we begin with some ex-
ternal appearances. In aneurism of the arch, we meet in many instan-
ces (eight out of twelve) with a peculiar knotty or congested state of
the veins, either of one or both upper extremities, or of the superficial
veins of the chest, appearances indicative of pressure on some internal
vascular trunk. In some cases the veins were so turgid as to resem-
ble hard cords, and pressure did not obliterate them. The colour was in
general blue, but in one case it had assumed a darker or purplish hue.
Bleeding did not notably diminish the tension of these veins, and the flow
of blood from them was not always readily stopped. The stasis of blood
has been found to be so great in some cases that its temperature has sensi-
bly diminished, and a separation of the fibrin has taken place during life
within the vessels. The movements of the thoracic parietes undergo im-
portant modifications in cases of intra-thoracic tumour, as in aneurism of
the arch ofthe aorta. The phenomenon most usually observed is non-ex-
pansion of one side ofthe chest, in ordinary or during forced inspiration ;
and depends on pressure on the corresponding bronchia. When the tra-
chea itself is compressed, and when the sac is large, the upper third of the
entire chest exhibits a comparative immobility in the act of respiration, and
abdominal respiration is strongly marked during the paroxysms of dyspnoea.
A feature of an opposite nature attends the disease, viz., an abnormal
movement which, though sometimes very slight, can be discovered very
early in the disease. It consists of a diffused expansive motion percepti-
ble under the upper portion of the sternum, or above or below the clavi-
cles: it is sometimes accompanied by a distant shock or impulse. This
symptom may be made more evident by making the patient walk for a
short time, so as moderately to excite the circulation without rendering the
respiration tumultuous ; and then when he stands and holds his breath, to
run the eye across the infra and supra-clavicular regions, and over the su-
perior portions ofthe sternum. A forward movement, arising from a force
in the interior distinct from that ofthe heart, is then clearly perceived.
Serous infiltration of one ofthe upper extremities frequently follows the
pressure of aneurismal tumour, and appears after the turgescent state of
the veins has existed for some time. The sarae appearance may exist
in both upper extremities, and even in the lower, when the disease has
lasted a long time, or when the sac is large, and the constitutional disturb-
ance severe. As anasarca also ensues in valvular disease, the safest
general rule is, that in valvular disease partial anasarca is rare, and in
412
DISEASES OF THE BLOODVESSELS.
aneurism common. Except in the pericardium there are seldom serous
effusions into the serous cavities. Coma from effusion into the ventricles
ofthe brain is not uncommon, however, in aneurisms of the arch.
The general symptoms are, first, dyspnoea. This exists in greater or
less severity, in all the cases. It comes on gradually, is progressively
increased, and finally ends in orthopncea. It is chiefly at night, that the
patient is roused from sleep, in all the terrors of impending suffocation.
Lying on the back either induces a paroxysm, or increases its violence.
Even attempts at deglutition will sometimes bring on a paroxysm. The
dyspnoea seems to be independent of atmospherical changes ; and in the
duration of its attack, does not exceed a period of two hours. A stridu-
lous sound heard during inspiration, occurred in eight of the twelve cases,
analysed by Dr. Greene, sometimes in ordinary but more frequently dur-
ing forced respiration. The inspiration is prolonged, and the sound gene-
rally raucous and deep-toned. The difficulty of breathing is mostly re-
ferred to the inferior part of the trachea. Both dyspnoea and stridulous
breathing diminish in intensity, after free venesection, or spontaneous
hemorrhage, if the patient survives it. The voice was modified in six cases:
its general character was that of hoarseness, but it was occasionally
shrill, clangose, whispering and interrupted. Dr. Greene never saw
aphonia from an aneurism of the arch. The causes of these various
modifications of voice, may be arranged under the heads of alteration in
the capacity or torsion of the air-tubes, compression or obliteration ofthe
recurrent nerves, and edema ofthe glottis. Cough was present in all the
twelve cases, and very similar in character in each, viz., loud, ringing,
paroxysmal, and occasionally dry. The paroxysm varies in duration: it
is generally long and suffocative. In many cases the cough and dys-
pnoea appeared simultaneously, and the former remained for a consider-
able time harsh and dry.
The nature and severity ofthe pain complained of varied considerably.
In most instances, however, it is that kind, which is indicative of irrita-
tion of the nerves ; and as such, it is lancinating, burning or terebrating;
at times appearing to originate in the centre of the chest, and to radiate
towards the circumference, at others, to shoot along the trachea, and
neck, or towards the shoulders and upper extremities; in some cases it is
accompanied by painful palpitations of the heart, and a sense of constric-
tion about the chest; but not by any prominent acceleration of pulse, or
other symptoms of fever. This pain is intermittent, is independent of at-
mospherical changes, and is much relieved by anodynes, especially bella-
donna, exhibited both internally and externally. There would appear to
be a connexion between this pain, and some irritation at the roots of the
sensitive nerves of the spinal cord : and this last again may, in some
cases at any rate, be referred to erosion of the vertebra?, by pressure of
the aneurismal sac. In several of the cases, pain of a decidedly inflam-
matory character made its appearance, and was accompanied by hardness
and acceleration of the pulse, with thirst, and other symptoms of fever,
which cupping and bleeding relieved. This was caused by an intercur-
rent pleurisy, or pneumonia, as was obvious from the stitch complained
of in the side, and the existence of crepitus in the lung. In nine out of
twelve cases, dysphagia existed, and it may be regarded as one of the
concomitant symptoms of aneurism of the arch of the aorta. The dyspha-
gia is subject to variation, being more marked in one day than another;
it may also disappear altogether before death.
TREATMENT OF ANEURISM OF THE AORTA. 413
The phenomena exhibited by the pulse are : 1. Weakness of the pulse
in one or both wrists, in comparison with the impulse of the heart; 2.
The pulse at the wrist later than the impulse of the heart; 3. Absence of
the pulse ; 4. Visible pulsation of the radial artery. A strongly marked
visible pulsation in the radial artery was observed by Dr. Greene in his
eleventh case, but the aortic orifice was patulous. Dr. Corrigan has
shown the value of this symptom in the lesion last named.
The following is the order of frequency.of the general symptoms ob-
served in Dr. Greene's cases, viz., dyspnoea and orthopncea, paroxysmal
cough, terebrating pains, dysphagia, modifications in the pulse, and modi-
fications in the voice.
If recourse be had to a study of the physical signs for diagnosis, we
discover, on percussion, a dull sound more or less strongly marked under
the upper half ofthe sternum, or at either side of that bone, and the pro-
duction of pain by this act; on auscultation, a bellows sound is heard
over the aneurismal sac, or at the upper third of the sternum, even in
cases in which there was no complication of valvular disease ofthe heart.
The interposition of a small portion of the lung, between the sac and the
parietes ofthe chest, will interfere with the results of percussion, particu-
larly if the lung be emphysematous, when an abnormal clear sound will
be produced. In cases where the bellows sound was soft, the opening
of the sac was smooth and round, and where a rasping sound existed,
apparently in the situation of the sac, the valves of the heart were dis-
eased and rigid, and the aorta contained morbid deposits. The common
respiratory murmur is lost when the tumour reaches the sternum. The
hand placed over this bone receives also the shock of the impulse com-
municated by the beating ofthe aneurismal tumour.
The attitude of the patient labouring under aortic aneurism is often
peculiar. He is seated in bed or on a chair with his body bent forwards.
I have witnessed a case of this kind in which the patient could not take
any other posture. It is true that he referred all his agonising pains, under
which he suffered, to his abdomen. After death we found large coagula
of blood that had come from ruptures of the thoracic aorta, and found their
way down between the crura ofthe diaphragm into the cavity of the peri-
toneum, and filled almost the left iliac region. It is worthy of notice,
however, that precisely the same symptoms,—attitude and pain, with
obstinate constipation, had been experienced by this patient twenty months
before. From all these he was relieved by what I deemed an appropriate
treatment; but without any suspicion of his having aortic aneurism. The
sac was adherent to the ninth and tenth dorsal vertebras, which were de-
nuded, and in part removed by absorption.
Treatment.—Although cures of aneurism of the aorta have been reported,
as the three mentioned by MM. Dusal and Legroux, our prognosis is deci-
dedly unfavourable in this disease; and the most we can generally hope for,
is to palliate the symptoms and suspend the progress ofthe aneurism. With
this view bloodletting sometimes to a great extent has been practised:
but as Dr. Hope has remarked, this is attended by a more hurried circu-
lation and increase in violence of the pulsations of the tumour. It will,
therefore, be more prudent, as was recommended in hypertrophy of the
heart, to have recourse to small and repeated bleedings, and to act on the
bowels with purgatives, while the action of the heart is still farther kept
down, and the tendency to the formation of coagula increased by digi-
414
DISEASES OF THE BLOODVESSELS.
talis. To meet the same indication, sugar of lead, in doses of from two,
three, and even seven grains, has been given with marked benefit.
Dupuytren carried the quantity as high as a drachm in the course of the
day ; and directed, at the same time, compresses wet with Goulard's
extract to be constantly applied on the aneurismal tumour, if it was per-
ceptible, or over the region of the heart.
The patient should be enjoined repose both of body and mind, and
restriction to a simple regimen. Moderate use of even the blandest drinks
is desirable so as to prevent the bloodvessels from being distended by
this means. But while trying to prevent, and, if it is present, to remove
any undue excitement, we must also keep the patient clear of anemia, the
irritable circulation in which could not fail to be injurious. Under such
circumstances an analeptic regimen, and the moderate use of chalybeates,
should be counselled.
Heterologous Formations in the Circulatory Organs.—The con-
sideration of these need not detain us long. The organs of circulation
are only for the most part secondarily diseased, and then less frequently by
far than other parts. No well-authenticated example is known of arterial
membranes being the seat of heterologous growths. It is otherwise with
the veins, which, though alike exempt from tubercle and atheroma, are
obnoxious in divers ways to fungous growths. " The veins may become
diseased in three distinct modes: first, by the development of fungous
and other growths between their membranes, either as the primary mani-
festation of an incipient morbid tendency, or the secondary one of a con-
firmed dycrasy, which has already shown itself elsewhere. Secondly,
by the proximity of carcinomatous tumours, which coalesce with, com-
press, and obliterate them, or else produce thickening, or softening, and
in certain instances, perforation of their membranes. Lastly, fungous
growths may penetrate into the channel of veins, where they evince a
tendency to advance in the direction ofthe heart, and to occupy its cavi-
ties."—(Hasse.)
Diseases of the Veins—Phlebitis—Inflammation of the Veins.—It
has been justly observed by Hasse, that no subject more amply illustrates
the essentia] services which the science and art of medicine have derived
from pathological anatomy, than that of phlebitis. By this study many an
obscure point in the phenomena of disease has been either thoroughly
elucidated, or at all events, rendered more comprehensible. We need
only refer to the so-termed malignant intermittents consequent upon
wounds and surgical operations—to certain typhoid conditions, puerperal
diseases, and the like.
The veins, owing probably to their double function, as vessels of
return and of absorption, as also to the protracted sojourn of their con-
tents at any one point, are more prone to inflammation than any system of
vessels. They may participate in the inflammation of organs or parts of
the body which they traverse, or become inflamed by irritating substances,
coming in immediate contact with their internal or external surface. The
internal membrane of the veins reacts, we are told, upon the application
of irritating substances, almost as quickly and intensely as the common
serous membranes. In this reaction we must suppose that the vascular
substratum plays the principal part; the lining membrane yielding merely
to the alternations of endosmosis and exosmosis, and not suffering any-
organic change until a later period. It is worthy of remark, that the
ANATOMICAL CHANGES IN PHLEBITIS.
415
veins which consist exclusively of a single, the internal membrane, like
the corpora spongiosa, are very rarely, and never extensively the seat of
true inflammation.
The study of phlebitis resolves itself into two heads ; the one restricted
to the consideration of the purely local, primary phenomena, the other to
the general, secondary consequences, diffused throughout the whole sys-
tem. First, let us observe the anatomical changes in an inflamed vein.
It is reddened internally and externally; and as the disease gains ground,
the parts become irregularly spotted, marbled, occasionally streaked, and,
at length, display every variety of shade, from the natural colour to a dirty
violet, on the one hand,—to a deep scarlet, on the other. There is inci-
pient infiltration of a faint-red serous'fluid, together with a dense network
of delicate little vessels. The coat of the vessel is thicker than common :
it is rough and unequal ; and it is lined by a fibrinous deposit, constitut-
ing a false membrane, at first connected with the internal membrane of
the vein by means of a tenacious mucus-like substance, which, after-
wards, is replaced by adherent cellular tissue. These fibrinous deposits
may go on increasing so as to fill up entirely the venous canal. With
this formation there ensues a loss of smoothness and polish in the internal
membrane, which assumes a dull, velvety, or slightly puckered appear-
ance. The external membrane, at the same time, appears thickened and
turgid, and soon becomes adherent to the cellular tissue, which in its turn
has become firmer and paler from the effusion of plastic lymph. Both
membranes are now easily torn. In this state of things the vein, when
cut asunder, does not collapse, even after the plug of deposited fibrinous
matter or coagulated blood has been removed, but remains open like an
artery.
If the disease continues, so that suppurative phlebitis has set in,, the
plug becomes softer, especially towards its middle ; it assumes a grey-
ish, yellowish-white, dotted appearance, and, finally, exhibits a straw
colour, and a semi-fluid consistence ; and is, finally, resolved into pus,
which is usually confined within a fibrinous layer raore or less thin, and
rarely found loose within the vein. But the contents of the vein being
unceasingly propelled towards the heart, the more or less solid products
are necessarily conveyed beyond the original site of inflammation. An
obstacle to the product of inflamraation passing along with the venous
current is derived from the tendency of pus when mingling with the blood
to cause its coagulation ; and hence, the pus becomes isolated by the coa-
gulation of blood, both above and below the place of its formation, and
is thus cut off from the remainder of the blood. Cruveilhier calls this the
sequestration of veins. The pus, under these circumstances, may be gra-
dually removed by the process of absorption, the vein becoming, in the
mean time, obliterated ; or it may make for itself an outlet through the
parietes of the vein. These abscesses, varying in size and number ac-
cording to the amount of inflammation, form beneath the skin, or between
the muscles, and the patient is thus protected against the dangerous con-
sequences of a general infection of the circulatory fluid. The membranes
ofthe veins are all changed at this time : their colour is a greyish-white ;
they become softened and thickened ; are no longer to be distinguished
from one another ; and they form, in conjunction with the surrounding
textures, a nearly uniform membranous layer, of a lardaceous aspect and
character.
416
DISEASES OF THE BLOODVESSELS.
It is a question still unsettled, whether the pus found in the veins be
the result of secretion from the inflamed surfaces, or of direct metamor-
phosis of the blood itself. Experiments, microscopical examinations, and
analogy, have been pressed in favour of each of the two sides of the ques-
tion ; these I shall not repeat here. Gulliver maintains that the puriform
fluid in veins contains no pus-globules, but consists merely of liquefied
fibrin.
Phlebitis varies in its extent; sometimes extending the whole length of
a vein, sometimes only an inch or two inches : it may be even restricted
to one side ofthe vessel.
Progress and Termination. — The organic changes, which are to be
viewed as the results ofthe morbid condition ofthe blood, display them-
selves in every variety of organ throughout the whole body. They are
all referable to stagnation of the blood, and are divisible into such as oc-
casion a stagnation and interruption ofthe sanguineous current in the cen-
tral portions of the vascular system, and such as have their seat in the
capillary system alone. The coagulation of the blood, consequent on phle-
bitis, has been observed most frequently in the pulmonary artery and its
branches. Coagulation of blood in the pulmonary arteries has been ob-
served in puerperal phlebitis by Dr. Robert Lee, and by Hasse in phle-
bitis consequent upon uterine carcinoma. In other rarer cases, similar
coagulation occurs in the right cavities of the heart. Extensive polypi
cordis, as they are commonly termed, are then found, of a greyish or pale
violet colour, and displaying, more or less, a stratiform and fibrinous
structure ; internally they are, sometimes, found considerably softened,
and, occasionally, even containing liquid pus. Externally they inter-
twine in various ways with the columncb carnece and with the valves of
the heart, being overspread with coagulated, black, and grey spotted
blood, or marbled with purulent streaks.
Organic changes in the capillary system constitute a most important
sequel to phlebitis. These have been designated by the appellations of
"lobular inflammations" and " lobular abscesses;" and they are of most
frequent occurrence in the lungs and in the liver. Peritonitis is an ex-
ception to the little proneness of serous membranes to this puriform effu-
sion.
Pathologists have been divided in opinion as to whether the pus formed
in the veins at the part originally inflamed, be substantively transmitted
through the medium of the circulating current to the lungs, the liver, &c,
to accumulate within certain points of the latter ; or whether it be actually
generated in the parenchyma of these organs. The latter view is now
the prevalent one, but in a modified shape, which does not exclude the
primary agency of pus formed in an inflamed vein, and serving as a cause
of stagnation, and an exciter, as it were, of purulent formations in distant
organs. The explanation of what does occur is in this fashion. The pus
is conveyed in substance by the veins to the heart, and forwarded thence ;
but those pus-globules which have reached the capillaries of the lungs
in their entire state, are unable, from their size, to permeate the latter
organs. These globules now become a central point of stagnation, and,
finally, of extravasation, in the adjacent branches ofthe pulmonary artery,
and thus determine, eventually, local inflammation and suppuration. In
like manner are accounted for, abscesses of the liver, in consequence of
inflammation within the tract of the portal system.
CAUSES AND SYMPTOMS OF PHLEBITIS. 417
Phlebitis may originate from rheumatic affections. It may, also, be
developed under epidemic influence, and, in this respect, be nearly allied
to erysipelas. Inflamraation of the umbilical vein in new-born infants
merits attention. The symptoras during life are jaundice, vomiting,
diarrhoea, and erysipelatous inflammation surrounding the umbilicus.
After death, all the signs of inflammation have been discovered in the
umbilical vein, extending, occasionally, to the vena portse and to the he-
patic veins ; but without the liver itself being implicated.
Causes.—Phlebitis is rarely idiopathic, but most generally it is owing
to physical causes. Thus, phlebitis of the limbs proceeds from external
violence, contusion or laceration of a vein, or puncture with a rusty or un-
clean instrument, as in venesection or in dissecting, also after amputations.
In fact it may occur after all great surgical operations and extensive sores,
whenever there is extensive suppuration in the neighbourhood of veins that
remain patulous when wounded, "either owing to anatomical situation, as in
the instance of the veins of the diploe, of the axillary veins, of those within
the uterus, within the liver, &c, or to some morbid change of structure
consequent upon inflammation, varicose distention and the like, or lastly
to the surrounding cellular tissue thickening, assuming a lardaceous cha-
racter, and thereby keeping the parietes of the veins upon the stretch.
This is the reason why phlebitis is so frequent and so fraught with danger
after wounds of the head, and after the operation of lithotomy ; and also
why phlebitis artificially induced, for the purpose of obliterating varicose
distentions, so readily spreads to an alarming extent when once it gets be-
yond the adhesive stage."
Symptoms.—These are local and general. The inflamed vein is the
seat of pain in a greater or less degree. If the vessel be superficial we
can feel a hard cord, of a red colour and unequal surface ; if deeper seated,
we only feel a kind of distention with some resistance, which corresponds
with the course ofthe vein, and ofthe pain to the patient. The diseased
part is with difficulty moved, and there is, if the vein be of any considera-
ble size, edema proportionate to the interruption ofthe circulation. To
these local symptoms are joined, afterwards, general uneasiness, headache,
want of appetite, thirst and febrile reaction, which may be either continued
or remittent. The inflammation may be limited to a particular region ;
but more commonly it extends to new parts following the course of the
blood in the veins, that is towards the heart; although sometimes it takes
a different direction and implicates the ramifications of the vein first
affected. After a few days, when the blood has become altered by the
purulent matter, new symptoms arise, which constitute the second period
of the disease or that of infection.
The patient now experiences chills at irregular intervals, but sometimes
recurring periodically, and followed by a dry and hot skin and often co-
pious sweats : he is agitated, tormented by fantastic imagery ; his ideas
are somewhat confused, and at last continued delirium sets in. The face
is shrunk, pale or of an earthy hue, and yellow ; the features indicate apa-
thy and loss of intellect; the eyes are encircled with a blue streak; the
tongue is dry and dark and trembling ; there is often a fetid diarrhoea ;
the pulse is small and weak and the strength entirely gone. In this period
we see break out in different parts of the body, such as the cellular tissue,
or in the thickness of the muscles, those abscesses already spoken of. In
some,jaundice supervenes,and coincides with lobular abscesses ofthe liver.
vol. n.—2H
418
DISEASES OF THE BLOODVESSELS.
Others complain grievously of violent terebrating pains in the joints, which
are now most generally filled with pus, while, again, others are attacked
with acute pleurisy, or are taken with a dry cough, oppression, and dys-
pnoea ; symptoms referable to the formation of lobular abscess in the lungs.
Under an aggravation ofthe disease by these lesions, the patient sinks at
the end of the third week. If the issue is to be favourable, there is a
gradual diminution of the local and general symptoms before the coming
on of the period of infection.
Varieties of Phlebitis.—Although the constitutional symptoms of phle-
bitis are the same, wherever may have been its seat, yet there are some clif-r,
ferences in the local symptoms. Those previously described were applicable
to phlebitis of the limbs ; but in inflammation of the splanchnic veins,
such as ofthe vena cava, vena portae, the iliac, the hypogastric, &c, the
local symptoms are wanting. Still, if these veins be entirely obstructed,
we may expect to see serous effusion in the limbs, the parietes of the trunk
or in the abdominal cavity, symptoms which taken in connexion with the
general ones of infection will enable us to diagnosticate the nature and
even seat ofthe disease.
Uterine or Puerperal Phlebitis—Metro-Phlebitis Puerperalis.—I spoke
of this disease incidentally, in connexion with puerperal peritonitis, of
which it constitutes often so important and alarming a feature, but without
giving at the time any anatomical details. It would be difficult to indi-
cate with equal brevity and terseness of phrase the prominent changes of
structure as is done by Hasse. I shall, therefore, let him speak for us on
the present occasion. " It is hardly possible to decide whether, in puer-
peral diseases,* septical influences co-operate, or whether the same causes
alone prevail as in simple wounds and injuries, with a disturbed and im-
perfect process of suppuration. At all events, puerperal phlebitis is one of
the most frequent varieties. It develops itself with uncommon rapidity
whenever, after expulsion of the foetus and of the placenta, the uterus does
not contract properly, so that an extensive raw surface with open-mouthed
veins is exposed.f In such cases the internal, spermatic, and a large por-
tion of the branches of the hypogastric veins, sometimes of both sides, but
more commonly of one side only, exhibits various stages of inflammation ;
and, whenever the inflamed parts are not partitioned from the great trunks
by means of the adhesive process, all the consequences before described
of general infection of the blood ensue. The venous sinuses in the sub-
stance of the uterus are distinctly distended with pus, sometimes fluid,
sometimes as if coagulated, and then adhering more or less firmly to the
parietes ofthe vessels, winding through every sinuosity and ramification,
and, when removed, readily liquefying or yielding to pressure. In many
cases these pus-conduits, appearing like little abscesses, are exposed by
every incision into the uterus ; frequently, however, more careful exami-
nation isoiecessary for detecting the source of suppuration. That nothing
may be overlooked, it is necessary to devote particular attention not only
to the locality where the placenta had been attached, but likewise to the
convolutions of veins which lead towards the cervix uteri. The branches
• R. Lee, m d. (Researches on the Pathology, &c, of the Diseases of Women [also
Lectures on the Theory and Practice of Midwifery]); Th. Helm (Uber Puerperal-Kran-
kheiten, 1839) ; Kiwisch (die Krankheiten der VVochnerinnen, 1840).
f Dance showed that fluids, injected into the vena cava inferior, penetrated with per-
fect ease into the uterine cavity, through that portion to which the placenta had adhered.
TREATMENT OF PHLEBITIS.
419
of the internal spermatic and of the hypogastric veins usually contain
grumous, soft, coagulated blood, speckled with greyish and yellowish
Jots,—or a firm plug consisting of concentric layers, or else more or less
fluid pus.' The substance of the uterus, according to the degree and
duration of the affection, is either slightly infiltrated with serum about the
venous sinuses only, and otherwise healthy, or it is inflamed and softened,
or in a state of putrescence. In more extensive disease we find the ovaries
inflamed, with abscesses in their interior. The lymphatics are frequently
involved, and filled with pus. In most instances there is concomitant pe-
ritonitis in various grades.of intensity."
Uterine phlebitis, within the observation of Dr. R. Lee, is most frequently
met with where inflammation of the uterus has appeared to be excited by
the contaminated air of a hospital, contagion and erysipelas. The blood
in this disease exhibits all the appearances belonging to hyperinosis; the
clot large, consistent and tenacious; the surface covered with a thin true
buffy coat, or more frequently with a rather thick buffy, often discoloured
stratum of gelatinous substance, forming what is called a false buffy coat.
Gelatinous coagula, of a similar nature, were also frequently seen floating
in the serum. Pus is often detected in the blood by the microscope, during
the course ofthe disease. The urine in metro-phlebitis is often dark-co-
loured, and deposits a dirty yellow sediment which appeared to the naked
eye to be purulent, but which was shown, by the microscope, to consist of
an immense number of mucus granules, of a few crystals of ammoniaco-
magnesian phosphate, and of an amorphous precipitate of phosphate of
lime and urate of ammonia.
Phlebitis ofthe Cerebral Sinuses.—This, anatomically considered, closely
resembles ordinary phlebitis. The same layers of fibrin fill the sinuses
and adhere to their parietes ; the same soft masses of coagula, speckled
with grey and of true pus, are discovered. The coagulation of the blood
extends in the same manner to the branches of the veins, and to the ves-
sels ofthe brain and its membranes. The inflammation and its products
proceed towards the trunks, and finally, through the jugular vein to the
heart. Commonly the sinuses of one side only are affected, even though
the longitudinal sinus may be implicated. The brain suffers by serous infil-
tration of its meninges, apoplectic ruptures and effusions and red softening,
—lesions which give rise to headache, somnolence, coma, convulsions,
palsy, &c. The causes of phlebitis ofthe sinuses show it to be mostly a
secondary affection : they are, jugular phlebitis, purulent exudation in the
arachnoid, caries of the cranial bones, suppressed porrigo, scrofulous ulce-
rations of the occiput,cerebral softening, and irritations caused by splinters
of fractured bones of the skull.
Treatment of Phlebitis.—In the first period the treatment should be
actively antiphlogistic, consisting of free and repeated bloodletting, if the
pulse be strong and the febrile reaction considerable. Purging and its
concomitants will, also, be had recourse to. When the vein is superficial,
leeches should be freely applied on it, and along the line of inflammation.
Cold or emollient applications according to the sensations of the patients
should also be made; frequent immersion of the part in tepid water will
be advisable. Inunction with mercurial ointment is also recommended ;
* Compare figure in Cruveilhier, livr. iv. pi. vi. (copied in Froriep's Klinische Kup-
fertafeln [clinical plates], plate xxvi.), and livr. xiii. pi. i. ii. iii.
420
DISEASES OF THE BLOODVESSELS.
but the remedy in which, from the strong recommendation and example
of Dr. Physick, American physicians and surgeons place the most confi-
dence is a blister applied directly over the inflamed vein, especially where
the disease has been caused by bleeding. If there be any evidence, as
by fluctuation at a particular point, of pus having been formed, a trans-
verse incision should be made so as to give issue to the purulent matter
and prevent its being introduced into the circulation. Compression of the
vein beyond the limits ofthe inflammation on the side towards the heart,
so as to cause adhesion of its walls or the formation of a coagulum, has also
been practised successfully in some cases, with a view of preventing the
transmission ofthe purulent matter to the heart. In some cases, however,
notwithstanding all the care taken in this way, the blood becomes infected
by the pus brought by the collateral or anastomosing veins. When the
symptoms of infection are evident, there is little hope for the patient by
any remedy or mode of treatment that may be attempted.
Crural Phlebitis—Phlegmasia Alba Dolens.—This disease might pro-
perly have been described among the varieties of phlebitis, although by
some it is still regarded as resulting from angioleucitis or inflammation of
the lymphatics, and by others classed under the head of dropsy, as painful
edema of lying-in women. Of its being the result of milk metastasis, few
attach importance to such a belief at the present time. In reference to the
etiology of this disease, it must not be forgotten that it has occurred in
females not in child-bed and even in males. Drs. Davis and Lee have
led the way to a more correct understanding of the pathology of this
disease, in which they have been followed by MM. Duges, Velpeau, Bouil-
laud and Boudant. Dr. Lee showed by cases and dissections, that crural
phlebitis is not peculiar to women who have been recently delivered, but
that it may also arise from suppressed menstruation, malignant ulceration
ofthe os and cervix uteri, polypus of the uterus, and other organic dis-
eases of the uterine organs. Cases are related by Dr. L. in which crural
phlebitis occurred in the male sex, and where the disease commenced
either in the hemorrhoidal, vesical, or in some of the other branches of
the internal iliac veins, in consequence of inflammation or organic changes
of structure in one or more ofthe pelvic viscera, or in the superficial veins
ofthe legs, which extended upwards and involved the great venous trunks
of the thighs and pelvis. In completely developed phlegmasia dolens,
with edema and tumefaction, not only the saphena but likewise the deep-
seated veins are inflamed and obstructed.
Anaifomical Characters.—These are various. Purulent collections have
been found disseminated in the sub-cutaneous cellular tissue and between
the layers of muscles ofthe inferior extremity ; in other cases the inguinal
lymphatic glands are swelled, softened and even suppurated ; and the
lymphatic vessels have been found swelled and containing phlegmonous
or reddish pus, which latter has been seen even in the thoracic duct.
The crural veins and their deeper seated branches and also the iliac and
hypogastric ones have been, also, in many cases filled with coagula or pus.
M. Velpeau has seen the symphyses ofthe pelvis inflamed and full of pus,
and their cartilages softened. Frequently in the same subject these various
lesions are met with.
Symptoms.—These cannot be conveyed in better terms than in the fol-
lowing extract from Dr. Lee's " Treatise on Puerperal Fever and Crural
SYMPTOMS OF CRURAL PHLEBITIS.
421
Phlebitis, Chap. V., Sect. 1 ; and, also, in his Lectures on Midwifery,
pp. 523-5, Am. Edit.
" In seven of the twenty-two cases of puerperal crural phlebitis which
I have observed, the disease has commenced between the fourth and
twelfth days after delivery, and in the remaining fifteen, it appeared sub-
sequent to the end of the second week after parturition. In most of the
patients there was either an attack of uterine inflammation in the interval
between delivery and the commencement ofthe swelling in the lower ex-
tremity, or there were certain symptoms present, which I have before de-
scribed as characteristic of venous inflammation, viz., rigors, headache,
prostration of strength, a small, rapid pulse, nausea, loaded tongue, and
thirst.
" The sense of pain at first experienced in the uterine region has after-
wards been chiefly felt along the brim ofthe pelvis, in the direction ofthe
iliac veins, and has been succeeded by tension and swelling of the part.
After an interval of one or more days, the painful tumefaction of the iliac
and inguinal regions has extended along the course of the crural vessels,
under Poupart's ligament, to the upper part of the thigh, and has de-
scended from thence in the direction ofthe great bloodvessels to the ham.
Pressure along the course of the iliac and femoral vessels has never failed
to aggravate the pain, and in no other part of the limb has pressure pro-
duced much uneasiness. There has generally been a sensible fulness per-
ceptible above Poupart's ligament before any tenderness has been expe-
rienced along the course of the femoral vessels ; and in every case, at the
commencement ofthe attack, I have been able to trace the femoral vein pro-
ceeding down the thigh like a hard cord, which rolled under the fingers.
" A considerable swelling of the limb, commencing in the thigh and
gradually descending to the ham, has generally taken place in the course
of two or three days, and in some cases immediately after the pain has
been experienced in the groin. In other cases the swelling has been first
observed in the ham or calf of the leg, and has spread from these parts
upward and downward until the whole extremity has become greatly
enlarged. The integuments have then become tense, elastic, hot, and
shining, and in most cases where the swelling has taken place rapidly,
there has been no pitting upon pressure, or discoloration ofthe skin. In
several well-marked cases, however, of crural phlebitis at the invasion of
the disease, the impression of the finger has remained in different parts
of the limb, raore particularly along the tibia ; but as the intumescence
has increased, the pitting upon pressure has disappeared, until the acute
stage of the complaint has passed away. At the onset of the disease I
have also observed, in several cases, a diffuse erythematous redness ofthe
integuments along the inner part of the thigh and leg. In one individual
only has suppuration ofthe glands taken place in the vicinity ofthe femo-
ral vein ; but in several, by an extension ofthe inflammation, the inguinal
glands have become indurated and enlarged. In some women the in-
flammation of the femoral vein has appeared to be suddenly arrested at
the part where the trunk of the saphena enters it, and the inflammation
has extended along the superficial veins to the leg and foot. The swell-
ing and pain in these instances have been greatest along the inner surface
of the thigh, in the course of the saphena veins. In most cases of crural
phlebitis, not only the whole lower extremity, but the nates and vulva,
have been affected with a glossy, hot, colourless, and painful swelling,
which has not retained the impression of the finger.
422
DISEASES OF THE BLOODVESSELS.
" The power of moving or extending the leg has been completely lost
after Ihe disease has been fully formed, and the greatest degree of freedom
from pain has been experienced by the patients in the horizontal posture
with the limb slightly flexed at the knee and hip-joints. The severity of
the pain and febrile symptoms has usually diminished in a few days after
the occurrence of the swelling; but this has not invariably happened, and
I have seen some individuals suffer from excruciating pain, and violent
febrile disturbance for many weeks, or through the whole period of the
acute stage of the disease.
" The duration of the acute local symptoms has been very various in
different cases. In the greater number they have subsided in two or three
weeks, and sometimes earlier, and the limb has then been left in a pow-
erless and edematous state. The swelling of the thigh has first disap-
peared, and the leg and foot have more slowly resumed their natural form.
In one case, after the swelling had subsided several months, large clusters
of dilated superficial veins were seen proceeding from the foot, along the
leg and thigh, to the trunk; and numerous veins as large as a finger were
observed over the lower part ofthe abdominal parietes. In some women
the extremity does not return to its natural state for many months, or years,
or even during life. In the summer of 1831, a lady was placed under
my care for an affection of the left lower extremity, who, forty years be-
fore, had suffered from an attack of crural phlebitis in the same side. The
left thigh and leg had remained larger and weaker than the other during
the whole of this long period, and was liable to suffer severely from
fatigue, and slight changes in the atmosphere. This lady was attended
in her confinement by a celebrated London accoucheur, who was so
strongly impressed with a belief of the truth of the doctrine of milky
deposits in crural phlebitis, that he ordered the infant to be kept night and
day at the breasts, lest the milk should make its way into the thigh.*
" In four cases of this affection, after the acute symptoras had begun to
subside, the sarae appearances were observed in the iliac and femoral
veins ofthe opposite extremity and the other thigh : the leg and the foot
became similarly affected. In two individuals only has the disease at-
tacked the same extremity twice. In one woman an interval of twelve
years elapsed between the first and second attack."
The treatment of crural phlebitis is conducted on the same principles
and by the same means as those to which we have recourse in phlebitis
from other causes. But there is this important reservation, that if the
patient be a puerperal female who has already lost much blood, or is
otherwise exhausted, bloodletting will either be withheld or practised
with moderation. I have directed it with advantage, both by venesection
and leeching the limb, in well-constituted subjects. Dr. Lee mentions
a case in which the abstraction of twenty ounces of blood seemed at once
to break the force of the attack. The leeches should be applied along the
limb in a line with the femoral and saphena veins. Warm cataplasms
often give great relief. Small doses of calomel and Dover's powder, alter-
nately with mild purgatives, are, also, of great service. Mild diaphoresis
should be kept up, but the heating treatment is to be avoided.
In the second stage, after the inflammation has subsided, edema and
* The Countess H. had an attack of crural phlebitis sor.n after delivery, at the same
time with the above lady, and died of the disease. So much for the accuracy of those
who have maintained that the disease was never known to be fatal till of late years.
phlebectiasis. 423
weakness of the limb remain. Recourse will then be had to occasional
leeching, stimulating embrocations, and bandages to the affected member.
Diuretics, at this time, are useful. The repeated application of blisters is,
also, recommended.
Phlebectiasis—Dilatation of Veins—Varicose Veins.—Three varie-
ties of disease equally frequent in occurrence are referable, anatomically
speaking, to the dilatation of veins: the properly, so-called, varicose
■veins,—varicocele,—and hemorrhoids. Of the two first of these I am not
required to speak. On the last I have, elsewhere, adequately enlarged.
The hereditary character of the several forms of phlebectiasis has been
observed. The assertion, that the development of one of the varieties
just named is incompatible with, or prevents the appearance of the others,
must be received with large qualifications. Age exerts an influence on
the relative susceptibility to phlebectiasis. Varicocele most frequently
commences between the age of puberty and the thirtieth year. Out of 45
cases, Landuzy found 13 set in between the 9th and the 15th ; 20 between
the 15th and 20th ; and 3 between the 25th and 35th years of age. Va-
ricose veins ofthe leg are, for the most part, developed from the twenty-
fifth year upwards, persist during manhood, and decline in old age. He-
morrhoids ofthe rectum usually set in from the twenty-fifth year upwards,
outlast the prime of life, and are often replaced after the grand climac-
teric, by vesical and vaginal hemorrhoids.
Onanism, immoderate sexual intercourse, riding, dancing, or walking
in excess, are to be considered as principally instrumental in originating
the disease.
Coagula of various shapes and extent frequently occur, and may be
ranked among the products of a sub-inflammatory condition of the parts.
Phlebolithes, or vein-stones within the varicose dilatations of the leg, and
in the varices of the bladder, are amongst the rarer phenomena. They
are produced by a gradual, but direct deposition of calcareous matter from
the blood, within the layers of the coagula. Hemorrhoids of the bladder,
as termed by Hasse, merit attention, and, accordingly, I refer to his work
for interesting views and particulars on the subject. This affection con-
sists in a dilatation of the veins of the prostatic and vesical plexuses ;—
sometimes so great as to give the prostate gland and the neck of the blad-
der the appearance of being shrouded in a dense venous tunic. " Many
an abscess of the cellular texture, within the perineum,—many a fistula,
—may have a much closer affinity with an affection of this nature than
has been generally suspected."
424 DROPSY.
DROPSY.
LECTURE CXXI.
DR. BELL.
Dropsy—Pathology of dropsy in general—Definition—Divisions—Dropsy chiefly symp-
tomatic—Disproportion between secretion and absorption—Active and passive, sthe-
nic and asthenic dropsy—Causes—Two chief causes,—retarded circulation of blood
in the veins, and altered composition of the blood—Inflammatory dropsy, or hydro-
phlegmasia—Instances of serous effusion by compression of veins, and by extreme
fulness of these vessels—Chief alteration in the blood, a diminution of albumen—
Connexion between this change and Bright's disease—Fatty deposit in the kidney
a cause of albuminous dropsy—Direct experiment to show how disordered nutri-
tion affects the kidneys—These organs affected by impressions on the skin—Ob-
struction of the cutaneous functions a cause of dropsy—Venous obstruction and
altered composition of the blood sometimes act together—Liver and kidneys, how
diseased—Anatomical characters—Restricted chiefly to differences in the appearances
ofthe fluid effused—1. Serous dropsy, resembles the serum of the blood—Appearances
of the serum,—is albuminous—its alkaline reaction—Its microscopical characters-
Chemical composition—2. Fibrinous dropsy, containing fibrin in solution, together
with albumen—resembles blood-plasma—Is a product of capillary dilatation—3. False
dropsies—The fluid in these is merely an increase and retention of the secretion of an
organ—Symptoms—Chiefly the appearances of sub-cutaneous edema, and these result-
ing from pressure on the skin—No organic symptoms peculiar to dropsy—Arterial
murmurs—Appearances of edema in particular region, according to the organ affected
—Inspection and examination of the urine—Circumstances under which albumen is
formed—Difficulty of diagnosis from observation of the states of the urine—Treatment
—Cautious prognosis—Importance of ascertaining the organic cause preparatory to
treatment—Few permanent cures—Great relief and suspension ofthe disease procured—
First indication, to remove the cause—The second to promote absorption—The first too
often beyond our control—We can but, for the most part, mitigate—Remedies addressed
to the liver and to the kidneys—Bright's disease—General principles and practice in
dropsy previously laid down—Action and reaction between the affected organ and the
dropsical effusion—Relief to the distended vessels by depletion—Bloodletting—Ob-
jects obtained by it—Attention to the physiological state of the organs—Diuretics—
To remove prior irritation or phlogosis of the kidneys—Free purging—Attention to
the state of the stomach,—Remedies to act on the skin, particularly in atonic dropsy-
Great importance of cutaneous medication—To watch the state of the heart, and to
administer tonics and narcotics, even while depleting—Special treatment according to
the organ affected—Pathology and treatment of dropsy from heart disease—Ascites, re-
medies beneficial in.
Dropsy.—I was about to make some remarks on dropsical effusion conse-
quent on diseases of the heart, when it occurred to me that a few element-
ary propositions on the pathology of dropsy, in general, would come in
appropriately enough at this time, after having spoken of the diseases of
the entire circulatory apparatus. I may premise, that the pathology of
serous effusions in different regions of the body, constituting what is desig-
nated by the term dropsy, resolves itself into that of the organ,—heart,
kidney, or liver, or of the membrane,—pleura, pericardium, peritoneum,
or arachnoid, on the lesion of which the serous effusion depends. If we
connect this proposition with that of an altered composition of the blood
we have the key to the pathology of dropsy.
Dropsy (from w//>o4, itself composed of «<»»/), water, and u-\., eye, or, figura-
tively, appearance) may be defined to be every pathological accumulation
of serosity, or liquid of a serous appearance, in a natural or accidental
divisions of dropsy. 425
cavity or in the areolae of the organic tissues. The definition in the Dic-
tionary ofthe French Academy is short, and to the point, viz.: a collec-
tion of serosity in any part of the body where it ought not to be. Dropsy
has been divided into general and partial. The first shows itself in the
general cellular tissue in all parts of the body: it receives the name of
anasarca (from «», through, and o-«tf, flesh). The second or partial are
found in the cavities of the serous membranes, and in the cellular tissue
subjacent to them. The most frequent of these is ascites (from aexistence of arachnitis. So far, then,
as these cases go, it appears that the mere fact of pain being relieved by
pressure, does not prove that it is unconnected with an inflammatory cause.
The pain, too, of an arachnitis may be intermittent, and continue to ex-
hibit this character even for a considerable length of time. I have seen
many instances of this in children, where the little patient was seized with
acute pain of the head at a particular time of the day, which, after a few
hours' duration, subsided, and then returned again the next day precisely
the same hour, and continued in this way for several weeks, until at length
his friends were surprised by the unexpected supervention of coma, con-
vulsions, or blindness. I knew two cases of this kind in which the in-
termittent character of the pain was so prominent as to engross the prac-
titioner's whole attention ; so that the real nature of the affection was
overlooked, and bark prescribed. I have now witnessed three or four of
these regular quotidian attacks of pain in children, which, after continuing
for days and even weeks, were suddenly followed by perfect blindness—
in some cases with and in others without coma.
You might here, ask, whether pain is to be considered as a diagnostic
of arachnitis ? I cannot say it is. We constantly meet with severe pain
in the head without arachnitis, and every one knows that the headache
of fever is by no means an indication of inflammation of the brain. In
many cases of hysteria, the headache and determination of blood to the
head are violent, and yet unconnected with inflammatory action. I know
a young lady who is frequently attacked with most agonizing headache,
accompanied by violent throbbing of the carotids and great heat of the
face and scalp. Yet, in this case it is plain that the pain cannot be in-
flammatory, for she has been subject to these attacks once or twice a-week
for the last six years, and yet continues otherwise in a state of good health.
If her disease were to be measured by the violence ofthe pain and deter-
mination of blood to the head, it would be natural to expect that death
would have long ago put a period to her sufferings. This is another proof
ofthe truth of the opinion, that there is no single pathognomonic symptom
of disease. Bear this in mind. I might go farther, and say, that, whether
we looked to symptoms or to signs, the rule was the same. The man
who merely looks to a single sign or symptom will frequently err; it is
only from the whole group of signs and symptoms presented by a disease
that we can arrive at any accurate diagnosis.
The state of the eye, in cases of arachnitis particularly, has attracted
much attention. Oti this subject much valuable information has been ob-
tained by the laborious investigations of Andral, of which I shall give an
abstract. He states that the phenomena of the eye, in cases of cerebral
SYMPTOMS OF CEREBRITIS.
483
inflammation, may be reduced to three classes : its motions, the various
conditions of the pupil, and the state of vision. With respect to the
first of these, it may be observed that in some cases we find the eyeball
in constant motion ; in others, it is quite fixed ; while in others the balance
of muscular power is lost, and there is a constant tendency to strabismus
of one eye or both. Of all these varieties in the state of motion, the last
appears to be the most valuable, so far as the diagnosis of arachnitis is con-
cerned. By many persons this strabismus is looked upon as a sign that
effusion has taken place, and that the disease has reached its incurable
stage ; a position which I am inclined to doubt, from having seen cases
recover in which this symptom was present. However, Andral looks
upon strabismus as a very valuable sign, and thinks that, of all the lesions
of motion of the eye, it is the most important with respect to the diagno-
sis of arachnitis of the ventricles. With respect to the condition of the
pupil, it is stated in books that in the early stage you have a contracted,
and in the advanced a dilated pupil, and that the latter condition signifies
that effusion into the brain has taken place. Now, the truth is, that this
statement must be received with great caution, and as admitting of nu-
merous exceptions; for it has been established that the same lesions%of
the brain are sometimes accompanied by very different conditions of the
pupil, and vice versd. Parent and Martinet, who have investigated the
subject carefully, are the best authorities on this point, and I shall give a
brief abstract of their experience. In cases where both pupils were dilated,
they observed that in some there was effusion into one of the ventricles,
in others into both. In cases where there was no dilatation, they ob-
served that in some there was serous or purulent effusion under the arach-
noid, while in others, in which there was no effusion whatever, the pupil
was dilated. Lastly, it was found that in some cases, where only one
pupil was dilated, there was effusion into both sides of the brain. You
might here ask, whether effusion into the substance, or on the surface of
one side of the brain, is connected with a dilated condition of pupil? In
reply to this, it may be stated that effusion into the substance—not of one,
but of both hemispheres—has been known to be accompanied by a con-
tracted state of the pupil to the last. You may also have one pupil con-
tracted and the other dilated ; nay, you may have an alteration of these
conditions—the right being dilated to-day, the left to-morrow. The mere
circumstance, then, of dilatation or contraction of the pupil is no sign,
when taken by itself, as to the seat or even the existence of effusion ; for
you may have either condition with or without effusion, and you may have
dilatation of the pupil of one eye with an effusion into both sides of the
brain. As a general rule, however, it seems to be made out, that, in
most cases of cerebral inflammation terminating in effusion, there is often,
towards the advanced period ofthe disease, some dilatation of pupil, and
that this condition generally marks the occurrence of effusion.
With respect to the affections of the function of vision, there are great
varieties. Some patients have double vision — others see sparks of fire,
or muscce volitantes. There are many other phenomena of the kind, caus-
ing a great variety in the symptoms ; and this variety is found to depend
more on the susceptibility of the brain to irritation, rather than on the
mere existence of irritation of the serous membrane investing it. The
same rule applies to all cases of serous inflammation, the phenomena of
inflammation varying according to the susceptibility of the orgin which
484
DISEASES OF THE NERVOUS SYSTEM.
the inflamed membrane covers. Thus, for instance, one patient will have
pericarditis with palpitations of the heart, another without them ; their
occurrence or non-occurrence merely showing that the heart is more or
less susceptible to irritation. So it is with respect to the brain, and the
symptoms of deranged vision are connected with the greater or less sus-
ceptibility of the organ, which we know varies very considerably in dif-
ferent persons. This remark applies to all the forms, and, I believe, all
the phenomena of meningitis.
In acute disease of the brain and its membranes, we often have convul-
sions and paralysis, and in these symptoms also we find great variations:
in some we have convulsions of one side, in some of both, in others we
have paral)sis, but scarcely any convulsions. The same remark also ap-
plies to these symptoms, as to some already mentioned—namely, that we
cannot from them alone form an accurate estimate ofthe situation or amount
of disease. You may have convulsions and paralysis of various kinds
with the same kind of lesion, and you may have a variety of lesions with
the same paralysis and convulsions. The only thing that appeals to be
pretty well established is this—that, generally speaking, in cases where
the right side of the brain is engaged, you have convulsions, and paraly-
sis' of the left side of the body, and vice versa.
Before I proceed to speak of delirium, I think it necessary to say a few
words more with respect to convulsions, as I find Andral has not touched
on a point to which I beg to call your attention. The occurrence of con-
vulsions in a child, labouring under symptoms of inflammation of the brain,
is always looked upon as formidable ; and indeed it is natural that con-
vulsions, to persons unacquainted with pathology, should seem to point
out a great intensity of disease. I have, however, been long of opinion
that convulsions occurring during the existence of hydrocephalus in chil-
dren, or of meningitis in adults, are not so dangerous as persons gene-
rally think. I will even go so far as to say, that the worst cases I have
seen in which a cure was effected, were those in which there were the
greatest and most violent convulsions; and that, in most of the cases
which appeared to go on without any benefit from medicine, there were
scarcely any. I am of opinion that convulsions are often of benefit by
giving relief to the brain. This statement must appear somewhat para-
doxical, but I trust I shall be able to prove to you that it has some foun-
dation in truth. Broussais has taught that there appear to be two great
modes of reaction in the economy, to obviate the effects of abnormal
stimulation applied to important viscera — fever and convulsions. The
irritations which attack the cerebro-spinal system may be relieved by con-
vulsions ; those which attack the viscera may be relieved by fever and
secretion. This doctrine, I think, might be expressed otherwise. The
irritations of organs are often relieved by an increase, with or without altera-
tion, of their secretions. But, as we have used the term secretion to ex-
press something material, we apply the proposition merely to the viscera
of organic life. Now, it may also be extended to the organs of animal
life. A violent expenditure of nervous power may relieve the brain or
spinal cord, and delirium and convulsions prevent or modify organic
changes, just as secretion from the lung or bowels may prevent ulcera-
tion.
I have said that the brain might be relieved by convulsions. Let us,
holding this assertion in view, compare the phenomena and results of apo-
SYMPTOMS OF CEREBRITIS.
485
plexy with those of epilepsy. In the first place, it is to be remarked that
the earlier phenomena of both are the sarae—namely, an active congestion
ofthe vessels of the head. Any one who has seen the first stage of both
must admit this. But let us follow them up through the remaining stages.
In the one, we have the determination to the head, followed by convul-
sions more or less violent and protracted, which, however, subside after
some time, and the patient gets well; in the other, there is either death
from the violent determination of blood and probable effusion, or if the
patient recovers, there is very often paralysis, showing that injury has been
done to the substance ofthe brain. Now, here we perceive that the case
of determination without convulsions is that in which there is either death
or recovery with paralysis ; there are no such bad consequences to be
dreaded where the determination to the head is followed by convulsive
fits. In apoplexy we have congestion followed by death, or recovery with
paralysis ; in epilepsy we have congestion, convulsions, and relief. It is
plain that, if we admit the identity ofthe phenomena in the early periods
of both, we must then also admit that the only cause of relief we can
ascertain is convulsions. This idea of the subject will explain how it is
that a man may continue for years subject to the repeated attacks of cere-
bral congestion, and yet to continue to enjoy tolerable health. It will also
explain why it is unnecessary and sometimes even dangerous to bleed in
epilepsy. It also shows why it is so often unaccompanied by paralysis,
because the brain is relieved by the expenditure of its nervous energy on
the muscular system. I think we should generally look upon the occur-
rence of convulsions, in a case of cerebro-spinal irritation, in the light of
an attempt at a crisis made by nature itself. What is a crisis ? An organ
labouring under irritation is suddenly relieved by a new process taking
place, either in itself or in some other part; and when we come to examine
what these modes of relief are, we find them to consist in the occurrence
of supersecretion, hemorrhage, exanthematous eruptions on the surface, or
convulsions. There is no doubt that, when we look to the results of the
sudden supervention of a copious secretion in an inflammatory affection of
any secreting organ, the source of relief is manifest. If we take two cases
of hepatitis or bronchitis—one attended with copious secretion, the other
without any secretion at all—it will be easy to conceive how much more
dangerous the latter is, and how much more difficult to manage. Now,
if we consider the brain in this point of view, we find that it is not a se-
creting organ, in the ordinary acceptation, and that the only mode in which
it can relieve itself is by the expenditure of its excess of nervous energy
on the muscular system, or by the sarae expenditure of mental energy, as
in the case of high delirium. I think we might fairly draw an analogy
between this mode of relief and that which, in other diseases, is the result
of hemorrhage or secretion. One fact, at all events, appears certain, that
in two most remarkable cases of different diseases—each, however, charac-
terized by the same phenomena in the early stage, namely, active deter-
mination to the head—we find that the case which turns out favourably is
that in which convulsions occur (namely, epilepsy) ; while in apoplexy,
where these symptoms are absent, we have either death or recovery with
paralysis.
If this opinion be well grounded, it would militate strongly against the
practice of checking the convulsions of meningitis by opiates. 1 feel con-
vinced that this practice is wrong and dangerous; its effects may be as
486
DISEASES OF THE NERVOUS SYSTEM.
injurious as the arresting the reactions by astringents in a case of acute
inflammation. There are two ways in which we can explain its bad effects.
In the first place, opiates prove detrimental by checking the convulsions,
which appear to be a mode of relief adopted by nature ; and, next, they
must do mischief from their well-known tendency to add to the existing
cerebral congestion. I have now seen a good many cases of meningeal
inflaramation in which convulsions took place, and where opiates were em-
ployed to remove them, and feel compelled to state that the opium has cer-
tainly relieved the convulsions, but the patients have afterwards fallen into
a state of profound coma, from which they never recovered. I have wit-
nessed this so often, that I should not discharge my duty properly, did I
not warn you against the employment of opium in arachnitis. The same
rule most commonly holds good in cases of visceral inflammation, where
an organ is in a state of irritation, and has its secretions suppressed. Here
a'so opium, by arresting secretion and increasing congestion, will be pro-
ductive of bad effects. I allude here particularly to the treatment of pneu-
monia by opium, as recommended by Dr. Armstrong, who lays great stress
upon its use in full doses after having premised a single bleeding. I have
had some experience of this mode of treatment, and find that the effect of
the opium is not to remove, but to convert a manifest into a latent disease.
I have seen the pain, dyspnoea, and cough subside, but the fever continued,
and the destructive process of the lung went on as usual. This is the
result of my experience.
I shall now make a few observations on the occurrence of delirium in
disease of the brain. In one of my former lectures 1 alluded to the import-
ant fact, that, in the majority of cases of meningitis, where delirium was
present, there was inflammation of the convexity of the brain. I stated also
that, when inflammation attacked the base ofthe brain, we might have it
going through all its stages without delirium, and pointed out the import-
ance of this in favour ofthe phrenological doctrines. Andral admits the
occurrence of delirium in case of inflammation on the convexity of the
brain, but his reasoning upon this subject appears to me to be inconclusive.
He divides affections of the convexity of the brain into those which are
characterized by delirium through their whole course, and those in which
coma is the most remarkable feature ; and seems to think that, where coma
is the most remarkable symptom, the results ofthe case are unfavourable
to phrenology. But we shall find, on examining these cases, that, in many
of them where coma was the predominant feature, there had been delirium
in the commencement. He gives the details of thirty-nine cases accom-
panied by delirium all through, in thirty-six of which there was disease of
the convexity ofthe brain, either simple or complicated with arachnitis.
As far, then, as his first set of cases go, they are in favour of the opinion
that inflammation ofthe convexity ofthe brain is most commonly attended
by delirium. It appears also, that in those cases in which coma was the
most remarkable symptom, there was more or less delirium in the com-
mencement ; so that, whether we take the cases in which there was deli-
rium all through, or those in which there was coma, the conclusions appear
to be in favour ofthe doctrines of phrenology.
I shall now proceed to make some remarks on the phenomena of organic
life in cases of cerebral inflammation. In the first place, with respect to
the tongue, we find that in simple arachnitis it is but slightly affected;
there may be some trifling degree of foulness, or it may be quite clean and
SYMPTOMS OF CEREBRITIS.
487
moist. You will observe the value of this, as connected with the diagno-
sis of irritation ofthe brain from disease ofthe digestive system. There
are many cases of irritation of the digestive system putting on the sem-
blance of hydrocephalus to such a degree as even to mislead an experi-
enced practitioner. Now, if it be true that in simple arachnitis the tongue
remains clean, it furnishes us with very material information, as, under
such circumstances, our attention will be directed to the true seat of dis-
ease. Andral says, that in some cases of arachnitis he has found the tongue
red, or dry, or foul, but that at the same time there was disease of the
digestive systera. The majority of his cases, however, were simple, and
exhibited no marks of an affection of the tongue or digestive system.
There is one more symptom on which I wish to offer a few observations,
and that is the occurrence of vomiting in the hydrocephalus of children.
In all cases where there is obstinate vomiting, particularly in children, you
should have your suspicions roused, and look carefully to the state ofthe
head. Vomiting is a symptom which occurs in many cases of arachnitis ;
in some it is slight, in others more constant, while in a third class it is ha-
rassing, incessant, and produced by swallowing the most unirritating sub-
stances. The nature of the fluid rejected from the stomach is various—
being sometimes bilious, sometimes mucous, sometimes only consisting of
what had been recently drunk. In some of these cases you will find the
symptoras of incessant voraiting, unaccompanied by pain of the stomach,
tenderness ofthe epigastrium, or any other sign of disease of the digestive
system. I have even seen it coexisting with a good appetite. Many per-
sons have been lost by such cases having been mistaken for disease of the
digestive system, the practitioner being ignorant that vomiting was here
only symptomatic of disease ofthe brain. No matter what the situation
ofthe meningitis may be, it is now established that you may have vomit-
ing as a common symptom. I recollect the case of a delicate child, about
seven years of age, who laboured for some time under catarrhal fever, on
the subsidence of which she got an attack of vomiting, which came on at
different times in the day, but without headache, delirium, or intolerance
of light. This vomiting continued from day to day; and, at the end of
the week, the pupils became suddenly dilated, and coma set in, under
which she died. There is one very remarkable circumstance connected
with this subject, with which I am anxious you should be acquainted.
Where this incessant vomiting is present, you will have the other symptoms
of meningitis more or less latent. This illustrates a law before alluded to,
that, where the. phenomena which are the result of sympathy with an affect-
ed organ are very prominent, those which characterize the disease of the
organ itself are more or less latent. If we take the reverse of the former
case, and consider a case of gastric disease, we know that the irritation
ofthe stomach will produce violent cerebral symptoms, and that here also
the same law is exemplified—for we shall have absence of pain, tender-
ness, and vomiting. The great value of this rule is, that a knowledge of
it will put you on your guard, and that the mere absence of the peculiar
symptoms of an affection of an organ possessing extensive sympathies,
should not lead you to conclude that there was no disease of that organ.
In some remarkable cases of gastritis, the principal symptoms observed
were convulsions and delirium ; there was no voraiting or thirst, very little
pain on pressure, and nothing remarkable in the condition of the tongue.
The same latency of inflammatory disease is frequently seen in cases of
delirium tremens.
488
DISEASES OF THE NERVOUS SYSTEM.
WTith respect to respiration and the state of the pulse in meningitis, there
is very little to be said. You may have meningeal inflammation with every
variety of pulse—strong, weak, full, rapid, slow, or intermittent. Gene-
rally speaking, the pulse is, towards the close of the disease, feeble and
intermitting, but you may have the disease running through all its stages,
without any peculiarity in the character ofthe pulse. Respiration seems
to be very little affected, and this would appear to favour the opinions of
Sir Charles Bell. There is no doubt, at least, that the sympathy of the
brain with the respiratory system is much weaker than with the digestive.
Treatment of Hydrocephalus.—I shall occupy your time but very
briefly on the treatment of hydrocephalus of children, as it appears to me
to be a disease in which, of all others, the principles of treatment are most
simple. The old idea of this affection was, that it was a species of dropsy
depending on the relaxed state ofthe cerebral vessels, and hence the term
hydrocephalus. Modern pathology has shown that the occurrence of serous
effusion is a mere accidental circumstance, as it is present in one case of
arachnitis and absent in another. When it does occur, however, it is the
result of inflammatory disease, and it is to the prevention and cure of this
that the practitioner must direct his attention. With the symptoms of this
disease I shall not take up your time, as you will find them sufficiently
detailed in books ; but, with respect to treatment, I shall say, that hydro-
cephalus is a disease much more under the influence of treatment than per-
sons generally think. It is said that, when once effusion has taken place,
the case is hopeless, and nothing can be done. This remark appears to
me to be unnecessary, for there is no symptom from which you can venture
to assert that effusion has set in. You may, from the inflammatory state
of the brain, have delirium, coma, deafness, blindness, and paralysis, with-
out any effusion of serum ; and in many cases, life has been saved, even
after the appearance of all these symptoms.
This term effusion is one of the bugbears of medicine. Many patients
are lost from the prevalence of false ideas connected with this subject;
for, as soon as effusion is supposed to have set in, the efforts ofthe prac-
titioner are given up. Hundreds of patients die of bronchitis and pneu-
monia, in whom life might be saved if the symptoms of effusion had been
treated for those of inflammation ; and so it is with respect to the brain.
This effusion is not the disease—it is not even a constant result of the dis-
ease. We have no certain means of ascertaining its existence ; and we
know that, by a persistence in antiphlogistic treatment, life may be often
saved, even after all the supposed symptoms have occurred.
Take this with you as a rule in medicine : always to keep your eye
more upon the causes than the effects of disease.
The treatment of hydrocephalus in the child should always be active,
and conducted on the same principles as those of general encephalitis in
the adult. Shaving the head, bleeding when practicable, repealed leech-
ing, cold affusion, calomel, and purgatives—these are the great measures
upon which we are to rely for success. It is satisfactory, too, to reflect
that many cases have been saved by the prompt and steady adoption of
this simple mode of treatment.
Of internal remedies.—The use of mercury seems to be that on which
you should most rely. Some of the most singular recoveries have oc-
curred after ptyalism has been produced. Let me remind you, however,
that the rules connected with this mode of treatment, which I pointed out
TREATMENT OF HYDROCEPHALUS.
489
in speaking of hepatitis, apply equally in this case. There is a terrible
consequence of mercurial action in the lymphatic temperament/with
which you should be acquainted ; I allude to violent and destructive
inflammation of the soft parts of the mouth and face, which has got the
name ofthe mercurial cancrum oris. An edematous inflamraation of the
cheeks, lips, and tongue takes place, and if not checked, rapidly runs on
to extensive ulceration. I have seen one cheek, half of the nose, and
lower eyelid, and the opposite angle of the mouth, utterly destroyed, in
a case where but five grains of calomel were used. This drawing repre-
sents the disease, after a frightful perforation of the cheek. In this case
the quantity used was nine grains. I have seen the disease from the use
of so small a quantity as a grain and a half of calomel ! These facts
show that there is a state of the constitution in which a minute dose of
calomel may have terrible effects. The same, too, may arise from the
external use of mercury. I recollect the case of a young woman in the
Meath Hospital, whose head was rubbed with one drachm only of mercu-
rial ointment, for the purpose of destroying vermin. She was attacked,
and with difficulty saved.
The disease may also come on suddenly in a patient who has been for
some time using mercury inconsiderable doses; but this is the rarest case.
You recognise this disease by the sudden supervention of great swelling
of the lips and cheeks, so as to completely alter the expression. The
tongue is also swollen. All these parts are hot and tender to pressure.
The breath is fetid, and the internal surface ofthe mouth excoriated, and
often covered here and there with patches of lymph. At other times we
have a circumscribed edematous swelling, occupying the centre of the
cheek, which runs on to ulceration ; but most commonly the ulceration
ofthe external parts begins at the depending angle ofthe mouth.
In a case of this kind, if you are called before ulceration has taken
place, I believe you can often save your patient, and prevent destruction
of the face. Treat the disease as a violent inflammation ; use repeated
leeching, poulticing, and the warm bath. While you do this, you must
keep up your patient's strength by light nourishment and wine. Apply to
the internal ulceration the mel aeruginis, the nitrate of silver, or the chlo-
ride of soda. I have now saved many cases by bold and repeated leech-
ing. I remember one case of a man in which ninety leeches were used ;
he recovered perfectly.
In the treatment of this affection, it is of the utmost consequence to
attend to the position of the patient. By keeping him as much as possi-
ble upright, or by preventing him leaning constantly on one side, we do
much to prevent the occurrence of the ulceration of the angle of the mouth.
As far as I can see, hydrocephalus, when taken in time, is a very
manageable disease ; and there is only one case in which it is difficult to
treat, and that is where the cerebral affection is accompanied by symp-
toms of gastro-enteric disease. In several cases of hydrocephalus, this
complication certainly exists ; and you have first symptoras of disease of
the digestive tube, and then of the head. Such cases as these are involved
in great difficulty, and in their treatment you run the hazard of falling into
a two-fold mistake. The first is your acting on the supposition that the
disease of the head is only sympathetic, and that it will subside as soon
as the abdominal symptoras are removed ; the other is occupying your
attention exclusively with the head. Now, there is one rule with respect
490
DISEASES OF THE NERVOUS SYSTEM.
to this, which I think will serve to guide you through many difficulties,
and this is, never to neglect the head. Though you have first an affection
of the digestive system, and then of the head, it is better (even though
the symptoms of the latter still continue) to pay attention to the head.
You can do this at the same time that you are attentive to the condition
of the digestive organs. Another rule is, that the cases of disease in
which the purgative plan does not answer are generally those in which
there is a primary inflammation of the digestive tube. Dr. Cheyne, in
speaking of the treatment of hydrocephalus, says, that some cases are
benefitted by purgatives, others not; and that the latter are those in which
there is disease ofthe' intestinal canal. In such cases you will not irritate
the bowels, or add to the existing inflammation by purgatives. Let the
bowels be kept open by enemata, and direct your attention immediately
to the head. Children with largely developed heads, and of a strumous
diathesis, are very subject to this disease ; and I feel convinced that the
present rage for the early mental education of children has a strong ten-
dency to produce it in subjects of this description. I believe there are
many cases of fatal hydrocephalus from which the poor victims would
have escaped, but for the pernicious efforts of the parents to make them
literally prodigies. I have observed many cases of this kind among the
children of persons who, having been originally situated in an humble
sphere, and deprived of the benefits of education, accumulate wealth ; and
then feeling in their new condition the want of education, are anxious to
communicate it to their offspring; and, with that view, have them edu-
cated with too much care, and from too early a period. The child is
constantly kept at his books—his little mind is perpetually tasked—a
degree of cerebral excitement is kept up—and, while he is delighting his
gratified parents with the manifestations of a precocious intellect, his
health is neglected, and the seeds of disease are insensibly sown. One
of the most ordinary consequences of this early application of the mental
powers is hydrocephalus. These little creatures, too, have a congenital dis-
position to disease of the brain, for they have generally large heads. Such
cases are examples ofthe results of an arrest of development. A relative
condition of head exists similar to that which occurs during foetal life, and
this is always accompanied by a remarkable susceptibility to inflammation.
This peculiar development of head also produces a precocious state of
intellect, wmich is increased by the pernicious habit of obliging children
to study at too early an age. Where you meet with children suffering
under these circumstances, you will not discharge your duty properly if
you do not point out to the parents the mischievous tendency of their
conduct. In such cases as these it may be justly said that ignorance is
bliss.
MENINGITIS.
491
LECTURE CXXVII.
DR. bell.
Meningitis—Its organic seat—Not a unit—Different membranes of the brain—Their
connexion with ea^h other and with ihe brain—Dura mater—Its organic lesions in-
considerable—Arachnoid membrane—Its morbid changes—Anatomical lesions of the
pia mater—Inflammation of the arachnoid and nf the pia mater generally conjoined—
Encephalitis often associated—An effectofmeningitis—hydrocephalus—long regarded
as a primary disease—Meningitis—simple and tuberculous kinds—Hydrocephalus
common with tuberculous meningitis—may occur without it.—Simple Acute Ence-
phalic Meningitis—Differences between this and tuberculous meningitis—Its attacks
sudden ; its course short—Subjects, the most healthy children—Symptoms—Headache
—vomiting—convulsions—fever—delirium—disorder ofthe senses, in augmented sen-
sibility—constipation—Two varieties—The convulsive and the phrenitic—Secondary
Meningitis—Diagnosis of Simple Meningitis—Anatomical characters—Chief lesions at
the convexity and summit of the brain—Spinal meningitis associated with the ence-
phalic—Causes—Not well understood—Treatment—Actively antiphlogistic—Blood-
letting, general and local—cold to the head—free purging—calomel—digitalis—
mercurial inunction—Counter-irritants, especially if the disease have followed repelled
eruptions—Appropriate time for the use of blisters—Inunction with warm olive oil.
Meningitis (from t**ny%, a membrane) is a disease which rests on an ana-
tomical basis, and, as such, would at first seem to allow of a ready ap-
preciation of distinctive symptoms. But a little inquiry soon shows that
this simplicity of view is fallacious, and that meningitis is a general, not
a specific term, that it indicates inflamraation, not of any single membrane
but of all the membranes of the brain ; and that we have no very clear
diagnosis between the inflammations of these several membranes, nor be-
tween them nor any one of them and inflammation of the brain, or ence-
phalitis. For a long time no attempt was made to connect the observation
of symptoms with anatomical lesions of the membranes or even of the
brain ; and the vital phenomena were all expressed vaguely by the words
phrenitis, delirium, cerebral fever, or, with some attempt at modification
of stage, by the word coma. Even now, after considerable pains have
been taken by competent and conscientious observers to introduce and
establish a more rigid system of investigation and induction, we are far
from having reached a satisfactory result.
The difficulties in the way of separating the affections of the several
membranes of the brain from each other, and of each respectively from
cerebral disease proper, if not absolutely insurmountable, are, in the
nature of the case, very great. Taking general anatomy as a standard,
it seems easy, in pointing out the three investing membranes of the brain,
viz.: the dura mater, the arachnoid, and the pia mater, to infer from
the differences in their tissues—fibrous, serous, and cellulo-vascular—that
they possess different vital properties in health, and must exhibit lesions
of different kinds when diseased. But, special or minute anatomy apprises
us that there is not that entire separation of membranous tissue in each
case which would allow an isolation of either physiological or pathological
phenomena. Thus, if we look at the dura mater, we find it intimately
connected, on one side, with the bones, cranial and spinal, which it in-
vests, by means of vascular and cellular prolongations ; and on the other,
closely adherent to the arachnoid membrane by means also of cellular
492
DISEASES OF THE NERVOUS SYSTEM.
tissue and vessels, the latter of which come from the dura mater, while
their absorbent and exhalent terminations are on the free surface of the
arachnoid. The ready and almost entire separation of the two parts of the
arachnoid—that lining the dura mater and that investing, to a consider-
able extent, the pia mater and the outer convoluted surface ofthe brain,
in fact the space constituting the arachnoid cavity, is not a peculiar ana-
tomical feature. We are to look for this in the connexion between the
outer surface of the cerebral arachnoid and the pia mater, which, at first
sight, seems, indeed, to be sufficiently contrasted ; the former being smooth,
of extreme thinness and transparency throughout, the latter on the con-
trary is made up of network of vessels with sorae intermediate cellular
tissue. A little farther inspection, however, shows that the arachnoid is
but a kind of epidermis, as has been ingeniously remarked, for the pia
mater, through which absorption and exhalation go on by the instrument-
ality of vessels supplied from the latter. There is then, in fact, commu-
nity, one might almost say, unity of physiological action between the
arachnoid and pia mater; the completion of function taking place in the
first, by means of vascular tissue supplied by the second. In refer-
ence to the arachnoid, to which, of late years, so important a part has
been ascribed in meningeal inflammations, although we class it properly
enough among the serous membranes, and point out the increase of na-
tural secretions and the formation of morbid ones on it in disease, we can-
not deny that, as it has two sets of connexions, one with the dura mater,
the other with the pia mater, it will modify and be modified in a somewhat
distinct manner, in its two sides, at this time.
I have shown how the membranes are thus united anatomically one
to the other. Their connexion in this way with the brain by the pia
mater is still more manifest. This membrane would seem to be chiefly
intended as a means for equal and regular distribution of blood to the
brain, which it covers, not merely on its outer convolutions like the
arachnoid, but it dips down between these, investing each, and finds its
way into the cavities or ventricles ; sending its vessels, now become more
and more attenuated, into the substance ofthe brain itself, which is nour-
ished by this means and fitted for the performance of its important func-
tions.
It is very easy to see, from this brief anatomical prodrome, that inflam-
mation of the pia mater can hardly exist without the surface, at least, of
the brain being similarly compromised, nor, e converso, is it probable that
primary inflammation of the brain could last beyond a short period with-
out causing, at any rate, afflux and congestion in the pia mater. In either
case, whether we suppose primary or secondary inflammation of the pia
mater, we cannot deny the probable concurrent disorder of the arachnoid ;
or, if it be alleged that arachnitis is of primary origin, we must also admit
that its persistence almost necessarily implicates the brain through the pia
mater.
Looking at the separation between the two free or inner surfaces ofthe
arachnoid, those corresponding with its cavity, and the connexions be-
tween the other outer surfaces, in one direction with the dura mater and
in another with the pia mater, there would seem to be room for a natural
division of membranes into cranial and cerebral, of which the first would
consist of the dura mater and its adherent arachnoid lining the cranial
cavity, and the second the pia mater and the arachnoid covering the brain
MENINGITIS.
493
and its convolutions and prolonged into its cavities. But although this
division would seem to separate sufficiently the lesions of the pia mater
from those ofthe dura mater, it would not for any practical purpose sepa-
rate the two halves of the arachnoid, nor this latter from either of the
other two membranes.
The dura mater is liable to affections implicating parts of its tissue, as
when one or more of the bones of the cranium or of the spine are diseased,
or when morbid growths of a fibrous nature occur in it. There is another
morbid feature, noticeable in the cellular tissue intervening between the
dura mater and the arachnoid, to which M. Foville (Art. Meningite, Dic-
tion, de Med. et de Chir. Prat.) directs attention. If we look at the arach-
noid surface ofthe cranial membrane, we find numerous stains, of various
sizes, disseminated over it, of a brown, or deep-yellow colour, somewhat
raised and separating the serous membrane from the dura mater. It is
easy to make the surfaces at these particular parts glide over each other,
a result owing to the absorption in a great measure of the intervening cel-
lular tissue. Not unfrequently blood is found infiltrated in some of these
spaces, causing projection, adequate to compress the brain and to give
rise to the characteristic symptoras of this state.
We are ignorant ofthe diagnosis of this morbid change, which we can
hardly designate as inflammation ; nor can anything be said of its treat-
ment. It is chiefly met with in subjects whose brain has been diseased
for a length of time, and in whom abnormal appearances, as regards the
supply of blood, are met with in all parts ofthe head.
Although of late years the state of the arachnoid membrane has obtained
paramount importance in the eyes of pathological inquirers into diseases of
the brain and its meninges, and to such an extent as to give the nomencla-
ture to the phlegmasia? of the latter, yet, in fact, very rarely are the lesions
of this membrane without concomitant affection of the pia mater, and even
those referred to the arachnoid have more generally their seat in the tissue
intermediate between it and the pia mater. It is worthy of remark, also,
that in the midst of serous effusions or purulent matter and false membranes,
the chief morbid products of arachnoid inflamraation, the membrane itself
preserves its normal anatomical characters, and is neither thickened nor in-
jected, nor even, in many cases, deprived of its proper smoothness. The ob-
server is often deceived by attributing to disease certain appearances ofthe
arachnoid, which in reality depend on fluid or other formations between it
and the pia mater and on morbid states of the latter seen through the
arachnoid.
The pia mater exhibits organic lesions more frequently than either ofthe
other membranes, as we might a priori be prepared to expect from a knowl-
edge of its great vascularity and its anatomical connexion with the brain,
of which, both as respects nutritive and functional purposes, it is the organ
for the regular and extended supply of blood. Its tissue may be infiltrated
either with clear colourless and transparent serum, or with a turbid and
lactescent fluid, or with pus ; or it may be studded with tubercles, or final-
ly, but in rare cases, it may be found in a state of scirrhous induration.
At other times, again, are seen serous cysts of various sizes and numbers,
cartilaginous or osseous laminae, and tubercles and adhesions between por-
tions ot the pia mater which dips down between the convolutions. These
changes of tissue are various in their situation and extent; and hence this
meningitis (piitis) may be either general or partial. In the latter case we
494
DISEASES OF THE NERVOUS SYSTEM.
distinguish, 1, that ofthe convexity of the hemispheres; 2, that of the
base ; both of these occupying one or both sides ; 3, a ventricular menin-
gitis, alone" or coexisting with the two first varieties, the chief lesion re-
cognisable in which being an effusion, has caused it to be called acute hy-
drocephalus ; 4, finally, a spinal meningitis, wThich, also, may be either
general or partial, confined to the upper or the lower portion or to one side.
What has just now been said ofthe infrequency of arachnitis alone, ap-
plies to inflammation ofthe pia mater; and hence the terms of arachnitis &nn\
of piitis, to distinguish two phlegmasia?, are not applicable, and by leading
to a restricted and partial view of the organic cause they must be misleading.
Meningitis, being indicative of inflammation ofthe meninges or membranes
of the encephalon and spinal marrow, ought to be the preferred, as it is the
more accurate terminology. We must not forget, also, that it is extremely
difficult, not to say impossible in practice to distinguish meningitis from
superficial encephalitis, or from meningo-encephalitis. That the brain is
directly affected in meningeal inflammation is clear, from the symptoms of
the latter which are the result of cerebral lesion, such as intense headache,
delirium, and convulsions, and also, from the anatomical changes in that
portion ofthe brain contiguous to the investing membranes. It is only of
late years that the separation of phlogosis of the membranes from that of
the nervous centres—encephalon and spinal marrow—has been made, at
least with the support of anatomical proof. Before the time of Sauvages
the term Phrenitis was used to designate both inflammation of the brain
and of its meninges, and, also, sympathetic delirium : and even this wri-
ter's distinction between cephalitis or inflammation ofthe brain and phreni-
tis or inflammation of the membranes \\4as purely arbitrary ; as he supposed
the former to be distinguished by coma with muttering delirium, and the
latter by wakefulness and pain. M. Requin queries whether the term me-
ningitis was not first employed by Herpin in his inaugural thesis entitled
Meningitis, ou Inflammation des Membranes de I'Encephale, Paris, 1803.
Good, a little more than twenty years ago, did not make use of it, although
he speaks of meningic inflammation.
Although we may not be able absolutely to establish a diagnosis between
inflammation of the membranes of the brain and that of the nervous sub-
stance ofthe latter, yet as we find, in a number of cases, meningitis with-
out any or with very slight implication of the encephalon anatomically
considered, we cannot refuse to admit and adopt the existing division.
In the instance of tubercular meningitis, it will be seen that the morbid
phenomena, evincing as they do great disturbance of the encephalic func-
tions and so generally preceding a fatal termination, are due to a purely
meningeal affection, viz. : tubercles in the pia mater.
For the last century the attention of pathologists and systematic writers
on medicine has been diverted from a careful observation ofthe symptoms
and organic lesions in meningeal inflaramation to that of an occasional
effect,—the effusion of serous fluid in the ventricles ; and hydrocephalus or
water in the brain had come to be regarded as itself the disease. But even
now, when we have become accustomed to see this effusion in its true
light, and have learned its connexion with, if not actual dependence on
tuberculous meningitis, there is still confusion ; some insisting on ranging
all the acute affections ofthe brain under the generic term of acute hydro-
cephalus, and others of tuberculous meningitis. An analysis of the
cases already published by different writers and of the observations col-
SIMPLE ACUTE MENINGITIS.
495
lected by himself will satisfy the practitioner, that there is acute meningitis
unconnected with tubercles and without hydrocephalus or ventricular effu-
sion at all; and that there is, also, acute meningitis, but of a tuberculous
kind, with almost always effusion into the ventricles, being hydrocephalus
as usually met with ; finally, there is effusion, true hydrocephalus, without
inflammation of the membranes, either simple or tuberculous, but occurring
under similar circumstances as dropsical effusions in other serous cavities.
I shall, therefore, speak first, of simple acute meningitis, secondly, of tuber-
culous meningitis-and its concomitant hydrocephalus ; thirdly, of chronic
meningitis ; fourthly, of hydrocephalus without inflammation. Epidemic
meningitis will afterwards be brought up for separate notice.
Simple Acute Encephalic Meningitis.—Parent-Duchatelet and Mar-
tinet in their valuable work on arachnitis, cerebral and spinal (1821), and
of later years Drs. Evanson and Maunsell, had indicated a difference in
symptoms between membranous inflammation at the base of the brain and
that of the convexity of its hemispheres, and the much greater frequency
of the former than ofthe latter ; but they were not aware that with these
differences in seat there were also essential and organic differences in the
kind of inflammation ; and that the meningeal, or as they term it arachnoid
inflammation at the base of the brain represents tuberculous meningitis,
and that of the convexity simple meningitis. This position with some con-
necting views had been laid down by MM. Rilliet and Barthez, and is since
advocated in detail by M. Rilliet (Archiv. Gen. de Med., 1846-7) with
more than plausibleness : his argument rests on a number of carefully col-
lated cases, partly from his own observation and partly derived from the
writings of others. Simple is something more than and different from
tuberculous meningitis, wanting the tuberculous element and retaining the
phlegmasia, as has been taught bysome late writers. The two differ in their
causes: they attack children under quite different circumstances ; do not
begin in the same manner, nor pursue the same march, nor reach a similar
termination, nor exhibit the sarae anatomical traits ; and, certainly, they do
not require an identical treatment. It may, however, be risking too much
for us to assent to the strong assertion of M. Rilliet, that simple meningitis
differs from the tuberculous as much as pneumonia differs from phthisis pul-
monalis. This writer and his associate M. Barthez believe meningitis in the
tuberculous to be identical with tuberculous meningitis, whether tubercles
be found in the pia mater or not: their seat, aspect, direct and coincident
lesions are the same, both occupying the base ofthe brain ; and as to the
tuberculous formation, if it is not present in the encephalic membranes, it
is certainly in some other organ. In a great majority of subjects, however,
in which the other conditions are present, tubercle is, also, present in the
membranes.
Simple meningitis attacks robust children in the midst of full health,
and who, born of healthy parents, are, also, exempt from any tuberculous
affection either internal or external. The disease may prevail epidemi-
cally. If it should be at any time a secondary disease, it usually makes
its appearance during the convalescence from some acute affection which
has nothing tuberculous in it. Its course is usually rapid. I have had a
case to terminate in twelve hours from the first attack of convulsions and
delirium to hemiplegia and death. The paralysis preceded the fatal ter-
mination two hours. •
,The symptoms which introduce simple meningitis are, violent convul-
496
DISEASES OF THE NERVOUS SYSTEM.
sions, accompanied by raging fever and greatly accelerated respiration in
very young children ; or by frontal cephalalgia with fever, bilious vomit-
ing, and at the expiration of the first, or in the course of the second, it may
be the third day, at farthest, excessive agitation preceded not unfrequently
by somnolency, and followed by acute delirium and all the phenomena of
ataxic or nervous fever. Constipation, but not of any great obstinacy, is
present. ,The progress ofthe disease is rapid, the aggravation of the symp-
toms being progressive ; convulsion succeeds convulsion, or in its place is
violent delirium, and other symptoms just enumerated. The duration of
simple meningitis is short: it has terminated in 24 and even 12 hours;
but commonly it lasts from three to six days; seldom beyond the last
period.
Headache is a constant symptom in subjects more than two and a half
or three years old : within this period its presence cannot be learned from
the little sufferers. It shows itself at the very onset of the disease and is
coexistent with the fever and vomiting, or it may precede them by a few
hours. It attains its maximum at once, and is much more severe than
in typhoid fever, and in the majority of cases than tuberculous meningitis,
in which latter disease it is never so intense for the first few days. Head-
ache yields to the delirium or coma, so that it does not last more than one,
two or three days.
Disorder of the intellectual faculties is a never-failing accompaniment
ofthe disease, whether the meningitis be primary or secondary. Usually,
in children more than four or five years old delirium precedes disorder of
the motor organs : and more especially convulsions. These are absent in
children of very tender age ; but when they do come on they are remarka-
ble for their violence, one fit quickly following another until death closes
the scene.
The senses of sight and hearing are at first exquisitely susceptible to
their respective exciters, from the beginning of the disease, and at an early
date strabismus and contraction ofthe pupil manifest themselves. Later,
the pupils are excessively dilated and insensible to light: tactile sensibility
is also deadened at this time.
The expression of the countenance is aniniated, the skin being high-
coloured, but soon it changes, being at one time red, at another pale. 'Ihe
features after a while assume a haggard and as it were grimacing appear-
ance, and express a high degree of anxiety and agitation, or it may be
dulness and stupidity ; the look is fixed for a few moments, and then
rapidly changes its character to wandering.
The fever, which is quite strong, generally shows itself from the very
beginning of the disease ; the pulse is frequent and the animal heat high.
Sometimes there is intermission of the fever ; the pulse falling in frequency
and then again rising. The respiration is very irregular ; the inspirations
being unequal and catching. The disorder of the digestive organs is mani-
fested by vomiting, which in primitive meningitis of the second period of
childhood is never absent: it is abundant and of a bilious character; and
may persist until death, although this is an unusual occurrence. Often, in
very young subjects attacked with the convulsive variety, and in others
somewhat older attacked with secondary inflammation, there is vomiting.
Constipation though of frequent occurrence is not uniformly so, and it is sel-
dom so obstinate as in tuberculous meningitis. The abdomen, as death
approaches, is drawn in, as we see it in the latter disease; but in young
DIAGNOSIS OF SIMPLE MENINGITIS.
497
subjects and in secondary meningitis, it preserves its form. Loss of ap-
petite and intense thirst are symptoms indicating the febrile character of
the disease.
Simple acute meningitis presents two distinct varieties; one which
may be called convulsive, the other phrenetic. The convulsive is met
with chiefly in very young children, who have not passed the first or
second year. The convulsions come on early and alternate with drowsi-
ness or coraa; they are followed by strabismus, contraction ofthe pupils,
and sometimes hemiplegia. In other cases, again, they supervene on fever
or prolonged stupor, and persist, with some intervals, to the last. Phre-
netic meningitis usually shows itself in the second period of childhood, or
from five to fifteen years of age, and bears a closer resemblance to menin-
gitis in the adult than the preceding variety. It is ushered in with chill,
followed by strong febrile reaction,—hot skin, frequent pulse, flushed
face, violent frontal or sub-orbitar headache, intolerance of light, loss of
appetite, and copious vomitings of bile. In some rare cases, there is a
remission of the symptoms, and the child may recover its intelligence and
recognise the persons around, but the fever returns ; the restlessness having
lasted all the while, and the nervous symptoms resuming all their violence,
death soon comes on.
Secondary Meningitis.—Simple inflammation of the meninges is some-
times the result, directly or remotely, of injury to the skull, or it may
supervene on another disease, as in pneumonia, albuminuria complicated
with pleuro-pneumonia, and intestinal disorder succeeding scarlatina.
Diagnosis of Simple Meningitis.—Numerous diseases may be con-
founded with the one now under consideration,—convulsions and deli-
rium, the almost constant symptoms ofthe two varieties of simple menin-
gitis, constituting a part of the symptomatology of a great many of the
diseases of infancy. The convulsions in meningitis come on suddenly, or
soon after fever and drowsiness, are general and violent, and repeated in
quick succession, without allowing of lucid intervals between them. The
fever and hurried respiration are not accompanied by any pulmonary
lesion ; and there is no visceral phlegmasia or indication of an eruptive
fever. Convulsions symptomatic of or secondary to irritation in a part
remote from the brain, in early infancy, are seldom violent or of long
duration, and are often produced by appreciable causes,—indigestion,
teething, &c. The fit over, the little patient is soon restored to conscious-
ness, and if there should be drowsiness and disordered muscular move-
ments they seldom last beyond a few hours. The respiration does not
continue to be hurried ; and the pulse, if it had been excited, soon
resumes its regular beats, and the senses are also restored to their wonted
state. The distinction between meningitis and cerebral phlegmasia is
drawn with more difficulty ; and frequently cannot be made out at all.
Practically this is not of much importance, as the inarch of the two dis-
eases and their treatment are nearly the same. Hydrocephalus, infiltration
of the pia mater, hydro-meningitis, and arachnoidean hemorrhage come
under this category. In this last disease, convulsions come on early and
are repeated in quick succession ; but in general they are less violent than
those in meningitis, and are not accompanied by the agitation, or the coma,
or the febrile movements, which occur so readily in the latter. In hemor-
rhage of the arachnoid, M. Legendre mentions a symptom of contraction
of the fingers and toes, which is not met with in meningitis. Cerebral
vo:.. ii. —33
498
DISEASES OF THE NERVOUS SYSTEM.
congestion, cerebral hemorrhage and encephalitis are also diseases which
resemble, in many of their symptoras, acute meningitis. The inception of
small-pox and of scarlet fever, and also of typhoid fever, simulate often
pretty closely this latter disease ; but a careful study of the antecedents
and concomitants will generally enable us to diagnosticate with tolerable
accuracy.
Anatomical Characters.—The dura mater is often considerably dis-
tended, and in a remarkable degree injected ; its sinus contains commonly
clots of blood half coagulated. So soon as this membrane is removed, we
discover nearly the whole of the convex surface of both hemispheres
covered with a layer of a bright yellow or greenish-yellow colour; which
is also found on the internal surfaces of the hemispheres, in the upper
part of the cerebellum, on a line with the anterior and posterior lobes,
often, also, at the base, which, in some cases, however, is entirely free
from any exuded deposit. Examination soon shows that this yellow
layer is either liquid or concrete pus or false membrane ; and that these
products of inflammation are always on the pia mater, which is deeply
injected ; often, also, in the arachnoid cavity, but this last is of much less
frequent occurrence than in the sub-arachnoid tissue. In epidemic menin-
gitis and in subjects who have fallen victims early to its attacks, we only
find cerebral congestion in place of pus on the arachnoid or the pia mater.
The arachnoid membrane, even when it contains inflammatory products,
exhibits, itself, no trace of inflammation ; but preserves its normal polish
and transparency. In very young children the quantity of fluid may be such
as to constitute a true effusion. Pus is secreted both on the surface and
in the areola? of the pia mater. The purulent layer always abounds
most in the course of the great vessels, and in the convolutions and an-
fractuosities of the upper and lateral portion of the brain, more than at the
corresponding parts of its inferior surface : from the base to a line with
the chiasma of the optic nerves and the tuber annulare, the pia mater is
sometiraes quite healthy. The substance of the brain is generally firm,
sometiraes even harder than natural; neither the grey nor the white mat-
ter is much coloured, when death has taken place on the fourth or fifth day
of the disease ; and, at a later period, they are, at times, quite healthy,
although more commonly the grey substance is of a rose colour, and the
white mottled. Sometiraes, although the body of the brain is firm, the
convolutions at their surface are somewhat softened, and the pia mater,
when detached, brings with it some fragments of the brain. The ence-
phalitis here is deeper and more extensive the longer the period before
death has taken place. The ventricles, as a general thing, are empty, at
least of transparent serosity. They contain, it is true, a teaspoonful or
two, and, at the most, one or two tablespoonfuls of purulent serosity.
Rarely are their sides lined with false membranes. The serous appen-
dages of the ventricle and the plexus choroides, exhibit, in some cases,
evident signs of inflammation. The central parts of the encephalon, the
fornix and the septum lucidum, are sometime* firm, sometimes diffluent.
In very young children, the brain is soft through its entire extent: the
ventricles contain, often, a large quantity of serum ; and we also see an
abundant sub-arachnoidean effusion of serum. As regards seat, general
meningitis, or that which includes the whole or nearly the whole of the
encephalic surface, occurs the most frequently ; meningitis ofthe convex-
ity next; and then that of the base and the ventricles, which, taken to-
gether, are much rarer than the first two.
TREATMENT OF SIMPLE MENINGITIS.
499
Among lesions of the other organs we must note inflammation of the
spinal meninges, which there is good reason to believe is far from being
a rare complication. In simple or idiopathic meningitis there is no spe-
cial lesion of the viscera of the thorax or abdomen, certainly no tubercles
in any of them.
Causes. — With these we are not accurately acquainted. M. Rilliet
points out the greater frequency of meningitis irt the first and the ninth
years from birth ; and hints at dentition having, probably, some share in
its production. The most robust children are generally the most liable
to the disease. The number of subjects in the two sexes would seem
to be nearly equal. Insolation has caused the disease ; but it does not
occur most frequently in the heats of summer. A not unusual cause is the
sudden drying up of eruptions on the scalp, or of sores behind the ears. I
have seen acute and fatal meningitis from this cause. External violence
must, also, count in the enumeration of causes of the disease.
Termination and Prognosis. — Simple meningitis of children may ter-
minate in three ways : in death, in a cure, or in a chronic disease. The
first is, unhappily, the most frequent termination ; although it is alleged
by most writers that simple is less fatal than tuberculous meningitis. The
prior good health of the patient, and the absence of the tuberculous ele-
ment, furnish grounds of hope ; but, on the other hand, the extent ofthe
inflamraation and the rapidity of its progress give little time for action,
and diminish the resources of the practitioner. The passage of acute
meningitis into the chronic state may occur when the ventricular mem-
brane is inflamed, and then there results chronic hydrocephalus.
Treatment. — Owing to the confounding of simple with tuberculous
meningitis, and of both with dropsy of the ventricles or hydrocephalus, we
cannot derive much instruction from the published cases, under the head
either of meningitis or of acute hydrocephalus. Even they who look
upon this last as an inflammatory disease, restrict the antiphlogistic treat-
ment to the period anterior to the effusion in the ventricles ; the symp-
toms of which last are, however, very unsatisfactory, since they are met
with in meningitis unaccompanied or followed by any ventricular effusion.
It is now, however, generally conceded that, at the onset of simple acute
meningitis, prompt and decided antiphlogistic measures are those impera-
tively called for ; and of these, that bloodletting is the foremost. The
best mode is by venesection, where it is practicable, carried to the extent
of producing a decided impression on the disease, by reducing the force
and frequency of the pulse, the labour of respiration and the severity of
the headache. If even syncope be induced thereby, we ought not to be
in any hurry to bring about reaction, or, as it will be called, restoration.
Next to the lancet, for ease of application and expeditious effect, is cup-
ping behind the ears and on the nucha; and, if they are readily procur-
able, and can be applied by an experienced hand, leeches over the mas-
toid process, and in a line behind the lower maxilla and below the ear.
Some have applied them to the inside of the nose ; and others, over the
sagittal suture. Local bloodletting will only be had recourse to in very
young subjects, in whom the vein is too small or cannot readily be found.
The same result should be looked for from the local as from general de-
traction of blood—a decided and an obvious impression on the system.
The repetition of the bleeding will depend on the persistence of the me-
ningeal inflammation, as measured by the symptoms already enumerated.
500
DISEASES OF THE NERVOUS SYSTEM.
Even after the supervention of coma, if it have been preceded by symp-
toms of great meningeal inflammation, and if bloodletting had been pre-
viously neglected, it may still be advisable to take away some blood,
but not with the same freedom as at first.
The head and shoulders ofthe little patient should be raised and made
to rest on a hair-pillow : the head should be shaved and cold steadily
applied to the scalp by cloths dipped in cold water or containing pounded
ice, frequently renewed. A less troublesome and more efficient plan will
be to envelop the head down to the eyes in flannel, and to keep this
continually moist by irrigation, or a succession of small douches, with
cold water. In any case, means should be used to carry off the water
which trickles down on each side of the head and neck, so that the rest
of the body and bed-clothes may not be wet. While cold is thus steadily
applied to the head, the feet or even the lower half of the body may be
advantageously immersed from time to time in warm water, 98° to 100°
Fahrenheit, or, in place of this, kept warm with heated bricks, or stimu-
lated by sinapisms.
Free purging with calomel and saline medicines will serve to relieve
the head by diminishing the fulness of the bloodvessels, and, also, by
derivation. Some have recommended emetics, with a view of abating
arterial excitement; but this object will be better attained by tartar
emetic in contra-stimulant doses, combined with nitre, to meet the like
indication, as well as to act on the kidneys. Digitalis has its advocates at
this time : in the form of tincture united with sweet spirits of nitre, it has
done good. Some prefer it in powder united with nitre and small doses
of calomel. In proportion as the first or violently febrile period with
acute headache and delirium subsides, will be the freedom with which we
shall give calomel in small doses every hour or two hours, under the ex-
pectation of its abating the inflammation and preventing the formation of
morbid products, as well as of promoting their absorption after they have
formed. With the like intention, mercurial inunctions have been prac-
tised very freely, both on the shaven scalp and on the neck, and even
parts of the trunk, axilla?, &c, in which absorption is most rapid. It is
when the comatose succeeds the delirious, or first period, that counter-
irritants, by means of blisters to the legs or under the arm-pits, should be
used. If the disease have followed the retrocession or the sudden drying
up of eruptions or other sores on the scalp and ears, croton oil, to the
extent of fifteen or twenty drops, should be well rubbed on the bare scalp,
with a glove, and the frictions renewed three, four, or five times a-day,
until they produce a confluent pustular eruption having some resemblance
to small-pox. The entire head becomes soon afterwards covered with a
purulent cap, as it were, of a bright yellow colour. Care must be taken, in
making these frictions, that the eyes are protected by a temporary ban-
dage over them, lest the oil should touch them and give rise to a painful
ophthalmia. A blister over the entire scalp, to remain on at least twelve
hours, and kept in a state of suppurative discharge by tartar-emetic oint-
ment, has been extolled by some. Pustular eruption and discharge caused
by tartar emetic applied over the sagittal suture is, also, obtained with
a similar view ; viz., of keeping up permanent counter-irritation and re-
vulsion. It is a question, however, with many, whether irritation of the
scalp, or even nucha, as when blisters are applied to this latter, does not
cause an afflux of blood to the head, and endanger an increase of the in-
TUBERCULOUS MENINGITIS.
501
flamraation. A compromise, still consonant with theory and justified, also,
by experience, would suggest a delay in the use of these means, applied
directly to the head, until general excitement and the violence of menin-
geal inflammation have been reduced by direct depletion, and have begun
to subside into drowsiness or incipient coma. Dr. Bauer recommends a
remedy simple in itself, and the mode of action of which is analogous to
the revulsive. It is oil slightly heated, and applied, by means of a soft
sponge, over the entire surface of the body, with the exception of the
head. The patient is then to be enveloped in a flannel wrapper or blanket,
and left in that condition for two hours. In most cases a copious sweat
breaks out over the whole body ; and sometimes there ensues, also, an
eruption like that of measles; the nervous system is calmed, and the
secretions are augmented in consequence of this medication.
If meningitis make its attack during the period of dentition, the gums
must be carefully examined, and, if need be, freely and even repeatedly
lanced.
LECTURE CXXVIII.
DR. BELL.
Tuberculous Meningitis—Acute Hydrocephalus—Its literary history—Certain characters
of this disease different from those of simple meningitis—Slower in its approach,
longer in its duration, H accompanied by ventricular effusions, and its anatomical
changes chiefly at the base ofthe brain—Its tuberculous element—Diagnostic feature,
the situation of the inflammation—Anatomical characters—Concurrent affection of the
brain—tubercles on surface of encephalon and in the pia mater—Other lesions in
common with simple meningitis—Symptoms—In general, similar to those of the simple
kind—The period of incubation longer—symptoms of disordered brain and nervous
system at large—Period of invasion—Headache—vomiting—costiveness—delirium—
Except costiveness, these are less violent than in the simple kind—Fever, with in-
termissions— Third period, of convulsions—palsy—coma and insensibility—Duration
—Diagnosis—Inferred from symptoms, and contrasted with simple meningitis before
enumerated — Prognosis— Causes—Tuberculous diathesis—Table—Treatment—Pro-
phylaxis—Remedies in the forming stage-^Those in the period of invasion nearly ihe
same as for simple meningitis—Iodine preferable to calomel—The alkalies—Tuber-
culous meningitis of adults—With worms.—Chronic Meningitis—Men more liable
than women—Symptoms, termination and treatment.—Hydrocephalus—Essential and
symptomatic varieties of the acute kind—The first occurs without meningeal or cerebral
inflammation—The second or symptomatic the most common—Examples ofthe essen-
tial variety—Hydrocephalus—what it represents—Proportion of deaths from this dis-
ease—Greatest in crowded cities—Proportion of the two sexes—Hydrocephalus in
adolescence and early manhood—Dr. Kennedy's description—In symptoms and ana-
tomical changes closely resembling tuberculous meningitis—Treatment little satisfac-
tory.—Chronic Hydrocephalus—Its probable connexion with chronic meningitis—
Often a separate origin from this—May be either congenital or acquired—Seats of effu
sion—Chiefly in the ventricles—Changes in the brain and the cranium—Symptoms—
Sometimes without symptoms—Progress—Duration—Causes—Treatment—Surgical
and medical—Results of puncturing the skull and brain—The good effects of iodine
—Ipecacuanha ointment. ,
Tuberculous Meningitis—Acute Hydrocephalus of authors. I shall
not attempt a formal exposition of the symptoms, causes, and treatment
of tuberculous meningitis, as, in many respects, these are the same as of
the simple form. The tuberculous, only noticed distinctly within the last
twenty years, is now admitted to be the most common as it is the most
502
DISEASES OF THE NERVOUS SYSTEM.
alarming of all meningeal inflammations. But first, let me say a few
words on the history ofthe detection of this disease, mainly derived from
the work of MM. Barthez and Rilliet.
Sauvages was the first to give a description of acute hydrocephalus
under the title of eclampsia. He pointed out the coexistence of this dis-
ease with scrofula and rickets. Anterior, however, to him, Dnverney,
St. Clair, and Paisley had recorded cases of the disease, and had noted
the coincidence of hydrocephalus with pulmonary and mesenteric tuber-
cles. To Robert Whytt, are we indebted for the first, as on the score of
accurately described symptomatology it is still the best description, under
the title of Dropsy of the Brain (1768). It was reserved for Quin, of
Dublin, father and son, to show that dropsy was not the essential feature
of the disease, but that this latter depended on a morbid accumulation of
blood in the vessels of the brain, which sometimes attained the point of
inflamraation, and which produced often, but not always, an effusion of
water before death. Ford, adopting in part the ideas of Quin, introduced
a more definite pathology, by pointing out a double origin; viz., inflam-
mation of the pia mater, and a scirrhous (tuberculous?) induration of the
brain. Since then, authors, while generally agreeing as to the inflamma-
tory character ofthe disease, have advanced different opinions respecting
its seat and extent. Goelis and Piorry call it arachnitis, so also do MM.
Parent-Duchatelet and Martinet in their work on arachnitis. Coindet
located it in the ventricles of the brain, and gave it the name of internal
cephalitis, whilst M. Brachet attributed it to disease of the lymphatics.
M. Senn, in his monograph (in 1825), gave the name of meningitis to
acute hydrocephalus, and referred the seat of the disease to the pia mater.
But, a step farther was requisite beyond the admission of mere inflam-
mation, in order to place meningitis in its proper light. M. Guersent,
without actually making it, pointed out the way to others, when he
adopted the title of granular meningitis, and noticed the frequent occur-
rence, at the same time, of tubercles in other organs. Still, although he
separated granular meningitis from the other kinds of inflammation ofthe
cerebral membranes, he did not look on the granulations as tubercles.
M. Papavoine was the first to show conclusively the tuberculous cha-
racter which meningitis so generally assumes. His cases, two in number,
are detailed under the title of tuberculous meningitis, in the Journal Heb-
domadaire (1830). After having described, with great minuteness, the
meningeal granulations, he divides these tuberculous productions into
two forms : the laminated and the granular. He points out the fact of
the tuberculous affection having preceded the inflammation ; and indicates
the coexistence of meningeal granulations with tubercles in other organs.
Finally, he shows that the granulations may exist without occasioning in-
flammation,—a proof of which was furnished in his second case.
Subsequently, MM. Fabre and Constant presented a memoir on this
subject to the Institute, which obtained a prize from that learned body.
To Dr. Gerhar^ (Amer. Jour. Med. Science, April, 1834), and to his friend
and associate in Paris, in this and other useful labours, Dr. Rufz, in an
inaugural dissertation (1835), and M. Piet, in his thesis (1836), we are
indebted for interesting monographs on this disease, for which they still
retain the title of tuberculous meningitis. These writers have established,
as so many general laws, the conclusions which M. Papavoine had drawn
from his own observations, viz., 1, that the meningeal granulations are of
ANATOMICAL CHARACTERS OF TUBERCULOUS MENINGITIS. 503
a tuberculous nature ; 2, that they are analogous to the granulations
of other membranes ; 3, that they are found only in subjects whose
other organs contain tubercles. M. Piet was, we are told, the first to
show that the meningeal granulations may exist without giving rise to
noticeable symptoms, To the number of investigators of this disease
should be added Dr. Green, who, in the London Lancet (1836), has re-
corded his observations, and given a division of tuberculous meningitis
into acute and chronic, and M. Legendre (Recherches, 8fc).
Tuberculous meningitis, with many features in common to it and sim-
ple meningitis, exhibits certain peculiarities which will greatly aid, if not
entirely enlighten us on the subject of its diagnosis. The subjects of
tuberculous meningeal inflammation are in large majority delicate and
puny, whose intellect is quite precocious in its manifestations. The dis-
ease is generally slow and insidious in its approach, lasts for a longer
period than the simple kind, is mostly accompanied by dropsical effusions
in the ventricles, and depends chiefly on inflamraation of the membranes
at the base of the brain, with the important addition to this state of a tu-
berculous deposit on and in the pia mater, and, at times, contemporane-
ously the brain.
So much importance do MM. Rilliet and Barthez attach to the situation
ofthe meningeal phlegmasia, as diagnostic of the disease before us, that,
in the language of'the former, " if there be presented to us the brain of a
child, in which the fissures of Sylvius were agglutinated together, and
whose base exhibited a pseudo-membranous or concrete purulent infiltra-
tion, whilst the arachnoid and pia mater of the convexity were exempt
from inflammation, we should not hesitate to say, from this simple inspec-
tion, and without any preparatory dissection, that the ventricles are or have
been distended with a serous effusion, and that there are certainly tuber-
cles, either in the lungs or in the bronchial glands, or in some other organ."
Anatomical Characters.—These have, just now, been mentioned in the
supposed case of M. Rilliet. They are,—1. A deposit of tuberculous
matter in the JamellcB ofthe pia mater, presented under the form of either
flattened or rounded granulations, which are disseminated through differ-
ent parts of the membrane, at the hemispheres and at the base of the brain,
along the course ofthe vessels, varying in size from that of a grain of millet
to a pin's head ; more generally opaline or white, sometimes grey and semi-
transparent ; commonly isolated, though sometimes grouped. In sorae
rare cases granulation is the only meningeal lesion ; 2. An inflammation
characterized by a secretion of concrete pus, or of false membranes on the
pia mater, which, itself, is deeply injected, thickened, and infiltrated with
an opaline or sanguinolent serum or imperfectly coagulated lymph : it is
sometimes adherent to the cerebral surface. Most commonly the inflam-
mation is at the base of the brain ; 3. A peculiar condition of the arach-
noid, manifested by its being glutinous or sticky to the touch ; 4. A soft-
ening of the central parts of the brain ; the tissue thus changed is white,
of a creamy appearance, and is generally situated at the septum lucidum,
and the fornix ; seldom extending to the inferior portions of the ventri-
cles ; 5. An effusion of serosity in the ventricles, varying from three to six
drachms, and sometimes even more ; 6. A deposit, in the other organs, of
tuberculous matter, which is generally in an incipient state and assumes
the acute form.
The brain is, concurrently with the membranes, in many instances, the
504
DISEASES OF THE NERVOUS SYSTEM.
seat of tubercle in children. It is not always easy to say whether the
tubercles on the periphery of the brain were primarily developed in the
cortical substance and contracted adhesions to the pia mater, or were de-
veloped originally in this membrane, and afterwards united to the brain.
The fluid contained in the ventricles is generally limpid and colourless ;
although, sometimes, it is opaline, and contains albuminous flocculi. In
the deep injection of the plexus choroides, and softening ofthe fornix and
inner surface of the corpora striata, and thalami and parietes of the ven-
tricles, and the flattened state of the convolutions, there is nothing to
distinguish tuberculous from simple meningitis. So, also, with injection
of the cortical or grey substance, and the red sandy appearances of the
white or medullary, and the separation of the superficial portion of the
encephalic mass when the pia mater is separated. The chief difference,
in addition to the presence of tubercles, is the abundant effusion into the
ventricles. In some instances, there is concomitant effusion of serum
in the arachnoid cavity on the upper surface of the brain.
Symptoms.—Tuberculous manifests itself by nearly the same symptoras
as simple meningitis. There is, however, as you have been already told,
this important difference : that the period of incubation is much longer in
the former than in the latter. Weeks and even months before the attack,
there has been a change in the appearance and health ofthe child : there
is languor and weakness, or disinclination to take exercise ; the disposi-
tion is fickle, usually sad and irritable by turns; the complexion is pale
or sallow, the appetite is unequal, commonly wanting; the digestion is
disordered and emaciation ensues. The sleep is disturbed by dreams,
and the little sufferer awakes in a fright, and with wild alarmed looks ;
sometimes grinds his teeth, giving rise to a belief of his being troubled
with worms. Occasionally febrile paroxysms come on and rapidly disap-
pear in the course of the day. In a few instances this period is wanting,
and the disease is ushered in at once with violence.
The period of invasion is distinguished by chills and febrile reaction,
which is more liable to take a periodical character than the fever in sim-
ple meningitis. Headache, vomiting, and constipation are prominent
symptoms, the first less severe, the last more obstinate than in the simple
form of the disease. The tongue is much furred, and the symptoms gene-
rally are those of infantile remittent fever. Excitement and depression
are exhibited in alternation. Little is said; but the words are uttered
abruptly, and with a peculiar intonation. Singular aversion is manifested
to raising the eyelids for the purpose of the physician looking at the pupil.
Some regard this as a diagnostic sign. The sleep is disturbed by dreams,
and the grinding of their teeth ; the face at this time is pale, but at
short intervals is flushed. The breathing, like the circulation, is hur-
ried, but also irregular, a partial suspension following several rapid inspi-
rations, constituting what has been termed suspirous respiration. M.
Trousseau believes this to be a valuable diagnostic sign. So also he
thinks is the great ease with which the skin is reddened by the slightest
friction. The pulse, also, undergoes changes in its being sometimes slow.
A copious sweat occasionally bedews the face. The temperature is irre-
gular, sometimes greater, sometimes, in the advanced stage, less than
natural. In place of delirium, as in simple meningitis, ushering in the
disease, the intellect is preserved in the tubercular form up to the last or
convulsive, and comatose stage ; or, if there be delirium, it is of a quiet
kind. Frequently, however, loud cries are uttered by the patient, appa-
CAUSES OF TUBERCULOUS MENINGITIS. 505
rently extorted by the violence ofthe pain ofthe head. Painful contrac-
tions of the cervical muscles is a constant and characteristic symptom.
The duration of this stage is from eight to ten days.
The third period or stage, termed by some the convulsive, is marked by stu-
por and coma, alternating with violent convulsions and spasmodic contrac-
tion of the limbs; strabismus, dilated pupil with oscillatory movements ofthe
eyes, diminished and even deadened sensibility, and, finally, paralysis, of
the hemiplegic variety. During all this time the pulse is greatly accele-
rated, its beats being from 140 to 160 pulsations in a minute, and with-
out any of the remissions so observable in the period of invasion. The
vomiting has ceased, but the constipation persists with great obstinacy.
This stage lasts from seven to ten days.
As respects the entire duration of the tuberculous meningitis, Dr. Green
gives the following results, which indicate a shorter course than would be
inferred from the length of time of the separate stages. In 31 patients
death took place on the 7th day ; in 49 on the 14th ; in 31 on the 20th ;
and in 6 after the 20th. These estimates are unsatisfactory, since they
assume that the disease began with the open and violent attack of the
stage of invasion ; whereas that of germination, though not distinguished
by violence or dangerous symptoras, is really a part of the period of the
disease. Thus, for example, when we meet with a child who .has ex-
hibited a series of nervous disorders—a mood fitful and capricious, rest-
lessness, grinding the teeth in sleep, and indigestion,—for a month, and
is then attacked with unequivocal meningitis, which carries it off* in a
fortnight, we ought to assign a duration to the case of 44 to 45 days.
The diagnosis of tuberculous meningitis must be, by this time, well
understood, as far as respects distinguishing it from the simple kind ; but
there are the same embarrassments when we would distinguish- it from
the period of incubation of eruptive fevers, common and tuberculous ence-
phalitis, and typhoid fever. For some ofthe means of diagnosis in these
circumstances, I must refer to my remarks on the diagnosis of simple
meningitis. The tender age of the vast majority of subjects, of both varie-
ties of meningeal inflammation, will prevent our confounding them with
typhoid fever, which so rarely attacks children.
The prognosis is ofthe most sinister kind in tuberculous meningitis ; so
much so, indeed, that not a few observers deny that a case of this disease
with all its distinctive traits and lesions has been cured. The general
result is certainly of a fatal kind ; but every now and then we meet with
cases in which all the worst symptoms even in an evidently scrofulous, if
not tuberculous subject, have, after a time, yielded, and the health has
been restored. I have seen such, myself, in which the child has laid
for days insensible to every external stimulus, and with strabismus and
coma, and yet recovery ensued.
The causes are not well understood. Predisposition from inheritance,
or the tuberculous diathesis and tender age, cannot be overlooked. The
relative frequency with which tubercles or granulations are found in other
organs, is expressed in the following table, made out by M. Legendre :—
In the lungs - - - 27 times.
" bronchial glands 24 "
" spleen - - - 18 "
" digestive canal 13 "
In the liver - - 14 times.
" kidney - 10 «
" peritoneum 8 "
" mesentery 6 "
506
DISEASES OF THE NERVOUS SYSTEM.
Antecedent diseases, and, particularly, scarlatina, develop the tuberculous
diathesis into meningeal inflammation. External injuries have a similar
effect.
Treatment.—Reference being had to the early and inherited predispo-
sition to tuberculous meningitis, we might expect much good from pro-
phylaxis ; and accordingly it should be our endeavour, while giving the
child adequate nourishment, to avoid all excitants of the brain, to keep
the head cool and the hair short, and at the same time the lower extremi-
ties well covered and warm. All appeals to over and even much exer-
tion ofthe intellect should be carefully avoided, and the more carefully,
the more ready and precocious the mental faculties of the child. Altera-
tive tonics, such as the milder preparations of iron, including the iodide,
with laxatives; and, also, the iodide of potassium and cod-liver oil;
moderate out-door exercise, the tepid or warm bath, and prolonged cuta-
neous frictions, will constitute a part of the preventive course. During
the period of incubation, if the physician is consulted respecting the child's
ailments, he will adopt a course of measures calculated to arrest what he
must believe to be incipient inflammation, at the same time that he tries
to prevent the increase of tubercular growth. With this view he will
abate cerebral irritation, by the detraction of a small quantity of blood,
by leeches to the mastoid or nucha, or cups on this region ; if, under a
belief of more complete revulsion, he does not direct them to the anus or
over the abdomen. Constipation must be removed by mercurial purga-
tives, alternating with castor oil, syrup of rhubarb, confection of senna,
and the like. Now would be a proper time to procure the desired deri-
vative effects from counter-irritants, such as blisters, seton„or the actual
cautery. Of these the first is preferable, unless we are content to attempt
to procure a similar result by the milder measure of rubbing in croton oil,
until an eruption is produced. But, whichever means we may use, it
ought to be continued until the unpleasant symptoms have disappeared.
The blister may be applied to the nucha or to the inside of the thighs.
Among internal remedies, iodide of potassium will merit a trial at this
period combined with a vegetable bitter, or with a saline, so as to insure a
moderate action of the bowels.
When the meningitis is fully declared, and the period of invasion
reached, the treatment will be very analogous to, if not identical with,
that laid down for simple meningitis. Considering the difference in
the constitutional vigour of the patient, and the less intensity of cere-
bral disease and of disorder of the circulation in the tuberculous kind, it
will hardly be necessary to practise bloodletting with quite the same free-
dom now as in simple meningitis; and when had recourse to, the topical may
be tried in place of venesection. If it be deemed necessary to apply cold
to the head, you will follow the directions formerly laid down on this
subject. Although calomel will be given to act on the bowels, its use
will not be continued with the same freedom as in the simple form ofthe
disease. In its stead iodinic preparations are preferable; and there are not
wanting cases illustrating the success of this remedy in acute hydro-
cephalus, even when the paralytic stage had been reached. The mode of
administration was a teaspoonful of a solution, consisting of iodide of po-
tassium, xvi. grains, and iodine iv. grains, in water, ^ij., every two hours.
The first indication of relief was in 36 hours after beginning this course.
The free use of the alkalies with iodine should also be recommended.
SYMPTOMS OF CHRONIC MENINGITIS.
507
The iodide is to be introduced both by the mouth, and through the skin
by inunction. It is not necessary that I should specify with more minute-
ness the different remedies that promise, more or less, a salutary result in
reducing the phlogosis in tuberculous meningitis, having already enume-
rated them in the simple form.
Dr. Brockman describes, under the name of meningitis encephalica, a
disease incident to childhood ; and the cause and seat of which is chiefly
inflammation of the membrane covering the medulla oblongata and pons
Varolii. Deafness and deficient articulation are pathognomonic symp-
toras, which, for the most part, resemble those of cerebral meningitis.
Tuberculous meningitis in the adult subject was described in my lecture
on the Symptomatology of Phthisis, and you have, therefore, now placed
before you a tolerably full history of a disease which is one of the most
alarming and unhappily fatal to which you will be called, but which, until
within these few years, has not been observed in its affinities with tuber-
culosis.
Before dismissing the subject entirely, I must direct your attention to
a complication of worms with tuberculous meningitis, in which the former
was regarded as the chief disease, and the cerebral symptoms as merely
sympathetic and secondary. But although the pathology be erroneous,
there is one encouraging feature in the history of the disease with these
double features, viz., that it has been frequently cured. Cases must have
been seen by nearly every physician who has had even a tolerable range
of practice, in which, with fever, hot and dry skin, constipation, unequal
appetite, and the occasional discharge of worms, there have been irrita-
bility, restlessness, frequent moaning, grinding of the teeth, and cries dur-
ing sleep, with heat of the scalp, headache and sometimes convulsions.
These terminate fatally by neglect and mismanagement; but if treated
after a rational plan, by local bloodletting, calomel followed by castor oil,
or calomel and jalap, revulsives and cooling regimen, the result will often
be restoration to health.
Chronic Meningitis is a disease of unfrequent occurrence : having been
chiefly met with in the inmates of hospitals for the insane. It may be
either primary, or what is more usual, secondary to acute inflammation
of the meninges. The anatomical characters resemble those of the acute
form — such as thickening of the membrane, effusion, &c. The more
characteristic alterations are, false membranes giving rise to adhesions at
different points and small granulated bodies erroneously called glands.
Men are more subject to chronic meningitis than women ; and it is a
disease of old age, or at any rate of adult life, rather than of infancy. It
seems to run in certain families. Sometimes it has followed strong emo-
tions and the depressing passions ; and in other cases has been referred
to the excessive use of alcoholic liquors. The disease has also resulted
from external injuries, as bruises and wounds, even ofthe scalp.
The symptoms of chronic meningitis are, in some cases, slow in show-
ing themselves. More commonly there are evidences of cerebral conges-
tion. Headache sometimes ushers in the disease, and is followed by
some disorder of the intellect and other phenomena. The derangement
of function is divisible into three periods." In the first, the patient is ex-
travagant on one subject only ; he babbles, is restless, and totters in
walking. This state may be continued or intermittent, or may last for
some weeks or perhaps years. In the second period there is more of
508
DISEASES OF THE NERVOUS SYSTEM.
general delirium, with great restlessness and impulse to motion, but the
movements are more and more difficult. The nutritive functions during this
time are often not affected ; the patient having even a voracious appetite,
and gaining flesh. In other cases he becomes emaciated to the ex-
tent of marasmus. The pulse is usually not affected in this period. In
the third period, the intellect is entirely gone, and the patient is in a state
of complete immobility, one effect of which is atrophy of the muscles.
The nutritive functions are now greatly affected. The emaciation in-
creases : diarrhoea, dyspnoea, and copious bronchial secretion close the
scene.
In each of these periods there may supervene other symptoms, such as
apoplectic or epileptic seizure, convulsions, tetanic spasm and rigidity,
tremours, &c.
The succession of symptoms in the different periods are explicable by
the changes in the membranes, from simple irritation, transmitted to the
brain on to effusion on the surface of this latter and in the ventricles, and
finally intercurrent cerebral inflammation.
The termination of chronic meningitis is generally in death, and this
occurs in the third stage, unless some intercurrent disease abbreviates the
life ofthe patient.
The treatment is simple, but, unhappily, of little efficacy. It consists
of bloodletting, of which we must be sparing in proportion to the duration
of the disease ; followed by drastic purgatives and counter-irritants, by
blisters, moxa, and setons. The patient should be exercised regularly,
and not crossed in his notions, except where they are such as would inter-
fere with his personal safety.
Acute Hydrocephalus.—While admitting that most cases of acute hy-
drocephalus are, in fact, those of tuberculous meningitis in which effusion
in the ventricles is so frequent, not to say constant an occurrence, I told
you, that there were many cases of this form of dropsy which could not
be attributed to inflammation either of the meninges or of the brain. This
variety of hydrocephalus ofthe acute form is called essential in contradis-
tinction to that following organic disease and chiefly the phlegmasia just
mentioned, and which is called symptomatic. Of the frequency of the es-
sential variety we cannot doubt after reading the observation of Louis, that
in three-fourths of the subjects who died from phthisis and were examined
by him there was extensive effusion into the ventricles ; and the statement
of Dr. Mauthner, that he met with fluid in the ventricles in 172 out of 229
post-mortem examinations of children who had died of various affections,
and that in 123 instances the fluid present was in considerable quantity.
Cerebral dropsy will take place under the same circumstances as those in
which general dropsy or ascites or hydrothorax is met with, viz. : from
Bright's disease, or organic affections of the heart or great bloodvessels,
without the occurrence of either meningeal or encephalic inflammation.
As described in medical writings generally we must, however, take the
title, acute hydrocephalus, as representing, without adequate specification,
cases both of meningeal and encephalic phlegmasia and tubercle, as well
as those occurring under the circumstances just mentioned, in which inflam-
mation is reasonably presumed to be wanting. Hence we cannot attach
much value to statistical returns, such as that of the Registrar-general in
England, from which it appears that five per cent, of all deaths under
fifteen years of age arise from this disease : the Berlin bills of mortality
ANATOMICAL CHARACTERS OF ACUTE HYDROCEPHALUS. 509
yield a similar result. It also seems to be proved, that residence in cities
greatly increases the tendency to hydrocephalus, and that this tendency
is almost in direct proportion to the degree of crowding of the popu
lation. If we admit the great predisposition to meningeal and cerebral
tubercle by a scrofulous diathesis and the want of fresh air, exercise and
adequate nourishment, we can readily understand the force of the assigned
causes of hydrocephalus.
The period of the greatest frequency of this cerebral and meningeal
dropsy is from two to seven years of age ; and the proportion of fatal cases
in males is twenty per cent, greater than in females; a fact for which we
can offer no adequate explanation ; it is the raore singular as being in direct
contrast with the results in hydrocephalus from meningeal inflammation at-
tacking older subjects with the phenomena which I am about to describe.
Dr. H. Kennedy of Dublin gives an interesting account of hydrocepha-
lus, as he terms it, coming on at a later period than it is commonly met
with, viz., between 12 and 25 years: about the 15th year is a common
time to see it. In Dr. K.'s experience it has been much more frequent
among females than males, in the proportion of two to one. Cheyne has
remarked that when hydrocephalus is seen in persons above ten years old,
it is most common in females. The following are the prominent points to
which Dr. Kennedy directs attention in his paper. The disease usually
commenced with the ordinary symptoms of fever, which lasted from ten to
twelve days. Sometimes there was complaint of headache, which last was
readily relieved by local bleeding. Restless sleep and crying out in the
night have awakened suspicion of impending disease of an alarming cha-
racter. Sometimes the first symptom that caught Dr. K.'s attention was
vomiting. From the twelfth to the sixteenth day,from the very commence-
ment of the illness, the pulse kept in or about 100 ; very seldom did it reach
120 ; the tongue, however, was a good deal furred, and this symptom, it
may be observed, was a constant one. As a general rule the pain was
referred to the forehead just over the eyes. Then would ensue trifling
strabismus and ptosis. " On the whole the appearances presented by the
eye are the most important, and most constant of any of the symptoms of
the disease. The pulse now undergoes great fluctuations, falling from
100 in one day to 60, 55, and in one instance to 48, and so remained for
a period of two days. This is a symptom which of course, as every one
knows, is very constantly observed in the hydrocephalus of childhood ; it
is if anything, however, more marked in the form of disease now under
consideration." The pulse would rise again to 130 or 140 and so remain
steadily until death. Convulsions of one side and a spastic state of the
upper extremities appeared the two or three last days of life. Death
seemed to take place by bronchial effusion. Constipation did not attract
Dr. Kennedy's notice. The entire duration ofthe disease was commonly
about three weeks. The posture of the patient in his bed is, very con-
stantly on one side and often with the limbs drawn up, and this until
within a day or two of death. It is very common to see the hand of the
patient applied to the head, and the brows strongly knit in sleep.
The anatomical characters were very uniform. Opacity of the arach-
noid with a large effusion of gelatinous lymph under it, varying in
colour between white and yellow and always particularly well marked in
the optic commissure and the fissure of Sylvius : next to these parts is the
pons Varolii, as being the most common seat of the effusion. Sometimes
510 DISEASES OF THE NERVOUS SYSTEM.
there was a distinct coating of lymph on the arachnoid ; and in three in-
stances this lymph had put on a granulated appearance. The upper sur-
face of the brain was often quite healthy, though at other times it was found
more or less congested, while serous fluid in small quantity existed under
the arachnoid. There was very constantly effusion into the ventricles, va-
rying from half an ounce to two ounces. Though no constant concomitant
organic lesions were found in the other cavities, yet any morbid appear-
ance in either of them was always ofthe same character, that is, the stru-
mous. You must be forcibly struck with the great coincidence in mode
of invasion and general symptoras and anatomical lesions between the hy-
drocephalus, now described by Dr. Kennedy, and tuberculous menin-
gitis under the aspect in which it is regarded by M. Rilliet. The diagnosis
is difficult, the disease having sometimes been mistaken for hysteria. From
treatment little so far can be expected, even when begun in the forming
stage. " Local bleedings with mercury and blisters hold out the best
prospect of success."
Chronic Hydrocephalus.—If acute hydrocephalus be really acute
meningitis, simple or tuberculous, it might be supposed that chronic
hydrocephalus would be represented by chronic meningitis. There are,
in fact, effusions on the brain and in the ventricles in chronic meningitis;
but these do not constitute so characteristic a feature of the disease as
they do in chronic hydrocephalus ; which last, moreover, is almost entirely
confined to infancy and childhood, whereas the other is restricted, mainly,
as we have seen, to adult and to advanced age.
There is, however, this much common to acute and chronic hydro-
cephalus, independently ofthe effusion, viz., that the tuberculous element
is found in a majority of both forms. Each, also, may display two varie-
ties, the simple and the tuberculous; and in both the last merits the most
consideration.
Chronic, hydrocephalus may be either congenital or acquired. In the
first kind, the size of the head prevents the passage ofthe child, and re-
quires the operation of craniotomy for its expulsion from the uterus ofthe
mother. In the second, the disease may follow the acute form, but more
generally by far comes on slowly and almost insensibly until it has made
considerable progress.
Hydrocephalus, both in its acute and chronic forms, may consist either
of effusion on the arachnoid, that is, in the arachnoidean cavity, or in the
ventricles. In the first case it is the result of hemorrhagic congestion and
effusion ; in the latter of tubercles or of encephalic tumours. In some
instances the dropsy is manifested by serous effusion between the lamellae
of the pia mater, and in others, again, by edema of the brain itself, the
tissue of which becomes pale and softer than natural.
The chief form of hydrocephalus is that of the ventricles, which latter
are enlarged in consequence ; this change is more particularly observed
in the lateral ventricles and next in the fifth, but less in the third. The
communications between the ventricles are, also, enlarged. The consist-
ence of the walls is sometimes increased, but, at other times, is greatly
diminished. Accompanying the dilatation of the ventricles is a thinning
and unfolding of the cerebral substance ; the hemispheres seem to have
partially disappeared, and to be reduced to delicate laminae of only a few
lines in thickness.
The external surface of the brain is also changed, the arachnoid cavity
SYMPTOMS OF CHRONIC HYDROCEPHALUS.
511
contains but a few drops of serosity ; the pia mater is thin and pale, and
scarcely indented with a few red vessels, and it is closely applied to the
brain, although, at the same time, it is easily detached from this latter.
The convolutions are flattened, pressing on each other, and not separated
by the usual anfractuosities: the distinction of grey and white matter is
lost. Through the walls of the firmer hemispheres it is easy to see the
fluctuations ofthe contained fluid.
In the arachnoidean hydrocephalus, the fluid is sanguinolent serum, or'
yellow serosity, in quantity more considerable even than in the ventri-
cular variety. One effect of this effusion is a separation ofthe brain from
its cranial case, and its being pushed towards the middle of the base of
the skull, just as the lung is pushed by pleuritic effusion against the ver-
tebra] column. The brain at this time is apparently small, but as its
dimensions cannot be very materially diminished, we are less surprised
to discover that an examination, by spreading out its several parts, shows
the cerebral mass to have undergone little alteration in this respect. In
the congenital variety the brain is sometimes quite rudimentary, sometimes
wanting.
The cranium is enlarged with the extension of the brain, and at times
acquires an enormous size, while the face, retaining its customary propor-
tions, seems to be smaller tljan natural. The fontanelles and sutures are
not only open but greatly dilated ; the bones of the cranium become ex-
tremely thin. In some cases the disease comes on after the sutures are
closed, and the size ofthe head continues unchanged ; but still raore fre-
quently, in this variety, the bones become gradually detached from each
other, and are only held together by a fibrous structure.
The symptoms of chronic hydrocephalus are, at first, wh#n the disease
is forming, irritability of disposition or unequal mood, and that state of the
senses and nutritive functions which is so generally associated with dis-
turbed brain. To these soon succeed great derangements of the ner-
vous system, marked by muscular feebleness, and sometimes epileptic
fits. The memory and senses are weakened, and there is sleeplessness,
and a dull heavy pain of the head. After the disease is formed, drow-
siness prevails. The pupil is dilated, and there is often strabismus.
The digestion is good. To show, however, the little dependence to be
placed on the mere effusion as an attribute of serious disease, it should
be known that there are well-authenticated cases of chronic hydroce-
phalus without symptoms during life. See passim, a case related by Dr.
Bank (Dublin Journal, 1846).
Dr. Fisher, of Boston, and Dr. J. R. Smyth, of London, have pointed
out the utility of cerebral auscultation in its application to the diagnosis of
chronic hydrocephalus. Dr. Whitney has frequently tried it with advan-
tage^ He has found that a cephalic bellows-sound constitutes a very
prominent symptom: it is heard most distinctly in those situations where
ossification of the skull is incomplete. It is a coarse, rough, and rasping-
sound, synchronous with the pulsations of the brain, and movement of the
circulatory apparatus. In one instance, in which the brain was punctured,
the sound was modified by the evacuation ofthe fluid, and became a low
and indistinct murmur, but regained much of its former character as the
fluid re-accumulated.
As the disease advances, the debility is greater, the patient is unable
to support himself in an erect posture, and he indicates a preference for
keeping the head lower than the rest of the body. The intellect is greatly
512
DISEASES OF THE NERVOUS SYSTEM.
weakened and after a time entirely lost, and the moral faculties in a mea-
sure are abolished. In a few cases, however, the mind is not sensibly
affected, or sorae one faculty may remain unimpaired to the last. The
sexual propensities are often strong, and in some cases of children the
organs are prematurely developed.
The duration of this disease is very various, the prognosis bad, and the
treatment of course unsatisfactory and discouraging. The causes of chronic
hydrocephalus have been referred to a scrofulous habit, mechanical inju-
ries by falls, &c, and the repulsion of certain eruptions. A more definite
attribution is to tuberculous growths, which, particularly at the base of the
brain, compress the sinuses and interfere with the circulation, particularly
the return of blood by the veins, and in this way give rise to dropsical
effusions on the brain.
The treatment of chronic hydrocephalus must be begun under great
discouragement. Just now it may be divided into the surgical and the
medical: the first consists in puncturing the cranium, meninges and brain,
and evacuating the fluid ; the second in the administration of remedies
calculated to produce absorption. Dr. J. T. Conquest is the originator, or
at any rate the successful introducer of the practice of tapping the head in
chronic hydrocephalus. " The most eligible point at which the trochar
can be introduced is in the course of the coronal suture, about midway
between the crista galli process ofthe ethmoid bone and the anteriorfon-
tanelle, so that the danger is avoided of wounding the corpus striatum on
the one hand and the longitudinal sinus on the other. The instrument
usually penetrates about two inches, and in most cases the serum has been
colourless, but occasionally tinged with blood." Dr. Conquest's first
paper (in the Lancet, 1838) contains a list of nineteen cases, of which 10
were living and 9 dead after the operation. In seven of these the tapping
was performed only once ; in five, twice ; in three, three times; in two,
four times ; in two, five times. Of these last two, one ended favourably,
the other fatally. Of the five cases in which tapping was only performed
once, four survived. There are now 63 authenticated cases on record in
which puncture ofthe brain has been performed : and in 18, or 28*5 per
cent, of these the child recovered. These have occurred chiefly in Great
Britain and in Germany. In France, both Dupuytren and Breschet have
failed to obtain successful results. M. Trousseau's experience is, we be-
lieve, more favourable. This gentleman recommends the following method
ofprocuringafirmand equal pressure on the head after the operation. "The
hair being clipped as short as possible, he applies strips of diachylon plas-
ter four lines broad. 1st. From each mastoid process to the outer part of
the orbit ofthe opposite side. 2. From the hair at the back of the neck,
along the longitudinal suture to the root of the nose. Across the whole
head, in such a manner that the different strips shall cross each other at
the vertex. 4th. A strip is cut, long enough to go thrice round the head.
Its first turn passes above the eyebrows, above the ears, and a little below
the occipital protuberances, so that the ends of all the other strips shall
project about three lines below the circular strip. These ends are next to
be doubled up on the circular strip, and its remaining two turns are then
to be passed over them just in the same direction as the first turn."
The medical treatment consists chiefly of diuretics and iodine internally,
and of counter-irritation externally. Among other cases of favourable result
from the administration of iodine, is the one recorded by Dr. Barber (St.
Louis Med. and Surgical Journal). The hydrocephalus was congenital.
EPIDEMIC MENINGITIS.
513
At the time there was diarrhoea and great marasmus. After mercury and
chalk, with Dover's powder and mild aperients, Dr. Barber gave the iodide
of potassium in a dose of two grains, in solution, three times a-day. He
also directed a blister to the head and frequent affusion of cold water over
this part. Six weeks' perseverance in this plan of treatment produced a
great change in the little patient: " the secretions rapidly improved ; the
irritative fever gradually yielded ; the head, day by day, diminished in
size; the convulsions did not recur; and the little boy, having gained
flesh, strength and complexion, left St. Louis, apparently perfectly well."
Dr. Hannay, Edinburgh, relates a case of chronic hydrocephalus, in which
he believes that recovery was in a great measure due to the employment
of ipecacuanha liniment to the scalp. The formula he adopts is, r. Ipe-
cac, pulv. jij. 01. Oliv. gij. Adopis ^ss. M. The employment of this
liniment three or four times daily is followed in about thirty-six hours by
a papular and vesicular eruption. This may be of greater use where it
replaces eruptions of the scalp that had dried up or been repelled. We
cannot doubt that the principles involved in Dr. Hannay's practice may be
carried out as well by the external use of croton oil, as recommended in
acute meningitis.
This would be the place to speak of tuberculosis of the brain, and to
point out in detail the various affections which have been vaguely attri-
buted to congestion or inflammation, and, as in the case of chronic hy-
drocephalus, to dropsy of the encephalic organs. I must be content
with simply stating the connexion between tubercle and effusion in the
ventricles constituting the chronic disease ; having indicated previously
and in some detail the connexion of tubercle of the meninges and effusion,
constituting the acute form of hydrocephalus.
The treatment will consist of the use of such alteratives as iodinic pre-
parations, including the iodide of potassium and the iodide of iron, alter-
nating with other chalybeates and vegetable bitters and diuretics. Of the
external remedies, the warm bath, frictions, and an issue or perpetual blis-
ter, will be the most worthy of attention.
LECTURE CXXIX.
DR. BELL.
Epidemic Meningitis—Its appearance of late years in France and other parts of Europe
arid in the United States—Prevailed in former times—Not confined to the military__
Etiology—Change of habits of young recruits—Excessive fatigue-^Crowded barracks
—In Gibraltar civilians, and of ihese the poor, most suffered—Young persons most
liable—In Tennessee occurred in civilians—Subjects young—In Ireland, boys__
Symptoms—Analogous t,o those of sporadic meningitis—Two successive periods—
First stage—Excitement and collapse—Cephalalgia—Convulsions—Tetanic rigidity
—Second stage—Collapse—Invariably coma—Differences in mode of attack—Sud-
denness—Sometimes a third stage or typhoid—Occasional incipient symptoms—Case
—Predominance of some one symptom—Periodicity of the disease—Suspicion of its
congestive character—Progress and duration—Termination—Diagnosis— Difficult to
distinguish from congestive or intermittent fever—Morbid anatomy^Evinces three
stagesi: congestion, inflammation and suppuration—Appearances of the membranes
and of the brain and spinal marrow—Suppuration mainly seen in epidemic meningitis
—(.astro-entorittc complications—State of the blood—Treatment—bloodletting— revul-
sives— M. Hoi el's use of actual cautery—blisters—purgatives—mercury not service-
, able—great value ot opium-sulphate of quinia—Tartar emetic—Inhalation of ether.
Meningitis, or rather cerebro-spinal meningitis, has, within a few years
vol. n.—34
514
DISEASES OF THE NERVOUS SYSTEM.
past, assumed in different parts ofthe world the character of a formidable
epidemic. By some ofthe writers who have described its progress and
peculiarities, reference has been made to the history of epidemics, in order
to show that an analogous disease has at different times, from 1510 to 1805,
prevailed with more or less intensity in various parts of Europe. With
what degree of correctness this opinion is advocated, I cannot now stop
to inquire. I may repeat, after M. Casimir Broussais, that retrospective
medical history seems to show that the disease has prevailed epidemically
in different countries of Europe, under the names ofcerebral fever, phrensy,
cephalalgia, fyc, chiefly in the years 1503, 1510, 1517, 1545, 1553,1559,
1571, 1580, 1582, 1616, 1661, 1757, 1788, and 1805. The symptoms
were, violent delirium, convulsive agitation, general rigidity of the limbs
speedily followed by prostration and coma ; sometimes the pulse was full
and frequent, at others slow and feeble. Death supervened at an early
period ; sometimes in a few hours, but more generally in three or four
days ; and it was observed that the malignity of the disease was manifested
less by the number of deaths proportionate to those attacked, than by the
rapidity of the case towards a fatal termination. Still, however, as we
learn from Ozanam, epidemic cephalalgia, combined with epidemic catarrh,
in 1580, carried off ten thousand persons in Rome, twelve thousand in
Venice, and two thousand in Madrid.
Many writers mentioned the presence of worms ; and they, also, spoke
much of sweats and eruptions, which were sometimes critical, but often
not ; and of chills, paroxysms, remissions and intermissions, sometimes
at the beginning, but more commonly towards the conclusion of the
disease.
M, Broussais completes hisbrief sketch of antecedent epidemic cerebro-
spinal meningitis, after Ozanam, by inference to a few and imperfectly
recorded cadaveric inspections, and the outlines of treatment, which latter,
as resting on no recognised pathological basis, was necessarily uncertain
and contradictory in different quarters. He proceeds, afterwards, with the
proper subject of his history, by a statement of the different accounts of
the disease, as it has appeared in France, which have been drawn up
chiefly by the army surgeons and physicians. First appearing at Bayonne,
Bordeaux, and Rochelle in 1837, and afterwards at Versailles and St.
Cloud in 1839, it seemed to be fixed in these two latter towns up to 1842.
From Versailles it branched off in one direction to Caen and Cherbourg in
1840 and 1841 ; and in another to Metz, Strasburg, Nancy, and Colmar,
in a period between 1839 and 1842. In a different direction it was met
with at Laval, Mans, Chateau-Gonthier, Tours, Blois, and Joigny, in 1840
and 1841. Finally, it gained the neighbourhood of Rambouillet. During
all this time the disease, with few exceptions, as in the Landes and at La-
val, Rambouillet, and Strasburg, was confined to the soldiery.
In another quarter of the kingdom, but still in the south, the disease
began at Narbonne and Foix in the year 1837 ; and thence in 1838 broke
out in Toulon ; but in the beginning of 1839 it showed itself at Nimes,
where its attacks were confined to the garrison. In the winter of 1839-40
it appeared at Avignon, and again in the following winter. In this town
the soldiers were the first attacked, but subsequently some oT the civil
population were sufferers from the disease. In 1840, it broke out at
Monthrison, and at Lyons in the winter of 1841-42. Finally, it branched
oiTin another direction to Fe;-;)ig:;n in the winter of 1840-41, and seem-
ETIOLOGY OF EPIDEMIC MENINGITIS.
515
ingly retraced its course to appear at Aigues-Mortes the following winter.
In this last town, no part of the civil population was exempt—children
suffering equally with the military.
Epidemic meningitis has appeared in other countries besides France. It
has been noticed in different cities in Italy during the winters of 1839-40
and 1810-41, and more particularly in the kingdom of Naples, where the
physicians designated it by the term convulsive or apoplectico-tetanic
typhus, &c. In Gibraltar the disease prevailed in the early part of the
year 1844; but almost entirely among the civil population. — (Gilkrest
—Med. Gaz.)
I took occasion, in the early part of the year 1843, to direct the attention
of the professional public, through the pages of my journal (Bulletin of
Medical Science, February, 1843), to a description of an epidemic ence-
phalo-meningitis in France, and to the occurrence of a similar disease in
Tennessee, in the beginning of the year 1841. Valuable additions to our
prior knowledge on this subject are presented in a monograph (Histoire
des Meningites Cerebro-spinales, fyc), by M. Casimir Broussais, son ofthe
celebrated teacher and reformer, who designates it appropriately as cere-
brospinal meningitis. By others it is called cerebro-spinal arachnitis. I
gave, in the Bulletin of May, 1843, a tolerably complete sketch of the
contents of this work, constituting, in fact, a miniature monograph, in
which the features and characteristics of the disease and treatment were,
I believe, faithfully exhibited. Under this impression I shall now re-pro-
duce it for your benefit; believing, also, that you will not yet, for some
time to come, find in other quarters so satisfactory a picture of this new
and formidable disease. I shall, as occasion requires, here and there in-
troduce some lines from the descriptions ofthe epidemic as it occurred in
Tennessee, Mississippi and Missouri in the United States, Ireland and
Gibraltar in Europe, and Algeria in north Africa.
Etiology.—Asthe disease in question attacks a greatnumberof persons in
a definite period, and cannot be referred to causes depending on season or
locality, it ought, M. Broussais thinks, to be called rightfully an epidemic.
The causes of cerebro-spinal meningitis, as it has been observed of late
years in France, are predisposing and exciting. Ofthe first we may enu-
merate fatigue, recent arrival at quarters, and crowded barracks.
We find an enormous disproportion of those attacked with the disease
among new recruits. M. Faure-Villar reports in his memoir, that of 154
sick with the epidemic in 1839, there were 103 recruits ; and that, of 66
deaths, 56 were of this latter class. It was the sarae with the epidemic
in 1841: all the patients at first were among the recently arrived recruits ;
and it was only at a later period that the older soldiers were attacked.
At Bayonne, in 1837 and 1839, M. Lalanne observes, that a great majo-
rity of the sick and those who died from the epidemic were composed of
recruits ; that most of them laboured under nostalgia, and that the disease
seldom extended to those men who had been more than two years in the
service.
At Metz, M. Gaste notes with peculiar emphasis the crowded state of
the barracks of the artillery, which furnished nearly all the diseases in
1839-1«40, from November to March ; and from this crowding he inferred
the evolution of a miasmatic poisoning. At Laval in 1840, out of 44
deaths, there were 37 new soldiers, and the increase of cases was always
in proportion to the arrival of recruits. On the other hand, the subjects
516
DISEASES OF THE NERVOUS SYSTEM.
of the disease in Algeria, according to Dr. Mogail, were robust healthy
men, who had been in the service for one or two years.
The modifying influence of a vitiated air from crowded barracks was
manifested in Metz, in the typhoid form of meningitis being the most fre-
quent. In Gibraltar the poor suffered most.
.dge has a powerfully predisposing effect. In France, the young sol-
diers were the chief sufferers. In Ireland and the United States, the dis-
ease has been almost confined to the young under the age of puberty.
Most ofthe cases in Gibraltar were of subjects under 18 years of age, or
between 2 and 15 years, and very few beyond the age of 30.
In Ireland, the disease has attacked boys exclusively, although girls
of the same age were placed with the former, under precisely the same
hygienic conditions.
On the evidence of all the members ofthe medical corps ofthe French
army, we must reject contagion, as at all noticeable in the etiology of epi-
demic meningitis.
The symptoms of epidemic meningitis are, in general, the same as those
ofthe sporadic ; but in making this remark, we ought to add that the dis-
ease presented itself with considerable varieties of stage and degree. Our
attention, however, will be more particularly arrested by two successive
periods of the epidemic: viz., of excitement and of collapse; but we
ought to be aware that those do not always show themselves in a uniform
order of succession, by excitement preceding collapse. The reverse, or
the introduction of the disease by collapse, is sometimes the case, although
of less frequent occurrence. When the patient, from the first, suffers from
prostration, somnolency, &c, the prognosis is unfavourable, and the result
generally fatal; to such a degree that sometimes death takes place in the
state of stupor. The two stages or forms of the disease are designated
by the authors of the several memoirs on the subject, under the terms of
ataxic and lethargic, inflammatory and typhoid.
In the first stage, or that of excitement, the eyes are sparkling; the
face red ; the pulse is strong and frequent; speech abrupt: complaint is
made of cephalalgia, of more or less intensity, and of an acute pain at the
nucha. There may be, at the same time, irregular movements, convul-
sive mobility of the muscles of the face, and convulsions of the limbs;
and loud and repeated complaints made by the patient. In the midst of
all these symptoms consciousness remains entire, or the intellect is but
slightly troubled by acute delirium, which is, however, of transient dura-
tion, coming and going at intervals. Often a tetanic contraction of the
jaw and back, trismus and opisthotonos, are met with. Dr. Richardson
(West. Journ. Med. and Surg., December, 1842) states, that in nearly all
the bad cases, the head was drawn back on the shoulders, and the whole
spine, from the head to the sacrum, was bent like a well-strung bow. So
great was the extension of the body that many patients could not lie on
the back at all. He never saw such a contraction of the spinal muscles,
except in the form of tetanus called opisthotonos.
Great intolerance of light and sound exists, to such a degree that the
smallest ray of light or a noise the least discordant is apt to provoke con-
vulsive movements.
This form of the disease, which is, also, most commonly the first stage,
is replaced in serious cases by the other form, which is really then the
second period. The latter is characterized by a general collapse, insensi-
bility and coma ; but these symptoms are not always present from the first.
SYMPTOMS OF EPIDEMIC MENINGITIS.
517
The symptoms immediately preceding death, as Dr. Richardson observes,
were much like those observed in children who die of acute arachnitis
terminating rapidly in effusion. Some patients complain of fatigue, uneasi-
ness, prostration and ennui, and acquire an undeserved reputation among
their comrades for being idlers, loungers, or, in barrack phrase, clampins
—malingerers. M. Broussais received in the hospital of the Val-de-Grace
a soldier in a state of coma, which terminated fatally in twenty-four hours.
—in whom no other symptoms than those just described were seen. A
vast purulent layer under the arachnoid enveloped the whole ofthe brain.
In such cases the pain of the head is obtuse and heavy, in place of
being acute and lancinating ; the eyes are dull and half closed ; speech
indistinct and laborious: there is a swimming of the head, and vertigo,
especially when the patient attempts to get up and walk, and his limbs
totter under him. After a period of variable duration, these preliminary
symptoms are replaced by a violent agitation, called period of reaction,
or by a complete stupor. The series of bad symptoras may begin with
this latter; so that, more than once, soldiers in the ranks, and apparently
in good health, have fallen down suddenly, deprived of all consciousness.
It is under such circumstances that the pulse is slow, sometimes full, at
others weak; the pupil is most commonly dilated and immovable ; there
is complete general insensibility: or, on the other hand, such an exalta-
tion of sensibility, that the least contact with any part of the body elicits
a plaintive cry from the patient. It is not unusual to hear, also, acute
cries spontaneously uttered, interrupting from time to time the stupor and
coma, and to observe the patient carry his hand mechanically to his head,
and sometimes to cry out—My head! my head! — as if he felt in that
region the most acute pain.
More frequently the stupor is not so great as to prevent the patient giv-
ing some signs of consciousness when he is suddenly called by name, by
moving his head and trying to articulate a few words which die away on
his lips, and half opening for a second his eyelids, which close almost as
suddenly.
Whether or no the symptoms now described be those of the second
period, or, as rarely happens, they introduce the disease, if the latter is
prolonged for any time there are manifested symptoms of a third stage.
This is the typhoid, in which the tongue is dry, the lips incrusted, the com-
mon calls of nature cease to be attended to, and the bladder is distended
with urine or is continually allowing it to escape : so, likewise, with the
fecal matters. This state is often complicated with paralysis of some sense
or with hemiplegia. Dr. Richardson met with partial deafness in almost
every case, and blindness in others.
M. Broussais does not deem it requisite to describe the initial symptoms
of meningitis, because they may often be wanting, and, besides, they are
not peculiar to this disease. Such are a chill and vomiting. Almost all
the writers on the subject designate, however, as a pathognomonic sign,
rachialgia, which, according to M. Tourdes, is only absent in the purely
cephalalgic variety and in the suddenly destructive cases. Constipation
and suspended secretions were common features ofthe disease.
^ Among the numerous cases recorded by M. Broussais is one headed
Coma—reaction—collapse—of a young soldier, of a thin but robust frame,
who had sickened in the evening, and suffered through the night with a
chill, followed by headache and fever. On the following morning he was
518
DISEASES OF THE NERVOUS SYSTEM.
sent to the hospital, and in a very short time after his arrival there the
physician found him in the following state : Complete loss of conscious-
ness, cold skin, pulse extremely small and slow, great alteration of the
features; eyes fixed and sunken, cheeks hollow, skin of a livid hue, of a
choleric appearance, hands sodden and blue.
Reaction followed this state of coma, and was manifested in convul-
sions and restlessness, so great as to compel the use of a straight-jacket.
To this succeeded entire collapse, from which the patient partially reco-
vered ; but he finally sank under the disease, on the seventh day from the
attack.
Some one symptom may predominate and impress its peculiar feature
on the disease, so far as to give the designating term, precisely as in per-
nicious (congestive) fevers ; and then we have cephalalgic, or delirious, or
convulsive, or vertiginous, or tetanic, or comatose meningitis.
If we analyse some of the most marked deviations from the normal
state, we shall find that the pulse, though often very slow, is still more
commonly quite frequent. In some few cases its beats have been found
to be as low as 48 to 50 ; but in 31 cases out of 65 they exceeded 90,
and were only below 60 in ten cases. Cutaneous eruptions were noticed
in this epidemic, both in France and in Tennessee, as they had been in
that of the sixteenth century. In general, neither the cutaneous eruptions,
nor epistaxes, nor urinary deposits, were critical.
Periodicity is quite common in epidemic meningitis. M. Lallemand,
in 1820, had pointed out this feature in the recurrence of spasmodic
phenomena accompanying arachnitis, and MM. Parent-Duchatelet and
Martinet, in their treatise on this latter disease, had also spoken of re-
missions and exacerbations as a frequent occurrence. They showed,
also, that inflammation of the arachnoid would take a distinctly intermit-
tent type,—quotidian or tertian ; and that even traumatic arachnitis was
distinguished by complete intermission—a quotidian return of symptoms
— whicii persisted until death. In all these cases, they detected suppura-
tion ofthe meninges, leaving no doubt ofthe fact of inflammation during
life.
Intermission was frequently noticed in the epidemics of phrenitis and
cerebral fever, in the sixteenth century. The same phenomenon was, we
repeat, quite common in the recent disease ; to such an extent, indeed,
that the amelioration, or a subsidence of all the symptoms, led to a hope
of recovery from the disease, which, however, was dashed by a return of
the exacerbation on the following day. So decided and characteristic was
the periodicity in some places, that, at Toulon, M. Leonard, after having
admitted the existence of an epidemic meningitis, finally believed in the
disease being an epidemic pernicious fever. At Bordeaux and Lyons,
similar discrepancy of opinion prevailed among some ofthe physicians of
those places. We are disposed to dwell on this point the more, as its
promulgation may contribute to a more enlarged and better pathology of
the fever, or class of fevers so prevalent in our own country, and desig-
nated among us here at home by the general term congestive.
In its progress and duration, epidemic meningitis resembled closely other
epidemics. Thus, a solitary case would be seen long before the mass were
attacked, and before a suspicion of the coming epidemic was entertained :
and again, after its apparently entire subsidence, a case would show itself,
renewing alarms which subsequent cases did not justify. The actual du-
MORBID ANATOMY OF EPIDEMIC MENINGITIS. 519
ration varied from three to fourteen months ; the approximative average
might be stated at seven months. The Gibraltar epidemic lasted from the
early part of January to the 20th of May, 1844. In the civil population
to which the disease was restricted in that town, amounting to 16,000 per-
sons, 450 cases of all grades occurred ; of these the deaths were 42.
The termination, among the French soldiers, was, in large proportions,
fatal, as scarcely one in two of those attacked wrere saved. Secondary
disease was apt to occur in those who survived the first, and finally car-
ried them off. Convalescence was often slow and lingering. The vio-
lence ofthe epidemic diminished towards its close.
In speaking of the diagnosis, M. Broussais admits, that it is by no means
easy to distinguish it, especially at the onset, from pernicious, or conges-
tive intermittent fever. Its frequent complication, also, with gastrointes-
tinal inflammation is another source of fallacy. If we look for character-
istic symptoms, we should expect to find them in the strabismus, muscular
agitation of the features, tetanic convulsions, acute and fixed pain of the
head and chiefly at the nucha, violent delirium, acute cries, coma and
general insensibility or, at other times, excessive sensibility. But in the
cerebral symptoms we should find little to point out a meningitis rather
than a congestive fever. Irregular and laboured respiration has been men-
tioned as a valuable sign by Dr. Mayne (Dub. Journ. Med. Scien.): Dr.
White (N Orleans Med. and Surg. Journ.) mentions also the great diffi-
culty in expanding the lungs.
The prognosis, as may be inferred from what was said respecting the
termination of epidemic meningitis, is of course unfavourable. Summing
up the returns procured from different places in which the disease pre-
vailed, M. Broussais shows us, that there were 592 deaths in 1035 sick,—
giving on an average 1 death in 1-76, or in somewhat less than two cases.
We might say, with a near approach to accuracy, that the deaths were to
the attacks as eight to fourteen—a mortality only paralleled by that in
cholera, or in malignant forms of the exanthemata. In our own country
the mortality is equally great. Dr. Philips, Boon Co., Missouri, says (Med.
Exam., 184*7), five-sixths died ; Dr. White, three-fourths ; Dr. Hicks (N.
Orleans Med. and Surg. Journ.), at least one-half.
Morbid Anatomy.—The chief seat of organic lesion in epidemic menin-
gitis, was the cerebro-spinal apparatus, and of this the meningeal enve-
lopes more than the nervous substance itself. The kind of lesion consisted
in inflammation of different degrees of intensity. M. Forget indicates
three degrees or stages, viz., congestion, inflammation, and suppuration.
The meninges, and especially the cerebro-spinal pia mater., was deeply
injected ; the bloodvessels and sinuses gorged with blood, and between
the arachnoid and the pia mater there was found sometimes a lactescent
serosity, turbid, yellowish, and semi-gelatinous, with a slight opacity ofthe
arachnoid ; at other times drops of a purulent appearance, yellow, dissem-
inated along the vessels, and still more frequently lamina? in form of
bands or plates, of a whitish-yellow substance and consistent, resembling
very closely concrete pus—seen either at the convexity of the brain or
upon its lateral parts, or more commonly still at the base, towards the
pons Varolii, following also the course of the vessels, the fossa of Sylvius,
between the convolutions, and spread over anfractuosities, which they
rarely penetrated. In the spinal cavity this purulent layer presented itself
in slips in the anterior or posterior face of the medulla, but in preference
520
DISEASES OF THE NERVOUS SYSTEM.
on the former. In some cases, in place of a simple pseudo-membranous
layer, there were met with true purulent collections, but always sub-arach-
noidean. Frequently, the spinal nerves, as far as the junction of the an-
terior and posterior roots, were buried in pus.
But although the common seat of lesion was between the pia mater and
the arachnoid, every now and then effusions were seen in the cavity proper
of the arachnoid itself, of a turbid or lactescent or even bloody serosity.
Most usually this effusion was met with in the ventricles, by M. Tourdes,
in 26 out of 43 cases. The parietal arachnoid was always found healthy.
Whenever pus was seen on the medulla spinalis, it was also found on
the brain ; but at times the suppuration in the latter was not met with in
the former, and hence M. Tourdes infers that the inflammation always
began in the encephalon, and only extended consecutively to the spinal
marrow. On this account, he divides meningitis into cerebral and spinal.
M. Chauffard frequently met with softening of the cerebral substance even
in the medullary portion.
M. Broussais takes occasion, after describing the post-mortem appear-
ances in those dead of the epidemic, to dwell on the fact of the infre-
quency, in common practice and times, of suppuration of the cerebro-spi-
nal meninges. During the twelve years in which he has been attached to
a large (military) hospital, he has only met with 49 cases of acute menin-
gitis, or encephalo-meningitis, in 15,000 cases of other diseases; and of
the 17 fatal cases, suppuration was not constantly met with, and was not
always extended to the spinal meninges. In the epidemic disease, these
suppurations took place with surprising rapidity. The shortest period is
of a case reported by M. Leonard, of Toulon, which ran its course to
suppuration in 15 hours. Other cases are recorded in the volume of M.
Broussais, in which this change occurred in 36 and 48 hours.
It is worthy of remark, that in a large majority of the fatal cases, in
which, during life, there was manifested great disorder of the cerebral
functions, the substance of the brain was not at all, or but slightly,
affected. Several cases are recorded confirmatory of this fact.
If, next, we inquire into the extent of gastro-enteritic complication with
meningitis, we learn that lesions of the intestinal canal were often seen,
particularly in those who outlived the first few' days of the disease. They
consisted in redness, arborizations, and dots on the stomach and intes-
tines, and sometimes patches in the glands of Peyer. Of 46 cases exa-
mined or recorded by M. Tourdes, 8 exhibited no change in the intestinal
canal, 32 showed a lesion of the follicles, but which was often slight, since
in two cases only were ulcerations met with. This was the general result
of observations made in other places. Seldom were the lesions of the
digestive organs of any gravity, or extent or depth, and in many cases
they were entirely wanting. They were then accessory or secondary,
more evidently even than the changes in the substance of the encephalo-
spinal centres. The disease was not, therefore, a gastro-cephalitis, or a
gastro-enteritic meningitis; but a meningitis sometimes complicated with
gastro-enteritis, and sometimes with encephalo-myelitis. The complica-
tions varied in frequency according to locality. Even in the cases recorded
by Dr. Mayne, in which there were vomiting and purging, and abdominal
pain, followed by collapse, with cold and bluish extremities, and a threaded
pulse, the abdominal viscera were sound. In Algeria, vomiting and con-
stipation were always present.
TREATMENT OF EPIDEMIC MENINGITIS.
521
According to M. Tourdes, the typhoid form of the meningitis was not
always accompanied by a follicular, or pretended follicular lesion of the
intestine.
Passing over the morbid alterations in other organs, which were only
occasional or accidental, M. Broussais dwells for a while on the state of
the blood in epidemic meningitis. According to the observations of M.
Faure-Villars on the disease, as it prevailed in Versailles in 1839, the left
cavities of the heart contained very little blood, but the right ones held
large yellow fibrinous coagula of some consistence. This appearance has
been specially noticed also in the Landes, at Strasburg, Nancy, Aigues-
Mortes, Lyons, and Colmar, in connexion with the plasticity of this fluid
during the lifetime of the patients; the blood drawn from whom was, for
the most part, buffy, and had little serosity. M. Tourdes informs us, as a
result of four analyses of the blood made according to the process of M.
Dumas, and followed by MM. Andral and Gavarret, that the fibrin was
in more than its normal proportion, viz., from 3-70 to 5*63 ; that the glo-
bules had also undergone a still greater change, since they were found to
be from 134 to 143 ; and that the solid matters of the serum were from
58 to 64, and the water was 780 to 796 in 1000. The analyses were
of blood procured in two cases at the fir^t venesection, once at the
second, and once at the third. The chief alteration of the blood was,
first, increase of the globules, then ofthe fibrin.
Treatment.—The various therapeutical measures had recourse to for
combating epidemic meningitis were, generally, bloodletting from the
arm, the jugular vein and temporal artery ; local bloodletting by leeches
or cups applied to the neck, the nucha, and along the spine ; the appli-
cation ofcold, by means of ice, to the head ; revulsion to the extremities,
by sinapisms, blisters, and stimulating frictions ; cauterizations by red-hot
iron along the spinal column ; then derivatives on the digestive organs,
such as emetics and purgatives ; some special medicines, viz., calomel,
mercurial frictions, and opium ; and finally, the sulphate of quinia.
First of the remedies in the order of precedence, both as regards the
time at which it was had recourse to and its efficacy, is bloodletting. Arte-
riotomy, by opening the temporal, and venesection at the jugular and the
veins of the foot, were abandoned, after some trials, as uncertain and
inconvenient, in favour of venesection at the arm. There was consider-
able unanimity of opinion in favour of this last remedy in the first period,
and in that of secondary excitement or of reaction. But while some
advise free depletion at the outset, others are in favour of moderate and
even small, although it may be frequent, bleedings. There are some
again who, fearing subsequent weakness, recommend a sparing detraction
of blood. In general, free bleedings from the arm at the beginning of
the meningitis have been quite efficacious; and when the evacuation
was carried to the extent of producing syncope, it was remarked that the
disease was at once arrested. M. Broussais very properly tells us, that it
is impossible to indicate, even in a general way, the quantity of blood
which should be drawn from the patient at each venesection, as this will
depend on the state of the pulse and the immediate effects of the opera-
tion. If a weak pulse rise, or a strong pulse preserve its character after
the flow of blood, we must let this continue, even were we to abstract
twenty ounces. M. Rollet went so far in some cases as to take away
nearly forty ounces, or a kilogramme. The author, in a note, refers to a
522
DISEASES OF THE NERVOUS SYSTEM.
case of a most alarming meningitis at the Val-de-Grace, in which he ab-
stracted a still larger quantity, and the patient, contrary to all expectation,
was cured. But when the pulse is rendered weak, and a moisture over-
spreads the surface, indicating imminent syncope, the farther flow of blood
ought to be stopped, even though we may be required to open the vein
again a few hours after, when the pulse rises and the face is once more
flushed. An important caution is given, in telling us not to proportion
the bleeding to the cerebral restlessness and delirium ; but, on the con-
trary, that we should be aware that these violent states of nervous ere-
thism speedily exhaust the powers of life, as Broussais (the father) had
been always in the habit of pointing out; and that at this time copious
sanguineous evacuations would bring on a sudden and speedily fatal col-
lapse.
Hence the state of the pulse, the heart, and the capillary circulation,
will serve as a means of measuring the quantity of blood to be abstracted.
One thing, remarks the author, is certain, that general copious bloodletting,
when well borne, is of sovereign efficacy at the outset ofthe disease, the
only sovereign remedy in the disease of w7hich we are now treating ; and
that small bleedings, no matter how frequently repeated, cannot be sub-
stituted for a free and prompt depletion. The disease is rapid in its
course, and all half-way measures, every act of temporising, can only be
followed by a fatal result.
In the forming stage, when the premonitory symptoms only are present,
bloodletting does wonders ; and some of the French surgeons attribute
the saving of the lives of entire companies to the use, thus early, of the
remedy. At the same time that we employ this means of cure, early re-
course should be had to cups repeatedly applied to the nucha and along
the spine, and leeches to the temples, forehead, neck and behind the ears;
keeping up, as M. Gama advises, a continued discharge by successive
applications of 6, 8, or 10 leeches, every 2, 3, or 4 hours. But, service-
able as this mode of evacuation may be after general bloodletting, its in-
efficiency would be signal if reliance were placed on it alone.
Bloodletting having been carried as far as seems justifiable or necessary
from its ascertained effects, recourse is next had to refrigerants and revul-
sives. The first are procured in a bladder half filled with pounded ice,
or in compresses dipped in cold water and vinegar applied to the head.
Cold affusions are with difficulty employed, and hence are not among the
directly available remedies in general practice.
Revulsives, usually indicated in the second stage of the disease, are
sometimes required in the first, as where there is an inversion of the usual
order of phenomena — prostration and stupor preceding excitement and
reaction. In such cases recourse is had to blisters, sinapisms, and boil-
ing water to the extremities, ammoniacal frictions to the different parts of
the surface, &c, repeated at short intervals. Sometimes the torpid sen-
sibility is roused by these means; but they are not alwTays adequate to
produce the effect desired ; and then cauterizations, as practised by M.
Rollet, will be found a powerful therapeutic means. They consist in the
application of iron at a white heat, which is to be passed six or eight
times transversely on so many different parts of the back on each side of
the spinal processes. In the worst cases, M. Rollet relates that the first
applications of the actual cautery do not elicit from the patients any sign
of sensibility ; and it is only at the third, fourth or fifth repetition that
TREATMENT OF EPIDEMIC MENINGITIS.
523
they make a slight muscular movement, which indicates that they expe-
rience a sensation. Some utter cries during the last applications, but re-
lapse immediately into their original comatose condition. An hour or
two after the cauterization, reaction begins ; and when it is suitably estab-
lished, but without waiting too long, M. Rollet advises that we should
have recourse to general and local bloodletting, to an extent proportion-
ate to the strength of the patient.
At this juncture, the patient must be watched with unceasing vigilance,
and measures taken to abate reaction, when it shows itself, by sanguineous
evacuations, repeated every two, three, or four hours, and by ice being
applied at the same time to the head. M. Rollet has seen this decisive
treatment crowned with entire success, even in cases of a desperate
nature.
Difference of opinion prevailed respecting the true remedial value of a
blister on the scalp after the latter has been shaved clear of the hair.
Its application does not answer in the first period of the disease, what-
ever may be its symptoms ; but when, consecutively to those of excite-
ment, the patient, already weakened by bloodletting, falls into a state of
collapse with insensibility, feeble pulse, and entire deficiency of reaction,
this kind of derivation on the head may be practised. At this epoch
effusion is most to be apprehended, and vesication on the cranium is the
most active counteracting agency. If fears be entertained of the too great
proximity of the blister to the seat of the lesion, it may be applied to the
back of the neck.
Emetics have been generally rejected in the treatment of epidemic me-
ningitis, except by a few who thought that they had to do with a cono-es-
tive (pernicious) fever.
Purgatives, on the other hand, have found more favour, especially after
the employment of the antiphlogistics already described, and in aid of
external revulsives, they ranking among the internal ones. Any restric-
tion in their use depended on the complication of gastro-enteritis with the
meningitis. Calomel, which "had become among a certain number of
anglomaniac physicians a kind of routine prescription in nearly all dis-
eases, and especially in cerebral affections," finds no favour wTith M.
Broussais. He refers also to the adverse testimony of M. Forget, who,
so far from realizing its therapeutic virtues, discovered it to be absolutely
deleterious in the disease now under consideration ; especially from its rea-
diness to induce intestinal lesions. Is this fact or theory ? He abstained
after a while from the prescription of any purgative except with a view
to its use as an enema, to act exclusively on the lower bowels.
Mercurial frictions are spoken of in quite disparaging terms by the
author, who is sustained in his objections to their use by the experience
of most of his colleagues in the array. But we have yet to learn the
effects of the internal use of calomel and opium in full doses, at short in-
tervals.
Of antispasmodics, the only ones favourably mentioned are the water of
the cherry laurel, and that of valerian mixed in a mucilaginous draught,
after antiphlogistics and revulsives. M. Mialhe recommends, in prefer-
ence, the distilled water of bitter almonds, as furnishing more definite
proportions of cyanhydric acid. Perhaps the cyanuret of potassium would
be still better on this account.
Among narcotics, the only one entitled to consideration in the treatment
524
DISEASES OF THE NERVOUS SYSTEM.
of the epidemic was opium. By M. Chauffard at Avignon, and M. For-
get at Strasburg, this medicine was employed, as we learn from them,
w7ith the happiest effects. But as M. Broussais very justly remarks, large
deductions must be made from these praises, when we learn that opium
was not used by either of these gentlemen until towards the decline of the
epidemic, when, as it is well known, many articles seem to exert effects
which were not manifest at an earlier period of the disease. We can
readily understand and believe, however, that, under wise restrictions,
such as those laid down by M. Forget, and as had been long ago by Sy-
denham in inflammatory diseases, the use of opium would be competent
to combat the nervous disturbances, — cephalalgia, delirium and spasms,
which persist after the subsidence of reaction. The time for recourse to
it was from the fifth to the seventh day of the disease ; and the dose in
M. Forget's hands, which was quite equal to all the effects desired, was
of a syrup equivalent to about half a grain of opium.
Sulphate of quinia, declared by some of the army surgeons to be the
only medicine by which they succeeded in saving their patients, was, on
the other hand, by a majority denounced as positively detrimental. In
some cases in which the meningitis was regularly intermittent, after the
removal of the state of more evident phlogosis, or where the disease was
complicated with periodical fevers, the sulphate of quinia was undoubt-
edly of considerable service ; but only under these circumstances.
No mention is made by the author, of the employment of tartar emetic,
as a counter-stimulant or sedative in meningitis ; nor of diaphoresis, as a
means of relieving the phlogosis of the arachnoid, in its second stage,
as it often does inflammations of other membranes. I observe that Dr.
Hicks speaks favourably of a union of tartar emetic with camphor; one-
sixth of a grain of the former, and five grains of the latter every two
hours. But, to be of essential service, the dose of the antimonial salt
ought to be greatly increased, so far, in fine, as the system will tolerate
its use.
Inspiration of ether has been directed by M. Basseron, chief physician
to the military hospital of Mustapha, in Algeria, with encouraging effects.
Cerebro-spinal meningitis had appeared in the French array in that region,
in December, 1846, and was attended with its usual mortality; some of
the subjects attacked dying after three or four days' sickness ; others in a
few hours. Nine soldiers attacked with this disease were placed under
M. Basseron's care. All of them were affected with rigidity of the spinal
column, headache, and rachialgia ; slight delirium was present in three,
and was violent and persistent in the rest of the number; three were
in the comatose state with muscular contraction, almost tetanic, which
disappeared after fifteen or twenty hours, to be replaced by the intense
cephalalgia, fever, and delirium, characteristic of the disease at its onset.
In all these patients, the. use of the ether was preceded by the antiphlo-
gistic treatment, that is to say, by six or seven venesections in two or
three days, and the application of leeches and cups. The ethereal inspi-
rations were had recourse to in broken doses: four, six, eight, or ten in-
spirations being taken and renewed every two hours, or every hour, or
even quarter of an hour, in the more alarming cases. The immediate
effects of the ether were increased rapidity of the circulation and ex-
alted sensibility, which were soon succeeded by marked sedation and
very decided tranquillity. In some of the worst cases, M. Basseron
CONVULSIONS WITH APOPLEXY.
525
noticed great intolerance to this employment of ethereal inspirations:
twenty-four or thirty-six hours were required to elapse before the tolera-
tion could be established. The first symptom which disappeared under
the use of the ether was wakefulness, then headache, disturbance of the
intellect, and muscular agitation ; the pulse was lowered and became re-
gular ; the skin cool and natural; the alvine evacuations also natural :
the rigidity of the spinal columnalone persisted, and was but slowlyand gra-
dually removed. Ofthe nine patients before alluded to, two perished,—
one in the third, the other in the fourth day ofthe treatment: three were
considered as cured; two were in a satisfactory state ; and as to the other
two, the issue is uncertain in one of them ; but, of the other, every ap-
pearance indicates its passage into a chronic state.
In speaking of convalescence, M. Broussais adverts to its lengthened
duration", and the dangers, and even death, incurred from the neglect of
prudential rules by some ofthe convalescents.
LECTURE CXXX.
DR. STOKES.
Apoplexy—Cerebritis and meningitis—Definition of apoplexy—Simple or nervous apo-
plexy without disorganization—Complication with other diseases—Congestive or
serous apoplexy—Dr. Abercrombie's opinions—Apoplexy with extravasation—Sites
of extravasation—Absorption of clot—Apoplexy in children.
We were occupied at our last meeting in considering some of the most
prominent symptoms of meningeal inflammation ; and I beg of you to re-
collect, that all these symptoms, with the exception of pain, are those
which ordinarily characterize inflammation of the substance of the brain
itself, and are to be explained by referring them to some lesion in the
functions of that organ. It appears, then, that the symptoms of menin-
gitis, with the exception of pain, are symptoms of an affection of the brain
itself; and this is a point which you must always bear in mind, when
you agitate the question as to the possibility of making a diagnosis be-
tween meningitis and encephalitis. We have a set of symptoras charac-
terizing meningeal inflammation, the majority of which belong to irrita-
tion ofthe brain itself; and we find that these may exist with or without
any perceptible alteration in the cerebral substance. Now, in cases where
you suppose the existence of meningeal inflammation, and find these
symptoms present, it would be venturing too much to assert that there
was no complication with organic disease of the brain ; and, therefore, we
must conclude that, in most cases, it is nearly impossible to distinguish
between inflammation of the substance of the brain and of its membranes.
In speaking ofthe more important symptoras of cerebral inflammation,
I alluded particularly to convulsions, and stated that, as far as my obser-
vations went, this symptom, formidable as it may appear, is not in reality
so unfavourable as it is generally thought to be. In fact, there are many
cases of affections ofthe brain, accompanied by convy^ions, in which the
danger is by no means so great as in others of a different description ; and
many of the worst cases are those in which convulsions are absent, or only
526
DISEASES OF THE NERVOUS SYSTEM.
trifling. I think we may look upon convulsion as being more or less a
source of relief to the brain, when labouring under the excitement of irri-
tation or inflammatory disease. You are all aware, that one of the func-
tions ofthe brain is to regulate and control the motions of the muscular
system. If a man exercise his limbs violently for some time, he becomes
tired and exhausted ; he cannot pursue the same exercise any longer, for
in addition to whatever the muscular system may suffer, there has been a
great expenditure of nervous energy ; and if he should attempt to keep
up the same exertions, such a degree of muscular and nervous debility is
superinduced that syncope is the consequence. Now, the expenditure of
energy produced by the supply of nervous powrer to the muscles, seems to
bear a strong analogy to the secretory discharges from other viscera. In
the case of irritation or inflammatory affections of other organs, you are all
aware that there is nothing which gives such speedy and effectual relief as
supersecretion, or an increased action of the secreting vessels of the affect-
ed organ. Now, if we look upon the expenditure of the nervous energy
in the same light (and I see no reason why we should not), we can easily
conceive why it is that convulsions relieve the irritation of an over-excited
brain. I drew your attention strongly, at my last lecture, to the curious
and important fact, that if we compare apoplexy and epilepsy, with respect
to the danger and the chance of disorganization attendant on each, we
shall find the danger is infinitely greater, and the chances of organic change
more numerous, in the former than in the latter. In epilepsy, where the
convulsions are violent, we seldom have a fatal termination of the fit, and
there is rarely lesion ofthe substance of the brain, until the disease has
lasted for a great length of time. This is not the case in apoplexy. Here,
as I have already stated, we have twTo cases of active determination to the
head : in one case there are no convulsions, and we frequently find the
result to be death, or extravasation with paralysis and slow convalescence;
in the other, we have violent convulsions, followed by rapid recovery and
no disorganization. From this, it would seem reasonable to conclude that
convulsions are a mode of relieving the brain, adopted by nature, and that
their occurrence in hydrocephalus should not be looked upon as unfavour-
able. Now, if this be true, it must strike you that nothing can be more
dangerous and improper than to take any steps to control an attack of con-
vulsion during the prevalence of hydrocephalic symptoms. The true mode
of treating them is to adopt measures calculated to relieve irritation ofthe
brain, and not hazard the patient's safety by following the ordinary but
mischievous mode of attempting to control the salutary efforts of nature.
I allude here particularly to the practice of administering opiates and anti-
spasmodics, a practice which I firmly believe to be fraught with danger.
We have to-day to consider another form of cerebral disease, scarcely
less important than those with which we have been hitherto engaged. In
all the former instances, we find the determination of blood to the brain
followed by that organic change which we term inflammation. But we may
have accumulations of blood in the brain, unaccompanied by inflammation,
and this brings us to the consideration of apoplectic disease. The term
apoplexy, as I suppose you all know, is derived from a Greek word, sig-
nifying a stroke or blow. It is a term which, in the present state of medi-
cine, has been vq^ frequently abused, or at least employed in very differ-
ent senses, and hence the many erroneous opinions respecting it. The true
meaning of the term expresses an alteration of the phenomena of the life
VARIETIES OF APOPLEXY.
527
of relation, that is, of the functions of the cerebro- spinal system. In taking
a view ofthe nature of this alteration, we find that the attack generally
comes on in a sudden manner, and that the functions of the brain are par-
tially or completely suspended. You are aware that the manifest pheno-
mena of the life of relation are those which belong to sensation, muscular
motion, and the intellect; and that the system of the life of relation is com-
posed ofthe brain, spinal cord, and nerves. Now suppose, for example,
that a man gets an attack of apoplexy, we find him paralytic—here is a
lesion of the muscular function. We find him insensible to external stimu-
lants, he feels no pain—here is a lesion of sensation. We may find his
sight, hearing, taste, smell, and touch, are injured ; he lies in a state of
insensibility, and is unconscious of everything passing around him—here
we have an example of interruption in the performance ofthe intellectual
functions. All these phenomena exhibit the various lesions superinduced
by an attack of apoplexy, in the functions of those organs which subserve
to the life of relation.
I have said that the term apoplexy is frequently abused in modern medi-
cine. From the circumstance of most cases being accompanied by an
effusion of blood on the surface or into the substance of the brain, the term
has been also applied to sanguineous effusions into other organs, and we
hear every day of pulmonary and hepatic apoplexy; terms implying the
extravasation of blood into the substance of the lung or liver. The ana-
logy, however, in such cases will on examination be found to be coarse,
and the application of the term loose and improper. Apoplexy, as a cere-
bral disease, may occur with or without effusion ; in either case, the disease,
quoad the lesion of function, is the same ; but to give the name of apoplexy
to hemorrhage into the lungs or liver, is improper. The term apoplexy
should be used only with reference to the brain, and applied to a particu-
lar train of lesions in the functions ofthe life of relation, occurring with or
without an effusion of blood, or even congestion. When we have effusion
of blood into other viscera, we may have them unaccompanied by any-
apparent lesion in the functions of the organ affected (a circumstance rarely
met with in the case ofthe brain); and it would be much better to give
some other name to those hemorrhages into the substance of the liver and
lungs, than to designate them by one drawn from a loose and imperfect
analogy.
The suspension of the phenomena of the life of relation, complete or
partial, which constitutes apoplexy, may be connected with any of the fol-
lowing pathological conditions :—First, great congestion of the brain, in
which the vascular system of that organ is overloaded, but without ex-
travasation of blood or serum ; this is termed the congestive apoplexy. In
the next place, we may have this congested state of the vessels of the brain
with an extravasation of blood on its surface. To the latter form, the me-
ningeal apoplexy has been applied. Thirdly, with an effusion of blood
into the substance of the brain, which is the most common case, and, lastly,
we may have complete apoplexy without morbid appearance, or, if there
be such, quite inefficient to account for this phenomenon. A man will fall
down suddenly, lie will lie in a state of insensibility, with stertorous breath-
ing, coma, and paralysis, he will die with all the symptoms of the worst
form of apoplexy, and yet, on dissection, the brain may be found, to all
appearance*, healthy. This is what has been termed, by the older authors,
the nervous or convulsive apoplexy ; of the real nature of which we are
528
DISEASES OF THE NERVOUS SYSTEM.
still as ignorant as we are ofthe real nature of tetanus, hydrophobia, and
other nervous diseases unaccompanied by perceptible organic change.
This is the simple apoplexy of Dr. Abercrombie, of which he gives several
most important cases, and refers to others related by the older authors.
You will at once admit that it is not more extraordinary that apoplexy
should exist without perceptible organic change, than mania, tetanus, hy-
drophobia, and other affections. Of the fact there is no doubt. Such cases,
indeed, are rare ; which, in one sense, may be looked on as a fortunate
circumstance. But in the progress of other diseases, this nervous coma,
or apoplexy, is by no means uncommon. Thus, there is no symptom
more common than coma in typhus; and yet, if you examine the head
after death, you generally either find no lesions at all, or such as will not
be sufficient to account for the symptoms. The coma, which occurs in
cases of painters' colic, too, appears to be closely connected with this ner-
vous apoplexy. You will recollect an interesting clinical experiment I
made in the case of a patient with painters' colic, who had profound coraa.
In this case, I thought it probable that the condition of the brain bore no
resemblance to sanguineous apoplexy, because the symptoms of painters'
colic are seldom or never accompanied by hyperaemia of the nervous or
other systems. Under this impression,. I prescribed a full opiate, and this
not only did not increase the coma, but, on the contrary, produced the
very best effect, for the patient was amazingly improved the next morning.
I do not so much mean to say, that opium is useful in nervous coma, as
that, in this instance, at least, the coma was not of the congestive kind.
It is not unlikely, too, that the coma of jaundice is of the same description,
and unconnected with any decided hyperaemia ofthe brain. I am aware
that in jaundice the coma is supposed by some to depend upon a bilious
condition of the blood circulating in the brain ; but there are so many cases
of persons who have laboured under jaundice for years without having
coma, that we must seek for some other explanation. Now, so far as we
know ofthe encephalon in persons who have died of jaundice, it appears
that little or no congestion exists; and hence it seems probable that the
coma of jaundice is similar to that of nervous apoplexy.
I shall now proceed to the consideration of those forms of apoplexy
which are connected with changes more or less apparent in the circulation
ofthe head, and with which we are, consequently, better acquainted. I
have told you that simple congestion of the brain may be accompanied by
symptoms of apoplexy, or that we may have the disease presenting, in ad-
dition to this, an effusion of blood into the substance, or on the surface of
the brain. The simplest idea you can get ofthe condition ofthe brain in
the congestive form, is to consider what its state is in persons who have
been hanged. These persons have the vessels of the brain loaded with
blood from the violent interruption of the venous circulation. Now, this
increase in the quantity of blood circulating in the brain may arise from
two causes, one depending on the interruption of the venous circulation,
the other produced by an increased action ofthe arterial system. Hence
in certain cases of disease of the heart, where the blood is sent with great
force to the head, there is a strong predisposition to apoplectic attacks.
The kind of disease of the heart, however, which has been found most
liable to produce this, is not, as you would suppose, Corvisart's active
aneurism, but simple hypertrophy ofthe heart, where the cavity of the left
ventricle continuing the same, its walls are increased in thickness and
SEROUS APOPLEXY.
529
strength, so that, on the natural quantity of fluid, an increased impulse is
exercised. Such, at least, is the result of Andral's researches, and there
is every reason to place confidence in the accuracy of his conclusion.*
About this congestive apoplexy there appears to have been a good deal
of misapprehension. You have all heard of the serous apoplexy. In this
form, it has been supposed that the cause ofthe compression of the brain,
and all the other symptoms, is an effusion of serum, just as an effusion of
serum into the cavity ofthe pleura will produce compression of the lung
and dyspnoea. The idea which has been generally entertained is, that •
the effusion of serum is the cause of all the symptoms ; and, in conse-
quence, the same active treatment has not been adopted as in the other
forms of apoplexy. This opinion will be best refuted by the investigations
of Dr. Abercrombie, and I cannot do better than read for you the opinions
of this eminent writer on the subject, as given in his celebrated and admi-
rable work, which, I have no hesitation in saying, constitutes one of the
brightest ornaments of British medicine.
" This distinction, which has been proposed between sanguineous and
serous apoplexy, is not supported by observation. The former is said to
be distinguished by flushing ofthe countenance and strong pulse, and by
occurring to persons in the vigour of life ; the latter by paleness of the
countenance and weakness ofthe pulse, and by affecting the aged and the
* [The connexion between hypertrophy ofthe left ventricle and apoplexy
was pointed out in one of my lectures (CX1V.) on Diseases of the Heart.
The brain suffers from apoplectic seizure in poor and apparently anemic
individuals with slight figures, but who at the same time are affected with
valvular disease of the heart. M. Bricheteau draws the conclusion, that
the periods of life at which fatal apoplexy is most prevalent, are those in
which disease ofthe heart (either hypertrophy of the muscular substance,
or ossification of the valves and vessels) is of most frequent occurrence,
namely, between forty and fifty, and between seventy and eighty years of
age. Dr. Burrows institutes an analytical comparison of the liabilities to
apoplexy and hemiplegia at different ages, in 215 well-marked cases,
whence it appears that the number of apoplectic seizures increases in each
successive decennial period from 20 to 70 years of age, while the numbers
living gradually diminish. It appears, also, from the researches of Dp.
Clendinning, that (he proportionate weight of the heart increases with
advancing life—so that hypertrophy of that organ is a change occurring
at the period of life when apoplexy is most prevalent. Dr. Clendinning
has moreover shown that, while the average weight of the adult brain,
when the heart was healthy, was 505 ounces, in diseases of the heart it
was 52-5 ounces—a condition which he regards as the effect of cardiac
disease.
Disease of the cerebral arteries, such as atheromatous deposits, which
occur in advanced life, ought not to be overlooked in the etiology of apo-
plexy.
The deductions for practical guidance, from these facts, are clear. They
are, an avoidance of all severe bodily exercise, as well as of all exciting
emotions of the mind. We ought also, as Bricheteau recommends, to
direct the occasional application of leeches over the region of the heart,
instead of to the temples or any other part of the head—the internal use
of digitalis, hydriodate of potassa, and other diuretics.—B.]
vol. n.—35
530
DISEASES OF THE NERVOUS SYSTEM.
infirm ; and much importance has been attached to this distinction, upon
the ground that the practice which is proper and necessary in the one case,
would be improper or injurious in the other. I submit that this distinc-
tion is not founded upon observation, for, in point of fact, it will be found
that many of the cases which terminate by serous effusion, exhibit in their
early stages all the symptoms which have been assigned to the sanguineous
apoplexy ; while many ofthe cases, which are accompanied by paleness
of the countenance and feebleness of the pulse, will be found to be purely
sanguineous ; and one modification of the disease in particular will be
described, in which these symptoms are very strikingly exhibited, while
the disease is found to be sanguineous apoplexy in its most hopeless form.
" Portal has described a series of cases which afford the same result; of
three, which presented all the symptoms of serous apoplexy, one was saved
by repeated bleeding, and in the other two, which were fatal, there was
found extensive extravasation of blood. Case XCVL, lately described,
forms a remarkable addition to these observations. If any case could be
confidently considered as serous apoplexy, this was such. Dropsical
effusion had existed in the body for months, and, in defiance of every
remedy, it had been progressively gaining ground. There were symptoms
indicating its existence, both in the thorax and in the abdomen ; the pa-
tient then became comatose, with pale countenance, and died ; but though
dropsy was found in other cavities, none could be detected in the brain.
" In other parts ofthe body serous effusion is very seldom a primary
disease : it arises as a result either of inflammatory action, or of impeded
circulation, and takes place slowly, not accumulating at once in such quan-
tity as to induce urgent symptoms. It is, therefore, in the highest degree
improbable, that it should occur in the brain as a primary disease, and
accumulate with such rapidity as to produce the symptoms of an apoplectic
attack.
" The quantity of fluid effused, bears no proportion to the degree of the
apoplectic symptoms. We find it in small quantity, though the apoplectic
symptoms had been strongly marked and long-continued ; we find it in
large quantity when the symptoms have been slight ; and, finally, we find
most extensive effusion in the brain where there have been no apoplectic
symptoms at all. The direct inference from these facts is, that, in the
cases of apoplexy with effusion, the presence of the fluid cannot be con-
sidered as the cause of the apoplectic symptoms."*
The same error has been committed with respect to hydrothorax, a dis-
ease almost never primary, but the result of either pleuritic inflammation,
obstruction ofthe heart or lungs, or some analogous cause. The cause of
the symptoms is not the mere effusion of fluid, but some pre-existing dis-
ease which has given rise to a serous effusion. In Dr. Abercrombie's work,
you will find the remarkable fact stated, that there may be a copious effu-
sion of serum in the head, without producing apoplectic symptoms. The
following case, mentioned by Dr. Abercrombie, furnishes a remarkable
illustration : A patient, who had laboured under hypochondriasis for up-
wards of thirty years, began to decline rapidly in health. He was ex-
* [This view had been taken so long ago as 1792, by Dr. Physick, in
his Inaugural Thesis, De Apoplexid, printed at Edinburgh. See Dr. J. R.
WT. Dunbar's Inaugural Essay on the Structure, Functions, and Diseases
ofthe Nervous System. Philadelphia, 1828.—B.]
APOPLEXY WITH EXTRAVASATION.
531
tremely feeble, his bowels costive, his sleep disturbed, and his appetite
gone. This state continued for some time, and he began to sink, but he
never complained of headache, giddiness, convulsions, or paralysis, and
his mental powers remained unimpaired until a very short time before his
death. Yet, on opening the head, there was an exceedingly copious effu-
sion of serum found under the arachnoid ; and in some places this was so
great as to give the arachnoid the appearance of small bladders filled with
water. The ventricles were distended with fluid. Dr. Abercrombie gives
another case, where the quantity amounted to eight ounces, and notices a
case, mentioned by Dr. Marshall, of a maniac who died of mortification of
the feet ; a few hours before death he became perfectly rational, yet effu-
sion was found both on the surface of the brain and in the ventricles,
amounting to more than a pound.
All these facts go to prove, that what has been termed serous apoplexy
is only an apoplectic attack depending on congestion of the brain ; that
in some cases we may have this congestion accompanied by serous effu-
sion, in others not; that the effusion is secondary, and by no means of
constant occurrence ; and that alternating our practice and pursuing a less
active plan of treatment, in such cases, would be improper. The same
treatment should be adopted in the serous, as in the congestive form of
the disease, for where the nature of the affection is the same, the same
curative means should be employed. Why it is that effusion takes place
in one case, and not in another, we cannot tell; such changes are con-
nected with laws of organization, of which we are at present ignorant.
We know as little why this should occur as why inflammation of the liver
in one case is followed by enlargement, in another by the secretion of pus,
in a third by cancer, or in a fourth by hydatids.
We now come to the consideration of apoplexy with extravasation of
blood. This is the form of the disease to which the term apoplexy has
been restricted by one of the last writers on the subject, M. Rochoux.
In this affection, the extravasation of blood, which constitutes the princi-
pal pathological feature of the disease, is found to exhibit a remarkable
variety as to its seat and extent. In some cases the blood is effused on
the surface ofthe brain ; in others, into its substance ; and in a few cases
into the ventricles. De Haen gives some cases of apoplexy produced by
rupture of the choroid plexus ; but in the great majority of cases, where
blood is found in the ventricles, the extravasation has taken place in one
hemisphere, and, tearing through the substance of the brain, has made
its way into their cavities. Of the three varieties of apoplectic effusions,
the ventricular is the rarest; the next to this is the meningeal, or that in
which blood is poured out on the surface of the brain ; and the most com-
mon is where it is effused into the substance. It has been also found that
certain parts of the brain are much more liable to sanguineous effusions
than others ; ofthe reason of this, as of many other phenomena connected
with the circulation of the brain, we are still in ignorance. The following
table, which you should bear in mind, exhibits a remarkable preponder-
ance in the liability to sanguineous effusions of certain parts of the brain.
It has been taken from the " Precis d'Anatomie Pathologique" of Andral.
The following is a summary ofthe results of 386 cases of apoplexy.
In -202 cases, the effusion took place into the substance of the hemi-
sphere of the brain, in that part which is on a level with the corpora
striata and optic thalami. The portion of the brain next most liable to
effusions, are the corpora striata ; and here we have 61 cases. Next to
532
DISEASES OF THE NERVOUS SYSTEM.
this are the optic thalami, in which we have 35 cases. In that propor-
tion of the hemispheres above the centrum ovale, 27 cases. Lateral lobes
of the cerebellum, a proportion of 16 cases. In those portions of the brain
anterior to the corpora striatum, 10 cases. In the mesocephalon, 9. Spi-
nal cord, 8. Posterior lobes of the brain, 7. Middle lobe of the cere-
bellum, 5. Peduncles ofthe brain, 3. Olivary bodies, peduncles ofthe
cerebellum, and pituitary gland, 1 in each, making 3—Total, 386. Out
of these, we find 325 cases occurring in the hemispheres of the brain,
corpus striatum, and optic thalamus.
In the number and size of these effusions we find the greatest varieties.
In some cases, an enormous effusion takes place, and many ounces are
extravasated into the substance of the brain ; in others, the quantity is
trifling, being sometimes as small as a pea, or even less. It has been ob-
served that in cases where numerous extravasations were discovered, they
wrere generally found to be in different states, as if they had occurred at
intervals, and not simultaneously. This leads us to a knowledge of one
ofthe most important facts in pathology, that in many cases of apoplexy,
after a clot has been formed, nature commences, at an early period, a
process of cure. This change, which takes place in cases where a patient
recovers, seems to be the following:—It becomes, at first, somewhat ge-
latinous ; it is next observed to be more consistent, and it loses its red
colour, and takes on a whitish or yellow appearance. The clot is gradu-
ally removed ; and along "with the absorption of the clot there is a process
of isolation going on. A fine membranous cyst, furnished with vessels,
is formed round the clot. In sorae cases, the clot is replaced by a quan-
tity of serous or gelatinous fluid ; but in the majority of instances this
does not occur, and the cyst has been found empty. This is a fact which
has been established by numerous observations.
There is the greatest possible difference as to the period at which the
absorption of the clot is completed ; but wTe may safely assert, from the
number of cases in which, after paralysis, a recovery takes place, that this
process is of very common occurrence. In several cases, where apoplexy,
followed by paralysis, has happened several times during the lifetime of
the patient, a number of those cysts, corresponding with the number of
attacks, and presenting various appearances according to the date of their
formation, have been found. It appears, then, that the cure of apoplexy
depends solely on the absorption of the clot; and that, as long as this
remains unabsorbed, the patient is in danger. In some cases, absorption
does not take place at all, the clot becomes organised ; and in this way
it is supposed that some of the tumours found in the brain are formed.
There are several circumstances which favour the absorption of the clot,
but nothing so powerfully as a healthy condition of the whole cerebral
circulation. This leads us to the consideration ofthe importance of pay-
ing attention to the head, long after an attack of apoplexy. It inculcates
the necessity of avoiding everything calculated to add to the existing con-
gestion ; and shows that, in the paralytic or after-stage of an apoplectic
attack, we should not neglect to deplete the head from time to time." The
great point is to keep the head perfectly free from irritation ; for it has
been found, that, where a cure appeared to be going on, any new irrita-
tion applied to the brain has had the effect of arresting the absorption of
the clot, and marring the process or cure.*
* [I have known this effect to be caused by the secondary irritation
TREATMENT OF APOPLEXY.
533
I regret I cannot dwell longer on this subject, as I wish to conclude
the pathology of apoplexy to-day. There are, however, two more ob-
servations to be made before I close the subject. The source of an apo-
plectic effusion is very hard to be discovered : it appears generally to
come from a number of minute vessels, for we are seldom or never able
to trace it to the rupture of a vessel of any size. The age at which per-
sons are most subject to apoplexy, appears to be from fifty to seventy.
You should, however, be aware that apoplexy with sanguineous effusion
is by no means uncommon, even in persons of a tender age. Billard de-
tails an instance of this in a child, soon after birth. There are also seve-
ral cases mentioned as occurring in children during the first three or four
years. Andral gives the case of a boy, of nine years of age, who died of
apoplexy, with a vast effusion of blood. One of the most remarkable
cases of this kind I ever witnessed, occurred in a child who had been just
weaned. This child had been labouring for some time under symptoras
resembling incipient hydrocephalus, and then suddenly got an attack of
convulsions, followed by coma and paralysis of one side. From a care-
ful study of the symptoms,-I ventured to make the diagnosis of apoplectic
effusion, and on examining the brain, after death, there were nearly three
ounces of blood found effused in the base ofthe brain.*
from a distended stomach. The patient, a female in advanced life, was
recovering from the first attack, for which active depletion had been used,
and rigid abstinence enjoined, when she yielded either to evil appetite,
or to evil suggestion of another, and ate heartily of strong, gross food. It
was her last meal.— B.]
* [Apoplexy showTs itself in two different forms in children : first,
at birth (the apoplexy of new-born infants), consisting of cerebral and
meningeal congestion, without, in general, hemorrhage or softening;
secondly, apoplexy occurring during childhood, and marked by hemor-
rhages., either in the ventricles or on the meninges.
The apoplexy of new-born infants, called, also, by the accoucheurs,
the apoplectic or apoplectiform state, is distinguished by a livid blue
colour of the skin, especially of the face ; the lips are of violet hue, and
the eyes closed, the beatings of the heart either arrested or feeble, and no
respiration. This affection results from difficult and prolonged labour, in
which the head ofthe child has been long engaged in the pelvic strait, or
in which a strangulation has been produced by the umbilical cord twined
round the neck ; or the placental circulation interrupted by compression
of the cord, as in breech presentations. The apoplexy has been con-
founded with the asphyxia of new-born infants, but the states of the sys-
tem are very different from each other. In asphyxia the child is pale, and
lips colourless, there is anemia and a defect of the vivifying influence of
blood on the brain. On the other hand, in apoplexy the brain is com-
pressed, and suffers from excess of blood ; and, probably, the lungs are in
a similar condition.
The treatment will consist in allowing some blood, half an ounce or more,
to flow from the cut end of the umbilical cord, before tying it ; or, if the
flow is not enough to procure this quantity, by two or three leeches behind
the ears, on each side. Counter-irritants are applied,at the same time, to the
skin by frictions, and on the chest and spine, and aspersions on the face
and chest with cold water or vinegar and water, and slapping smartly the
534
DISEASES OF THE NERVOUS SYSTEM.
buttocks, stimulating the nostrils by burnt feathers, ether, or ammonia. Pul-
monary insufflation is practised with more safety, by the physician or expe-
rienced nurse blowing moderately for a second or two, through a tube—
a quill will answer on an emergency, introduced into one of the nostrils,
while the other and the mouth are kept closed, and immediately after-
wards withdrawing the instrument, and leaving the mouth and nose open.
Blowing with any force, as by means of a bellowrs, into the lungs of an
infant, may give rise to pulmonary emphysema from rupture of the air-cells
and vesicles. Both in this disease and in asphyxia the greatest perseve-
rance is required for a length of time, in some cases, which by this means
have had, eventually, a favourable termination.
True sanguineous apoplexy, or hemorrhage of the brain or its meninges,
may occur at any period in childhood. Dr. Campbell relates a case, the sub-
ject of which was only eleven days old. The more frequent variety, how-
ever, of infantile apoplexy is hemorrhage of the meninges, and, more particu-
larly, into the cavity of the arachnoid, covering equally both hemispheres.
M. Hewett distributes these extravasations into four principal groups : 1st.
Those in which the blood is either liquid or coagulated ; if the latter, it is
spread out in the form of a membranous layer ; 2d. Those in which the
extravasation presents itself in the shape of a false membrane ; 3d. Those
in which the blood is enveloped in a sac having every appearance of a
newly-formed serous membrane ; and, 4th. Those in which the blood is
fluid and encysted. These differences to a certain extent depend on the
duration of the disease : the blood is at first fluid, and, after the lapse of a
few days, it becomes coagulated. The cases of sub-arachnoid hemor-
rhage are fewer in number. The symptomatology of meningeal apoplexy
in young subjects is by no means clearly made out. The attack is generally
sudden : but in a certain proportion of cases it is preceded by headache,
drowsiness, and vertigo. M. Prius tells us that paralysis is common in the
intra-arachnoid hemorrhage, but less so in the sub-arachnoid variety. In
three of eight cases sudden loss of consciousness occurred. In both these
forms of hemorrhage, somnolence and coma came on almost invariably to-
wards the close. Out of 14 cases of meningeal apoplexy, sudden loss of
consciousness existed in but 2—contrasting greatly in this respect with cere-
bral hemorrhage or apoplexy. Paralysis of movement is not generally as
complete in the meningeal as in the cerebral form of the disease ; and it
is more frequently recovered from in the former than in the latter. In the
intra-arachnoid variety, cephalalgia, dryness of the tongue, fever, and
delirium, are almost always observed. The duration of the disease may
extend to a month or upwards ; and recovery may take place, as shown
by the cysts found in the cavity of the serous sac. In the sub-arachnoid
variety, the only invariable symptom was coma: the intellectual faculties
were scarcely ever perverted, but merely weakened. Death occurs almost
certainly, and in a short period, not exceeding eight days.
M. Legendre enumerates the following symptoms of intra-arachnoid
hemorrhage, the only one, in his opinion, which occurs. Vomiting,
fever, convulsive movements, commonly about the globes of the eyes, and
some strabismus. Intestinal evacuations natural and easily excited. A
permanent contraction of the hands and feet, followed by convulsions of
either a tonic or clonic nature, are farther symptoms. Between these pa-
roxysms there was stupor, increasing from day to day, and fever also gra-
dually augmenting in intensity until the close of life. As this approached,
APOPLECTIC EFFUSIONS.
535
the convulsions were more frequent, and hardly allowed of an interval
between them. Intercurrent thoracic phlegmasiae sometimes prove to be
the immediate cause of death.
Of the causes of meningeal apoplexy we know very little, and of the
treatment scarcely any more. As far as analogous symptoms present
themselves with fever, the remedies will be the same as those recom-
mended in meningitis. This form of apoplexy, which is far from being
confined to children, may occur at any age, but it is most frequent among
the insane, and particularly the fatuous paralytics.
There is yet another form of apoplexy in children, which may be called
passive or apoplexia venosa, in which apoplectic symptoms occur in young
subjects, who are neither plethoric nor possessed of vigour of constitution.
On this kind of apoplexy in adults, I refer to what is said by Dr. Mar-
shall Hall, at the close ofthe next lecture.—B.]
LECTURE CXXXI.
DR. STOKES.
Apoplectic Effusions—Curative process adopted by nature—Periods of life most sub-
ject to apoplexy—Connexions of temperaments [and sex] with disposition to apoplexy
—Researches of Rochoux—Principles of diagnosis—Varieties of apoplexy—Con-
nexion of symptoms with pathological appearances—Rostan's division of—Different
symptoms of—Double effusions—Rupture into the ventricles—Hemiplegia—Value of
the suddenness of paralysis as a diagnostic examined—Symptoms of apoplectic effu-
sion.
At my last lecture, I spoke ofthe nature of apoplectic effusions : I stated
that they exhibited a considerable variety as to their situation, extent,
number, and condition in different cases ; that it was frequently a matter
of great difficulty to ascertain their source, and that they might occur at
any age, but chiefly from that of fifty to seventy. I gave a brief sketch
of the process adopted by nature in effecting a cure, and showed that in
many cases, where the effused blood is absorbed, there is scarcely any
trace of the disease, except a slight cicatrix ; but that in some instances,
where the sanguineous effusion has been removed, its place becomes occu-
pied by a quantity of serous fluid, and this, with the cyst wThich contains
it, seems to explain what the old anatomists termed false ventricles. You
will find, by looking over some of the earlier writers on anatomy, that
they have described the brain as containing more than the ordinary num-
ber of ventricles, and the mistake seems to have arisen from their* taking
for ventricles those serous cysts or cavities which remained after the
absorption of an apoplectic effusion. Of course other causes, such as
congenital formation, may give rise to the appearance. You will see in
the Aluseum of the College of Surgeons a fine specimen of abnormal
cavities filled with serum in different parts ofthe brain.
In speaking of the period of life at which apoplectic disease is most
frequent, I stated, that though it might occur at any time of life, still
there was a particular period at which there is a greater liability than any
other. Rochoux has shown that the tendency to apoplexy is greatest
towards sixty, and diminishes towards seventy years of age. The num-
536
DISEASES OF THE NERVOUS SYSTEM.
ber of cases which occur between sixty and seventy are very great, when
compared with those between seventy and eighty ; and after eighty he
considers the liability to be still farther diminished. It seems strange,
that persons after seventy should not be so liable to attacks of apoplexy
as before that period, but such is the fact. It has been thought that this
may be explained by the anemic state of the brain in old persons ; it is
said, that at such an advanced age general emaciation generally takes
place, and the quantity of blood is greatly diminished. This explanation,
however, is doubtful, because it is at present well ascertained, that per-
sons of ordinary development, who are neither fat nor thin, and also of
persons of spare and delicate habit, are as much, and even more, liable
to apoplexy than the fat and plethoric. It has been ascertained by careful
investigations, that a high degree of plethora does not necessarily predis-
pose to the disease, and that it is oftener met with in persons not of a
plethoric habit than in those who are. These considerations throw some
doubt on the opinion that an exemption from apoplectic attacks is con-
nected with an anemic condition of the system. It generally happens,
however, that at this advanced period of life, from the general debility of
the system and the incapacity for active exertion, a man ceases to employ
his thoughts about business, and there is little exercise for the intellectual
functions. We now have finished the task ; the brain reposes from the
turmoil of active and incessant thought ; there is a comparative absence
of mental exertion, and this may in some degree account for the rarity of
apoplexy after the age of seventy.*
With respect to the different temperaments as bearing on this point,
Rochoux shows that in Paris, at least, there was a nearly equal frequency
ofthe disease in individuals of the sanguine, sanguineo-bilious, and san-
guineo-lymphatic constitutions. The bilious temperaments, however, are
much less liable. Such is the result ofthe observations in Paris ; but it
must be recollected, as Rochoux observes, that in that city the bilious tem-
perament is the rarest. With respect to the sanguine or plethoric, it has
been found that this temperament does not predispose to apoplexy so much
as has been generally supposed. The disease has been observed to be most
common in persons of ordinary development, next to those in persons of
thin, spare habit, and last of all in the plethoric and fat. Rochoux's
researches lead him to conclude that the number of persons of ordinary
development, attacked by apoplexy, is three times that of the plethoric,
and that that ofthe spare habits is little more than twice as great as that
ofthe fat and plethoric. If these researches are correct, they afford great
consolation to stout gentlemen.
* [Of 69 cases recorded by Rochoux, the distribution, in respect to
age, was as follows :—
From 20 to 30 years, ...... 2 cases.
" 30 to 40 * "......10 "
" 40 to 50 " ......7 "
" 50 to 60 "......13 "
" 60 to 70 " ......24 "
" 70 to 80 "......12 "
" 80 to 90 " ......1 "
69.—B.]
APOPLECTIC EFFUSIONS.
537
The conclusion, which has been come to, with respect to temperaments
as bearing on the liability to apoplexy, appears to be true, namely, that
there is no sign appreciable by the senses which will unequivocally point
out a predisposition to apoplexy. This is of great importance in a prac-
tical point of view. You may expect the disease in the fair or dark-haired,
the thin or fat, alike. The frequent occurrence of this disease in persons
who were never suspected to have any predisposition to it is another proof
in favour of this opinion. With respect to the mere medical diagnosis of
apoplectic effusion, it would be well if, in making it, you would always
bear in mind the anatomical characters of the disease. Extravasation of
blood into the substance ofthe brain generally takes place by a tearing or
separating ofthe cerebral tissue. A quantity of blood is rapidly effused,
the substance of the brain torn, and a cavity formed. There can be no
doubt that the tissue of the brain is torn, for we can see the loose shreds
hanging on each side ofthe cavity, and mixed up with the clot. Now,
what are the principles which should guide us in making our diagnosis ?
They are exactly the same as those in other diseases connected with a sud-
den solution of continuity iti the substance of internal organs. We have,
with or without any preceding symptoms of a different kind, the sudden
supervention of new and remarkable phenomena. The phenomena which
are the result of disease proceeding in its ordinary course are gradual and
progressive ; but occurrences of this kind are almost always characterized
by sudden and well-defined symptoms. Thus, we make the diagnosis of
the rupture of an aneurism of the aorta from the sudden vomiting or ex-
pectoration of blood, followed by the death of the patient. Here, you
perceive, the diagnosis is founded on the sudden supervention of new
symptoms. In the same way we make the diagnosis of pneumothorax with
a fistulous opening communicating with the bronchial tubes, and calculate,
from the sudden occurrence of pain in the side and the other signs of pneu-
mothorax, that there has been a solution of continuity in the pleura. Again ;
if a person labouring under hepatic abscess is seized with a fit of coughing,
and suddenly expectorates a quantity of pus, and that this is found to be
accompanied by a subsidence ofthe tumour in the region ofthe liver, we
make the diagnosis of perforation of the diaphragm and pleura, and the
escape ofthe contents ofthe abscess into the substance of the lung. Or
he may, under the same circumstances, be seized with sudden and rapid pe-
ritonitis,and here we make the diagnosis of an effusion into the peritoneum.
It is on precisely the same principles that Louis has established the diagno-
sis of perforation of the small intestines in cases of gastro-enteritis. The
patient is lying in bed, perhaps apparently improving; he is not exposed
to any exciting cause, and every care may have been taken of him. On
a sudden he exhibits symptoms of intense peritonitis, and rapidly dies. Any
one conversant with such cases can easily make a correct diagnosis. On
the same principles we found the diagnosis of apoplectic effusion. Almost
all the instances of disease which I have given occur with a sudden violent
invasion ; and the same thing may be said of apoplexy with extravasation.
It is true, that there are some cases which do not exhibit this character,
but the general rule is suddenness of attack.*
[As regards the predisposition to apoplexy dependent on sex, we find
that more men than women are attacked with the disease. P. Frank shows
that, out of 1241 cases of fatal apoplexy in the hospital at Vienna, during
538
DISEASES OF THE NERVOUS SYSTEM.
We may divide apoplectic attacks accompanied by extravasation into
three great classes ; and, if you look to the great majority of cases of this
disease, you will find that, although they appear to pass by insensible de-
grees into one another, still, when taken and examined singly, there will
be found a difference between them. This classification is that of Rostan,
and I have known his principles verified in many instances. In the first
class of cases, which are the worst and generally prove fatal, the extrava-
sation is enormous. A person, apparently in perfect health, will fall down
in a fit of apoplexy, remain for a short time insensible and paralytic, and
then die. In such a case as this, the ordinary pathological character is
an enormous effusion of blood, or excessive congestion. In a case of the
second class, we have an apoplectic seizure with coma, which disappears
after some time, and the patient recovers his intelligence, but with paralysis
of one side. The pathological character of this form is, that the effusion
is more limited, and exists only on one side of the brain. Neither is the
congestion so severe, and the patient recovers from the coma. In the third
form, we have an attack of apoplexy of a milder description ; there is
scarcely any coma or loss of intelligence, and the paralysis is slight, gene-
rally affecting the muscles of one side of the face or of one ofthe extremities.
Let us repeat these varieties. In the first, which constitutes the apoplexie
foudroyante of the French, there is an enormous extravasation of blood in
both sides of the brain ; or, if it be only on one side, the amount of the
effusion is frequently such as to burst through the walls of the ventricles
and get into their cavities, and in this way we may have an effusion of
one side getting into the other hemisphere, or exercising such pressure on
it as may give rise to general symptoms. Such a case as this is, I believe,
generally fatal; its progress, too, is very rapid, several persons under such
circumstances having died in the space of an hour or less. In the second
form, there is coma and loss of intelligence, and the patient recovers with
paralysis of one side. Here the extravasation is never so great as in the
foregoing case ; the effused blood is confined to one side, and does not get
into the ventricles. In the third form, the effusion is very much circum-
scribed, the signs of general congestion or extravasation are slight, the
quantity of blood poured out is not, perhaps, larger than a nut, it is followed
by partial paralysis, and there is little or no coma or loss of intelligence.
Let us take a brief review ofthe symptoms which attend each of these
forms. In a case of the first description, we find a person, hitherto in
the enjoyment of health, suddenly attacked with symptoms of intense
apoplexy. You will recollect that in my last lecture, I told you that apo-
plexy consisted in various lesions ofthe phenomena ofthe life of relation.
In the most violent form of apoplexy, many authors are of opinion that
there is a total paralysis in the functions of animal life. The patient falls
down and remains in a state of complete insensibility, the eye no longer
obeys the stimulus of light, no sounds make any impression on the ear,
of odour on the sense of smelling, the sense of taste is destroyed, the skin
may now be seared with a red-hot iron without the slightest indication of
suffering; in fact, sensation, one of the great phenomena of animal life,
the period between 1787 and 1804, there were 637 men and 604 women.
M. Fabret, in his statistics of apoplexy, indicates a greater difference.
Thus, out of 2297 cases of the disease, there were 1670 men and 627
women.—B.]
APOPLECTIC EFFUSIONS.
539
appears to be annihilated. If we examine further, we find that there is a
total suspension of the intellectual functions, and that the patient is un-
conscious of anything passing around him. If we go to the muscular
system, we find that all that part of it which subserves to the purposes of
animal life is completely paralysed. The neck, trunk and extremities
have lost their power; and if you raise the head, trunk, or one of the
limbs, they fall down like dead masses, as soon as the support is with-
drawn. In some cases there is a certain degree of rigidity in the mus-
cular system, in others not. We may observe also, that from the para-
lysis of the buccinators, the cheeks are alternately puffed out and sucked
in during respiration. As far as ray experience goes, I believe that this
symptom is fatal. Here, then, w$ see that the great phenomena of the
life of relation are suspended. The functions of organic life, however, still
continue to be performed, the heart beats, respiration goes on, and the
power of secretion remains ; but, after some time, the functions of organic
life are also suspended, and the patient dies. In some of these cases,
we observe evident signs of determination of blood to the head, the face
is swollen, and the lips livid ; there is considerable turgescence of the
vessels ofthe neck, with heat ofthe head, the skin hot, and the pulse full
and strong. In other cases, however, we have a feeble pulse, and a cold
and collapsed state of the surface.
Let us nowr turn for a moment to the pathology of this form ofthe dis-
ease. I have already mentioned, that the extravasation sometimes occu-
pies both hemispheres of the brain, or that it occurs on one side, and, by
tearing through the substance of the brain, gets into the ventricles, and
produces symptoms referable to a lesion of both sides. With respect to
the simultaneous double effusion, the following is a short notice of some
cases taken from the " Clinique Medicate" of M. Andral. A man, about
thirty-seven years of age, fell down near La Charite in a fit of apoplexy.
He was immediately brought into the hospital, had prompt and careful
attention paid to him, but without any effect; he lay in a state of profound
coma, with complete suspension ofthe phenomena of animal life, and died
in an hour and a half. On examination there was a double effusion of
blood found in the brain, but it had not got into the ventricles. In an-
other case, marked by simple intensity, there was an enormous effusion
discovered in the substance of one hemisphere, which burst into the ven-
tricle, tore through the septum lucidum, and passed into the ventricle of
the opposite side. In the next case, no distinct trace of optic thalamus
or corpus striatum could be seen, their substance being completely broken
up and destroyed by the effusion. I have told you that, after a rupture
ofthe substance of the brain and the escape of the effused blood into the
ventricles, persons have not recovered, but it is a fact, and a consolatory-
one indeed, that a person may recover from a simultaneous double effusion.
A case in proof of this is given by Andral. A female who had been for
some time a patient at La Charite, died of cancer of the stomach. The
history of her case was, that nine years before she had an attack of apo-
plexy, she had fallen down in a state of insensibility, and remained coma-
tose for a considerable time, and this was followed by paralysis of both
sides of ihe body, which continued for two years, after which she gradu-
ally recovered the use of her limbs. In this case, two serous cysts, such
as are met with in cases where patients have recovered from apoplectic
attacks, were found, one in each hemisphere of the brain. In another
540
DISEASES OF THE NERVOUS SYSTEM.
case, the subject of which died of visceral disease, the patient had twenty-
two years before an attack of apoplexy with double paralysis, and reco-
vered with the loss of the use of one side ; here there were two cysts also
found. It appears, then, that though extravasation, with rupture of the
walls of the ventricles, and escape of blood into their cavities, always
proves fatal, a recovery may take place after a simultaneous double effu-
sion.
Let us now inquire briefly, whether an apoplectic attack, followed by
paralysis of both sides of the body, gives sufficient grounds to enable us
to make the diagnosis of either of these accidents. Does it follow, if a
person has an attack of apoplexy, succeeded by paralysis of both sides,
that the effused blood has burst into th^ ventricles, or that a simultaneous
double effusion has occurred? Andral inclines to this opinion, as far as I
can recollect. Dr. Abercrombie appears to differ from him, and gives
cases in illustration of his opinions. The following is one : — A private
of the 10th Hussars has been complaining for some time of a pain in the
head, for which he was blistered, and the pain soon went off. On the
22d of July, 1819, he was seized with giddiness and fell down ; on being
raised, he vomited, and complained of violent headache and faintness,
but was quite sensible. He was very pale, and his pulse slow and lan-
guid. He was brought into the hospital, where he asked for some cold
water, made a few inspirations, and expired. From the moment of his
last seizure he had been paralytic of both extremities. Here we have an
attack resembling the first form of apoplexy, so far as complete loss of
power in the upper and lower extremities is concerned, but observe, the
patient was not comatose, and retained his faculties to the last. On exami-
nation there was nothing found amiss with the brain, but, on removing
the cerebellum, a coagulum to the amount of about two ounces was found
under and surrounding the foramen magnum. Here the paralysis appears
to have been produced by the pressure of the effused blood on the upper
part of the spinal cord. This case is an interesting one. It appears that
the injury done to the functions of the life of relation was partial, there
was a lesion of the muscular function, but there was no coma, and the
intellectual faculties were unimpaired. As far, then, as a single case goes,
we may come to the conclusion, that we are not to make the diagnosis of
the first form of apoplexy, unless, in addition to the double paralysis, there
are coma and loss of intelligence and sensation. The great points of diag-
nosis are coma, suspension of the phenomena of the mind, and paralysis
of both sides of the body, both of motion and sensation. We now come
to consider the symptoms ofthe second or milder form ofthe disease. A
person falls down in a state of insensibility, but when you come to examine
him, you find that the coma is not so profound, nor is the paralysis and loss
of sensation so complete. The eyes are to a certain degree susceptible of
the impressions of light, signs of uneasiness are exhibited when strong
pungent odours are applied to the nostrils, and indications of suffering are
given if you pinch or burn the skin. All these circumstances prove that
the paralysis of sensation is by no means so complete in this as in the for-
mer case. You observe here, too, that instead ofthe cheeks being pulled
out in the manner before described, there is only a partial paralysis of the
muscles of the face, and the mouth is drawn towards the sound side. The
patient, too, instead of dying in a comatose state, gradually regains his
intelligence, and is only paralysed on one side, or one extremity. All these
APOPLECTIC EFFUSIONS.
541
circumstances point out that the injury done to the brain is not so extensive,
and the occurrence of paralysis on one side shows that the effusion is lim-
ited to a single hemisphere of the brain. All this, too, is borne out by pa-
thological anatomy, which shows us, in the first place, that the extent of
the effusion is much less, that it exists only on one side of the brain, and
never bursts into the ventricles. The general congestion of the head also
is much less than in the former case. In the third form, the congestion
and other symptoms are sometimes very slight. A person in health may
feel a stunning sensation in the head, followed by some thickness of speech
and drawing ofthe mouth to one side, or slight paralysis of one arm or
hand, but he has no coma or loss of intelligence, and the paralysis quickly
disappears. Everything connected with the attack show's that it is very
slight, the effusion is extremely limited, and this is confirmed by patholo-
gical anatomy.
I have now given you a brief sketch of the three varieties of apoplexy ;
between these you will meet many intermediate cases.
Let us inquire how far does the circumstance of paralysis point out the
occurrence of an extravasation of blood into the substance or on the sur-
face of the brain ; that is, how far we can say that this patient has effusion,
because he has become suddenly paralytic. It would appear, that the mere
suddenness of the attack will not alone lead to the formation of a certain
and accurate diagnosis. You will find in various authors many instances
of affections of the head, not of an apoplectic character, in which thene was
sudden paralysis. Thus, for instance, there are many cases of tumours
and encysted abscesses on record in which there was sudden paralysis,
and where, if you should pronounce the disease to be apoplexy, you would
be certainly wrong. We had lately, at the Meath Hospital, a remarkable
instance of this. A patient who had been for a considerable time labouring
under aneurism of the innominata, in the course ofthe night became sud-
denly hemiplegic. On examining the brain,post-mortem, there was a cir-
cumscribed abscess found in one ofthe hemispheres, but no sanguineous
effusion. If you look to the works of Abercrombie, Rostan, Lallemand,
&c, you will find many cases detailed in which sudden paralysis occurred
from other causes than apoplexy.
But are there no circumstances, which, combined with the suddenness
of the attack, wrould lead us to form the diagnosis of apoplexy ? Now, it
would appear that, as a diagnostic of apoplectic effusion, suddenness of
paralysis is only to be relied on where there have been no premonitory
symptoms of a local disease of the brain. In the great majority of cases
of cerebral abscess, you will find that pains and cramps in some of the
limbs, and pain ofthe head in the situation ofthe abscess, have preceded
for some time the paralytic attack. But if a person in health, without any
of these cramps or pains, gets a sudden attack of apoplexy, and becomes
hemiplegic, you may make the diagnosis of apoplectic effusion with tole-
rable certainty. The fact of the paralysis occurring with an apoplectic
seizure, renders it highly probable that the case is really one of the hemor-
rhagic diseases ofthe brain. On the other hand, it is true that we may
have apoplectic effusions ushered in by symptoms of irritation of the brain,
as in the case of an apoplectic effusion occurring in the centre of a softening
of the brain. The absence, therefore, of these premonitory symptoms ap-
pears to be necessary towards forming the diagnosis of simple apoplectic
effusion.
542
DISEASES OF THE NERVOUS SYSTEM.
[As the phenomena of apoplexy, at least so far as regards the loss of
consciousness and of motion and the stertorous breathing, may proceed
from other causes than fulness and congestion of the cerebral vessels and
general plethora, the Observations on the Prevention and Treatment of Apo-
plexy and Hemiplegia, read by Dr. Marshall Hall at a meeting of the Medi-
cal Society of London, April 4, J 842, come in opportunely in illustration
of this subject. Also, Practical Observations and Suggestions in Medicine,
1845. Dr. Hall says :—The question ofthe causes, nature, prevention, and
treatment of apoplexy and hemiplegia was a very complicated one. He
thought the attention of physicians, in reference to the prevention and treat-
ment of apoplectic and hemiplegic attacks, had been far too much confined
to the question of plethora as the disease, and of depletion as the remedy.
It was to him certain that such attacks might and did occur quite irrespec-
tive of general plethora ; nay, that they occurred in connexion with the
opposite condition of the system, that of inanition and anemia. Nor was a
state of anemia the only other condition besides plethora which led to the
apoplectic, or hemiplegic attack. Morbid conditions of the stomach and
morbid conditions of the intestines were other sources of these seizures.
But he had also observed the occurrence of apoplectic affections under
other circumstances ; other indubitably predisposing causes of the apo-
plectic seizure were dyspepsia, cachexia, and gout. Nor was even this
view of the subject sufficiently extended ; the liver and kidney must do
their office. These sources of the apoplectic or hemiplegic seizure con-
sisted in conditions ofthe general circulatory system, and of the blood itself.
There were still others of a different kind.
The first of these was disease of the heart ; and this consisted, first, in
hypertrophy, with augmented impulse given to the arterial blood ; or,
second, in dilatation of the heart and disease of its valves, impeding the
reflux ofthe blood along the veins.
The second was disease ofthe capillary vessels, ofthe minute arteries,
or ofthe minute veins ofthe brain and its membranes.
Lastly, there were causes of apoplexy in the muscular efforts, by which
the action of the heart itself was augmented, as in violent running, the
ascent of a mountain, &c, and in other muscular efforts, by which the
return of venous blood was impeded, as the efforts of vomiting, or for the
expulsion of the feces ; and still more of parturition.
This view ofthe causes of apoplexy would sufficiently denote the com-
plexity of the problem of the prevention and treatment of the apoplectic
and hemiplegic attack ; for that prevention depended on restoring the sys-
tem to a state of what may be termed equilibrium, in regard to plethora
and inanition ; to the removal of irritating or morbid matters from the
prims viae ; to the correction of the morbid diathesis in dyspepsia, gout,
and cachexia. The prescription must include remedies and regimen to
meet all these circumstances, and, as he had stated, the problem was by
no means either an easy or a simple one. Yet another element in the
problem was that which related to the local or topical remedies. On
each of these sources of the apoplectic and hemiplegic attack, he proposed
to make a few observations. These observations would be principally
addressed to the medical practitioner; but as far as they might relate to
regimen, they might, he thought, be profitably considered by the patient.
1. Plethora.—When plethora is the cause ofthe threatening of apoplexy,
the remedy and safety of the patient consist in depletion. How are we
SOURCE OF APOPLECTIC SEIZURE.
543
to be certain of the fact (of plethora) ? There may be the appearance
ofthe sanguineous temperament, an athletic form, &c.; and with all this
there may be headache, vertigo, and other symptoms of head affection.
But is it certain that the symptoms in such a case depend upon fulness ?
If there be, in addition to the symptoms enumerated, a disposition to doze,
it is nearly so. But in the absence of such symptom, and even with such
symptom, may not the real case be indigestion ? Certainly ; then what is
to be done ?
There is a [diagnostic] symptom of great value, when it can be clearly
ascertained to exist. It is the occurrence of vertigo, first, in the act of
stooping, and secondly, in an unusually erect posture, especially when
suddenly assumed. But if this be absent, what is then to be done ?
There is a resource in such a case, which, in spite of the criticism of a
respectable author, I will again venture to assert is of immense value.
There is no case in which a patient, if bled from a good orifice, in the
erect posture, bears to lose so much blood before syncope takes place, as
in that of real congestion ofthe cerebral vessels ; there is no case in which
full abstraction of blood is so necessary. On the other hand, in the case
of vertigo, and other cerebral symptoms arising from dyspepsia, the pa-
tient neither bears the loss of much blood, nor requires it.
In a doubtful case, I propose to adopt this mode of bloodletting, first,
as a guard against the undue loss of blood, and secondly, as a means of
diagnosis, and a prompter of ulterior proceedings. I have adopted this
measure so often, and with such satisfactory results, that I cannot recom-
mend it too strongly to my medical brethren. In cases, on the other hand,
in which it has not been adopted, I have seen one class of patients become
a prey to apoplectic or paralytic seizures, for want of bloodletting, and
another affected with headache and vertigo, drained of blood (uselessly)
by repeated cupping and leeches.
2. Anemia—Inanition.—It was constantly his lot to see patients who
were in jeopardy notfrom fulness but from inanition, and who had long been
kept in a state of anemia by bloodletting, general or topical, when an oppo-
site treatment was required to restore the equilibrium ofthe system, and to
remove the vertigo and other symptoms threatening an attack of apoplexy.
A state of pallor, a disposition to vertigo, faintishness, palpitation, and ner-
vous timidity,the occurrence of the symptoms when the stomach wasempty,
when the bowels had been relieved, and on suddenly looking upwards,
or resuming the upright position on rising from bed, or after stooping, or
the recumbent position : such were the diagnostic signs of a state of in-
anition from a state of plethora. The history of the case also afforded a
diagnosis; for, although depletion might have appeared to afford a mo-
mentary relief of the symptoms, it had issued in their •aggravation in ge-
neral. An opposite mode of treatment, very cautiously and prudently
adopted and pursued, would confirm the diagnosis, by affording a more
permanent, though possibly a less immediate and marked relief. It wTas
to the important distinction between the immediate and permanent relief,
indeed, that he would draw the attention of the profession. In the case
of symptoms portending apoplexy or hemiplegia, although these might
arise from inanition, yet they were invariably relieved by depletion, al-
though they afterwards returned with augmented force. This effect was
very puzzling to the inexperienced practitioner. It was explained by the
fact, that the symptoms ceased under the influence of a condition allied
544
DISEASES OF THE NERVOUS SYSTEM.
to syncope, but returned with the reaction. This subject must be care-
fully studied, in order that the nature and treatment of the case might be
understood. He had next particularly to notice that the state of anemia
was not one of safety. In such circumstances apoplexy and hemiplegia,
with the actual effusion of blood into the cerebrum, had occurred.
3. Dyspepsia and Cachexia.—There could be little doubt that in dys-
pepsia the blood itself became contaminated, and, as it were, cachectic ; on
this principle we accounted for the appearance of furunculus and parony-
chia ; for the morbid condition of the tongue and interior of the mouth,
the general cutaneous surface, the secretions, &c. He had so often ob-
served symptoms threatening the apoplectic or hemiplegic attack, in con-
junction with symptoras of dyspepsia and cachexia, that he had no doubt
of the vast importance of a strict attention to this subject. That very day
(Oct. 1, 1841) he had been consulted by a medical gentleman under these
circumstances. One form of this affection was the following: vertigo
occurred with faintishness, sickishness, and a cold clammy perspiration ;
sometimes there was actual sickness, sometimes much flatus. In these
cases the feet and other extreme parts were apt to be cold. The secre-
tion of the liver was frequently defective, and the urine was apt to depo-
sit the lithic acid salts. Nothing could be so injurious as bloodletting.
In no case was the loss of blood repaired with such difficulty. The ap-
plication of a few leeches frequently left a state of debility and pallor,
which were felt and seen for weeks. The treatment consisted in the cor-
rection of the secretions, and in the infusion of tone and general health
into the systera. The compound decoction of aloes, the infusion of rhu-
barb, of gentian, of cinchona, singly, or, better, mixed together; sarsa-
parilla ; the vinum ferri; the bicarbonate of potass, stomachics, tonics,
and antacids, in a word, were the principal internal remedies. But with
these a mild, nutritious diet, a system of gentle exercises, early hours, the
tepid salt-water shower-bath, and a strict attention to the condition ofthe
feet and general surface, by means of the flesh-brush, flannel, and a fre-
quent change of shoes and stockings, should be conjoined. Those en-
gaged in the harassing affairs of a London life should sleep in the country,
and cherish the utmost quiet of mind.
4. Gout.—But he had frequently traced a connexion between gout and
its frequent attendant, the lithic acid diathesis, and the apoplectic and
hemiplegic seizure. It was not merely plethora, or the opposite state of
inanition, which led to the apoplectic attack. The morbid state ofthe
blood in dyspepsia and cachexia also disposes, as he had already said, to
this affection. The same remark applied to the condition of the systera
and of the blood, especially in gout; and, as he should have to observe
immediately, the same disposition obtained in several morbid conditions
of the liver and kidney. A nobleman, now no more, suffered in succes-
sion from gout and the herpes zoster, and the urine deposited the lithites
copiously. He was relieved by the appropriate remedies, and became
affected with an apoplectic (or epileptic) attack. A similar attack (with-
out hemiplegia) occurred several months afterwards, and a third attack
proved fatal. This gentleman was pallid, the prolabium being white. A
steady perseverance in such remedies as the decoctium aloes compositum,
the bicarbonate of potass, and the vinum ferri, had in other cases effectu-
ally averted the threatened evil. But he must make another remark.
The vinum colchici should be given in very minute doses, as five drops
PARALYSIS CONSEQUENT ON APOPLEXY.
545
thrice a-day, also steadily and persevering to overcome the specific gouty
diathesis. The lithic acid diathesis was not the only urinary disorder
which led to apoplexy and hemiplegia. This attack, it is well known,
occurs in the case of diabetes, and in that of albuminous urine. Although
he had designated the attack apoplectic and hemiplegic, it was some-
tiraes more allied to epilepsy than apoplexy. The gentleman to whose
case he had briefly adverted, was affected with minute ecchymosed spots
on the forehead, which he had only observed under three circumstances,
viz., after severe vomiting, the effects of parturition, and the epileptic
attack; when he saw him soon after the second seizure, the insensibility
had passed away, and there was no hemiplegia.
5. Muscular Efforts.—He might make the same remark in regard to
muscular efforts which he had done in regard to disease of the heart—
those efforts, which opposed resistance to the reflux of the venous blood,
were much more efficient causes of the apoplectic seizure than those efforts
which augmented the momentum of the arterial blood. Thus we rarely
heard of the occurrence of apoplexy during the violence ofthe race, during
the ascent of mountains, &c, but such an occurrence at the water-closet
was by no means uncommon ; and we all know how apt the parturient
efforts were to induce congestion of the brain, and the consequent apo-
plectic seizure. It would be most interesting to correct our ideas on these
subjects by a cautious appeal to facts.—B.]
LECTURE CXXXII.
DR. STOKES.
Apoplexy from ramollissement (softening) of the brain—Supervention of apoplexy on
encephalitis—Inflammation round the clot—Variety of paralysis consequent on apo-
plexy—Paralysis croissee—Different forms of paralysis—Origin—Phenomena of face
and tongue—Paralysis of the tongue—[Contraction with paralysis]—Treatment of
apoplexy—[Deductions from 250cases]—Bloodletting—Purgatives—Lotions, benefi-
cial effects of—Emetics, dangerous effects of—Use of revulsives and stimulants-
Treatment of paralysis—Efficacy of strychnine—Its modus operandi—Brucine,
proposed employment.
I left off at my last lecture in considering how far the mere circumstance
of suddenness of attack with paralysis could be considered as leading to
the diagnosis of apoplectic effusion, and endeavoured to show that mere
suddenness of attack with paralysis was insufficient to form a diagnosis,
except where they occurred in a person who had no previous symptoms
of irritation of the brain ;—these symptoms being pain of the head, and
pains, spasms, and rigidity of the limbs. I wish to impress upon you
that you may have an attack of apoplexy with effusion ushered in by all
these symptoms, particularly in cases where the apoplectic effusion is con-
sequent on a localized inflammation of the brain. A portion ofthe brain,
for instance, becomes inflamed and disorganised ; local ramollissement
(softening) takes place ; and it may happen that this, acting as a point
of attraction to the fluids, may lead to the occurrence of an apoplectic
effusion in the originally affected portion; and in this way you will have
apoplexy preceded by all the symptoms which characterize a partial ence-
phalitis. You will perceive, then, that the absence of these premonitory
vol. n.—3(3
546
DISEASES OF THE NERVOUS SYSTEM.
symptoms is necessary towards forming a certain diagnosis of apoplexy
with effusion. If these symptoms have preceded the attack, it is proba-
bly either circumscribed abscess of the brain, or it is local inflammation
followed by effusion. Between these two forms of disease we have no
means of distinguishing.
Before I speak of paralysis I wish to make some remarks on a condition
of the brain which supervenes in certain cases of apoplexy. In cases where
absorption of the clot takes place, we cannot suppose that any inflamma-
tory condition of the brain exists ; on the contrary, we have every reason to
believe that a non-inflammatory condition of the brain is highly favoura-
ble to this process, for whenever anything of an opposite character hap-
pens, we find that it prevents absorption. But sometimes cases occur, in
which, at an earlier or later period, inflammation is set up round the clot.
Now, what happens in many of these cases ? Here let me repeat, that
there are many exceptions to the rules given for forming the diagnosis of
disease of the brain ; the variety in the symptoms of cerebral affections
being so great, that it is sometimes difficult to deduce from them rules of
general application. In most cases we have apoplexy followed by para-
lysis with resolution ; but, in cases where inflammation takes place round
the clot, it has been observed that the paralysed limb which had been
previously in a state of resolution becomes contracted, and then we have
paralysis with contraction. This contraction generally comes on in a gra-
dual manner, but when the case is severe, it is frequently ushered in by
violent spasmodic action of the affected limbs. We have, then, the fol-
lowing order of phenomena : first, paralysis with resolution, and then
paralysis with contraction. In circumscribed inflammation of the brain,
the phenomena are the reverse of these : we have, first, rigidity and con-
traction of the limbs, and then symptoms of apoplexy followed by para-
lysis with resolution.
With respect to the paralysis which is consequent on an attack of apo-
plexy, there is the greatest possible variety. In some cases there seems
to be paralysis of all, or almost all, of the muscles of animal life ; in others,
it affects only the muscles of one side of the body. A rare and extraor-
dinary form of paralysis has been described by the French writers, who
have given it the name of paralysis croissee. In this form of the disease
there is an affection of both sides, but not of the symmetrical members ; we
find the left arm and the right leg paralysed, and vice versd. This is an
unusual form, in fact the rarest to be met with in practice. We may also
have great varieties in the amount of the paralysis ; in some cases both
sides being affected, in others only one, while in others there is only a
single extremity or one side of the face paralysed. We may also have
complete paralysis of one side without any affection of the face. I re-
member a remarkable case of this kind, of which I shall give you an ab-
stract. A gentleman, of stout muscular habit and a strong full pulse, had
been suffering for a long time under an obstinate gouty affection. From
a repetition of the gouty attacks he got a chronic swelled state of the
lower extremities, which continued for some time, he being in other re-
spects in the enjoyment of excellent health. The swelling, however, pre-
venting him from taking his usual exercise, he applied for advice. Laced
stockings were advised, the effect of which was, that the edema subsided,
and the motion ofthe lower extremities was restored. It is curious that,
between the period of the removal of the edema and the paralytic attack
PARALYSIS CONSEQUENT ON APOPLEXY.
547
which I am about to describe, this gentleman enjoyed excellent health.
At the end of that time, on attempting to go over a step that led into the
yard, he found he could not accomplish his purpose, and struck his foot
against the stone. He immediately became alarmed and sat down, and
soon after found that he had lost the power of using his arm. I saw him
in a short time after the accident, and found that there was complete
paralysis of the arm and leg, but no distortion of the face or tongue, or
the slightest lesion of intelligence. He continued in this state for some
time, and then recovered, but it was necessary to take a large quantity of
blood from hiin. In the first bleeding, as the pulse was full and bound-
ing, I took sixty ounces of blood from the arm, and I think it was owing
to the activity of the measures adopted that he recovered so speedily. I
mention the case merely to show that we may have paralysis of the leg
and arm, without any affection of the face, or loss of intelligence. In
some cases we find the paralysis affecting the tongue, face, and muscles
of the eyelids; in some we have paralysis of the sphincter ani, or of the
muscles of deglutition, or of the bladder, but these are rare, and the most
ordinary form is paralysis of the muscles of one side, and distortion of the
face. There is another circumstance, which seems to be so exceedingly
frequent as to form a law, perhaps the most general of any in medicine,
that paralysis occurs on the side of the body which is opposite to that on
which the effusion occurs. If you have an effusion into the right hemi-
sphere, you will have paralysis of the left side of the body, and, if the
effusion be on the left side, the paralysis will be on the right. To this
rule, however, it has been stated that there have been a few exceptions ;
how they have occurred it is totally impossible to explain : it is sufficient
for us to know that such exceptions have been witnessed. Cases of this
description have been very rarely seen since pathological anatomy has
been studied with more diligence ; it is, however, true, that a few have
been detailed by men of great professional eminence. We want facts to
throw light on this point, and, until this is accomplished, we must remain
in ignorance of the cause of the anomaly. In the vast majority of in-
stances, the paralysis is on the opposite side to that on which the effusion
takes place, and this appears to be explained by the decussation of the
fibres ofthe brain at the upper part of the spinal marrow, the fibres ofthe
left side passing to the right, and vice versd. It is an interesting fact con-
nected with this subject, that the muscles of the face follow the same law
as the muscles of the extremities, and yet it is a fact, as you are well
aware, that the nerves which supply the muscles of the face come on be-
fore the decussation of the fibres of the brain takes place. The fifth nerve,
which supplies the face with muscular branches, is given off at a consider-
able distance from the decussation of these fibres, and yet we perceive
that the muscles to which it is distributed obey the same law as those
which derive their nerves from the spinal cord. Now, if this decussation
was the only cause of the paralytic symptoms being observed on the side
opposite to that in which the effusion occurs, the muscles of the face should
be an exception to this law; but we find that they correspond with other
parts of the muscular system in this respect. Thus, if a man gets an
attack of apoplexy, followed by paralysis of the left arm, we find the left
side of the face affected, and vice versd. We must conclude from this,
that the mere decussation of the fibres is not the sole cause of this pecu-
liarity, and must look for an explanation elsewhere, by referring it to the
548
DISEASES OF THE NERVOUS SYSTEM.
intimate communication which exists between both sides of the brain by
means of its commissures. Many persons are not familiar with the phe-
nomena of the face and tongue in paralysis ; they are, however, simple
and easily explained. Let this diagram represent the head — here we
have the'right hemisphere/ of the brain, here the left. Now, suppose you
have an apoplectic effusion in the right hemisphere, the consequence is
that you have paralysis of the left side of the body, according to the law
already mentioned. What will then happen with respect to the face is,
that the muscles of the left side being paralysed, and their antagonism
destroyed, the mouth is drawn by the sound muscles of the opposite side
from the paralysed side, and this is invariably the case. Recollect, then,
that the mouth is always drawrn from the paralysed side, and towards that
side where the disease exists in the brain. But when you desire the pa-
tient to put out his tongue, do you find that the tongue follows the direc-
tion of the mouth ? No ; it goes towards the opposite side. This appears
somewhat paradoxical at first, but is easily explained. The protrusion
of the tongue is effected by the action of the genio-hyoglossi muscles,
which are, as you all know, a pair of fan-shaped muscles, attached to the
inside of the chin, the middle line of the tongue, and the body of the os
hyoides. This diagram will represent it. Here is the muscle of the left
side, and here is the right. When the patient puts out his tongue, this
left half being paralysed, and having lost its antagonism, the tongue obeys
the action of this, the right half, and the fixed point of attachment ofthe
muscle being to the right- of the mesial line, the base of the tongue is
brought forward, and to the right, and its point consequently deviates to
the left or paralysed side. It has been remarked, also, that there is some
variety with respect to the paralysis of the tongue ; some patients can pro-
trude it, others cannot. In some cases, too, the patient can put out his
tongue well enough, but he cannot employ it in the articulation of sounds,
and his speech is quite indistinct.
I might occupy your time for several lectures with these subjects ; and,
did my time permit, I could lay before you a vast quantity of interesting
matter on the subject of paralysis from apoplexy ; but, as the number of
lectures is limited, all I can hope to accomplish is, to point out the great
landmarks to you, and leave the rest to your own study and experience.
With respect to paralysis of the extremities, the upper are paralysed more
frequently than the lower ; and, when both extremities are engaged, the
upper are generally more completely affected than the lower. When a
person recovers, also, we find that the lower extremities are the first to
retain their lost power and sensibility. These circumstances have been
attempted to be explained by considering the particular parts of the brain
in which the effusion has occurred ; but, as this has not as yet been suffi-
ciently made out, I shall pass it over. I regret, also, that I have not time
to enter into the subject of different varieties of lesion of intelligence in
cases of apoplexy. I must, however, observe, that the varieties are infi-
nite, and your trouble will be amply repaid by reading what has been
written on this point by Dr. Abercrombie, and Dr. Cooke in his Trea-
tise on Nervous Diseases. You will find in the latter work an extraor-
dinary collection of facts with respect to lesions of the intellectual func-
tions.*
* [Contraction sometimes accompanies hemiplegia. From the researches
TREATMENT OF APOPLEXY.
549
I shall now endeavour to get through the treatment of apoplexy as briefly
as the important nature of the subject will admit. I shall commence by
saying, in the words of Dr. Abercrombie, that the remedies for apoplexy
are few and simple. The great point is to relieve the head from the ac-
cumulation of blood, to prevent farther congestion, and to obviate inflam-
matory action ; and for these purposes the only efficient means we possess
is bleeding. There is no disease in which the efficacy of free and bold
depletion by the lancet is more remarkable than in apoplexy. I agree
completely with Dr. Abercrombie^n thinking that the symptoms which
denote serous apoplexy by no means contra-indicate the use of the lancet;
for I have already shown, that serous apoplexy was nothing but conges-
tion, that the serous effusion was one of the consequences of this conges-
tion, and by no means the cause ofthe apoplectic symptoms. Dr. Aber-
crombie thinks that, in the commencement of the disease, you may bleed
where the pulse is feeble as well as where it is strong and full, and gives
many important cases in which the disease yielded to a copious abstrac-
tion of blood, though the state of the patient's pulse and general system at
the time were such as would deter many from bleeding. He gives three
cases of persons about seventy years of age, on whom this mode of treat-
ment was practised with success, and another of a person of spare habit,
aged eighty years, whose life was saved by a bold and timely use of the
lancet. There is also another case detailed of a patient who was worn
down and dropsical at the time of the attack, and received considerable
relief from bleeding. I do not wish you to conclude from this that you
should bleed as boldly in the one case as in another ; what I wish to im-
press is this, that in a vast majority of cases it is advisable to have recourse
to the lancet. With respect to the first bleeding, I think that where the
pulse is full and strong it should be large, and such as will produce some
effect on the symptoras. This may be repeated afterwards to a smaller
amount if necessary ; but the subsequent bleedings should be rather local
than general, except where there is any renewal of the cerebral and cir-
culatory excitement, which must be always met with activity. I believe
the cases in which you must make the largest bleedings are those in which
there are symptoms of a hypertrophied heart. But where this is not pre-
sent, one or two bold bleedings, followed by local depletion ofthe head,
will be sufficient. In cases of apoplexy, you may either open a vein or
the temporal artery, for the objections made to arteridtomy in phrenitis do
not apply so much to cases of apoplexy. There is no violence on the part
of the patient, nor is there the same chance of the vessel giving way. The
head should be shaved and freely leeched, and the patient may be cupped
on the temples or the back ofthe neck.*
of M. Durand-Fardel (Archiv. Gen. de Med., 1843), it may be inferred,
that, in cerebral hemorrhage, contraction of the paralysed or non-paralysed
limbs almost invariably accompanies the rupture of the apoplectic cavity
into the ventricles or between the membranes ; that contraction rarely
attends hemorrhage into the substance ofthe hemispheres ; and, lastly, that
contraction is a very frequent symptom in cerebral hemorrhage.—B.]
* [The following conclusions, relating to the treatment of apoplexy, de-
rived from an analysis of two hundred and fifty cases by Mr. Copeman,
are interesting. They do not say much in favour of bloodletting.
550
DISEASES OF THE NERVOUS SYSTEM.
Next in efficacy to general and local bleeding seems to be the adminis-
tration of strong purgatives. There are many cases on record in which the
coraa and other symptoms have resisted bleeding, both general and local,
but have disappeared under the influence of active purgation. One of
the great objects in the treatment of apoplexy should be to get rid of the
coma as soon as possible ; and for this purpose nothing appears to answer
better than the early use of brisk purgatives. Dr. Abercrombie recom-
mends croton oil as the best purgative that can be employed, and indeed
it is an excellent one ; but if the patient can swallow, you need not be very
anxious about the kind of purgatives you prescribe ; any active purgative
followed by a strong enema will do. Where the patient cannot swallow,
you may mix the dose of croton oil with some mucilage, and pass it into
the oesophagus by means of a gum-elastic tube.
After purgation, the next thing is to apply cold to the head by means of
cold lotions, or iced water, or by pouring a stream of cold water on the
head. This is a measure of great efficacy, and one which you may employ
with safety and advantage.
Males. Females. Total. Cured. Retieved. Died.
170 80 250 68 7 175
Proportion of males to females . . . . . 2^ to 1
Proportion of deaths to cases . . . . . 1 in ly
Proportion of deathsto recoveries, including those relieved 2j to 1
No. not bled, 26. Cured, 18 ; died, 8
No. bled, 129. " 51 ; " 78
No. of cases in which the treatment is specified
Proportion of cures in cases treated by bleeding
Proportion of deaths in ditto, about
Proportion of cures in cases not bled .
Proportion of deaths in ditto
155
lin2J
3
1 " 1*
1 " ]$
1 "3£
No.
n , ^ -, Proportion of
Cured. Died. Cure^t0 Deathg]
Temporal artery opened 2 2
Cupping employed ... 11 6 5
Leeching .... 14 4 10 1 to2J
Bleeding in the foot^ . . 17 13 4 3£ " 1
General and copious' bleeding .85 28 57 1 '' 2
129 51 78 (pp. 15-6.)
Dr. Burrows (Observations on the Treatment of Apoplexy and Hemiple-
gia) enforces the necessity of attention to the posture of the apoplectic
subject, and especially to the state of the heart, before the question of a
large abstraction of blood is decided upon. The usual practice of raising
the head and chest is more important than is generally imagined, since it
contributes very decidedly to empty the vessels of the cranium. The
states ofthe heart that contra-indicate bleeding are valvular disease, and
a dilated condition of the ventricles accompanying emphysema of the
lungs.
Croton oil has been recommended by, I think, Dr. Allison, in cerebral
affections, with a view to its directly reducing as well as to its more known
and acknowledged purgative and derivative effects.—B.]
TREATMENT OF APOPLEXY.
551
In cases of apoplexy, where the coma has resisted free bleeding, both
general and local, and where purgation and cold applications to the head
have been employed without any decided effect, it seems advisable to
apply a blister to the head or nape ofthe neck. You will recollect that I
told you that blisters were always dangerous in the early periods of all
acute visceral inflammations. This, however, does not apply so much to
cases of hemorrhagic effusion like apoplexy, in which blisters may be em-
ployed at an earlier period than in cases of active inflamraation. I would
advise you, therefore, to use blisters in cases of apoplexy attended by per-
sistent coma, having first put into practice the means already mentioned.
Many persons advise the use of emetics in apoplexy, but the facts bear-
ing on this point, to which I have drawn your attention when speaking of
inflammation of the brain, will also apply here. You may take it as a
general rule, that where congestion of the head exists vomiting will
always increase it, and must be therefore exceedingly dangerous. As
far as theory goes it is totally against this practice, and I believe expe-
rience also is opposed to it. In a number of cases of disease of the brain,
where emetics were employed, it has been found that an unfavourable
result ensued, and there are some cases of apoplexy on record in which
the exciting cause was a fit of vomiting.
Suppose that, after having taken away blood, purged actively, used cold
applications, and blistered the head, the coma still remains, accompanied
by a feeble pulse and cold skin, what are you to do ? I believe, under these
circumstances, and these alone, you may venture on the use of internal
stimulants. Though this is at best but a forlorn hope, still the practice
appears rational; we have analogy to guide us in the use of stimulants in
such cases, and there are cases on record of persons who have recovered
from this state by their judicious employment. The remedies most gene-
rally prescribed for this purpose are camphor, musk, and carbonate of
ammonia. In the cases of typhus, we know that these remedies have fre-
quently succeeded in removing the coraa ; but I repeat, that you should
never have recourse to stimulants until the period for depletion has passed
by, and all the ordinary means have failed.
I shall now suppose that we have succeeded in removing the coma,
that consciousness has returned, and that nothing remains but paralysis of
one side. Our great object is to get rid ofthe paralysis as soon as possi-
ble. Here you will recollect that you have to deal with paralysis depend-
ing on extravasation, a paralysis which, as far as we know, will not
disappear under any form of treatment until the extravasated blood has
been absorbed. The first thing, then, you have to do, is to adopt mea-
sures to prevent a return of the attack. This is to be effected by carefully
restricting the patient in his diet, by avoiding all causes of cerebral irrita-
tion, whether physical or moral, and by obviating everything capable of
exciting the circulation. But you should not be content with this: you
should from time to time employ local depletion, which in cases of this
kind has a double utility. It tends to prevent a repetition of the attack,
and, by lowering the circulation, keeps the brain in that non-inflamma-
tory condition which is most favourable towards promoting the absorption
of the coagulum. In many cases, also, you will find it of great advan-
tage to establish a drain in the vicinity ofthe disease, and a great deal of
good may be done by putting aseton, or an issue, in the neck. You must
also pay constant attention to the state of the bowels and urinary system
552
DISEASES OF THE NERVOUS SYSTEM.
in cases of paralysis ; keeping up a steady but mild action ofthe bowels
has an excellent effect, and I need not impress upon you the necessity of
paying strict attention to the bladder.
The paralysis which supervenes on an attack of apoplexy, is to be treated
always in the first place by means directed to the head, and the brain is
to be put in such a state as will favour the removal of the clot by the
means already recommended ; in addition to which it will be necessary
that the body and extremities should be kept in a warm temperature. But
there is this very singular circumstance connected with some cases of para-
lysis, that a period will arrive when, although the original disease of the
brain has been removed, and the clot absorbed, the paralysis still con-
tinues. It is not easy to explain the circumstance ; but it has been ob-
served in many persons who have been paralytic, that the clot was com-
pletely absorbed, and no existing trace of disease discoverable, such as
would account for the continuance of the paralysis. In cases like this we
must adopt a different mode of practice, and have recourse to measures
capable of exciting the brain, and we have reason to believe that what-
ever will excite the brain and restore its energy (I must use this phrase
for the want of a better) will cure the paralysis. We find that in some
cases where the brain of a patient, under such circumstances, has been
exposed to any sudden stimulus, whether physical or moral, the symp-
toms of paralysis have disappeared, sometimes gradually and slowly, at
other times rapidly and at once. Now, this disappearance of the symp-
toms shows that the paralysis did not then depend on the presence of a
clot, for if an unabsorbed coagulum remained in the situation of the ori-
ginal extravasation, the paralysis would not disappear. But it has been
frequently observed, that a patient, labouring under paralysis, may get rid
of his symptoms suddenly, or that, at a certain period, they begin to de-
cline, and then go away altogether. From a consideration of these cir-
cumstances we are led to divide the treatment of paralysis of this descrip-
tion into two parts, and endeavour first to excite the brain itself, and
next the nerves which supply the paralysed limbs. For this purpose
several remedies, supposed to be capable of stimulating the brain, so far
as its action on the muscular system is concerned, have been recommend-
ed, the most important of which is the nux vomica, or its active principle,
strychnine. The researches and experiments of modern medicine have
already established the efficacy of strychnine in such cases, but you will
recollect, as I before stated, that this powerful remedy can be employed
with safety only in cases where the paralysis continues after the disap-
pearance of organic disease of the brain. Until that period arrives,
and all symptoms of congestion and excitement are removed, it would be
improper to prescribe the use of strychnine. One of the most recent pub-
lications on this subject is from the pen of Dr. Bardsley of Manchester, in
which you will find an exceedingly interesting series of cases treated with
strychnine, and many of them with the most decided success. In most
of these cases you will find that Dr. Bardsley, even where the disease has
been of some standing, precedes the use of strychnine by measures calculated
to deplete the head, even though the cases were chronic. Hence, when-
ever you are about to prescribe this remedy, you should be satisfied that
depletion has been sufficiently performed. You may be called to treat a
patient for paralysis after an apoplectic attack. Here you must consider
how far you are to premise the use of strychnine by depleting measures,
TREATMENT OF APOPLEXY.
553
and you must also reflect that we here have shadowed out one ofthe most
important principles in medicine, that in almost all cases where a cure is to
be attained by stimulation, it will be effected more readily, and with more
certainty, when preceded by local depletion, no matter how long the disease
may have lasted. The efficacy of strychnine in paralysis seems to be de-
pendent on the antecedence of local or general depletion.
Strychnine being an exceedingly active remedy, and having a most
powerful effect in stimulating the brain, it being also one of the accumu-
lative class of medicines, it will be proper to commence its exhibition
with a very small dose, and watch its effects with care. The following
is the formula which I would recommend you to employ : You take a
grain of strychnine, and your object being to divide it into a number of
equal parts (say sixteen), to insure an accurate division, you dissolve it
in a small quantity of alcohol, and, having mixed this solution with a
quantity of bread-crumb or conserve of roses, you divide it carefully into
sixteen equal pills. In this way you may be tolerably certain that each
pill contains one-sixteenth of the grain. Begin at first with one pill a-day,
next day you may give two, and so on until you have brought it up to
half a grain or a grain, watching carefully its effects. Now, what are
these effects? They are very analogous to the phenomena produced by
inflammation of the brain taking place in the vicinity of the clot, namely,
spasms of the muscular system.
It is also a curious fact, that these spasms are principally observed on
the paralysed side ; in other words, that the portion of the brain which
has been affected by this disease is more sensible to the stimulus of the
strychnine, the consequence of which is spasmodic twitches in the para-
lysed limbs. The great nicety of practice in the treatment of paralysis in
this way, is to keep up a certain degree of this irritation without letting
it proceed to any degree of violence, and to omit it whenever the follow-
ing symptoms become manifest—headache, giddiness, weakness, and sick-
ness ofthe stomach, and too violent spasmodic twitches ofthe limbs.
There is a great difference with respect to susceptibility of the effects
of this remedy in different individuals : in some the effects speedily ap-
pear, and you are obliged to intermit its use ; others will bear large doses
for a considerable time, and you may push the strychnine until a grain or
a grain and a half is taken in the day. I have myself given to one patient
a grain every day for the space of a fortnight without any intermission.
In all cases, however, it will be necessary to watch the symptoms. There
is one effect of strychnine which appears to be unfavourable, and when-
ever it occurs you should either omit the medicine or diminish the dose.
Along with or succeeding the spasms, there is a tonic rigidity of the limbs ;
when this occurs you should be cautious in the administration of strych-
nine. The length of time which it should be continued will of course
vary according to circumstances, but you should be awarfe that it requires
a considerable period of time to produce its effects. In all Dr. Bardsley's
cases, and in all those treated at the Meath Hospital, it has been continued
for a considerable time, certainly more than a month. It is also necessary
for you to recollect that strychnine is one of those medicines which are
termed accumulative, that is to say, remedies, the operation of which,
after remaining latent for some time, suddenly explode with great vio-
lence. When this occurs, the strychnine must be immediately given up,
and steps taken to control its effects. One of the best things for this pur-
554
DISEASES OF THE NERVOUS SYSTEM.
pose is the carbonate of ammonia with some mild anodyne. I have seen
very severe spasms from the use of this medicine. In one case these
spasms were so violent as to roll the patient nearly out of bed.
It has been proposed to employ brucine as a substitute for strychnine.
Of this remedy I can say but very little ; I have given it but very seldom ;
I believe in only twro cases, and in these without any sensible effect. It
is much weaker than the former remedy, one-fourth of a grain of strych-
nine being equal to six grains of brucine. Other remedies have been
proposed for the same purpose, among the rest, iodine, which has been
recommended by Dr. Mansfield.
The next class of remedies are those which are employed for the pur-
pose of exciting the nerves of the paralysed limb. As my time, however,
has expired, I must postpone the consideration of these until our next
meeting.
LECTURE CXXXIII.
DR. STOKES.
Paralysis—Local treatment of—Flesh-brush, shower-bath, &c.—Application of moxa
—Cases in which it is useful—Professor M'Namara's plan—Acupuncture with gal-
vanism — Electro-puncturation — Method of applying — Powerful action of small bat-
tery—Mr. Hamilton's observations—Value of galvanism and electricity—Use of, in
paralysis ofthe muscles of the face—Paralysis from disease of the arterial system—
Case of, by Dr. Graves—Diagnosis of this affection—Pathology of Pott's gangrene—
Dupuytren's mode of treatment.
Having spoken of the general treatment of paralysis after apoplexy, we
come now to the local management of the disease, or that portion of its
treatment which consists in the application of stimulants to the nerves and
their organs. Local stimulation or paralytic limbs may be performed in
a variety of ways ; all the usual stimulant embrocations may be employed
for this purpose with the best effects. I shall not take up your time in
detailing the different kinds of liniments which are used on such occasions;
they are universally known, and may be varied ad infinitum. The flesh-
brush, shower-bath, either tepid or cold, occasional blisters to the spine,
or along the course of the nerves, croton oil and terebinthinate frictions—
all these are measures that may be employed with advantage. The use
of the moxa has been also strongly recommended, and appears to be de-
cidedly beneficial. The efficacy of all these remedies, however, seems
to depend chiefly on the particular stage and nature of the disease, and
hence their good effects are most apparent in those cases where the para-
lysis no longer depends on organic disease of the brain, but seems to be
connected with that peculiar state of the nervous system which arises from
a long interruption of the power of transmitting volition. It is in cases
like this that the application of the moxa has been found to produce the
most favourable results. Where the lower extremities are affected, it may
be applied over the sciatic nerve on the loins, or a little below and to the
outer side of the popliteal space over the track of the peroneal nerve.
In case of paralysis of the upper extremity, you may apply it to the back
of the neck, or in the neighbourhood of the brachial plexus.
LOCAL TREATMENT OF PARALYSIS. 555
A gentleman who does me the honour of attending these lectures, has
related to me the particulars of a remarkable case, which I shall raention
en passant. A young female was subject to repeated violent attacks of
spasms with contraction in one of the upper extremities. She had la-
boured under this affection for a long time, and tried various remedies
without benefit. At the suggestion of this gentleman she tried cupping
in the neighbourhood ofthe shoulder and brachial plexus, and found that
it produced decided relief to the symptoms. In this case it is highly pro-
bable that the disease was seated in the brachial plexus, and had no con-
nexion with the brain, for it had continued for a great length of time
(raore than three years, I believe) without any remarkable variation in its
symptoms. If the spasms of the arm had been produced by irritation of
the brain, she would in all probability have had paralysis long before this
period ; this, however, did not occur, and the probability that the disease
was seated in the brachial plexus is still further confirmed by the fact,
that the spasms were relieved by local bleedings. Here we have the
spasras relieved by antiphlogistic means, but in a case of atony of the
same nerves most benefit would be derived from the use of stimulants.
The more completely the paralysis is of this description, the more sure
will be the effects of local stimulation. You will sometimes meet with
cases of paralysis from pressure on the nerves without organic.disease.
Thus there is a case on record of a person who lost the use of one of his
upper extremities, from having leaned too long over a bench at a public
meeting. I recollect the case of a man, who during a fit of intoxication
fell asleep with his arm thrown over the back of a chair, and awoke with
perfect paralysis of the hand. Cases like these are seldom of long dura-
tion, and are much improved by the application of the moxa. I may state,
however, that permanent paralysis has been induced in this way. The
best way of using the moxa is, not to make a deep eschar, but to touch
the parts slightly, and repeat the application frequently. In the case of
paralysis of the hand, immediate relief followed the use ofthe moxa to the
back of the wrist.
While on this subject I may advise you always to employ the moxa in
the mode first, I believe, devised by my friend and colleague, Professor
M'Namara. The top ofthe moxa is to be dipped in a strong solution of
the oxymuriate of potass, which is to be allowred to dry upon it. The
moxa being fixed to the part by a little gum, a drop of strong sulphuric
acid will produce immediate ignition. In this way you prevent all the
alarm which the patient feels at seeing a lighted candle brought to the
bedside. The same rule is to be observed when you employ electricity,
the best mode of using which is to place the patient on an insulated stool,
and draw sparks from, or shocks through, the affected limbs. Electricity
frequently does much good in such cases; but, in order to obtain decided
benefit from it, you must persevere for some time in its employment. It
has been lately proposed to employ the stimulus of electricity and galvan-
ism in a different way, by transmitting it directly to the muscles of the
affected limbs by means of needles, which are to be inserted into different
parts of paralysed extremities, and which are intended to act as conduct-
ors for transmitting the galvanic influence. This has been termed electro
or galvanic puncturation, and forms an excellent mode of applying the
stimulus of galvanism. I have made many experiments as to its effects,
to which 1 shall briefly direct your attention.
556
DISEASES OF THE NERVOUS SYSTEM.
The first thing to be considered is the manner of its application. The
following is that which I use at the Meath Hospital:—Having procured
two fine sewing needles, your first step will be to take the temper out of
them ; for, if you employ them in the tempered state, you will run the
risk of their breaking in the flesh, and this would be very disagreeable.
You can easily take the temper out of them by holding them in a candle
until they become red-hot, and then letting them cool gradually. The
next thing is to place a head which will remain firm on the needle, and
for this purpose you pass a small portion of thread through the eye, and
then cover it with a bit of melted sealing-wax. Having thus formed a
head for the needle, you sharpen its point, and polish it by the emery pin-
cushion, and the sharper it is the better. There is nothing more simple
than to introduce the needles. You make the part ofthe skin tense with
your finger and thumb, where you intend to introduce them, and, placing
the point of the needle perpendicularly on it, you press it downwards in
a slanting direction, using, at the same time, a rotatory motion, and thus
easily pass it in ; when you have pierced the skin and fascia, there is no
difficulty in introducing it into the muscular fibres. The distance between
the needles must be regulated according to circumstances. You then
proceed to send the galvanic fluid to the part, and, for this purpose, the
best mode is to employ a small galvanic battery with a limited number of
plates. If you have plates of from two to three square inches you will
find that from fifteen to twenty of these, in a state of ordinary action, will
be quite sufficient, particularly in the commencement of the treatment.
It is a curious fact, that the intensity of the shock is increased to an ex-
traordinary degree by means of the needles. A battery which in the usual
manner would not communicate any shock, will, when used with the
needles, give a violent one, and communicate such a stimulus to the
nerves as will throw the whole limb into violent spasms, and cause a co-
pious perspiration to break out over the body. I have seen very great
effects from a feeble battery in this way, and it would appear that this is
the result of the direct transmission of the galvanic influence to the mus-
cular fibre. In most cases a perspiration is brought on, the limb con-
vulsed, and sometimes the whole body is thrown into spasms. As an
illustration of the power of the battery when used in this way, I shall men-
tion the following case :—A patient, who was under the care of Mr. Ha-
milton, laboured under amaurosis ; he was anxious to try the effect of gal-
vanism, and with this view inserted one needle in the upper part of the
back ofthe neck, and another over the orbit, so as to direct the course of
the fluid across the base of the brain. He intended at first to use a small
battery of twenty-five plates, but it struck him that even twenty-five might
be too much. He made the experiment with three pairs of plates, and,
the shock being given, the patient, to his astonishment, fell back as if he
had been stunned by a violent blow on the head, and remained for nearly
a minute in a state of insensibility. In other cases, too, where the gal-
vanism was applied in the vicinity of the head, I have found that severe
headache, giddiness, and even a stiffness of the muscles ofthe face were
produced ; all showing its powerful action on the nervous centre.
Some singular circumstances connected with this subject were observed
in the Meath Hospital. It was found that after a certain number of shocks
had been communicated to the parts, when you came to withdraw the
needles there was a very remarkable difference in the ease of removing
GALVANISM IN PARALYSIS.
557
them. The needle through which the positive galvanic influence had been
transmitted, was found to be strongly fastened in its situation, while that
to which the negative pole had been applied, slipped out with the greatest
ease. This result was constant. In some cases, where half a dozen
shocks or so have been given, the extraction of the positive needle has
been only accomplished with considerable pain to the patient.
It has been suggested by a distinguished scientific friend of mine, that
this results from the coagulation of albumen at the positive pole. Mr.
Hamilton, however, who performed most ofthe operations forme, thinks
that the true explanation is the paralysing effecr of the negative pole on
the muscular fibre, while the positive needle is firmly grasped by the
increased contraction. Further researches are necessary on this point.
Another fact connected with this subject is, that when the needles have
been inserted into a large muscular mass, the positive needle is powerfully
retracted, and carried, as it were, into the muscles. In one case, where
the needle was inserted into the lumbar muscles, in a patient labouring
under sciatica, more than one-twelfth of an inch of it was drawm in at each
shock ; so that, after a certain number of shocks, it passed up to the head.
This is one reason for using the sealing-wax head, in order to prevent the
complete passing in of the needle.
With respect to our experience of the value of this mode of employing
electricity or galvanism, I have to remark that, if galvanism or electricity
can be of any use to paralysed limbs, this is one ofthe best modes in which
it can be supplied. The apparatus is simple, can be prepared in a mo-
ment, and does not depend on the state of the weather, like the ordinary
electrical machines. There is another advantage, also ; it is not so likely
to excite alarm in the mind of the patient. We have employed it in several
rheumatic and paralytic cases in the Meath Hospital, but have not as yet
been able to say that decided benefit has accrued from it to the majority
ofthe patients on whom it has been tried. This is more particularly true
with respect to paralytic patients ; in the rheumatic cases we have found
it more beneficial. In a remarkable case, where the deltoid muscle was
paralysed and atrophied from some affection of its nerves, Mr. Hamilton
tried it for a fortnight without any good effects. In a case of senile
amaurosis, its effect was to produce flashes of light before the eyes, lachry-
raation, and contraction ofthe pupil, but after a fortnight's trial there was
no improvement in the sight. We have had, however, distinct and une-
quivocal proofs of its value in one case of paralysis of the muscles of the
face, which had all the characters of that described by Sir C. Bell, as re-
sulting from an affection of the seventh pair of nerves. I have not the
notes of this case at present, but shall bring them down and lay them be-
fore you on to-morrow. I may, however, observe at present, that this
patient had been for a long time labouring under an affection of one side
of the face, and had used a variety of remedies. Those principally em-
ployed were stimulating liniments and the internal use of strychnine, from
which he derived some slight benefit; but the application of the galvanic
fluid, in the way I mentioned, was followed by decided and rapid improve-
ment. Indeed, from the time it was first applied, the patient recovered
rapidly, so that in a very short time all the deformity of face disappeared.
Now the value of the application is to be estimated in this way. Here we
have a case of paralysis of a local nature, and not depending upon any
disease ofthe brain ; in this case the galvano-puncturation was tried, and
558
DISEASES OF THE NERVOUS SYSTEM.
found to be most beneficial. The conclusion, then, as far as a single case
goes, is, that this mode of treatment is best adapted to the form of paralysis
just mentioned, in which we find an affection of some of the muscles re-
maining after the original disease of the brain has been removed. The
same observation, I need not tell you, applies to all other remedies which
are employed for the purpose of local stimulation.
Before I leave the subject of paralysis, there are two points to which I
wish to call your attention. One of these involves the consideration of a
remarkable form of paralysis in which the disease appears, as far as we can
see, not to depend on any primary lesion of the nervous system. In this
form we have a paralysis, not the result of any disease of the brain or
nerves, but connected with an affection of the vessels of the part. This is
a very singular disease, and I am anxious you should be acquainted with
it, for I believe it is by no means so rare as many persons think. The
other point to which I would direct your attention refers to the influence
of magnetism on the human body ; of this I shall speak on a future occa-
sion, confining myself for the present to that form of paralysis which is
connected with disease ofthe vascular system.
So as to give you some idea of this affection, I think I cannot do better
than read for you the notes of a case of it, published by Dr. Graves and
myself in the fifth volume ofthe Dublin Hospital Reports.
A man, aged 44 years, was attacked in December, 1828, with alternate
sensations of cold and burning heat in the toes of the right foot. These
extended to the leg, of which the power became diminished. Pains in
the foot next occurred, and in a month the part became cold and wholly
deprived of sensation.
On the day of his admission the pain suddenly extended to the calf of
the leg ; and from this time he lost all power of motion in the leg. On
admission, the temperature of the body, with the exception of the affected
limb, was natural. The pain had extended to the thigh during the night.
The temperature of the limb was but 58° of Fahrenheit. Slight edema
existed about the ankle. There was complete loss of sensation from the
middle of the thigh to the toes ; the patient could rotate the thigh slightly,
but there was no other voluntary motion possible. The femoral artery
appeared like a hard cord, painful on pressure, and without pulsation.
By the stethoscope we found that pulsation was also wanting in the com-
mon iliac on this side, while that of the left iliac was plainly perceptible.
The patient died on the fourth day after admission, the limb having be-
come purple, tender, and covered with vesications.
On dissection, the right common iliac appeared distended and livid, and
was completely plugged up by a dark clot, extending to the external and
internal iliacs, and engaging the ghiteal and obturator arteries. The same
occurred in the femoral and profunda, and extended, as far as they could
be traced, to the tibial arteries, and to the peroneal. The lining mem-
brane of these vessels was soft, villous, and red; the clot in some places
being separated from it by a layer of puriform matter. No disease in the
veins. A large portion of the vasti and rectus muscles was white and hard-
ened. Here you perceive a train of symptoms, some of which might be
referred to disease of the brain, if the man had any cerebral symptoms,
which was not the case, for his intellect was sound, and he had no evi-
dence of cerebral disease except the paralysis.
His constitutional symptoms were emaciation, prostration of strength,
REMARKABLE FORM OF PARALYSIS.
559
and loss of appetite. The temperature of the body was natural, but, on
examining the limb, we found (and this is a point of great importance)
that it was as low as 58° of Fahrenheit; in fact it was quite cold. There
was also complete loss of sensation from the middle of the thigh to the
toes, and though he could rotate the limb slightly, it was, in all other
respects, powerless. Here we have paralysis of motion and sensation in
one of the extremities, with remarkable coldness of the limb. On making
an examination along the track of the femoral artery, we found that it was
painful on pressure, without any pulsation, and conveying to the finger
the feel of a piece of hard cord. From a consideration of these circum-
stances, we came to the conclusion that it was not pervious, and that this
would account for the state of the limb. In this case, also, we made an-
other remark, and this, I believe, is the only instance on record in which
such a diagnosis was made. Up as high as the groin the pulsation of the
femoral artery could not be felt, and we were anxious to ascertain how
far farther the disease extended. The state of the femoral artery in the
left groin was natural. On making an examination with the stethoscope,
we found that the pulsations of the aorta were perceptible down to its bifur-
cation, but when the stethoscope was applied below this on either side,
we observed that there was no pulsation in the right common iliac artery,
but on the left side it could be traced distinctly down to the groin. Here,
then, we had a train of phenomena, such as ordinarily occur in paralysis
affecting the right lower extremity, and along with this an obstruction to
the circulation in the thigh and leg. From these circumstances we made
the diagnosis of obstruction of the right iliac and femoral arteries. On
dissection, we found that the aorta was healthy to within about six inches
of its bifurcation; below this point it was partly filled by a red clot.
The left common iliac was healthy, but the right was plugged up with a
dark-red clot, which extended into the external iliac and obturator arte-
ries, filling up also the femoral and its branches. The case, in fact, was
nothing more or less than one of chronic arteritis. ,
This remarkable form of disease has been also observed by other authors.
You will find it well described in Rostan's work on Diseases of the Brain,
where he mentions that this loss of sensation and motion in a limb is
sometiraes produced by obstruction of its vessels. In persons advanced
in life, the arteries are also frequently obstructed by the formation of
ossific deposits within them, producing loss of power, coldness, and dimi-
nution of sensation, as in the foregoing case. A similar effect may occur
from the pressure of an adjoining tumour on the trunk of a principal artery.
Paralysis resulting from disease of the arterial system is distinguished
from paralysis caused by cerebral disease, by the following marks: first,
by the colour of the integuments of the affected limb, which, in a case of
the former description, are generally of a violet hue, or of a much deeper
tinge than in the latter case, or in a state of health. It is very rare to
find the two limbs of the same colour, as we do in cases of cerebral para-
lysis. Another mark is, that the temperature ofthe limb is always lower
than that of the healthy one ; but the distinctive sign of this form of para-
lysis is the absence of pulsation in the arteries in parts where it should be
naturally observed. If to this description you join the absence of cerebral
symptoms, you will seldom fail in making a correct diagnosis. I have
had two cases of this disease under my care ; one of them occurred in the
upper, the other in the lower extremity, and from observing the charac-
560
DISEASES OF THE NERVOUS SYSTEM.
teristic marks already detailed, I had no difficulty in making the diagnosis.
It is to that peculiar form of this disease, which is considered by some
authors to depend on ossification ofthe arteries, that the name of" Pott's
gangrene" has been applied. A great deal of light has been thrown on
this disease by the researches of modern pathology. It is now pretty well
established that we may have this gangrene, not only in old persons from
ossification of the arteries, but also in the young from arteritis. In truth, the
pathology of Pott's gangrene appears to be one of two changes—either an
arteritis or ossification ofthe arteries themselves; and of these two causes
the first is by far the most frequent. You will see at once the importance
of this view of the question, for if the gangrene occurs in a young person,
and is connected with inflammation of the arteries, it is a disease more or
less under the control of medical treatment; but if it be produced by ossi-
fication of the arteries, the results of treatment are far less likely to be suc-
cessful.
We have, then, in a case of paralysis of this description, more or less
loss of sensation and motion, coldness ofthe limb, and absence of arterial
pulsation. With respect to coldness, it may be said that it is of little
value as a sign, being frequently observed in cases of cerebral paralysis.
To this it may be replied, that though coldness is sometimes present
in cases of ordinary paralysis, still it is never so remarkable as in tthis
form ofthe disease, and the temperature of the limb is but a few degrees
below the standard of health. Dr. Abercrombie makes a very interesting
conjecture on this subject. He says the temperature of paralysed limbs is
generally considered to be lower than that of the healthy ones, and,
indeed, such is the case ; but the true explanation of this occurrence is,
that in this condition the limb loses its power of preserving a medium
temperature, and hence it is, that, according to the temperature to which
it has been exposed, it becomes hotter or colder than the healthy limb.
A case is mentioned, of a medical man who laboured under paralysis of
one of the upper extremities. This gentleman, on one occasion, after
having applied some warm bran to the paralysed limb, was astonished to
find, on touching it with the sound hand, that he could not bear the heat,
though he was at the same time unconscious of any increase in the para-
lytic extremity.
The symptoms, then, of this form of paralysis are, diminution or aboli-
tion of sensation and the power of motion, a dark or violet hue of the skin,
a remarkable coldness, and absence of pulsation in the arterial trunks which
supply the affected limb. These, with a tendency to the formation of gan-
grene, are the characteristic marks ofthe disease, and by bearing them in
mind you will seldom err in making a diagnosis. In the great majority
of cases the disease is confined to one extremity ; but Rostan gives some
cases in which it was more general. We might also add to the diagnosis,
that paralysis connected with disease ofthe brain often comes on suddenly
while in this case its invasion is slow and gradual. It is, however, true,
that some cases of paralysis, depending on this cause, have come on so
suddenly as to render this circumstance of less value as a diagnostic.
With respect to the treatment of this form of paralysis, if the patient be
young and the disease recognised at an early state, it is possible that you
may be able to arrest it by free local depletion and other antiphlogistic
means. In the case which was under treatment in the Meath Hospital,
the symptoms had lasted for a considerable time before the disease ex-
PARALYSIS FROM ARTERIAL DISEASE.
561
hibited any remarkable violence. The man was admitted on the 7th of
February, and at this time the disease had been five weeks in existence,
having begun at the lower part of the limb, and extended gradually up-
wards until it involved the whole leg and thigh. Yet it is very probable
that this patient might, have been saved, if proper means had been taken
to arrest the inflammation of the vessels at an early period. Baron Du-
puytren has published a case, in which it appeared that this disease was
setting in, but was checked at once by bold antiphlogistic treatment
directed to the affected limb.
LECTURE CXXXIV.
DR. STOKES.
Paralysis from Arterial Disease—Singular cases of, by Rostan—Diagnosis of para-
lysis from arterial obstruction—Magnetism, use and action of—Effect of magnetism
in disease—Result of trial3 in the Meath Hospital—Paraplegia—Mechanical hypere-
mia—Occurrence without disease of the cord or vertebra—Cases by Mr. Stanley—
Effects on urine by division of the spinal cord—Ammoniacal urine—Caries of the ver-
tebrae—Diagnosis of paralysis with disease ofthe kidney—Prognosis in paraplegia—
[Dr. Graves's views and cases of paraplegia—A sequence of fever—Means of preven-
tion and cure—Local injury to a nerve causing partial paralysis.]
At my last lecture I spoke of that form of paralysis which depends on
arterial obstruction, and mentioned, as one ofthe principal diagnostics, a
remarkable coldness of the diseased limb. I quoted for you a passage
from Dr. Abercrombie's work, in which he suggests that it is probable that
the actual condition of paralytic limbs, in the usual acceptation, so far as
temperature is concerned, depends upon their having lost that power which
aniraal bodies possess of preserving a medium temperature ; so that their
temperature becomes elevated or lowered, according to that of the sur-
rounding matter. The general rule in cases of this description is, that the
temperature of a paralysed member is a little lower (say two or three de-
grees) than the rest of the body ; but when we find a limb reduced to the
temperature of 58°, as in the case I mentioned, it is quite a different thing,
and, under such circumstances, the great probability is, that the paralysis
is connected with arterial obstruction.
You will see, in Rostan's work on the Softening of the Brain, the reports
of two cases of this disease, occurring in patients of extremely advanced
age. In one, there was complete paralysis of the right arm, which was
cold and livid. The fingers were threatened with gangrene, and no pul-
sation could be felt in the radial artery. By stimulating frictions, a cer-
tain degree of warmth and motion was restored, and it was even thought
that pulsation could be perceived. By degrees, the power of the left arm
and ofthe lower extremities began to fail, with diminution ofthe force of
the pulsation. On dissection, extensive disease of the arteries was found ;
the right brachial, at the insertion of the deltoid, was obliterated by a mass
of fibrin, below which the vessel was contracted and closed ; the left bra-
chial artery was also narrowed, but without any clot; and this condition
was farther met with in the crural vessels. The cerebral arteries and the
aorta were diseased. In the second case, the patient, aged 80, was
vol. n.—37
562
DISEASES OF THE NERVOUS SYSTEM.
attacked with violent pains in the left leg, which became cold and bluish.
There was no lesion of intelligence, and the corresponding arm was unaf-
fected. In fifteen days, the pains having augmented, a certain degree of
paralysis supervened, which, however, was never complete. On dissec-
tion (the disease having lasted a month), the crural artery was found ex-
tensively obliterated by a fibrinous clot. Here you observe that notwith-
standing the great age of both patients, the disease was not ossification,
but, in all probability, arteritis.
At our last meeting, I forgot to mention the particulars of a case, bear-
ing on this part of the subject, and which goes to prove that even com-
plete coldness of the affected limb is not, in itself, sufficient to establish
the diagnosis of paralysis from arterial obstruction. I have had lately
under my care a gentleman who has been for the last four or five years
labouring under paralysis of the lower extremities, unaccompanied by any
symptoms indicating disease ofthe brain. His intellect remains not only
unimpaired, but in a state of high activity ; and, what is equally singular,
he has had none of the usual symptoms of disease of the vertebrae or spi-
nal cord. His limbs, however, are quite powerless, and are of an icy cold-
ness ; and yet you will hardly believe me, when I tell you that I have
repeatedly felt the femoral, popliteal, and even the anterior tibial arteries,
pulsating distinctly. This is a singular fact, but I have verified it by a
number of observations. You will perceive, then, that in taking a re-
markably diminished temperature as a diagnostic of paralysis from arte-
rial obstruction, we must admit that, as a sign, it is only valuable when
combined with absence of arterial pulsation. In this case, the fact of such
extreme coldness of the lower extremities, at the same time that their
circulation continues with undiminished activity, becomes of great im-
portance, as tending to prove that the temperature of the body depends more
upon the state of innervation than on arterial action. There are, indeed,
many facts which go to prove that animal heat is more closely connected
with the nervous system than with the circulating.
I spoke of the employment of electricity and galvanism in the local
treatment of paralysis. While on this subject, I shall take an opportunity
of briefly drawing your attention to the use of magnetism in certain
cases of nervous disease. Here let me be understood, I am not going
to lecture on animal magnetism; it is, at present, a theme unsuited for
the practical physician ; no one more firmly disbelieves, no one more
thoroughly despises, than I do, the countless absurdities which have ema-
nated from the imaginative disciples of animal magnetism. But, as in
almost every human hypothesis there is a fraction of truth, so in the doc-
trines of animal magnetism there is, perhaps, something which may not be
entirely visionary ; and it is possible that there may be some modification
of the nervous influence, communicable from one person to another; this
is one of the doctrines of animal magnetism. Another leading doctrine
is, that organs, which are adapted by nature for the discharge of some
peculiar function, appear in their magnetised state to take on a new func-
tion. Now, without saying thatwe are to believe in this, or in the extraor-
dinary romances which are given in illustration of it, still it is right to
admit the possibility of its occurrence, to a certain degree ; because we
frequently observe, in pathology, many instances of organs taking on func-
tions, not merely new, but even totally repugnant to our ideas of their
structural arrangements. We may, then, 1 think, without going too far,
MAGNETISM IN NERVOUS DISEASES.
563
admit the possibility of a communication of some modification of the ner-
vous influence from one person to another, and that organs under this
influence may take on new functions ; but, in the present state of this
subject, this is as far as we can go.
But we have to deal, at present, with a more tangible and important
subject—namely, the action of magnetism, in its proper acceptation, on
the human body. You are aware that the term animal magnetism was
first applied to the results of certain effects on the human system, which
were supposed to be brought about by the aid of metallic contact; and
you are all acquainted with the history of the metallic tractors. The term
magnetism, however, is totally inapplicable to the communication of ner-
vous influence from one individual to another ; nor have we any grounds
for connecting such phenomena with magnetism, in its proper acceptation.
That a magnet should act on the human body, is neither extraordinary
nor incredible. You know that electricity, and its modification galva-
nism, have a powerful influence on the system ; and modern researches
have shown that there is a close connexion, if not an absolute identity,
between electricity and magnetism. Now, on this subject of magnetism,
the researches of some eminent men have been, latterly, employed, and
the results of their labours have been received by some with an undistin-
guishing credulity, and by others with unphilosophical skepticism. One
ofthe principal things which has prevented medical men from entering on
this subject, is, that many persons have confounded the results of magnetic
action on the human body with the absurdities of animal magnetism and
metallic tractors. There is, however, I need not repeat to you, an essen-
tial difference between them. In the Meath Hospital I have lately
made a number of experiments, with a view to ascertain the effects of a
powerful magnet on the human body. The magnet which I used was
one of considerable power, being, in its highest state of action, capable of
supporting a weight of more than twenty pounds. Now, in almost every
instance where this instrument was used, we found that, when brought near
to sensible surfaces, phenomena were produced which were very similar,
indeed, to those of electricity. These phenomena also appeared in so many
cases, and with such a remarkable constancy, that they could not be ac-
counted for by any supposition of accident. We have applied it in cases
of rheumatism, sometimes to a healthy part ofthe body, sometimes to the
part affected. In one of these cases, the application of the magnet was
followed by a very rapid subsidence of the morbid symptoms, and the
patient got well in a few days. Here let me remark that there is no one
more opposqd than I am to the publication of the result of a single case
as a proof of the success of any particular remedy ; and in putting forward
this case, I do not wish it to be received as an instance of a decided
cure of rheumatism by magnetism. The only reason why I quote it, is,
because in other cases of rheumatism we had distinct evidence of the
influence of the magnet to a greater or less extent. The patient, a stout
man, of good constitution, and in the prime of life, was brought into the
hospital for an attack of rheumatism in the back and left shoulder, which
had come on after exposure to wet. The first seizure was three days
before admission. When brought in, he had severe pain in the back and
shoulder, increased on pressure ; he could neither elevate his arm to his
head, nor could he bend the head towards the shoulder, without great
difficulty and suffering. The value of this case consists chiefly in this,
564
DISEASES OF THE NERVOUS SYSTEM.
that except using the magnet there was no other remedy employed ; if any
other medicinal agency had been used, it would have been difficult to
attribute ihe merit ofthe cure to magnetism. I applied, in this case, the
large magnet to the shoulder, within a short distance from the skin. In
about half a minute the patient remarked that he felt a kind of pricking
sensation immediately under the magnet; this was succeeded by a feeling
of heat in the part, which became increased by continuing the application,
while at the same time the pain was sensibly relieved. The sensation of
warmth continued in the shoulder for about ten minutes after the magnet
had been removed, and the patient declared that he received great bene-
fit from the application. On the following day, the magnet was applied
again with precisely the same results ; the same thing was done on the
third day, when the pain was very much reduced, and the arm became
more movable. On the fourth day, the mobility of the limb" was in-
creased, and he could bend his head in the direction of the shoulder with
very little inconvenience. On the eighth day, the power of motion was
restored, the pain gone, and the patient left the hospital quite well. I
have heard nothing of him since ; but if he had not experienced perma-
nent relief, it is very probable he would have returned again, for he
seemed quite pleased with his treatment. If this was the only case in
which the magnet had been employed, it would prove nothing neither for
nor against its use. It might be said, that the cure, in this instance, was
the result of keeping the patient in a warm bed, and that any good sup-
posed to be effected by the magnet, might be attributed to the influence
of imagination. But to this it may be answered, that the sensations ob-
served by this patient were exactly the same as in others, each having
noticed the peculiar pricking sensation in the part to which the magnet
was applied, and the subsequent feeling of warmth. Again, it is to be
remarked, that although the symptoms in this case were severe, the cure
was extremely rapid ; and when you recollect the obstinacy of most affec-
tions of this kind, you must allow that a week was a very short space of
time for its accomplishment.
The following is another equally interesting case. A woman was ad-
mitted into Meath Hospital, labouring under paralysis of the right side of
three weeks' standing. The history of her case was, that she had fallen
into a state of mental despondency, after the death of her husband, who
was her only support; she then got symptoms of derangement of the sto-
mach, and hypochondriasis, followed by an attack of paralysis, which de-
prived her of the power of using one side. On examination, we found
that, as far as motion was concerned, the paralysis was not complete, but
that there was a total loss of sensation in the side affected. It was curious
to observe what the effect of the magnet would be, and accordingly applied
it to the spine, moving it upwards and downwards along the cervical
and dorsal regions, at about half an inch from the surface. After it had
been applied for a few seconds, she remarked that she felt a sensation " of
wind" passing over the left shoulder, but not over the right. Observe, it
was on the right side ofthe body that the paralysis existed in this case;
nd you will also recollect that it was chiefly a paralysis of sensation.
Now, it is quite contrary to chances that she should have described it in
this way, if she had not really felt it in this situation. The action ofthe
magnet was naturally felt on the left, which was the sensible side, for, on
applying it to the opposite or paralysed side, she said she no longer felt
PARAPLEGIA.
565
the sensation of "the wind." During the operation, she saw the instru-
ment ; and if disposed to draw upon her imagination for a description of
her sensations, she might say that she felt the aura on the paralysed side ;
but this was not the case, for she stated that it was no longer perceptible,
when the magnet was moved from the sound to the paralysed side. In
this case, I must tell you that magnetism was not the sole remedial agent
employed, for she had been also leeched and blistered. She was admitted
on the 12th of August, and on the 17th of the same month the power of
motion in the upper extremity was so much increased, that she could
grasp objects with force, and place her hand on the top of her head with
facility. On this day, after having applied the magnet, she immediately
exclaimed that she felt the wind for the first time over the right shoulder,
and, on examination, it was found that sensation, to a certain degree,
had returned to the right side ; and here you will perceive that the first
manifestation of the return of sensibility was denoted by her feeling the
magnetic influence in the paralysed side.
I shall not take up your time any longer by detailing cases : it will be
sufficient to state, that it was used in many other instances of a similar
kind, and in all with the sarae result. Each patient described the same
sensation, with very little variety ; in sorae, it consisted in a feeling of
pricking or tingling ; in others, of an aura passing over the part. Some
stated that they felt a sensation of warmth in the part, some time after the
magnet had been applied ; and some a kind of suction as if the skin was
drawn towards the magnet. When it was applied over a very sensible or
a blistered surface, the patient felt the pricking sensation to amount to
pain, and the feeling of warmth and suction was proportionally increased.
I have also to observe, that it was employed on a set of patients, the
majority of whom were totally ignorant of its nature and effects ; and yet
it is very remarkable that there was an almost universal accordance in
their descriptions of the sensation produced. It has been stated by some
writers on the subject, that the sensations differ according to the pole of
the magnet employed. This statement does not accord with our expe-
rience ; for in every one of our cases the sensation was the same, whe-
ther we made use of one pole or the other. As far as our experience
goes, it is, I think, fair to conclude that a very perceptible influence may
be produced on the human body by the application of the magnet; it is
another matter to ascertain how far it may be rendered available as a
therapeutic agent. The cases in which I think it might be employed with
advantage, are cases of nervous and spasmodic affections, and muscular
rheumatism. That the sensations described by our patients had an actual
existence, and were not the result of imagination, I am firmly convinced.
Before I leave the subject of paralysis, I wish to draw your attention to
one more form ofthe disease, by no means uncommon ; I allude to that
in which both the lower extremities are exclusively engaged. This is a
disease, or symptom, which may arise from a great number of causes, and
be obseived under a variety of circumstances. Generally speaking, how-
ever, it will, in almost every instance, be found to depend on some cause
which engages the spinal marrow, either primarily or secondarily. I be-
lieve that this paraplegia, as the result of disease of the brain, is never
met with except in combination with paralysis of the upper extremities.
General paralysis may be produced by cerebral disease ; and in describing
the various forms of paralysis which depend on disease of the brain, this
566
DISEASES OF THE NERVOUS SYSTEM.
form has been particularly noticed ; but when paralysis of the lower ex-
tremities alone occurs, it is generally the result of some lesion of the spinal
marrow, either organic or functional, below the situation in which the bra-
chial nerves are given off. Among the causes by which this paraplegia
is produced, the following are the principal : inflammations of the mem-
branous coverings of the spinal cord, with effusion of lymph or serum ;
spinal apoplexy, ramollissement from inflammation of its substance ; pres-
sure on the cord, by solid tumours from a variety of causes; the bursting
of abscesses or aneurismal swellings into the vertebral canal, as occurs in
some cases of aneurism of the abdominal aorta. Thus, during the progress
of a case of this description, it has been observed that the patient suddenly
became paraplegic, and, on examination after death, a quantity of blood
which escaped from the aneurismal tumour has been found compressing
the spinal marrow. Lastly, recent investigations have established the fact,
that we may have paralysis ofthe lower extremities, and yet, on dissec-
tion, we cannot detect any traces of disease ofthe bones ofthe vertebral
canal, or in the membranes or substance of the spinal cord. Hence you see
how cautious you should be in making the diagnosis, so common among
surgeons, of caries ofthe vertebras, in cases of paralysis of the lower ex-
tremities. The truth is, that in the present state of medicine on this sub-
ject, we labour under very great difficulties ; the diagnosis of these affec-
tions is exceedingly obscure : it is a subject still open to investigation, and
I need not remark, that it is one of paramount importance.
Paraplegia is one of the most miserable diseases to which the human
body is liable. It is almost always obstinate and unmanageable, and in the
majority of cases incurable. How far the fatality of the disease depends
upon the want of an accurate diagnosis, and a correct plan of treatment,
must be determined by future observations ; but it is a fact, that a vast
proportion of paraplegic patients die, and under the most melancholy cir-
cumstances. In many cases, the formation of gangrenous sores on the back
and loins is a common occurrence. For this there are two reasons: first,
the vessels of those parts exposed to pressure from position fall into that
state which Andral terms mechanical hyperemia, the result of which is that
they are unable to unload themselves]; a stasis of blood follows, and this
leads to mortification of the part; secondly, there is a lesion of innervation.
Hence it is, that the great majority of patients of this kind die with gan-
grenous sores on the back and loins. They have also most constantly pa-
ralysis of the bladder, or its sphincter, or both, producing retention of
urine, or retention with incontinence, or stillicidium urinee. The sphincter
ani, too, is generally paralysed, and we have a most melancholy and dis-
gusting source of annoyance. The frequent passing of urine and feces
keeps the unfortunate sufferer in a state at once pitiable and loathsome,
and when, in addition to his other calamities, the gangrenous sores form,
the supervention of low diffused erysipelatous inflammation may prove
fatal ; or he may be carried off with symptoms of typhous fever, from the
absorption of putrid matter.
While on the subject of paraplegia, I am anxious to lay before you a
sketch of some important opinions lately put forward by Mr. Stanley, of
London. In the last number of the Medico-Chirurgical Transactions, this
gentleman has written a most interesting paper, in which he gives the
history of several cases of paraplegia, the majority of which were supposed
to be examples of caries ofthe vertebras, but in which, on dissection, no
/
PARAPLEGIA. 567
disease could be discovered, either in the bones ofthe vertebral canal, or
in the membranes or substance of the spinal cord. You will ask, were
there no pathological phenomena in these cases ? There were ; but they
belonged not to the spine or its contents, but to an organ in its immediate
vicinity—the kidney. From a candid review of Mr. Stanley's cases, there
appears to be reason to believe that disease of the kidneys may produce
all those symptoms which have been attributed to lesions of the spinal
marrow, or caries of the vertebras. In the four first cases, the symptoms
given as of caries of the vertebras were present, and the cases treated as
such. On dissection, no caries, or disease of the cord, could be discovered
in any of them, but the kidneys were found to be the seat of extensive
disease. The fifth case was a remarkable one ; the patient had been ad-
mitted for retention of urine, the consequence of severe gonorrhoea, which
had been checked by injections. The bladder and sphincter ani became
paralytic, and he lost the power of the lower extremities to a certain degree.
He also complained of severe pain at the fifth lumbar vertebra. He dis-
tinctly traced the pain from the bladder to the left kidney, and then to the
right. Paralysis of motion, and, nearly, completely of sensation of the
lower limbs, next supervened, and in about a fortnight he died. On dis-
section the kidneys were found in a state of inflammatory softening, and
with numerous minute depositions of pus. The bladder was inflamed,
but the brain and spinal cord were perfectly healthy. In the sixth case,
a patient, while in progress of cure of a gonorrhoea with phymosis, was
suddenly seized with paraplegia. The functions of the brain were unaf-
fected. He had suffered for a day or two from pain in the loins. Sixteen
hours after this attack he suddenly died.
From considering the former cases, Mr. Stanley predicted that inflam-
mation wTould be found in the kidneys. A slight turgescence of the vessels
ofthe cord, with a little transparent effusion in the theca, were found, but
the kidneys were in a state of the most intense engorgement. In this case,
it was remarkable that, from the period of the paraplegia, there was an
inordinate secretion of urine. The seventh case was that of a patient who,
for two years, had been labouring under pain of the back, increased by
pressure, and incontinence of urine. On dissection, there was some vas-
cularity and effusion of the cord, but both the kidneys were almost en-
tirely destroyed by disease. In addition to these, Mr. Stanley mentions
four more cases, which were seen by a friend of his, Mr. Hunt, of Dart-
mouth, which corroborate his opinions.
Here, then, we may have well-marked paraplegia, without any percep-
tible organic change in the spinal cord, or its investments, but presenting
distinct traces of disease of the kidneys. This leads us to observe the
very close connexion which exists between the kidneys and spinal cord,
a connexion which has been long recognised by medical practitioners, but
only in a limited point of view ; for though they were of opinion that dis-
ease of the kidneys, and a discharge of ammoniacal urine, were the re-
sults of spinal disease, they never seem to have reflected that the reverse
of this might happen. It seems now, however, to be almost completely
established, that disease ofthe kidneys may produce symptoms which are
referable to disease of the spine ; and Mr. Stanley has the credit of having
been the first who directed the attention of the profession to this circum-
stance, and his paper must be considered as one of the most important,
and practically useful, which has appeared for a length of time. You
568
DISEASES OF THE NERVOUS SYSTEM.
should all peruse it carefully. The fact that disease of the spine will give
rise to affections of the kidney, is long known, and has been proved by
numerous experiments. Thus, Olliviet details the experiments of a Ger-
man physiologist, M. Kreimer, who, by dividing the lower part of the spi-
nal cord in animals, made the urine almost immediately ammoniacal.
You will also find, in Dr. Prout's work, that an ammoniacal state of the
urine may be rapidly brought on by injuries of the back, from falls or
bruises on the spine. It is, indeed, singular how quickly those profound
functional lesions of the kidneys supervene on injuries of the spine, some-
times appearing in four or five days, sometimes sooner. Medical men
have hitherto been in the habit of looking at this matter only in one point
of view ; they know that disease of the spine will produce disease of the
kidneys, and here they stop ; but it has been shown that the reverse of
this may happen, and that renal disease may produce very remarkable
lesions in the functions ofthe spine. Of this very curious occurrence we
have many analogies in pathology. Thus, for instance, in several cases
of cerebral disease, but chiefly in hydrocephalus, we have vomiting ; here
we have functional disease of the stomach depending on an affection of
the brain. Take the reverse of this—observe the delirium which attends
a case of gastro-enteritis — here you have the functions of the brain de-
ranged in a most remarkable manner, and this produced by sympathy with
an inflamed mucous membrane. The truth is, that in the spine and kid-
ney, as well as in various other parts of the system, we have two organs
which are so closely connected by sympathy, that disease of one will bring
on serous functional lesion of the other.
Observe, then, the great importance of these inquiries. When you meet
with a case of paraplegia, you are not at once to conclude that it depends
on disease of the spine, or caries of the vertebras. You must carefully
investigate its history, and ascertain whether it may be referred to either
of these causes, or whether it may not rather depend on disease of the
kidneys. That it may depend on the latter cause is now established, for
the cases are too numerous for us to suppose the complication accidental.
You will observe the importance of making an accurate diagnosis, when
you consider that this point will most materially influence your treatment.
In the one case, your treatment will be directed to the bones and carti-
lages of the spine; in the next, to the spinal cord itself; and, lastly, to
the kidney, a parenchymatous organ, to which there is a great determina-
tion of blood. No one will venture to assert that the principles of treat-
ment in each of these cases are the same ; and the chances are, that, if
you do not make a correct diagnosis, you will practice improperly and with-
out success. I have now seen a number of these cases, but there were
only two of this description in which I was fortunate enough to obtain a
post-mortem examination. I cannot say that my dissection exhibited re-
markable disease of the kidneys (they were large and very vascular), but
from the many points of resemblance they bore to Mr. Stanley's cases, I
was led to conclude, that if they were not examples of actual chronic dis-
ease of the kidney, they were cases of lesions of function in the spine,
unaccompanied by any organic change to account for the symptoms. I
shall briefly detail these cases: the first was that of an unfortunate man
from the country, who was discovered by two friends of mine, under pe-
culiar circumstances. While on an excursion, they were requested to
visit a poor man who was lying ill at a remote farm-house. They heard
PARAPLEGIA.
569
he had been labouring under a dropsical affection for a long time, and
had been treated for ascites. On arriving at the cottage, they found the
man lying in bed, with his abdomen very much enlarged ; and, on fur-
ther investigation, discovered that he was quite paralytic ofthe lower ex-
tremities. On examining the belly more particularly, they found that the
swelling was produced, not by ascites, but by an enormously distended
bladder. He bad, also, stillicidium urinas, with paralysis of the blad-
der ; and this having been mistaken, by the medical practitioner who
attended him, for suppression of urine, he had prescribed diuretics, and
continued this plan of treatment for sorae weeks, totally overlooking the
paralysis of the bladder. As little or nothing could be done for him in
the remote situation in which he lived, it was determined to send him up
by easy stages to Dublin, and procure him admission at one of the public
hospitals. On his arrival, he was received at the Meath Hospital; and,
when I visited the wards next day, I found that he was quite paralytic of
both lower extremities, that the bladder wras in the state above described,
and that his health had suffered considerably, and that bed-sores had
formed on his back, and were increased by his journey. I prescribed
cupping and blistering, which were productive of some slight relief; but
in the space of a few days he began to exhibit symptoms of low typhus,
as if from the absorption of pus, and sank rapidly. On examining his body,
we could not detect any traces of disease in the bones or cartilages ofthe
spine ; neither did the cord, or its membranes, present any marks of or-
ganic lesion, except that towards its lower portion, where it begins to
spread out into the cauda equina, it was perhaps a little softer than natu-
ral. I regret very much that I did not note the circumstances of this case
more fully ; but, as far as my recollection of it goes, the general features
were as I have just mentioned. I had another case, some time since in
the Meath Hospital, in which the following circumstances wrere observed:
—The patient, a labouring man, generally employed about the quays, was
brought into the hospital with paraplegia of some standing. The first
symptom in his case belonged not to the spine, but to the urinary system ;
he had had an attack of gonorrhoea, for which he had used stimulants and
balsams; and, in some weeks after, without any injury to the spine, he
lost the use of his lower extremities. During his stay in the hospital, the
urine was intensely ammoniacal. On examining his body after death, we
could not discover any disease of the bones or spinal marrow. *A layer
of substance, resembling fat or organised lymph, was found lying on the
theca of the spinal marrow, but it was so very small as to be scarcely
sufficient to account for the symptoms. The kidneys were pale, flabby,
and without any vascularity, but did not present any marked traces of
organic lesion.
Here, then, were two cases which, before the publication of Mr. Stan-
ley's paper, would be considered as examples of organic disease of the
spinal cord, or its investments; and yet, on dissection, we can find no-
thing to establish this opinion ; and, in the last one, the first affection was
ofthe urinary system.
Is it possible that a functional disease of the urinary system may pro-1
duce also a Junctional disease ofthe spinal cord ?
With respect to the diagnosis of caries of the spine, I wish to make a
few observations. The diagnosis where there is distortion ofthe spine is
extremely easy, but this does not hold where the caries is accompanied
570
DISEASES OF THE NERVOUS SYSTEM.
by distortion. Let us inquire. Are there any circumstances which would
enable us to arrive at the diagnosis of caries without distortion ? One
symptom, not observed as far as I can see, in paralysis, connected with
disease of the kidney, is, that the patient feels exquisite pain on motion.
This is an exceedingly common symptom in caries of the vertebras, but I
am not aware that it occurs in cases where the disease is situated in the
kidney, or the spinal cord itself. There is another remarkable circum-
stance : — When the patient attempts to move, he often feels a crackling
sensation in the affected portion of the spine ; and this has not only been
observed by the patient himself, but is also perceptible to his medical
attendants. When this occurs, it may, I think, be looked upon as a diag-
nostic symptom. The exquisite pain on motion, the tenderness of the
spine on pressure, and the crackling sensation, these might be sufficient
to make the diagnosis of caries of the vertebras, even in cases where there
was no distortion. But if you had a case of paralysis of motion and sen-
sation of the lower extremities, and if these symptoms came on without
any injury of the spine — if there was little or no tenderness on pressure
—if the patient felt scarcely any pain in turning or moving, and if he had
at the same time symptoms of disease of the kidney or bladder, and am-
moniacal urine— under these circumstances the great probability would
be, that it was not a case of caries of the vertebras, or original disease of
the spinal cord, or its investments, but a lesion of function of the spine,
connected with organic or functional derangement of the kidneys. It
must be acknowledged, however, that the diagnosis of this affection is
rather obscure. The circumstances which I have just mentioned, might
enable you to get rid of the opinion that it was caries of the vertebras or
organic disease ofthe spinal cord, and that it was probably such a case as
Mr. Stanley has described ; and if you could arrive at this diagnosis at an
early period of the case, it would be a matter of great importance. By
doing this, you would then be aware that you had to deal with an inflam-
matory affection of a highly vascular organ ; you would not be led away
from the real state of the case, or waste time in treatment calculated to
stimulate the spine, or remove disease of the vertebras. Your plan would
be simple, and your treatment defined, and all your efforts would be
directed towards removing the disease of the kidneys. You will easily
perceive that diagnosis is here of vast importance ; unfortunately it is still
involve*! in obscurity.
The prognosis of cases of paraplegia, when once complete paralysis is
established, should be always unfavourable. The fact of paralysis occur-
ring, is sufficient in itself to prove the existence of extensive disease in
most cases. There may be, however, some cases susceptible of cure, and
this particularly occurs in young females, in whom a perfect cure has been
frequently accomplished by the use of stimulant embrocations to the loins.
I have seen one case of this kind, in which the patient was paraplegic for
a year and a half, cured by the application of hot oil of turpentine over
the lower part of the spine. Simple as the treatment may appear in this
case, its success was rapid and complete. Mr. Crampton has mentioned
to me the particulars of another case, in which the patient's limbs were
quite rigid, and could not be moved without great difficulty ; in this case,
complete relief was obtained by applying Pearson's liniment over the
lower part of the spine. This liniment produced powerful counter-irrita-
tion, and an eruption of bullae over the body, which were speedily fol-
PARAPLEGIA.
571
lowed by relief. The patient is now in the enjoyment of perfect health ;
and since the period of her cure, which is now better than six years ago,
has had no return of the disease.
[In confirmation ofthe occasional origin of paraplegia from visceral dis-
ease, as stated in the preceding lecture, the following facts are added :
Dr. Graves (Clinical Lectures) relates the case of a man who had, conse-
quent on exposure to cold, wet and fatigue, become affected with pain
and weakness of the lower extremities. During the time his legs and
back were getting weak, he was obliged to pass water about three times
in an hour, which he did with pain and tenesmus. At the time of his
admission into the hospital, he appeared somewhat broken down in his
general health ; he was pale, emaciated, and laboured under derangement
of his digestive organs. He suffered from occasional chills, succeeded by
heats and sweating, which occurred at irregular periods ; he, also, laboured
under micturition, dysuria, and the stream of urine was much diminished.
The pain in his back was very severe, and he lost the use of his limbs,
but not completely, for he could support himself, and even walk a little,
with the aid of two sticks.
His treatment was as follows :—First, cupping over the loins, then
moxas in the same situation ; attention to his digestive organs, diluents
and opiates for the urethral symptoms. On the tenth day after his admis-
sion, a very close stricture was found to exist in the membranous portion
ofthe urethra. A small cat-gut bougie of double length was introduced,
so that one-half of it projected from the meatus ; over this was slided a
small gum-elastic catheter of ordinary length, and open at each end, until
it traversed the stricture, and reached the bladder ; the cat-gut bougie was
then withdrawn, and the gum-elastic catheter secured. A little constitu-
tional disturbance followed, but soon subsided, and in a few days gum-
elastic catheters of a much increased size were introduced with facility.
" A very remarkable amendment took place in his back and lower extrem-
ities, in a very few days after the first introduction of Ihe instrument: in
fact it was almost sudden. Warm baths, friction to his limbs, &c, com-
pleted his cure." He was discharged on the 25th February (admission
on the 16th January), at which time the powrer of his lower limbs was
perfectly restored, and the symptoms affecting the urinary system had dis-
appeared. This case was reported to Dr. Graves by Dr. Hutton, under
whose care the patient was placed. It proves, as Dr. G. remarks, " that
urethral irritation may, as well as inflammation ofthe kidneys, give rise to
paraplegia." This man had gonorrhoea, followed by gleet, from which he
recovered five years before his attack of paraplegia.
Several examples have been witnessed by Dr. Graves of more or less
complete loss of power of the lower extremities, supervening on inflam-
mation of the gastro-intestinal mucous surface.
Paraplegia sometimes occurs during the course of a fever. Here, as Dr.
Graves remarks, the other sufferings of the patient, and his general debi-
lity, attract our notice so exclusively, that the paralysis entirely escapes
notice until convalescence is established—until, in fact, the patient wishes
to support himself on his legs. He then finds, much to his surprise, that
his limbs yield under him. This appears to him the more extraordinary
on account of his having recovered a good deal of strength in his upper
extremities. Mr. Carmichael has seen several cases of paraplegia follow-
572
DISEASES OF THE NERVOUS SYSTEM.
ing the remittent gastric fever of children, totally unconnected with spinal
disease. Such an occurrence is most usual in children of a scrofulous
temperament, and is seldom, Dr. Graves thinks, remedied either by time
or medicine. A remarkable exception to this unfavourable prognosis has
recently occurred in a young patient of mine, aged nine years. This boy,
who is of a scrofulous habit, has had bad health from infancy ; at first
bowel complaints, long and exhausting, then bronchial disease, also pro-
tracted and harassing, and enlarged tonsils. To these succeeded a pos-
terior curvature ofthe first dorsal vertebras ; and about ten months ago an
inability to wralk well and a leaning to one side. He was subjected at this
time to regular treatment—a horizontal posture, counter-irritation along
the spine, and took the iodide of iron and laxatives internally. Ere long
he lost the use of his lower limbs entirely, and continued thus helpless
throughout the winter—with, at times, a partial stoppage of urine, and
alternately involuntary discharges of feces and constipation. During this
period a scrofulous tumour appeared on the left side of his neck, which
eventually suppurated, and has continued to discharge up to the present
date (June). Another but smaller tumour on the opposite side soon reached
the suppurative stage, some time after the other was emptied, and has left
a small opening, from which oozes out a fluid. In the early part of the
spring this boy recovered the use of his limbs so as to be able to perform
the movements of flexion and extension in bed or on a sofa ; and since
then, and for about two months past, is able to stand with the aid of sorae
support. That of which he chiefly makes use is the spine-cart, in which
he now walks with tolerable ease. In addition to the other symptoms the
patient had, during much of the winter, a troublesome cough and hectic
w7ith night swreats. His chief and almost sole medicine, which he has
taken for some months past, is the sulphate of quinia, and occasionally an
alkaline mixture with a little laudanum for his cough, which is now much
better, and the hectic has in a great measure disappeared. A.fter the ces-
sation of the use of irritating ointments, and of blisters applied to the spine,
the external treatment for a long time past, and anterior to the restoration
of muscular power of the lower limbs, has been friction with a flannel, and
sometimes the hand, and rubbing in of the common volatile or soap lini-
ment on the spine and lower limbs.
The preceding account was written in 1842 ; at the present time (1844),
this boy is in tolerable health—goes to school, and enjoys the sports of his
age. But he is deformed by spinal curvature—projecting sternum, &c.
Now (1848) he is in China, in the counting-room of his uncle.
Without adopting, in all their entireness, the opinions of Dr. Graves,
we ought to imitate his practice more frequently than we do, by employ-
ing appropriate measures for the relief ofthe pain in the back, which is so
common in the beginning of fever. " When headache is the prominent
feature of the first stage of fever, how few will omit bleeding, leeching,
cupping, cold or hot applications, &c. WThen, on the contrary, the lumbar
spinal marrow is the seat ofthe congestion, how generally do practitioners
neglect the application of topical bleeding and other appropriate remedies.
Were such neglect of less frequent occurrence, it is probable that para-
plegia after fever would not probably be met with."
Partial paralysis, as that of a limb, sometimes ensues on irritation trans-
mitted from some part of the surface. Thus, in a case of erysipelas of the
calf and inside ofthe right leg, described by Dr. Graves, which yielded
to appropriate treatment, there was for some time a loss of power of mo-
PARALYSIS FROM ABSCESS OF THE BRAIN. 573
tion in the affected limb. Sometimes the reverse happens, and pressure,
as of the head on the arm in sleeping, has been followed by a palsy of the
limb of several years' duration ; and in another case a fall on the hip and
trochanter produced a permanently paralytic state of the left lower extrem-
ity. No injury ofthe spine could be detected, and there was no numb-
ness, pain, or formication, in the affected limb.
In the views of treatment of paraplegia supervening on visceral disease
laid down by Dr. Graves, I fully coincide. He says that he has never
seen any benefit derived from applications to the spine, and that the appli-
cation of blisters or issues over the back or loins does not appear to be
productive of the least good effect. He is in the habit of applying his
local remedies to the legs and thighs, selecting those parts in which the
greatest sensibility exists. Confirmatory of the propriety of this course
is a circumstance which occurred in the case of my little patient, whose
case I have already described. At a time when he was completely para-
plegic and unable to move either of his lower limbs except by grasping
one or other of them with his hands, and dragging it up a little from the
bed, moderate friction of the skin of the lower part ofthe leg would often
be followed by a regular but involuntary contraction ofthe muscles both
ofthe leg and thigh, so that the knee was partially bent, and the thigh
partially flexed on the pelvis. This fact encouraged me to urge a con-
tinuance of the frictions, which had been before irregularly practised, of the
feet and legs.
Dr. Graves generally keeps up a succession of blisters along the inside
of the legs, and over the anterior and inner part of the thighs, aided by
the use of liniments of a stimulating kind, applied to the cutaneous sur-
face of these parts. The two internal remedies on which he relies most,
are strychnia and sulphur; the former of these he continues until some
sensible effect on the system is produced ; when he omits its farther use
and has recourse to the exhibition of sulphur in the form of an electuary.
Much, also, will be accomplished by the external use of sulphur, and of
course sulphur water, and hence cases of paraplegia have been materially
benefited by the external use, combined with drinking them, of the waters
of Harrogate, Bareges, &c, and of our own White Sulphur in Virginia.—B.]
LECTURE CXXXV.
DR. STOKES.
Paralysis, sudden, from abscess ofthe brain—Curious case of paralysis without effu-
sion—Previous symptoms of—Demonstration of the cellular tissue ofthe brain—Com-
pressibility of the brain—Inaccuracy ofthe opinions of Drs. Abercrombie and Clutter-
buck—Pathological states—Arachnitis without delirium—Traumatic apoplexy—Case
of paralysis ofthe portio dura—Peculiar appearance ofthe affected side ofthe face__
Use of the electro-puncturation—Bad effects from—Mechanical support of the para-
lysed pans.—Neuroses, active and passive—General pathology of—Principles of
diagnosis—Case of neuralgic liver—Neuroses from moral causes.
Before I leave the subject of organic affections of the brain, I wish to
exhibit a few preparations illustrative of some of the principal diseases
dwelt on in the preceding lectures. You will recollect that, in a former
574
DISEASES OF THE NERVOUS SYSTEM.
lecture, I alluded particularly to the question, how far we are able to
judge ofthe existence of apoplectic effusion, by the sudden occurrence of
an attack of paralysis. I endeavoured then to impress upon you that we
may have sudden paralysis from other causes, as well as apoplectic effu-
sion, and stated that there were numerous cases of sudden paralysis, with
disorganization of the brain, on record, depending, not on apoplectic
effusion, but on circumscribed abscess of the brain ; and that, conse-
quently, the diagnosis of apoplectic effusion from suddenness of attack
was only valuable when it came on unpreceded by symptoms of local dis-
ease of the brain. I alluded to a remarkable case of aneurism of the
arteria innominata, in which the patient, soon after the date of his admis-
sion into the hospital, had become suddenly hemiplegic. This was a case
in which one would be led to expect an effusion of blood into the brain,
as the circulation of the head was evidently impeded by the pressure of
the aneurismal tumour on the great veins, and as there was a remarkable
distention of the jugular and other superficial veins. Ofthe existence of
the aneurism there was not the slightest doubt ; the tumour could be felt
pulsating below and above the clavicle on the right side, compressing the.
trachea, so as to cause stridulous breathing, and producing a varicose
state of the veins of the neck by its pressure. We accordingly made the
diagnosis of aneurism of the arch of the aorta, or of the arteria innomi-
nata, In this case two circumstances—the sudden paralysis of one side,
and the obstruction to the circulation ofthe neck and head—would, as I
have said before, lead to the supposition of an apoplectic effusion. On
dissection, however, the paralysis was found to depend, not en this cir-
cumstance, but on the existence of a circumscribed abscess in the ante-
rior part of the opposite hemisphere of the brain. I have the pleasure of
exhibiting to you to-day this interesting and important preparation. It is
too large to send round, but you can all inspect it after lecture. Here is
the aorta from its commencement at the left ventricle—here is the enor-
mous aneurism of the arteria innominata compressing the trachea—so that
it has not only pushed it far to the left side, but it has flattened it in such
a manner as to produce a curious alteration in the appearance of its mus-
culo-membranous structure. The terminations of the rings of the trachea
are brought close together, and the muscular parts are folded in between
them. There is another circumstance here deserving of your notice ; the
right carotid, you see, is obliterated ; it is interesting to connect this fact
with the absence of true apoplectic effusion. The case altogether is a
curious one, and presents two remarkable circumstances—great mechani-
cal obstruction to the venous circulation of the head, and sudden para-
lysis without effusion. It is, however, to be remarked, that in this case,
though the paralysis was sudden and unexpected, it was preceded by
some symptoms of local disease of the brain. The patient had pain in
the head and limbs of one side, accompanied by a sense of formication.
These symptoms were remarked some days before the attack of paralysis,
but their importance was not at that time thoroughly estimated, in con-
sequence of a greater share of attention being directed to the aneurismal
disease.
In this bottle you have a specimen of that species of ramollissement
which supervenes on local inflammation of the brain. We have every
reason, 1 think, to believe that when this disease occurs in the young, or
in the adult, it is the result of an active inflammatory process ; and that
PARALYSIS FROM ABSCESS OF THE BRAIN. 575
softening of the brain has in it nothing more specific or peculiar than
softening of the liver or lungs from inflammation. Here, you see, is the
disease—an irregular cavity filled with broken-up cerebral matter, some-
what resembling cream in appearance and consistence. I may remark
here, that it is in cases of this description that we are able to demonstrate
the existence of the cellular membrane ofthe brain. This cellular mem-
brane is extremely fine and delicate—so much so, indeed, that some
anatomists of high authority have asserted that the brain possessed no
interstitial cellular tissue. This preparation, however, gives a proof of
the great light which pathology frequently throws on obscure points of
anatomy and physiology ; for, though the interstitial cellular tissue cannot
be seen in the sound brain, we are able, in the preparation before us, to
demonstrate its existence with certainty. It is, however, to be observed,
that it is only in recent cases of ramollissement that this phenomenon can
be examined with advantage ; for, in those of long standing, the cellu-
lar membrane shares in the general destruction, more or less, and gives
way. But if you get a case where the softening is recent, and then take
the softened portion of the brain and expose it to the dropping of a filter,
you will find that the soft cerebral matter will be gradually washed away,
leaving behind it a delicate tissue ; and in this way you can prove the
existence of cellular membrane in the substance of the brain, like that of
other parenchymatous organs.
Here is a specimen of apoplectic effusion : see how extensively the
substance of the brain has been torn ; the cavity formed in this way is,
you will perceive, filled up with a large clot. Now, there is one considera-
tion which strikes us at once, in looking at an effusion of this kind into
the substance of the brain, whatever may be its situation or extent—and
this is, that the brain mast be a very compressible organ. Here we see
the brain torn, a cavity of large size formed, and this completely filled
with blood. Now, it is obvious that the rest of the brain must give way,
in order to give room for the formation of this cavity. If, then, it be true
that the brain is compressible, so far as to admit of the formation of a large
cavity, it necessarily follows that, contrary to the opinion of Drs. Aber-
crombie and Clutterbuck, the quantity of blood in the brain may vary,
and be greater at one time than another. These authors think that the
quantity of blood circulating in the brain never varies, but here you will
perceive, we have a remarkable cavity ; and it is plain that the rest of the
brain must have yielded before it could be formed : and it follows, as a
natural inference, that the brain must be compressible, and that, conse-
quently, the quantity of blood contained may vary at different times. It
may be argued against this, that the illustrative proof in this case is de-
rived from a pathological condition, and that, under such circumstances,
the brain has room for the formation of a cavity, by the emptying of some
of its vessels. Here, it is urged, is a cavity, but the emptying of the
vessels ofthe brain compensates for it; thus room is found, and there is
no increase in the quantity of blood circulating in the brain. This, how-
ever, I look upon as a mere petitio principii; nor have we any reason to
think, that in a case of apoplectic effusion, there is any corresponding
emptying of the vessels, for dissection almost always shows a surcharged
state of all the vessels. The result, then, in my opinion is, that the brain
is compressible, and may admit a larger quantity of blood at one time than
it dojs at another. On this subject I advise you to consult Dr. Mackin-
576
DISEASES OF THE NERVOUS SYSTEM.
tosh's work on the Practice of Physic, and also the review of Dr. Clutter-
buck's Essay on Apoplexy, in the London Cyclopasdia of Practical Medi-
cine, as given in the Dublin Medical Journal, vol. ii.
Here is another specimen. You see the brain, with a small clot in its
substance about the size of a hazel-nut. The patient in this case did not
die suddenly ; the clot has nearly lost the appearance of blood, and the
processes of absorption were going on. I have got here another prepara-
tion illustrative of this effect on one of those effusions. I told you, in a
former lecture, that in these cases one of two things occurred : either the
clot was wholly absorbed, and a serous cyst left in its place, or it was not
absorbed, and became to a certain extent organised ; and that this might
be the history of many of the anomalous tumours we meet with in the
brain. Here is a clot fully as large as a walnut, in wThich no absorption
has taken place, and you perceive it has been converted into a mass of a
dense solid texture. You can easily conceive that the brain, having a
clot of such a texture in its substance, could not easily recover its func-
tions, and that the paralysis would be persistent. Here is another large
apoplectic effusion, in which a certain degree of change has been pro-
duced ; the clot, you see, has lost a good deal of its colour, and is not so
red as in its recent state. Here is an excellent specimen of circumscribed
abscess ofthe brain, in the centre of one ofthe hemispheres. In this you
can, to a certain degree, demonstrate the cellular membrane of the sub-
stance of the brain; but, if the preparation had been manipulated in the
way I have mentioned, I have no doubt that it would exhibit it much
better — that is, provided the abscess was of recent occurrence. If it
should happen to be of long standing, the cellular membrane generally
gives way, and you have nothing but a cavity filled with softened matter.
This large preparation exhibits an enormous effusion on the surface of one
of the hemispheres of the brain ; it was the result of an injury of the head,
and was accompanied by paralysis of the opposite side. It furnishes an
example of what has been termed traumatic apoplexy. The other prepa-
rations on the table do not apply so immediately to the illustration of apo-
plectic effusions, and I shall pass them over.
Here is a preparation which I would draw your attention to, as it be-
longs to a very remarkable case. I mentioned before, that, in certain
cases of arachnitis, where the disease was chiefly situated at the base
of the brain, it had been observed that there was seldom delirium. In
this case the patient complained of pain along the base of the skull,
which occasionally remitted and then returned with violence, and it was
at first supposed to be neuralgic. He continued in this state for some
time, having a recurrence of violent pain in the ear, temporal and mastoid
regions, which lasted for several days; when, all of a sudden, without
any preceding delirium, he became comatose, and died shortly afterwards.
On dissection, the arachnoid covering ofthe brain was found to be in a state
of extensive disease over the inferior surface of the anterior lobe, and to-
wards the posterior part ofthe base ofthe brain. Here we had a case of
extensive and fatal arachnitis, with total absence of delirium.
When speaking ofthe employment of galvano-puncturation in the local
treatment of paralytic affections, I stated that the case in which the most
decided benefit was observed occurred in paralysis of one side of the face,
apparently unconnected with actual disease of the brain, and of a local
nature. This is in accordance with what has been observed with respect
PARALYSIS TREATED BY GALVANO-PUNCTURATION. 577
to the efficacy of all local measures employed in the treatment of paralysis :
and, accordingly, the more the affection is purely of the nerves of the part,
the raore satisfactory should be the results of galvanism. I shall read for^
you the notes of this case, and I am happy to have it in my power to lay
before you two excellent drawings ofthe patient's appearance before and
after the use of the galvanic battery, from the pencil of my friend, Mr.
Berthon.
" A bricklayer, named T. Hogan, got an attack of erysipelas of one side
ofthe face, accompanied by a feeling of pain and stiffness between the
angle of the jaw and mastoid process of the right side. This was followed
by an attack of paralysis of the right side of the face, and he presented
himself for admission at the Meath Hospital in the following state :—The
features at the right side ofthe face are blank, unmeaning, and motion-
less, while those ofthe left side retain their natural cast, except that their
lines are more strongly marked, and the angle of the mouth is drawn up-
wards and towards the left side to a considerable extent. The skin of the
right side of the forehead is smooth, that of the left furrowed and puckered.
The lids of the right eye are half closed, and he has not the power of mo-
ving the upper one. When desired to close his eyelids, the eyeball rolls
upwards, and the transparent cornea is carried behind the curtain of the
upper lid. By this movement the patient excluded all objects, and was
under the impression that he had shut his eye. The lower lid hangs down,
and is partly everted, exposing the conjunctiva, and allowing the tears to
trickle down the cheek. When he breathes, the right cheek is puffed out;
it becomes still more distended by an attempt at blowing ; and, when
attempting to drink, a quantity ofthe fluid escapes at the right angle of
the mouth. On being requested to draw the right angle of the mouth
towards the corresponding ear, not the slightest movement was made, ex-
cept by the muscles of the opposite side. In masticating the food, the
morsel gets between the cheek and gum of the right side, and he is obliged
to put in his finger to dislodge it. Sensation on the paralysed side is un-
impaired, and there is no deafness, alteration of taste, or loss of vision.
With respect to the muscular functions of the tongue, they appear to have
suffered no injury, and he can direct it with facility to either side. Here
was a fact to show that the paralysis of the face in this instance had no
connexion with cerebral disease. In the majority of cases of paralysis of
one side of the face, from diseases of the brain, there is lesion of motion of
the tongue, but here it was in its natural condition. There is a slight
degree of thickness of speech, which can be remedied by supporting the
paralysed cheek with the palm of his hand. He complains of a feeling of.
stiffness in the jaws, and cannot open his mouth more than what would be
capable of admitting a teaspoon. He has had some tenderness over the
mastoid process. He can press hard substances with his teeth ; and the
temporal, pterygoid, and masseter muscles seem to be as strong on the
paralysed as they are on the sound side. He can move the lower jaw so
as to incline the symphysis to either side, but more to the left than to the
right. His general health is good, and his bowels regular." I shall hand
round the drawings of this case for your inspection. You will observe the
peculiar appearance ofthe left side of the face, with the mouth drawn up-
wards, and the skin of the nose and forehead thrown into deep wrinkles.
There can be no doubt that the exciting cause of the paralysis in this in-
stance was connected with the erysipelas of the face. He had no symptoms
vol. u.—38
578
DISEASES OF THE NERVOUS SYSTEM.
of any cerebral affection, and the paralysis was limited to those muscles
which are supplied by the seventh pair of nerves. The tongue was quite
unimpaired in its motions, and there was no lesion of taste, hearing, or
smell. It was, in fact, a case of purely local paralysis, and bore a deci-
ded analogy to those cases which have been so accurately described by Sir
Charles Bell as depending on an affection ofthe seventh pair of nerves.
The treatment of this case was in accordance with the views already
detailed ; the diagnosis was paralysis of the seventh nerve, and the treat-
ment founded on this diagnosis proved eminently successful. The first
thing done was to apply a few leeches to the ramus of the jaw ; we then
used stimulating applications, and he used for some time the liniment,
camphoras compos, with extract of belladonna. After this he was put on
strychnine, which did him some good ; but there was so great a suscepti-
bility of its action that we were ultimately obliged to give it up. The last
remedy employed was electro-puncturation, under the use of which he
improved rapidly. On the 5th of March, the galvanic battery was first
applied ; the needles at that time were inserted—one in front of the ear,
and the other near the symphysis of the chin ; subsequently they were
inserted in various parts of the right side of the face, following the different
branches of the portio dura. On the first application of the galvanic influ-
ence, he had spasmodic twitches ofthe paralysed muscles, and soon after-
wards he began to complain of a burning sensation in the cheek and pain
in the head. Here, it would appear that headache was the result of the
proximity ofthe stimulus to the brain. On the 11th, the symptoms were
nearly the same, and his general health continued to improve. On the
15th, the application of the galvanic influence was followed by severe
headache, which lasted for half an hour. On the 19th, his appearance
was much improved, and the galvanic battery was not used. On the 20th,
it was again applied, and in an hour afterwards he had rigors and slight
headache. On the 21st, after using the battery, he had rigors again, fol-
lowed by headache and a prickling sensation in the cheek. On the 24th,
he left the hospital in a remarkably improved state. Expression bad
returned to the side of the face which had been previously unmeaning and
blank ; the furrows which had deformed the opposite side were removed,
the thickness of speech diminished, and the paralysis of the buccinator had
been so far relieved that he was able to manage soft articles of food without
being under the necessity of removing them from between the cheek and
gum with his finger. In this case we employed an adjuvant which should
be mentioned ; we supported the paralysed parts for some days with strips
of adhesive plaster, to restore the position of the mouth. This wras done
on the principle recommended by Dr. Pemberton, in the treatment of pa-
ralysis of the fore-arm and hand from painters' colic. By applying strips
of plaster near the angle ofthe mouth, and drawing them back and fixing
them behind the ear, we endeavoured to counteract the preponderating
antagonism of the muscles of the opposite side. For the report of this
case, I am indebted to Mr. K. Eiiison, of Liverpool, who had the charge
ofthe patient in the Meath Hospital, a gentleman whose talents are only
equalled by his untiring zeal in the study of pathological medicine.
The foregoing case is interesting in two points of view ; first, as to its
peculiar phenomena, and, in the next place, as to the success of local
treatment. It also shows that we may go too far with electro-punc-
turation, particularly when it is applied to parts which are situated close
NEUROSES.
579
to the brain. You recollect that, in Mr. Hamilton's case of amaurosis,
three pairs of plates were capable of producing a degree of stunning and
insensibility which lasted for some time. In this case the rigors and head-
ache showed that the galvanic fluid had a powerful effect, and would lead
us to be cautious in using it too freely, where the parts to which it is to
be applied are situated in the vicinity ofthe brain.*
We have now taken a very brief sketch of some ofthe most important
organic affections ofthe brain ; but, in the study of disease, we constantly
meet with a vast number of cases presenting the most extraordinary nerv-
ous phenomena, and yet we are unable to discover, by the closest pathologi-
cal investigation, any appreciable lesion ofthe nerves, spinal cord, or brain.
These are the class of diseases which have received the name of neuroses.
We find, in most of these affections, a remarkable alteration in the nerv-
ous functions without any perceptible or constant organic change; we
* [The actual cautery has been tried at different times for the cure of
paralysis, and, in some instances, with marked effect. A milder, and, as
he alleges, equally efficient means of nervous excitation, is procured by
Dr. Corrigan, by the process of " firing." The instrument he uses for
• the purpose, consists of a thick iron wire shank, about two inches long,
inserted into a small wooden handle, and having on its extremity, which
is slightly curved, a disc or button of iron, a quarter of an inch thick, and
half an inch in diameter; the whole instrument being six inches in length.
The face of the disc for application is quite flat. This, trifling as it may
seem, must be attended to. The only other portion of apparatus required
is a small brass spirit-lamp, so small that it can be carried in the waist-
coat pocket. To use the instrument it is necessary to light the lamp, and
hold the button over the flame, keeping the forefinger of the hand holding
the instrument at the distance of about half an inch from the button. As
soon as the finger feels uncomfortably hot the instrument is ready for use,
and the time required for heating it to this degree is only about a quarter
of a minute. It is applied as quickly as possible, the skin being tipped
successively at intervals of half an inch over the affected part, as lightly
and as rapidly as possible, always taking care to bring the flat surface of
the disc fairly in contact with the skin. In this way the process of firing
a whole limb, or the loins, making about 100 applications, does not
occupy a minute, and the one heating by the lamp suffices. You can
ascertain at once whether the heat be sufficient. If you look sidewise at
the spots as you touch them, you will observe that each spot the iron has
touched immediately becomes of a glistening white, much whiter than the
surrounding skin. In the course of a quarter of an hour, or sometimes
of a very few minutes, the whole skin becomes of a bright red, and the
patient feels a glow of heat over the part. In most cases he is quite un-
conscious of what has been done. So little painful is it that some of the
resident clinical clerks in the hospital under Dr. Corrigan's care, preferred
the " firing" in their own cases, when suffering under local muscular
rheumatism, to any other mode of counter-irritation. Dr. C. never makes
an eschar with the instrument, and very rarely raises a blister. On the
following day a number of red circular marks are seen on the skin, but
without the cuticle being even raised. Dr. C. has used the " firing"
with the greatest advantage in paralysis ofthe portio dura ofthe seventh,
and also in neuralgia ofthe fifth pair of nerves.—B.]
580
DISEASES OF THE NERVOUS SYSTEM-
find, too, that this alteration may be connected with an exaltation or a
depression ofthe nervous power; and from this circumstance results the
division of neurotic affections into active and passive—active where the
nervous power is elevated, and passive where it is depressed. The spasms
which accompany an attack of flatulent colic, the exquisite pain of tic
douloureux, and the wild intellectual exaltation of mania, are examples
of active neuroses. A patient in the second stage of painters' colic will
have paralysis of motion and sensation of the fore-arm ; there is here an
obliteration, or at least a diminution ofthe nervous function, and the dis-
ease furnishes us with an example of passive neurosis.
Of these two classes the active are certainly the most interesting in
many points of view. We find, under the class of active neuroses, some
ofthe most extraordinary diseases to which the human body is subject;
all the different varieties of spasmodic affections—chorea, epilepsy, tetanus,
hydrophobia, tic douloureux, hysteria, and a host of others, come under this
denomination. It is a melancholy reflection, then, that, in the present state
of medical science, we are not only ignorant of the ultimate cause of most of
these diseases, but even of the causes of the variation in their phenomena.
You will recollect that, in a former lecture, I threw out a conjecture on
this point, and stated that there might be ehanges of an organic nature .
connected with these affections, not appreciable by any mode of investi-
gation at present known : and that it was possible that there might be a
change in the nervous substance, quite independent of any addition or
subtraction from the component sura of their organic molecules, but in all
probability connected with a new and different arrangement of these mole-
cules. The analogy, in this instance, is drawn from chemistry, and, I think,
may obtain here, as well as in the phenomena of Isomerism in inorganic
bodies. You are aware that many bodies, which seem to present exactly
the same component elements, are found to be extremely different in their
properties, and that this difference has been accounted for by supposing
that it depends, not on any addition or subtraction of the component
molecules, but on some difference in their mode of arrangement. Now, if
this happens in the case of inorganic bodies, there is no reason why it might
not also occur in organic substances ; and, if so, we may understand why
a state of the brain and nerves, which appears to us to be normal and
healthy, may still be essentially different, and give rise to the most ex-
traordinary phenomena.
I shall not detain you with any further remarks on this subject—it is too
obscure to be treated of in a course of lectures on the practice of medicine ;
let us turn to the consideration of the actual state of our knowledge on the
subject of nervous affections. In the first place, we know that in the neu-
roses there is no change discoverable which could account for the symp-
toms ; and that, if we examine the nervous centres to explain the phenome-
na of paralysis in one instance, of epilepsy in another, of mama in a third,
of hydrophobia in a fourth, and so on, the minute investigations will not,
in the majority of cases, point out any deviation from the healthy condition
sufficient to account for the phenomena. We find, too, not only that the
state of the brain does not present any constant difference in the foregoing
diseases, but also that there is often not the slightest trace of anything like
inflammatory action—a fact borne out by the most extensive experience—
and showing that treatment which would relieve ordinary cases of inflam-
mation of the brain will here prove useless. There is one curious circum-
PATHOLOGY OF NEUROSES.
581
stance connected with these neuroses which you should be aware of, and
this is—where the patient, after suffering from a nervous affection for a
long time, dies, you may find organic disease on dissection ; but here there
appears reason to believe that organic changes ofthe cerebro-spinal centres,
taken in the proper acceptation of the term, are, in reality, the result of
some state of these centres which existed previous to the attack, and was the
cause of all the nervous phenomena. We arrive at this conclusion, for two
reasons : first, because such changes are by no means constant; and se-
condly, because they are only found where disease has been for along time
in existence.
Nervous phenomena, independent of organic lesion, have been divided
into twTo classes—namely, neuroses ofthe nerves of animal, and neuroses
of the nerves of organic life. With respect to animal life, or the life
of relation, we may have its neurotic affections of an active or passive
kind ; we may have pains, spasms, and exaltation of intellect, under the
active form : under the passive, we may have extinction of muscular
motion, sense, and the intellectual functions — the life of the individual
being still preserved. With respect to the system of organic life, it would
appear that, if we are to speak in general terms, we must admit that there
is no passive paralysis of the nerves of organic life, they being liable to
the active neuroses alone—for a passive neurosis of the ganglionic system
implies death ; yet, to a certain degree, as I have formerly stated, such a
passive neurosis might exist in the visceral nerves. But we may have
the phenomena of the active neuroses in all parts of the body, w'hether
muscular or visceral. It is a singular fact, that in sorae visceral diseases
we have signs of high exaltation of the nervous functions ofthe parts, in
others not. Why is this the case ? I think it must chiefly depend on the
mode or degree of excitability ofthe brain, which is very different in dif-
ferent persons. There is no known organic difference between the gas-
tritis with delirium, and the gastritis of a man in his senses: nor is there
any difference between the hepatitis of a man of bilious, and the hepatitis
of a man of nervous temperament: and we have, in order to explain the
variety of the symptoras, to refer to some original conformation or mode
of excitability of the sentient centre. Whether this difference depends
on an original organization, or on excess or deficiency of parts, or on phe-
nomena similar to those of Isomerism, we know not. As the result of
experience, we are forced to admit that these phenomena have no neces-
sary connexion with the inflaramation of the suffering part, or of the brain ;
and this proposition applies to the great majority of cases which are called
nervous. Experience has also proved the truth of this from the results of
treatment— for it has proved that the most successful treatment is that
which is by no means calculated to remove inflammation (in its ordinary
acceptation), either from the brain or from the suffering parts. The pro-
gress and duration of these cases, also, tend to prove the sarae thing ; for,
if we were to measure the degree of inflamraation by the amount of pain
suffered, it would be of an intense character and rapid fatality ; and yet
we find that, notwithstanding the violence of the symptoms, these diseases
may go on for a number of years.
It is quite plain, then, that the pathological condition of a neurosis is
not inflammation. Now, one of the most common mistakes in the prac-
tice of medicine is the taking these neuroses for cases of local inflamma-
tion ; and this, I need not tell you, is frequently productive of most dis-
582
DISEASES OF THE NERVOUS SYSTEM.
tressing consequences. There is one point connected with those violent
nervous attacks which leads to a persistence in this error; and this is, that
local antiphlogistic treatment gives temporary relief, although, in the ma-
jority of instances, this is of very brief duration, and the pain and other
symptoms relurn, leaving the patient worse than he was before. From
the fact of temporary alleviation following depleting means, however, the
idea of inflammation gets into the practitioner's mind, and the patient
himself is favourably disposed to that plan of treatment from which he has
obtained a momentary relief. The consequence is, that a system of gene-
ral and local depletion is continued, until a period arrives when the ner-
vous excitability gets to an alarming height. Now, is there any circum-
stance, or class of circumstances, which would lead to the diagnosis of
these affections ? I feel certain that in many instances this must be a mat-
ter of some difficulty. By a careful study of the symptoms, however, you
will, in most cases, be able to arrive at the truth. The first thing to which
I would direct your attention, in studying the diagnosis of such cases, is
the extreme violence of the pain. Now, this intensity of suffering seldom
occurs in cases of inflammation ; and it is a curious fact, that the most
painful diseases are the non-inflammatory. The agonies of a patient la-
bouring under neuralgia ofthe liver, or ofthe left side, or under tic dou-
loureux, are dreadful ; the pain is far more intense than in any case of
inflammation : and yet, notwithstanding all this excess and persistence of
suffering, we do not see that the duration of life is necessarily curtailed.
In the next place, you will observe that these attacks frequently recur,
and that, though long-continued and violent, they do not affect the patient's
life, which would not be the case if they were connected with inflamma-
tory action. If you add to all these circumstances a knowledge of the
constitution, temperament, and habits of the patient, you will have still
clearer notions. But there are other circumstances besides these to guide
you. In the majority of cases, you will find that all the local and general
signs of inflammation, with the exception of pain, are absent. A female
labouring under neuralgia of the liver, will have frightful pains in the right
hypochondrium, and yet, if you examine her, you find that she has little
or no hepatic derangement, no tumour in the region of the liver, no de-
rangement ofthe digestive system, and (though the disease has lasted for
years) no dropsy, and in many cases no appearance of jaundice. She has
no fever, thirst, or loss of appetite ; her tongue is clean, her complexion
clear, her stools natural, and her pulse soft. All these circumstances tend
to show that, however violent the pain may be, it has no connexion with
inflammation. You will be assisted further in your diagnosis, by finding
that the access and cessation of these attacks are equally sudden and un-
expected—two characters which do not belong to organic diseases. The
quick supervention and sudden cessation of these diseases should lead you
to suspect that they were not inflammatory. It may happen, in cases of
inflammation, that pain may come on suddenly, and as rapidly cease ; but,
though it may come and go in a brief space of time, still you will find that
lesion of function or structure remains. Thus, in a case of pleuro-pneu-
monia, the pain ofthe side may cease suddenly under treatment; but the
stethoscope informs you that the layers ofthe pleura do not as yet glide
freely on each other, and that there is some obstruction still to the free
passage of air into the air vesicles. There is also another point. When
we come to inquire into the exciting causes of these neuroses, we observe
NEURALGIC AFFECTIONS.
583
that they are most generally found to depend upon various circumstances
connected with improper nutrition and with moral influences. Of these
two classes of causes, the latter, though perhaps not the most numerous,
are by far the most remarkable. A violent neurosis may be brought on
in a single instant by moral causes. A nervous female, in apparent good
health, may, from a sudden fright or fit of passion, get an instantaneous
attack of neuralgia of the liver, and be thrown into a state of intolerable
agony. Lastly, you will be greatly assisted in these cases by a knowledge
of their history and previous treatment. What you will generally find is,«
that the patient has gone through a long and harassing course of general
antiphlogistic treatment. The failure of this treatment will be of great
value in guiding you to a correct diagnosis ; and you will be further con-
firmed in this view of the case, by finding that the treatment which has
the power of relieving or curing consists in improving the state of the
whole system by the use of tonic, and, in many cases, of stimulant reme-
dies. These observations will apply to almost all cases of purely nervous
affections.
LECTURE CXXXVI.
DR. STOKES.
Neuralgic Affections—Principles of treatment of—Connexion with organic disease
—Neuralgia ofthe liver—Treatment—Hemicrania—Treatment—Use of iron, quinine,
and opium—Endermic method of using opium—Tic douloureux—Opinions of Sir C.
Bell—Remarkable case related by—Inflammation of frontal sinuses—Violent symp-
toms—Mr. Crampton's treatment—Affections of the fifth and seventh nerves in cases
of cerebral disease—Neuralgia of the side—Researches of Lombard and Brande on
the effect of nitrate of silver—Injury to the skin.
To-day I purpose to speak of some of the general principles connected
with the treatment of neuralgic affections ; and here I beg leave to remind
you, that we mean by neuralgic affections an exaltation of the nervous sen-
sibility independent, quoad its production, of any organic disease which we
can detect in the nerves, brain, or spinal cord. There is no proposition
better proved than this, that the phenomena of nervous affections are not
the same as those of inflammatory diseases ; everything tends to prove
it, whether we look to the history and symptoms of the case, the results of
treatment, or the appearances seen on dissection.
As the nervous system is diffused all over the body, and as there is no
part of the system which does not, under certain circumstances, exhibit
indications of sensibility, it follows that we may have neuralgic pains in
any of the component tissues. Still it is remarkable, that neuralgic affec-
tions are much more frequent in some parts than in others ; and we find
that, of all parts of the nervous system, the superficial nerves are those
which are most commonly affected. With respect to the nervous affec-
tions of the viscera, we know very little as to their exact seat, but it has
been generally observed that the pain is situated in the situations of the
plexuses ofthe great sympathetic.
In entering upon the principles which should regulate the treatment of
neuralgic diseases, I have to remark that they are but slightly modified by
584
DISEASES OF THE NERVOUS SYSTEM.
their situation ; in fact it may be stated generally that the same principles
of treatment apply, no matter where the disease maybe situated. But are
we to consider this subject as totally apart and having no connexion with
the occurrence of inflammatory or organic disease ? If we did so, we should
get but a limited and erroneous view of the matter. I have told you before,
that in long-continued cases of functional disease organic alterations were
very apt to take place. The reverse of this proposition also is true, that
organic affections may precede an attack of nervous symptoms; in other
words, you may have cases presenting, at first, phenomena, amenable to
antiphlogistic treatment, and yet a period will arrive when new symptoras
occur, and this mode of treatment will be no longer applicable. This is of
importance in the practice of medicine, for if, in such a case, you perse-
vere in the use of depleting measures, you will effect nothing towards the
removal of distressing symptoms, and may do your patient's constitution
much injury. A common example of this is, where a person receives some
local injury, as, for instance, a blow on the cheek. This is followed by all
the symptoms of inflammation, as pain, swelling, heat, redness, &c. Well,
then, you have a case of local inflammation to deal with, and you must
treat it as such. But a period may arrive, when the heat, swelling and
other symptoms of an inflammatory affection subsiding, the pain alone con-
tinues. Here the pain may be purely nervous ; and if you were to go on
leeching, purging, and depleting your patient, you would not only lose
your time, but in all probability do mischief. Here, as in many other
cases, we have local inflammation followed by an active neurosis. You
remember, when speaking of hepatitis, I remarked that many persons were
subject to pains in the regions of the liver, independent of any known or-
ganic disease. I also drew your attention to the fact, that after the symp-
toms of hepatitis are removed, the pain sometimes continues, having no
longer any connexion with organic disease, and taking on the character of
a neurosis. You will see of what importance this is when you reflect on
the mischief done to such patients by persevering in bleeding, blistering,
and the use of mercury, when the disease is amenable, not to this, but to
a plan of treatment calculated to remove the neuralgia of the liver. It is
the same thing with regard to the mammas, injuries of which are frequently
followed by severe neuralgic affections. In the case of the heart, it some-
times happens that, after an attack of pericarditis, the patient will be subject
to pain in that region, which may continue for years. Dr. Bright gives a
very remarkable case of neuralgia which supervened on the disappearance
of a cutaneous affection. All these facts tend to show, that the mere pre-
existence of local inflammation in any individual case does not prove that
the pain is not neuralgic, and hence it is plain that in such a case it might
be improper to persevere in the treatment used for local inflamraation.
This persisting in the taking of a neuralgic pain for the continuance of
inflammatory or organic disease is a common error, and often productive
ofthe most frightful consequences. Without a careful consideration of such
cases, you will fall constantly into error. Never forget that, although neu-
ralgia may be the first and sole affection, yet that it is often combined with
organic disease, which it may precede, accompany, or follow.
One of the most common forms of neuralgia which you will meet with
in private practice, is what has been termed hemicrania, the chief symptom
of which is violent pain on one side of the head and face. The symptoras
are exceedingly violent; there is a high degree of exaltation in the sensi-
HEMICRANIA.
585
bility ofthe surface of the face; the eye is exquisitely sensible to light,
and the ear to sound. The patient is very much prostrated, and his spirits
depressed, and the slightest cause is sufficient to bring on an attack of pain.
In some cases the pain is constant, in some remittent, in others intermit-
tent. The sensibility is deranged only at one side ofthe head and face ;
and the pain seldom extends beyond the median line. As far as we know
of this affection, it seems to depend on some morbid state, either of the
sentient extremities of the fifth nerve, or of that portion ofthe brain which
receives its impressions.
In cases of hemicrania we may have symptoms existing elsewhere, and
this leads us to the consideration of the exciting causes. These will be
often found to depend on deranged digestion. Here the irritation is re-
flected through the sympathetic system to the brain and sentient branches
of the fifth pair, for there exists between these two nerves a very close
and remarkable sympathy. Thus we frequently observe, that tic doulou-
reux, as well as hemicrania, are the result of sorae injury or irritation of
those parts to which the ganglionic nerves are distributed. In treating a
case of hemicrania, then, you must inquire whether there be any visceral
irritation present, and remove it as soon as possible. You must also care-
fully inspect the teeth and gums, for a carious tooth or a diseased gum will
prove the exciting cause of an attack. I have seen many cases of hemi-
crania where the patient was subjected to a variety of treatment without
success, and where complete relief was obtained by the simple process of
extracting a carious tooth. It is a very curious fact, that in those instan-
ces the pain was referred, not to the diseased tooth, but to the whole sur-
face of the face. Cases of this kind are given in which the pain lasted
for many years, resisting every form of treatment, and were afterwards
cured by the extraction of a decayed tooth. There is one circumstance
in these cases wdiich is very apt to mislead, and this is, that the pain is
often not referred to the tooth ; and relief, to a certain extent, is obtained
by the use of narcotics and carbonate of iron. This, however, should not
lead you to think that the disease has no connexion with the state of the
tooth and gum ; and this fact is illustrative of a most important principle,
viz., that temporary relief by a purely anti-neuralgic treatment does not prove
that no organic origin exists. How often has hysteria depended on local
disease, and the practitioner been misled by the temporary relief afforded
by anti-spasmodics. 1 have seen the most melancholy examples of this,
and I have more than once been misled myself.
With respect to the remedies most generally employed in the treatment
of hemicrania, they are chiefly preparations of arsenic, iron, sulphate of
quinine, and opium. Of these, the recently precipitated carbonate of iron
appears to be the best; indeed its success is frequently heroic. In proof
of this you will find several very interesting cases detailed by Mr. Hut-
chinson in his excellent work. The best way of giving it is to combine
it with an aromatic and a laxative ; a small quantity of the pulv. cinna-
momi comp., a few grains of rhubarb, and fifteen grains or a scruple of
the carbonate of iron, will form a powder which may be given two or
three times a-day with advantage. It has been asserted, that the carbonate
of iron is suited for fixed, and not for intermittent cases of neuralgia ; I
have found the contrary to be the fact. I had lately a lady under my care,
who, in attempting to remove some furniture, received an injury by strik-
ing her cheek against a chest. She was treated for six weeks with pur-
586 DISEASES OF THE NERVOUS SYSTEM.
gatives, local bleeding, and mercury ; the swelling, heat, and redness of
the part went off, but the pain remained, being regularly intermittent, and
occasionally very severe. This lady was perfectly cured by a tonic regi-
men, and the carbonate of iron, in scruple doses, three times a-day. The
sulphate of quinine has been proposed as being peculiarly adapted for
intermittent cases ; it will sometimes succeed, but I have known several
cases where it completely failed. I grant that the character of intermission
would naturally induce a practitioner to have recourse to it, but I have
known so many instances of its failure, in purely intermittent neuralgia,
that I gave a decided preference to the carbonate of iron ; I recollect the
case of a gentleman who for six weeks had daily attacks of terrible hemi-
crania. When the attack came on he was obliged to remain perfectly
motionless, the tears streaming from the eye of the affected side, the ear
was exquisitely sensible to the slightest sounds, and he remained in a state
of intolerable suffering for some hours. For the space of six weeks he
took quinine in enormous doses without any improvement, and was ulti-
mately obliged to give it up as useless. I have seen the same result in a
great many cases, and as far as my experience goes, I would not place
much reliance on quinine, even where the attack was of a purely intermit-
tent character. I have seen some cases, indeed, where it has done good,
and you may try it; but if, after three or four full doses, you find there is
no improvement, you may be almost sure that it will prove useless. When
it succeeds, one of the first effects produced by it is to put back the pa-
roxysm for an hour or two, just as occurs when it is successfully given in
a case of ague. But I feel certain, that if it is likely to succeed, its bene-
ficial effects will be seen in the course of a few days, and to persist for
weeks in using it is not only unnecessary but improper. In the very remark-
able case to which I have just alluded, the gentleman, after having tried
quinine without the slightest improvement for six weeks, was suddenly
and completely relieved by a full dose of opium. At night, on retiring to
rest, he took a strong opiate, awoke in the morning refreshed and free from
pain, and has continued from that time to the present (a period of ten years)
without any symptoms of hemicrania. Dr. Mackintosh says that the seda-
tive solution of opium, or the acetate of morphia, are the best remedies
for this disease he is acquainted with, and that he has seen many cases
where they succeeded, after everything else had failed. You may also em-
ploy in such cases the external use of narcotics with great advantage, of
which one of the best is the extract of belladonna. If you prescribe a
liniment composed of a drachm of the extract of belladonna with an ounce
of the compound camphor liniment, you will have a powerful remedy, and
one which, when applied to the surface of the affected parts, will often
produce a great relief. I have sometimes used the acetate of morphia in
the endermic mode, by putting on a small blister, and leaving it on until
vesication was produced, when the raised cuticle was cut away with a pair
of fine scissors, and the surface dressed with an ointment composed of a
drachm of lard, and from a grain to a grain and a half of the acetate of
morphia. I remember two cases of intermittent hemicrania which yielded
to this treatment. You will also frequently derive benefit from the inter-
nal use of stramonium and belladonna. There are many other remedies
used for this purpose, but I shall not detain you any longer on this part of
the subject; it will be sufficient to remark that the carbonate of iron, sul-
phate of quinine, and opium, externally and internally, are the remedies
on which the most reliance is to be placed.
TIC DOULOUREUX.
587
We have now to consider one of the most painful affections to which
man is subject. This affection has been generally considered under two
points of view, either as functional or organic. The functional, as far as
we can judge of it, appears to be a pure neurosis ; in the organ it is sup-
posed that the disease is connected with an organic affection of some part
of the brain ; of these the first kind is that most commonly met with in
practice.
'lie douloureux is one of the most melancholy and harassing affections
to which the human frame is liable ; in some instances the poor sufferer,
after having lived for years in a state of exquisite misery, is at last worn
out by the intensity and persistence of his agonies. Such was the fate of
the late celebrated but unfortunate Dr. Pemberton. A great deal of light
has been thrown on the nature of this affection by the researches of Sir
Charles Bell. He seems to have succeeded in establishing several points
connected with the nature and seat of this affection, one of the most im-
portant of which is, that the seat of this disease is in the sentient branches
of the fifth pair of nerves, and not, as it has been supposed, in the portio
dura. He has shown pretty clearly that the portio dura is the nerve wThich
regulates the muscular motions of the face, producing all those modifica-
tions of features which we call expression, and also peculiar motions or
changes connected with certain states of respiration ; in a word, that it is
the expressive and respiratory nerve ofthe face. It is, according to him,
never the seat of tic douloureux, and the practice of dividing it for this
complaint is as unscientific as unsuccessful. The division of the portio
dura in such cases, not only fails to give relief, but also entails disgrace
on the practitioner, and disfigurement and misery on the patient. Its
effect is paralysis of the muscles of one side of the face, and great distortion,
without the slightest relief. Yet it is a melancholy fact that such opera-
tions have been performed. Sir C. Bell's researches, however, have put
an end to this malpractice, for he has shown that the fifth nerve is that
which supplies the face with sensation, and that it is in its branches the
disease is situated. We are then, I think, to look upon this disease as a
neurosis situated in the expansions of the facial branches of the fifth pair
of nerves. Sir C. Bell relates a very remarkable case, in which the pa-
tient had suffered from a series of dreadful attacks, the pain coming on
in violent paroxysms. From the accounts given by this patient, and from
personal observation, he says that one could trace with anatomical pre-
cision the course and direction of the branches ofthe fifth nerve, for, on
the recurrence of an attack of pain, he applied his fingers to his face,
and made pressure on the foramina, where the different branches of the
fifth nerve issue. Having done this, he would press the nerves with all
his force, and remain in a fixed posture while thp paroxysm continued.
Sir Charles Bell's idea with respect to the cause of this disease, is, that
it generally depends on some visceral irritation reflected through the sen-
tient branches of the fifth pair of nerves.
1 have told you that this disease is one of the most melancholy affec-
tions to which man is subject: it is also one of the most obstinate. A vast
number of remedies have been employed or proposed for its treatment,
and this affords an illustration of the fact, that the more incurable a dis-
ease is, the more extensive is the list of its remedies. A few only are
deserving of attention, and these I have already mentioned when speak-
ing of hemicrania, namely, the preparations of arsenic, iron and quinine,
and opium. Where these fail after a full trial, Dr. Bright looks upon the
588
DISEASES OF THE NERVOUS SYSTEM.
case as hopeless. Narcotics in every form and of every description have
been employed, both externally, and internally, but to all these the same
remark applies; many of these remedies will give temporary relief, and
the physician will flatter himself on the prospect of a favourable termina-
tion, but in a short time he is annoyed at finding that the disease has re-
turned and left the patient as bad as ever. Many a time have I seen/a
poor sufferer excited by hope on receiving temporary alleviation from the
use of arsenic or iron, and sinking into despair when he found'that his tor-
turing malady returned, and that the remedies which on the first trial gave
relief, on the second proved useless. The general principles which should
guide you in your treatment are, first, to investigate carefully whether any
visceral irritation exists, and remove it as far as possible, taking care at
the same time to improve the general state of the patient's health ; and
the next thing is to allay the sensibility of the nerves of the part, and
avoid all exciting causes. In certain cases this disease appears to be con-
nected with an affection ofthe brain, and this seems to be an explanation
ofthe fact before mentioned, that, in some cases, where all specific treat-
ment had completely failed, relief had been obtained by shaving the head
and applying ice to the scalp during the paroxysms. 1 have already men-
tioned to you a case in which this mode of treatment proved eminently
successful. This is a curious fact, and one which, being of practical im-
portance, you should hold in memory.
We have a form of disease consisting of violent paroxysms of pain, ap-
parently nervous, and in which no doubt the branches of the fifth pair of
nerves are engaged ; it is generally found to depend on a local cause, be-
ing connected with some disease of the bones of the face or skull, and
bears a close analogy to tic douloureux. I have now witnessed several
instances of this disease ; in some cases it is produced by a carious tooth,
in others by disease of the maxillary bones, and I have observed it to
occur in one case of abscess of the antrum. The same thing has been
observed by Dr. Bright, who gives a case in which the extraction of one
of the bicuspids was followed by a gush of matter from the antrum and
complete relief of the violent pain. I have also seen cases in which this
affection appeared to be the result of disease of the lining membrane of
the frontal sinus ; of this also Dr. Bright gives an example. The case I
witnessed was that of a lady who got a dreadful attack resembling hemi-
crania, in consequence of being exposed to cold shortly after leaving a
warm climate. She suffered the most violent agonies for some time, until
one day she had a discharge of purulent matter from the nostrils, which
was almost immediately followed by relief. This has recurred at intervals
since that period, the pain ceasing when the discharge comes on, and re-
turning when the discharge goes away. The pain is most intense, and
situated in the direction ofthe frontal sinus, and running down along the
side of the face ; it is constant, and without any intermissions, returns
upon the occurrence of any cause which checks the discharge, and is some-
times so excessive as to render her quite frantic. Whenever an attack
comes on she applies a number of leeches over the frontal sinus, then
warm fomentations, and this has the effect of bringing on the discharge
and giving relief. In a conversation which I had with Mr. Crampton on
this case, he stated to me that he had met with two similar ones, and that
he had succeeded in accomplishing a perfect cure by inserting a large
caustic issue over the top ofthe head. I accordingly advised my patient
to have the same thing done. She has since that time left the country ;
NEURALGIA WITH DISEASED BRAIN.
589
but previous to her departure I certainly observed an improvement in her
symptoms, and the principle of treatment appears to be perfectly rational.
This leads us to consider some affections of the sentient and motor
branches of the fifth pair of nerves, in which the disease is connected with
an affection ofthe brain. A very interesting and important case bearing
on this point is given by Sir Charles Bell, w7hich I shall briefly relate.
The patient, a lady, had remarked, that for twelve months before the case
began to assume a serious character, she felt an unusual sensation on the
tip of the tongue, towards the left side, as if it had been burned. This
sensation gradually extended over the whole ofthe left half of the tongue,
the left half ofthe palate, gums, and face, accompanied by an almost total
loss of proper sensation in the parts affected. The sensation of heat and
uneasiness was increased by the least motion of the face, the application
of her hand, and other trifling causes. This case was communicated to
Sir Charles Bell by Dr. Whiting, under whose care it was. She had pa-
ralysis ofthe buccinator of the affected side, and the morsels of food had
to be removed on that side with the finger, so that she was obliged to
perform mastication with the opposite jaw alone. The motions ofthe face,
however, were properly performed, showing that the functions ofthe super-
ficial branches ofthe portio dura were unimpaired, and the temporal and
masseter muscles continued in their natural state. Her general health also
was pretty good, and she complained of nothing but the affection of the
side of the face, tongue, and palate, and the impossibility of masticating
her food with comfort on the left side, in consequence of the state of the
buccinator. Some time afterwards, while engaged in eating, she found
that a new train of symptoms were in progress; her face became distorted
by the'retraction ofthe mouth to one side, the masseter and temporal mus-
cles of the left side ceased to act, the tongue became protruded, with its
tip directed to the left side, hearing ceased on the same side, she had
some difficulty in performing the motions of the eye, and the eyeball began
to waste and diminish. About a month before her death she became
quite stupid, and spoke very distinctly. She died after the disease had
continued for two years.
Here wTas a case, presenting in the first instance symptoms of a nervous
affection of the left side of the face, tongue, and palate, unaccompanied
at that time by any paralysis of the muscles of the face. About a year
afterwards, however, she began to exhibit symptoms of paralysis of that
side affecting those muscles which are supplied by the branches of the
portio dura and fifth nerve. Expression was now lost, the temporal and
masseter muscles ceased to act, the mouth wTas drawn to one side, and
the tongue protruded. In addition to this the sense of hearing on one
side was lost, and the globe of the eye began to waste. On dissection,
it was found that a tumour, appearing to be a morbid growth from the left
crus cerebri, about the size of a pigeon's-egg, and containing some fluid,
was situated over the left temporal bone. This production was partly
cellular and partly membranous. But the most interesting part of the case
was the examination of the state of the nerves. The first and second
nerves were undisturbed, and so was the fourth. The third was slightly
displaced ; but it was on the fifth that the principal impression seemed to
have been made, for it was flattened, thin, and wasted, as if from the
direct pressure of the tumour. The sixth nerve was uninjured. The
seventh was involved and lost in the tumour, from within a quarter of an
590
DISEASES OF THE NERVOUS SYSTEM.
inch of its origin as far as the meatus auditorius internus. Here is a draw-
ing of the case ; here is the fifth nerve flattened and wasted, and here is
the seventh involved in the tumour.
Mr. Stanley gives a case very similar to the foregoing, of which I shall
give you an abstract. The patient had hemiplegia ofthe left side, with-
out loss of sensation in the affected arm or leg, but in the left side of the
face there was a complete loss of sensation and motion. The loss of sen-
sation and motion in this case would argue that there was an injury of the
seventh nerve as well as the fifth. The mucous membrane of the left nos-
tril was red, and there was opacity and disorganization of the cornea of
the left eye, with total loss of hearing on the same side. The patient died
some time after the paralytic symptoms were established. On dissection,
a tumour was found lying close to the tuber annulare, and compressing
the fifth and seventh nerves.
Here was a case in which there was hemiplegia of one side, and com-
plete loss of motion and sensation in the corresponding half of the face,
with an erysipelatous redness of the nostril, inflammation of the conjunc-
tiva, and disorganization of the cornea. It is a curious fact, that in cases
where the sentient branches of the fifth nerve, which are distributed to
the face, become affected, the eye is frequently disorganised. The cause
of this appears to be that the eye, under such circumstances, loses the
sensibility of its external surface, which is supplied by the branches of
the fifth pair, and is consequently left in a state in which it can no longer
protect itself from external injuries. In a case of this description which
came under the notice of Mr. Crampton, the finger could be rubbed over
the eyeball without giving the patient any pain, and there was chronic
inflammation ofthe conjunctiva.
The principles which should guide us in the treatment of neuralgic
affections of other parts of the body are the same as those which have
been laid down in speaking of the neuralgic affections ofthe face. You
will often meet with affections of this nature in females : they are situated
generally in the right or left side, and are frequently, I regret to say, mis-
taken for cases of local inflammation. I have already dwelt on the dis-
astrous consequences of mistaking a neuralgia of the liver for hepatitis,
and showed the mischievous consequences of treating it with purgatives,
leeching, blistering, and mercury. There is an analogous affection of the
left side, which has frequently been mistaken for disease of the heart,
and treated accordingly. It is most commonly observed in females of a
nervous habit. To this affection the same principles will apply as to
hepatic neuralgia ; by regulating the patient's general health, prescribing
a mild nutritious diet, giving up all antiphlogistic measures and the judi-
cious employment of tonics and narcotics, you will be able to effect a
cure.
It has been lately proposed to use the nitrate of silver in the treatment
of cases of this description, from its success in epilepsy. A very interest-
ing memoir on this subject has been recently transmitted to me from
Paris, by Dr. Lombard, in which he dwells on the utility of the nitrate
of silver in several nervous affections. Some persons, but in particular
the disciples of the physiological school, think that nitrate of silver re-
lieves cerebro-spinal irritation by creating a new irritation elsewhere :
that its efficacy consists in its causing a revulsion of the gastro-intestina!
mucous membrane ; and that thus we cure an epilepsy by substituting a
TREATMENT OF NEURALGIC AFFECTIONS. 591
gastritis. In proof of this they bring forward cases where a chronic gas-
tritis was found to supervene on the removal of an epilepsy by this remedy.
This, however, is by no means a fair or logical deduction. The epilepsy
might have been preceded and produced by the chronic gastritis, though
the symptoms ofthe latter were not recognised, owing to the existence of
other symptoms of a more prominent and striking character. The gas-
tritis might have had a priority of existence, and might have been the
cause ofthe epilepsy ; the epilepsy might be cured, and the patient die
afterwards with symptoms of chronic gastritis. This shows you how cau-
tious you should be in receiving, on medical subjects, the post hoc ergo
propter hoc argument. This mode of explanation ofthe cure of one irri-
tation by the substitution of another, sprung from the denial of all specifi-
cism, in disease and its remedies, by the school of Broussais, one of the
greatest errors of the " physiological doctrine." The use of mercury in
syphilis, of bark in ague, and many other instances, have been quoted
against it. If in these diseases there be nothing but local irritation, why
does not ordinary antiphlogistic treatment always suffice for their removal?
Why is it that mercury is the best revulsive in syphilis ? The specific
character appears under this view, as well as under any other. The term
specific may be objectionable as not being precise, but we use it for want
of a better, and it rather expresses what the disease is not than what it is.
There is another and a more rational objection to the employment of
nitrate of silver; namely, that it has produced a blackening or discolora-
tion of the skin. This, in my opinion, is an objection which will always
weigh against the use ofthe remedy, for there are few who would like to
encounter the risk and consequent blame of such an event. It has not
been proved that nitrate of silver has cured epilepsy by superinducing
gastritis, but it has been proved that it may blacken the skin. Dr. Lom-
bard admits that this may and does occur, but he thinks the frequency of
its occurrence much overrated, and states that in the majority of his cases
it did not happen at all. He mentions a very interesting fact connected
with this subject. It has been supposed that exposure of the skin to the
influence of sunlight during the use ofthe nitrate of silver is the cause of
the blackening. Now Dr. Lombard says that this cannot be the case, for
one-half of his patients were peasants who worked in the open air, and
never took the slightest precaution against exposure to the sun's rays;
and yet, among them all; there was no instance of discoloration. He is
of opinion, therefore, that the influence of the sun's rays should not be
taken into account in a case of blackening of the skin ; and this appears
to be confirmed by the fact, that in all cases where the nitrate of silver
produced discoloration, the patients were inhabitants of towns, and con-
sequently less liable to exposure. This blackening ofthe skin, though a
rare circumstance, will, as long as we are ignorant of the causes which
produce it, and the means of controlling them, be a great obstacle to the
internal use of nitrate of silver. I have used this remedy in cases of epi-
lepsy and other diseases, and cannot say much for it ; in the hands of
some of my friends, however, it has been much more successful. Dr.
Lombard thinks very highly of its value. In some cases in which he
prescribed it a perfect cure followed, in others more or less relief. He
gives some cases of facial neuralgia, in which it appears to have pro-
duced a cure. He has also prescribed it with success in epilepsy and
chorea.
592
DISEASES OF THE NERVOUS SYSTEM.
There is one fact, which appears to show that the cause of the black-
ening of the skin is connected with something else besides the influence
of the solar rays, which I had almost forgotten. In a late number of the
Quarterly Journal of ihe Medical Sciences, Mr. Brande gives an account
of some experiments he made on the bodies of persons who were tinged
by the nitrate of silver. He found on examination that the deep-seated
parts were tinged as well as the superficial, and was able to detect the
oxide of silver in the bones, and even in the substance of the viscera, as
well as in the skin. If this be the case, we cannot attribute the discolor-
ation to the solar rays, though it generally happens that the face appears
to be darker than other parts ofthe body in persons who have undergone
this change of colour. The fact, however, that in Dr. Lombard's cases
the peasant escaped while the citizen became tinged, and Mr. Brande's
discovery that the deep-seated parts are equally liable to discoloration,
furnish a weighty objection to the opinion that the blackening of the cuti-
cle is produced by the decomposing power ofthe sun's rays.
LECTURE CXXXVII.
DR. BELL.
Neuralgia—Appropriateness ofthe term—This disease maybe caused by inflammation
ofthe sheah—Origin of neuralgia sometimes in the nervous centres—Change in the
state of the nerves themselves and in their extremities—Diagnosis of neuralgia—
Nerves and regions chiefly affected with neuralgia—the fifth pair and the dorsal and
sacral nerves—Varieties of neuralgia specified—Dorso-intercostal neuralgia mistaken
for irritation of the spinal cord—Its seat, symptoms, and diagnosis—Lumbar neuralgia
—Crural neuralgia—Femoro-popliteal neuralgia, or sciatica—Membranous, ganglionic,
and visceral neuralgia—Treatment of neuralgia. •
Neuralgia is a term of modern origin, for which we are indebted to
Chaussier; and a better one could not be framed, since it simply ex-
presses a fact (pain of, or in a nerve), the chief feature in the case, with-
out its being connected with or derived from any hypothesis. The occa-
sional changes of the neurilema of a nerve affected with neuralgia, by in-
jection, thickening, and effusions, show that the disease may be of an in-
flammatory nature ; but in many, and perhaps a majority of cases, there
is no structural lesion evident. The chief seats of neuralgia are in the
first and second branches of the fifth, in the sensitive portions ofthe dor-
sal nerves and of the par vagum, and in the sciatic nerve. A distinction
has been drawn between neuralgia of the nerves of animal and that of the
nerves of organic life, in the paroxysmal returns of the former coming on
in the. latter part of the day or in the evening, and those of the latter early
in the morning. But an exception to this rule is presented in the history
of twenty-two cases of frontal neuralgia reported by Dr. Rennes, in which
the attacks for the most part were in the morning, and in sixteen of dor-
sal neuralgia by Dr. Valleix, which came on in the day as well as in the
night.
In attempting to ascertain the seat of neuralgia we are not to regard the
part pained as that in which the primary nervous lesion exists. This
latter may be at the sentient and percipient centre, in the medulla oblon-
DIAGNOSIS OF NEURALGIA.
593
gata and brain, as in the instance of pain still referred to a limb which
had been long before removed by amputation, or strongly felt in a parti-
cular nerve during a dream, or induced during the waking state by strong
mental emotion. All the causes which influence powerfully the nervous
centres, such as great atmospherical mutations, moral affections, intellec-
tual labour, prolonged watching, a habit of body peculiarly sensitive and
nervous, may give rise to neuralgia. Bearing this fact in mind we are
the less surprised at the occurrence of intense pain along the course of a
nerve whose structure is perfect, whilst, at other times, a manifest and
great laceration of a nerve is productive of slight and scarcely painful
sensation. Connected with this general condition ofthe nervous system,
not measured by anatomical change or lesion, is the greater predisposition
to neuralgia at particular periods of life more than others; the two ex-
tremes of life, infancy and old age, being in a measure exempt. Although
the general proposition be admitted, that neuralgia may depend on certain
unappreciable modifications of the nervous centres, — we must not stop
here in our inquiries, but proceed to note the vital and organic changes
in the nerves themselves. Organic and hygienic causes may act directly
on a nervous cord, increase its sensitive property, or continuedly work on
its sensibility, and give rise to neuralgia. We generally find that the
superficial or sub-cutaneous nerves are most subject to this disease. Per-
sons who by their calling are habitually exposed to the effects of cold and
humidity, such as fishermen, sailors, inhabitants of marshy countries, the
workers in certain manufactories, are very liable to neuralgia:—half, that
is fashionably, dressed females often suffer in the same way from the same
cause. Physical and mechanical causes, by which nerves are compressed,
stretched, or pricked ; organic changes by tubercles or neuromas deve-
loped in their tissue, inflammations of the neurilema or in the substance
of a nerve, making part of or situated in the neighbourhood of an in-
flamed organ, may also all, severally, give rise to neuralgia. Of this last
nature are the facial neuralgias which so often accompany extensive inflana>
mation of the pituitary membrane, and the sympathetic pains relulting
from a phlegmasia ofthe kidneys, uterus, and testicle.
The extremities of nerves may be so impressed as to give rise to.
neuralgia ■— continued pressure of a boot or shoe on the end of the
great toe will cause this disease. Of a similar nature is the neuralcia
depending on a carious tooth and inflamed gum ; although this* is a
case which ought, perhaps, to be regarded as neurotis, or inflamma-
tion of a nerve, rather than neuralgia. There are other cases in which
inflammation ofthe gum as well as organic changes ofthe tooth had long
ceased, and yet the pain still continues, and constitutes often one of the
most troublesome facial neuralgias, or tic douloureux. Even here the
influence of the nervous centre is every now and then powerfully and in-
stantaneously manifested, as when the protracted and racking pain of
toothache disappears with the arrival, or announcement of the arrival, of
a dentist, who comes to extract the decayed tooth.
The diagnosis of neuralgia, although laid down by some writers with
great precision, is not quite so easy as would appear from their showing.
Periodicity or paroxysmal recurrence at irregular intervals, relief by pres-
sure and friction, absence of heat, redness, and tumefaction, and occa-
sionally even a sensation of coldness in the part affected, are the common
symptoras of neuralgia, whether this disease attacks the organs of animal
vol. n.—39
594
DISEASES OF THE NERVOUS SYSTEM.
or of organic life. Thus, one almost instinctively presses the abdomen in
neuralgia ofthe stomach and intestines, or in gastralgia and enteralgia—
whereas, if neurotis, or other phlegmasia be present, the least degree of
pressure cannot be borne. The sarae difference is often observable in
facial neuralgia. But, on the other hand, we see, at times, cases in which
the slightest touch, or even the jar communicated by shaking the bed or
sofa on which the patient lies, gives the most violent pain. Writers are
not careful enough to separate neurotis from neuralgia, nor in fact is it easy
to do so, combined as these two states are in certain cases of recognised
neuralgia. Thus, Dr. Elliotson says, neuralgia is very inflammatory, so
that the surface is tender, hot, swollen, and even red. If the absence of
pain on pressure were to be received as diagnostic of neuralgia, we should
have to exclude from this class that large variety depending on or con-
nected with spinal irritation, in which augmented sensibility of the parts
supplied by the affected nerve is one of the most constant symptoms.
Mention has been made already ofthe nerves chiefly affected with neu-
ralgia. I will just add a rapid sketch of the chief varieties of the disease,
in reference to the regions affected and the organs which are the greatest
sufferers. The nervous centres themselves, at least the sentient part of.
them, may be the seat of neuralgia, the pains of which are felt at the sur-
face and envelopes of the brain and spinal marrow, rather than in the sub-
stance of the organs themselves. In this respect there is an analogy to
what takes place in the neuralgia of a nervous cord, the symptoms of which
are felt at the extremity or expansion of the nerve on the surface of the
organ. Cephalalgia, therefore, as we call it, instead of cerebralgia, may,
like neuralgia of the cords and their extremities of the nerves, be de-
pendent on or associated either with simple irritation or phlogosis—an
important consideration which it behooves us to bear in mind in practice.
In delirium tremens and certain other varieties of cerebral disease, there is
more cerebralgia than cerebritis, and we ought not to be misled by pain,
and exaltation and disturbance of function under such circumstances, so
far as"to take them for unequivocal symptoms of inflammation. Opium
and narcotics, if our diagnosis be a correct one, would take precedence
over, and be substituted for the lancet, leeches, and purging. I might,
did space permit, illustrate this proposition by describing the phenomena
of myelalgia, and show that these were manifested at a distance from the
medulla spinalis, sometimes by exquisite tenderness of the skin of one
or more limbs, and of the muscles of particular regions, sometimes by
irregularity of movement consequent on morbid sensation, as in cer-
tain changes of the voice, spasms of the oesophagus, convulsive cough,
dyspnoea, vomiting, colics, and cramps. Most ofthe neuralgic affections
however, which have been attributed to a morbid state of a part of the
spinal cord, proceed, as I shall have occasion soon to show, from the spi-
nal nerves, and particularly the intercostal. In all these affections of the
cord or its nerves, the neuralgia so far predominates over neurotis, that
we shall often find counter-irritation and anodynes suffice for entire relief
without having recourse to sanguineous depletion.
The neuralgice ofthe encephalo- spinal nerves are, mainly, the facial, inter-
costal, lumbar, and sacral. The first or facial include a great variety of
pains in different parts ofthe face, in the course ofthe branches and some-
tiraes twigs of the trigeminal or fifth pair. I shall notice the chief of these,
but must premise that, more frequently, the pain is met with in the three
SUB-ORBITAR AND MAXILLARV NEURALGIA. 595
branches ofthe nerve on one side, than in anyone or two of its branches.
Pain on pressure corresponds, in the majority of cases, with the pain com-
plained of by the patient in the course of the nerve—1. The frontal or sw
pra-orbitar, the pains of which, beginning at the supra-orbitar foramen,
extend to the upper eyelid and eyebrow, and the corresponding side ofthe
forehead and face, following all the nervous ramifications and anastomoses
of the orbito-frontal nerve. Sometimes the pain is fixed in the nasal arch
and frontal sinus, or on the ramifications ofthe nerve over the globe of the
eye, constituting in the first place a coryza, and in the second ophthalmo-
dynia, or an eye painful, watery, and intolerant of light, with commonly
some tenderness of the conjunctiva. Frontal neuralgia is usually inter-
mittent, and sometiraes merely remittent,—the paroxysm coming on daily
in the evening, lasting a part of the night, and disappearing towards morn-
ing and during the day. At other times, and particularly wdiere the neu-
ralgia is either associated with disease of the chylopoietic viscera, or is
brought on by the common causes of intermittent fevers, the paroxysm is
in the morning. Dr. Rennes (Eclectic Journal of Medicine, 1836-7, from
the Archives Generates, June, 1836) describes thirty-twro cases of the dis-
ease depending on atmospherical vicissitudes, and occurring in a rural dis-
trict, and at the same time with influenza, which were of this mture.
2. Sub-orbitar Neuralgia.—This kind is described by waiters under the
names of prosopalgia and odontalgia. As its title indicates, it affects the
sub-orbitar branch or superior maxillary of the fifth or trifacial nerve. The
pain radiating from the sub-orbitar foramen, is sometimes continued in the
line of the muscular branches of the face, sometimes in that of the deeper-
seated or dental branch, and extends in the first instance to the lower eye-
lid, the internal angle ofthe eye,the cheek, the ala nasi; and in the second,
to the maxillary sinus, the palate, uvula, base of the tongue, and often to
the whole side ofthe face, following the anastomoses of the fifth with the
ramifications ofthe portio dura ofthe same side. In this case the pain is
apt to be accompanied by convulsive twitchings ofthe lower eyelid, cheeks,
and upper lip :—the arteries of the affected side beat with more force, but
not, as has been commonly asserted, with more frequency: the veins are
more dilated, and sometimes we see all the symptoms of a true fluxion,
such as redness ofthe eyes and face, tumefaction of the eyelids, and an
abundant excretion of tears and nasal mucus.
This variety of neuralgia exhibits the intermittent type ; sometimes it
is remittent; but in either case its paroxysmal returns are in the evening.
At times the neuralgia is confined to a single twTig of the superior maxil-
lary branch, and hence the names given to each of these sub-varieties of
sub-orbito-nasal, labial, palpebral, and dental.
3. Maxillary Neuralgia.—In this variety the pain follows the course
ofthe inferior maxillary branch of the trifacial or fifth nerve, and coi ss-
quently extends not only from the superior mental foramen to the alveoli,
lower teeth, sides of the tongue and to the chin, but it also may be irra-
diated over the cheeks, temples, and the external and anterior portion of
the ear, by following the anastomosis ofthe nerve with the ramifications
of the portio dura in this region. The right side is somewhat more fre-
quently affected than the left. This neuralgia is less evidently periodical
than those already described, but like them may be sometiraes accompa-
nied by partial convulsions and deformity of the mouth and eyelids.
Facial neuralgia, complicated with muscular contractions, though less
painful, is generally more obstinate than simple neuralgia. To these
596
DISEASES OF THE NERVOUS SYSTEM.
sudden and jerking movements, as it were, of the muscles, the term tic
has been applied, and the sensations accompanying it caused it to be
qualified with the epithet douloureux, or painful. These twitchings are
met with in a small proportion of facial neuralgias. When the neuralgia
affects chiefly the alveoli and roots ofthe teeth, it simulates closely tooth-
ache—the more readily, because a carious tooth will give rise to both
diseases, which may also, notwithstanding the persistence of the cause,
be periodical, and yield to remedies directed against periodicity.
Facial neuralgia rarely makes its attack suddenly ; it is often intermit-
tent, and I have seen it alternate occasionally with lumbar neuralgia.
Commonly, it is most apt to occur when the weather is cool and damp,
but I know of two cases in which the worst paroxysms used to come on
in the hottest days of summer.
This variety of neuralgia is often kept up, if not primarily caused by
caries of the teeth, even long after they have ceased to give any pain.
I have succeeded in removing pains of the face and temples, and side of
the head, tic and hemicrania, of years' duration, in aged persons, by indu-
cing them to have extracted the stumps of decayed teeth, which giving
them no uneasiness, they were with great difficulty persuaded could be
the cause of their long sufferings. There are cases on record, of palsy of
the parts supplied by the portio dura being produced, at any rate having
followed, apparently as an effect, neuralgia of the fifth pair on the corre-
sponding side.
4. Neuralgia of the Cord ofthe Tympanum.—This variety, described
by Itard under the name of otalgia, more particularly attacks children and
sometimes adults, in connexion with facial neuralgia. The intermission
of pain, its darting and divergent character, the absence of fever, and
other symptoms of phlogosis, distinguish it from internal otitis. The intro-
duction of a little soothing balsam, or even sweet oil, and two or three drops
of laudanum, or an injection of warm water, will often suffice for its cure.
5. Cervical Neuralgia.—This is of rare occurrence. Sometimes it has
been caused by bleeding in the jugular vein, and by the bites of leeches.
6. Thoracic and Intercostal Neuralgia.—Under this head are properly
included those neuralgic pains affecting the mammas, shoulders, thorax,
and the hypochondriac and epigastric regions, and which are connected
with, or as it has of late years been generally thought, originate from spinal
irritation itself, manifested by tenderness of one or more vertebras on
pressure. Omitting, as either generally known or not germain to our
present purpose, a notice of the essays which have appeared within the
last twenty years, on both sides of the Atlantic, on the subject of spinal
irritation, neuralgia, functional affections of the spinal cord, &c, I am for-
tunately able to indicate, with more precision than has hitherto been
attempted, the seat and character ofthe kind of neuralgia now under con-
sideration, by borrowing from the very clear and detailed essay by Dr.
Valleix, in the Archives Generates de Medicine, for January, February, and
March, 1840, the facts in which he has subsequently extended and pub-
lished in a volume entitled Traite des Neuralgies ou Affections Doulou-
reuses des Nerfs, 1841.
The title of the chief variety of the disease examined by Dr. Valleix
is dorsal or intercostal, in his book called dorso-intercostal neuralgia.
When pointing out the fact of the roots of the dorsal nerves being much
higher than the point of their exit from the vertebral canal, he takes occa-
DORSO-INTERCOSTAL NEURALGIA.
597
sion, from this anatomical fact, to expose the inaccuracy of the English
writers, who attribute the disease in question to irritation or other
lesion of the spinal cord. The pain caused by pressure on the spine,
according to their own description, exists always at the posterior end of
the intercostal space, in which last is found the painful point in front. It
is then at the very exit of the nerve, and in a line with the intervertebral
foramen, that we discover the pain. Were the irritation really of the
spine, we ought to detect the pain at the origin of the nerve, and conse-
quently at the spot higher up than the foramen. Each dorsal nerve at its
departure from the intervertebral foramen is divided into two branches ;
one, posterior, goes directly backwards, and gives off filaments variously
distributed, some of which, and they the ones mojst interesting in the pre-
sent question, pass between the transverse processes and the muscles
which cover them, and are distributed to the skin ofthe back. The ante-
rior branch is, properly speaking, the continuation ofthe nerve. That of
the first dorsal nerve comes out below the first rib, and that of the twelfth
below the last or twelfth rib. It is important for us to know that this
branch is not subdivided in any notable manner until towards the middle
ofthe intercostal space : at first it is situated beneath the intercostal mus-
cles, and is only covered internally by the pleura ; then it is engaged in
the muscles, and passes between them until it has reached the middle of
the intercostal space, where it divides in the manner just indicated. The
ramifications are not distributed in a uniform fashion. Thus, in the first
three dorsal nerves, there is an intercostal branch which continues in the
original direction, or rather towards the inferior part of the intercostal
space, and another branch which goes to the shoulder. The eight fol-
lowing dorsal nerves furnish, also, an intercostal branch, which is con-
tinued in the original course, and only penetrates the muscles which cover
it at a short distance from the sternum, or from the outer border of the
external part of the great abdominal oblique muscle, whence it distributes
its filaments to the integuments ofthe anterior part ofthe chest and supe-
rior ofthe abdomen. In place of a brachial branch, such as was given
out by the first three nerves, these eight furnish, each of them, an exter-
nal pectoral branch which penetrates the externa] intercostal muscle, and
distributes filaments to the integuments. The last or twelfth dorsal
nerve is appropriated to the muscles and integuments of the abdomen,
and is divided into a superficial and a deep-seated abdominal branch ; a
division this analogous to that of the preceding nerves.
In summing up these anatomical details, the application of which will
soon be obvious, we find that the dorsal nerves have three principal divi-
sions,— the first immediately after their exit from the intervertebral fora-
men,— the second about the raiddle of the intercostal space, measuring
from the spine to the sternum ;—and the third a little external to the ster-
num or to the upper part of the rectus muscle. Thus, at each of the points
of division, there is a branch which is superficial and gives twigs to the
integuments. There are three of these perforating branches,—one ante-
rior, near the sternum ; a second, or middle, the name of which indicates
its situation: and a third, or posterior.
Under anatomical guidance we can now speak more understandingly
of the seat of dorso-intercostal neuralgia. As to the side which is chiefly
affected we find notable differences. In twenty-five cases noted by M.
Valleix, the neuralgia was on the left side in seventeen ; the right in
598
DISEASES OF THE NERVOUS SYSTEM.
seven; and in both sides in one. M. Nicod, the only writer who ex-
amined this subject in a methodical manner before M. Valleix, makes
the proportion in which the two sides were affected as 15 of the left to 1
of the right. M. Bassereau designates the proportions as follows, in
thirty-seven cases: on the left side, twelve ; on the right side, six ; and
in both sides, nineteen. It requires, after all, a good stock of numerals to
enable as to reach a positive conclusion.
The number of the intercostal spaces occupied by the neuralgia varies
from 2 to 8. This last number was only met with in two cases. Fre-
quently (six times) there were but two of the spaces affected ; and if we
were to take a mean term expressive of the whole, it would be three and
a fraction. But even when a considerable number of intercostal spaces
was the seat of neuralgia, more commonly two or three of them, and gene-
rally the sixth and seventh, were much more sensitive than the others,
and appeared to be the centre of the pain. To extend the proposition a
little more, we might say as the result of a table given by M. Valleix, that
dorsal neuralgia would seem to display itself in'preference, on the fifth,
sixth, seventh, eighth, and ninth intercostal spaces, and that, in an espe-
cial manner, it is met with most frequently from the sixth to the ninth—
a result very nearly the same with that announced by M. Nicod. M.
Bassereau makes the fourth, fifth, and sixth, the preferred spots.
The spaces which were the seat of pain were in no instance affected
through their whole extent, at least during the entire course of the disease.
In speaking of neuralgic pains, we ought, however, to state separately the
pain caused by pressure, that caused by various movements, and that felt
spontaneously,as of certain dragging, pricking,and dartingsensations. The
latter sometimes extended over the whole space. Three principal parts
were the seat of pain on pressure,—the vertebral or posterior point was
alwrays sensitive, viz., in 25 cases; the anterior point in 19 of these ; the
middle or lateral in 17. The posterior or vertebral point is on one ofthe
sides of the spinal column, between two vertebras, and precisely at the
spot corresponding with the intervertebral foramen. This painful spot
was of circumscribed extent, varying from half an inch to an inch and a
half. Hence it happens, that at a very short distance from a point at
which pressure gave great pain, considerable force might be used without
exciting any unpleasant sensation. This fact will be referred to when
we speak of the diagnosis. The direction of the line of pain from the
posterior point was always forwards, and neither backwards on the ver-
tebras, nor upwrards or downwards on the spinous processes.
The middle point at which pain on pressure was felt, is, the mid-
dle of the antero-posterior direction of the intercostal space, or rather
in the prolongation of a vertical line drawn from the axilla to the crest
of the ilium, for the first five or six intercostal spaces, and an inch or
an inch and a half farther back for the lower ones. The middle space
was also circumscribed like the posterior was found to be ; its limits
being from half an inch to an inch and a half. In the cases in which the
pain extended more than half an inch it was in the longitudinal or antero-
posterior line, and consequently in the course ofthe nerve, as in the case
of the posterior point.
As to the anterior point, the pains were more variable and multiple
even than at the preceding ones. In the fourteen cases in which it was
met with, pressure gave rise to it at a point not far from the sternum, and
D0RS0-INTERC0STAL NEURALGIA. 599
always between this point and the beginning of the cartilaginous portion
of the ribs. But the extent of the space affected was hardly greater than
that of the posterior and middle spaces. A variety in the point affected
in this last or anterior division is worthy of being recorded : it is in the
epigastric location, or rather termination of the pain. Thus, when pres-
sure on the spaces between the cartilages was productive of pain, if it was
continued forwards under the angular curvature, and on the epigastrium
for an equal breadth, the pain was equally felt. This line of direction of
pressure of course passed over some of the cartilages of the ribs, and there
was an interruption accordingly in the course of the pain between the
inter-cartilaginous point and the epigastric point, for a space equal to the
breadth of the cartilages. The limitation of the region of epigastric pain,
and its line of direction from the anterior and inner point, externally and
outwardly in the track of the intercostal nerve to the spine, will serve to
distinguish this neuralgia from gastritis.
The painful spots above indicated are so not by pressure alone, but
even in consequence of strong inspirations, cough, movements of the arms
and sometimes of the trunk ; and the darting pains themselves had com-
monly their point of departure from these spots, which we may regard as
so many centres of pain from which it radiated in the course of the nerve.
An explanation ofthe occurrence of pain at these spots is furnished by
the anatomical details already premised. Thus, backwards at the exit of
the nerve from the intervertebral foramen, a branch is detached which
traverses the muscle, and is distributed to the skin ; here is the first pain-
ful spot or point. Towards the middle of the intercostal space the nerve
becomes also superficial, and detaches another branch which passes on to
the teguments, giving a second spot for painful sensation. Finally, at the
anterior spot, near the sternum and towards the epigastrium, the nerve
again comes nearer to the surface than before, and distributes its filaments
to the integuments of the anterior part of the thorax, making the third
painful point. I have had cases under treatment in which the symptoms
correspond precisely with those here detailed. The seventh, eighth, and
ninth intercostal spaces were the ones affected, and the epigastric pain
terminated exactly at the median line. The right was the side affected ;
pressure on the spine itself was not productive of pain. More than two
years elapsed before recovery took place in one case. For the greater
part of this period, the patient, an unmarried female, was unable to walk
without great difficulty, owing to loss of power ofthe lower limbs. Pain
alternated between the intercostal spaces and back ofthe sacro-iliac junc-
tion and hip of the right side.
A complaint of pain in any part ofthe chest, without cough, or even at
the epigastrium, should induce the physician to run his finger down with
a moderate pressure on each side ofthe spinal column, at the spino-costal
junction and in the direction of the intervertebral foramina. If there be an
intercostal neuralgia, the patient shrinks from pressure at the affected point,
and cries out at the pain which he experiences. By continuing the pres-
sure downwards, the physician arrives at a line beyond which no positive
sensation is felt, and he thus has the limits, upper and lower, ofthe space
affected with neuralgia. By next passing his finger in a line from the pos-
terior point of pain in the first intercostal space affected to the sternum, he
learns the direction and limits anteriorly ofthe disease.
M. Valleix was not led to any positive inference respecting the causes,
600 DISEASES OF THE NERVOUS SYSTEM.
either predisposing or occasional, varying from the received opinions on
the subject. It was found that the most frequent complaints of pain were
in snowy weather, even by patients in their rooms ; and returns ofthe dis-
ease were most common in winter. The duration ofthe neuralgia was from
one to six months ; and where it assumed an intermittent character the
disease recurred at intervals from one year to four years, whether or not
remedial means were had recourse to, or whether at each return the pain
was left to disappear of itself. Women are affected in much larger pro-
portion than men. The association of dorso-intercostal neuralgia with
uterine disease has been often noticed.
But our etiological inquiries respecting neuralgia are far from being com-
pleted when we trace pains apparently in different viscera to the intercostal
nerves, as if in their morbid state we had found the primary cause of the
series of morbid sensations and disease. Much more frequently, it will,
I think, be found that the neuralgia is itself the result of long-continued
irritation of a viscus transmitted to the intercostal nerves by their anasto-
moses with the great sympathetic, and subsequently irradiated on different
points by the intercostals. The uterus in females, and the digestive organs
in both sexes, are the parts which most frequently, by their diseases, give
origin to the intercostal neuralgias so common attendants of uterine disease
and different forms of dyspepsia.
The diagnosis of intercostal neuralgia has been already stated inci-
dentally. We distinguish the disease from "affections of the respiratory
organs by means of auscultation and percussion, and by taking cognizance
ofthe seat, direction, and limits ofthe pain ; and from rheumatism ofthe
muscles of the thorax, by remembering that the pain in this latter is more
diffused, less acute under pressure, and more so by motion. Angina pec-
toris has been thought to depend on intercostal neuralgia, but it is distin-
guishable from this latter, by its paroxysm, and the feeling of constriction
and agonising distress which accompanies it. The diseases of the spinal
cord cause sometimes a local pain, which is situated on the spinal pro-
cesses and not on the sides. In caries of the vertebras, pressure on the ribs,
by these latter acting on the diseased bone, causes pain at the spine, which
is not the case in neuralgia.
I resume the enumeration of the different varieties of neuralgia by men-
tioning lumbar neuralgia, lumbo-abdominal of M. Valleix, which has been
called by Chaussier and others, ilio-scrotal and spermatic, and, by some,
lumbago. It may occupy one or several ofthe different lumbar branches,
and be felt, according to the extent of these nerves, in the loins, at the
crest of the ilium and over the great trochanter, or along the spermatic
cord, in the scrotum, vulva, bladder, urethra, &c, giving rise to a crowd
of symptoms calculated to render the diagnosis obscure. I have had under
care a young person with this kind of neuralgia, in whom the symptoms
of disease ofthe bladder were such as to induce fears of gravel associated
with those of prolapsus uteri—all of which disappeared by the removal of
the lumbar neuralgia. In another case there were so many of the symp-
toms of prolapsus uteri present, that I deemed it my duty to recommend
an examination per vaginam. Somewhat to my surprise the uterus was
high up, perfectly in situ, but the os tinccc painful to the touch. A per-
sistence, however, in the remedies which had been already prescribed
for the lumbar neuralgia, which also was present in this case, was fol-
lowed by entire relief of all pain and abnormal sensation. The patient
VARIETIES OF NEURALGIA OF THE LIMBS. 601
has since then become pregnant, for the first time, after a marriage of some
years' duration, and given birth to a healthy child.
It will be sufficient to mention some other varieties of neuralgia, without
making any additional remarks on them. These are, the scapular or del-
toidean ; the cubito-digilal, which extends from the olecranon to the index
and middle fingers ; the femoro-pretibial or anterior crural. The femoro-
popliteal, or sciatic neuralgia, demands more attention by its frequency of
occurrence, its obstinacy, and the agonising pain with which it is every
now and then accompanied. Under the name of sciatic it is usually spo-
ken of as one of the varieties of rheumatism. General experience does not
correspond with the opinion advanced by M. Jolly (from whose article
Neuralgia in the Dictionnaire de Med. et de Chirurgie Pratiques, I have
taken so largely), that sciatica is more common in women than in men,
owing to the cause of pregnancy and labour of child-birth operating on the
former. The nerve is, no doubt, in different states in different persons,
and at different times in the same person—its neurilema being sometimes
inflamed and thickened, and sometimes containing gelatinous effusions, by
all which the nerve proper must suffer. At other times again, this latter
is intact in its structure, and the affection is then one of simple neuralgia.
In the first case, cups or leeches on the hips and behind the great trochanter,
or on the outer side of the thigh, with other parts of an antiphlogistic treat-
ment, will benefit, if not cure. In the second, the customary modifiers of
sensibility, especially narcotics and tonics, must be the chief curative
agents.
The principal seats of pain in femoro-popliteal neuralgia are, according
to M. Valleix (Traite, fyc), 1, in the haunch and hip ; 2, the thigh ; 3,
the knee, to the head ofthe fibula; 4, the leg ; 5, the foot. Pain in the
lumbar region is not unusual, it being in the proportion of cases as often
to thirty-six ; and on both sides in eight out of the ten. Pain was uni-
formly complained of at the posterior and superior spine of the ileum, in
a line from the upper portion of the coccyx to near the border of the sa-
crum. Out of the thirty-six cases, the knee was the seat of pain in seven-
teen. In fifteen cases ofthe thirty-six, pain was felt in the calf of the leg
at the part where the gastrocnemii and soleus are separated by a fibrous
sheath. The foot was painful in twenty-four out of thirty-six cases. Mo-
tion of any kind, as by turning in bed, coughing or laughing, exasperates
the pain of sciatica. Darting or shooting pains were felt in nearly all the
cases. In some, pains were experienced in other parts, such as the head,
chest, loins, and abdomen, but especially the head and chest. Semi-pa-
ralysis and shrinking or atrophy of the limb, are not unusual occurrences in
sciatic neuralgia. The functions of respiration, digestion, and circulation,
are not affected with any uniformity. Obstinate coldness and damp skin
of the extremities, both upper and lower, I have seen in this disease.
The sensible states of the atmosphere make little difference in the fre-
quency of pain. Periodicity, but without uniformity, is met with. As
regards sex, the proportion of males affected out of the entire number
counted (124) was three-fifths.
Plantar neuralgia is occasionally met with, and is not a little annoying
to the patient, who complains of a pain in the sole of his foot to which the
plantar portion ofthe popliteal nerve is distributed.
Neuralgias of the nervous extremities where they are lost in, or blended
with the tissues, are common enough, as neuralgia of the muscular tis-
602
DISEASES OF THE NERVOUS SYSTEM.
sue, which is not at all connected with inflammation, but is met with in
the outset of certain typhoid fevers, acute gastro-enteritis, and in the chill
of an intermittent fever, or from suppressed perspiration, atmospherical
changes, &c, and which is commonly designated as rheumatic. Akin
to this variety is that attacking the fibrous and osseous tissues, and which
is attributed to, and, in fact, is occasionally caused by syphilis, mercury
in excess, scurvy, &c.
Neuralgia of the serous tissues shows itself sometimes in violent pain of
an intermittent character, attacking the meninges of the brain, the pleura
and the peritoneum, but which yields readily to sulphate of quinia and
opium.
Neuralgia of the mucous tissues comes, for the most part, within the
list of ganglionic neuralgia ; but we have examples of it on surfaces which
belong to the cerebro-spinal system, as in the pituitary membrane, the
conjunctiva, the bronchias, and the large intestine, &c. The skin is oc-
casionally the seat of violent pain without inflammation, just as the paren-
chymatous tissues are.
Although their course and extent be indicated with less precision than
those already specified, the neuralgias of the organs supplied by the sym-
pathetic nerve or ganglionic system, cannot well be doubted. Bichat
had early, in this path of inquiry, expressed an opinion that there are
colics essentially nervous, independently of any local affection of the
serous, mucous, and muscular coats of the intestines. These colics have
obviously, he continues, their seat in the nerves of the semi-lunar ganglion,
which are distributed along the whole course of the abdominal arteries ;
they are true neuralgias of the nervous system of organic life, although
they have nothing (little) in common with tic douloureux, sciatica, &c.
Ganglionic neuralgias, like those of the other order, are intermittent, but
less distinctly so than these. They are accompanied often with a great
fluxion and discharge of fluids, as of urine, bronchial mucus in asthma,
hooping-cough, and suffocative catarrh ; hence also, probably, the deluge
of fluid in cholera morbus, dysentery, &c.
In the nervous system of a mixed nature, that which connects the two
lives, organic and animal, although it belongs more particularly to the
latter, and wThich is sometimes called the nervous apparatus of association,
we meet with marked examples of neuralgic diseases. Pneumogastric
neuralgia may result from direct irritation of the nerve itself, as in the
phlegmasia? of the pulmonary and gastric mucous membranes : it is mani-
fested by a convulsive cough, spasms of the air-passages, and ofthe dia-
phragm and stomach. Or it may be the effect of a sympathetic irritation
transmitted from some remote organ by the medium of the ganglionic
plexus, as in inflamraation of the kidneys, testicle, and uterus, or even
simple pregnancy, which will give rise to dyspnoea, or to obstinate vom-
iting, with acute and tearing pains ofthe epigastrium. Finally, pneumo-
gastric neuralgia may, like all the neuralgias, depend on some lesion of the
nervous centres. Of this nature are intermittent asthma, periodical coughs,
nervous dyspnoea and vomiting. Gastralgia is a variety of this kind of
neuralgia, and either appears alone or is recurrent, and constitutes the
chief symptom of some pernicious intermittent fevers.
Diaphragmatic Neuralgia is manifested by pains, more or less acute,
with a constriction at the epigastrium and back, accompanied with hiccup,
eructations, and vomiting. This may readily be confounded with rheu-
TREATMENT OF NEURALGIA.
603
matism and inflammation of the diaphragm, of which I shall speak in a
subsequent part of these lectures.
I have not much to say on the treatment of neuralgia in addition to the
judicious remarks of Dr. Stokes. This should be based on a knowledge
of all the circumstances, physical, hygienic, and physiological, which have
any influence in the production of the disease ; and should include, of
course, a just appreciation of its seat and its idiopathic or symptomatic
nature. I have dwelt the more on the various seats of neuralgia, and the
symptoras by which its varieties are recognised, because, in so doing, I
believed that I was conveying most valuable instruction to the younger
portion of my medical brethren, by teaching them to shun the common, I
might say barbarous empiricism which confounds pain and derangement
of function with inflammation, and prompts to bloodletting, purging, and
the heroical generally in place of the narcotic and soothing treatment.
Every resident in marshy and low situations is aware of the common-
ness of intermittent pains, hemicrania, frontal and facial neuralgia, oph-
thalmia, sciatica, &c, which sometimes accompany intermittent fever,
and sometimes succeed to or are substitutes for it. The successful em-
ployment of the bark in former times and quinia now, is also pretty well
known to the practitioner in such cases. I have found, on occasions, the
local detraction of blood, by means of a few cups or leeches, beneficial
under these circumstances, both by the relief which they gave, and the
speedier and more complete effect subsequently of sulphate of quinia.
Arsenic has, I know, been administered often in these intermittent as well
as some of the more untractable remittent forms of neuralgias. Without
intending to prohibit its use, I still think that a physician who administers
it to his patient ought to give approved security that he will not injure
the stomach of the latter, by bringing on chronic gastritis and its accom-
paniments.
In cases of feeble action of the organs generally, or of a sensation of
coldness at the part affected, stimulants are indicated, and of these ammo-
nia, camphor, and guaiacum are entitled to confidence :—The ammonia-
ted tincture of guaiacum is a favourite prescription with some,—exhibited
in such quantities as to keep the patient comfortably warm. With this
view a dose of half a drachm, or even four times the quantity, has been
given and repeated three times daily, and sometimes every two hours.
Where there is debility, with paleness, iron is preferable to quinia ; or it
may be combined with this latter. Mercury so as to cause ptyalism has
cured ; but unless the subject have some strength, and a certain degree of
excitement,he will only be more depressed and positively injured by such a
course. Of the narcotics, the extract of stramonium, which we can so rea-
dily procure fresh in the United States, is entitled to fuller and more frequent
trials than it receives; externally, also, in the form of tincture, or ointment
spread as a plaster, it will be a good topical application to the affected
part. When given, the stramonium should be continued in such a dose and
at such intervals until its peculiar and marked effects on the brain and ner-
vous system are produced. The most opposite means have been used
with occasional success, as in one instance steam, in another ice. Dr. La
Roche, of this city, succeeded in allaying and completely removing the
pain of acute and protracted sciatica, which had resisted various remedies
directed with no common skill and experience, by the application of ice
over the affected part. The patient went to sleep shortly after it was put
604
DISEASES OF THE NERVOUS SYSTEM.
on. I have procured for my patient similar relief in facial neuralgia by
this means. Ether used with the same intention is inferior to ice. Oil
of turpentine in divided doses, so that a drachm or two be used daily, has
been found to be very successful in a number of cases of sciatica, and in
some other varieties of neuralgia by M. Martinet; and the same medicine
in a full dose of half an ounce to an ounce by enema has been used with
advantage. M. Valleix estimates the number of cases of sciatica cured
by this remedy to be thirty-five out of fifty-seven, or the proportion of
five-eighths.
Veratria and its salts and aconitine are certainly entitled to considera-
tion, notwithstanding the unmeasured praise lavished on them by Dr.
Turnbull; for assuredly the practice has been retarded by the indiscreet
zeal of its advocate. In one case of tic douloureux in a lady, in which I
had employed sulphate of quinia, and iron and opium, after purgatives
and alteratives, with only partial relief, an ointment, composed of twenty
grains of veratria and an ounce of lard, was directed to be rubbed on the
affected cheek, and in a short time with a most satisfactory result. The
common proportion is ten to twenty grains to the ounce of lard or cerate.
The cure was complete ; and there has been no relapse up to the present
time, which is upwards of three years from the date of the treatment.
The sensation of heat and tingling was experienced by my patient shortly
after rubbing in the ointment. Dr. Turnbull mentions these symptoms as an
evidence ofthe desired operation of the veratria, and indeed of its genu-
ineness. Sometimes it gives speedy relief after its first application, but a
renewal of subsequent trials, even though the tingling be felt, fails to be-
nefit at all. A neater preparation is the alcoholic tincture, which is to be
applied to the skin over the affected part. Of the internal use of veratria
and its salts, and of delphinia and aconitine, which have been also recom-
mended in neuralgic and rheumatic affections, I am not prepared to speak
from personal experience. The dose of veratria, or of tartrate of veratria,
the salt preferred by Dr. Turnbull, is a sixth of a grain in pill writh half
a grain of extract of hyosciamus, and some convenient vehicle, such as
liquorice powder,—repeated three times a-day. For the last two ingre-
dients rhubarb should be substituted, wThen there is costiveness. The
dose may be gradually increased to a grain and a half or two grains in
the course of the day. (See Dr. Turnbull's Essay on the Medical Pro-
perties of the Natural Order Rununculacce.) Extract of belladonna, in
grain doses, gradually increased, is a remedy of power. Plaster of the
extract on the affected part has also given relief. So, also, has the ex-
pressed juice and extract of mistletoe applied in the same way. The
powder of valerian and the Sedura acre, in large doses, have been recom-
mended by M. Merat. xMr. Donovan expresses his belief in the sooth-
ing powers of Cannabis Indica, and Mr. Chippendale of tobacco. After
curing two cases of neuralgia by an infusion of tobacco, rubbed on the
part, this gentleman, for the convenience of application, prepares an oint-
ment, the composition of which is as follows: Take ofthe best strong to-
bacco four ounces; distilled water two pints: boil for two or three hours,
strain and then wash the tobacco in two pints more of boiling water;
strain a second time, and add it to the former liquor. Then evaporate to
the consistence of an extract. One part of the extract is applied to seven
parts of simple cerate to form an ointment. Of this half a drachm night
and morning, and in some cases, at night only, is to be rubbed in. Cases
TREATMENT OF NEURALGIA.
605
are related in which the acetate of morphia, in solution, introduced by
means of puncture or inoculation, was eminently successful. Strychnia
has been applied in like manner. Inhalation of ether has been used in a
number of cases of neuralgia of different organs. For the most part im-
mediate relief was procured by a suspension of pain for some hours to
some days: but as yet this new fashion of medication cannot be said to
have effected a cure. "Firing" in the manner already described in a note
in Lecture CXXXV. on paralysis, has been used successfully by Dr. Corri-
gan in neuralgia of the fifth pair. An issue established over the affected
organ or at some distant point, especially if there be a disposition in the
pain to wander to these, has been found very efficacious.
That variety*of neuralgia which is most common, and, in reference to
its extensive symptoms the most important in the eyes of a practitioner,
is the dorso-intercostal. Under the name of spinal irritation it has been
commonly, and I cannot but think successfully, treated by counter-irrita- ,
tion and tonics, as by means of a small blister over the most painful spot,
and kept discharging, or by tartar-emetic ointment, or croton oil, and quinia
and chalybeates preceded by and alternating with laxatives. In many in-
stances, the first step has been to detract some blood by means of cups or
leeches applied near the affected part. Of the advantages of this latter pre-
scription, I can speak with much confidence, based upon repeated expe-
rience. I must add, however, that although the relief was in most cases in
which I directed it immediate, yet that this remedy was far from removing
the disease. lam sure that it materially abbreviated its duration. Dr. Val-
leix found small blisters applied in the course of the affected nerve, and
renewed at short distances, or on the painful points, to be the most suc-
cessful remedy. Muriate of morphia applied endermically only served in
his experience to allay temporarily the pain. He did not find cupping or
leeches to cure the neuralgia; but, on the contrary, they seemed to aggra-
vate it. Narcotics, quinia and iron, were not, in his observation, produc-
tive of any notable result.
I would refer you to a paper on Tic Douloureux, drawn up with
great fulness by Dr. Chapman, in vol. xiv. of the American Journal
of Medical Science. In the same volume there is an account, by Dr.
Thomas Harris, of several cases of facial neuralgia, some cured, others
greatly mitigated by galvanism, applied through the apparatus directed
by Mansford, the mode of using which will be described in the next
lecture.
Neuritis.—Although in by far the greater number of cases of pain of the
dorso-intercostal and the other nerves which I have enumerated are neuralgic,
yet there are undoubtedly instances of true neuritis or inflammation of these
same nerves. Examples of this are met with in violent contusion of the
side and in fractures of the ribs, in which the intercostal nerve is impli-
cated and inflamed. But more frequently still do we find intercostal neu-
ritis in pleurisy. The stitch or pain in the side in this disease is caused
by the phlegmasia of the pleura extending to the nerve. M. Beau has
found the inflammation to extend to the whole of the nerve that was
in contact with the pleura. 1 ne phlogosis was marked by an intense in-
jection not only ofthe neurilema, but ofthe nerve itself, which was more
voluminous than the healthy cord and slightly adherent to the pleura. An
explanation of the fact, that while inflammation of the pleura, either sim-
ple or compound, as in concomitant pneumonia, is seated at the posterior
606
DISEASES OF THE NERVOUS SYSTEM.
part of the thorax, the pleuritic stitch is anterior or in the region of the
mamma, is offered by M. Beau. He refers, in illustration of the lesion
being at one part and the pain at another of the same nerve, to the fami-
liar example of the effects of a blow upon the elbow, by which the ulnar
nerve is for the moment contused at this point, but yet the chief pain is at
the remote extremity in the little finger. It has been observed, also, by
surgeons, Fricke of Berlin, for instance, that in amputations, the greatest
pain was complained of at the parts where the nerves terminated rather
than at the spot where the nerves were cut.
LECTURE CXXXVIII.
DR. BELL.
Epilepsy—The true basis for treatment of this disease—Different causes and conditions
require different treatment—Varieties—Epileptic Vertigo—Absence—Hysterical Ep-
ilepsy associated with Insanity—Causes—Women more subject to it than men—Age
—Hereditary predisposition ; sometimes dependent on cerebral conformation—Epi-
lepsy may exist with great menial endowments—Occasional exciting causes—Symp-
toms—No uniform structural lesions—Prognosis—Duration—Treatment; ought to be
rational not emp/rical—Remedies for the plethoric state; the anemic—Paramount
importance of hygienic means of treatment, especially as regards food, and exercise of
mind and body—Bathing and frictions—The chief indications, to abate morbid sus-
ceptibility and to withhold all irritants to the nervous system—Vegetable diet prefer-
able—Intoxicating drinks and tobacco to be abstained from—Probable morbid irri-
tants—Chief remedies relied on in epilepsy ; chalybeates ; nitrate of silver ; sulphate
and oxide of zinc; sulphate of copper; oil of turpentine; digitalis—Galvanism—
Test ofthe effects of nitrate of silver—Strong mental emotion a preventive of a par-
oxysm.
In the few remarks which I shall make on epilepsy [I do not propose
more than merely to fix your attention on the prominent traits of the dis-
ease and the philosophy of its treatment. I knowT that it may seem to argue
no small presumption to speak of giving a philosophical character to the
treatment of a disease which is for the most part deemed to be incurable.
But let me at once explain my meaning, in order to avoid imputation and
criticism which I hope not to merit. Epilepsy, although a cerebral dis-
ease, inasmuch as its distinctive phenomena consist in disorder of the
cerebral functions, is, often, only so in a secondary manner, by the brain's
becoming the recipient of irritative impressions from other and remote
organs. The orgasm into which the brain is thrown, by its distended and
congested vessels, is rather an effect than a cause ofthe epileptic paroxysm.
The brain is forced by some other organ into that state of excitement which
ends in violent muscular movements or convulsions, and the abolition of
intellect. Ignorant as we so generally are of any fixed organic cause,
certainly of any structural lesion in the brain productive of epilepsy, we
must inquire into all the preceding and concomitant circumstances by
which the disease is brought on ; and having done so, adapt our remedies
and general treatment to the various and varying exigencies of the case.
At one time the complaints of the patient are referable entirely to the brain,
at another.to the heart; sometimes to the digestive systera ; and again to
some part of the spinal cord and its nerves, or of the periphery, on the skin.
EPILEPSY.
607
In sorae cases the patient is plethoric, in others he is thin and emaciated.
Some manifest in the intervals between the paroxysms extreme mobility,—
a sensibility open to all impressions,—an irritability which borders con-
tinually on passion. Others are sad, melancholy, and torpid—hard to be
roused, and sinking immediately after being excited into their former
apathy. With these differences in the accompanying features, and func-
tional disorders of other organs besides the brain, in epilepsy, would it
accord with the common principles of reason, and the more direct rules of
therapeutics, to pretend to seek for a specific, a unit remedy, against all
these multifarious and variable disorders, merely because the brain is
affected- As well might we ask for a single or specific remedy, and com-
plain that it is not found, against all convulsions, in all ages and under
most opposite states of the body and lesions of particular organs—merely
because the brain is necessarily implicated in causing the convulsions.
Epilepsy, if not strictly a hereditary disease, is readily developed in
those persons one or other of whose parents was either epileptic or had
suffered from cerebral disease in some form, or had been distinguished for
some eccentricity or startling peculiarity of mental feature. In this point
of view the treatment of such persons from early infancy ought to be care-
fully attended to, both in a hygienic and moral view, if indeed hygiene
can ever be regarded apart from morals, or if there can be acceptable
morality to the Creator when health is made to suffer. No specific either
of amulet or physic can afford protection. Epilepsy is brought on by causes
which either unduly excite or greatly enfeeble the nervous system and
brain generally,—such as the large use of alcoholic drinks, insolation, vio-
lent passions, intense exertion of the intellect, and plethora on the one
hand,—or fear, sexual intercourse in extreme, masturbation, close and im-
pure air, want of sleep, and general feebleness on the other. Can we ex-
pect any one remedy to countervail the deleterious operation of all these
various causes? Epilepsy, most common in tender age, disappears often
when the period of puberty is reached. Surely we cannot suppose any
specific cause, certainly any fixed organic lesion in the brain or elsewrhere,
which had originally predisposed to this disease. The tendency to epi-
lepsy, or the precursory state of the functions antecedently to a paroxysm
ofthe disease, is manifested in disordered health in various ways. An
amelioration of this and a consequent prevention of the disease is not,
however, to be procured by any one medicine or specific. The occasion-
ally distinct periodical character of epilepsy, and the length of the period,
sometimes a year, between the paroxysms, seem to preclude the idea, in
such cases at least, of a fixed organic cause, either in the brain or in any
part ofthe nervous system, or in the blood, by deterioration of this fluid.
In fine, whether we regard the predisposition, hereditary or acquired, to
epilepsy, the causes inducing and the phenomena which accompany it, or
the absence of any characteristic or even fixed lesion in the brain or other
organ of those who have died of the disease, we cannot persuade ourselves
of anything peculiar in its pathology beyond a predisposition in the brain
to be impressed by various agents, some external to the organs, some in
their intimate structure. It is true that this very predisposition may de-
pend on minute or molecular peculiarity of structure, as yet inappreciable.
Still, in the abating of this predisposition and withholding or removing as
much as possible the exciting causes, will consist the treatment of epilep-
sy. For the treatment to be successful i^ must not be specific ; but rather
608
DISEASES OF THE NERVOUS SYSTEM.
adapted to the varying constitutions, habits, and functional disorders ofthe
patient; and it must be both hygienic and medical, and continued for a
length of time. One of the physiognomical characteristics of epilepsy,
constituting in fact a predisposition itself, is a strumous habit. Now, every
one the least conversant with pathology, knows that in order to produce
a change in a habit of this kind, and thus to ward off the diseases inci-
dental to it, whether they be scrofula, tubercle, or certain forms of dropsy,
as well as epilepsy, we must, if not re-constitute the tissues, at least pro-
cure and maintain a sustained healthy digestion and hematosis until the
work of absorption and nutritive secretion has been carried on so long as
to have replaced the old by new materials—both of interstitial deposit and
of rhythmic excitement of the organs, as by new blood and lymph. But
this requires time, perseverance, and methodical hygiene, all of which
elements and means must be enlisted in our favour, and in aid of, it might
be medical heresy to say, in place of, agents strictly medical. Of little
avail, then, will it be for any of you, who may hereafter be called upon
for the purpose, to prescribe for a case of epilepsy, unless you make up
your mind to carry out these conditions faithfully and patiently, as far as
you are concerned, and obtain the consent of the patients and friends to
aid you and to do themselves justice in the case, as far as they are con-
cerned.
Varieties.—Epilepsy has been divided by M. Esquirol, who has made
the disease a subject of special study and investigation, particularly in con-
nexion with insanity, into two species, the idiopathic or the true, and the
symptomatic or sympathetic. Of these are several varieties, viz., 1, that
in which the seat or point of departure of irritation is in the digestive ap-
paratus ; 2, the angiotenic or bloodvessel system ; 3, the system of white
vessels; 4, the reproductive apparatus; 5, the periphery of the body.
In all these the causes are more or less active according to the predis-
position ofthe individual.
Epileptic vertigo is rather a precursor, one of the prodromes of epilepsy,
than a distinct variety. The patient suddenly loses consciousness while
uttering, sometiraes, a faint cry. If he is standing, he falls unless he can
grasp, at the moment, some solid body calculated to give him support:
if seated, he is able to retain this position. In general, the body is mo-
tionless ; the eyes fixed and of a haggard expression, seemingly gazing on
a particular object. The face is pale and, occasionally, undergoes slight
convulsions. After some seconds, or, at most, one or two minutes, this
state ceases; and then, in some cases, the patient recovers at once his
intelligence and resumes the thread of conversation, or continues the em-
ployment which had been thus suddenly interrupted. Others, again, re-
main in a state of stupor and hebetude for some minutes ; and others wan-
der in their speech, commit extravagances of deportment, and regain their
reason, while they preserve, sometimes, the recollection of what has passed
in their moments of aberration only. To a vertigo of this description
must we refer those cases in which the patients, impelled by an irresistible
power, run forwards or backwards, or pirouette, and then fall down in-
sensible, soon to rise up, feeling quite well or, at most, somewhat giddy.
Of an epileptic character and pertaining to vertigo is that state described
by M. Calmeil, under the name of absence. In the fit, the patient lets fall
any object or work which he may have had in his hands ; and then, with-
out exhibiting any oddity of marjner, forgets everything around him ; and,
CAUSES OF EPILEPSY.
609
though seemingly awake, his senses are momentarily dead to impressions.
This is a true ecstacy. If, at the very beginning, the patient be spoken to,
the absence ceases; and even if those near him remain silent spectators,
the fit still goes off, but after a few seconds' duration. These vertigoes
often precede, by a year or two years, the more violent convulsive attacks ;
more frequently still, they intervene between the true epileptic seizures.
Hysterical epilepsy is a variety which is quite common in females; and
is analogous to the sympathetic epilepsy. The scream is wanting, con-
sciousness is not lost, nor is the patient comatose. But there is moaning,
twitching, and working of the eyelids, hands, and wrists ; and, some-
times, convulsions of considerable violence. Uterine epilepsy comes
under this head.
Epilepsy is associated with insanity in its various forms of monomania,
mania, and dementia.
Causes.—Women are more subject to epilepsy than men. As respects
age, the tendency to epilepsy is greatest in early life. Of sixty-six cases
of epileptic women noted by MM. Bouchet and Cazauvielh, the larger
number were females first affected with this disease between birth and
the fifth year. Thirty-eight of these were victims to epilepsy before men-
struation, and twenty-eight afterwards. M. Leuret says the frequency in-
creases from birth to the sixteenth or twentieth year. It is rare in old
age. The hereditary character of the disease is generally admitted. The
writers just named tell us, that in 110 patients respecting whom they had
made the inquiry, 31 were hereditary cases ; and Esquirol found that in
321 cases of epileptic insanity, 105 were descended from either epileptic
or insane parents. A very limited acquaintance with the disease must soon
convince one ofthe truth of this feature in its history. A particular con-
formation of brain, indicated by a flatness and squareness of cranium, or
such as generally accompanies idiocy, evinces, also, an epileptic predispo-
sition. In such cases it is not uncommon to see the complications of these
two forms of disease. Dumas avers, that in constitutional or inherited epi-
lepsy, including the incurable class, the facial angle is less by 5°, 8°, or
10 than that of average European heads, which is about 80°. But we
are not to suppose epilepsy the product or associate always of imperfectly
developed brains and feeble intellects, when history points out its having
attacked Julius Cassar, Mohammed, Petrarch, Rousseau, and Napoleon.
Knowing, however, that all inordinate affections ofthe mind may induce
a seizure in persons predisposed to the disease, we cannot wonder that
they should have been sufferers in this way. Esquirol states that fits of
passion, distress of mind, and venereal excesses, hold the next rank to
terror, sudden alarm, &c, in exciting the disease. According to Licher,
cited by Dr. Copland (Med. Diet.), out of 80 cases, 60 were occasioned
by frights of various kinds and degrees ; but of 69 cases MM. Bouchet
and Cazauvielh found only 21 that could be referred to this cause. Sum-
ming up, however, as M. Grisolle remarks, all the chief statistical returns,
we find that more than half, even three-fourths of the whole number are
due to fright, which even in sleep has brought on an attack. Storms
have a similar effect, even unconnected with the alarm to which they
sometimes give rise. Winter and autumn are the chief seasons in which
the disease appears.
With a cerebral predisposition, various and unlooked-for changes in the
general health, or local irritation, will bring on an attack of epilepsy. A
vol. n.—40
610 DISEASES OF THE NERVOUS SYSTEM.
man who had received a blow on his head was seized with epilepsy after
the wound healed ; and he only procured exemption from the attacks by
its being again opened. A young man, twenty-eight years of age, expe-
rienced epileptic attacks whenever the weather was stormy. In his case
atmospheric electricity acted on a carious tooth, the extraction of which
was followed by a cessation of the epilepsy. A person who had contracted
a syphilitic disease, and who had a bubo in the groin, was seized with
epilepsy when he was cured of the bubo.
A small piece of undigested meat, or a nut or other fruit hard of diges-
tion ; worms ; unduly retained or too abundant fecal matter ; irritation of
the bladder or of its neck ; pressure by a slight node on a sentient nerve;
any sudden impression on one ofthe senses, or strong emotion or intellec-
tual strain ; too much sleep, or sleeping with the head low, will, severally,
suffice to bring on an epileptic attack in the person predisposed.
The symptoms of epilepsy, on which I shall not, however, enlarge, have
been divided into those — 1, before the coining on of the paroxysm ; 2,
during the paroxysm ; 3, immediately after this occurrence ; 4, in the in-
terval between the paroxysms. Sometimes there are no premonitory
symptoms, and then the paroxysm comes on suddenly and with fearful
violence. When these symptoms are present they vary both in number
and intensity. Commonly some complaint is made of vertigo and head-
ache, and the eyes and face are more or less injected and suffused. Va-
rious abnormal sensations are complained of in some part of the head or
one of the limbs. The passage of this pain or anomalous sensation from
the part where it is first felt, as at the end of a finger or in the foot, is
towards the brain. When it reaches this organ the fit comes on ; the
patient falls down insensible, and is seized with violent convulsions,
foaming at the mouth, deeply injected and almost livid face, starting eyes,
&c. I have known this sensation, called aura epileptica, when it reached
the heart, to cause violent palpitations, and sometimes to cease here ; but,
more commonly, it would pass thence to the brain and be followed by the
epileptic convulsions. Occasionally, it will begin at the face, in the
cheeks or temples, and be accompanied by severe twitches and a feeling
of dragging or darting of the muscles of the part before the brain is af-
fected. Not unfrequently it is in the power of the patient, when he first
feels the aura in a limb, to arrest its upward course by quickly drawing a
ligature or a handkerchief tightly round the limb between the aura and the
brain.
Various are the degrees of sensibility, cutaneous and other kinds, mani-
fested by epileptics, or by the same person in different stages of the dis-
ease. Sometimes there is insensibility to common excitants, and even
sinapisms and vesicatories produce little effect in this respect; and at
other times the sensibility of the skin is extreme. Spinal irritation will
show itself in the progress of the disease, but not in any uniform relation
to it. Often the brain is the only organ which seems to be diseased ; and
if we except palpitations, the functions of nutritive life, generally, are
active, the appetite good, and digestion vigorous.
The duration of a fit of epilepsy varies from a minute to more com-
monly five and ten or fifteen minutes, and in some cases to one, two,
and even fourteen hours. The number of fits varies, also, in different
subjects. Some have only one, and this is the most common case:
but, sometimes, the attacks succeed each other in quick succession, from
two or three in number to twenty, thirty, and even sixty in the course
TREATMENT OF EPILEPSY.
6J1
ofthe twenty-four hours. If the fits are simple or single, and only return
at long intervals, as several months, a year or years, the subject of them
may retain an average good health and vigour of intellect; but if, on the
other hand, the fits become frequent and compound, or in successive
paroxysms, the raind suffers greatly, and, ultimately, idiocy or drivelling
dementia is the consequence.
The organic or textural lesions, in persons dead of epilepsy, are in large
proportion found in the brain, its meninges, or the cranium ; and espe-
cially are the cerebral vessels congested if death had taken place during
the fit. MM. Bouchet and Cazauvielh have endeavoured to show that
the disease is inflammatory, and is localized in the medullary substance.
But, on the other hand, there are cases in w7hich no change, either in the
structure of the brain or of any other organ, can be found adequate to cause
the disease.
Unfavourable as the prognosis in epilepsy generally is, we ought not to
be discouraged from carrying out a properly designed treatment, which we
know will on occasions reward our exertions. Even when complicated
with disease of the heart, most probably obliteration of the mitral valves,
and deficient power in the ventricle, I have found epilepsy to be amena-
ble to remedies, and the sufferer restored to usefulness and ability to fulfil
the active duties of life ; the exemption at any rate for a whole year re-
placing paroxysms of every few days' recurrence.
Treatment.—Notwithstanding the occasional cures performed by an
empirical treatment, the rational ought to have the preference. Hence,
instead of forthwith beginning to dose an epileptic patient with sulphate
of zinc, nitrate of silver, indigo, oil of turpentine, or digitalis, the remedies
which just now rank highest in medical opinion, it is more fit, reasoning
from the principles of medicine and our knowledge ofthe variety of phases
in which epilepsy manifests itself, to adapt the treatment, both hygienical
and medical, to the different exigencies growing out of peculiarities of
temperament and constitution, prior habits, and present exposures, and
also complication of sorae other disease with the assumed one, or morbid
susceptibility of the brain. Little good can we promise ourselves from
any remedy or course of treatment so long as the exciting causes are in
action, whether these be the depressing or the more exciting and pertur-
bating passions, excessive or even common venereal indulgences, either
allowed by the marriage tie, or unlawfully procured by promiscuous inter-
course, or worse than all, by self-pollution or masturbation. Even the
at other times laudable exercise of intellect on some favourite subject,
and especially intense mental occupation, either in the pursuit of science
or of ambition, must be refrained from. If woman be the subject, we
must have ascertained the state both of her moral as well as physical being,
before we can prescribe with a prospect of success, that is after knowl-
edge of cause.
If the patient be plethoric suitable means of reduction will be directed ;
but we must distinguish well between real and simulated fulness of
the bloodvessel system, and also between the temporary congestion
of the cerebral vessels which follows high nervous excitement and sub-
sides with the disappearance of the latter, and the real excess of blood
sent to the brain as well as to all the other organs. It is not often that
large, certainly not repeated, bloodlettings are required in epilepsy.
More is gained in equalizing the circulation by the occasional detrac-
612
DISEASES OF THE NERVOUS SYSTEM.
tion of blood topically, followed by revulsives, than by venesection.
The class of revulsives on the present occasion should consist of purga-
tives, from which the patient will often declare himself to be much re-
lieved ; irritants to the skin of the extremities, or, if there be a local
pain or morbid sensibility in some part ofthe spine or intercostal spaces, or
at some spot near the heart, a blister to one or other of these parts. Cold,
in the form of a douche, to the head, and warmth to the extremities, will
contribute to equalize the circulation, and take the place of bleeding and
sinapisms. Fixed cerebral disorder, manifested by alternate vertigo and
faintness, drowsiness, unequal frame of mind, deviation from the natural
feelings, ought to prompt to the keeping up a discharge from the nucha by
a series of blisters or by a seton ; or that which I prefer, a succession of
small blisters along one or other side of the spine. This last practice is
useful, also, when there is a weakness and an evident diminution of loco-
motive power on one side, manifested by, among other symptoms, a slight
halt in the gait, and a less ready grasp of an object with the weakened
hand.
If anemia and a soft and flabby state of the voluntary muscles, and a
correspondingly soft and flaccid state of the heart, as indicated by auscul-
tation and the pulse, exist, we must not think of detracting blood, but
rather have recourse at once to tonics ; sulphate of quinia where the pa-
roxysms assume anything like a periodical character, as they sometimes
do, and in other cases chalybeates combined with aloes, or an equivalent
purgative to keep up a soluble state of the bowels.
But our success eventually in the cure of epilepsy will be found to
turn onfthe adoption of and perseverance in hygienic means of treatment
—so adapted to the constitution of the patient and circumstances of the
case as to act on the several organs in a manner corresponding with the
effect produced by medical agents. More especially are the functions of
the stomach, brain, and locomotive apparatus to be regulated by the
soundest discretion. Thus, the food must be of such a nature as to fur-
nish adequate nourishment without irritating the stomach or bowels, and
be calculated at the same time to obviate constipation. This last would
cause a fulness of the cerebral vessels inviting the disease ; whilst diar-
rhoea or occasional looseness, by interfering with regular digestion, con-
tributes to a mobility of the nervous system by which it is more open to
the operation of common exciting causes. Permanent and efficient deri-
vation from the brain will be obtained by regulated and full bodily exer-
cise, so as to divert a large amount of blood into the voluntary muscles
and at the same time to determine to the skin and maintain a sensible
perspiration. The tepid bath, and after a while the cool bath, and assi-
duous friction, will contribute to the proposed design of derivation, and
also to give that tone to the nervous system by which it is rendered less
morbidly impressible to the common excitations ; either those from with-
out or those occurring in the discharge of the organic functions. Equable
temperature ofthe skin and its uniformly agreeable.sensation ought to be
maintained by warmth ofthe feet and an avoidance of a heavy hat or head-
dress, or even of a thick head of hair, and ligature of any kind, as by
stock, tight cravat or shirt collar, round the neck. Some recommend
that the scalp should be shaved once a-week and well rubbed daily with
a flesh-brush, after the tepid shower-bath or a simple process of pouring a
flagon of cool water on the head inclined over a large basin. There is,
TREATMENT OF EPILEPSY.
613
however, after all, no means so efficient to remove the morbid excitability
of the nervous system, which so continually invites to a paroxysm of epi-
lepsy, as regular and full exercise. With this view the patient must put
himself in a course of training, and persist in it for a long period, until he
feels that his whole constitution is changed, and that he is proof against all
the trials which before, at each moment, would make his heart palpitate with
violence, his limbs tremble, and his mind confused in all its perceptions.
But in order that the expected benefit may be derived from exercise, the
extremes of undue repletion and abstinence must be avoided. A full
meal will oppress the brain, encourage drowsiness and disinclination to
exercise, and fasting will pervert healthy sensibility, and break the rhythm
of the functions of the nervous system. More especially prejudicial is a
full meal or a repast of stimulating food at an advanced hour in the day
or in the evening ; while, on the other hand, the period of fasting should
not be long between rising and breakfast. Suitable variety can be pro-
cured, from day to day, without much mixture of articles of food on the
same day, or above all, at the same meal. Never ought more than one
kind of meat, plain roast or boiled, or, preferably to either, stewed, be
eaten at a meal. In the selection of vegetables and the use of fruit a
similar rule should be followed, so as to avoid, primarily, irritation of the
stomach, and, secondarily, that of the intestines, and particularly of the
lower, by a needless amount or imperfect change of the excrementitial
portion to be exonerated. If the patient be young, or of a full and ple-
thoric habit, it will be advisable to abstain entirely from animal food, or
to use it in very restricted quantity. Drs. Fothergill, Heberden, and
Abercrombie, recommend an exclusively vegetable diet; and the first
and last lay great and deserved stress on entire abstinence from strong or
intoxicating drinks. Little prospect of permanent recovery can be held
out so long as they are used by the patient. Tobacco, as a perturbator
of the nervous system, which suffers alike by the large use of and by oc-
casional abstinence from this vile weed, ought to be thrown aside at the
sarae time. Nor can coffee and tea be regarded as admissible ; disturb-
ing, as they do, the nervous'and vascular systems, and contributing to
keep up irregular action in both. In fine, if we w:ould give the patient a
fair chance of entire restoration, he ought to be exempt as much as possi-
ble from all those causes, which either wreaken the nervous system, and
thus augment unduly its susceptibility to impression of every kind, or
which cause or increase plethora, and thus multiply and give additional
force to common and otherwise physiological stimulants. While we are
engaged, on the one hand, in diminishing by a proper tonic course, con-
sisting chiefly of hygienic means, the original undue susceptibility of the
brain and nervous system generally, we must sedulously withhold every
irritant which might task this system beyond its powers.
A brief mention of some of the most prized medicines, chiefly of the
class of tonics, which are employed in epilepsy, will conclude my re-
marks on the disease at this time. 1 have spoken of chalybeates, as ap-
plicable to a particular state of the system in epilepsy, characterized by
anemia and a soft aad flabby state of the voluntary muscles with palpitation
and feeble pulse. Not dissimilar to this state of things are the nervous
epilepsy and the uterine epilepsy of authors, for the relief or cure of which
the preparations of iron are among our best remedies. In strumous habits
or decidedly scrofulous subjects the iodide of iron is serviceable.
614
DISEASES OF THE NERVOUS SYSTEM.
Nitrate of silver has perhaps obtained more suffrages in its favour than
any one medicine for the cure of epilepsy, especially among the English prac-
titioners. But Esquirol, after many careful trials, expresses his entire want
of confidence in this medicine for the cure of the disease. The dose is a
sixth of a grain gradually increased to three or four grains, three times a-
day. Dr. Powell in some cases has increased the dose to fifteen grains,
in pills, but he rarely found stomachs that could bear more than five grains
in solution. The usual mode of administering it, in pills made with bread,
has been objected to, on account of the chloride of sodium which this con-
tains: it is easy, therefore, to substitute some simple vegetable powder or
mucilage. The great objection to the prolonged use of lunar caustic is
the blue or bronzed colour of the skin to which it gives rise. Dr. John-
son asserts, however, that there is no instance on record where the com-
plexion has been affected by the medicine when restricted to three months'
duration. But even to this point it is not necessary, or at least advisable,
to go; and hence we ought to discontinue it for a while, after a month or
six weeks' use. Nitrate of silver is best adapted to the asthenic stage or
form of the disease, and may be usefully combined with hyosciamus or
with camphor.
Sulphate of zinc and oxide of zinc have always maintained a reputation
in epilepsy. Dr. Babington (Guy's Hospital Reports, No. xii.), in a paper
on this disease, indicates his preference for the sulphate of zinc, which, if
not quite so efficacious as the nitrate of silver, is free from the objections
to which the latter is subject, viz., its'strong action on the stomach and
the discoloration of the skin. This gentleman has given the sulphate in
larger doses than are generally recommended. In some instances he has
directed as much as thirty-six grains three times a-day. He has found this
quantity to be taken eq ually as well in solution as in pills, care being taken
gradually to increase the dose. Dr. Aldridge records several cases of
successful results after the use of this salt.
Sulphate of copper has been recommended by not a few practitioners,
on the strength ofthe numerous cures alleged to have been performed by
it. Dr. Hawkins prescribed it in a dose of a fourth of a grain combined
with sulphate of quinia. The cuprum ammoniatum was by some believed
to be still more efficacious, but later extended trials have not sanctioned
the first impressions on this head.
Oil of turpentine should be regarded as one of our best, if not the best
remedy in epilepsy. I have not compared it with nitrate of silver; but
have found it far preferable to any of the other metallic preparations and
to indigo. I direct it often in large and purgative doses, or from ^ss. to
|i., usually conjoined with castor oil in the same quantity; and in the in-
tervals give it in smaller, or drachm and half-drachm doses with muci-
lage of gum arabic. When the patient is enfeebled, and the skin cold or
torpid in its functions, I prescribe the sulphate of quinia with the oil of
turpentine, with good effect. In some nervous and irritable subjects, its
action on the neck of the bladder is injurious by exciting the brain and
endangering a return of the paroxysm.
Recently the praises of digitalis have been revived by Dr. Sharkey,
whose essay (An Inquiry into the Effects of Digitalis in the Treatment of
Idiopathic Epilepsy) is chiefly intended to set forth the efficacy of this
medicine in the disease. Doctor Sharkey, as the title of his essay im-
plies, believes digitalis to be adapted only to the idiopathic and uncom-
TREATMENT OF EPILEPSY.
615
plicated forms of epilepsy. The best mode of exhibiting the medicine is
in infusion with strong beer or porter, in the proportion of 3^ ounces of
the recent leaves of digitalis, bruised, to a pint of the malt liquor. Mace-
rate for seven hours, and then strain. Of this, four ounces are to be taken
with ten grains of the dried leaves, or of the dried root, of the Polypod.
quercus. Few who have once taken this dose, however, will be willing
for a repetition. Its effects are, vomiting, soreness of epigastrium, cold
extremities, cold sweats, cramps, and great depression and irregularity of
pulse, with sometiraes double vision, continuing for several days. Dr. Cor-
rigan recommends, in preference, the infusion of digitalis of the Dublin
Pharmacopoeia, which is the same as that of the United States, except in
the employment of half a fluid ounce ofthe spirit of cinnamon by the for-
mer in place of a fluid ounce of the tincture. Of this infusion Dr. Corri-
gan directs an ounce to be taken every night at bed-time, increasing it
after a week to an ounce and a half, and after another week to gij., be-
yond which it is rarely necessary to go, and continuing it until sickness
of the stomach and dilated pupils are observed, when the dose is to be
diminished by 3ss. or §j., until the maximum dose that can be borne with-
out inconvenience is ascertained. Thence the administration is to be
continued for twro or three months. Beyond an occasional attack of slight
sickness of stomach in the morning, or headache, when the medicine is to
be omitted for a day or two, there is no perceptible effect beyond slow
action of the heart, and the patient during its use is able to follow his
usual avocations. A case is related by Dr. C. of a gentleman aged 27,
who during the previous seven months had suffered from repeated attacks
of epilepsy followed by delirium. He was kept under the influence of
the medicine for about five months, when the attacks became milder and
milder, and at length ceased altogether. The patient had remained, when
the account was published, free from a return of the disease for four years.
The treatment of epilepsy with digitalis should be begun immediately
after rather than immediately preceding a fit. It is best adapted to cases
in which there is much palpitation, implying disordered action ofthe heart.
This itself tends to keep up irregular circulation in the brain.
Etherization has been tried in epilepsy, but without any very definite
or encouraging results. Temporary aggravation seemed to be followed
by longer intervals of freedom from attacks; but there was nothing like
an approach to cure.
Mr. Mansford attaches great value to galvanism in the treatment of epi-
lepsy. The apparatus which he used is described by him as follows :—
It was said, that in order to fulfil the indication stated at the commence-
ment of this section, it was desirable to establish a negative point as near
the brain as possible, and a positive one in some distant part ofthe body.
Accordingly, a portion ofthe cuticle ofthe size of a sixpence being re-
moved by means of a small blister on the back of the neck, as close to
the root of the hair as possible, and a similar portion in the hollow beneath,
and on the inside of the knee, as the most convenient place : to the wound
in the neck a plate of silver, varying according to the age of the patient,
from the size of a sixpence to that of a half-crown, was applied—having
affixed to its back part a handle or shank, and to its lower edge, and pa-
rallel with the shank, a small staple, to which the conducting wire was
fastened. This wire descended the back till it reached a belt of chamois
leather, buttoned round the waist—it then followed the course of the belt,
616
DISEASES OF THE NERVOUS SYSTEM.
to which it was attached, till it arrived opposite the groin on the side it
was wished to be used ; it then passed down the inside ofthe thigh, and
was fastened to the zinc plate in the same manner as to the silver one.
The apparatus so contrived was thus applied :—A small bit of sponge
moistened with water, and corresponding in size to the aperture in the neck,
was first placed directly upon it—over this a larger piece of sponge ofthe
same size as the metallic plate, also wetted, was laid—and next to this
the plate itself, which was secured in its situation by a strip of adhesive
plaster passed through the shank on its back, another above, and another
below it. If these be properly placed, and the wire which passes down
the back be allowed sufficient room that it may not drag, the plate will not
be moved from its position by any ordinary motion ofthe body. The zinc
plate was fastened in the same manner—but in place of the second layer
of sponge, a bit of muscle answering in size to the zinc plate was inter-
posed : that is, a small bit of moistened sponge being first fitted to the
aperture below the knee, the piece of muscle (a piece of soft buckskin is
more cleanly than the muscle and equally as efficacious), also wetted, then
followed, and on this the plate of zinc. The apparatus thus arranged will
continue in gentle and uninterrupted action from twelve to twenty-four
hours, according to circumstances. This last is the longest period that it
can be allowed to go unremoved : the sores require cleaning and dressing,
and the surface of the zinc becomes covered with a thick oxide, which
must be removed to restore its freedom of action ; this may be done by
scraping or polishing : but it will be better if removed twice a-day, both
for the greater security of a permanent action,"and for the additional com-
fort of the patient. In one case prolonged convulsion but without loss of
consciousness followed, in a patient of mine, the application of the plates
in the manner just now directed. Dr. Lee, .in his edition of Copland's
Dictionary of Practical Medicine, recommends, in preference to the compli-
cated apparatus of Mansford, the portable rotary (now vibrating) magnetic
machine of Dr. H. H. Sherwood.
Incisions ofthe scalp, three or four inches in length, and dressed with
turpentine cerate for four or five days, and also longer ones kept open
with pea issues, have been used successfully by Dr. Isaac Parrish (Med.
Exam., 1843), and others. M. Selade reported cures by means of inter-
mittent fever artificially induced, through prolonged immersion ofthe pa-
tient in cold water, and his being then placed in a heated room and covered
with bed-clothes, until the hot and sweating stages are counterfeited. A
repetition of this process for a few times establishes the artificial intermit-
tent without the bath. Dr. Branson of Sheffield has contributed a statis-
tical record of 42 cases of epilepsy—18 males and 24 females. The result
ofthe different modes of treatment which he has recorded is in favour of
the nitrate of silver. The approach of discoloration of the skin by this
medicine may be always recognised by attention to the state of the gums,
upon which the effects of this medicine are first seen in the shape of a
blue line of the same colour, but narrower than that produced by lead.
Strong mental emotion which sometimes brings on a fit may, when of
a particular kind, prevent its recurrence, as in the instance in which Boer-
haave arrested the progress of the fits with which the patients in a hos-
pital were seized in quick succession on seeing others with the disease.
This distinguished physician directed iron to be heated in the presence of
the patients and to be applied to the very next person who had a fit. The
DISEASES OF THE EYE.
617
fear of the cautery was, we learn, more powerful as a preventive than the
dread and tendency to imitation from the sight of those in a fit.
The treatment during a paroxysm will be very simple. The tight parts
ofthe dress, if there be any such, should be loosened ; the head a little
raised ; and a piece of wood or wire introduced into the mouth and held
between the teeth to prevent the tongue from being bitten. The face may
be sprinkled with cold water.
For a plain sensible view of the treatment of epilepsy, I refer you to
the article on the disease by Dr. Cheyne (Cyclop. Pract. Med.), and for
copious details on all the points of pathology and treatment to Dr. Cop-
land's Medical Dictionary ; the former edited by Dr. Dunglison ; the latter
by Dr. Lee. 4
DISEASES OF THE EYE.
LECTURE CXXXIX.
DR. BELL.
The chief diseases of the eye are inflammatory—All the tissues represented in the eye
—Pathological illustrations, in conjunctivitis and sclerotitis—representing inflamma-
tion ofthe mucous and fibrous systems—Inflammation ofthe eye farther modified by
cause, diathesis, and constitutional diseases—Necessity of a knowledge of pathology
and therapeutics for correct treatment of diseases of the eye—Danger of specialties—
Ophthalmia—Ophthalmitis—Inflammations ofthe several humours of the eye to be de-
scribed.—Conjunctivitis—Extent and connexions of the conjunctiva — Varieties of
conjunctivitis.—1. Catarrhal Ophthalmia—Usually the type of conjunctival inflam-
mation—Symptoms—Increased redness of the conjunctiva—Serous exudation or edema
—Chernosis—Eyelids swelled—Cornea and iris not changed—Pain at first not great
— Constitutional symptoms few— Causes — Same as of other catarrhal affections —
Diagnosis—Prognosis—Treatment—Antiphlogistic—Local applications—Congestion
of conjunctiva, to be treated by blisters to the nucha, and solution of nitrate of silver
to the eye — Testimony in favour ofthe nitrate — Shade for the eye — Remedies for
weakness ofthe eye.—II. Purulknt Ophthalmia—Its common character—Three va-
rieties—a. Ophthalmia of New-born Infants—The most destructive form of ophthalmic
disease — Attacks infants soon after birth— Necessity of watching the very first ap-
pearances of disease—Symptoms—Three stages—At first, disease confined to the pal-
pebral conjunctiva, tarsal borders, and Meibomian glands—Extension of phlogosis to
the sclerotic conjunctiva—Muco-purulent secretion established and very copious—
Its characters—Cornea participates in the disease—Adhesion of the iris—Sometimes
the humours ofthe eye evacuateJ—Constitutional symptoms—Causes—Chiefly vagi-
nal secretions of the mother—Constitutional weakness—Bad air—Defective nutriment
—Prognosis—Treatment—In the forming stage, mild laxatives internally and solution
of alum or nitrate of silver to the e\e itself—In acute cases and more advanced stage,
antiphlogistics required—Calomel and laxatives—Early and free use of astringents and
stimulating applications to the eye—The lecturer's own experience — Precautions in
examining the eye.
Compelled, as I am, to restrict myself within narrow limits, in what I
have to say on Diseases of the Eye, I may as well premise, at once, my
intention to touch only on the inflammatory affections of this organ, as the
most common and the most serious, and those which will most frequently
come under your observation for treatment. To surgery proper belongs
the description of fixed structural lesions of one or more of the several
618
DISEASES OF THE EYE.
parts of the organ of vision, and of the various procedures requiring
instrumental aid for their removal. Many of the most important of these
cases are, however, the result of inflammation, and too often they attest the
want of skill of the physician in failing to arrest this disorganising process,
fully as much as any extraordinary violence ofthe cause.
In a merely pathological point of view, and apart even from the clinical
bearings of the subject, the morbid changes of structure in the eye are
curious and full of instruction. In its composition the eye, including its
orbit and appendages, exhibits a specimen of every tissue of the body
from the cellular to the parenchymatous and erectile ; and in the inflam-
mation of these several tissues we are enabled often to see and study the
successive stages of disease, the analqgies of which for the most part lie
deep and hidden from our inspection. Thus, for example, in conjuncti-
vitis or inflammation of the conjunctiva, we have before us a good picture
of phlegmasia of the gastro-pulmonary mucous membrane, of which the
former is a part, while sclerotitis or inflammation of the sclerotic membrane
or coat gives out the symptoms of phlegmasia of the fibrous system, which
in other parts designates rheumatism and gout. It would seem, therefore,
to be necessary, for a correct view of the diseases of the organ, to study
first the lesions of its several tissues; for, although seldom is the inflam-
mation confined to one of these exclusively, yet it cannot be denied that
the morbid phenomena are modified in a peculiar and. even distinctive
manner from this cause. The common features and sympathies of inflam-
mation are, however, of course met with in the eye by its vascular and
nervous connexions with the rest of the system. The nervous relations
are established both with the organs of animal life, through the brain and
spinal marrow, and with those of nutritive life through the great sympa-
thetic.
Other modifications of inflammation ofthe eye grow out of the differ-
ences in the exciting causes, and also particular diatheses and constitu-
tional diseases. It is obvious enough, after a very slight survey of the
premises furnished by general and morbid anatomy and by physiology and
pathology, that the study of the most important and the greater number of
the diseases of the eye cannot be resolved into mere ophthalmic surgery,
in the narrow and arbitrary sense in which this is generally understood,
viz., readiness and some dexterity in the use of instruments, or as it is
generally termed performance of operations, and recourse to certain local
applications of conventional or empirical repute. Unless a man by the ex-
tent and accuracy of his knowledge of pathology and therapeutics be fitted
to assume the management of diseases in general andespeciallyof the phleg-
masia?, he ought not to presume to treat diseases of the eye and its inflam-
mations, whatever may be the dexterity of his manipulations, or in the
use of cataract knife or needle. No part of the practice of medicine
can be thus resolved into a branch of mechanical skill. What should
we say of a man's competency, and not only competency but superior
claims, to treat peritoneal inflammation and ascites because he could perform
readily the operations for paracentesis abdominis, or anasarca on the strength
of his being able to apply neatly a bandage ? It behooves the general
practitioner, and most medical men in the United States are of this class,
to check the continual tendency in the community to take out of his hands
the treatment ofthe disease of a particular organ,—the eye or the ear, it
may be even the lungs or the uterus—and assign it to some specialist, who
CONJUNCTIVITIS.
619
is apt to forget that his favourite organ has both structural and vital con-
nexions with other organs, and that it acts on them and is impressed in
its turn by them in a manner and through causes, hygienic and medicinal,
of a wider range than comes within the scope of his mental vision. Mr.
Travers, himself a distinguished surgeon, remarks, on this subject, in the
preface to his valuable Synopsis of the Diseases of the Eye, Sfc. : " I have
always thought that the advantages obtained by the sub-division of profes-
sional talent and labour are infinitely overbalanced by those which arise
from the general and undivided application of these instruments of knowl-
edge. No fact more strikingly illustrates the truth of the doctrine, that
the confinement of any branch of the profession to the hands of a few
operates prejudicially to science, than the state of information in this coun-
try, concerning the Diseases ofthe Eye."
Ophthalmia (from cqdtxpot, the eye) is a generic term for inflammation
of the eye'without specification of particular seat, and also of its several
tissues or other parts which are more especially affected by the phlogistic
process. Ophthalmitis is somewhat arbitrarily restricted to inflammation
ofthe globe, in which the internal and external parts are attacked at the
same time. Mr. T. Wharton Jones designates this morbid condition of
the eye by the term Panophthalmitis. Ophthalmia obtains a designating
prefix according to the tissue affected, or its real or supposed cause. But
of late years, it has become customary to speak ofthe inflammation ofthe
particular tissue, or coat or membrane, under the terminology similar to that
used in naming other phlegmasia? ; and hence, in place of conjunctival and
sclerotic ophthalmia, we have conjunctivitis and sclerotitis. As I have
no design to inflict on you " the crabbed vocabulary of ophthalmologists,"
nor, certainly,to add to " the nomenclaturing mania," I shall merely speak,
and with due brevity, of conjunctivitis and its most important varieties,
sclerotitis, corneitis and corneal opacities, choroiditis, retinitis, including
amaurosis, and scrofulous, erysipelatous, pustular, variolous, and catarrho-
rheumatic ophthalmice,—diseases all affecting the ball or globe of the eye.
Then will come a few remarks on ophthalmia tarsi, a disease ofthe glandular
structure and tarsal borders of the eyelids. In thus abbreviating the list
of ophthalmic diseases, we may take with us the consoling remarks ofthe
experienced and accomplished Lawrence, on the numbers which frighten
the student; " that these various affections may, for the most part, be re-
ferred to a common origin, that they partake of a common nature, and
that, as they are nearly all the offspring of inflammation, so the treat-
ment of them is, in essential circumstances, similar. The more atten-
tively we consider the phenomena of disease, and consider the effects of
remedies, the more we shall be led to adopt simplicity of treatment,
and the less confidence shall we place in complicated plans, or great
diversity of remedial means."
Conjunctivitis.—Allusion has been made to the conjunctiva as part of
the system of mucous membranes, and as such to its exhibiting, when
inflamed, analogous phenomena to those occurring in the other parts of
this system. Lining both the upper and lower eyelid and reflected over
the middle and anterior part of the globe of the eye itself, the conjunctiva
of necessity receives the impressions of foreign agents of whatever nature
these may be,—light, heat, air, gases, dust and even grosser particles of
various physical bodies, and specific poisons secreted from the body of
another person, or even the individual himself. Connected at one angle of
620
DISEASES OF THE EYE.
the eye with the lachrymal gland and at the other with the lachrymal sac
and duct, and at each border with the Meibomian glands, the conjunctiva,
when it is diseased, transmits and receives irritations of these parts, and in
this way, in addition to those purely ocular, gives rise to quite an exten-
sive series of sympathetic actions, some of the continuous, others of the
remote kind. In appearance the conjunctiva, although transparent, differs
according as it lines the palpebral, or covers the visible part of the globe—
or the sclerotic and cornea ; being in the first instance of a pale red tint,
and in the latter colourless. It is closely adherent to the tarsi; but sits
looser on the sclerotica, owing to intervening cellular tissue, so as to allow
of its sliding on this latter membrane, but at the same time without its get-
ting into folds. At the border ofthe cornea, again, the mixed texture of
cellular and vasculo-nervous stops, and the epithelium alone covers the
cornea, to which it is closely adherent. Under the operation of compar-
atively slight causes barely transcending its physiological state, the scle-
rotic conjunctiva may admit red blood into its superficial vessels and as-
sume a congested aspect, which will often disappear as speedily as it came.
Such an appearance is, however, rare in the corneal conjunctiva unless
in the highest degree and most protracted stage of inflammation.
Conjunctivitis, or inflamraation of the conjunctiva, embraces several va-
rieties, or with Mr. T. Wharton Jones, regarding it as a genus, we might
say species and varieties. Ofthe first are, 1. The puro-mucous; 2. The
erysipelatous ; 3. The pustuloid or aphthous. The different forms or vari-
eties of puro-mucous ophthalmia are, catarrhal opthalmia ; Egyptian or
contagious ophthalmia ; ophthalmia neonatorum ; gonorrhoeal ophthalmia,
to which may be added the ophthalmia sometimes met with in female
children in connexion with puro-mucous vaginal discharge. The last
four varieties belong to the purulent ophthalmia orpurulent conjunctivitis.
I. Catarrhal Ophthalmia—Conjunctivitis Calarrhalis, called also
puro-mucous catarrhal inflammation ofthe conjunctiva, also mild purulent
ophthalmia. This form of inflammation is usually considered the type
of conjunctival inflammation.
Symptoms.—A feeling of dryness and smarting, with watering, external
redness and undue sensibility to light, announce the coming disease.
The conjunctiva lining the eyelids, as may be seen by everting the lower
lid, is of a deep-red colour, which extends, after a while, over the sclerotic
portion, or white of the eye, but there it assumes more of a scarlet colour,
and the palpebral conjunctiva is thickened and velvety-looking: the
semi-lunar fold and lachrymal caruncle are, also, red and swollen. At
the beginning of the inflammation a serous exudation or edema of the
conjunctiva, accompanying the watering of the eye, and an effusion of
lymph (chemosis), take place, by which the membrane is thickened.
Soon afterwards there ensues a prolongation of the extreme vessels in
the form of villi, giving rise to the secretion of pus or of a puro-mucous
discharge. In the severer cases there is some degree of elevation depend-
ing on chemosis, especially at the lower margin of the conjunctiva. The
cornea may remain quite clear and the iris unchanged. The eyelids are
somewhat red and swollen, especially at the edges,—the upper eyelid may
be so much swollen as to overlap the edge of the lower. The pain at the
beginning of the disease is not considerable, except in severe cases; the
patient complaining of stiffness and dryness, and of a sensation as if a
foreign body were in the eye. The pain is chiefly across the forehead
TREATMENT OF CATARRHAL OPHTHALMIA. 621
and in the region of the frontal and maxillary sinuses, but there is none
of the rheumatic kind around the orbit or on the temples. This sen-
sation is owing to the distention and inequality of surface of the con-
junctiva, and its increased friction against the globe of the eye. It sub-
sides or is lessened by bloodletting." The constitutional sympathies are
often inconsiderable: at other times they amount to more or less catarrhal
fever, chilliness, headache, foul tongue and disordered digestion. There
is, for the most part, a remission ofthe disease in the morning and exacer-
bation in the evening.
Causes.—These are the same as of other catarrhal affections, and con-
sist chiefly of sudden exposures to cold and moisture, or to currents of
cold air directed on the head and face, and the prevalence of raw easterly
winds. In the predisposed, whatever interrupts cutaneous transpiration
will cause the disease.
The diagnosis of catarrhal ophthalmia, unless it be of a violent grade,
is easy. The varieties with which it is most apt to be confounded are the
phlyctenular and catarrho-rheumatic; the former occurring in young per-
sons, the latter in adults. In phlyctenular ophthalmia, the cornea is the
essential seat ofthe disease, and early becomes suffused or presents phlyc-
tenulae, which bursting, leave ulcers,—whereas in catarrhal ophthalmia the
cornea is at first quite unaffected, and often remains so during the whole
course of the disease. The redness in the phlyctenular variety exhibits
itself in a faint blush in one side or all around the cornea; and the injected
conjunctival vessels are few in number. There are also great lachryma-
tion and intolerance of light. In the catarrhal ophthalmia, the redness be-
gins at the outer margin and approaches after a while to the cornea. In
catarrho-rheumatic ophthalmia, the conjunctiva and sclerotica are injected,
and the latter is of a pink colour; the iris is discoloured and the pupil
slow to contract; the cornea appears muddy and not unfrequently presents
a phlyctenula or ulcer. In the catarrhal variety, the sclerotic membrane
is observed while under the vascular network of the conjunctiva. In-
stead of the pain across the forehead or in the frontal sinuses, which may
exist in this variety, ihere is in the rheumatic more or less circumscribed
or temporal pain, aggravated when the patient is warm in bed.
The prognosis in catarrhal ophthalmia is favourable ; as the disease
will be found to pass through a certain course and then to subside. It
yields readily to treatment, and is, generally speaking, free from danger.
Treatment.—-Antiphlogistic remedies are required, but in common those
of a milder kind will suffice, and such as consist in rest, abstinence, a
mercurial purge, or a saline one, followed, if need be, by tartar emetic'in
contra-stimulant doses, and if the phlogosis be abated and febrile reaction
small, Dover's powder and warm pediluvium at night. In a young sub-
ject of a full habit, and both of whose eyes are inflamed, venesection to
the extent of twelve or sixteen ounces will be serviceable ; or, in its stead
cups to the nucha and temples.
The best local application is tepid or warm water; and, if agreeable to
the patient, cold water. In subjects predisposed to rheumatism, or of
weakened constitutions, the prolonged or frequent application of cold is
productive of injury. At bed-time, the borders of the eyelids are to be
anointed with a little simple ointment, in order to prevent the lids from
sticking together during the night.
Congestion of the conjunctiva, or even sub-acute inflammation with
622
DISEASES OF THE EYE.
some pain remaining, a blister may be applied to the back of the neck or
behind the ears, or some irritating ointment to the same part; and the
vessels of the palpebral conjunctiva scarified, and afterwards pencilled
with ointment of nitrate of silver or of red precipitate. So much import-
tance do some surgeons attach to stimulants and astringent applications
to inflamed conjunctiva, that they are content to rely on this treatment alone
from the beginning,—a practice which has its analogies in inflamraation
of other parts of the raucous system, as in urethritis, and in bronchitis
even.
Mr. Melin and Mr. Mackenzie, as quoted by Mr. Lawrence, record their
experience, on a large scale, in favour of the use of a solution of nitrate
of silver,— from two to four grains in an ounce of distilled water, — of
which a drop or two drops are applied to the eye once or twice a-day.
Mr. Mackenzie foments the eye, thrice daily, with a collyrium of one
grain of corrosive sublimate in eight ounces of lukewarm water. Mr.
Lawrence, while he approves of the use of astringents, does not, however,
as the surgeons just mentioned did, rely on it to the exclusion of anti-
phlogistic measures. Previous to the use of the nitrate of silver in solu-
tion, or in conjunction with it, we ought to use such other means as are
required to fulfil the indications already pointed out.
The common pasteboard shade covered with green silk will afford suffi-
cient protection to the eye from light, under the usual exposure : and in
the house this matter can be regulated by the aid of shutters or blinds to
the windows. After the first or acute stage is over, the patient need not
be subjected to confinement within doors unless the weather be inclement.
" Free exposure to a mild atmosphere is advantageous."
Weakness of the eye, left after catarrhal conjunctivitis, will be greatly
benefited by the use of vinum opii; and if the general system be in a lan-
guid state, or left enfeebled by treatment, mild tonics and nutritive regi-
men should be resorted to among the restorative means,—among which
are, also, properly included change of air and travelling.
II. Purulent Ophthalmia.—It may be asked, why separate purulent
from catarrhal ophthalmia, as if the latter were exempt from the secretion
of pus, and the former had not any serous and mucous discharge. The
reply must be, that in the catarrhal kind purulent secretion is not neces-
sary to constitute the disease, in which, sometimes, if not frequently, this
formation is wanting ; but that, on the other hand, in purulent ophthalmia,
including the chief varieties, an early and persistent feature is the abun-
dant secretion of pus.
Purulent ophthalmia may be represented in three varieties: viz., a,
ophthalmia neonatorum, or the ophthalmia of new-born infants ; b, puru-
lent ophthalmia of adults, including Egyptian ophthalmia ; and c, gonor-
rhoeal ophthalmia.
a. Ophthalmia of New-born Infants—Purulent Ophthalmia of Infants.
—This, if not the most frequent, is, in proportion to the numbers which it
attacks, the most destructive form of ophthalmic disease. Attacking in-
fants sometimes at birth, but, more commonly, three or four days after
this event, the uneasiness and pain which it excites are not communicable
by the little sufferer; and as it instinctively keeps its eyes closed, the ac-
tual condition of these organs is not readily seen, sometimes not noticed,
until disorganization of one or both of the eyes has taken place, followed
by permanent loss of vision. Whenever, therefore, an infant, soon after
birth, keeps its eyes long or permanently closed, during its waking hours,
SYMPTOMS OF PURULENT OPHTHALMIA.
and the edges ofthe eyelids are redder than natural, and stick together a
little when the child awakes from sleep, your suspicions should be at
once excited as to the probable nature of the disease and the danger
incurred.
Symptoms.—Commonly, there is some tumefaction of the eyelid ; and
MM. Baron and Billard have remarked a red line at the transversal fold
of the upper eyelid, before the secretion begins. When the eyelid is
opened for examination, a whitish sero-muculent matter is seen, which
soon becomes a discharge; the palpebral conjunctiva is observed, when the
lids are raised or slightly everted, to be red, swollen, and velvety ; the
globe may still retain its natural state. So far, the disease is properly
blepharo-blenorrhoea or purulent inflammation of the palpebrae, in which
the tarsal borders and Meibomian glands are implicated with the palpe-
bral conjunctiva. The child manifests an intolerance of light, by turning
away its head. As the disease advances and reaches its second stage, the
swelling ofthe eyelids is greatly increased, and their skin assumes a dark-
red colour and becomes tense and shining: the upper eyelid, the more
swollen of the two, overlaps the edge of the lower. The inflammation
extends from the palpebral to the sclerotic conjunctiva, which is of a bright
scarlet or verraillion colour, resembling, as Saunders remarks, the gastric
mucous membrane of an infant. The muco-purulent secretion is now
fully established, and is so copious as to flow down the cheek, or to come
out in jets when the ey e is opened, and after the lids have been agglutinated
sorae time. Photophobia is so great that a still farther effort is made to close
the eyelids, by which the corrugator muscles, in addition to the palpebra-
lis, are strongly contracted, and, hence, the frown which the little sufferer
wears. This contraction is opposed to opening the eye, to such a degree
that attempts with this view often cause eversion of the eyelids and
tarsi,—ectropiura of either lid, or of both lids. The disease is now oph-
ihalmo-blenorrhoza. Sometimes this eversion of the eyelids, and, also,
protrusion of the loose folds of the swollen palpebral conjunctiva, take
place when the child cries : these folds are seen to have a granular aspect,
owing, it is believed, to a morbid development ofthe muciparous glands.
The lachrymal caruncle is very much swelled, and the sclerotic conjunc-
tiva suffers from chemosis. The discharge varies somewhat in colour,
from a white to a green or yellow, and increases, also, in consistence.
From its being collected in quantity during the night, beneath the eyelids,
we are better able in the morning to judge of its quantity, consistence,
and colour. Although, on opening the eye with the fingers of the phy-
sician or nurse, and in the cries of the child itself, matter flows out abun-
dantly, there still remains a tolerably thick and rather tenacious layer,
which cannot be reached with a moistened sponge or moistened rag, but
requires the injection of water by means of a syringe for its expulsion.
The borders of the eyes are so tightly glued together in the morning that
some time elapses, during which they must be soaked with warm water,
before they can be opened. In some very severe cases, streaks of blood
are intermixed with the purulent discharge.
The cornea, although at first not affected or only slightly hazy, partici-
pates after a while in the inflammation, and more especially after the pu-
rulent secretion has been established. It then becomes the seat of ulcera-
tion, or destructive infiltration, partial or general, accompanied with
opacities; or a portion ofthe cornea separating entirely, the iris protrudes
624
DISEASES OF THE EYE.
through the aperture, presenting an irregular dirty brownish prominence.
Adhesion of the iris to the inflamed or ulcerated cornea (synechia anterior)
is one of the effects of infantile purulent conjunctivitis extending to the
cornea. In some instances all the humours ofthe eye are evacuated through
the ulcerated cornea, and the globe shrinks to a third of its original size.
Interstitial deposit into the corneal tissue leaves permanent opacity, which,
when dense, is called leucoma or albugo.
The constitutional symptoms of purulent ophthalmia of infants are ma-
nifested by fretfulness, refusing to suck, sleeplessness, want of appetite
and other febrile disturbance, and apthous stomatitis.
In what has been called the third stage of the disease, there is a gra-
dual abatement of all the symptoms,—redness, swelling, discharge, and
intolerance of light.
The causes of this variety of purulent ophthalmia are, chiefly, vaginal se-
cretions, leucorrhceal or gonorrhoeal, applied to the eye ofthe infant in its
passage from the womb, during parturition. Undoubted as are these
sources, and communicable as is the disease by matter from the eye of a
child thus suffering to the eye of an adult, yet there are cases of the dis-
ease to which no such origin can be attributed ; and we are fain to admit
the common causes of catarrhal ophthalmia. Peculiarity of predisposition
and readiness to take on this purulent form are found to depend greatly on
constitutional weakness, and bad air and defective nutriment, as in found-
ling hospitals.
The prognosis will depend very much on the period ofthe disease and
the early use of appropriate remedies. Left to itself, the purulent oph-
thalmia of new-born children is dangerous, and apt to end in destruc-
tion ofthe tissues and humours ofthe eye, and consequent loss of vision.
On the other hand, if subjected, in good time, to a rational treatment, it
is readily controlled and led to a favourable termination ; but even then
not always without some persistent defect, such as partial opacity of the
cornea.
Treatment.—In the first or forming stage, when the inflammation is con-
fined to the palpebral conjunctiva, it will be sufficient to administer a lax-
ative of castor oil or magnesia, and to apply a diluted astringent or stimu-
lating wash to the eye, either by means of a syringe or by moderately press-
ing on the borders of the closed eyelids a sponge or rag soaked with the so-
lution. Mr. Lawrence tells us emphatically, that under the circumstances,
as regards the state of the eye just described, " such was the treatment
in forty-nine cases out of fifty at the London Ophthalmic Infirmary : using
no other means than magnesia internally, and the solution of alum locally,
and out of many hundred instances, I hardly recollect one where the eye
suffered in any respect, if the cornea was clear when the infant was first
seen." The strength of the alum solution was two to four grains in the
ounce of distilled water. If there be occasion to change the lotion, from
the eye being accustomed to the stimulus of the alum, recourse may be had
advantageously to the nitrate of silver, beginning with one grain to the
ounce, and doubling the strength if necessary. This solution may be
dropped between the lids two or three times a-day. The requisite quan-
tity of fluid is procured by immersing one ofthe two open ends of a quill
in the solution, while the finger is kept applied to the other both then and
after the withdrawal of the quill. The free or lower end which was in the
solution will be found to contain enough of the fluid for a collyrium, and
TREATMENT OF PURULENT OPHTHALMIA. 625
if it be held over the eye, and the finger removed from the upper end, the
contents will fall in drops on the exposed organ.
In the more acute cases, and in a more advanced stage of the disease,
the antiphlogistic treatment will have to be carried out. With this in-
tention two or three leeches (American) will be applied to the middle of
the upper eyelid just under the projecting orbitar ridge ; or if these are
not procurable, free scarification ofthe chemosed conjunctiva, where it is
everted, will be practised. The eyes, or at any rate the borders of the
eyelids, are to be freely bathed with warm water — some recommend
the constant application of cloths dipped in cold water. Internally, a
grain or two of calomel, followed by aMeaspoonful of castor oil, is ad-
ministered. When by these means tne inflammation is abated, re-
course will be had to astringents, the use of "yhich is declared by Mr.
Lawrence to be both safer and more advantageous in this form of oph-
thalmic inflammation than in any other. In my own practice, while early
impressed with the propriety of prompt recourse to collyria of the stimula-
ting and astringent class, I have, however, always laid much stress on
remedies calculated to act on the alimentary canal; and hence I have
prescribed at first, calomel and rhubarb, rhubarb and magnesia; and
afterwards calomel in minute doses, mixed with carbonate of magne-
sia or with chalk, three or four times a-day. Sometimes I direct
leeches, and generally find a solution of the sulphate of zinc answer as a
collyrium. But I have rarely failed to notice a rapid amelioration of the
worst symptoras under the use of calomel and laxatives. When the child
has been neglected or is of a cachectic habit, a solution of sulphate of,
quinia, so as to give an eighth or a sixth of a grain twice a-day, will form,
a useful addition and sequence to the other parts ofthe treatment just laid
down. If the disease assume a sub-acute or chronic form, blisters to the
nucha, or still better on the arm, and kept discharging, will come in oppor-
tunely. At an early period it is of doubtful efficacy. The warm bath will
also be found both to refresh and benefit the child at this timft.
Occurring as it does epidemically at irregular intervals, the purulent
ophthalmia of infants soon after birth is not always identical in its patho-
logical features, or at any rate it is not always relieved by the same reme-
dies. M. Guersent, who has witnessed several such epidemics, has found
the antiphlogistic method, followed by astringents, to be the most service-
able. Cauterization of the mucous membrane of the palpebrse with ni-
trate of silver failed completely. Quite recently, M. Chassaignac has
employed irrigation with great benefit. The child is laid on a table, and
water allowed to flow from a small tap through a tube over the surface of
the eye, from five to fifteen minutes, several times a-day.
The best and easiest mode of examining the eye is when the infant is asleep;
or if it be a wake, the time chosen should be that when it is quiet, and the lids
separated quickly before the muscles can resist. In opening the lids, not
the skin alone, but the tarsus, should be laid hold of and pushed upwards
and backwards, so as to prevent an eversion of the lid. If this latter oc-
cur, the tarsus should be seized between the finger and thumb, and, while
drawing it a little from the eyeball, be turned down. Forcible and long-
continued efforts should be carefully avoided, as they will aggravate the
inflammation.
vol. n.—41
626
DISEASES OF THE EYE.
LECTURE CXL.
DR. BELL.
Diseases or the Eye (continued)—b. Purulent Ophthalmia of Adults—Egyptian Ophthal-
mia—Shows itself at any time after infancy—First and main seat, the conjunctival
lining ofthe eyelids—Subsequent extension to the anterior part of the eye, including
cornea and iris—Upper eyelid suffers most—The disease most noticed by military
surgeons—May prevail epidemically-—shows itself in schools and asylums—Symptoms
—Disease divided into three stagjPi—In the first stage, the symptoms analogous to
those of catarrhal ophthalmia—The second stage brings the purulent discharge, with
redness, pufflness, and elevation of the conjunctiva—In the third stage, the proper
tunics of the eye are affected—Tendency of the second stage to become chronic—Pro-
fuseness of the discharge—Pain great—Remissions periodical—Symptoms in com-
mon with those of the ophthalmia of new-born infants—Variety in the symptoms—
Diseasesometimesmilder,and confined to the upper eyelid—Appearancescharacteristic
of this disease in adults—granular eruption with phlyctenule—Chronic the first form
of the disease—The acute ingrafted on it—Early appearances on the conjunctival
surface—Effects of purulent conjunctivitis on the tunics of the eye and the eyelids—
—General symptoms, in the beginning slight; in the advanced stage, are of a febrile
nature—Diagnosis—Prognosis unfavourable—Causes—Opinions divided respecting a
contagious origin-—Positive testimony in favour of contagion—Purulent ophthalmia
has originated in persons not exposed to the disease in others—Slates of the weather
—Crowded barracks—Close air on board ship—Treatment—In the first stage, anti-
phlogistic to a certain extent-—Early use of nitrate of silver and analogous remedies
—Moderate exercise in the open air—In the second stage, decidedly antiphlogistic—
Excision of a part of the conjunctiva—In lymphatic habits and in secondary attacks,
and in a civic population, a less energetic and a mixed treatment, including tonic re-
medies, the best—Topical applications, from the first, and the cold douche—Stimu-
lating remedies to the eye even before the inflammation is gone—Granular conjunctiva
—A constant occurrence in chronic purulent ophthalmia—Its appearances and conse-
quences—Affection of the cornea—Treatment—Combination of general with topical re-
medies—Vascularity and opacity ofthe cornea, common results of granular conjunctiva
—Gonorrhaal Ophthalmia—A consequence of gonorrhoea or of inoculation with gonor-
rhoeal matter—Theories to explain its attack—Three forms of gonorrheal inflammation
—Chief and most violent—Symptoms and immediate effects—Diagnosis—Prognosis—
Treatment—Fearful rapidity ofthe disease—Antiphlogistics ; cauterization, and exci-
sion and incision ofthe conjunctiva—Mild gonorrhoeal ophthalmia—-Gonorrhoeal
inflammation of ihe external tunics andj iris—Its analogy to rheumatic ophthalmia—
Simultaneous occurrence of rheumatism with gonorrhoea and gonorrhceal ophthalmia.
b. Purulent Ophthalmia of Adults—Egyptian Ophthalmia—Conjunctivitis
puro-mucosa contagiosa vel Egyptiaca.—Although called purulent ophthal-
mia of adults, the same disease shows itself at any time beyond the age
of infancy. Its first and main seat is the conjunctiva lining the eyelids,
and, by continuous sympathy, the glands of these latter : more commonly,
the sclerotic or ocular conjunctiva is also implicated, and, sometimes, in
despite even of all remedies, the disease extends to the cornea and iris and
produces organic lesions and destruction of these parts, analogous to those
in the purulent variety in new-born infants, already detailed. Although
the lower eyelid be the first affected, yet the upper one eventually suffers
most and " remains the nest ofthe disease."
Purulent ophthalmia of adults has attracted most attention in the annals
of military surgery, but only since the struggle for supremacy in Egypt be-
tween the armies of England and France in the year 1800. The disease
has, subsequently, appeared with great virulence among the troops of both
countries at home, and indeed of most others in Europe. It has been
SYMPTOMS OF PURULENT OPHTHALMIA IN ADULTS. 627
said that 30,000 cases occurred in the Prussian army, from 1813 to 1821,
and that blindness followed in 1100. The disease is endemic in Egypt,
and may prevail, epidemically, elsewhere : it has attacked civil as well
as military bodies—schools and asylums, for instance.
Symptoms.—This variety of purulent ophthalmia has been divided into
three stages, corresponding with the parts affected, viz. : 1, the palpebral;
2, the palpebro-ocular; and 3, the ocular proper. In the first stage, the
symptoms are analogous to those of catarrhal ophthalmia and the purulent
variety in children ; but, as yet, Ihere is no decided blenorrhoea. In the
second stage, the inflamraation extends to the ocular conjunctiva, which
is now marked by great^vascular action and bright redness, great tume-
faction ofthe membrane, and profuse discharge. The redness is uniform
and bright, and there are often red patches, apparently of ecchymosis.
The conjunctiva is loosened and raised up into chemotic folds, at the
lower edge of the cornea, which they sometimes almost completely over-
lap, and there is more or less blenorrhoea. In the third stage, " the che-
mosis is complete, the eyelids are enormously swollen, there is profuse
discharge of muco-purulent matter, and the proper tunics of the eyeball
are either already involved, or in imminent danger of becoming so." The
second stage has a great tendency either to become chronic or to pass
into the third stage, and this especially if neglected or improperly treated.
The chambers of the aqueous humour may be distended by an increased
exhalation of that fluid ; but there is no formation of pus ; nor is there
effusion of lymph into the chambers ; and, hence, hypopion is not met
with. Dr. Vetch asserts, that before bloodletting had been adopted, the
quantity of matter discharged in the day must have amounted to several
ounces. The disease begins with a sensation of stiffness in the eyelids
and globe, and then, as if sand or gravel were on the surface ofthe eye :
as it advances, the pain is considerable, and progressively, in many cases,
severe and excruciating. It is deep seated in the eye, often with fulness
and throbbing of the temples and headache. Remissions, and even dis-
tinct intermissions sometimes occur, of a distinctly periodical character.
The swelling ofthe eyelids, the overlapping ofthe upper, the great diffi-
culty of inspecting the eye, the extension of inflammation to the cornea,
and the risk of disorganization of this tunic, and protrusion and adhesion
of the iris, are features common to this form of ophthalmia and that at-
tacking infants, and need not, in detail, be repeated here.
We are not, however, to take the symptomatology of purulent ophthal-
mia, thus sketched, as a picture ofthe disease in all places and classes of
subjects. Not unfrequently, and more especially in civil life, it does not
advance beyond that which is the first stage of the more violent form, and
the conjunctiva of the eyelids continues throughout the entire period to
be, in the language of Walther, " the proper seat, the birth-place, the
nest of the disease." But, although comparatively mild, the palpebral
form is the most liable to become chronic, and, at any rate, it exhibits
an appearance which maybe regarded as mainly characteristic ofthe puru-
lent ophthalmia of adults. This is an exanthematous eruption termed
granular, with phlyctenular or small cysts, particularly observable at the re-
flexion of the conjunctiva from the eyelid to the globe, where we see in
the membrane a crowd of yellowish-red grains, something like the ova in
the roe of a fish. " Fissures and grooves are seen in the velvety lining
of the lids, entirely destroying its natural smoothness. Thus, the palpe-
628
DISEASES OF THE EYE.
bral conjunctiva is gradually changed into a fleshy, sarcomatous, some-
tiraes condylomatous mass, from the uneven surface of which an abundant
muco-purulent discharge proceeds." ( Walther in Lawrence, op. cit.) It
would seem as if the chronic were the first form of the disease, and that
the acute is ingrafted in it. At the earliest period of the former, when
as yet no complaint is made, and the individual is not aware even that
any disease exists, Erie, an army surgeon in the Austrian service, has
found small serous cysts or phlyctenular on the surface ofthe conjunctiva,
which are soon lost in the subsequent thickening and granulation of mera-
brane. Muller, the Prussian array surgeon, has attentively studied and
carefully described the disease, which he divides into three gradations,
in the second of which the conjunctiva of the eyelid looks as if it were
strewed with coarse sand. The third degree more commonly supervenes
on the second ; but, sometimes, the symptoms which it represents come
on at once in all their violence ; and the organ may be destroyed in
twenty-four or thirty-six hours. Muller asserts, " that the disease begins
at the inner edge of the ciliary margin, not including the puncta lachry-
malia, occupies the lining of the tarsi, and ends one line beyond these
cartilages. Everything beyond these limits is a symptomatic affection, to
which head we must refer the very frequent participations of the rest of
the mucous membrane."
The effects ofthe inflammation of purulent conjunctivitis in the adult are
nearly the same as those already described to occur in the infant ; viz.,
sloughing, bursting, suppuration and opacity of the cornea, prolapsus iridis,
total (staphyloma racemosum) or partial, adhesion of the iris to the cornea
(synechia anterior), staphyloma, dropsical enlargement of the globe, or col-
lapse of the tunics, a weak and irritable state of the eye, impaired vision
(amblyopia), temporary and permanent eclropium and entropium.
The general or constitutional symptoms in the beginning of the disease
are slight, but when the globe of the eye becomes inflamed, the patient
exhibits a febrile condition, and in the farther progress of the disease
loses both strength and spirits.
The diagnosis of purulent ophthalmia is not difficult, reference being
had to its first palpebral seat, the great swelling, chemotic and palpebral,
the violent vascular congestion, profuse purulent discharge, long con-
tinuance and relapses.
The prognosis is still more grave in the purulent ophthalmia of adults
than in the variety attacking infants—owing to the less manageable cha-
racter of the disease. " If the cornea retain its natural transparency we
may expect to arrest the inflammation by vigorous treatment; if it be dull,
and deep-seated pain of the eye and head announces extension of the in-
flammation to the globe, the event is doubtful," as far as regards the in-
tegrity of the eye and the recovery of vision.
Causes.—Opinions are divided respecting the contagious origin of pu-
rulent ophthalmia of adults. Some, with Mackenzie and Vetch, believe
that every variety of ophthalmia, including the catarrhal itself when it
becomes puriform, is capable of communicating the disease to previously
healthy eyes, as any animal virus gives rise to its specific poison when
inserted by inoculation in another subject. A great number of surgeons
and surgical writers are firmly convinced of the contagious character of
the variety now under notice ; and adduce direct experiments in proof of
the disease having followed immediately either the accidental or the pur-
TREATMENT OF PURULENT OPHTHALMIA IN ADULTS. 629
posed transfer of the matter on a diseased eye to a healthy one. Some
would restrict the transmission to direct contact with the purulent matter ;
while others believe that the disease may be transmitted through the air
within a certain distance of those affected. Amidst a large mass of con-
flicting testimony, which you will find in the pages of Mr. Lawrence's
valuable volume, it is not easy, if possible at all, to reach a satisfactory
conclusion in this matter. Of two things, however, we are sure. Puru-
lent ophthalmia has frequently originated in persons and under circum-
stances where no contagious origin couid be even suspected, still more
proved ; and in no case, with scarcely an exception, does it extend where
a collection of individuals actually suffering from the disease at the time
has been broken up, as when troops are disbanded and go into civil life.
With Mr. Lawrence we should say, "that this disease may be produced
by common causes, without the application of morbific matter to the eye.
But when once excited, it appears capable of propagating itself, under
particular circumstances, in a way which we cannot .distinguish from a
contagious propagation."
Certain states ofthe weather and local peculiarities, such as when the first
is hot, sultry, and humid, and when the latter consist in proximity to marsh-
es and in crowed barracks, favour the coming on of the disease. The vitia-
ted atmosphere between decks, on board a ship, has developed the disease
to an alarming extent, as in the instance of the French slave ship, in her
passage from Africa to the West Indies. Personal causes are found in bad
food, want of cleanliness, abuse [always read use] of spirituous liquors.
Treatment.—It would be a blind rejection of the revelation made by
pathological anatomy and the entire symptomatology ofthe purulent oph-
thalmia of adults if, looking only at the inflammation ofthe conjunctiva
and the tunics of the eye, when the disease is at its height, we were to
rely entirely on antiphlogistic means for its removal. For the safety of
the eye these are undoubtedly, at a particular stage of the disease, of para-
mount importance ; but they alone will neither prevent the development
of the granular formation into phlogosis, nor remove this formation by the
subjection of the latter. In the first degree, when the disease is confined
to the palpebral and even tarsal conjunctiva, it will be prudent to direct
a few leeches round the eyelids at the margin of the orbit, or cups to the
temples ; and, at any rate, to give a brisk cathartic, and apply the nitrate
of silver either in solution or in a solid state. If the former, a camel's-
hair brush or the end of a feather wet with the fluid will be applied to the
conjunctival surface, the lid having been previously everted; if the latter,
a stick of lunar caustic nearly reduced to a point will be applied to the
same surface, exposed in the like manner. Some recommend strong red
precipitate ointment or a solution of alum or sulphate of copper to be ap-
plied to the tarsal conjunctiva. The operation in any case will be repeat-
ed daily until the granular appearance is removed, or unless acute and vio-
lent inflammation supervenes requiring still more active antiphlogistic
measures than those already indicated. If the disease persist in a sub-
acute or chronic form, or if after more violent symptoms this ensues, the
liquor plumbi diacetatis undiluted may be used. Moderate exercise in
the open air is of service to ophthalmic patients in this stage of the dis-
ease, and when the light is strong recourse will be had to the protection
of a shade. Experience has shown, that even after marches in bad wea-
ther, soldiers afflicted with the disease have been benefited.
630
DISEASES OF THE EYE.
The treatment ofthe second stage of acute purulent ophthalmia, when
the sclerotic or ocular conjunctiva is deeply implicated—inflamed and
chemosed, and the cornea threatened, must be of the most active kind.
Army surgeons do not hesitate to abstract at once a large quantity of
blood, by venesection, so as to produce a decided impression on the sys-
tem, and more especially to remove all feeling of pain and uneasiness in
the eye. Thirty or forty ounces are, with this view, taken away at once,
and with results far more beneficial than can be obtained by bloodletting
in the usual quantity, and repeated, it may be, at intervals. If, which
rarely happens, the disease resume its violence or continue its aggra-
vated course, the same means must be resorted to. Auxiliary to vene-
section are active purgatives, antimony and low diet. Walther recom-
mends very strongly the practice of cutting out a large piece of the swollen
conjunctiva, either from the eyelid or the globe, after general bleeding.
The excision, at this time, of even a large piece is marked, after the in-
flammatory tumefaction has subsided, by a mere line. Mercury adminis-
tered after venesection with a view to prevent the effusion of lymph may
do good. As a sialagogue in the purulent stage it is powerless; and in
many cases mu;st be mischievous. After free and suitable depletion, blis-
ters to the nucha and kept discharging with savin ointment, have been
recommended.
In lymphatic habits, and in second attacks or relapses and among the
mixed population of a city, the bold and simple treatment found so suc-
cessful among robust soldiers in the vigour of life, cannot often be carried
out. The general principles to guide us remain the same ; but the en-
forcement will be by milder means, such as a single moderate venesection,
or in its place local bloodletting, laxatives, calomel with tartrate of anti-
mony and opium,—the use of balsams of copaiba and cubebs internally,
and, on occasions, of vegetable bitters and the sulphate of quinia. The
tonic regimen, in its large signification, consisting of good nutritive food,
fresh air, moderate exercise, with bitters and chalybeates, is demanded
also in the decline of the more acute cases of purulent ophthalmia, the
subjects of which are nervous and greatly depressed.
Even in the violent acute form and second and third degrees or stages
of purulent ophthalmia, our main reliance isfar from being on constitutional
treatment, and especially on active depletion, useful as this may be. To-
pical applications are not to be lost sight of in any period of the disease.
Pending the violence of inflammation, excellent effects have been obtained
from the use of cold applied to the eye, by means, severally, of rags dipped
in cold water, and the eye repeatedly washed and cleansed with this fluid.
Cold douche on the head, or free and frequent ablution of this part with
cold water, will also prove to be both refreshing and curative. Dr. Geucke
thus describes the good effects ofthe practice which he adopted. " The
cold douche was resorted to in conjunction with powerful antiphlogistic
means. It was used in all cases attended with chemosis, and it never
failed to give immediate relief. When the affection was obstinate it was
often repeated. The patient was seated in a bathing-tub half full of warm
or cold water ; perhaps the .former is preferable. Cold water was then
poured over the head from a height of five feet: it produced a great shock.
The douche was repeated three or four times, the patient was then put to
bed ; considerable perspiration ensued, and relief from pain." The heat
and vascular turgescence of the conjunctiva is increased by warm fluids,
TREATMENT OF GRANULAR CONJUNCTIVA.
631
fomentations, poultices and steam. Dr. Vetch, if I recollect right, for his
work is not now at hand, gives some instances of the lamentable effects
of poulticing an inflamed eye in purulent ophthalmia, and denounces the
practice in no very qualified terms.
After a decided reduction of the redness and tumefaction of the con-
junctiva, even although it should not have regained its natural paleness
and transparency, and remains relaxed and flabby, recourse must be had
to .astringents and stimulants, as specified in the treatment of ophthalmia
neonatorum. Solutions of alum, chloride of mercury, and acetate of cop-
per and diluted sulphuric acid,have, severally, been used and recommended
bydifferent surgeons. Theproportion of thechloride of mercury to the water
is one grain or two grains to the ounce. One, two, or three drops of sulphu-
ric acid in an ounce of water, and two or three grains of the acetate of cop-
per in the same quantity of fluid, are the formula recommended by Muller.
Preferably to these, will be solutions ofthe nitrate of silver, or ofthe sul-
phate of copper. The latter may be rubbed over the conjunctiva of the
eyelids after everting the latter. The experience of Dr. Hays, editor of
Mr. Lawrence's Treatise on the Eye, and one of the surgeons to Wills'
Hospital, in favour of the early use of a strong solution of nitrate of silver,
is corroborated by his colleagues Drs. Littell, Parrish, and Fox, and
abundantly, also, by others in both public and private practice. " In
cases of comparative mildness," Dr. Littell writes in his excellent Manual
of Diseases of the Eye, " a solution of four, eight, or ten grains should be
dropped upon the eye, or applied to the conjunctiva by means of a camel-
hair pencil, once or twice a-day ; but, in higher grades of inflammation,
it may be safely increased to fifteen or twenty grains, care being taken to
reduce its strength as the puriform discharge abates, and the membrane
resumes its healthy condition. Under circumstances of still greater aggra-
vation, the nitrate, in substance, may be lightly drawn along the inflamed
surface of the lower lid, or, where the cellular infiltration ofthe conjunc-
tiva is so considerable as to threaten disorganization of the cornea, applied
after free scarifications to the chemotic swelling."
Granular Conjunctiva. — In the recognised chronic forms of purulent
ophthalmia, our chief attention is directed to the diseased condition of the
palpebral conjunctiva. This tunic undergoes that morbid change desig-
nated by the term granular, and which has been before referred to. The
term is not, perhaps, the best that could be devised. Granular conjunc-
tiva has been named from its resemblance to a granulating sore,—whereas
it consists, in fact, of hypertrophy of the papillae, with which the palpebral
conjunctiva is beset. Associated with this affection, often, is thickening
and opacity of the cornea, with, also, at times, obvious vascularity. These
lesions of the cornea have been attributed and probably are, in part, owing
to the repeated friction of the granular eyelid on the cornea. But, as Mr.
T. W. Jones (op. cit.) judiciously observes, the morbid state ofthe cornea
may be met with where no granular conjunctiva is present, and it may be»
absent in cases in which the latter is greatly developed. We must look
for the true cause of vascular and inflamed cornea to an extension of the
inflamraation from the palpebral and sclerotic conjunctiva to the cornea.
In the treatment of granular conjunctiva, we must combine the use of
general with topical remedies,—not relying, as sorae surgeons have done,
on the latter to the almost entire exclusion of the former, and especially
of the most active and stimulating of the class, such as sulphate of copper.
632
DISEASES OF THE EYE.
Perseverance is demanded in almost every case ; and while we direct
suitable alteratives—mild mercurials and iodinic preparations, laxatives
and tonics, with good food and pure air—we also see to the application
of astringent or stimulating substances to the eye,—relying more on the
steady use of those of moderate strength than ofthe escharotic, so called.
Counter-irritation, by repeatedly blistering the nape ofthe neck, or by issue
on the temple, is not to be overlooked. " If the granulations are large and
prominent, instead of simply scarifying them, they may be shaved off with
a lancet-shaped knife, or, if pedunculated, they may be snipped off one by
one with curved scissors." (Jones, op. cit.) Dr. Hays speaks in favourable
terms ofthe iodide of zinc; and lays great stress on the remedial value
of a solution of common salt as a wash to the eye, when this organ is
very irritable, and there are injection of the ocular conjunctiva and lachry-
mation. He quotes M. Tavignot's extensive trials of the chloride of so-
dium in different forms of ophthalmic inflamraation, and, more especially,
in ulcerations of the cornea. Ofthe different modes of using the salt—in
its solid state, in the form of ointment, and as a collyrium — M. T. pre-
fers the last, in strength varying from one to three drachms to the ounce
of water.
The vascularity and opacity of the cornea which have been enumerated
among the effects of purulent ophthalmia, and especially of that stage of
this disease called granular conjunctiva, require a removal or notable
abatement of this last affection before we can hope to do much for their
relief. In confirmation of the influence of granular conjunctiva to produce
corneal opacity, is the fact of this being frequently confined to the upper
part of the cornea, that is, to the portion over which the rough surface of
the upper eyelid moves, while the lower half remains transparent. Now,
it is known that granulations are comparatively rare on the narrow surface
ofthe lower lid, which has a more limited range of action than the upper.
These morbid states of the cornea are, properly, modifications of cornei-
tis, and as such will claim our notice when it comes before us in due
sequence.
Gonorrhoeal Ophthalmia.— Causes.—This variety of ophthalmia is an oc-
casional, and both painful and alarming consequence of gonorrhoea. The
common belief, that advanced even by M. Ricord, of its being always the
result of direct contagion, following the application to the eye of the
matter discharged from the urethra, is not borne out by all the facts ofthe
case. Even if we were to admit that ophthalmia is sometimes contracted
by the person labouring under gonorrhoea rubbing his eyes after having
handled his penis, or. otherwise soiled his fingers with the matter dis-
charged from the urethra, yet we are sure that in other cases no such mode
of origin can be traced ; and, besides, the sarae or a closely analogous
affection ofthe eyes sometimes occurs in women suffering under leucor-
rhcea. Direct contagion has sometimes occurred, by a person, while he
laboured under gonorrhoea, washing his eyes with the urine, owing to a
vulgar notion that this fluid is strengthening to weak or otherwise diseased
eyes ; but in some experiments by Beer and Scarpa, in which gonorrhoeal
matter was applied to the eye, only a slight inflammation followed. On
the other hand; intense gonorrhoea has been produced by inoculating the
urethra with purulent matter from the eyes, while suffering under gonor-
rhoeal ophthalmia.
Other explanations of the occurrence of the disease are given, under the
SYMPTOMS AND DIAGNOSIS OF GONORRHEAL OPHTHALMIA. 633
suppositions of there being a metastasis of morbific matter from the urethra
to the eyes, or of there being such a sympathy or co-relation between these
organs, that irritation of the one is readily responded to by the other.
This last is the most plausible view, and one sustained by both direct and
collateral evidence. The doctrine of metastasis ought to rest on the oph-
thalmia following a suppression ofthe urethral discharge, whereas in most
of the cases there has been no arrest of this latter. With Mr. Lawrence,
I am disposed to refer the occurrence of the disease of the eye to a par-
ticular state of the constitution, but without being able to point o\it in what
it consists; and to regard it as a pathological phenomenon analogous to
those successive attacks of different parts which are observed in gout and
rheumatism. Of the three forms of ophthalmic inflammation which occur
in conjunction with or dependent upon gonorrhoea, two show themselves
only in rheumatic subjects. The disease, unless by direct inoculation, is
confined almost entirely to men: attempts have been made to refer the
purulent ophthalmia of new-born children to gonorrhoeal infection ; but
erroneously, as the disease repeatedly shows itself in offspring in whose
mothers no taint of either a gonorrhoeal or a leucorrhoeal nature exists.
The three forms of gonorrhoeal ophthalmia alluded to are — 1. Acute
inflamraation of the conjunctiva. 2. Mild inflammation of this membrane.
3. Inflammation ofthe sclerotic coat, sometimes extending to the iris.
Symptoms.—The most frequent of these forms is the first or acute gonor-
rhoeal inflamraation of the conjunctiva, gonorrhoeal ophthalmia, blephar-
ophthalmia, or ophthalmia gonorrhoica. Its symptoms are often those of
purulent ophthalmia, running its course with great rapidity and violence.
There is the greatest degree of vascular congestion, the most intense and
general external redness ; excessive tumefaction of the conjunctiva ; great
chemosis or circular puttiness and projection of the conjunctiva of the
globe beyond and concealing almost the cornea, with corresponding swell-
ing of the palpebra?, and profuse yellow discharge. The affection soon
extends to the cornea, with severe and lancinating pain in the globe, orbit,
and head, augmented to intolerable suffering on exposure to light, and
with febrile disturbance of the system of an inflammatory nature.
The acute character and rapid march of the disease are such that twelve
hours have sufficed for it to run its course, ending in the loss of the eye by
rupture of the membranes and evacuations of the humours. Commonly
one eye alone is affected ; although sometimes, on the subsidence of inflam-
mation, the other is similarly attacked.
The immediate effects ofthe inflamraation ofthe cornea are sloughing,
suppuration, ulceration and interstitial deposits ; and the remoter ones,
after escape ofthe humours and collapse of the globe, are, in the several
cases, obliteration of the anterior chamber and flattening of the front of
the eye, staphyloma, prolapsus iridis, obliteration of the pupil, corneal
opacity, and anterior adhesion ofthe iris. The cornea becomes dull and
hazy before it sloughs, or indeed before undergoing any of the changes just
mentioned. Contraction or obliteration of the pupil may occur in conse-
quence of protrusion of the iris in partial staphyloma, or at the smallest
apertures attended by ulceration ; or of its adhesion to a leucoraatous por-
tion of the cornea.
The diagnosis between gonorrhoeal and purulent ophthalmia, the two
kinds of inflammation of the eye most nearly resembling each other, is
not so easy; although with careful observation some differences may be
made out. In gonorrhoeal ophthalmia the inflammation first attacks the
634
DISEASES OF THE EYE.
conjunctiva oculi, comes on suddenly, and runs its course to either reco-
very, or more commonly destruction of the organ. While the conjunc-
tiva oculi is more swelled, the discharge is also more abundant and thicker.
The cornea is frequently destroyed by sloughing. In the purulent oph-
thalmia, there is generally a milder period at the beginning ; the palpebral
conjunctiva is the part first affected, and the eyelids are more swelled than
in the gonorrhoeal form. In the former we note also the phlyctenae and
granulations of the palpebral conjunctiva in the acute, and tedious and
obstinate state of granulation in the chronic form. Add to these the frightful
ectropia, or eversion ofthe lids consequent at times upon these changes,
and the greater frequency of both eyes being affected, and we shall be
able to form a tolerably good diagnosis of the disease now before us. But
its history will furnish the best ground of judgment.
Our prognosis, as Mr. Lawrence remarks, will principally turn on the
state of the cornea ; if that should possess its natural clearness the eye
may be saved. If it should be hazy and dull, and more particularly if it
should have assumed a nebulous appearance, consequences raore or less
serious will inevitably ensue. Great swelling of the conjunctiva, more
particularly great chemosis, profuse discharge of a yellow colour, and bright
redness of the swollen upper eyelid, are unfavourable circumstances, as
indicating a high degree of inflamraation. The changes to which the cor-
nea is liable, do not always destroy sight: their effect depends on their
extent and situation. Sight maybe restored after partial sloughing ofthe
cornea ; and extensive ulceration may occur in its circumference without
injury to vision.
The treatment of gonorrhoeal ophthalmia, however decided, energetic,
and early begun it may be, does not promise any uniformity of success.
This is in part owing to the hold taken by the disease before application
is made for relief, and in part owing to the peculiarity of the inflammation
itself. In young and full or sanguine subjects, and while the inflammation
is in its first stage, the antiphlogistic treatment should be carried out to its
full extent, by general and local bloodletting, purging, and antiraonials;
and before even the completion of these measures, and so soon as an evi-
dent impression is made on the circulation, recourse is to be had to topical
remedies to the eye, and counter-irritants and discharge kept up by blisters
to the nucha. A seton is generally preferred for this purpose ; but its
prompt and active properties are not equal to those of a blister.
To give you an idea of the fearful rapidity with which this disease some-
times progresses to its termination, by ulceration of the membranes ofthe
eye and loss ofthe humours, I will just raention two cases that occurred
to Sanson, and are related by him (Diction, de Med. et de Chir. Pratiques).
A young man presented himself one morning at the Hotel Dieu with a
double blenorrhagic ophthalmia, which had made its first attack the even-
ing before. Copious venesection, followed by arteriotomy and the appli-
cation of leeches continually renewed during a period of four days, a seton
to the nucha, drastic purgatives, and collyria with the bichloride of
mercury (corrosive sublimate), were inadequate to prevent the perforative
ulceration of both corneae ; and the patient became blind.
Some time afterwards a Pole presented himself with ophthalmia of the
same kind, but only affecting one eye, and of thirty-four hours' duration.
On the evening ofthe day ofthe entrance of this patient into the hospital,
twenty-five leeches were applied to the temple ; and the next morning,
TREATMENT OF GONORRHEAL OPHTHALMIA. 635
when he was seen by M. Sanson for the first time, he was largely bled,
and on the same day a seton was introduced in the neck; he took Chopart's
potion, then a drastic purgative : between the evening and the following
morning, fresh leeches were applied in such detachments as to produce a
flow of blood that lasted all night and a part of the next day. In addition
to these measures, astringent collyria were frequently injected between
the eyelids and globe from the time ofthe patient's entrance into the hos-
pital. On the second day the cornea became softened and was perforated
and the eye was lost. Some days afterwards, the other eye was similarly
attacked. As the patient was no longer in a state to bear fresh loss of
blood, and as, besides, the most energetic treatment that could be practised
was inadequate to prevent structural changes in the cornea and loss of
sight in the eye attacked, M. Sanson determined on another course. This
consisted in the removal, by excision, of the secreting surface, and the
consequent arrest ofthe morbid secretion, whose product exerted such a
destructive effect on the cornea. I give you, without vouching for its ac-
curacy, the French surgeon's pathological indications in the case that
pointed out his remedy. He excised all the ocular conjunctiva, and then
cauterized with nitrate of silver the whole of the palpebral conjunctiva,
which was too adherent to allow of its being removed by the cutting
instrument. The eye, in this case, was preserved completely. Here,
however, a reflection occurs, tending to detract somewhat from our faith
in this heroic treatment, viz., that when both eyes are attacked with
gonorrhoeal ophthalmia in succession, the disease is less severe in the one
last affected, which is, therefore, usually saved. So confident was M.
Sanson of the efficacy and superiority of the method just described, that he
gave it the preference in all similar cases, and declared that if he saw a
case in which the tumefaction of the lids prevented their separation, he
would not hesitate to enlarge by incision the external commissure, in order
to be able to procure opening enough for the performance of the operation
by excision. Scarpa had, at an earlier period, recommended circular ex-
cision ofthe projecting portion ofthe conjunctiva with curved scissors, at
the part where the cornea and sclerotica unite.
We can only hope for benefit from bloodletting and kindred means
when resorted to before the cornea is affected ; and in the other circum-
stances already mentioned. When, on the other hand, the constitution is
weak, and the previous health bad, general bloodletting is improper, and
even the local abstraction of blood must be had recourse to with caution.
The safer, and indeed the only allowable plan, will be to use immediately
after bloodletting, if this be advisable, and if not from the very outset,
astringent and stimulating applications to the eyes. Of these, the nitrate
of silver is the best, either in the form of a collyrium, ten to twenty
grains to the ounce of water, or in its solid state by pencilling rapidly
all the accessible portions of the conjunctiva. The solution is to be ap-
plied to the same surface by dropping it on the eye, or preferably, by-
carrying a fine camel's-hair brush or even the end of a stiff feather, as that
which terminates a goose-quill, previously dipped in the solution, over
the conjunctival surface. This may be repeated daily, or twice daily,
according to the subsidence of pain and of temporary inflammation induced
by the caustic. After the application of this latter, compresses wet with
the diacetate of lead in solution, mixed with decoction of poppies, may
be applied to the eyelid, and frequently renewed.
636
DISEASES OF THE EYE.
If inflammation should continue after partial sloughing, active depletion
may still be required, both to limit the extent of the mischief and to
favour the process of reparation and restoration. Mr. Lawrence, in his
Treatise on Venereal Diseases of the Eye, relates two cases in which free
depletion, both general and local, was employed after the cornea had
suffered partially in this way ; and the treatment was completely success-
ful in preserving sight.
Free circular incisions of the sclerotica or ocular cornea have been prac-
tised by Mr. Tyrrell, with, as he assures us, the happiest effects. He
recommends the incisions to be made through the conjunctiva and its
subjacent cellular tissue, beginning at the margin of the cornea and ex-
tending towards the edge of the orbit, but avoiding the transverse and
perpendicular diameters of the globe, that the larger vessels passing to the
cornea may not be injured. Mr. Tyrrel feels satisfied that the adoption
of this plan will certainly save the cornea, which has not already become
affected, whatever may be the extent and violence of the surrounding con-
junctival disease ; that when the cornea has become hazy, but still retains
its brilliancy, or, property of reflecting light, the operation will prevent
farther mischief, and that the cornea will probably be restored to its ori-
ginal integrity ; at all events, in such a case submitted to this treatment,
the cornea will suffer but triflingly ; and that where part of the cornea has
lost its vitality, which is indicated by its perfectly opaque state and dul-
ness, or loss of reflecting property, the division of the chemosis will pre-
vent the extension of the mortification, and save that part ofthe cornea
which may still retain life.
Mr. Midlemore also strenuously recommends free scarifications of the
chemosed conjunctiva, by making very numerous incisions, and carrying
them deeply, so as to let out the fluid effused into the subjacent tissue.
Of astringents proper for collyria, the best are the solutions of alum
and of sulphate of copper, from five to ten grains to the ounce of water.
The early administration of tonics, such as the sulphate of quinia and
some chalybeate preparation, contributes towards complete convalescence
and to prevent the disease assuming a chronic form.
Mild gonorrhoeal ophthalmia, marked by external redness of a bright
scarlet tint from distention of the superficial vessels of the globe, and in-
creased mucous secretion, is easily managed by a mild antiphlogistic
treatment and the early use of local stimulants : of these, the nitrate of
silver is the best. When more severe, this form approaches in its symp-
toms to those of acute purulent ophthalmia.
Gonorrhoeal inflaramation of the external tunics and iris exhibits the ves-
sels lying between the conjunctiva and sclerotica distended, and the ante-
rior portion of the latter membrane of a pink or purplish red. As the
conjunctiva participates but slightly in these changes, they are distinctly
seen through it. There is increased lachrymal secretion, severe pain in
the eye, with sense of tension, intolerance of light, and discharge of tears
on the slightest exposure.
The inflammation soon extends to the iris, which loses its brilliancy,
assuming a dull and deeper hue. The pupil contracts, and lymph is
effused into its margin. The external redness is increased, the vessels of
the conjunctiva being more distended. The cornea, at the sarae time,
becomes hazy, and vision is more or less impaired. Nebulous opacity
and speck of the cornea are sometimes produced. With the subsidence
SCLEROTITIS.
637
of inflammation the iris regains its natural colour, and vision is restored.
Or, in the opposite case of persistence, there may be adhesions ofthe
pupil with contractions ofthe iris.
This disease, as Mr. Lawrence justly remarks, is exactly the same as
rheumatic inflammation of the sclerotica and iris, occurring independently
of gonorrhoea. Both this, and the mild purulent inflammation of the con-
junctiva are, he adds, to be regarded as among affections of the organ
excited by gonorrhoea.
The treatment consists in bloodletting, either general or local, accord-
ing to circumstances indicated when speaking of the acute conjunc-
tival form. In milder cases cupping and- leeches will also be aided by
aperients and a reduced diet. Warm local applications are generally
preferred by the patient, and the poppy fomentation is among the best.
Colchicum is given with advantage, owing to the rheumatic character of
the disease ; but its use must be considered as secondary for the removal
of active inflammation. Mercury is required if the iris should be involved
in the affection.
LECTURE CXLI.
DR. BELL.
Diseases of the: E ye(continued) -Sclerotitis-Is rheumatic—Symptoms—Redness of
a pink hue, and particular direction,—vessels running in straight lines—cornea dim, and
receiving vessels from the Xerotic*—Diagnosis—Causes—The same as of rheumatism
in o her organs—Continuation of disease ofthe cornea and iris—Treatment— At first in
milder cases purgatives and Dover's powder-In the fully formed stage, venesection,
cuppmg, and leeching—calomel and opium—tartar emetic and nitre with opium—Calo-
mel where the disease is merely suspended—colchicum with salines—iodide of potas-
h^m^Hi'JT,r,tantSrTLOli0rnS and oiniinentLs l0 allay P«in-When the inflammation
has subsided, bark or sulphate of qnima—For chronic sclerotitis, rely on reeimen occa-
Zl^rTl' ,Bxa".ves' and quinine.-CoRNEiTis-^Structure of the cornea-Is sus-
cept ble of inflammauon-acute or chronic,-primary or secondary-SW^OTns-Con-
com.tant affection of ihe ms-Scrofulous corneitis, occurs in young%ersons-Co^,eitis
is an obstinate dLease-r^m^-Antiphlogistic, with reserve Pand restricUon !!!
E;Ti,i.:cPnSxt °imuch ser;r_Si,mrnary °f treatment whpn «««o^.ni«tion
is threatened— Phlyctenular or scrofulous corneitis—Changes in the cornea consentient
allrugo-Treatment of opaque comea.-lRixis-Structure of the iris—Iritis is eitherpri-
mary or secondary-S^™ and progress-The most characteristic symptoms,-a
change in the appearance and colour ofthe iris, and a red band round the corne^-In-
flammat.on, begins at the pupilary border-Changes of figure of the pupil-Siche".
ZT^T^hTl a"d effeCtS #?°™ i»ti«_Con«i.utionf 1 di.iarb.nc^Cfl^.the
same as of ophthalmia m general—Particular ones, or those of diathesis—rheumatic
S7YyeatZ°nftalT;- u' ? t™ dj8eMe' M VPh»i«-Qae.tion of mercury, as 1 se
-7Vrar7nmt-Ant.phlogist.cs and mercury-Iodide of potassium in sub-acute and
r8ICofri,;!ti71:ralme|tin,theSe SlaFs-Use «f bel.ad'onna and stramonium- Va-
r.ettes of .r t.s-General mdicat.ons of treatment.-CHoRoiD.Tis-Vascularity of the
choroid coat-Few external symptoms-Functional disorders-Case of the lecturer's
-Keatment-n the ma.n, an,,phlogistic-but with early recourse to tonics.-R^!
N.T.s-D.fficulty of distinguishing it from choroiditis-Cau^-Case-JmawoS-
Its^diversified causes-Pract.cal inferences to guide us in the treatment of 3„™i.
-Scrofulous OPHTHALMrA-One of the mixed forms of ophthalmia_S™nX5-£
most common in chtdren-lis organic features-Physiognomy of those affTted wi h
the disease-Org-a^ cAan^-hnplications of the" tarli and Meibommn glan^-
7W™n/-Lhange of hab.tation-Moderate depletion and laxatives-Tonfcs-sul-
638
DISEASES OF THE EYE.
phate of quinia and iodide of iron—Narcotics—Regulation of the diet—Clothing—
Change of air—Collyria—pencilling the eyelids with solutions of nitrate of silver and
of iodine—General plan of treatment—Disorganising inflammation of the cornea—
Extract of belladonna—Erysipelatous ophthalmia—Symptoms and treatment—Pustular
ophthalmia—Symptoms and treatment—Variolous ophthalmia—Time of its appearance—
Treatment—Catarrho-rheumatic ophthalmia—Symptoms and treatment referable to those
of catarrhal and of rheumatic ophthalmia.—Ophthalmia Tarsi—Its two varieties,
catarrhal and scrofulous—Symptoms of catarrhal ophthalmia tarsi—Chronic form, or
lippitudo—Entropium—Ectropium—Causes— Treatment — Scrofulous ophthalmia tarsi—
has features in common with the catarrhal—Its scrofulous ones, hordeola, vesicles,
or pustules and ulcers—Psorophthalmia—a wrong term—This variety may he con-
nected vi\th favus dixpersus or impetigo figurata—Tylosis—Madarosis—Treatment of scro-
fulous ophthalmia tarsi.
Sclerotitis—Sclerotitis Rheumatica— Ophthalmia Rheumatica.—Belong-
ing, as the sclerotic membrane does, to the fibrous system, its inflamma-
tion, except from traumatic causes, is of a rheumatic kind. Its connexion
with the iris and cornea is very intimate, and, hence, inflammation ofthe
sclerotic soon affects the iris and cornea in a similar manner, as these, in
their turn, readily transmit their phlogosis to the sclerotic.
Symptoms.—Redness beginning on the anterior part of the globe, in
the form of a pink or lake-coloured zone, encircling the cornea, intole-
rance of light, increased lachrymation, but no mucous secretion from the
conjunctiva, rheumatic pain around the orbit, in the temples, face, &c,
with exacerbations at night when the patient gets warm in bed. After
a time the redness is uniformly diffused through the sclerotica, as if it had
been tinged with some colouring substance : the inflamed vessels of the
sclerotica run in straight lines, from behind forwards, while the vessels of
the conjunctiva are irregular and tortuous. The cornea becomes dim
from exudation into it, and over its margin : at one side or even all round,
vessels may be seen shooting into it, to the extent of one-twentieth or one-
tenth of an inch, and then suddenly stopping. The iris is discoloured,
the pupil contracted, sluggish in its motions, and perhaps hazy.
Diagnosis.—In addition to the distinguishing symptoms between scle-
rotitis and conjunctivitis, just mentioned, viz., the kind of discharge from
the eyes, the seat of pain, the colour of the inflamed tunics, and the direc-
tion of the vessels,—we find that in the disease now under notice the eye-
lids do not participate in the phlogosis of the sclerotica as they do in that
ofthe conjunctiva.
Causes.—These are the same as of rheumatism in other organs, although
the sufferers from sclerotitis may never have been affected previously with
rheumatism in any other part. Sclerotitis participates, as you have been
already told, in inflaramation of the cornea and iris, and, also, it may be
added, ofthe internal tunics.
Treatment.—Sclerotitis is liable to continue to a certain point of culmi-
nation, then to assume a milder character, but to remain some time in a
sub-acute, if it does not degenerate into a chronic form. We should be
aware of this fact in the selection of remedies as well as in awarding our
preference for particular ones. If the habit and state of the system allow,
a brisk purgative should be given at once, followed by Dover's powder
and warm pediluvium. These remedies failing to arrest the disease, re-
course should be had without farther delay to the lancet and blood ab-
stracted so as to produce a decided impression on the system and present
relief from pain. If further depletion be required, you will make your
choice, according to the constitution of your patient and the intensity of
TREATMENT OF SCLEROTITIS.
639
the symptoms, between farther venesection, or cups or leeches to the tem-
ples. In the first stage of acute rheumatic inflammation ofthe sclerotica,
I have observed that we gain more by general than by local bloodletting.
The latter answers a good purpose when the general febrile disturbance
is abated and the pain becomes more paroxysmal. Calomel and opium
constitute a part ofthe routine course of treatment of the English physi-
cians and ophthalmic surgeons, but we are left in doubt as to the relative
value of the two articles. Opium in certain stages of rheumatism, and
especially when it determines to the skin, affords the greatest relief; and
accordingly Dover's powder in doses of five grains every four hours
through the day may be directed with manifest benefit after due deple-
tion. If the inflammatory action in the eye be still considerable, tartar
emetic should be conjoined with the opium, in the proportion of an eighth
to a fourth and even half a grain with a sixth to a third of a grain of
opium and ten grains of nitre, every two hours ; the tartar emetic to be
increased or diminished according to the toleration by the stomach of its
use. When there is a suspension merely, without marked diminution of
the disease, calomel in doses of two or three grains with minute doses of
opium so as to keep it from teasing the bowels, three times a-day, will
come in seasonably. Colchicum, from its occasional efficacy in common
rheumatism, has been administered with good effect in sclerotitis. The
dose is from twenty drops to half a drachm three times a-day, with mag-
nesia or, as I more commonly prescribe it, with magnesia and its sulphate
combined. Its beneficial operation ought to be manifested in twenty-four
to thirty-six hours, to justify a perseverance in its use. When the disease
assumes a sub-acute form or has lost its progressive character, but still
torments the patient with pain of a paroxysmal kind, the iodide of po-
tassium, in a dose of from three to five grains three times a-day, in solu-
tion, with sweet spirits of nitre, or, if the bowels are torpid, with sulphate
of magnesia, may be had recourse to with pleasant results. It is particu-
larly useful in those cases in which the iris is threatened and in which
calomel is usually prescribed.
Counter-irritants, in the form of blisters, or tartar-emetic ointment or
croton oil to the back of the neck, or to the temple of the affected side,
are demanded, under the customary conditions for their use in the phleg-
masiae generally. Ofthe topical remedies to the eye and its vicinity, the first
used and the most soothing are sponging with warm water, aqueous va-
pour applied to the organ, and poppy fomentations. As a means of allay-
ing pain, friction of the eyelids and round the orbitar projection with
various ointments and lotions, has been recommended ; such as mercurial
ointment combined with an equal part of extract of belladonna, tincture
of tobacco, morphia dissolved in almond oil, or laudanum combined with
the extract of belladonna in the proportion of ^ss. ofthe latter to ^ss. of
the former—also tincture of stramonium alone, or combined with an equal
quantity of camphorated soap liniment.
Bark and its representatives, the salts of quinia, have often proved emi-
nently serviceable in sclerotitis when congestion succeeds inflammation.
Even when, to the eye of the physician, there is little abatement of the
sclerotitis as far as regards the deep injection and colour of the part, and
the pain is still acute and violent, but the pulse has lost its hardness and
volume, sulphate of quinia should be given in a dose of two to five grains
twice a-day. The effect is soon most obvious and grateful. In the more
640
DISEASES OF THE EYK.
chronic form of the disease bark or sulphate of quinia is still more impera-
tively required. We must be prepared, in some protracted cases of chronic
sclerotitis, to rely mainly on regimen, occasional cupping, laxatives and
quinine.
Corneitis— Ceratitis — Keratitis — Inflammation of the Cornea. — The
cornea, from a superficial view of its texture, which is horny, would seem
to be scarcely susceptible of inflammation. But a more minute inspection
shows it to consist of concentric lamellae connected together by intervening
delicate cellular tissue and transparent fluid, in which lymphatics and
nerves are distributed. This tissue is more abundant and at the sarae
time more lax between the anterior than between the posterior lamellae.
The peculiar polish and brilliancy of the anterior and external surface of
the cornea depends on the transparent epithelial portion of the conjunctiva
spread over it. It is quite probable that the cornea obtains its nutrition
from the blood circulating in the vessels of the adjoining portions of the
conjunctiva and sclerotica ; and hence that the vascular congestion which
accompanies inflammation is in the adjoining tunics rather than in the
cornea itself, while the cornea is the seat ofthe exudation, and undergoes
changes consequent on this process. But independently of thisphenomenon,
the cornea admits red blood and its surface becomes generally red under
active and long-continued inflammation. The vessels, in this case, are,
however, commonly represented to be the product of the inflammation
itself. Be this as it may, the cornea is susceptible of inflammation and its
effects of adhesion, interstitial deposit, softening, thickening, induration,
ulceration, suppuration, sloughing or mortification, in as marked a manner
as tissues the vascularity of which is considerable. Inflammation of the
cornea may be acute or chronic, primary or secondary.
Symptoms.—There is little redness of the white of the eye, and tkat
principally sclerotic. The cornea itself is at first hazy, then exhibits a
greyish-white opacity like ground glass, denser in some parts than others,
which, after a while, becomes streaked with red, owing to the develop-
ment of vessels in the exuded matter. If inflammation of the conjuncti-
- val expansion be added, the cornea is, in some parts, opaque, thickened,
and vascular. Increased prominence of the cornea takes place, owing
to softening of its laminae and increased accumulation of aqueous humour.
Affection ofthe iris, a not unfrequent concomitant of corneitis, is not easily
seen, in consequence ofthe opacity ofthe cornea. There are little pain,
some intolerance of light, and lachrymation and dimness of vision. At
times, however, pain and a sense of tightness in the eye or forehead are
complained of. When the local symptoms are severe, the constitutional
sympathies amount to headache and feverishness with exacerbations and
remissions of the disease.
When the disease occurs in young persons of a strumous habit, it is
called scrofulous corneitis; and when in persons in middle age accompanied
by gouty or rheumatic characters, it is designated accordingly. In refe-
rence to causes, it is found to prevail more in young subjects, from eight to
eighteen years, than in older ones ; and it is more frequent in females than
in males. Sometimes the inflammation follows retrocession of diseases of
the skin.
Corneitis proper, that is inflammation of the substance of the cornea,
is an obstinate disease ; but under proper treatment the interstitial effu-
sion or exudation is removed and the cornea regains its transparency.
VARIETIES OF SCROFULOUS CORNEITIS.
641
The iris sometimes retains the changed colour which it contracted in the
corneitis, and on occasions it may be dark-coloured,and the pupil adherent.
The cornea, also, under less favourable circumstances than those first de-
scribed, loses its transparency and becomes changed in various degrees,
from leucoma to slight nebula.
The treatment of corneitis will be antiphlogistic, but with the reserve
and restrictions imposed on us by the delicate constitutions of so many of
those who suffer from the disease. Occasionally a few cups to ihe temples
or leeches to the eyelid will be required ; but for the most part we rely
on an antimonial emetic, followed by purgatives and tartar emetic in
contra-stimulant doses, then calomel with chalk, and finally vegetable bit-
ters, small doses of the sulphate of quinia, and, if the habit be scrofulous,
iodide of iron. Blistering or tartar-emetic ointment on the nucha, or
behind the mastoid process, has good testimony in its favour. Local ap-
plications are not of much service in acute corneitis : but when used the
milder ones should be tried first, and after the acute symptoms have been
overcome, recourse may be had to a solution of the nitrate of silver
dropped into the eye once a-day.
" 662. If under this treatment the case does not improve, but the
inflammation, on the contrary, continues active and severe, the iris, per-
haps, becoming discoloured, with the pupil contracted and ulceration
threatening to penetrate the cornea, the following treatment should, with-
out delay, be had recourse to. Evacuation of the aqueous humour,
leeches round the eye, followed by renewed blisters behind the ears,
small doses of calomel internally, to the extent of affecting the gums, the
quinia being still given ; and in addition to the continuance ofthe bella-
donna fomentation, the drops of belladonna or atropia, to keep the pupil
dilated if it is the centre which is threatened to be penetrated with ulce-
ration, in order, if penetration should take place, prolapsus iridis may be
prevented." (T. W. Jones, op. cit.)
Corneitis Scrofulosa vet Strumosa — Phlyctenular Corneitis. — This
belongs to scrofulous ophthalmia, which will soon engage our attention.
It differs from corneitis, already described, more in concomitant and espe-
cially constitutional symptoms of long duration and great obstinacy than
in the appearance and changes ofthe cornea itself.
A few words, which might, if space allowed, be replaced by many pages,
must suffice for a notice of the changes in the cornea, consequent on inflam-
mation, or vascular congestion of this tunic.
Vascularity of the cornea, manifested by the passage of vessels containing
red blood, may be produced by the enlarged vessels ofthe conjunctival
layer, or they may be more deeply seated, perhaps in the eorneal laminae.
This may be one of the effects of inflammation of the conjunctiva, or of
that ofthe cornea, or of scrofulous ophthalmia. More generaily,however,
the vascularity is the slow consequence of chronic irritation, as from
granular conjunctiva in purulent ophthalmia. When the vascularity and
thickening of the corneal conjunctiva are so great that the cornea appears
as if covered with a bit of red cloth,, the state is named pannus.
Ulcers of the Cornea occur frequently in various forms of ophthalmia,
as in the purulent of infants, and also that of adults and in the gonorrhoeal,
scrofulous and variolous varieties. But it ought also to be known,
that destructive ulceration of the cornea may exist without any or with
very slight inflammation, as in cases of great exhaustion ofthe system, and,
vol. n.—42
642
DISEASES OF THE EYE.
also, of diseases ofthe fifth pair of nerves. In spreading ulcerations of
the cornea, accompanying purulent or gonorrhoeal ophthalmia and attended
with debility, a decidedly tonic and stimulating treatment is the best, that
is, nutritive food with malt liquor, wine, the sulphate of quinia, and local
astringents. In general, ulcerated cornea will require the treatment
adapted to the ophthalmia of which the corneal disease is a part and an
effect. In that peculiar kind of ulceration, where there is a deep groove
in the margin of the cornea, after stopping the inflammation, Mr. Law-
rence recommends us to raise the general powers by good diet and tonics
and leave the ulcer to nature. The most rapid recoveries he has seen in
extensive ulcers of this kind have been where no local means but simple
tepid ablutions have been employed. In general if we succeed in arresting
the inflammatory action, the ulcer will soon heal without any particular
local treatment. Any obvious cause of corneal irritation, such as granular
conjunctiva, must of course be removed. When a deep ulcer threatens
to penetrate into the anterior chamber, evacuation of the aqueous humour
often proves of great service, by taking off the strain from the ulcerated
part. So, likewise, following another advice of Mr. Jones—when an ulcer
ofthe cornea threatens to penetrate, it is advisable to keep the pupil con-
stantly under the influence of belladonna, in order that, should perforation
and consequent escape of the aqueous humour take place, prolapsus of
the iris may not follow. In obstinate cases of creeping ulceration of the
icornea, Mr. Lawrence has found great benefit from an issue on the temple.
An appearance of the cornea resembling wet chalk is met with in
eases of ophthalmia, which, although not violent, are peculiarly obstinate
and intractable. Dr. Jacob ascribes this appearance to the acetate of lead
used in collyria, which he says is decomposed, and a white precipitate is
deposited in the ulcer, to which it adheres tenaciously, and in the healing
becomes permanently and indelibly imbedded in the structure of the cor-
nea. A single application will produce the opacity. Mr. Tyrrell shows,
however, that the appearance in question cannot be produced, in all cases,
by the use ofthe lead lotion.
Opacity ofthe Cornea is a frequent consequence of inflammation, and
is owing either to interstitial absorption or to the cicatrization of an ulcer.
In its slighter form opacity is called nebula, haziness or dulness, the part
exhibiting a milky,, cloudy, or smoky appearance. In a greater degree
the opacity amounts to leucoma or albugo, words of similar signification,
the former having a Greek, the latter a Latin derivation. Albugo is the
result of circumscribed exudation giving rise to a phlyctenula or pustule,
which has receded without being matured. The term macula is applied
to a small patch or speck. Opacity may be confined to the external or
mucous layer: it may be seated in the corneal substance, or in the inter-
nal serous membrane ; or it may extend through the whole body of the
cornea.
The treatment of opaque cornea will be relative to stage or duration,
and the degree of accompanying inflammation. The latter being removed
we may wait patiently for a removal of the opacity, which in children,
whose absorbent function is active, takes place with often considerable
rapidity. After the call for direct antiphlogistic measures has ceased, the
treatment will consist in counter-irritants to the nucha or behind the ears,
or to the temples, of a kind already described, and in laxatives and alter-
atives, calculated to remove disorder of digestion, or to restore this func-
SYMPTOMS OF IRITIS.
643
tion if it have been weakened. It is now that topical astringents and
stimulants to the eye are indicated. Of these the best is a solution of
nitrate of silver, two grains to the ounce of water, and gradually increased
in strength. Mr. Midlemore recommends, to be used in succession, the
solution of the nitrate of silver, and also that of the bichloride of mer-
cury, the vinum opii, and an ointment consisting of one part of the citrine
ointment (ung. hydrarg. nitrat.) in three of lard or simple cerate. Dr.
Hays thinks well of a solution of the sulphate of cadmium, one to four
grains in the ounce of water. Dupuytren's favourite preparation, I well
remember, was an impalpable powder, composed of equal parts of im-
pure oxide of zinc (prepared tutty), sugar candy, and calomel—to be
blown into the eye through a quill. Substitution ofthe transparent cor-
nea of an animal, by transplantation, for the opaque one in the human
subject, has been tried, but as we learn from M. Plouviez with very
indifferent success. Excision of the superficial opaque lamina of the cor-
nea has been practised at different times; but although M. Malagaigne's
case was a successful one, the operation is, for good reasons, discouraged
by the great majority of ophthalmic surgeons.
The firm white shining cicatrix of wounds or ulcers of the cornea (leu-
coma), Mr. Lawrence thinks, does not admit of cure. Mr. Midlemore's
opinion is more favourable. He uses the strong nitrate of silver ointment
every day to the part, and directs the administration of mercury so as to
keep up a slight ptyalism, occasional leeching, counter-irritation behind
the ears or at the back of the neck, or, by means of an issue, on the temple.
Iritis—Inflammation ofthe Iris.—A knowledge ofthe structure of the
iris, coming as it does under the head of the erectile tissues, and of course
being very vascular and nervous, would prepare us for a discovery of its
frequent lesions and functional,disorders. Iritis may be either primary or
secondary. In the latter case it follows inflammation ofthe tunics ofthe
eye, as of the conjunctiva, sclerotica, cornea, choroid and retina. This
inflammation has a great tendency to an effusion of coagulable lymph and
to the formation of adhesions of the iris, particularly of its pupilary mar-
gin. It is acute or chronic in its stages and duration, and exhibits nume-
rous varieties depending on constitutional diathesis or taint.
Symptoms and progress.—Acute iritis occurring in persons of a full
habit and sanguine temperament, has run its course with such rapidity as
to destroy vision in a few days. In other cases it is slower in its pro-
gress, not seriously impairing vision until after the lapse of many weeks.
These have been termed sub-acute. In a third class, again, the chronic,
the inflammation is so slow and productive of so little inconvenience to
the patient, as hardly to excite attention until decided functional obstruc-
tion occurs.
The symptoras of acute iritis are a dull pain or sensation of fulness,
accompanied with pricking of various degrees of intensity, slight photo-
phobia and confused vision, contraction and diminished mobility of the
pupil, which is fixed and of a dark colour. But the most characteristic
symptoms of iritis are, a general change in the appearance of the iris,
beginning at its inner or pupilary margin, and redness ofthe white ofthe
eye, in the form of a red circle or band round the cornea. With a red-
dish or rusty-brown discoloration of the inner circle, there is, also, thick-
ening of the pupilary border. " A light-coloured iris assumes, under
inflammation, a yellowish or greenish tint; occasionally, it is distinctly
644
DISEASES OF THE EYE.
yellow ; and if the eye be blue, a bright green is sometimes seen.
Generally, however, the tint, whether yellow or green, is of a dull and
muddy cast, and darker than in the sound state. In case of the iris
being naturally dark-coloured, it is less altered under inflammation, pre-
senting merely a reddish tinge. Together with these changes of colour,
there is a complete loss of its natural brilliancy ; it becomes dull and
dark, and the beautiful fibrous arrangement, which characterizes it in the
healthy state, is either confused or entirely lost." (Lawrence, op. cit.)
The inflammation of the iris which begins at the inner circle is sometimes
restricted to this part, but more commonly it extends to the outer or ciliary
border, and it is then that the red band round the cornea, formed by the
vessels of the sclerotica, is observed. The colour of this band is of a
vivid red in acute iritis, and if this latter be intense the whole visible sur-
face of the eye is of a uniform fiery redness. The red zone lasts as long
as the inflammation of the iris continues ; and if there should be only a
section inflamed, the redness of the sclerotica is confined to the part cor-
responding with it.
When the disease becomes fully developed, the pain is raore severe
and even acute, extending from the eye to the supra-orbitar region, and
it is accompanied with increased lachrymation. The motions of the pupil
are more and more impaired, until, with the increasing effusion of lymph,
they are lost entirely : the pupil becomes gradually smaller and smaller,
and it may be entirely closed if the disease is not arrested. Short of this
termination, the pupil undergoes alteration in its situation ; its edge being
fixed at one or more points, and free elsewhere. Sometimes it is angular
and otherwise irregular. The diagnosis derived from the altered figure
ofthe pupil, as alleged by Sichel, is not sanctioned by the experience of
others. Thus he tells us that in rheumatic iritis, it is elongated or oval,
its long diameter being in a vertical direction ; in the arthritic variety it
is transversal, and in the syphilitic it is obliquely oval or in a direction
from below upwards, and from without inwards. The effusion of lymph
in iritis shows itself in the texture of the iris, causing the changes of
colour already described, in the form of a thin layer ; or in distinct masses
of a yellow or reddish-brown colour, varying in size from that of a pin's
head to a split pea, which may be deposited on the edge of the pupil, or
on any part of the anterior surface of the iris. A true abscess of the iris
itself may be formed. Effusion may take place into the anterior chamber
under the form of hypopion. Lymph may be poured out from the margin
ofthe pupil or uvea, so as to agglutinate them partially or generally to the
capsule of the crystalline. A mass of lymph sometimes fills the pupil;
but, more commonly, a thin greyish web or film stretches across the open-
ing, which loses its clear black colour, and has a cloudy appearance.
The iris during the progress of inflammation swells, or at least appears
to swell ; and it approaches towards the cornea, becoming convex in
front, diminishing the anterior chamber and sometimes having its surface
puckered and irregular. If the disease be not checked, the inflammation
passes from the ciliary circumference of the iris to the corpus ciliare, the
choroid coat and retina, with increase of pain and fever, and ultimately
with irrecoverable loss of vision, from change in the structure of the re-
tina. Forwards, the cornea becomes more opaque, the conjunctiva more
inflamed, " so that the case which was, at first, simple iritis, becomes
subsequently ophthalmitis, or inflammation involving the external and
CAUSES AND TREATMENT OF IRITIS.
645
internal tunics generally." Adhesions and the formation of an adven-
titious membrane on the pupil, and its final closure, are farther conse-
quences of iritis.
The constitutional disturbance in acute iritis is often considerable, in its
being attended with headache, thirst, loss of appetite, costiveness, and a
full and strong pulse.
Causes.—These are the same with the causes of ophthalmia in general
—wounds, surgical operations, particularly for cataract and artificial
pupil, excessive exercise of the eye on minute objects, suppressed perspi-
ration ; other diseases, such as gout, rheumatism, syphilis and scrofula.
Some writers, and among them is Mr. Travers, believe that the excessive
use of mercury is a cause of iritis. It has been alleged that the greater
frequency ofthe disease in syphilitic subjects is owing to the large use or
abuse of mercury in these cases. On this point Mr. Lawrence shows that
iritis has occurred in very many persons labouring under syphilis who had
not taken any mercury.
Treatment.—This should be actively antiphlogistic, while, at the same
time, the tendency to closure of the pupil and adhesions of its border is
prevented by the external application of belladonna. Venesection should be
early and freely resorted to, and active purging procured at the same time.
The common indication for bloodletting, in a strong and full pulse, need
not be regarded as a necessary guide in the disease before us, tf the organ
itself manifest the symptoms of active phlogosis, and deposition of lymph
with its associate effects. As in other phlegmasiae, however, when we
have controlled the morbid excitement of the heart by venesection, but
the inflammation ofthe iris still continues, we may have recourse to local
depletion by means of cups or leeches to the temples, or behind the mas-
toid processes. Auxiliary to sanguineous evacuations will be the regular
use, at short intervals, of tartar emetic as a contra-stimulant. In the opi-
nion of many ophthalmic surgeons and writers, there is a still more urgent
call for the use of mercury, which they allege to have a peculiarly con-
trolling power over iritis. Calomel and tartar emetic may be advan-
tageously combined together, and both with nitrate of potassa, as in the
treatment of most of the phlegmasiae in this country. In harmony also
with our experience in this class of diseases, is the fact that mercury can-
not be relied on unless and until prior depletion by bloodletting and pur-
gatives have been employed. Then will its good effects be conspicuous.
On the other hand, although the antiphlogistic and antimonial treatment
alone will suffice in some cases, yet in others, notwithstanding that, it was
highly proper and indeed necessary in the very early stage, yet it fails to
cure, without the aid of mercury.
In cases of sub-acute iritis, small doses of mercury continued for a
length of time, but without causing salivation, are preferable to larger
doses of the medicine. I have derived the best effects in this form of
disease, after topical depletion, from the use of the iodide of potassium,
administered in moderate doses during the day, and a pill of blue mass
and hyosciamus at night, aided by sustained pustulation of the temple of
the affected side with tartar emetic. It is in the sub-acute and still more
in the chronic form of iritis, that counter-irritation, either by the means
just mentioned or by blisters or even a seton to the temple or to the nucha,
will be found serviceable. Active purging, with the use of the blue pill
daily, will contribute not a little to the desired end. When confidence is
646
DISEASES OF THE EYE.
reposed in the efficacy of mercury as an alterative, its combination with
chalk, as in the hydrargyrum cum. cretd, should be preferred as least liable
to disturb the digestive organs.
The use of belladonna or of stramonium, in the form of extract diluted
with water, or made into ointment, rubbed on the eyebrows and eye-
lids, is an important aid to the general treatment, by its active effects in
dilating the pupil, and preventing and even breaking up adhesions ofthe
iris to adjoining parts, and especially the membrane of the crystalline.
In order to give effect to the narcotic action of the belladonna active
depletion ought to be premised in acute iritis.
I shall not enter into details of treatment for the several varieties of
iritis, viz., the rheumatic, gouty, syphilitic, and scrofulous, as the modi-
fications in the general outline which I have just now sketched, will
readily occur to you. I may just say, however, that in rheumatic iritis
free depletion is required, although afterwards we may deem it advisable
to give colchicum and the iodide of potassium ; and that in gouty iritis
we shall lay more stress on purgatives ; and in the scrofulous variety, on
purgatives and tonics with chalybeates. Syphilitic iritis may seem to call
imperatively for the use of mercury ; but on this point we shall be guided
by the same considerations that influence us in the treatment of syphilis
affecting other tissues and organs. You will soon learn that mercury is
not by an^* means a medicine of such indispensable use in any form or
stage of syphilis as was for a long time implicitly believed. Of late years
the oil of turpentine has been recommended, on the score of its success in
the hands of Mr. Hugh Carmichael, of Dublin. He more particularly
advises this article in syphilitic iritis—in cases in which the use of mer-
cury is inadmissible. The dose is a drachm, three times a-day, in almond
emulsion, as the least offensive mode of administering it.
Choroiditis—Sclerotico-Choroiditis—Inflammation of the Choroid
Coat. — Of the diseases of the choroid we are unable to form a positive
opinion, as it is invisible to our observation ; nor are they revealed to us
by functional disorders, as in the case ofthe retina. Its great vascularity
would prepare us to look for its liability to various forms of congestion and
inflammation. The subjects of this affection are usually adults, and fe-
males more than males. There is no general external redness, nor, in-
deed, any obvious organic change. In a case of considerable intensity
which came under my care last year (1847), I could not, after the. most
careful.inspection, with the aid of a magnifying glass, detect any change
of colour or other abnormal appearance of the eye, except, perhaps, that
the pupil did not contract quite as readily as that of the healthy eye. Mr.
Mackenzie mentions a small batch of vessels near the edge ofthe cornea,
and some displacement of the pupil, the iris being drawn towards the
affected portion of the choroid. This tissue may be involved in the dis-
ease or remain sound. Serious changes may be produced by choroiditis;
viz., staphyloma scleroticae, effusion of fluid between the sclerotica and
choroid, or between the latter and the retina, and general dropsical en-
largement of the globe. Mr. Tyrrell believes that disorders of the cho-
roid coat are of frequent occurrence. In its morbid condition, its tissue
is changed by distention, and, in greater degree, by permanent varicosity
of its vessels, disturbing the retina by pressure ; it is, also, subject to
acute or chronic inflamraation extending to the iris and sclerotica by vas-
cular connexion.
RETINITIS.
647
To choroiditis may be referred various forms of rauscae and impaired
vision, often distinguished by objects being coloured (photopsia) or seen
through a mist, cloud, or network. My patient, a female aged twenty-
eight years, of a strumous habit, was suddenly affected, in the seventh
month of her pregnancy, with loss of vision in one eye, accompanied with
a sensation of a red flame before the diseased eye. On first awaking in the
morning, the colour was green, which, after a while, became ofthe usual
red or crimson. There was a sense of fulness in the eye, and very con-
siderable pain in the supra-orbitar and contiguous temporal space. As
the disease began to yield, there were intermissions through the day in
the sensation of red colour ; and, after a time, this was replaced by an ap-
pearance of numerous branches or twigs, then of open network, and then
of a gauze and a mist. Gradually, with the changes in this respect, the
vision was improved, so that objects, the outlines of which could not be
discerned at all, became more and more visible. In this latter period,
the vision would sometimes be completely restored for an hour or two,
and then be suddenly lost or impaired in the manner just described. The
duration of the disease in this patient was about six weeks, and nearly up
to the date of the birth of her child. At this time, although the eye had
nearly recovered its functions, there was occasional dimness of vision,
which, however, soon disappeared after her confinement (June, 1847).
The prognosis in choroiditis is unfavourable, as the obscurity of vision
is apt to increase and to terminate, although slowly, in blindness.
The treatment of choroiditis, although in the main antiphlogistic, must
be modified a good deal by the diathesis and general health of the patient.
The assertion of Mr. Tyrrell that the disease is connected with general
debility, in nineteen cases out of twenty, and that a tonic treatment should
be used, is, perhaps, laid down rather too broadly. He advises nutritious
diet and tonic medicines, such as bark, the mineral acids, sarsaparilla,
steel, in conjunction with small doses of mercury ; using the latter more
freely when the state of the iris and of vision indicates considerable and
advancing disorganization. In the case which I have described, I be-
lieved myself to be obliged, with a pulse for some time full and resisting,
to have recourse to venesection twice, and the repeated application of
leeches to the temple of the affected side. An eruption was kept up in this
region with croton oil. I also gave tartrate of antimony, for some days, in a
dose of an eighth to a sixth of a grain every two or three hours, with, it
seemed to me, manifestly good effect. I would have carried its use far-
ther, but for the peculiar state of my patient. Calomel was, also, given at
intervals, combined, sometimes, with ipecacuanha, sometimes with tartar
emetic. Purgatives were, also, administered, but not with the same free-
dom as in a patient differently circumstanced. After her confinement I
directed a more stimulating diet, and the use of quinine and chalybeates
to this person, who then manifested symptoms of anemia.
Retinitis—Inflammation of the Retina.—It. is difficult to distinguish
inflammation of the retina from that of the choroid, and, hence, both
affections have been classed under the head of ophthalmia interna poste-
rior. If we were to say, that in choroiditis, photopsy is the chief pecu-
liarity, and in retinitis there is merely dimness of vision, it might be re-
plied, that the latter defect exists, also, in some cases of inflammation of
the choroid, and in which photopsy is not always present. You will
have a better idea of the character and treatment of inflammation of the
648
DISEASES OF THE EYE.
retina from the following case, related by Mr. Lawrence, than from a sys-
tematic description of the disease. Dimness of sight and pain in various
degrees, are the early symptoms; the pupil is at first contracted, and af-
terwards enlarged. It is caused by long exposure to strong light and
heat, and lightning.
" Case.—Retinitis from Exposure to Light and Heat.—A young woman,
of florid complexion and full habit, came to the London Ophthalmic In-
firmary, complaining that she had lost the sight of one eye. She was
cook in a family, and occupied for several hours daily before large fires,
supporting her strength by free living. The pupil was slightly dilated,
the iris motionless ; a faint and scarcely perceptible pink tint was observed
in the sclerotica near the cornea. Vision was dim and had been so for
three days. There was headache, flushed countenance, heat of skin,
whitish tongue, and thirst. I considered the case to be pure retinitis,
and to afford a favourable opportunity for showing whether the affec-
tion could be arrested by antiphlogistic treatment. At that time (now
many years ago), I did not possess the knowledge of the powers of mer-
cury in inflammation of the retina, which subsequent experience has given
me. I directed a full bleeding from the arm, free purging, low diet, re-
pose of the organ, and general rest. At the end of two days the sight was
worse; cupping and blister were now ordered, but there was no improve-
ment at the end of two days more. I now determined on trying mercury,
and ordered two grains of calomel every four hours. Before the remedy
had affected the system, vision was quite lost, or at least reduced to the
mere power of distinguishing light from darkness. Full salivation, which
took place in about a week from the first application of this patient at the
Infirmary, suspended all the symptoms ; sight immediately improved and
was soon completely restored."
Amaurosis naturally comes up for notice, after our speaking of organic
change and functional disturbance of the retina. Into a description of this
disease it is not my purpose now to enter. A mere enumeration of some of
its chief causes and associated disorders will, however, of itself be so far
serviceable as to prevent your indulging in a routine or empirical treat-
ment, under the impression that it is a disease depending on weakness or
palsy of the optic nerve. Amaurosis may be caused by excessive exer-
tion of the retina, by a stroke of lightning, by inflammation of other
parts of the eye, or from sympathy between the nervous structure of the
eye and the nerves of the fifth pair, or a remote organ, as the stomach; or
it may result from organic lesion of some part of the brain, as of one of the
quadrigeminal tubercles and part of the optic thalamus,—or from pressure
on the optic nerve. It is obvious that we are unable to say whether the
nervous structure ofthe eye is affected organically, or only functionally.
Plethora, pregnancy, suckling, syphilis, worms, and masturbation have,
severally, given rise to amaurosis.
It follows from this enumeration that, according as we shall have as-
certained whether amaurosis depends on congestion, chronic inflammation
or functional disorder, will be the kind of treatment put in practice for its
cure.
Scrofulous or Phlyctenular or Strumous Ophthalmia.—Scrofulous
is one of the mixed forms of ophthalmia, involving several of the tunics
of the eye and the eyelids and other appendages in its progress, and there-
SYMPTOMS AND TREATMENT OF SCROFULOUS OPHTHALMIA. 649
fore not referable to any of the phlegmasiae of those parts of which I have
hitherto spoken. Manifesting many of the phenomena of inflammation
and an exalted sensibility, the eye in this modification requires a treat-
ment the measure of which is not to be found in the class of antiphlogis-
tics, although we do not by any means reject their occasional and moderate
use.
Symptoms.—Scrofulous ophthalmia is most seen among children. It
is distinguished, in addition to symptoms common to it and conjuncti-
vitis, by small pustules, phlyctaenae on the cornea or sclerotica, or most
frequently on the boundary between them. The occurrence of these cha-
racteristic elevations in strumous ophthalmia, has led Mr. Mackenzie to
regard this latter as an eruptive disease, affecting the conjunctiva, not as
a mucous membrane, but as a continuation ofthe skin over the eyes; and
hence he calls it phlyctenular ophthalmia. Another system very common
in this disease is the great sensibility of the retina to light (photophobia
scrofulosa), which has no proportion to the redness of the conjunctiva,
nor to the inflamraation. " The child makes every effort to protect the or-
gan from the painful impression of light, contracts the brows, throws the
integuments between them into wrinkles, draws down the skin of the
forehead, elevates the lips and alae of the nose, and, in short, puts into ac-
tion all the muscles of the face to protect the suffering organ. Hence
arises a peculiar and characteristic physiognomy of the disease, so that we
can easily determine its nature on the first sight of the patient."—Law-
rence.
Redness, by the way, is not a necessary feature of scrofulous ophthal-
mia; and when it does occur, it is more apt to affect the palpebral lining
than the extension of the conjunctiva over the globe of the eye. There
is often a copious flow of tears when the affection begins. With the mor-
bid and excessive sensibility of the eye to light is generally associated
disordered state ofthe digestive canal—white and furred tongue, costive-
ness, distended abdomen, morbid appetite, and grinding of the teeth du-
ring sleep. In the beginning the head is hot. There is generally an ag-
gravation of symptoms during the day.
The organic changes often produced in the eye by this ophthalmia are,
thickening and irritation ofthe conjunctiva and ulceration of the phlytae-
nae, or the vessels which pass from the conjunctiva to the cornea, in place
of ending in the ulcers, extend and unite by their ramifications over the
latter, and make the whole corneal covering or conjunctiva thick and vas-
cular (pannus). The cornea becomes of a dull and brownish tint from in-
terstitial deposition and sometimes effusion of blood. The iris occasion-
ally becomes adherent to the cornea, which latter being weakened, yields
to the pressure from within, and then is produced the unseemly protube-
rance called staphyloma. In more advanced stages, or in originally more
violent cases, the sclerotic coat and iris may be implicated, and we have
hyjlropthalmia and staphyloma sleroticsc. The eyelids, or more particu-
larly the tarsal border and Meibomian glands, are frequently the seat of
scrofulous irritation.
The treatment of scrofulous ophthalmia must be begun, if possible, by a
removal ofthe child from the spot in which the disease originated, and in
which it was subjected to the deleterious influence of impure air, as in
crowded rooms by day and dormitories by night. Good must be substi-
tuted for inadequate food. The first remedies will be laxatives of calo-
650
DISEASES OF THE EYE.
mel and rhubarb, followed by compound powder of jalap. To these suc-
ceed calomel with chalk, or very minute doses of tartar emetic, or some laxa-
tive saline solution. This latter will contribute to restore the skin to its
healthy function. For this end ipecacuanha and magnesia will also be use-
ful. Occasionally leeches to the angles ofthe eyelids or the temples, or cups
on this region, may be called for by the violence of the inflamraation, al-
though this will generally be amenable to the judicious use of antimonials.
Aware ofthe scrofulous nature ofthe disease and witness to the feeble-
ness of nutritive life in the little patient, we shall soon have recourse to
tonics after preliminary evacuation, but without waiting for that entire
absence of all febrile irritation which, in the case of the simple phlegma-
siae, would be the most judicious practice. Of the class, the sulphate of
quinia and the iodide of iron are entitled to the preference: they may be
used in succession in the order in which I now speak of them, or in alter-
nation. Between these may be interposed narcotics, if there be much ir-
ritation either of the eye or the general system. Kopp and Otto both
speak in terms of the highest praise of the use of the conium maculatum
in scrofulous ophthalmia. The formula is—R. Extract, con. maculat. ^i.,
Aquae cinnam. spirit. 3ss. Solve. Of this, give to children from three
to five years, four drops three times a-day, increasing the dose a drop at
each time, even till it reach ten.
The regulation of the diet is of paramount importance in this, as it is,
indeed, in all the forms of scrofula. At first the food should be of a re-
duced kind and in small quantity ; but, before long, nutritious, without,
howTever, being stimulating. Together with a liberal allowance of arti-
cles of varied vegetable origin we allow animal food once a-day in mo-
derate proportion.
The clothing ought to be warm and adequate to the covering of the
whole body ; particular vigilance being displayed in protecting well the
feet against both cold and moisture.
Change of air laid down in limine as one of the preliminaries for treat-
ment, often works wonders; and more especially if it be from town to
country, and in the summer season to the sea-shore, with the additional
benefit of sea-bathing.
Various collyria of the narcotic and stimulating kind are had recourse
to earlier in this species of ophthalmia than in the simple inflammatory.
Of these, preference has been given to tincture of opium, alone or in union
with camphorated mixture, and solution of nitrate of silver, four or five
grains to the ounce. Pencilling the skin of the eyelids by this solution,
but of greater strength, or with the tincture of iodine, has been set forth
as a good remedy. Counter-irritation by small blisters behind the ear or
on the nucha, or, better still, croton oil or tartar-emetic ointment rubbed
on these parts or between the shoulders is serviceable. In irritable ha-
bits, and in those in whom there is little organic life, blisters are trouble-
some, and sometimes have created mortification.
As a general plan of treatment, Mr. Lawrence (Treatise on Diseases of
the Eye) finds " none more successful, after putting the alimentary canal
in proper order, than the use of the emetic-tartar ointment, with the sul-
phate of quinine internally, tepid fomentation, and regulation of the bow-
els by means of rhubarb."
Disorganising inflammation of the cornea, or in the more deep-seated
structure of the eye, is to be resisted by the cautious use of mercury,
PUSTULAR AND VARIOLOUS OPHTHALMIA. 651
while the tonics before mentioned are to be given. But, ofthe treatment
required here I have spoken under the head of Corneitis. In those insi-
dious ulcerations affecting other tissues than the eye, I have had reason
to be satisfied with the alternate use of mercury and of some iodine pre-
paration. If the extreme irritability of the eye is not speedily relieved by
the general treatment, recourse may be had, with promptly good effects,
to the extract of belladonna, in solution, introduced between the lids. Dr.
Mackenzie has directed, with good effect, the inhalation of ether, for the
relief of intense photophobia in scrofulous ophthalmia and in corneitis ;
also in sympathetic ophthalmia.
Erysipelatous Ophthalmia is a compound of inflammation and edema.
It is characterized by considerable infiltration of serum into the substance
ofthe conjunctiva as well as into the subjacent cellular tissue, by which
the former is raised into folds which protrude like vesicles between the
eyelids. " The conjunctiva is of a light red colour inclining to yellow,
and presents here and there spots of ecchymosis, but individual vessels
are not readily discernible. The mucous secretion of the conjunctiva is
somewhat increased in quantity."—Jones. In severer cases the palpebrae
and surrounding parts exhibit some erysipelatous redness and swelling;
there is pain in the head, with furred tongue, nausea, and general fever-
ishness. The affection is seen in persons of, or after middle age, and
generally of an unhealthy constitution and suffering from gastric disorder.
The treatment will consist of, at first, remedies to act on the primae
viae, as a mild emetic followed by laxatives, and if need be, mercury with
chalk. For a collyrium use either the bichloride of mercury or solution
of nitrate of silver with vinum opii. Warm fomentations and sometimes
dry warmth by means of medicated bags hung over the eye, are the most
agreeable applications. Nutritive diet and tonics complete the cure.
Pustular Ophthalmia, as intermediate between catarrhal and strumous
inflammation, might have been noticed before this latter. The pustular or
aphthous is an inflammation seated in the sclerotic conjunctiva close to the
cornea, is confined to young subjects, and is attended with the formation
of pustules. The symptoms are few and of little moment; the chief
inconvenience being a sensation like that of a foreign body in the eye,
which is excited by the pustule and its enlarged vessels. Simple pustular
ophthalmia uncombined with the scrofulous requires no general treatment
beyond a laxative. The local remedies are saturnine lotions, or a solu-
tion of nitrate of silver or red precipitate ointment, applied to the pustule.
Variolous Ophthalmia, contrary to what has been generally believed, is
not owing to the specific poison and pustulation cf small-pox, but is merely
of the same nature with those which may occur in any acute external
ophthalmia. The period of invasion of the variolous kind is when the
general eruption is in the decline and secondary fever shows itself. Va-
riolous ophthalmia puts on a form resembling scrofulo-catarrhal ophthalmia,
but with more of the characters of the scrofulous than the catarrhal.
Sometimes it is purulent ophthalmia. After conjunctival and sclerotic
redness, with other symptoms of inflammation, the cornea is very liable
to suffer from pustules or abscesses, running into ulceration, and to be
destroyed by this last process or by sloughing. Sometimes the lens es-
capes, sometimes there is an evacuation of all the humours.
The treatment of variolous ophthalmia will be conducted on the princi-
ples already laid down for inflammation ofthe eye, modified in their prac-
652
DISEASES OF THE EYE.
tical application by the violence of the variolous disease itself and the
strength ofthe patient. Local will be preferred to general depletion, fol-
lowed by purgatives and counter-irritation to the nucha or behind the ear;
and the application to the eye of a tepid belladonna lotion, and a weak solu-
tion ofthe nitrate of silver. Pains will betaken, if the system is exhausted,
to renovate it by good diet and tonics, but with a sparing use of cordials.
Catarrho-rheumatic ophthalmia is a compound inflammation of the con-
junctiva and the sclerotica, and hence it is called also conjunctiva-sclero-
titis, and, reference being had to the implication of the cornea in the dis-
ease, conjunctivo-sclero-keratitis. I need not enumerate the symptoms
of this form of ophthalmia, which are not materially different from those of
the catarrhal and the rheumatic already described, except that we have
the chief features of the two. In addition to inflammation of the conjunc-
tiva we have circumcorneal sclerotic injection, with haziness and even
opacity ofthe cornea. The treatment comprises the use of the remedies
for rheumatic ophthalmia, and ofthe local ones for catarrhal, as already
laid down.
Of the diseases of the appendages of the eye, I shall only direct your
attention to Ophthalmia Tarsi. This is divided into two varieties ; the
catarrhal and the scrofulous. The last is the most frequent.
Catarrhal ophthalmia tarsi begins with dryness, soreness, smarting, and
burning ofthe ciliary margins, which are red, a little swelled and painful,
sometimes acutely so. The angles are generally affected first, and they
may suffer alone or the whole margin may be inflamed, the palpebral con-
junctiva is red, perhaps a little thickened and villous. There is also a
feeling as if of a foreign body in the eye ; and hence, in an acute attack,
the lids are kept closed and quiet. The Meibomian glands participate in
the affection, and then secretion is suspended ; and even when restored
it is at first unhealthy, and being spread over the cornea affects its polish
and transparency. Hence, also, when vision becomes worse in the
evening, exacerbation of the symptoms, rings, haloes, and the irides, are
seen round the candle, or its flame is split into stars. By a loss of their
epidermis, the ciliary margins become raw, and the lids are so irritated
and excoriated by the morbid secretions from the Meibomian glands and
conjunctiva that they become ulcerated, particularly towards the angles
and in the lower lid. This chronic form of the disease is called lippitudo,
or blear-eye, and often lasts for a long period. Owing to its being raore
exposed to the increased morbid secretions from the eye and the ciliary
glands, the lower lid suffers most. When the complaint has been of long
duration, many ofthe eyelashes fall out and some become misdirected,
and not unfrequently slight inversion (entropium) or eversion (ectropium)
ofthe lids takes place.
The causes of ophthalmia tarsi are the same, in part, as those of the
catarrhal variety. Sometimes the disease assumes almost an epidemic
form, from cold dry winds at a particular season of the year. To these
causes may be added exposure to a close impure air, the large use of
spirituous liquors and a constitution weakened by age.
The treatment in the first or acute stage will be mildly antiphlogistic,
with an avoidance of the known causes of the disease. A few leeches to
the eyelids or scarification of the palpebral conjunctiva, from one end to
the other, with the shoulder of a lancet, the lid having been previously
TREATMENT OF SCROFULOUS OPHTHALMIA TARSI. 653
everted, will be of great if not indispensable service. The simple tepid
lotions used at first will be replaced by a weak solution of bichloride of
mercury, one grain to six ounces of water, or a stronger one of nitrate of
silver, with which latter the palpebral conjunctiva will be pencilled..
Weak red precipitate ointment or the liquor aluminis compositus diluted
with five or six times the quantity of rose water or the vinum opii, has
each been used with similar intentions. The citrine ointment, in a melted
state, applied to the borders ofthe lid, with a soft camel's-hair brush, is
one of the best topical remedies.
Scrofulous ophthalmia tarsi exhibits features in common with the ca-
tarrhal variety, with the addition of others of a strumous nature ; among
which are hordeolae or styes, itching, small vesicles or pustules, or ulcers
left by them, and a gluing together of the eyelids in the morning. The
term psorophthalmia given to this variety, as implying an itch of the eye-
lids, is erroneous. Taking into view the pustular feature and the loss of
the eyelashes, the complication is, most probably, that of favus dispersus, if
not impetigo figurata, a variety of which last, as Rayer (Theoretical and
Practical Treatise on Diseases of the Skin) remarks, is commonly compli-
cated with a particular species of ophthalmia, or with an inflammatory
affection of the follicles of the ciliae. In an advanced stage of the disease,
the eyelids are much thickened and nodulated at their borders, from en-
largement ofthe glandular structures situated there (tylosis). In old and
neglected cases, nearly all, if not all, the eyelashes fall out (madarosis)
from destruction of their bulbs. Among the evidences of the strumous
diathesis in subjects of this disease, are disordered digestion, tumid abdo-
men, enlargements of the glands of the neck, cutaneous eruptions, and
sore ears.
The treatment of scrofulous ophthalmia tarsi must be mainly constitu-
tional, although not to the neglect of local applications. The remedies
are nearly the same, at first, as were mentioned in the catarrhal variety ;
but we are required to persist, in the present case, in the use of laxatives,
alternating with such alteratives as mercury with chalk, and, still better,
with the iodide of potassium, or, in the more advanced stage, the iodide
of iron. The local treatment will consist in, at first, mild tepid washes,
and cerates or unguents to the borders of the eyelids to prevent their
agglutination together ; and, afterwards, collyria and ointments, as recom-
mended in catarrhal ophthalmia tarsi. When the eyelashes are inverted
(trichiasis) they should be plucked out, if they are loose enough to allow
of this being done by the finger and thumb.
654
DISEASES OF NUTRITION.
DISEASES OF NUTRITION — CACHEXLE.
LECTURE CXLII.
DR. BELL.
Difficulty of Classification of Diseases, termed Cachexia;—Cullen's and Cop.
land's definition—Dr. Williams's explanation of morbid deposits.—'Scrofula—Its
multiplied relations and associations—Anatomical and histological characters—Resem-
blance of the scrofulous to typhous deposit—State of the blood—Scrofulous pus—
Identity of scrofulous and tubercular diseases—Symptoms andprogi-ess—Cullen's de-
finition; its incompleteness—Countenance—Swelling of lymphatic glands, cellular
tissue, and joints—tumid abdomen—Irrita:ion of the ocular, nasal, and pharyngeal
mucous membrane—Swelling and other changes of the tonsils; cough; ulcerations
of the tongue ; disorder of the digestive mucous membrane—The scrofulous/acies—In
a more advanced stage, inflammation and ulceration of the lymphatic glands of neck—
Discharge of pus and cheese-like product of tubercle—Abscess of cellular tissue—
Similar cacoplastic deposits in serous membranes, and in the pancreas, liver, mesen-
teric glands and urinary and genital organs—The bones, especially the extremities of
long bones and the vertebrae affected—Curvature of the spine and distortion of the
thorax—Scrofulous disorders of the skin, eye, and ear—Irregularity in nervous and
muscular systems—Brain and senses sometimes very susceptible—Sometimes great
vivacity—sometimes dulness—Intellect sometimes precocious, sometimes deficient—
Irritative fever—Complicated with uterine disorders, hysteria and epilepsy—Special
pathology of scrofula—deterioration of blood and deposit of granular pus and tubercle
—Causes—Inherited predisposition the chief cause—Scrofula preserving its character-
istic features in all countries and climates—Transmission by descent more general
than supposed—Affinity between tubercle and scrofula—Acquired diseases of parents
—Causes of scrofula in their children—syphilis; excessive venery; paralysis; in-
sanity—Hereditariness does not pass over one generation to appear in another—Cause
not unit—Difference in the age of the parents—Effects of French conscription—
Crowded lodgings—impure air—defective nutriment—Examples—Scrofula prevails
in the negro population—Morbid states—as the exanthemata—exciting causes of
scrofula.
Hitherto a tolerably natural division of diseases, on a physiological basis,
has been followed in these lectures, by Dr. Stokes and myself, and you
have had placed before you, in regular series, descriptions ofthe diseases
of the digestive, biliary, renal, genital, respiratory, circulatory, and nervous
apparatus, a great majority of which you were taught to observe and to
combat under two aspects, of increase or of diminution ofthe phenomena
of tissue and organ ; inflammation and its morbid products coming under
the head of the former, debility and anemia with various associated dis-
turbances of the nervous system under that of the latter. There have
been, however, even thus far, notable exceptions to this simplicity of pa-
thological outline, as in the instances of tuberculosis of the lungs, bron-
chial glands and meninges of the brain, and, also, of melanosis and
cancer ofthe lungs. These might properly enough be studied under the
head of the class of diseases to which I purpose now, for a brief period,
directing your attention, viz., those of nutrition, or the cachexias ; but con-
sidering the irritation and inflammation of the lungs, glands, and menin-
ges, respectively, and ofthe functional disturbances of respiration and in-
nervation to which tuberculosis and cancer give rise in the organs in which
they are deposited, our present distribution of them must, upon the whole,
be regarded as the most appropriate.
SCROFULA.
655
In the diseased states of the economy, of which I am next to speak, the
case is widely different. Whether it be a vitiated and often an inorganic
product that may be found in very different and remote parts, and with
which are associated disturbances and depravation of nutritive life in ge-
neral, as in scrofula, or a gradual and successive poisoning of the tissues
and a perversion of nutritive functions, as in syphilis, we shall find it im-
possible to refer these diseases to any one apparatus, or to measure their
anatomical lesions by the changes in any one texture. In the progress of
these and some other analogous diseases, we meet, it is true, with inflam-
mation and its destructive effects in different tissues ; but still, no one of
them can be called phlegmasia of any one tissue nor of the tissues in succes-
sion ; so, although they may be accompanied often by great debility and
languor of function, neither can we speak of them as diseases of mere de-
bility, measurable by dynamic forces. They are often, generally indeed,
in their advanced stages characterized by anemia ; but both an explana-
tion of cause and a ratio medendi, deduced from defective composition of
the blood, would be fallacious.
These difficulties in the way of classification occurred even to noso-
logists, who did not confine themselves either to an organic or to a
physiological basis, but who were content if they could find affinities in
groups of symptoms, as in febres, phlegmasice, &c. The diseases now
under notice they were obliged to designate by the term cachexia, from
*«koc, ill or bad, and «|k, habit, which by its extreme generality conveyed
really an abstract idea, not deducible from the state of any one organ, or
even combination of organs, but of the whole body without specification.
Thus we find the definition of cachexia, which is the third class in Cullen's
Nosology, to be—"a depraved habit of the whole, or great part of the
body, without any primary fever or nervous affection." Dr. Copland
(Diet. Pract. Med.) amplifies the definition in these terms : " Depravity
of the constitution, without fever, affecting more or less the solids, the
circulating fluids, and the secretions." In the third order of this class,
or Impetigines, Cullen places scrofula, syphilis, scurvy, elephantiasis and
lepra, as genera in the order here mentioned.
Even at the present day, with a more intimate knowledge of the con-
dition of both the solids and fluids and of their precise products in the
diseases now under consideration, we have made little advance in their
nomenclature and classification, and we are fain still to use the epithet
cachectic to express a state of general feebleness of function and depraved
secretions, associated with altered relations ofthe component elements of
the blood to each other. Nor, if we wish to be more specific, can we do
without the expletive prefix, of kakos, or bad, as, for example, in the
terra cacoplastic, applied by Dr. Williams (Principles of Medicine, par.
452) to that low grade of morbid action in which, owing to the poverty
ofthe blood in red particles, lymph of a granular nature or the formations
described under the names of cirrhosis and granular degeneration of the
kidney, and yellow tubercle, are effused and deposited. These products
have still some organization, although of a very low grade. In degree
beyond this again, more or less of the product of morbid action is aplastic,
or totally incapable of organization ; as we find to be the case with scro-
fulous pus or common tubercle (op. cit., par. 485, and 556, 557).
Scrofula.—After this brief introduction, I now proceed to speak of
scrofula, a disease which, in its multiplied relations to other morbid con-
656
DISEASES OF NUTRITION.
ditions of the economy and in the associated derangements of function and
its morbid and sometiraes irremovable products, as also by its frequency
and hereditary transmission, assumes an importance beyond that of most
diseases in the nosological catalog le.
Anatomical and Histological Characters.—Scrofula is a constitutional
disease, manifested more particularly by engorgement and low chronic in-
flammation of the lymphatic glands, which, after softening, yield a pecu-
liar deposit closely analogous to if not identical with tubercle. Scrofula
belongs to the class of pseudoplasmata, the tumours in which are charac-
terized by the circumstance that, during the whole process of their deve-
lopment, from their first appearance to their softening, they show a very
low degree of organization: the product of their softening is an indeter-
minate granular detritris. Their formation is usually followed by a de-
struction of contiguous normal tissues and ulceration.
In an anatomical and histological point of view, as remarked by Vogel,
the scrofulous matter bears a close resemblance to the typhous. The es-
sential difference is, that here the whole proceeding is accomplished much
more slowly—the deposit and the softening generally lasting as many
weeks, or even months, as in the other case days. Scrofulous matter,
continues the author just cited, also exhibits in different cases great ana-
tomical variations ; it is sometimes dense and firm, so that thin sections
can be made ; sometimes it is lardaceous, sometimes soft and crumbling
like new curds. It is likewise sometimes colourless and semi-transparent,
sometimes whitish, sometimes of a yellow tint. Histologically, it is per-
fectly similar to typhous matter, and consists essentially of the same ele-
ments : it presents an amorphous stroma, molecular granules, and unde-
fined cells and cytoblasts, varying in diameter from the 600th to the 300th
of a line, occurring in very different proportions and mixed with fat-glo-
bules. The granules are partly protein-compounds, partly fat, and in part
calcareous salts: the latter disappear with effervescence on the addition of
nitric acid.
After its softening, the matter consists of the same indeterminate granu-
lar " detritus" as the typhoid deposit. Softening and ulceration do not,
however, always ensue : in many cases the above mentioned calcareous
deposition becomes predominant, and the mass is converted into a con-
cretion.
Dr. Glover (On the Pathology and Treatment of Scrofula), from his own
observations, is led to the belief that the ordinary element of tubercle,
including scrofulous deposits, is the granular corpuscle described b) se-
veral writers.
The changes in the blood of the scrofulous consist chiefly in a diminu-
tion ofthe red globules or blood-corpuscles and an increase of the solids
ofthe serum. This increase is of the albumen, as there is but little aug-
mentation ofthe extractive matters. There is no deficiency of fatty mat-
ter in the blood of scrofulous subjects. The pus in this disease appears
to differ from ordinary pus chiefly in the fluid part being thinner and
mixed with albuminous granules, proceeding from a decomposition of scro-
fulous or tuberculous matter. The pus-globules are fewer and more irre-
gular in their form than in healthy pus.
The now prevailing opinion ofthe identity of scrofulous and tubercular
diseases is sustained by Dr. Glover. The diseased products in the two
classes of disease are similar. Microscopical observations and chemical
SYMPTOMS AND PROGRESS OF SCROFULA.
657
analysis fail in establishing any essential difference ; the characters of the
blood are the same, the two affections are frequently united in the same
individual, take a similar course, and are relieved by a similar treatment.
Mr. Phillips (op. cit.) asserts, on the other hand, that scrofulous deposit and
tubercle are different. #
Symptoms and Progress.—Scrofula is defined by Cullen : " Tumours of
the conglobate glands, especially in the neck, swelling of the upper lip
and columna nasi; redness of the face and softness ofthe skin ; bloating
of the abdomen;" but this is quite too imperfect a specification either of
seat or of leading symptoms; and is withal not distinctive even as far as
it goes. Redness of the face and softness of the skin, for example, so far
from being characteristic features, are only seen in some individuals of
the sanguineo-lymphatic temperament. A white or muddy complexion
and dry rough skin are quite as commonly met with in the scrofulous dia-
thesis. The tumid abdomen is often associated with swelling of the me-
senteric glands, which are, at the time, in a state of engorgement, similar
to?that of the lymphatic glands of the neck and the bronchial glands.
Either occurring at the same time or alternating with the disorder of these
glands, is indolent swelling of the cellular tissue, and some one or raore
ofthe joints. Irritation ofthe mucous membrane is seen at the conjunc-
tiva and borders of the eyelids, and in the nose and throat, implicating,
also, the tonsils, which are in a state of mixed chronic and sub-acute in-
flammation for a long period. The enlargement of these bodies irritates
the glottis and keeps up a harassing cough, which, in its paroxysms, is
accompanied by much hawking and thick mucous secretions, and, occa-
sionally, by partial efforts at vomiting.
It is of some importance for us to be aware of the appearance and or-
ganic changes of the tonsils in scrofulous subjects. These parts are so af-
fected as to jut out in rounded tumours from between the arches of the
fauces; and they are peculiarly prone to inflammation, which, when it oc-
curs, is often attended by so much swelling as to threaten suffocation,
especially when stimulant astringent gargles have been incautiously em-
ployed. The inflamed tonsils become speedily spotted with aphthous
crusts, which are succeeded by superficial ulcerations, always indolent,
and sometimes ending in brown excavated ulcers, which have been known
to exist for weeks without any remedy being used, and then to yield to
quinia or other preparations of cinchona.
Scrofula occasionally attacks the tongue, the disease alternating with
strumous eruptions, especially on the face, and exhibiting in its progress
small knots or nodules superficially imbedded in the substance of the
organ, which are succeeded by sloughing ulcers, with much pain, profuse
salivation, furred tongue, and fetid breath. Under proper treatment these
ulcers become clean, contract and heal ; but the hardness remains and
smaller fresh ulcers form. The contiguous mucous membranes are fre-
quently affected with scrofulous disease ; as well those on the inside of the
lips and cheeks and on the fauces, as on the pituitary membrane, consti-
tuting in the last case one oTthe varieties of ozaena.
The digestive mucous membrane is the seat of disorder at this time,
manifested by irregular appetite and abnormal secretions—with alternations
of constipation and diarrhoea.
As respects the scrofulous fades or countenance, M. Lugol justly re-
marks, that it is not so much indicative of the disease in general as of its
vol. n.—43
658
DISEASES OF NUTRITION.
appearance on the face. To this latter variety more peculiarly belong
thickening and induration of the skin and cellular tissue, coryza, hyper-
trophy of the lips, septum nasi, cheeks, eyelids, and especially the borders
of these latter, the lobe of the ear, but most of all the upper lip. These
traits often prelude the invasion of tubercular phthisis ; but wre are not to
look for them in the majority of manifestly scrofulous subjects.
In the occasional development of adipose and cellular tissue, constitu-
ting a certain degree of embonpoint and even freshness of complexion, the
scrofulous diathesis may sometimes be so concealed as to simulate full
health, particularly in women ; but these appearances are deceptive, and
too often are replaced by undoubted evidences of disease.
In a more advanced stage of scrofula we meet with inflammation and
ulceration of the lymphatic glands, in which the skin also is destroyed,
leaving an open sore, with irregular, jagged, and thickened borders, of a
dull red colour. It is now that a characteristic secretion of imperfect
granular pus and cheesy-like products or tubercle are seen. At times,
the sub-cutaneous cellular tissue is the seat of chronic phlegmon passing
into abscess—the cold abscess of some writers—which is accompanied
with very little heat, and, in place of being circular, is usually oval.
Tuberculous matter is occasionally found mixed with the imperfect pus
and serous matter of these abscesses. Similar cacoplastic deposits are
sometiraes detected in the serous membranes, and in the pancreas and
liver and mesenteric glands, also in the urinary and genital organs of both
sexes. Scrofulous ulceration of the uterus is a not unfrequent malady.
The bones are often affected in scrofula : they become soft and vascular
and especially in the spongy portions at the head of the long bones and
the bodies of the vertebrae—giving rise to white swelling, separation of
the cartilaginous coverings and caries, and to curvature of the spine and
alteration in the natural size and shape ofthe thorax.
The skin is often the seat of troublesome and protracted scrofulous dis-
orders, and particularly of the eruptive kind. The chief of these is the
tubercular, which appear in preference on the face, neck, and upper
extremities, and more frequently isolated than in clusters. Softening is
one of their principal characters: but this is accomplished with extreme
slowness.
Scrofulous irritation ofthe mucous membrane ofthe eye has been already
mentioned among the earlier symptoms. I wrould now make the addi-
tional remark, that scrofulous or strumous ophthalmia is the most common
variety of inflamraation ofthe eye, and is, in fact, the chief disease among
the children who are collected together in large numbers and are deprived
of adequate exercise and fresh air, and not seldom, at the same time, of a
suitable supply of wholesome and nutritive aliment. Beer relates that, in
Vienna, nine-tenths of all the cases of ophthalmia in children are of a scrofu-
louscharacter; and Benedict of Breslau estimates the proportion in that city
as high as ninety-five in the hundred. With the variety termed ophthal-
mia palpebrarum vet tarsi, we are, also, familiar—the margins of the eye-
lids and the Meibomian follicles being the seat of the disease which causes
vesicles and ulcerations in these parts, as quite recently detailed to you.
One of the most obstinate forms of scrofula, or rather a fixation of the dis-
ease, which it is most difficult to remove, is that seated in the lining mem-
brane of the external auditory passage. It is usually marked by a profuse
watery, thin mucus, and at length purulent discharge, forming what may
SPECIAL PATHOLOGY AND DIAGNOSIS OF SCROFULA. 659
be termed strumous otorrhoea. Seldom does it disappear under a period
of some duration and without injury to the sense of hearing. In cases of
greater gravity the membrane of the tympanum becomes inflamed and is
perforated, the small bones of the ear are discharged and irremediable
deafness ensues; or, perhaps, caries of the petrous portion of the tem-
poral bone takes place, and the result is fatal.
Frequent irregularities are observed in the state of the nervous and
muscular systems and in the circulation from the beginning of the first
or forming period of scrofula. The brain and senses are often susceptible;
the young subject manifesting great desire for variety of excitement and
bodily movement, but soon tiring if indulged in this way. The disposi-
tion is capricious, in some cases prone to gaiety—in others habitually dull
and sad. Equal differences are met with in the intellect, which is far
from being as active and precocious as it is generally represented, in per-
sons ofthe scrofulous diatheses. On the contrary, they are often slow of
apprehension, if not positively stupid. The sleep is not sound, and is
often disturbed by dreams.
Fever of the irritative kind, or that with a very frequent pulse and dry
skin, and alternations of heat and cold, is quite common through the
whole progress of the disease. I have counted from 120 to 140 pulsa-
tions for weeks and even months in scrofulous children, from three to five
years of age, in whom, at the time, there was no evident organic lesion,
nor indeed any great functional disturbance except this of the circulation.
Various complications, if not themselves belonging to the disease, are
met with in scrofula. Of these, I may mention uterine disorders, and
particularly dysrnenorrhoea and leucorrhoea, and great disturbances of the
nervous system, such as hysteria, epilepsy, and certain forms of mental
derangement.
The special pathology of scrofula may, in fine, be declared to consist in
an altered condition of the blood, especially in a diminution of its red
particles, and morbid or cacoplastic and aplastic deposits, granular pus,
and crude and, at times, infiltrated tubercle.
Diagnosis.—In addition to the remarks, under the head of symptoms,
respecting the external characters of scrofula, the following observation of
Dr. Wilshire (Med. Times, 1847), is worth repeating, although we may
not place much confidence in the accuracy of the picture as a general
representation. " In allusion to the tuberculous forms of scrofulous dis-
order, there is a point of great interest and importance, in my.mind, and
to which I would direct your attention for a moment. It is to a means of
diagnosis I refer—a means I have nowhere read about, nor did I hear
anything of it until I alluded to it one evening at the London Medical
Society, where, although certain statements were made, I heard nothing
to warrant me in refusing myself the credit, if there is any, of its first pro-
mulgation. It is this : you shall have a child brought to you who has
dark irides, no colour in the cheeks, and darkish hair ; the eye is often
very full and large, looking (to use the words of one of the late house-
surgeons ofthe infirmary, to whom I was talking about the subject) ' as
if they would eat you ;' the eyelashes very long, close together, so long
as sometiraes to be three or four times their common length ; I have seen
them so long that, when the eye was closed, they quite rested on the cheek.
Now, if you examine the forehead of such a child, you will find it covered
with close-lying hair, sometiraes almost down to the eyebrows ; if you
660
DISEASES OF NUTRITION.
strip the child you will find its arms covered too, and the back from the
hair ofthe head down between the shoulder-blades quite hairy, the hairs
often being very thickly placed, and dark in colour; in fact, the child is
quite a hairy child — not quite an Orson, but still very hairy. Often,
indeed, the whole appearance ofthe patient is cachectic as well. Now,
in nine cases out of ten, such a child is tuberculous ; it either has tuber-
cles already deposited, or else is liable, is tending to it, and that perhaps
in almost every organ of the body, and in the lungs especially. This
hairy condition in a cachectic or unhealthy-looking child is a sign, gene-
rally speaking, of a constitution miserable in the extreme—saturated with
scrofula."
Causes.—Of all the causes of scrofula, inherited predisposition is, as in
the case of so many other diseases, the most powerful. Identical in its
main and characteristic features in all countries and climates, these are
reproduced afresh from generation to generation until the prolific germ is
lost by final deterioration of frame and constitution—a natural means de-
vised by Providence for the extinction of disease in a particular family or
race. Even where the births are numerous, if the scrofulous constitution
prevail, death carries off the great majority before they reach the age of
puberty. Hence, although scrofula is not contagious, yet a community,
in a period of years, will, in large numbers, be poisoned, one may say,
by its diffusion, by means of alliances contracted between the diseased
with the healthy ; and their offspring again become so many fresh sources
of propagation by subsequent marriage and parentage.
The transmission of scrofulous tendency from parents to children occurs
to a much greater extent than would at first be supposed, were we to
restrict our observation to the common evidences of scrofulous diathesis
in the former. Tuberculous consumption and scrofula are closely allied,
and they who die ofthe former disease, after having had children, have
transmitted the tendency to scrofula. Commonly, indeed, the same form
of the disease, whether it be pulmonary tubercle, obstinate ophthalmia,
abscess, caries, rachialgia, &c, is inherited ; but still a large number of
the scrofulous are descended from parents who perished by pulmonary
tubercle. In children of the same family we see some tuberculous, others
scrofulous, if we may still be allowed to designate by different titles that
which is probably the same disease, modified by the tissues in which it
appears. Hence, also, the scrofulous become readily j in no small num-
bers, phthisical. Even when parents apparently in good health, but who
were scrofulous in early life, have children, these latter are extremely
liable to, and often, in fact, suffer from, the disease. So, likewise, although
jhe parents may themselves be exempt from scrofula, yet if their brothers
or sisters have been afflicted with it, their children may also become vic-
tims to the disease.
Acquired diseases of the parents often give rise to scrofulous inheritance
in their children, as, for example, when the former have had syphilis. So
strong was a belief of this nature at one time, that Astruc and many phy-
sicians of the latter half of the eighteenth century asserted scrofula to be
but degenerated or modified syphilis. It was, also, believed that a child
would become scrofulous if the mother or wet nurse were affected with a
syphilitic taint. The physical degeneration and extinction of so many
families in Spain, caused by scrofula, are alleged to have for anterior
cause syphilis, which became so common and committed such ravages after
CAUSES OF SCROFULA.
661
the discovery of America, and the trade, wealth and vices which followed
that memorable event.
I am aware that the prominence thus given to hereditary influence in
the production of scrofula is denied, but not, as I think, for sound reasons,
by Mr. Benjamin Phillips in his valuable work — Scrofula ; its Nature,
its Causes, its Prevalence, and the Principles of Treatment.
Excessive indulgence in venereal pleasures has been indicated as
another cause operating on those who afterwards became parents, towards
their procreation of scrofulous children. Precocious marriages, as well
as where the parties were far advanced in life before becoming parents,
are enumerated as farther causes of the inherited predisposition to scrofula.
So, also, disproportion between the ages of the parents is alleged to act in
a similar manner.
Still farther extension is given to the inherited causes of scrofula by M.
Lugol (Recherches et Observations sur les Causes des Maladies Scrofuleuses),
in his supposing, in addition to those enumerated, transmission by parents
who have been paralytic, epileptic, or insane.
On this topic M. Lugol protests against the common belief that the he-
reditariness of scrofula may skip one generation to re-appear at the next ;
or, in other words, that the disease of the grandparent, passing entirely
over the immediate offspring, may show itself in the grandchild. This
supposition would imply that a man can transmit to his child that which
he himself has not, or that there can be an effect without a cause. It
seems to me, however, that the proposition is not fairly stated. It simply
means, as I understand it, that the diathesis is not so active in the father
as to manifest itself in him, and yet he may transmit his constitutional
peculiarities, which will be sufficiently strong, with the aid of external
causes, to develop in his child scrofula as it had appeared in the grandpa-
rent. More probably, however, the additional tendency in the child is the
result of the transmission of something of a scrofulous diathesis from the
other parent. The cause is not always a unit, even as respects hereditary
transmission. Thus, for instance, the father is scrofulous and the mother
too young, or the latter may be scrofulous, and the father have suffered
from syphilis.
M. Lugol makes emphatic mention of the conscription in France, as a
great cause of the extension of scrofula among the people, and their phy-
sical deterioration in consequence. During the wars of the Revolution,
or from 1790 to 1814, nearly a quarter of a century, France was in a state
of almost continual war, at first for defence and subsequently for aggran-
dizement, requiring all the time immense levies of men in the prime and
vigour of life. The invalid, the infirm, or those who married in haste to
avoid the conscription, were those that remained to become the heads of
families and keep up the population. One of the effects ofthe deteriora-
tion noticed after the peace was the shorter average stature of the soldiers,
so that the requisite number could not be found of the standard height,
which was in consequence lowered. Peace, we learn, has brought about
an opposite and better state of things.
Congregation of many children in the same house or room, and stinted
or bad food, with deficient exercise in the open air, are frequent external
or exciting causes of scrofula, and hence foundling hospitals and orphan
asylums furnish everywhere such a large quota of the disease. Im-
proved ventilation in some of these establishments has also arrested its
662 DISEASES OF NUTRITION.
extension among their inmates. Animals congregated together, in a
confined space, as in the Zoological Garden, London, suffer greatly from
scrofula.
The direct or immediate effects of deficient and bad food are not so evi-
dent as we might at first suppose, in the production of scrofula. This
cause, when continued to the second generation, will have effected such
a change in the growth of the tissues and deterioration in the nutritive
functions as probably to develop the disease, more especially if the de-
praving operation of bad air have been concurrently active. A friend of
Mr. Phillips (Lectures on Surgery) furnished him with the following results
obtained from one parish in Wiltshire (England) : " There are in this
parish forty-nine families, the heads of which earn seven, eight, or nine
shillings per week. The number of children in these families amounts to
one hundred and fifty-three ; they have many of them scarcely rags to
cover them; they scarcely get any aniraal food, and live principally on
what would seera to be an insufficient quantity of coarse bread, potatoes,
and some butter-milk. Of these children only three presented any of the
usual symptoms of scrofula." Compared with this is the picture of a
London population given by Mr. Phillips himself. In four courts in the
parish of St. Marylebone, he found ninety-three families, containing two
hundred and one children, the greater number running about, some en-
gaged as errand boys ; very few with shoes or stockings, most of them
with clothing insufficient to cover them ; scarcely any of them with enough
to protect them from the cold ; fed upon pretty good bread, potatoes, and
an occasional piece of meat—in fact, much better fed than the children of
the Wiltshire agricultural labourer. Of these children nineteen presented
manifest signs of scrofula, affecting the glandular system, the eyes, or the
bones.
In our own country, scrofula is far from being so prevalent as it is in
different parts of Europe ; but, on the other hand, we do not enjoy that
entire immunity from the disease which some have pretended. In the
negro population it is of not unfrequent occurrence. But it would be an
error to suppose that the attacks of scrofula are restricted to the children
ofthe needy, and the destitute with insufficient food. We know that, in
Europe and occasionally in this country, we meet with it in persons very
differently circumstanced ; and I remember well hearing Alibert, when
lecturing on the subject at the Hospital St. Louis, ask, with .a somewhat
triumphant air—if poor and insufficient food and other sedative causes
brought on scrofula, and if it was a disease of mere debility, how came it
to be so common among the well-fed English who ate beef-steak and
drank porter ? The sons of George the Third were sufferers from this
disease ; and it was to hide the disfiguration produced by the scars from
scrofulous ulcers of the neck in the young princes, that the fashion of large
rolling cravats was introduced.
After giving full weight to these exceptional cases, it is still, however,
pretty evident that that portion of a people who live congregated together
in close narrow streets, and dark and illy ventilated and damp or under-
ground apartments, and whose food is bad and scanty, and clothing not
adequate to protect them against atmospherical vicissitudes, are the great-
est sufferers from scrofula. Deficient ventilation and want of active bodily
exercise in the open air are the causes which can be most insisted on.
Various pathological causes, in the prior occurrence of different diseases,
TREATMENT OF SCROFULA.
663
have been specified as productive of scrofula. Among these are hooping-
cough, and the exanthemata generally, and above all measles: these should
however be regarded as causes exciting into morbid activity the scrofulous
diathesis, but not as producing it. Other morbid states, commonly spoken
of as exciting or occasional causes of the disease, are, in fact, prodromes
or precursors. Of this class are slow gastric fever, the fever of growth,
slow dentition, and worms. Scrofula, supposed to follow at times abor-
tion, is rather the predisposing cause of this state. Erysipelas is common
in scrofulous subjects, and should be considered, moreover, as an exciting
cause of the disease in them.
M. Lugol attaches little importance to all the occasional causes of scro-
fula, to which I have just made brief reference. Their action he believes
to be dependent entirely on the degree of inherited predisposition. He
admits, indeed, that when some of these causes are permanent, they be-
come decidedly injurious to the persons or people subjected to their influ-
ence, and preclude the possibility of their having robust children. The
study of this part of the etiology of scrofula is important in connexion
with treatment, which cannot be efficacious so long as patients affected
with the disease continue to live surrounded by and subjected to the
causes.
For an extended view of the etiology of scrofula, I would recommend
Mr. Phillips's treatise already referred to, with the reservation made by
me on the point of hereditary predisposition to the disease.
LECTURE CXLIII.
DR. BELL.
Scrofula (Continued)—Treatment—Indications of cure—Elements of disease presented
by Dr. Williams—Importance of prophylaxis—Knowledge of causes suggests means of
prevention—Outlines of prophylaxis and cure—Necessity of perseverance and of time
for a cure—Proper notions respecting the tonic treatment—Purgatives to precede iron
and iodine—Fresh air, wholesome food, and exercise, necessary conditions for curing
scrofula—Use and effects of iodinic preparations—Small doses with large dilution to
be preferred—No necessity for the large doses used by some physicians—Iodide of
iron—Mr. Phillips's success with—Most convenient form—Iodide of zinc—Hydro-
chlorate of lime—Lime-water—Arsenic, to be kept back until other remedies are
tried—Alternate use of iodide of potassium and carbonate of iron, or the potassio-tar-
trate of iron—Bromine—Bromides of potassium and of iron—Ointment of bromide of
potassium—Cod-liver oil—Preparations of walnut leaves—Mercury ; when admissible
—When narcotics are proper—These combined with mercury or iodine—Most com-
mon forms or varieties of scrofula—Tabes mesenterica—Alleged connexion with ente-
ritis—Outlines of treatment—White swellings—Modified treatment—Tuberculous affec-
tions of the skin—General indications of cure, including hygienical measures.
Treatment.—You are in a measure prepared, after the sketch which I
have placed before you, of the scrofulous modifications of structural lesions
of the tissues aad organs, so different from simple inflaramation and its
consequences, and of the radical changes in the function of nutrition, to
deduce the indications of cure of scrofula. Repeating the language of
Dr. Williams (op. cit., par. 565): " The elements of disease chiefly to be
kept in view in the treatment are :—1, the disordered condition of the blood,
and its causes ; 2, the disordered distribution of the blood, and its causes ;
664
DISEASES OF NUTRITION.
and 3, the presence of the deposit, and its effects and changes. The second
element comprehends the varieties of local hyperemia, which we have
found to be so much concerned in producing the higher kind of cacoplas-
tic deposit (§ 553), and in promoting the formation and changes of those
of a lower character (§ 560). Hence, the remedies against inflammation,
determination of blood, and congestion, are frequently more or less needed
in the prevention and treatment of cacoplastic and aplastic deposits.
But, except as preventives, the utility of this class of remedies is gene-
rally limited to those of a topical kind, such as local bloodletting, counter-
irritants, revulsives, derivants, and alteratives (§ 174)."
If in any disease the prophylaxis be regarded of paramount import-
ance it must be in scrofula, of the approach of the bad symptoms of which
such early premonition is given by the occurrence of various minor dis-
orders, even if not by a marked and characteristic physiognomy. A knowl-
edge of causes ought of course to suggest the necessity and means for
their removal, and this alone will often go far towards an entire suspen-
sion of disease, and give the hygienic, and, if need be, therapeutical reme-
dies, opportunity for complete recuperation.
In order to give the requisite opportunities for the efficacious operation
of the different agencies enlisted in the prophylactic and curative treatment
of scrofula, their regular and persistent use for a length of time is of para-
mount necessity. Patients in chronic maladies or invalids threatened
with the approach of disease are wearied if positively curative and reno-
vating effects are not manifest in a short period of time ; and physicians
are too often prone either to partake of their discouragement or to fail to
attach adequate importance to the prodromes or insidious approach of the
disease. The change, whether it imply a removal from locality and lodg-
ings in which the air is close and impure, or the substitution of plain,
wholesome, and nutritive food for that deficient in these qualities, must
be extended beyond a few days or weeks, or even months, if we hope to
produce any change in the diathesis and to prevent the speedy recurrence
ofthe disease under the operation ofthe very first unfavourable causes.
The same rule of regularity and persistence for a lengthened period
must govern in the use of analeptics or euplastic remedies, such as chaly-
beates and other tonics, so soon as we detect the even slight ophthalmia
or chronic enlargement of the tonsils and certain physiognomical traits of
facial scrofula. If there be thickening of tissues and glandular swellings,
and the iodide of potassium be deemed useful, it also ought to be perse-
vered in for a long time, alternately with suitable laxatives, or itself com-
bined with a saline laxative, until the symptoms disappear and the dia-
thesis be, in a measure at least, altered. In specifying chalybeates and
iodine salt, I do not mean that the preliminary treatment should consist in
the use of these articles, or be restricted to the classes which they respec-
tively represent, but I instance them as the most active and the most
generally useful both in incipient and in confirmed scrofula ; and in order
to impress on your mind the absolute necessity of continuing for a length
of time either one article or a succession of articles until the organism may
be supposed to be fully and permanently affected by them.
In undertaking the cure of scrofula, while we hold steadily in view the
primary indications favourable to alter and modify the state of the blood and
to prevent morbid deposit, or failing in this, then to bring about the absorp-
tion or safe discharge of the latter, we are not to overlook the secondary func-
TREATMENT OF SCROFULA.
665
tional disorders, nor omit to use the customary remedies for their removal.
Hence, clear as may be the indications, under the general propositions
just mentioned, to adopt the invigorating treatment, we are not to carry
it out in the vulgar sense, by the uninterrupted administration of nutri-
tive and medicinal stimulants, without regard to the state ofthe digestion
and to visceral complications. The system can never be invigorated
unless the stomach and bowels be fitted to discharge their chyliferous
office. With this view it is necessary, in the disease before us, to act on
them, at first, and occasionally at intervals in the subsequent treatment,
by purgatives—compound powder of jalap, rhubarb, and magnesia, senna
and salts, sulphur water with a predominance in the first stage of saline
substances, and, in the second, of iron. By moderate purging in scrofula
we quicken th# digestive action and increase the activity of lacteal absorp-
tion in one direction, and that of lymphatic and interstitial absorption in
another. We prepare also the way for tonics, so called, viz., vegetable
bitters, quinia, and the preparations of iron, and the alteratives, such as
iodine and the alkalies; the effects of which will be more sensible and
salutary if laxatives be occasionally interposed.
But in order to render the above means at all available, we must enlist
those other and antagonizing ones to the causes of the disease. These are
wholesome nutritive food supplied in a quantity short of oppressing the
digestive systera, and country, at any rate, fresh and pure air. Sea air
and sea bathing have operated in many cases most beneficial changes.
If, in addition to these, we can obtain the operation of active mus-
cular exercise, wre place the system of the patient under the sway of
the genial and kindlier influences, by which health is at all times most
surely preserved, and readily recovered when lost. Mr. Phillips believes,
" that by the well-directed employment of strong muscular exercise, many
cases of this disease, where even tumours are found in the neck, may be
cured." M. Lugol speaks with great confidence of this means of cure,
even in cases of white swelling of the knees and the joints of the lower
limbs.
Ofthe iodine, in the form ofthe iodide of potassium in solution, and of
a watery solution of the iodine through the medium of the salt just named,
I can speak favourably from personal experience. But I must add, that
I have found this medicine more serviceable in bringing about a healing
process of the scrofulous ulcers, than in preventing the tumours from be-
coming open ulcers. In some cases, indeed, I succeeded in discussing
the scrofulous tumours in the neck, which to all appearances would have
ere long ended in ulceration. Commonly, I have directed an ointment
ofthe iodine and the iodide of potassium to be rubbed on the part in the
form of ointment, at the same time that the watery solution was taken
internally.
The proportion of the iodine to the iodide of potassium in the compound
or Lugol's solution, is as one to two, viz., H. Iodin., gr. x., potass, iodid.,
9i., aquae destillatae vel pluvialis, ^ij. Dose, ten to fifteen drops in a little
sugared water for an adult and proportionately less for a child. More will
be gained by the gradual introduction of the medicine into the system
than by attempts at immediate saturation with full or large doses. These
often irritate the stomach and cause peculiar symptoms (ioddsm), such as
accelerated pulse, palpitations, vigilance, flushings of the face, throbbing
of the temporals, dryness of the mouth, throat, and nose, and soraetimes
666 DISEASES OF NUTRITION.
i
symptoms of coryza, with tremours, and, if the medicine be still continued,
rapid emaciation. To give effect to any of the simple or compound saline
preparations, large dilution is necessary, and hence the efficacy of various
mineral waters which are strong therapeutically, owing to their very weak-
ness pharmaceutically considered. On this account, I should give a pre-
ference to the weaker of the preparations recommended by M. Lugol under
the head of ioduretted mineral water, as follows:—R. Pulv. Iodin. gr. £,
Iodid. Potass, gr. iss., Aquae destillatse, ^viij. Of this an ounce to two
ounces, farther diluted in sweetened water, may be taken two or three
times daily by a child, and the entire quantity, or from six to eight ounces,
by an adult, in the course of the day. The compound tincture of iodine,
in wThich alcohol is substituted for water, in the solution of the iodine with
the iodide of potassium, is also directed in scrofula, but as tnore stimula-
ting, its use should be restricted to lymphatic temperaments, in which
there is an absence of undue gastric sensibility and, h fortiori, of irritation
or phlogosis. The dose is ten drops, which may be gradually increased.
A simpler and still safer and quite efficacious preparation is the iodide
of potassium alone, in simple watery solution. The dose for a child is
from a quarter of a grain to a grain, gradually increased, in some instances,
to two and even three grains, although such an augmentation will seldom
be required. Three grains is as much as is proper for a young subject
during the twenty-four hours. I do not think that the instances recorded
by different writers of the toleration by certain patients of enormous doses
of this salt and of other preparations of iodine, ought to be received as a
measure or guide for their habitual prescription and use in such doses.
Iodine with iron, as in the iodide of iron, is admirably adapted to a
large number of scrofulous subjects. The most convenient form for ad-
ministering it is the Liquor Ferri lodidi of the American Pharmacopoeia,
in a dose of from fifteen to thirty drops twice a-day in a little sugar and
water. The iodide of zinc has been used with advantage. Muriate of
lime and also lime-water have had their admirers. Arsenic is one of those
remedies which ought to be kept in reserve until others have had a full
trial. The alternate use, either from day to day, or from week to week,
of the iodide of potassium, and of the carbonate of iron, or of another
preparation to which I am partial, the potassio-tartrate of iron, will be
followed by the good effects expected from the iodide of iron itself. This
practice is to be preferred where the latter cannot be procured in a state
of entire solution, as in the liquor ferri iodidi. The citrate of iron and
quinia will meet, often, a double indication in scrofula.
Bromine, combined with an alkaline base, and particularly the bromide
of potassium, has been found quite efficacious both in scrofula and in
chronic enlargements of the liver and spleen, and in some other affections
in which the iodide of potassium is raore frequently employed. The bro-
mide is given in doses of from four to ten grains, three times a-day, in the
form of pill or solution, for an adult, but a fourth or a sixth of this quan-
tity would be enough to begin wTith, in the case of a child between three
and five years of age. This remedy is directed also in the form of oint-
ment. Bromide of iron is, perhaps, Dr. Glover thinks, the most agreeable
of the strong preparations of iron—a praise which cannot be awarded to
bromine itself, the sensation attending the swallowing of which is " truly
horrid." He believes that of the three non-metallic elementary bodies
which have analogous therapeutic action as well as a chemical relation,
TREATMENT OF SCROFULA.
667
chlorine is the most powerful, bromine the next, and then iodine. With
regard to their compounds, Dr. Glover is of opinion that the chloride of
potassium might be advantageously substituted for the iodide. The bro-
mide, in a certain class of cases, might, also, be substituted. The bromide
and iodide of barium have the same physiological properties as the chlo-
ride. Dr. Glover thinks that the value of sea air and sea water, as reme-
dies for scrofula, may be, in some degree, dependent on the chlorine in
the former and the chlorides in the latter. I have recommended, in some
instances, with good effect, a wineglassful of sea water every morning,
fasting, to scrofulous subjects.
CooU^ver oil has been not a little extolled for its curative powers in
scrofuff The dose is from half an ounce, gradually increased to two or
three ounces, three times a-day—with a necessary proviso, that the sto-
mach of the patient can tolerate its use. Something of its disagreeable
flavour may be mitigated by some aromatic oil or peppermint water or
lozenges. In a child within the year a teaspoonful is an adequate dose.
Containing as this oil does both iodine and bromine, it is a quite probable
supposition that its virtues depend on these active elements. Its first or
sensible effects are often nausea, sometimes vomiting, afterwards diuresis
and diaphoresis, and action on the bowels.
M. Negrier, of Angers, assures us that he has derived the most satis-
factory results from the use of the preparations of green walnut leaves.
Each patient took daily two or three cups of infusion of bruised walnut
leaves, sweetened with sugar or honey, and a four-grain pill of the extract
of the leaves, or a spoonful of syrup prepared with eight grains of the
same extract to ten drachms of syrup. All the sores were washed with a
strong decoction of the leaves, and covered with linen compresses steeped
in the decoction, or poultices made with flour and the decoction. Seven
of seventeen patients submitted to this treatment were cured after six
months, and five nearly so. M. Negrier indicates his preference for the
walnut leaves over all other anti-scrofulous remedies.
It was at one time an established rule in the treatment of scrofula, or
where we had to deal with disease in a manifestly scrofulous habit, never
to administer mercury. That there were good grounds for this prejudice
one cannot deny ; but to carry it to the entire exclusion of an occasional
mercurial purge, and even mercurial alteratives, is going beyond the limits
justified by experience. Thus, a purge of rhubarb and calomel will be
useful to unload the bowels of accumulations which are so apt to form in
strumous cases, and occasionally small doses of calomel, followed by rhu-
barb, magnesia, or saline medicines, serve to promote proper secretions
both from the liver and the raucous follicles ofthe intestines, and thus aid
towards a restoration of healthy digestion. The real error and positive
mischief consist in a protracted use of mercury, or in making the whole
treatment turn on the employment of the preparations of this metal, in
place of regarding it as a preparation for the true alterative course, of fresh
air, exercise, plain and nutritive food, bathing and friction, and the drink-
ing of certain mineral waters. Failing soon to accomplish our purpose
with mercurial alteratives, we must desist from their use, and rely on the
means last mentioned, or have recourse to analogous agents of less equivo-
cally salutary effects on the system. Of these, iodine in various forms, as
already indicated, is entitled to our confidence, alternately, or even com-
bined with certain vegetable bitters and earthy salts. If we have been
668 DISEASES OF NUTRITION.
properly instructed by a knowledge of the modifications which scrofula
impresses on the morbid changes of the organs, we shall have recourse
earlier to iodine and other alterative stimulants and tonics than the per-
sistence of some sub-acute inflammatory symptoms might otherwise seem
to justify.
A new compound of chlorine, iodine and mercury has of late been
strongly recommended in the treatment of scrofulous affections, and inve-
terate cutaneous diseases. It was first introduced by M. Boutigni, who
calls it the iodihydrargyrite of mercurial chloride. M. Rochard states, that
after having obtained some rapid cures in psoriaris, lichen, chronic ecze-
ma, herpes, maculae, &c, the idea occurred to him of extending^ts em-
ployment to the treatment of scrofula. He cites among othe^ some
successful cases of white swelling with caries and fistulous canals ; of nu-
merous enlarged lymphatic glands, indurated or ulcerated, of chronic oph-
thalmia, complicated with ulcerating keratitis; of ulcerated lupus, of goitre;
and finally of large scrofulous abscesses, succeeding to an anti-syphilitic
treatment. In these several cases the action of the remedy was quick and
permanent, though varying in the various forms of the diseases. M.
Rochard employs the medicine externally in the form of ointment.
Ofthe class of tonics the sulphate of quinia merits the earliest and most
frequent trials. There is a state, however, of parts accompanied with
great pain and some evidences of increased action of both the white
and red vessels, constituting mixed inflammation, which, though al-
leviated, is not cured by moderate depletion, and yet in which the use
of tonics and stimulants is premature and injurious. In these cases, and
they will include scrofulous tumours, both of the neck and mammae, and
of the mesenteric glands, as well as scrofulous enlargements of the uterus,
testicles, &c, much benefit, certainly ease, is procured by selections from
the class of narcotics. Of these, opium will, we must believe, ever hold
the first place : next to it come cicuta, hyosciamus, belladonna, and stra-
monium.
The use of external remedies in scrofula is not the least important
part of the treatment. In addition to their internal use, their external
application, in the form of poultices of the leaves, of fomentations by
their decoctions, or of ointments and plasters directly on the part, should
be resorted to. I have, at times, combined the extract of belladonna, or,
in other cases, of stramonium, with mercurial or iodide of potassium oint-
ment, for a topical application, in part to be rubbed on, and in part spread
on muslin and put over the tumour. An old and favourite preparation, the
camphorated mercurial ointment, in cases of indolent glandular swellings
and diseased joints of a scrofulous nature, still deserves our confidence.
Simple enlargement of the lymphatic glands of the neck and other parts
will be benefited by inunction with ointment of the iodide of potassium
made of one drachm of this salt carefully triturated in a mortar with a
drachm of olive oil, and then mixed up with six drachms of unguentum
cetacei or of altheae (simple cerate); or, in cold weather, of hog's lard.
The ointment should be carefully rubbed in by moderate and prolonged
friction, night and morning, over and along the line or region of enlarged
glands. A.still stronger preparation is the compound ointment of iodine,
made of a scruple of this substance with half a drachm ofthe iodide and
seven drachms of lard, intimately mixed together in a mortar. The addi-
tion of half a drachm of rectified spirit to the two active ingredients prior
TREATMENT OF SCROFULA. 669
to their incorporation with the lard will secure more entirely this process.
Bromine, in the proportion of eight or twelve minims to a pint or half a
pint of water, makes an elegant lotion.
When the glands assume a more inflamed aspect, are tender to the
touch or otherwise painful, washes of a solution of the acetate of lead, or
cold poultices, kept moistened with the fluid, are serviceable. Contri-
buting to this end, and at the same time acting as a discutient, is the
iodide of lead, applied in the form of plaster or ointment. Ointment of
cod-liver oil, made of this oil, ^ss., Saturnine extract. 31J., Yolk of eggs,
Jiij., is well spoken of by German physicians. Thinly spread upon lint
it is applied to the swelling or ulcers.
As it is very desirable to prevent ulceration of glands affected with
scrofulous inflammation, we shall not be backward in directing the appli-
cation of leeches to the base and around the swelled gland, and afterwards
warm fomentations. Then we have recourse to the cooling preparations
already mentioned. These may be, on occasions, usefully alternated with
some ointment or liniment of a narcotic extract, as of belladonna, or stra-
monium, cicuta, &c.
For scrofulous sores or ulcers, a great variety of external applications
have been used ; in the selection and succession of which you should be
regulated by the degree of irritation and inflammation in them at the time ;
giving a preference at first to the sedative and narcotic with the emollient,
and subsequently to the stimulating and even caustic articles. Seldom
are scrofulous ulcers cured without recourse to this latter class, and that at
a much earlier period than in the case of ulcers resulting from common in-
flammation.
Stimulant, rubefacient, and caustic solutions of iodine, are employed
by M. Lugol, of the following strengths :—
Stimulating Washes. Rubefacient Solution. Caustic Solution.
No. 1. Iodine . . . gr. ii. Iodide of Potassium . gr. iv. Distilled Water . Ibi. 2. gr. iii. gr. vi. flsi. 3. gr. iv. gr. viii. tbi. 3iv. Si-5vi. Sf. §ij-
M. Lugol uses the stimulating washes in scrofulous ulcers, ophthalmia,
fistulous abscesses, &c. When the scrofulous surface requires stronger
excitement than usual, he employs the rubefacient solution. In tubercu-
lar tumours which have obstinately resisted all other means of treatment,
the rubefacient solution may be applied in admixture with linseed meal
(forming the ioduretted cataplasm of Lugol). To prepare the mixture, the
poultice is first made in the ordinary manner; and, when moderately
cool, a sufficient quantity of the rubefacient liquid is poured on it with a
wooden measure. The caustic solution is used for touching the eyelids
and nasal fossae, to repress granulations, &c.—Bell's Dictionary of Mate-
ria Medica—Art. Iodinum.
Mr. Phillips makes an observation, in the accuracy of which I fully
concur, viz., the rapid change which follows the employment of the iodine
or the iodide externally, and which is manifested in a striking diminution
of the tumour: but after a fortnight or three weeks the latter appears sta-
tionary. Then is the time to resort to a new form, which should be em-
670 DISEASES OF NUTRITION.
ployed for a similar period, and in its turn give place to a third. Mr.
Phillips, also, as I think, justly adds, that, without a concurrent internal
administration of some preparation ofthe medicine, the effects of external
applications are much less decided.
On the termination and mode of treating ulcerated scrofulous tumours,
the remarks of Mr. Phillips will be found practically valuable. He warns
us, that in the cases in which scrofulous matter has been deposited in its
cheese-like form, " neither iodine nor any other remedy which we know,
has power to procure its absorption ; when it is deposited there it must
remain ; a point around which irritation is easily kept up, and about
which, sooner or later, suppuration will take place, the abscess will either
break, or art will interpose to facilitate this result by puncture, and it may
thus be eliminated from the system." How very similar in these respects
is tubercle to the cheese-like matter of scrofula? In a large number of
cases, in spite of the most prudent treatment, the local disease will end in
abscess; for instance, out of 89 cases, 33 presented this termination. It
would of course be desirable that not only the thin sero-purulent matter,
which is usually contained in such abscesses, but also the scrofulous pro-
duct should be evacuated before the thinning of the integuments has pro-
ceeded far and a violent colour is assumed. If the product have not un-
dergone softening, often no evacuation of the matter will take place, but
if it have, a slight oozing, bringing away from day to day small portions
of this matter, will be the course of evacuation; and often, many months
will elapse before the gland and its contents shall have been evacuated,
and at the end of that time an unsightly cicatrix will be the consequence.
This result is accomplished in the following way: one or two small open-
ings in the thin violet-coloured integuments are the channels through
which the matter is discharged. A more or less extended cavity exists
under, produced by the breaking down of the gland and its surrounding
cellular tissue. When the whole of the structure is broken down and
evacuated, this surface presents granulations, which have a tendency to
skin over, without adhering at all, or on other occasions only partially, to
the superjacent thinned integuments. The consequence of this is an irre-
gular puckering surface, and when, as is often the case, the subjacent tis-
sue becomes adherent to the deeper-seated parts, the deformity is increased
by a pitting. To prevent this aggravation, two modes may be resorted
to. When the time for procuring the evacuation of such a tumour has
arrived—when the integuments have become much thinned—the best
mode of opening it is by applying the Vienna caustic paste to the part,
taking care that the paste shall include the whole ofthe thinned structure.
A fair and sufficient opening will be thus made; the evacuation will be
more speedy, the remaining tissues will be more healthy, and the cicatrix
will be comparatively trifling. If, however, this have been neglected, or
another course pursued—if the discharge be going on from one or more
small points—if the integuments over the parts be very thin, then with
scissors we should excise the whole of the violet integument, and we may
then hope to lessen the deformity, which would otherwise succeed to the
disease. Much valuable time would probably be lost, in the endea-
vour to heal the sinuses connected with the cavity; the various forms of
iodine, in a more or less concentrated state, would have been applied to
them, and the patient subjected to much suffering. Here, Mr. Phillips
states in conclusion, that after much experience of such applications
TREATMENT OF SCROFULA.
671
to these sinuses, he is decidedly of opinion that they occasion more pain
and are much less efficacious than the nitrate of silver. When iodine in-
jections are deemed advisable, they should be used of the strength of M.
Lugol's rubejacient solution, diluted to a pale cherry colour.
I must not terminate my remarks on the use of iodine externally in scro-
fula without mention of its application by means of a bath, as so strenu-
ously recommended by M. Lugol. The following table exhibits the pro-
portions to which he gives a preference, after many trials.
Baths for Children. - ■■ 4 Baths for Adults.
Age. Water. Iodine. Hydriodate of Potassa. Degree. Water. Iodine. Hydriodate of Potassa.
4 to 7 7—11 11 — 14 Quarts. 36 75 125 Grs. (Troy.) 30 to 36 48 — 60—72 72—96 Grs. (Troy.) 60 to 72 96—120—144 144—192 1 2 3 Ouans. 200 240 300 Drms. (Troy.) 2 to 2 2—2£— 3-3£ Drms. (Troy.) 4 to 5 4_5_6 6—7
Hitherto I have spoken of the pathology and treatment of scrofula in
general, without particular specification of seat, and of the modifications
called for in the use of remedies. A few remarks must suffice on this
-latter part ofthe subject, which, viewed in all its amplitude, would bring
under notice most ofthe diseases ofthe human frame,—since in nearly all
of them we meet with scrofulous modifications.
The five most common varieties or forms of scrofula, are,—1, inflamma-
tion, swelling, ulceration, and tuberculous deposit in the lymphatic glands
of the neck, which alone, in popular belief, constitutes scrofula ; 2, analo-
gous changes in the mesenteric glands, giving rise to a disease, tabes me-
senterica, more thought of once than at present; 3, strumous ophthalmia ;
4, white swelling; 5, certain skin diseases, of the tubercular kind more
especially. To this enumeration might with propriety be added those va-
rious disorders of the Eustachian tube and cavity of the tympanum, by
which the sense of hearing is so often weakened and not seldom lost.
As much of what has been said on the general and topical treatment of
scrofula was raore directly applicable to the first form, or that in which
the lymphatic glands of the neck are chiefly attacked, I shall not enlarge
on it. The second, or tabes mesenterica, was briefly touched upon by
Dr. Stokes in connexion with ileitis. Without adopting it in all its en-
tireness, he rather gave his sanction to the opinion of the Broussais school,
that the. irritation and enlargement, and subsequent morbid changes in the
mesenteric glands, are consequent on the prior irritation and generally in-
flammation of the mucous coat of the ileum and its muciparous glands,
and more especially at the origin ofthe lacteal-lymphatics that end in the
glands. Now, although every one, who has made a few post-mortem ex-
aminations of subjects who during life had suffered from sub-acute and
chronic enteritis, must have noticed this connexion, yet it would be an
extreme and incorrect view to insist on these phenomena always thus co-
existing. Every variety almost of morbid structural change has been
seen in the mesenteric glands, in persons who have had either tubercular
disease ofthe lungs or the tabes named after these glands, but without
any lesion worth mentioning of the small intestines. Still, as the two
forms of disease often coexist, it is most prudent, while administering
remedies with a view of curing the scrofulous diathesis, &c, resolving, if
672
DISEASES OF NUTRITION.
possible, the glandular tumours, to avoid irritating stimulants, whether
they be nutritive or medicinal, in our anxiety to meet the proposed indi-
cations from the tonic and invigorating treatment. We should keep clear,
on the one hand, of diffusible stimulants, spices and concentrated animal
food, and on the other of drastic purgatives. Excitable as many scrofu-
lous patients are, and with their sensitive tissues very irritable, most stimu-
lants would be almost as prejudicial as prolonged depletion. The former
would increase any existing phlogosis in the glands or other organs, and
in this Vay hasten their disorganization and the formation of tubercle,
while the latter would at most only predispose to such formations.
If the diagnosis be clearly made out, and we have tumid abdomen and
other symptoms of disorder of the lacteal glands, leeching at the iliac re-
gions and a few mercurial laxatives may well precede and, with a wise
discretion, alternate with the use of the recognised tonics. With these
latter remedies we shall be more inclined, in the disease now before us,
marked throughout its course as it so often is by symptoms both of intes-
tinal and vascular irritation, to combine narcotico-sedatives, such as cicuta,
stramonium, &c. It is under such circumstances that the blue pill and
mercury with chalk have been found to be of undoubted efficacy, but never
continued so as to produce ptyalism. Inunction ofthe iliac and inguinal
regions with mercurial ointment, or, if fears be entertained of its specific
action, with ointment of the iodide of potassium, may now be employed
as a discutient or resolvent wTith benefit. Cod-liver oil rubbed into the skin
of the abdomen has been directed with a similar intention. With these
remedies should be associated the simpler vegetable bitters, and decoction
and syrup of sarsaparilla; and in completion ofthe course, if need be, to
correct increasing or persisting anemia, the use of chalybeates, including
the iodide and bromide of iron, with which maybe occasionally alternated
the sulphurous waters or the sulphuret of potassa, in small doses, with
large dilution. •
As the skin is dry and harsh in this disease, it will be necessary to act
on it by at first the warm and vapour bath, and afterwards the cool salt
bath ; and, if season and other circumstances allow, sea-bathing.
White Swelling of the Joints.—Under this common, although far from
expressive or pathologically accurate title, I shall make a few remarks,
chiefly in relation to the scrofulous diathesis of the subjects of this disease
and the modifications of treatment demanded.
The scrofulous affections of the joints appear either in the form of in-
flammation of the synovial merabrane with the secretion of curdy pus, or
in that of inflammation in the cancellous structure of the bones, from
which tuberculous matter is deposited. In this latter the cartilages and
synovial membrane are secondarily affected. The most frequent seats of
scrofulous articular disease are at the hip and knee-joints.
The disease sometimes begins with a dull and occasionally an acute
pain of the joint, which is seldom continued, and may, after a period of
varying duration, disappear, to return again, however, and become more
persistent. Pressure increases the pain, or first develops it in sorae cases,
whilst in others it elicits no complaint. Generally the pain is greater at
the hip than the knee. I have seldom seen greater suffering than in a
case of scrofulous inflammation ofthe hip in a little girl between five and
six years of age, who had been allowed to remain in this state for some
weeks without any regular treatment. Swelling of the part now shows
TREATMENT OF SCROFULOUS AFFECTIONS OF THE JOINTS. 673
itself, at first, from increased secretion of the synovial fluid ; and, after-
wards, or, in other subjects, from the inflammation and deposition at the
spongy termination of the long bones where they contribute to form the
joint. It is needless to describe minutely the anatomical changes in the
synovial, osseous, and cartilaginous systems of the joint; but of their dan-
ger and often intractable character we can have a good idea, from seeing
the progress and results of inflammation ofthe cervical lymphatic glands.
If cheesy or tuberculous deposits remain, interfering with and stuffing up,
as it were, the glandular tissue, how much greater is the risk of their
mischievous action when interfering with the organic functions as well as
the physiological ones of the joints, the attrition of which on each other
is often painfully interrupted by the dryness and loss of secreting power
of even a minute portion of the investing synovial membrane. Fever,
night sweats and diarrhoea show the shock which the constitution has re-
ceived from the protracted irritation of scrofulous joints, under the effects <•>
of which the patient ultimately sinks, emaciated and in the extreme of ex-
haustion. •
The treatment of scrofulous affections of the joints will be general and
local. The first is the more important of the twTo, and, until fully estab-
lished, we cannot promise ourselves much from the latter. It consists,
at first, of free purging ; and if the inflammation of the joint, pain and fe-
brile disturbance be considerable, bloodletting, preferably by cups or
leeches on or near the joint; but if these means are not at hand, by vene-
section. But it should be borne in mind that even although the blood
may show a buffy coat, for there may be an excess of fibrin in this fluid
in scrofulous subjects, with temporary phlogosis, still you are not justified
in having recourse primarily to, or in repeating the operation, merely on
account ofthe violence ofthe pain, but rather with a hope of moderating
the local inflammation and gaining time for the administration of remedies
calculated to alter the scrofulous diathesis. Holding this intention steadily
in view, you are not to carry out a rigid antiphlogistic treatment, such as
would be called for in the simple phlegmasiae; but after bloodletting, if it
was necessary, and after and in the intervals between the administration of
purgatives, you must allow the patient a moderate supply of nutritious sub-
stances; such as bread or rice and milk, well-boiled potatoes mashed with
milk, or flavoured with a little butter; bread and molasses, &c. So soon
as the disease assumes a chronic character you should allow animal food
once a-day, in addition to an adequate supply of vegetable matters.
If you begin purging by calomel and rhubarb, you should continue it at
short intervals with some one of the following preparations: compound
powder of jalap, senna and salts with manna, rhubarb and magnesia, sul-
phate of potassa and rhubarb ; or compound extract of colocynth. Early
recourse should be had to the use, internally, of the iodide of potassium,
and if there be much languor of the functions, and cold skin, the iodide
of iron, alternating with the sulphate of quinia. Narcotic extracts will be
administered here with similar views to those by which they were direct-
ed in scrofulous ophthalmia.
Counter-irritation to the skin of the joint constitutes the chief part of
the local treatment. I need not specify the means by which this is ac-
complished. According as you desire simple rubefaction, vesicular erup-
tion, vesication or pustular inflamraation and ulceration, you will have
recourse to liniments, with water of ammonia or oil of turpentine as the
vol. n.—11
674
DISEASES OF NUTRITION.
basis, then croton oil, cantharides plaster, or tartar-emetic ointment. Firm
and equable pressure by compresses and roller sometimes gives relief and
aids absorption in the more indolent varieties of white swelling. Like
all other parts of the treatment of scrofulous disease, counter-irritation
must be maintained for a length of time before we can expect to see any
notable change. Some physicians have spoken highly of the effects of
tincture of iodine rubbed freely over the whole joint, and after fomenta-
tions or cataplasms, to be again applied at moderate intervals. Coincident
with the view under which the tincture is advised, is the use ofthe oint-
ment, simple or compound, of iodine, to be rubbed over the joint, for a
quarter of an hour at a time, twice daily.
Tubercular affections of the skin and others of a different class, such as
eczema and some of the varieties of herpes, if not of direct scrofulous
origin, are so much modified in their progress by the diathesis of scrofula
# as to require a constitutional treatment in accordance with this view ; and
local remedies must be regarded as of secondary importance in our me-
thodus medendi in such cases. It is in these that, in addition to-the alter-
nation of antimonials with mercurials in alterative doses, and the free use
of iodine and chalybeates, we sometimes find it necessary in the end to
use arsenic. A powerful combination of mercury, iodine, and arsenic,
called Donovan's solution, or solution ofthe iodide of arsenic and mer-
cury, has been of late employed with great success in these and some other
ofthe more intractable diseases ofthe skin. Beginning dose, five drops.
LECTURE CXLIV.
DR. BELL.
Syphilis—Lues Venerea—Its divisions into local or primary, and constitutional or se-
condary syphilis—Two varieties of the local form—First, or gonorrhoea, not properly
a syphilitic disease—Already treated of.—Local or Primary Syphilis—Symptoms;
chancres or sore of genitals; characters of Hunterian chancre; not diagnostic of
syphilis; appearance of sore varying with the tissue affected —Not different degrees
of poisoning and corresponding sores—Alleged connexion between different primary
sores and secondary eruption—True test of a venereal sore; inoculation propagating
the like—A certain period of maturity for the poison to be transmissible; four or five
days—Mistakes in diagnosis of sores on the genital organs and of those on other
organs—Poison sometimes transmitted by the medium of a person who does noi
receive the contagion—Bubo, secondary to chancre and to other sores on the penis, and
other causes—Inoculation, test of venereal bubo—Treatment of Primary Syphilis—Pro-
phylaxis to prevent disease at all, and next to prevent progress after first symptoms—
Destruction of chancre necessary, or its conversion into a common sore—Remedies—
General treatment; rest and antiphlogistic regimen ; chancre persisting, the treatment
required—Phagedenic ulcers—Mercurial dressings not required—Mercurial treatment
of primary syphilis compared with non-mercurial—Safety and greater expedition of
the latter — Mercury useful at limes — Salivation unnecessary—Treatment ofbubc—
French practice successful before suppuration : Ricord's directions after suppuration.
Syphilis—Lues Venerea—Pox.—In the practical summary which I pro-
pose to make of the venereal disease, it will be my endeavour to avoid
giving additional cause of complaint, that, while treatise is added to trea-
tise and volume heaped upon volume, the elucidation of the mysteries of
the disease is not yet accomplished. I shall not be voluminous, nor shall
LOCAL OR PRIMARY" SYPHILIS.
675
I mysticisc you by new and startling deductions ; nor indulge in the
oracular on the strength of alleged discoveries. After this pledge, it would
hardly be consistent for me to attempt even a brief sketch of the contra-
dictory opinions which have been advanced respecting the epoch and the
place at which syphilis first appeared — whether it was known to the
ancients, or whether it is a modern disease; and, admitting the latter,
whether it is of European origin, or derived from America by the first
discoverers of this continent. Of one thing we are pretty sure, that the
disease did not attract general attention, nor become the subject of formal
and repeated professional description and narrative, until after the siege
of Naples by Charles VIII. and his French troops in 1494. Comparing
the accounts of syphilis at that period with its symptoms and progress at
the present day, it is palpable that, although we fail to trace it to any
distinct source, it engaged general attention in the latter part of the
fifteenth century, owing to an epidemic aggravation by which it assumed
the character of an eruptive fever almost contemporaneously with the
appearance of the local contagion : or at a date after this Jatter incom-
parably earlier than the cutaneous symptoras now show themselves.
Divisionsof Syphilis.—Syphilis has been divided by Hunter into local
and constitutional: the first is that in which the parts only to which the
poison is applied are affected ; the second that occurring " in consequence
ofthe absorption of the venereal pus, which affects parts while diffused
in the circulation." Of the local form he and most writers make two
varieties. " In the first, there is a formation of matter without a breach
ofthe solids called a gonorrhoea ; in the second, there is a breach in the
solids called a chancre." The local, also called primary syphilis, includes,
—1, gonorrhoea and gonorrhoeal ophthalmia, or catarrhal affections, the non-
virulent venereal diseases of Ricord ; and 2, chancre or primary syphilitic
sores, the virulent affections of Ricord.
The first of these varieties, or gonorrhoea, although a contagious disease,
the product of a specific virus, cannot, it seems to me, be classed properly
under the head of true syphilis, nor allied to chancre, which is the first
or true primary stage of this latter. Gonorrhoea is a local disease, whether
the matter producing it be in its usual seat, the urethra, or, as sometiraes
happens, affects the eye. No secondary symptoms properly constitutional
appear, nor do we meet with a poisoning of the different tissues, nor, as
we have reason to believe, the blood itself. For this reason I described
gonorrhoea among the diseases of the genital organs, and postponed any
notice of syphilis until I could speak of it in its proper place under the
head of cachexia?, as a disease affecting the whole system ; although it is
undoubtedly local in its origin, and this origin generally in the superficial
part ofthe genital organs. But to describe syphilis as a malady of these
organs would be as unpathological as to call inoculated small-pox a disease
ofthe skin ofthe arm, because the virus had been inserted in that part,
and the first pustule appeared there.
Local or Primary Syphilis.—I shall, therefore* regard chancre, or an
analogous sore on the genitals, as that which represents and is included
under the title of local or primary syphilis ; and shall afterwards notice,
under that of secondary and constitutional, a series of symptoms and
morbid phenomena evincing lesions of tissues and diseases of remote and
dissimilar organs.
After a period varying from twenty-four hours to some weeks, after the
G76
DISEASES OF NUTRITION.
date of sexual intercourse with a diseased person, the one hitherto healthy
will have a sore on some part ofthe genital organs, which may be either
erythematous or pustular. It shows itself in the male most frequently on
the frsenum or in the angle between the prepuce and glans. There is at
first itching of the part, which is gradually changed into pain ; the sur-
face of the prepuce is excoriated and afterwards ulcerates, or in other
cases a small pimple or abscess appears, which forms an ulcer. "A
thickening of the part comes on, which at first, and while of the true
venereal kind, is very circumscribed, not diffusing itself gradually and
imperceptibly into the surrounding parts, but terminating rather abruptly.
Its base is hard and its edges a little prominent." Such is the description
by the author himself ofthe so much talked of Hunterian chancre, which
was by him and many others believed to have a distinctive appearance,
wanting which, any ulcers on the parts could not be truly venereal. But
an observation which Mr. Hunter himself makes immediately afterwards,
might have saved a deal of useless argument and commentary on this sub-
ject. It is, that, if the venereal poison be applied to the skin where the cuti-
cle is more dense than that of the glans penis or frsenum, such as that upon
the body ofthe penis or forepart ofthe scrotum, a pimple results, which is
commonly allowed to scab, owing to its being exposed to evaporation. The
scab is generally rubbed off, and one larger than the first forms. Here we
see that the same poison applied to two different tissues, or rather to two
varieties of the same tissue, the muco-cutaneous and the cutaneous, will
give rise to sores with different physiognomies.
The fact is, that a great number of sores of different aspects may appear
after impure coition, and be truly venereal. Mr. Carmichaei in his work
has directed the attention of others to this point, and by them we find the
primary sores arranged under distinct heads ; viz., 1, simple venereal
ulcer; 2, ulcer with elevated edges; 3, the Hunterian chancre; 4, the
phagedenic ulcer; the sloughing ulcer and the sloughing phagedena ; each
variety of sore having, it is alleged, its peculiar train of secondary symp-
toms'. With Dr. Colles we may say, primary venereal ulcers present an
almost endless variety of character. As a sequence to this proposition, we
are safe in denying that any definite relation exists between a particular
form of primary ulcer and of secondary syphilis, as of eruption, for exam-
ple. Have we any diagnostic test of true primary venereal sore ? Until
within these few years past the reply would have been in the negative,
unless it had been said that the subsequent symptoms and course of dis-
ease, such as secondary syphilis, would decide. Now, however, owing
to the talent and persevering industry of M. Ricord, we have such a test
established by inoculation of the fluid of the suspected sore. If this latter
be truly venereal, its fluid product introduced by inoculation into any part
of the cutaneous surface will produce a similar sore ; from which again
its like may be transmitted in a similar manner, and so on indefinitely.
But if the sore be not venereal, no result will follow the inoculation.
Tried by this test, the fluid of gonorrhoea did not give rise to a venereal
ulcer, and but seldom to any kind of sore.
The experiments by inoculation were made on the patients themselves;
that is, the matter ofthe sores with which they were affected was applied
by inoculation to their skin alone—M. Ricord not believing himself jus-
tifiable in inoculating the healthy, at the risk of inflicting on them a serious
and, in many of its aspects, a hideous and terrific malady. M. Ricord
DIAGNOSIS OF PRIMARY SYPHILIS—BUBO. 677
experimented with the matter of all the sores of secondary syphilis, but in
no instance was any one of them propagated by inoculation. Even the
primary syphilitic ulcer or sore is not transmissible in this way in all its
stages ; and hence one chief cause of the failures reported by those who
assert that they have followed the suggestion and practice of M. R-icord.
In order that secondary syphilis should supervene, it must be after a
chancre or venereal ulcer of some (four or five days) duration, counting
from the date of the infection. The most characteristic feature of chancre,
the indurated margin, begins, according to M. Ricord, at the fifth day.
" Mostly," he adds, " they are indurated chancres which are followed
by secondary symptoms, and this induration would seem to indicate that
the venereal principle has penetrated the system, and as long as it does
not take place, we may conclude that the disease is superficial. .1 shall
have occasion soon to show that, although in most cases the secondary
has no other origin than the local and primary syphilis, yet in some other
cases, it is caused directly by contamination from those who are at the
time suffering from the secondary disease."
Two errors are sometimes committed in the diagnosis of primary sy-
philitic sores, owing to their commonly having but one seat, viz., the
genital organs of either sex : first, when any sore is seen on these parts,
it is too readily assumed, or at any rate suspected to be venereal, particu-
larly where the general character of the individual does not present a
guaranty against exposure to the cause ; and second, sores really syphi-
litic may be overlooked, or their nature misunderstood, when they appear
on other parts than the genital organs. Any part of a mucous surface or
abraded skin may serve for the reception of venereal matter of chancre ;
and, accordingly, we find, at times, the accidental application of this latter
to the anus, mouth, eyes, and ears, has been followed by similar chancre
or sore and its customary consequences. Dressers in the hospitals, or
accoucheurs in making examination per vaginam, who may have had
slight excoriations on the finger or at the junction of the epidermis near
the nail, will sometimes contract primary syphilis. Although the disease
is caught almost uniformly from another who was suffering under it at the
time of sexual connexion, yet there are instances of women who have
had intercourse with diseased individuals, and afterwards communicated
it to other men, without having become infected themselves.
Bubo, enlargement with inflammation of the lymphatic glands, for the
most part of the groin, is an occasional and, it must be admitted, a trouble-
some aggravation of primary syphilis. Neither its absence nor its presence
makes a difference in the features of the primary sore ; nor do the second-
ary symptoms assume any peculiarity by its intercurrence. Bubo, in its
appearance, or tested by any organic change and symptom, offers no indi-
cation of its origin or real nature. Any lesion of the glans penis and
often of the urethra at its upper part will give rise to bubo ; hence we
must expect to meet with this kind of glandular enlargement as merely
sympathetic, following common abrasion and irritation of the glans penis
and preputial covering, and even the pressure on the toe by a tight boot.
There is, also, the*bubo from gonorrhoea, which is sympathetic, and finally
the true venereal bubo, the product of the absorption of virulent matter
of chancre. The test by which to determine the real character of the bubo
is stated by M. Ricord to be inoculation. If it be venereal, the pus in it
after suppuration will give rise to chancre and its sequences; but other-
678
DISEASES OF NUTRITION.
wise not.' In some rare cases we are told that bubo appears without any
antecedent abrasion or ulcer of the penis : but even these may be supposed
to have proceeded from concealed chancre in the urethra, or to have fol-
lowed a minute sore, too slight to have engaged attention before it had
dried up ; for, on questioning closely the patient, he will sometimes ad-
mit that there was such a slight sore on the glans penis or the prepuce.
It is not sufficient, however, that a bubo ensue on a chancre in order to
be virulent: it must be the consequence of the direct absorption of the
virus by the lymphatics and its introduction into a gland or ganglion.
Sometimes in a large bubo we find suppuration of the cellular tissue sur-
rounding the gland ; and this latter itself in a similar condition. In this
case it is the pus from ihe gland alone that, by inoculation, will give rise
to primary syphilitic ulcer.
Treatment of Primary Syphilis.—It may be asked, before speaking of
the remedies for actual chancre, whether something may not be done in
the way of prophylaxis, and thus entirely prevent the disease. In reply,
it is known that various washes have been recommended, some even be-
fore coition, but most immediately after it, with a view to neutralize the
poison, supposing that the other party may, at the time, be labouring under
the disease. The success of some of these applications has been asserted
with considerable confidence, because we are told they neutralize and de-
stroy the venereal virus. But this fact is not conclusive of their efficacy
under the particular circumstances required ; as they cannot always be
applied to the delicate surface of the glans and corona penis, ofthe strength
that would prove adequate to destroy the contagion. M. Ricord found,
indeed, that whenever he added to the virulent pus of a chancre a caustic
alkali or a weak acid, it was decomposed as dry animal or organic matter
would be. In the same way the mineral acids and acetic acid, and the
pure chlorides mixed with virulent pus, prevented it from producing its
specific or poisonous effect by inoculation. The decomposing or prophy-
lactic power of these substances does not extend, howTever, to the virus
after it has been introduced into the tissues and infected them.
It remains then to determine, whether prophylaxis in a more restricted
sense may still be carried out so as to prevent the successive stages of
primary and the coming on at all of secondary syphilis. On this point
there is considerable difference of opinion among practical men. M. Ri-
cord, in unison with Parker, Lane, and Miller, assumes, as the first and
essential part ofthe treatment, the destruction by caustic (cauterization) of
any sore, be the solution of continuity ever so slight, that appears in the
genitals after suspicious coition. Even after the lapse of three or four
days the complete destruction of a primary venereal sore, chancre, or
other variety, will sometiraes prevent any farther progress of the disease.
" Whatever form a chancre may assume in its commencement, it ought
to be treated by the abortive method ; for there is no authenticated instance
of ulcers destroyed within the first five days after infection, having after-
wards given rise to secondary symptoms." Mr. Carmichael, Dr. Wallace,
Sir George Ballingall, and other gentlemen with large practical opportu-
nities of observation, adopt a like course. When we speak of cauteriza-
tion you will understand, not the entire destruction of the sore, but that
of its virus and of its features, so that it is converted into a common ulcer
or simple sore. Until this result is procured, the application ofthe caus-
tic (nitrate of silver) is to be renewed after the fall of each eschar. When
TREATMENT OF PRIMARY SYPHILIS.
679
the ulceration is farther advanced, the Vienna paste fused, or the fused
potassa, penetrating more deeply the tissues, is more efficacious. In
the meantirae the ulcer should be covered with dry lint, and spread, as
some advise, with simple ointment, on which may be placed a bread
poultice on fine linen moistened with dilute solution of sugar of lead, and
the whole covered with a piece of oiled silk. So long as suspicion at-
taches to the ulcer, it is extremely desirable to check the secretion and to
absorb it as soon as secreted. Dry lint, by forming a kind of sponge,
fulfils one of these indications; astringent washes carry out the other.
Of these, M. Ricord is particularly partial to the aromatic wine of the
French pharmacopoeia; which is made by digesting four ounces of aro-
matic herbs, rosemary, rue, &c, in twTo pints of wine for eight days. The
ulcer is to be well washed with this liquid, but not so as to make it bleed,
and then lint moistened with the wine is to be applied. Before removing
the dressings they should be moistened with the same liquid. In some
cases of more copious secretion, a wine of tannin, made by the addition
of two scruples of pure tannin to eight ounces of wine, may be advan-
tageously substituted. If a more sedative action be desired, the addition
of eight or ten grains of opium to the ounce will be directed.
This method of treating primary syphilitic ulcers without complication
is the one which I have myself adopted with entire satisfaction, and is to
my mind preferable to that advocated by Dr. Colles, who recommends
that no attempt should be made to alter the natural features of the ulcer,
the true Hunterian chancre, from the observing which, he alleges, so
many useful indications to guide us in the administration of mercury may
be drawn.
During this first period of syphilis the patient should be enjoined to
remain at rest, to adhere to a cooling regimen ; and, if his habit require it,
antiphlogistic remedies are to be used. Much irritation at the sore itself
and symptomatic fever may sometimes require the use of leeches ; but
from the tendency ofthe bites to give rise to sores analogous to the pri-
mary one, it is advisable to apply them to the ulcerated spot itself. But,
as this is not easy, it will be safer still to select a surface in the neigh-
bourhood, such as the dorsum penis or groin, carefully protecting it by
cerate and lint from the possible application of virulent pus until the leech-
bites are healed. In anemic constitutions, on the other hand, a mild nu-
tritive regimen and the simpler tonics are admissible.
The aborting treatment by cauterization not proving successful, or the
period of chancrous ulceration having been too long to allow of a hope of
immediate eradication, the milder measures should be resorted to, if we
would avoid the complications and exasperation of symptoms arising out
of erysipelatous inflammation and phagedenic ulcer. But, even although
we may not encounter these in the case of our patient, we still must be
prepared to meet with an indolent and stationary ulcer in which the secre-
tion is dried up. If this is secondary on, or an imperfect cure of, the
simple chancre, we suspend the use of the stimulants and astringents be-
fore recommended, and have recourse to opiate cerate, made by adding
an ounce ofthe vinum opii to a pound of lard, or emollient fomentations
with the addition of a decoction of poppy. 1 have used in such a case,
and I may add in venereal ulcers generally when cauterization was not
practised, the chloride of lime or of soda in solution.
Phagedenic ulcers, including the ulcerative and the sloughing, must be
680
DISEASES OF NUTRITION.
treated "according to the extent of inflammation ofthe parts and the con-
stitutional sympathies, as well as prior habit of body of the patient. In
the inflammatory variety, the cooling and antiphlogistic course is to be
fully carried out; and after the subsidence of local and constitutional irri-
tation, recourse may be had to the nitrate of silver, pure nitric or nitro-
muriatic acid, and an alcoholic solution of corrosive sublimate for topical
applications, and the iodide of potassium internally. Fistulous cavities
are to be laid open. In the irritable phagedenic ulcers, these local reme-
dies are preferable.
I have said nothing, hitherto, of mercurial dressings, ointments or
washes, in primary syphilitic ulcers; and if I now advert to the subject,
it is to caution you against their use, in the early periods particularly, as
they have caused complications and results of the most troublesome kind ;
such as increase of secretion, a disposition to spread and burrow, and
augmented sensibility.
A few years ago and it would have been regarded a still more serious
if not criminal oversight to neglect the constitutional treatment of primary
syphilis in all its varieties by mercury in some form or another. Into the
history ofthe fluctuations of opinion and practice respecting the employ-
ment of this powerful medicine for good and for evil, I have not space to
enter ; nor is it necessary for our guidance. It is sufficient for me to say,
that tens of thousands of regularly recorded cases of primary syphilis have
been treated without the use of mercury, in hospital, army, and private
practice, and with results that attest the entire safety and propriety of this
course. In Sweden, cases have been under treatment to the number of
40,000, in the various hospitals, both civil and military ; one-half by the
simple, the other by the mercurial method. The proportion of relapses by
the former is stated to have been seven and a half, and that by the latter
thirteen and two-thirds per cent. Dr. Fricke, in the Hamburg General
Hospital, found, after an experience of four years, in which 582 patients
were subjected to a mild mercurial treatment, and 1067 to a non-mercu-
rial one, that the period of treatment was longer, relapses were more fre-
quent, and secondary syphilis more severe when the mercury had been
administered. Dr. Fricke insists on the four following conditions in his
non-mercurial treatment: the observance of strict cleanliness ; perfect re-
pose ; a rigid diet; and the employment of antiphlogistics. More than
five thousand patients have been treated by him without mercury, and he
tells us, he " has still to seek cases in which that remedy may be advan-
tageously employed." MM. Devergie and Rufz give returns correspond-
ing with those of the German physician, just quoted. Dr. Fricke and M.
Devergie make the duration ofthe mercurial treatment to be, respectively,
eighty-five, and eighty to ninety days, and ofthe non-mercurial, fifty-one,
and from thirty to fifty days. Without adducing further evidence, we
are now justified in replying in the affirmative and in an opposite sense,
to the answer given by Sir Charles Bell to his own question : " Is there
any experienced member of the profession, who, having a son of eighteen
or twenty, and that son having a chancre, that would treat him without
mercury? No: there is not such an unnatural person." (Institutes of Sur-
gery.) The comment on this is brief. That course of treatment which a
professional man would recommend to any one of his patients, be he rich
or be he poor, on a point especially touching the health in all after-life,
is such as he would recommend for his son ; and that which he may deem
TREATMENT OF BUBO. 681
essential for the latter cannot be withheld from the former. I, for one,
would not hesitate, from the results of my own experience, to continue
the non-mercurial practice. It is that which I have carried out for many
years, and I have found no reason for misgivings as to its propriety.
But it would be absurd, on the other hand, to refuse determinately to
give mercury in all cases and in every stage of syphilis. Where the ulcer
is stationary, especially where it is indurated, we should prescribe mer-
cury as we would do in any kind of obstinate ulcer, as an alterative, alter-
nately or in combination with purgatives at one time and tonics at another.
There is an additional propriety in using mercury in this state of things,
to expedite the entire healing ofthe ulcer, which cannot be said to take
place if a hardened cicatrix remains, from the fact, that the risk of the oc-
currence ofthe secondary symptoms is in direct proportion to the period
a primary sore remains open. Assuming this to be correct, the milder
preparation ofthe blue pill, and next to this calomel, alone or conjoined
with some narcotic extract, is to be preferred. Of late years the iodides
of mercury have been highly extolled, but upon somewhat speculative
grounds. The indication for continuing the use of mercury will be a salu-
tary change in the sore : but if the latter be aggravated by extending the
inflammation or in other ways, we desist from this medicine. In no case
is it necessary to salivate the patient, and in every one a proper regimen
should be insisted on, and the common and probable causes of disease
sedulously withheld. Most ofthe bad effects of mercury and ofthe pre-
judices against it have arisen from its being pushed to the extent of causing
ptyalism, and the associated irritative fever and subsequent feebleness of
function. Any notable deviation from the usual slate will be a signal
rather to desist from than empirically to continue the use of mercury.
The treatment of bubo is to be conducted on the same principles and by
the same remedies as in chancre. If there be febrile excitement or dis-
ordered digestion we may sometimes direct venesection and always pur-
gatives. We shall have recourse more freely to leeches in the first stage
of swelling, with heat and other phenomena of inflammation. Preference
may be given to the method of M. Gama, chief surgeon to the Military
Hospital of Val-de-Grace, which consists in applying four or five leeches
at first, and when the bleeding begins to be diminished, to apply another
relay of leeches, and so on, in order to keep up a flow of blood for a day.
The disease still persisting, a blister is to be put on, of the requisite size
to cover the tumour, and on the following day, when the epidermis is de-
tached, a small portion of the lint is to be moistened with a solution of
the bichloride of mercury, twenty grains to the ounce of water, and laid
upon the denuded surface. This is to be kept in its place for two hours
by bandages, or strips of adhesive plaster ; when it is removed, a dark
brown eschar will be found already formed. The parts are now to be
covered with a simple poultice, a cooling lotion, or a solution of opium,
and the patient is to keep as quiet as possible till the eschar thus produced
has separated : when this has taken place the tumour is found materially
diminished, or altogether gone. If the tumour be of large size, or very
indolent, a second or even third repetition of the process may become
necessary. This practice, recommended by M. Malapert, a French army
surgeon, against the incipient bubo, either indolent or inflamed, has
since been extended by M. Reynaud, with almost equal success, against
bubo in its second and third stages, even where the collection of pus has
682 DISEASES OF NUTRITION.
been considerable. Hundreds of cases of bubo have been and are daily
thus treated successfully in the French army, without the patients being
confined to bed, or without their taking mercury internally, or using it by
friction. The practice has been adopted in the French Venereal Hos-
pital, by MM. Cullerier and Ricord, with marked success. (Parker—The.
Modern Treatment of Syphilitic Diseases, fyc.) The popular treatment for
a number of years past in the United States, one from which I have found
often advantage, consists in the application of a blister to the bubo and
dressing the vesicated surface with mercurial ointment. If objections be
made to the blister, or if the tumour be indolent, assiduous friction with
mercurial or iodide of potassium ointment, and dressings of the same kept
on the part, will sometimes prove to be an excellent discutient. It has
even been recommended to use this kind of friction around the base of
the swelled gland, while the vesicated process was going on over its
summit and body. Compression alone and friction with mercury, or of
sorae iodinic preparation, will sometimes resolve the bubo : compresses
soaked in a dilute tincture of iodine also tend to the same end.
When suppuration has taken place, the practice generally recommended
is to open the abscess, even though it may be at some depth below the
surface ; but it is only when the skin is deadened that caustic is used for
the purpose. The open sore assumes very much the appearance of a
scrofulous ulcer, and is to be treated accordingly. If, however, the edges
of the incision ulcerate and the cavity enlarges under the skin, M. Ricord,
after the second day, fills the latter with powdered cantharides, and covers
the whole with a blister. The next day, if any induration be present, he
applies mercurial ointment, and dresses the cavity with aromatic wine :
but if otherwise, he dresses the surface of the blister with cerate, and
covers it with compresses dipped in white decoctions, continuing the
wTine for the cavity. When the skin at the margin of the opened bubo
hangs loose, is bluish and indurated, the repeated application of the
nitrate of silver restores its borders to a healthy granulating action, and
saves the necessity of recourse to its removal by excision or destructive
cauterization.
As regards the anti-syphilitic, by which so many understand the mercu-
rial treatment, it is not more called for in bubo than in chancre. On gene-
ral principles we may have recourse to mercury, as a salutary alterative
and with a viewr to resolve glandular swellings, but not to correct or neu-
tralize any specific taint or virus. With similar intention, iodinic pre-
parations and the compound syrup of sarsaparilla should be used : their
effects, judging from the results of my own experience, are decidedly
beneficial.
SECONDARY OR CONSTITUTIONAL SYPHILIS. 683
LECTURE CXLV.
DR. BELL.
Syphilis (Continued).—Secondary or Constitutional Syphilis—When syphilis is consti-
tutional— Progress of the disease in itssucressivestages-- Hunter's description-- His first
and second stages correspond with Ricord's secondary and tertiary forms—Proportion of
rases in which secondary symptoms occur—The less proportion the sooner the primary
disease is cured—Modes of transmission of secondary syphilis—Generally notcommu-
nicahle—Secondary symptoms in new-horn children—Occasional suspension of symp-
toms—Difficulty of diagnosis of secondary syphilis—Varieties of venereal eruptions—
Description of—Sore throat—Treatment of Secondary Syphilis—Attention to coexisting
acute diseases—These to he cured first—Derangements of function to be removed—
Treatment, varying with the constitution, hahits, and other diseases of the patient—
Remedies in first stage or secondary form of constitutional syphilis—Mercurials use-
ful ; and still more iodine—Donovan's solution—Syphilitic ulcerations—Their appear-
ance and treatment—Vegetations—Treatment of.—Tertiary Syphilis—Symptoms
appear late—Order of parts affected—Not transmitted hereditarily—Secondary symp-
toms often disappear when hereditary without treatment—Tertiary symptoms may
then seem to he primary—In tertiary symptoms, or the second stage of Hunter, the
iodide of potassium the chief remedy—Attention to the symptoms of phlogosis ;
these to be met by appropriate measures—Cyanuret of mercury; its advantages over
the bichloride—General treatment and cautions.
Secondary or Constitutional Syphilis.—After the absorption of the
venereal poison and its passage through the lymphatics and glands into
the general system, a new series of disorders is gone through, to which
we affix the term of secondary or constitutional syphilis. They are divided
into two stages: the first shows itself in disorders of the skin, throat, or
mouth ; the second, not so well marked as the former, is manifested by
disorders of the periosteum, tendons, fasciae, and ligaments. The pro-
gress of the disease, in its successive stages, is admirably portrayed by
Hunter, to whose Treatise on the Venereal Disease, with Mr. Babington's
notes, I would earnestly recommend you. If not the only work, it ought,
of right, to be the first to which you will give a place on your shelves.
Next to Hunter, for originality and useful applicableness of principles, is
the Treatise of M. Ricord on Venereal Diseases. This latter p-entleman
divides the phenomena of constitutional syphilis into secondary and ter-
tiary, which correspond closely to the two stages in the first and second
order of parts affected in lues venerea, as laid down by Hunter. These
divisions are not arbitrary nor unproductive of practical results, since the
remedies useful in the one stage or order of parts diseased, are inappli-
cable, and, in some instances, positively injurious in another stage.
The proportion of cases of primary syphilis, in which the secondary or
constitutional disease shows itself, has not been accurately ascertained.
Its occurrence has been variously estimated after the two modes of prac-
tice, the mercurial and non-mercurial, adopted in the primary disease.
If the latter have been followed out, the proportion of relapses or second-
ary symptoms is, we learn from one series of estimates, reduced to ten at
the lowest, or at the highest to twenty, in the hundred. Mr. Bacot's sum-
mary makes the proportion at least one in ten, of secondary symptoras
where no mercury had been given ; whereas, on the contrary, the propor-
tion of such cases is only one in seventy-five, where that remedy had
684
DISEASES OF NUTRITION.
been employed. But, on the other hand, the advocates of the non-mer-
curial practice allege that the cure, which in so many cases was a syste-
matic abuse of mercury, since it implied salivation, and that often pro-
fuse, gave rise to those very secondary or at least analogous symptoms
which it was intended to prevent ; or at any rate, that a hybrid disorder,
more complicated, more exhausting, and not seldom more fatal, was in-
duced by the liberal employment of mercury in primary syphilis. If we
are to receive as accurate the estimates deduced from so many thousands
of cases in different countries treated without mercury, the duration of
which was so much shorter than that of those in which the mercurial prac-
tice had been followed, and then connect this fact with the postulate, that
the speedier the cure of the primary disease the less risk is there of the
secondary supervening, we cannot but believe there is some fallacy in Mr.
Bacot's deductions, or imperfection in his data.
All persons are not susceptible of secondary symptoms, and with M.
Ricord, we are obliged to admit, that the occurrence of the latter is fa-
voured by certain constitutional peculiarities which we cannot define.
Sudden changes in the habits, generally, of the patient, pregnancy, disor-
ders of the digestive system, habitual irritation of the throat, mouth or
skin, and scrofula, are specified by him as causes predisposing to the su-
pervention of constitutional disease. A practical inference of great mo-
ment deducible from this belief, is, that, in connexion with the early cure
of primary symptoms, should be careful attention to the general health.
The general proposition, that secondary syphilis in all its stages is in-
communicable, is liable to some exceptions. A mother labouring under
syphilis may communicate it to her child in utero, or a child may be
infected after birth by a nurse who has at the time syphilitic ulceration of
the nipples, or by its mother under the same circumstances, if the disease
of the nipple have been derived from a strange child ; but we are told,
curiously enough, that no instance is known of a child, diseased in the
manner just specified, infecting its own mother, although it will readily
transmit the syphilitic disorder to a strange nurse. A woman thus affect-
ed, and in whom, together with ulceration of the throat and cutaneous
eruptions, there are moist excrescences about the pudenda, may transmit
the disease to the husband. The symptoms in a new-born infant, which
are those of secondary syphilis, commonly present at birth, are desquama-
tion of the cuticle,, a senile expression of countenance, and rarely a few
eruptive blotches. The history of the case is necessary, however, to ena-
ble us to form a diagnosis. But, continues Dr. Egan, when a child is born
apparently healthy, the diagnosis is clear on the supervention of a peculiar
train of symptoms. The characteristic snuffling, the puckered mouth, the
position of the eruption round the lips and anus, in addition to the pecu-
liar varnished and fissured appearance of the parts from which the scales
have faded, will seldom fail to convert a suspicion into a positive certain-
ty. Dr. Colles believes that the secondary form of syphilis may be farther
imparted to other members of the family, by contact, use of the same
utensils, &c. He asserts, that its contagious property, but not its viru-
lence, increases in proportion as it extends farther from its source.
The period which elapses between the appearance of primary syphilis
and the occurrence of the secondary disease varies. It may be within
two weeks, more commonly it is two or three months, and even longer.
Tertiary symptoms, those occurring in the second stage or second order
SYMPTOMS OF SECONDARY SYPHILIS.
685
of parts of Hunter, appear at an indeterminate period ; rarely, however,
within six months of the primary affection. The stationary nature and
occasional suspension of all the secondary symptoms are well described
by Dr. Colles (Practical Observations on the frenereal Disease and on the
Use of Mercury)
The precise symptoms of secondary syphilis and the order of succession
are admirably described by Hunter; but with all the attention that has
been given by him and others to the subject, the task of diagnosis is still
difficult, whether we have regard to the ulcerations of the throat and
mouth, the eruptions on the skin, or nodes and other affections of the
fibrous system. In this, as in other cases of doubt, we must form our
opinion, not so much from any one symptom as from a review of all the
symptoms and circumstances connected with the disease. The variety of
venereal eruptions is so great as to baffle description ; and if we were to
try to affix certain characteristics to them in general, such as copper-co-
loured or circular blotches or a mottled state ofthe skin, we should only
mislead. Most of the forms of skin disease may show themselves with a
syphilitic hue or modification. The more distinct forms of these eruptions
ate described, under the following divisions, by Mr. Babington (Notes to
Hunter on the Venereal Disease, Am. Edit., p. 262-4), into—1. Tubercle ;
2. Lichens; 3. Psoriasis and Lepra; 4. Rupia. M. Rayer, in his great
work on the Diseases ofthe Skin, with Notes and other Additions by John
Bell,M.D.,—Illustrated with forty beautifully coloured Plates,—1845, after
enumerating under the head of Syphilidas, or venereal eruptions, tw'elve
forms, specifies them in the following order of frequency : Tubercles, squa-
mae, papulae, excrescences, exanthemata, secondary cutaneous ulcers,
phlyzacious pustules, psydraceous pustules, alopecia, onychia, bulla?, ve-
sicular. To the description of these he devotes nearly a hundred pages
of his book. Equally full, and also illustrated with finely coloured plates,
is the Traite des Syphilides by M. Cazenave.
Syphilitic eruptions are sometimes preceded by febrile symptoms, which
often cease as soon as the eruption makes its appearance. They are, also,
frequently preceded by nocturnal pains in the bones or joints, and com-
monly by ulcers on the throat. The duration of these precursory symptoms
varies from one to two or three weeks, or more. Whatever may be the
elementary form of the syphilitic eruption, it very uniformly shows itself
upon the external organs of generation, about the verge of the anus, on
the face, especially on the forehead and angles of the mouth, on the back,
&c. Syphilitic eruptions have a peculiar colour, the shades of which vary
from a violet red to an earthy yellow, but which is generally characterized
by the term coppery. They display a great tendency to ulceration. Com-
monly they are associated with other symptoms of constitutional infection,
such as ulcerated throat, pain in the bones, &c. The period of their du-
ration varies. Nowr and then these eruptions disappear, for a time, during
the invasion of an acute or other violent disease, but only to recur with
more intensity after convalescence from the latter.
The three chief forms of syphilitic eruptions, as Mr. Skey remarks,
(Lectures on the Venereal Disease), are mottling, psoriasis and lepra. The
first or mottling, although a frequent attendant of is not peculiar to syphi-
litic disease. It consists in a patchy discoloration ofthe skin, varying in
depth of colour from the lightest pink to a distinct red, abrupt in its mar-
gin, and slightly rough to the touch. It appears most generally on the
686
DISEASES OF NUTRITION.
chest, front of the anus, and on the groin ; it may also appear on the face
or forehead. Syphilitic psoriasis appears in the form of circular spots,
about the size of a small finger-nail, generally round, or nearly so. The
skin is inflamed and thickened, giving to the spots a slight degree of ele-
vation. The base is red or of a reddish brown, and from which the cuti-
cle peels in dry scales or flakes, from the period of their first appearance.
This early desquamation constitutes the prominent feature of the disease,
by which it is distinguished from the desquamation of pustular, vesicu-
lar, or papular eruptions, for in these the desquamation attends the latter
stage only. The syphilitic psoriasis often makes its first appearance on
the scalp or forehead, on the chin or upper lip, and back ofthe neck, or,
more frequently, extends to the chest, abdomen, front or inner surfaces of
the arm5:, chiefly about the elbow joints, to the palms of the hands ; also,
to the front and inner part of the thighs. On the palms of the hands it
assumes a peculiar appearance, constituting what has been called a honey-
comb eruption. The third form of syphilitic eruption is that of lepra,
which is, obviously, pathologically identical with the last described erup-
tion ; but it appears in larger and deeper patches, surrounded by a narrow
inflammatory ring, and based rather on the sub-cutaneous tissue than on the
skin. These eruptions form incrustations of a brown colour, raised con-
siderably above the surface, which separate as the substance ulcerates.
Syphilida, unless in a very advanced form, rarely affect the whole surface.
In venereal sore throats the variety is little short of that observed in
venereal eruptions. They are described by Hunter and Babington, and
classified by the latter. The most general form appears to begin in the
centre of the tonsil. In the early stages, it is attended with very little pain
or swelling,-and is seldom observed until it has formed a distinct ulcer.
This species of sore throat often attends tubercular eruptions on the skin.
Venereal sores often commence on the surface ofthe mucous membranes,
by a small foul ulceration, which passes at an early period into rapid and
extensive sloughing. These ulcers frequently accompany rupia. A third
appearance, which is shortly described by Hunter tinder the name of an
ulcerous excoriation, is of very common occurrence. It is distinguished
by an opaque white colour of the surface. This complaint very often
accompanies psoriasis ofthe skin.
Treatment of Secondary Syphilis.—The great outlines of treatment of
constitutional syphilis are soon laid down. They include attention to the
state ofthe system generally and the removal first of acute diseases which
may be associated with the venereal. The young and hitherto vigorous
subject, or one of a full habit, may require venesection and the antiphlo-
gistic regimen, including the free use of antimonials and low diet. He
whose digestion has long suffered must have this rectified by appropriate
means, medicinal and hygienic. The reduced and exhausted by long
dissipation and profligacy, and the constitutionally lymphatic and anemic,
will be benefited by tonics and nutritive food, and indispensably require
fresh air, and if it can be procured, tepid and warm bathing. To these
latter the iodide of iron will do double service, both by giving tone and
removing in a degree at least the syphilitic disorder.
In the first stage, or secondary form, of constitutional syphilis, that in
which the mucous membranes and skin are more especially affected, mer-
cury finds its most numerous and rational advocates ; nor does scrofulous
complication prevent its use by some of the most experienced of these.
TREATMENT OF SECONDARY SYPHILIS.
687
In English and American practice, inunction and the blue pill, or calomel
and opium, are more commonly directed. In France and on the conti-
nent generally, a marked preference is given for corrosive sublimate, com-
bined with opium or aconite. I ought, however, to except M. Ricord
and a few others, who recommend at this time the proto-iodide of mercury.
He begins with one grain for a dose, combined with opium or extract.
cicutee, the latter in quantity from three to five grains, and he carries the
iodide as far as six grains in the day, but does not exceed this. Where
there is much restlessness and irritability, no uncommon associates of con-
stitutional syphilis, opium, extolled almost as a specific in the early times
of the venereal disease in Europe, has been of late more appreciated for
its curative virtues, in addition to its purely anodyne properties. As an
adjuvant to mercury and iodine, it is worthy of all notice. I shall not
pretend to deny the utility ofthe mercurial practice in secondary syphilis,
but I can speak confidently, after positive experience, of the success attend-
ing the use of iodine in tincture, and ofthe iodide of potassium, with the
compound syrup and decoction of sarsaparilla in cases of venereal disease,
both of the tonsils and mouth, arid tubercular ulcerations—after mercury
had been prescribed in vain by those who preceded me. In the more
rebellious cases, Donovan's solution, beginning with a dose of five drops
and gradually increased to thirty daily, has been of signal service.
In speaking of secondary forms of syphilis I did not advert to the sy-
philitic ulcerations which properly belong to them. They have generally
a specific character, are excavated, have thickened and defined edges and
a foul surface, and secreting an offensive pus. Their situation is generally
about the nose, the edges of the mouth, the eyelids, the ears, or the mas-
toidean region ; they are also common upon the mammas, near the um-
bilicus, in the axilla, the groins, or around the edges of the nails. The
constitutional syphilitic ulcer often makes its appearance in the form of
fissures, depending upon the disposition ofthe skin in the parts where the
ulceration then takes place. These varieties are seen upon the skin of the
scrotum, in the vicinity ofthe anus, the umbilicus, or the commissures of
the fingers and toes, the folds of the skin of the eyelids, the lips, the palms
ofthe hands or soles ofthe feet.—(Parker, op. cit.)
The treatment of these ulcers will be governed by the same principles
as those by which wre are guided in that of primary syphilitic sores and
tubercular ulcerations ; but, in addition to local remedies, constitutional
ones will, also, be demanded, such as the preparations of iodine, or of
mercury or arsenic, as recommended in the syphilida generally.
Vegetations or excrescences, of varied form and appearance, upon the
skin or edges of the mucous membranes, Constitute the last variety of the
syphilida or venereal diseases of the skin ; and I may add, that they are
often, to the last degree, hard to remove. Sometimes they are mere results
of balanitis or posthitis. Professor Miller thinks that these condylomata
pertain to three classes or stages of symptoras, and that they may be com-
municated by a distinct variety of poison, being attended with a peculiar
exanthematous eruption.
The effect of syphilis in its secondary form, in the production of diseased
testis, merits a separate notice. This I have given in my lecture (LXIX.)
on Orchitis, when describing the nature and treatment of Diseases of the
Genital Organs.
Various stimulating and cauterizing applications have been used for their
688
DISEASES OF NUTRITION.
removal, such as solutions of corrosive sublimate, sulphate of copper,
nitrate of silver, and chloride of zinc ; or chlorides of lime or soda, mild
but very useful remedies in these cases. The article which is most eulo-
gised, however, at the present time, for topical use, is the muriate of gold.
A concentrated solution of opium has lately been found most efficacious.
M. Venot's formula is Aq. destill. ffej. extract, opii. ^ij., extract, cicutae,
^j. When the vegetations are clearly of venereal origin, or coincide with
constitutional symptoras, an internal treatment is required, mercurial or
otherwise, as may be indicated by all the circumstances ofthe case.
Tertiary Syphilis.— The symptoms belonging to this form, the second
stage of Hunter, are, as before stated, late in showing themselves. They
have been known to occur in ten, fifteen, or twenty years, or even a
longer period after infection ; but it rarely happens, when the interval is
so lengthened, that the patient has not experienced some intermediate
symptom. One ofthe principal characteristics of tertiary syphilis is its
tendency to concentrate itself in the internal structures. Tertiary symp-
toms are more serious than secondary, for the older syphilis is, the more
formidable it becomes, and the more firmly does it establish itself in the
system. Among the effects or evidences of tertiary syphilis are, nodes,
deep-seated tubercles, periostitis ofthe tibia and other long bones, and of
the cranium or sternum, pains in the bones, exostosis, caries and syphilitic
necrosis ; and, also, deep ulcerations of the velum of the palate, nasal fos-
sae, &c, which are distinguishable from the secondary ulcerations by their
highly destructive character. The tertiary form of syphilis is not trans-
missible hereditarily, as is the case with the secondary form. In some
instances, the secondary symptoms may be so slight as not to have been
perceived, and then the tertiary ones supervening are thought, but erro-
neously, to appear primarily. When transmitted hereditarily, secondary
symptoms appear within five or six months after birth, and subsequently
disappear, whether treated or not, and accordingly, they may never be
recognised by the parents.
It is more especially in the tertiary symptoms, or where the fibrous and
osseous systems are affected, as with nodes, periostitis, nocturnal pains,
caries and tumours ofthe bones, &c, that the best results have been ob-
tained from the use of the iodide of potassium. M. Ricord begins with a
dose often grains, dissolved in an ounce of distilled water, distributed
through the day ; and increases it by ten grains every three days. He
has carried it as far as a hundred and forty grains in the day without any
bad effect. I give you the observations of this able writer and practi-
tioner, but without recommending you to imitate him in administering
such very large doses of this medicine. I have derived all the desired
effects from it in doses not exceeding five grains daily. Its salutary ope-
ration is aided by preparations of sarsaparilla. In constitutional syphilis
supervening on a scrofulous diathesis, the iodide of potassium, while it is
a powerful, is, also, a safe and benign remedy, and it has, under such cir-
cumstances, great advantages over mercury. I employ it in alternation
with the iodide of iron in these cases.
In periostitis forming a node, you will not neglect to use the remedies
indicated by this inflammation as if it had occurred without any syphilitic
origin; and hence cups around and close to the node, or leeches directly
on it, followed by blisters, will be found of themselves excellent discu-
tients, and prepare admirably for the use of the iodide of potassium, both
by inunction on the part and internally.
TREATMENT OF SECONDARY SYPHILIS. 689
In these tertiary forms of syphilis, mercury has been found to be gene-
rally inefficacious. M. Biett has treated some cases successfully with the
arseniate of soda.
When, a little while ago, I told you that the bichloride of mercury was
the favourite preparation with continental surgeons in the treatment of
constitutional syphilis, but added that with some of them the iodide of
this metal was of late preferred, I ought to have apprised you of the fact
ofthe cyanuret of mercury having supplanted the bichloride in the prac-
tice of such experienced persons as M. Cullerier, for example. The cya-
nuret is more soluble and not so liable to decomposition, acts more quickly,
and does not occasion those pains in the stomach and bowels that so fre-
quently accompany the prolonged administration of the bichloride. It
may be administered internally in pills or in solution, and externally in
form of pommade or ointment. Dose, from a sixteenth of a grain to a
grain. Mr. Parker, in his useful summary ofthe pathology and most ap-
proved modes of practice in syphilis, gives a number of formulas for the
administration, both internally and externally, ofthe cyanuret of mercury.
Before concluding the subject I must direct your attention to the ca-
chectic character of syphilis, and to the continual tendency of its poison
to impoverish the blood, and deteriorate the system at large. There is a
diminution of the blood-corpuscles, productive of an anemic condition,
and a ready development of the strumous diathesis into scrofulous com-
plications, at this time. The obvious inferences are, to abstain as far as
consistent with the urgent requirements of the case from the use or per-
sistence in the use of those means which still farther diminish the crasis
and colour of the blood, and enfeeble the functions of the assimilating and
nervous systems. Hence bloodletting and the antiphlogistic course gene-
rally will not be directed on light grounds ; nor will a mercurial course be
urged as a mere matter of routine, and " to make things sure" as sorae
allege. In a scrofulous subject weakened by antiphlogistics, or mercury
pushed to the extent of causing ptyalism, and confined in a close room,
or breathing the impure air of a hospital ward, syphilis makes rapid ad-
vances, and the patient is prostrated to an alarming degree, as well as
becomes predisposed to tuberculous disease. Whenever secondary sy-.
philis sets in, the patient ought to be encouraged to take moderate exer-
cise in the open air, even though it be of wintry coldness ; and be s.us--
tained with a good nutritive diet, and the use of vegetable bitters.; and,
on occasions, malt liquors or wine and water at his dinner. Undei!these
circumstances, I have found the iodide of iron to display excellent recu-
perative powers, while, at the same time, it exerts a decidedly restraining
and curative influence over the syphilitic disorder. The. warm bath
during the prevalence of the symptoms, and afterwards the tepid, and even
the cold bath, when the ulcers and eruption are in processof being healed,
will contribute both to the comfort and to the refusing health ofthe pa'
tient. ' °" ' r '
vol. 11.—45
690
FEVERS.
FEVERS.
LECTURE CXLV1.
DR. STOKES.
Fever—General considerations on—Krroneous modes of investigation—Importance of
the labours of French pathologists—Complication of fever with local disease—Pri-
mary and secondary fevers—Relation of, to local changes—tendency to spontaneous
termination—Principles of treatment—Errors of Brown and Broussiiis—Researches
of MM. Gaspard and Magendie—Their pathological conclusions—Importance of the
knowledge of secondary lesions—Effect in preventing crisis—Treatment—Humoralism
and solidism.
It may be safely asserted, that in the whole range of medical science,
there is no subject on which so much has been written and so little known
as fever. You will find, in the writings attributed to Hippocrates, a series
of observations on the rise, progress, and termination of febrile affections,
which it must be acknowledged are characterized by singular beauty and
truth ; and I think I may venture to say, that such is their extreme accu-
racy, such the comprehensiveness, acumen, and power of the master mind
that made them, that scarcely a single one has been overturned by the re-
searches of modern times. From the period of Hippocrates almost down
to the present day, the contributions to this department of medicine,
though numerous and varied, were of very inconsiderable importance;
they effected little towards the improvement of our knowledge of fever,
and many of them were calculated rather to puzzle and mislead, than to
throw light upon what was difficult and obscure. In place of studying
the phenomena and effects of fever, instead of applying themselves to
what was tangible and useful, the minds of medical men were occupied
in tedious but profitless attempts to discover the proximate cause of fever,
and it was to this subject that the labours of some ofthe greatest men in
medicine were exclusively directed for a series of years. The conse-
quence of this was, that our knowledge made no real progress, and as
little was known about fever in the time of Cullen an 1 Brown as in that
of Hippocrates. We had innumerable discussions as to its cause and
nature, we had a vast quantity of learned writings and ingenious specula-
tions, but they produced nothing available for practical purposes, nothing
tangible or real. The investigators failed, because they reversed the
Baconian method of arriving at the truth ; they first built up a theory,
and then thought to make the phenomena of nature square with it: they
forgot that, to be truly philosophical, we must first recollect, compare, and
arrange facts ; and, when we have done this, we may deduce from them
a theory, cautiously, and with a strict regard to truth. They did not
pursue this course, and the consequence is that they added nothing to the
sum of our valuable knowledge. Their disciples knew nothing more than
was known to Hippocrates ; in fact, they knew less, for their notions on
the subject of fever had reached them through an erroneous and distorted
medium. The followers of Cullen viewed it through the theories of Cul-
len, the Brownists through those of Brown ; both alike forgot nature, and
both were consequently inferior to Hippocrates in true knowledge. They
GENERAL CONSIDERATIONS ON FEVER.
691
attempted to discover the proximate cause of fever, and they failed, as
men generally do when they attempt to investigate first causes. WTe know
very little, indeed nothing, of the nature of first causes ; they are, and
will in all probability remain forever, beyond the range of human intel-
lect. It may be argued, that Cullen and Brown did not seek to ascertain
the first cause, but only the proximate cause of fever; but this is only a
play upon words: both are shrouded in the same obscurity, and in both
the sarae difficulty attends our investigations. Even suppose we say with
Cullen, that fever is a spasm ofthe extreme vessels ; or with Brown, that
it is asthenia of the whole system, what do we learn by this, or of what use
is our knowledge ? Have we more defined and accurate notions of fever ?
—Certainly not. They failed, as all men do, who occupy themselves in the
fruitless labour of searching after first causes. There is but one First Cause,
and even of Him we know nothing accurate, but what He has vouchsafed
to reveal.
Modern pathologists have pursued a course very different from this, and
the consequence has been that they have arrived at the most splendid re-
sults. Instead of attempting to investigate proximate causes, they have
studied the phenomena and effects of fever, they have examined dead
bodies, they have accurately appreciated the series of pathological changes
they present, and endeavoured to connect those changes with the symptoms.
In this great work the French pathologists took a prominent part; indeed,
I think it may be asserted, without fear of contradiction, that a vast pro-
portion of our improved knowledge on the subject of fever is due to the
French. It has been, I regret to say, too much the fashion to decry the
labours of the French pathologists ; but I believe this has been chiefly
done by persons who would gladly possess the knowledge they affect to
despise. The French pathologists have pursued with respect to fever the
same method they have so successfully employed in the investigation of
other diseases ; and though their researches have not thrown any import-
ant light on its proximate cause, they have taught us a vast deal as to its
phenomena and complications, they have established a great number of
valuable facts, and unfolded a series of beautiful truths ; and, I need not
say, that it is in the appreciation of these facts that a proper knowledge
of fever consists.
In the first place, they have strongly drawn the attention ofthe medi-
cal world to this great truth, which should be engraven on your minds—
that mere fever, without local disease, is of very rare occurrence. Here was
a new and extraordinary light thrown upon the misty doctrines of the
older pathologists. With them fever was a nonentity, something they
endeavoured to describe but could not, something apart from and totally
unconnected with organic change. The result of this mode of viewing
the question was a variety of crude hypotheses and fanciful speculations.
Bear this always in mind—mere fever, unaccompanied by local disease,
is very rarely met with. Recollect, too, that it has been established be-
yond the possibility of doubt, that fever, complicated with local disease, is
the rule, and Us non-complication the exception. We have further learned
from modern pathology, that every system and every organ in the body
may be, and frequently is, diseased during the course of fever, and that, in
the vast majority of cases, death is the result of one or many local inflam-
mations. We further learn, that the character and symptoms of fever are
infinitely varied, and that the cause of this variation mainly depends on
692
FEVERS.
the seat, the number, and the nature ofthe local affections. It is to these
that we are to attribute the principal modifications in the character and
phenomena of fever, and it is by these that its course and termination are
mainly influenced.
Dr. Fordyce, in his work on fever, attempts to give a definition ofthe
disease, and as I feel convinced that it is, if not a definition, at least one
ofthe best descriptions of fever, I shall give it as nearly as possible in his
own words. The style of this description is quaint but expressive.
" Fever," says he, " is a disease which affects the whole system; it
affects the head, trunk, and extremities ; it affects the circulation, absorp-
tion, and the nervous systera ; it affects the skin, fibres, muscles, and
membranes ; it affects the body, and it affects the mind ; it is, therefore,
a disease of the whole system in the fullest sense of the term. It does not,
however," says he, " affect the various parts of the system uniformly and
equally, but, on the contrary, sometimes one part is more affected than
another." This last observation is totally at variance with the idea that
fever is a mere morbid condition ofthe whole system without reference to
local lesions, for he expressly states that it does not affect the whole sys-
tem uniformly and equally. This excellent view of fever seems to be
borne out completely by modern pathology, and particularly the last part,
where he says, that in cases of fever one part is more affected than another.
We have, for instance, cerebral fevers, nervous, bilious, gastric, and ca-
tarrhal fevers, by which, it is to be observed, we do not mean to imply
that there is nothing more than simple disease of the brain, or nerves, or
liver, or bowels, or respiratory system, but that in each of these fevers
disease predominates in some particular part. So that when we speak of
these fevers, we speak of such a disease as Fordyce has described, in
which one part of the body is affected more than the rest. In many of
the schools you will still meet with Cullen's division into synocha, syno-
chus, and typhus, a division by which we gain nothing at all, these terms
being but mere words and no more. Will any one define what is meant
by synocha, or synochus ? Will any one say what is typhus ? Will any
one say that a particular class and character of symptoms and morbid
changes apply to any of these affections ? It would be quite impossible.
What we generally find is, that in the different cases of what have been
termed synocha, synochus, and typhus, though they may present the symp-
toms belonging to each separately, yet in these same cases, at some period
or other, the symptoms pass into one another so as to confound the origi-
nal distinction. We have synocha to-day, synochus to-morrow, and then
typhus : or we may have typhoid symptoms at first, and inflammatory
ones afterwards, and so on. We find, too, that similar causes will pro-
duce in different individuals essentially different forms of fever, and hence
it is that we cannot found any distinction of fevers on their exciting causes.
Nothing is more common than to see in two patients the same lesion pro-
ducing, in one the synocha, in the other the typhus of Cullen. Thus,
whether we look to the progress, symptoms, or exciting causes of fever,
we find that this division has no foundation in nature, and is purely scho-
lastic* Synocha, synochus, and typhus, are but mere names without
* [This important truth, so long familiar to the profession in the United
States, through the writings and lectures of Dr. Benjamin Mush, is not yet
fully admitted and appreciated by the European schools of medicine.—B.]
VARIETY OF INDICATIONS IN FEVERS.
693
meaning, terms which belong to the dogmatism of theory, and not to the
expression of truth, yet it is dreadful to think of the numerous lives which
have been sacrificed at the shrine of this dogmatism.
Fevers may be divided into two classes. We have, in the first place,
fevers which we may call primary or essential, in which we find (as far
as human investigation can go) affection ofthe whole system, of the fluids
as well as of the solids. This general state of the whole system seems in
such fevers to have the initiative, constituting the first step in the process
of disease ; but it is also true, that in almost every instance of essential
fever, local disease springs up at some period or other of its course. We
have, then, in these fevers this primary state of the system, the cause and
nature of which are unknown, and we have this followed by various se-
condary lesions, affecting different parts of the body, and presenting
characters by which we can arrive at a knowledge of their nature, more or
less.
In the second class of fevers, we place all those in which the first affec-
tion is local, and the fever secondary. Observe the distinction between
this and the former class. In the first kind, or primary, the local disease
is consequent on the fever ; in the secondary, fever is the result of local
disease. Let us take an example of each. A person in health is exposed
to the contagion of typhus ; he becomes languid and weak, has troubled
sleep, bad digestion, and low spirits ; after some time, what is called fever
sets in, and during the course of this, various local diseases may super-
vene. In the other case a person, also in health, from exposure to cold,
or from some local injury, gets an attack of inflammation ofthe lungs, or
some other local lesion, and, as a consequence of that lesion, has sympto-
matic fever.
Now the relation which the fever bears to the local symptoras in each
of these cases is different. In the first case, the fever is primary, and the
local affections secondary ; and it may happen that, although the local
diseases may be modified or removed, the fever will still continue ; but
in the second, the fever alwTays vanishes on the removal of the local dis-
ease. We have to enter on the consideration of the first of these to-day,
and to examine that morbid state ofthe whole system in which local dis-
ease supervenes at some period ofthe fever; in other words, where the
lesions of particular parts or organs are symptomatic ofthe fever.
I have already mentioned, that one of the great truths at which modern
pathologists have arrived, is, that local disease commonly occurs during
the course of fevers. It has also been established that, in the great majo-
rity of cases, the cause of death is one or more local inflammations. The
experience of every candid pathologist is in favour of this doctrine. Pa-
tients seem to die of fever, but the fact is that some die by the brain, some
by the lungs, others by the digestive system, that is to say, during the
course of fever they get disease of various organs, some ofthe brain, some
ofthe lung, and a vast number ofthe digestive system, often sufficient to
destroy life if there was no fever at all. It is an undeniable fact, that, in
the great majority of cases, there is local disease of some part or other of
the body, and that a vast proportion of fever patients are carried off by
local inflammation. How plain, then, is the deduction from these facts,
that the man who neglects the viscera in fever is practising with his eyes
shut.
So much for the first great fact of the complication of fever with local
694
FEVERS.
disease, and its important bearing on practical medicine. But there is
another general consideration with respect to these primary fevers: they
have a tendency to terminate spontaneously ; of the cause of this spon-
taneous termination we are still in ignorance. One of the most simple and
familiar examples of this is the paroxysm of an intermittent. A patient,
who is at present apparently in good health, will in the space of an hour
or less be attacked wTith severe rigors, followed by all the symptoms of
fever, a flushed countenance, hot skin, quick pulse, and high-coloured
urine, and in some time afterwards a copious perspiration breaks out, which
is attended with complete relief to the symptoms, and the patient gets well
again. From this time until the period of the next attack he continues to
all appearance in health. Now, if we consider each of these paroxysms
as an attack of fever, we see in them an evident disposition to terminate
spontaneously. The same thing occurs in the case of the exanthemata.
Scarlatina, measles, and small-pox have a regular course, which gene-
rally terminates at stated periods ; they also exhibit a succession of stages
characterized by corresponding symptoms. We observe the same dispo-
sition to terminate spontaneously in most continued fevers, and it has
been further remarked, that this spontaneous termination generally occurs
on particular days. We have then two great leading facts in the history
of all primary fevers, first, that they are most commonly complicated with
local disease, and in the next place, that they have a great tendency to
terminate spontaneously and on particular days.
Now, gentlemen, you will please to observe, that a knowledge of these
two very important facts furnishes us with two great indications—one, to
discover and remove, or modify the local inflammation ; the other to sup-
port the patient's strength so that he may not become exhausted during
the progress of the disease, and thus lose his chance of this spontaneous
favourable termination. These two indications, though apparently in-
compatible, are not so in reality. You will of course understand that the
extent to w7hich we pursue one or other of these indications, must neces-
sarily vary according to circumstances. The rapidity, violence, and par-
ticular seat of the local inflammation, the duration of the attack, the age,
sex, and constitution of the individual, all these are circumstances which
must be taken into account in adopting any plan of treatment, whether
calculated to remove local disease, or support the patient's strength.
The similarity between the different individual cases of fever, is too
faintly shadowed out to amount to any thing like identity ; in fact there
are no two cases of fever perfectly alike. You might as well expect to
find two human beings exactly alike as to find two cases of fever perfectly
similar. The causes of this remarkable variation are reducible to the ex-
tent, variety, seat and complication of local disease, and to the peculiari-
ties of the patient's constitution. These two classes of circumstances
produce infinite varieties in the appearance and character of fevers.
The followers of Brown saw nothing in fever but debility, and their
practice was to support the strength, and give stimulants from the com-
mencement, ignorant of the fact, that neglected local inflammation will
produce and keep up debility. The followers of M. Broussais, on the
other hand, think that fever is sympathetic, that it depends on local in-
flammation, and that it must be subdued by depletion. Truth lies be-
tween. We must do both, we must combat the local inflammations by
antiphlogistic means, and we must support the patient's strength by a well-
VARIETY OF INDICATIONS IN FEVERS.
695
regulated regimen. These two indications are by no means incompatible,
but their application must vary according to circumstances. If it be true,
then, that local disease is very common in fever and a frequent cause of
death, it is plain that to practice without a knowledge of the state of the
viscera, would be acting like the physician mentioned by D'Alembert.
He compares him to a blind man armed with a club, who comes to inter-
fere between nature and disease. If he strikes the disease, he kills the
disease ; if he strikes nature, he kills nature.
A discussion has arisen in modern times, as to whether we should look
upon all fevers as sympathetic. This is one of the leading doctrines of
the school of M. Broussais. He declares that all fevers are sympathetic,
that there is no such thing as an essential fever, or, in other words, that
there never exists that peculiar morbid state ofthe whole system to which
we apply the terra fever; that in all cases fever is the result of local le-
♦ sions, and that on the removal of these lesions its cure will depend. To
this conclusion the school of M. Broussais was compelled to come in con-
sequence of their exclusive solidism. They endeavour to reduce all the
phenomena of life, whether in a state of health or disease, to the mutual
action and influence of the viscera and solid parts on each other. They
are solidists, in the strict sense of the word, and can have no conception
of fever as existing independently of some primary local lesion. But it
seems that the leading points of this doctrine have not been able to stand
the test of an impartial examination, and may at present be looked upon
as disproved. You will see at once the importance of this, when you
consider that if it be true that all fevers are sympathetic, the practice
must necessarily consist in the discovery and removal of local lesions,
and no more. But I said that these doctrines are now disproved, and the
following arguments may be laid before you in proof of this statement.
In the first place, let us inquire whether any cause acting on the whole
economy is capable of producing local disease. Mark, the object of our
inquiry is to ascertain whether any cause operating on the whole economy
is capable of producing local disease. Now, I believe it is quite certain
that such is the fact, and that we may have, first, a morbid condition of
the whole system, and, consequent on this, various local lesions. Several
continental pathologists, but in particular MM. Gaspard and Magendie,
have shown, by repeated experiments, that we can produce all the phe-
nomena of typhus in the lower animals by introducing putrid substances
into the system. These gentlemen injected putrid substances into the
veins of animals, and applied them to the surfaces of the wounds, and in
every case where these experiments were performed, they observed that
the animals became ill, had languor, loss of appetite, thirst, prostration—
in fact, all the symptoms of bad typhus ; and, in case of death, that they
exhibited, on dissection, local lesions corresponding with those we meet with
in the human subject in fever. Now, observe, these animals were, pre-
vious to the experiment, in a state of perfect health ; they are, then, sub-
jected to the operation of a cause which is found to produce a morbid
state of the whole system; they die, and on dissection inflammation and
ulceration ofthe mucous membrane ofthe digestive tube, and other lesions,
are discovered in almost every instance. It would be quite absurd to say
here, that the ulceration of the bowels was the cause of the morbid symp-
toms, for the animals were previously healthy. We can come to no con-
clusion, then, but that the introduction of putrid matter produced that
696
FEVERS.
morbid state of the whole system which is termed fever, and that the local
inflammation was the result of this state. It is the same thing with respect
to the exanthemata. A child is exposed to the contagion of small-pox ;
for sorae time nothing particular is observed ; he then gets ill and feverish,
and this is followed by an eruption of variolous pustules. Here we have
a local disease consequent upon a circumstance affecting the whole sys-
tem, and in this, as in the former examples, the local lesion is secondary.
We might as well argue that the pustules were the cause ofthe symptoms
in one case, as to say that the ulceration of the intestines was the cause
ofthe other. Every one, I think, will admit that the pustular eruption in
a case of small-pox is secondary, and not the cause of the symptoms; and
the same argument will apply to the secondary affections of typhus. If it
be true, as appears by M. Magendie's cases, that fever follows the intro-
duction of putrid substances into the body, and that the morbid state of
the system produces inflammation of the intestinal mucous membrane; if, #
too, we admit that in small-pox the pustules are secondary, and conse-
quent on a morbid state ofthe whole system originating in contagion, the
same argument will hold good in all cases of local inflammation (whether
ofthe liver, lungs, brain, or any other organ), which may arise during the
progress of fever. These facts are adduced in support of the first part of
the argument—that local lesions may be and are consequent on that mor-
bid state ofthe whole system to which the name of fever is applied.
The next thing to be observed with reference to this question is, that if
it be true that typhus is merely symptomatic of local disease, it would then
follow that there should be as constant a relation between the symptoms during
life and the morbid changes seen on dissection, as there is between the fever
of pneumonia and the changes presented by the lung. But this is not at
all the case, for we find that there is no constancy, no uniformity, either
in the seat or extent of the local disease. Two patients will exhibit symp-
toms of typhus not differing in any material point, and yet, on dissection,
you will find little or no traces of disease in the intestinal canal of one; in
the other, you will find in the same parts a vast amount of disease. Two
others will also present symptoms very similar; in the one you will find
the lung healthy and normal, in the other you will find it extensively dis-
organised. Would it not be absurd to assert here, that the fever was
symptomatic of the local lesion, seeing that there is no constant relation
between the symptoms and the morbid changes, either as to situation or
extent ? Again ; it is a fact, that you may have several patients present-
ing different symptoms, and yet, when you come to examine their bodies,
you find the same morbid changes in all. One may exhibit all the phe-
nomena of typhus; in another, this condition is but slightly marked ; in
a third, it is absent; and yet, on dissection, you find a similarity of local
lesion. Lastly, it may be argued that if typhus were symptomatic of any
particular local lesion, we should be able to cure it by removing that local
lesion. This, however, is not always the case ; that it soraetimes does
occur I am willing to admit, and this is therefore to be considered as the
weakest of my arguments. But, on the other hand, if it be admitted that
the local lesions are accidental and secondary, we can easily understand
why their removal should not necessarily cause the removal of the fever.
Such are the arguments on which I ground my objections to the doctrine—
that all fevers are merely symptomatic of local disease ; and in these views
I think I am borne out by the opinions of the soundest modern pathologists.
ATTENTION TO THE VISCERA IN FEVERS. 697
But though we admit that local inflammations are secondary, and bear
the same relation to typhus as the eruption of small-pox to the morbid
state that precedes it, still they are not the less important ; and it is by a
careful study of them that we arrive at a key to correct and successful
treatment. They are of great importance from being exceedingly common
in fever ; in fact, so common that their occurrence is the rule, their ab-
sence the exception. They are also, in the majority of cases, the cause
of death, and this they bring about in two different ways. First, directly,
as in a case of simple inflaramation. A patient in fever who gets an attack
of violent enteritis, may die of it as well as if he got an attack of primary
enteritis ; or he may die of pneumonia coming on during the course of his
fever as well as the man who dies of pneumonia from cold. Thus we
see that the secondary inflammations may produce death directly. They
may also produce it indirectly, by preventing the efforts of nature towards
a favourable termination. You recollect I told you, that in fevers there
is a strong tendency to terminate spontaneously and on particular days.
Now, we find that this disposition is greatly impeded by the presence of
local inflammation, so that local inflamraation may operate to the destruc-
tion of life in two ways : either directly, by its intensity and extent, or indi-
rectly, by preventing a critical termination.
This leads us to look still deeper into the matter. We find that these
local or secondary affections may also produce a train of sympathetic phe-
nomena of a very remarkable character. There is no reason why enteritis
coming on during the course of a fever may not react on the economy as
well as the enteritis from cold, which we know generally produces symp-
tomatic fever. In the case of two patients, one, for instance, meets with
some lesion of the intestinal mucous membrane, and, as a consequence,
gets enteritis and sympathetic fever; another gets enteritis during the
course of a typhus: in the one case, the local lesion plainly reacts on the
system, in the other this is less apparent, but there is no reason to sup-
pose that it does not produce some effect on the system in one case as
well as in the other. The law appears to be this, that in almost all cases
of fever there is a combination of the essential and sympathetic fevers, the
essential the result of the first cause, and the sympathetic the result of the
local lesions which arise during its course. Indeed, nothing seems to be
better established than that local disease reacts on the system and prevents
a critical termination. You will get a very good idea of this by consider-
ing the paroxysms of an intermittent. What are the periods in which an
intermittent is most liable to terminate favourably? The earlier ones.
What are the periods in which a favourable termination is least likely to
happen ? The later ones. Now wThat are the periods in which there is little
or no accompanying organic lesion ? The first or earlier. What are those
in which there is more or less of organic change ? The later, in which we
generally find, on making a careful examination, that disease of some or-
gan, or organs, has taken place, and is presenting an obstacle to a favour-
able termination. It is the same thing with respect to fever.
In the treatment of fever it is a most important rule to investigate the
condition of the viscera, and remove, if possible, any existing local in-
flammation. By this we accomplish a double purpose; we prevent the
direct danger of death from the violence of local disease, and we obviate
the inconveniences arising from sympathetic irritation. We give nature
fair play, we reduce the case to a state ofthe greatest simplicity, we pre-
698
FEVERS.
vent the liability to new local affections, and we thus effect a great deal
towards a favourable termination. It is an interesting and singular fact,
and one dwelt on by the school of Broussais, that in many cases of fever,
the removal of the local inflammations is speedily followed by a subsi-
dence of the fever. It is chiefly from this fact that they argue in favour
of the opinion that all fevers are symptomatic of local disease. This argu-
ment, however, as I have already proved, is more specious than solid.
The true reason is, that by removing local disease we remove the barrier
which opposes the salutary operations of nature. Every attempt at a fa-
vourable termination is impeded by the coexistence of local disease, and
the more intense and extensive this is, the greater is the obstruction. You
are not by any means to conclude that a fever is symptomatic, because it
disappears on the removal of local disease: the true explanation is, that
by subduing the local inflammation you have removed a focus of irritation,
and given scope to the preservative powers of nature.
These I believe most firmly to be the true principles which should
guide us in considering the subject of fever. They have been obtained
by careful and accurate deductions, and are based on a numerous series
of well-conducted experiments. Weigh the matter calmly, and I think
you will be disposed to agree with me, that fever in its origin implies no
tangible condition of the system, and that we know it only as consisting
of a group of phenomena, varying as to their cause, seat, effect, and du-
ration. The humoralists erred by fixing its seat in the fluids, the solidists
by limiting its locality to the solids. We recognise no distinction between
the fluids and solids, so far as fever is concerned : they all form parts of
the great whole ; one cannot act without the other, but their mutual re-
action is extensive and various. From these considerations we deduce
the important rule, that there is no mode of treatment universally applica-
ble, and the man who treats fever with wine and stimulants only, or he
who contents himself with purgatives and diaphoretics, or he who limits
his practice to leeches and the lancet, that man knowTs nothing of fever.
Though his hair be grey and his authority high, he is but a child in know-
ledge, and his reputation an error. On a level with the child so far as a
correct appreciation of the great truths of medicine is concerned, he is
very different in other respects; his powers of doing mischief are greater,
he is far more dangerous. Oh! that men would stoop to learn, or at least
cease to destroy!
LECTURE CXLVII.
DR. STOKES.
Intermittent Fever—Definition and character of—Phenomena ofthe paroxysm—Cold
staae—Internal congestions—Pathology of—Hot sta
Aquae Cinnam. f^i.
Syrup. Zingib. fjss. M.
Dose, a tablespoonful every two or three hours, as indicated by the case.
vol. II,—47
722
FEVERS.
The powder in half-drachm or drachm doses is sometimes given, mixed
with two or three ounces of the decoction. A popular and useful addition
to the bark is the serpentaria root, in powder, or preferably in decoction.
As respects the dose of the bark, we had not some years ago the choice
which we now have. Bulky and unpleasant to the taste as it is, the pa-
tient could seldom be persuaded to take more than a drachm or two at a
time, and even then it was not without difficulty that it could be retained
by stomachs rendered often irritable by the disease itself. If decoctions
or infusions were substituted, still the same objection to a certain extent
applied, and, at any rate, they seldom furnished an adequate quantity of
the active principles of the bark. Tinctures, simple and compound, made
more drunkards than cures. Against adulteration of the bark itself it was
hard also to be protected. Great, then, ought to be our gratitude to
Messrs. Pelletier and Caventou, for placing at our disposal the alkaloids
of bark and their salts, which possess a uniform strength, are readily solu-
ble in different menstrua, and prepared in different ways, and which allow
of so many adjuvants of a more or less agreeable nature being used with
them.
Difference of opinion prevails respecting the dose of the salts of quinia
and the quantity requisite in a case of intermittent fever. The present
fashion is to administer more than is probably required by the exigencies
of the case. Dr. Geddes, in the intermittents of India, directed three
grains every two or three hours, and states that from a scruple to a drachm
and a half was required to effect a cure. The average stay in the hospital,
including those with the different types—quotidian and tertian—was six
days. M. Trollier, who recommends an immediate recourse to the sulphate
of quinia in the intermittent fevers of Algeria, is, however, no advocate for
the very large doses given by some of his confreres. He found that from a grain
and a half to three grains or four grains and a half prevented the returns of
the fit as well as when fifteen, thirty and forty-five grains were given. My
own experience is coincident with that of the French writer just cited.
In proportion, however, as there is manifested a tendency, owing to the
season or locality, in the fever to assume a congestive or pernicious
character, the dose of the sulphate should be increased—the more espe-
cially if it is given by the rectum. Dr. McCormick, in Remarks on the
Treatment of Fevers in Florida (N. Orleans Med. and Surg. Journ., vol.
ii.), relates his failures at first, when he gave the sulphate of quinia in
doses of two grains every hour, although during the apyrexia, 12, 18, or
24 grains had been given. But very different was the result when he
gave it, in a much shorter period, in single doses of 10 to 15 or 20 grains,
according to the violence of the disease. There was much less excitement
produced by the full dose than the divided ones.
Difference of opinion still prevails respecting the time at which the
anti-periodic should be given, as well as the dose. Guided alike by phy-
siology and therapeutical experience, we should, it seems to me, direct a
full dose, adequate to impress strongly and diffusively the nervous system,
and establish a new action in it, before the approach even of the morbid
change which constitutes the paroxysm. Some time must elapse for pre-
paration for the morbid process—and some time ought to be allowed for
the remedial one to be set up. The salts of quinia are not active until
they enter the circulation, which occurs very soon after their administra-
tion by the mouth. The presence of sulphate of quinia has been detected
TREATMENT OF INTERMITTENT FEVER.
723
in the urine of a dog forty-five minutes after the injection of twelve grains
of the medicine, and traces of it were still discoverable fifteen hours after-
wards. The period in which it most abounds in the blood is about four
or five hours after its administration. The more rapid its absorption and
subsequent passage into the urine the more complete is the anti-periodic
virtue of the sulphate of quinia. It follows, therefore, that it should be
taken into the stomach, rather than introduced into the rectum by enema
or applied to a denuded skin by what is called the endermic method.
There are, it is true, occasions where, owing to gastritis or a peculiar irri-
tability of the stomach, this organ will not tolerate this salt, or the
patient may be in a state of delirium or of coma so as to prevent his
swallowing. Then should trials be made, first of enemata and afterwards
of its endermic application—care being taken to dissolve the salt in water
so as to insure its more ready absorption, either from the mucous surface
ofthe rectum or from the skin denuded of its epidermis.
If we are to rely on one dose alone of the sulphate of quinia, it ought to
be administered at the latest two hours and at the earliest four hours before
the time ofthe expected paroxysm. The bark in substance, or vegetable
bitters and astringents, with their woody fibre and extractive matters, being
of course more slowly absorbed, require to be administered at an earlier
period than saline substances. Where, as in a majority of cases it can be
done, the medicine is to be administered at certain intervals, you had
better, so soon as the paroxysm is well over, by the subsidence of the hot
stage into sweat, give five grains of the sulphate of quinia, and repeat it
every four hours, until four doses, or twenty grains, have been taken before
the expected return of the next paroxysm. Opium or laudanum, according
as you prescribe the sulphate of quinia in pill or in solution, may be com-
bined with it, if the symptoms seem to require it. Dr. McCormick's
practice was to give fifteen grains immediately after the paroxysm was over,
and to follow this with a dose of five grains every hour, until half a drachm
was taken during the interval, or even in the twenty-four hours. In the
few cases of quartan ague which he met with, he gave, in addition to the
fifteen grains at the end of the paroxysm, 10 to 15 grains an hour or two
before the period for the accession ofthe next paroxysm.
M. Ducros, of Marseilles, recommends, as the most efficient means of
introducing the sulphate of quinia into^he system, to apply it to the rau-
cous surface ofthe mouth and throat,—tongue, velum palati, inside ofthe
cheeks, vertebral face ofthe pharynx. In the dose of a grain applied in this
way it causes abundant salivation, and a more active reaction through
the medium ofthe medulla spinalis than if a dose of thirty grains were
given by the stomach or rectum. M. Ducros lays great stress on the ex-
treme promptness of the therapeutical operation of the salt of quinia when
introduced by buccal friction, and of course the superior advantages of
this method in pernicious (congestive) fevers, and also in temporo-facial
neuralgia. Its not producing any intoxicating or stupefying effects, in this
way, is an assertion the accuracy of which we may well doubt. As an
offset to so pleasant a picture, we must be aware that few7 patients can
allow of their mouth and throats being rubbed in this style without their
suffering from nausea and efforts to vomit. If trials are to-be made of
buccal friction with sulphate of quinia, or the salts of morphia in other
circumstances of disease, the frictions should be confined to the inside
of the cheeks and on the gums, and the under surface and edges of the
tongue.
724
FEVERS.
In the frequent complications of gastro-enteritis and of broncho-pulmo-
nary irritation and phlogosis, a modified treatment should be instituted.
Often, after the fever has lasted some time, and if the patient has been
careless in his regimen and continued to expose himself to atmospherical
vicissitudes, that which was simple irritation with congestion of the di-
gestive mucous surface becomes now phlogosis,—a state participated in
by the liver and measurably by the spleen; and we find, in consequence,
a pulse of some tension and frequency during the interval between the
paroxysms, a symptom which will be more decided if there be coincident
pulmonary disorder. There will be, also, pain in the right hypochondri-
um extending round to the epigastrium, a sallow complexion, yellowness
ofthe conjunctiva, and other symptoms which seem to point conclusively
to derangement of the liver. •
Now comes a time of trial, if not of peril, for the patient. He is liable
to farther suffering from the disease, and he is subjected to some risk from
the treatment that may be directed by his physician. If bark or sulphate
of quinia have been used up to this time, the continuance of the chills
seems to call for increased doses of this anti-periodic; and if it fail to pre-
vent the fit, other medicines, both vegetable and mineral, are had recourse
to with similar intention; and the poor patient's stomach is subjected to a
succession of stimuli, and not seldom of irritants, which still further de-
range, if they do not positively either inflame it, or increase existing
phlogosis. Other practitioners, again, under the influence of an hepatic
pathology, set about giving mercury in order to salivate, and thus " to
cure the chills." Hardly, however, have they had time to boast of the
success, which at first rewarded their efforts, by a suspension for a while
of the paroxysm, when they find the fever returning with, it is true, not
as much violence as before,—only because the patient is weakened by
the mercurial course. When in Canton and a sufferer from double tertian
fever, and not in a fit state to take the bark, twice I put my system under
the influence of mercury so far as to have my gums slightly touched. For a
while the disease was suspended, but it soon re-appeared on my first ex-
posure to night air, when administering for the diseases of others. So
have I always found it to be in the few whom, without intending it, I have
salivated in intermittent fever—provided the bark of quinia were not
given immediately afterwards in adequately full and repeated doses.
There is yet another mode of treatment at this juncture, such as I have
described it, where there is some gastro-enteric disease with hepatic and
splenic congestion, and perhaps corresponding disorders ofthe pulmonary
if not cerebral circulation. It consists in recourse to venesection, or oc-
casionally, in place of it, to local bloodletting. I can speak in terms of
very decided commendation of this practice, to which, when yet a student
of medicine in Virginia, I had recourse, in the case of a young man of a
spare habit of body who had been much reduced by repeated attacks of
intermittent fever. Bark and arsenic hud been administered in vain.
Influenced by the recommendation of Senac, whose work on Intermitting
and Remitting Fevers I had just perused, I opened a vein in the arm of
my patient during the next hot fit, and took away a pint of blood. The
relief was immediate ; the force of the paroxysm soon subsided ; the apy-
rexia was complete ; and a few doses of bark were sufficient to prevent
the next fit. He speedily recovered his health and strength, and re-
mained clear of intermittent fever. From that time to the present I have
TREATMENT OF INTERMITTENT FEVER. 725
not hesitated to use the lancet in every case of periodical fever, in which
either the apyrexia was not so complete as to leave the patient entirely
clear of all gastric and cerebral distress, or in which the paroxysms had
been of frequent recurrence and intractable under the use ofthe bark. I
have usually preferred, when the choice wras in my power, to bleed during
the hot stage to the doing it in the apyrexia; but the experience of every
additional season convinces me that in this latter period, also, the employ-
ment of the lancet will realize all our best hopes.
Local bloodletting, which as yet I have merely alluded to, in connexion
with our present subject, will become a more conspicuous part of the
treatment thanlieretofore, if we adopt the pathology of intermittent fever
which supposes this disease to be a lesion of the nervous system, and more
particularly ofthe cerebro-spinal axis ; and that the sensation ofcold and
the pain of aching of the back and limbs result from a disorder of the spi-
nal cord. Dr. Kremer, near Aix-la-Chapelle, has, within these few years
past, pointed out a symptom in corroboration of this pathology, which
will more directly indicate the propriety of local bloodletting. It is, a
more or less severe pain on pressure of the first dorsal vertebra, made
from behind forwards with the fingers upon the spinous processes of the
individual vertebras, and not upon several together. If intermittent fever
is considerable, or old or masked, pressure on the first dorsal vertebra, by
giving pain, will, as Dr. "Kremer alleges, suffice to evince the existence of
fever. The pain exists during the paroxysms, as well as in the apyretic
interval, is stronger in epidemic than in sporadic intermittent fever, exists in
both of them, and continues during the sequela? (Brit, and For. Med. Rev.,
vol. viii.). Corroborative of this view are the observations based on fifty
cases by Dr. Grossheim, who does not, however, pretend to restrict the
pain to one vertebra, as Dr. Kremer did. Dr. Grossheim found the
pain to be most frequent in the middle of the dorsal portion, especially
in quotidian intermittents. Its extent also varies considerably ; one or
two of the vertebrae only may be tender; and the pain rarely occu-
pies the space of more than five or six ; it may also be situated at distant
parts with intervals in which none is excited by pressure. The pain was
more severe during the paroxysms than in the intermissions. Do we not
see a strong affinity between these pains, in their seat and character too,
and those of dorso-intercostal neuralgia which I have so recently described
to you ? Dr. Grossheim was led to try the effect of reducing the local
excitement or irritation in the fever; and, accordingly, in five cases he ap-
plied eight or ten (German) leeches over the spine in the situation in
which pressure gave the most pain. In four of these the application suf-
ficed without any other remedy being used to prevent a return of the pa-
roxysm. I shall make the application both of the pathology and the prac-
tice deduced from it, which I have now briefly noticed, when I speak of
congestive fever, to a proper view of which the remarks already made are
intended as an introduction.
Confirmatory of the views of the German writers, is a case which I find
recorded in the Amer. Jour, of Med. Sciences, vol. xvii., by Dr. Malone
of Florida, and which is the more valuable because it occurred at a date
(1834) anterior, by some years, to the published statements in Europe.
Dr. Malone, in his Remarks on Spinal Irritation, gives the following par-
ticulars respecting the second of the two cases which are the subject of
his paper. It was of a lady of a sanguine temperament, aged thirty-five.
726
FEVERS.
who had just recovered from an attack of bilious remittent fever, after a
sickness of two weeks' duration. When visited by Dr. Malone, she had
chills every day, with complaint of pain in the back, and general aching
sensations all over. Believing that the disease was kept up by spinal
irritation secondarily developed, he made an examination and found the
lower part of the neck and upper half of the dorsal column lender in several
places. Just before the comirjg on of the chill, Dr. Malone applied a large
mustard cataplasm between her shoulders, and continued the camomile
infusion, which he had before prescribed, in moderate doses. The result
was the prevention of the chill. She applied the cataplasm once after-
wards, and had no more chills. Dr. M. adds, that the^applications of
mustard cataplasms to the spine is quite a common thing in the country
(Florida). He deduces a conclusion from the above case and analogous
facts, that intermittents are frequently continued, if not actually produced
by spinal irritation. M. Gouzee (Annates de la Soc. de Med. d'Anvers,
1843) has found the tender spot to be chiefly the region betwTeen the
third and fifth dorsal vertebrae. In cases of this nature he has derived the
best effects from local depletion and counter-irritation.
Whether we believe that the phenomena of pain in the back and limbs
and rigors proceed from a disorder of the spinal marrow itself, or of the
spinal nerves, and probably the ganglions of the sympathetic, contiguous
to and connected with them, we shall find indications for topical remedies
to the spinal region. Of these, leeches or cups might be first used, and
afterwrards, if necessary, counter-irritants by mustard, vesicatories, &c.
The latter order of irritants will be more beneficial in this way in warding
off an attack of fever than when applied either to the abdomen or the
extremities. I have had five vesicated surfaces on me at once, but with-
out their preventing the recurrence of a paroxysm of intermittent, a double
tertian, from which I was suffering at the time in Canton. Bark, subse-
quently, in drachm doses, taken four or five times a-day, sufficed to arrest
the disease, of which there has not since, in a period of thirty years, been
a relapse. Of the various modes of local depletion, that by leeches ap-
plied over the spleen has succeeded in some protracted and obstinate
cases, to break the periodicity, and allow of the good effects of the sul-
phate ofquinia, which had previously been inoperative.
But let me not be misunderstood as an advocate for bloodletting to the
exclusion of bark and its equivalent tonics. No cure can be considered
permanent unless this medicine or analogous articles be given ; and every
other means ought to be regarded as preparative or adjuvant to this, the
remedy in intermittent fever. Whoever relies on bloodletting alone, or
on mercury alone, or on the cold bath alone, or on all these in due alter-
nation for the cure of intermittent fever, trifles with the health if not the
life of his patient, and manifests both an ignorance of the experience of
the past and a blindness to the present. The opposite and extreme opi-
nion and practice are equally reprehensible ; as when no means of relief
or cure are thought of, except in the use of bark or other bitters and
astringents, and arsenic, and no other cause of failure is admitted than the
want of power in the drug. Hence, if bark or its preparations fail, these
empirics try bitters singly and in combination, or vegetable astringents
with these : then mineral preparations,—of arsenic, iron, zinc, and cop-
per. They run the round of the grossest empiricism, following the pre-
scription of every professional friend, ransack books, confer with old
TREATMENT OF INTERMITTENT FEVER.
727
women and nurses, and dream of nothing but of some new tonic, or new
combination of old tonics, strengthened by various wines, tinctures, and
the like. It never occurs to these good men, that excellent as bark and its
congeners are, and indispensable for the cure, there are complications of vis-
ceral disease with the disorder of the nervous system that require a sus-
pension for a while of the tonic course, and even the use of remedies of
an opposite nature. Often, after the patient has suffered from intermittent
fever for weeks and even months, during all which time he may have been
duly dosed with the most approved tonics in the most approved doses, a
suspension of all remedies, of either the tonic or the stimulant class—
bark, and serpentaria, wine, and brandy, whether it be simple or medi-
cated, under the name of tincture ; and abstinence from common food,
restricting himself to simple water for drink, and jellies or amylaceous
articles for aliment, have been followed by freedom from the paroxysm
and comparative comfort. But let us not, in a spirit of hasty generaliza-
tion, proclaim, that intermittent fever is caused and kept up by gastritis
or gastro-enteritis, and that leeches over the epigastrium and gum-water
will suffice to cure it. Doubtless, if the poor patient has been stimulated
for some time with highly-seasoned animal food and liquors, or has volun-
tarily kept himself half intoxicated, in order to be " a little above par,"
he will be, very likely, a sufferer from high gastric irritation, perhaps gastri-
tis itself, and doubtless, also,he will find relief in leeches to the epigastrium,
gum-water, cooling drinks, and laxative enemata. But these are not so
much a means of cure as for putting the system in a proper state to be cured
by bark or sulphate of quinia. Of the preparatory and auxiliary means,
calomel, or, that which I prefer, blue pill, in a dose of five grains taken
at bed-time, so as, either alone or with the aid of a few grains of rhubarb
in the morning, to act on the bowels as a mild laxative, is worthy of com-
mendation. This may be repeated every night for three or four nights,
and should constitute, for this period, the only medicine ; or, if the case
be urgent, we can give, with a much better prospect of its displaying its
anti-periodic properties, sulphate of quinia in the morning or early part of
the following day.
Another extreme of opinion is that on which I have already animad-
verted, and which consists in treating intermittent fever as but a modifi-
cation of remittent bilious fever, and as such, after equalizing morbid
excitement, or placing the system " at par," by venesection and purga-
tives, to let the cook administer the tonics procured from the butcher, and
the poulterer, and the baker, and disregard all others. Failure and dis-
aster will attend still more signally the course of this advocate for unity,
than they did that ofthe other who relied on bark alone.
But there is a period in intermittent fever, or rather there is a class of
subjects labouring under this disease in its own appropriate regions who
will be signally benefited by nutritive tonics. They are the sallow, the
emaciated,—except where the spleen is protuberant,—the ill-fed, having
lived on crude fruit, and drunk bad water; and, in fine, they who have
become, among the men, anemic,—among the women, chlorotic. These
are the subjects on whom iron works wonders, increasing the red particles
in their blood, and giving them colour, animation, and new life. By the
influence exerted, also, secondarily through the blood on the nervous
system, the latter acquires such tone as to be able to resist the operation
of the atmospheric and the other unhealthy influences, such as of bad food
728
FEVERS.
and bad water. By chalybeates the disease may be prevented from mak-
ing its attacks on those hitherto exempt; and by these same means it may be
suspended in those suffering under its inflictions, and even in some cases
entirely cured. As a general rule, however, we can only rely on iron
as an indirect, but yet, under the circumstances nowr sketched, a very
important curative agent, by its improving the quality ofthe blood, dimi-
nishing and to a certain extent removing congestion, and giving to the
nervous system, by richer blood, a better nutriment to its healthy sensi-
bility wrhich is indispensable for the discharge of its functions.
I have alluded to cold bathing in intermittent fever; but as a remedy
used both in the paroxysm and during the interval, it merits a more dis-
tinct notice. Occasionally we hear of practitioners relying exclusively on
the cold bath for the cure of intermittents. A knowledge of the directly
sedative effects of cold, and an observation of its power of reducing febrile
action to the normal healthy standard, as in the hot stage of intermittent
fever, will make us slow to direct it during the interval, when there is
often little or no superfluous excitement, and the predisposition to chill is
manifestly great. It is hardly wise to imitate a paroxysm of fever by sub-
jecting an individual, whose nervous system is rather enfeebled than ex-
cited, to a cold bath. He is necessarily chilled ; has some rigors; and
in the most favourable state a subsequent glow and reaction. Nor does
the disturbance end here ; pains in the limbs and head, and languor are
often complained of by those who use the cold bath, when the system is
not above the natural level of excitement. From these premises, not a
little strengthened by experience, I should feel inclined to regard habitual
cold bathing, in the interval, as a hazardous remedy, and rendered often
mischievous by the prevalent errors regarding its modus operandi. Very
different are its effects when used in the hot stage of intermittent, or in
the more permanent capillary excitement of gastro-cerebral fever, usually
denominated typhus. Then the morbid excitement ofthe sanguineo-ner-
vous structures which enter into the composition of the membranes and
are chiefly instrumental in the secretions, including that of caloric, is aba-
ted and often entirely removed ; the patient is rendered tranquil, and
enjoys a pleasant slumber, unbroken by the former irritations of heat and
thirst. Just in proportion as the state of the patient during the interval
approaches to that exhibited in the hot stage will cold bathing be useful,
but not otherwise. Hence, if there be a continued dry heat of the skin,
frequent pulse with thirst, and little or no appetite, we shall derive good
effects from cold affusion in the period between the paroxysms. This
remedy is not, therefore, as often taught, akin to bark : the two stand
contrasted with each other in their effects, and their use is only properly
called for under different and opposite circumstances ; the one to allay
morbid irritation and inflammation ; the other to give tone to parts already
feeble.
Confirmatory of these views, which I have long held and expressed,
is the experience of Dr. C. Broussais in the use of enemata of cold water.
They seem to have had the effect of preventing a paroxysm of fever,
which the heat of the skin, especially of the abdomen, headache, uneasi-
ness, and loss of appetite, proved to have been imminent. In slight cases
ofthe disease it often sufficed to diminish the amount of food, and to ad-
minister a few cold injections to restore the health entirely in a few days.
In other cases, M. Broussais had recourse to this remedy in conjunction
with the use of quinine.
TREATMENT OF INTERMITTENT FEVER.
729
After having laid clown the principles which ought to guide us in the
treatment of intermittent fever, and stated the chief remedies to render the
treatment effective, I do not feel myself called upon to enumerate all the
substances, which, from the different impulses of love of novelty, empiri-
cism, ignorance, and false hypothesis, have been used with a view of curing
this disease. Regarding it as one of debility, all the tonics and astrin-
gents, and some of the stimulants of the materia mediea, have been, at
some time or another, enlisted for the purpose. Bitterness, even when
allied to narcotic properties, has been, also, supposed to be a sufficient
indication for adding to the long and tedious list. A physician who can
procure Peruvian bark, or the sulphate of quinia, need scarcely regret his
ignorance ofthe whole class of imperfect substitutes for this febrifugum
magnum : but as there are times and places in which bark is either not
procurable at all, or in scant quantity, it is right that some of the most
readily attained and cheapest of these should be known to him.
But first, let me briefly call your attention to some of the salts of quinia
in which the alkali is combined with other acids than the sulphate, or with
a mineral basis and an acid, so as to make a triple salt. Within a few
years past the valerianate of quinine comes to us highly recommended for
its anti-periodic virtues and for its tranquillizing effects in those cases of
intermittent fever complicated with much nervous disorder and exhaus-
tion. It is in fact a decided neurosthenic remedy, well adapted both to
the cases just mentfoned and to those of a congestive character. The
valerianate of quinine operates in smaller doses than the sulphate, and
without causing any cerebral disturbance, as the latter sometiraes does.
The mean period of treatment by the former was, in an average of twelve
cases, about three days and a half.
Arseniate of quinia would a priori seem to be a medicine of great power,
and there is not wanting testimony in its favour. M. Boudin, however,
tells us that he did not find it superior to arsenic alone. Of this gentle-
man's great partiality for arsenic in the treatment of intermittent fever, I
shall soon speak, and you will then be inclined to receive, with some cau-
tion, his opinions in whatever relates to quinine in the disease in question.
If the combination ofthe two substances be thought advisable in practice
this salt should be preferred.
The citrate of iron and quinia and the ferro cyanate of quinia are,
respectively, triple salts, which, in patients of cachectic habits with en-
larged spleens, and suffering long from intermittent fever, will do good
service. The pharmaceutical combination of sulphate of quinia and
carbonate of iron, or sulphate of iron, has proved curative in cases of
intermittent fever with enlarged spleen. The following recipe may be
acceptable. Carbonate of Iron and Sulphate of Quinia, each 15 grains,
Extract of Taraxacum, ^j. M. To be made into thirty pills. Let two
be taken every two hours. The carbonate of iron may be increased to
30 grains. Under somewhat similar circumstances, and where there is
complication of hepatic congestion and enlargement, the iodide of quinia
and the iodide of cinchona, lately introduced by Dr. Thomson, are worthy
of our remembrance.
Next to the bark, on the score of alleged remedial value, and, in the
minds of some physicians, excelling it, in certain cases, is the arsenious
acid or white arsenic of the shops, and among its preparations, solution
ofthe arsenite of potassa (liquor potasscc arsenitis), or " Fowler's mineral
730
FEVERS.
solution," By a strained analogy, arsenic is familiarly spoken of as a
tonic, when, in fact, its operation on the animal economy rather contrasts
with, than resembles, that of cinchona, and the vegetable tonics generally.
So far from exciting, it rather depresses, and hence it may be given in the
paroxysm and in states ofthe system in which other articles of the class
to which it is referred are generally admitted to be uncalled for and inju-
rious. This, added to the smallness of the dose and the insipidity of the
article and its cheapness, has contributed to give vogue to arsenic as a
febrifuge among different classes of people. By children, and those who
are like children in their aversion to any medicine with a disagreeable
taste, the solution of the arsenite of potassa is taken with a readiness
and regularity, which are often impossible when the bark or any of its
preparations is prescribed. We cannot, however, despite the recom-
mendation of Fowler, who first introduced it into regular practice, and of
Arnold, Withering, and more recently Dr. Brown (Cyclopcedia of Medi-
cine), forget that arsenic is a most active poison, determining its influence
more particularly on the alimentary canal, heart, and nervous system ; and
that its use, even in small quantities, and especially its prolonged use,
requires great circumspection, and is only justifiable after suitable trials
have been made with safer and well-ascertained remedies.
As an impartial historian of therapeutic experience, I must not, how-
ever, omit to apprise you that, of late years, the arsenical practice in
periodical fevers has been resumed, and carried to a greater extent than
before. Foremost among its advocates is M. Boudin, who, in the military
hospital at Versailles (near Paris), has made large use of arsenic in the
treatment of intermittent fevers, to the entire exclusion of sulphate ofqui-
nia. After giving an emetic of ipecacuanha 15 gr., and tartrate of anti-
mony 1^ gr., he prescribes for his patient from one to three doses, each
containing a fifth of a grain of arsenic, ofthe following solution:—Arse-
nious acid, a grain and a half; distilled water, two pints. Four ounces
of this solution contain not quite a fifth of arsenious acid. We are not
told the intervals between the doses ; but as regards the last one-fifth of a
grain dose, M. B. advises that it should be taken four hours before the
expected paroxysm. It will be easy therefore to regulate the periods for
the administration of the other doses, according as the case is one of a
quotidian or a tertian type. Even after the fever has ceased to recur, M.
Boudin deems it most prudent that a dose or two doses of the strength
already indicated, should be taken by the patient every day until he leaves
the hospital. As we learn that the patients are detained in the hospital a
fortnight after the last fit of ague, and that the mean duration ofthe treat-
ment, including this period, is twenty-two days, we can tell pretty accu-
rately the entire quantity of arsenic taken by each patient. From 1840
to 1846 M. Boudin has had under his charge 2947 patients with intermit-
tent fever, of both sexes and of all ages, whom he has treated with arsenic.
Of these more than 2000 had been previously under treatment from one
to ten times by the sulphate of quinia, and had suffered from relapse.
M. Masellot, assistant surgeon to the military hospital at Versailles,
gives, together with an historical sketch of the opinions and practice re-
specting the use of arsenic in intermittent fevers, statistical returns of the
results of the treatment by arsenic compared with that by quinine, from the
1st Jan. 1843 to the 1st Jan. 1846. During this period (three years) 574
persons labouring under intermittent fever had been admitted into the hos-
TREATMENT OF INTERMITTENT FEVER.
731
pital. Of these, 142 having but slight attacks, which were, at any rate,
looked upon as such, were subjected only to emetics and simple hygienic
conditions. The others, whose fever was well marked and contracted in
marshy localities, were put on a course of either sulphate of quinia or of
arsenious acid and an emetic. It may be well to mention that M. Boudin
was not on duty when the treatment by the salt of quinia was practised.
The results are given by M. Masellot as follows:—
Relapses.
Patients who had taken neither quinine nor
arsenic......142 8, or 5-6 per cent.
-------treated by sulphate of quinia - 111 14, " 12-5 :'
,-------treated by arsenious acid - - 311 10," 3-2 "
More than two-thirds of those who took arsenic had been previously sub-
jected to the use of the sulphate of quinia. The mean duration of the
cases in the hospital in which the latter had been administered, was 30
days ; and of those in which arsenic had been given, was 22 days. If
you call to mind the average period of stay in the hospital of the patients
(soldiers) with intermittent fever in India, who were treated by Dr.
Geddes, viz., 6 days, and that the curative agent was the salt of quinia,
you will see the vast differences which climate must make in our estimates
of the duration of the sarae disease and of its araenableness to the same
medicine. In other words, the numeral method as yet cannot be said to
rest on a scientific basis. It gives elements for forming a definite conclu-
sion, but something else besides mere numbers must be brought into the
estimate in order to give these any real value.
On the question of the comparative promptness of effect of the two arti-
cles, M. Masellot candidly admits, that, in a case of intermittent fever of a
congestive or pernicious character, which threatens after three or four
paroxysms to end fatally, he would prefer the sulphate of quinia, but that
if it were at his disposal he would add arsenic to this salt and admi-
nister both remedies together.
The quantity of arsenic in the twenty-four hours adequate to the cure of
intermittent fever is quite small: it may be as low as three or four hun-
dredths of a grain, and need not exceed a grain. There are well-authen-
ticated cases of cure by the use of a hundredth or two-hundredth part of a
grain, and even without repetition of the dose. In augmenting the dose this
should be done by very minute fractions and with very gradual additions.
A stomachic effect is claimed for arsenic by MM. Boudin and Masellot;
and they allege that it improves the appetite and digestive powers of the
patient in a much greater degree than quinine, to which, indeed, they are
disposed to attribute opposite effects.
Contrary to the opinion of Dr. Paris, that arsenic accumulates in the
system of those who continue to use it, and that in certain habits it may,
in consequence, produce serious diseases, M. Masellot asserts that the me-
dicine is eliminated by the usual emunctories within a limited period,
and that the diseases, such as dropsy and debility with increase of ca-
chexia, attributed to the ingestion of arsenic, are really the effects ofthe
fever for the cure of which it had been administered. We cannot forget
nor deny that the same accusations have been brought at different times
against Peruvian bark.
The dose of arsenious acid, commonly used in this country, is from a
sixteenth to an eighth of a grain, twice or three times a-day ; and it has
732
FEVERS.
been extended to a grain within this period. You will see, however,
from preceding remarks, how very minute a dose will often suffice. The
arsenic should be well rubbed in a mortar with some fine sugar, or a few
drops of water added to dissolve it, so as to insure its complete divi-
sion, after which it is mixed with crumbs of bread to be made into pills.
The preferable and more generally safe mode of exhibition, is arsenic in
solution with potash, in the form of an arsenite, of which the dose is five
to ten drops, three times a-day. Both pill and solution are better given
after a meal than on an empty stomach, and to both, in cases of an irrita-
ble or very sensitive state of this organ, opium is usefully added. The
arsenite is best administered in some aromatic water.
Prussian blue (ferro-cyanuret ofiron)has been recommended and used
by Dr. Zollickoffer, of Maryland, as even more prompt and efficacious
than bark and its preparations, in intermittent and remittent fevers, and as
particularly adapted to children on account of its insipidity and smallness
of dose. Dr. Stokes, also, expresses himself in terms of decided com-
mendation of this substance, which, " from its cheapness, is particularly
adapted for dispensatories and institutions where the funds are limited."
He has given it in doses of from a scruple to half a drachm, three times
a-day.
On one occasion, in Paris, when during the long war the supply of the
bark was deficient, sulphate of iron was freely used, at the suggestion of
Dr. Marc, and, as we are told, with entire success.
Sulphate of copper is represented by some writers and practitioners, viz.,
Dr. Donald Monro and Dr. Physick, to be a powerful remedy in obsti-
nate quartan fevers. Dose, two grains^with half a grain of opium, in pill,
twice a-day.
Sulphate of zinc, in a dose of a grain and a half every two hours, was
found by Dr. Irvine, to succeed better than Peruvian bark in cases of
intermittent fever in Sicily, accompanied with symptoms of" an inflamma-
tory diathesis," as where there were a strong pulse, heat of the stomach,
flushed face, and greater headache than usual. So, also, in the compli-
cation of dysentery with intermittent fever, " no medicine answered so
well," as the solution of sulphate of zinc, or sulphate of zinc and alum,
which tended to the cure of both disorders. Valerianate of zinc, in addi-
tion to its powers in facial neuralgia, has been quite serviceable in some
cases of intermittent fever.
Narcotine, or narcotina, once thought to be the stimulant principle of
opium, but now regarded as a simple bitter of no great power, has, how-
ever, been used by Dr. O'Shaughnessy and his friends and pupils at Cal-
cutta, in nearly 200 cases of periodical fever, with a success fully equal
to, if not greater than, that which follows the sulphate of quinia.
Piperin is another vegetable principle which has obtained, on the re-
commendation of Mets and others, a reputation as a febrifuge in intermit-
tent fevers. Dose, six to eight grains, in pills or powder. Two or three
scruples have been considered sufficient to cure intermittent fever. A
spirituous infusion of the black pepper itself had long been a popular
remedy in this disease.
The testimony respecting salicine is contradictory. Dr. Fenner (New
Orleans Med. Journ., vol. i.), after clinical experiments, goes on to speak of
its virtues, but has " no idea it can ever be relied on as a substitute for
quinine." M. Chomel found it to be inefficacious.
Bebeerine, an alkali from the genus Nectandria, natural order Lauriace. 466
with visceral disease, i. 37, ii. 703
;rs, affinity among, ii 092
continued, ii. 808
etiology of, ii. 810
eruptive or exanthematous, ii. 858, 872 ;
see Exanthemata.
local disease in, ii. 693, 695
local inflammation in secondary, ii. 697
spontaneous termination of, ii. 694
two classes of, ii. 693
INDEX.
969
Fevers, typhous and typhoid, comparison be-
tween, ii 817
close resemblance of, to
each other, ii. 822, 841
urine in, ii. 842
Fissures of the anus, i. 298
Fistula in ano, caution respecting, i. 299
Follicular enteritis of infants, i. 185
Gall-bladder, distended, i. 514
diagnosis of, i. 515
inflammation of the, i. 515
rupture ofthe, i. 516
Gall-stones ; see Biliary Calculi.
Gangrene ofthe lungs, ii. 305 ; see Lungs.
of the mouth, i. 58
Gastralgia, i. 155
causes of, i. 157
diagnosis of, i. 156
proper drink in, i. 161
treatment of, i. 158
Gastric remittent fever ; see Fever, Bilious Re-
mittent.
Gastritis, i. 105
acute, anatomical lesions in, i. 107
and chronic,difference between, i.132
delirium tremens with, i. 129, 454
diagnosis in, i. 116
hematemesis in, i. 127
secondary disease from, i. 114
softening of the stomach in, i. 109
state of the tongue in, i. 112
symptoms of, i. 110, 120
treatment of, i. 121
chronic, i. 130
symptoms of, i. 131
treatment of, i. 133
Gastro-duodenitis, analogy of to yellow fever,
i. 475
causing jaundice, i. 479
epidemic, i. 483
Gastrodynia, i. 155
Generation, diseases of female organs of, i. 672
male organs of, i. 614
Genito-urinary apparatus, i. 673
Glossitis, i. 63
Glottis, spasm of the, ii. 90
Gonorrhoea, i. 615
causes of, i. 615
diagnosis of, i. 638
effects of, i. 632
forms of, i. 638
inoculation in, i. 618
in women, i. 702
ophthalmia from, i. 638
pathology of, i. 617
period of incubation in, i. 616
prognosis of, i. 638
symptoms of, i. 616
termination and consequences of, i- 617
topical remedies in, i. 629
treatment of, i. 618, 621, 638
Gout, ii. 938
acute, ii. 939
ages most liable to, ii. 943
symptoms of, ii. 940
causes of, ii. 941
chronic, ii. 948
vol. ii.—63
Gout, chronic, causes of, ii. 948
prophylaxis in, ii. 953
symptoms of, ii. 949
treatment of, ii. 950
general pathology of, ii. 953
lithic acid causing, ii. 944
treatment of, ii. 945
varieties of, ii. 952
Gouty diathesis, ii. 939
Gravel, red, i. 597
white, i. 602
Grippe ; see Influenza.
Gums, lancing the, i. 72
Haemaphrein in urine, ii. 555
Hay asthma, ii. 175
fever, ii. 175
Headache in colonic dyspepsia, i. 242
Hearing impeded in tonsillitis, i. 90
Heart, aneurism of the, ii. 353
of the auricles of the, ii. 354
atrophy of the valves of the, ii. 372
beat or impulse of the, ii. 347
capacity of ventricles ofthe, ii. 356
diagnosis in, ii. 373
diameters ofthe, ii. 371
dilatation ofthe, ii. 368
causes and signs of, ii. 369
treatment of, ii. 370
diseases ofthe, ii. 345
diseases of the valves and orifices of the, ii.
370
in Bright's disease, i. 575
physical signs of, ii. 374
prognosis in, ii. 374
pulse in, ii. 373
symptoms and effects of, ii. 373
treatment of, ii. 386
division of diseases of the, ii. 350
examination of other states ofthe, ii. 348
functional disease ofthe, ii. 397
hypertrophy ofthe, ii. 355
anatomical character of, ii. 357
arterial pulse in, ii. 365
causes of, ii. 358
diseased brain with, ii. 360
effects of, ii. 359
forms and complications of,ii.359
of right ventricle, ii. 366
of the auricles, ii. 358
of the left ventricle with diseased
brain, ii. 360
sounds of the heart in, ii. 363
symptoms of, ii. 362
treatment of, ii. 366
perseverance in, ii. 367
with dilatation, ii. 363
with palpitation, ii. 363
inflammation of substance ofthe, ii. 351
length ofthe, ii. 356
mechanism of the, ii. 346
murmurs of the, ii. 374
valvular, ii. 374
venous, ii. 375
neuralgia ofthe, ii. 400
palpitation ofthe, ii. 398
physical signs of, ii. 399
treatment of, ii. 400
970
INDEX.
Heart, palpitation ofthe, varieties of, ii. 398
perforative ulceration ofthe, ii. 352
position and structure of the, ii. 346
rupture of the, ii. 353
softening ofthe, ii. 351
treatment of the, ii. 352
structure ofthe, ii. 346
thrill ofthe, ii. 376
weight of the, ii. 355
Hematemesis, with acute gastritis, i. 127
Hematuria, i. 608
treatment of, i. 609
Hemicrania, remedies in, ii. 585
Hemoptysis, changes of structure in, ii. 177
chronic, ii. 187
treatment of, ii. 188
connected with tubercular phthisis,
ii. 178, 273
diagnosis of, ii. 182
from disease of the heart, ii. 179
from pulmonary apoplexy, ii. 179
in phthisis, ii. 273
prognosis in, ii. 183
progress of, ii. 182
symptoms of, ii. 181
treatment of, ii. 183
varieties and causes of, ii. 176
Hemorrhage, bronchial, symptoms of; see
Hemoptysis.
Hemorrhoidal excrescences, i. 288
Hemorrhoids, i. 269
causes of, i. 274
complications with, i. 277
discharges in, i. 273
external, i. 287
is it safe to cure 1 i. 280
mucous or serous, i. 273
natural cure of, i. 286
periodical, treatment of, i. 283
structure of, i. 271
treatment of, i. 277
varieties of, i. 270
Hepatalgia, i. 536
Hepatic abscess ; see Abscess.
artery, aneurism ofthe, i. 517
flux, i. 229
neuralgia, i. 536
Hepatitis, i. 498
acute, symptoms of, i. 500
termination of, i. 506
treatment of, i. 519
varieties of, i. 499
chronic, symptoms of, i. 525
disease of the heart with, i. 525
treatment of, i. 527
Hernia, i. 254
Hiccup in gastritis, i. 112
Hippocratic observers, i. 32
Hooping-cough, ii. 167
causes of, ii. 169
complications with, ii. 169
symptoms of, ii. 168
treatment of, ii. 171
Hydrocephalus, acute, ii. 487, 501, 508
anatomical characters of, ii.
509
causes of, ii. 490, 508
Hydrocephalus, acute, symptoms of, ii. 487,
509
treatment of, ii. 488, 510
chronic, ii. 510
causes of, ii. 512
chief form of, ii 510
puncturing the cranium in, ii.
512
symptoms of, ii. 511
treatment of, ii. 512
when it is most, frequent, ii. 509;
see Chronic Meningitis.
Hydrometra, its varieties, i. 715
treatment of, i. 716
Hydropericardium, ii. 388
Hydrothorax, ii. 343
treatment of, ii. 345
Hydruria, i. 586
in epidemic cholera, i. 423
treatment of, i. 586-
Hysteralgia, i. 675
causes of, i. 676
treatment of, i. 677
Icterus Infantum, i. 478
Ileitis, i. 179
diarrhoea in, i. 194
frequent in children, i. 184
treatment of, i. 190
Ileus, i. 321
anatomical characters of, i. 322
treatment of, i. 326
Impotence, i. 671
treatment of, i. 671
Inflammation, cerebral, ii. 442 ; see Encepha-
litis.
membranous, of the brain, ii. 443
of the testicle, i. 644; see Orchitis.
Influenza, ii. 154
treatment of, ii. 155
Inspection, for physical diagnosis, ii. 44
Intellect, doubtful test of, ii. 448
preservation of, after loss of brain,
ii. 447
Intemperance, a chief cause of diseased kidney,
i. 578
Intermittent fever, ii. 698
blood in, ii. 714
causes of, ii. 706
cerebro-spinal, pathology of, ii.
725
congested viscera in, ii. 700,702
geological causes of. ii. 713
inflammatory condition of or-
gans in, ii. 701
not a simple fever, ii. 702
not owing to miasm or malaria,
ii. 706
pernicious or malignant; see
Congestive Fever.
splenic doctrine of, ii. 715
time of recurrence of, ii. 717
treatment of, ii. 708
types of, ii. 716, 787
Intestinal worms, i. 454
Intus-susception, i. 323
Invagination, intestinal, i. 323
Iritis, ii. 643
INDEX.
971
Iritis, causes of, ii. 645
symptoms and progress of, ii. 643
treatment of, ii. 645
Ischuria renalis, lesions in, i. 585
prognosis of, i. 585
symptoms of, i. 584
treatment of, i. 585
vesicalis, i. 611
causes of, i. 612
Jaundice, causes of, various, i. 473
comatose state in, i. 481
diagnosis of, i. 482, 489
from aneurism of the hepatic artery,
i. 519
from biliary calculi, i. 486
from cerebral and other nervous dis-
eases, i. 475, 493
from enlargement of the capsule of
Glisson,i. 488
from gastro-duodenitis, i. 479, 483
in children, i. 478
pathology of, i. 472
spasmodic, i. 492
state of the fluids in, i. 476
treatment of, i. 483,490
vision in, i. 476
Joints, white swelling of the, ii. 672
treatment ofthe, ii. 673
Kidneys, diseased structure of the, i. 559
exploration of the, i. 560
functional diseases of the, i. 584
granular degeneration of the, i. 568
granulated structure of the, i. 574
healthy standard of the, i. 559
morbid secretions ofthe, i. 585
small sensibility ofthe, i. 559
suppuration of the, i. 566
Lactic acid, disorders owing to, i. 607
Language, organ ofthe, ii. 453
Laryngismus stridulus, ii. 73, 90
causes of, ii. 92
convulsions with, ii. 94
essential facts respecting, ii. 92
prophylaxis of, ii. 95
symptoms of, ii. 90
treatment of, ii. 93
Laryngitis, acute, edematous, ii. 55
laryngotomy in, ii. 61
mortality great in, ii. 62
symptoms of, ii. 55
treatment of, ii. 57
catarrhal, ii. 54
treatment of, ii. 55
chronic, ii. 96
causes of, ii. 102
cauterization in, ii. 109
complications with, ii. 104
diagnosis of, ii. 101
examination of theche"st in, ii. 101
prevention of, ii. 112
state of fauces in, ii. 100
symptoms of, ii. 97
syphilitic, ii. 100, 111
tracheotomy in, ii. Ill
treatment of, ii. 104
with angina pharyngea, ii. 110
erythematic, ii. 54
Laryngitis, erythematic, treatment of, ii. 54
membranacea : see Croup.
Laryngotomy in laryngitis, ii. 61
Lead, anaesthesia from, i. 336
carbonate of, deleterious, i. 339
diseases from, i. 332
Leucorrhcea, i. 693
causes of, i. 696
treatment of, i. 700
Lime, oxalate of, i. 605
Lithates in the urine, i. 555
Lithic or uric acid, i. 555
diathesis, i. 597
sediments, i. 597
causes of, i. 598
treatment of, i. 600
Liver, acute yellow atrophy of the, i. 493
cancer of the, i. 535
distention ofthe, with bile, i. 519
epidemical affection of the, i. 500
exploration of the, i. 502
fatty degeneration ofthe, i. 534
hydatid tumours of, i. 536
hyperemia ofthe, i. 505
inflammation ofthe, i. 498; see Hepatitis.
neuralgia ofthe, i. 536
treatment of, i. 537
scrofulous enlargement ofthe, i. 534
suppuration ofthe, i. 522
whiskey, i. 534
Lues venerea, ii. 674 ; see Syphilis.
Lumbago, ii. 925
Lumbricus, i. 461
treatment of, i. 468
Lungs, cancer of the, ii. 316
diagnosis of, ii. 308
secondary, ii. 317
varieties of, ii. 317
edema of the, ii. 229
gangrene of the, ii. 305
stages of, ii. 305
symptoms and diagnosis of, ii.
306
part of, most affected with tubercle, ii.
238 ; see Pneumonia and Phthisis.
Lymphatic glands, scrofulous inflammation and
ulceration of, ii. 658
Masturbation, i. 664
Measles, causes of, ii. 881
complications and sequelae of, ii. 880
diagnosis between and scarlet fever, ii.
889
morbid anatomy of, ii. 881
symptoms of, ii. 879
treatment of, ii. 882
varieties of, ii. 880
Medicine, ancient authors on, i. 29
objects of, i. 27
theory of, i. 26
the whole of, to be studied, i. 28
Melanosis, or Melanoma, ii. 309
causes of, ii. 310
divisions of, ii. 309
histological elements of, ii. 310
reparation of tubercle in connexion
with, ii. 314
treatment of, ii. 314
972
INDEX.
Melituria ; see Diabetes Mellitus.
Meningitis, ii. 491
anatomical characters of, ii. 503
cerebro-spinal, ii. 513
epidemic, ii. 513
etiology of, ii. 515
morbid anatomy of, ii. 519
symptoms of, ii. 516
treatment of, ii. 521
membranes of brain inflamed in, ii.
493
organic seat of, ii. 491
simple acute encephalic, ii. 495
anatomical characters of,
ii. 499
diagnosis of, ii. 497
symptoms of, ii. 495
treatment of, ii. 499
tuberculous, ii. 501
causes of, ii. 505
diagnosis of, ii. 505
prognosis of, ii. 505
symptoms of, ii. 504
treatment of, ii. 506
Menorrhagia, acute, i. 688
treatment of, i. 690
passive or chronic, i. 691
treatment of, i. 692
Menses, chronic suppression of, i. 681
retention of, i. 679
suppression of, i. 680
Mercurial cancrum oris, ii. 489
Mesenteric glands, inflammation of, in enteri-
tis, i. 187
Metritis, i. 703
acute, i. 704
treatment of, i. 705
chronic, i. 706
treatment of, i. 708
ulcerous or granular, i. 709
treatment of, i. 710
Metroperitonitis, i. 771
Metro-phlebitis puerperalis, ii.418
Metro-vaginitis, acute, i. 694
chronic, i. 695
Morbid anatomy, neglect of, i. 40
Mouth and pharynx, diseases ofthe, i. 44
Muguet, i. 51 ; see Stomatitis.
Mumps, i. 67; see Cynanche Parotidea.
Murmurs, musical venous, ii. 376
valvular, ii. 374
venous, ii. 375
Nephritis, acute, i. 561
anatomical lesions in, i. 562
causes of, i. 563
secretions of urine in, i. 562
suppuration in, i. 566
symptoms of, i. 561
treatment of, i. 564
varieties of, i. 560
albuminous, i. 568
chronic, i. 563
causes of, i. 564
lesions in, i. 564
treatment of, i. 565
Nephthralgia, i. 565
Nervous systera, diseases of the, ii. 438
Nervous system, pathology of the, ii. 439
Neuralgia, ii. 583, 592
causes of, ii. 593
chief seats of, ii. 592
diagnosis of, ii. 593
dorso-intercostal, ii. 596
femoro-popliteal, or sciatica, ii 601
hepatic, i. 536
treatment of, i. 537
lead, i. 335
maxillary, ii. 595
of the heart, i. 400, ii. 588
ofthe ovaries, i. 678
of the testicle, i. 654
treatment of, i. 655
of the urethra, i. 652
treatment of, i. 653
ofthe uterus, i.677 ;see Hysteralgia.
ofthe vagina, i. 678
origin of, ii. 592
treatment of, ii. 603
varieties of, ii. 594
with diseased brain, ii. 588
with intermittent fever, ii. 602
treatment of, ii. 603
Neuralgic affections, ii. 583
treatment of, ii. 603
Neuritis, i. 605
Neuroses, active, ii. 580
pathology of, ii. 581
peculiar symptoms of, ii. 440
Ophthalmia, ii. 619
catarrhal, ii. 620, 632
causes of, ii. 621
symptoms of, ii. 620
treatment of, ii. 621
Egyptian, or purulent of adults, ii. 626
causes of, ii. 628
effects of, ii. 628
symptoms of, ii. 627
treatment of, ii. 629
erysipelatous, ii. 651
gonorrhoeal, i. 638, ii. 632
causes of, ii. 632
diagnosis of, ii. 633
prognosis of, ii. 634
symptoms of, ii. 633
treatment of, ii. 634
granular, ii. 631
treatment of, ii. 631
of new-born infants, ii. 622
symptoms of, ii. 623
treatment of, ii. 624
purulent, ii. 622
pustular, ii. 651
rheumatica, ii. 638 ; see Sclerotitis.
scrofulous, ii. 648
symptoms of, ii. 649
treatment of, ii. 649
tarsi, ii. 652
catarrhal, ii. 652
scrofulous, ii. 653, 658
Optic thalami, influence of, upon upper extre-
mities, ii. 454
Orchitis, acute, i. 644
symptoms of, i. 644
treatment of, i. 646
index. 973
Orchitis, chronic, i. 648
treatment of, i. 650
syphilitic, i. 651
treatment of, i. 652
Os uteri, granulations of, i. 713
Ovaries, dropsy of the, i. 736
inflammation ofthe, i. 733
neuralgia of the, i. 678
tumours of the, i. 736
Ovaritis, i. 733
symptoms of, i. 734
treatment of, i. 735
Oxalic acid diathesis,!. 605
treatment of the, i. 606
Oxyuris vermicularis; see Threadworm.
Ozaena, symptoms of, ii. 51
treatment of, ii. 53
Painters' colic, pathology of, i. 339
symptoms of, i. 334
treatment of, i. 342
Palpitations, ii. 397
Pancreas, diseases ofthe, i. 538
treatment of, i. 540
morbid secretions of the, i. 540
pathology of the, not known, i. 539
Panophthalmitis, ii. 619
Paracentesis thoracis, ii. 337
Paralysis, diagnosis of, ii. 562
from apoplexy, ii. 538, 546
from arterial disease, ii. 561
from encephalitis, ii. 452
from local lesions of a nerve, ii. 576
in painters, i. 345
local treatment of, ii. 554
sudden, from abscess of the brain, ii.
573
treatment of, ii. 551
Paraphimosis, i. 642
treatment of, i. 643
Paraplegia, ii. 565
from visceral disease, ii. 571
prognosis of, ii. 570
treatment of, ii. 573
with renal disease, ii. 557
Parotitis, i. 67
secondary and mercurial, i. 68 • ■
Pathological anatomy, uses of, i. 31
Pathology, i. 26
Percussion in heart disease, ii. 348
of the chest, ii. 40
sounds furnished by, ii. 42
Pericarditis, ii. 378
anatomical appearances in, ii. 378
causes of, ii. 384
physical signs of, ii. 381
prognosis in, ii. 384
symptoms of, ii. 380
treatment of, ii. 386
Pericardium, adhesions ofthe, ii. 383
Peripneumony : see Pneumonia.
Peritonitis, i. 754
acute, primary, i. 755
diagnosis of, i. 758
symptoms of, i. 755
treatment of, i. 760
hemorrhagic, i. 757
partial or circumscribed, i. 757
vol. n.—64
Peritonitis, chronic, i. 764
Fymptoms of, i. 765
treatment of, i. 768
consecutive, or symptomatic acute, i.
781
erysipelatous, i. 764, 769
in infants, i. 762
puerperal, i. 771
causes of, i 776
diagnosis of, i. 775
symptoms of, i. 774
treatment of, i. 777
Perityphilitis, i. 261 •
Pertussis; see Hooping-cough.
Pestilences, the great, i. 357-8
Pharyngitis, erythematic, i. 82
gangrenosa, i. 103
Phimosis, i. 640
treatment of, i. 641
Phlebectiasis, ii. 423 ; see Veins, Varicose.
Phlebitis, ii. 414
anatomical changes in, ii. 415
causes of, ii. 417
crural, ii. 420
symptoms of, ii. 420
treatment of, ii. 42 2
ofthe cerebral sinuses, ii. 419
ofthe portal veins, ii. 530
suppurative, ii. 415
symptoms of, ii. 417
uterine, i. 773,ii.418
treatment of, ii. 419
varieties of, 418
Phlegmon, retro-pharyngeal, i. 78
Phosphates in the urine, i. 602
causes of, i. 602
mixed, in the urine, i. 603
treatment of, i. 604
Phrenological society of Dublin, ii. 452
Phrenology, discussion on, ii. 453
doctrines of, ii. 449
obligations of, to pathology, ii. 451
Phthisis, bronchial glandular, ii. 299
laryngeal; see Chronic Laryngitis.
pulmonalis, ii. 230
acute and latent, ii. 264
bronchitic variety of, ii. 288
causes of, ii. 247
climatic effects on, ii. 248
conformation of the chest in,
ii. 259
curableness of, ii. 281
diagnosis of, ii. 272, 279
diseases of digestive organs in,
ii. 245
duration of, ii. 260
influence of inflammation ofthe
respiratory organs in causing,
ii. 259
internal causes of, ii. 256
age and sex, ii. 257, 258
hereditary predisposition
to, ii. 258
kidney disease, with, i. 576
periods of, ii. 262
physical signs of, ii. 275
prognosis of, ii. 280
974
INDEX.
Phthisis pulmonalis, state of the air-passages
in, ii. 237
lungs in, ii. 238
symptomatology of, ii. 261
termination of, ii. 261
treatment of, alleged curative, ii.
294
palliative, ii. 286
prophylactic, ii. 284
tubercular meningitis with, ii.
270
see Tubercle.
Physometra, i. 714
symptoms and diagnosis of, i. 714
treatment of, i. 715
Piles; see Hemorrhoids.
Pleura, air in the, ii. 339
description of the, ii. 324
Pleurisy, anatomical changes in, ii. 324
bastard, ii. 338
bilious, ii. 327
causes of, ii. 326
chronic, ii. 332
symptoms of, ii. 333
treatment of, ii. 335
complications with, ii. 328
dry, ii. 323
physical signs of, ii. 321
prognosis in, ii. 328
puerperal, ii. 331
seat of, ii. 326
symptoms of, ii. 320
treatment of, ii. 328
typhoid, ii. 331
varieties of, ii. 326
Pleurodynia, ii. 338
diagnosis of, ii. 338
treatment of, ii. 338
Pneumonia, catarrhal, ii. 189
causes of, ii. 207
chronic, ii. 2.29
convalescence in, ii. 219
defined, ii. 189
diagnosis of, ii. 190
hypostalic, ii. 189, 194
infantile, ii. 189, 225
symptoms of, ii. 200
see Atelectasis.
morbid anatomy of, ii. 193
precursory symptoms of, ii. 202
prognosis and termination of, ii.
204
progress of, ii. 203
stages of, ii. 189
symptoms, local, of, ii. 189
general, of, ii. 197
treatment of, ii. 208
typhoid, ii. 220
treatment of, ii. 223
varieties of, ii. 189
Pneumonitis; see Pneumonia.
Pneumothorax, ii. 339
diagnosis in, ii. 340
symptoms of, ii. 339
treatment of, ii. 340
Podagra, see Gout.
Polycholia, i.493 I
Polypus ; see Rectum and Uterus.
Portal veins, phlebitis ofthe, i. 530
Posthitis, see Balanitis.
.Pott's gangrene, ii. 560
treatment of, ii. 560
Prolapsus ani, i. 290
uteri, i. 729
Prostatitis, acute, i. 656
treatment of,, i. 659
chronic, i. 660
treatment of, i. 661
Pseudo-plasmata growths, 231, 316, 656,825
Pulmonary organs, diseases of the, ii. 47
Pulse, arterial, changes of the, ii. 364
differential, ii. 365
proportion of beats of, to a respiration, ii. 366
venous, ii. 375
Putrid sore throat; see Angina maligna.
Pyelitis, i. 567
lesions in, i. 567
treatment of, i. 568
Pyrosis, morbid anatomy of, i. 152
symptoms and causes of, i. 151
treatment of, i. 152
Quinsy, i. 84
Ramollissement: see Brain, softening of the.
Rectitis, i. 268
Rectum, carcinoma ofthe, i. 299
diseases of the, i. 266
inflammation of the ; see Rectitis.
neuralgia of the, i. 301
prolapsus ofthe, i. 290
treatment of, i. 291
stricture of the, i. 293
treatment of, i. 295
spasmodic, i. 297
treatment of, i. 297
ulceration of the, i. 289
Remittent fever; see Fever remitting.
Remitting continued fever, ii. 795
Renal deposits and calculi, i. 597
symptoms and treatment of, i. 607
Respiration, morbid phenomena of. ii. 28
Retinitis, ii. 647
case of, ii. 648
Retrn-pharyngeal phlegmon, i. 78
Retro-vaccination, ii. 909
Rheumatism, ii. 913
acute articular, ii. 915
diagnosis of, ii. 916
symptoms and progress of, ii. 915
the blood in, ii. 916
treatment of, ii. 919
anatomical changes in, ii. 917
capsular, ii. 924
causes of, ii. 918
chronic, ii. 928
blood in, ii. 929
causes of, ii. 929
diagnosis of, ii. 930
hygienic course in, ii. 936
symptoms of, ii. 929
treatment of, ii. 930
divisions of, ii. 913
lead, i. 335
muscular, ii. 925
other varieties of, ii. 923
INDEX. 975
Rheumatism,seat and complications of, ii. 914
Rhinitis; see Coryza.
Rhonchi or rattles, ii. 28
Roseola, ii. 870
sestiva, ii. 870
symptoms of, ii. 870
choleric, ii. 871
infantilis, ii. 870
rheumatic, ii. 871
varieties of, ii. 870
Round-worm; see Lumbricus.
Rubeola ; see Measles.
Salivation, critical, i. 69
spontaneous, i. 69
Satyriasis, treatment of, i. 663
Scarlatina, anginosa, ii. 887
symptoms of, ii. 887
maligna, ii. 888
symptoms of, ii. 888
simplex, ii. 887
symptoms of, ii. 887
sine exanthemate, ii. 889
Scarlet Fever, ii. 886
causes of, ii. 886
complications and sequelae of, ii. 892
diagnosis between, and measles, cho-
lera, and typhous fever, ii. 889
dropsy following, ii. 897
morbid anatomy of, ii. 891
prophylaxis of, ji. 898
treatment of, ii. 893
varieties of, ii. 886
Sciatica, ii. 601, 925
Sclerotico-choroiditis, ii. 646 ; see Choroiditis.
Sclerotitis, ii. 638
rheumatica, ii. 638
causes of, ii. 638
symptoms of, ii. 638
treatment of, ii. 638
Scrofula, ii. 655
causes of, ii. 660
special pathology of, ii. 659
symptoms and progress of, ii. 657
treatment of, ii. 663
Scrofulous ophthalmia ; see Ophthalmia.
Sects of Hippocratists, i. 34
pathologico-anatomists, i. 34
Sediments, crystallized, i. 597
Signs, i. 31
physical, in thoracic disease, ii. 65
Skin, division of diseases ofthe, ii. 858
scrofulous disorders of the, ii. 658
syphilitic ulcers of the, ii. 687
eruptions ofthe, ii. 685
tubercular affections of the, ii. 674
Small-pox, ii. 898
after vaccination, ii. 910 ; see Vario-
loid.
coincident exanthemata with, ii. 901
inoculated, ii. 901
progress of, ii. 901
morbid anatomy of, ii. 900
prognosis of, ii. 902
prophylaxis of, ii. 905
second attacks of, ii. 911
symptoms and progress of, ii 900
treatment of, ii. 903
Sounds, compound, ii. 28
in respiration, ii. 27
of the voice, ii. 30
on percussion of the chest, ii. 42
Spermatorrhoea, i. 665
treatment of, i. 667
Spinal irritation ; see INeuralgia Dorso-inter-
costal.
in intermittent fever, ii. 725
Spleen, congestion of the, i. 546
diseases of the, i. 541
treatment of, i. 547
enlarged, symptoms of, i. 546
a cause of intermittent fever, ii. 715
exploration ofthe, i. 542
healthy proportions of the, i. 542
hyperemia of, i. 548
softening ofthe, i. 545
suppuration of the, i. 545
Splenitis, acute, i. 543
chronic, i. 544
treatment of, i. 547
Stethoscope, its uses, ii. 37
Stomach, inflammation of the, i. 107; see
Gastritis.
organic disease ofthe, i. 141
Stomatitis, i. 44
erythematic, i. 45
follicular or aphthous, i. 46
gangrenous, i. 57
mercurial, i. 50
nutricum, i. 61
pseudo-membranous, i. 53
pultaceous or curdy, i. 51
pustular, i. 50
ulcerous, i. 50
Succussion, as a means of diagnosis, ii. 44
Symptoms, i. 31
Syncope, ii. 399
treatment of, ii. 400
Synocha, ii. 814
Synochus, ii. 814; see Continued remitting
fever, and Simple continued fever.
Syphilis, ii. 674
cachectic characters of, ii. 689
divisions of, ii. 675
local or primary, ii. 675
treatment of, ii. 67S
secondary or constitutional, ii. 683
symptoms of, ii. 685
treatment of, ii. 686
skin eruptions in, ii. 685
tertiary, ii. 688
symptoms and treatment of, ii.
688
Tabes mesenterica, i. 186, 197
treatment of, i. 189
Taenia, i. 462
treatment of, i. 467, 471
Tape-worm ; see Taenia.
Testicle, inflammation ofthe ; see Orchitis.
Testis, irritable, i. 654
Thread-worm, i. 461
treatment of, i. 468
Throat, diseases of the, i. 77
Thrush, white, i. 53 ; see Stomatitis.
Tic douloureux, ii. !>S7
976
INDEX.
Tic douloureux, cases and treatment of, ii. 589
causes of, ii. 587
Tissue modifies intestinal disease, i. 43
Tobacco, injurious effects of, i. 149
Tongue, appearance of, in gastritis, i. 112
inflammation of the, i. 63
Tonsil, diseased follicles of the, i. 90
excision ofthe, i. 89
hypertrophied, i. 88
Tonsillitis, i. 84
chronic, i. 88
impeded hearing in, i. 90
Tubercle, pulmonary, ii. 231
cicatrization of, ii. 280, 315
distribution of, ii. 235
organic relations of, to other
parts, ii. 242
origin and growth of, ii. 232
reparation of, in connexion
with black pulmonary de-
posits, ii. 314
seats of, ii. 237
stages of, ii. 239
structure and elementary
composition of, ii. 235
varieties of, ii. 233
see Phthisis.
Tuberculosis, ii. 231
of the brain, ii. 513
ofthe bronchial glands, ii. 299
Tumours, cancerous, ii. 723
definition of, ii. 716
polypoid, ofthe uterus, ii. 721
uterine, ii. 718
varieties of, ii. 717
Tympanites, i.210
Typhilitis; see Caecitis.
Typhus mitior; see Typhous Fever.
Urethritis, bubo in, i. 633
chancre with, ii. 678
chordee in, i. 617, 633
treatment of, i. 633
gonorrhoeal, i. 615 ; see Gonorrhoea.
effects of, i. 632, 638
stricture of urethra in, ii. 633
treatment of, i. 634
Uric or lithic acid, i. 555
formations or deposits of the, i. 598
Urinary apparatus, diseases of the, i. 552
progress of inquiry in,
i. 552
proportion of mortality
- from, i. 612
Urine, albuminous, i. 559
tests of, i. 572
bile in the, i. 557, ii. 431
composition of, i. 554
diabetic, i. 589
effects of animal food on the, i. 556
vegetable on the, i. 557
healthy, i. 554
in diabetes mellitus, i. 588
lithates, or urates in the, i. 555
pathological states of the, i. 557
phosphates in the, i. 603
principles ofthe, and of bile, i. 557
pus in the, i. 558
THE
Urine, retention of, i. 612
in encephalitis, ii. 475
saccharine, i. 588
secretion of, i. 553
in nephritis, i. 562
semeiological relations of, i. 558
solid extract in, i. 589, 590
state of, in Bright's disease, i. 571
suppression of, i. 584; see Ischuria Re-
nalis.
urea in the, i. 555
Uterus, cancer of the, i. 725 ; see Cancer.
displacements ofthe, i. 729
dropsy of the, i. 715
inflammation ofthe, i. 703
irritable, i. 675
neuralgia of the, i. 677
organic diseases of the, i. 677
polypus ofthe, i. 721
prolapsus of the, i. 729
treatment of, ii. 730
tumours of the, i. 717
Vaccination, age for performing, ii. 908
its reputed and its real efficacy, ii.
907
number of incisions for, ii. 909
selection of matter, ii. 909
Vaccine anatomy ofthe, ii. 910
pustule, ii. 909
Vaccinia, ii. 905
course of, ii. 909
habits of, ii. 906
history of, ii. 905
Vaccinine, a modified variola, ii. 906
or vaccine poison, habits ofthe, ii. 906
Vagina, neuralgia ofthe, i. 678
Variola; see Small-pox.
Variola?, ii. 898
two series of, ii. 898
Varioloid, phenomena of, ii. 911
same source of as that of small-pox, ii.
912
Veins, dilatation of the, ii. 423
diseases of the, ii. 414
inflammation of the, ii. 415
see Phlebitis.
varicose, ii. 423
Verminous fever, i. 466
Voice, change of, after excision of tonsils, i. 91
sounds of the, in pulmonary diseases,
ii. 30
Volvulus, i. 323
Vomicae, formation of, ii. 240
membrane lining, ii. 241
White swelling of the joints, ii. 672
treatment of, ii. 673
Whites, i. 693 ; see Leucorrhoea.
Windy colic, i. 211
Worms, exciting causes of, i. 465
intestinal, i. 454
origin of, i. 455
symptoms of, i. 462
treatment of, i. 466,469
varieties of, i. 461
Wrist-drop, from lead, i. 342
Yellow gum ; see Icterus Infantum.
END.
NATIONAL LIBRARY OF MEDICINE
nlh oanE^Q1* i
NLM031929041