fr/c. h*K-/fi A^- 16~ /ff? J f~£d /U^e^dAL *- h i l,/^ c f— Jhrx /ftnruc^ [Yl^ //^ ■ 4»*~* &^{ *"^f&~tfi*b$gi §fW /-L ( u^l- A. C- Ts- ^ c~ Jk-i.<£c* y i^^ £^v*-"fc*—\~i (L /$*fc ^ >e /3~^ Ac A^^, * tf ^ ty >-f~ ~ Cut^T^ frrrf*-f A^ mm «wm« -- ~\ n. ! A PRACTICAL TREATISE PULMONARY TUBERCULOSIS. EMBRACING ITS HISTORY, PATHOLOGY, AND TREATMENT. BY / HORACE GREEN, M.D., LL.D. LATE PRESIDENT, AND EMERITUS PROFESSOR OF THE THEORY AND PRACTICE OP MEDICINE IK THE NEW YORK MEDICAL COLLEGE ; CORRESPONDING FELLOW OF THE LONDON MEDICAL SOCIETY ; FELLOW OF THE NEW YORK ACADEMY OF MEDICINE, AND MEMBER OF THE AMERICAN MEDICAL ASSOCIATION, ETC., ETC. NEW YORK: JOHN WILEY, 535 BROADWAY 1864. VnFA Entered according to Act of Congress, in the year 1864, by JOHN WILEY, In the Clerk's Office of the District Court of the United States for the Southern District of New York. B» CRAIGHKAD, t'rinwr, Slcreulyper, ami Kleclrolyper, Carton JSuiltitng, 81,83, and 83 Ctrurc Sirtcl. ■*s> / MRS. H. DOUGLAS GREEN. BEING PERFECTLY AWARE, MY DEAR WIFE, THAT TO YOU BELONG ALL THE VIRTUES THAT ORDINARILY ADORN YOUR SEX, AND THAT, THEREFORE, THIS WORK MAY WITH PROPRIETY BE INSCRIBED TO YOU J YET, AS THE WORK OWES ITS EXISTENCE TO YOUR CONSTANT FAITH AND ENCOURAGEMENT, I EDeMcaic tl)£ bolnme TO YOU, AS A SLIGHT TESTIMONIAL OF THE LOVE AND RESPECT OF YOUR HUSB AND. PREFACE. I am quite aware of the charge of presumption which, very properly perhaps, may be brought against me for venturing to give my own views on the subject of tuberculous disease, when our country is so full of mature and learned works on this subject. But I have no apology or excuse to offer. I am not ambitious of thrusting forward new or peculiar opinions on any medical subject. I have only embodied views which twenty-five years of con- stant and extensive experience in the treatment of this class of diseases have given me, and do not ask my professional brethren to accept them, only so far as they are convinced of their truth. This work has been divided into three parts. The first embodies a historical sketch of the views of many of the most ancient and modern writers on the Nature and Treatment of Tuberculosis. The sources from which these views are derived are generally named. For some of the earliest acts to which reference is made I am indebted to the excellent work of Dr. Young; for those of more modern times to the different authors who have written on this subject. It has not been in my power to allude to all the works pub- lished on this disease, but I have intended by a brief reference to the writings of a sufficient number of them, to give an epi- tome of the most prominent views entertained by different authors of different ages on Tuberculosis. The second part is devoted to an account of my own views of the pathology of the disease, or of the Nature and Origin of I iv PREFACE. Chronic Phthisis. I do not assume that all cases of Tuber- culosis have their origin in a deterioration of the epithelial element, but of the truth of the theory in regard to the initiality of Chronic Tuberculosis after twenty-five years' experience in the constant treatment of the disease, I am quite positive. In the third part, I have considered the treatment of the dis- ease. I have endeavored to show the importance of local treatment in the early stage of the affection, particularly in the chronic form, especially where follicular degeneration has preceded the development of tubercles in the lungs. Great pains were taken in the examination of the cases of phthisis which presented themselves for treatment. Of 558 cases of phthisis that came under my observation, 311 were males and 247 females. Of this number, 377 had disease in the right lung, and 234 in the left. Of the females (247) 147 were first diseased in the right lung, and 100 in the left. In the treatment of a large number of cases during many years of observation, about the same proportion in the nature of the lesion and in its location was remarked. Hence, the plan of treatment I have recommended, was adopted, and has been carried out during a period of over twenty-five years. Great care has been taken with the microscopic illustrations. Most of them are original, with the exception of two from Kolliker, one from the work of Virchow, and one from that of Waters, on the Pathology of the Human Lung. These views are submitted to the profession with entire confidence in their willingness to carry out the injunction, " Prove all things; hold fast that which is good." Horace Green. New York, August, 1864 CONTENTS. PART I . CHAPTER I. PAOR Pulmonary Consumption—General Remarks,.....1 CHAPTER II. Brief Sketches of the Views and Writings of Distinguished Medical Writers from Hippocrates to the present day on the Subject of Consumptive Diseases,........4 PART II. CHAPTER I. § 1. Of the Elementary Parts,.......117 § 2. Cells, or Elementary Organs of Animal Tissue, . . . 118 CHAPTER II. Histological Inquiries,..........123 § 1. Special Histology of the Respiratory Organs, . . . 123 § 2. Oral Cavity,..........125 § 3. The Pharynx,.........127 § 4. The Larynx,.........128 § 5. The Trachea..........133 § 6. The Lungs,..........135 § 7. The Ultimate Pulmonary Tissue,......136 CHAPTER III Theses, or Propositions regarding the Inceptive Pathology and the True Nature of Phthisis, . .....148 CHAPTER IV. Morphological Changes in the Tissues,......150 CHAPTER V. Nature and Progress of the Tuberculous Dyscrasia, .... 162 vi CONTENTS. CHAPTER VI. PAOB Early Symptoms of Chronic Phthisis; or, Tubercular Dyscrasia, . H;8 CHAPTER VII. § 1. Primary Symptoms of Tuberculosis,.....177 § 2. Extension of the Morbid Process along the Trachea, and into the Bronchia, and their Ramifications, .... 181 CHAPTER VIII. § 1. Second Stage,.........185 § 2. Condition of the System Preceding and Attending the Full Development of Tuberculosis,......188 CHAPTER IX. § 1. Third, or Tubercular Stage,.......191 § 2. Softening,..........192 § 3. General Remarks,........194 PART III. CHAPTER I. Treatment of the Prse-Tubercular Stage of Chronic Phthisis, . . 201 History of a Family, showing that Diseased Action of the Glandular Follicles may result in the Development of Hereditary Tuber- culous Dyscrasia,.........201 CHAPTER II. 205 205 211 214 226 240 245 Primary Lesions,........ § 1. Lesions of the Fossae Nasales. Illustrative Cases, Elongation of the Uvula. Case described, . § 2. Lesions of the Tonsillar Glands, with Case, . General Remarks, and Illustrative Cases, § 3. Lesions of the Pyriform Sinuses, .... § 4. Lesions of the Epiglottic Cartilage. Cases reported, § 5. Ulceration of the Mucous Membrane, or of the Glands of the Epiglottis. Cases described,......257 CHAPTER III. Treatment of Chronic Phthisis, following Follicular Degeneration of the Mucous Membrane of the Air-Passages, .... 279 § 1. The First, or Pras-Tubercular Stage of Phthisis. Illustrative Cases,..........279 § 2. The Bronchitic Stage of Phthisis. Cases narrated, . . 290 § 3. The Tubercular Stage of Phthisis,.....297 CONTENTS. vii CHAPTER IV. PAGB § 1. Catheterism of the Bronchial Tubes. Reports of Cases, . 300 CHAPTER V. Continuation of the Treatment of Chronic Phthisis, Local and General,...........325 Topical Remedies,..........325 Sedatives,............328 CHAPTER VL General Remedies,.......... 329 Iodine,............329 Arsenic,............332 Manganese,...........333 Ir°n,.............334 Hydrocyanic Acid,..........335 Formula,............336 Appendix,.......... 344 Index, 349 LIST OF ILLUSTRATIONS. Figure 1. Specimens of Normal Cells, each cell composed of its Membranes and Cell Contents; Isolated Nuclei and Nucleoli; Molecules or Granules isolated, . . . 119 " 2. Portion of a Cartilage from the Humerus of a Child, show- ing the cell-territories,.......121 " 3. Ciliated Epithelium from the human trachea, . . . 132 " 4. Diseased Follicles of Posterior Nares, in the commence- ment of follicular degeneration,.....180 " 5. Expectoration from the Trachea, in chronic folliculitis, . 182 " 6. Tubercular Matter from the lungs of a patient dead of tubercular phthisis,.......193 " 7. Cells taken from the Tonsils of the calf, .... 216 " 8. Hypertrophied and Diseased Tonsils, removed from patient laboring under chronic folliculitis,.....218 u 9. Disintegrated Matter taken from the cavity of a Tonsillary gland, greatly diseased,.......219 Plate X. See Appendix,.........344 LITHOGRAPHIC PLATES. Plate XL Tonsils slightly enlarged, not showing much External Disease. Ulcerated Portion on cut surface, as seen after excision, cavity filled with disintegrated or cheesy matter,.......237 " XII. Disease and Ulceration in Pyriform Sinus, . . . 243 " XIII. Healthy Throat,........205 " XIV. Ulceration of Pyriform Sinus,.....241 " XV Erosion of the Left Side of the Epiglottis, . . . 249 " XVI. Ulceration of the Centre of the Epiglottis, . . 261 " XVTI. Ulceration of the Epiglottis,.....'262 " XVIII. Erosions of the Entire Edge of the Epiglottis, . . 255 " XIX. (Edema and Ulceration of the Epiglottis, . . . 270 " XX. Ulceration of the Pyriform Sinus healed, . . . 244 " XXI. Elongated Uvula and Commencement of Follicular Disease,.........212 " XXII. Ulcerations of Mucous Membrane of Larynx and Trachea,.........296 A TREATISE ON PULMONARY TUBERCULOSIS. PART I. CHAPTER I. PULMONARY CONSUMPTION. Since the publication of the writings of Bayle and Laennec, Pulmonary Tuberculosis has been denned to be that form of disease which is characterized by a deve- lopment in the air-spaces of the lungs, of a soft, brittle, adventitious substance, denominated tubercle or tuber- culous matter. The physical characters, the microscopic structure, and even the chemical composition of tubercle are well under- stood by the modern pathologist. With the effects, too, of this morbid product on the animal economy ; with the signs of its earliest manifestation in the lungs, as well as with those of its subsequent progress in the ultimate destruction of their vascular parenchyma, all well in- structed practitioners are now familiar. But of the primary origin of phthisis—of those morphological con- ditions of the living body which precede and control the inception of the nascent tubercle, we are altogether ignorant. So, likewise, if we regard consumption as a 2 PULMONARY CONSUMPTION. general disease, we know absolutely nothing of the abnormal phenomena which precede that condition of the animal frame, whether hereditary or acquired, to which the term phthisical constitution, or scrofulous diathesis, is applied. Unfortunately, it is not until the antecedents have given place to the consequent,—not until the morbid product has, to some extent, blocked up the air-cells, that the physical signs which constitute the only positive evidence of the actual presence of tuberculous disease, disclose to us the true nature of the malady. It must therefore be apparent to all those who have directed any inquiries to this subject, that farther re- searches on this vital point are absolutely required; and that until our knowledge in the primary morphological changes which occur in early phthisis is extended, our success in its treatment must remain, as heretofore, limit- ed and uncertain. " Before we can hope to acquire an accurate knowledge of Consumption," says Sir James Clark, "we must carry our inquiries beyond the pul- monary disease, which is only a secondary affection." The great object of the present work is to contribute something to the attainment of this most desirable end; to extend, if possible, our knowledge of the causes of phthisis, that we may be enabled thereby to adopt a more appropriate and successful method of treatment. Diseases of the pulmonary thoracic organs, it will be admitted, are more constantly observed than those of any other part of the human system; and, of the differ- ent affections of these organs, no one is so frequently present, or so generally fatal, as tubercular consumption. To contemplate the vast mortality caused by this world- pervading disease, is indeed humbling to our professional PULMONAEY CONSUMPTION. 3 pride. Great pains have been taken in this country and in Europe to obtain correct statistics on this subject, and from most extensive and reliable data it has been calcu- lated that one fourth part of all the deaths occurring from disease, in all temperate latitudes, are caused by tubercu- lar phthisis. Indeed, Sir James Clark, who is high authority, has declared it to be his opinion, that if we add to consumption of the lungs, tuberculous diseases of other organs, and deduct the mortality which occurs during the first months of life, it will probably be within the truth, to state that a third part of the mortality arises from tuberculous diseases ! So long, therefore, as a cause of mortality so universal and efficient, remains in force, every medical man, who possesses opportunities for observation, in any degree extended, will have failed in discharging his duty to his profession, and to humanity, until he has contributed something to advance our knowledge of the nature of this cause, or to insure the mitigation of its consequen- ces. But, before we can pursue, intelligently, inquiries which refer to primary morbid alterations in tuberculosis, it will be necessary to consider not only those views of the pathology of consumption, which the ancients enter- tained, but to refer to those which constitute present received opinions, concerning the nature of this disease. 4 MEDICINE OF THE ANCIENTS. CHAPTER 11. BRIEF HISTORICAL SKETCHES FROM THE TIME OF HIPPO- CRATES TO THE PRESENT DAY. It is not my purpose to review the many obsolete opinions entertained by the ancients, of the nature of Consumption: still, in a treatise of this kind, it is mani- festly proper not only to refer to the opinions recorded by the more distinguished medical writers of the past, but to compare these views, that by combining the vari- ous discoveries of different epochs in medicine, we may gather material aid in our further researches from the accumulated experience of medical observers of all ages. If we examine the earliest writings of the physicians of ancient Greece and Rome, we shall be surprised at the amount of accurate knowledge they possessed with re- gard to the nature, etiology, and treatment of Phthisis ; and equally surprised to find what little progress, with all our boasted advantages and increased pathological knowledge, modern practitioners have made in the successful treatment of this malady. OPINIONS OF HIPPOCRATES. The prominent rational symptoms of genuine consump- tion are all accurately described by Hippocrates. In the Predictions and Aphorisms, Hippocrates alludes with much accuracy to the characteristic alterations occurring in Consumptive diseases. The "suppuration of the lungs," following the " short dry cough," " pain in the chest," and " temporary flashes of heat," attended with MEDICINE OF THE ANCIENTS. 5 " purulent expectoration after haemoptysis, and succeeded by emaciation and colliquation," describes the genuine tuberculosis of the present day; and from his description it is at once recognised as such, by the modern patholo- gist. The great pathological doctrine advanced by Hippocrates is this, that the fluids are the primary seat of all disease; the formation of tubercles was attributed by him to the putrefaction of phlegm or of bile. The most dangerous form of consumption, Hippocrates declares, is " caused by a rupture of the great vessels, or by a deflexion of matter proceeding from the head." The collected humors putrefy and produce the disease. " The lungs are filled with phlegm," remarks he, " and pus is formed which corrodes the lungs."* He distinguishes the difference between pus and mucus by the greater specific gravity of the former. " If the expectorated matter sinks in sea-water," observes Hippocrates, " the disease will be shortly fatal." In the treatment of Consumption, Emetics are par- ticularly and very constantly recommended by Hippo- crates. Occasional mild cathartics are advised, together with the external application of powerful caustics to the chest and the back. Oxymel, or honey, was the favorite demulcent employed by the ancients to allay the irrita- tion which attended the cough. A milk diet (asses' and mares1* milk are particularly mentioned), with meat in moderate quantities, is recom- mended. Avoiding the vicissitudes of heat and cold, and employing exercise in the open air, especially that of walking, which should be gradually increased until a distance of ten or fifteen miles is accomplished daily— * Hippocrates. Aph. Vol. II. p. 125, and Predictions, p. 71. 6 MEDICINE OF THE ANCIENTS. these are among the most prominent of the measures recommended by the Father of Medicine for the treat- ment of Consumption. It does not appear that Hippocrates knew aught of the remedy so universally employed at the present day in the treatment of Consumption, for we find no mention made of cod-liver oil in any of his writings; but the oil or fat of different animals, and particularly that of the wild boar, is advised by him in several portions of his works to be taken freely by consumptive patients. DIOSCORIDES. Few among the immediate successors of Hippocrates ventured to entertain any opinions, or to recommend any measures for the treatment of disease, different from those entertained and advised by the Father of Medicine. The employment of fumigations in the treatment of Con- sumption, and the internal administration of sulphur, were recommended by Dioscorides, the physician of Cleopatra. ARET/EUS. Aretaeus, of the exact period of whose writings we are not positive, but who practised in the reign of Ves- pasian, employed the term of phthae or phthisis to desig- nate a disease characterized by a chronic cough, haemo- ptysis, a purulent expectoration, and attended with ulcera- tion of the lungs. In remarking upon affections of the chest, Aretaeus makes the observation that in those where the disease proves fatal, the patient seldom des- pairs of recovery to the last. \ His work on General Disease is written with much elegance, and his description of the rational signs of Consumption is uncommonly accurate. A more graphic MEDICINE OF THE ANCIENTS. 7 description of disease is not to be found in any writings, ancient or modern, than that which Aretaeus gives of a patient dying of Consumption. "The patient," he observes, " feels a weight in the chest, with nausea, and chills in the evening, succeeded by heat towards the morning: he has partial sweats about the thorax: his voice is hoarse: his neck is slender, and as if contracted : the fingers too are shrunk, except at the joints, which become prominent: the nails are bent for want of sup- port, and become painful: the nose is sharp, the cheeks are red, the eyes sunk, but bright, the countenance as if smiling: the whole body is shrivelled : the spine projects, instead of sinking, from the decay of the muscles; and the shoulder blades stand out like the winsrs of birds. O At last a diarrhoea supervenes, and the case becomes hopeless." Sea voyages and milk diet are recommended by Are- taeus as the great remedies for the cure of Phthisis. CELSUS. The precise period at which Celsus, one of the most accomplished and learned of the Roman physicians, flourished, is not known ; although from some expressions in his writings, it has been conjectured that he lived under the reigns of Augustus and Tiberius. He is the earliest Roman physician whose writings on Consumption have com.e down to us. In his treatise " On Medicine," he alludes to Phthisis as the most dangerous species of Ta- bes, " which beginning from the head descends to the lungs, and is accompanied by ulceration and fever, with cough and expectoration of purulent, and often bloody matter." Some revulsives are advised by Celsus in the treatment 8 MEDICINE OF THE ANCIENTS. of genuine Consumption. The cautery is to be applied at several different locations, under the chin, over each breast, and under the scapulae; and the ulcers, he directs, should not be healed until the cough has subsided. Tur- pentine, butter, and honey simmered together, are to be administered internally to allay the cough. The juice of the plantain with honey, and vinegar of squills, are also recommended by Celsus in the treatment of this disease. But the remedy on which he most re- lied was a long sea-voyage, with a change of climate, in- asmuch as the worst air for any disease, he declares, is that in which it has originated. Among the earlier Roman physicians, some of the most eminent gave much attention to the improvement of pharmacy. The Materia Medica of the ancients, even at this early day, was quite extensive, but it consisted almost entirely of vegetable products. PLINY. Pliny the Elder, who was celebrated as a naturalist^ describes many remedies, which by him, and in his time, were held to be specifics for the treatment of Consump- tion. He was the first to recommend a residence in woods affording an abundance of resinous effluvia, as a most favorable location for the consumptive. The fat of the mountain goat, taken in gruel, with honey, or dissolv- ed in milk, was a very popular remedy in his day. GALEN. It is admitted by all writers on the history of Medi- cine, that Galen was " one of the most remarkable men that ever appeared either in ancient or in modern times." He was a great admirer and in many respects a follower r MEDICINE OF THE ANCIENTS. 9 of Hippocrates, adopting as the foundation of his theory, the doctrine which he had advocated in his voluminous writings, that the fluids are the primary seat of all dis- ease. In his knowledge of Physiology, as evinced by his treatises on this subject, Galen greatly exceeded his con- temporaries, and in the progress which he made in patho- logical anatomy, he surpassed all that had been accom- plished by any of the ancients; and yet his views of the nature of Consumption were exceedingly erroneous. He describes hectic fever as existing independent of Con- sumption, and as frequently accompanying Marasmus, which is a disease generally incurable. Hectic fever, he admits, may be occasioned by affections of the liver, the colon, the bladder, or the kidneys, or indeed by chronic inflammations of any kind, but that it never succeeds to any visceral disease, without some affection of the heart itself being present. In its advanced stage it consti- tutes an incurable form of marasmus, in which " the sub- stance of the heart is wholly dried up." In the collection of Galen's works is a treatise on Medical Definitions, which, it is supposed, is not a genu- ine Galenic production. Phthisis, or Consumption, is " described in this treatise as an emaciation, occasioned by an ulceration of the lungs, attended by a cough and a slow fever," a definition evincing considerable advance in pathological anatomy. In Galen's treatment of pulmonary consumption, which is considered at length in the fifth book of the Method of Healing, he alludes to the difficulties which occur in arresting haemorrhages, and in healing ulcerations of the lungs. Such ulcers, he observes, require very power- ful remedies, because the ulcers cannot be reached by 10 MEDICINE OF THE ANCIENTS. the immediate application of these remedies. The heal- ing process is prevented, moreover, by the act of cough- ing, as well as by the movement of respiration. When a vessel has burst, unless it unites without inflammation, the disease, he declares, is incurable. The indications are, to relieve the cough, and to obviate the defluxion from the head. To meet these indications, cathartics and bleeding are recommended, each to be repeated occasionally; observ- ing proper intervals for recruiting the strength of the patient by nourishing food. The remedies employed by Galen for relieving the cough, and promoting expectoration in diseases of the lungs, were principally such as had been recommended by medical writers of eminence who had preceded him, and in most instances were simple remedies, such as liquorice, saffron, frankincense, and other similar substan- ces. The juice of hyoscyamus, but more frequently the seed of hyoscyamus, was occasionally administered. A milk diet was advised by him for his consumptive pa- tients ; and the milk of the ass and the goat was pre- ferred to that of the cow. Whatever kind used, he re- commended it to be drunk warm from the animal. His dependence, however, in the treatment of Consumption, was not so much, after all, on these mild remedies and diet, for he expressly states that, " All that are curable are cured by bleediug, purging, and strengthening the head,"—a depressing and "perturbating" plan of treat- ing disease too common even at the present day. So exalted was the estimation entertained of the opinions of " the divine Galen " by his contemporaries and successors, that for centuries after his death no im- portant discoveries were effected in medicine; and few MEDICINE OF THE ANCIENTS. 11 indeed, and feeble, were the attempts which were made to improve the science. "Mankind," says Dr. Good, " seemed to be satisfied with the progress which had been made in the science, or were conscious of their ina- bility to surpass the limits which had been assigned to it." Up to the middle of the sixteenth century, medi- cal authors, both among the Greeks and the Arabians, adhered to the opinions and precepts of Galen. PARACELSUS. Paracelsus, who flourished before this period, pre- sumed, it is true, to deviate from the practices of the ancients; and he even attempted to counteract the doc- trines of Galen. Consumption is attributed by Para- celsus to a deficiency of moisture in the system ; but he defines it to be a disease by which the whole body is dried up. In his treatment of the disease he advised the employ- ment of mineral remedies, such as crude antimony and crocus martis ; recommending these to be fully admi- nistered. The frequent use of the bath, and universal friction with ointments, night and morning, together with a vegetable diet, are advised by Paracelsus in the treatment of Consumption. RHOZAS. Among the Arabians, Rhozas, who was not only well acquainted with general science, but was regarded as one of the most illustrious physicians of the ninth cen- tury, recommends, in addition to the measures advised by Galen, and others of the Greek physicians, for the treatment of Consumption, fumigations with a mixture which contained a portion of arsenic. 12 MEDICINE OF THE ANCIENTS. This is not the first instance, however, in which arseni- cal preparations had been recommended by the ancients 1 in the treatment of pulmonic disease, for, in the third book of the Euporistics, addressed to Solon, we find that the yellow sulph. of arsenic, which is a less poison- ous preparation than the oxide, is advised, not only for smoking, but to be taken internally with honey, as a useful remedy in pulmonary disease. But it was not until several centuries after the death of Galen that the chirurgists, who for a long period were considered the empirics of the day, were able to introduce into the popular pharmacopoeias of that period, active metallic preparations to any considerable extent. The Materia Medica of the Galenists was composed al- most entirely of articles taken from the vegetable king- dom. In the writings of the Greek physicians, as well as in those of the Arabians, whose works consist prin- - cipally in abridgments from, and commentaries on, the voluminous labors of Galen, frequent allusion is made to the injurious effects produced upon consumptive pa- tients by the use of metallic remedies, whilst positive recoveries from the advanced stage of Consumption are frequently attributed to remedies many of which were perfectly inert. Forestus restored patients from a hope- less condition, by means of sugar of roses and chicken- broth ; and Plateras, who copied very closely the doc- trines and opinions of the Greeks, put great confidence in " the distilled water of snails," for the treatment of phthisis. Another effected remarkable cures with saf- fron and the whites of eggs; whilst Solenander arrested incipient consumption by administering the dew gath- ered from certain medicinal plants, such as the hyssop, bergamot, and betony (betonica officinalis), the last MEDICINE OF THE ANCIENTS. 13 of which was much employed in ancient medicine, in the treatment of consumption, gout, and sciatica. The opinions of Galen were adopted, and the ineffi- cient practice of the Greek physicians in the treatment of Consumption was very generally followed by medi- cal practitioners in all civilized countries, during a period of nearly ten centuries after the death of Galen. There are some exceptions to this passive submission to the great authorities of antiquity. But whenever inquiring observers in medicine ventured to express opinions, and to advocate plans of treatment, different in any degree from the views and practices of the ancients, they were certain to be characterized, by the conservative portion of the profession, as irregular and empirical practi- tioners. PATERIAS. Paterias, who was physician to the King of France, employed many powerful chemical preparations, some of which have proved valuable remedies for the treat- ment of disease. In Consumption he administered the preparations of antimony, mercury, and gold, as well as those of phosphorus and the acetate of lead. Paterias also employed, according to Hoffman, who was his com- mentator, in addition to these remedies, inhalations of the vapor of sulphur, and other medicines, with great advantage, in the treatment of many cases of Consump- tion. With regard to the nature of Consumption, the pa- thologists of the fifteenth and sixteenth centuries enter- tained and expressed views exceedingly fanciful and erroneous. But we shall not be surprised at this, when we remember how little was known of the minute struc- u MEDICINE OF THE ANCIENTS. ture of the human body by the ancients of this period. Some knowledge had been attained in anatomy by the earlier Italians, for in a few instances they had ventured to dissect the human body; yet scarcely any discovery, or any improvement deserving of notice, says Dr. Good, had been made for many years, until VESALIUS, about the middle of the sixteenth century, entered upon his course of inquiry. " He was the first anatomist who threw off the yoke of authority, which had been im- posed by a blind veneration for the opinion of the an- cients, and who ventured to conceive the possibility of error in the writings of Galen. Vesalius prosecuted his researches with unwearied diligence ; and disregarding the obloquy which was heaped upon him, he succeeded in publishing an anatomical work, which at this day we behold with admiration, and which maintains its charac- ter as a faithful transcript of nature." But, notwithstanding these improvements made in anatomical investigations by Vesalius, and by Eusta- chius and Fallopius, who were also of that period, and who were deservedly celebrated for their great anato- mical skill, the progress which was made in pathological anatomy by the medical inquirers of this age was com- paratively unimportant. WILLIS. As late even as the middle of the sixteenth century, Willis, who is considered by many writers as one of the most eminent medical philosophers of that age, and who was celebrated for his great learning and anatomical accuracy, says of Consumption, that it is not the disease TUBERCULOSIS. 15 derived from the head, as the ancients asserted, but the " human expectoration," he declares, " exudes from the minute vessels of the trachea, the whole mass of blood contributing to overwhelm the lungs with its serous por- tion ; and when the discharge putrefies, it forms ulcers." SYDENHAM. The views of Sydenham, whose commencing reputa- tion as a medical philosopher and successful practitioner equalled that of any writer of any age, did not differ essentially from those of his predecessor, Willis, for he ascribed the primary origin of disease to certain morbid fermentations which take place in the fluids; and, like Hippocrates, he defined diseased action to consist essen- tially in the efforts of nature to rid the system of these morbific causes. In accordance with this theory, he de- scribes Consumption as having its origin in cold taken ordinarily in winter, and which becomes fatal gradually in the course of the succeeding summer. " As the diseased action progresses, the lungs become incapable of assimilating the proper aliment, they are overwhelmed by a crude phlegm, and scatter the mias- mata over the whole body; hence arises a putrid fever, of which the paroxysms are terminated by sweating ; and afterwards a diarrhoea, from the accumulation of humors and the loss of tone of the viscera. A part of the humors, which ought to be thrown off by perspiration, is retained in the lungs; another part is secreted by the salivary glands, and descending the trachea, causes coughing." It will not be difficult to imagine the treatment that would be based upon these views of the nature of the disease. In all cases Sydenham recommended that 16 HISTORICAL SKETCH. class of therapeutic agents which were deemed efficient in assisting nature to bring about the proper causes and to regulate the actions of the system. Bleeding with mild cathartics ; refrigerants during the stage of febrile excitement; opiates, balsams, and emulsions for the cough, with the universally prescribed milk diet, these are among the measures advised by Sydenham, in the treatment of pulmonary consumption. But the great remedy on which he mostly relied in the treatment of the disease, was riding on horseback. Of the benefit to be derived from this measure he thus speaks in his epistle to Cole. " Horse exercise is no less useful to the consumptive than to the hypochondriac: in several instances, some of my own relations have been restored to health by taking very long journeys on horse- back, at my recommendation, when medicines had been of no avail: and not in slight cases only, but where night sweats and diarrhoea had supervened, as usually happens in the last stage. In short, notwithstanding the acknowledged fatality of this disease, which carries off two thirds of those who die of chronic affections, I do not hesitate solemnly to affirm, that neither mercury in syphilis, nor bark in interna ittents, is more effectual than riding in Consumption: provided that the patient take care to have his linen well aired and to continue his journey long enough ; the longer, as he is more advanced in life; and this I have learned by multiplied experience, which I have scarcely ever found to fail: nor is carriage exercise by any means to be despised, though not equal to riding." STAHL. In examining the works of Stahl and Hoffman, whose writings exerted a widespread influence on the opinions TUBERCULOSIS. 17 and practice of the physicians of the latter part of the seventeenth century, we find no evidence that the true nature of phthisis was any better understood by these celebrated medical philosophers, than it was by the pathologists of a much earlier period. Stahl admitted that hectic was truly a symptomatic fever, but he denied the doctrine of the humoral patho- logists, that Consumption is dependent on the presence of any morbific matter in the fluids of the system ; hence those modes of practice which tend to promote the evacuation of such matters from the system are generally unattended with success in the treatment of the disease.—(Stahl de Hectica, etc.) Disapproving of many of the remedies recommended by Sydenham, Willis, and Paterius, Stahl relied princi- pally on bleeding, inhalations, the internal administra- tion of the distilled waters of different medicinal plants, particularly of such as were considered by the ancients to possess traumatic properties, and the persevering employment of horseback exercise. He disapproved of the employment of balsams, expectorants, and opi- ates ; but to allay the cough advised the use of the ex- tract of tobacco, and the inhalation of the fumes of crude antimony. A milk diet he considers of no ac- count in Consumption, for in his commentary on Gideon Harvey's vulgar Latin, " The Art of Curing by Expec- toration," Stahl alludes to this author's opinion, that milk is as useless in the cure of all internal disease as in that of a luxation. That ass's milk, so highly com- mended by the ancients, contains no fattening particles, for when set aside for twelve hours it exhibits no cream; it is therefore nothing but a cold mucus, and " fit only for asses."—(Stahl, Theoria Medica Vera, p. 1014.) 2 , 18 HISTORICAL SKETCH. MORTON. Early in the sixteenth century, the " Phthisiologia of Morton" was published, a work containing opinions concerning the nature and treatment of Consumption, not differing materially from those advanced by Syden- ham and Willis, except in this, that the author consi- dered the fever occurring in the confirmed stage of phthisis to be of a putrid intermittent character, the type of which is generally quotidian, but occasionally tertian; consequently the Peruvian Bark was the great remedy recommended and employed by Morton, not only as a preventive of phthisis, after the occurrence of haemoptysis indicated its approach, but for the treat- ment of the affection in all its stages.—(Morton, Phthisi- ologia, pp. 174, 258.) The employment of this therapeutic agent Stahl un- qualifiedly condemns, declaring that the use of the bark has often induced not only Consumption, but jaundice and dropsy, after intermittents. HOFFMAN. Hoffman, who was the rival of Stahl, and his col- league in the University of Halle, advocated views which differed essentially from those advanced by his distinguished opponent. Rejecting the doctrines of the humoral pathologists, he embraced the opposite opinion, and contributed much, by his inquiries into the condi- tion of the muscular and nervous systems, to advance the theory first promulgated by Baglevi, that the solids, and not the fluids, are principally affected in disease. Hoffman believed that phthisis, in a large number of cases, originated in haemoptysis, and he recommended TUBERCULOSIS. 19 that caution should be observed in the use of astrin- gents, that the bleeding be not too suddenly arrested. Exercise in the open air, small bleedings frequently repeated, opium to allay the cough and check the colli- quative sweats, and nitrate of potash as a refrigerant, are among the remedies embraced in the plan of treat- ment recommended by Hoffman. The use of emetics and active cathartics he condemns; but he urges the employment of ass's milk and mineral waters, as im- portant aids in the successful treatment of pulmonary consumption. Hoffman was not alone in the opinion he expresses, that phthisis in many cases has its origin in haemoptysis. ' Several eminent writers and pathologists before him had adduced the same opinion.—(Hofmanni Opera, iv. 112.) The nearly universal practice of this period—that of employing venesection frequently as a prophylactic in persons predisposed to Consumption, had its origin mainly in the views which were entertained with regard to the exciting .cause of the disease. BOERHAAVE. The celebrated Boerhaave, whose writings were pub- lished as late as the commencement of the eighteenth century, had no just idea of the true nature of Con- sumption, for he considered that both the blood and the chyle in this disease are converted into pus, and that when the ulceration which attends this condition of the fluids has destroyed the substance of the lungs, " so that the whole habit of the body is thereby wasted and con- sumed, the patient is said to labor under phthisis pulmo- nalis."—(Commentaries upon Boerhaave's Aphorisms, etc., by Van Swieten, v. xii. p. 1.) 20 HISTORICAL SKETCH. DESSAULT. ■ In 1733 Dessault of Bordeaux published a work con- taining a dissertation on the nature of Consumption, in which he declares that tubercles constitute the true es- sence of phthisis, and that the ulcerations of the lungs are secondary—the effect and not the cause. Dessault adopts the opinion entertained by Galen, and many others of the ancient physicians, that Consumption is a contagious disease.—(Dessault sur les Malades, etc.) For its treatment, he advises the adoption of measures not differing materially from those recommended by Sydenham, Baglevi, and Hoffman. Although the inquiries and commentaries of many distinguished writers, on the nature and management of phthisis, were published during the middle, and towards the close of the eighteenth century, yet among the writings of this period few improvements are found re- corded, either in regard to the pathology of the disease, or its treatment. VALSALVA, MORGAGNI. It is somewhat singular that the two great patholo- gists of this time, Valsalva and Morgagni, as it would appear, give less attention to the study of the nature of this important disease, than to that of any other which came under their observation. This is attributed by Dr. Young to the fears entertained by both these distinguished physicians, that in the dissection of sub- jects, dead of Consumption, the disease may be propa- gated by contagion ! Valsalva advanced the opinion that the upper part of the lungs is more frequently in- TUBERCULOSIS. 21 volved in the disease than the lower. Morgagni, on the contrary, believed that tubercles are found to occur as frequently in one part of the lungs as another, but he had not dissected consumptive patients enough, to deter- mine with accuracy the immediate seat of the disease.— (Morgagni, De Sedibus et Causis Mor., Ep. xxii.) VAN SWIETEN. Van Swieten, who was a favorite pupil of the cele- brated Boerhaave, and who adopted principally his the- ory of the nature of disease, has left on record in his " Commentaries on the Aphorisms of Boerhaave," some interesting observations on the cause and pathology of phthisis pulmonalis. He coincides in the opinion advanced by Boerhaave, that any cause capable of stopping the circulation through the lungs, so as to convert the blood into pus, producing thereby ulceration of these organs, may justly be called the cause of a phthisis pulmonalis.—(Com- mentaries on Boerhaave's Aphorisms, etc., vol. xii., p. 3.) Attributing the night perspirations and diarrhoea, which occur in Consumption, to the presence of a putri- dity in the system, Van Swieten recommends the use of powerful antiseptics, such as bark, camphor, myrrh, etc., in the treatment of the disease. Riding on horseback, with a milk diet, and opiates to allay the cough and ex- pectoration, are also advised by him. Blood-letting, oft repeated and the practice long continued, is the im- portant remedy urged by Van Swieten for the cure of Consumption.— (Commentaries on Boerhaave's Apho- risms, etc., vol. xii., pp. 90-91.) Although the master mind of Cullen enabled him to 22 HISTORICAL SKETCH. grasp almost the whole subject of medical science, and to contribute greatly to the advancement of general pathology and practical medicine, yet from an examina- tion of his works we do not find that the special patho- logy of Consumption was any better understood by him than it was by his predecessors, Hoffman and Stahl. CULLEN. Cullen defines Pulmonary Consumption to be a disease or an expectoration of purulent matter from the lungs, attended with a hectic fever. The opinion seems to have been entertained by him, that ulceration of the lungs is perpetuated by the peculiar acid character of the pus, and that this condition of the purulent matter in Consumption is the cause of the hectic fever which is present. Ulceration of the lungs is presumed by Cullen to ex- ist, in every instance where an expectoration of pus is present. But he discards in his first lines the opinion he had previously entertained, that Consumption is no- thing more than a sequel of haemoptysis, and that this symptom is naturally, and almost necessarily, followed by an ulceration of the lungs. Several other causes of Consumption are enumerated by Cullen, but the pre- sence of tubercles found in the lungs, is considered by him to be the most frequent of any, and when arising from an hereditary taint is believed to be almost cer- tainly fatal. An antiphlogistic or depleting plan of treatment is recommended by Cullen. To the preparations of bark and chalybeates he objects, as they tend " to increase the phlogistic diathesis." But counter-irritation in the form of blisters, issues, and rubefacients; he advocates, TUBERCULOSIS. 23 together with opiates, vegetable acids, moderate exer- cise, and a milk diet. RAULIN. Among the French authors who wrote on Consump- tion towards the close of the seventeenth century is one of considerable celebrity, M. Raulin, whose work on Phthisis Pulmonalis (Traite de la Phthisie Pulmonaire) contains the history of some curious cases; he has also recorded many remarkable cases of Consumption. Rau- lin alludes to the employment of a remedy nearly a century ago, which has been greatly extolled recently by some writers. He says that in the West Indies it was the custom, where the negroes were threatened with disease of the lungs, to place them in the sugar-houses of the planters, where, from breathing the vapor arising from the boiling sugar, they were generally restored to health in a few months.—(Traite de la Phthisie Pulmo- naire, p. 207, et seq.) VOGEL. About this period an elaborate treatise on the nature and treatment of the disease was published by Vogel (Vogel's Handbook, etc.), who was a firm believer in the contagious nature of Consumption. He consi- dered hectic to be only a severe form of slow fever, during the progress of which the lungs, in nearly all cases, became sooner or later affected. Although Vogel has not furnished us with any new or peculiar views with regard to the treatment of the disease, yet he has done more than any other writer who preceded him, to call the attention of the profession to the fact that phthisis pulmonalis cannot be considered altogether a 24 HISTORICAL SKETCH. local disease of the lungs, but as depending on a pecu- liar condition of the constitution denominated tubercu- lar diathesis, or tuberculosis. BAUMES. In 1783, Baumes, who believed Consumption to de- pend upon a specific contagion, and to be distinct from scrofula, considered the latter as dependent upon the existence of an acid principle of a phosphorous or a phosphoric nature, which in the first instance thickens the lymph, and renders it liable to concrete, and ulti- mately tends to putridity. WhetHer this " acido-putrid" depravation takes its origin from the morbid blood in its passage through the glands, or from a fluid exhaled from the blood into the general cellular system, or whether it is formed previously within the lymphatic vessels, Baumes was uncertain. MOSELY. Dr. Mosely, who published a treatise on Tropical Diseases in 1787, has devoted many pages to the con- sideration of Consumption. For the treatment of the disease he urges the employment of vitriolic and alum emetics. Three drachms of the sulphate of zinc, with one of alum, are dissolved in a pint of water, of which solution a large spoonful is administered fasting. Vomit- ing is thereby promptly induced. After the employ- ment of a course of emetics, a sea voyage is recom- mended by Dr. Mosely. MASCAGNI. It was during the same year that the great work of Mascagni, on the absorbents, was published (Mascagni, TUBERCULOSIS. 25 Vasorum, etc.), in which he expresses his opinion with regard to the nature of the bronchial bodies, namely, that they are conglobate glands, and that the obstruction which is often found in them is caused by black particles brought there by the lymphatics; and that in treating Consumption the great indication is to remove the obstruction, which is best done by the exhibition of medicines in the form of vapor BAILLIE. But it was not until the publication of the " Morbid Anatomy" of Dr. Baillie in 1793, that we find any- thing like a correct description of tubercles of the lungs, as a true cause of Consumption. In this work of Dr. Baillie, tubercles are described as firm, white bodies, interspersed through the substance of the lungs. They are very minute at first, but ulti- mately they unite in clusters of the size of a pea, or larger, and these clusters again uniting form large masses, which occasionally are changed into abscesses.— (M. Baillie's Morbid Anatomy of the Human Body.) RUSH. It was about this period, and near the close of the seventeenth century, that Dr. Rush, in his " Inquiries and Observations," published some new views on the nature and management of Consumption. In the opi- nion of Doctor Rush, Consumption is not essentially a disease of the lungs, but one affecting primarily the general system. That tubercles are the result of a col- lection of inorganic mucus in the lungs, and that in their nature they differ especially from scrofula. It is well known in America that Dr. Rush considered the 26 HISTORICAL SKETCH. disease to be one of a decidedly inflammatory nature— as a kind of chronic pneumonia, particularly in its early stages. In accordance with his belief, in the unity of disease, Dr. Rush expressly declares " the two diseases, pneumonia and phthisis, differ from each other only by the shorter or longer operation of the causes which induced them, and by the greater or less violence and duration of the symptoms. The pneumonia appears to be an acute Consumption, and the Consumption a chronic pneumonia." In the treatment of Consumption, Dr. Rush recom- mends frequent and copious bleedings in the early or inflammatory stage, together with repeated blisters and small emetics. The milk diet of the ancients, and much exercise in the open air, or long journeys, are advised by him, to be followed by tonics, opiates, and a nutri- tious diet, in the hectic stage, when bleeding is no longer-indicated. Sea voyages are also considered bene- ficial ; but a residence on the sea coast is prohibited — because a mixture of sea and land air is deemed by Dr. Rush to be decidedly injurious to the consumptive in- valid. Inhalations of the vapor of tar, and of the smoke of resin, are thought to be beneficial in some stages of the disease. About the same period that the " Inquiries and Observations" of Dr. Rush were published in America, medical writers of England were advancing views con- cerning the nature of the disease, differing essentially from those entertained by Dr. Rush. In the opinion of those writers Consumption was con- sidered as originating in a scrofulous condition of the system. It was maintained by them that hectic fever was not peculiar to this disease—that it might occur TUBERCULOSIS. 27 without the presence of suppuration, as it did in in- stances in nursing and in diabetes. The contagious nature of the disease was denied, but no observations were made to advance a knowledge of its true pathology. In the treatment of Consumption more dependence seems to have been placed on a resi- dence in a mild climate than upon therapeutic agents. Mercury was prohibited. Counter-irritation was recom- mended in cases attended with haemoptysis. Emetics, a spare diet, and warm clothing, were considered appro- priate in the treatment of the affection. DARWIN. Darwin, who in his "Zoonomia," published in 1794-6, alludes to the nature and treatment of Consumption, but without contributing anything to our knowledge of its special pathology, supposed the disease to arise from a deficient action in the absorbent vessels, and from an acid poison which he believed to exist in the ulcerous matters of the lungs. He therefore advised for the treatment of the disease the inhalation of the vapor of ammonia, to neutralize this acid, and the employment of nauseating medicines, in order to arouse the action of the absorbents. Digi- talis, the preparations of bark, a moderately generous diet, with weak wine or beer, and occasional small doses of opium, are among the remedies recommended by Dr. Darwin. About the period of the publication of the writings of Darwin, and during several years subsequent to 1796, inhalations for the cure of Consumption were much recommended and employed, not only by some of the physicians of Great Britain, but by others on dif- 28 HISTORICAL SKETCH. ferent parts of the Continent. The vapor of ether, impregnated with hemlock, was advised by Dr. Rich- ard Pearson to be inhaled several times a day, and to be continued for one or two months.—(Duncan's An- nals, 1796.) Meechay, of Gottingen, recommended the respiration of carbonic acid in cure of Consumption. ROLLO. Rollo, who published a work in London in 1797, con- fined consumptives in small apartments filled with " hydrocarbonate and etherial vapor," which they were required to respire for a short period several times daily; and in 1799, Dr. Beddoes, in his "Contributions to Physical and Medical Knowledge," recommends the inhalation of the different gases, alone or in combina- tion with the vapor of ether or hemlock, in the treat- ment of pulmonary disease. Another class of physicians revived the use of digi- talis, and during the first ten years of the eighteenth century its power as a therapeutic remedy in the treat- ment of Consumption was widely discussed in the Euro- pean journals. As early as 1542, the foxglove, which had been described and recommended by Fuchius as a valuable medicinal agent, was employed by the German physicians for the purpose of " evacuating pus from the thorax," and for the "healing of ulcers." From this time digitalis, or the foxglove, was employed at different periods in the treatment of pulmonary affections; but although highly extolled by Solman, an English writer in 1710, yet it failed to gain much celebrity until just at the close of the eighteenth century, when, haying been employed, and the virtues greatly extolled by TUBERCULOSIS. 29 several English physicians, it was adopted very gene- rally by the profession, and came to be considered by many practitioners as almost a specific for the treatment of pulmonary disease. So sanguine, indeed, was DR. BEDDOES with regard to the powers of this plant, that, having seen, as he declares, " many patients advancing towards recovery with so firm a pace," he was led confi- dently to hope that Consumption will henceforth be as regularly cured by foxglove as ague by the Peruvian bark.—(Essay on the Causes and Early Signs of Pulmo- nary Consumption. London, 1799.) It was condemned, however, by Dr. Parr in 1809, who declares in his "Medical Dictionary," published in London during this year, that digitalis is productive of more harm than good in the treatment of Consumption. (London Medical Dictionary, London, 1802.) During these discussions, which were continued through several years, respecting the therapeutic powers of digitalis, but little progress seems to have been made, either in Eng- land or on the Continent, in the pathology of phthisis. HEBERDEN. Heberden discussed the question of the contagious nature of Consumption and of its treatment, but adds no important contribution to the special pathology of the disease. BADHAM. In 1808, Dr. Badham published his " Observations on the Inflammatory Affections of the Mucous Membrane of the Bronchi*," in which he first described and 30 HISTORICAL SKETCH. named the disease denominated bronchitis, a disease which up to that time had been confounded with the other affections of the chest. PORTAL. The work of Portal (Observations sur le Nature, etc., 432), on the nature and treatment of pulmonary phthisis, was regarded as a very important contribution to medical pathology. It was translated into several languages, and some of his views, in France, Germany, and Italy, were entertained favorably by many of the profession. Portal subdivided the disease into nume- rous species, and gives several varieties of tubercles as occurring in these different forms of Consumption. The presence of tubercles, in the opinion of Portal, was owing to engorgement of the glands. He believed that there existed two kinds of tubercles—one kind found in the cellular membrane, and the other occupying the lymphatic glands. In his treatment of the disease, mercurials, in combi- nation with tonics, counter-irritants, exercise in the open air, as riding on horseback, sea-voyages, etc., are among the remedies proposed. In Consumption following intermittent fever, in well marked atony, and in very aged persons laboring under phthisis, the administration of bark is advised by Por- tal. Of his knowledge with regard to the organic changes which occur in the disease, we may judge from his reference to the opinions of Fernelius, and some other authors who had preceded him, and who had described Consumption as being an " ulceration of the lungs." Such an opinion Portal condemns, inasmuch as it must depend on a fact which cannot be ascertained, TUBERCULOSIS. 31 he believes, during the life of the patient. He therefore approves of the method adopted by Sauvages, as the more eligible, that of determining the nature of dis- eases from the symptoms only. BAYLE. Highly as the labors of Portal were esteemed by the profession at the time, his work on Consumption was soon followed, and in a great degree was eclipsed by the more elaborate observations of Bayle; who, in 1810, published in Paris a treatise on pulmonary phthisis (Recherches sur la Phthisie Pulmonaire, par G. I. Bayle, etc.), which for scientific research, and pathological accu- racy, surpassed all other works previously published on this important subject. Having devoted many years to the study of the disease in the Hopital de la Charite, and in the examination of the bodies of patients who had died of Consumption, Bayle adopted and promul- gated the opinion, that the organic lesions which are found to constitute phthisis authorize .a division of the disease into six varieties or species, which he denomi- nates tubercular, granular, melanotic, ulcerous, calcu- lous, and cancerous Consumption. Not aware that the different forms of tubercle are effected principally by mechanical causes, and that the minute anatomy of this morbid product is everywhere the same, Bayle pro- posed, as other pathologists who preceded him had done, a division of the disease into several varieties. The granular form of phthisis was first described by Bayle, and the distinction which he draws between this and his first, or tubercular variety, is thus stated: " The lungs are stuffed with transparent, shining, miliary gra- nulations, which appear to be of a cartilaginous nature 32 HISTORICAL SKETCH. and consistence. Their size varies from that of a milletr seed to that of a grain of wheat; they are never opaque, and they do not dissolve. These different cha- racters perfectly distinguish them from miliary tuber- cles, which are of the same size, but which are always grey, or white and opaque, and in the end totally dis- solve." Tubercular Consumption, in the opinion of Bayle, always depends on a peculiarity of constitution, although it may be accelerated, and sometimes excited, by other diseases, particularly by pleurisy, fever, ca- tarrh, or disease of the heart. Haemoptysis is a fre- quent symptom of Consumption, and when present is considered by Bayle to depend ordinarily upon the presence of tubercles in the lungs. The plan of treatment proposed by Bayle must be varied according to the nature or rather the symptoms of the disease. He believed that the lives of consump- tives may be often greatly prolonged by treatment, but he was altogether incredulous with regard to the cura- bility of the genuine affection. It is somewhat curious that Bayle himself ultimately sank under the ravages of a disease, " of which," says Dr. Forbes, " he had been the most successful illustrator, and the inevitable fatality of which he had been the most strenuous assertor." The measures recommended by him do not differ essen- tially from those advised by Portal, Morton, and other authors who had preceded him, in their writings on the nature and treatment of Tubercular Consumption. To prevent the disease in persons predisposed to Consump- tion, he advises the employment of tonics, alkalies, a nutritious diet, the use of the voice, as in public speak- ing, travelling, etc. Repeated emetics, with bitter pur- gatives and sea voyaging, in the opinion of Bayle, TUBERCULOSIS. 33 have sometimes arrested the disease in its incipient state. CAYOL. During the same year that the work of Bayle was issued (1810), M. Cayol published an essay on Tracheal Consumption (Recherches sur la Phthisie Tracheale), in which he refers to a distinction between tra- cheal and laryngeal phthisis. The former, which he believes is not an infrequent disease, is indicated by severe or spasmodic fits of coughing, attended with dyspnoea, and a rattling respiration. WELLES. The attention of the medical profession in London was called to the subject of the antagonism of intermit- tent fever, or malaria, and Pulmonary Consumption, by Dr. Welles, in 1812, in a paper published in the trans- actions of the " Society for the Improvement of Medi- cal and Surgical Knowledge." Dr. Welles advances the opinion that a residence in a malarious atmosphere affords a preventive for Consumption; and he adduces testimony from many physicians residing in fenny dis- tricts, which goes far to prove that Tubercular Con- sumption and intermittent fever, as diseases, are opposed to each other. As intermittents have decreased in Lon- don, Consumption, he declares, has increased; and he advises that people in the incipient stage of phthisis be sent to marshy countries, rather than to Madeira or Italy. SOUTHEY. Two years after the appearance of the essay of Dr. Welles, Dr. Southey, of London, published some inte- resting statistical observations respecting the frequency 3 34 HISTORICAL SKETCH. of the occurrence of the disease in the different coun- tries. — (H. H. Southey on Pulmonary Consumption, London, 1814, pp. 473.) The author's views do not confirm the opinion ex- pressed by Dr. Welles, that Consumption occurs less frequently in malarious districts than in places exempt from marshy exhalations. The apparent advantages, he believes, arise from the circumstance that in agueish countries, feeble children are carried off before they are of an age to die o£ Consumption. In the opinion of Dr. Southey, the butchers of Eng- land and France, and the fishermen of Scotland, are less liable to Consumption, as well as other diseases, than the generality of mankind ; whilst those persons of every clime, who are much exposed to the inhalation of floating particles of dust, as the coal-heavers, chim- ney-sweepers, and dressers of flax and feathers, are peculiarly liable to the disease. The internal exhibition of digitalis, and the employ- ment of the pea-issue, are deemed by Dr. Southey as being among the most important remedies for the treat- ment of Consumption. Riding, sea voyaging, and a removal to a warm climate, are advocated as remedial measures. Confinement to a room with a regular tem- perature, the thermometer being kept at sixty or sixty- five degrees, by appropriate means, may be substituted for a residence in a warm climate, and is especially advised for persons of strumous constitutions. It was about this period, or soon after the commence- ment of the nineteenth century, that the spirit of ra- tional empiricism, which from the time of Cullen espe- cially had prevailed with, and had characterized the profession, began to decline; and medical philosophers TUBERCULOSIS. 35 disregarding theories, and devoting themselves to the observation and collection of facts, began to be fully aware of " the great principle, which is the foundation of true philosophy, as well in medicine as in every Other department of science, that all theory not derived from the generalization of facts is objectionable, and almost necessarily leads to erroneous conclusions." In tracing, therefore, the literature of Consumption from this period up to the present time, we shall allude to the views of those only whose opinions with regard to the nature and pathology of Consumption, seem to have been derived from an intelligent and extended observa- tion of facts, and from their cautious generalization. LAENNEC. With the publication of the labors of Bayle, and the more extended and important discoveries of Laennec, who was the contemporary and friend of Bayle, medi- cine began to assume more than it had at any former period—the true character of an inductive science. We have seen that Bayle, who describes witlr great accuracy certain organic'lesions which occur in disease of the lungs, yet admits, besides the tuberculous affec- tion, the existence of a granular, an ulcerous, a calcu- lous, a cancerous, and a melanic form of phthisis ; whilst Laennec, on the contrary, maintains that there is but one single organic lesion of the lungs, namely, a tuber- cular deposition, occurring in those who die of phthisi- cal disease. With respect to the first of these species described by Bayle, it is, Laennec observes, a mere variety of the tubercular; the third is a partial gangrene of the lungs; and the three others are affections which have- nothing 36 HISTORICAL SKETCH. in common with tubercular phthisis, except that they have their seat in the same organ.—(Laennec on Dis- T ease of the Chest, etc, Forbes's Translation.) Subsequent pathologists have confirmed this opinion of Laennec. Laennec published his great work on " Diseases of the Chest and on Mediate Auscultation," in 1819. (De l'Auscultation Mediate ou Traite du Diagnostique des Maladies des Poumons et du Cceur. Paris, 1819.) In this work are recorded those discoveries with re- gard to the true pathology of thoracic disease, and rules by which we are enabled to discriminate morbid changes in the pulmonary organs, with a degree of cer- tainty and precision hitherto unknown in the diagnosis of these affections. So well known to the profession of the present day is the history of Laennec's immortal discoveries, that only a brief allusion will be made in this place to his labors. By means of auscultation and percussion he was enabled, as he in his work declares, " to deduce a set of new signs of diseases of the chest, for the most part certain, simple, and permanent, and calculated perhaps to render the diagnosis of diseases of the lungs, and heart, and pleura, as decided and circum- stantial, as the indications furnished to the surgeon by the introduction of the finger or sound in the com- plaints wherein these are used." By means, then, of the application of physical diag- nosis to diseases of the chest, Laennec was enabled to establish certain signs founded on pathological anatomy, which when present seem to indicate with a great de- gree of certainty the existence of tubercles in the lungs. The diseases in which this method was chiefly employed by him, are phthisis, dropsy of the chest, chronic pleu- TUBERCULOSIS. 37 risy, pneumonia, bronchial disease, emphysema, and diseases of the chest. According to Laennec, tuberculous matter, which con- stitutes the true pathological cause of phthisis, com- mences ordinarily to be deposited in the upper and pos- terior parts of the lungs, although tubercles may be found indiscriminately in all parts of the cellular tissue of the lungs, continuing to augment after their deposi- tion, until they have acquired a certain size. The tubercles commence at length to soften in the centre, and then open by one or more small apertures into the neighboring bronchiae ; or they may remain for a longer time closed, and constitute small vomicae, containing a curdy, imperfectly formed pus. This matter being ex- pelled through the bronchiae, cavities are left, which Laennec denominated tubercular excavations. In the treatment of phthisis pulmonalis, Laennec declares that although its cure is not beyond the powers of nature, yet our art possesses no certain means of obtaining this desirable end. " We may be well as- sured," remarks he, " that a disease is irremediable, when we find employed in its treatment almost every known medicament, however different or even opposite in nature; when we see new remedies proposed every day, and old ones revived, after having long lain in oblivion; when, in short, we find no plan constant but that of giving palliatives, and no means persevered in but such as are proper for fulfilling indications purely symptomatic."—(A Treatise on Diseases of the Chest, etc., translated by Forbes, p. 320.) In the opinion of Laennec, a successive development of tubercles in different parts of the lungs ordinarily takes place in the progress of phthisis. When the first 38 HISTORICAL SKETCH. tubercular deposit begins to be softened, a secondary crop is about this time produced ; and still later other deposits follow, composed of crude, miliary tubercles, situated in the more inferior portion of the substance of the lung. The indications of cure therefore are, as soon as the existence of the disease is ascertained, to prevent in the first stage the secondary eruption of tubercles. The second indication should be to promote the softening and evacuation or absorption of the existing crop of tubercles. To meet the first indication, Laennec recom- mends- counter-irritation, which may be employed by means of small moxas, or, what is preferable, the caustic potass applied beneath the clavicle, or in the supra- spinal fossa. Bleeding ought never to be employed, declares Laennec, in the treatment of Consumption, except to remove the inflammation, *or active determi- nation of blood, with which the disease may be compli- cated. If blisters are employed, they should not be applied to the chest itself. Laennec prefers that their application be restricted to the arm, or the inner part of the thigh. To promote the softening of the tubercles, not much dependence, in the opinion of Laennec, can be placed upon the inhalation of vapors or the gases, or the fumes of different kinds of resin, although these have been much employed by many practitioners of different ages, in many countries, A change of climate is considered by him as the important remedy in the treatment of phthisis. A residence by the sea-side, particularly in mild and temperate climates, is, in his opinion, unques- tionably the situation where most consumptive patients have been known to recover: As palliatives for the TUBERCULOSIS. 39 treatment of troublesome symptoms, emollient and mu- cilaginous drinks, antimonials, small doses of opium, and hydrocyanic acid, are recommended. Derivation, which Laennec considers the most rational of our indications, and change of air, are the measures on which he places the most reliance. Yet the cure of tubercular phthisis, he repeats, is not effected by medicine. In order to make a direct attack upon the disease, continues he, we ought probably to be able to correct an unknown aberration in the assimilation or nutrition; that is, an alteration in the state of the fluids of the body. BARON. Dr. Baron, physician to the Gloucester Infirmary, published in 1819 the first volume of his "Inquiries Illustrating the Nature of Tuberculated Accretion." His second volume was published in 1822. In this work he advances the hypothesis, that tubercles in their origin are of a vesicular or hydatid nature. In their incipient state, according to this author, they appear as small transparent vesicular bodies with fluid contents, and may be distinguished by their shining surface, from the tissue which surrounds them. They may occur on the surface, or be deposited be- tween the layers of membranes, or they may be depo- sited in any viscus whose textures are of such a nature as to admit of their growth. In the first stage of the disease, the surrounding tissues experience little or no alteration, but, increasing in number and size, they be- come opaque, acquire consistence, and finally assume that state termed induration, or hepatization, which is directly the reverse of their ultimate condition as described by Laennec. 40 HISTORICAL SKETCH. In this state they remain, and there is the strongest reason for believing, says Dr. Baron, that tubercles do not subsequently soften! BROUSSAIS. As early as 1816, Broussais, in his "Examination of Medical Doctrines," advanced views concerning the na- ture and origin of tubercles, in opposition to those of Bayle ; and on the publication of Laennec's works, Broussais, in 1820, attempted a refutation of the doc- trines of this eminent pathologist, by endeavoring to show that it is a very gross error, to attribute the pri- mary cause of every pulmonary phthisis to tubercular granulations. The opinion advanced by Broussais is, that tubercles seated in the lymphatic system of the respiratory apparatus (their ordinary location in the belief of this author), or in any of the other systems or tissues of the body, owe their origin to a long continued irritation or inflammation of the organ or parts affected. Whenever organs which contain numerous lymphatic ganglions, mucous follicles, or glandular grains, experi- ence inflammation, these small bodies must necessarily become tumefied. If the inflammation is slight, ob- serves Broussais, and rapidly disappears, these bodies regain readily their normal state. If it is acute and violent, they are destroyed by the suppuration which follows; but if it is chronic and continuous, they dege- nerate, according to their organization and location, into variously colored granulations. But these granulations, or lymphatic effusions, which are met with in a great number of phthisical patients, and which may become softened and reduced to a caseous matter, destroying the lung, or leaving a cavity, are not referred by Broussais TUBERCULOSIS. 41 to a tubercular principle, nor do they merit, he asserts, the name of tubercles. To this form of phthisis Brous- sais would give the term chronic pneumonia. But when instead of these various colored granulations we find in the lungs white, roundish bodies, which resemble opaque mesenteric glands ; when these bodies are seen softened in some places, reduced to a pulp in others, and fol- lowed by cavities and disorganization of the paren- chyma, this form of phthisis merits the name of tuber- cular. (Examination of Medical Doctrines, etc., p. 445, et seq. ; also Principles of Physiological Medicine, translated by Hays, pp. 253-9.) Persons predisposed to irritations of the lymphatic system are most liable to tubercular deposits, and in these they are the most freely developed. Without a preceding inflammation Broussais has never seen tubercles in the lungs.—(Op. citat., p. 252.) GOOD. Dr. Good, whose learned treatise on the " Study of Medicine " wras published in 1822, devotes many pages of his work to the consideration of the nature and treat- ment of phthisis. Dr. Good alludes to the division of the disease as considered by Morton, Portal, and Bayle; and, although he admits the existence of the three forms of Consumption, yet he expresses his belief that by far the most frequent of these varieties is the tubercular.—(The Study of Medicine, by John Mason Good, American Edition, Vol. II., p. 31.) Tubercles may be developed in every organ and tis- sue of the body, and in their origin, says Dr. Good, they seem to be single cysts, or, often perhaps, single follicles. Although inflammation in a certain degree may be often favorable to the growth and general spread of 42 HISTORICAL SKETCH. tubercles, yet the absence of all signs of inflammation in by far the greater number of passing cases, at least till the morbid growth has fully established itself, and operates by mechanical pressure, or some other excite- ment, is sufficient proof, in the opinion of Dr. Good, that this condition is not absolutely necessary for the produc- tion of tubercles. Where a consumptive diathesis has once originated, it is often very evidently transmitted to succeeding generations, and there is great reason to believe, says Good, that the disease is in a certain degree contagious. (Op. citat., p. 45.) Dr. Good differs from Bayle and Laennec in believing that tubercular phthisis is not always a fatal disease, inasmuch as he has seen it termi- nate favorably in cases where the individuals appeared to be in the last stage of the disease; but whether from the treatment pursued, or a remedial exertion of nature, he will not undertake to say. In the treatment of Consumption, Dr. Good advises that the remedies be varied according to the form or variety of the disease. The general indications are, to abate the inflammatory action, to correct the phthisical diathesis, to support under debility, to subdue the local irritation, and to improve the expectoration. If the symptoms indicate considerable inflammation, whether in the lungs or bronchiae, our object should be to dimi- nish vascular action, by every means in our power. Consequently, venesection is recommended by Dr. Good, and its repetition advised even to the third, fourth, or fifth time, if necessary, in the commencement of the disease. The employment of this agent should be fol- lowed by small doses of antimony or ipecacuanha, and when sufficient inroad has thus been made upon the in- TUBERCULOSIS. 43 flammatory diathesis, cooling neutrals, with foxglove, the extract of hyoscyamus, etc., may be administered. An attempt should be made to correct the predisposed dia- thesis, by the internal and external use of the prepara- tions of iodine, or minute doses of antimony in solution, as advised by Balfour and M. Leuthors (one grain of tartarized antimony dissolved in from eight to twelve pints of water), may be employed by the patient, for common drink, in every stage of Consumption. Among the means recommended by Dr. Good for supporting the system are these: tonics that unite an astringent with a bitter principle, the preparations of iron, a mijd but nourishing diet, exercise in the open air, etc. To subdue the local irritation, and improve the secretion from the lungs, terebinthinate fumigations are employed, together with the ordinary expectorants, such as squills, ipecacuanha, balsam of copaiva, etc. At the time of the publication of the observations of M. An- dral on tubercular disease (Clinique Medicale, Part III., Diseases of the Chest), there prevailed in Europe three different opinions, which were especially prominent, respecting the nature of pulmonary granulations. The granulations observed by Bayle were considered by him an accidental production, having nothing analo- gous in the healthy state. In the opinion of Laennec and others, these granulations were not essentially dif- ferent from tubercles; indeed they were considered by them as being the first degree of tubercles ; whilst Broussais and his followers reiterated the doctrine of Morton, that tubercles were lymphatic glands engorged. 44 HISTORICAL SKETCH. ANDRAL. M. Andral, after giving much attention to the patho- logy of the disease, and after making many critical ob- servations, was led to dissent from all these opinions, and to consider tuberculous matter always presenting itself as a simple product of secretion. (Clinique Medi- cale, Tome III.) This product, according to M. Andral, appears principally in a liquid state, unorganized, but becoming solid according as its more fluid particles become absorbed. Every tissue capable of* inflammation and suppura- tion may secrete tuberculous matter. In the lungs it may equally be produced on the surface of their mucous membrane, in the pulmonary vesicles themselves, or in the areolar tissue of these organs. Whenever a strong disposition to tubercles is present, the slightest local congestion of blood will give rise to them; but when there exists no such predisposition, the most intense and the longest inflammation will not produce a tubercle. (Clinique Medicale, Tome III., p. 13.) Pulmonary tubercles, therefore* in the opinion of An- dral are the product of a morbid secretion, and the deposition of this tuberculous matter within a tissue does not necessarily require that there should have been in this tissue either an increase or diminution of vital action ; there is merely a perversion of its natural powers of secretion. The pathological process which ordinarily precedes the tuberculons secretion is a san- guineous congestion, more or less active, similar to that which precedes every process of secretion, normal or otherwise. The previous existence of any degree of TUBERCULOSIS. 45 hyperaemia, however, is not necessary to the formation of tubercle.—(Clinique Medicale, Tome III.) M. Andral, in his later writings (Notes et Additions au Traite de 1'Auscultation Mediale de Laennec, par MM. Laennec et M. Andral. Paris, 1836) deprecates, in a still more decided manner, the attempts of the follow- ers of Broussais to refer these lesions entirely to the presence of increased irritation or inflammation ; al- though inflammation, he admits, may accelerate or deter- mine the production of tubercle, when that modifying influence which is the real cause of tubercle is already present. Irritation does not always precede tubercles, yet it constantly follows them; for in every case where an organ has been invaded by these products there takes place around them a reaction, the result of which is an inflammatory process, and the end of which is the expulsion of the tubercles. Phthisis is a constitutional disease ; a depraved condi- tion of the blood, being, in the opinion of M. Andral, the chief element in the tuberculous diathesis. LOUIS. In 1825, M. Louis issued his great work on phthisis (Recherches sur la Phthisie, par P. Ch. A. Louis. Paris), a work in which are recorded most important patholo- gical results, obtained through careful and minute obser- vation, and numerical analysis of a large number of facts. After devoting many years to clinical observa- tions in the Hopital de la Charite, M. Louis was able fully to confirm the opinion first announced and main- tained by Laennec, that there is but one species of phthisis, and that the deposition of tubercles in the lungs constitutes the true anatomical character of the disease. 46 HISTORICAL SKETCH. Tubercles, as defined by M. Louis, are small yellowish white tumors which soften after a certain time, and being evacuated into the bronchiae, leave cavities in the lungs of variable size in their room. Associated with these tubercles, small bodies of a different aspect were observed by Louis, varying in size from a pea to that of a millet- seed, denominated by Laennec the " grey semi-transpa- rent granulation," which are considered by Louis to be the first stage of tubercles; a stage through which the latter must necessarily pass before acquiring their own peculiar character. In almost every case examined by Louis, both the tubercles and the grey granulations were found by him of larger size and in greater number at the apex, than at the base of the lungs. In a great majority of instances, tubercles, and grey, semi-transpa- rent granulations coexist in the same organs. Louis in all his observations met with only one case of encysted tubercles ; and Laennec, in the space of twenty four years, observed only three or four instances of this species of the disease. The time necessary to change tjie pri- mary deposition, the grey granulation, into the fully developed tubercle, is not positively known ; it is doubt- less extremely variable. In the acute form of phthisis, the development of tubercles is, occasionally, extremely rapid : on the other hand, many cases justify the opinion that years may elapse between their origin and the full manifestation of tubercular disease. When the process of softening of the tubercles begins, which is also effected at different periods—the change commences in the centre of the tubercle, and with those first which occupy the apex of the lungs, so that, as the morbid process advances from the apex to the base of the lungs, the observer may successively discover cavities, TUBERCULOSIS. 47 softened tubercles, crude tubercles, and grey semi-trans- parent granulations, in the same organ. In some rare cases, Louis observed softening to take place simultaneous- ly, in every part of an entire lobe. These cases always belonged to the acute form of phthisis. Tuberculous cavities, whether large or small, and whether they were recently formed or had existed for a long period, were found to communicate with the bron- chi by a variable number of openings. Large tubercu- lous excavations existing in the upper lobe, were found closer to the posterior than the anterior surface of the lung. Large cavities are not observed in any instance in the centre of the inferior lobe of the lung.—(lb., pp. 9--10.) The mucous membrane of the bronchi in the imme- diate vicinity of tuberculous cavities was found in a majority of instances thickened and of a light red color; in some cases, it was the seat of small ulcerations. This increased vascularity of the membrane is attributed by M. Louis to the frequently repeated passage of the purulent matter over its surface.—(lb., p. 27.) With regard to the seat of the rudimentary tubercu- lar deposit, Louis, in the later edition of his work, con- forms in his opinion to that professed by Dr. Carswell, namely, that the terminal bronchial ramifications in the air-cells of the lungs are ordinarily the seat of the pri- mary tubercular exudation. (Op. citat., p. 31.) The terminal bronchial ramifications and the air-cells are not, however, the exclusive seats of tubercles in the lungs, for this morbid matter has been detected in other por- tions of the pulmonary organs. Moreover, both tuber- cles and the grey granulations in which they originate, may be, and actually are, developed in all organs. M. 48 HISTORICAL SKETCH. Louis does not accord with the opinion expressed by M. Andral, that tubercle is nothing more than concrete pus; nor with that of Baron and other pathologists, who re- gard tubercles as transformed hydatids.—(lb., pp. 32-3.) Ulcerations of the epiglottis occurring in the progress of phthisis, were noticed by Louis in about one quarter of the whole number of cases observed by him. They were in most instances superficial, and occupied almost exclusively the laryngeal surface of the epiglot- tis. The larynx was found ulcerated more frequently than the epiglottis. In a hundred and ninety-three sub jects ulceration of the larynx occurred in sixty-three cases. These ulcers of the larynx differed in their cha- racters from those of the epiglottis, or of the trachea, being rarely superficial, but of a certain depth, and looking as if made with a punch. Elsewhere the mucous membrane exhibited the appearance of perfect health. The most common seat of these ulcerations was at the point of junction of the chordae vocales. The chordae vocales themselves, the base of the arytenoid cartilages, the upper part of the larynx, and the interior of the ventri- cles, were also the seat of ulcerations; these ulcerations occurring in order of frequency as above named. Ulcerations of the mucous membrane of the trachea occurred in upwards of one-third of the whole number of phthisical subjects examined by Louis. When ulcerations were present the mucous membrane was commonly of a bright red color; and co-existing with this redness, a slight thickening and also softening of the membrane were observed in about one-fifth of the cases. These ulcerations being superficial, in many instances, of a pinkish color, and having flattened edges, frequently escape notice, unless due precautions are taken by wash- TUBERCULOSIS. 49 ing the trachea, and conducting the examination with great care. M. Louis likewise discovered that ulcera- tions of the lining membrane of the bronchi are of fre- quent occurrence in phthisis. Indeed, this pathological fact may be considered as perfectly established, that ulcerations of the mucous membrane of the air passages increase in frequency from the epiglottis to the lungs. Of forty-nine phthisical subjects examined by Louis, ulcerations of the bronchial membrane were found in twenty-two instances.—(lb., pp. 38-44.) These ulcerations of the mucous membrane of the air passages were found to occur in males much more fre- quently than in females. In the same number of pa- tients furnished by each sex, ulcerations were of double as frequent occurrence in men as in women. M. Louis, in his pathological inquiries, found that the lungs were not the sole organs rendered incapable, dur- ing the progress of phthisis, of performing their func- tions. The heart was found frequently softened; and in a tenth part of the cases examined, the pericardium contained a considerable quantity of perfectly clear serosity. The stomach in many instances was much disturbed, its mucous membrane more or less inflamed, and fre- quently slightly softened. Ulcerations in the small intestines were of almost universal occurrence. In five-sixths of the bodies examined these ulcers were found in the small intestines, and they were of almost as frequent occurrence in the large intestines. Fatty degenerations of the liver were present in one-third of the cases. The walls of the gall-bladder were some- times thickened and ulcerated; and the spleen and kid- neys presented tubercles in a sixth part of the bodies 50 HISTORICAL SKETCH. examined. The tissues of the brain, the arachnoid, and the subarachnoid, were in many instances the seat of a greater or less number of grey, semi-transparent, or actually tuberculous granulations. Various anatomical changes were observed in many other locations, some of which Louis considered proper to phthisis, and others which may be observed existing in different degrees, in chronic diseases of all kinds. Among the former he has classed ulcerations of the larynx, more especially those of the trachea and epiglottis ; ulcerations of the small intestines and fatty disease of the liver. " So true is this," remarks Louis, " that the detection of an ulcera- tion in one of the organs just named, etc., might, inde- pendently of all further investigation, be considered as the certain announcement of the individual presenting it—having died phthisical."—(Op. citat., pp. 152-3.) Another general law laid down by Louis is, that after the age of fifteen, tubercles do not present themselves in any organ without being likewise seated in the lungs.— (lb., p. 477.) On the important point in the history of phthisis, its etiology, M. Louis declares that facts are wanting to demonstrate any class of causes which may be said to predispose to, or determine, the actual development of the disease; that is, that facts accurately established, facts of such a stamp as to qualify them for taking part in advancing the limits of knowledge, are wanting in regard to almost any question that may be started.— (lb., p. 477.) Among the predisposing causes which may influence the development of tubercles, M. Louis has classed age, sex, constitution, and hereditary influence. With regard to the latter cause, hereditary transmis- TUBERCULOSIS. 51 sion, inasmuch as only a tenth part of the subjects who fell under his observation came of phthisical parents, and as this disease might have been transmitted in these cases; or have been developed independently of such influence, "it follows in reality," remarks Louis, "that I have observed nothing decisive in favor of the here- ditary character of phthisis."—(lb., p. 483.) The subject of the influence of climate in exciting or preventing the development of tubercles is considered at length by M. Louis, and the result of his inquiries on this point is, that phthisis, as it has been shown by the statistical evidence of many modern observers, is preva- lent in all countries, the hottest as well as the coldest.— (lb, p. 491.)_ Haemoptysis is not regarded by M. Louis " either of considerable or trifling account, as an exciting cause of tubercles." Indeed, with regard to this whole subject of causes of phthisis, whether predisposing o*r existing, M. Louis is of the opinion that observations accurately made are not sufficient to establish the fact that the ex- istence of any one condition contributes a positive cause of tubercular disease. On the subject of the successful treatment of pulmonary phthisis, by any plan hitherto adopted, M. Louis is equally sceptical. He examines separately many of the prominent medicinal agents, which from time to time have been recounted as successful remedies for the treatment of tubercular disease. The proto-ioduret of iron, introduced into medical prac- tice by M. Dupasquier, of Lyons; the chloride of sodium, recommended by Latour, as of immense utility in the treatment of phthisis; the subcarbonate of potass, em- ployed by M. Pascal, of Strasburg; sal ammoniac, from the use of which Dr. Cless, of St. Catharine's Hospital 52 HISTORICAL SKETCH. of Stuttgard, declares he derived great advantage ; chlorine gas, which for a time attracted great attention as a means of curing phthisis ; digitalis, which through a long period was esteemed by many in the profession, " capable not only of improving the state of phthisical patients, but of curing them;" these, with hydrocyanic acid, creasote, and iodine, have all been considered by Louis, and their claims, as being efficient remedies for the treatment of phthisis, thoroughly examined, and the conclusion to which the physician of La Charite has arrived is, that little or no dependence can be placed upon any one of these agents in exercising a curative influence on diseases of the pulmonary organs ! This disparaging appreciation of the therapeutic value of many of those means which hitherto had been esteemed more or less efficient in the treatment of phthisis, is followed by what the experience of M. Louis allows hina to state, as the most plausible views con- cerning the prophylactic and palliative treatment of phthisis. Under the head of prophylactic treatment, M. Louis admits what is not so fully stated in his chapter on etiology, that hereditary influence and lymphatic tem- perament really constitute a strong predisposition to the development of the disease.—(Pp. cit., p. 539.) The prophylactic treatment, therefore, is recom- mended in the case of lymphatic children, and those born of phthisical parents. The chief things to be relied upon, in the opinion of Louis, for the modifica- tion of the lymphatic temperament, " are activity of life, a succulent diet, the use of bitters, complete change of habits, if the individual be of a certain age, and a judiciously laid out and healthful place of abode." All TUBERCULOSIS. 53 these points are fully elaborated, and most excellent and judicious measures advised by the author, for managing in early life the child of a lymphatic temperament. In considering the palliative treatment to be adopted, M. Louis remarks : " Although we cannot, in the exist- ing state of knowledge, entertain the hope of curing phthisis, we may at least hope to retard its progress by a well-directed system."—(lb., p. 544.) In the first period of chronic phthisis, gentle vegeta- ble tonics are indicated, provided the patient be of a lymphatic temperament, and nefther febrile action, tho- racic pain, nor diarrhoea, be present. For the cough, preparations of opium or stramonium are advised, toge- ther with the inhalation daily of the vapor of warm water, or of some narcotic infusion. Chalybeate waters, or some artificial preparation of iron, as the proto-iodu- ret, may be administered with the bitters. A milk diet, particularly in large towns, is not recommended by M. Louis, because it is well known that cows in large towns frequently die phthisical. To guard the patient against the effects of atmospherical vicissitudes, flannel should be worn, and a removal from a cold to a warm climate during the severe part of the year is recommended. No great confidence, however, is placed by M. Louis on the beneficial influence of change of climate on tuberculous disease. The effect of sea-voyages on the progress of phthisis is estimated in like manner with that of change of climate, by M. Louis. Bloodletting, unless signs of plethora or haemoptysis occur, is not recommended in phthisis. A moderate diet is advised, weak broth, eggs in milk, jelly, isinglass, a few oysters, etc., etc., are allowed. If haemoptysis occurs, and does not soon cease sponta- 54 HISTORICAL SKETCH. neously, hot foot-baths, sinapisms to the lower extremi- ties, cold acidulated drinks, and laxative enemata, may be employed; whilst the observance of silence, the re- pose of mind and body, must-be enjoined. Should the haemorrhage be copious, and especially if the effusion be such as to endanger life by suffocation, venesection may be employed; the extract of rhatany-root, tannin, cate- chu, or other analogous medicines, be administered; and if the case is urgent, and the patient possesses some share of strength, we should not hesitate to apply ice to the chest. To abate perspiration and check the diar- rhoea which so frequently coexists with perspiration, take bitters, chalybeates, astringents, acidulated drinks, cold infusion of bark, etc., etc.; these are indicated for the ulcerations of the trachea, larynx, and epiglottis. Inas- much as the measures commonly employed are almost always powrerless ; " should we have more influence," asks Louis, " over the progress of these ulcerations and their destructive action by touching them with a sponge soaked in a solution, more or less concentrated, of nitrate of silver ? I know not, but the plan deserves trial."—(lb, p. 559.) Many of these views of M. Louis on the etiology and treatment of phthisis were advanced in a subsequent edition of his work, published several years after the first edition of 1825. CRUVEILHIER. In a paper published by M. Cruveilhier, in 1826, this distinguished pathologist advanced the doctrine, that by simple irritation of the bronchial membrane, or the air- cells, by mechanical means, true tubercular disease may be produced. These views were based on the following, TUBERCULOSIS. „ 55 and similar experiments : " I injected," says M. Cruveil- hier, " ten ounces of mercury by an opening in the tra- chea of a dog; the greater part was rejected by cough- ing ; he showed symptoms of phthisis, and died in a state of marasmus in a month; the lungs were studded with tubercles, isolated and agglomerated, having all the characters of miliary tubercles."—(Nouveau Biblioth. Med, 1826, p. 381.) The centre of each tubercle contained a globule of mercury, and the substance of these tubercles appeared to M. Cruveilhier to be concrete pus ; whence the author draws the conclusion that pulmonary tubercles have their origin in the bronchial vessels; that phthisis is probably produced by certain foreign bodies acting on the internal surface of the lining bronchial membrane. In the opinion of M. Cruveilhier, the tuberculous mat- ter, which is the consequence of mechanical irritation, exists in a fluid form previously to that period when it is found presenting itself as a firm substance. These experiments of M. Cruveilhier, and their results, awa- kened much interest at the time among medical inqui- rers. They seemed to establish some direct communi- cation between bronchial irritation and tubercular disease. They were repeated by MM. Andral and Lombard, and by some other pathologists, but failed entirely in their hands to establish the doctrine pro- pounded by Cruveilhier. In the experiments instituted by Andral and Lombard, the globules of mercury found in the small bronchiae were thickly coated with puriform mucus, and in many cases the bronchial parietes were ruptured, and the mercury being extravasated into the parenchyma of the lung, was found there also, sur- rounded by purulent matter ; but these pathologists 56 , HISTORICAL SKETCH. observed no other changes. — (Precis d'Anat. Pathol, vol. XI, p. 551; Campbell, p. 99.) In other instances the globule of the metal was sur- rounded by a thin layer of'whitish matter, the lung remaining perfectly healthy, and presenting no appear- ance whatever of tubercular disease. Hence, as we have stated, subsequent experiments failed to establish this supposed immediate connexion between bronchial irritation and tuberculosis. BAUDELOCQUE. In a memoir published in the " Revue Medicale," in 1832, on the causes of scrofula, M. Baudelocque main- tains that the sole cause of a scrofulous degeneration in the system, is the respiration of a vitiated atmosphere. Tubercular disease is, according to this author, one of imperfect nutrition, arising from this cause. The respiration of an atmosphere not sufficiently re- newed vitiates the blood; the materials of the secre- tions and of nutrition, participate at length in the bad qualities of the blood, and all the tissues are developed or repaired with elements of a vitiated nature. Hence M. Baudelocque declares, " however well chosen and nutritious the food, however minute the attention paid to cleanliness, with whatever care the clothing be adapted to the temperature or the duration of exercise, sleep and waking be regulated, if the houses are so placed that the sun's rays cannot reach them, or the fresh air cannot be renewed without difficulty, if, in short, they are small, low, dark, and badly aired, scro- fulous disease will inevitably supervene."—(Memoire sur les Scrofules, Revue Medicale, 1832, vol. I, p. 10.) TUBERCULOSIS. 57 CARSWELL. Some important researches on the nature of tubercle were contributed by Professor Robert Carswell, in the first Fasciculus of his " Illustrations of the Elementary Forms of Disease." Dr. Carswell supposes tuberculous matter to be one of the inorganizable products of the system, having its origin ordinarily in the blood, and its seat upon mucous and serous surfaces. But " in whatever organ the for- mation of tubercular matter takes place, the mucous sys- tem, if constituting a part of that organ, is in general either the exclusive seat of this morbid product, or is far more extensively affected with it than any of the other systems or tissues of the same organ." Thus the mucous system of the respiratory, digestive, biliary, urinary, and generative organs is much more frequently the seat of tuberculous matter than any system or tissue which enters into the composition of these organs.* As the mucous membrane among the tissues is the one altogether most frequently the seat of tuberculous mat- ter, so, of all the organs of the body, those of respira- tion occupy the first rank both as regards the 'extent and the frequency of tuberculous deposition. The defi- nite rounded form of the tubercular deposit, a form which may have induced the belief that it is an organ- ized substance, is considered by Dr. Carswell as purely an accidental circumstance, being determined altogether by the mechanical condition of the parts in which it occurs. When the process of softening takes place in tuberculous matter, this change, as Dr. Carswell ob- * Illustrations of Elementary Forms of Disease. 58 HISTORICAL SKETCH. serves, cannot originate in the substance itself, as this matter is inorganic ; the doctrine, therefore, which has been advanced by many pathologists, that the softening of tubercles alwrays begins in their centres, is extremely incorrect. This process, he affirms, commences most fre- quently at the circumference of firm tuberculous matter, where its presence as a foreign body-is most felt, by the surrounding tissues. The chemical composition of tuber- culous matter is not always the same ; it varies not only at different periods at which it is examined, but in dif- ferent animals, and probably in different organs. In man, tubercle is chiefly composed of albumen, with vari- ous proportions of gelatin and fibrin, and, " either from the nature of its constituent parts, the mode in which they are combined, or the condition in which they are placed, they are not susceptible of organization, and consequently, give rise to a morbid compound, capable of undergoing no change that is not induced in it by the influence of external agents." — (Illustrations of the Elementary Forms of Disease.) On the subject of the origin of tuberculous affections, Dr. Carswell remarks, that whilst the presence of tuber- culous* matter constitutes the material element of the disease, the origin of this morbid product must be as- cribed to a pre-existing, general morbid condition of the economy. It cannot arise from inflammation, inasmuch as inflammation in all its degrees has occurred in all organs and tissues without being followed by the forma- tion of tuberculous matter ; and, on the contrary, the formation of tuberculous matter is found to take place in organs the functions of which were never observed to have been deranged, and in which after death none of those lesions could be detected which are known to fol- TUBERCULOSIS. 59 low the presence of inflammation. In what, then, this general morbid condition of the economy consists, we have no means of ascertaining. It may depend, Dr. Carswell suggests, on a change, more especially in the function of nutrition in general, and which is made manifest to us by the presence of a particular morbid product, through the medium of secretion. CLARK. In 1834, Doctor (since Sir) James Clark published an article in the " Cyclopaedia of Practical Medicine," on " Tubercular Phthisis," which met with such a favorable reception that the author was induced to revise, enlarge, and publish it, the subsequent year, as a separate " Trea- tise on Pulmonary Consumption." In this work Dr. Clark, after Laennec and Louis, restricts the term, pul- monary phthisis, to that form of Consumption which, for its anatomical character, depends on the presence of tubercles in the lungs. The opinion that tubercular dis- ease is the result of inflammation, or local morbid action, is regarded by Dr. Clark " as not only erroneous, but productive of a very mischievous practice."—(A Trea- tise on Pulmonary Consumption, etc., by James Clark, M.D, p. 10.) A pre-existing unhealthy state of the constitution, a condition which Dr. Clark denominates a tuberculous or strumous cachexia, is the necessary condition of the ani- mal economy which determines the production of tuber- cles. Laying no claims to originality in the views he has advocated, Dr. Clark has sought, in his treatise, to make known a correct knowledge of the origin, nature, and treatment of tubercular disease. In this condition of the system, which Dr. Clark describes under the title 60 HISTORICAL SKETCH. of tuberculous cachexia, a peculiar matter is poured out by the extreme vessels, and is deposited in the various tissues and organs of the body. This matter, from the rounded form which it assumes in certain situations, has received the name of tubercle.—(lb, p. 193.) Tubercle is described by Dr. Clark as a morbid, un- organizable product, having for its remote or predis- posing cause a cachectic state of the human system, and for its immediate production some abnormal action of the vessels of the part in which it is deposited, but with the nature of which action we are not acquainted. (lb, p. 144.) The circumstances under which this peculiar morbid condition of the animal economy may occur are thus explained by Dr. Clark. It is necessary to the maintenance of health that both these functions— the nutritive and excretory—should be performed in a certain ratio; and thus it may happen that imperfect assimilation on the one hand, or defective secretion and elimination on the other, shall give rise to such a disor- dered state of the constitution as may ultimately termi- nate in tuberculous cachexia.—(lb, p. 175.) In relation to the causes of the disease, it is earnestly inculcated that the ordinary exciting causes of Pulmo- nary Consumption will fail to awaken the disease unless a cachectic or tuberculous condition of the system be present; and this condition may exist from birth, or it may be accidentally acquired at almost any period of the subsequent life of the individual. Among the causes which serve to awaken a strumous cachexia, in persons not hereditarily predisposed, Dr. Clark classed improper diet, impure air, abuse of spiritu- ous liquors, and affections of the mind. But of all causes which act primarily on the constitution he TUBERCULOSIS. 61 believes dyspepsia to be "the most fertile source of cachexia in every form." Although Dr. Clark admits that Tuberculous Con- sumption in all its forms has essentially the same ana- tomical character and constitutional origin, yet he de- scribes the disease as presenting in its external features five different varieties that may be recognised in their earlier stages. Acute or rapid Consumption, which is the one form of the disease, is still further subdivided into two varieties, in the first of which all the ordinary symptoms of Consumption are present, in an unusual degree of severity, and succeed each other with great rapidity; the patient often sinking in the course of six or eight weeks, and dying of what is properly and ex- pressively termed as " Galloping Consumption."—(Op. citat, p. 35.) The second variety, which is observed most frequently in delicate young persons of the female sex, is a most insidious form of Consumption, the symptoms appear- ing but little marked at first, and often escaping obser- vation till the lungs are fully tuberculous. Rapid ema- ciation, great prostration of strength, and quick, op- pressed breathing, are the prominent symptoms, which manifest themselves as this variety of the disease pro- gresses. Febrile Consumption, which most frequently attacks young persons, is characterized by an unusual degree of fever. The disease is ushered in by fever, and is at- tended by it during its whole course. It attacks per- sons in a state of apparent health, often after exposure to cold, and commences with shivering, followed by a hot skin, frequent pulse, and other symptoms of fever. A cough soon comes on, with pain in one or both sides, 62 HISTORICAL SKETCH. hurried respiration, and an expectoration, at first color- less, but afterwards assuming a yellowish or greenish hue, and being occasionally streaked with blood. Chronic Consumption differs from the acute forms which have been noticed, in that it often occupies more years than the former do weeks; and it attacks most frequently persons of a more advanced period of life, and occurs in those not having hereditary or tubercu- lar diathesis. The cough for a long period is little thought of, giving *the patient very slight trouble, and often during the summer ceasing nearly altogether. Latent Consumption is the term given by Dr. Clark to that variety of the disease in which a tuberculous deposit may exist in the lungs for a long time, and even to a considerable extent, without occasioning any local symptoms indicative of its presence, although silently effecting its work of destruction. Consumption in infancy and childhood is the fifth and last form of Dr. Clark's subdivision of phthisis. In his opinion, Consumption occurring in the early period of life differs somewhat from the disease in adults, both in its symptoms and the site of the tuberculous deposit. The cough frequently occurs in paroxysms, resembling those of whooping-cough. Haemoptysis is rarely pre- sent ; and the hectic fever is likewise less frequently found, and the respiration generally less abundant than in the adult. Consumption in children is frequently preceded or accompanied by considerable derange- ment of the digestive organs ; it often commences in the bronchial glands, and occasionally proves fatal ■ without affecting the lungs or any other organ. Respecting the treatment of phthisis, Dr. Clark ob- serves that the condition of the constitutional disorder, TUBERCULOSIS. 63 in which tuberculous disease has its origin, constitutes the most important part of the treatment. (Op. citat, p. 230.) Not only the individual constitution is to be regarded, but our treatment of tuberculous cachexia must be regulated, according to the predominance of particular symptoms. In many cases the most promi- nent derangement is a disordered state of the digestive organs. The diet, therefore, must be mild, and free from all stimulating condiments. Gentle, aperient medi- cines, preceded by mild mercurials, where there is tor- por of the bowels, or defective biliary secretion, are advised, together with the occasional use of the warm bath and daily frictions over the whole surface. Until this disorder of the digestive organs is removed, all tonics, such as bark, steel, wine, etc., as well as a stimu- lating diet, are deprecated by Dr. Clark. This object being effected, tonics, internal and external, change of air, and such other means as act by exciting and bracing the general system, will prove of great utility.—(Pp. 281-3.) Among the various medicines which are considered most useful, in correcting that cachectic state of the sys- tem which precedes and accompanies the formation of tubercles, Dr. Clark enumerates the following as deserv- ing of most attention, namely, mercury, iodine, anti- mony, sulphur, taraxacum, sarsaparilla, mineral waters, alkalies, the nitrate of lime and of barytes, and chaly- beates. Blood-letting, under certain circumstances, as when pulmonary congestion exists, may prove beneficial; but its employment, in the opinion of Dr. Clark, requires " great judgment and circumspection." Emetics are re- garded by him as of great value in the treatment of * 64 HISTORICAL SKETCH. Consumption. Those emetics which act most quickly, such as the sulphate of zinc, and sulphate of copper, are the kind best suited for consumptive patients. Iodine and its salts are recommended to be employed in the early stages of pulmonary tubercle. No great reliance is placed on digitalis as a curative remedy in Consump- tion, but wrhen this disease is complicated with disease of the heart, it is a medicine of great utility. As local remedies, the application of leeches, dry-cup- ping, counter-irritation, the employment of issues and setons, and the inhalation of medicated vapors, are all useful in different cases; but the practice of relying on any local remedy as a principal means of curing a dis- ease, which originates in, and depends upon a morbid condition of the whole system, is decidedly condemned by Dr. Clark. DAVIES. The lectures of Dr. Davies on Diseases of the Luno-s o and Heart* contain a history of the nature, and remote causes of phthisis pulmonalis; but no attempt is made by the author to throw any light upon the proximate cause of the disease. Tubercular formation, in the opinion of Dr. Davies, is a deposit from the blood-vessels. All adventitious matters are derived from the same source. To determine the proximate cause of phthisis would be to determine the reason why the blood vessels should deposit tubercle in one case, medullary sarcoma in a second, melanosis in a third, etc. The cause, Dr. Davies believes, " would probably be found in certain cotfditions of the system 01 * Lectures on the Diseases of the Lungs and Heart, by Thomas Davies, M.D. *c----; '0 --------^v PRIMARY LESIONS. 213 largest diameter nearly half an inch in thickness. The cause of the patient's most distressing symptom was now apparent. When lying upon his back, the elongated uvula would hang before the opening of the glottis, and in the act of inspiration its extremity would occasionally be drawn into the aperture, producing that suffocating sensation with which the patient had been so frequently annoyed. (See Plate.) The operation for the removal of this morbid growth was immediately performed. This was followed by the exhibition of topical and general remedies, as in the preceding case of disease of the fossae nasales, under the employment of which the cough, the irritation about the throat, and every other symptom of laryngeal dis- ease rapidly disappeared, and the captain, in a few weeks, was enabled to resume, and ever since has been occupied in the discharge of his official duties. Frequently, in my opinion, have the declarations of Dr. Stokes, recorded in a former chapter, with regard to the effects produced by a relaxed or elongated uvula, been corroborated. I have been called upon frequently by physicians to examine such cases occurring in their own practice, where the lesion existed, and to decide in regard to the plan of treatment indicated. When this elongation has existed for some time, hav- ing become a chronic lesion, I do not hesitate to recom- mend an excision of the elongated portion. It never fails to afford relief; and I have not been aware, in a single instance, of this operation being followed by any injury to vocalization. Only a few months since, a dis- tinguished physician of this city called to consult me on the subject of a difficulty under which he had labored 214 PRIMARY LESIONS. for more than a year. He had during the time been subject to violent paroxysms of coughing, which for several months previous to his seeking my advice had so increased in violence and frequency as to cause great alarm to him and his friends; for he had on several occasions suffered from such severe fits of spasmodic coughing, and threatened suffocation, as to induce the belief that he was actually dying ! I found, on examination, indications of folliculitis be- ing present, although the disease had not extended into the trachea, with very great elongation of the uvula. This organ was over three inches in length, and was correspondingly enlarged. Its excision was followed by entire relief from the attacks of suffocation, and a few applications of the sponge-probang to the faucial region completely arrested the cough. SECTION II.--LESIONS OF THE TONSILLAR GLANDS. In the chapter on the Special Histology of the Respi- ratory Organs, I have spoken of the anatomy of the tonsillar glands. These bodies are composed of an aggregation of compound follicular glandules, which bodies are closely united and bound together by a fibrous investment, consisting of connective tissue and elastic fibres; whilst certain muscular fibres, coming from the superior constrictor of the pharynx, help to invest and bind together the different portions of the tonsil, into a large hemispherical globe. The epithelial por- tion of the membrane, which covers the oral cavity, enters into the separate divisions of the tonsil, asd com- pletely lines all the secondary cavities of the gland. The soft fibrous tissue that connects the follicles of the tonsil, consists, as we have said, of connective tissue PRIMARY LESIONS. 215 with elastic fibres, and contains numerous vessels; and although these follicles do not exhibit such a complex arrangement, as we find in a lymphatic gland, yet, as Virchow declares, they possess a similar structure, and are analogous to the individual follicles of the Peyerian glands, only in the intestine the follicles lie spread out in an even surface, whilst in the tonsil the surface is in- verted, and the individual follicles lie around the invo- luted membrane. With respect to the nature of the secretion from the human tonsil, histologists .are not entirely uniform in their views. Rokitansky is of the opinion that persons of scrofu- lous diathesis are disposed to a peculiar blennorrhoea of the tonsils, and to the formation of " tubercular or cheesy plugs," or secretions of a tuberculous character. Kolliker observes that the secretion of the tonsils is a greyish white mucous substance, which, so far as he has been able to observe, contains no mucus, but is com- posed either of cast off epithelial cells alone, or of a mixture of these, with cells and nuclei. That in man this secretion is very generally abnormal ;* that when diseased the contents of the follicles of the tonsil appear to alter, the follicles themselves becoming distended, and finally bursting yield a purulent or caseous mass ; which secretion is frequently found accumulated in the large cavities of the tonsil. This secretion, observes * It is a singular but interesting pathological fact, that among the mammalia man is the only one in which we find any change or deterioration in the follicles of the tonsils. I have made the examination in many instances, especially in those of the calf, sheep, and other animals, without finding disease in the follicular cells, or in their secretions. The engraving on the next page represents the mucous or epithe- lial cells from the tonsils of the calf. 216 PRIMARY LESIONS. Wedl, has heretofore frequently been regarded as crude tubercles. They have, he adds, " occasionally been hawked up from the trachea and bronchioe, by both Fig. 7. Cells taken from the tonsils of the calf, greatly enlarged healthy and diseased individuals, and have heretofore frequently been regarded as crude tubercles ;" but they have been found by Hofle to be constituted mostly of masses of epithelium, derived from the mucous follicles of the tonsils. I have for many years given most careful and minute attention to the abnormal changes that occur in the human tonsil. Having long been led to believe that the tonsillar follicles, the lingual follicles, and those of the pyriform sinuses, but especially those of the former, are ordinarily the foci from which emanates the dyscra- sial process, whose course we have endeavored to trace, I have continued through a period of years to make almost daily most careful microscopic examinations of the tonsils, which have come from time to time under my observation. By repeated examinations of a very large number of PRIMARY LESIONS. 217 cases, made through a series of years, I have been fully confirmed in my views, namely, that with many adults, and with most children of lymphatic temperament, the secretion from the tonsillar glands is generally abnormal, in health as well as in disease. It does not always pre- sent the same degree of deterioration, but, like the changes of the epithelial degeneration in the air-cells of the lungs, the tonsillar secretion undergoes several meta- morphoses in the progress of diseased action. Indeed, we may regard the tonsil as the analogue of the lung, inasmuch as the abnormal changes which occur in it very nearly simulate those that take place in tubercular disease of the lung. Proliferation occurs in the epithe- lia of the follicles, they finally burst, and pour out masses of secretion into the cavities of the tonsil, which, on microscopic examination, are found to be composed at first, as Kolliker has observed, of " cast off epithelial plates, cells, and nuclei." These are the masses which, when further degenerated, constitute the " tubercular cheesy plugs" of Rokitansky, and other pathologists. " I have," says Professor Lawson, " carefully examined this substance with the microscope. * * * Upon the whole, it appears to me that this cheesy substance is of a tubercular character, and that it may undergo the cretaceous transformation, as tubercles do in the lungs." The blennorrhoea, then, mentioned by Rokitansky, or the abnormal secretion found so often accumulated in the cavities of the tonsil, is a degeneration commencing in the cellular elements of the tonsillary follicles, and is composed, as we have stated, when first discharged into the cavities, of deteriorated epithelial plates, nuclei and nucleoli. (See Fig. 8.) After a time further changes take place in the secreted mass, for we find, on micro- 218 PRIMARY LESIONS. scopic examination, the matter greatly disintegrated, and composed of broken up epithelial cells, granules, and oil-globules, some nucleoli, but no nuclei; and ulti- mately a granular, homogenous mass, with oil-globules, but showing neither nuclei nor nucleoli (see Fig. 9), and filling, in many instances, large cavities in the tonsil, with caseous masses of " cheesy " matter. In some way, as we shall find, this pathological condi- tion of the tonsil has great influence in determining dis- ease of the lung! How, I do not attempt to explain ; but a large experience has fully established the fact, as before announced, for of several thousand cases that have come under my observation, where tubercular dis- ease of the lungs had followed apparently the develop- ment of follicular disease, and one tonsillar gland only has been found involved, it has been proved universally Fig. 8! Two cases of hypertrophied and diseased tonsils, removed from pa- tients laboring under chronic folliculitis. Both present the excised surfaces. The one on the right side, from a patient most diseased, the cavity large and filled with disintegrated or " cheesy " matter, which under the microscope exhibited diseased, shrunken cells, with some granules and oil-globules. The one on the left much less diseased, the nuclei or cells larger, and no granules. that the diseased tonsil and the diseased lung were both on the same side ! Again, we find, where both tonsils are involved— which is the case in many instances—and the degenera- tion has reached the cellular elements of the bronchial PRIMARY LESIONS. 219 membrane, or those lining the air-vesicles of the lungs, then it will appear that both lungs are more or less implicated in the morbid process. To these points I desire to call the special attention of the profession, for it is in the power of every practi- tioner to substantiate or to disprove these assertions, namely, that in all cases when we examine a patient laboring under chronic follicular disease, and we find one tonsil only—wThich is frequently the case—involved in the diseased action, we shall not fail to perceive, if the morbid process has continued until either the bron- chiae or tbe lungs are implicated, that it is invariably the bronchiae, or the lung of the side which corresponds with the diseased gland ; and, on the other hand, where both tonsils have long been involved in the ulcerative process, we are quite sure to find* the bronchiae, or the Fig. 9. Disintegrated matter taken from the cavity of a tonsillary gland, greatly diseased, d, Cheesy matter, to which a drop of water has been added, causing a current, and showing a homogenous mass flowing along, in which nucleoli, oil-globules, molecules, or granules, are plainly seen; a, Molecules, or Granules, isolated ; b, Nucleoli, isolated; c, Oil-globules, isolated. parenchyma of both sides, more or less involved in the diseased action. 220 PRIMARY LESIONS. The pathological change in the cellular elements of the tonsil, or that degeneration which constitutes the primary alteration in this dyscrasic process, does not always begin in the same portion of the organ. In some cases, the follicles occupying the superior portion of the tonsil are the first to deteriorate. In other instances, those on its anterior surface are primarily involved. But not unfrequently the morbid action commences in the follicles occupying the interior or central portion of the gland. (Vide Case VII.) But whether the deterio- ration commences in the epithelia of the follicles occu- pying the superior portion of the gland, or in those upon its surface, or in those in the interior of the gland, the deterioration is communicated to the surrounding elementary tissues, until all the follicles of the tonsil, together with the connective and fibrous tissues, are more or less involved. Consequent on proliferation, or a rapid multiplication of the cells, the organ, in many cases, enlarges at first, or becomes hypertrophied, and we then have the " en- larged tonsil." In other cases, the proliferated cells lose their vital properties, perish, and the gland becomes atrophied. In many instances the process of prolifera- tion will exceed that of ulceration, and the organs will continue to be more or less hypertrophied; or the ulcer- ation may be in excess, and one follicle after another disappear, until the gland is in part or altogether wasted away. In the mean time, as we must not forget, from the period proliferation begins, the exudation from the diseased glands becomes completely abnormal, and it is here that the local dyscrasia commences; and through the absorbents, the numerous glandular elements of the aerial membrane, are diseased, and ultimately through PRIMARY LESIONS. 221 these and the lymphatic vessels, as we have shown, the lymphatic fluid and the blood itself become deterio- rated ; and that general dyscrasia, of which we have spoken, is finally established. The following case will illustrate some of these points. Case LL—William L. H., son of a merchant of New York, aged seventeen, was brought for treatment to my oflice, by his parents, Dec. 4th, 1861. He had been ill, his parents said, " over two years, having had more or less cough during that time." He had been under the treatment of an excellent physician, who resided some twenty miles from New York, near the country seat of his parents. The family, on the mother's side, were predisposed to Consumption—several members had died of the disease. Twelve years before, his mother, then residing in the city of New York, came under my care, and was treated for chronic folliculitis. She had en- larged and diseased tonsils, cough, and follicular bron- chitis, and presented many of the early rational signs of tuberculosis. The hypertrophied tonsils were ex- cised, topical and general treatment was employed, during several weeks, followed by an entire restoration to health, which after fifteen years is still continued. Three years previous to the visit of the son, whose case we are now considering, an older brother, then of the same age (seventeen), began to decline ; debility and a cough supervened. He was treated with great care, taken to a southern clime during the cold season, and every attention that friends and wealth could bestow was rendered. But all was of no avail; he died the year before of confirmed phthisis. His case I did not see. At about the same age, William began to manifest the same unfavorable symptoms which his elder bro- 222 PRIMARY LESIONS. ther, who died, exhibited. Eight years before his visit to me, his mother stated, " William began to hem or to clear his throat, and for the last two years had had more or less cough, grew feeble, lost his appetite and his activity, and was losing his flesh." At the request of his parents, and their physician, who advised him to visit me, I made a careful examina- tion of his chest. On percussion, neither side sounded entirely normal, but there was decided dulness beneath the collar-bone on the left side, and dry rales were dis- tinctly audible on this side. Expiration was considera- * bly prolonged ; the expiratory murmur was louder than the inspiratory. Expiration on the right side was also slightly prolonged, skin dry and heated, and the pulse ninety. The mucous follicles on the posterior and lateral part of the pharyngeal membrane were found enlarged, and much inflamed. The tonsils on both sides were conside- rably hypertrophied, the left much the largest, and appearing the most diseased. Its surface near its upper portion presented several small openings, from which, on pressure with the finger, " cheesy matter" could be freely discharged. The presence of chronic follicular disease, and the aus- cultatory signs revealed on examination, convinced me that a deposition of tubercles, following the development of continued follicular disease, had already taken place, especially in the left lung, and softening, I found, had already commenced. I therefore declined entering upon any plan of treatment until I had seen the physi- cian who had attended the patient during the past two years, and I asked the parents to request him to be pre- sent with their son at his next visit. PRIMARY LESIONS. 223 Dec. 12th.—The patient called, and his physician, Dr. W., with him, from whom I received a more minute history of his case. Dr. W. pronounced the case to be "decidedly one of incipient phthisis." This opinion, together with a careful re-examination of the patient at this time with Dr. W., confirmed me in my first opinion of his case. I proposed, by the employment of topical and general measures, to attempt to arrest the morbid process, and to restore the depraved state of the sys- tem to a healthy condition. The enlarged and diseased portion of both tonsils was removed by excision. The enlarged follicles in the posterior nares, and on the lateral portion of the pha- ryngeal membrane, were fully cauterized with a solution of argent, nitrat. He was recommended to live in the country, to take horseback exercise freely, in good weather, and to live on generous diet. The topical application with the sponge-probang was continued every other day until the first of January, 1862, carrying the probang, saturated with a solution of nitrate of silver (40 grs. to the ounce), after the first wTeek, down through the larynx into the trachea. On the first of January, the elastic tube was introduced into the trachea, and a drachm of the solution (10 grs. to § j), injected into the right bron- chia, and this operation was repeated about twice a week, alternating with the use of the probang, through the months of January and February. After the patient had continued the use of the alter- ative (No. 16) through the first six weeks, he was put upon a decidedly tonic and invigorating course. From half to 3J of mixture No. 10 was taken twice, and sub- sequently thrice a day, until early in March, when, 224 PRIMARY LESIONS. on examination, the follicular disease of the throat had almost entirely disappeared; but little cough was pre- sent, pulse seventy-eight in a minute, respiration was stronger on both sides, expiration was still slightly pro- longed on the left side. Here, also, was some degree of dulness, but less distinct than at first. The patient was much stronger, and during the three months of treat- ment had gained several pounds of flesh. As the break- ing up of winter, during the months of March and April, is in this climate more likely than at any other season of the year to affect injuriously persons laboring under thoracic disease, he was advised to spend these months in the milder climate of the West Indies, and he and his mother sailed for Nassau, N. P., the last of February, with directions to continue the general invi- gorating treatment during his absence. Arriving at Nassau early in March, he remained there nearly three weeks. But the climate, as he and his mother thought, did not agree with him, his cough increased, and his strength diminished. And Mrs. H., alarmed at these results, took the returning steamer, and came back to New York. March 24th.—He called on me; I found him in about the same condition as when he left home. The return- ing voyage appeared to be of service to him, as his cough, aggravated apparently by his visit to Nassau, was, on his arrival home, better than when he left Nassau. Still he coughed and expectorated moderately every day. An examination of his chest revealed some dulness on the right side, with indistinct bronchial rales on auscul- tating the same side. The applications of the solution of silver were resumed, by the use of the probang twice and the tube once a week, and two weeks, and these PRIMARY LESIONS. OOfC _ — u measures, together with supporting agents—quinine and Fowler's solution — through the summer months, and into September. During the latter part of the spring and all the sum- mer months, H. had continued slowly but constantly to improve. He had become robust and quite strong, had lost his cough, and had gained some fifteen pounds in flesh. In October, I made a careful examination of his chest, without discovering an abnormal sound,, save a very slight dulness under the left clavicle, and a moderately diminished respiratory murmur on the same side. As the cold season of 1862 came on, I urged upon him great care in regard to exposure in unfavorable weather. He came almost every day by rail (twenty miles) to attend to his business in the city. On the 29th of December he called at my office, where there chanced to be present a distinguished auscultator, Dr. E., who at my request, without knowing anything what- ever in regard to the patient and his treatment, made a careful examination of his chest, and pronounced it entirely free of any indication of disease. Nearly four years have passed since W. H. first came under my care, and now, at this present time of writing, he is apparently in perfect health. July 1, 1863.—On the day of the above date, W. H. called at my office, and I took the opportunity of re- peating my examination. I could not discover any evi- dences of disease in the throat, or, from a careful exam- ination of his chest, of any appearance of disease of the lungs. On the other hand, his case exhibits every appearance of one of arrested tuberculosis. Oct. 3d, 1863.—His uncle informed me, to-day, that his nephew remains quite well. 15 226 PRIMARY LESIONS. REMARKS. So important have I been led to consider the removal of an enlarged or hypertrophied tonsil by excision of the abnormal portion, where the follicles of the organ are involved, that when objections are interposed, which are not unfrequent for the past ten years, I have deci- dedly refused to take charge of any case, if this opera- tion be prohibited ! During the first few years of my employment of topical treatment, in diseases of this na- ture, I made frequent efforts, in those instances where one or both tonsils were involved, and strenuous objec- tions were made by the parties interested to any " cut- ting operation," to overcome the ulcerated action by other methods of treatment—by the use of solid caus- tic, by the employment of the different preparations of iodine, or of zinc, or of the acids, but each and all of them entirely failed to arrest permanently the deteriora- tion ; whilst the use of every one of these agents proved more or less remedial for a time, yet all failed of entire success; for patients thus treated were sure to return, at the end of a few months, as bad or worse than ever, or I would hear of such cases being sick, or dying of lung disease ! I therefore relinquished the palliative course, and adopted the radical and more certain me- thod, namely, excision of the diseased gland; and ulti- mate success, in the treatment of these cases, has been altogether more certain. Case LLL—December 5th, 1861, Rev. J. S. K., aged twenty-six, called for treatment. Two years be- fore, in 1859, he had visited me for the same purpose, in company with several of his friends. With a predis- position to phthisis, Rev. Mr. K. had been in ill health PRIMARY LESIONS. 227 for several years, and he had been obliged on this ac- count to relinquish his official duties about eighteen months before. His mother, who for many years was very feeble, and had frequent haemorrhages, died appa- rently (judging from the history given by the family) of tuberculosis. For several years previous to his first visit to me, Mr. K. had manifested a strong tendency to the disease. He had complained of much irritation of his throat. It was occasionally " ulcerated," and his voice was hoarse. He was sallow, but not pale, being more inclined to a flushed countenance, with some cough, and increased expectoration. An examination of his chest revealed slight flatness and increased expiration on the left side—normal under the right clavicle. Both tonsils were enlarged ; the left organ much more hypertrophied than the one on the right side. Pressure on the left gland brought out much diseased secretion, a discharge which was con- stantly percolating through the openings on its surface. The right tonsil was also changed in size, but not to the extent of the organ on the left side. The enlarged and inflamed follicles, on the pharyngeal mucous membrane, were numerous, extending down as far as could be seen by depressing the tongue, showing that the disease was spreading by continuity along the aerial membrane. I proposed as treatment, excision of the diseased por- tion of the tonsillar glands, followed by topical and general treatment. Decided objections to any " cut- ting " were made at once, not by the patient himself, but by his friends. The young clergyman had married the daughter of a wealthy gentleman of the city, who protested decidedly against the performance of any " cutting operation," in the case of his son-in-law. I 228 PRIMARY LESIONS. decided that I could not treat the patient, except in my own way, and the party left. t During the two years that followed hi3 first visit to me, this patient had been treated by several practition- ers, but with one exception, I am unable to speak of the treatment which he received. Early in 1861, he was several weeks under the treatment of Dr. D., of this city, an excellent practitioner, who at once detected the nature of his disease, and recommended the excision of the diseased tonsils, and topical treatment. But this first operation was promptly refused again by the pa- tient and his friends, but with this exception, the physi- cian was requested to carry out his plan of treatment. The doctor consented, and commenced the local appli- cations of argent, nitrat. to the fauces and upper portion of the respiratory mucous membrane. This, together with the general treatment indicated, was continued through several months, under which Mr. K. improved decidedly in health and appearance; and for a time he and his friends indulged a hope that he would quite recover. But this amendment did not long continue. The contraction of a cold was followed by ulceration of the throat, an increase of the cough, and expectoration. A change of climate was now recommended, and ac- companied by his wife, and his wife's parents, all sailed for Cuba, and passed the winter and spring in that island, returning home early in the summer of 1862. His residence in a milder climate improved apparently Mr. K.'s health, but he came back not altogether re- stored, as he had still a weak voice, cough and expecto- ration, symptoms that remained about the same during the summer; but as the inclement season of 1862 came on, his health was again greatly impaired, and early in PRIMARY LESIONS. 229 December he came and placed himself once more under my care, without proposing any conditions of treatment. I examined the case a second time. The tonsillar glands were more enlarged, and the left one more diseased than it was two years before; several openings of considera- ble size and quite deep were observed in the upper third of the organ, apparently full of caseous matter. The follicles of the pharynx were large, red, and rugous. Examination of the lungs revealed increased dulness, on the left side. Expiration was prolonged, crepitation and harsh respiration were manifest on the same side. He appeared much more anaemic and debilitated, and his cough and expectoration more than they were two years before. I commenced the treatment by removing at once the enlarged and abnormal tonsils, drawing out with the double tenaculum the left gland, and excising as much of the diseased organ as I well could in the operation. The right gland was removed in the same way. The follicles of the fauces and pharyngeal membrane, down into the pyriform sinuses, were then freely cauterized. The iodide of potassium, with the proto-iodide hydr. (Form. No. 19), was prescribed, together with the fol- lowing ointment (Formula No. 32), to be applied with friction, night and morning, to the chest. When the throat had healed from the cutting opera- tion, the topical applications were renewed, and were carried down into the pyriform sinuses, as well as into the trachea, in order to get the solution of silver into the bronchial ramifications. The applications were con- tinued at proper intervals through the winter months, and tonics and good living prescribed. On the twenty-first of January, I examined, with 230 PRIMARY LESIONS. great care, the chest of Mr. K. Under the clavicle, on the left side, slight dulness and vocal resonance were still perceptible, but no crepitation could be discovered. All other sounds appeared perfectly normal, the throat presented a smoother and healthier appearance; he had no cough, his general health had much improved, and his weight and health had greatly increased. The supporting plan of treatment, with an occasional recourse to the topical applications, was continued through the subsequent six months. It is now nearly three years since the commencement of local treatment in Mr. K.'s case. He has had no cough for the last twelve months, no weakness or tenderness of the throat, but he has a clear and strong voice, and has regained an entirely robust and healthy appearance, being now able to discharge perfectly his official duties. We are quite aware of the importance of not decid- ing too hastily, with regard to the permanent arrest- ment of disease, in cases in which tuberculosis has been positively detected. But in the treatment of so large a number of instances, now amounting to many hun- dreds, in which positive indications, both physical and rational, have been diagnosticated, not only by myself, but also by experienced auscultators—cases which have for years since being treated, enjoyed perfect health, I do not hesitate to declare my firm conviction that, in many of these cases of incipient tuberculosis, dependent originally upon cellular degeneration, positive and per- manent cures have been effected by the treatment I advocate. Case 77.—Mrs. William S., the wife of Judge S., aged twenty-two years, formerly of Boston, came to PRIMARY LESIONS. 231 receive medical treatment, Nov. 25th, 1848. Mrs. S. was strongly predisposed to Consumption; the family had mostly died of the disease before reaching the age of thirty. The year before her visit to me, she had lost her last and only brother by the disease. She her- self had been troubled with a cough, with irritation of the throat, about two years. Had had several attacks of haemoptysis during the previous half year. Her countenance was sallow and anaemic. Her emaciation, feebleness, quick pulse, together with the physical signs revealed by auscultation and percussion, gave unmistakable indications of the presence of incipient tuberculosis. On an examination of the throat of Mrs. S., both tonsils were found hypertrophied and ulcerated, and all the lining membrane in sight studded with inflamed prominent follicles. After thoroughly examining the case, I explained to Mrs. S. and the Judge the plan of treatment I should adopt, if she came under my care, expressing at the same time my doubts with regard to the permanent ar- restment of the disease. It was the request of both that the plan of treatment I proposed should be adopted. Nov. 27th, 1848.—The enlarged and diseased tonsils were removed. On the second day after their excision, a strong solution of argent, nitrat. was applied to all the inflamed follicles in sight, and the alterative mixture (No. 16) was directed to be taken in drachm doses twice daily. On each alternate day, through the month of December, the topical medicament was applied, first to the superior part of the throat, then into the glottis. and still later, down to the tracheal bifurcation and 232 PRIMARY LESIONS. bronchi. Invigorating treatment was persistently em- ployed, and with the topical measures (employed at longer intervals) was continued through January and February, until March 3d, at which time I examined with care the chest of Mrs. S., and found most de- cided improvement in regard to any abnormal symp- toms. During the three or four months in which she had been under treatment, Mrs. S. had improved greatly in strength, and was several pounds heavier than when she first came under my care. Respiration was nearly normal, and her cough and expectoration occurring only occasionally. Fearing the effects of the vicissitudes of a Northern climate during the spring months, she was advised to pass that season in one of the Southern States. Accordingly Mrs. S. went to Savannah, Georgia, and passed several months in that region. Early in the summer she returned to New York, apparently in robust health. She had no cough or expectoration, and the sounds of her lungs were found to be entirely nor- mal. It is now fifteen years since Mrs. S. was under my care ; she is strong and robust, and presents at this hour the appearance of being in excellent health. " Indeed ever since her treatment," she has been, as she says, "perfectly well." The question is frequently asked, by medical men, if in chronic follicular disease, with enlarged or slightly enlarged tonsillar glands, excision is always necessary ? Most generally it is, but not always. If, on examination, the organ presents no abnormity, except hypertrophy, it may not be absolutely necessary. The topical application of proper medicaments to PRIMARY LESIONS. 233 both single and compound, or aggregated, diseased follicles, together with the internal exhibition of altera- tive medicines, will in some cases succeed in arresting the local dyscrasiae. But as all adventitious growths take an irritable or diseased action much more readily than naturally organized parts, these enlargements are quite liable to become violently irritated from causes of a slight nature ; and therefore experience has shown that in folliculitis, attended with hypertrophied tonsils, the excision of the morbid growth is always the safest expedient. But we have shown that the increase of the gland, in follicular disease, depends upon proliferation of the epi- thelial element, and therefore the removal of the dege- nerated portion aids essentially in diminishing the amount of the damaging secretions which proceed ultimately from these localities. This operation for excision of the tonsillary glands was opposed for many years by many members of the profession. Unless the glands were so enlarged as to present a physical obstruction, interfering with degluti- tion or with the voice, or causing a cough, the operation, it w^as declared by many, is not required. An expe- rience in the treatment of a very large number of cases, one which has extended through many years, has con- vinced me that this is the most important operation in the successful treatment of these cases. Case V.—A lady with her husband came from the country for medical treatment. She was emaciated, had a cough, was pale, and during the last year had com- plained of a constant sore throat. Examination of her case revealed hypertrophied folli- cles on the pharyngeal membrane, with slightly enlarged 234 PRIMARY LESIONS. and diseased tonsils. Her lungs appeared normal. I advised the excision of the diseased portion of the glands, to be followed by the topical application of the silver solution. Some objections to an operation were made, and she and her husband left, promising to return in a day or two. I saw nothing more of them, and had for- gotten altogether the circumstance of their visit to me. Eleven months after this visit, a patient was brought to my office, apparently in an advanced stage of tubercu- losis. I did not recognise her at all as one I had ever seen before. She was greatly emaciated, her voice aphonic, cough and expectoration almost constant. On examining the case, particularly the lungs, they appeared to be much affected, but whether it was altogether bron- chial, or whether a deposit had ocurred in the parenchyma of the lungs (such was the amount of the bronchial rales), I was, at first, at a loss to decide. Inspecting the throat, I expressed the opinion that the numerous and enlarged follicles, and the greatly diseased glands, showed conclusively, that diseased action had long been at work in those parts, and I remarked that the enlarged and diseased tonsils should have been excised long before, as all the indications proved the disease to have commenced in the upper region of the air-passages. The lady and her husband then remarked that I had expressed that opinion nearly a year before ! They then gave me a his- tory of her case, after the first visit to me; and, as much notoriety was given to this case (for it was published in the Medical Journals at the time to my injury), and a£ it> illustrates the point now under observation, I shall here give it. After receiving my opinion, about the necessity of an operation, they consulted an eminent surgeon in the city, who, on examination of the case, declared that such PRIMARY LESIONS. 235 an operation was entirely unnecessary, that the case was one that had its origin in the stomach, and required a very different plan of treatment from the one I had advised. As this opinion was confirmed by several other physicians who were invited to examine the case, and confirm the diagnosis of the surgeon, it was deemed a most favorable case to disprove the doctrine I had advanced, and con- sequently the history of the case was published, as above stated, in the Medical Journal of the city. The lady thus advised returned to her home, and again placed herself under the treatment of her family physician. Still her symptoms did not improve, and after a few weeks, a consulting physician, living in the neighbor- hood, was called in; and the course of treatment, slightly varied, was continued. The patient getting constantly worse, a third physician (after several months) from an adjacent town was called in, in consultation upon the case. Fortunately this last gentleman had spent a day or two a short time before at my office, and having seen some similar cases, and my method of treating them, had changed his views on this subject. • Having heard the history of, and examined this case, he declared that the opinion given by myself was cor- rect, and that the patient could not recover unless the operation and the treatment I had proposed were carried out. Here were opinions brought at once in collision. " Was not the attending physician right, and had he not » been sustained in his opinion by the distinguished sur- geon, of New York ?" said the attending physicians. In short the doctors could not agree, and the husband of the lady, learning this, dismissed them all, and taking his wife to the boat, brought her down to the city, and placed her under my care. This same operation, excision 236 PRIMARY LESIONS. of the tonsils—an operation which should have been per- formed a twelvemonth before, was now adopted, followed by topical medication, and an invigorating plan of gene- ral treatment, and in six weeks' time the patient was restored to robust health. After a period of twelve or fifteen years, she is still living, and in good health. As we have before stated, in a large number of in- stances, the children of parents, one or both of whom have died of phthisis, as well as most members of their families, have been brought to me for treatment, pre- senting positive indications of the presence of incipient tuberculosis, with whom all indications of diseased action have disappeared under treatment. The question with me, in such cases, is—Has softening commenced, and to what extent has this deterioration progressed ? If it has not begun, or has not advanced much, I enter upon the treatment of such cases with much confidence of ultimate success. Case VI. —H. B. T., a young gentleman of Newport, R. L, aet. 17, was brought to me by his mother, April 15, * 861. Eight years before, his father had died of Con- sumption. He had also lost two sisters and an older brother, of the same disease, and an uncle on his father's side, and several cousins had died of phthisis. Two years before, when fifteen years of age, he commenced to clear his throat, just as his brother and sister had done, who died of Consumption. This alarmed the mother, and her physician was called. But his treatment, of which I have no knowledge, failed to arrest his complaint. I found him exhibiting unfavorable symptoms ; he was pale, emaciated, with cough and expectoration, and fre- quent pulse. The follicles on the pharyngeal membrane, and those in the posterior nares, were enlarged and 239 PATTMIUSY M TTGOE iOSEASE %Xl! ;&> Tonsils slightly enlarged not showing much external disease. Ulcerated portion on cut surface, as seen after excision, cavity filled with disintegrated, or "cheesy" matter. PRIMARY LESIONS. 237 inflamed, and both tonsils hypertrophied and diseased. The right gland considerably more diseased than the left one. This lung was also decidedly more affected than the other; percussion on the right side evinced dulness under the clavicle, with prolonged expiration on auscul- tation, and dry crepitant rales were apparent in the same location. In the left lung the respiratory murmur was increased in strength, but otherwise normal. Taking the strong hereditary tendency, the age of the patient, and the phy- sical signs into consideration, no doubt remained in my mind that an adventitious deposit had already occurred in the air-sacs, at the upper portion of the right lung. Both tonsils were removed. In the right several large cavities existed, filled with "cheesy matter" or degenerated epithelium (see Appendix), while the contents of the left were much less changed. April 16th.—A preparation of crystallized nitrate of silver dissolved in glycerine was freely applied to the lining membrance of the pharynx, and of the posterior nares, and the mixture (Form. No. 17) was administered in drachm doses, twice daily. This local therapeutic agent was continued, and in a few days was carried down into the pyriform sinus, on each side of the opening of the glottis, and subsequently into the glottis, and into the right tracheal bifurcation. The topical treatment, toge- ther with appropriate general and supporting measures, was continued. Every day or every other day through the months of April and May the local applications were made, until June 8th, when he had so greatly improved, that it was deemed advisable to send him for a change of climate to St. Paul, in Minnesota. To this place he went, and remained six weeks or two months, then 238 PRIMARY LESIONS. returned to New York with his health greatly improved. He had no cough, his lungs appeared normal; the sounds were equal on both sides; he had increased in weight and strength, and manifested in every respect the appearance of having confirmed health. In December, 1862, Mr. T. called at my office, and at my request had his throat and chest re-examined by myself and Dr. Richards. The enlarged follicles had disappeared, the membrane had become smooth, and presented a healthy appearance More than two years have passed since Mr. T. came under my care. He has been, during that time, pursuing his collegiate studies, has enjoyed good health, and has lost all appearance of the strumous diathesis, which, at the age of seventeen, was so manifest in his case. I could enumerate many hundreds of cases, which during the last twelve or fifteen years have been treated in a way to arrest the epithelial degeneration that origi- nates in the cellular elements of the superior portion of the air-passages ; and have thereby succeeded in prevent- ing the full development of a general pathological dys- crasia—one that is sure to end in confirmed phthisis. Case VII.—Mrs. P. came to me, at the suggestion of medical men in Boston twelve years ago. She had been the subject of follicular disease for several years, during a part of which time Dr. W. of Boston had em- ployed topical measures in treating her throat, with- out arresting a constant and harassing cough, under which she had labored two or three years. The hyper- trophied follicles had disappeared under the local treat- ment, the pharyngeal membrane became smooth, and presented a healthy appearance. Dr. W., her attend- ing physician, and Dr. J., one of the best auscultators PRIMARY LESIONS. 239 of Boston, had repeatedly examined her lungs, and pro- nounced them fr^e of all diseased action. At length these medical gentlemen said to her husband, "You must take your wife to Dr. Green, and see if he can ascertain the cause of her incessant cough." In accord- ance with this advice, she came to New York. On examining the throat of Mrs. P., it presented a perfectly healthy appearance; the tonsils were concealed by the anterior limbs of the columnal arch. I then examined the epiglottis by depressing the tongue, having found that erosions or ulcerations of this organ would cause a cough constantly, despite of every remedy, while these lesions remained. But it appeared quite healthy. Lastly, I made a careful exa- mination of the lungs, and found them entirely normal. On putting the point of my index finger into Mrs. P.'s mouth (see Plate XI), and pressing back the ante- rior column, I observed the gland to be slightly enlarged, and on its smooth surface several small openings through which, on pressure, purulent matter exuded! This showed conclusively that the central follicles of the gland were diseased, and that the ichorous secretion, percolating from the abnormal glandules, kept up a con- stant irritation below, and caused the cough ! And I decided that their excision would be necessary to arrest the disease. Passing the double hook into their centre, I drew them out, and amputated them directly through the centre of the gland (see Plate), cutting through a sin- gle large ulceration, situated in the centre of the organ, which was lined by an adventitious membrane, and formed a perpetual sinus. The repeated application of nitrate of silver by Dr. W. had brought and kept 240 PRIMARY LESIONS. the surface of the gland in a healthy state, without affecting the ulcerated cavity. I applied the solid crystal to, and destroyed the false membrane that lined the half cavity remaining in the gland, which in a few days healed up, and her cough and all other unfavorable symptoms disappeared, and she entirely regained her health. SECTION in.--LESIONS OF THE PYRIFORM SINUSES. We have seen that the numerous large follicles which occupy the subtonsillar fossae, or pyriform sinuses at the sides and roots of the tongue, being situated directly under the tonsillary glands, are quite sure to be affected by the diseased secretion that may exude from these bodies. Ulcerations or granulations in this position are often productive of much mischief, and from their position they are very likely to, and frequently do, escape detec- tion. The author was engaged in treating cases of chronic folliculitis constantly, during several years, before the diseased glandulce in this locality were readily detected. Unless great pains are taken to draw the whole mass of the tongue downwards and forwards, their situation will not be observed. Being protected by the abasement of the tongue, unless this organ is drawn forward and depressed, in the manner just de- scribed, they are not ordinarily reached by the topical application in the attempt to cauterize the throat. The symptoms which characterize the presence of these lesions do not differ essentially from those which indicate the existence of ulcers in the laryngeal cavity; they are soreness on one or both sides of the throat, just under the cornua of the os hyoides; hoarseness, often POTIWSY fflF THE'DISEASE Plate XIV. " Ulceration of PyrifEin. Sinus PRIMARY LESIONS. 241 with more or less cough, and expectoration of an opaque secretion—sometimes free—which seems to come from the opening of the windpipe or very near the top of the throat. This expectoration is frequently increased after eating, and is sometimes tinged with blood; or small masses of dark, almost coagulated blood, will be mingled with the sputum. The following cases will illustrate the nature and symptoms of these lesions. A clergyman who had suf- fered several years from laryngeal disease, and whose official duties had long been interrupted by the effect produced upon his voice, came under my care for medi- cal treatment. The measures employed—which were such as have been enumerated in other cases—were so successful, that his voice improved, and he was enabled to return to his official public duties. But still this gen- tleman returned to my office again and again, complain- ing of great soreness in the upper part of the throat, back of the os hyoides; and yet at this time no disease whatever could be detected in the fauces or laryngeal cavity; nor were the above symptoms in the least degree relieved by applications to these parts. At length, with considerable difficulty, by placing the patient in a full light, and depressing the base of his tongue, I discovered in the fossae or pyriform sinus on each side of the root of this organ, deep and ragged ulcerations, which, until this moment, had altogether escaped my observation. These were now freely caute- rized, and by repeating the topical measure occa- sionally, were healed at length, when the soreness and irritation which had been complained of, subsided entirely. In some instances I have found ulcerations of the folli- 16 242 PRIMARY LESIONS. cles situated in the pyriform sinus very obstinate, and from their peculiar position difficult to heal. Case VIII.—F. C, aged thirty years, a planter, from Tallahassee, Florida, came to New York for the purpose of seeing me. But after arriving here he fell in with some friends, who advised him to consult their physician, " who being one of the physicians of the New York Hospital, would understand and treat his case success- fully." Accordingly he placed himself under the care of Dr. M., who employed appropriate means in the treatment of his case, in the form of local and general measures, during a period of several months. At first his health improved, and he was encouraged by the hope of ultimately recovering. But as the cold season came one, his unfavorable symptoms increased. His cough and expectoration were aggravated, and his physician recommended him to return to Florida, and spend the winter. Before returning home, however, he called at my office, and requested me to examine his case, without acquainting me with the above facts. It was not until he had been some time under my care, that I was aware that he had been under treatment in the city. The following is the history of the case, as given by himself. In 1848 he had follicular disease of the throat. He was treated by Dr.----, of Tallahassee, who excised both tonsils and employed topical measures to the throat. After which he was in better health for several years. In 1855 he was hoarse, and in the fall of that year he came to New York in search of further aid. On coming under my care, there was found, on percus- sion, comparative dulness on the left side, and on applying the stethoscope to this side, the act of respiration was found to be prolonged, and dry crepitant rales were heard. 243 Fig. XII PMMttJgY if THE m&lh\ Disease and UlceraLion in Pyriform Lmus PRIMARY LESIONS. 243 On the right side, the lung appeared nearly normal; the respiratory murmur was distinct and puerile; he was pallid and emaciated. The cause of these difficulties was found, in part certainly, in the condition of the throat. The pharyngeal membrane appeared dry and devoid of follicles. A portion of the diseased gland was found from which the ichorous excretion was still exuding, and com- mencing near the base of the tonsil was an old ulcera- tion extending down into, and occupying the whole of the left pyriform sinus (see Plate XII). I stated to the patient the condition in which I found the left lung; but as I could not ascertain that he had any hereditary tendencies to phthisis, I encouraged him with the hope that his disease might in time be arrested by appropriate measures. He decided not to return home immediately, but to remain, and attempt to obtain relief. I removed the remaining part of the diseased tonsil, January 5th, 1856. With the solid crystal I cauterized the ulceration from the base of the gland down to the bottom of the pyriforni sinus. The alterative mixtures (Form. No. 19 and 31) were exhibited night and morning in drachm doses. An invigorating course with regard to tonics and diet was advised; and every plan that would tend to improve the general health of the patient was adopted. After one or two applications of the solid nitrate to the diseased sinuses, a strong solution of the crystals was adopted, and a sponge-probang wet with it, was applied at first to the diseased parts above the glot- tis, then to the trachea, and subsequently the instrument, saturated with the solution, was carried down in*o the left tracheal bifurcation, every other day through the months of January and February, when, as the disagreeable 244 PRIMARY LESIONS. spring months were coming on, he was advised to go to a milder climate. But before he left he was examined, r and his symptoms found to be greatly improved. I sent for the same artist, who sketched No. XII, and had another drawing of C.'s throat taken. The ulceration had healed, his cough had greatly diminished, al- though every morning he still had some expectoration; the crepitation had ceased in the left lung, yet some degree of dulness remained. He returned to Florida, with the understanding that early in the summer he would return to this city and continue the treatment. But I saw nothing more of him until the 5th of September follow- ing, when he returned in nearly the same condition he was in when he left for home. Certainly he was no worse, and the treatment was renewed, and was con- tinued through the fall and winter, until February 4th, 1858, the topical application being made twice, and a part of the time three times a week during the above period, during which time the patient, although exposed to a rigorous climate, continued constantly to improve. He had no cough, and his lungs on the 4th of February gave, on examination, no signs of disease. The respira- tion, although feeble, was otherwise normal. He had regained his usual weight, and was strong and robust. His health remained very good until the spring of 1859, when he took a severe cold which was attended with soreness of throat, and followed with a cough. Being alarmed, he came early in June to New York. I found him on the 18th of June with an ulcerated throat, but his lungs were healthy. A few applications to the upper portion of the air-passages relieved his throat, and his cough soon subsided. The next year the Rebellion broke out, and I have known nothing of his case since. i FCTwajisY m ire m$ih\ Plate XX. ■z. z ^ yriform Sinus healed PRIMARY LESIONS. 24^ SECTION IV.--LESIONS OF THE EPIGLOTTIC CARTILAGE. The epiglottis is subjected to lesions which not only interfere with the functions of this organ, but which are often the exciting cause of general disease—sometimes of a serious character. Some of these morbid changes occur much more fre- quently than we have been accustomed to suppose; and the symptoms to which they give rise are often erroneously attributed to organic disease of the lungs, or to other structural changes which may not exist. Anatomically viewed, the epiglottis is a fibro-cartilage of an ovoid form, and of a tissue very elastic. It is covered by a mucous membrane which consists of a ciliated epithelium externally, and beneath this a base- ment layer which is the true membrane, and a quantity of connective tissue, all abundantly supplied with blood- vessels. Scattered over the surface of this lining membrane, and situated in the sub-mucous tissue, are numerous fol- licular glandules, many of which have the openings of their excretory tubes on the laryngeal face of this carti- lage. One of these glands, which is composed of several granules, is located between the epiglottis and the os hyoides, and is called the epiglottic gland. On the laryngeal face of the epiglottis, the mucous membrane adheres closely to the cartilage ; there being no connec- tive tissue whatever interposed between the lining mem- brane and the cartilage. Beneath the mucous mem- brane on its anterior or lingual surface, considerable con- nective tissue is deposited. Disease, therefore, affecting this fibro-cartilage must have its seat, either in the mu- 246 PRIMARY LESIONS. cous membrane or its follicles, or in the subjacent con- nective tissue. We find, accordingly, the principal lesions of the epiglottis to be:— 1st. Erosions or abrasions of its mucous membrane. 2d. Ulcerations of the membrane and of its glands. 3d. (Edema, or infiltration of its connective tissue. These alterations of structure occur, with regard to frequency, in the order in which they are named. Some of the erosions and ulcerations of the epiglottis to which I propose to call attention, (a portion of them) are entirely independent of those described by M. Louis as lesions proper to phthisis, which he found were pre- sent in about one-sixth of his patients who died of this disease; and were caused, in the opinion of M. Louis, by the constant passage of pus over the mucous membrane. In many instances I have found these structural altera- tions to occur as primary and independent affections, so far as tubercular disease is concerned. In other cases they are not only complicated with similar lesions of the tonsils, fauces, and pharynx, but are often associated with tuberculosis. 1. Erosions of the mucous membrane of the Epiglottis. Prof. Hasse, who describes quite minutely those ero- sions of the mucous membrane of the air-passages, first pointed out by Louis, as alterations peculiar to phthisis, says that these lesions always remain superficial; the upper layer of the mucous membrane, probably the epithelium, being alone engaged. They are seen in certain localities, as the inferior surface of the epiglottis, the posterior surface of the trachea, and occupying the mucous membrane of the two main bronchi. " These erosions," continues Prof. Hasse," are obviously the sequence of superficial irritation of the mucous mem- PRIMARY LESIONS. 247 brane; and as they are principally met with in parts which come in contact with tuberculous matter expecto- rated from the lung, they not improbably owe their existence to this source."* M. Trousseau entertains a similar opinion; for, in speaking of these lesions as described by M. Louis, he remarks: "We have never found erosions except in patients attacked with pulmonary phthisis, which obser- vation would seem to justify the opinion of M. Louis, that these erosions are owing to the contact of pus which is constantly passing over the mucous membrane of the larynx and bronchi."f The same opinion with regard to the origin of these lesions is expressed by Andral and Cruveilhier; and more recently by Ryland and Gellerstedt. Indeed, most writers on the pathology of " diseases of the air-passages," since the promulgation of this doctrine by M. Louis, have adopted, and have copied into their writings—some of them, apparently, without any personal investigation—these views of the origin of erosions and ulcerations of the epiglottis and larynx. Both Hasse and Rokitansky describe another form of superficial erosions which occur in certain cases of typhus fever, and are found seated " on the posterior wall of the larynx ; on the lateral edges, and on the inferior surface of the epiglottis," where they present at first a roundish or lenticular form, with black or discolored edges ; and which, often, change gradually into dirty eating ulcers. During the past few years a large number of cases of erosions of the epiglottis have been noticed among my pa- tients, occurring under circumstances altogether different * Pathological Anatomy, pp. 357-8. f Treatise on Laryngeal Phthisis, «£c. By Trousseau & Belloe. p. 20. 9 248 PRIMARY LESIONS. from those under which they were observed by the above pathologists. They have generally been noticed as being complicated, either with follicular inflammation, or associated with catarrhal irritation of the mucous membrane of the respiratory passages, but in a large majority of cases entirely independent of tubercular disease. During the Winter and Spring of 1856,* especially, a much larger number of cases occurred, of erosions and ulcerations of the epiglottis, than had been observed during any previous season. These instances, for the most part, were found occur- ring in those cases, in which a persistent, teazing cough following chronic follicular disease, or common catarrhal inflammation, obstinately resisted all the ordinary mea- sures for its arrestment. On depressing the tongue in such cases, by means of the ordinary bent spatula, or " tongue depressor," so as to bring the epiglottis into view, this cartilage was found frequently inflamed, vascular, and its superior border marked, at one or more points, by distinct erosions. In much the largest proportion of cases, these erosions make their first appearance on the left superior edge of the epiglottis. Next in frequency they will be found occupying its centre; and occasionally, but very rarely, in comparison with the two preceding locations, they have been ob- served on its right border. These erosions are not readily detected, at first, by the inattentive observer; as they are quite small, are only slightly depressed, with a pallid base, sometimes a little reddened, and with \whitish, linear edges. ■* During these seasons influenza and colds were more prevalent than usual • PAT HI Oil (J BIT itF TK1E DDS^ME Plate: XV Erosion of tke left side of ths Epiglottic— PRIMARY LESIONS. 249 The surrounding mucous membrane is generally in- flamed, its delicate network of superficial vessels is red and injected, and the epiglottis itself more or less thick- ened. The appearance and effects of these erosions may be still further illustrated by the following case:— Case I.—I. H, a lawyer, from Virginia, and late State's Attorney, consulted me, May 28th, 1856. He had been affected nearly two years with chronic follicular disease of the throat, for which he had received both topical and general treatment, and had been greatly relieved. Some six weeks or two months before his visit to New York, a severe cough came on, and was, after a time, attended by a free (apparently) bronchial expectoration, a cough which resisted all the ordinary means employed for its relief. His chest, which was remarkably well developed, was carefully examined, without detecting any signs of pulmonary or bronchial lesions. On exami- nation, the throat revealed some remains of the follicular disease, but nothing sufficient to account for the symp- toms present. Indeed, as no cough had existed when the throat was in its worst condition, it could not be attributed to the presence of follicular disease, which appeared to be confined to the upper part of the throat. In pursuing the investigation, the tongue of the patient was forcibly depressed so as to bring the epiglottis into view, when this cartilage was found to be inflamed and thickened, its mucous membrane red and vascular, and its left superior border covered with erosions. (PI. XV.) The patient at this time was harassed by a constant cough, which was attended by an abundant expectora- tion, and this had been his condition for many weeks. It will not be supposed that these erosions of the epi- glottis were the whole cause of this cough, and of the ex- 250 PRIMARY LESIONS. pectoration. I had seen at this time, and have since seen frequently, cases with these erosions present, unattended by any great amount of cough; but a cough once esta- blished, from any cause, and these lesions supervening, I have never seen a case in which this symptom did not obstinately resist all ordinary measures, so long as the erosions continued. These means having been fully em- ployed in this case, the indication seemed to be to check the irritation caused by the erosions. To accomplish this, the tongue was depressed so as to bring the epi- glottis into view, and with an instrument prepared for this purpose, the erosions were touched with the solid nitrate of silver, whilst the body of the cartilage was freely sponged with a strong solution of the same remedy. This was done on the 28th of May, and the operation was repeated two days afterwards, and was followed by a most happy result. The cough was greatly diminished by the first application ; and on the 31st, the day after the second application, the patient called, and reported himself almost entirely free from cough and expectoration. A few more applications of the solution were made to the affected parts, in the course of the subsequent week, and Mr. H. returned to his home, appa- rently entirely free from the unfavorable symptoms with which he came. I have stated that some lesions of the epiglottis occur with much greater frequency than the profession have been accustomed to suppose. This is certainly true with regard to these erosions. Within a few months quite a number of physicians have brought or sent their patients to my office for examination, who were suffering from a severe cough, and were apparently laboring under bron- chial or laryngeal disease, for the treatment of which PRIMARY LESIONS. 251 both general and topical measures had been unavailingly employed by these practitioners. In many of these in- stances the persistent cough was found to have been kept up by the presence of undetected erosions of the epiglottis; for in nearly all such cases, the arrestment of these lesions was found efficient in promptly relieving the cough. Several most interesting cases have come under my notice, in which the disease has occurred among physi- cians themselves. In one instance a young physician was brought to my office by his friend, an older physician of this city, under whose care and treatment the patient had been for seve- ral weeks before I saw him. But inasmuch as a severe and obstinate cough, attended with free expectoration and with pains in the chest, continued to harass' him, further aid was sought by both patient and attendant. On -examining the chest and finding no evidence of lesions there, sufficient to account for the symptoms, the throat was inspected, and the patient's epiglottis was found to be twice its natural thickness, was highly vas- cular, and its entire superior border covered with ero- sions. In this case, the principal erosion occupied the right superior lateral border of the cartilage, and the doctor was constantly referring to the right side of his throat as the seat of the greatest amount of irritation. His cough had been very severe for nearly two months, and was attended with much expectoration and with more or less pain in the chest. He had consequently suffered much anxiety about the safety of his lungs. Cauterizations of the border of the epiglottis, with the solid crystal of the nitrate of silver, gave almost imme- 252 PRIMARY LESIONS. diate relief. The cough and expectoration began to subside, as soon as this remedy was employed. After a few applications of the solid nitrate, a strong solution was employed, and was applied every few days, for seve- ral weeks, not only to the border of the epiglottis, but also to the whole body of the cartilage. Under this treatment, the patient recovered perfectly. Although, in almost all cases, lesions of this nature are promptly relieved by cauterizations, yet, in some instances, I have observed a marked tendency in the disease to return, whenever the patient was exposed to the ordinary causes of catarrh. In July, 1855, Dr. Bowen, of Jeffersontown, Virginia, brought his sister, a young lady, to New York, for medical treatment. Miss B. had many of the early symptoms of phthisis, for the treatment of which the ordinary remedies had been long employed by her brother. Complicated with chronic follicular disease, erosion of the epiglottis was found pre- sent, and this lesion proved to have been the principal exciting cause of a long continued cough; for, after a few applications to the diseased parts the erosions disap- peared, and the cough ceased altogether. On taking cold a few weeks after, the cough returned, with nearly as much severity as at first; and when the epiglottis was examined, it was found to be again eroded. The topical applications were once more successful in affording prompt relief. Miss B. remained three or four months in this city, and during that period, she had several severe attacks of cough, and in every instance erosions of the epiglottic cartilage were ascertained to exist, and these were always removed, and the cough arrested, by topical medication. She, however, ultimately, quite re- covered. PRIMARY LESIONS. 253 Under the head of erosions, I will allude to only one other instance of this affection. It is a case of much interest, as it occurred in an elderly physician of this city —a member of the Academy, and a gentleman well known to most of its fellows. This physician came to me early in the Winter of 1856, expressing much anxiety about his case. He had had an obstinate cough for several months; had em- ployed in his own case, he said, all the ordinary means which he had been accustomed to use with his patients; but had found no permanent relief. He had only slight expectoration, but a harassing dry cough. Sometimes the cough would occur in paroxysms, and with great severity. The Doctor was confident the irritation was seated in the larynx, and as he had himself applied topical reme- dies to his own throat for some time, he desired that the sponge-probang should be carried down to the superior portion of the larynx. This was done, on several occasions, and was followed by considerable relief; but still the cough continued, and was always greatly aggravated by exposure to cold, and by the vicissitudes of the weather. In the meantime, the Doctor's epiglottis had not been examined, because attention having been called so directly to the larynx, as the seat of the disease, this organ had been overlooked. It was now inspected, and found in an inflamed and thickened condition; its delicate network of vessels was red, and highly injected, and its border eroded. Applications made to this organ, as in the preceding cases, gave prompt relief, and for a time Dr. M. thought his disease was removed. But he soon found that on 254 PRIMARY LESIONS. every slight exposure to cold, his cough was sure to return, and that too, after the epiglottis appeared to be in nearly a healthful state. As the applications now only afforded temporary relief, they were for a time sus- pended. Irritation in the throat soon became more ha- rassing than ever; and on the 20th of March, Dr. M. called and declared that for several days and nights his cough had been almost unbearable—that he had coughed every five minutes night and day, and that neither ex- pectorants nor anodynes gave him any relief. The Doctor had given much attention to his own case, and he expressed the opinion that the same irritation that affected the epiglottis had extended along its lateral border, to the aryteno-epiglottic folds, and that erosions or ulcerations in this location were causing the incessant cough. This opinion could not be confirmed by inspection, as in the'case of erosions of the border of the epiglottis, for these epiglottic folds are concealed from view, behind this cartilage; they can be reached, however, by topical applications, and at the patient's request, I applied, by means of a small sponge-probang, a strong solution (50 grains to the oz. of water) to the membranous folds, extending from the base of the epiglottis to the aryte- noid cartilage, which folds form the lateral borders of the aperture of the glottis. The relief was immediate. Before this application, the great irritation at the open- ing of the glottis had caused an almost incessant cough, for forty-eight hours. For several hours succeeding the operation, the Doctor declared that he did not cough once, and the following night with him was one of quiet sleep. The prompt relief which a single application of the PMMIUeY OF TBI I MUM Flale XVIII Erosions of tie entire edge of lie Epiglottis PRIMARY LESIONS. 255 caustic to an irritated and eroded epiglottis will sometimes afford, has often been with me a matter of great surprise, as well as of gratification. Within a few weeks, a gentleman came to New York from St. Louis, who had been treated several months by a skilful and eminent physician for chronic follicular dis- ease. Frequent applications of the nitrate of silver solu- tion had been made to the fauces and pharynx of the patient, and with much benefit, so far as the disease of these parts was concerned. Still the patient complained of great irritation at the top of the wind-pipe ; and, fol- lowing the advice of his physician, he consulted me. An examination of his case revealed an epiglottis in- flamed, and considerably thickened at its apex, with an erosion directly in its centre. A single free application of the solid nitrate of silver at this point gave, for a time, entire relief, and these applications being repeated daily for a few days, removed permanently a tickling and an irritation that had continued, and had caused a cough for many months. In some instances the erosion will occupy all the supe- rior edge of the epiglottis. I had an opportunity of exhibiting a case of this nature to Dr. A. H. Stevens, and to the chairman of that committee which was ap- pointed by the Academy of Medicine, a few years ago, to visit me on another subject. It was the case of a lady from Rhode Island, who, for a twelvemonth or more, had labored under a severe spasmodic cough, occasioned, as her physician supposed^ by chronic follicular disease. In this instance the entire superior border of the epi- glottis was covered by a linear erosion. It was a well- marked instance of this lesion, and these gentlemen may remember the case. 256 PRIMARY LESIONS. So far as my observation goes, these erosions are of rare occurrence in very young persons. To one such instance, however, I will briefly allude, as it is a case of much interest. See No. " 4." Some time ago, Mr. H. Hurlburt, a merchant of this city, brought one morning to my office his young daughter, a child some five or six years of age, who, as the father stated, had had a cough for several weeks, for which the family physician, who is an experienced practitioner and a member of the Academy, had prescribed many of the ordinary remedies. Still her cough increased, and for several days preceding her visit to my office, had harassed her night and day, until the child was nearly worn out with the increasing irritation—an irrita- tion which the patient constantly referred to the throat. Suspecting the nature and locality of the irritation, I attempted to examine the throat; the fauces and pharynx were inflamed, and although it was difficult to bring the epiglottis into view, so as to decide positively that ero- sions were present in that location, yet the symptoms were so like those which had occurred in other cases where erosions of this cartilage were found, that I ven- tured to make a free application of a strong solution of the nitrate of silver to the epiglottis. The result con- firmed the diagnosis ; the cough ceased immediately after this single cauterization ; nor was there any return what- ever of this symptom thereafter. This occurred many months ago, and within the present week Mr. Hurlburt assured me that his daughter "had not coughed since that visit to my office." The announcement of the great frequency with which these lesions which we have been considering occur, will, I doubt not, surprise the profession. PRIMARY LESIONS. 257 Since my attention has been called to their existence, I confess I have been amazed, not only at the number of cases in which they have been found, but at the occa- sional severity of the symptoms caused by these appa- rently insignificant lesions, and the frequency with which these symptoms have been attributed to other causes. I am indebted to my assistant, Dr. Richards, who has kept a careful record of these cases, for an account of the number of instances in which, during the last twelve months, erosions of the epiglottis have been observed. Of four hundred and two patients affected with some form of disease of the respiratory passages, who were examined and treated between the 1st of May, 1856, and the 30th of April, 1857, there were found thirty- four instances of well marked erosions of the epiglottis. Of this nurnber twenty-one cases occurred in males, and thirteen in females. In upwards of twenty of the above cases, these lesions existed entirely independent of tuber- cular disease. SECTION V.--ULCERATIONS OF THE MUCOUS MEMBRANE, OR OF THE GLANDS OF THE EPIGLOTTIS. It is important to understand the pathological differ- ences, if any exist, between erosions and ulcerations of the mucous membrane. M. Louis, in describing the lesions of the mucous membrane of the epiglottis and larynx, in phthisis, to which I have alluded in a former chapter, caused by the contact of tuberculous matter, speaks only of ulcerations. He undoubtedly considered erosions as but the first degree of ulceration, for he re- marks that some of these ulcerations escape notice on account of the flattening of their edges, and "their pinkish color," and that "in two cases only did the 17 258 PRIMARY LESIONS. superficial ulcerations of the epiglottis reach the fibro- cartilage beneath." Prof. Hasse declares that tuberculous erosions are limited to the epithelial covering, and " hence they are not always detected at first sight, but that true ulcera- tion of the mucous membrane in phthisis presents a nota- ble difference from the above."* I have watched these lesions with great care, and, however long continued, have found them always re- maining superficial. I have never observed an erosion to degenerate into a true ulceration. They commence with, and are confined to the epithelium of the membrane. Primary ulcerations of the epiglottis—many instances of which I have observed to exist entirely independent of tuberculous disease—differ essentially, in their ana- tomical characters, from the erosions of the same organ. According to Hasse, the tuberculous ulcer, or the ulcer peculiar to phthisis, occurs most frequently in the larynx, but they are found in many instances, observes Hasse, on the posterior face of the epiglottis, and they appear to originate in various ways. " Tubercle commonly," says he, " accumulates within the capsules of the muciparous glands, elevating the latter into little eminences, and ultimately, when the softening process is completed, leaving corresponding ulcers in their stead."f In other cases, again, tubercle cells, instead of normal cells, form beneath the epithelial covering, and irritating the contiguous textures, produce first, loss of substance, and finally ulcers. So far as I have been able to notice the inception of primary ulcers of the epiglottis, they have seemed to ori * Op. citat. pp. 357-8. f Op. citat. p. 359. PRIMARY LESIONS. 259 ginate in the follicles of the membrane, and not to be the result of erosions. At first, an enlarged or pimple-like follicle appears on the border of the epiglottis, surrounded by an inflamed and highly injected portion of mucous membrane. Soon the follicle softens, and degenerates into an ulcer, with irregular edges and an inflamed and reddened circum- ference. In many instances these ulcers remain for some time superficial, destroying only the mucous membrane; in others, they penetrate deep into the fibro-cartilage, and occasionally they result in the total destruction of the epiglottis. Two such instances have been observed by me in which the epiglottic cartilage was completely de- stroyed by ulceration. To these cases I may allude here- after. To the first case of primary ulceration of the epiglot- tis, which I have on record, my attention was accidentally called. I had no preconceived opinion of any lesions of this nature, except such as Louis, Cruveilhier, and other pathologists, had described, as being peculiar to, and complicated with, tuberculosis—lesions, in short, which have only claimed the attention of the practitioner after the death of his patient; and not such as are the efficient cause of disease, and whose removal will effec- tually arrest diseased action. The following is the case to which I refer:— Several years ago, Mr. E. Bulkley, a shipping mer- chant, of this city, aged about twenty-five years, applied to me on account of a cough under which he had labored for several weeks. It came on gradually, at first, but latterly had much increased in severity. A careful ex- amination was made to ascertain the cause of the cough. 260 PRIMARY LESIONS. Slight redness was observed about the fauces, but not sufficient to account for the severity and persistence of the most prominent symptom. Not the slightest indica- tion of disease could be found about the chest of the patient. The epiglottis was not inspected, because at this time we were not accustomed to examine this organ for pathological revelations. Indeed, at this period, large numbers of the profession had never seen a living epi- glottis !* General measures were adopted in the treatment of this case, and for several weeks alteratives, followed by ano- dynes, expectorants, sedatives, and various other means, were employed to relieve the cough, without producing any permanently beneficial effect. On the contrary, at the end of the third week this symptom was much aug- mented ; and was attended, moreover, with a free expec- toration. The patient was daily losing flesh, and he now began to complain of erratic pains in his chest. These symptoms alarmed both himself and his friends; and, urged by the latter, he determined on taking a sea voyage. To inform me of this, his intention, he called about four weeks after he first came under treatment. At this visit I again examined his chest, without discovering any evidence of thoracic disease. His throat, too, was more thoroughly inspected than at any former time. On exposing the epiglottis to view, I was surprised to find the upper border near the centre of this organ occupied by a large ulcer, which had destroyed a considerable * This present season (1863), a physician of extensive practice, and of many years' experience, called on me, to see my practice, to whom I exhibited a diseased epiglottis; who declared that he had " never before seen the living epiglottis"—an admission frequently made by physicians. OTMBJdTf w m lk%E Fig.XVI Ulceration of the centre of the Epiglottis. PRIMARY LESIONS. 261 part of the superior central portion of this cartilage. (See Plate XVI.) I informed my patient of the discovery, and proposed immediate cauterization. The ulcer was touched with the solid nitrate of silver without producing any pain or irritation whatever! Mr. B. has since frequently de- clared that his " cough ceased from that hour." It was not altogether arrested by this single applica- tion ; but the relief was remarkable. He coughed but little for the next twenty-four hours ; and two or three similar applications subsequently made, were effectual in entirely arresting the cough; and my patient regained, rapidly and permanently, his health. It cannot be doubted, I think, had this local source of irritation been continued, that disease of the lungs, in this case, would have been ultimately developed; and it is equally probable that an ulcer of the epiglottis, dis- covered after the fatal termination in such a case, would be considered not the antecedent and exciting cause of the general disease, but as the sequent, and would be classed among the tuberculous ulcers of M. Louis. In several instances, all the prominent rational signs, with some of the earlier physical manifestations of pul- monary disease, have been observed to follow long-con- tinued ulceration of the epiglottis, all of which symp- toms have been seen to disappear after these lesions have been healed. Within the last five or six years I have treated several medical men with erosions or ulcerations of this cartilage, whose symptoms were such as to have given them much anxiety about the safety of their lungs. I will here give briefly the case of a physician well known to the profession of New Jersey. Dr. L. S. called on me in June, 1855, to consult me 262 PRIMARY LESIONS. about his health. During the preceding year he had been aware, he informed me, of some chronic irritation of his throat, for which he had occasionally applied the nitrate of silver solution. This gave him relief for a time, but three or four months before his visit to me, he began to cough, apparently from an increased irritation in the throat, but this irritation was not now relieved by the cauterizations. The cough, on the contrary,.in- creased in severity, was obstinate, not being much influ- enced by any measures taken to relieve it. After a time some expectoration accompanied the cough, and these symptoms were followed by uneasy sensations or wandering pains about the chest. He lost flesh, and his strength diminished. Under these circumstances he determined, as he informed me, to give up his profes- sional duties for a time, and seek to restore his health by a change of climate. It was at this stage of his impaired health that I saw him. After hearing the doctor's history of his case, and particularly after examining his chest, and finding there no adequate cause for his severe and protracted cough, and other unfavorable symptoms, I suspected the presence of concealed erosions or ulcerations about the glottic or epiglottic regions. His throat was examined; the mucous membrane of the fauces and pharynx was moderately inflamed, and some of its follicles were enlarged. With some difficulty the epiglottis was brought into view, when an ulcer, which had destroyed the mucous membrane and had penetrated into the cartilage, was found in the centre of the apex of this organ. (Plate XVII.) I was at once satisfied that the teazing and persistent cough which for several months had so an- T Y ©IF ni MUM Fi£. XVII Ulceration of the Epiglottis PRIMARY LESIONS. 263 noyed Dr. S., was kept up by this condition of the epi- glottis; and the result of the treatment adopted con- firmed this opinion. The ulcer was well cauterized with the solid crystal of the nitrate of silver, and a strong solution applied to the mucous membrane of the fauces and pharynx. As in the preceding case, this single cau- terization arrested the cough; and although Dr. S. returned several times subsequently and had the appli- cations repeated on account of some remaining irritation, yet no further paroxysms of coughing occurred ; his un- favorable symptoms all disappeared, and he regained a good degree of health, which, I believe, still continues* I have had an opportunity to exhibit these lesions of the epiglottis to many physicians who had never before seen anything of the kind in the living. Within a few weeks, when honored by a visit from three of the Senior Surgeons of the U. S. A.—Drs. McDougal, of Baltimore ; Finley, of Philadelphia; and Satterlee, of New York— the case of a gentleman of this city, with a central ul- ceration of the epiglottis, was exhibited. This gentle- man had been affected for two years with a cough, which he compared to the hooping-cough, because of its severe and spasmodic character. Topical applications to the local disease in this case arrested the cough in the course of a few days. When ulcerations occur on the laryngeal face of the epiglottis—and in the tubercular cases observed by M. Louis, this surface of the organ, and generally speaking its lower half, was their almost exclusive seat—it will be * August 14th, 1863, being on a visit to Saratoga Springs, I to day saw Dr. S., who is well, and has been able to attend to his professional duties ever since his treatment in 1855. 264 PRIMARY LESIONS. impossible to detect their presence by ocular inspection, as you can in those cases in which the border is invaded. I have described elsewhere the alteration which takes place in the aspect of the epiglottis, when that cluster of follicles which is situated at the base of this organ, and which constitutes the epiglottic gland, becomes the seat of ulceration. Its naturally crescentic shape will be considerably increased when ulceration to any extent exists in this location.* In addition to the symptoms which have been enume- rated, there is frequently some degree of pain in the larynx when the lower portion of the cartilage is ulcer ated, together with more or less difficulty in deglutition. Aphonia is also present, because, generally speaking, there are, coincident with these lesions, at the base of the epiglottic gland, ulcerations in the larynx, and about the vocal cords. I shall be pardoned, I hope, for alluding to one other instance of epiglottic and laryngeal disease, inasmuch as the gentleman of whose case I shall briefly speak, was several months under the treatment of the celebrated Hahnemann, and his final directions, as given to this gentleman, illustrate a principle in Hahnemannic prac- tice which I believe has not yet been published to the world. Mr. G. B., a merchant, formerly in this city, visited Europe in 1838, principally on account of a disease— laryngeal phthisis—under which he had labored for several years. After consulting several eminent men in London, he went to Paris, and placed himself under the immediate care of Hahnemann. * At the present day, however, with the laryngoscope, these and other lesions of the air-passages are readily discovered. PRIMARY LESIONS. 265 Being in Paris at that time, and occupying rooms in the same house with Mr. B., I saw him daily, and watched with much interest the effects of Hahnemann's treatment on the case. Mr. B., who had been under the treatment of Dr. G. (a Homoeopathic physician of this city), before leaving for Paris, had the most implicit confidence in this plan of treatment, and gave, therefore, during a period of three months, undeviating attention to all the rules and directions of his physician. It is sufficient to say, however, that no effect whatever was wrought upon his disease; and, at the chose of the above period of time, he left Paris for home, utterly disheartened, " to die among his friends." I had preceded him, and arrived in New York a few weeks before he came. Soon after he reached home, or early in 1839, I was called to see him, and his case was one of the first I ever treated by topical medication. It was a strongly marked case of chronic laryngitis, attended with ulcerations of the epiglottis, and of the larynx and trachea. He was much emaciated; had severe cough, with expectoration of purulent matter. Mr. B. now gave me the history of his treatment un- der Hahnemann, and why he quitted him so abruptly. Until within a short period of the time he left, Hahne- mann had assured him of the positive, ultimate success in his case, of the " potentized" remedies. But finding, at length, that no effect was produced on the disease, he informed Mr. B. that such was the peculiar character of his disease, that it could not be influenced by Homoeo- pathic potions, and that the nature of the disease must be changed. He, therefore, advised Mr. B. to con- tract syphilitic disease, and await its secondary effect- - 266 PRIMARY LESIONS. the occurrence of ulcers of the throat; that these would eradicate his present disorder, and that Homoeopathy, in turn, would find no difficulty in expelling from his sys- tem the syphilitic poison Mr. B., therefore, losing confidence in Hahnemann, gave up homoeopathic treatment; and as his disease had greatly advanced in the meantime, involving the bron- chial divisions, and was attended by a severe cough and expectoration, he came home to New York, and placed himself under my care. This patient was treated by me, through many months, by topical applications, as in the preceding cases, con- joined with appropriate general remedies, and ultimately quite recovered his health. Mr. B. is still living, and will bear testimony to the correctness of the above state- ment.* The number of cases of ulcerations of the epiglottis, which occurred among the four hundred and two patients, treated during the period of one year, amounts to twenty six, as estimated by Dr. Richards: about one-third of this number were females. I am confident, however, that a part of these cases, which have been recorded as ulcerations, were, in reality, erosions; because, at first, an erosion was considered as but the first stage of ulcer- * I publish this statement concerning the practice of Hahnemann, for the parti- cular benefit of Prof. Henderson, of Edinburgh. When Prof. Simpson was pre- paring his masterly exposition of the " Tenets and Tendencies of Homoeopathy," I was in Edinburgh, and at his request gave him some illustrations of the principles and practices of Homoeopathy in America. These he embodied in the above work. In Prof. Henderson's Reply to Dr. Simpson's unanswerable facts and arguments, he devotes several pages of his work to a most appalling attack on me, and to the ridiculing of my name, instead of attempting to reply to the facts and illustrations I had given. I therefore record the above, concerning the practice of that great light iu Medicine, that Prof. H. may have it to comment upon, in the next edition of hia defence of Homoeopathy. PRIMARY LESIONS. 267 ation. The exact proportion of these lesions, therefore, has not been definitely ascertained. From more recent and careful observation, I am inclined to the opinion, that erosions of the epiglottis occur with fourfold more frequency than ulcerations of this organ. 3. (Edema of the Epiglottis, or infiltration of its con- nective tissue. It has been stated that the mucous membrane of the epiglottis adheres closely to its posterior surface; there being no connective tissue whatever interposed between the membrane and this cartilage on its laryngeal face. Consequently, in oedema of this organ, the infiltration of fluid must take place on the lingual surface, where con- siderable connective tissue is deposited, and cannot by any possibility be effused on the posterior or laryn- geal face of the epiglottis. It is not claimed by any pathological wrriter, that oedema of the epiglottis, like the erosions and ulcerations of this organ, is peculiar to phthisis, or to any other disease of the air-passages. It is an alteration of structure, having its origin, generally, in catarrhal inflammation ; and is most frequently ob- served in epidemic catarrhs, or influenzas. During the prevalence of an influenza, that occurred to some extent in New York, in the winter of 1853, and again in 1854, I observed many cases of oedema of the epiglottis. In the course of the past winter, also, several persons, with this affection, have consulted me at my office for medical treatment. As we have stated, the infiltration of the sub-mucous connective tissue occurs on the lingual surface of the cartilage, causing the epiglottis frequently to assume a most anomalous aspect. Its lateral edges being rolled back and approximated, it presents, when the intumescence is considerable, much the appearance 268 PRIMARY LESIONS. of a round tumor at the base of the tongue. Partial, and in some instances complete aphonia, is caused by this lesion of the epiglottic cartilage. In a paper which was furnished by the writer, and which was read before the London Medical Society in April, 1854, on "Aphonia, arising from organic lesions," the following case of oedema of the epiglottis is related: Case—" A young gentleman, who, three weeks before, had had an attack of the prevailing epidemic [influenza], called on me, January 29th, 1853. The disease, in its early stage, was attended by a total loss of voice; and it was in reference to this voiceless condition that my opinion was desired. Some degree of cough was present, attended with slight expectoration, but the respiration was but little affected. On depressing the tongue of the patient, the epiglottis was readily brought into view, and it clearly presented that very anomalous aspect to which I have alluded. Extensive infiltration having taken place in the sub- mucous tissue, on its anterior face, the cartilage was enor- mously enlarged, its lateral borders were turned back- wards and approximated, and its whole appearance was that of a round, puffy tumor, lying at the opening of the glottis. Examining with the finger, for the aryte- noid cartilages, they were found to be not involved in the cedematous infiltration; and this exemption from the disease, in this location, accounted at once for the slight degree of difficulty presented in the respiration of the patient. To procure a reabsorption of the infiltrated serum, a strong solution of nit. argent, was applied freely to the epiglottis, and to the whole faucial region. A profuse expectoration of adhesive mucus, from these parts, fol- PRIMARY LESIONS. 269 lowed the application. The topical remedy was con- tinued daily, for several days. Under its use, the tume- fied epiglottis diminished constantly; at the end of a week the patient could speak aloud, although his voice had a muffled sound. Continuing the applications a few days longer, the epiglottis, at the end of this time, was found reduced to its normal size, and the patient's voice and general health were fully restored. That the loss of voice in this case, as well as in many similar cases which have been observed, depended on the intumescence of the epiglottis, has been proved repeat- edly by the fact, that when the epiglottis has been thus oedematous, voicelessness in most cases has been present, and also by the other fact, that the voice in most of these cases returned after the oedema of the cartilage had been removed. In some cases we have had oedema of the epiglottis complicated with ulceration of this cartilage. The following interesting case is of recent occurrence, and is one of this nature: Case.—Mr. J. Dillon, a watchmaker, residing in the eastern part of the city, was brought to me, March 24th, 1857, in an extremely feeble condition. His wife, a strong, robust woman, accompanied him, and aided him from the carriage into my office. I was struck with his pecu- liar appearance. In some respects he resembled a pa- tient in the last stage of phthisis. He was entirely ansemic ; his countenance sallow and bloated, with com- plete aphonia, and a most harassing cough; and, although very feeble, was not emaciated. His wife gave a history of his case ; stating that her husband had enjoyed good health (with the exception of having been occasionally slightly troubled with haemor- 270 PRIMARY LESIONS. rhoids), until about three weeks before, when he took a hard cold, which was followed by inflammation and ulceration of the throat, and an entire loss of voice. A' most severe spasmodic cough, likewise, came on, which for nearly three weeks had harassed him day and night. To relieve this obstinate cough, and improve vocaliza- tion, his attending physician had administered repeated emetics. The operation of these, together with the vio- lent coughing, greatly increased his hemorrhoidal diffi- culty, so that, as both declared, the patient had lost from half a pint to a pint of blood daily, during the last two weeks. This accounted for the anaemic condition of the patient, and for his great feebleness. In searching out the cause of his cough, the lungs and throat were exa- mined. The sounds on the right side were nearly healthy, a slight dulness on percussion was observed under the left clavicle, the inspiratory murmur was diminished in intensity, in comparison with the right side, and expiration was prolonged. The thoracic symptoms, however, were not sufficient to account for the severity of the cough. The patient stated that his throat had been ulcerated, but his physi- cian, who had cauterized it repeatedly, assured him that the ulcers were all healed. Still, as his cough was in no degree relieved, he had come to ask my opinion of his case. Depressing the patient's tongue with sotne force, so as to bring the epiglottis into view, this cartilage was found not only greatly cedematous, but its left superior border was covered by a large unhealthy looking ulcer. Judging from past experience, in such cases, I was at once fully satisfied that this lesion of the epiglottis was the cause of the protracted cough. I therefore desired him to return to his physician, and request him to come PAT DM0) LIB) ©Y ®F IK 15i>LM:I Plate XIX T"- --ation of the Epiglottis PRIMARY LESIONS. 271 to my office, with the patient, the following day (for I was very anxious that he should know of this concealed local difficulty in his patient's case) ; or, if this was not convenient, to request him to examine for himself the epiglottis; confident that if the Doctor discovered the ulceration he would be able to relieve it, as he had already relieved others, in the upper part of the patient's throat. But the patient returned the next day, without the Doctor, bringing the request that I should treat the case, and the assurance of the Doctor that it was not ne- cessary he should be present. The treatment of this case was commenced by apply- ing a solution of the crystals of nitrate of silver, 80 grs. to the ounce, not only to the ulcerated border of the epiglottis, but to its whole lingual surface, and an altera- tive was also prescribed, in doses of a fluid drachm twice daily. Form. No. 19. (Plate XVIII.) March 26th. Find the patient greatly relieved, so far as his cough is concerned, but extremely prostrated, from the great loss of blood, which had escaped from the haemorrhoidal tumors. He has discharged, say his attend- ants, " half a pint of blood" several times in the twenty- four hours. The last discharge being still in the vessel, was examined, and found to consist of dark coagulated blood, half a pint at least, in amount. The patient's face, hands, and feet, are bloated, and it is quite evident that unless the haemorrhage be speedily checked, he will die from loss of blood. An examina- tion was made immediately after an evacuation of blood, when three large hsemorrhoidal tumors were found. The mucous membrane which covered these was ulcerated at many points, through which openings the blood was constantly oozing. 272 PRIMARY LESIONS. It was determined to operate upon these tumors with the nitric acid, instead of the knife or ligature ; accord- ingly the next day, the 27th, aided by my assistants— Drs. Richards and Farrington—the tumors being brought down by an effort of the patient, I painted their surface freely with the nitric acid; a sponge wet with a solution of carbonate of soda was then applied to neutralize the redundant acid, and the parts being well smeared with sweet oil, were pressed back above the sphincter. The haemorrhage was almost entirely arrested. A small amount of blood was discharged the next day, when the remaining portions of the tumors were again cauterized with the acid, after which the haemorrhage ceased alto- gether. The operation proved perfectly successful. During the two days in which attention was given to the treatment of the piles, the epiglottis was neglected, and the patient's cough again increased. A few more applications were made to the epiglottis, which reduced the oedema, and healed the ulcer. Tonics were adminis- tered to the patient, and he made a rapid recovery. He is now quite well, and is attending daily to his ordinary occupation. It will be difficult to give the exact proportion of pa- tients affected with oedema of the epiglottis, for in most instances of ulceration of the epiglottis, and in many cases of long-continued erosions of this organ, more or less oedema of the cartilage was found to be present. Dr. Richards has recorded twenty-nine cases of this lesion, which were observed among the four hundred and two patients to whom reference has been made. Eight only of the twenty-nine were females. With those physiologists who have been accustomed to consider the integrity of the epiglottis as being essen- PRIMARY LESIONS. 273 tial to the perfect act of deglutition, this may be an in- teresting inquiry—how far are the functions of this organ interfered with by the lesions we have described? .Ordinarily, neither erosions nor ulcerations of the border of the epiglottis will increase, to any extent, the diffi- culty of deglutition. Two cases have come under my notice, in which the epiglottis of the patient was entirely destroyed by oedema and ulceration; and yet, in both instances, these patients, after a few weeks, could swallow either solids or liquids without the slightest inconvenience. In both these instances the destruction of the epiglottis was caused by ulceration following extensive oedema of this organ ; a condition which supervened upon a consti- tutional syphilitic taint. In the first instance, I did not see the case until the epiglottis was nearly destroyed by ulceration. The second case was that of an unmarried gentleman, of New York, who, several years before, had contracted syphilis, of which he had supposed himself to have been cured. After taking a severe cold in May, 1855, which was attended with inflammation of the throat, ulceration of the tonsils and soft palate set in, and was followed by oedema and ulceration of the epiglottis. When I first saw this patient, the disease had been progressing several weeks. A large ulcer had perforated the velum, and several smaller ones were about the left palatine arch, and in the sub-tonsillary fossa. The epi- glottis was extensively cedematous, and its superior por- tion much ulcerated. The act of swallowing was both difficult and painful. Constitutional remedies were ad- ministered, and the ulcerated points were touched with the solid caustic. Under this treatment the ulcerations healed rapidly; the oedema of the epiglottis was reduced, 274 PRIMARY LESIONS. and the patient, at the end of two or three weeks, could swallow without difficulty. He returned to his home in the country, and continued better until some time in July, when he had another attack, and came back to the city for further treatment. Similar measures were adopted, and at the end of a week he again returned home greatly improved in health. I saw no more of him until the 19th of October following, when he again called on me ; and on inspecting his throat at this time, I was greatly surprised to find that two-thirds of the epiglottic cartilage were already destroyed by ulceration. The remaining portion was freely cauterized with solid nitrate, but the ulceration was not arrested until the epi- glottis was almost entirely destroyed, a very small part of the cartilage only remaining. During the progress of the ulceration, the patient found but little difficulty in swallowing morsels of solid food in moderate quantities, but when he attempted to take liquids of any kind a violent spasmodic and suffocative cough ensued, by which the fluids were frequently ejected through the nose. After a few weeks, however, the parts adjusted them- selves to the exigency of the case, the glottis was closed without the aid of the epiglottis, and deglutition was ac- complished, and has ever since been performed without any embarrassment whatever; nor has phonation, in any degree, been interfered with by the loss of the epiglottis. This gentleman's case I have had opportunities of ex- hibiting to many physicians. By forcibly depressing the tongue, the lips of the glottis—not being concealed by the epiglottis—can be seen, and on directing the patient to make an effort at deglutition, the superior parts of the arytenoid cartilages have been seen to close laterally, like a double valve, over the glottic cavity. PRIMARY LESIONS. 275 In still another way we are able to demonstrate that the glottis in this case is closed after the manner I have described. By thrusting the middle and longest finger over the base, or roots of the tongue, the opening of the glottis can be reached by its point; and, on the moment of its touching the lips of the glottis, the irritation will cause a spasmodic closure of this opening, which can be distinctly felt by the finger. All this accords with the facts elicited, and the con- clusions adopted, by M. Longet, who has performed many interesting experiments on dogs, by completely excising the epiglottis, in several of these animals, and observing, subsequently, the effect of this operation on the act of deglutition. He found that solid food, after the removal of the epiglottis, still passed with facility, but that in the deglu- tition of liquids, some portions of the fluid would escape into the glottis, causing the convulsive cough. M. Longet also established this fact, that the closure of the glottis, sufficient to protect the trachea in deglutition, is still effected, ultimately not only after the loss of the epiglottis, but after a division of the nerves which control all the muscles proper to the larynx. This occlusion of the glottis, under such circumstances, he found was effected, not through the influence of the crico-thyroid, nor the thyro-hyoid muscles, for these were paralysed by a division of the nerves, but through the inferior constrictors of the pharynx, which by embracing the diverging alae of the thyroid cartilage, folded them one against the other; thus approximating the borders of the glottis, and closing, effectually, the opening of the larynx. In the cases to which I have referred, in which ulceration had destroyed entirely the epiglottis of the 276 PRIMARY LESIONS. patients, the occlusion was effected apparently in the man- ner pointed out by Longet, for in both these patients T (and the experiment was made by several medical men besides myself), in touching the opening of the glottis, the apices of the arytenoid cartilages, which form the lateral borders of this aperture, could be felt distinctly to close upon the end of the finger. What, then, is the special function of the epiglottis, if its presence is not absolutely necessary to the integrity of deglutition? The arytenoid muscles are the especial constrictor mus- cles of the glottis, and most physiologists have asserted that these muscles receive their nerves from the superior laryngeal; but M. Longet has demonstrated that they are supplied with filaments from the recurrent nerve, and that the mucous membrane covering the lips of the glottis, or the supra-glottic vestibule, in which is located that exquisite sensibility which is disturbed by the smallest drop of fluid, or the contact of any foreign body —that this space receives its filaments from the internal branch of the superior laryngeal nerve. These two nerves communicate freely with each other, but they have no connexion with the epiglottis, consequently the application of irritants to this body will have no influ- ence upon either the motor or sentient nerves, peculiar to the larynx. But when the irritation of the sensitive mucous membrane at the entrance of the glottis, occurs, it is quickly transferred to the constrictor muscles of the larynx. It is therefore not correct to state, as many anatomists do, that the epiglottis of itself " closes com- pletely the opening of the larynx" in deglutition. This cartilage being placed between the entrance of the larynx and the base of the tongue, is pressed down- PRIMARY LESIONS. 277 wards by the abasement of the latter, at the same mo- ment that the larynx is moved upwards and forwards in the act of deglutition, and the epiglottis is, in this way, moulded upon, and partially closes the glottis, protect- ing, at the same time, the sensitive mucous membrane which covers the supra-glottic space. Although contrary to the ordinary belief, yet we an- nounce the fact, one which can be demonstrated any day —as it has been a score of times, to medical men—that the epiglottis in its normal condition is an almost insen- sible organ ; it may be touched with the finger, with the handle of an instrument, without producing any irrita- tion. It may even be cauterized with the solid nitrate of silver, and no unpleasant sensation will be perceived by the patient, until the mucus which dissolves the caus- tic runs down and reaches the lips of the glottis, when a convulsive cough is produced. When, however, this cartilage is eroded, or ulcerated, these lesions cause an irritation, which is not unfrequently followed by a severe and persistent spasmodic cough. This irritation, and consequent cough, I have been in- clined to attribute to the morbid, or ulcerated secretion, running down and coming in contact with the exquisitely sensitive mucous membrane which covers the supra- glottic space; for this cough ceases at once, as we have seen, when this morbid exudation is arrested or changed. The special functions of the epiglottis, therefore, are, first, to render perfect the integrity of deglutition ; for, as M. Longet affirms, although men and animals when deprived of it, swallow without difficulty solid food, yet it is not the same with liquids, for this cartilage serves to direct, past the two lateral portions of the larynx, the drops of liquid which, after deglutition, still lie upon the 278 PRIMARY LESIONS. dorsum of the tongue, and which flow over the epiglot- tis, and by it are prevented from falling into the supra- glottic vestibule. 2d. In the act of vomiting, the occlusion of the glot- tis is effected by this cartilage, and thus the matters vomited are prevented from entering the trachea. In rumination also, in animals, the alimentary ball is, in the same way, hindered from falling into the glottis. TREATMENT OF CHRONIC PHTHISIS. 279 CHAPTER III. TREATMENT OF CHRONIC PHTHISIS FOLLOWING FOLLICULAR DEGENERATION OF THE MUCOUS MEMBRANE OF THE AIR- PASSAGES. In my view of the pathology of this disease, I have endeavored to show that the cellular degeneration com- menced in the follicles situated in the superior portion of the air-passages; that its progress is from above down- wards ; that the abnormal change beginning generally in the follicles of the posterior nares, or those of the pharynx or tonsils, extends into the valleculas, the pyri- form sinuses, to the epiglottis, and the superior opening of the glottis, and that the occupation of the glandulae in these locations constitutes the First or Proa-Tubercular stage of the disease. I shall therefore observe the following stages: 1. The First or Prae-Tubercular Stage of Phthisis. 2. The Bronchitic Stage of Phthisis. 3. The Tubercular Stage of Phthisis. Section I.—1. the first, or pr^e-tubercular stage of PHTHISIS. In the work to which I have frequently alluded, " Diseases of the Air-Passages," it is stated that the disease consists essentially in its formative stage of an inflammation—sub-acute in its character—of the mucous glandules of the nares, fauces, and pharynx; and is ex- 2SO TREATMENT OF CHRONIC PHTHISIS. tended thence by continuity to the glands of the epi- glottis, larynx, and trachea. After many years' experience in the treatment of a great number of cases of follicular disease, I have found it more convenient, and I think it is pathologically more correct, to limit the primary manifestation or prae-tuber- cular stage of phthisis to a degeneration of the epithelial element of the glandules of the aerial mucous membrane located in the fossa nasalis, the tonsillary glands, the pyriform sinus, and to those of the epiglottis, and about the opening of the glottis. As the follicles of these parts are ordinarily affected in the order they are here named, and as disease generally lingers for months, and often for years, about these follicles, before affecting those of the trachea and bronchi; and, moreover, as it is while the deterioration is limited to the epithelium of these parts, that the affection is more certainly reached by remedial measures, and the dyscrasia it produces more certainly arrested in this, than at a later stage of the disease, it seems most appropriate to consider this the first, or precursory stage of Tuberculosis. As it is in this precursory stage of the affection that the plan of treatment indicated is altogether the most likely to prove permanently effectual in arresting the malady, it is greatly to be deprecated that the attention of the physician is so seldom called to the disease, in this, its prae-tubercular stage. It has been stated in a former chapter that the onset of this disease is in many cases so insidious and its* pro- gress so gradual, that it may have continued for months, and even for years, making considerable advance before the presence of any prominent local symptom shall have called the attention of the individual to the permanent TREATMENT OF CHRONIC PHTHISIS. 281 existence of the affection. At length the patient per- ceives an uneasy sensation in the upper part of the throat; or his friends, perhaps, are first to observe in him a habit of repeatedly attempting by " hawking," or by the act of deglutition, to clear the throat of some- thing sticking, apparently, in the posterior fauces, or at the top of the windpipe. Earlier, or it may be about the same time, the voice appears changed; slight hoarse- ness is present, which at first is hardly perceived in the morning, or after meals, but which is increased towards evening, and after speaking or reading longer or louder than usual. The glandules, which in their normal state secrete a bland and transparent mucus, now pour out an increased quantity, which having become viscid, opaque, and adherent, and changed in quality, not only commu- nicates the disease to related neighboring parts, but in- creases the irritation in these parts. In this condition the symptoms may remain for a long period, nearly disappearing at times, and then being greatly aggravated by vicissitudes of temperature, in- creased exercise of the vocal organs, and by various other morbific causes. Yet I have seldom known the disease to disappear spontaneously after progressing to this extent, although it may continue for many years, and even through life, without awakening tubercu-" losis. If we examine the throat during the progress of the above symptoms, we shall find the epithelium that covers this tissue in its normal state, more or less destroyed, its absence being manifested by the slightly raw or granu- lated appearance presented by that tissue. The membrane itself is frequently thickened, the follicles will be found hypertrophied, and to have become distinctly visible, 282 TREATMENT OF CHRONIC PHTHISIS. particularly those studding the upper posterior and late- ral parts of the pharyngeal membrane. (Vide Fig.) In those cases where the disease has been long con- tinued, a portion of the follicles will be found in some instances greatly enlarged and filled with a yellowish substance, having a resemblance to, and presenting the physical character of, tubercular matter. These single diseased and distended follicles are not readily observed, and are therefore frequently overlooked. A single fol- licle situated in the tonsil or in the lateral tissues of the fauces, will in some instances become greatly enlarged by active heterogenous proliferation, its membrane stretching so as to become the size of a large pea or even that of a hazel-nut, and be filled with degenerated epi- thelial cells. A gentleman of this city, whom I treated for long- continued and severe chronic folliculitis, was greatly dis- posed, during treatment, to this morbid distension of single follicles. When he came under treatment several were observed, filled with cheesy matter ; one located at the side of the throat, just above the pyriform sinus, was distended by this characteristic lardaceous matter, which, on microscopic examination, presented the same tubercu- lar appearance found in the cavities of diseased tonsils. '(Fig. p. 218.) As these distended follicles frequently do not burst for many months, they should be opened, the contents pressed out, and the sac cauterized with the solid crystal. It has been stated that the tonsillar glands are com- posed of aggregated follicles. In many cases, as we have seen, the deterioration commences in the cellular ele- ment of these organs, and we frequently find the tonsils hypertrophied, and exhibiting positive evidence that TREATMENT OF CHRONIC PHTHISIS. 283 some portion of the gland is in a morbid condition, and is constantly furnishing a pathological fluid, " which, when brought into contact with the neighboring parts, may then exercise an unfavorable contagious or irritative influence." (Virchow, p. 487.) It is at this stage of the progress of the disease that so much will depend upon the course to be adopted by the attending physician, that success, ordinarily, will not attend a temporizing method of treatment. Case.—Dr. D. P., a physician of Brooklyn, called on me January 28th, 1863. Some two or three years be- fore he began to be troubled with irritation in the throat, which would occasionally interrupt for a few days his professional duties. Still he continued to attend his patients in the city the principal part of the year, although very slight exposure was quite sure to make him worse, and oblige him to intermit his duties for some days. About four months before he called to con- sult me, he began to have almost constant trouble in his throat, with pain and irritation at the top of his larynx, causing a desire to "hem," or to clear the throat of viscid phlegm, or matter, which appeared to be con- tinually collecting in the fauces. He called on several of his professional brethren for advice, all of whom, on examination, assured him that his throat was not much '' diseased," that the difficulty came from his stomach, etc., and advised a course of blue pills, followed by tonics, etc. This course, pursued several weeks, did not seem to relieve him permanently. Objections were made to propositions to visit me, as several physicians declared his disease was not in the throat; and as he had no con- stant cough, it could not arise from disease of the lungs. He was therefore dissuaded, for many months, from con- 284 TREATMENT OF CHRONIC PHTHISIS. suiting me. However, he came at the time above named, notwithstanding a professional friend in New York, after examining his case a few weeks before he came to me, had said that it was not diseased. But so positive was Dr. P. that disease existed there, that the very day he visited me, he called on his friend, and requested another examination, but the Doctor again assured him most po- sitively, that no disease existed in his throat! and he advised him to have no local treatment, as that was not indicated in his case. On auscultating his chest, a normal state of both lungs was found to be present; slight bronchial rale, alone, on one side was found. But an examination of the throat revealed extensive chronic folliculitis. Enlarged and in- durated follicles studded the lateral posterior fauces, the tonsils were greatly hypertrophied and diseased, from which quantities of purulent or caseous matter could easily be discharged by pressure with the finger. (See Figs. 11 and 18.) The uvula was elongated; and on depressing the tongue, so as to see the epiglottis, much of its superior border was found to be serrated with old ulcerations and erosions. Without then knowing what his medical friends had told him, I expressed the opinion that his disease origi- nated in the cellular element of his throat, and that the excision of the tonsillary glands, and amputation of the uvula, followed by topical medication, etc., wrould be ne- cessary for the successful treatment of the case. As some objections were made to this plan of treat- ment, I refused to,take charge of the case, unless it could be carried out. On the 30th the Doctor returned, and requested that the treatment might be employed. The hypertrophied portions of the tonsils were excised, TREATMENT OF CHRONIC PHTHISIS. 285 the uvula truncated, and a solution of crystals of nitrate of silver, of the strength of 80 grains to the ounce, was applied to the enlarged follicles, and to the epiglot- tis; and Form. No. 16 advised, in drachm doses to be taken twice daily. The topical applications were con- tinued every few days until the last of February. Improvement began immediately. The throat healed in a few days, and on the first of March Dr. P. called to # tell me that he had entirely recovered. He has been ever since in robust health. Every year during the last twelve or fifteen years I have saved many valuable lives, I believe, by the em- ployment of prompt and radical measures in the treat- ment of these well marked cases of follicular degenera- tion. When the diseased glandules can be reached (those occupying the surface of the tonsils, and those stud- ding the mucous membrane ordinarily can be) by topical medicaments, the pathological change can gene- rally be arrested by these measures; but when conglome- rated follicles are involved, and particularly those located in the centre of the gland, excision of the diseased por- tion becomes absolutely necessary to insure the success- ful treatment of the case. That the operation is attended with but little pain, and when properly performed, is without danger, the author endeavored several years ago to show in his work on "Diseases of the Air-Passages," p. 216, etc. With a knife, having a long and slender blade, termi- natino- in a probe point, and a pair of double hooks, the gland is seized, drawn out from between the pillars of the fauces, and excised at any point chosen. Having operated with these instruments in many 286 TREATMENT OF CHRONIC PHTHISIS. thousand cases with perfect success I can truly aver that I have never known an instance where any real danger attended this operation. The haemorrhage that follows is in some cases quite free, but never in such excess as to endanger the patient. Indeed the occur- rence of pretty free haemorrhage in these cases is always followed by good effects. Nor is there any difficulty to be apprehended in trun- cating an elongated uvula. Various instruments have . been employed for performing this operation. The most simple and altogether the most convenient instruments are the curved scissors, and a pair of long and slender forceps, having finely serrated blades. With these forceps the extremity of the uvula is seized, and the scissors being carried into the mouth, the excision of the organ at any point may be safely per- formed. It is rarely indeed that the operation for excising the tonsils has to be performed a second time; and yet cases occur where it becomes necessary several times in the same individual to remove a diseased portion of the gland. Occasionally a case occurs where a strong tendency to tubercular dyscrasia exists, in which the remaining ele- ments of the gland will take on proliferation, and diseased hypertrophy will again occur. In such cases I have found that the permanent health of the patient will depend on the removal of the deteriorated portion. A gentleman of Massachusetts came under my care several years ago, who had labored under chronic folli- cular disease some three or four years before coming to me for advice. He was predisposed to tuberculosis, and he presented many of the earlier signs of the disease. TREATMENT OF CHRONIC PHTHISIS. 287 His tonsils were greally hypertrophied and diseased. These were freely excised, followed by appropriate local and general treatment for five or six weeks. Under this treatment all his unpromising symptoms disappeared, and he returned to his business apparently restored to perma- nent health. About six months afterwards he returned to me, pre- senting very much the same appearance he did on his first visit. He stated that his health after his first visit continued good several months; that he had never been better during any period of his life; when, about ten months previous, after taking a slight cold, he began to perceive a little uneasiness on one side of his throat. This at length caused a frequent desire, as at first, to clear the throat; a cough soon after came on, which, con- tinuing to increase, alarmed him about his lungs, and he determined to visit me again. On auscultating his chest, evidences of bronchial disease were quite apparent on the right side; the lungs were normal. The throat appeared healthy, all save the right tonsil, which was enlarged to nearly the extent it was when he first came to me, from the distended cryptae of which ichorous juice was being constantly secreted. The enlarged and diseased portion was immediately excised, and topical applications of nitrate of silver were made into the pyriform sinus of that side, and into the laryngeal cavity. His cough soon subsided, and in a week or two he returned to his home again, quite recovered. He nowr continued to enjoy good health for nearly a year longer, when he returned the third time, with the follicles of the left tonsil enlarged again by proliferation, and causing the same class of symptoms on that side, which was awakened the previous year by disease in the 288 TREATMENT OF CHRONIC PHTHISIS. cellular element of the right tonsil. The operation for excision, of the diseased portion of the gland, was per- formed the third time in this case, and the patient has since, during a period of six years, enjoyed uninterrupted health. Cases of this nature seldom occur when the operation is at first well performed, yet they are occasionally found; and whenever heterogenous proliferation in the elements of the tonsillar organ occurs, it will become necessary, as we have remarked, to excise the degenerated portion. Ten years ago, a merchant of Boston, whose mother and several other members of whose family had died of phthisis, called on me for advice. His tonsils, which were very much enlarged and much ulcerated, and which for two years before had caused him great trouble, were excised ; and the hypertrophied and diseased follicles of the aerial passages were appa- rently permanently removed by the employment of appropriate topical and general measures. For eight years after this treatment he enjoyed excellent health, until two years ago, when he called on me, exhibiting many of the symptoms of the prae-tubercular stage of phthisis. An examination of the throat revealed no diseased follicles of the membrane; but the right gland, which ten years before had been pretty freely removed, was again hypertrophied and was discharging a pathological fluid, which, when brought into contact with the neigh- boring parts, was exercising an unfavorable contagious or irritative influence. I advised an immediate operation for its removal. This was done, and was followed by a few applications of a solution of nitrate of silver to the surface of the TREATMENT OF CHRONIC PHTHISIS. 289 gland, and down into the pyriform sinus of that side. All the unfavorable symptoms which for two or three months had been present, disappeared, and for two years he had been in most robust health. A microscopic examination of the part named pre- sented the appearance shown in Fig. 6 in the Appendix. I desire, sincerely desire to impress upon the profes- sion the great importance of excision of the heterologous or pathological formations which are so frequently found in degenerated tonsils. Every day of my life I have per- sons presenting themselves at my office, whose lives are saved only by this operation, followed by appropriate remedies. This very day two gentlemen came from the army, the one a chaplain, the other a surgeon, from each of whom I removed greatly enlarged and diseased ton- sils, and both of whom have suffered many years under severe chronic follicular disease. Both of these gentlemen have been repeatedly examined by different physicians, who attributed their ill-health to some other cause. The surgeon had been examined and treated by two eminent professors of one of our medical colleges, who declared to him that the difficulty, the disease in the throat, of which he had made great complaint, was of little conse- quence, and would result in no injury to him. I found the cavities in the pathological hypertrophies filled with a caseous, contagious fluid, which had already conveyed disease into the pyriform sinus, and had extended into the bronchi of the right side. Cough and expectoration showed this extension of the disease; and as two or three members of his family had already died of phthisis, he became alarmed, and obtaining a furlough for the pur- pose, he left the division of Burnside, and came directly to New York for medical treatment. I feel confident 19 290 TREATMENT OF CHRONIC PHTHISIS. that I shall be able in a tew weeks to restore this patient to confirmed health. I have stated on a former page that the numerous compound glandules in the pyriform sinuses were very likely to be early affected by the ichorous exudation that is constantly passing from a diseased tonsil over the lining membrane of the throat to the parts below. When this occurs the symptoms of which the patient complains are ordinarily intensified. The desire to swal- low, or to clear the throat by hemming, is more frequent. Frequently the patient complains of pain, or of a con- stant uneasy sensation on one or both sides of the throat. If both sides are affected, he will refer the sensation to the central portion of the throat, near the position of the pomum adami. By depressing the tongue with a bent spatula, the inflamed or granular appearance of the membrane can be at once detected. This pathological condition of the sinus is most readily observed by the use of the reflector of the laryngoscope. The repeated application of the local remedy, by means of a small sponge-probang down into the sinus, will very soon arrest the diseased action in this position. The same treatment will be required when the follicles situated in the small valleculas at the roots of the tongue are involved. SECTION II.--THE BRONCHITIC STAGE OF PHTHISIS. We frequently find nearly the same class of symptoms manifested in the bronchitic stage of the disease, or after the degeneration has extended to the follicles of the trachea and bronchi, that was present whilst the affec- tion remained principally about the superior portion of the air-passages. The sputum soon 'becomes increased in TREATMENT OF CHRONIC PHTHISIS. 291 quantity, and is changed in quality, for on examination of the expectoration coming from the trachea, we find the microscopic changes that are observed in the collec- tion, taken from the cavities of the tonsils, or from the glands of the pyriform sinus. (See Fig. 6.) As the pathological exudation extends to the neigh- boring follicles of the trachea and bronchial divisions, the sputum will frequently not only be increased in volume, but will often present a yellowish white or a greenish yellow appearance; and the patient often begins to exhibit that dyscrasic or ancemic condition of the sys- tem, to which we have alluded on a former page. The countenance appears more pallid than in health, and the mucous membrane after a time, as we have said, par- takes of the same morbid condition. But this condition frequently exists a long time before tuberculosis is recog- nised as a disease. In this stage alterative medicines (Form. No. 16, vel No. 19) and tonics (Form. No. 10, vet No. 11) should be continued in connexion with the topical measures through many weeks. Since the commencement of the present unhappy war, I have treated a large number of soldiers from the fi«ld, laboring under follicular disease, which appeared to result fro*m repeated colds contracted by exposure in camp. These cases were attended by partial and complete aphonia in many instances, from which, generally, they recover readily by early and appropriate treatment. But in other cases the disease, when neglected, becomes difficult to arrest. October 15, 1861, Gen. G., U. S. A., set. 30, came to me, aphonic, with cough and expectoration. I examined his case. He had had catarrhal symptoms, wTith some difficulty in his throat, during several years; but sup- 292 TREATMENT OF CHRONIC PHTHISIS. posing it to originate from a cold, he hoped it would soon pass away. But the hoarseness and cough continued, 1 until they began to interfere with the discharge of his military duties, and he came to consult me concerning the difficulty. On examining his case, I found the post-pharyngeal membrane, the sides of the fauces, and the nares, covered with hypertrophied glandules. He coughed and expec- torated constantly, but not very freely. Auscultation revealed some bronchial affection, but the lungs were found in a normal condition. I advised topical and general treatment, and expressed the opinion that the disease might be removed, proba- bly, in a few weeks. I made an application to the pharyngeal and faucial-membrane, but as he could not at that time remain for treatment, I prescribed a solution of iodide of potassium, and a gargle of creasote and tinct. myrrh, and he returned to the army, promising to obtain a furlough, and return for further treatment in a few weeks. By the use of the gargle and the alteratives, he was much relieved, and his engagements being press- ing, I saw nothing more of him till after the attack upon and siege of Fort Pulaski, which was conducted by him. After which he obtained a furlough for several wee*ks, and came back for treatment in April, 1863, eighteen months after I first saw him. He had suffered almost constantly in the meantime with ulcerated throat. April 23d. His cough has increased, expectoration more abundant. Enlarged and inflamed glandules are numerous in the membrane of the throat, the pyriform sinus, and aperture of the glottis. The upper part or central portion of the border of the epiglottis is serrated with erosions, and auscultation reveals the presence of TREATMENT OF CHRONIC PHTHISIS. 293 follicular bronchitis on both sides. But the follicles of the tonsils appear to have escaped, and present nearly a normal condition—a condition which I always consider favorable in cases where follicular disease has been pro- gressing through several years. But the aphonic voice, the cough, and increased bronchial expectoration, as well as the physical signs revealed, indicate the extension of the disease along the membrane of the bronchi and their divisions. But a careful exploration does not reveal any abnormal condition of the lungs themselves. The General stated that he had been sent on for treat- ment, and any length of time he might need for the same should be allowed. April 28th. I commenced the topical treatment, and administered Form. No. 16 as an alterative. The appli- cation of the argent, nitrat. was repeated on the 29th, and was continued every day, until the 20th of May. Under this treatment Gen. G. improved constantly. The diseased follicles disappeared entirely, and the mem- brane, as far as could be seen, presented nearly a normal appearance. The cough was greatly diminished, but as it continued to some extent, and the expectoration, although much less, continued, it was deemed advisable to inject the bronchi. On the 19th of May I introduced the elastic tube, and injected through it a drachm and a half of the solution of the strength of ten grains to the ounce of water. No cough or pain followed this operation. This treatment was continued until the 6th of June, when Gen. G. felt able to return to duty. He was imme- diately ordered to Charleston, to commence the siege of that city, and has since continued in the faithful dis- charge of his duty. 294 TREATMENT OF CHRONIC PHTHISIS. The following case is of much interest, inasmuch as it not only illustrates the plan of treatment employed, but it afforded an opportunity after treatment, of comparing the lesions with the symptoms which existed during life, and of observing the effects of the treatment upon these lesions. G. H. W. called on me for medical advice, May 10, 1850. His case presented all the well marked symptoms of laryngeal phthisis. There was ulceration of the larynx; the epiglottic gland, which we have seen is composed of a nest of cel- lular granules,was found early in the case to be occupied by an open ulcer. Complete aphonia existed, with a severe cough ; diffi- culty of swallowing, with dryness and heat in the throat; some pain was present, which was increased on cough- ing. On examining the chest, there were found indica- tions of the presence of tubercles in both lungs, and evidence of a cavity in the left lung. The throat was inflamed, the epiglottis thickened and vascular, its bor- der serrated with erosions, and its lateral edges approxi- mated, so as to give the cartilage a more crescentic shape than is natural. It is unnecessary to detail at length the treatment adopted. Both topical and general remedies were employed. Applications of a strong solution of nitrate of silver were made successively to the fauces, the epi- glottis—its border and laryngeal surface—to the glottis, and subsequently into the larynx, and thoroughly down into the trachea and bronchi; the patient was invigo- rated by tonics and good living. Under this treatment the patient gradually and con- stantly improved. He regained his voice, his cough TREATMENT OF CHRONIC PHTHISIS. 295 diminished, and his strength and flesh were considerably increased. Mr. W. was absent during the month of August, but he returned in September, and the applica- tions being again renewed, and for a time continued, were followed by such an improved state of health, that he returned to his occupation, which was that of book- keeper in a large mercantile house in this city. On the 1st of January he called on me. At this time he coughed occasionally, and had some slight purulent expectoration, but he still continued greatly improved. After this I lost sight of him for several years, and knew nothing more of him until informed of his death by my colleague, Dr. H. G. Cox, who has kindly fur- nished me with the history of his last fatal attack, and of the autopsy of the case. Until within a few days of his death, Mr. W. had continued to enjoy such health that he was able to attend constantly to the duties of his calling. Dr. Cox, who attended his family, had seen him often, and had occa- sionally prescribed for him. Early in September, 1853, nearly four years after I first saw and treated him, he had left his place of business, one very cold and windy day in December, and was returning to his home. Wish- ing to see a gentleman who lived in the west part of the city, he jumped from the omnibus at Canal street, and ran for some distance, facing a strong, cold wind, when lie was suddenly arrested by a haemorrhage from the lungs. He was obliged to be taken home in a carriage. Dr. Cox was sent for, who found him raising, quite fre- quently, masses of coagulated blood. Every effort was made to arrest the bleeding, but all measures were equally unavailing. The haemorrhage, which lasted two or three days, continued till the patient died. The 296 TREATMENT OF CHRONIC PHTHISIS. body was examined by Dr. Cox. Evidences of former tubercles were found in the lungs, but no recent ones. In the left lung were the remains of a tuberculous cavity; and opening into this dry cavity, was the mouth of a small ruptured blood-vessel, the haemorrhage from which had caused the patient's death. On examining the epiglottis, larynx, and trachea, Dr. Cox found the cicatrix of a large ulcer at the centre and base of the epiglottis; and scattered over the mucous membrane of the larynx and trachea the cicatrices of numerous small superficial ulcerations were found. All had been perfectly healed. (Plate XXII.) Knowing that this patient had been under my care for several years before (as above detailed) Dr. Cox removed the larynx and a portion of the trachea, and sent the morbid specimen to me. By examining this pathological preparation, the marks of the follicular ulcerations along the tracheal membrane may be plainly seen, particularly the cicatrix of the large ulcer at the base of the epiglottis. Now, I respectfully submit, if these erosions and ulcerations were caused, primarily, by the passage of tuberculous matter over the mucous membrane of the parts where they were found, as M. Louis and others believe, how is it that they were healed ? (for the puru- lent expectoration continued long after being arrested) or, being healed, how should they have continued healed, through so long a period, when the cause of their pro- duction was remaining, for a time, constantly in opera- tion ? PATCH®IU!§Y M 1M ODSEME Plate. XXII Ulcerations of Mllcoa V^ribrane of Larynx St Trachea. TREATMENT OF CHRONIC PHTHISIS. 297 SECTION III.—THE TUBERCULAR STAGE OF PHTHISIS. The attempt has not been made in this work to trace distinctly and positively the line of demarcation between . the non-tubercular and the bronchitic stage of phthisis, on the one hand, and the tubercular stage of the disease, on the other. In the first chapter of the work we alluded to the unfortunate fact, that it is not until the antecedents have given place to the consequent—not until the morbid product has to some extent blocked up the air-cells, that the physical signs, which constitute the only positive evidence of the actual presence of tuber- cular disease, disclose to us the true nature of the malady. It has been constantly insisted upon that deterioration in the cellular elements of the aerial membrane may com- mence, and often continue through an indefinite period, before proliferation shall take place in the air-cells of the lungs. Where no hereditary or tubercular taint is pre- sent, the dyscrasia which accompanies, and which marks the advent of this stage, is generally slow in its approach; and to my mind, the absence of all hereditary predis- position affords the best evidence of the curability of the case. But let this pathological degeneration be con- tinued in the cellular element of the tissues, and sooner or later that anaemic condition of the fluids to which we have alluded, as indicative of the presence of a tubercu- lar dyscrasia, will be quite likely to occur. It is a matter, therefore, of the highest importance, that the treatment of the disease be entered upon before it has reached this stage. Whenever the system is reduced by long-continued follicular disease, and especially if the anaemic condition of the fluids to which we have referred be present 298 TREATMENT OF CHRONIC PHTHISIS. alterative medicines and tonics, both vegetable and mineral, should be adopted; and together with topical treatment, be persistently employed. The iodide of potassium (or Form. No. 19) should be given in teaspoonful doses night and morning, and Form. No. 11, or Form. No. 8, may be administered in drachm doses, either alone, and continued; or one of the tonic preparations should be alternated with the others, and the tonic, together with the topical applications, may be continued with advantage through many months. Local measures of the same character are to be employed in the treatment of the affection, after the pathological change has involved the epithelial cells of the bronchial membrane, and those of the air-sacs, as those recommended in the treatment of the disease in the first stages. In the management of the bronchitic stage, a difficulty at first arose from our inability to intro- duce, by means of the sponge-probang, a sufficient quan- tity of the caustic solution into the bronchial division; for on passing the instrument into the glottic opening, and through the rima of the glottis, much of the fluid would be discharged from the sponge before it reached the tracheal division. On this account I was accustomed, in a multitude of instances, when treating the bronchitic or early stage of tuberculosis, to introduce the satu- rated sponge several times at the same sitting, in order that an increased amount of the fluid might be conveyed into the bronchiae; and it frequently happened that patients observing the effects, would return in a few days, and request that as much of the fluid as possible should be passed into the windpipe, as the cough and expecto- ration, they declared, were invariably greatly improved ,by the operation. TREATMENT OF CHRONIC PHTHISIS. 299 For these reasons bronchial injections were adopted, and have been constantly employed more or less in the treatment of the bronchitic and tubercular stages of tuberculosis. I do not intend here to enter into a discussion of the anatomico-physiological questions involved in the subject of the possibility or the practicability of this operation, of introducing medication into the air-tubes by means of either the sponge probang or the bronchial tube. Much unprofitable disputation on these subjects has, in former times, occupied the attention of the profession—a ques- tion which may be, as it has been, settled by the laryngo- scopists; as with this instrument the sponge-probang and the tube may be seen, and has been seen, to enter the trachea with perfect ease. But the important fact to be remembered is, that in the incipient stage of follicular deterioration, the disease is often successfully treated without entering the windpipe by either of these instru- ments. Many of these cases to which I have referred, were restored to perfect health, by applications made to the diseased membrane, above the trachea. The cases in the following chapter are intended to illustrate the benefit to be derived from catheterism of the air-passages in this stage of the disease. 300 CATHETERISM OF THE BRONCHIAL TUBES. CHAPTEK IV. SECTION I.—CATHETERISM OF THE BRONCHIAL TUBES. In December, 1854,1 read a paper before the Academy of Medicine of New York, " On the Injection of the Bronchial Tubes and Tubercular Cavities of the Lungs;" and subsequently, namely, in March, 1856, I published in the American Medical Monthly a detailed report, containing a statistical table of one hundred and six cases of pulmonary and bronchial diseases, treated by means of catheterism of the air-passages, conjoined with appropriate general remedies. Still continuing this plan of topical treatment in diseases of the chest, I have since had opportunities to confirm the truth of some of my early observations; and, what is of equal importance, to correct other views which later experience and more extended observations have shown to be erroneous conclusions. It is to record and announce these recognised errors, and to point out some of the difficulties, as well as the advantages that attend this plan of treatment, that I bring the subject of Topical Medication before the profession. I propose briefly to consider the following questions: 1. Can the operation of catheterism of the air-passages be performed with certainty and facility ? 2. What are the difficulties and dangers of the opera- tion? 3. What advantages are to be derived from this method of treatment ? catheterism of the bronchial tubes. 301 1. With regard to the first inquiry—the possible prac- ticability of the operation ? On this point it will not be necessary long to dwell. As very few of the profes- sion, at the present day, will deny its performance, under favorable circumstances, I shall only refer to the opinion of a few members of the profession, from among,many of those who have considered this question. At the discussion that followed the reading of my paper, to which I have alluded, on bronchial injections, before the Academy of Medicine, several years ago, it was remarked by a distinguished member of that body, who denied the practicability of the operation, that " the Academy-must not decide this question until we had heard from Europe on the subject, as the profession there would act without prejudice or partiality." Already, testimony has come to us from eminent men of the profession, in Great Britain, France, and Germany, that this operation of injecting the bronchi has by them been successfully performed. Prof. J. Hughes Bennett, of Edinburgh, in his work, Clinical Lectures on Medicine, says: " I have now intro- duced the catheter publicly in the clinical wards of the Iloyal Infirmary, in several patients affected with phthisis in various stages, in laryngitis, and in chronic bronchitis, with severe paroxysms of asthma. * * * I have been surprised at the circumstance of the injections not being followed by the slightest irritation whatever, but rather by a pleasant feeling of warmth in the chest (some have experienced a sensation of coolness), fol- lowed by ease to the cough, and a check for a time to all expectoration." " These facts are made known to the profession," Dr. Bennett declares, " with a view of recommending a practice which, if judiciously employed, 302 ' catheterism of the bronchial tubes. may form a new era in the treatment of pulmonary diseases."* t In Paris, Prof. Trousseau, Loiseau, Blondeau, and others, have succeeded in injecting the air-passages, in various diseases of these parts. It has been employed in early phthisis, by M. Trousseau, as well as in diphthe- rite, in which latter disease it was attended with com- plete success. It has been still more extensively employed by Loiseau, in the treatment of both diphtheritis and. croup. The method of Loiseau is thus described by Trousseau, who was appointed by the Imperial Academy of Medicine, of Paris, to report upon his plan of treatment: " With the extremity of the forefinger," says M. Trousseau, " he (Loiseau) depresses the tongue, seizes the epiglottis, raises it, and presses the end of the finger between the aretino-epiglottic folds. There is then nothing more easy than to make the end of the tube glide over the finger. The air which escapes through the exterior ex- tremity of the tube proves that it has really entered into the larynx. Through this tube, serving as a conductor, a caustic, the nitrate of silver, for example, or any other medicated substance, may be carried." In the discussion which took place at the time, before the Academy, on this subject, M. Depaul said, "The process of catheterism of the larynx, as proposed by Dr. Green, was declared by some as being very difficult, even upon the cadaver; but I maintain," said he, " that nothing is easier than this catheterism for those who have performed it a certain number of times." Still more recently than this, comes to us the testimony of Prof. * See Clinical Lectures on Medicine, p. 609. CATHETERISM OF THE BRONCHIAL TUBES. 303 Greisenger, of Germany, as reported in the Deutsche Klinik, and in the Gazette Hebdomadaire. Prof. Greisen- ger has been able, as he affirms, to introduce medications of nitrate of silver solution into the air-passages. In regard to the practicability and danger of this operation, Prof. G. says: " For us, after the experiments we have made, we can affirm that these fears are illusory, and that the different parts of the operation can be performed with a rigorous exactitude." And, finally, we have the testimony of the Committee, appointed by the New York Academy of Medicine, to inquire into the truth of the performance of this operation ; for they affirm, in their report made to the Academy, that of the thirty- two patients upon whom the attempt was made to inject the bronchi, the operation was performed in eleven cases successfully, and to the entire satisfaction of the com- mittee. It must, therefore, be concluded that the " operation of catheterism of the air-passages," under appropriate circumstances, can be positively per- formed. Notwithstanding this operation is being daily per- formed at the present time, yet it is not always accom- plished with certainty and facility. Nature has so guarded the opening into the aerial passages that cathe- terism of the bronchi is an operation that will be found difficult often to accomplish. In many cases, I am confi- dent, the tube passes over the glottic aperture, and enters the oesophagus, even when the operator feels quite cer- tain that it has been introduced into the larynx. In my own practice I have found myself deceived, not unfre- quently, especially in the first years of my experience in this mode of treatment. At first I believed the instru- ment to have taken the right course, but afterwards 304: CATHETERISM OF THE BRONCHIAL TUBES. ascertained, in many instances, that it had entered the oesophagus. 2. What, then, are the difficulties that oppose them- selves to the facile performance of this operation, and what the dangers % The epiglottis does not of itself close entirely the aper- ture of the glottis. This cartilage being placed between the entrance of the larynx and base of the tongue, is pressed downward by the abasement of the latter, in the act of deglutition, and being moulded upon, only par- tially closes the glottis. It is not, therefore, correct to state, as many anatomists do, that the epiglottis " closes completely, of itself, the opening of the larynx" in deglu- tition. The arytenoid muscles are the especial constrictors of the glottis. These muscles (as Longet has demonstrated) receive filaments from the recurrent nerve. Covering the lips of the glottis is a narrow zone of exquisitely sen- sitive mucous membrance, which receives its nervous filaments from the internal branch of the superior laryn- geal nerve. These two nerves, the one supplying the constrictors, and the other this strip of mucous mem- brane, communicate freely with each other, but they have no connexion whatever with the epiglottis. The irritation of this body, therefore, will have no effect upon either the motive or sentient nerves peculiar to the larynx. This is important to remember, namely: that the epiglottis, in its normal state, is an organ nearly insensible; but when the least irritation of that sensitive portion of the mucous membrane which covers the supra- glottic space occurs, this irritation is quickly communi- cated to the constrictor muscles, through filaments of the recurrent and laryngeal nerves, and the aperture of the CATHETERISM OF THE BRONCHIAL TUBES. 305 glottis is as quickly shut up. When it is desirable, there- fore, to medicate the aerial passages in disease of these parts, it is necessary, as all are aware, to educate the glottic aperture, by repeated cauterizations of this open- ing. For if, under ordinary circumstances, the attempt be made to pass the sound, or probang, into the larynx before the exquisitely normal sensitiveness of this point of membrane be partially subdued, it will prove abor- tive ; or, if successful, and the instrument be made to pass the supra-glottic guard, a violent spasmodic action, not only of the constrictors, but of all the other muscles of the larynx, will occur, followed, often, by great irrita- tion of the parts, and a suffocative cough; and if, under these circumstances, the operator persist in finishing the operation, by injecting a solution of the nitrate of silver into the bronchi, the irritation and cough are both greatly increased, and in some instances inflammation of the bronchial and pulmonary tissue has been awakened, apparently by these combined disturbing causes. This condition, as the result of these causes, may be illustrated by the following case : Mrs. F., a widow lady, aged 35, recently returned from California, came under my care July 31, 1858 ; she was in the second stage of tubercular consumption. Auscul- tation revealed tubercles, with softening in the right lung. The disease of the lungs had been preceded by follicular laryngitis for many months. The right tonsil, which was still ulcerated, was nearly destroyed, and the pharynx was granular from the diseased and enlarged follicles. She was placed under general treatment, ordinarily adopted in such cases, together with the application of a solution of nitrate of silver to the throat. This treatment was continued until the 13th of August, 20 306 CATHETERISM OF THE BRONCHIAL TUBES. when the parts were thought to be sufficiently prepared to allow the introduction of the injecting tube. On this day I introduced, without any difficulty, the tube, and injected a drachm of the nitrate of silver solution into the right bronchus. No irritation followed the opera- tions. As is the case almost invariably, after injections in either pulmonary or bronchial diseases, the cough and expectoration were considerably diminished for several days after this operation. With intermediate cauteriza- tions with the sponge-probang, the bronchial injection was employed on the 16th, the 20th, and the 24th, with similar beneficial results with the first operation, the patient continuing constantly to improve. On the 26th of the month, in attempting to use the tube, the throat of the patient was found to be unusually sensitive, and it was with some difficulty that the instrument was intro- duced into the larynx. It was passed, however, into the trachea, in precisely the same way that it had been done on former occasions. A spasm of the glottis immediately succeeded its introduction, and instead of withdrawing it at once, as it should have been done, I proceeded to finish the operation, and injected a drachm of the solu- tion (15 grains to the ounce) into the bronchi. By the time the operation was completed, the whole chest seemed thrown into a violent spasmodic action; a con- vulsive cough, with dyspnoea, followed, which continued during several hours, but was finally somewhat relieved by the use of chloroform, and the administration of ano- dynes. The cough and dyspnoea, however, with increased expectoration, and pleuritic pains, continued for several days; and, although the patient became in the course of a week quite cofnfortable again, under general treat- ment, yet she never entirely recovered the favorable CATHETERISM OF THE BRONCHIAL TUBES. 30 7 state she was in before the occurrence of the spasm. As the patient and friends were greatly opposed to any fur- ther topical treatment, it was never afterwards employed. The pulmonary symptoms increased, the disease pro- gressed, as usual in such cases, and the patient died on the 10th of October, about two months after the last employment of the tube. Remarks.—The above was a well-marked instance of tubercular disease of the lungs, following a long-con- tinued case of folliculitis; one of those .cases, in short, a great number of which in their early stage, in the hands of other practitioners, as well as in my own, have been, and are, successfully treated by topical medication, con- joined with general remedies; and, although a cure in this case could not, probably, have been effected, yet, from the favorable progress made before the operation on the 26th, I am confident in the belief that the life of the patient would have been prolonged by the treat- ment, if it had not been for this untoward occurrence. A case, similar to the one I have related, came under the observation of my assistant, Dr. Richards. Not havino" been present when the operation was performed by Dr. R.T I take his account of the case. The patient, Mr. D. M., had been long under treat- ment for obstinate chronic bronchitis. Topical medica- tion, by means of the tube and sponge-probang, had been repeatedly employed, and the patient had been greatly benefited by the treatment. Mr. M. is the same patient whose case is mentioned by the Committee of the Academy of Medicine in their report on Bronchial Injections. His case is No. 30; and the Commission thus speak of the success of the operation, as then per- formed in their presence: " The tube," say the Commit- 308 CATHETERISM OF THE BRONCHIAL TUBES. tee, " was passed without much strangling; the air was freely expelled through the tube. An injection of two or three drachms of a solution of the nitrate of silver, of the strength of thirty or forty grains to the ounce, was then thrown in. All present were satisfied that the experiment was successful." In this instance, as the report affirms, no irritation followed the operation, nor had any irritation attended any previous operations. But on a subsequent occasion, namely, on the 20th of May, 1856, he called to have this tubing operation repeated. Dr. Richards, being in attendance that morn- ing, introduced the tube in the same manner as it had been done, both by Dr. R. and myself, on many former occasions. At this time, however, a spasm, from some cause, was immediately induced; Dr. R. did not with- draw the instrument, but proceeded to inject, as at other times. By the time the operation was finished, the mus- cles of the throat and chest were violently convulsed, and this was followed by a suffocative cough and profuse expectoration. This irritation, increased cough, and expectoration lasted during several days; but it finally subsided, and the patient ultimately regained a good degree of health. I have before stated that Prof. Bennett has employed bronchial injections in the treatment of pulmonic diseases. In the Edinburgh Medical Journal, and in his work, recently published, on " Clinical Medicine," he has reported some most interesting cases, in which this method of treatment was employed. Since the publication of the above work, by Professor Bennett, I have been favored with a letter from him, on the subject of bronchial injections, in which, among other things, he alludes to the occurrence of an accident, CATHETERISM OF THE BRONCHIAL TUBES. 309 in his own practice, similar to those whose history has been given. He writes: " A gentleman, in the last stage of phthisis, with cavities in both lungs, and tubercles very generally distributed among them, after long treat- ment with the probang, allowed me to inject the bronchi. I did so, and he was immediately seized with the most violent dyspnoea. I thought he would have died in my study. It continued several days, and then gradually declined. After five weeks' confinement to bed, he was restored to the same condition he was in formerly. This was six months ago. My opinion is, that he made a too violent effort to hold his breath and retain the catheter, and either ruptured an emphysematous portion of the lung, or caused a small abscess to break, as the operation was followed by abundant purulent expectoration." In a letter which I received several years ago from the distinguished professor of Clinical Medicine in Paris, M. Trousseau, he, among other interesting statements made on topical medication, mentions the occurrence of an accident in his practice, from the use of nitrate of sil- ver solution, under circumstances different from any that have come under my own observation. He remarks: " I often cauterize the interior of the larynx. I some- times, but rarely, use a hollow caustic holder like that of Dr. Loiseau's, and I have also injected into the trachea solutions of nitrate of silver and sulphate of copper. This practice, in my hands, has never been attended by any danger, and I have never heard that Dr. Loiseau has had any accident to deplore. * * * * I have intro- duced caustic solutions very frequently into the trachea and bronchial tubes, after tracheotomy, in cases of croup. For six years I never operated for tracheotomy without injecting caustic solution." "Once this practice," con- 310 CATHETERISM OF THE BRONCHIAL TUBES. tinues M. Trousseau, " in my hands, caused the imme- diate death of a child. The case was as follows: I had operated upon a child two and a half years old; he breathed very well. I dropped into the trachea ten or fifteen drops of a solution of nitrate of silver; a coagu- lation of thickened mucus, which was in the principal bronchi, immediately followed, and the child died, stran- gled, in less than a minute." " An accident of this kind,'' he adds, " can never happen if a sponge, moderately wet with the caustic solution,' be used; and with the instru- ment which you use, a model of which you have sent to me, I cannot see how an accident can occur to the lungs." It would also seem impossible that this accident, to which Prof. Trousseau alludes, could have resulted from the cause to which he refers it. He had used it fre- quently before in the same manner, during a period of six years, without the occurrence of any such accident. During the winter of 1859, it will be remembered that many severe cases of membranous croup and diph- theritic inflammation occurred in some of our larger cities. This was the case particularly in Boston, Mass., in which city the physicians reported some almost hope- less cases that were saved through the combined measures of tracheotomy, followed by repeated injections of a solution of nitrate of silver, through the artificial opening into the trachea and bronchi. In one instance, as reported in the Boston Medical and Surgical Journal in the case of a child aged four and a half years, Dr. Gay, assisted by Drs. Bowditch and Perry, "injected through the artificial opening into the trachea, every four hours, about one-third of a tea-spoonful of the solu- tion of nitrate of silver, of the strength of 20 grains to CATHETERISM OF THE BRONCHIAL TUBES. 311 the ounce of water." This treatment was continued through several successive days and nights, and resulted in the complete recovery of the patient. It would seem, therefore, that in the case reported by M. Trousseau, the patient must have died from some other cause than the one mentioned, namely : dropping " ten -or fifteen drops of a solution of nitrate of silver into the trachea." Nor is there any need of the occurrence of any acci- dent from the employment of catheterism of the bronchi, if proper cautions are adopted; for, with our present knowledge and experience in the use of this measure, it is one, we maintain, that may be employed with as much safety as any of our other remedial agents. To the precautionary measures necessary to be adopted in topical medication, I shall refer, after alluding to another supposed danger. When the attempt was first made to inject the trachea and bronchi, it must be remembered that there were no precedents, no recorded cases, in which this practice had been adopted, to which we could refer, for guiding us in regard to the strength of the remedies, or to the amount of medicaments that could with safety be injected; con- sequently, it became necessary to proceed with much caution in the inauguration of this practice. Fortu- nately, those persons upon whom the attempt was first made to employ this method of treatment, were among those patients who for a long time had been under treat- ment for laryngeal and bronchial diseases; to whose larynges the sponge-probang had been frequently, and for a long time, applied; consequently they were parti- cularly well prepared for the introduction of the inject- ing tube, and for the employment of the injections ; and it was for these reasons that bronchial injections, in the 312 CATHETERISM OF THE BRONCHIAL TUBES. first instances in which they were employed, were better borne, and were accomplished with more facility than they have been in most instances since. At any rate, I soon found that in recent cases I had more difficulty in effecting the introduction of the tube, and that it was necessary to employ, at first, a very mild solution, which cou],d be subsequently increased in strength. The fol- lowing case will illustrate one of the difficulties to which I refer: In September, 1854, Miss H, a young lady of this city, was recommended to my care, by her friend and physician, Dr. C, for the treatment of a bronchial affec- tion. The ordinary signs of bronchitis were very marked. Topical applications, of the nitrate of silver solution, were made to the glottis and larynx, and the general remedies, ordinarily recommended in such cases, were administered. This course of treatment was con- tinued several weeks, without producing any decidedly beneficial effect upon the patient. About this time I saw the patient on several occasions in consultation with the physician who had recommended her to my care. He advised a further perseverance in the plan of treat- ment, but suggested the employment of catheterism of the bronchi (an operation he had seen performed, in similar cases, several times upon my patients), if the pre- sent measures, after a further trial, should be unsuccess- ful. But her disease continued to resist the influence of those measures which had proved quite successful in the management of other apparently similar cases. On the 7th of November, therefore, the bronchial tube was, with some difficulty, introduced, and nearly a drachm of the solution injected into the bronchi. An unusual amount of irritation followed this operation. CATHETERISM OF THE BRONCHIAL TUBES. 313 The introduction of the tube induced a spasm of the glottis; the patient coughed severely, and complained, while she remained in my office, of pain in the larynx and bronchi. She, however, left soon after the opera- tion, for her house, in the upper part of the city, but did not return for any further treatment. The subsequent history of her case was obtained afterwards from her- self and her mother. The cough and bronchial irritation continuing after her return home, the patient and her friends became alarmed, and called in their ordinary medical attendant, who, in turn, called in a consulting physician, but both concluded to do nothing, for the irritation gradually subsided, and, along with it, the alarm of the patient and her friends; and, still better, the cough and bron- chial disease, which had so long and so obstinately resisted other measures, entirely disappeared, and the young lady has continued in good health up to the pre- sent time.* Spasms of the glottis will, as I have before stated, occasionally occur, caused by the irritation of the supra- glottic space, in the introduction of the tube, although great pains may have been taken to prepare the parts by previous training. In this case, I at first attributed the spasm and subsequent cough and dyspnoea to irritation, produced at the glottic opening. But from some obser- vations and experiments which I have since made, I am fully satisfied that the disturbance in this instance, and probably in the case mentioned by Dr. Bennett, as well as in some others, similarly affected, was caused by the * She has since married, is in excellent health, and has become the mother of several children. 14 314 CATHETERISM OF THE BRONCHIAL TUBES. employment, at first, of a solution of too great strength. I have recently.instituted some interesting experiments upon animals (the cat and dog), in order to ascertain how strong a solution of nitrate of silver can be borne, when injected into the trachea and bronchi. I experi- mented upon these different animals, but found the results the same, under similar circumstances, in both the cat and dog. But I will detail the history of only one case. A young dog, eight months old, weight fifty pounds, was treated by bronchial injections. His jaws were opened by an assistant; a cord being placed round his tongue, it was readily drawn out of his mouth, when the epiglottis, and the opening of the glottis, were seen with- out any difficulty. I passed the tube quite readily into the larynx, and carried it down eight inches, into the trachea. Here it was allowed to remain several minutes, without producing the least disturbance, while the respired air passed freely through the tube. After a time I injected a small amount of a weak solution of the nitrate of sil- ver through the tube into the lungs of the animal; but as he did not seem to be at all affected by this, I soon after threw in half an ounce of a solution of the strength of fifteen grains to the ounce. After being released, he commenced playing about as usual, without showing a symptom of any disturbance whatever. The next day he appeared perfectly well, and was as playful as ever. At 5 o'clock p. m. on the following day, I again intro- duced the tube into the dog's larynx, and conveying it down, nearly the whole length of his trachea, but not below the tracheal bifurcation, I injected into the bron- chi the ounce syringe full of a strong solution of the nitrate of silver, of the strength of thirty grains to the CATHETERISM OF THE BRONCHIAL TUBES. 315 ounce of water. This amount, in proportion to the weight of the animal, would be equivalent to three ounces of the solution of this strength to an adult. The respiration of the animal was not impeded at the time, nor did any signs of suffocation follow immediately this operation of injecting so large an amount of fluid into the air- passages. The dog, for a time, ran about as usual. At 7 o'clock, two hours after the operation, I visited him at his kennel, and calling him out, found him with tail hanging down, eyes dull, and breathing with some diffi- culty, and uttering occasionally a short cough. On listening to his sides, moist, bronchial, and crepitant rales were heard throughout both lungs. He was allowed to lie down in his kennel. At 10 o'clock I went to him again, when I found that all these symptoms had greatly increased ; the dyspnoea was quite difficult, and the dog was disinclined to move about. He died during the night. I examined the lungs the next day; the bronchial mucous membrane was highly inflamed. Both lungs were inflamed, and gorged with blood; and bloody and frothy mucus blocked up the bronchial tubes. The ani- mal died, therefore, of inflammation of the lungs and bronchi, superinduced by the large and strong injection of a solution of nitrate of silver into the bronchi. Remarks.—It is evident, then, that nitrate of silver may be used of that strength, and to that amount, in bronchial injections, as to prove fatal to animal life. So, also, may the too frequent use of all or of any of the potent remedies destroy life. 3rd. In relation, then, to the third inquiry, " What advantages are to be derived from this method of treat- ment?" I reply: bronchial injections of a solution of 316 CATHETERISM OF THE BRONCHIAL TUBES. nitrate of silver, when judiciously employed, have proved to be, and will continue, I believe, to be a valuable therapeutic means in thoracic disease. In the commencement of this paper, I referred to the detailed report which was published by me two or three years ago—a report containing a statistical table of one hundred and six cases of pulmonary and bronchial diseases, treated by means of catheterism of the air- passages, conjoined with appropriate general remedies. The following is the brief analysis given at the conclu- sion of the report of the above cases: " If we analyze the one hundred and six cases, reported in the table, it will be found that seventy-one of the sum-total have been recorded as cases of advanced phthisis—cases in which tubercular cavities were recognized, in one or both lungs ; and thirty-nine cases of early phthisis. Of the first division—advanced phthisis—fourteen have since died. Twenty-five were more or less improved; their lives, apparently, being prolonged by this means of medica- tion. Seven only of the thirty-two cases of advanced phthisis were not benefited by the injections. Of the thirty-nine cases of incipient tuberculosis, twelve of this division have apparently recovered. Five more of this number are now, or were, at the last report, in the enjoy- ment of a good degree of health. These five cases were classed by my assistant, Dr. Richards, with the twelve recoveries; making seventeen, in all, of the thirty-nine cases of early tuberculosis which have apparently recovered. " Of the remaining twenty-two cases, many of whom are still under treatment, seventeen have been greatly improved by topical medication; three more have been moderately benefited; while three only have failed to CATHETERISM OF THE BRONCHIAL TUBES. 317 obtain any advantage from the local measures which have been adopted. " Of the twenty-eight cases of bronchitis, sixteen have been dismissed, cured, or so much improved as to require no further treatment. All the others have been greatly benefited."* This method of treatment, in this class of diseases, has been continued, more or less, since the report to which I have referred was made ; and such has been the amount of success which has continued to attend this plan of treatment up to the present time, I am now ready to affirm, after an experience of many years, in a field of observation unusually large, that if I was required to re- linquish all other known therapeutic measures or topical medication in tlie treatment of diseases of the chest, I should choose the latter, with hygienic means alone, in preference to the entire class of remedies ordinarily employed in the treatment of these diseases. But I shall now refer briefly to the opinion of other physicians as to the value of this mode of treatment. In chronic bronchitis, in asthma, and in early tuber- culosis, cauterization of the air-passages has been found to be a most valuable and efficient remedy. As I have stated, topical medication, in the treatment of thoracic diseases, has been continued by me since the publi- cation of the " Report of the One Hundred and Six Cases" to which reference has been made. During this period of three or four years, large numbers of patients, affected with chronic laryngeal and bronchial diseases, with asthma, and with tubercular phthisis, have been * See published " Report of One Hundred and Six Cases of Pulmonary Diseases, treatea by Bronchial Injections," &c, pp 34-5. 318 CATHETERISM OF THE BRONCHIAL TUBES. treated, and the success which has continued to attend this practice has served to increase greatly my confidence in this measure, as a therapeutic agent. I shall, however, omit a further detail of these cases coming under my own observation, and only refer briefly to the opinion of other physicians on the value of this mode of treat- ment. At a meeting of the French Academy of Medicine, subsequent to the reading of M. Loiseau's paper on Catheterism of the Larynx in Disease, a very favorable report on the management of some of the diseases of the air-passages by this method was adopted; the commis- sion making the report declaring that catheterism of the air-passages in the treatment of diphtheritic inflammation and other kindred affections is not only practicable, but is of great utility.* " I believe this method," said M. Velpeau, " to be a good one. While diphtheritis is at the opening of the air-passages, it is curable, and M. Loiseau has ascertained that it is not difficult to carry medica- tions into the larynx."f "As a therapeutic means," says the editor of the Gazette Medicale de Paris, "it merits a more serious attention. What is the relation of cauterization to croup ? It is a powerful, energetic means, the only one which, up to this time, has really succeeded. When the disease is limited to the upper part of the air-passages, we cauterize, and all practitioners agree that this means is truly of great benefit. What is laryngeal cauteriza- tion other than carrying beyond the limits of ordinary cauterization, a remedy recognized as good, efficacious, not only against the essence of the disease itself, but * See Union Medicale, Aug., 1857. f Ibid. \ Ibid. CATHETERISM OF THE BRONCHIAL TUBES. 319 also against the pathological secretion ?"* And the learned editor of the Gazette Hebdomadaire, after calling attention to what had been done in America in the treatment of croup by cauterization, adds : " These expe- riments should be repeated by us, with that attention which the authority and the honorable position of our American confreres command. M. Loiseau, anticipated, as it is seen, in every particular, has given us, however, a useful example, and his merit will still be great if he succeeds in introducing into use a practice worthy of more attention than it has yet received."f During the last year the Gazette Hebdomadaire and other French journals have contained the histories of several severe cases of diphtheria, which, under the care of Loiseau, Trousseau, Gros, and other physicians of Paris, were successfully treated by catheterism of the larynx. In alluding to one case reported by M. Gros, where the diphtheritic inflammation had extended deeply into the air-tubes, threatening immediate suffocation, but which was permanently cured by injections into the larynx, the editor of the Gazette Hebdomadaire says: " This fact has an important practical signification, and speaks loudly in favor of the advantages which may be derived from catheterism of the air-passages, and from topical applications, carried by this measure directly into the larynx and trachea."J Indeed, M. Trousseau has recently expressed, before the French Academy, his want of confidence in all the ordinary violent remedies in the treatment of croup, such as severe vomiting, blisters, leeches, etc., declaring * See Union Medicale, Aug., 1857. f Ul supra, Aug., 1857. % Gazette Hebdomadaire, Sept., 1858, p. 660 320 CATHETERISM OF THE BRONCHIAL TUBES. his belief that' we must place our main dependence upon direct catheterism, or cauterization of the air-passages, followed, if this measure is unsuccessful, by tracheotomy. All this goes to prove, in the opinion of eminent medical men, the entire practicability of catheterism of the air- passages. In Dr. J. Hughes Bennett's work, to which I have already alluded, he has devoted a chapter to the consi- deration of "Injections of the Bronchi in Pulmonary Diseases." He remarks, " Whilst tuberculosis is at first a constitutional disease, its localization in any part reacts more or less on the general health; and the opinion I have long entertained, that any means which could ena- ble the physician to act directly on the tissue of the lung or inflamed bronchi, would assist his efforts at cure, at once led me to take a favorable view of this new mode of treatment. The nitrate of silver ought to act as beneficially on the mucous membrane of the trachea and bronchi as on that of any other hollow viscus, and we have seen previously that the remedy may be applied to the tracheal mucous membrane, by means of an artificial opening, not only without injury, but with decided benefit." He further adds, " Without entering into minute particulars, I have only to say that I have confirmed the statements made by Dr. Horace Green." The cases in which Dr. Bennett employed this method of treatment, as he states in his work, were patients " affected with phthisis in various stages, with laryngitis, and in chronic bronchitis, with severe paroxysms of asthma. In other cases in which I attempted to pass the tube, it was found to be impossible ; in some because the epiglottis could not be fairly exposed, and in others on account of the irritability of the fauces, and too CATHETERISM OF THE BRONCHIAL TUBES. 321 ready excitation of cough from pressure of the spa- tula."* This, then, is only a part of what has been done in France, Germany, England, and Scotland, in the employ- ment of topical medication in disease. In some of these countries, far more extensive observations on this mode of treatment have been made than in our own country ; certainly more than in our own city! But I shall not stop here to compare the careful inquiries, the scientific observations made, and the frankness and candor exhibit- ed, by the profession of other countries, on this subject, with the course pursued by many of my "American confreres." If necessary, I could give the opinion of many other practitioners, in Europe and America, who have tested topical medication, in the treatment of diseases of the air-passages, and who profess to have derived signal advantage from this therapeutical measure. I will only refer to some favorable testimony from some parts of our own country. During the last year, as it was remarked on a former page, croup and diphthe- ria were more than ordinarily prevalent in some of our larger cities. This was the case particularly in Boston; and here, many very severe cases of diphtheria occurred, and some almost hopeless cases were saved by cauteriza- tions of the larynx; and others, by tracheotomy, followed by repeated injections of a solution of nitrate of silver, through the opening, into the trachea and bronchi. In a report of some most interesting cases of the dis- ease, read before the Boston Society for "Medical Improvement," and subsequently published in the Boston Medical and Surgical Journal, Dr. Gay says, " After * Clinical Lectures, &c, p. 609. 21 322 CATHETERESM OF TnE BRONCHIAL TUBES. tracheotomy, and the insertion of the tube, the injection of a solution of nit. argent, through the tube, into the trachea and bronchi, is our strongest dependence, and most of the other measures are mere auxiliaries." " In seven cases of decided menbranous croup," says Dr. Gay, " in which these combined measures were employed, and in which the membrane was expelled through the tube, there have been five recoveries, and two deaths." Many other severe cases were successfully treated by cauteriza- tions of the larynx and trachea, employed before the operation of tracheotomy became imperative. I shall close this chapter by describing the method I employ in practising catheterism of the bronchi. I have received letters from many medical men, requesting me to give them an account of the manner of performing the operation, and a description of the instruments em- ployed. As it has been, and is, impossible for me to comply with all these individual requests, I cannot do better than to reproduce the directions I sent to Prof. J. Hughes Bennett, who several years ago wrote to me, desiring me to send him a description of the operation, and a set of the instruments I employed. My reply is published at length in Prof. Bennett's recent volume of " Clinical Lectures," from which I shall extract. " I would, with pleasure, send you the instruments I employ, but they are simple, and may be obtained at any surgical" instrument maker's shop. They consist of an ordinary flexible, or gum catheter, and a small silver, or glass syringe. The catheter is Hutching's gum-elastic catheter (No. 11 or 12), which is 12^ inches in length; and, as the distance from the incisor teeth to the tracheal bifurcation is, ordinarily, in the adult, about eight inches; if this instrument is introduced so as to leave only l.wo CATHETERISM OF THE BRONCHIAL TUBES. 323 inches of the catheter projecting from the mouth, its lower extremity must, of course (if it enter the trachea), reach into one or the other of its divisions. I first pre- pare my patients by making applications with the sponge- probang, and nitrate of silver solution, for a period of one or two weeks, to the opening of the glottis and the larynx, until the sensibility of the parts is greatly dimi- nished. Then, having the tube slightly bent, I dip the instrument in cold water (which serves to stiffen it for a moment, and obviates the necessity of using a wire), and with the patient's head thrown well back, and the tongue depressed, I place the bent extremity of the instrument on the laryngeal face of the epiglottis, and gliding it quickly through the rima glottidis, carry it down to, or below, the bifurcation, as the case may require. It is necessary that the patient continue to respire, and the instrument is most readily passed during the act of inspi- ration. The tube being introduced, the point of the syringe is inserted into its opening, and the solution injected. This latter part of the operation must be done as quickly as possible, or a spasm of the glottis is likely to occur. Indeed, if the natural sensibility of the aper- ture of the glottis is not well subdued by previous applications of the nitrate of silver solution, or if the tube, in its introduction, touches roughly the border or lips of the glottis, a spasm of the glottis is certain to follow, which will arrest the further progress of the opera- tion. The epiglottis, which is nearly insensible (and this you may prove on any person, by thrusting two fingers over the base of the tongue, and touching, or even scratching, with the nail, this cartilage), should be our guide in performing the operation. The strength of the solution, for injecting, is from 10 to 25 grains to the 324 CATHETERISM OF THE BRONCHIAL TUBES. ounce of water. Commencing with 10 or 15 grains to the ounce, its strength is subsequently increased, and the amount I now employ is from £ to 1£ drachms of this solution."* Allow me further to add, that, latterly, in commencing the injections, I have used a solution still weaker than above denoted. When my patients are prepared for catheterism, by repeated cauterizations of the opening of the glottis and larynx, to reduce the normal sensitive- ness of the parts, the tube is then introduced, and a drachm of a solution of nitrate argent., of the strength of from 5 to 10 grains to the ounce of water, is injected through the trachea. Afterwards, the solution may be gradually increased in power; but, at the present day, I seldom employ the remedy in bronchial injections, of a strength above 20 grains of the salt to an ounce of water. Should a spasm of the glottis occur, as I have before remarked in this paper, on the insertion of the tube into the larynx, the instrument should be promptly with- drawn, and no further attempt be made to proceed with the operation, until the irritation has fully subsided. It is necessary that the applications of the sponge-probang be continued in the intervals of the employment of the tube. In cases of bronchitis, and in early phthisis pulmonalis, even, the use of injections into the bronchi, once or twice a week, operates to diminish the cough, expectoration, and dyspnoea, with great certainty, and very many cases of these diseases have recovered under local treatment, after other measures had failed. * " Clinical Lectures on Medicine," pp. 608-9. TREATMENT OF CHRONIC PHTHISIS. 325 CHAPTER V. CONTINUATION OF THE TREATMENT OF CHRONIC PHTHISIS J LOCAL AND GENERAL. If the views I have advanced, with regard to the nature and pathology of chronic phthisis, be correct, the treatment advocated in the preceding chapter will claim the attention of the profession. I shall, therefore, endeavor to describe more particularly the therapeutical measures which are recommended. Topical Remedies.—In the employment of local mea- sures, allusion has been made, generally, to one remedy —the nitrate of silver. Other medicaments are fre- quently employed, such as the different preparations of iodine, zinc, and glycerine; and of the sedatives, mor- phine, atropine, conia, etc. But in the treatment of chronic disease of the respiratory apparatus, the remedy most generally efficacious, is the solution of nitrate of silver. After having tried most of the remedies to which allusion has been made, I became fully satisfied that for safety, efficacy, and certainty of action, no known local therapeutic agent can compare with the crystals of the nitrate of silver, in the treatment of laryngeal, bron- chial, and pulmonary affections. I speak of the crystals of the nitrate ; for in preparing the solution for topical applications to the aerial mucous membrane, the argenti nifrras fusum, or the solid nitrate, should not be em- ployed, as it is much more likely than are the crystals, 326 TREATMENT OF CHRONIC PHTHISIS. to contain the nitrate of potash, or copper, or lead, in combination. When pure, the crystals are transparent, white or nearly colorless, and are completely soluble in distilled water. A solution of the strength of from two to four drachms of the salt in an ounce of distilled water, when applied freely to the mucous membrane, does not act, as has been supposed, by burning, or by a destruction of textural matter; it forms immediately a union with the albumen and other secretions of the mucous lining, and this compound, thus formed, defends the living tis- sue from the action of the caustic, whilst it operates to produce a most favorable change in the vital action of the part. Method of applying the solution.—In the treatment of laryngeal disease, by the direct application of the nitrate of silver to the diseased surface, I have em- ployed, ordinarily, a solution of this substance, of the strength of from two to four scruples of the nitrate, to an ounce of distilled water. When, however, there are found extensive ulcerations of the epiglottis, or about the opening of the larynx—ulcerations, which it is desir- able to arrest at once, I have not hesitated to apply directly to the diseased parts, a solution of double the strength of the last named. Or, what I generally pre- fer in such cases, the solid crystal may be used to touch, at first, the ulcerated points, but one or two applications of the crystals, only, or of a medicine of the above power, should be made at one time; for, ordinarily, however extensive the lesions may be, it will not be necessary to employ a solution of greater strength than one composed of four scruples of the salt to an ounce of water. On the other hand, it has been found, that TREATMENT OF CHRONIC PHTHISIS. 327 one of less strength than of from forty to fifty grains of the nitrate to an ounce of fluid, will have but little effect upon a diseased mucous surface, where ulcerations exist. Iodine.—In many cases, and in certain stages of nearly all cases, of follicular disease, iodine, in combina- tion with other remedies, will prove valuable as a local agent. Employing glycerine as a solution, I have often used the following combination: B Iodine, - - - - 3j. Iodid. Potass., - - 3i. Glycerine, - - - ij. Misce. After applying the solution of nitrate of silver in chronic cases requiring this treatment, for a great length of time, it not unfrequently happens that the caustic solution loses apparently its effects. A resort to the iodine mixture for a short period will often prove more efficacious for a time, when a return to the nitrate of silver will be attended with results as beneficial as at first. Zinc.—A solution of zinc may be employed, not only for the same purpose, but often, when the diseased folli- cles on the pharyngeal membrane prove obstinate, the use for a time of a strong solution of the sulphate of zinc will frequently serve to change the action of the membrane; when the subsequent use of the nitrate will again prove more efficacious. Glycerine is employed more as a medium for the application of other remedies, than as a local remedial agent alone. Still, in cases of tracheal and bronchial disease, attended with a sensation of dryness, its occa- 328 TREATMENT OF CHRONIC PHTHISIS. sional application to these parts will be followed by an agreeable sensation of blandness and moisture of the lining membrane. SEDATIVES. Moiphine.—Dissolved in glycerine or mucilage, I have often employed this sedative as a local agent with much advantage. Dr. Scott Alison, who speaks favor- ably of this remedy, says: " I have employed this solu- tion of morphine with mucilage; I have observed a reduction in the cough and sense of irritation. I have employed morphia to no greater extent than the eighth of a grain. The practice is perfectly safe. I have not seen the slightest bad effects from it; and of course, by exhibiting morphia in this way, we do not induce dys- pepsia and constipation as we often do when we give it by the stomach. I think it not unlikely that a larger quantity of morphia might be conveyed into the larynx than into the stomach, as the nervous constitution of the part is less delicate, and less connected with the brain and the heart." Preparations of atropine and of conia have also been employed by Dr. Alison in medicating the larynx and trachea; and often, he says, with decided advan- tage. But I have never used, in this manner, either of these remedies. GENERAL REMEDIES. 329 CHAPTER VI GENERAL REMEDIES. When the deterioration first commences in the folli- cles of the pharyngo-nasal membrane in sound constitu- tions, topical medication alone, judiciously and persever- ingly employed,-will prove efficacious in arresting the local affection in a large proportion of cases. But when the disease has continued until the general system is implicated, constitutional measures, in connexion with topical remedies, will be required. Iodine.—Iodine and its compounds are arranged by Dr. Thomas under the head of excitants. In quite a large portion of the cases of follicular dis- ease which have come under my notice, where the mor- bid affection of the mucous cryptae had been long con- tinued, it has been found that there existed more or less of a diseased condition of other parts of the glandular system. Symptoms indicative of the presence of de- rangement of the hepatic organs have frequently been manifested in connexion with follicular disease. Hence, iodine, or some of its preparations, have proved in my hands of essential service, in the treatment of this com- plicated form of the affection. It is the opinion of Dr. Clark, that the action, of iodine on the animal economy resembles, in a great degree, that of mercury. The effects of the two reme- dies may be similar in some respects. The action of the organs of excretion, it is true, is promoted by both medicines, but not in the same degree. Paleness or 330 GENERAL REMEDIES. blanching, it is well known, is frequently produced by a course of mercury ; an effect which has been ascribed to the diminished number of the red globules of the blood; while, on the other hand, an increased nutrition of the body, or embonpoint, is the frequent result of the em- ployment of iodine. Under its influence, Dr. Clark himself remarks—"when it is judiciously employed, the patient recovers flesh, health, strength, and color; hitherto pale, relaxed, and feeble, he becomes full, strong, and florid. From the influence which iodine has in causing the disappearance of visceral and glandular enlargements, it has been supposed that its continued use would have the effect to produce general emaciation; but this has been denied by many." Lugol asserts, that instead of producing emaciation, it encourages growth and increase of size, and Dr. Manson also, in his Medi- cal Researches on Iodine, states that it exerts no peculiar or specific influence on the absorbents. In the administration of iodine in follicular disease, I have found, almost invariably, a specific effect produced upon the organs of secretion by the use of the medicine. For some time after commencing the remedy, an in- creased quantity of viscid mucus is thrown off by the diseased glandulae; and the patient often complains of a disagreeable taste, produced by the morbid secretions from the faucial and pharyngeal membrane; and in some instances, the irritation of the throat is at first increased by this salt. After a while, the secreted fluid is diminished in quantity, becomes bland, and is of a healthier quality, while the lining membrane presents an improved condition. Equally salutary are the effects produced,' ordinarily, on the secretions of the digestive organs by the use of iodine. GENERAL REMEDIES. 331 The iodide of potassium I generally consider the best preparation for administration, in disease of the mucous follicles. Although the constitutional effects of iodide of potassium are very analogous to those of iodine, yet it may be given in larger doses, and for a longer period, without producing disorder of the system, than the free iodine. When indications of a scrofulous diathesis are present in any case, it will be preferable, and will prove more efficacious, to exhibit the two preparations in com- bination. In the earliest stages of follicular disease, when the symptoms indicate the presence of chronic thickening of the lining membrane of the laryngeal cavity, or when we have evidence of the presence of any constitutional syphilitic affection, in combination with follicular derangement, the iodide of potassium, conjoined with the iodide of mercury, will prove a valuable remedy. The apothecary will sometimes object to the above com- binations, because a decomposition is effected, the prot- iodide of mercury being converted by the iodide of potas- sium into the biniodide and metallic mercury. But it is well known to chemists that these different iodides will unite together in different proportions, by which those compounds, which Berzelius terms double iodides, are formed. The biniodide thus formed in the above solution, immediately unites with a portion of the iodide of potassium in solution, and a double salt—the hydrargyro-iodide of potassium—is the result. In such cases, this combination of the iodides, as in Form. No. 19, has proved highly advantageous. 332 GENERAL REMEDIES. ARSENIC. Arsenic is not only a valuable antiperiodic, but it is a most powerful alterative, and its use for many years has proved highly efficacious as a tonic, in the treat- ment of all stages of chronic phthisis where debility is present. A few years ago, in a number of the Edinburgh Medical Journal (May, 1858), a highly valuable paper, on the "Physiological and Therapeutical Effects of Arsenic," was published by Dr. James Bigbie, in which the author expresses, in strong terms, his confidence in arsenic, as a most useful and available therapeutical agent, powerful in many intractable affections, and exer- cising a commanding influence over diseases hitherto considered incurable." Under its use, in the treatment of numerous and various diseases, Dr. Bigbie affirms that an improved digestion and a better appetite inva- riably occur; and in no instance has he observed any injurious consequences to result from its employment. The liquor arsenicalis of the pharmacopoeia is the preparation ordinarily employed for securing the reme- dial effects of the medicine. In exhibiting this prepara- tion, it is given by him to adults in doses of five drops of the solution, after each meal, largely diluted with water—the medicine being increased one drop every third day, until the physiological action of the remedy is manifested, such as itchiness and swelling of the eye- lids, a silvered tongue or tenderness of the epigastrium. The dose, on the occurrence of any of these symptoms, should be diminished, or the intervals of its administra- tion lengthened. It is in the persistent use of arsenic, in cases of folli- GENERAL REMEDIES. 333 cular disease, that the highest beneficial effects are ulti- mately obtained-. But throughout the entire use of this mineral, its poisonous action should be guarded against, by limiting its exhibition to the production of those symptoms only which indicate its earliest physiological action. In the treatment of chronic phthisis, I am accustomed to administer this remedy, in combination with some bitter tonic, as in Form. No. 9, or with quinine, as in No. 10, in which combination it has proved, in my hands, a powerful and valuable remedial agent. MANGANESE. In the management of chronic phthisis, it is important^ in the stage of debility, to keep the system of the patient well supported by the employment of such tonics as tend to improve the condition of the blood, which, as we have seen, always becomes more or less deteriorated in this affection. For many years, in the treatment of this disease, I have employed with signal benefit some of the preparations of Manganese. I have had much experience in the use of this mineral tonic, and have been fully satisfied that the remedy will prove a most valuable addition to our therapeutic pre- parations. The presence of manganese in the blood has been fully established by the experiments of MM. Millou, Hannon, and others; and recently, M. Burin, in a memoir presented to the French Academy of Medicine, has given an analysis by which he shows the amount of manganese in the blood globules, and exhibits the con- dition in which it exists. It is, indeed, as constant an ingredient of this fluid, in its normal condition, as iron, 334 GENERAL REMEDIES. and it is well known that a deficiency in quantity, of both these metals, may be observed in the blood in many cases of anaemia, chlorosis, tuberculosis, etc.; and hence the employment of manganese is proper in most instances, where the administration of iron is indicated. It can be administered, moreover, with entire safety in those cases in which haemoptysis is an occasional symp- tom. Frequently both remedies may be given in com- bination with great advantage. The most important preparations of Manganese, for pharmaceutical purposes, are the phosphate and the malate. We have administered, in tuberculosis, to a large number of patients, the phosphate of manganese, as in Forms Nos. 11 and 12, with most favorable results. These mixtures should be kept in well closed bottles, and as the manganese is not altogether soluble, the medicine should be shaken before beinsr administered. The malate of manganese is considered by some prac- titioners a more eligible preparation, inasmuch as it is quite soluble, and the base of the salt is in the form of protoxide, the acid being easily digested IRON. In some cases where tonics are indicated, and yet for some cause are not well borne, they may be adminis- tered, especially some of the martial preparations, with much safety, and often with advantage, by combining them with some of the sedative preparations. The different forms of iron, whether employed as found in the natural chalybeates, or in the artificial prepara- tions of the chemist, make their primary impression on the digestive organs, augmenting, ultimately, the power GENERAL REMEDIES. 335 of the secretory and excretory systems, and rousing the nutritive faculty in every part of the body. The combination of a chalybeate with a stimulus, as in Form. No. 33,1 have found to be a most valuable tonic in the treatment of tuberculosis. In debilitated and anaemic patients, or in females pre- senting indications of a chlorotic condition of the system, the phosphate and the citrate of iron have been found aseful preparations. Syrup of the iodide of iron is a valuable therapeutic agent, and may be used as a tonic in doses of from fif- teen to twenty-five drops. HYDROCYANIC ACID. In the treatment of chronic bronchitis or in allaying the cough present in the tubercular stage of the affection, I have derived great benefit from the use of this remedy combined as in Form. No. 1. or 2. Follicular bronchitis is occasionally complicated with an irritable condition of the gastric membrane, manifested by tenderness of the epigastrium, a red tongue, frequent headache, and a fever- ish condition of the system. In such cases, where the inflammation has extended to the mucous membrane of the stomach, producing this not uncommon form of bron- chogastritis, the exhibition of the above combination with the hydrocyanic acid, the alkali, and the bitter vegetable infusion, as in Form. No. 4, will exert a prompt and decidedly happy influence on this diseased action. The anhydrous or pure hydrocyanic acid, which con- sists of one equiv. of cyanogen and one equiv. of hydro- gen, is of a nature so exceedingly poisonous, that it cannot be employed with safety in medicine. The medicinal 336 GENERAL REMEDIES. acid, which is the preparation that should always be directed to be used in our prescriptions, contains only 25 per cent. (United States Pharmacopoeia) of the pure acid. That of the Apothecaries' Hall, London, contains 3.2 per cent.; whilst the medicinal acid of the French apothecaries is nearly equal to that of the United States Pharmacopoeia, namely, 2.4 per cent, of the pure acid of Gay Lussac. FORMULAE. Form. JVo. 1. fy Acidi hydrocyanici (Med.) gtt. Ix. Morphiae sulph., gr. iij. Tinct. sanguinariae ) Vini ipecacuanhae j ^ Syr. pruni virginianae vel misturae amygdalae Fiat mistura cujus sumat cochlearium parvum bis terve in die. Form. JVo. 2. 1$, Acidi hydrocyanici, gtt. xl. Vini antimonii f § ss. Syrupi tolutan. f § ss. Mucil. acaciae f § ij. Fiat mistura, capiat cochl. pai'vum ter quaterve in die. Form. No. 3. ]J Acidi hydrocyanici (Med.) gtt. xxv. Vini ipecacuanha? f 3 ij. Syr. tolutan. f 3 j. Aquae destillatae f § iij. Fiat mistura, cujus sumatur cochl. parv. quarta quaque hora. Form. JVo. 4. 3, Extract, belladonnas, gr. x. Acidi hydrocyanici (Med.) gtt. Ix. Tine, calumbae ) „_. Vaa. f 3 j. Syr. simp. ) Aquae destillatae f 1 ij. 22 338 FORMULAE. Form. JVo. 5. $ Extracti hyoscyami 3j. Argenti nitratis, gr. x. Bismuthi subnitratis, 3 iss. Fiant pilulae xl.; quarum sumatur una mane ac nocte. Form. JVo. 6. 3 Extracti conii vel lupuli 3 j. Argenti nitratis, gr. x. Capsici pulv. ) Quimae disulphatis ) Fiat massa, in pilulas xl. dividenda. Capiat unam bis terve in die. Form. JVo. 7. 3 Extracti lupulinae 3j. Argenti nitratis, gr. x. Bismuthi subnitratis 3 iss. * Quiniae disulphatis 3ij. Fiant pilulae xl.; cujus sumatur una bis terve in die. Form. JVo. 8. 3 Extracti conii 3 j- Sesqui-oxydi ferri 3 ij- Tinct. calumbae f § iss. Syr. tolutan. f § ss. 01. gaultheriae, gtt. x. Aquae fontanae f § ij. Fiat mistura, cujus sumat coch. parv. mane ac nocte. Form. JVo. 9. $ Liquor, potassae arsenitis f 3 iss. Tinct. cinchonae f § iij. Syr. aurantiae f § j. Hujus mist, sumat cochl. uiin. bis terve in die. FORMULAE 339 Form. JVo. 10. I> Quiniae disulph. 3 j. Liquor, potassae arsenitis f 3 ij. Acidi sulph. aromat. f 3 j. Tinct. cinch, co. ) Syr. zinziberis ) ^ Form. JVo. 11. IJ, Manganesii phosphatis 3 ij- Tinct. cinchonae f § iij. Syr. sarzae f § iv. Mucil. acaciae f § j. 01. gaultheriae gtt. xx. Fiat mistura, cujus sumantur coch. duo vel tria minima bis terve in die. Form. JVo. 12. ^ Manganesii phosphatis 3 iss. Ferri phosphatis 3 iij- Tinct. calumbae f § ij. Syr. tolutan. f § iv. Ess. gaultheriae f 3 j. Form, JVo. 13. !r> Extracti nucis vom. 3 ss. Argent, nitratis, gr. xii. Fiat massa et in pil. xl. divid.; sumat j. mane et nocte. Form. No. 14. R: Extract, nucis vomicae, gr. xxxii. Tinct. cardamom. ) ._ . . ., • ^aa-f3J. Syr. zinziberis ) Aquae font, f § ij. Fiat mistura, cujus cap. gtt. xx. vel xxx. bis terve in die. 340 . FORMULAE. Form. JVo. 15. # Strychniae, gr. xii. Acidi acetici, gtt. Ix. Alcohol f 1 j. Aquae font, f § xi. Fiat mistura. Capiat gtt. x. usque ad xxx., bis terve in Form. JVo. 16. IJ Potass, iodid. 3 ij. Tinct. rhei f f i. Syr. sarzae co. ) .. . „ y aa. f x n. Aquae font. ) J Fiat mistura, cujus sumatur cochl. parv. mane ac nocte. Form. JVo. 17. $ Decoc. polygalae § v. Potass iodid. 3 iij. Tr. opii camphor, f § j. Syrupi tolutan. f § ij. Fiat mistura. Capiat cochleare parvum bis in die. Form. JVo. 18. IJ, Iodini purae, gr. vj. Potass, iodid. 3 iss. Tinct. cardamom, f § i. Syr. sarzae co. f § iij. Fiat mistura. Exhibe cochl. parv. bis terve in die. Form. JVo. 19. ^ Protiodid. hydrarg., gr. iij. Potass, iodid. 3 ij. Tinct. rhei f f j. Syr. sarzae co. f § iij. Fiat mistura, et detur cochl. parv. bis in die. FORMULAE. Form. JVo. 20. R Potass, iodid. 3 ij. Protiodid. hydrarg., gr. ijss. Tinct. gentianae ) „ .. b [aa.f§ij. Syr. sarzae co. ) Sumatur cochl. parv. bis terve in die. Form. JVo. 21. R Hydrarg. chlorid. corrosiv., gr. iv. Tinct. gentianae § iv. Syr. aurantii ^ ij. Fiat mistura, cujus detur cochl. parv. ter in die. Form. JVo. 22. R Tinct. sanguinariae | j. Tinct. opii 3 ij- Vini ipecacuanhae 3 vj. Syr. tolutan. 1 ij. Fiat mistura, quarum capiat TU, xxx. usque ad lx. quater in Form. JVo. 23. R Tinct. sanguinariae § j. Morph. sulph., gr. iss. Tinct. digitalis ) TT. . . J-aa. Vini antimo. ) 01. gaultheriae, gtt. x. Form. JVo. 24. R Tinct. cimicifugae racemosae ) _ . _,. . . >■ aa. 3 j. Tinct. sanguinariae ) Morph. sulph., gr. ij. Syr. acaciae 1 ij. Ft. mistura; exhibe cochl. parv. tusse urgenti. 342 FORMULA. Form. JVo. 25. R Zinci sulphatis, gr. x. Ipecacuanhae pulv. 3j. Aquae tepidae f | iv. Fiat mistura. Form. JVo. 26. R Liquor, ammon. acetatis f § ij. Misturae camphorae f § iijss. Vini ipecacuanhae f § ss. Syrupi tolutan. f § ij. Fiat mistura, cujus exhibe cochl. mag. sextis horis vel ssepius. Form. JVo. 27. R Ant. et potass, tart., gr. ijss. Aquae cinnam. f i ij. Syrupi simp, f § ss. Aquae purae f § iijss. Fiat mist., cujus sumat. cochl. parv. secunda vel tertia hora. Form. JVo. 28. R Ferri citrat. 3 ij. Syrupi aurantii^ laa#f?ij# Aquae menth. pip. ) Aquae purae f § iv. Fiat mistura, de qua sumatur cochl. parv. bis terve in die. Form. JVo. 29. R Argent, nitratis 3j. Aquae rosae f § iv. Fiat gargarisma. FORMULAE. 343 Form. JVo. 30. R Tinct. aconiti Tinct. opii , \ aa. § ss. Tinct. camphorat. Chloroformi Misce pro liniment. Form. JVo. 31. R Unguent, stramonii | j. Plumbi carb. pulv. 3 j Opii pulv. 3 iss. Fiat unguent. Form. JVo. 32. R Proto-iod. hydrarg., gr. x. Potass, iodid. 3j. Cerati simp. § j. Fiat unguent. Form. JVo. 33. R Extracti conii 3 j Sesqui-oxydi ferri 3 ij. Tinct. calumbae fjss. Syr. tolutan. | ss. 01. gaultheriae, gtt. x. Aquae fontanae 1 ij. Fiat mistura, cujus sumat. coch. parv. mane ac nocte. THE END. APPENDIX. PLATE X. 500 DlAMETEBS. Fig. 1 represents follicles of the tonsils greatly enlarged by proli- ferated epithelial cells. Fig. 2. Two cases of hypertrophied and diseased tonsils from patients laboring under chronic folliculitis. The one on the left side (a) from a patient most diseased, the cavity large and filled with disintegrated or " cheesy" matter. The one on the right side not much diseased; the nuclei or cells larger, and no granules. Fig. 3. The appearance of matter taken from Ihe cavity (a) in tonsil of Fig. 2. Its resemblance to tuberculous matter, as seen in Fig. 6 on page 193, will be apparent. Fio\ 4. Another large and diseased tonsil full of ulcerations contain- ing diseased or " cheesy" matter. The microscopic appearance of this matter as seen in Figures 7, 8, and 9 in Plate II. Fig. 5 shows the appearance of the epithelial cells lining the air-sacs, highly magnified, and treated with acetic acid. Some of the centre cells were drawn by the aid of the camera lucida ; their outline being traced as thrown down on the paper. Fig. 6. An excised tonsil greatly hypertrophied and diseased, a and b, large ulcerated cavities filled with broken up epithelial cells, c, an iucision in the healthy portion of the cut surface of the gland; the matter from which showed cells almost perfectly healthy. APPENDIX. 345 Plate X.—500 Diameters. Fig. 1. 346 APPENDIX. Plate X.—(Continued.) 500 Diameters. Fig. 7. APPENDIX. 347 PLATE X.—(Continued.) 500 Diameters. Fig. 7 exhibits the microscopic appearance of matter from disinte- grated epithelial cells, a, Nuclei with granules or molecules, b, Nuclei with small epithelial cells, c, Nucleoli and granules, d, Nuclei, with small epithelial cells and oil-globules. Fig. 8. Matter from a diseased gland, a, Granules isolated, b, Nuclei, with some granules, oil-globules, and small fragments of epithelial cells. c, Nuclei, with unbroken epithelial cells, d, Nuclei, oil-globules, and granules. Fig. 9. From diseased gland, No. 6. a, Oil-globules and granules, b, Isolated nuclei and large epithelial cells, c, Nuclei and smaller epithe- lial cells, isolated. INDEX. Addison, Dr. "W., his theory of consumption, 98 Air-cells, structure of the, 136; disintegration of, in tuberculosis, 191. Air-passages, catheterism. of the, 300; description of the operation, 322; cauteriza- tion of, in asthma, 317. Alison, Dr. Scott, on the use of morphine in chronic phthisis, 328. Alveoli, of the air-cells, 138. Amygdalae, the, or tonsillary glands, 126. Anaemia, peculiar, symptomatic of tuberculosis, 188. Anatomical investigations, improvements made by Vesalius in, 14. Ancell, Mr., his opinion that phthisis is a blood disease, 106, 117 ; on the lymphatic vessels, 145; on the lymphatic temperament, 166; on ulcerations of the mucous membrane of the air-passages, 187. Andral, on the origin of pulmonary tubercles, 44, 144. Animal tissue, its elementary cells, 118; three groups of, 120. Aretaeus, his accurate description of the rational signs of consumption, 6. Arsenic, its use recommended by Rhozas and others in pulmonary disease, 11, 12 ; used in chronic phthisis, 332. Arytenoid cartilages, the, 129. Asses' milk, 10, 17, 19. Asthma, cauterization of the air-passages in, 317. Auscultation, medial, Laennec on, 36. Badham, Dr., the first to describe bronchitis, 29. Baillie, Dr., the first correct describer of tubercles of the lungs as the cause of con- sumption, 25. Bark, Peruvian, a remedy recommended by Morton, ] 8 ; by Portal, 30. Baron, Dr., his hypothesis of the origin of tubercles, 39. Barthez, on tubercle, 79. Basement membrane, structure of the, 124. Baudelocque, attributes tubercular disease to imperfect nutrition, 56. Baumes, his views on consumption, 24, 101, 144. Bayle, his elaborate work on phthisis, 31; treatment proposed by, 32. Beddoes, Dr., his treatment referred to, 28, 29. Bennett, Professor J. Hughes, on the nature of tubercle and the treatment of con- sumption, 92, 117, 199; on catheterism of the air-passages, 301, 320. Blood, the, not the primary seat of the tuberculous dyscrasiae, 118; intimate rela- tionship between the contents of the lymphatic vessels, diseased cellular ele- ments of tissues, and the circulation of the, 164; contamination of the, 165. Boerhaave, ignorant of the true nature of consumption, 19, 144. 350 INDEX. Bronchi, the, 134. Bronchia?, the, 136. Bronchial injections, 299. Bronchial tubes, catheterism of the, 300. Bronchitic stage of phthisis, the, 290. Bronchitis, chronic, cauterization of the air-passages in, 317; description of the operation, 322. Broussais, on the nature and origin of tubercles, 40. Buffalini, Professor, on the identity of tuberculous disease and scrofula, 91. Campbell, Dr. J. J., his views on the nature, pathology, and cure of pulmonary phthisis, 72. Capillary plexus, the, 140. Carmichael, Dr., on the origin of consumption, 65. Carswell, Robert, on the nature and origin of tuberculous affections, 57. Cartilages, the thyroid, cricoid, and arytenoid, 129. Catheterism of the bronchial tubes, 300; statistics of cases, 316; opinions of physi- cians, 318; method of practising, 322. Cauterization of the air-passages, 300 et seq. Cautery, the, recommended by Celsus, 8. Cayol, distinguishes between tracheal and ^laryngeal phthisis, 33. Cell territories, the, of Virchow, 121. Cells, elementary, constituents of, 118; the nucleus and nucleolus, 118, 119; all the tissues not composed of the same type of, 120; structure of the air-cells, 136; epithelial, the seat of the initial lesion in chronic tuberculosis, 152 ; pathologi- cal metamorphosis of cell-contents, 155 ; steps of the morbid process in the degeneration of the epithelial cells, 168; disintegration or softening of the air- cells in tuberculosis, 191. Celsus, treatment advised by, in consumption, 7. Chapman, N., on the distinction between phthisis and scrofula, 81; treatment of phthisis, 82, 83. Chordae vocales, or vocal ligaments, 130. Ciliated epithelium of the larynx, 132. Clark, Sir James, 2, 3 ; on the nature, causes, and treatment of tuberculous disease, 59; five different varieties described by, 61; on the hereditary transmission of consumption, 157 ; on the early symptoms of consumption, 174. Connective tissue, 124. Constadt, M., his theory as to the nature of tuberculosis, 71. Consumption, pulmonary, definition of, 1; great mortality from, 2; knowledge of the ancients with regard to its nature, etiology, and treatment, 4; its pathology and true nature, 148 ; preliminary manifestations of, 150 ; hereditary transmis- sion of, 157 ; earliest symptoms, 171; extension of the morbid process, 181 ; second stage, 185; third stage, 191; treatment of the prae-tubercular stage, 201; primary lesions, 205. And see Phthisis. Copland, Dr., considers tubercle and scrofula identical, 107; on the treatment of consumption, ib. Cottori, Dr., on the nature and treatment of phthisis, 105. Cough, one of the earliest symptoms of tubercular phthisis, 172. Cricoid cartilage, the, 129. Cruveilhier, M., on the production of tuberculous disease by irritation of the air- cells, 54; observations ou the lymphatic glands, 144. Cullen, views of, on consumption, 22. INDEX. 351 Darwin, Dr., on the nature and treatment of consumption, 27. Davies, Dr., his views on consumption, 64. Dessault, on the nature and treatment of consumption, 20. Digitalis, as a remedy in the treatment of consumption, 27, 28. Dioscorides, recommends fumigations and the external use of sulphur -in consump- tion, 6. Dyscrasia, tuberculous, does not originate in the blood, 160. Epiglottis, anatomy of the, 130, 245; ulcerations of, in tubercular phthisis, 182; principal lesions, 246; ulceration of the mucous membrane of the, 257 ; oedema of the, 267 ; its special function, 276 ; insensible in its normal state, 304. Epithelial cells, the seat of the initial lesion in chronic tuberculosis, 152; steps of the morbid process in the degeneration of the, 168. Epithelium, the, composition of, 123; ciliated, of the larynx, 132; tesselated, of the lungs, 139 ; degeneration of the epithelium of the glandular follicles, 155. Erosions and ulcerations of the mucous membrane, difference between, 257. Exercise, horseback, recommended by Sydenham, 16. Expectoration, nature of the, in early phthisis, 181. Family, history of a, illustrating the transmission of a tuberculous dyscrasia to off- spring, 201. Fat of the goat, a popular remedy in Pliny's day, 8. Fauces, pillars of the, 126. Fever, hectic, as described by Galen, 9. Follicles, subcutaneous mucous, of the uvula and tonsils, 126, 127; nature and order of the pathological changes in the glandular follicles, 153. Follicular disease, topical treatment of, 207. Follicular glands, position and structure of the, 125. Forestus, his remedies for consumption, 12. Fossae nasales, lesions of the, 205. Fournet, M, his researches on the physical signs of the early stage of phthisis, 70. Foxglove, as a remedy in the treatment of consumption, 28. Galen, erroneous views of, on the nature of consumption, 8, 9; remedies employed by, 10. Galenists, the, their materia medica almost entirely vegetable, 12. Gellerstedt, Dr., on the pathology of phthisis, 83. Gibbs, Dr., on ulcerations in the mucous membrane of the air-passages, 187; on diseases of the throat, epiglottis, and windpipe, 196. Gilbert, Dr. Henry, his views on the pathology of phthisis, 73. Glands, position and structure of the follicular, 125; tonsillary, 126; racemous mucous, of the pharynx, 128; racemose, of the larynx, 132; of the trachea, 133 ; the origin of all glands depends upon a process called proliferation, 152 ; lesions of the tonsillary, 214. Glandular follicles, nature and order of the pathological changes in the, 153; appearance of the, in the initial stage of tuberculosis, 179. Glover, Dr. R. M., on tubercle and scrofula, 87-89. Goat, fat of the, a popular remedy in Pliny's day, 8; milk of, 10,17. Godwin, on the study of the nature of pulmonary consumption, 175. Good, Dr., on the nature and treatment of consumption, 41. Graves, Dr. R. J., on the pathology and treatment of phthisis, 77. 352 INDEX. Hahnemann's treatment of chronic laryngitis, 265. Hall, C. Radcliffe, on the mode of development of tubercle, 108. Hasse, Professor, on the origin and nature of tuberculosis, 89 • on the lymphatic glaads, 145; on erosions of the epiglottis, 258. Heberden, no important contributions by, 29. Hectic fever, as described by Galen, 9. Hereditary influence, 50, 157, 160; cases illustrative of, 201 Hippocrates, consumption as described by, 4; treatment recommended by, 5 ; attri- butes glandular swellings in scrofula to an excess of lymph, 143. Histology, special, of the respiratory organs, 123, 162. Hoffman, his theory of phthisis, 18 ; treatment, 19. Horseback exercise, recommended by Sydenham, 16. Hydrocyanic acid, use of, in chronic phthisis, 335.' Inhalations, 13 ; recommended by Darwin, 27 ; not much to be depended on, accord- ing to Laennec,' 38. Injections, bronchial, 299. Intercellular matter, or the material out of which cells are developed, 121. Iodine, a valuable local remedy in follicular disease, 327; as a general remedy, 329. Iron, use of, in chronic phthisis, 334. Isthmus faucium, the, 125. Kolliker, on the structure of the air-cells of the lungs, 137 ; on the lymphatic ves- sels of the lungs, 140. Laennec, his views on the nature and treatment of consumption, 35 ; on the earliest symptoms of consumption, 171. Larynx, anatomy of the, 128; peculiarities in its mucous membrane, 131; lympha tic vessels of the, 134, 163 ; ulcerations of, in tubercular phthisis, 182. Lawson, Professor, on the symptoms of the precursory stage of phthisis, 195. Lebert, his peculiar views on the nature and constitution of tubercle, 85; on its identity with scrofula, 86. Legrand, A., on the difference between tuberculous and scrofulous diseases, 99. Lesions, primary, of the aerial membrane, 205; of the tonsillary glands, 214; of the pyriform sinuses, 240; of the epiglottis, 245. Lobules of the lungs, structure of the, 137. Louis, M., on the pathology and treatment of phthisis, 45; on hereditary influence, 160; on the earliest symptoms of tubercular phthisis, 172; on the ulcerations of the mucous membrane of the aerial passages, 182. Lungs, the, structure of, 135, 164; great influence of the tonsils in determining dis- ease of, 178, 218. Lymph, nature of, 142. Lymphatic system, tuberculous affections more or less allied with changes in the, 143. Lymphatic vessels of the trachea, 134, 16b; of the lungs, 140; similarity between the contents of the tubercle granule and those of the lymphatic vessels, 146 ; relationship between the contents of, and the circulation of the blood, 164. Madden, "W. H., on the origin and treatment of phthisis, 96. Manganese, use of, in chronic phthisis, 333. Mascagni, on the treatment of consumption, 24. Materia medica, the, of the Galenists, almost entirely taken from the vegetable kingdom, 12. INDEX. 353 Meechay, of Gottingen, on consumption, 28. Metallic preparations not used to any great extent until many centuries after the death of Galen, 12. Milk diet recommended by Galen, 10; rejected by Stahl, 17. Morgagni, views of, 20. Morphine, as a local agent in chronic phthisis, 328. Mortality caused by tubercular consumption, 2. Morphological changes in the tissues, 150. Morton, the use of Peruvian bark recommended by, 18. Mosely, on the treatment of consumption, 24. Mucous membrane, essential constituents of the, 123; peculiarities in the, of the larynx, 131; of the lungs, 136; ulceration of the mucous membrane of the aerial passages, in tubercular phthisis, 182; difference between ulcerations and erosions of, 257. Nitrate of silver, topical application of, in follicular disease, 207; in lesions of the epiglottis, 251; advantages to be derived from its use, 315; method of apply- ing, 326. Nucleolus, the presence of, marks the highest degree of cell-development, 119. Nucleus, the, of the elementary cell, 118. Oral cavity, anatomy of the, 125. Padline, Dr., theoretical views on the nature of tuberculosis, 65. Paget, Professor, on tho softening of tubercle, 112; on the identity of scrofula and tuberculosis, 113. Palate, the soft, 125. Paracelsus, attributes consumption to a deficiency of moisture in the system, 11; advises mineral remedies, ib. Parola, Louigi, his theory that tuberculosis originates in defective respiration, 100 Parr, Dr., his objection to the use of digitalis, 29. Paterias, remedies used by, in the treatment of phthisis, 13. Pathological changes in the glandular follicles, nature and order of the, 153. Peruvian bark, employed by Morton, 18; recommended by Portal, 30. Pharynx, anatomy of the, 127; appearance of the glandular follicles, in the initial stage of tuberculosis, 179. Phillips, Dr., on the identity of tubercle and scrofula, 86. 'Phthisiologia,' the, of Morton, 18. Phthisis, the pathology and true nature of, 148; early symptoms of, 168, 171; first or prse-tubercular stage of, 279; the bronchitic stage of, 290; the tuber- cular stage of, 297; local and general treatment of, 325. And see Consump- tion. Pillars of the fauces, the, 126. Plexus, capillary, 140. Pliny the elder, the first to recommend the use of resinous effluvia, 8. Portal, an important contributor to medical pathology. 30. Pne-tubercular stage of chronic phthisis, treatment of, 201. ' Predictions and Aphorisms,' the, of Hippocrates, 4. Proliferation, the process of, 152. Pneumonia, chronic, as described by Broussais, 41. Propositions regarding the inceptive pathology and true nature of phthisis, 148. Pulmonary consumption, definition of, 1 354 INDEX. Pulmonary vesicles, or air-cells, structure of the, 136. Pyriform sinuses, lesions of the, 240. Raulin, his treatise on consumption, 23. Remedies, topical, 325. Respiratory organs, special histology of the, 123, 162. Rhozas, an Arabian physician, advises fumigations with arsenic, 11. Rilliet, researches of, on tubercle, 79. Rima glottidis, the, 130. Rokitansky, Karl, his views on the nature of tuberculosis, 75. Rollo, on inhalation, 28. Rush, Dr., views of, on the nature and management of consumption, 25. * Schultz, Prof., on the origin of ulcerations, 145. Schwann, the homogenous substance of, 121. Scrofula, and consumption. For the opinions of various writers on the identity of, see 26, 56, 78, 81, 86, 88, 90, 91, 98, 99, 105, 107, 113, 144. Sea-voyage, the remedy most relied on by Celsus, 8. Sieveking, Dr. E. H., on the seat of pulmonary tubercle, 111. Simon, M., his theory that tuberculosis is a disease of the lymph in the glands, 101. Sinuses, pyriform, lesions of the, 240. Softening, process of, different opinions entertained by physicians on, 192. Solenander, his plan of arresting incipient consumption, 12. Southey, Dr., of London, statistical observations by, 33. Sputa, nature of the, in early phthisis, 181. Stahl on hectic and consumption, 17 ; treatment advised by, ib.; condemns the use of bark, 18. Stokes, Dr., on the treatment of consumption, 66. Sulphur, vapor of, 13. Sydenham, his views of the nature of consumption, and treatment recommended bj, 15, 16; regarded phthisis as scrofula of the lungs, 144. Theses relating to the inceptive pathology and true nature of phthisis, 148. Thyroid cartilage, the, 129. Timms, Dr. Godwin, on the true nature of consumption, 115. Tissue, animal, consists of elementary cells, 118, 162; three groups of, 120; con- nective, 124; ultimate pulmonary, 136; morphological changes in the, 150; relation between their cellular elements and the circulation of the blood, 164. Tonsillary glands, the, 126, 162, 214. Tonsils, histologists not agreed as to the nature of the secretion from the, 215; great influence of the, in determining disease of the lung, 218; pathological changes in degeneration of the, 220; importance of the excision of the abnormal por- tion in enlarged, 226, 233, 285. Topical treatment of follicular disease, 207. Trachea, anatomy of the, 133 ; lymphatic vessels of the, 163. Treatment of the pne-tubercular stage of chronic phthisis, 201; local and general treatment of chronic phthisis, 325. Trousseau, on cauterizing the air-passages, 309. Tubercle, or tuberculous matter, 1; Laennec, on the development of, 37 ; Baron on the origin of, 39; Broussais on, 40; Dr. Good on, 41; Andral on the origin of, 44; as defined by Louis, 46; Cruveilhier on, 55 ; Carswell en, 57 ; Dr. James Clark on, 59; Dr. Davies on, 64; Dr. Stokes on, 66; W illiams on, 67; Con- INDEX. 355 Tubercle, continued. statt and Campbell on, 71, 72 ; Rokitanski on, 76; Graves, Dr., on, 77; Rilliet and Barthez on, 79; Gellerstedt on, 84; Lebert on, 85; Phillips and Glover on, 87 ; Professor Hasse on, 89; J. Hughes Bennett on, 92 ; Virchow on, 102. Van der Kolk on, 103; C. R. Hall on, 108; Sieveking on, 111; Paget on, 112; Dr. S. Wilks on, 114. Tubercle granule, striking similarity between the contents of and those of the lym- phatic vessels, 146. Tubercular stage of phthisis, the, 297. Tuberculosis, pulmonary, definition of, 1; primary symptoms of, 177, 178 ; in its initial ^tage, amenable to treatment, 177 ; cauterization of the air-passages in, 317 ; description of the operation, 322. And see Consumption and Phthisis. Tuberculous dyscrasia, nature and origin of, 162 : may be transmitted to offspring 201. Ulcerations, tubercular, in the glandulae of the mucous membrane of the air-pas- sages, 186; difference between ulcerations and erosions of the mucous mem- brane, 257. Uvula, appearance of the, in the initial stage of tuberculosis, 179 ; relaxation of, presenting some of the symptoms of phthisis, 180; pathology of the elonga- tion of the, and case, 211. Valsalva, opinions of, 20. Van der Kolk, on the origin and formation of tubercle, 103. Van Swieten, opinions of, on consumption, 21. Vasa afferentia and efferentia, the, 142. Velum pendulum palati, 125. Venesection, recommended by Dr. Good, 42 ; by Dr. Clark, 63. Vesalius, improvements made in anatomical investigations by, 14. Vesicles, pulmonary, or air-cells, structure of the, 136. Virchow, on the origin of tubercle, 102; his theory of ce41-territories, 121; on the lymphatic vessels of the lungs, 140; cell-doctrine of, 153; on cellular patho- logy, 161; on the development of tubercular corpuscles, 170. Vogel, a firm believer in the contagious nature of consumption, 23. "Waters, Dr., on the structure of the air-cells of the lungs, 137. Welles, Dr., on the antagonism between intermittent fever and tubercular consump- tion, 33. "Wilkinson, Dr., on the proximate cause of tuberculosis, 146. Wilks, Dr. Samuel, on miliary and yellow tubercle, 114. Williams, Dr. C. J. B., on the nature and treatment of tuberculosis, 67. Willis, views of, on consumption, 14. Zinc, use of, in follicular disease,- 327. *S\l41S\i&S\. UU /s ■jt/\ OF MEDICINE NLM Q32772U NLM032772112