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MAP96 1990

Provincial Medical and Surgical Association,





18 5 2.




E. H. B.



circulating in the blood; or may take place in the CLINICAL LECTURES

course of severe pneumonia, or bronchitis. Its marked

characteristics are,-pain, and a sense of intense especial ON THE

heat in the part, even while the rest of the body is of PRACTICE OF PHYSIC, very exalted temperature, difficulty of swallowing, diffi

culty of speech, and intensely laboured and harsh

respiration. This latter symptom is the most obvious THEATRE OF QUEEN'S COLLEGE, BIRMINGHAM.

one to any bystander, and the most painful and alarming BY DAVID NELSON, M.D., Edin.,

to the patient himself. At first, of course, these

sensations are comparatively slight, but, as the disease Physician to the Queen's Hospital, and Professor of Clinical Medicine, &c.

runs on, they become dreadful in the extreme, and

exhibit all that you might expect from a protracted LECTURE XI.

suffocation. Even though mercury, antimony, and

abstraction of blood, be resorted to at the beginning, ON THE MORBID CONDITIONS OF THE LUNGS, ETC.,

the affection will too often run its course in spite of all CONTINUED.

efforts, and terminate fatally within a very short time, GENTLEMEN,-Inflammation, whether it attack one exhibiting after death a red and thickened indurated or other portion of the respiratory system, must always condition of all the tissues of the larynx, and its be viewed in a serious light; for even when only aperture narrowed to a mere slit. In the young woman affecting the first passages, such as the nostrils, it is Perkins, who came in with continued fever, and whose very apt, if neglected, to be propagated downwards, chief local inflammation lay in the chest, we had an and terminate in more vital parts. An acute inflam- instance of this disease. The fever, pneumonia, and mation of the nostrils usually proceeds from retained bronchitis had already been gradually subdued, when, excretions, or atmospheric poisons, and is the first and being a little light-headed, and believing she was quite most obvious symptom of a common cold, or nasal well, she walked into the stone passage, and stood there catarrh, and more especially of influenza. It is charac- for a time. Shortly after she complained of sore-throat, terized by redness, dryness, heat, and swelling, and a when, fearing what might be the result, two re-lays of concurrent febrile excitement. The patient is unable leeches were applied, and she was placed under mercury to draw air through the passages; and at length there and antimony, with a nitrate of silver gargle. In spite is angmented discharge, at first of mucus, and after- of these efforts the inflammation increased, the respirawards it may be of pus and blood. It may be treated tion became hissing, and then harsh, the lips and cheeks by leeching, though that is seldom resorted to, inasmuch became blue, the pulse rose to 140, the ala nasi were as the vessels, if much gorged, usually relieve themselves expanded, and the greatest anxiety was depicted in the by a spontaneous bæmorrhage. Most generally it is brow and eyes. At length, as you will see, on referring met by such medicines as will open the various emunc to the case, matters came to such an extremity, that tories, and procure vent for the peccant humours." | Mr. Moore thought of performing tracheotomy; before Strong saline purgation is one very efficacious remedy. doing so he sent to ask my consent, but meanwhile the If hæmorrhage proceed too far, it may be stopped poor girl had died. This was the more annoying as it either by plugging, or by snuffing up a little of the was the only instance during eighteen months in which acetate of lead; and if a chronic inflammatory action be we had lost a case of fever here, the death occurring, continued, after the subsidence of the acute attack, too, just on the verge of convalescence. In like giving rise to a constant flow of muco-purulent matter, manner, with numerous young children, though the a similar snuffing up of calomel will be most likely to symptoms may be temporarily subdued, yet they are arrest so disagreeable a symptom. But INFLAMMATION apt to return with renewed force, and too often terminate OF THE LARYNX is one of the most formidable diseases fatally, in spite of all efforts. I have said that the that can assail the human frame, especially on account of treatment must consist of local abstraction of blood, its tending to induce suffocation. It may arise from with mercury and antimony, in frequently repeated the application of some external irritant, or from poison | doses, and the warm bath. Tracheotomy should also

No. I., January 7, 1852.

be kept in view, but, as in private practice, there is dispersed. He left the hospital tolerably well, but I frequently such a prejudice against this proceeding, as have not heard of him since. Some good has also been to deter the attendant from resorting to it, or even effected by the application of strong solutions of the suggesting it; so in hospitals it is very seldom had nitrate of silver; but, upon the whole, I can speak most recourse to, except until too late. Both physicians and favourably of the iodine and conium as giving relief surgeons seem generally to feel that they are not called almost invariably. This, as you may be aware, was the upon to use such a remedy until all others have proved favourite remedial application of Sir Charles Scudamore of no avail. They are liable to consider that while, on in almost all respiratory cases whatever. Such narrow the one hand, any certainty of recovery after the opera- | views of pathology are altogether untenable, yet each tion is very problematical, the probability of death, on favourite remedy, like this, may be found highly useful the other hand, is pretty strong, and therefore shrink for its own specific purpose, that of this one being to from the responsibility of the death being imputed to allay irritation and promote absorption. the operation, rather than the disease. But it should In INFLAMMATION OF THE TRACHEA, or CROUP, we be recollected that it is the delay of the operation that have a specimen of one more very formidable disease, gives the victim so little chance of benefit from it. It chiefly attacking young persons. It is most commonly should also be borne in mind that it is only done with traceable to some exposure to cold during raw and damp the view of allowing the patient to have breath, while weather, or in cold moist situations. Sometimes it is the other remedies are exerting their influence on the preceded by all the characteristics of a simple cold, larynx ; and that, even though it should fail as an with rough cough, hoarsness, and some amount of expedient of cure, it is very likely to operate so far as fever; but the true and alarming symptoms of fibrinous to procure a comparatively easy death. All this makes croup are generally rather sudden in their manifestation, me inclined to be an advocate for the timely perform- and either appear rather unexpectedly, after some ance of tracheotomy in this disease, and, in the next continuance of the above condition, or all at once with case that occurs in the hospital, I shall certainly resort scarcely any premonitary symptoms whatever, so thatto it at an earlier period than heretofore ; and, indeed, as observed by a vigorous describer of disease, the the house-surgeon has my authority for its performance mother of a family may be suddenly startled from her without waiting for my presence.

sleep, by that terrible clanging cough which is so peculiar The slow chronic inflammation and thickening of the to croup, and which bodes so ominously of a quick and laryngeal textures which are apt to occur in certain fatal issue. The essence of the disease consists in the strumous and syphilitic habits, giving rise to loss of exudation of fibrinous lymph from the inflamed surface voice, great hoarseness, and some slight sense of pain, of the trachea, so solid and tenacious, that it is firmly accompanied with the presence of something that can moulded to all the irregularities of the organ, adhering never be hawked up, is an equally formidable disease, to it like a true membrane, and becoming thicker and with the last and not less fatal, though not so sudden and thicker as the morbid action advances. Many beautiful startling. The morbid appearances after death are, a specimens are to be seen of this fibrinous coating after great thickening of all the tissues, including those of the it has been thrown off, when it exhibits itself as an vocal chords. The surface has the appearance of the exact mould of the trachea, as if taken in pliable skin of the hand, softened, thickened, and puckered, by wax. This, you know, is rather an exceptional event long steeping in hot water, covered with a thick glairy in mucous surfaces, unless inflammation run exceedmucus, and here and there a patch of inflammation, or ingly high indeed, and its frequent occurrence in congestion. The accurate pathological theory of such this situation is doubtless due, partly to the intense local appearances I do not profess at all to understand. action going on, and partly to some peculiarity in the That there is a degenerate hypertrophy is obvious, but natural organization of the part. Almost invariably, in why this seat should be specially chosen for the deposit, such situations, it is pus, and not fibrinous lymph, is quite another question ; I cannot answer it, and that is thrown out. But for this law the most disshall, therefore, only state facts. It is almost always astrous consequences might frequently happen from accompanied with a very large or universal deposit of inflammatory attacks of the nostrils, the wesophagus, tubercle in the lungs, and those who are seized with it the rectum, the urethra, &c., leading to the blocking seldom or never recover. Good examples have been up of such passages. As it is, it is singular enough exhibited of this morbid condition in the cases of how such an event should so much more often occur Claridge and Dremer. Both of them died mere skele- in so essential an organ as the trachea than anywhere tons, with their lungs riddled throughout, yet Dremer else, but such is the fact, and it must make us view the declared himself to the last as getting well fast. Greig affection in a very serious light. furnishes us, on the other hand, with an instance of its The great object in such a case must be to abate the partial arrest. In each of these cases the remedies for hyperæmia and to evacuate the existing obstructions to phthisis, were employed, but, in addition, local leeching respiration. The first is to be attained by abstraction was also resorted to, and an inhalation used, composed of blood, and the administration of such remedies as of conium and iodine, which seemed to produce very may lessen the force of the circulation, as antimony and beneficial effects. In the two fatal cases the feelings of digitalis, though both are to be avoided if the powers uneasiness were relieved, and in that of Greig the voice of life be very low. A few leeches along the track of pas restored, and the pain on swallowing, &c., quite the windpipe, and a quarter of a grain of antimony every

hour, will soon take some effect on the constitutional habitual asthma, and also thereby induces emphysema. action, and by the addition of mercury, the natural in the first stage of bronchial inflammation, there will secretions will be promoted, the tenacious exudations be heard, from the dryness of the membrane, a harsh rendered more fluid, and also absorbed. If the false hissing sound under respiration, over the course of the membranes are inclined to be loosened from their larger tubes, while the vesicular murmur may be unattachments to the mucous surface, their expulsion altered, and this will be accompanied with dry cough, will be much promoted in a mechanical way by and some sense of rawness down the centre of the the exhibition of emetics ; but, upon the whole, the chest. As exudations make their appearance, those greatest sources of confidence must be in abstraction sounds will become rough, and more complicated with of blood, and the speedy influence of antimony and others, arising from the air bubbles traversing the mercury, the latter being applied by friction as well as effused fluids, and bursting therein. This stage will by the mouth. Tracheotomy does not, in this instance, now be marked by a moister cough, accompanied with hold out such hopes as in laryngitis, because we can an expectoration, the more thin the more easy, and the scarcely tell how far the inflammation has proceeded, more tenacious the more painful. While, therefore, and therefore even after making an opening at the lowest these proofs of bronchial inflammation may be gathered point, we may find it of no use.

from the stethoscope, the general expansion of the From the peculiarities connected with the local chest may be pretty good, and the vesicular murmur inflammations already described, it was necessary to soft and regular. The sounds on percussion may also treat of them individually; but, for the remaining por- be universally good; though, sometimes, when a pellet tions of the respiratory apparatus, I shall reduce them of hardened mucus may have blocked up one or more synthetically to one head of hyperæmia, instead of of the air passages, there may be a good sound over the dividing them into bronchitis, pneumonia, &c. Acute obstructed portion of lung; but yet no proper expansion HYPERÆMIA may attack either the mucous membrane and no vesicular murmur. So far, a simple bronchitis of the bronchi and bronchilli, with their sub-tissues, in is easily diagnosticated, but it must be recollected that which event it is considered BRONCAITIS, or it may seize the question is too often complicated with previouslyon the vesicular portions of the lungs, in which case it existing disease, such as solidification of the lung from is called PNEUMONIA. Both, however, are to be viewed tubercle or plastic lymph, or the exudation of serum, as the same action, differing only in extent of surface or pus, or lymph from pleurisy, or the presence of a and certain distinctive effects referable to certain differ- tumour; or an obliteration of the lung altogether. ences as to function and structure. Thus, the bronchi | Under such circumstances, it becomes extremely difficult being merely air passages, their diseased condition is of to form any decided opinion ; unless you are already less importance than that of the vesicles, within which master of the previous history of the patient, in which the proper function of the respiration is carried on. case it were comparatively easy to know whether any The bronchi are also more apt to be affected on both such solidification were of old standing or not, and what sides equally than the vesicles ; and from their greater was its real nature. The various solidifications that may openness they are more likely to throw out simply occur are often not to be distinguished from one another protective mucus or expectorable pus, than that fibrin except by such history and other collateral evidence. ous lymph, which is too often the result of vesicular Fluid effusions cannot be discovered by succussion inflammation. The ordinary causes of this inflammation, when the cavity is perfectly full of any homogenous like those in other internal organs, are the application mass. The chief proof, therefore, is the absence of the of external irritants, or revulsed excretions, or febrile vocal thrill, and as to whether the fluid be serum or and other poisons circulating in the blood. When the pus, or an admixture of both, that is only to be known bronchi alone are affected, there will necessarily be, by the preceding symptoms, or by the trocar. An according to the extent or severity of the action, more obliteration of the lung is of course still more difficult or less cough, and more or less impeded respiration. to be proved. The nature of such difficulties may be The cough will at first be dry, as the immediate con instanced in certain actual cases treated within the sequence of all inflammation is a stoppage of the natural hospital. Thus, in the case of the boy Green, the claysecretions; but, in due time, if not checked at the first like dulness of the right side was referred to tubercle onset, there will follow first an expectoration of mucus, from collateral evidence alone, inasmuch as he was pale more or less tenacious, which will afterwards become and emaciated, and had had degenerative disease in the muco-purulent, or entirely purulent, according to cir knee-joint, &c.; yet it is not impossible that it may cumstances. When the membranes have become so thick- be hepatization. In the policeman, James Hughes, the ened by the exudations of inflammation, or so obstructed same dulness on the left side was referred to hepatization by the superficial discharges, some difficulty of breath on account of the sudden illness, and yet it might be ing will be experienced. This, arising from a physical tubercle or something else. In the phthisical cases of cause, will be so far permanent and equal; but as some Eliza Sleuth, and Ann West, a similar dulness on the nervous irritation must arise under the presence of such left side was attributed to tubercle; but the fact was, foreign matter, so this difficulty of breathing will be that the old tubercle had softened and disappeared, and liable to rather sudden fits of increase, due to occasional the entire organ bad become absorbed. In the young asthmatic constriction. A chronic inflammation there woman, H. S., this dulness of the left side was viewed fore, of the bronchitic kind, usually gives rise to with great uncertainty ; but she died almost immediately

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