JOHN HENRY WALSH, ESQ., F. R. C. S. 1852. LONDON: JOHN CHURCHILL, PRINCES STREET, SOHO. WORCESTER: DEIGHTON AND CO., HIGH STREET. PROVINCIAL MEDICAL & SURGICAL JOURNAL. CLINICAL LECTURES ON THE PRACTICE OF PHYSIC, DELIVERED IN THE THEATRE OF QUEEN'S COLLEGE, BIRMINGHAM. BY DAVID NELSON, M.D., EDIN., Physician to the Queen's Hospital, and Professor of Clinical Medicine, &c. LECTURE XI. circulating in the blood; or may take place in the course of severe pneumonia, or bronchitis. Its marked characteristics are,-pain, and a sense of intense especial heat in the part, even while the rest of the body is of very exalted temperature, difficulty of swallowing, difficulty of speech, and intensely laboured and harsh respiration. This latter symptom is the most obvious one to any bystander, and the most painful and alarming to the patient himself. At first, of course, these sensations are comparatively slight, but, as the disease runs on, they become dreadful in the extreme, and exhibit all that you might expect from a protracted 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. GENTLEMEN,-Inflammation, whether it attack one or other portion of the respiratory system, must always be viewed in a serious light; for even when only affecting the first passages, such as the nostrils, it is very apt, if neglected, to be propagated downwards, and terminate in more vital parts. An acute inflammation of the nostrils usually proceeds from retained excretions, or atmospheric poisons, and is the first and most obvious symptom of a common cold, or nasal catarrh, and more especially of influenza. It is characterized by redness, dryness, heat, and swelling, and a concurrent febrile excitement. The patient is unable to draw air through the passages; and at length there is augmented discharge, at first of mucus, and afterwards it may be of pus and blood. It may be treated by leeching, though that is seldom resorted to, inasmuch as the vessels, if much gorged, usually relieve themselves by a spontaneous hæmorrhage. Most generally it is met by such medicines as will open the various emunctories, and procure vent for the "peccant humours." Strong saline purgation is one very efficacious remedy. If hæmorrhage proceed too far, it may be stopped either by plugging, or by snuffing up a little of the acetate of lead; and if a chronic inflammatory action be continued, after the subsidence of the acute attack, giving rise to a constant flow of muco-purulent matter, a similar snuffing up of calomel will be most likely to arrest so disagreeable a symptom. But INFLAMMATION OF THE LARYNX is one of the most formidable diseases that can assail the human frame, especially on account of its tending to induce suffocation. It may arise from the application of some external irritant, or from poison No. I., January 7, 1852. efforts, and terminate fatally within a very short time, exhibiting after death a red and thickened indurated condition of all the tissues of the larynx, and its aperture narrowed to a mere slit. In the young woman Perkins, who came in with continued fever, and whose chief local inflammation lay in the chest, we had an instance of this disease. The fever, pneumonia, and bronchitis had already been gradually subdued, when, being a little light-headed, and believing she was quite well, she walked into the stone passage, and stood there for a time. Shortly after she complained of sore-throat, when, fearing what might be the result, two re-lays of leeches were applied, and she was placed under mercury and antimony, with a nitrate of silver gargle. In spite of these efforts the inflammation increased, the respiration became hissing, and then harsh, the lips and cheeks became blue, the pulse rose to 140, the ala nasi were expanded, and the greatest anxiety was depicted in the brow and eyes. At length, as you will see, on referring to the case, matters came to such an extremity, that Mr. Moore thought of performing tracheotomy; before doing so he sent to ask my consent, but meanwhile the poor girl had died. This was the more annoying as it was the only instance during eighteen months in which we had lost a case of fever here, the death occurring, too, just on the verge of convalescence. In like manner, with numerous young children, though the symptoms may be temporarily subdued, yet they are apt to return with renewed force, and too often terminate fatally, in spite of all efforts. I have said that the treatment must consist of local abstraction of blood, with mercury and antimony, in frequently repeated doses, and the warm bath. Tracheotomy should also be kept in view, but, as in private practice, there is frequently such a prejudice against this proceeding, as to deter the attendant from resorting to it, or even suggesting it; so in hospitals it is very seldom had recourse to, except until too late. Both physicians and surgeons seem generally to feel that they are not called upon to use such a remedy until all others have proved of no avail. They are liable to consider that while, on the one hand, any certainty of recovery after the operation is very problematical, the probability of death, on the other hand, is pretty strong, and therefore shrink from the responsibility of the death being imputed to the operation, rather than the disease. But it should be recollected that it is the delay of the operation that gives the victim so little chance of benefit from it. It should also be borne in mind that it is only done with the view of allowing the patient to have breath, while the other remedies are exerting their influence on the larynx; and that, even though it should fail as an expedient of cure, it is very likely to operate so far as to procure a comparatively easy death. All this makes me inclined to be an advocate for the timely performance of tracheotomy in this disease, and, in the next case that occurs in the hospital, I shall certainly resort to it at an earlier period than heretofore; and, indeed, the house-surgeon has my authority for its performance without waiting for my presence. The slow chronic inflammation and thickening of the laryngeal textures which are apt to occur in certain strumous and syphilitic habits, giving rise to loss of voice, great hoarseness, and some slight sense of pain, accompanied with the presence of something that can never be hawked up, is an equally formidable disease, with the last and not less fatal, though not so sudden and startling. The morbid appearances after death are, a great thickening of all the tissues, including those of the vocal chords. The surface has the appearance of the skin of the hand, softened, thickened, and puckered, by long steeping in hot water, covered with a thick glairy mucus, and here and there a patch of inflammation, or congestion. The accurate pathological theory of such local appearances I do not profess at all to understand. That there is a degenerate hypertrophy is obvious, but why this seat should be specially chosen for the deposit, is quite another question; I cannot answer it, and shall, therefore, only state facts. It is almost always accompanied with a very large or universal deposit of tubercle in the lungs, and those who are seized with it seldom or never recover. Good examples have been exhibited of this morbid condition in the cases of Claridge and Dremer. Both of them died mere skeletons, with their lungs riddled throughout, yet Dremer declared himself to the last as getting well fast. Greig furnishes us, on the other hand, with an instance of its partial arrest. In each of these cases the remedies for phthisis were employed, but, in addition, local leeching was also resorted to, and an inhalation used, composed of conium and iodine, which seemed to produce very beneficial effects. In the two fatal cases the feelings of uneasiness were relieved, and in that of Greig the voice was restored, and the pain on swallowing, &c., quite dispersed. He left the hospital tolerably well, but I have not heard of him since. Some good has also been effected by the application of strong solutions of the nitrate of silver; but, upon the whole, I can speak most favourably of the iodine and conium as giving relief almost invariably. This, as you may be aware, was the favourite remedial application of Sir Charles Scudamore in almost all respiratory cases whatever. Such narrow views of pathology are altogether untenable, yet each favourite remedy, like this, may be found highly useful for its own specific purpose, that of this one being to allay irritation and promote absorption. In INFLAMMATION OF THE TRACHEA, or CROUP, we have a specimen of one more very formidable disease, chiefly attacking young persons. It is most commonly traceable to some exposure to cold during raw and damp weather, or in cold moist situations. Sometimes it is preceded by all the characteristics of a simple cold, with rough cough, hoarsness, and some amount of fever; but the true and alarming symptoms of fibrinous croup are generally rather sudden in their manifestation, and either appear rather unexpectedly, after some continuance of the above condition, or all at once with scarcely any premonitary symptoms whatever, so that— as observed by a vigorous describer of disease, the mother of a family may be suddenly startled from her sleep, by that terrible clanging cough which is so peculiar to croup, and which bodes so ominously of a quick and fatal issue. The essence of the disease consists in the exudation of fibrinous lymph from the inflamed surface of the trachea, so solid and tenacious, that it is firmly moulded to all the irregularities of the organ, adhering to it like a true membrane, and becoming thicker and thicker as the morbid action advances. Many beautiful specimens are to be seen of this fibrinous coating after it has been thrown off, when it exhibits itself as an exact mould of the trachea, as if taken in pliable wax. This, you know, is rather an exceptional event in mucous surfaces, unless inflammation run exceedingly high indeed, and its frequent occurrence in this situation is doubtless due, partly to the intense action going on, and partly to some peculiarity in the natural organization of the part. Almost invariably, in such situations, it is pus, and not fibrinous lymph, that is thrown out. But for this law the most disastrous consequences might frequently happen from inflammatory attacks of the nostrils, the oesophagus, the rectum, the urethra, &c., leading to the blocking up of such passages. As it is, it is singular enough how such an event should so much more often occur in so essential an organ as the trachea than anywhere else, but such is the fact, and it must make us view the affection in a very serious light. The great object in such a case must be to abate the hyperemia and to evacuate the existing obstructions to respiration. The first is to be attained by abstraction of blood, and the administration of such remedies as may lessen the force of the circulation, as antimony and digitalis, though both are to be avoided if the powers of life be very low. A few leeches along the track of the windpipe, and a quarter of a grain of antimony every hour, will soon take some effect on the constitutional action, and by the addition of mercury, the natural secretions will be promoted, the tenacious exudations rendered more fluid, and also absorbed. If the false membranes are inclined to be loosened from their attachments to the mucous surface, their expulsion will be much promoted in a mechanical way by the exhibition of emetics; but, upon the whole, the greatest sources of confidence must be in abstraction of blood, and the speedy influence of antimony and mercury, the latter being applied by friction as well as by the mouth. Tracheotomy does not, in this instance, hold out such hopes as in laryngitis, because we can scarcely tell how far the inflammation has proceeded, and therefore even after making an opening at the lowest point, we may find it of no use. habitual asthma, and also thereby induces emphysema. In the first stage of bronchial inflammation, there will be heard, from the dryness of the membrane, a harsh hissing sound under respiration, over the course of the larger tubes, while the vesicular murmur may be unaltered, and this will be accompanied with dry cough, and some sense of rawness down the centre of the chest. As exudations make their appearance, those sounds will become rough, and more complicated with others, arising from the air bubbles traversing the effused fluids, and bursting therein. This stage will now be marked by a moister cough, accompanied with an expectoration, the more thin the more easy, and the more tenacious the more painful. While, therefore, these proofs of bronchial inflammation may be gathered 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 BRONCHITIS, 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 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 had 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 cause, |