« 이전계속 »
charge of the famous embryologist, Dr Martin Barry. These essays have already excited an extraordinary amount of criticism favourable and adverse. Our only intention at present, in regard to them, is to recommend them to the careful perusal of the profession, as not only excellent specimens of able medical writing, but as everywhere teeming with facts and observations of the greatest interest, important suggestions, and elaborate research.
When the second volume of the work appears, we shall return again to this notice. It is destined to contain, among others, the papers on the use of chloroform as an anæsthetic agent, which on the wings of fame have carried the name of Dr Simpson to every quarter of the globe, and to the bosoms of myriads of the afflicted.
On Injection of the Bronchial Tubes, and Tubercular Cavities of the
Lungs. By HORACE GREEN, M.D. New York, 1855. 8vo. Pp. 20.
The reader who may be startled, as we have been, by the title of this pamphlet, will be at no loss to understand the feelings with which we approach it as reviewers and critics. The judicial tone which is universally conceded to remarks divested of the weight of personal authority, must be laid aside before an achievement on which it would be absurd to suppose that any one of our mysterious brotherhood is in a condition to pronounce judgment. Even if we could conscientiously profess (which we cannot and do not) to have performed the operation here described by Dr Horace Green, President of the Faculty, and Professor of the Theory and Practice of Medicine in the New York Medical College, we should barely have had time to recognize, in one or two cases, its immediate, to say nothing of its ultimate, results. It will be more in accordance with our present views and intentions, as well as with the position held by the author, and the object and habitual purpose of this Journal, if we keep our readers informed as to the manner in which our neighbours across the water are, as usual, “ going a-head” of us in the practical business of life; and vindicate to the world the claim of Dr Horace Green and some of his friends, “as Americans, .... to perform operations of which the conservative Englishmen and sceptical Frenchmen have never dreamed !” We here catch a glimpse of the policy of the “Know-nothings," and might be tempted to discuss, with the author, the propriety of mixing up medical and scientific improvements with the other objects of the “great American party;" but we forbear, remembering that for this time, at least, we have sworn to sit humbly, not as teachers, but as disciples, at the feet of our transatlantic Gamaliel.
Dr Horace Green, who is sufficiently well-known to our readers as having been the first to propose the direct local treatment of parts of the air passages beyond the glottis (by means of the introduction of a whalebone probang, armed with a piece of sponge saturated with solution of nitrate of silver), was led to the present extension of his views, and improvement of his practice, by the doubt which some “ conservative Englishmen and sceptical Frenchmen” regarded his former undertaking. We cannot charge ourselves with having been in this matter, among those shortsighted persons pointed at by the author. On the contrary, in reviewing his former works in 1849 (vol. ix., p. 1081), and in 1850 (vol. x., p. 546), we have uniformly allowed the author's statements on practical points to reach our readers unaccompanied by any expressions of our opinion, except in those cases in which we were able to corroborate his experience by our own. This, too, at a time when we were well aware, that the ill-founded and loosely expressed pathological views of the author, and of some of his adherents in this country, had given birth to not 'a little of that specialist quackery, which is ever ready to spring up for a season under the sun of fashion, like a bed of weeds on the virgin soil of a railway embankment. We are well aware, that sound improvements, as well as novelties which are not improvements, may be attended by such an efflorescence; and if Dr Green can make good to his brethren and to ourselves his new project, we shall be well content to let him drive his engine through the tunnel of the glottis without molestation, not reckoning to his disadvantage the character of the flora which is springing up on each side of his peculiar “ line.”
The present extension of Dr Horace Green's operations owes its origin, as we said, to certain doubts which had arisen as to the possibility of overcoming the engineering difficulties in the construction of the original trunk-line along the trachea. M.M. Trousseau and Belloc (to say nothing of M. Bretonneau) had been accustomed, as all the world knows, to maintain a pretty considerable traffic as far as the glottis; and when it was announced from the far west that Dr Horace Green's explorations had extended “deeper than did ever plummet sound," at all events that his sponge had gone where never European sponge went before (excepting by accident); there were found some daring sceptics and obstinate conservatives who, on the strength of ten paltry degrees of latitude, fancied themselves a little too far north" for the Professor of Theory and Practice of Physic in New York. Foolish Mr Erichsen! to declare with " as much positiveness" (sic) that the sponge “has never been passed in the living subject beyond the true vocal chords.” Doubly foolish Dr Marshall Hall ! to hold, and still worse to express within a thousand miles of Dr Green's office (“ where he had an opportunity of witnessing its accomplishment in many instances,”) the belief that Dr Green's operation could not be done, because “ the passage of a sponge wet with the caustic solution into the larynx and trachea would prove fatal to animal life.” To the scepticism of Dr Marshall Hall in particular, or perhaps rather to his strong i and decided convictions upon the subject of reflex action, we owe
it that Dr Green, acting on a suggestion of the English physiologist, "procured several of Hutching's flexible tubes, of different sizes, and to the extremity of one of these, thirteen inches in length, attached a sponge of the same size with those which are used with the ordinary throat probang." With this new instrument, “on the 5th of October, in the presence of several physicians," Dr Green succeeded in affording to the most sceptical among them positive proof that he had passed the sponge beyond the glottis ; and Dr Marshall Hall must have felt considerably “chawed up," when, in spite of reflex action, two respectable clergymen, on whom Dr Horace Green had repeatedly passed the sponge in the ordinary way, were able, by means of the tube aforesaid, to blow out a lamp, collapse or inflate an elastic bag, and perform a number of other satisfactory and convincing feats for the edification and benefit of sceptical humanity. The names of these gentlemen may hereafter deserve to be mentioned along with that of James Phipps, the first subject of vaccination in the hands of Dr Jenner. We therefore regret that in regard to the first of these, we are not able to communicate more than that he was “an intelligent clergyman from Canada.” The other was “the Rev. Mr M‘Ann, the superior third of whose epiglottis could be seen easily by depressing the tongue.” This gentleman deserves also to be commemorated as having nearly fallen a martyr to his zeal for illustrating the obscure truths of medical science. In operating with a tube thirteen inches long, with an elastic bag at the end of it, Dr Green happened to let the latter slip out of his fingers. “ Just then the patient made a strong inspiration, when the whole instrument, sac and all, was drawn suddenly in, and for a moment disappeared out of sight. Thrusting my fingers immediately into the throat of the patient, I could barely reach, at the base of the tongue, the upper extremity of the bag, which I seized with my thumb and finger, and drew out the whole together.” Dr Green contemplates this little mischance in the true spirit of a philosopher and a man of science. Referring to it he says :-"An incident which, had the tube been shorter, might have proved an accident, is an additional proof of the position of the instrument.” We shudder to think that the incidental accident thus coolly contemplated might have proved, in the person of the Rev. Mr M'Ann, an incident (in, into, and cado, I fall) which would have demonstrated to all Europe as well as America, the position of the instrument, by connecting Dr Horace Green's name with a verdict of manslaughter.
Hitherto we have seen the “ catheterism of the air passages” performed, not with the expectation of any new benefit to the patient, but for the satisfaction of Dr Marshall Hall, and other sceptics as to Dr Green's earlier operations. We do not doubt that they came away fully satisfied. Dr Green now, however, determined upon a new venture, which occurred to him in the form of the following questions : “ What shall now hinder the introduction
of medicinal agents, through this tube, into the lungs, or directly into the bronchi and their terminations! What will prevent the injecting even of a vomica under favourable circumstances, with appropriate remedies?”
No sooner said than done. Dr Green had not to wait long for “ favourable circumstances.” On the 13th of October he injected one drachm of a solution of nitrate of silver (gr. al. to zi.), into the " left bronchial division” of a lady from Connecticut, in the advanced stage of tubercular consumption, and having, according to several experienced auscultators, a large excavation in the apex of the left lung. We give the account of the sequel in the author's own words :
“No cough whatever, or any sense of suffocation, was produced by this operation, nor did the patient observe in the least the ordinary bitter taste of the solution. A few minutes after the operation she stated that she “felt a warm sensation' in the upper portion of the left lung, but no pain, or any unpleasant feeling whatever, followed the operation. Mrs A. did not return to have the operation repeated until the 17th, four days afterwards, when she stated that for twentyfour hours after the use of the injecting tube, her cough and expectoration were both greatly diminished, that she had breathed with more freedom than before ; that these favourable symptoms had continued, though not as marked as at first, up to the present time. She was therefore much disposed to have the operation repeated. The tube was again introduced through the trachea its entire length, and at this time one and a half fluid drachms of the solution were thrown into the lungs. The immediate results were the same as at first, but after some minutes, she began to cough, and expectorated easily, and at once, nearly two ounces of purulent matter, changed in its colour and consistence, apparently, by its iminediate contact with the argentine solution. Indeed, the expectorated matter presented precisely the appearance which is observed to take place with the purulent matter of an external ulcer when cauterized with the nitrate of silver. This changed condition of the expectoration was observed by several physicians who were present when the operation was performed. The relief which followed this last operation in Mrs A.'s case was still more marked and decided than in the first instance. Her cough she stated was much relieved, the expectoration yet more diminished, and her breathing was easier. A pain in the chest of which she had complained was removed ; and during the two nights which followed the operation her sleep was better than it had been for a long period before. Mrs A. remained until the 26th, during which time the elastic tube was introduced into the left bronchial division seven times, and on each occasion from one and a half to two drachms of a strong solution of the nitrate of silver were injected into the lungs. Her improvement was constant. She grew stronger, and gained flesh in this period ; but, being obliged at this time to return to her home, she left with the intention of coming back to renew the treatment in a few weeks.
“The same day on which I succeeded in introducing medication into the airtubes of the above patient, I commenced in like manner the treatment of other cases, and since the thirteenth day of October, there have been treated for a longer or a shorter period, thirty-two patients labouring under tubercular or bronchial diseases, by the direct introduction into the lungs of a strong solution of the nitrate of silver injected through the elastic tube. Of these thirty-two cases, nineteen showed unequivocal physical signs and symptoms of tuberculosis in the different stages of the disease; complicated, many of them, with bronchial inflammation. Thirteen of the number are cases of chronic bronchitis, the disease in some of them being of many years' standing. Of the nineteen cases of tuberculosis, nine of the number presented, on auscultation, the usual signs of the presence of tubercular cavities in one or both lungs. All these cases of thoracic disease, with
one or two exceptions, appear to be benefited, some of them greatly, by this method of topical treatment."
We conclude our extracts with the following testimony of “ Dr Pittard, an intelligent and experienced physician from North Carolina, who came to this city (New York) to be treated for a severe and long-continued bronchial disease":
“ In compliance with your request, I give you a simple statement of the effect of an injection into my lungs of the nitrate of silver. The application of the remedy caused a considerable glow through the chest, which was felt for several hours. There was no irritation produced on the bronchial membrane, by the introduction of the fluid ; but, on the contrary, the cough was suspended, or greatly moderated for a day or two.
“ It may be said that the injection passed into the stomach, instead of the lungs. This may have been possible in some other instances ; but in my case there could be no doubt of its having entered the air-passages, for you will recollect that the breath was passed out through the tube, as soon as it was inserted, which may be considered conclusive evidence ; besides, I tasted the nitrate of silver in the matter expectorated for twelve or fifteen hours after the administration of the remedy."
Our readers are now in possession of the principal facts adduced by Dr Horace Green in this pamphlet. We are content simply to narrate them. We trust we have
“ Nothing extenuate, Nor aught set down in malice.”
That the operation proposed by the author is practicable, we see no reason to deny; whether it will prove useful, or even justifiable, are points on which we have grave doubts, but on which we do not feel bound to offer any opinion at present. We cannot say that we feel ourselves strongly moved, on the sole authority of Dr Horace Green, to repeat experiments fraught with so many possible “incidents” and « accidents," on all our “ cases of thoracic disease, with one or two exceptions;" yet Dr Green does not inform us as to the principle on which he selected his cases for this treatment, but leaves us to suppose that it is applicable to all cases of tubercular and bronchial disease indifferently. We must take the liberty of remarking, that the history of the “one or two exceptions" above alluded to, would have been no small addition to the value of his pamphlet. It is impossible to avoid a suspicion that a gentleman who views with such remarkable sang-froid the narrow escape of our friend Mr M'Ann from being throttled for the benefit of science, may have allowed these opposing instances (to which he only alludes in the above half line) to weigh too lightly in the balance of his judgment. Dr Green is an enthusiast. It is his boast, as an American, to demonstrate what is possible, rather than to separate with a discerning glance and a cautious hand what is good from what is bad in practice. The latter is the task of the “conservative Englishman." NEW SERIES.-NO, V. MAY 1855.