543

you that the heart is surrounded by andcontained in the thorax, a cavity whose Iparietes, in all directions, are extremelyelastic, and thus calculated to transmitfrom the interior to the exterior anysounds which may be produced within it.At each contraction of the heart, the mus-cular body strike against the anteriorwall of the chest; at each pulsation, as itis familiarly called, the organ undergoes a ikind of redressement; the point strikes

I

against the elastic surface of the ribs, anda sound is thus produced, which you mayreadily distinguish by placing the ear onthe chest of a healthy individual, andwhich, in some cases, is so clearly de- z,veloped, as to be heard at a considerabledistance. Those who have paid any atten-tion to diseases of the heart, must have re-marked the great force with which itstrikes against the chest in several affec-tions of the aortic valves, &c.

’

This phenomenon, Gentlemen, has al-

ready received at least ten different ex-planations, and everybody has endea-voured to discover its true cause; but

nothing appears to me more natural ormore simple than to say, that: whenone body suddenly strikes against anotherbody we have a sound produced. Thereis, however, another sound of the heartwhich we shall examine and ascribe to itscause in a future lecture. You know thebruit of the heart is not single; it gives atic-tac sound like that of a watch ; thereare two shocks, one immediately follow-ing and perfectly distinct from the other ;this sound, in my theory, is connectedwith dilatation of the ventricle, whichstrikes against the sternum; but, as I saidbefore, we must defer the examination ofthese bruits. I have merely mentionedthem here, as an example of sounds pro-duced in the human body by the shock ofone part against another. We also havean example in the sound which school-

boys produce in the articulations of thefingers. This certainly arises from a kindof shock; though, I must confess, I can-not well explain how it occurs ; the two ar-ticulating surfaces are suddenly separatedand brought in contact again as quickly,but there is something peculiar in themanner, which escapes our sagacity.

Thus, Gentlemen, the physical laws ofsound in general are applicable to thesounds which we hear in the human body,either during health or disease ; and thelatter, as I have endeavoured to show youin the present lecture, are developed bypercussion, or the shock of one hard partagainst another,-by the rubbing of thedifferent parts, or by the passage of a fluidthrough a narrow cavity, where it meetssome resistance from a foreign body. These

are, in fact, physical phenomena, commonto all parts of the natural world; they arenot incompatible with life, nor do theyseem to be modified by it; although we emight venture to affirm, that in the livingbody sounds are produced under certain.conditions, and in a way capable of bring-ing to light some new facts in naturalphilosophy, and that the latter science

may be advanced by the study of thesesounds, in the same way as the manufac-ture of musical instruments has been im-

proved by the study of the human larynx,and of the means employed to producethat exquisite instrument the humanvoice.

CLINICAL MEDICINE.

LECTURES

DELIVERED AT THE

NORTH LONDON HOSPITAL,BY

A. T. THOMSON, M.D.,Physician to the Hospital, and Professor of Materia

Medica in the University of London.

LECTURE V.

CHRONIC LARYNGITIB.-Merc2Gry in In-

flammation of the Larynx; Combinationof Laryngitis and Phthisis.

GENTLEMEN,-In the lecture before thelast, I mentioned the case of Maurice Welshas one of considerable interest; but Irefrained from making any particularcomments upon it, at that time, from theexpectation that its fatal termination,which was thpn drawing near, wouldenable me to verify, by dissection, thediagnosis which I had hazarded, namely,that the complaint was confined to the la-rynx and trachea, or was chronic laryngitis.What I anticipated took place; Welshdied on the 19th ; but my expectation of apost-mortem examination of the body wasdefeated by the cupidity of his friends,who intimated their hopes of obtaining asum of money for the permission to openthe body ; and, as that was refused, theopportunity which I so much desired wasdenied to me. The case, nevertheless,affords matter both of instruction andinterest.The patient was thirty-seven years of

age, a schoolmaster, of a tall, sparehabit of body, and a melancholic tem-perament. He stated that he had enjoyedexcellent health, until about five monthsbefore his admission to the hospital, when

544

he was attacked with a slight cough, from tincture of henbane. Little advantage,exposure to cold, for which he sought no however, was obtained, until, from themedical advice. It, however, gradually repetition of the calomel, my gums be-increased, and in two months he became came severely affected; the cough thenso hoarse that he could not speak above a almost immediately moderated; and, bywhisper, without a considerable effort, and continuing the use of the calomel, it al-he experienced some uneasiness in swal- together ceased in the course of a fewlowing. When he was admitted to the days. On discontinuing the use of the

hospital, the cough was very frequent, at- remedy, the irritation returned. I have,tended with a muco-purulent expectora- therefore, kept up a slight action upon thetion, and a similar discharge from one gums to this moment; and as I am nownostril ; the expectorated matter tasted taking, at the same time, a tonic, I feelsalt, and when it ceased or became scanty, that my health and strength are rapidlythe discharge from the nostril also ceased. returning.At no time had any blood appeared, either But this salutary influence of a mer-in the sputa or in the discharge from the curial in inflammation of the larynx, isnostril. The violence of the cough and only striking at the commencement of thethe quantity of expectorated matter had disease. After it has proceeded to thelately diminished; but he had lost strength, height to which it had extended in Welsh’sbecome sallow and emaciated,and the cough case, little benefit can be obtained fromwas excited by the smallest irritation of mercury; and it then becomes of morethe glottis. He experienced some degree importance to allay irritation than toof pain, which he referred to the larynx. reduce inflammation, which by this timeThe pulse was 92, small, and irritable; has, generally, run into ulceration. Underthe tongue slightly furred; the bowels these circumstances, after clearing thewere natural; and although the urine was bowels, Welsh was ordered a mixture, com-high-coloured, yet it deposited no sedi- posed of a scruple of Compound Powder ofment. His nights were wakeful and dis- Ipecacuanha, fifteen minims of Hydra-turbed by his cough, but he had no per- cyanic Acid; 3.i of the Compound Powderspirations. of Tragacanth, and f. 1’jviij of Water; ofNow these are the symptoms which which a tablespoonful was directed to

usually attend this affection of the larynx. be taken every fourth hour, and a blisterThe inflammation is at first slight, and was applied to the fore part of the neck.may be easily overcome by topical bleed- The cough, however, continued unabated,ing with leeches, the application of a and the hoarseness remained considerableblister, and the administration of calomel until the lst of December, when lie statedin doses of a grain, combined with three that he felt much relieved; the pain onor four grains of James’s powder, once in coughing, he said, was gone, and hesix or eight hours, until the mouth is merely experienced a slight oppression atslightly affected; and keeping the surface the chest when he spoke. The expectora-warm, whilst the patient is confined to a tion, however, had increased in quantity;summer temperature. Indeed, the in- it was in round masses, of a greenishfluence of mercury in inflammation of the colour. The tongue was also red, indi-larynx, even when it is the result of me- eating an extension of the inflammatorychanical irritants, or acrid substances, is action to the mucous membrane of themost striking; and I am enabled to cite alimentary canal, and into the trachea;my own case in illustration of this fact. his condition was, nevertheless, on theIt is well known to the greater number of whole improved. This improvement,you, Gentlemen, that I was lately attacked however, was fallacious. On the 8th ofwith extensive inflammation of the fauces, December all the bad symptoms returned;the pharynx, and the larynx, from having and every effort to swallow was productiveaccidentally inhaled about eight ounces of of a violent fit of coughing. Leechesconcentrated chlorine gas. The innam- were applied ; and the followieg mixturemation increased, and I was unable to ordered. R Morphio Muriatis Solut.speak without coughing being immediately f. 3j; Lichenis Decoct. f. ,3vj. M. Sumaturexcited; and this, also, was the case cochlearium amplum 3tia quaque hora.when the smallest quantity of cold air was The cough was kept down, during theinspired. I was, therefore, obliged to day, by this narcotic; but, as the nightsdiscontinue my duties both in the Uni- were still much disturbed, he was, on theversity and in the hospital, and to confine 12th, directed to take one grain of the ex-myself to my room. Leeches were applied tract of opium, at bed-time, daily. Thisto the neck ; large doses of calomel were procured some sleep; the disease, how-administered with the view of aiding the ever, was still gaining ground ; and theinfluence of purgatives; and I inhaled the strength of the patient rapidly failing.vapour of hot water impregnated with He requested to have the dose of extract

545

of opium increased, and it was, according- ciated, the strength exhausted to a greatly, augmented to one grain and a half on degree, with quickness of the pulse, andthe 15th; but no advantage having been irregular chills and heats, indicating thederived from it, the dose was further in- approach, if not the presence of hectic,creased to two grains on the 17th, when that the attention of friends is directed tohis strength sank rapidly, and on the the condition of the patient, and medicalevening of the 19th he expired. aid is demanded. But it is now as hopeless

As no post-mortem examination was as a case of confirmed phthisis. In a stagepermitted, I can say nothing of the state much less advanced, but still beyond theof the larynx; but it may be useful to first

stage of the disease, I have seen themention to you, that in similar cases, the greatest benefit derived, and even com-mucous membrane lining the fauces and Plete cures effected, by a voyage to Ma-pharynx has been found inflamed, the deira, and a six months residence in that

epiglottis and its ligaments much thick- soft and genial climate. But, when theened, the chordae vocales nearly destroy- disease occurs in the poor, if we can placeed by ulceration, and the whole of the in- confidence on anything, it must be on

terior surface of the larynx studded with counter-irritation; and the internal admi-minute ulcers, the greater number of them nistration of calomel, tartar emetic, andnot larger than the head of a moderate- opium, with a rigid milk and farinaceoussized pin. In some instances, I have seen diet; and the daily, nay almost hourly, inha-this state of ulceration extend into the tra- lation of watery vapour; and confinementchea, as far as its bifurcation; but, when the to a graduated temperature. I wish, how-inflammation has commenced in the la- ever, that I could conscientiously say thatrynx, I have never seen it extend to the I can bear my testimony to the efficacy ofmucous membrane of the bronchi. Al- this plan of treatment; for, indeed, I havethough, when it commences in the scarcely seen any instance where the dis-bronchi, it is by no means uncommon to ease had advanced beyond its first stagefind that it has spread to the larynx. that has recovered im this country.When this disease attacks persons of a In strumous habits, such a condition of

scrofulous diathesis, especially when there the larynx, as in Welsh’s case, is not un-are nascent tubercles, it rouses these frequently an accompaniment of secondaryinto activity; but, nevertheless, the condi- syphilis. It is usually indicated by stri-tion of the larynx often so engrosses the dulous cough and hoarseness, attending aattention of the practitioner, as to make cachectic and febrile state of the body,him overlook those symptoms of phthisis, with emaciation. In such cases, I havewhich under other circumstances would generally seen the disease, if not too farbe the first objects of his attention. This advanced, yield to an alterative course ofobservation you have had an oppor- calomel, antimony, and opium ; at the

tunity of seeing illustrated in the case of same time maintaining the strength, eitherThomas Hodgson, the post-mortem exa- by full doses of nitro-muriatic acid, in anymination of whose body took place yes- demulcent fluid, combined with sirup ofterday. That combination of laryngitis poppies; or by a continued use of decoc-and phthisis is generally the result of ex- tion of sarsaparilla, and a milk diet.posure to cold, or damp night air, under a you will perceive, Gentlemen, that Istate of mental depression and bodily fa- have made this case the means of intro-tigue, in those predisposed to tubercular ducing a more general view of the diseasedisease. Dr. CHEYNR remarks, that it in question than is usual in a clinical dis-is a frequent disease with those wretched course; but, in my opinion, one of thefemales who walk the streets at night ; great objects of clinical teaching is to en-and that the flush which spreads their able the student to reason, as it were, fromcheeks is not always the glow of intempe- particulars to generals; and to render, inrance, nor the factitious blush of effrontery, what the hospital affords us, the means ofbut the crimson of consuming hectic drawing forth the experience of the teacher,which is rapidly hurrying them to a pre- both in his private and in his public capa-mature grave. city. I conceive this to be particularly

In the progress of your professional requisite in commenting upon such a casecareer, Gentlemen, you will meet with few as the one now before us. In every in-diseases which so insidiously steal on to stance it is important to keep in view thean irremediable state as that now under slow progress of the disease to its fatalconsideration. It is very frequently mis- issue; and to reflect that as it is undoubt-taken, at first, for what is termed a sto- edly the most fatal of those inflammatorymach cough ; and it is not until the cough affections which are considered tmoacute,has become hollow, the voice raucous, the so it is requisite, in every stage, to deliverinspiration muco-sibilant, the Ít"ame cma- your prognosis with the utmost caution.

546

TUBERCULAR PRTHISIS. - Ulceration of The report on the 22nd was,-the voicethe Larynx; Unusual Localities of Tu- was better in the morning, the chest feelsberculous Matter ; Spurious Melano8U/; ; relieved, and he rests better at night, butOrigin and Varieties of Pulmonary Tu- the appetite is not so good as before. Hebercles.

z

continued to improve until the 27th, theThe next case to which I have to direct blister to the throat having been repeated

your attention, is the one to which I have in the interval. On the morning of thisalluded, as having terminated fatally two day he complained of having caught freshdays ago. The name of the patient was cold, which had produced a sore throat,Thomas Hodgson, by trade a silver-plater, with difficulty of swallowing food. On

aged thirty-one years. He was admitted examining the throat, however, there wason the 16th of December with a cough, not much swelling of the tonsils, butwhich had existed, more or less, from the the whole of the fauces was covered

1st of October last, and had, within a few with an inflammatory blush. The pulsedays before his admission, assumed the was 92, and sharp; the skin felt rather

character of bronchitis. In appearance hot and dry, and his tongue, which had

the patient was tall, extremely muscular, previously cleansed, was again parchedwith a broad capacious thorax, and of a and furred. Under the suspicion that a

melancholic temperament. He complained current of air in the general ward mightof tightness across the chest, a teazing have occasioned this change, he was re-cough, and great hoarseness, but of no moved to one of the small private wards,other ailment. There was little or no ex- and bled to the amount of eight ounces;pectoration at the time of his admission, after which he took a pill containing fivealthough he stated that he had previously grains of calomel, which was ordered toexpectorated freely. Previous to the at- be repeated every third or fourth hour, totack in October, he had enjoyed good the third time. On the 28th he was muchhealth for many years, and he affirmed worse, and the pulse had risen to 114. Mr.that he had always lived a regular life. TAYLOR, the house-apothecary, bled himFrom the pearly appearance of the eye, largely, but the untoward symptoms con-the curved aspect of the nails, and a slight tinued to increase, and at ten o’clock onhectic flush, which occasionally appeared the 29th he suddenly expired.upon the cheek, with the deranged respi- Post-mO1’tem Appearances.-Five hoursration indicated by the stethoscope, there after the death of the patient the bodywas reason for suspecting the existence was examined. As my first object was toof tubercles in an advanced stage in the investigate the condition of the larynx,lungs. The tongue was furred, the skin this was carefully dissected out, and thenatural, the appetite good, and the bowels whole of the lungs was removed from thewere open. The urine was high-coloured thorax. On examining the larynx, the

and thickish, and deposited a pinky sedi- epiglottis was found to be rather thickerment. He was ordered to apply a large than usual, but not oedematous. A de-blister upon the fore part of the neck, and Posit of tuberculous matter was found neara pill, containing one grain of opium and the base of the epiglottis, where it forms

three of extract of conium, was ordered to an angle of union with the thyroid carti-be taken at bed-time. On the following lage. The corclm vocales of the glottisday he was bled to the amount of eight were ulcerated, and a small ulcer perfo-ounces, and a pill containing three grains rated the larynx immediately at the centreof calomel, and the same quantity of of the base of the epiglottis, whilst a clus-James’s powder, and one grain of opium, ter of seven small ulcers surrounded the

was ordered to be taken immediately after perforating one. The mucous membrane

the venesection, and to be followed by a of the larynx and trachea was thickened,black dose in the morning. This pro-

but it was not particularly vascular. (Theduced considerable relief from the symp-

lecturer here evhibited the part.) This is

toms, and he felt improving until the 20th, an unusual locality of tuberculous matter,when the cough having again increased,

but it occasionally occurs. In the presentand there being some degree of sharpness stance it affords a fact, pointed of anof the pulse, the following change of medi- Important etiological fact, pointed out bycine was ordered:- Dr. CARSWELL, that mucous and serous

tissues in immediate contact with tubercu-R. Antimonii Tart. gr. vj ; Aquae Distil- lous matter, may be found of their natural

late f. vi. M. Sumantur cochl. character in every respect." In this in-iij majora, vel quarta misturae pars, stance, although the epiglottis is slightly4ta quAque hora. thickened, yet it is not altered in any

R. Morphice Muriatis Slut. f. 3ss; Aquae other respect in its appearance. TheÐzstzlatae f. 31, sit haustus hor-4 lungs were, on the upper and posteriorsomni sumendus. portions of the superior and middle lobes

547

of both sides, thickly studded on the sur- the greatest accumulation of tubercles,face with miliary tubercles, each sur- was adhering, from some old diseasedrounded by an elevated areola of black action. From the extent and numbermatter of that description which consti- of the miliary tubercles, I am autho-tutes what is termed spurious melanosis. rized in regarding this as an instanceThis appears to be the result of retarded of evident hereditary disease, in whichor obstructed circulation in the venous probably the tubercles originated at a

capillaries, in consequence of the mass of very early age, and remained nascent untilmiliary tubercles occupying the whole called into activity at the period fromsubstance of the superior lobes in both which the patient dated the commence-lungs, which was demonstrated by cutting ment of his cough.into them, and is well displayed in the This is not the place to enter into anportions which I now show to you. It is examination of the various opinions ad-only when it is produced by tubercles, as vanced with respect to the origin of tu-in the case before us, that it is displayed berculous matter. In the lungs now

in separate points, or forms areolae. Some- under inspection it is seen in every stagetimes, as Dr. CARSWELL has observed, of its progress, from the firm, miliary gra-when it occupies the circumference of the nule, to the softened tubercle, and thetubercles, it assumes a stillated appear- purulent excavation, or vomica. Dr. CARS-ance. The distinction between its depo- WELL, contrary to the general opinion, as-sition under such circumstances, and when serts that the softening takes place at theit extends in one uniform manner around circumference of the firm tuberculousvomicae, or tubercular excavations, was matter, or where its presence, as a foreignsatisfactorily demonstrated in the lungs of body, is most felt by the surroundingthis patient, in which there was an ample tissues ; and many of the tubercles in thevomica in the upper part of the superior, portions of lung now in your hands fullylobe of the right lung, capable of holding verify this observation. I would espe-nearly half a pint of pus, and the bursting cially direct your attention to the differ-of which into the trachea was probably ence between the matter of tubercles inthe cause of the sudden death of the pa- the tissae of the lungs, and that depositedtient, for no expectoration of decided pus at the angle which the epiglottis forms byhad been previously observed. its junction with the thyroid cartilage.

There was also a smaller vomica in the In this spot it has the aspect of putty, orupper portion of the superior lobe of the half-dissolved bone; and it is probable thatleft lung, more deeply seated than its op- the perforation of the larynx, which I haveponent, besides several smaller vomica;, pointed out to you, and the small ulcers inabout the size of a hazelnut, in various its lining membrane, contained matter ofparts of both lungs. Contrary to gene- a similar description. When the tu-ral observation, the greater quantity of bercles enlarge and suppurate, and exca-tuberculous matter existed in the right vation takes place, a communication withlung in the patient whose case is before us ; the large bronchial tubes is formed, by thebut it, nevertheless, confirmed the equally smaller being involved in the ulcerativegeneral observation that the superior and process, and thus the pus is expectorated,posterior portion of the upper lobes in and the vomicaa are more or less emptiedboth lungs, is the most usual situation of during the life of the individual. Butthe largest deposits; and, probably, that when this does not occur, and the cavityin which it first occurs. Dr. CARSWELL continues shut until a large accumulationhas explained this locality, by the corn- of pus takes place, then a sudden ruptureparison of the functional activity, or ex- admits it into the bronchial tubes, of thetent of mobility, of the inferior and supe- first or secondary series, and suffocationrior lobes, fixing the greatest deposit is likely to be the result, unless sickness,where there is the least motion, namely, or a powerful effort of coughing, occurs toin the superior lobes. " Tbe inferior clear the tubes, and again admit thelobes," he justly remarks, "ascend and air into the bronchial cells. Dissolutiondescend throughout a space equal to that from such a cause is very likely to takein which the diaphragm is capable of con- place in the congested and hepatized con-tracting, and expanding in all directions dition of lungs which this case presents,to the fullest extent of the dilated inferior and in which a small portion only of thiswalls of the thorax;" whereas the superior organ on either side, was capable of car-lohes have a very limited ascent and de- rying on the function of respiration.scent, and an equally limited lateral ex- Besides this state of the lungs, the

pansion." The truth of this opinion is heart was in a state of moderate hyper-demonstrated in these lungs; for the su- trophy; and a considerable quantity ofperior lobe of the right side, in which the , water was found in the pericardium.vomica existed, and in which there was I In such a condition of the thoracic

548

viscera there could be no hope of recovery;and it is probable that the pneumonic at-tack which supervened, only anticipated,by a few weeks, what must have takenplace. The man was not emaciated, and,to look at him when he was not moving,which always displayed the deranged con-dition of the breathing organ, he did notappear to be in such a state of diseaseas would have led one to suspect the ex-istence of so much mischief in the lungs.But disease did not even terminate here;the liver, also, displayed a morbid con-dition of structure, and ossification wasdetected upon the dura mater.This case, Gentlemen, is one of the most

important which I have witnessed for

many years, in the extent of instruction Iwhich it affords to the student, and it shall I,be my endeavour to point out those fea- Itures of it that are most likely to prove i

useful to you in a practical point of view; Ibut our present time is expired. I

CLINICAL SURGERY.

LECTURES

DELIVERED AT THE

NORTH LONDON HOSPITAL,

BY

ROBERT LISTON, ESQ.,Surgeon to the Hospital, and Professor of Clinical

Surgery in the University of London.

LECTURE II.*

THE TREATMENT OF DISEASE.

AT our last meeting here, Gentlemen,before the Christmas holidays, I insistedat some length on the removal of the ex-citing cause of disease, as one of the pri-mary and principal means of effecting acure. I illustrated the subject by severalcases; one more I may be permitted torelate, in addition, as being apposite andinteresting of itself, and as enabling meto introduce to your notice one of an ex-tensive series of plans of disease which Ihave employed with great advantage inillustrating surgical lectures, and whichothers have found most useful in teachingvarious branches of medical science. Thestyle in which 1 have had these paintedlately, pleases me more than that of anywhich I have hitherto used, or seen in thepossession of other teachers. The plan ofthis eye exhibits a violent state of inflam-

"* DeHvered on Saturday, Jannary 3rd, 1835.

mation of the tunics, attended with che-mosis. It had been treated bv variousgeneral and local measures, but the actiondid not in any way abate, and no impres-sion was made upon it, until, through theopening represented over the superciliaryridge, a piece of necrosed bone was ex-

tracted. The disease of the eye was pro-duced, and kept up by the excitement at-

tendant upon the discharge of the deadpart, and had this not been removed, intime the organ must have been destroyed.The case is not an uncommon one.As a most essential plan of cure, next in

importance to the removal of the cause, Imay mention rest, and in the majority ofcases, also, particular attention to posi-tion must be enjoined. It is almost al-ways possible in diseases affecting themore external parts, to suspend the ac-tion of those parts, and this is anothercircumstance which may account for ourdepartment of the science being moresuccessful and certain in its results. The

putting of a part at rest is equally ne-cessary in cases of disease, as of injuryin affections of the eye, of the lip, of theparts of generation, of the extremity of thealimentary canal, as in sprain, bruise, orfracture. What are many of our mostcommon surgical operations undertakento accomplish, but this principle of treat-ment,- the division of the sphincter ani infistula, for instance ? How seldom shouldwe have to leech, foment, and blister jointsfor the effects of sprain, were rest givento the injured parts from the first ! Posi-tion no less requires to be attended to in avariety of injuries and diseases. Withoutattention to position, very many cases can-not be managed at a.11; and many opera-tions well planned and conducted are fol-lowed by troublesome results and by te-dious cure. Attention to this principle isrequisite to favour the return of blood, toprevent accumulations, to relax the cover-ing of the body, as well as the muscularapparatus, to favour union and preventdeformities. All this I shall have ampleopportunities of illustrating to you on

many occasions and in various ways.Now, Gentlemen, the treatment of dis-

eases, constitutional as well as local, shouldbe as simple as possible; it has alwaysbeen my aim to make it so, but let it byall means be founded upon a knowledge ofthe laws of the animal economy, and uponrational and common - sense principles.Set out with a determination to pursue nomethod of cure because it has been re-commended or practised by this person,or the other, how high soever their stand-ing and their authority in the professionmay be, unless a good, substantial, and in-telligible reason for every step can be, or