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Entered according to Act of Congress, in the year 1880, by

In the Office of the Librarian of Congress at Washington.



PHILADELPHIA, OCTOBER 11, 1879. be suffering from a simple asthmatic seizure;

but important differences from ordinary ORIGINAL LECTURES.

asthma are easily recognized.

There are three varieties of asthma

which we clinically confront; one of these CLINICAL LECTURE is the common variety of asthma often asON DYSPNEA AS A SYMPTOM OF sociated with or preceded by emphysema INTRATHORACIC PRESSURE.

and bronchitis, and which is attended with

spasm of the bronchial tubes and other Delivered in Philadelphia Hospital, September 20, 1879,

familiar phenomena, but its etiology is yet BY EDWARD T. BRUEN, M.D.,

an unsolved problem. Physician to the Hospital, Lecturer on Pathology of the Is our patient the victim of ordinary Urine in the University of Pennsylvania, etc.

asthma? I think not, because, in the first THE patient before you this morning is place, the initial paroxysm occurred only admitted to the hospital September 9, enjoyed excellent health. 1879. Type-maker by trade; of good The paroxysms also at first were very family history; denying any form of syph-light,-merely noticed by him as spells of ilis, but acknowledging the excessive use shortness of breath; but they have rapidly of alcohol for many years. Six weeks ago increased in severity and frequency, till at he had an attack of what he called asthma, present they occur almost daily. In the but very mild in its manifestations, amount intervals of the attacks he has dyspnoea, ing only to shortness of breath, with with whistling respiration, although there coughing. A week before his admission is no bronchitis, while in the ordinary the dyspnoea increased, his voice began to attacks of asthma, unless there is conbe hoarse, and at intervals he lost the comitant bronchitis and emphysema, the power of speech.

close of the paroxysm brings with it a September 15, he had a most terrible marked remission or entire relief of the paroxysm of dyspnea, with all the attend symptoms. ant phenomena of asthma, but the suffo- Another variety is the asthma which is cative symptoms were far more severe than sometimes associated with Bright's disease in most cases of asthma. The pulse was of the kidneys, called uræmic asthma. very weak and irregular; the surface of This variety is dependent upon a spasm the body was blue and clammy, even the of the arterioles of the lungs, induced by arms becoming purple. The paroxysms the direct impression of circulating unlasted until it was thought death would depurated blood upon the controlling follow, when he slowly began to revive, vaso-motor centres. although the spasm of the bronchial tubes This form is not associated with spasm appeared to persist as before.

of the bronchial tubes, for auscultation September 18 and 19, he had similar can furnish satisfactory evidence that air paroxysms, perhaps not quite so violent. enters and passes from the bronchial tubes There is much difficulty experienced by without hindrance. It is very easy to exhim in swallowing both solids and liquids, clude this species of asthma, for there is but no pain.

no dropsy or other evidence of Bright's This morning, the 20th, he had another disease, and the urine is normal. paroxysm at six o'clock, which passed away But we also have asthma with spasm of leaving him in the condition of dyspnoea the bronchial tubes from the pressure of a above described.

tumor upon the pneumogastric nerve or The important symptoms to remember its branches. as a group are, the recent date of the first We are taught by physiology that the attack, the character of the dyspnea, the tenth nerve contains both accelerator afferdysphagia, and the impairment of voice.ent fibres and inhibitory afferent fibres, the Finally, it will be well for you to recall accelerator fibres predominating. Rosenthe expression of the patient's face, as un- thal declares the respiratory centre to be like that of an asthmatic individual. If the seat of two forces of conflicting nature, you had casually glanced at our patient in the one laboring to generate respiratory the ward, you might have supposed him to influences, the other tending to offer re

VOL. X.-1

sistance to the generation of these impulses, of their union with the sternum.

The tuthe alternate victory of the one over the mor extends laterally three and one-quarter other leading to rhythmic discharges of inches to the right side from the median force and the regulation of respiration as we line of the sternum, as demonstrated by find it in health. We also know that the percussion. The right side of the chest superior recurrent laryngeal nerve is com- measures eighteen inches, the left sixteen posed mainly of inhibitory afferent fibres, inches, at the level of the second rib. by the stimulation of which respiration The cardiac dulness appears to begin as can be brought to a stand-still, the respi- usual, but cannot be defined accurately, ratory apparatus remaining as at the close because it is covered with emphysematous of expiration. This effect can also be lung-tissue ; but the apex-beat can be felt produced by first exhausting (so to speak) in the sixth interspace, three-quarters of the neurility of the accelerator afferent an inch to the left of the nipple, indicating fibres of the main trunk of the pneumo- hypertrophy. There is also a pulsation in gastric nerve, which permits the inhibitory the second interspace, at the seat of tumor, fibres to obtain the controlling influence, which is heaving in character. The radial and thus reduces or stops the respiratory pulses occur later than the femoral,—an action, just as when the superior laryngeal important sign of aneurism of the arch of branches are stimulated.

the aorta. There is also a systolic murmur Now, if pressure is brought to bear on to be heard over the base, but more distinct the pneumogastric nerve or its branches at the tumor; it is low and prolonged in which supply the bronchial tubes, as hap- character; it is transmitted into the arpens in some cases of tumors within the teries of the neck, but is faintly heard at chest, it appears to me we can have two the apex, and at the ensiform cartilage is effects,-first, a continued irritation of the nearly lost. There is no murmur in the afferent nerves, and a continuous spasm of femorals or down the aorta posteriorly. the tubes in consequence; which implies, The variations in murmur in aortic ansecondly, deficient aeration of the blood. eurism are, perhaps, familiar to you, from

The accelerator fibres are, in common your studies of Walsh and from the demwith the whole nerve, excessively sensitive onstrations in the ward classes ; time forto the influence of the non-aerated blood; bids me to enter upon their discussion in therefore we can understand that there this case. A tumor situated as I have must be continuous over-stimulation of the described is very suggestive of aortic anaccelerator fibres. It seems to me, there- eurism, the symptoms of which are often fore, that at intervals the neurility of these dependent upon the direction of growth fibres will become exhausted, and thus will of the tumor. be brought about a paroxysm which may In this case we have dysphagia, but the end in almost absolute asphyxia through difficulty is as great when there is an atthe temporary ascendency of the inhibitory tempt to swallow liquids as solids, and is fibres. This does not prevail in simple not associated with pain, but merely with asthma to the same extent, because the the sense of choking, which the act of attacks cease with the relaxation of the swallowing induces by causing the patient bronchial tubes, and the symptoms of suf- to hold his breath. Therefore I decide focation in cases of pressure arise from that he has no pressure on the esophagus. the prolonged deficient aeration of the He has aphonia at intervals; this implies blood. In the case before us there has irritation of the recurrent laryngeal nerve, been constant spasm of the bronchial tubes which supplies all the muscles of the larynx since his admission to the house, but at except the crico-thyroid, and by rendering times he has seemed about to die; he it possible to approximate the vocal cords, becomes cyanosed, cold, and respiration and also to render them tense, is prinalmost ceases, — due, I believe, to the cipally concerned in phonation. There inhibitory influence I have attempted to is, I believe, simply irritation, not direct describe. If it is possible to explain these pressure on it, because at intervals his symptoms by pressure, can we find in our voice is distinct. We should not, indeed, patient any evidences of pressure? expect that the recurrent laryngeal should

Physical examination tells us that there suffer pressure, because it is only on the is a tumor situated between the second and left side that it curves under the aorta. the fourth rib on the right side, at the point But if it is not pressed upon, and if the paralysis of the vocal cords induced by ous pressure-symptoms present. Pending irritation is only temporary, we must seek a decision on this point, we must have elsewhere for the explanation of the symp- recourse to the antispasmodic treatment toms of dyspnea, from which our patient employed in asthma in order to alleviate suffers so much torture that his life is the paroxysms. Upon this class of remthreatened. For this explanation I refer edies I wish to address you later in the you to the views mentioned in the early winter. part of my lecture upon the effects of pressure on the pneumogastric nerve. Indeed, from but one other source could the

ORIGINAL COMMUNICATIONS. symptoms arise (I allude to the possible pressure of the tumor on the bronchial A CASE OF BONE-SYPHILIS IN tubes); but there is no evidence of pul- AN INFANT, ACCOMPANIED BY monary collapse, and everywhere we hear PSEUDO-PARALYSIS AND A PEvesicular murmur. Have we evidence CULIAR INTERMITTENT LARYNfrom his history that we can use to support

GEAL SPASM. the diagnosis of aneurism? There is no BY ARTHUR VAN HARLINGEN, M.D., syphilis to which we can trace arteritis,

Chief of the Skin Clinic, Hospital of the University of Pennas so often can be done,- but we have his

sylvania acknowledgment of a life spent in the free 'HE case I am about to describe belongs

THE indulgence of the passion for alcohol.

to a class of which not very many exWhat more potent cause of arteritis ? amples are upon record, and which, in this For you must agree with those who con- country at least, has not attracted much sider this the antecedent to aneurism, be- attention. With the exception of a few cause in your daily experience you see in- scattered cases reported in the journals dividuals constantly engaged in lifting or (none of which are in all respects similar carrying (i.e., placing an undue strain to the one I am about to report), the admiupon their arterial system) with impunity, rable monograph of Prof. R. W. Taylor,* while in others much less exertion sows and a brief mention by MacNamara, † the seeds of aneurism. We have no evi- little or nothing, so far as I am aware, has dence of heart disease or its result, dropsy; been written in English on this subject. so that we may, I think, consider that the I feel, therefore, that no apology is needed evidence points in one direction only. for placing the case upon record, although

It is true that I have seen an abscess the it is but a single one, and although I have result of caries of bone point in this situ- but few remarks to offer upon the affection ation, as well as abscess from softening in general. gummata. But, although our patient re

Pauline Vivien H., a colored infant, was ceived a kick in the chest, I can detect born of parents both of whom had been under no evidence of local injury, and, as I have my care for syphilitic disease during more than said, there is no admission of syphilis, nor, a year previously. The child, though fat and indeed, are there any symptoms indicating well nourished at birth, displayed mucous suppuration. The comparatively short pe- papules about the anus, in connection with riod since he noticed any departure from catarrh of the nasal passages, about the behealth militates against malignant or other ginning of the second week. No other symp. new growth; nor is there any distention at the end of which time a certain progressive

tom of disease appeared for several weeks, of the superficial veins of the chest, as falling off in flesh began to be observed. would be the case if this tumor had its when the child was about seven or eight origin in the mediastinum.

weeks old, the mother noticed, one day, that I regret to say that I fear nothing can be the left leg had become suddenly powerless, done to relieve our patient permanently. and that there was a certain amount of swellTracheotomy is not to be thought of, as ing about the knee-joint. This seemed to the obstruction is not in the larynx.

In- pass away spontaneously, but a few weeks

later the left arm also became similarly afdeed, electrolysis seems to be the only fected, the fingers only being moved, and the operation capable of giving succor, for, limb hanging down as if paralyzed. When if successful, the layers of fibrine will prob- the arm was raised at the shoulder the child ably gradually contract as they accumulate. All other modes of treatment will be too * Syphilitic Lesions of the Osseous System in Infants and slow to be trusted, in the face of the seri- | Young Children. New York, 1875.

+ Clinical Lectures on Diseases of Bone. London, 1878.

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