BY JAMES M. GREEN, M. D., OF MACON, Georgia.

Continuation of the case of T. L. S., published in the Medical Intelligencer, for Dec. 1, 1839, p. 262 He with great difficulty acquired strength enough to walk about, which he continued to do for about a month, and would do, in the very worst weather, in defiance of all expostulation, notwithstanding he had severe attacks of dyspnoea and difficult expectoration several times daily, and several quite severe exacerbations-he occasionally had exhausting perspirations,-he complained that he did not "breathe in his right lung," and the respiration became more and more indistinct, and the heart I thought moved higher up in the chest-his temper became so irritable that he frequently rejected all advice, professional or other. On the 9th of December, I was sent for in haste, and found him again prostrated, and on inquiry ascertained that he had exposed himself much lately by going out and remaining frequently a long time in the rain and damp. He was most evidently labouring under inflammation of the brain-he complained of great pain in his head, with frequent and sudden "darts" of pain in his right eye, great difficulty in expressing himself, every few minutes his breathing became "catching," very restless-sometimes delirious-skin hot-pulse very quick-he also had great pain in his chest under the sternum. I did not notice any changes in the respiratory phenomena worth relating, though from his extreme restlessness and constant exclamations it was imperfectly done. Notwithstanding the immediate adoption of as vigorous an antiphlogistic treatment as I thought proper in his case, by moderate general depletion; local depletion from various parts of the thorax; blistering to the back of the head and neck, and to the breast, right side, epigastrium, and subsequently to the extremities; he soon sank into a hopeless condition, although his life was prolonged for two weeks-during the last week of which he was much troubled with ocular spectra and floccitation, he saw "thousands of beautiful white cattle," "smoke arising from a pincushion," "gold dust rising in clouds from the floor," "white bedbugs on the ceiling," &c.-last four days had retention of urine requiring the catheter-involuntary alvine discharges -and the last day, he spat up and discharged by stool a considerable quantity of matter resembling coffee-grounds-muscular strength considerable and voice strong. I forgot to mention in the preceding report that he was also troubled with hydrocele in the left scrotal cavity, which I tapped in April, 1839, and again four weeks preceding his death, as it caused a good deal of irritation in his urinary organs. He died about 5 o'clock on the evening of the 23d December.

Post mortem examination, eighteen hours after death, assisted by Doct. John B. Wiley. In consequence of my own indifferent health and great asperity of the weather, the examination was rapidly and imperfectly con

:

ducted. Body not very much emaciated; left side of thorax very resonant on percussion; right side dull. On raising the sternum our attention was first attracted by the left lung, a portion of the upper and anterior edge projecting as far to the right of the sternum as the junction of the ribs and cartilages; this portion of lung was about two and a half inches wide, and under the upper part of the sternum and cartilages of the three superior ribs -the anterior edge of the lung (or the pleural cavity) then extended obliquely downwards and to the left, until it reached the interval between the eleventh and twelfth ribs, (to ascertain this fact I passed my hand down to the lowest part of the pleural cavity, and on pressing my fingers outwards, found that they projected out between the eleventh and twelfth ribs); the pleura was smooth and glistening throughout its whole extent; the lung was of natural colour, though it felt lumpy on the surface and was pretty thickly interspersed with botryoidal masses of tuberculous matter, (which I was unprepared to find, recollecting the clear resonance and puerile respiration); the masses were generally not nearer than half an inch, and varied in size from a grain of barley to the end of the finger, and were surrounded by healthy vesicular structure; no surrounding induration or inflammation. They were apparently of recent formation; none of them suppurated or calcareous; the posterior and inferior edge of the lung was solidified, of a light red colour, and on incision there flowed out a frothy serosity; the anterior and inferior edge of the lung was divided into many lobules by corresponding sulci.

Right lung was a dense, oblong, flattened mass, about as large as two fists, and drawn up into the apex of the thoracic cavity; with the exception of a little tolerably healthy vesicular structure in its lower and anterior part, this lung was a mass of dark red, indurated hepatisation (both chronic and recent I suppose) interspersed with tubercles in various states of developement from the soft cartilaginous granulations to hard calcareous concretions; in its lower and posterior part there were several insulated cavities, varying in size from a pea to a marble, and lined with a thick adherent puslike matter; in taking it out of the thorax we tore open a round tuberculous excavation, as large as a walnut, and containing a teaspoonful of a purulent serosity; below the lung there was an empty empyemal cavity capable of holding a pint, and lined with thick, dry, cream-coloured false membranes. The trachea was dilated to its utmost extent and shaped like a stirrup, situated on the left of the vertebral column: its bronchial continuation down into the left lung was also dilated; the right bronchus very large, and terminating abruptly in three nearly obsolete tubes; this nearly complete closure of these bronchial tubes took place a little after the bronchus passed into the lung. On slitting up the pericardium we found about two teaspoonfuls of lemon-coloured serum. Heart-this organ was apparently of natural size, its situation was precisely where we might have anticipated from the stethoscopic phenomena during life, its base was behind the cartilages of the fourth, fifth, and sixth ribs, its apex pointing downwards and to the left, was near the middle of the sternum. In the right ventricle we found a fibrinous concretion, nine inches long; it was attached by many ramifications to the right and posterior part of the ventricle; was as large as the little finger where it passed into the pulmonary artery, and gradually tapered to a point; in the left ventricle there was another concretion perfectly similar to the latter, but only six inches long; there was a good deal of coagulated blood attached to the posterior surfaces of these concretions, but it did not surround them, and could be easily rubbed off without injuring them; in the right auricle there was another polypus about one and a half inches long. The inquiry presents itself to our minds,-of what date were these fibrinous concretions, (they were evidently not recent,) and did they during life enter this distance in the pulmonary artery and aorta, or were they doubled up in the ventricles? During life I examined his heart both with ear and stethoscope, and never heard any morbid sound connected with

the reflux of blood against the semilunar valves. Connected with this subject I may mention, that I opened the body of a woman named Sally Sinans, two years since, who died of deep-seated inflammation of the brain, and in whose heart, in the right ventricle, we found three of these polypoid concretions, two of which entered into the pulmonary artery two or three inches, the other was shorter and thicker.

T. L. S.'s left lung presents another instance, which may be added to Dr. Graves's case, of partially solidified lung with clear resonance.

Yours respectfully,

DOCT. R. DUNGLISON.

JAMES M. GREEN.

ART. II.-ON THE TREATMENT OF BRONCHOCELE.

'BY JOHN CHARLES HALL,'

F. L. S., F. M. B. S., Member of the Royal College of Surgeons, London, &c. &c. The first questions a student asks when the name of any disease arrests his attention, are (or ought to be,) what is this complaint? where situate? on what does it depend? Possessed of this information, it behoves him, in the second place, to inquire, what are the most successful means of treating it.

The term bronchocele is derived from the Greek words, porxos, the windpipe, and an, a tumour; it is named by the Swiss gotre, or goitre; you frequently see it among the inhabitants of the hills of Derbyshire, where it is commonly known as Derbyshire-neck.

Bronchocele may be either simple or compound; the thyrophraxia of Alibert is the most common form of the disease, and is nothing more than an enlargement of the thyroid gland, the skin covering the part being unaltered in structure, and not involved in the disease. For the most part it is free from danger, unless it becomes so large as to impede respiration. It is free from danger, simply because the duties of this gland in the economy of our nature are not so important as to be essential to the continuance of life. One case, however, is mentioned, in which the disease assumed a cancerous form, and the woman afflicted with it perished in consequence.

The seat of bronchocele, therefore, is generally found to be the thyroid glaud, although cysts are sometimes formed in the cellular membrane surrounding it: this leads us to speak

2dly, Of compound bronchocele.-Here we have the disease in the greatest possible severity: sometimes calcareous and other heterogeneous substances are connected with it; at others the gland itself is attacked with

true sarcoma.

The term bronchocele, in England, always signifies simply an enlargement of the thyroid gland, which not unfrequently occupies a space extending from one angle of the jaw to the other; and also forms a swelling on the front part of the neck.

This swelling is more or less irregular in form. At the first it is generally of a soft spongy feel; the skin retaining its usual hue. If the disease, however, remains for a considerable time unattended to, the veins of the neck frequently become varicose.

Prosser remarks "The tumour generally begins between the eighth and twelfth years; it enlarges slowly during a few years, but at last it augments very rapidly, and forms a bulky pendulous tumour. Women are far more subject to the disease than men; and the tumour rapidly increases during their confinement in childbed." Sometimes bronchocele affects the whole of the thyroid gland, that is to say, the two lateral lobes and the 'Lond. Med. Gaz. Dec. 6, 1839, p. 385.

middle portion; and here it sometimes happens that you may observe three tumours of unequal size. Sometimes after death the gland has been found perfectly free from disease, the tumour having formed among the surrounding lymphatic glands and cellular substance.

Burns, in his Anatomy of the Head and Neck, remarks, "that when one lobe of the thyroid gland is affected, it may extend in front of the carotid artery, and be lifted up by each diastole of this vessel, so as to have the pulsatory vibrations of an aneurism." Some authors have observed, also, that the right lobe is more frequently enlarged than the left; this fact, I believe, was first mentioned by Alibert; and Mr. Rickwood tells us "that he has witnessed the same thing in every case that came under his notice in the neighbourhood of Horsham, Sussex."

This disease is common in most of the valleys of the Pyrenees, Appennines, and Alps. In fact, there are certain localities where it is so frequent, that you can scarcely find a single individual altogether free from it. In the Tyrol and Corinthia there are to be found whole villages in which, without exception, all the inhabitants have these swellings; and they are considered indicative of additional personal charms. In many the swellings are so large as not to be concealed by any kind of clothing.

A state of idiotism is another affliction not unfrequently attendant upon bronchocele, particularly in countries where it abounds; yet all who are attacked with bronchocele are not idiots, or cretins as they have been called. In Italy and elsewhere it is met with in persons whose mental endowments are of the highest possible order. A patient whose case I shall shortly mention was a young lady of considerable talent, showing an aptitude to acquire whatever she attempted to learn. Several writers, and among them Fodéré, have ascribed the state of the mind to the affection of the thyroid gland. This opinion, however, seems to have been arrived at without any reason; for in idiots the mental faculties are weak from their earliest years. In many, also, idiotism is complete where we find no enlargement of this gland, or even a tendency to enlargenient, and in cases where the tumour is too small to impede the current of blood to the head. It would consequently appear that the cases in which weakness of intellect and goitre have been observed coexisting, must have been accidental; and this conclusion appears strengthened, when I remember that I have of late frequently observed bronchocele in particular districts, and at the same time seldom or never observed any of the inhabitants to be idiots.

Mr. Cooper, in his last edition of his Surgical Dictionary, remarks, "that bronchocele is not confined to Europe; it is met with in almost every part of the globe. Professor Barton, in his travels amongst the Indians settled at Oneida, in the state of New York, saw the complaint in an old woman, the wife of the chief of their tribe. From this woman he learned that bronchoceles were by no means uncommon amongst Oneida Indians, the complaint existing in several of their villages. He found also that the varieties of the disease were the same as in Europe."

The great danger of bronchocele in this country, appears to be, as above stated, the difficulty of respiration produced by the pressure upon the windpipe by the tumour, and other glands which become enlarged; for by disordering the pulmonary circulation the pulse becomes quickened, irregular, and very frequently intermittent. A strong throbbing is excited in the region of the chest, followed, as some writers remark they have observed, by even fatal disease of the lungs; consequences frequently not supposed to have any connection with this disease, though, in truth, the bronchocele has been the primary cause of them.

Causes of Bronchocele.

It would appear from what we have stated-from the observations of all

1 1 Vide Med. and Phys. Journal, 1823.

writers upon this subject-that certain districts tend to produce this affection of the thyroid gland. Some have gone so far as to assert that change of air is more efficacious than any remedy that can be used. Again, it has been attributed (and apparently with some degree of reason) to certain chemical properties in the water; and Dr. Odier gives credit to this theory, because he observed that distilled water not only prevented the increase of the swelling, but also tended to lessen its bulk. However, every explanation is very unsatisfactory, particularly when we call to mind this passage in the writings of that justly celebrated physiologist, Humboldt. "Persons afflicted with bronchocele (he observes) are met with from Honda to the conflux of the Cauca, in the upper part of the course of the Magdalen river; and on the high flat country of Bigota, 6000 feet above the bed of the river. Now the first of these three regions is a thick forest, while the second and third have a soil destitute of vegetation; the first and third are particularly damp; the second is peculiarly dry. In the second and third region the winds are very tempestuous; in the first the air is stagnant.

First and second region,
In the third,

Temperature.

Centigrade degrees.

22 and 33
4 and 17

Again, the waters drunk by the inhabitants of Mariquita, Honda, and Santa Fé de Bogota, where bronchoceles occur, are not those of snow, and issue from rocks of granite, freestone, and lime. The temperature of the waters of Santa Fé and Mompor, drunk by such as have this disease, varies from nine to ten degrees. Bronchoceles are more horrid at Mariquita, where the springs which flow over granite are, according to my experiments, chemically more pure."

So much, then, for the influence of local causes in producing this disease; at the same time we must admit that certain districts are more subject to goitre, although there are few parts of England altogether free from it. This leads me to speak, lastly, of the

Treatment of Bronchocele.

I have divided bronchocele into two kinds-1st, simple; and 2dly, compound; to the treatment of the former, however, I shall confine my remarks in the present paper. Without entering into a critical examination of the favourite plans of different surgeons, I shall extract a few cases from my note-book, illustrative of the method of treatment that I found to be most successful.

CASE I.-Miss Mary R. æt. 17, somewhat below the middle height, thin, and of rather a sallow complexion, came with an enlargement of the thyroid and glands, which she said she had been suffering under for the last six months, during three of which she had been under the care of a surgeon who had given her Tr. Iodine in large doses. The catamenial discharge, though not altogether wanting, was pale and scanty, the periods being very irregular; the tongue was furred, with red edges; the bowels costive; frequent headach; and a disinclination to move about; fancies she is thinner since she took the iodine.

I thought it would be useless to attend to the enlarged gland until her general health was improved; I therefore ordered her to live upon

New milk with meat once a day; the meat to be dressed in the plainest manner; to avoid pastry and vegetables, and to take as much exercise as her strength would permit.

I likewise ordered her to take the following pills three times a week, at bed-time.

. Pil. Hydrarg. gr. ij.; Pil. Rhei co. (E. P.) gr. viij. Misce ft. pil. ij.