ON THE DIFFICULTIES AND ADVANTAGES 
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iitletmm ®f tie §ik-ffi«pei 
IX 
DISEASES OF THE CHEST. 
By HORACE GREEN, M.D, LLJ)., &c. ON THE 
DIFFICULTIES AND ADVANTAGES 
O JF 
GMjcfcristn of % |dr-|) assagcs 
IN DISEASES OF THE CHEST. 
By HORACE GREEN, M.D , LL.D., &c. 
(Read before the Medico-Chirurgical College, Dec. 22, 1859.) 
In December, 1854, I read a paper before the Academy of Medi- 
cine of New York, “ On the Injection of the Bronchial Tubes and 
Tubercular Cavities of the Lungs;” and subsequently, namely, in 
March, 1856,1 published in the American Medical Monthly a detail- 
ed report, containing a statistical table of one hundred and six cases of 
pulmonary and bronchial diseases, treated by means of catheterism of 
the air-passages, conjoined with appropriate general remedies. 
Still continuing, to some extent, this plan of topical treatment in 
thoracic disease, I have since had opportunities to confirm the truth 
of some of my early observations; and, what is of equal importance, 
to correct other views which later experience and more extended ob- 
servations have shown to have been erroneous conclusions. It is to 
record and announce these recognized errors, and to point out some 
of the difficulties, as well as the advantages that attend this plan of 
treatment, that I bring, at this time, the subject of Topical Medica- 
tion before the College. 
I propose briefly to consider the following questions: 
1. Can the operation of catheterism of the air-passages be per- 
formed with certainty and facility? 
2. What are the difficulties and dangers of the operation? 2 
3. What advantages are to be derived from this method of treat- 
ment? 
1. With regard to the first inquiry—the possible practicability of 
the operation? On this point it will not be necessary long to dwell. 
As very few of the profession, at the present day, will deny its per- 
formance, under favorable circumstances, I shall only refer to the 
opinion of a few members of the profession, from among many of 
those who have considered this question. 
At the discussion that followed the reading of my paper, to which 
I have alluded, on bronchial injections, before the Academy of Medi- 
cine, several years ago, it was remarked by a distinguished member 
of that body, who denied the practicability of the operation, that 
“ the Academy must not decide this question until we had heard from 
Europe on the subject, as the profession there would act without pre- 
judice or partiality.” 
Already, testimony has come to us from eminent men of the pro- 
fession, in Great Britain, France, and Germany, that this operation 
of injecting the bronchi has by them been successfully performed. 
Prof. J. Hughes Bennett, of Edinburgh, in his work, “ Clinical 
Lectures on Medicine,” says: “ I have now introduced the catheter 
publicly in the clinical wards of the Royal Infirmary, in several pa- 
tients affected with phthisis, in various stages, in laryngitis, and in 
chronic bronchitis, with severe paroxyms of asthma. * * * I have 
been surprised at the circumstance of the injections not being follow- 
ed by the slightest irritation whatever, but rather by a pleasant feel- 
ing of warmth in the chest, (some have experienced a sensation of 
coolness,) followed by ease to the cough, and a check for a time to all 
expectoration.” “ These facts are made known to the profession,” 
Dr. Bennett declares, “ with a view of recommending a practice which, 
if judiciously employed, may form a new era in the treatment of pul- 
monary diseases.”* 
In Paris, Prof. Trousseau, Loiseau, Blondeau, and others, have 
succeeded in injecting the air-passages, in various diseases of these 
parts. It has been employed in early phthisis, by M. Trousseau, as 
well as in diphtherite, in which latter disease it was attended with 
complete success. 
It has been still more extensively employed by Loiseau, in the 
treatment of both diphtheritis and croup. The method of Loiseau is 
thus described by Trousseau, who was appointed by the Imperial 
*See Clinical Lectures on Medicine, p. 609. 3 
Academy of Medicine, of Paris, to report upon his plan of treat- 
ment: “ With the extremity of the forefinger,” says M. Trousseau, 
“ he (Loiseau) depresses the tongue, seizes the epiglottis, raises it, 
and presses the end of the finger between the arytino-epiglottic folds. 
There is then nothing more easy than to make the end of the tube 
glide over the finger. The air which escapes through the exterior ex- 
tremity of the tube proves that it has really entered into the larynx. 
Through this tube, serving as a conductor, a caustic, the nitrate of 
silver, for example, or any other medicated substance, may be carried.” 
In the discussion which took place at the time, before the Acade- 
my, on this subject, M. Depaul said, “ The process of catlieterism of 
the larynx, as proposed by Dr. Green, was declared by some as being 
very difficult, even upon the cadaver; but I maintain,” said he, “that 
nothing is easier than this catlieterism for those who have performed 
it a certain number of times.” Still more recently than this, comes 
to us the testimony of Prof. Greiseuger, of Germany, as reported in 
the Deutsche Klinik, and in the Gazette Idebdomadaire. Prof. Greisen- 
ger has been able, as he affirms, to introduce medications of nitrate 
of silver solution into the air-passages. In regard to the practica- 
bility and danger of this operation, Prof. G. says: “ For us, after the 
experiments we have made, we can affirm that these fears are illusory, 
and that the different parts of the operation can be performed with a 
rigorous exactitude.” And, finally, we have the testimony of the 
Committee, appointed by the New York Academy of Medicine, to 
inquire into the truth of the performance of this operation; for they 
affirm, in their report, made to the Academy, that of the thirty-two 
patients upon whom the attempt was made to inject the bronchi, the 
operation was performed in eleven cases successfully, and to the entire 
satisfaction of the committee. It must, therefore, be concluded that 
the “ operation of catlieterism of the air-passages,” under appropriate 
circumstances, can be positively performed. 
Notwithstanding this operation is being daily performed at the 
present time, yet it is not always accomplished with certainty and 
facility. Nature has so guarded the opening into the mrien passages 
that catheterism of the bronchi is an operation that will be found diffi- 
cult often to accomplish. In many cases, I am confident, the 
tube passes over the glottic aperture, and enters the oesophagus, even 
when the operator feels quite certain that it has been introduced into 
the larynx. In my own practice I have found myself deceived, not nnfre- 
quently, especially in the first years of my experience in this mode 
of treatment. At first I believed the instrument to have taken the 4 
right course, but afterwards ascertained, in many instances, that it 
had entered the oesophagus. 
2. What, then, the difficulties that oppose themselves to the 
facile performance of this operation, and what the dangers? 
The epiglottis does not of itself close entirely the aperture of the 
glottis. This cartilage being placed between the entrance of the 
larynx and base of the tongue, is pressed downward by the abase- 
ment of the latter, in the act of deglutition, and being moulded upon, 
only partially closes the glottis. It is not, therefore, correct to state, 
as many anatomists do, that the epiglottis “ closes completely, of it- 
self, the opening of the larynx,” in deglutition. 
The arytenoid muscles are the especial constrictors of the glottis. 
These muscles (as Longet has demonstrated) receive filaments from 
the recurrent nerve. Covering the lips of the glottis is a narrow 
zone of exquisitely sensitive mucous membrane, which receives its nerv- 
ous filaments from the internal branch of the superior laryngeal 
nerve. These two nerves, the one supplying the constrictors, and the 
other this strip of mucous membrane, commuuicate freely with each 
other, but they have no connection whatever with the epiglottis. The 
irritation of this body, therefore, will have no effect upon either the 
motive or sentient nerves peculiar to the larynx. This is important 
to remember, namely: that the epiglottis, in its normal state, is an 
organ nearly insensible; but when the least irritation of that sensitive 
portion of the mucous membrane which covers the supra-glottic space 
occurs, this irritation is quickly communicated to the constrictor mus- 
cles, through filaments of the recurrent aud laryngeal nerves, and 
the aperture of the glottis is as quickly shut up. When it is desirable, 
therefore, to medicate the aerien passages in disease of these parts, it 
is necessary, as all are aware, to educate the glottic aperture, by re- 
peated cauterizations of this opening. For if, under ordinary circum- 
stances, the attempt be made to pass the sound, or probang, into the 
larynx before the exquisitely normal sensitiveness of this point of mem- 
brane be partially subdued, it will probably prove abortive; or, if suc- 
cessful, and the instrument be made to pass the supra-glottic guard, a 
violent spasmodic action, not only of the constrictors, but of all the 
other muscles of the larynx, will occur, followed, often, by great irri- 
tation of the parts, and a suffocative cough; and if, under these cir- 
cumstances, the operator persist in finishing the operation, by injecting 
a solution of the nitrate of silver into the bronchi, the irritation aud 
cough are both greatly increased, and in some instances inflammation 
of the bronchial aud pulmonary tissue have been awakened, apparently 5 
by these combined disturbing causes. This condition, as the result 
of these causes, may be illustrated by the following case: 
Mrs. F., a widow lady, aged 35, recently returned from California, 
came under my care July 31, 1858; she was in the second stage of 
tubercular consumption. Auscultation revealed tubrn’cles, with soften- 
ing in the right lung. The disease of the lungs had been preceded by 
follicular laryngitis for many months. The right tousil, which was 
still ulcerated, was nearly destroyed, and the pharynx was granular 
from the diseased and enlarged follicles. 
She was placed under general treatment, ordinarily adopted in such 
cases, together with the application of a solution of nitrate of silver 
to the throat. 
This treatment was continued until the 13th of August, when the 
parts were thought to be sufficiently prepared to allow the introduc- 
tion of the injecting tube. On this day I introduced, without any 
difficulty, the tube, and injected a drachm of the nitrate of silver so- 
lution into the right bronchus. No irritation followed the operation. 
As is the case almost invariably, after injections in either pulmonary or 
bronchial diseases, the cough and expectoration were considerably 
diminished for several days after this operation. With intermediate 
cauterizations with the sponge-probang, the bronchial injection was 
employed on the 16th, the 20th, and the 24th, with similar beneficial 
results with the first operation, the patient continuing constantly to 
improve. On the 26th of the month, in attempting to use the tube, 
the throat of the patient was found to be unusually sensitive, and it 
was with some difficulty that the instrument was introduced into the 
larynx. It was passed, however, into the trachea, in precisely the 
same way that it had been done on former occasions. A spasm of the 
glottis immediately succeeded its introduction, and instead of with- 
drawing it at once, as should have been done, I proceeded to finish 
the operation, and injected a drachm of the solution (15 grains to 
the ounce) into the bronchi. By the time the operation was com- 
pleted, the whole chest seemed thrown into a violent spasmodic action; 
a convulsive cough, with dyspnoea, followed, which continued during sev- 
eral hours, but was finally somewhat relieved by the use of chloroform, 
and the administration of anodynes. The cough and dyspnoea, however, 
with increased expectoration, and pleuritic pains, continued for several 
days; and, although the patient became in the course of a week quite 
comfortable again, under general treatment, yet she never entirely re- 
covered the favorable state she was in before the occurrence of the 6 
spasm. As the patient and friends were greatly opposed to any fur- 
ther topical treatment, it was never afterwards employed. The pul- 
monary symptoms increased, the disease progressed, as usual in such 
cases, and the patient died on the 10th of October, about two months 
after the last employment of the tube. 
Remarks.—The above was a well-marked instance of tubercular 
disease of the lungs, following a long-continued case of folliculitis; 
one of those cases, in short, a great number of which in their early 
stage, in the hands of other practitioners, as well as in my own, have 
been, and are, successfully treated by topical medication, conjoined 
with general remedies; and, although a cure in this case could not, 
probably, have been effected, yet, from the favorable progress made 
before the operation on the 26th, I am confident in the belief that 
the life of the patient would have been prolonged by the treatment, 
if it had not been for this untoward occurrence. 
A case, similar to the one I have related, came under the observa- 
tion of my assistant, Dr. Richards. Not having been present when 
the operation was performed by Dr. R., I take his account of 
the case. 
The patient, Mr. D. M., had been long under treatment for obsti- 
nate chronic bronchitis. Topical medication, by means of the tube 
and sponge-probang, had been repeatedly employed, and the patient 
had been greatly benefited by the treatment. Mr. M. is the same 
patient whose case is mentioned by the Committee of the Academy 
of Medicine in their report, on Bronchial Injections. His case is No. 
30; and the Commission thus speak of the success of the operation, 
as then performed in their presence: “The tube,” say the Committee, 
“ was passed without much strangling; the air was freely expelled 
through the tube. An injection of two or three drachms of a solution 
of the nitrate of silver, of the strength of thirty or forty grains to 
the ounce, was then thrown in. All present were satisfied that the 
experiment was successful.” In this instance, as the report affirms, 
no irritation followed the operation, nor had any irritation attended 
any previous operations. But on a subsequent occasion, namely, on 
the 20th of May, 1856, he called to have this tubing operation re- 
peated. Dr. Richards, being in attendance that morning, introduced 
the tube in the same manner as it had been done, both by Dr. R. 
and myself, on many former occasions. At this time, however, a 
spasm, from some cause, was immediately - induced; Dr. R. did 
not withdraw the instrument, but proceeded to inject, as at other 
times. By the time the operation was finished, the muscles of the 7 
throat and chest were violently convulsed, and this was followed by 
a suffocative cough and profuse expectoration. This irritation, in- 
creased cough, and expectoration lasted during several days; but it 
finally subsided, and the patient ultimately regained a good degree of 
health. 
I have before stated that Prof. Bennett has employed bronchial in- 
jections in the treatment of pulmonic diseases. In the Edinburgh 
Medical Journal, and in his work, recently published, on “ Clinical 
Medicine,” he has reported some most interesting cases, in which this 
method of treatment was employed. 
Since the publication of the above work, by Professor Bennett, I 
have been favored with a letter from him, on the subject of bronchial 
injections, in which, among other things, he alludes to the occurrence 
of an accident, in his own practice, similar to those whose history has 
been given. He writes: “ A gentleman, in the last stage of phthisis, 
with cavities in both lungs, and tubercles very generally distributed 
among them, after long treatment with the probang, allowed me to 
inject the bronchi. I did so, and he was immediately seized with the 
most violent dyspnoea. I thought he would have died in my study. It 
continued several days, and then gradually declined. After five weeks 
confinement to bed, he was restored to the same condition he was in 
formerly. This was six months ago. My opinion is, that he made a 
too violent effort to hold his breath and retain the catheter, and either 
ruptured an emphysematous portion of the lung, or caused a small 
abscess to break, as the operation was followed by abundant purulent 
expectoration.” 
In a letter which I have received during the present year, from the 
distinguished professor of Clinical Medicine in Paris, M. Trousseau, 
he, among other interesting statements made on topical medication, 
mentions the occurrence of an accident in his practice, from the use of 
nitrate of silver solution, under circumstances different from any that 
have come under my own observation. lie remarks: “I often cau- 
terize the interior of the larynx. I sometimes, but rarely, use a hollow 
caustic holder like that of Dr. Loiseau’s, and I have also injected into 
the trachea solutions of nitrate of silver and sulphate of copper. This 
practice, in my hands, has never been attended by any danger, and I 
have never heard that Dr. Loiseau has had any accident to deplore. 
* * * * j ]iave introduced caustic solutions very frequently into 
the trachea and bronchial tubes, after tracheotomy, in cases of croup. 
For six years I never operated for tracheotomy without injecting 
caustic solution.” “ Once this practice,” continuesM. Trousseau, “in 8 
my hands, caused the immediate death of a child. The case was as 
follows: 1 had operated upon a child two and a half years old; he 
breathed very well. I dropped into the trachea ten or fifteen drops 
of a solution of nitrate of silver; a coagulation of thickened mucus, 
which was in the principal bronchi, immediately followed, and the child 
died, strangled, in less than a minute.” “ An accident of this kind,” 
he adds, “ can never happen if a sponge, moderately wet with the 
caustic solution, be used; and with the instrument which you use, a 
model of which you have sent to me, I cannot see how an accident can 
occur to the lungs.” 
It would also seem impossible that this accident, to which Prof. 
Trousseau alludes, could have resulted from the cause to which he re- 
fers it. He had used it frequently before in the same manner, during 
a period of six years, without the occurrence of any such accident. 
During the last winter, it will be remembered that many severe 
cases of membranous croup and diphtheritic inflammation occurred in 
some of our larger cities. This was the case particularly in Boston, 
Mass., in which city the physicians have reported some almost hope- 
less cases that were saved through the combined measures of trache- 
otomy, followed by repeated injections of a solution of nitrate of silver, 
through the artificial opening into the trachea and bronchi. In one 
instance, as reported in the Boston Medical and Surgical Journal, in 
the case of a child, aged four and a half years, Dr. Gay, assisted by 
Drs. Bowditch and Perry, “ injected through the artificial opening 
into the trachea, every four hours, about one-third of a tea-spoonful of 
the solution of nitrate of silver, of the strength of 20 grains to the ounce 
of water.” This treatment was continued through several successive 
days and nights, and resulted in the complete recovery of the patient. 
It would seem, therefore, that in the case reported by M. Trousseau, 
the patient must have died from some other cause than the one men- 
tioned, namely: dropping “ ten or fifteen drops of a solution of nitrate 
of silver into the trachea.” 
Kor is there any need of the occurrence of any accident from the 
employment of catheterism of the bronchi, if proper cautions are 
adopted; for, with our present knowledge and experience in the use of 
this measure, it is one, we maintain, that may be employed with as 
much safety as any of our other remedial agents. 
To the precautionary measures necessary to be adopted in topical 
medication I shall refer, after alluding to another danger. 
When the attempt was first made to inject the trachea and 
bronchi, it must be remembered that there were no precedents, no 9 
recorded cases, in which this practice had been adopted, to which we 
could refer, for guiding us in regard to the strength of the remedies, 
or to the amount of medicaments that could with safety be injected; 
consequently, it became necessary to proceed with much caution, in 
the inauguration of this practice. Fortunately, those persons upon 
whom the attempt was first made to employ this method of treatment, 
were among those patients who for a long time had been under treat- 
ment for laryngeal and bronchial diseases; to whose larynges the 
sponge-probang had been frequently, and for a long time, applied; 
consequently they were particularly well prepared for the introduction 
of the injecting tube, and for the employment of the injections; and it 
was for these reasons that bronchial injections, in the first instances in 
which they were employed, were better borne, and were accomplished 
with more facility, than they have been in most instances since. At 
any rate, I soon found that in recent cases, I had more difficulty in 
effecting the introduction of the tube, and that it wras necessary to 
employ, at first, a very mild solution, which could be subsequently in- 
creased in strength. The following case will illustrate one of the 
difficulties to which I refer: 
In September, 1854, Miss H., a young lady of this city, was recom- 
mended to my care, by her friend and physician, Dr. C , for the 
treatment of a bronchial affection. The ordinary signs of bronchitis 
were very marked. Topical applications, of the nitrate of silver solu- 
tion, were made to the glottis and larynx, and the general remedies, 
ordinarily recommended in such cases, were administered. This course 
of treatment was continued several weeks, without producing any de- 
cidedly beneficial effect upon the patient. About this time, I saw the 
patient, on several, occasions, in consultation with the physician who 
had recommended her to my care. He advised a further perseverance 
in the plan of treatment, but suggested the employment of catheterism 
of the bronchi, (an operation he had seen performed, in similar cases, 
several times upon my patients,) if the present measures, after a fur- 
ther trial, should be unsuccessful. But her disease continued to resist 
the influence of those measures which had proved quite successful in 
the management of other, apparently similar, cases. On the 7th of 
November, therefore, the bronchial tube was, with some difficulty, in- 
troduced, and nearly a drachm of the solution injected into the bron- 
chi. An unusual amount of irritation followed this operation. 
The introduction of the tube induced a spasm of the glottis; the 
patient coughed severely, and complained, while she remained in my 
office, of pain in the larynx and bronchi. She, however, left, soon 10 
after the operation, for her house, in the upper part of the city, but 
did not return for any further treatment. The subsequent history of 
her case was obtained afterwards, from herself and her mother. 
• The cough and bronchial irritation continuing after her return home, 
the patient and her friends became alarmed, and called in their ordi- 
nary medical attendant, who, in turn, called in a consulting physician, 
but both concluded to do nothing, for the irritation gradually subsi- 
ded, and, along with it, the alarm of the patient and her friends; and, 
still better, the cough and bronchial disease, which had so long and so 
obstinately resisted other measures, entirely disappeared, and the 
young lady has continued in good health, up to the present time. 
Spasms of the glottis will, as I have before stated, occasionally oc- 
cur, caused by the irritation of the supra-glottic space, in the intro- 
duction of the tube, although great pains may have been taken to pre- 
pare the parts by previous training. In this case, I at first attributed 
the spasm and subsequent cough and dyspnoea to irritation, produced 
at the glottic opening. But from some observations and experiments 
which I have since made, I am fully satisfied that the disturbance in 
this instance, and probably in the case mentioned by Dr. Bennett, as 
well as in some others, similarly affected, was caused by the employ- 
ment, at first, of a solution of too great strength. 
I have recently instituted some interesting experiments upon ani- 
mals, (the cat and dog,) in order to ascertain how strong a solution 
of nitrate of silver can be borne, when injected into the trachea and 
bronchi. I experimented upon these different animals, but found the 
results the same, under similar circumstances, in both the cat and dog. 
But I will detain the College with the history of only one case. 
A young dog, eight months old, weight fifty pounds, was treated by 
bronchial injections. His jaws were opened by an assistant; a cord 
being placed around his tongue, it was readily drawn out of his mouth, 
when the epiglottis, and the opening of the glottis, were seen without 
any difficulty. I passed the tube quite readily into the larynx, and 
carried it down eight inches, into the trachea. Here it was allowed 
to remain several minutes, without producing the least disturbance, 
while the respired air passed freely through the tube. After a time I in- 
jected a small amount of a weak solution of the nitrate of silver through 
the tube into the lungs of the animal; but, as he did not seem to be at 
all affected by this, I soon after threw in half an ounce of a solution of 
the strength of fifteen grains to the ounce. After being released, he 
commenced playing ahout as usual, without showing a symptom of any 
disturbance whatever. The next day he appeared perfectly well, and 11 
was as playful as ever. At 5 o’clock p. m. on the following day, I 
again introduced the tube into the dog’s larynx, and conveying it 
down, nearly the whole length of his trachea, but not below the tra- 
cheal bifurcation, I injected into the bronchi the ounce syringe full of * 
a strong solution of the nitrate of silver, of the strength of thirty 
grains to the ounce of water. This amount, in proportion to the weight 
of the animal, would be equivalent to three ounces of the solution of 
this strength to an adult. The respiration of the animal was not im- 
peded at the time, nor did any signs of suffocation follow immediately 
this operation of injecting so large an amount of fluid into the air-pas- 
sages. The dog, for a time, ran about as usual. At t o’clock, two 
hours after the operation, I visited him at his kennel, and calling him 
out, found him with tail hanging down, eyes dull, and breathing with 
some difficulty, and uttering occasionally a short cough. On listening 
to his sides, moist, bronchial, and crepitant rales were heard throughout 
both luugs. He was allowed to lie down in his kennel. At 10 o’clock 
I went to him again, when I found that all these symptoms had greatly 
increased; the dyspnoea was quite difficult, and the dog was disinclined 
to move about. He died during the night. 
I examined the lungs the next day ; the bronchial mucous mem- 
brane was highly inflamed. Both lungs were inflamed, and gorged 
with blood; and bloody and frothy mucus blocked up the bronchial 
tubes. The animal died, therefore, of inflammation of the lungs and 
bronchi, superinduced by the large and strong injection of a solution 
of nitrate of silver into the bronchi. 
Remarks.—It is evident, then, that nitrate of silver may be used of 
that strength, and to that amount, in bronchial injections, as to prove 
fatal to animal life. So, also, may the too frequent use of all or of 
any of the potent remedies destroy life. 
3rd. In relation, then, to the third inquiry, “ What advantages are 
to be derived from this method of treatment?” I reply: bronchial in- 
jections of a solution of nitrate of silver, when judiciously employed, 
have proved to be, and will continue, I believe, to be, a valuable ther- 
apeutic means in thoracic disease. 
In the commencement of this paper, I referred to the detailed re- 
port which was published by me, two or three years ago—a report 
containing a statistical table of one hundred and six cases of pulmo- 
nary and bronchial diseases, treated by means of catheterism of the 
air-passages, conjoined with appropriate general remedies. The fol- 
lowing is the brief analysis given at the conclusion of the report of 
the above cases: “ If we analyze the one hundred and six cases, re- 12 
ported in the table, it will be found that seventy-one of the sum-total 
have been recorded as cases of advanced phthisis—cases in which tu- 
bercular cavities were recognized, in one or both luugs; and thirty nine 
-cases of early phthisis. Of the first division—advanced phthisis—four- 
teen have since died. Twenty-five were more or less improved; their 
lives, apparently, being prolonged by this means of medication. Seven 
only of the thirty-two cases of advanced phthisis were not benefited 
by the injections. Of the thirty-nine cases of incipient tuberculosis, 
twelve of this division have apparently recovered. Five more of this 
number are now, or were, at the last report, in the enjoyment of a 
good degree of health. These -five cases were classed by my assistant, 
Dr. Richards, with the twelve recoveries; making seventeen, in all, of 
the thirty-nine cases of early tuberculosis which have apparently re- 
covered. 
“ Of the remaining twenty-two cases, many of whom are still under 
treatment, seventeen have been greatly improved by topical medication; 
three more have been moderately benefited; while three only have 
failed to obtain any advantage from the local measures which have 
been adopted. 
“ Of the twenty-eight cases of bronchitis, sixteen have been dismissed, 
cured, or so much improved as to require no further treatment. All 
the others have been greatly benefited.”* 
This method of treatment, in this class of diseases, has been contin- 
ued, more or less, since the report to which I have referred was made; 
and such has been the amount of success which has continued to at- 
tend this plan of treatment up to the present time, I am now ready to 
affirm, after an experience of many years, in a field of observation 
unusually large, that, if I teas required to relinquish all other known 
therapeutic measures or topical medication in the treatment of thoracic 
diseases, I should choose the latter, with hygienic means alone, in prefer- 
ence to the entire class of remedies ordinarily employed in the treatment of 
these diseases. But I shall now refer briefly to the opinion of other 
physicians as to the value of this mode of treatment. 
In chronic bronchitis, in asthma, and in early tuberculosis, cauteri- 
zation of the air-passages has been found to be a most valuable and 
efficient remedy. As I have stated, topical medication, in the treat- 
ment of thoracic diseases, has been continued in my hands since the 
*See published “ Report of One Hundred and Six Cases of Pulmonary Dis- 
eases, treated by Bronchial Injections,” &c., pp. 34-5. 13 
publication of the “ Report of the One Hundred and Six Cases” to 
which reference has been made. During this period of three or four 
years, large numbers of patients, affected with chronic laryngeal and 
bronchial diseases, with asthma, and with tubercular phthisis, have' 
been treated, and the success which has continued to attend this prac- 
tice has served to increase greatly my confidence in this measure, as 
a therapeutic agent. I shall, however, omit a detail of any of these 
cases coming under my own observation, and only refer briefly to the 
opinion of other physicians on the value of this mode of treatment. 
At a meeting of the French Academy of Medicine, subsequent to 
the re'ading of M. Loiseau’s paper on Catheterism of the Larynx in 
Disease, a very favorable report on the management of some of the 
diseases of the air-passages by this method was adopted; the com- 
mission making the report declaring that catheterism of the air-passa- 
ges in the treatment of diphtheritic inflammation and other kindred 
affections is not only practicable, but is of great utility.* “ I believe 
this method,” said M Velpeau, “ to be a good one. While diphthe- 
ritis is at the opening of the air-passages, it is curable, and M. Loiseau 
has ascertained that it is not difficult to carry medications into the 
larynx.”f 
“ As a therapeutic means,” says the editor of the Gazette Medicate 
de Paris, “ it merits a more serious attention. What is the relation 
of cauterization to croup? It is a powerful, energetic means, the only 
one which, up to this time, has really succeeded. When the disease is 
limited to the upper part of the air-passages, we cauterize, and all 
practitioners agree that this means is truly of great benefit. What 
is laryngeal cauterization other than carrying beyond the limits of or- 
dinary cauterization, a remedy recognized as good, efficacious, not 
only against the essence of the disease itself, but also against the path- 
ological secretion?”| And the learned editor of the Gazette IJebdo- 
maduire, after calling attention to what had been done in America in 
the treatment of croup by cauterization, adds: “ These experiments 
should be repeated by us, with that attention which the authority and 
the honorable position of our American confreres command. M. Loi- 
seau, anticipated, as it is seen, in every particular, has given 11s, however, 
a useful example, and his merit will still be great if he succeeds in in- 
troducing into use a practice worthy of more attention than it has yet 
received.Ӥ 
* See Union Medicate, Aug., 1857. 
§ Ut supra, Aug., 1857. 
f Ibid- 
% Ibid. 14 
During the last year, the Gazette Hebdomadaire, and other French 
journals, have contained the histories of several severe cases of diph- 
theria, which, under the care of Loiseau, Trousseau, Gros, and other 
physicians of Paris, were successfully treated, by catheterism of the 
larynx. In alluding to one case reported by M. Gros, where the 
diphtheritic inflammation had extended deeply into the air-tubes, 
threatening immediate suffocation, but which was permanently cured 
by injections into the larynx, the editor of the Gazette Hebdomadaire 
says: 
“ This fact has an important practical signification, and speaks loudly 
in favor of the advantages which may be derived from catheterism of 
the air-passages, and from topical applications, carried by this meas- 
ure directly into the larynx and trachea.”* 
Indeed, M. Trousseau has quite recently expressed, before the 
French Academy, his want of confidence in all the ordinary violent 
remedies in the treatment of croup, such as severe vomiting, blisters, 
leeches, etc., declaring his belief that we must place our main depend- 
ence upon direct catheterism, or cauterization of the air-passages, fol- 
lowed, if this measure is unsuccessful, by tracheotomy. 
In Dr. J. Hughes Bennett’s work, to which I have already alluded, 
he has devoted a chapter to the consideration of “ Injections of the 
Bronchi in Pulmonary Diseases.” He remarks, “ Whilst tuberculosis 
is at first a constitutional disease, its localization in any part reacts 
more or less on the general health; and the opinion I have long enter- 
tained, that any means which could enable the physician to act direct- 
ly on the tissue of the lung or inflamed bronchi, would assist his efforts 
at cure, at once led me to take a favorable view of this new mode of 
treatment. The nitrate of silver ought to act as beneficially on the mu- 
cous membrane of the trachea and bronchi as on that of any other hol- 
low viscus, and we have seen previously that the remedy may be applied 
to the tracheal mucous membrane, by means of an artificial opening, 
not only without injury, but with decided benefit.” He further adds, 
“ Without entering into minute particulars, I have only to say that I 
have confirmed the statements made by Dr. Horace Green.” 
The cases in which Dr. Bennett employed this method of treatment, 
as he states in his work, were, patients “ affected with phthisis in va- 
rious stages, with laryngitis, and in chronic bronchitis, with severe 
paroxysms of asthma. In other cases in which I attempted to pass 
the tube, it was found to be impossible; in some because the epiglottis 
* Gazette Hebdomadaire, Sept., 1858, p. 660. 15 
could not be fairly exposed, and in others on account of the irritability 
of the fauces, and too ready excitation of cough from pressure of the 
spatula.”* 
This, then, is only a part of what has been done in France, 
Germany, England, and Scotland, in the employment of topical 
medication in disease. In some of these countries, far more ex- 
tensive observations on this mode of treatment have been made 
than in our own country; certainly, more than in our own city ! But 
I shall not stop here to compare the careful inquiries, the scientific 
observations made, and the frankness and candor exhibited, by the 
profession of other countries, on this subject; with the course pursued 
by many of my “American confreres;” nor, especially, with the non- 
committalism of the New York Academy of Medicine, before which body 
this matter of catheterism was first brought; and whose report on 
this subject has slept for five years, unmolested, on their table ! 
If necessary, I could give the opinion of many other practitioners, 
in Europe and America, who have tested topical medication, in the 
treatment of diseases of the air-passages, and who profess to have de- 
rived signal advantage from this therapeutical measure. 
I will only refer to some favorable testimony from some parts of 
our own country. During the last year, as it was remarked on a for- 
mer page, croup and diphtheria were more than ordinarily prevalent 
in some of our larger cities. This was the case particularly in Boston; 
and here, many very severe cases of diphtheria occurred, and some 
almost hopeless cases were saved by cauterizations of the larynx; and 
others, by tracheotomy; followed by repeated injections of a solution of 
nitrate of silver, through the opening, into the trachea and bronchi. 
In a report of some most interesting cases of the disease, read be- 
fore the Boston Society for “ Medical Improvement,” and subsequent- 
ly published in the Boston Medical and Surgical Journal, Dr. Gay 
says, “ After tracheotomy, and the insertion of the tube, the injection 
of a solution of nit. argent, through the tube, into the trachea and 
bronchi, is our strongest dependence, and most of the other measures 
are mere auxiliaries.” “ In seven cases of decided membranous croup,” 
says Dr. Gay, “ in which these combined measures were employed, 
and in which the membrane was expelled through the tube, there 
have been five recoveries, and two deaths.” Many other severe cases 
were successfully treated by cauterizations of the larynx and trachea, 
employed before the operation of tracheotomy became imperative. 
I shall close this paper by describing the method I employ in prac- 
* Clinical Lectures, &c., p. 609. 16 
ticing catheterism of the bronchi. I have received letters from many 
medical men, requesting me to give them an account of the manner of 
performing the operation, and a description of the instruments em- 
ployed. As it has been, and is, impossible for me to comply with all 
these individual requests, I cannot do better than to reproduce the 
directions 1 sent to Prof. J. Hughes Bennett, who several years ago 
wrote to me, desiring me to send him a description of the operation, 
and a set of the instruments I employed. My reply is published at 
length in Prof. Bennett’s recent volume of “ Clinical Lectures,” from 
which I shall extract. 
“ I would, with pleasure, send you the instruments I employ, but 
they are simple, and may be obtained at any surgical instrument ma- 
ker’s shop. They consist of an ordinary flexible, or gum catheter, 
and a small silver, or glass syringe. The catheter is Hutching’s gum- 
elastic catheter, (Xo. 11 or 12,) which is 12| inches in length; and, 
as the distance from the incisor teeth to the tracheal bifurcation is, 
ordinarily, in the adult, about eight inches; if this instrument is intro- 
duced so as to leave only two inches of the catheter projecting from 
the mouth, its lower extremity must, of course, (if it enter the 
trachea,) reach into one or the other of its divisions. I first prepare 
my patients by making applications, with the sponge probang, and 
nitrate of siiver solution, fur a period of one or two weeks, to the 
opening of the glottis and the larynx, until the sensibility of the parts 
is greatly diminished. Then, having the tube slightly bent, I dip the 
instrument in cold water, (which serves to stiffen it for a moment, 
and obviates the necessity of using a wire,) and with the patient’s 
head thrown well back, and the tongue depressed, I place the bent 
extremity of the instrument on 1 he laryngeal face of the epiglottis, and 
gliding it quickly through the rima glottidis, carry it down to, or be- 
low, the bifurcation, as the case may require. It is necessary that 
the patient continue to respire, and the instrument is most readily 
passed during the act of inspiration. The tube being introduced, the 
point of the syringe is inserted into its opening, and the solution in- 
jected. This latter part of the operation must lie done as quickly as 
possible, or a. spasm of the glottis is likely to occur. Indeed, if the 
natural sensibility of the aperture of the glottis is not well subdued by 
previous applications of the nitrate of silver solution, or if the tube, 
in its introduction, touches roughly the border or lips of the glottis, a 
spasm of the glottis is certain to follow, which will arrest the further 
progress of the operation. The epiglottis, which is nearly insensible, 
(and this you may prove on any person, by thrusting two fingers over 17 
the base of the tongue, and touching, or even scratching, with the 
nail, this cartilage,) should be our guide in performing the operation. 
The strength of the solution, for injecting, is from 10 to 25 grains to 
the ounce of water. Commencing with 10 or 15 grains to the ounce, 
its strength is subsequently increased, and the amount I now employ 
is from | to 1| drachms of this solution.”* 
Allow me further to add, that, latterly, in commencing the injec- 
tions, I have used a solution still weaker than above denoted. When 
my patients are prepared for catheterism, by repeated cauterizations 
of the opening of the glottis and larynx, to reduce the normal sensi- 
tiveness of the parts, the tube is then introduced, and a drachm of a 
solution of nitrate argent, of the strength of from 5 to 10 grains to 
the ounce of water, is injected through the trachea. Afterwards, the 
solution may be gradually increased in power; but, at the present day, 
I seldom employ the remedy, in bronchial injections, of a strength 
above 20 grains of the salt to an ounce of water. 
Should a spasm of the glottis occur, as 1 have before remarked in 
this paper, on the insertion of the tube into the larynx, the instrument 
should be promptly withdrawn, and no further attempt be made to 
proceed with the operation, until the irritation has fully subsided. It 
is necessary that the applications of the sponge-probang be continued 
in the intervals of the employment of the tube. 
In cases of bronchitis, in asthma, aud in early phthisis pulmonalis, 
even, the use of injections into the bronchi, once or twice a week, 
operate to diminish the cough, expectoration and dyspnoea, with great 
certainty, and very many cases of these diseases have recovered under 
local treatment, after other measures had failed. 
* “ Clinical Lectures on Medicine,” pp. 608-9. APPENDIX 
It will be remembered by the medical profession, that about this 
time last year, the attention of the New York Academy of Medi- 
cine was occupied, during several of its sittings, with the case of 
Mr. Whitney, and that powerful efforts were then made to connect the 
death of this individual with “ Topical Medication.” As the oppo- 
nents of this method of treatment, both in and out of the profession, 
have taken ever since, and continue to take, advantage of this case, 
and of the utterly unfounded, adverse opinions then expressed, to pre- 
judice the profession and the community against a practice which, in 
the hands of the scientific practitioner in almost every part of the 
civilized world, is now employed, in the treatment of diseases of the 
air-passages,* I shall give, in this Appendix, the opinions of the three 
great pathologists of Europe, Profs. Trousseau, Bennett, and Roki- 
tansky, in contradistinction to those of Drs. Mott and Beales, on this 
subject. 
The opinion of M. Trousseau, referred to on page I of this pamph- 
let, is contained in a letter which was written by him for the purpose 
of expressing his views of the case of Mr. Whitney. In this letter, 
which was received a few months ago, M. Trousseau thus writes: 
“ I regard it as impossible that your operation produced the ab- 
scess of the pharynx, and all the difficulties reported in the case of 
Mr. Whitney. I am convinced that that abscess existed before your 
operation; that perhaps, performed at a time when it could not be 
properly done, it increased the cough, and accelerated, by a few hours, 
* A late number of the Gazette Hebdomadaire contains a communication 
from M. Loiseau, in which he reports ninety-five cases of diphtheria treated by 
topical measures, of which number thus treated, ninety-three recovered perfect- 
ly. Many other cases came under the care of M. Loiseau, which had been 
previously treated by emetics and other remedies; and of these, more than one- 
half died, whilst the remaining portion convalesced slowly; suffering, many of 
them, from anasarca, oedema, or other unpleasant sequelae. M. Loiseau, there- 
fore, strongly opposes the use of all nauseating and debilitating remedies, and 
urges the employment of topical measures in the treatment of diphtheria. 19 
the development of the severe symptoms which were observed; but 
still, once more I must say, that I believe you to be entirely innocent 
of that death. 
“ I, who have so often injected into the trachea, after tracheotomy, 
large quantities of caustic solutions, repeating this operation four, 
five, and six times a day, and many days consecutively, have found 
at the autopsy irritation of the bronchi, but never an eschar or an 
abscess; and my evidence, in this respect, cannot be doubted. * * * 
“ Receive, my dear doctor, the expression of my most distinguished 
sentiments. A. Trousseau.” 
The following letters from Professors Bennett, of Edinburgh, and 
Rokitansky, of Vienna, are taken from the Medical Monthly, of Sep- 
tember, 1859. The prefatory remarks are by the editor of the 
Monthly: 
“ The following opinions, relative to the pathological appearances 
found at the autopsy of the late Mr. Whitney, are of great interest, in 
connection with the history of this remarkable case. Comment is 
unnecessary. The agreement of both of these celebrated pathologists, 
whose opinions are here given upon all the essential points in the case, 
is conclusive. To both of them was forwarded a copy of the Febru- 
ary number of the Monthly, containing a full report of the proceed- 
ings of the Academy of Medicine when this subject was under its con- 
sideration. In addition to this, a copy of the original post-mortem, 
certified by his Honor the Mayor of New York, was sent to Prof. 
Rokitansky, by his former pupil and personal friend, Dr. Charles 
Bernacki, of this city. Dr. Bernacki has kindly placed Prof. Roki- 
tansky’s reply at our disposal. The letters are placed in the order of 
time in ■which they were received.” 
Edinburgh, May 18, 1859. 
My dear Doctor—I have hesitated for some time as to how I 
ought to reply to your letter; that is, whether it would be better to 
enter into a lengthy criticism of Mr. Whitney’s case, or simply answer 
the two queries you have put to me. After carefully studying the 
case itself, I find so much to comment on in the various branches of 
diagnosis, pathology, treatment and ethics, that I feel constrained to 
throw my notes aside, and give up the idea of entering into the matter 
fully, as it would oblige me to write a treatise rather than a letter. 
prof, bennett’s letter. 20 
You request my opiniou: 1. As to the tubercular character of the 
pulmonary abscess; 2. As to whether such effect as Dr. Beales inti- 
mates could have been produced by the injection of nitrate of silver, 
which was employed. 
1st. As to the tubercular character of the pulmonary abscess.—The 
description given by Dr. Green of the physical signs on the 25th 
October, 1858, is remarkably clear, (see Am. Monthly, p. 104,) and 
can leave no doubt as to the existence of condensation of the left lung 
at the apex, with softening of the tissue. When Dr. Beales was 
called in, Dec. 14th, he does not seem to have made any physical ex- 
amination of the chest. At all events, no account of any is given 
from that time up to the period of the patient’s death, (Monthly, 
p. Ill to p. 115.) But he tells us afterwards, that he had previously 
made such examination (p. Ill) towards the end of October; he gives 
no description of these signs, but only states his opinion, viz., that “ he 
could not discover any tubercles in his lungs, and did not believe any 
existed.” The report of the post-mortem, however, demonstrates that 
the physical examination of the lung made by Dr. Green was in every 
respect correct, (Monthly, p. 116.) “The whole of the upper part 
of this lobe (the left) was red, and solid—hepatized.” “ At the com- 
mencement of the bronchial ramifications there was an open cavity, 
about the size of a small black walnut, of a reddish-brown color, and 
irregular villous surface, as though a slough had separated.” This 
answers thoroughly for the flat sound, detected two months previously, 
over the upper portion of the left lung, and the humid rale audible 
below the left clavicle, on inspiration and expiration. 
As to the nature of the disease, Dr. Beales conceives it to have 
been acute and recent pneumonia, (p. 118.) I cannot think so, when 
I consider the accurate account of physical signs given two months 
previously, then indicating the condensation and softening which were 
subsequently found. It must have been chronic pneumonia passing 
into gangrene, or a limited tubercular abscess accompanied by chronic 
pneumonia of the apex. The descriptions given of the lesions do not 
enable me to say which of these it was. In fact, I consider it a matter 
of little importance, because a chronic exudation of the apex so read- 
ily passes into tubercle, and an old tubercular abscess is so commonly 
accompanied by chronic pneumonia, that, in truth, it often becomes 
difficult, if not impossible, to say where tubercle ends and pneumonia 
begins. It is enough that a chronic exudation was there, and that, I 
consider, Dr. Green fully indicated by his physical signs six or seven 
weeks before Dr. Beales was called in. 21 
2d. As to whether the treatment caused the disease.—Dr. Beales informs 
us that Dr. Mott told the family, after the post-mortem examination, 
that they had not seen any disease that might not have been produced 
within a week, (Monthly, p. 118.) According to this idea, it could 
not have been the injection into the trachea which caused the pulmo- 
nary disease, as that operation was performed on the 6th of Decem- 
ber, without causing any irritation, and he died on the 21st. Besides, 
the pulmonary lesion existed on the 25th October, as proved by phys- 
ical signs. The injection, therefore, could not have caused that lesion. 
Is it not more probable that, a chronic exudation having existed at the 
apex, and a cavity formed, this latter perforated the pleura, causing 
the pleural exudation, followed by the emphysema of the cellular 
tissue ? At what moment did this perforation take place ? We are 
told that Mr. Whitney visited Dr. Green on the 14th of December, 
after breakfast, (the time is not stated;) the doctor passed an instru- 
ment into his throat, and finding some obstruction, he pushed the in- 
strument with some force; he (Mr, W.) felt something give way, 
immediately experienced severe pain about the top of the windpipe, and 
told the doctor he had “hurt him;” he returned home, informed the 
family of what had occurred, and was seen by Dr. Beales at 1 p. m., 
(p. 112.) Dr. Green’s account of wrhat happened on the 14th is dif- 
ferent. According to him, (Monthly, p. 106,) when the sponge 
reached the glottic opening, the patient partially closed the throat, so 
that the instrument did not enter the windpipe at all. It was at once 
removed, no more force having been used than that which is constant- 
ly employed every day in operations on the air-passages. The patient, 
after talking a while with Dr. Foy and myself, and remarking that “ the 
operation hurt him more,” or that “ he felt it more than usual,” he 
left, with the arrangement that he should return the next day and have 
the tube employed. The patient’s account to Dr. Beales is, that at the 
moment the probang was arrested at the glottis, he felt something give 
way, and experienced severe pain about the top of the windpipe, (p. 
112.) But is this consistent with the fact that he talked for a while 
with Drs. Foy and Green, and went home intending to come next day, 
&c.? Again, was the pain, if felt at the top of the windpipe, symp- 
tomatic of perforation of the pleura in the chest ? It appears to me 
difficult to answer these questions, more especially when we read the 
account of the alarming condition of Mr. W. at 1 o’clock, when first 
seen by Dr. Beales, (Monthly, p. 111.) I am, therefore, inclined to 
ask, What occurred in the interval between the patient’s leaving Dr. 22 
Green and his seeing Dr. Beales ? This may have been an interval of 
three or four hours, and of this most important period I can find no 
account whatever. It is true, Mr. Whitney seems to have had the 
impression that his severe symptoms commenced when the sponge was 
arrested, but this is negatived by the evidence of Drs. Green and Foy, 
who saw no evidence of severe pain even in the throat. When, then, 
did the pulmonary and pleural perforation take place, which induced 
the emphysema and subsequent symptoms ? With the facts at present 
before me, I cannot answer this question, but it is clear to my mind 
that it may have occurred during the hours not accounted for; that it 
might have been altogether spontaneous, connected only with the 
progress of the chronic pulmonary lesion; and that it had no relation 
whatever to the operation performed by Dr. Green. 
In addition to the lesion already referred to, it appeared, on dissec- 
tion, that there was an abscess behind the larynx, and stretching to- 
wards the left of the pharynx, the size of a hen’s egg, with an opening 
at its upper and posterior part, into the pharynx, large enough to 
admit the end of the forefinger. This abscess was not discovered 
before death, by any of his attendants, medical or surgical. Dr. 
Mott, a great authority in surgery, asserts that this was an acute 
abscess. Dr. Beales distinctly states, (Monthly, p. 119,) that in his 
opinion it was caused on the 14th December, by the accidental lacer- 
ation of the pharynx by the probang; and his account of the symptoms, 
as he observed them at 1 p. m. on that day, supports the supposition, 
especially the intense pain in the region of the larynx, shooting 
through to the cervical vertebra, and down the course of the trachea 
to the chest; he kept grasping the larynx, &c. (p. 111.) Now, as 
the larynx was shown subsequently to be healthy, it is very probable 
that these symptoms were connected with the pharyngeal abscess. 
But how? Is such pain consistent with the first commencement of 
an abscess, or did it accompany the rupture of an abscess previously 
formed ? By what signs was it pronounced to be acute ? Might it 
not have existed before the operation of the 14th ? Might it not 
have come on subsequently ? On all these points I will not venture 
to speak. But having now used the probang in many hundred cases, 
and under all circumstances, I am at a loss to understand how its 
being arrested at the glottis would either lacerate the pharynx, so 
as to give rise to an abscess, or cause the bursting of an abscess 
which had already formed—“ downward, behind and below the thyroid 
cartilage.” I cannot but think that the application of the sponge 23 
had no more to do with this abscess, than it had with the exudation 
into the apex of the left lung. , 
Yours, very truly and sincerely, 
J. Hughes Bennett. 
prof. Rokitansky’s letter. 
Most esteemed Friend— 
I received your letter on the 8th, along with the documents relat- 
ing to the sickness and death of Mr. S. S. Whitney, through Mr. 
Wallner, or rather, as I was not at home, through my wife. First 
permit me to express my most heartfelt thanks to you, and my trans- 
Atlantic friends, for the friendly remembrance which you show in the 
recognition of my scientific labors, and the honorable confidence re- 
posed in me. And now to my task. I have devoted my entire atten- 
tion to the documents you sent me, as you will perceive, absque omni 
partium studio. 
Certainly the most important point is to determine the nature of 
the cavity in the left lung, “just at the root, or the commencement of 
the ramifications of the bronchise.” This is very difficult, for two 
reasons: 1. Because the description of the cavity is very imperfect; 
and 2. Because the whole report (Gesammtbefund) is very defective, 
inasmuch as a complete dissection was not made. Neither sufficient 
local nor sufficient general data are given for a diagnosis. 
In the last point of view, particularly, we are not certain whether a 
tuberculous individual or not is under consideration. It would seem 
as though no actual tuberculization was present. 
If, under these circumstances, I give my opinion in compliance with 
your request, it can be of value only as a supposition. 
1. The abscess in the larynx might be the result of a perichondritis; 
this abscess broke externally into the contiguous circumjacent areolar 
tissue. The red point found in the larynx was probably connected 
with the abscess. The reddening of the mucous membrane of the 
air-passages is of no importance. 
2. I do not consider it as proved that the condition of the upper 
lobe of the left lung was that of recent hepatization. True, there was 
noticed a considerable pleuritic exudation on the exterior of the lobe, 
but I presume that this lobe of the luug had been partially attacked 
with atelectasis, (obturation,) in consequence of a bronchial catarrh, 
and was in a state of incipient destruction, (induration.) 
3. The cavity in this lung (this lobe of the lung) I would consider 24 
as a bronchial sac, or rather as a cavern, (bronchial cavern,) reciting 
from the ulcerous destruction of such a' sac. 
Was this ulcerative process due to a continuous, exacerbating, ca- 
tarrhal inflammation of the mucous membrane of the sac, or to a 
tuberculization of the mucous membrane of the same? We are 
obliged to accept the former solution of the question, inasmuch as the 
report denies the presence of any tubercles. 
This cavernous opening must then be considered, since from it a 
destruction of both layers of the pleura proceeded, as the source of 
the extravasation of the inspired atmospheric air into the circumjacent 
areolar tissues. This, then, is my opinion with reference to the sig- 
nificance of the results of the post-mortem examination. As regards 
the operative treatment, I have not been requested, in fact, to give an 
opinion; still, you may perhaps like to hear that also. It is very 
evident that the two conditions met with, i. e., the abscess in the 
larynx, and especially the cavity in the left lung, existed before the 
treatment; and I also believe that the latter (the treatment) was not 
the cause of the death of the patient. 
Your sincere friend, 
Vienna, June 14 th, 1859. 
Rokitansky. 
[From the American Medical Monthly for February, I860.]