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LUMLEIAN LECTURES 
 
 OF 
 
 THE ROYAL COLLEGE OF PHYSICIANS 
 
 1876 
 
ON THE 
 
 PATHOLOGY 
 
 OF THE 
 
 PNEUMOGASTRIC NERVE, 
 
 BEING THE LUMLEIAN LECTURES 
 DELIVERED AT THE ROYAL COLLEGE OF PHYSICIANS 
 OF LONDON, 1876; 
 
 ALSO 
 
 COLD SHOCK IN ITS ACTION ON THE 
 PNEUMOGASTEIC NERVE. 
 
 S. 0. HABEESHON, M.D. Lond., E.E.C.P. 
 
 LATE SENIOR PHYSICTAN TO, AND LECTUEEE ON MEDICINE AT, GUT'S HOSPITAL; 
 LATE PEESIDENT OF THE MEDICAL SOCIETY OF LONDON. 
 
 SECOND EDITION. 
 
 LONDON 
 J. & A. C HUE CHILL 
 
 11, NEW BURLINGTON STREET 
 1885 
 
PREFACE TO SECOND EDITION. 
 
 These Lectures on the Pneumogastric Nerve have 
 been so favorably received by the profession, that 
 we venture to publish a second edition, as the former 
 one has been for some little time out of print. 
 
 The symptoms of diseases of the throat, the lungs 
 and the heart, as well as those of the stomach and 
 liver, which are due to the connections of the pneumo- 
 gastric nerve are so varied, that the full description 
 of them would form a treatise on the maladies of 
 the chest and abdomen, and we have therefore 
 refrained from any enlargement of the previous 
 Lectures ; but we have appended a paper that was 
 read before the Medical Society of London, on the 
 effect of Cold Shock upon the branches of the 
 Pneumogastric Nerve. 
 
 The effect of cold, in an exhausted system, is to 
 produce a condition that may, with some correctness, 
 be designated paralysis of the pneumogastric nerve ; 
 rapid congestion of the lung is induced, and the 
 patient may die before the ordinary symptoms of in- 
 flammation are developed ; or very severe bronchitis 
 or pneumonia may supervene, and the patient's life is 
 
VI PREFACE TO SECOND EDITION. 
 
 placed in imminent jeopardy. In another class of 
 caseSj the peripheral nerves supplied to the stomach 
 and the liver are first attacked, then those of the 
 lungs and heart ; and the character of the disease is 
 only correctly diagnosed when the connection of the 
 pneumogastric nerve with the several structures is 
 borne in mind. Some of these cases are regarded 
 as fever^ or as blood-poisoning, for the absence of 
 the physical signs of disease are not attributed to 
 their true cause. We hope that our observations 
 will tend to elucidate these interesting and severe 
 forms of disease. 
 
 70, Beook Street, 
 
 Geosvenob Squaee ; 1885. 
 
PEEFACE TO FIRST EDITION. 
 
 Having received many expressions of interest in 
 tlie Lectures wMcli I had tlie honour of delivering 
 before the President and Fellows of the Royal 
 College of Physicians^ I have ventured to present 
 them to the profession in a collected form. I regret 
 that I have not been able to expand the Lectures as 
 I had desired. The subject is a complex one, and 
 it is important, inasmuch as the pneumogastric nerve 
 has relation to every vital function of the body ; but 
 although it is necessarily treated in an abbreviated 
 form — for I have only traced some of its leading 
 features — I trust the thoughts may prove suggestive 
 and of practical value. 
 
CONTENTS, 
 
 LECTURE I. 
 
 PAGE 
 
 On the anatomical arrangement of the pneumogastric nerve — 
 Its physiology, in respiration, in deglutition, in the action 
 of the heart, in digestion — Effect of division of the nerve ; 
 its association with the fifth and with other nerves — 
 Cervical branches — Laryngeal symptoms, spasmodic and 
 paralytic 1-35 
 
 LECTURE II. 
 
 Thoracic branches — (Esophagus — Spasmodic stricture — Para- 
 lysis — Iflings — Spasmodic irritation, paralysis — Seart — 
 Spasmodic irritation, angina — Paralysis .... 36-60 
 
 LECTURE III. 
 
 Abdominal branches — Stomach — Spasmodic irritation — Vomit- 
 ing — Pain — Paralysis, anorexia, distension . . . 61-90 
 
 Cold Shock in its action on the Pnefmogasteic Keeve 91-107 
 
PATHOLOGY 
 
 OF THE 
 
 PNEUMOGASTRIC NERVE. 
 
 LECTUEE I. 
 
 ANATOMY AND PHYSIOLOGY PATHOLOGY OF CERVICAL 
 
 BRANCHES. 
 
 One of the most deeply interesting questions in phy- 
 siological science is^ in what manner the harmony of 
 the different animal functions is maintained. The most 
 delicately adjusted machinery is at work ; actions of 
 an entirely different character are performed without 
 interfering the one with the other, and the result is 
 recognised and expressed by the term of health. 
 The body is a microcosm ; and, as in the external 
 world there is harmony in the working of natural 
 forces, so in man's organism there is an adjustment 
 of forces, an even balancing of the Hying power in its 
 functional integrity, so that, with diversity of opera- 
 tion in the several parts, there is unity in the complex 
 
 A 
 
2 PATHOLOGY OF THE PNEUMOGASTRIC NERVE. 
 
 whole. The light of the sun exerts its silent but 
 irresistible power on the vegetable life of the globe ; 
 and the plant, and flower, and tree grow and thrive 
 as if Nature were alone for them. The chemical 
 force in the plant is in operation, and the physical 
 forces are ever in exercise ; but the same light has 
 equal power on animal organism ; the heat and life 
 go hand in hand, and move on undisturbed, and 
 chemical and physical and living forces are found in 
 correlative action : but not less powerful is the same 
 influence of the sun upon the physical world, upon 
 the waters of the ocean, in producing evaporation, in 
 determining the currents of the sea, and in regulating 
 the winds. There is wonderful harmony in the 
 adjustment of these different spheres of operation, 
 the vegetable kingdom with the animal, and these 
 with the physical conditions by which the one and 
 the other can exist and flourish. 
 
 The functions of animal life are equally diverse. 
 Respiration is a function separate in itself, to ensure 
 the admission and expulsion of air, for the purifica- 
 tion and oxidation of the blood ; it has its system of 
 muscles and nerves, and adjustment of force. So 
 also is that of the circulation of the blood, the 
 central organ of which is the heart, a living, active, 
 propulsive engine, by which the vital fluid is pro- 
 pelled both into the lungs and into the whole system. 
 Equally distinct are those of deglutition and diges- 
 tion, by which food is prepared and dissolved, and 
 then absorbed into the circulatory system. Each of 
 
ANATOMICAL DISTRIBUTION. 6 
 
 these functions — that of the respiration^ that of the 
 circulation, and that of digestion — acts independently, 
 but still in unison. If one or other be disturbed, 
 the whole system is thrown into disorder. Like the 
 apparently complex mechanism of a locomotive engine, 
 the disarrangement of one valve or of one connection 
 will interfere with every part^ and bring the power 
 to a stand. In physiology, it is only a small part of 
 the science to study one structure and 07ie function ; 
 each must be taken in its connection with the whole ; 
 and so in pathological science. Few diseases can be 
 regarded as strictly local in their character, and the 
 morbid processes in one part are inseparably con- 
 nected with those which take place in another. The 
 union may be one of structure or of function ; the 
 connection may be by means of the supply of blood 
 or the supply of nerves. If we would rightly know 
 the diseases of one organ, we must be acquainted 
 with those which have functional relationship with it. 
 The pneumogastric nerve is a regulating medium, a 
 bond of union between parts which are otherwise 
 dissociated, separate in structure and in function, but 
 united in the healthy working of the body. It holds 
 in check structures which would individually act, but 
 which without it would hever harmonise. 
 
 I have ventured to submit some remarks on the 
 '' Pathology of the Pneumogastric Nerve/ ^ because 
 there are some questions respecting it which have 
 not received the attention which they deserve, and 
 there are some clinical aspects of disease which are 
 
4 PATHOLOGY OF THE PNEUMOGASTEIC NERVE. 
 
 essentially connected with disturbance of the func- 
 tional integrity of this nerve. In the animal economy, 
 the pneumogastric nerve stands pre-eminent ; the 
 functions of the body with which it is connected are 
 of the greatest importance for the maintenance of life, 
 for it is connected with respiration, with circulation, 
 and with digestion. These three most important 
 functions are guided and controlled by this nerve, 
 and to effect these purposes it is distributed to 
 numerous structures, and its relations are of the 
 most complex kind. 
 
 Before speaking of the pathology of the nerve, it 
 will be well to review very briefly its anatomical 
 distribution and its physiological action. The nerve 
 appears at the base of the brain, at the side of the 
 medulla oblongata, and at the front part of the resti- 
 form body, and behind the olivary. At this part it 
 is in close proximity with the glosso-pharyngeal and 
 with the spinal accessory nerves. The nerve passes 
 through the medulla in the direction of the floor of 
 the fourth ventricle, where several enlargements or 
 nuclei are observed, which are connected with the 
 nerves having origin at this part. The root of the 
 pneumogastric is in the closest relation with the 
 origin of the hypoglossal nerve — the nerve of the 
 tongue ; with the fifth nerve — the sensory nerve of 
 the face, and of the orifices of the nose and mouth ; 
 with the seventh, that supplies the muscles of the 
 face ; with the glosso-pharyngeal, the nerve of the 
 throat ; and with the spinal accessory nerve, an 
 
ANATOMICAL DISTRIBUTION. 5 
 
 important nerve of respiration. There is the most 
 intimate connection between the nerves at this part, 
 the fifth and seventh, the hypoglossal, the glosso- 
 pharyngeal, spinal accessory, and pneumogastric 
 nerves. " The fibres of origin of the vagus and 
 glosso-pharyngeal nerves pass tbrough the sensory 
 portion of th.e fifth. ^^* The beautiful sections made 
 by Lockbart Clarke sbow the varied unions of the 
 origin of tbese nerves. The latter author states,t 
 that " the vesicular column that gives origin to the 
 accessory nerve, after reaching the surface of the 
 fourth ventricle as the nucleus of the vagus, sinks 
 beneath the auditory ganglion, and, diminishing in 
 size, becomes part of the nucleus of the glosso- 
 pharyngeal nerve.^^ It is here that the sensory or 
 afferent impressions brought to the centre are re- 
 flected by the nerves of motion, which arise at the 
 same part. As the fibres of the pneumogastric 
 emerge from the brain, they pass to the jugular 
 foramen (foramen lacerum basis cranii), where the 
 nerve is surrounded by the same sheath of dura 
 mater as the spinal accessory, and by the same layer 
 of arachnoid membrane, but separated from the 
 glosso -pharyngeal. In the foramen is a ganglionic 
 enlargement : and there are connections, as described 
 by Quain,J with the facial, with the spinal accessory, 
 with the petrous ganglion of the glosso-pharyngeal, 
 
 * Carpenter's * Physiology,' 7th ed., p. 558. 
 
 t ' Philos. Trans.,' pt. i, 1858. 
 
 X ' Anatomy,' 8th edition, vol. i, p. 559. 
 
6 PATHOLOaY OF THE PNEUMOGASTRTC NERVE. 
 
 and with tlie sympathetic nerves. Half an inch lower 
 down is a second ganglion of the pneumogastric, 
 which is said not to include the branches of the 
 spinal accessory sent to join the vagus ; but the 
 ganglion communicates not only with that nerve, but 
 with the hypoglossal, the first two spinal, and with 
 the upper ganglion of the sympathetic. The branches 
 of the spinal accessory sent to join the pneumogastric, 
 after leaving the foramen, may serve to explain the 
 conflicting opinions of physiologists in reference to 
 the motor fibres of the nerve. The spinal accessory 
 nerve is in this way traced to the motor nerve of the 
 larynx and to the palate, and is regarded as con- 
 trolling the movements connected with vocalisa- 
 tion. 
 
 The first branch of the pneumogastric nerve is 
 the pharyngeal, and it arises from the upper part of 
 the trunk, and, uniting with branches from the 
 glosso -pharyngeal, the superior laryngeal, and sym- 
 pathetic, forms the pharyngeal plexus, from which 
 branches are distributed to the muscles and to the 
 mucous membrane of the pharynx. 
 
 The superior laryngeal is the sensory nerve of the 
 larynx, and is divided into an external branch and an 
 internal. The former branch is of great importance, 
 inasmuch as deglutition and respiration require to be 
 adjusted, otherwise food might more frequently pass 
 into the larynx. It supplies the crico-thyroid 
 muscle, the lower constrictor, and thyroid body, and 
 sends a branch to the pharyngeal plexus. The ex- 
 
ANATOMICAL DISTRIBUTION. 7 
 
 planation given by Mr Hilton in reference to tliis 
 muscular supply is, that the larynx is prepared for 
 the more delicate contractions due to the supply of 
 branches from the recurrent nerve. The internal 
 laryngeal supplies the mucous membrane of the 
 larynx, the vocal cords, the epiglottis, and the base 
 of the tongue ; and it sends filaments to join the 
 recurrent nerve. 
 
 The recurrent nerve is the motor nerve of the 
 larynx, supplying its muscles, with the exception 
 just mentioned ; and it supplies branches to the 
 trachea, the oesophagus, the mucous membrane of 
 the pharynx, and also communicating filaments to 
 the deep cardiac plexuses and to the superior laryn- 
 geal. It leaves the trunk of the nerve at the 
 superior opening of the thorax, and then turns 
 upward, passing round the subclavian artery on the 
 right side, and the aorta on the left. The next 
 branches of the pneumogastric are to the cardiac 
 plexus, and then to the pulmonary ; afterwards, upon 
 the oesophagus we find the oesophageal plexus — 
 plexus guise ; thence it passes through the dia- 
 phragm into the abdomen. In the abdomen, nume- 
 rous branches are distributed to the walls of the 
 stomach.* The nerve joins the large sympathetic 
 ganglion, the semilunar; branches may be traced to 
 the liver, to the duodenum, to the ganglion on the 
 vena cava, by which it is brought into connection 
 with the phrenic. This connection of the pneumo- 
 * See preparation in the museum of Guy's Hospital. 
 
8 PATHOLOGY OF THE PNEUMOGASTRIC NERVE. 
 
 gastric and phrenic nerves is of great physiological 
 and pathological interest.* The phrenic is distri- 
 buted to the diaphragm, and afterwards it unites 
 with both the pneumogastric and sympathetic nerve 
 in a ganglion upon the vena cava. The diaphragm 
 is the most important muscle of respiration, and is 
 tbus brought into harmonious action with the lungs 
 by means of the pneumogastric. The same muscle 
 has to do with the passage of food through the end 
 of the oesophagus into the stomach — the closing act 
 of deglutition. We find evidence of this connection 
 in the spasmodic action of the diaphragm in hiccough, 
 and we recognise it in the attempt to maintain the 
 greatest quietness in the muscle during acute dis- 
 ease of the abdomen ; so also in the intimate con- 
 nection of disease immediately below the diaphragm 
 with the pleura and the lung above it. In gall- 
 stone and other diseases of that kind we often find 
 pleuritic disease at the same time. Branches of the 
 pneumogastric also may be traced to the pancreas, 
 to the suprarenal capsule, and to the kidney, beside 
 uniting with the sympathetic branches upon the 
 aorta. 
 
 Such is the extensive distribution of the pneumo- 
 gastric nerve : and, before speaking of the pathology 
 and the morbid conditions due to altered nerve- 
 supply, we must very briefly refer to the physiology 
 of the nerve. The nerve is of a double character, 
 
 * See dissection of mine and preparation in the museum of Guy's 
 Hospital. 
 
PHYSIOLOGY. 9 
 
 and contains both afferent and efferent fibres. It 
 regulates tbe respiratory function. It is the minute 
 afferent branches from the pulmonary plexus of this 
 nerve that reach the structure of the lung and 
 bronchi ; and the impressions there received are 
 transmitted to the brain^ and are followed by reflex 
 movements. By its connection with the fifth and 
 seventh nerves, the entrance of air by the mp uth is / 
 
 regulated ; by means of the hypoglossal the tongue " 
 
 is adjusted so as not to interfere with the free pas- 
 sage of air ; the glosso-pharyngeal and external 
 branch of the superior laryngeal bring the pharynx 
 into right sympathetic action ; the internal branches 
 and the recurrent regulate the glottis ; and the 
 muscles of respiration supplied by the spinal acces- 
 sory^ the phrenic, and branches of the spinal nerves, 
 complete the respiratory act. The important nerve- 
 centre of this function is at the origin of the pneu- 
 mogastric at the floor of the fourth ventricle. It is 
 the minute branches of this nerve which, distributed 
 to the bronchial tubes, produce constriction and 
 narrowing of the tubes, so painfully manifested in 
 spasmodic asthma. According to Eosenthal, the 
 superior laryngeal nerve has inhibitory action upon 
 the movements of respiration and upon the dia- 
 phragm, and acts centripetally on the brain ; and 
 Burkart has shown that the inferior or recurrent 
 nerve exerts similar power. 
 
 Another important function which is controlled by 
 the pneumogastric is the process of deglutition ; the 
 
10 PATHOLOGY OF THE PNEUMOGASTRIC NERVE. 
 
 movements of tlie oesophagus are accelerated^ and 
 tlie cardiac orifice may be closed by it. 
 
 Still more important is its influence upon tbe 
 movements of tbe heart ; it controls its movements, 
 and irritation of the nerve retards its action, whilst a 
 strong electric current will stop it in diastole. 
 
 The connection of the heart's action with respira- 
 tion is most important, for the one is essentially 
 dependent upon the other ; unless the respiration be 
 performed, the heart will quickly cease, and vice 
 versa. The presence of carbonic acid in the pulmo- 
 nary capillaries — the venous blood h-aving been 
 impelled by the right side of the heart — and perhaps 
 also the deficiency of oxygen in the blood, exert 
 their influence on the minute afferent branches of 
 the pneumogastric, and through the medulla lead to 
 the completion of the respiratory movement. 
 
 The supply of the pneumogastric to the organs of 
 digestion is essential for the right performance of 
 that function. We have already mentioned, that the 
 passage of food in the oesophagus is promoted by the 
 pneumogastric, and so also are the movements of 
 the stomach. ; the nerve contains afferent sensory 
 fibres, and the irritation of these afferent fibres during 
 digestion causes dilatation of the gastric vessels, 
 according to the experiments of Bernard and Ruther- 
 ford, and in disease these fibres become acutely active. 
 In an instance of ulceration of the stomach in which 
 the patient suffered intense pain, I found a large branch 
 of the pneumogastric nerve passing across the floor 
 
PHYSIOLOGY. 1 1 
 
 of the ulcer. (Preparation in Guy's Museum.) It 
 is probable, also, that the condition of the pylorus is 
 regulated by the same nerve. Most interesting have 
 been the observations made by Claude Bernard in 
 reference to the action of the pneumogastric upon 
 the liver. By experiment he found that a puncture 
 of the floor of the fourth ventricle, at the root of 
 the pneumogastric nerve, disturbed the glycogenic 
 function of the liver, and produced saccharine urine. 
 These experiments have been repeated, and the 
 observations extended, by our colleague Dr Pavy ; 
 but we will not dwell upon them. The connection 
 of the pneumogastric with the suprarenal capsule, 
 with the renal plexus and the other portions of the 
 sympathetic nerve of the abdomen, with the uterus, 
 etc., leads to the reflex irritation of the stomach, so 
 frecLuently observed in diseases affecting those 
 organs. 
 
 Numerous experiments have been made by phy- 
 siologists, illustrating the effect of division of the 
 nerve upon the several organs to which it is distri- 
 buted. After division, there is loss of sensation in 
 the throat, and foreign substances may pass un- 
 heeded into the larynx, a remarkable contrast to the 
 violent spasmodic action produced during the integ- 
 rity of the nerve ; again, after division, there is loss 
 of power in the throat, and of action in the vocal 
 cord ; the glottis is partially closed ; and, if life be 
 prolonged, the muscles supplied by the divided nerve 
 become wasted ; the action of the heart is impeded. 
 
12 PATHOLOGY OF THE PNEUMOaASTEIC NERVE. 
 
 at first it is more frequent, and tlie force is increased ; 
 the pulse is larger, because there is diminished ten- 
 sion in the vessels ; the lungs lose their sensibility, 
 the movements of the chest-walls are less active, and 
 respiration becomes less frequent, but more deep, 
 till it ceases altogether. The capillaries of the lung 
 become filled with blood ; the lung is deprived of 
 air j the mucous membrane is congested, and frothy- 
 serum exudes into the air-cells ; the nutrition of the 
 part is altered, and inflammatory changes are in- 
 duced. This inflammation is often found where the 
 pneumogastric is injured by pressure. Where the 
 nerve is divided the cardiac orifice of the stomach 
 does not act, the mucous membrane of the stomach 
 becomes pale, and the secretion is for a time checked, 
 whilst, on irritation of the divided central end of the 
 nerve, the colour is restored. A common effect of 
 irritation of the gastric branches of the pneumo- 
 gastric is that vomiting is produced, and, when the 
 nerves are divided, and the peripheral ends are irri- 
 tated, movements of the stomach are induced 
 (Lauder Brunton) ; but when these nerves are para- 
 lysed vomiting ceases, and the stomach more easily 
 yields to expansive forces, and becomes distended. 
 This condition, we would remark, is very different 
 from those instances in which, from sudden over- 
 distension from gaseous formation and other causes, 
 the muscular coat is unequal to the force required 
 for contraction ; the nerve-power is overtaxed, and 
 thereby inoperative. 
 
PHYSIOLOGY. ]3 
 
 In considering' tlie diminished power of the 
 pneumogastric in the abdomen, we can scarcely 
 separate its individual action from that in which it 
 is associated with the vaso-motor nerve. In the 
 effects produced by an ordinary bilious attack, or in 
 those consequent on violent vomiting, the afferent 
 fibres of the pneumogastric are in unison with those 
 of the vaso-motor or sympathetic ; they are weakened, 
 and the vessels expand ; at the same time the car- 
 diac branches sympathise, and the pulse becomes 
 weak and compressible, and the heart's action 
 feeble. After violent vomiting the secreting power 
 of the liver is interfered with, and the motions 
 become exceedingly pale, at the same time that the 
 nervous supply to the lower lobe of the right lung 
 becomes sympathetically affected. This connection 
 is seen, also, in most cases of inflammation of the 
 stomach; but to this we shall again have to refer. 
 The sudden shock of cold water upon the afferent 
 nerves of the stomach may by reflex action stop the 
 heart, and the application of cold to the back of the v 
 neck and shoulders may not only disturb the action 
 of the heart, but produce gasping for breath in con- 
 sequence of reflex action, the upper spinal nerves 
 being connected with the spinal accessory and so 
 with the pneumogastric nerve. y 
 
 The intimate union of the pneumogastric nerve 
 with branches of the spinal end of the sympathetic 
 nerve may lead to the development of symptoms, as 
 if the branches of the pneumogastric were themselves 
 
y 
 
 14 PATHOLOGY OF THE PNEUMOGASTEIC NERVE. 
 
 irritated. We shall subsequently note instances of 
 this reflex action ; and a remarkable instance of it is 
 mentioned by Dr Burdon Sanderson, in reference to 
 the fifth nerve affecting the pneumogastric in the 
 rabbit, by causing the animal to smell ammonia. 
 ^^ The effect is immediate, according to the strength 
 of the ammonia ; the heart is arrested in diastole, or 
 the diastolic intervals may be lengthened. Inhala- 
 tion of chloroform may stop the heart in the same 
 way."*^ This connection of the fifth nerve is of great 
 interest in some diseases ; in hydrophobia the whole 
 of the branches of the fifth nerve are in a state of 
 intense irritability ; the least breath of cold air, as 
 merely passing the hand near the face, will induce 
 the most intense spasm of the throat ; the branches 
 of the superior laryngeal nerve and of the glosso- 
 pharyngeal are at once acted upon, and so are other 
 branches of the pneumogastric nerve. The fifth 
 nerve having acted by its afferent branches upon the 
 medullary centres, reflex action is at once induced. 
 It has been stated that inflammation of the sheath of 
 the nerve has been observed, and also of the cervical 
 nerves at their origin ; but these statements require 
 confirmation (Ziemssen^s ' Encyclopaedia of Practical 
 Medicine ') . In this terrible disease we have a condi- 
 tion of extreme hypergesthesia of these cerebral 
 nerves and their centres ; whilst conversely in labio- 
 glosso-laryngeal paralysis we have diminished power 
 of these centres. The seventh nerve is paralysed, 
 and the fifth is weakened j and with these the 
 
PHYSIOLOGY. 15 
 
 branches of the superior laryngeal nerve are devoid 
 of sensibility ; deglutition is impaired, and becomes 
 a dangerous process, for th.e natural safeguards are 
 removed. In the clinical wards of Guy's Hospital, 
 during the session of 1875, a man with this disease was 
 admitted under my care ; his countenance was expres- 
 sionless, bis tongue had lost its power, and deglutition 
 was so difficult that he was fed by the means of the 
 stomach-pump. To relieve his tbirst however, he 
 made the attempt to swallow a draugbt of milk ; the 
 superior laryngeal nerve had lost its sensibility, and 
 some of the milk passed into tbe trachea and bronchi. 
 Tbis was quickly followed by a fatal result ; and on 
 tbe jpost-mortem table tbe milk was found in the 
 respiratory passages. In this case the afferent 
 brancbes of the pneumogastric failed to excite tbe 
 sensory centre, and to induce tbe expulsory efforts 
 of violent cougb. Tbe afferent fibres of the fifth 
 were also weakened. We bave in this latter disease 
 tbe opposite condition to that observed in hydro- 
 phobia j bypergestbesia in the one, anaesthesia in tbe 
 otber. 
 
 Tbe same connection of the fifth nerve witb tbe 
 pneumogastric is found in tbe effect of severe chill 
 or sbock from cold ; this reflex action is sbown in 
 ordinary sneezing, but it is more decided when tbe 
 power of the pneumogastric is weakened, and severe 
 bronchitis or pneumonia is induced. Tbe sbock on 
 the nerve-power of tbe respiratory organs may be so 
 great tbat tbe patient is in a few bours in a state of 
 
16 PATHOLOGY OP THE PNBUMOGASTEIC NERVE. 
 
 the greatest prostration, witli dry and brown tongue, 
 resembling advanced fever, but without cough or 
 ordinary external signs of inflammation of the chest. 
 The pneumogastric is almost paralysed ; but the first 
 effect is upon the fifth nerve, and a mistake is 
 made in the treatment of these diseases, if this con- 
 nection of the fifth nerve be overlooked. The face 
 should be kept warm, and no draughts of cold air 
 allowed to play upon it. It is quite true that in the 
 perspiration and craving for air in severe pneumonia 
 fanning the face is a temporary relief to the patient ; 
 but this is an expression of the exhaustion and of the 
 desire for pure air which the system needs. 
 
 We might adduce other instances of the manner 
 in which the pneumogastric nerve is affected by 
 reflex action, but would only here advert to the 
 effect produced upon the centres of the nerve by 
 disturbance on the cerebral aspect of the ganglia. 
 It is powerfully influenced by the emotions and by 
 the passions. The special senses directly influence 
 it j an offensive object, and, still more, a disgusting 
 smell, induce violent retching : sudden alarm at the 
 sight of danger, or any sound that terrifies, at once 
 affects the heart and the respiration, as well as the 
 action of the abdominal viscera supplied by the nerve. 
 The nerve is placed as the custodian of essentially vital 
 functions, but it is, as it were, the ready handmaid 
 of the mind and will. We have spoken of its exten- 
 sive distribution, and each branch of the nerve has, 
 we believe, a definite purpose ; and by its means the 
 
PHYSIOLOGY. 17 
 
 throat, the larynx, the lungs and the heart, the 
 stomach, the liver and other abdominal viscera are 
 brought into the closest union. During health the 
 hidden connections are united in harmonious work- 
 ing ; but in disease the jarring of disturbed action 
 spreads its sympathy to all the parts thus linked 
 together. The following laws of action are often 
 observed in the study of clinical medicine. 
 
 1. Disease at the origin of the nerve may induce 
 symptoms in any of the peripheral branches ; and 
 this reflex state may be one of irritation and hyper- 
 sesthesia, or one of diminished power and anaesthesia ; 
 the one is spasmodic in character, the other para- 
 lytic. 
 
 2. Irritation in any set of peripheral branches may 
 produce disturbance in any other part to which the 
 nerve is distributed, or in the centre itself. 
 
 3. Alternation of irritation may be induced, at 
 first one set of nerves, then another, becoming 
 implicated. This alternating character of functional 
 diseases is of great clinical interest. We see an 
 irregularity of type and rapidity of recovery which 
 contrast remarkably with the severity of the disease. 
 Spasmodic asthma of the most distressing kind 
 suddenly gives place to disturbance of stomach, this 
 to cerebral symptoms, and these to severe neuralgia. 
 Violent vomiting and marked gastric irritation are 
 followed by loud cough and by loss of voice, indicat- 
 ing that an affection of one set of nerves has given 
 place to change in another set of branches. In 
 
 B 
 
18 TATHOLOGY OP THE PNEUMOGASTEIC NERVE. 
 
 general weakness, tliere is loss of power in all the 
 parts supplied by tlie nerve, and this fact is often of 
 great importance in the close of disease. In exhaus- 
 tion, the voice fails ; many patients who are suffering 
 from chronic disease are said to die from the super- 
 vention of bronchitis or of pneumonia, when the 
 pulmonary condition is really the expression of 
 exhaustion of the pneumogastric nerve ; so, also, 
 when the strength has failed, there is great liability 
 to affections described as bronchitis and inflammation 
 of the lungs, the power of the respiratory centres 
 being lessened, disturbance of nutrition more readily 
 takes place. Still further, when patients are reduced 
 by chronic disease of the stomach, or of the kidney, 
 similar pulmonary changes may be due to exhaustion ; 
 this statement is not opposed by the fact of oedema 
 of the lung and broncho-pneumonia coming on from 
 ursemic poisoning. 
 
 A further evidence of exhaustion of the pneumo- 
 gastric nerve is the loss of appetite, and the 
 diminished power in the stomach to digest food 
 placed in it. 
 
 The pneumogastric may be affected as a whole, 
 and the symptoms presented in diabetes are perhaps 
 the best illustrations of this general condition of 
 disease. An interesting paper on this state was 
 published in the ' Medical Times ' of 1856 by the late 
 Dr Charles Shearman, on Neurosis of the Pneumo- 
 gastric Nerve; he drew attention to the depression 
 of spirits, to the loss of memory, the malaise, the 
 
LARYNX. ' 19 
 
 sense of exhaustion at the stomach, with yawning 
 and sighing, and often with palpitation ; to the dis- 
 turbance of digestion, and, in many instances, to 
 the diabetic condition of the urine : these symptoms 
 often manifested a periodical character, and, when 
 the condition was early recognised, were amenable 
 to treatment. In true diabetes the branches of the 
 pneumogastric are especially affected, and we find 
 not only the glycogenic function of the liver dis- 
 turbed, but the other parts supplied by the pneumo- 
 gastric are involved, the pulmonary nutrition is 
 interfered with, and a chronic pneumonia is often 
 induced ; palpitation and disturbance of the heart 
 are common symptoms, and the voice is often altered 
 in character. There is the closest sympathy between 
 the pneumogastric and the sympathetic nerve ; 
 hence other common symptoms attending diabetes, 
 such as the impaired nutrition, the red tongue, the 
 dry skin, the altered appetite, the confined state of 
 the bowels, and, at a later period, diarrhoea ; and, as 
 to the brain itself, the same sympathy is shown in 
 the melancholia which is often induced. The con- 
 nection of the pneumogastric branches with the 
 vaso- motor nerve is also seen in that remarkable 
 disease, exophthalmic goitre. With impaired nutri- 
 tion we find enlargement of the thyroid, protrusion 
 of the eyeballs, and an irritable condition of the 
 heart ; and sometimes with a saccharine condition of 
 the urine, as in a young gentleman lately under my 
 care, aged about twenty-three, in whom, with an 
 
20 
 
 PATHOLOGY OF THE PNEUMOGASTRIO NEEVE. 
 
 extremely sensitive condition of nervous system, we 
 tad well marked exophthalmic disease with a recur- 
 rent glycosuria; the branches of the pneumogastric 
 in him were especially prone to morbid action. 
 
 LARYNX. 
 
 It may facilitate the right understanding of our 
 subject if we take the several parts supplied by the 
 nerve in connection with the laws which have been 
 just adduced ; and first as to the larynx. The larynx 
 may be affected by spasmodic irritation, or weakened 
 by paralysis ; and each of these may be central in 
 character, or be produced by local or by peripheral 
 causes. 
 
 C In epilepsy and functional disease of brain, 
 / Central < In laryngismus stridulus, 
 (^ In whooping-cough. 
 ^ In catarrh and laryngitis, 
 ^ In croup and diphtheria, 
 i C -^^ *^® different forms of ulceration, &c. 
 
 ^ In irritation of the uvula. 
 
 In aneurism pressing on the recurrent nerve. 
 
 In early phthisis. 
 
 In heart disease, 
 
 In enlarged glands. 
 
 In hysteria. 
 
 In exhaustion. 
 
 In disease of brain, as apoplexy. 
 
 In cerebral aphonia. 
 
 In glosso-labio-pharyngeal paralysis. 
 Local In diphtheria. 
 
 / In aneurism, 
 
 \ In pressure on the pneumogastric or re- 
 V reripheral -s current nerve by tumours, 
 (^ In hysterical aphonia. 
 
 Spasmodic 
 irritation 
 
 Local 
 
 L Peripheral •{ 
 
 ( Central 
 
 Paralytic 
 weakness 
 
LARYNX. 21 
 
 In the paroxysm of an epileptic convulsion, tlie 
 larynx is spasmodically affected ; but, in this dis- 
 ease, not only are the premonitory symptoms of the 
 most varied character, but we find that_, in the in- 
 terval between the paroxysms, vague sensations are 
 produced, which are evidently traceable to the same 
 cause. An impression is made upon the nervous 
 system of which the patient alone may be conscious, 
 and one or other branch of the pneumogastric may 
 in this way be involved : either that of the stomach, 
 the heart, the lungs, or the throat. It may be a 
 sense of choking or of dyspnoea, or more severe 
 spasmodic irritation. If the cause be recognised, 
 treatment will be more successful. The following 
 may serve as an instance of this kind of irritation of 
 the pneumogastric nerve. An oflScer, aged forty- 
 five, who had served some years ago in India, and 
 afterwards in the West Indies and Canada, whilst in 
 India had a fall from his horse, which was attributed 
 to sun-stroke ; there was concussion of the brain, 
 and he lost the sense of hearing on the left side, and 
 also the sense of smell. From that time he had 
 become nervous and dyspeptic ; he did not suffer 
 from headache, but slept badly, and had morning 
 cough, his pulse was feeble, but otherwise he seemed 
 in good health ; his chest was strong, abdomen con- 
 tracted, urine normal; but he had repeated attacks 
 of ^' sighing,^^ with sense of choking and distress 
 about the upper part of his chest. He had never 
 contracted any syphilitic disease, and was a water- 
 
22 PATHOLOGY OF THE PNEUMOGASTEIC NERVE. 
 
 drinker. In tlie West Indies lie had fever slightly. 
 It was quite evident that this condition was due to 
 functional disturbance of the brain, and the '' chok- 
 ing '' sensation and sighing to the state of the 
 pneumogastric nerve. Bromide of potassium, with 
 arsenic and cinchona bark, relieved these unpleasant 
 symptoms. 
 
 In an undergraduate, aged nineteen, attacks of 
 the most violent spasm of the throat came on in the 
 following manner. He had previously felt well till 
 lie over-fatigued himself with a long walk ; the 
 following day he had a paroxysm of difficulty in 
 breathing, and there was a recurrence each day with 
 increasing severity. He would suddenly start up, 
 throwing his arms into the air, the face becoming 
 livid, the eyes staring ; he would then, in the wildest 
 manner, force his hand into his mouth, as if to tear 
 something from the throat ; after a few minutes, 
 there was the expectoration of thick mucus and a 
 little blood ; the attack then gradually subsided. A 
 loud crowing inspiration took place during the 
 paroxysm. The attacks were so severe, that it 
 seemed as if the danger to life were imminent. 
 When seen at 10 p.m., the respiration was 28 ; pulse, 
 100 j temperature, 100*4° ; the skin perspiring, the 
 throat free from injection ; and there was no diph- 
 theritic membrane. The tongue was clean, the 
 bowels confined, the respiration was easy ; there 
 was no sibilus and no laryngeal sound produced 
 during ordinary respiration ; no rhonchi, nor change 
 
LARYNX. 23 
 
 in resonance in the chest ; the respiration was, how- 
 ever, rather less free than normal at the right base ; 
 he could swallow fluids ; there was no dysphagia, but 
 great sensibility of the epiglottis. He had no 
 cough ; in fact, he was afraid to cough, on account 
 of the throat-spasm. He was ordered a dose of 
 castor-oil, and bromide of potassium, 3j ; tincture of 
 belladonna, n{K ; dilute hydrocyanic acid, TT\ij ; and 
 compound tincture of chloroform, v\x, in water every 
 four hours. He inhaled steam with two drachms of 
 hemlock-juice in it. 
 
 About half-past three another severe paroxysm 
 came on, but soon subsided, and the spasms became 
 less frequent. In a few days he recovered, and 
 there has been no return of laryngeal or other sym- 
 ptoms of disease since — now five years ago. This 
 severe form of disease was spasm of the glottis, and 
 closely resembled the laryngismus stridulus which is 
 more frequently found at an earlier age. It was 
 evident that there was irritation either of the 
 pneumogastric nerve at its root, or of the recurrent 
 laryngeal nerve ; it was a neurosis of the larynx, 
 and a condition of hyperaesthesia ; and it was due, not 
 to any local change in the part, but to an affection 
 of its nerves. This, in fact, is the pathology of 
 laryngismus stridulus ; sometimes it is due to mis- 
 chief at the origin of the nerve, and the spasm of 
 the glottis is a slight convulsion, which may be 
 followed by a more general one, the fingers and the 
 toes being turned in, as in membranous inflammation 
 
24 PATHOLOaY OP THE PNEUMOGASTRIC NERVE. 
 
 of the brain ; or it may be produced by reflex irri- 
 tation, as by intestinal affections, or by the pressure 
 of enlarged glands on the recurrent nerve of the 
 neck. In infants this form of malady may be pro- 
 duced by slight disturbance, as from the teeth, or 
 from the bowels, and an attack, even the first one, 
 may be so severe as to lead to a fatal result. 
 
 There is much doubt as to the true pathology of 
 whooping-cough ; according to Dr Copland, it has 
 its seat in the medulla oblongata, and some speak 
 of it as a neurosis of the pneumogastric nerve ; but 
 there can be no doubt that the parts supplied by the 
 pneumogastric are especially affected. The spasmodic 
 condition of the glottis, the urgent dyspnoea and 
 cough, vp^ith the closed state of the rima, producing 
 the lividity of the countenance and the long drawn 
 inspiratory sigh, then also the irritability of the 
 chest, often followed by cough and by emphysema, 
 and the great sensibility of the stomach, so that 
 vomiting is very easily induced, show that the whole 
 of the branches of this nerve are exquisitively sen- 
 sitive. The fact that it is a disease communicable 
 by contagion does not militate against the idea that 
 it is the pneumogastric that is especially affected. 
 The same remedies which are available in relieving 
 spasm of the throat lessen the severity of this dis- 
 ease ; and, when the malady becomes more severe, 
 the irritation is prolonged from the origin of the 
 pneumogastric to other nerve-centres, and general 
 convulsion is induced. In measles also, another 
 
LARYNX. 25 
 
 contagious disease, we find great sensibility of the 
 pulmonary branches of the pneumogastric. 
 
 In reference to spasmodic affections of the throat 
 produced by local irritation we have not space to 
 describe them, but would only say that, in all forms 
 of local disease, such as catarrh, laryn^tis, croup, 
 diphtheria, strumous or syphilitic or cancerous ulcer- 
 ation, the affection of the mucous membrane very 
 readily induces spasmodic contraction of the muscles 
 of the part, and this condition aggravates the dis- 
 tress due to the inflammatory disease. 
 
 The spasmodic diseases of the larynx which are due 
 to peripheral irritation are of a very interesting kind, 
 and we will very briefly advert to them. In many 
 instances of relaxation of the uvula and mischief about 
 the throat, cough and irritation of the epiglottis are due 
 to direct disturbance. The elongated uvula may come 
 into contact with the epiglottis itself; this, however, is 
 not always the case and the disturbance of the superior 
 laryngeal is reflex. 
 
 This reflex disturbance is more decided in aneu- 
 rismal disease of the aorta and of the large vessels of 
 the neck, which may induce pressure upon the recur- 
 rent nerve. At first this may be mere spasmodic 
 irritation from slight disturbance, and afterwards the 
 disease may lead to paralysis of the part from long- 
 continued pressure. As the recurrent laryngeal 
 nerve supplies nearly all the muscles of the larynx, 
 spasmodic contraction is easily induced. At first, 
 there is very little affection of the voice, but sudden 
 
26 PATHOLOGY OP THE PNEUMOGASTRIC NERVE. 
 
 paroxysmal dyspnoea, whicli often comes on at night. 
 The patient awakes in great distress, and is unable 
 to get his breath. The distress is sometimes extreme, 
 and this symptom is often one of the most prominent 
 indications of aneurismal disease of the aorta. There 
 may be nothing observable on laryngoscopic exami- 
 nation of the throat ; no change in the voice, no 
 affection of the pupil ; and the general physical signs 
 of disease may be very imperfectly developed. A 
 case of this kind occurred many years ago in Guy's 
 Hospital before, I would say, the laryngoscope was 
 used. The patient was a strong man, without any 
 symptoms of heart disease, but with occasional diffi- 
 culty in swallowing, and with the paroxysmal distress 
 just mentioned. My former teacher and colleague, 
 Dr Addison, diagnosed aneurism, although the oeso- 
 pbageal symptoms were more decided than the other 
 indications of disease ; and the termination of the 
 case showed the disease to be aneurismal in char- 
 acter. In pressure upon the larynx and trachea from 
 aneurism and tumour, laryngeal spasm greatly 
 aggravates the dyspnoea and distress. 
 
 Another form of reflex irritation is that affection of 
 the larynx which is produced by disturbance of the 
 peripheral branches of the fneumo gastric in the lung. 
 The voice is changed, and a dry hacking cough, with 
 laryngeal irritation, seems to indicate mischief in the 
 windpipe, but it is really due to reflex irritation. A 
 patient will ofteu describe the mischief as being in the 
 throat itself, when, by careful examination, the com- 
 
LARYNX. 27 
 
 raencement of tubercular disease is found in the lung. 
 These instances are, of course, to be distinguished from 
 those in which, at a later stage of chronic phthisis, 
 disease in the larynx and in the vocal cords is induced 
 and ulceration takes place. 
 
 Again, in heart disease of an organic kind, we also 
 find reflex irritation of the laryngeal nerves. This 
 state must not be confounded with the urgent dyspnoea 
 which is produced by the disturbed relations of the 
 lungs and heart ; thus the blood is unable to pass 
 from the lungs, in consequence of contracted mitral 
 valve, and thereby the respiratory act is imperfectly 
 and hurriedly performed, and the lung is surcharged 
 with blood. Besides these cases, we have instances 
 of heart disease, whether from valvular disease or 
 weakness in which sudden laryngeal distress and 
 urgent dyspnoea are produced. This paroxysm often 
 takes place about two or three in the morning; the 
 patient is suddenly roused from sleep, because the 
 respiratory centre does not receive its proper supply 
 of aerated blood ; the involuntary muscles of respira- 
 tion during sleep being unassisted by the muscles of 
 forced respiration, which had served to maintain the 
 balance of the respiration and circulation, are alone 
 insuflBcient, and, after a time, the need of the system 
 rouses the patient to take a deep inspiration and to 
 supply more oxygen. This explanation will, however, 
 not suffice for many instances in which the patient 
 may be awake, and breathing to the utmost of his 
 capabilities, but still the laryngeal spasm comes on. 
 
28 PATHOLOGY OP THE PNEUMOQASTRIC NEEVE. 
 
 In other instances of functional disease of tlie heart, 
 from weakness and from dilatation^ we find similar 
 sudden laryngeal spasm produced. 
 
 The same symptoms of reflex irritation by pressure 
 upon the recurrent laryngeal nerves may be caused 
 by enlarged glands in the neck or in the upper part 
 of the chest ; and, in some instances during early 
 life, the condition is one precisely resembling that of 
 laryngismus stridulus produced by cerebral irritation. 
 In gastric disturbance, an irritable dry cough and 
 perverted sensation of the superior laryngeal nerve 
 may be induced ; a tickling in the throat which the 
 patient can scarcely distinguish from actual local 
 irritation of the part, or the spasmodic affection may 
 be more decided in character. 
 
 In hysteria y the spasmodic affections of the larynx 
 are closely connected with those of the oesophagus ; 
 a sense of choking from spasmodic contraction in the 
 latter is associated with difficulty of breathing from 
 spasm of the former. The sensation as of a ball in 
 the throat, the globus hystericus, is not limited to 
 the gullet, but extends to the windpipe ; there is 
 gasping for breath, with irregularity, and often after- 
 wards with hurried respiration. 
 
 It is not necessary to dwell further upon these 
 spasmodic laryngeal affections ; but we pass on to 
 consider those which are of a paralytic character, 
 where there is loss of power or anassthesia ; these 
 also may be divided into those which are of central 
 origin, those which are local in character, and, lastly 
 
LARYNX. 29 
 
 peripheral. As to the first, we find loss of power in 
 both recurrent nerves in states of great exhaustion ; 
 and when the origin of the par vagum has lost its 
 active power, the insensibility of the superior laryn- 
 geal nerve may allow food to pass into the larynx, as 
 during syncope, and also towards the close of life ; it 
 is of importance to bear this fact in mind, otherwise 
 sudden cessation of life may be produced by laryn- 
 geal obstruction. This loss of sensibility is to be 
 remembered in the severe form of disease which has 
 been designated glosso-lahio-pha^-yngeal paralysis; and 
 we have already referred to an instance in which the 
 attempt of a patient to swallow milk when the larynx 
 had lost its sensibility led to its sudden passage into 
 the trachea, and caused death. In this disease, the 
 malady is central ; it is at the central origin of the 
 nerve, and probably at the part where the spinal 
 accessory, facial, the hypoglossal, and the par 
 vagum are brought into close relationship at the 
 floor of the fourth ventricle. Trousseau refers the 
 disease to the spinal accessory nerve, and regards the 
 branches of nerve supplied to the larynx as being 
 derived from that nerve, at least as far as the power 
 of speech is concerned ; whilst the pneumogastric has 
 especially to do with the respiratory act. 
 
 A plumber by trade, aged forty-six, was admitted 
 into Guy^s Hospital, under my care, on ISTovember 
 9th, 1874. He had not suffered from lead-poisoning 
 nor from syphilis. Twelve months previously he 
 began to lose the power of mastication, and he had 
 
30 PATHOLOGY OF THE PNEUMOGASTEIC NEEVE. 
 
 some difficulty in swallowing ; there was partial 
 deafness on the left side. The symptoms came on 
 gradually, and steadily increased in severity. The 
 appearance of the patient was very peculiar; the 
 vacant expressionless countenance, with the mouth 
 partially open, was very characteristic of the disease. 
 The symptom which first attracted attention was the 
 diminished power of the muscles of mastication, and 
 this was associated with gradually increasing weak- 
 ness. At length, one month before admission, he 
 could only take fluid food ; the facial nerve was 
 greatly diminished in power, but was not completely 
 paralysed, for he could close the eye and partially 
 distend the cheeks ; the mouth was half open. The 
 left auditory was affected, but the sensory portion of 
 the fifth was unaffected ; for there was no loss of 
 sensation of the face. The appearance of the tongue 
 was most distinctive ; it remained powerless at the 
 floor of the mouth, and the soft palate was motionless. 
 This state led to the most prominent of the symptoms 
 of disease, the inability to swallow or to masticate 
 food properly, and also to pronounce those sounds 
 which require the action of the tongue and of the 
 lips j deglutition could not be performed, the move- 
 ments could not be executed, and the attempt was 
 followed by choking ; food reached the edges of the 
 epiglottis, and was violently ejected by the nostrils, 
 and the patient was nearly asphyxiatedby the attempt. 
 He coughed up a good deal of phlegm, but he did 
 not seem to have power to clear his throat thoroughly. 
 
LARYNX. 31 
 
 With the laryngoscope, the vocal cords could be seen 
 to open and close as in health ; still the superior 
 laryngeal nerve did not seem to possess its normal 
 sensibility. He was greatly exhausted when admitted, 
 and, as the paralysis of the hypoglossal was marked 
 and swallowing could not be performed, it was 
 directed that he should be fed with the stomach- 
 pump ; milk was administered in this way. The fol- 
 lowing evening, however, he again attempted to swal- 
 low ; and a few hours afterwards he died. Some of 
 the milk had passed into the larynx, for white coagula 
 were found in the bronchi. The post-mortem exam- 
 ination, very carefully made by Dr Goodhart, showed 
 that there was a small patch of softening immediately 
 above the right corpus olivare ; the floor of the fourth 
 ventricle was deep in colour ; its lateral angles and the 
 valve of Yieussens were softened, and there was a 
 minute patch of the same change in the structure of 
 the cerebellum beneath. The right hypoglossal was 
 smaller than the left, and, in the cervical spinal cord, 
 the right anterior horn was softened. The parts 
 affected were the origins of the hypo-glossal and 
 facial nerves, but those of the spinal accessory and 
 pneumogastric presented less decided change. It 
 was interesting to find, however, that the recurrent 
 nerve seemed to retain its power over the vocal 
 cords, although the superior laryngeal nerves had 
 diminished sensibility. 
 
 In reference to a weakened condition of the vocal 
 cords, or diminished tension, or loss of contractile 
 
82 PATHOLOGY OF THE PNEUMOGASTEIC NERVE. 
 
 power, tlie disease may be of central origin, or it 
 may be of a local or of a reflex cbaracter. We often 
 find, in reference to the first, tbat tbe disease is in 
 tlie will ; the effort to produce contraction of the 
 cords is not made ; the patient speaks in a whisper. 
 A few months ago, a patient of this kind was under 
 my care in Gruy^s Hospital who had not spoken for 
 two years ; there was no evidence of organic disease, 
 and the first application of an electric current to the 
 larynx produced the loudest protestations that she 
 could speak. This state has been called by Homberg 
 psychical aphonia. Sudden nervous shock may also 
 produce this loss of power of the vocal cords. Other 
 weakened conditions of the nerves of this part are 
 due to local disease, to diphtheria, and to croupous 
 diseases ; and even after catarrh, the muscles become 
 weakened, and sympathise in the inflammatory affec- 
 tion of the mucous membrane. The application 
 of electricity often affords great relief, and, in 
 milder cases, the effort to produce musical notes and 
 to sing, tends to increase the tension of the weakened 
 cords. 
 
 Still more interesting are the forms of paralysis of 
 tbe recurrent nerve and of the vocal cords which are 
 due to reflex action. Any form of pressure upon 
 the recurrent nerve may induce altered nutrition 
 and hoarseness, the consequence of the paralysis ; 
 for the recurrent supplies the vocal cords, and, with 
 one exception, the muscles of the larynx. The 
 larynx may be examined by the laryngoscope, which 
 
LARYNX. 83 
 
 becomes an important help in diagnosis, and the 
 vocal cord may be seen on one or other side to be 
 weakened or powerless. In an interesting paper by 
 Dr George Johnson in the ' Medico- Chirurgical 
 Transactions ' of 1875, he shows that, whilst pressure 
 on one recurrent nerve, on the same side, will pro- 
 duce spasmodic action or paralysis, pressure on the 
 trunk of the nerve will cause atrophy or spasmodic 
 action on both sides. Aneurismal disease* is perhaps 
 the most frequent cause of this reflex paralysis — 
 reflex in its being produced, not by direct injury of 
 the larynx, but by secondary pressure upon it ; not 
 reflex in the sense of an impression being conveyed 
 to the nerve-centre, and then propagated to the 
 affected part. These instances are very different in 
 character from those already described as due to a 
 central cause. Enlarged bronchial glands, cancerous 
 disease, and it is said, pleuritic thickening about 
 tuberculous lungs, will induce this paralysis of the 
 vocal cords by affecting the recurrent nerve. 
 
 A very interesting case of this kind was formerly 
 under my care in Gruy^s Hospital. A strong man, 
 aged forty-three, an engineer, who, with the excep- 
 tion of rheumatism, had good health till Christmas ; 
 cough then came on, and increased in severity, with 
 dyspnoea, till his admission on February 23rd. His 
 face and neck were swollen and cedematous, and the 
 
 * See comnranication in 'Med.-Chir. Trans.,' 1864, vol. xlvii, 
 on "Implication of Branches of the Pneumogastric Nerve in 
 Aneurismal Tumours," by the author. 
 
 C 
 
34 PATHOLOGY OF THE PNEUMOGASTRIC NERVE. 
 
 superficial veins of the thorax were enlarged ; there 
 was complete dulness on the right side of the chest, 
 with absence of respiratory murmur ; the signs of 
 thoracic tumour were well marked ; the arms became 
 swollen^ the dyspnoea increased greatly in severity, 
 and erysipelatous inflammation affected the right 
 arm. The voice was feeble, but was not lost. . He 
 died on March 14th. On inspection, a cancerous 
 tumour was found in the anterior mediastinum ; it 
 pressed upon the innominate and azygos veins ; the 
 right lung was in a sloughing condition ; the right 
 pneumogastric was involved, and there was very 
 marked affection of the recurrent on the same side ; 
 it was involved in the growth, and, to quote the 
 description of Dr Fagge, " the larynx was healthy, 
 except the right vocal cord, which was swollen and 
 yellow.^' The swelling was very decided, and the 
 nutrition was so affected that suppurative changes 
 had commenced ; but there was no suppuration 
 about the muscles of the neck. The patient was too 
 ill to bear the use of the laryngoscope. 
 
 Many of the instances of reflex paralysis which are 
 associated with functional disturbance of the uterine 
 organs are closely allied to those which have been 
 referred to as hysterical aphonia. 
 
 These varied affections of the larynx may be pro- 
 duced by disease at the origin of the nerve — the 
 pneumogastric — or the disease may be reflex in cha- 
 racter, the irritation of one series of nerves affecting 
 other branches, as of the lungs, or of the stomach, or 
 
LARYNX. 35 
 
 of the larynx ; and, lastly, these laryngeal affections 
 may give place to disturbance of the lungs or of the 
 stomach, alternating the one with the other; a 
 patient at one time having aphonia, then spasmodic 
 irritation of the bronchial tubes, or functional dis- 
 turbance of the digestive organs. In the first case, 
 the attempt should be made to relieve the central 
 mischief ; in the second, to lessen the primary 
 source of peripheral disturbance ; in the third, to 
 remove the general irritability of the nervous 
 system. 
 
LECTUEE II. 
 
 THOEACIC BRANCHES. 
 
 In this lecture we pass on to tlie consideration of 
 those pathological changes in the oesophagus, in the 
 lungs, and in the heart, which are connected with 
 disturbances of the par vagum ; and we shall find 
 fresh exemplification of the three laws upon which 
 we dwelt in our last lecture. 
 
 1. Disease at the central origin of the nerve may 
 induce symptoms of irritation in any other part 
 supplied by the same nerve. 
 
 2. Irritation in any set of peripheral branches may 
 produce disturbance in any other part to which the 
 nerve is distributed, or in the centre itself. 
 
 3. Alternation of irritation may be produced : at 
 first one set of nerves, then another, becoming im- 
 plicated. 
 
 (ESOPHAGUS. 
 
 The oesophagus receives a large supply from the 
 pneumogastric, and the branches of the nerve form 
 a plexus upon it ; but besides these branches direct 
 from the trunk of the nerve, others are derived from 
 
(ESOPHAGUS. 
 
 37 
 
 tlie recurrent nerve, as well as from tlie sympathetic. 
 This nervous supply is especially concerned with the 
 regulation of the movements of the muscular layers 
 of the canalj for the oesophagus is a mere channel of 
 communication between the pharynx and the sto- 
 mach.. This muscular layer is thrown into a state 
 of spasmodic contraction, from the increased irrita- 
 bility of its nervous supply ; or, from exhaustion of 
 nerve power, it is weakened and paralysed. When 
 the power of the pneumogastric is destroyed, as by 
 division of the nerve, the food is retarded in its pas- 
 sage down the tube. It may be convenient, there- 
 fore, to divide the nervous affections of the oesopha- 
 gus, which have to do with the pneumogastric nerve, 
 into those which are of a spasmodic and those which 
 are of a paralytic character ; and each of these may be 
 traced to central or to local disease, or they may be 
 produced by peripheral irritation. 
 
 Spasmodic 
 stricture 
 
 / Central 
 
 r Mar 
 
 ) Epi] 
 (Ner 
 
 Paralysis 
 
 Mania, 
 
 Epilepsy, 
 
 Nervous irritability. 
 /" Foreign bodies, 
 
 \ Pressure on the canal by tumours, en- 
 ■\ j larged glands, aneurism, 
 
 V, Organic obstruction and ulceration. 
 
 ! Hysteria, 
 Disease of heart. 
 Disease of aorta, and aneurism. 
 Flatulence. 
 ' Central Exhaustion. 
 
 Local Pressure on pneumogastric nerve, aneu* 
 
 rism, &c. 
 Peripheral Disease of stomach, &c. 
 
38 PATHOLOGY OF THE PNEDMOGASTRIC NERVE. 
 
 Althougli the mucous membrane of the oesophagus 
 does not possess great sensibility, still there are 
 decided sensations produced by the passage of food 
 down the canal, as a sense heat or of coldness, of 
 fulness and distension, or of severe pain ; and some- 
 times the sensibility is increased, so that patients 
 complain of a sense of soreness, of roughness, or the 
 whole canal is unduly sensitive : at other times this 
 augmented sensibility exists only in the imagination 
 of the patient. The process of deglutition is com- 
 pleted by the passage of food down the oesophagus 
 into the stomach, but food or saliva or other sub- 
 stance must be present to excite the act : a person 
 cannot swallow without something to excite the con- 
 traction by reflex irritation. A young gentleman 
 called upon me in great distress, believing that he 
 had organic obstruction in the gullet. During the 
 whole of his journey from Rugby to London he had 
 been trying to swallow, but without success, as he 
 could not complete the act when saliva had already 
 been swallowed. He did not understand the physio- 
 logical process, and his mind was at once calmed and 
 his fears dissipated when a glass of water was given 
 to him to drink. In some cases of mania, as also in 
 many cases of spasmodic reflex irritation in hysteria, 
 patients believe that there is obstruction, and that 
 there is no passage. Nothing is swallowed, because 
 the attempt is not made ; the cerebral centre is at 
 fault. The loudest protestations are made that food 
 will not pass, and the patients will often refuse to 
 
(ESOPHAGUS. 89 
 
 make tho attempt. The paHsage of an ooBOphageal 
 bougie proves that there is no obstruction, and some 
 may be induced to make the attempt after this ope- 
 ration has once been performed. It is probable that 
 some spasmodic contraction induces the sensation of 
 obstruction. This form of spasmodic affection is a \ 
 common symptom in many cases of mental disease, /" 
 and sometimes it is one of the earliest indications 
 of the malady. 
 
 A similar kind of spasmodic obstruction occurs in 
 some cases of epilepsy, and after sunstroke a sense of 
 choking and obstruction in the throat is produced 
 somewhat similar to globus hystericus, although due 
 not to reflex but to central mischief ; and again, in 
 other patients, local spasmodic irritation and con- 
 traction of some part of the oosophagus may be 
 produced, which cannot bo traced to local disease or 
 to irritation of a reflex kind. For years persons 
 complain of hindrance to the free passage of food 
 where no stricture exists ; it may be at the centre 
 of the canal or at its termination. In an instance of 
 this kind a member of our profession was, for a time, 
 in great fear that organic disease existed, and he 
 took his meals alone, on account of the care that he 
 required in getting the food to pass into the stomach 
 but he found that by taking a deep inspiration the 
 spasmodic contraction, probably near the diaphragm, 
 became relaxed, and the food slipped onwards into 
 the stomach. It must, however, be remembered that 
 all local disease of the (jesophagus produces spasmodic 
 
40 PATHOLOGY OF THE PNEUMOGASTRIC NERVE. 
 
 contraction from irritation of tlie part j and that 
 a partial obstruction or narrowing of tlie canal is 
 often rendered complete from this cause ; some, 
 indeed, have believed that long continued spasmodic 
 contraction may produce thickening of the connective 
 tissue, and lead to organic obstruction. It would be 
 foreign to our purpose here to describe organic 
 obstruction, whether from external disease or 
 pressure of glands, tumours, or aneurism ; or from 
 internal thickening of the coats of the canal, as from 
 fibro- cellular growth, from the healing of ulcers, from 
 the deposit of cancerous or other material, further 
 than to remark that spasmodic contraction always 
 plays an important part in the symptoms produced. 
 
 The spasmodic contractions which are of a reflex 
 character are well known. In the globus JiystericuSj 
 a sudden sensation as of a ball in the throat and a 
 sense of suffocation are produced; the respiration is 
 disturbed, with sighing and irregular breathing, and 
 the emotional centres and often the whole of the 
 spinal nerves are excited to perverted action. Peri- 
 pheral disturbance of sentient nerves leads to the 
 excitement of the medulla oblongata at the origin of 
 the par vagum ; and the irregular contraction of 
 fibres of the oesophagus, especially of the circular 
 fibres, leads to this sensation as of a ball in the 
 throat. In many instances there is disordered 
 uterine and ovarian function ; whilst in others, from 
 general weakness, the emotional centres of the brain 
 react upon the medulla and its nerves. 
 
(ESOPHAGUS. 41 
 
 Yery similar sensations are produced by flatulent 
 distension of the stomach and transverse colon ; the 
 sensation of weight and oppression at the upper part 
 of the chest is a purely reflex one, and it is princi- 
 pally due to the pneumogastric, but it is increased 
 by the connection of the upper dorsal nerves with 
 the splanchnic nerves, since the latter have their 
 origin in the dorsal nerves, and pass down to the 
 abdominal viscera. 
 
 In some cases of heart disease spasmodic irritation 
 of the oesophagus is induced, and it comes on sud- 
 denly, with most distressing sense of obstruction. 
 Some refer this reflex action to the branches of the 
 cardiac plexus uniting with the pneumogastric, others 
 to the recurrent nerve which sends a branch to the 
 cardiac plexus, whilst others attribute the sensation 
 to a mechanical cause, the distension of the left 
 auricle, which is in close proximity with the oeso- 
 phagus. The pathology of these cases of disease is 
 very different, and the simple spasmodic obstruction 
 may be easily mistaken for that which, is organic. 
 In the first kind it is important to compel the oeso- 
 phagus to do its work j in the second, it is equally 
 important to allow it to rest j whilst, in the last, the 
 removal of the peripheral mischief will soon dissipate 
 the spasmodic hindrance. 
 
 The paralytic affections of the oesophagus are 
 found at the close of other diseases, but these also 
 arise from central, local, or from peripheral distur- 
 bance. In general exhaustion, deglutition is slow, 
 
42 PATHOLOGY OF THE PNEUMOGASTRIC NERVE. 
 
 because tlie pneumogastric is in a weakened state, 
 and food may even on this account remain in the 
 oesophagus itself, or it may perhaps pass from the 
 stomach into the lower part of the canal, and produce 
 solution by the action of the gastric fluids ; in this 
 way the oesophagus may be dissolved and even per- 
 forated during life. Local pressure upon the pneu- 
 mogastric nerve, or ulceration, may also destroy its 
 power and paralyse the muscular energy and the sen- 
 sibility of the canal ; and lastly, at the close of some 
 abdominal diseases, as of the stomach and uterus, 
 the power of the oesophagus is lost, and patients are 
 unable to get food into the stomach. In these 
 instances, the condition is one of exhaustion, and of 
 the cessation of living power in the system ; and with 
 this loss of sensibility in the oesophageal branches of 
 the nerve, there is only a slight step to the cessation 
 of the more essentially vital act, that of respiration. 
 
 LUNGS. 
 
 The pathological relations of the pneumogastric 
 nerve with the lungs and with respiration next 
 demand our attention. The pulmonary plexuses are 
 situated at the root of the lungs ; they are connected 
 with the sympathetic and with the cardiac branches 
 of nerves, and are distributed to the minute struc- 
 tures of the lungs ; and it has been shown that irri- 
 tation of the pneumogastric will cause the bronchi to 
 contract. In the morbid processes which are recog- 
 
LUNGS. 
 
 43 
 
 nised, we may adopt the same arrangement as pre- 
 viously, namely, into those of a spasmodic and into 
 those of a paralytic kind ; in the former there is in- 
 creased irritability of the sentient centre, the respi- 
 ration is quickened, and there may be violent cough 
 and dyspnoea ; in the latter, the respiratory centre is 
 weakened or paralysed, there may be but little or no 
 cough, and no effect may be produced by irritants ; 
 the respiration is slow, but deep and irregular, a deep 
 long-drawn inspiration being followed by shorter 
 breathing till it seems to cease — Cheyne- Stokes 
 respiration ; or the respiration may be short, the lung 
 being very partially inflated. 
 
 f Irritability from exhaustion, 
 
 \ In fevers, &c., 
 
 j Asthma (spasmodic), 
 
 (^ Whooping-cough. 
 
 S Hay-asthma, 
 Bronchitis, 
 Pneumonia, 
 Emphysema, &c. 
 
 iln hysteria, producing hurried breathing, 
 &c., 
 In heart disease, producing cardiac asthma, 
 In gastric disease. 
 In gout, &c. 
 
 S Respiration slow; congestion, producing 
 pneumonia and bronchitis. 
 Poisoning by opium. 
 Apoplexy, &c. 
 ( Cold shock, producing bronchitis, pneu- 
 
 Spasmodic 
 irritation 
 
 Central 
 
 Local 
 
 / Central 
 
 Paralysis 
 
 Local 
 
 Peripheral 
 
 monia, often without cough. 
 Patients dying of cancer of stomach, or 
 of uterus, of chronic gastric ulcer, &c., 
 often have pneumonia, which is not due 
 to septic changes. 
 
44 PATHOLOGY OP THE PNEUMOGASTRIC NERVE. 
 
 A few words in reference to some of these condi- 
 tions. With weakness of the system there is 
 increased irritability of the nervous centres, and the 
 centre of respiration is no exception to this rule. In 
 continued fevers J as enteric or typhus, with increas- 
 ing exhaustion the respiration becomes more hurried, 
 and this is often an unfavourable sign ; the lungs 
 have become engorged with blood at the posterior 
 and more depending parts ; the power of the heart 
 is lessened, and the nervous energy has become 
 exhausted. In whooping-cough, to which we have 
 previously referred, the principal symptoms are those 
 connected with the throat, but it often happens 
 that severe cough and bronchial complications 
 follow, and, in not a few cases emphysema. The 
 mechanical pressure upon the delicate air-cells may 
 have to do with this effect ; but it must be remem- 
 bered that the par vagum which supplies the 
 larynx also supplies the lung. The nerve-power 
 is lessened, and the nutrition of the lung-tissue 
 interfered with ; and this condition is favourable to 
 the production of emphysema of the lung and its 
 attendant circumstances. There can, I think, be no 
 doubt that true spasmodic asthma may arise from 
 disturbance of the origin of the pneumogastric as 
 well as from peripheral irritation. In true spasmodic 
 asthma, it is remarkable with what suddenness and 
 with what severity the symptoms may come on. The 
 greatest distress of breathing may be produced almost 
 at once, so that the patient is unable to move, but 
 
LUNGS. 46 
 
 remains witli tlie head thrown back, the eyes full and 
 protruding, the muscles of forced respiration brought 
 into violent exercise, and the countenance, becoming 
 of a livid colour, is covered with profuse perspiration. 
 The attack often comes on at night. If we listen at 
 the chest, scarcely any air is heard to enter ; but 
 some sibilus may be detected ; less and less blood is 
 aerated ; the heart becomes feeble, the right side is 
 distended, and but little blood passes to the left side, 
 so that the pulse is necessarily small. The bronchi 
 are spasmodically contracted, and will not allow air 
 to enter; the branches of the pneumogastric are in a 
 state of extreme irritability ; the afferent nerves are 
 intensely excited, and induce corresponding action in 
 the efferent filaments ; as, however, the centre 
 becomes narcotised by the imperfectly aerated blood, 
 it relaxes its spasmodic grasp, and^ in a quarter to 
 half an hour, a little secretion takes place from the 
 engorged vessels, a small quantity of mucus is 
 discharged, more air gradually enters, and the 
 paroxysm subsides. This state is a most painful one 
 to witness, and is most distressing to the patient. 
 It may be associated, in less severe degree, with 
 diseases of the bronchi and with affections of the 
 heart ; but cardiac asthma and bronchitic asthma are 
 very different in regard to the suddenness of the 
 attack and the previous absence of symptoms of 
 organic disease. Various means may be used to 
 quiet this intense spasm, and the most serviceable 
 are the bromide of potassium with the juice of the 
 
46 PATHOLOGY OF THE PNEUMOGASTRIC NEEVE. 
 
 hemlock^ lobelia and ether, hydrocyanic acid, and 
 stramonium, and narcotics in varied forms ; but upon 
 these, and also the means by which the paroxysms 
 may be averted, I must refrain from dwelling. 
 
 I was called to see a patient, aged twenty-four, 
 some years ago (1870), who had, in the early morn- 
 ing hours, paroxysms of intense dyspnoea. He was, 
 when I saw him in November, sitting up in bed ; the 
 respiration was easy, but there were some sibilant 
 rales, and prolonged expiratory murmur was heard. 
 He had been out of health for several months, but 
 his attack was of about a week's duration, and came 
 on with sneezing, with cough and gasping for breath ; 
 the heart was irritable, but no bruit was heard ; the 
 expectoration was frothy, the tongue was clean, the 
 abdomen supple, the pulse compressible, the urine 
 healthy. He was spare ; his countenance anxious, 
 and there was much irritability of the whole system. 
 In the following May he had remained free from 
 severe attacks of dyspnoea; he had no asthma, but 
 his heart was irritable and irregular in rhythm, and 
 he had also complained of faintness and flatulence. 
 In October he went to Margate, and his health 
 improved; but he said, that he suffered from his 
 stomach. He then took cold, and had his old chest- 
 disturbance ; he was, moreover, very nervous, and 
 dwelt upon his ailments. The winter of 1871 he 
 spent at Ramsgate and Margate ; his general health 
 was better, but he complained of pain in his head 
 (July, 1872), so that he felt uncertain about himself ; 
 
LUNGS. 47 
 
 his scalp was very sensitive ; his breathing was 
 perfectly quiet^ and he was free from asthma, but 
 the pulse was irritable. In September he was free 
 from pain in the head, but had nervous twitching 
 and hysterical crying. In November the pulse was 
 very rapid (160), the tongue clean, the appetite 
 tolerable ; he had dull headache, and for several 
 months complained of " queer- feelings '^ in his head, 
 afterwards in his mouth and throat. In July, 1873, 
 he had some return of the asthma, and the heart was 
 affected as on a previous occasion. In 1874 he had 
 passed the winter well ; but his mind was fretful, 
 '^ his stomach queer,^^ and there was a threatening of 
 the return of his chest symptoms ; still his general 
 health was decidedly improved, and he was able to 
 return to business. 
 
 This was at first a well-marked case of spasmodic 
 asthma ; but the irritation of the pulmonary branches 
 of the pneumogastric was followed by disturbance of 
 the heart, then by neuralgia ; afterwards, his nervous 
 system and his brain became disturbed ; then the 
 stomach and digestion were interfered with. It was 
 evident that his malady was connected with the state 
 of the pneumogastric, and there was a remarkable 
 alteration in the part affected ; it was the lung at one 
 time, then the heart, then the brain and the stomach. 
 There was no certainty as to which part would be 
 next attacked. The disease was the same, but its 
 manifestation was different ; it was relieved by 
 bromide of potassium, by arsenic, by belladonna. 
 
48 PATHOLOGY OF THE PNEUMOGASTEIC NERVE. 
 
 and by tonics, such as steel and quinine. His mother 
 described herself as of a nervous temperament, and 
 his sister died from acute epileptiform disease. We 
 might narrate numerous instances to show this effect 
 on the pulmonary branches of the pneumogastric 
 from central disturbance. It would lead us far 
 beyond the limits of these lectures were we to dwell 
 upon the several forms of spasmodic affection of the 
 bronchial tubes produced by local irritation ; and, 
 although we speak of this as produced by local 
 irritation, it must be borne in mind that it is the 
 impression upon the afferent branches in the lungs 
 which is local, as distinguished from those instances 
 in which the irritation is central or traceable to 
 peripheral mischief in the abdomen ; the action upon 
 the efferent branches is the same in each case. In 
 hay-asthma, the irritant is directly inhaled, whether 
 it be the pollen of grass or other particles.; and, in 
 many inflammatory diseases of the chest — bronchitis, 
 broncho -pneumonia, emphysema, etc. — the muscular 
 fibres of the bronchial tubes are excited to spasmodic 
 contraction, and thereby the dyspnoea is increased. 
 It is an important part in the treatment of many of 
 these diseases, so to soothe the branches of the par 
 vagum as to lessen the irritation of these bronchial 
 muscular fibres. Yery minute doses of morphia, of 
 belladonna, of hemlock, may in this way greatly 
 mitigate the disease, when a large dose, especially of 
 the former, does great injury by narcotising the 
 respiratory centre. 
 
LUNGS. 49 
 
 The instances of sjDasmodic disease which are due 
 to reflex irritation are very different both in character 
 and in severity. In the nervous irritability of 
 hysteria or uterine disease, an impression is carried 
 to the medulla oblongata by spinal or sympathetic 
 nerves, and thence by efferent fibres to the lungs, so 
 that the respiration becomes greatly excited. Some- 
 times these patients may be seen breathing one 
 hundred times a minute or more rapidly, equally in 
 quickness with the pulsations of the heart ; but the 
 disease, though weakening, is comparatively harmless ; 
 it will give place perhaps to irritation of the stomach 
 or neuralgic pain in the head. Yery different is th.e 
 asthma which is due to cardiac disease, especially 
 where there is mitral stenosis, or great dilatation of 
 the left ventricle. The blood is delayed in the 
 pulmonary capillaries, and the system is deprived of 
 its normal proportion of aerated blood. This distur- 
 bance of the balance between the circulatory and respi- 
 ratory system leads to urgent dyspnoea ; but we must 
 not dwell upon this subject. Again, in simple gastric 
 disease, we find that the afferent branches induce 
 disturbance of the origin of the pneumogastric, which 
 is expressed in the pulmonary branches, and there is 
 truth, in the assertion that the cough is ^^ stomach, 
 cough ;'^ too often, however, the gastric disturbance 
 associated with a dry and hacking cough is itself, as 
 we shall have to mention, the effect of disturbance of 
 pulmonary branches of the pneumogastric by tuber- 
 cular deposit, and not the cause of the cough. A 
 
50 PATHOLOGY OF THE PNEUMOGASTEIC NERVE. 
 
 stomacli-cougli is a very doubtful symptom in delicate 
 patients, and one that should be watclied with 
 extreme care. In gouty subjects, and also in syphilis, 
 in ague, and in remittent fevers, we have modifica- 
 tions of action of the respiratory nerves, and condi- 
 tions are produced which are very different from 
 ordinary inflammatory disease, and their causes 
 require to be recognised, otherwise they baffle the 
 practitioner in the treatment of them. In this way 
 iodide of potassium becomes a most important remedy 
 for syphilitic bronchitis, if I may use such an expres- 
 sion, and quinine and arsenic are of great service in 
 the severe asthma that is sometimes observed in 
 aguish districts. 
 
 The conditions that are produced by paralysis of 
 the pulmonary branches of the 'par vagum closely 
 resemble those observed after experimental division 
 of the nerve. We may take one or two instances to 
 illustrate this fact, and we would premise by stating 
 that this paralytic condition may be of central origin, 
 or it may be due to local or to reflex influence. In 
 reference to the first condition, the medulla oblon- 
 gata and the origin of the nerve at the floor of the 
 fourth ventricle is directly affected in severe apo- 
 plexy, in such cases as ingravescent apoplexy, when 
 a clot has broken into the lateral ventricle, and the 
 blood has passed onwards into the fourth ventricle, 
 or, again, in apoplectic effusion into the pons Varolii. 
 The respiration becomes very slow ; one or two deep 
 inspirations are followed by several slight and more 
 
LUNGS. 51 
 
 shallow ones, tlien to be compensated for by a full 
 and deep act. The lungs become congested, there 
 is serous effusion into the air-cells, and a form of 
 broncho-pneumonia is produced, if life be prolonged. 
 In poisoning by opium, an almost similar condition 
 is observed. This paralytic state of the pulmonary 
 branches may, however, be the result of a local 
 cause, as a severe chill affecting the extreme branches 
 of the par vagum. Scarcely a winter passes — we 
 might say no winter passes by — without many per- 
 sons thus becoming struck down almost at once, 
 especially in the extremes of life, the aged and the 
 young. Sometimes the attack is spoken of as a 
 mere cold or catarrh, but the shock is so great that 
 the patient is unable to rally, bronchitis or pneu- 
 monia is almost at once produced, it may be without 
 cough, and the patient quickly becomes prostrate. 
 Sometimes these patients sink before the congestive 
 changes in the lungs are thoroughly developed, as 
 if the pneumogastric nerve was paralysed by the 
 effect of the cold. In a very few hours patients 
 thus pass away ; unless, perchance, by powerful sti- 
 mulants, such as brandy, ammonia, ether, etc., there 
 is a quick invigoration of these important nerves and 
 centres. Pressure upon the nerve by aneurismal or 
 other tumours produces paralysis of the nerve and 
 congestion of the lung, which may lead to pneumonic 
 changes or even gangrene. This condition is often 
 found in aneurism of the aorta. One other reference 
 to this paralytic condition, and in this instance it is 
 
52 PATHOLOGY OF THE PNEUMOGASTRIC NERVE. 
 
 due to reflex action. It is very common at tlie close 
 of organic disease of tlie stomacli and of the uterus 
 to find that patients have bronclio-pneumonia^ and 
 that this appears to exhaust the last spark of life ; 
 this condition may be quite independent of septic 
 change and of alteration in the blood, but it is pro- 
 duced by the gradual exhaustion of nerve-power, 
 until, at length., the respiratory act is ineflSciently 
 performed, and the least irritation suffices to produce 
 these inflammatory changes in the lung-tissue. 
 Sometimes, by watcbing tbe gradual progress by 
 which life is fading away, we may for a short time 
 retard dissolution and prolong life. 
 
 HEAET. 
 
 The most important of the animal functions, that 
 of the circulation, is very directly influenced by the 
 state of its nervous supply. A very large plexus of 
 nerves is formed by the branches of the pneumogas- 
 tric with those of the sympathetic ; these pass down 
 from the neck, and at the arch of the aorta the 
 cardiac plexuses are situated, from which numerous 
 branches pass down to the heart itself. Irritation 
 of the cardiac nerves and of the pneumogastric pro- 
 duces distress and pain, and it has been shown that 
 from the same cause the movements of the heart may 
 be retarded, the diastole may be prolonged, and the 
 pressure in the vessels diminished. When the nerve 
 is paralysed, as by experimental section, the inhibi- 
 
HEART. 
 
 53 
 
 tory power is taken away, and the heart beats at first 
 with increased force. We find, in pathological in- 
 vestigations, that disease presents us with some sym- 
 ptoms which are due to spasmodic irritation, whilst 
 others may be traced to exhaustion, or paralysis of 
 the nerve. 
 
 The spasmodic affections and the paralytic ones 
 also, may be referred to central, to local, or to peri- 
 pheral causes. 
 
 
 ^ . , ' 
 
 ' Nervous shock, 
 
 Spasmodic ^ 
 
 Central 
 
 Renal disease (?). 
 
 irritation ) 
 
 Local 
 
 Diseased coronary arteries. 
 
 Angina ( 
 
 . Peripheral 
 
 Gout, &c. 
 
 
 r Central 
 
 Apoplexy ; diphtheritic paralysis. 
 
 
 Local 
 
 Pericardial efEusion, carditis, &c. 
 
 Paralysis 
 
 
 '' Acute disease of the abdomen, peritonitis. 
 
 
 Peripheral - 
 
 &c., 
 ^ Cold in the stomach, or a sudden blow. 
 
 It is not necessary to do more than very briefly to 
 refer to these conditions. The cardiac distress which 
 is produced by nervous shock is an instance of the 
 action of the cerebrum and the emotional centres 
 upon the origin of the pneumogastric, and thus upon 
 the lungs and heart. The effect is due in a greater 
 degree to the pneumogastric than to the sympathetic 
 nerve ; although, in all cardiac affections, the action 
 of the vaso-motor nerve is exceedingly important. 
 Altered nerve- supply is the cause of the great distress 
 in many organic diseases of the heart ; the afferent 
 fibres of the cardiac branches of the pneumogastric 
 are closely united with the sympathetic in the cardiac 
 
54 PATHOLOGY OF THE PNEUMOGASTEIC NEKVE. 
 
 plexus, and by the efferent fibres from the pneumo- 
 gastric centre tbe respiration becomes affected as 
 well as tlie action of tlie heart. Whilst saying this, 
 we would not overlook the mechanical interference 
 with the heart in disease of the valves, in dilatation, 
 and in disordered states of the muscular walls of the 
 heart. 
 
 In renal disease, attacks of severe angina come on 
 where there is chronic disease of the gland, as in the 
 small granular kidney, but many considerations must 
 be borne in mind in reference to this disease ; there 
 is degeneration of the minute capillary vessels and 
 altered tension of the arteries, the muscular coat of 
 the ventricles is hypertrophied, the blood is changed 
 in character, and the respiratory centres are affected 
 by this impure blood. At the same time, also, that 
 the afferent nerves convey impression from the 
 pneumogastric branch to the kidney and renal plexus 
 of nerves, the branches of the sympathetic nerve 
 connected with the vessels also affect the same nerve 
 centres. The action of the cardiac ganglia upon the 
 heart is also a more direct source of disturbance in 
 these cases. 
 
 The same remarks apply to those instances of 
 angina pectoris where the coronary vessels are 
 extensively diseased, and also to those in which 
 gouty disease has led to degenerative change without 
 the production of renal disease and albuminuria. 
 These patients complain of distress, and sometimes 
 severe pain at the chest, there is breathlessness on 
 
HEART. 65 
 
 exertion, or on going up stairs, it may be with a 
 sense of choking, and with a dry cough ; at night, 
 however, especially after the first sleep, the patient 
 awakes in great distress at the heart, with irregular 
 fluttering movements, palpitation, and inability to 
 get the breath. The paroxysm soon subsides, but 
 it greatly alarms and distresses. Sometimes, when 
 the disease is more severe, the distress at the chest, 
 the pain, or rather the " breast-pang,' ' occurs after 
 very slight exertion. On the most careful physical 
 examination, no abnormal sound may be heard ; but 
 there is evidently disturbance of the function of the 
 heart. There is inhibitory action of the nerves of 
 the heart, and the pneumogastric is at fault. The 
 suffering complained of is that of agonising fear of 
 death, unless the heart recovers its power ; but in 
 other cases, it is intense darting pain through the 
 left side in the direction of the heart. To stimulate 
 the heart to increased action, by ether, and by 
 diffusible stimulants, as ammonia, may be of value 
 when they can be resorted to ; the nitrite of amyl is 
 sometimes of great service and so also extremely 
 minute doses of nitro- glycerine. These remedies 
 lessen the cardiac tension, it is believed by producing 
 peripheral fulness of the capillary vessels. 
 
 ' It is interesting to find in some of these instances 
 of gouty disease affecting sometimes the heart, and 
 sometimes the kidneys, that the hepatic function is 
 also disturbed and a transient glycosuria is induced; it 
 would seem that other branches of the pneumogastric 
 
tj6 PATHOLOGY OF THE PNEUMOGASTRIC NERVE. 
 
 besides tliose to the thoracic viscera are involved, 
 and this condition of sugar in the urine, although 
 decided in quantity, may be the more easily over- 
 looked, from the comparatively low specific gravity 
 of the urine. It is well known that in gouty disease 
 with chronic affection of the kidney, the urine is often 
 of a low specific gravity, and sugar may be present 
 whilst the urine only attains a density of 1,015 to 
 1,020, or a little more. This state is important to 
 be recognised, for it has an essential bearing both 
 upon the progress and the treatment of the disease ; 
 and, if it be overlooked, the malady may make rapid 
 and downward progress. 
 / Some have referred the sudden cessation of the 
 hearths action during the administration of chloroform 
 to this inhibitory action of the pneumogastric, and 
 they state, that the heart would act more efficiently 
 if this restraining force were removed by the full 
 narcotic action upon the centre of the nerve.* 
 
 The pathological states produced by severe apo- 
 plectic effusions are of great interest in connection 
 with the pneumogastric. We have already referred 
 to the slow and irregular breathing which is observed 
 when a clot of blood in the fourth ventricle directly 
 interferes with the origin of the nerve, but the effect 
 is also shown upon "the heart ; the restraining power 
 is removed, it is partially paralysed, and the heart 
 beats with increased force. It is, however, in many 
 
 * See an interesting communication on this subject by Dr Lauder 
 Brunton in the ' British Medical Journal.' 
 
HEART. 57 
 
 of these cases, tliat the vessels are diseased and the 
 left ventricle hypertrophied. A sense of exhaustion 
 and apparent weakness of the heart's action is often 
 complained of by the patients suffering from cerebral 
 oppression. The weakness is imaginary rather than 
 real, and we find that such patients will try sometimes 
 to relieve their state by freely partaking of wine and 
 similar stimulants, which augment rather than palliate 
 their condition. A gentleman who had suffered from 
 exposure on the West Coast of Africa, which had 
 caused sun-stroke, etc., was found taking a glass of 
 champagne every two hours to relieve his " debility; ^' 
 but the disease was more effectually removed by 
 spare diet and by smart action of the bowels. 
 
 After diphtheritic inflammation of the throat, 
 the heart sometimes becomes feeble and irregular, 
 and fatal syncope occasionally takes place. The 
 weakened pneumogastric exerts an inhibitory action 
 upon the heart. 
 
 In pericardiac effusion and in inflammatory carditis 
 the heart's action is diminished in power, and there 
 is exhaustion of the nerve-supply. This is especially 
 connected with the condition of the sympathetic nerve, 
 and with the cardiac ganglia ; the pneumogastric 
 nerve is however affected, for we find that the 
 respiration is quickened, and the whole of the parts 
 supplied by the pneumogastric sympathise ; the 
 voice is feeble, and the digestion is impaired. This 
 is one of the diseases in which it is of great 
 importance, whilst we recognise the local, not to 
 
58 PATHOLOGY OF THE PNEUMOGASTEIC NERVE. 
 
 forget tlie general condition of tlie patient^ to try to 
 lessen the local affection, but to sustain tlie exhausted 
 functional activity of this, the most important nerve 
 of animal life. 
 
 The ganglionic nerve-supply of the stomach and 
 abdomen is in intimate relation with the cardiac 
 plexus. The pneumogastric nerve, although it is 
 especially distributed to the muscular coat of the 
 stomach, is also in the closest connection with both 
 the peritoneal and the mucous layers. In acute 
 diseases of the mucous membrane of the stomach, as 
 in poisoning by arsenic, the heart's action becomes 
 extremely feeble, and the pulse compressible, and 
 the same is true in acute peritonitis j the collapse of 
 the patient is an expression of this intimate relation- 
 ship. Witness the almost instantaneous effect of a 
 perforating ulcer producing acute peritonitis ; the 
 heart's power at once fails, the patient becomes cold 
 and almost pulseless ; the eye is sunken and the ex- 
 tremities cold j the cardiac plexus and the pneumo- 
 gastric of the heart at once sympathise with the 
 solar plexus and the pneumogastric branches of the 
 abdomen — the afferent branches of the latter, in their 
 action on the medullary centre, cause reflex action 
 on both pulmonary and cardiac nerves. 
 
 In many other affections of the gastric mucous 
 memhranej this reflex action on the heart is recog- 
 nised, in ordinary stomach disturbance, as a bilious 
 attack ; the nerve-power is weakened by irritation 
 of the mucous membrane, perhaps the sympathetic 
 
HEART. 59 
 
 nerve is exhausted^ the vessels dilated, and we thus 
 find a sense of exhaustion produced_, with feebleness 
 of the hearths action ; too often, when this state is 
 produced by the irritation of alcoholic stimulants, the 
 patient seeks to relieve the symptom by a fresh dose 
 of the stimulant, and thereby increases and per- 
 petuates the disease. The constant repetition of 
 this process of exhaustion and renewed overstimu- 
 lation leads to the most disastrous results, in causing 
 chronic disease of the stomach and of the liver, with 
 disorder of the nervous system. It is of no avail to 
 attempt to relieve the weakened power of the heart, 
 and exhausted nervous energy, if the patient persist 
 even in moderate potations of alcohol ; and, as a 
 rule, it is the better plan at once to cease from all 
 alcoholic stimulant ; the stomach and the heart will 
 then recover in a great degree their former energy 
 and strength. 
 
 A siidden blow upon the epigastrium has been 
 known at once to stop the heart's action and to pro- 
 duce instant death, and with almost equal power a 
 shock from cold will stop the action of the heart; 
 these, also, are instances of reflex action affecting 
 the heart from peripheral disturbance. 
 
 We have thus brought before your notice patho- 
 logical conditions of a very diverse character affecting 
 the branches of the pneumogastric nerve supplied to 
 the thoracic viscera. To mistake those which arise 
 from a central origin, as if from a local cause, is to 
 misunderstand the whole character of the disease; 
 
60 PATHOLOGY OP THE PNEUMOGASTRIC NERVE. 
 
 SO J also, if we refer those whicli are produced by 
 peripheral disturbance to mere irritation in the parts 
 only affected by reflex action, we fail to relieve the 
 symptoms, because the treatment is misdirected, and 
 therefore unavailing. 
 
LECTURE III. 
 
 ABDOMINAL BRANCHES. 
 
 The pneumogastric nerve in the abdomen is 
 brought into the closest relationship with the solar 
 plexus and semilunar ganglia of the sympathetic 
 nerve^ and it is very difficult to separate the patho- 
 logical changes incident to the one from those which 
 have their origin in the other. The par vagum 
 reaches not only to the stomach but to the liver^ to 
 the duodenum^ to the suprarenal capsules, and to the 
 kidney ; and it unites with the phrenic nerve as the 
 branches of the latter pass through the diaphragm. 
 Although the pneumogastric is especially distributed 
 to the muscular coats of the stomach, and regulates 
 its movements, still it has sentient branches, and 
 when these are irritated pain is produced ; neuralgic 
 pain at the stomach may be due to disturbance of 
 this nerve as well as of the sympathetic nerve. 
 Romberg describes gastrodynia neuralgia as due to 
 hypersesthesia of the pneumogastric nerve, and 
 neuralgia caeliaca as traceable to hypersesthesia of 
 the solar plexus. Irritation of the nerve will not 
 only produce pain and muscular contraction, as hour- 
 glass contraction, but vomiting, and this of several 
 
62 
 
 PATHOLOGY OP THE PNEUMOGASTRIC NERVE. 
 
 kinds ; altered secretion^ and sometimes perverted 
 sensation, as craving appetite, may be due to the 
 same cause. Wlien tlie nerve is weakened or para- 
 lysed, another set of symptoms is observed, and we 
 have loss of appetite, anorexia, and distension of the 
 stomach. It will be a convenient method to consider 
 those conditions in which we have increased irrita- 
 bility or spasmodic action, as shown by pain, neu- 
 ralgia, hour-glass contraction, or vomiting ; and, 
 secondly, those in which there is diminished power 
 or paralysis, in which we find anorexia or distension ; 
 and each of these may be traced to central, local, or 
 peripheral causes. 
 
 / Concussion of brain, 
 
 Acute cerebral disease. 
 
 Abscess in the brain. 
 
 Tumour in the brain. 
 
 Tubercle in the brain. 
 
 Apoplexy, 
 
 Over-anxiety and distress. 
 
 Epilepsy, 
 
 Persistent irritability of stomach from 
 nervous exhaustion. 
 
 Inflammation of mucous membrane, 
 
 Ulceration, 
 
 Cancerous disease. 
 / Phthisis ; tubercle in the lung. 
 
 Disease of heart. 
 
 Uterine disease. 
 
 Ovarian disease. 
 
 Chlorosis ; hysterical vomiting, 
 
 Eenal disease; disease of suprarenal cap- 
 sule, 
 
 Hepatic disease. 
 
 Intestinal disease, 
 
 Peritonitis. 
 
 Central 
 
 i 
 
 Spasmodic 
 vomiting 
 
 Local 
 
 Peripheral a 
 
STOMACH. 
 
 63 
 
 Spasmodic 
 pains and 
 perverted 
 sensation 
 
 Central 
 
 Paralysis 
 producing 
 anorexia or 
 distension 
 
 (' Mania, 
 
 ) Functional disease of brain. 
 f Hour-glass contraction, 
 -! Local < Ulceration, &c., 
 
 (_ Organic disease. 
 
 , Peripheral I ^''"^.'"^ ^''^^'^' 
 ( Uterine disease. 
 
 r Distension from exhaustion and nervous 
 
 I shock, 
 Central -^ Anorexia from religious melancholia, 
 „ from mania, 
 
 ^ „ from hysterical weakness. 
 
 r Rapid fermentation, causing distension, 
 Local < Distension from obstruction at the pylorus, 
 
 (^ Anorexia after gastralgia. 
 
 r Distension from peritonitis, 
 Peripheral < „ from abscess, 
 
 (^ „ from empyema. 
 
 The vomiting produced by cerebral disease is often 
 of the most decided character, and it is of the 
 greatest importance that the nature of the malady 
 should be correctly understood. To treat the stomach 
 while the irritation is at the cerebral extremity of the 
 nerve, is often the greatest injury to the patient. 
 The bilious attacks of early life are very frequently 
 to be traced to cerebral disease, and are too often 
 overlooked till the true character of the disease is 
 unmistakably indicated. It is not, however, every 
 form of acute disease of the brain which induces this 
 irritation of the pneumogastric nerve, but especially 
 those cases where the base of the brain or the floor 
 of the fourth ventricle is implicated. In an instance 
 of acute meningeal inflammation in a muscular young 
 man in G-uy's Hospital, the stomach was so exquisitely 
 sensitive that if water, milk, or any fluid were 
 
64 PATHOLOGY OF THE PNEUMOGASTEIC NERVE. 
 
 swallowed^ it was at once ejected with sucli violence 
 that it was projected beyond the foot of the bed. 
 After death a collection of pus was found in the 
 meninges of the brain^ directly pressing upon the 
 pneumogastric nerve at its exit from the brain-sub- 
 stance at the medulla. 
 
 In tumours of the brain^ especially at the cere- 
 bellum^ the vomiting is often of the most marked 
 character ; it comes on independently of food, the 
 tongue may be clean, and the bowels in a normal 
 condition, but still food is rejected at irregular 
 intervals, and especially in the morning ; sometimes 
 several days may elapse between the periods of 
 vomiting. At times this is the prominent symptom 
 of commencing disease of the brain, but in other 
 cases vomiting is associated with severe pain, and 
 with affection of other nerves, as the optic and 
 olfactory ; with giddiness and intolerance of sound, 
 or with epileptiform convulsion. I have narrated a 
 deeply interesting case of this kind in the ' Guy's 
 Hospital Reports ' of 1874, and, in the clinical session 
 of 1876 a child, about twelve years of age, was ad- 
 mitted under my care quite amaurotic with one eye, 
 and with the other she could only distinguish day 
 from night. The symptoms had come on a month 
 previously, with severe vomiting and pain in the 
 head ; the pupils were widely dilated, but there were 
 no febrile symptoms. The condition appeared to 
 indicate organic disease of the brain, such as tumour, 
 and the prognosis was a very unfavourable one ; but, 
 
STOMACH. 65 
 
 under tlie steady use of percLloride of mercury, with 
 iodide of potassium, tlie symptoms entirely disap- 
 peared. Tlie vomiting had ceased previously, but 
 the amaurosis gradually lessened, at first in one eye, 
 then in the other ; and she was seen to be amusing 
 herself, then nursing a doll, and soon afterwards an 
 infant patient in the ward. 
 
 It is scarcely needful to refer to the vomiting, which 
 is one of the earliest, although most insidious, sym- 
 ptoms of tuberculosis of the brain and its meninges 
 in early life. It is often ascribed to a bilious attack, 
 till severe convulsion comes on, or the child has 
 severe pain in the head, or is noticed to become 
 listless and indifferent to its ordinary amusements ; 
 as effusion takes place, and coma comes on, this irri- 
 table condition of the stomach ceases, but it is often 
 reproduced if the recumbent position of the patient 
 be changed. The pupils, at first small and irregular, 
 become dilated and insensible ; the abdomen is often 
 contracted ; the respiration is also irregular and 
 sighing, and the skin sensitive to cold. The capil- 
 laries, losing their tonicity, easily yield to sudden 
 pressure or blow, and again become overcharged — 
 the tache cerebrale. This irritable condition of the 
 stomach, however, does not always exist in tubercu- 
 losis, for many instances of tuberculosis occur in 
 adults where vomiting is absent. These cases closely 
 resemble enteric or typhus fever, and are only re- 
 cognised by close observation of the temperature and 
 general symptoms. 
 
 E 
 
/ 
 
 66 PATHOLOGY OP THE PNEUMOGASTRIC NERVE. 
 
 The same action upon tlie pneumogastric is ob- 
 served in direct injury to the brain^ as in severe 
 concussion, and it is a noticeable symptom in ingra- 
 vescent apoplexy ; a minute vessel gives way in the 
 brain, and the first effects are those of sudden 
 disturbance, as in concussion, severe pain in the head, 
 faintness and pallor, with vomiting ; then, as reaction 
 follows, further effusion of blood takes place, and 
 the worst symptoms of apoplectic effusion infco the 
 brain are produced. It is the greatest mistake, and 
 often very disastrous, to treat this faintness with 
 ardent spirits ; to stimulate the action of the heart 
 increases the subsequent effusion; and that which 
 might be only a partial injury of brain-tissue is thus 
 rjBndered destructive of most important organs. The 
 apoplectic clot breaks through into the lateral ven*- 
 tricle, and, reaching to the fourth ventricle, exerts 
 direct pressure upon the origin of the respiratory and 
 other nerves. 
 
 Disturbance of the cerebral centre of the pneumo- 
 gastric may be produced by over-anxiety of mind and 
 distress. A junior partner in a large commercial 
 house had vomiting every morning ; he had no pain 
 at the stomach, the tongue was clean, the bowels 
 regular or relaxed, the pulse compressible; there 
 were no intemperate habits or dissipation to induce 
 this morning sickness ; the meal was taken, but in 
 a very short space of time rejected. It was evident 
 that the irritability of the stomach was not due to 
 disease of that organ ; and, on making inquiry, it 
 
STOMACH. 67 
 
 was found that the patient had had a fall from his 
 horse some time previously^ and the fear was enter- 
 tained that organic disease of the brain had com- 
 menced. Mercantile collapse came at lengthy the 
 heavy clouds of disaster broke, and when a more 
 healthy state of money affairs was obtained, then the y 
 cerebral disquietude also ceased. 
 
 Again, we find the same irritation of the stomach 
 produced by epilepsy and commencing insanity. 
 The epileptic paroxysm may entirely cease, but may 
 be replaced by attacks of nausea and vomiting, with 
 epileptic vertigo. It is difl&cult to define the precise 
 condition of brain in these cases. The cerebral dis- 
 turbance, whether ansemia or other atonic chanofe, is 
 sufficient to produce, not a loss of consciousness, but 
 a transient affection of the pneumogastric nerve ; in 
 the same manner, some epileptics will describe a 
 sensation passing over them without loss of conscious- 
 ness, sometimes affecting sight, sometimes the 
 hearing, or general sensation; in these cases, it is 
 at the cerebral origin of the pneumogastric that the 
 gastric disorder originates. 
 
 These symptoms are sometimes very peculiar, and 
 the following may be taken as an example. A gentle- 
 man, aged forty- nine, whose father was epileptic, was 
 brought to me by his medical attendant. The patient 
 was nervous and dyspeptic, and troubled with flatu- 
 lence j he had a choking sensation as if he could not 
 swallow, and became very uneasy. The heart's action 
 was occasionally irregular ; the pulse was compressible 
 
G8 PATHOLOGY OF THE PNEUMOGASTRIC NEEVE. 
 
 and irritable^ but there was no evidence of any 
 organic disease ; tbe tongue was pale and flabby, and 
 he complained of pain at the back of the head ; the 
 countenance was not expressive of distress, but the 
 patient said the pain was intense. It was evident 
 that the branches of the pneumogastric were espe- 
 cially affected, and that the malady was connected 
 with disorder of the nervous system, and did not 
 arise from organic mischief at the stomach. It was 
 not one, but several branches of the nerve that were 
 involved ; and sometimes one, sometimes another, was 
 affected. 
 
 In another, a gentleman aged forty-two, whose 
 brother died of phthisis, had attacks of intense 
 nausea, which came on every two or three months 
 during seven years ; the attacks, he said, amounted 
 to ^^ agony.^^ He had a distressed countenance, and 
 a sense of fulness of the head ; the appetite was poor, 
 and the bowels confined ; there was aching, or rather 
 increased sensitiveness, in the spine ; the abdomen 
 was relaxed, and nothing abnormal could be felt. 
 The recti sometimes became rigid; the urine was of 
 specific gravity 1,020, and was free from albumen 
 and from sugar. This patient was relieved by the 
 injection of morphia, but more effectually by 
 strengthening the nervous system. Sometimes 
 nervous twitchings came on in these patients, as if 
 there were a slight epileptiform convulsion ; in others, 
 the excessive irritability of the stomach is followed by 
 melancholia. 
 
STOMACH. 69 
 
 Closely connected with these instances are others 
 of persistent irritation of the mucous membrane of 
 the stomach from nervous exhaustion ; the vomiting 
 is constant, and continues every day year after year 
 till the patient is emaciated to the last degree. 
 These cases are different from the irritable stomach 
 which is found in hysteria, in chlorosis, and in 
 uterine disease — the hysterical stomach, as it has 
 been called ; to these we shall have to refer presently. 
 At first, there may have been some local or peripheral 
 disturbance, some dysmenorrhoea, or affection of that 
 kind, to originate the disease, but that soon subsides, 
 and leaves a condition of great nervous exhaustion ; 
 still the symptoms may be worse during menstruation, 
 because the weakness is greater. The food is 
 rejected from the stomach almost at once, it may be 
 without pain ; but, in many instances, there is sore- 
 ness at the scrobiculus cordis ; there is no haemor- 
 rhage, or only of the slightest kind ; mucus is 
 rejected, and patients often refer to this as the cause 
 of the disease. The tongue is clean, or nearly so ; 
 the bowels are inactive ; neuralgic headache is also 
 complained of. In many cases these patients are 
 said to have organic disease of the stomach, ulcera- 
 tion, or even malignant disease ; the reduction of 
 strength may be extreme ; and ordinary remedies 
 fail to lessen the irritation. It will generally be 
 found that those remedies are most effective which 
 lessen nerve-exhaustion ; and few are better than 
 very small doses of ammonio-citrate of iron, alone or 
 
70 PATHOLOGY OF THE PNEUMOGASTRIC NERVE. 
 
 given in a state of effervescence ; sometimes nux 
 vomica does good^ and even arsenical compounds 
 may be used witli advantage, and we may remark 
 en passant tliat it is of great importance to give 
 some kind of vegetable food. Mistakes are often 
 made in tbe entire abstinence from vegetables for 
 lengtbened periods ; the system becomes weakened 
 thereby, and I have seen severe scurvy produced. 
 
 It would occupy too much time to enter into the 
 general symptoms of diseases of the stomach, but we 
 may remark that vomiting is a common symptom of 
 inflammation of this organ, both when the disease is 
 acute and when less severe in character, but that 
 although the vomiting may be exceedingly severe, 
 there may be no pain so long as the mucous 
 membrane only is affected. Even in acute poisoning, 
 as by arsenic, pain may be absent at the stomach, 
 except the soreness from continual vomiting ; and in 
 the gastritis from chronic poisoning by alcohol, 
 excessive irritability is a constant symptom, with 
 craving for cold drinks, but with only slight tender- 
 ness of the stomach itself. It is in ulceration of the 
 stomach that pain is such a common symptom, and 
 it is associated with the vomiting of food ; pain 
 comes on, both at the scorbiculus cordis and through 
 to the back, soon after the food reaches the stomach, 
 and is only relieved by the passage of food into the 
 pylorus, or by vomiting. These patients will often 
 produce sickness by putting the finger into the 
 throat, in order to spare themselves the pain of 
 
STOMACH. 71 
 
 digestion. In one instance^ in which the patient 
 with chronic ulcer of the stomach gradually sank 
 from exhaustion^ I found a large branch of pneumo- 
 gastric nerve passing across the floor of the ulcer ; 
 we have previously referred to this in speaking of 
 the physiology of the nerve. In cancerous diseases, 
 also, vomiting and pain are common symptoms ; but 
 the former may be entirely absent if the oesophageal 
 and pyloric orifices be free from obstruction. 
 
 In reference to those instances which are more 
 strictly reflex in character and produced by disturb- 
 ance of jperipheral nerves, there are some most 
 interesting illustrations in ordinary practice. The 
 irritation of the jpulmonary branches of the pneumo- 
 gastric is a common cause of disturbance of the 
 stomach, and constant vomiting is often produced. 
 It is true that, in the early stages of phthisis, there 
 are often dyspeptic symptoms, such as a dislike of 
 fatty food, and an impairment of digestion, with 
 tenderness at the scorbiculus cordis, a furred or 
 patchy condition of the tongue, and irregular action 
 of the bowels, but these symptoms are less decided 
 than the vomiting to which we refer. The irritation 
 of the stomach is then the prominent symptom ; all 
 food is rejected, the tongue may be furred, and, 
 unless the chest be examined with care, the true 
 nature of the malady is overlooked. The state of 
 the stomach may lead to a cough, but the '' stomach- 
 cough '^ of early phthisis is a most treacherous sym- 
 ptom, and equally so the vomiting to which we refer. 
 
72 PATHOLOGY OF THE PNEUMOGASTRIC NERVE. 
 
 It will often be found tliat when tlie disease in the 
 chesty tlie tubercular deposit^ and pneumonic and 
 degenerative changes have advanced, the vomiting 
 suddenly ceases, but only to reveal disease of the 
 lung, which has made insidious progress during the 
 time when treatment of the thoracic disease might 
 have been most efficacious. This subsidence of the 
 gastric symptoms often takes place on the occurrence 
 of acute pneumonia or of acute pleurisy. The chest 
 should be carefully examined, and the ther mo metric 
 temperature recorded in these instances ; and, if we 
 can quiet the disturbance of the pulmonary branches 
 of the pneumogastric, the gastric mischief will 
 cease. 
 
 In disease of the heart of an organic kind, with 
 obstruction, the stomach is affected by the mechanical 
 hindrance to the blood j the right side of the heart 
 being engorged, the liver is also distended, and with 
 it the branches of the portal system of veins. In 
 this way the coronary veins of the stomach are filled ; 
 there is profuse secretion of mucus, gastric catarrh 
 with its attendant symptoms of flatulence, pain, dis- 
 tress, and sometimes heemorrhagic erosion. We do 
 not refer to this condition, troublesome as it is, but 
 to one of still more serious import, namely, severe 
 vomiting ; we have this occurring in mitral stenosis, 
 as well as in dilatation of the heart. It would seem 
 that the cardiac nerves of the pneumogastric and 
 sympathetic induce this reflex action upon the gas- 
 tric nerves — perhaps the connection of the pneumo- 
 
STOMACH. 73 
 
 gastric witli the phrenic on the large hepatic vein 
 may be the source of this connection. The vomiting 
 thus coming on at the later stage is often the pre- 
 cursor of a fatal termination. 
 
 The vomiting which is produced by uterine disease 
 and by pregnancy is too well known to need even 
 mention^ but that which is a symptom of early 
 ovarian disease is often overlooked. There may be 
 no pain in the region of the ovary, no enlargement 
 there, and the gastric symptoms may be so decided 
 as to mislead experienced practitioners. I was 
 called to see a lady in consultation who had vomiting 
 a few hours after food ; the vomiting was not con- 
 stant, but irregular ; still the emaciation was decided 
 and progressive, the abdomen was not distended, it 
 was free from pain, and the pylorus could be felt. 
 This led to the opinion of organic disease at that 
 part ; the irregularity of the vomiting, however, in- 
 duced me to believe that this might not be the case, 
 and I could not consent to the decided opinion of 
 malignant disease being present. This lady was 
 about fifty-five years of age, and menstruation had 
 ceased for several years. She went into the country, 
 and, whilst there, all the gastric symptoms ceased, 
 but the abdomen began to swell ; she returned to 
 town with evident symptoms of ovarian dropsy. 
 The fluid was drawn off by paracentesis abdominis, 
 and afterwards a large ovarian cyst was successfully 
 removed. Yery similar are those cases of gastric 
 trouble in young married people, where conception 
 
74 PATHOLOGY OF THE PNEUMOGASTEIC NEEVE. 
 
 has not taken place^ but where there is reflex action 
 and sympathetic disturbance of the pneumogastric 
 nerve from ovarian and uterine irritation. These in- 
 stances are often misunderstood, because menstrua- 
 tion continues regularly, and it may be, without 
 pain. The gastric branches in this way become 
 exceedingly irritable, and vomiting is a troublesome 
 and harassing symptom ; sometimes it is almost 
 constant, at other times only on slight nervous ex- 
 citement or over-fatigue ; the excitement of going 
 into company, or of . mixing in society, may be quite 
 suJBScient to bring on severe vomiting. Of the same 
 kind is the troublesome vomiting present in young 
 people, with scanty or disordered menstruation and 
 chlorosis. The food is rejected at once, almost as 
 soon as it reaches the stomach, but without much 
 distress ; there may be scarcely any pain, and some 
 of these patients appear to be plump and well 
 nourished. This condition has been aptly called the 
 " hysterical stomach,^' and certainly the condition is 
 one of functional irritability. Some food is retained, 
 for the body is not wasted ; the bowels are generally 
 confined ; the pulse irritable ; the abdomen often 
 fairly distended; with this state there are other 
 indications of nervous excitement. The determina- 
 tion of the patient may do an immense deal to 
 restrain this condition, and in a young hospital 
 patient the cure was eft'ected by the nurse refusing 
 to bring anything into which she could vomit. The 
 occupation of the mind, fresh air, chalybeate tonics. 
 
STOMACH. 76 
 
 free action on the bowels by aloetic and assafoetida 
 purgatives often relieve this state. The steel may- 
 be given with advantage in a state of effervescence ; 
 in other instances, however, it is necessary to allow 
 the stomach to rest entirely, and to feed the patient 
 by nutrient injections. If the uterine and ovarian 
 functions be disordered, these must, if possible, be 
 rectified ; and in the instances of married women, to 
 which we have referred, it is often of great value to 
 lessen pelvic irritation by opiate suppositories. It 
 is of little use to treat one symptom while the cause 
 of disturbance remains. 
 
 There are many other causes of peripheral disturb- 
 ance of the pneumogastric nerve in the abdomen 
 which we can only mention. Thus, in consequence 
 of its connection with the duodenum, and with the 
 liver and gall-bladder, we find vomiting a common 
 symptom of many diseases of these organs. The 
 same may be said of the hidney ; a branch of the 
 pneumogastric may be traced to the renal plexus, and 
 the sympathy of the kidney with the stomach is due 
 to this nervous connection as much as to the dis- 
 ordered secretion and altered blood. This alteration 
 of the blood and gastric juice does not account for 
 the vomiting and gastric disturbance which we have 
 in calculus and some other renal affections. The 
 function of the supra-renal capsules is still unknown, 
 but the symptoms of a disease of this structure were 
 well brought out in the learned lectures delivered by 
 Dr Greenhow in 1876. It is interesting to note the 
 
76 PATHOLOGY OF THE PNEUMOGASTRIC NERVE. 
 
 very large supply of nerves distributed to this organ, 
 and the connection of the pneumogastric with it, as 
 explanatory of the violent vomiting, which is a 
 prominent symptom of disease of the supra-renal 
 capsule. 
 
 The vomiting in peritonitis is reflex in character, so 
 also in those instances in which mechanical obstruc- 
 tion produces similar symptoms ; but on these we need 
 not dwell. 
 
 We pass on to consider pain and perverted sensa- 
 tion connected with the stomach as expressive of 
 pathological change in the pneumogastric nerve. 
 These changes may be traced to central disturbance, 
 or to local or peripheral mischief. It is well known 
 that in some conditions of mania patients swallow 
 the strangest substances ; but, without any disturb- 
 ance of the mind, we may find the appetite perverted ; 
 sometimes an excessive craving is produced, with 
 gnawing pain at the stomach j the appetite is not 
 satisfied, but the pain is relieved by food. These 
 instances occur without any alteration in the urine 
 and without the presence of any sugar. These 
 patients are often spare and cachectic, nervous and 
 irritable, and the disease is one of disordered nerve- 
 function. So also is the intense neuralgic pain which 
 sometimes comes on at the stomach quite unconnected 
 with organic disease, but often due to disturbance of 
 the uterine function, as we have mentioned in con- 
 nection with vomiting. The pain is often very severe, 
 and in young and weakened subjects the pain may 
 
STOMACH. 77 
 
 be intense ; but if tlie attention of the patient be 
 completely absorbed, tbe pain is forgotten ; it comes 
 on at irregular intervals, with or without vomiting, 
 and not necessarily in connection with food ; there 
 may be great demonstration of pain when the hand 
 is placed on the abdomen ; but, by careful manipu- 
 lation, it is found that the pain is not deeply seated ; 
 there is no real tenderness, the bowels are generally 
 confined, flatulence is often present, and menstruation 
 is disturbed. 
 
 We believe that we justly refer these cases to the 
 state of the pneumogastric on account of the alter- 
 nating manner in which other branches of the nerve 
 become affected, although there can be no doubt 
 that the whole nervous system is disordered. The 
 diagnosis of these cases is sometimes extremely diffi- 
 cult ; the fear is of ulceration of the stomach j but, 
 by careful examination, it is found that there is an 
 irregularity of the symptoms which we do not find 
 in organic disease, the pain is not especially after 
 food, and the symptoms are increased by the sympa- 
 thising attention of friends ; vomiting can be con- 
 trolled, and the pain disappears if the attention be 
 thoroughly absorbed. Steel medicine is often of 
 service, given in one of the milder forms or in effer- 
 vescence j bromide of potassium, valerianate of zinc, 
 and assafoetida, are beneficial ; and also bismuth 
 with alkalies. Sometimes the pain is so severe that 
 the hypodermic injection of morphia is of great value. 
 It is very desirable that these patients should not be 
 
78 PATHOLOGY OF THE PNEUMOGASTEIC NERVE. 
 
 allowed to remain in bed and to brood over their 
 malady. Fresli air^ and even horse exercise, greatly 
 promote restoration to health. A young lady, aged 
 sixteen, tall and thin, and of delicate constitution, 
 had suffered from neuralgia in the face, but other- 
 wise had enjoyed good health. About the beginning 
 of May she took cold, and soon afterwards was 
 seized with severe pain in the region of the stomach 
 towards the right side, about the pyloric region, and 
 at the scrobiculus cordis. She was free from head- 
 ache and from cough, and there was no evidence of 
 any disease about the lungs or the heart ; there was 
 no vomiting till the later period of the complaint, 
 and no evidence of .gastric ha3morrhage either in the 
 matter vomited or in the motions. There was no 
 disease of the spine ; the abdomen was contracted ; 
 and, although, she complained of pain on superficial 
 pressure at the scrobiculus cordis, there was no con- 
 sciousness of pain when the attention was absorbed. 
 The pain came on in severe paroxysms, and it was 
 accompanied with great demonstration of suffering, 
 but was not aggravated by food ; the tongue was 
 white, the bowels were confined, the motions were 
 pale and clayey, menstruation was scanty. The 
 urine was of specific gravity 1,020, and for a few 
 days contained a trace of albumen ; this, however, 
 soon ceased ; and there was no irritability of the 
 bladder nor pain in the loins, no blood in the urine, 
 no symptom of renal calculus nor of renal disease. 
 The pulse was rapid, sometimes 140 to 150 per 
 
STOMACH. 79 
 
 minute. The temperature varied from 98*4° to 100°. 
 The bowels were very confined, and required strong 
 aperients to act upon them. This state was con- 
 tinued for several weeks, and was unrelieved by 
 bismuth, bromide of potassium, steel, etc. ; every 
 medicine appeared to aggravate the pain. The 
 hypodermic injection of morphia by Mr C. Hunter 
 afforded great relief, and certainly promoted recovery. 
 Still, th.e symptoms persisted week after week ; irri- 
 tability of the stomach came on, but it was observed 
 that, by a strong effort of the will, the patient could 
 both take food and retain it. She was not allowed 
 to remain in bed, but was dressed and taken out in 
 a carriage ; every effort was made to prevent her 
 mind from dwelling upon her own weak state of 
 health and upon her pain ; she was then allowed 
 to take horse exercise, and the pain soon afterwards 
 entirely ceased. 
 
 The diagnosis of this case was at first obscure ; the 
 presence of albuminous urine suggested the idea that 
 she had renal calculus, but there was no evidence of 
 persistent renal irritation, and the trace of albumen 
 soon subsided ; although menstruation was scanty, 
 there was no proof of any ovarian disease ; again, 
 the fear of gastric ulcer was present to our minds, 
 but the pain was irregular in its onset ; it was not 
 increased by food, and for many days there was no 
 vomiting, and sometimes the symptoms entirely 
 ceased. Neither was there anything to indicate 
 spinal disease, for the fresh air in carriage and horse 
 
80 PATHOLOGY OF THE PNEUMOGASTEIC NERVE. 
 
 exercise relieved the suffering. It was evident that, 
 as the general strength failed, the nervous system 
 became more irritable, and the pain increased. The 
 disease was due to the state of the nervous supply 
 of the stomach, and it is probable that spasmodic 
 contraction of the muscular coats took place. The 
 vaso-motor nerve of the abdomen was affected, but 
 it was manifest that the pneumogastric was especially 
 implicated. The case was different from what has 
 been described as hysterical stomach, in which food 
 is quickly rejected, but it was a severe case of 
 functional gastralgia. If the patient had been 
 allowed to brood over her suffering, and to abstain 
 from nourishment, the disease would have persisted, 
 or might have terminated fatally. This spasmodic 
 pain is, however, not confined to young and delicate 
 women ; it is found in men of mature age, and in 
 some instances leads to a fatal result. The pain is 
 severe and paroxysmal, and somewhat resembles 
 that of gall-stone. In a gentleman between sixty 
 and seventy years of age, this form of gastric affec- 
 tion terminated fatally ; but, after death, no organic 
 disease of the stomach, pylorus, liver, or gall-bladder 
 could be detected. The symptoms suggest also the 
 idea of aneurism, disease of the spine, etc. Hour- 
 glass contraction of the stomach has sometimes been 
 found in these cases without any evidence of ulcera- 
 tion. Again, severe neuralgic pain at the stomach 
 comes on in organic disease of the heart, quite 
 independently of mere flatulence or congestion of 
 
STOMACH. 81 
 
 the mucous membrane. The continuance of these 
 attacks of pain, and their recurrence almost at the 
 same period of the day_, indicate that they do not 
 arise from thrombosis, and they come on unconnected 
 with food. 
 
 We have especially spoken of those cases in which 
 there is spasmodic or other irritation of the par vagum 
 producing pain or vomiting, but have now to turn to 
 that condition in which there is diminished power, 
 and in which we find (1) anorexia and (2) dilatation 
 of the stomach ; here^ also, we have states which 
 may be due to central disturbance, or be caused by 
 local or by peripheral mischief. 
 
 The mere loss of appetite may be a symptom of 
 febrile excitement, or it may be due to varied causes ; 
 but in the cases to which we refer, and which have 
 been graphically described by Sir William GruU as 
 " anorexia nervosa,^^ the appetite fails, food is not 
 taken, and the body wastes to an extreme degree, 
 the countenance has a distressed appearance, the eyes 
 are sunken, the cheeks hollow, and the whole system 
 is impoverished : the body has fed upon itself, and 
 all superfluous fat has become absorbed. This con- 
 dition may be entirely due to the state of the brain, 
 and the disease has been correctly described as one 
 affecting the will. Some of these instances are cases 
 of religious melancholia. One admitted under my care 
 into Guy's Hospital appeared like a case of enteric 
 fever, in the dry and brown tongue and in the ex- 
 pression of the countenance ; there was, however, no 
 
 p 
 
82 PATHOLOGY OF THE PNEUMOGASTHIC NEEVE. 
 
 febrile disturbance^ and the symptoms bad extended 
 over several years ; tbe young patient completely 
 recovered when made to swallow milk and other food. 
 In another case of extreme emaciation in a man, 
 aged fifty, also admitted into Guy's, the patient had 
 symptoms which had been attributed to organic 
 disease of the oesophagus ; he stated that he was 
 unable to swallow, but it was soon found that the 
 disease was in the will ; he would not make the 
 attempt, and when fed by the stomach-pump he 
 soon recovered. Some months after leaving the 
 hospital, his mind completely broke down, and 
 symptoms of mania were developed. These cases 
 are frequently found in asylums for the treatment of 
 mental disease, and may necessitate the introduction 
 of food for months, and even for years, by means of 
 the stomach-pump or nasal tube. 
 
 There is, however, another class of cases in which 
 the anorexia comes on after gastralgia ; the patients, 
 often young women, state that food produces severe 
 pain, and gradually less and less' of it is taken ; the 
 strength necessarily fails, and the digestion, as a 
 consequence, becomes also more feeble, and in pro- 
 portion as the strength fails the nervous suscepti- 
 bility increases. Some of these patients become 
 completely blanched, thin, and weak, and for months 
 may have taken very little more than bread and 
 water. Many of them rapidly recover, partly from 
 the use of chalybeate medicines, but still more when 
 they can be induced to persevere with food, although 
 
STOMACH. 83 
 
 pain is produced ; the patient is more willing to 
 make tlie effort when assured that the suffering is 
 temporary, and that it will subside as strength is 
 regained. As regards the diet_, although we are often 
 told that milk disagrees, it is well to use it in one or 
 other form ; it is important also to vary the dietary, 
 and to give vegetable or fruit ; and in most cases of 
 this kind good draught ale or porter is much to be 
 preferred as a stimulant, when that is necessary, to 
 any form of ardent spirit or wine. 
 
 Another condition, due to a weakened state of the 
 pneumogastric nerve, is dilatation or distension of 
 the stomach. In a healthy state the stomach con- 
 tracts upon its contents, and by its vermicular 
 action facilitates the movements and churninsr of 
 those contents, by which their thorough mixture with 
 the gastric juice is promoted, their solution accom- 
 plished, and the resulting fluid propelled onwards 
 through the pyloric valve. The pneumogastric nerve 
 regulates these movements, and when it is paralysed 
 these movements are more feeble, and distension 
 readily takes place. G-reat distension occurs, how- 
 ever, from several causes ; it may arise from an ex- 
 hausted state of the nervous supply ^ both of the 
 pneumogastric, as mentioned by Traube, and also of 
 the vaso-motor nerve. In these instances no peri- 
 stalsis of the stomach is observed, for the muscle is 
 weakened ; this form of distension may be due to 
 long fasting, or to hysteria, or to nervous shock. 
 The distension produces distress and breathlessness. 
 
84 PATHOLOGY OP THE PNEUMOGASTEIC NEEVE. 
 
 from pressure upon the diaphragm, sometimes severe 
 pain at the stomach and through to the spine, or 
 across the upper part of the chest. It would seem 
 that long-continued vomiting may induce. this form 
 of nervous exhaustion ; and it has been recognised 
 in diseases of the brain and spinal cord, in typhus, 
 in cholera, and in puerperal fever ; again, the fulness 
 of the stomach sometimes occurs in phthisis, and the 
 flaccid condition in which the stomach is found after 
 death, may be due to this gradual exhaustion of the 
 pneumogastric nerve. 
 
 In reference to the forms of distension due to 
 local change in the stomach itself, we have those 
 which are consequent on obstruction at the pylorus, 
 and those in which sudden formation of gas and 
 enormous distension render the muscular coats 
 powerless to contract, and so cause paralysis. We 
 have just referred to paralysis causing distension, 
 but in these cases the distension causes the paralysis. 
 It is at the pylorus that the muscular fibre, espe- 
 cially the circular coat, has its fullest development. 
 When there is any obstruction at this part, particu- 
 larly if it be gradual at its origin, the muscular coat 
 becomes proportionately increased; and, when the 
 muscular contraction is unable to overcome the 
 hindrance then dilatation takes place, and gradually 
 attains an enormous size. Bamberger quotes a case 
 in which ninety pounds of fluid filled the stomach. 
 As the muscular coat endeavours to overcome ob- 
 struction, peristaltic movement may be observed 
 
STOMACH. 85 
 
 througb. tlie abdominal wall ; a small quantity of 
 food or of water taken into the stomacli may suffice 
 to produce tbis contraction. 
 
 But the sudden formation of gas from fermentation 
 or other cause may lead to enormous distension. 
 The dilatation is then so great that the very disten- 
 sion is the cause of the paralysis, as just mentioned. 
 Attention was drawn to this condition of distension 
 by Sir William Gull many years ago, in a case under 
 his care, in which the stomach filled the abdomen, 
 and thus led to a fatal result. It has also been well 
 described by my colleague Dr Hilton Fagge, in a 
 communication to the ' Guy's Hospital Reports ' of 
 1872. The form of abdomen is peculiar in this kind 
 of distension ; it is full in the left hypochondrium, 
 but hollow in the epigastric space, the curve of the 
 upper portion of the stomach being dragged obliquely 
 downwards, and the pylorus being situated low down 
 on the right side or near the pubes ; whilst the 
 greater curvature of the stomach describes an arc 
 from the left hypochondrium following the curve of 
 the abdomen. The distension may resemble an 
 urinary bladder, or hydatid cyst, or distended colon. 
 It is partially resonant ; but, on percussion, a 
 splashing sound may be produced from the admixture 
 of air and fluid. 
 
 This state may come on suddenly, or it may be 
 very gradual ; in a lady under my care the sym- 
 ptoms extended over eighteen months ; and great 
 relief was afforded by removing the contents of the 
 
86 PATHOLOGY OF THE PNEUMOGASTEIC NEEVE. 
 
 stomacli, and thereby allowing the distended viscus 
 to contract. 
 
 In other cases it would appear that branches of 
 the sympathetic nerve, by their connection with the 
 pneumogastric and by reflex action, lead to this 
 weakened condition of the muscular fibre of the 
 stomach ; thus we find it in peritonitis, and in a 
 remarkable case recorded by Dr Fagge, it was due 
 to abscess behind the ascending colon opening into 
 the duodenum. In other cases empyema has been 
 the apparent cause of the exhaustion and distension. 
 However induced the condition is one which indi- 
 cates weakness of the pneumogastric nerve, and of 
 the muscular coat of the stomach to which it is 
 supplied. 
 
 LIVER. 
 
 The function of the liver is a complex one ; it has 
 to do not only with the secretion of bile, but it is 
 intimately associated with the maintenance of the 
 healthy blood condition, and it possesses a glyco- 
 genic function as described by Claude Bernard, and 
 still further developed by the experiments of my 
 colleague Dr Pavy. It is not our intention to dwell 
 upon these subjects ; but the action of the pneumo- 
 gastric upon the liver is of the greatest interest ; 
 branches of this nerve may be traced in unison 
 with the vaso-motor to the fissure of the liver, and 
 into its substance; and it is also closely connected 
 
lilVER. 87 
 
 witli the phrenic in the ganglion upon the vena 
 cava. The glycogenic function of the liver, as well 
 as the secretion of bile, may be greatly affected by 
 the condition of its nervous supply, and it is well 
 known that puncture of the root of the nerve at the 
 floor of the fourth ventricle produces a saccharine 
 condition of the urine, so also division of the sym- 
 pathetic nerve in the neck ; this change in the urine 
 may be referred to the altered blood-supply in con- 
 sequence of the pneumogastric affecting the lungs 
 and the heart ; but this hypothesis does not satisfac- 
 torily explain the symptoms, and the nerve appears to 
 have a more direct action upon tke secreting struc- 
 ture of the liver than can be explained in this way, 
 for there are many and decided changes in the state 
 of the circulation of the liver connected with heart 
 disease which do not produce glycosuria. We find 
 many instances of transient glycosuria from func- 
 tional disease of the liver, especially where the 
 nervous system is implicated ; and the instances of 
 almost sudden jaundice being produced by severe 
 nervous shock are notorious, and have often been 
 recorded. In one of my hospital patients, a poor 
 washerwoman, jaundice was at once produced when 
 she found that the clothes she was engaged to wash 
 had taken fire whilst hanging up to dry ; and, 
 again, it is well known that acute yellow atrophy of 
 the liver is often connected with great mental 
 depression. In these instances, the influence of the 
 pneumogastric nerve is inseparably associated with 
 
88 PATHOLOGY OF THE PNEUMOGASTRIC NERVE. 
 
 that of the great nerve of organic life^ the vaso- 
 motor or sympathetic. 
 
 The connection of the pneumogastric nerve with 
 the hepatic function is shown in the gastric sym- 
 ptoms which are produced by many morbid changes 
 in the liver and bile-ducts ; the stomach is irritated, 
 and vomiting is one of the common indications of 
 hepatic disturbance. It is true that the same 
 exciting cause of the disease of the liver may also 
 act upon the mucous membrane of the stomach, but 
 this cannot be said of those instances in which the 
 passage of a gall-stone produces excessive vomiting. 
 
 Again, the pneumogastric nerve not only supplies 
 the stomach, and sends nervous filaments to the liver, 
 but branches may also be traced to the first portion of 
 the duodenum. It is this portion which is in the 
 closest functional relationship with the stomach, and 
 also with the liver. Irritation in this part of the 
 intestinal tract from the pylorus to the opening of the 
 bile-ducts may, we believe, be the cause of spasmodic 
 contraction of the bile -ducts, and induce, not only 
 vomiting but also jaundice. These symptoms are 
 sometimes mistaken for acute yellow atrophy of the 
 liver. 
 
 It is doubtful how far the pneumogastric is con- 
 cerned in the production of the cardiac symptoms that 
 are due to indigestion and to hepatic disease ; in an 
 ordinary "bilious attack " the irritation of the stomach 
 is followed by faintness and by sallowness, by bilious 
 vomiting and general distress. It may be that the 
 
LIVER. 89 
 
 vaso-motor nerve becomes exhausted from prolonged 
 irritation, and tliat this is followed by sympathy with 
 the cardiac branches, but the pneumogastric is also 
 implicated. 
 
 The pancreas is also supplied by the same nerve ; 
 and we doubt not that the regulation of its functional 
 activity is influenced by this nerve, as well as by the 
 vaso-motor. We are not acquainted, however, with 
 any direct action upon the pancreas from experiments 
 made upon the pneumogastric ; nor, in examinations 
 after death, where the nerve has been implicated, 
 have we been able to discover any change that 
 demonstrates the influence of this nerve upon the 
 pancreas. 
 
 To describe fully the pathological conditions of the 
 pneumogastric nerve would lead us into each branch 
 of clinical medicine, and into nearly every organ of 
 the body, if we considered its wide-spread ramifica- 
 tions. As succinctly as possible we have reviewed its 
 more important connections, and, as we noticed the 
 several structures immediately controlled by it, we 
 have seen that each one may be directly influenced by 
 mischief at the cerebral centre. Those parts which 
 are most remote are often the first to express the 
 central disease ; it may be, that the restraining power 
 being less effective in the more remote structures, the 
 irritability consequent on morbid change is more 
 manifest. In ordinary hemiplegia, we find the 
 extreme muscles of the limb the last to recover their 
 power ; so in the pathological symptoms due to dis- 
 
90 PATHOLOGY OF THE PNEUMOGASTRIC NERVE. 
 
 ease at tlie cerebral centre of the pneumogastric, tlie 
 branches to the stomacb. and to the abdominal viscera 
 are often especially disturbed. Equally do we find 
 that disease affecting one group of nerves may mani- 
 fest reflex action upon those supplied to other organs. 
 That restraining power which in health controls the 
 functional activity of separate parts of the body is 
 best seen in its beautiful adaptation and beneficent 
 design^ when we contrast the quiet harmony of 
 health with the disorder in the whole economy when 
 that restraint is taken away. 
 
COLD SHOCK 
 
 IN ITS 
 
 ACTION ON THE BRANCHES OF THE PNETIMOGASTRIG 
 NERVE *-PARALYSIS OF THE NERVE. 
 
 There can he no daubt of tlie fact that physical 
 forces are continuaHy in operation upon Hving or- 
 ganisms, but the manner in which that action is 
 produced, and its fuH effect, may be matter for 
 investigation. Chemical action takes place, we know 
 full well, in the animal frame, and heat and cold 
 continually produce changes in our system. It is 
 to the action of cold in some of its aspects that we 
 would direct attention^ and to some special pheno- 
 mena which are due to its operation. It is generally 
 acknowledged that cold acts — 1st, upon the circula- 
 tion of any part to which it may be applied ; 2ndly, 
 upon the nerves of the part ; and 3rdly, upon the 
 nutrition in a direct or in a secondary manner ; that 
 it is to say, the nutrition of the part may be affected 
 
 * Read before the Medical Society of London, December 5th, 
 1881. 
 
92 COLD SHOCK. 
 
 by tlie direct application of the cold ; or secondarily, 
 on account of tlie altered state of the nervous supply. 
 We may sometimes almost watch these phenomena; 
 if ice or the coldness from ethereal evaporation be 
 made to act upon any part, the blood supply is 
 lessened and the colour changed, and at the same 
 time the sensibility of the part is lessened. The 
 capillary vessels are contracted, the peripheral nerves 
 are paralysed, and sensibility is lessened or destroyed. 
 The vital power of the part is reduced, and it is 
 checked or entirely stopped ; if after a short time 
 the cold is removed, and the circulation is restored, 
 or reaction take place, then the part becomes 
 warm and the colour is regained, the contracted 
 vessels become relaxed, and at the same time the 
 activity of the nervous supply is more or less 
 restored ; severe burning pain, or smarting or dis- 
 tressing itching of the skin may supervene. These 
 are the symptoms so often observed in chilblains ; 
 if, however, the effect is more severe, the vitality 
 of the part is more imperfectly, if at all, restored ; 
 and frostbite or sloughing is the result. The circu- 
 lation of the part cannot be disturbed without the 
 vital changes becoming affected, as shown in the 
 altered secretion of the part. These changes may 
 be especially seen in the action upon the capillaries 
 of the part, as we find in conjunctivitis ; there the 
 congestion of the vessels is followed by altered 
 secretion from the eyelid, and the morbid sensibility 
 of the part produces a sensation, as if there were 
 
COLD SHOCK. 93 
 
 dust in the eye. The effect produced by a continued 
 draught of cold air upon the side of the face is often 
 seen in the consequent paralysis of the seventh or 
 facial nerve ; the nerve of expression and motion 
 rather than that of sensation being affected, although 
 there is often a certain amount of numbness of the 
 part. 
 
 Again, the action of cold upon the branches of 
 the fifth nerve is often seen in ordinary catarrh ; 
 the nose receives its branches from the divisions of 
 the fifth nerve, and exposure to cold contracts the 
 vessels which by reaction become distended, and the 
 secretion at first checked becomes abundant and 
 profuse. The fifth nerve is closely connected with 
 the eighth, and, in fact, scarcely ought to be sepa- 
 rated from it. If the branches of the fifth nerve on 
 the face, the nose, and the pharynx be affected by a 
 cold chill, those of the pneumogastric nerve or the 
 eighth pair quickly become involved, and it is to -^ 
 the action on this, the large pneumogastric nerve, /^ 
 that we would especially direct attention. In our 
 own climate, with its great variations of tempera- 
 ture and its sudden changes, the effects of cold 
 shock on the nerves of the throat and chest are 
 continually seen, but some facts connected with 
 these changes deserve our attention. We may note 
 the action, first, upon the pulmonary branches of 
 the pneumogastric j then, secondly, upon the abdo- 
 minal branches ; and, thirdly, upon the cerebral 
 centre of the nerve. 
 
94 COLD SHOCK. 
 
 I. The pulmonary brandies of tlie pneumogastric. 
 — It is not necessary to do more tlian to note tlie 
 catarrhal state of the throat and larynx, which is due 
 to cold, and the congestion of the mucous mem- 
 brane, the irritability of the part, the loss of voice,^ 
 the febrile excitement, and the pain with some 
 dysphagia which ensue. 
 
 Bronchitis in its more or less acute form is due 
 to a similar cause, and it may be traced either to 
 the direct action of cold on the bronchial mucous 
 membrane, or to its secondary action through the 
 branches of the pneumogastric; the bronchial sym- 
 ptoms must necessarily vary according to the 
 severity of the affection, and whether the large, the 
 small, or the capillary bronchi be involved in the 
 complaint. If there be undue irritability of the 
 ^/muscular coat of the bronchi we find that attacks of 
 . asthma more or less spasmodic in character may be 
 \ produced. These conditions we pass over to advert 
 to one which is, I think, often overlooked, namely, 
 the acute congestion of the lung or the acute pneu- 
 monia, due to diminished power or paralysis of the 
 peripheral branches of the pneumogastric nerve. Are 
 we correct in referring this condition to paralysis of 
 the nerve or to an inhibitory action exerted upon it ? 
 When the cerebral centres of respiration lose their 
 power we know that the respiration is altered ; it is 
 diminished in frequency or is irregular, and the 
 lobes of the lungs become congested and oedema- 
 tous j so also if one of the branches of the pneumo- 
 
COLD SHOCK. 95 
 
 gastric nerve become pressed upon by an aneurismal 
 or otber tumour, or the nerve be in any way 
 destroyed, then the corresponding lobe of the lung 
 on that side becomes congested, and a low form of 
 inflammatory action takes place. These are the 
 conditions that we find produced by cold, either 
 when severe in its action or operating upon an 
 enfeebled state of the system. These states are apt 
 to be overlooked because the symptoms are not 
 those of ordinary bronchitis nor of pneumonia. A 
 patient who is advanced in years takes cold, or, in 
 other words, becomes chilled ; the strength is sud- 
 denly prostrated, there is febrile excitement though 
 sometimes scarcely recognised, the tongue becomes 
 dry, and the pulse feeble ; the mind may become dis- 
 turbed and wandering; the breathing hurried, and 
 in a marked degree shallow. If the lungs be 
 examined the resonance is found to be imperfect, 
 and very little air seems to enter the lower lobes of 
 the lungs ; there may be a little crepitation, but 
 that is often wanting ; there is no cough, no expec- 
 toration, and on that account the condition is often 
 overlooked. The lung is found to be in a state of 
 acute congestion, and very cedematous ; the patients 
 rapidly sink, and death may be referred to fever or 
 to brain disease, whereas it is due to the state of 
 the respiratory nerve, and we might almost with 
 accuracy designate it, as some have done, paralysis 
 of the nerves of respiration. In some cases the 
 mind is perfectly conscious, and the patient is free 
 
96 COLD SHOCK. 
 
 from pain or distress ; there is neither cougli nor 
 headache, and the hurried breathing does not greatly 
 disturb the patient. 
 
 Such persons will sometimes remark, that there is 
 no need for anxiety and alarm, whereas it is evident 
 that the result will in all probability be fatal ; though 
 not necessarily so, for sometimes the patient may 
 rally under the effect of stimulants, such as brandy, 
 ammonia, ether, squill, senega, etc. 
 
 Some of the cases of rapid death produced by 
 severe cold, by dense fogs, by exposure to wet and 
 snow are of this kind ; and every winter witnesses 
 many such cases amongst the wealthy, and still more 
 amongst the poor. The only chance of relief lies in 
 the restoration of the respiratory power, so as to 
 purify the blood and free the engorged lungs. 
 Cases of this kind will suggest themselves to the 
 mind of every practitioner, but we have known such 
 cases regarded as fever or simple prostration, because 
 there was no cough. The absence of cough is due 
 to the fact that the patient has no power to complete 
 the act of coughing, and in that inability to clear 
 the lung the danger of the malady consists. These 
 cases are often not regarded as pneumonia, and 
 they do not find their way into the statistics of that 
 disease j they occur in persons advanced in life, and 
 are different in their whole clinical course from the 
 acute inflammation of the lungs occurring in early 
 life. 
 
 Let me give two instances : 
 
COLD SHOCK. 97 
 
 Case 1.— Pulmonary congestion; death in a few hours. — A 
 lady, aged about seventy, had been in poor health for several 
 years, and had suffered from difficulty in swallow^ing, from shingles, 
 and from a feeble state of the heart. In 1877 she complained 
 of a painful stiffness of the arms, but it was relieved by quinine 
 and by bromide of potassium. Her nervous system was in a 
 weakened state. 
 
 On Friday, February 11th, 1878, she complained of cough, and 
 when I saw her, about nine in the morning of the 12th, I found 
 her pale ; the pulse was rapid bat feeble ; the respiration was 
 shallow and hurried, and very little air entered the chest. It was 
 evident that she was in great danger, but she was unaware of it, 
 saying that she would like to go downstairs, and did not under- 
 stand " why there should be a fuss." She was free from pain and 
 there was very little cough. The breathing became more and more 
 feeble, and she sank the same evening soon after eight o'clock. 
 
 The state of the oesopliagus and its spasmodic 
 stricture were connected with a feeble state of the 
 oesophageal branches of the pneumogastric nerve 
 but in the last attack the pulmonary branches were 
 apparently paralysed. 
 
 Case 2. Sudden pulmonary congestion ; acute or old bron- 
 chitis. — A lady, aged 64, the wife of a clergyman, had suffered 
 from repeated attacks of bronchitis. One of them was veiy severe 
 three years previously, and almost led to a fatal result. She, how- 
 ever, regained her health, and was comparatively well during the 
 summer. On October 31st she took a slight cold durino- the severe 
 change and foggy weather, but she thought nothing of it and 
 seemed better during the week. On N'ovember 6th she was not 
 quite so well, but on the 7th became rapidly worse, and at nine 
 o'clock in the evening I saw her sitting up in her drawing-room, 
 but very pale, prostrate, and ill. She had some pain in the abdo- 
 men, but her respiration was very short and hurried, 40 per minute • 
 scarcely any air entered the lower lobes of the lungs. There was 
 no cough to speak of, the pulse was 120, the temp. 103*5°, the 
 skin was dry and hot. She was ordered white wine whey, brandy 
 
 Q 
 
^8 COLD SHOCK. 
 
 with milk, linseed poultice to the chest, and saline diaphoretic 
 medicine. 
 
 On the 8th she unwisely left her bed, and was found at midday- 
 sitting up, but still pale and ill. She felt a little better, and 
 rather more air was entering the lower lobes of the lungs. There 
 was a little cough, and she was able to expectorate a small quantity 
 of thick tenacious mucus. The temperature was 102°, respiration 
 40, pulse 120 and feeble. 
 
 The brandy, with nourishment and white wine whey, were con- 
 tinued, and she was directed to remain in bed. I had been greatly 
 surprised to find her sitting up, for so ill did I find her the pre- 
 vious evening, that I scarcely expected she would survive the night. 
 
 Nov. 9th. — She had had a restless night, and suffered from severe 
 pain in the abdomen with flatulent distension. Eather more air 
 entered the lower lobes of the lungs, but there were no mucous 
 rales nor wheezing except in the slightest degree. The expectora- 
 tion was scanty, thick, and tenacious, and of a greyish colour. 
 The lips were slightly livid, and the fingers dusky. The pulse 140, 
 temp. 101°, respiration 40. The bowels had not been open, so that 
 a small dose of castor-oil was given. Some chloroform and bella- 
 donna liniment was applied to the abdomen, and senega and am- 
 monia prescribed. The brandy was continued freely. She had a 
 good night and appeared decidedly better at nine in the morning. 
 In a short time, however, the strength failed suddenly, she became 
 insensible, and died about four o'clock in the afternoon, either from 
 obstruction of some of the larger bronchi by the tenacious mucus, 
 or coagulation of blood in the pulmonary vessels and ventricles of 
 the heart. 
 
 In this case the symptoms were very different from 
 those of ordinary bronchitis ; the lung became 
 suddenly congested^ there was pallor and loss of 
 power, and the respiratory act was very imperfectly 
 performed. There was no cough at first, but with 
 slight rallying, cough came on. Like the case pre- 
 viously mentioned, she was at first quite unconscious 
 
COLD SHOCK. 99 
 
 of the severity of her illness, and was in bed sitting 
 up, and on the following day was dressed. The flatu- 
 lent distension of the abdomen was also an indication 
 of diminished nervous power. 
 
 If the patient have more strength, and some 
 reaction ensue, then bronchitis is developed, and the 
 symptoms of capilliary bronchitis are manifested ; but 
 although the condition is a severe one, and the 
 dyspnoea may become urgent, it is one most likely 
 to be relieved by sustaining the patient, and often 
 by a stimulating plan of treatment, for the cause is 
 to be referred to nerve exhaustion. This form of 
 bronchitis, where the cause is general and the w^hole 
 nervous power is exhausted, rapidly extends from 
 the large bronchi to the smallest branches on both 
 sides, and it is in proportion as the capillary branches 
 are involved, that it is attended with danger. The 
 countenance soon becomes livid, the respiration 
 hurried, the expectoration, if any, is tenacious or 
 frothy, the pulse feeble, and the strength soon fails. 
 Small mucous rales are heard, and the right side 
 of the heart, which is distended from the impeded 
 action of the lungs, beats more forcibly than the left ; 
 its cavities are distended ; the liver is engorged, and 
 so are the kidneys ; the urine is scanty and often 
 albuminous, and the bowels are confined. The mind 
 occasionally wanders, but the brain is often clear till 
 nearly the last. 
 
 A different class of symptoms is produced if the 
 lungs become involved. There may be rapid pros- 
 
100 COLD SHOCK. 
 
 tration ; the tongue in a few hours is brown and dry, 
 tlie countenance is sallow or sliglitly livid from con- 
 gestion, the breathing is hurried, the appetite is lost. 
 The action of the liver and kidneys is disturbed ; 
 there may be little or no cough, and rusty expec- 
 toration may be looked for in vain, or it maybe like 
 prune juice. 
 
 If the chest be examined, the lower lobe of one 
 lung may be found deficient in resonance or actually 
 dull j there may be minute crepitation or loud bron- 
 chial breathing and voice ; tactile vibration is in- 
 creased, the temperature is raised to 103 or 104 
 or more ; there may be no pain in the chest, and no 
 evidence of pleurisy, but the lung has rapidly become 
 solidified. These cases are very apt to be mistaken 
 for fever from the rapidity of the prostration, the 
 dry and brown tongue, and from the manner in 
 which the chest symptoms are held in abeyance. 
 Another peculiarity is the rapidity with which one 
 portion of the lung after another becomes involved ; 
 it will extend from the lower to the upper lobe, then 
 to the other lung in a very short space of time, and 
 the physical symptoms almost hourly change. If 
 such a case be overlooked the pulmonary obstruction 
 will soon lead to a fatal result, and the only hope 
 lies in a stimulating treatment, as ammonia freely, 
 and brandy or champagne. We should be sorry to 
 advocate stimulants in all cases, but where the dis- 
 ease arises from cold shock, and the system is ex- 
 hausted, it is the only plan of treatment attended 
 
COLD SHOCK. 101 
 
 with benefit. We must forget the disease and treat 
 the patient. 
 
 The following case occurred many years ago, but 
 it is a remarkable instance of the sudden prostration 
 produced by pneumonia, and also of the value of the 
 plan of treatment we have advocated. 
 
 Case 3. Acute pneumonia ; sudden prostration. — Captain D — , 
 aged 65, was seen in consultation with the late Mr Brett, of Stoke 
 Newington Green. On the Good Friday of 1861 (March 29th) he 
 attended the church of which he was churchwarden. The church 
 was exceedingly cold, and he experienced a severe rigor, which he 
 said was ague, and was followed by headache and by febrile excite- 
 ment. On the following morning he was unable to get up, and 
 Mr Brett found him prostrate and very ill. His illness was so 
 sudden that he had been unable to postpone the visit of friends 
 who were coming to dine with him, and who found him very ill in 
 bed. At 10 p.m. I saw him, and found his appearance resembling 
 a man in the third week of enteric fever ; his countenance was 
 flushed, and he had an anxious and distressed expression. He com- 
 plained of pains in the head, the back, and the limbs ; the bowels 
 had been acted on freely ; the skin was hot, but the feet were per- 
 spiring ; the respiration was hurried, and there was slight cough. 
 The breathing at the base of the left lung was less clear than on 
 the right side, and in front there was a doubtful pleuritic rub ; the 
 tongue was dry and brown ; the urine was scanty, high coloured, 
 and it contained a little albumen. Carbonate of ammonia with the 
 acetate of ammonia was given, and wine freely. On the following 
 day there were evident signs of -consolidation of the left lung, and 
 the disease was rapidly spreading ; the expectoration was scanty 
 and rusty in colour. The right side of the chest became involved 
 on the 1st of April, and the prostration increased. Eespiration 
 was 40 per minute, pulse compressible, and the tongue was dry 
 and brown. On April 2nd the patient appeared to be dying ; his 
 hands were cold and clammy, the tongue was brown and cracked, 
 and the pulse was very compressible. Stimulants were given freely, 
 and the patient rallied under their action. Excitement was relieved 
 
102 COLD SHOCK. 
 
 by henbane and cbloric etber, and afterwards by opium. On the 
 7th erysipelas of the side of the face came on, and again he was so 
 prostrate that the friends thought he was dying. Brandy was 
 given very freely and with the desired effect, for the patient 
 rallied. The parotid gland became swollen, and on the 12th it 
 was in a dusky and softened state, and an incision was made into 
 it ; a discharge of pus also came from the ear. On the 15th he 
 was decidedly better, and the large quantity of brandy was 
 lessened, but on the 16th he was again extremely prostrate, and a 
 white diphtheritic patch was seen on the throat. It was necessary 
 to return to the free use of stimulants, and the patient slowly 
 rallied, and ultimately recovered. He lived for several years 
 afterwards. 
 
 This case is mentioned to illustrate tlie rapidity 
 of the prostration in some cases of pneumonia ; in a 
 few hours the strength, was completely gone, as if 
 the nervous power of the lung had been almost lost, 
 and it was only with the free use of stimulants that 
 any rallying took place. 
 
 In another class of cases due to the same cause, 
 namely, cold shock affecting the pneumogastric nerve, 
 the abdominal branches of the nerve appear to be 
 primarily affected, and the malady is said to be a 
 bilious attack, or it may be called " bilious fever/' 
 The patient, after exposure to sudden cold, becomes 
 sallow, and, it may be, is seized with vomiting ; bile 
 is rejected ; the bowels may be constipated or loose ; 
 the tongue is furred, and the breath is often offen- 
 sive ; the pulse is quickened, the temperature raised, 
 and the patient is greatly distressed ; he feels ill. 
 Careful examination of the chest reveals no morbid 
 sign j there is neither pain, nor cough, nor distress 
 
COLD SHOCK. 103 
 
 of breathing. After twenty-four or forty-eight 
 hours the sickness and hepatic disturbance lessen, 
 but still the patient is sallow; he is feverish; the 
 urine is high coloured, and it often contains a little 
 albumen. Severe pain may be experienced in the 
 side in the region of the liver, without any physical 
 sign of disease of the pleura, and the whole malady 
 is ascribed to the liver. It is said to be a case of 
 hepatitis or acute congestion of the liver, and pro- 
 bably the liver is congested, but that is only a small 
 portion of the trouble. In a short time, it may be 
 in twenty-four or forty-eight hours, the examination 
 of the chest shows that that also is affected ; at the 
 lower part, pleurisy, which at first affects the dia- 
 phragmatic surface, creeps round to the costal pleura, 
 and then a rub can be detected ; the lung tissue 
 becomes implicated, and consolidation of the lung 
 rapidly advances. Many of these cases recover, if 
 the strength of the patient does not rapidly fail, but 
 it is most important to recognise the fact that the 
 malady is more above than below the diaphragm, 
 although first indicated by disturbance of the abdo- 
 minal viscera. The explanation is that which I 
 have already mentioned, that cold has affected the 
 pneumogastric nerve, but that its first action is 
 shown on the gastric and hepatic branches of the 
 nerve. It is well for the patient if the secondary 
 effect on the chest is not overlooked. 
 
 The frequency of these cases must be my apology 
 for referring to them. They often occur, and are 
 
104 COLD SHOCK. 
 
 easily overlooked^ because for twenty-four or forty- 
 eight hours no physical signs of chest disease are 
 developed. It is well known that exposure to cold 
 will greatly affect the condition of the liver, that it 
 will produce catarrh of the bile-ducts and inflam- 
 matory congestion, but the same cause that leads to 
 the disturbance of the liver and stomach, may also 
 affect the pleura and the lungs. The two following 
 instances well illustrate the state I have described. 
 These cases have been frequently observed, and Dr 
 Waters, in an interesting paper on pneumonia pub- 
 lished in 1876, states : " Some cases of pneumonia 
 are ushered in with severe gastric disturbance, bilious 
 vomiting, &c., while in a few the attack is preceded 
 by a distinct attack of jaundice. ''' 
 
 Case 4. Acute pleuro -pneumonia commencing with symptoms 
 of hepatic disturbance. — A. B — , aged 62, a gentleman in good 
 general health, tall and proportionately stout, on October 6th, 1880 
 took a chill, and on the following morning, after a disturbed night, 
 was seized with vomiting ; his complexion was sallow, the tongue 
 was furred, and the bowels were confined ; he felt poorly, and com- 
 plained of pain on the outer side of the thigh ; there was no pain 
 in the abdomen, and the chest appeared quite free. The pulse was 
 compressible, and he was feverish. A purgative was given and 
 saline effervescing medicine. At 6 p.m. he was sallow, nervous 
 and restless, feverish, and the pain on the outer side of the thigh 
 was more decided ; the respiration was quiet, the pulse 100, the 
 temp. 102'7°. The bowels acted twice in the evening. 
 
 On October 8th the feverishness continued, but was rather less ; 
 temp. 102°, pulse 100. He complained of pain in the right side 
 over the lower ribs, but no friction sound could be heard, althougli 
 the pain was of a pleuritic character ; the skin was hot. At 5.30 
 p.m. he was less feverish, but still felt very poorly ; temp. 101°, 
 
COLD SHOCK. 105 
 
 pulse 120 and full. The pain in the side continued, but on 
 careful examination no friction sound was heard, but the respira- 
 tory murmur at the lower part of the right lung was harsh, as if 
 becoming bronchial. I expressed the opinion that the pain was of 
 a pleuritic character, but a relative, a surgeon, thought the disease 
 was below the diaphragm rather than above. Chloroform liniment 
 and belladonna liniment were applied. 
 
 On October 9th he was found in the morning to be very ill. 
 There was a very distinct pleuritic friction sound heard on the right 
 side, with consolidation of the lung ; the respiration was 50 per 
 minute, pulse 140, temp. 102*6°. At 2 p.m. the inflammatory 
 mischief had rapidly increased. Sir William Jenner met us in 
 consultation, and he strongly urged that the patient should not be 
 allowed to get out of bed, on account of the feeble state of the 
 heart and the extreme severity of the lung affection. We had, 
 however, scarcely left the house when the patient, being alone for 
 a few minutes, got out of bed and fainted on the floor ; he did not 
 rally, but sank in about half an hour. The pain on the outer side V 
 of the thigh was probably due to irritation of the branches of the 
 last dorsal nerve, the branches of which extend to the glutealy^ 
 region. 
 
 Case 5. Pneumonia, preceded hy great irritation of the stomach 
 and hlach vomit. — J. T — , a gentleman, aged 77, who had been in 
 tolerably good health except that he suffered from dyspepsia and 
 flatulent distension of the stomach, went out on the morning of 
 November 2nd to look after the alterations in a chapel, and was 
 standing about on damp ground. He became chilled, and expe- 
 rienced a severe rigor ; he returned home, but felt ill. Nausea 
 came on and then vomiting, and these symptoms continued for 
 several days. On the 5th November the vomited matters were 
 almost black, a deep, coffee-ground looking substance. On the 
 same day distress and shortness of the breath came on, with pain 
 at first in the right, then in the left side ; there was great weak- 
 ness and shortness of breath. The temperature rose to 100°, the 
 urine was free from albumen, the bowels were open. 
 
 On the 9th he was slightly sallow, distressed, and prostrate ; 
 respiration 40, temp. 101°, pulse 100. The abdomen was flatulent, 
 
 H 
 
106 COLD SHOCK. 
 
 there was no expectoration nor cough, but there was consolidation 
 of the lower lobe of the right lung. 
 
 Dr Hall, of Crouch End, whom I had the pleasure of meeting 
 in consultation, and who had the care of the patient, kindly 
 informed me that the symptoms gradually subsided and the patient 
 completely recovered. 
 
 Whilst we liave referred to these conditions of tlie 
 pulmonary and abdominal branclies of tlie pneumo- 
 gastric nerve as due to cold shocks it is well known 
 tliat cold affects in a more direct manner the respi- 
 ratory centres. Gradual drowsiness and an irresistible 
 tendency to sleep^ passing into profound coma, are 
 the results of severe cold, and the lowering of the 
 temperature of the body. It is doubtful how these 
 effects are produced ; whether the brain is affected 
 primarily, or only from the supply of imperfectly 
 arterialized blood ; the circulation of the blood is no 
 doubt impeded, the internal organs become congested, 
 and the venous circulation of the brain is retarded. 
 It may be, that the cerebro- spinal fluid is increased 
 from congestion of the large plexuses of spinal veins, 
 the blood being driven from the surface ; the increase 
 of cerebro -spinal fluid would lead to undue pressure 
 upon the floor of the fourth ventricle, and upon the 
 medulla oblongata ; but this is hypothetical. The 
 fact, however, remains, that cold acts upon the brain 
 and that coma is produced ; we believe that the 
 altered condition on the respiratory act, and the 
 inhibitory effect on the pneumogastric branches to 
 the heart are amongst the chief causes of the torpor 
 of the brain. 
 
COLD SHOCK. 107 
 
 Happily in this climate we have not to do with the 
 extremes of cold which lead to these dire results, 
 unless unforeseen exposure take place ; but with the 
 almost equally disastrous effects of sudden cold shock 
 we are too familiar. The extreme cold of the winter 
 of 1880 — 81, and the dense fogs that spread over 
 London led to terrible disease, which was in many 
 cases quickly fatal. Men were struck down in a few 
 hours, or even in the street whilst at their daily 
 occupation, and the fear is, that every winter such 
 cases occur, and that their true nature is overlooked. 
 The human body cannot bear extremes of temperature 
 without endangering health and life. 
 
 Cold will produce disturbance, weakness, or even 
 paralysis of the branches of the pneumogastric 
 nerve ; and these effects are shown, as we have 
 endeavoured to illustrate, in the acute congestion or 
 oedema of the lung which is due to the exposure to 
 cold in persons advanced in life, and in which cases 
 the prominent symptoms are prostration of strength, 
 and hurried breathing, often without any cough ; 
 and secondly, in other instances, the primary action 
 of the cold is seen in disturbance of the liver, which 
 quickly gives place to more serious affection of the 
 lung, and from the absence of thoracic symptoms at 
 the commencement of the attack is often referred 
 throughout, to acute disease of the liver itself. 
 
 PEINTBD BY J. E. ADLAED, BARTHOLOMEW CLOSE, 
 
OTHER WORKS BY DR. HABERSHON, 
 
 Fellow of the Royal College of Physicians ; late Senior Physician to, 
 and Lecturer on Medicine at, Guy's Sosjpital. 
 
 Third Edition, considerably enlarged and revised, with Plates, 
 8vo, cloth, 21*. 
 
 ON DISEASES OF THE ABDOMEN, STOMACH, 
 
 AND OTHER PARTS OE THE ALIMENTARY CANAL. 
 
 OESOPHAGUS, Cv€CUM, INTESTINES, AND PERITONEUM. 
 
 " The practitioner will find it a very valuable work of reference." — Med. Times and 
 Gazette. 
 
 " A long life with much practice, or a shorter one with the observation of a vastly 
 concentrated mass of facts, could alone furnish the material of this work. . . . We 
 recommend Dr. Habershon's treatise as a valuable repertory of clinical experience of 
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 — London Review. * 
 
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