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BRONCHO-ŒSOPHAGEAL FISTULA DUE TO AORTIC ANEURYSM.
1529
impossible to ignore the beneficial effect of this important factor in public health administration, having special regard to the exceptional decline in London where hospital isolation has been so successfully developed under the Metropolitan Asylums Board. No fewer than 16,958 cases of scarlet fever were admitted to the hospitals of that Board during last year, considerably exceeding the number in any previous year since the Board commenced its operations in 1871; the nearest approach to so high a number occurred in 1896, when 15,982 cases were admitted. It is true that a constantly increasing proportion of this disease in London now receives hospital isolation, but the statistics quoted above seem to suggest that while the type of the disease has in recent years assumed a milder form, its prevalence does not appear to have declined notably. This theory of a milder type of disease is somewhat supported by the marked decline in the case-mortality of the patients treated in the Asylums Board hospitals, after due allowance for the larger proportion of the total cases of the disease now treated therein. The case-mortality among scarlet fever patients treated in those hospitals averaged 12’6 per cent. during the ten years 1874-83, whereas the mean percentage in the last ten years has not exceeded 3’ 5; the decline of case-mortality, indeed, has been almost steadily maintained during the whole period. As indicating, however, a possible decline in the prevalence as well as of the fatality of this disease in London, it should be pointed out that while the annual number of notified cases averaged 22,177 during the eight years 1890-97, the average annual number during the more recent eight years 1898-1905 had declined to 16,356. On the whole there seems little ground for doubting that hospital isolation has been one of the most influential factors in the recent remarkable decline in fatality of scarlet fever, at any rate in London.
the A
DANGER THE
OF
ELECTRIC SUSPENSION
LAMPS.
they are technically termed " the leads," lamp are frequently made to serve two purposes-namely, to carry the current to the lamp and to suspend it from the ceiling. As a rule all goes well so long as the insulating material covering the wires is intact. But this material, especially in certain atmospheres, tends to rot or to wear out. By the continual kinking also of the wire, as by doubling it or looping it up in order to reduce the distance of the lamp from the ceiling, a similar effect may easily be produced. The two naked wires may thus become in dangerous proximity to each other and occasionally contact results, and therefore short circuiting, and The support the wires for some length are destroyed. and is thus withdrawn it falls to of the lamp suddenly the ground. If a person happens to be immediately underneath the lamp at the moment he may receive severe injury. The results might easily be serious-as, for example, when the lamp is inclosed in a weighty globe or is fitted with a heavy shade. The vacuum bulb, as everybody ends in a knows, quite sharp point, and if this point with the weight of a heavy shade above it should happen to strike anybody’s head a very serious injury might be inflicted. The event of an electric suspension lamp falling in this way is no figment of the imagination. of
a
wires,
or as
suspension
We have
seen
electric
such
an occurrence on
several occasions,
though luckily without personal injury, simply because no one happened to be under the lamp at the time of the accident. Apart from such an undesirable result the fall of the lamp is preceded by a sharp terrifying flash, then the lamp comes to the ground with a crash, the bulb itself ’’imploding," and the result is an unpleasant shock to most persons All this could, of course, be avoided by for one function-that is, of conthe wires setting apart the current. They should not be trusted as a means veying
of
support for the lamp.
It would
surely be quite a simple
matter to provide cords or special wires not connected with the current and used exclusively for suspending the lamp from the ceiling. -
BRONCHO-ŒSOPHAGEAL FISTULA DUE TO AORTIC ANEURYSM. IN the University of Pennsylvania Med’ical Bulletin for October Dr. A. 0. J. Kelly and Dr. R. S. Lavenson have reported the following case. A woman, aged 37 years, was admitted into hospital on Nov. 13th, 1905. About two and a half months previously she began to suffer from pain in the right chest which became worse on exertion. About six weeks before admission a pulsating lump was noticed on her chest. There were also dyspnoea, palpitation, cough, and huskiness. The apex beat was visible in the fifth interspace almost in the anterior axillary line. To the right of the sternum from the first to the third interspace was a globular pulsating tumour about one and a half centimetres high. It showed expansile pulsation, systolic and diastolic thrill, and diastolic shock, and a double murmur was heard over it. At the cardiac apex was a blowing systolic murmur. The pulse was less marked in the right carotid and radial arteries than in the left. The left pupil was larger than the right. On the left side the respiratory murmur was very faint and expansion was defective. There was impaired resonance from the third to the seventh ribs in both interscapular spaces. The patient was comfortable only when propped up and leaning forward. On the 23rd she complained of a lump rising in her throat when she tried to swallow. On the 24th the dysphagia had increased and solid food could not be swallowed. There was pain in the back, the prxcordium, and over the aneurysm. On the 25th the bulging had subsided almost to the level of the chest but posteriorly the right side was prominent and the interscapular space was dull from the third to the eighth rib. Over the dull area breath sounds and vocal fremitus were absent. The patient rapidly lost strength and weight. On Dec. 9th expansile pulsation was no longer visible to the right of the sternum and the murmurs were less loud. The dysphagia and cough increased and there was considerable expectoration of thick lumps of mucus. On the llth swallowing produced such severe paroxysms of coughing that it was necessary to resort to rectal feeding. At times the respiration was harsh and noisy as if the bronchi were compressed. On the 15th the patient was cyanosed and loud bronchial rules could be heard at a distance of some feet from the bed. She could no longer swallow and complained of pain over the whole chest. She suddenly became extremely cyanosed and fell back dead. The necropsy showed an aneurysm arising from the junction of the ascending and transverse portions of the aortic arch and adherent to the sternum It con. at the junction of the second costal cartilage. tained greyish-red laminated clot which projected into the left ventricle and was attached to the musculi pectinati. On the posterior wall of the ascending arch was a second aneurysm which extended posteriorly and compressed the trachea at the level of the bifurcation. The tracheal rings were broken down and the pressure on the posterior wall had produced necrosis with a resulting fistula between the left bronchus and œsophagus. The perforation was half a centimetre in diameter and its edges were necrotic and foulsmelling. Above the level of the fistula the trachea was filled with a milky substance presenting the characters of liquid food. The mucous membrane of the trachea was intensely congested. The bronchi were partially filled with a similar fluid to that contained in the trachea. Throughout the lungs were areas of consolidation which were Dr. Kelly and Dr. confluent in the right lower lobe. Lavenson explain the subsidence of the tumour in the
1530 Two persons who were so sensitive to golden rod that they suffered from paroxysms of sneezing when near it inspired air taken from the midst of a bunch of golden rod. In a few minutes after breathing the filtered air they became comfortable and the irritation ceased. Dr. Heath then made an appliance consisting of two rings to fit the nostrils connected by a bridge. Over the rings he stretched fine "grass linen " or silk chiffon. To get the best results a fine mesh (at least 100 to the inch) was necessary. The rings were placed in the nostrils at a distance of about half an inch from the orifice, so that all inspired air had to pass through the fine netting covering them. They did not interfere with respiration and were worn comfortably. One man wore them continuously for 24 hours, at business and during sleep. The rings were used in a number of severe cases of hay THE CORRASSA COMPOUND. fever and in every one relief was apparent in from 15 NEARLY ten years ago, or, to be exact, in THE LANCET of minutes to an hour. Sometimes the appliance was difficult Dec. 19th, 1896, in an annotation headed "An Infamous to use if the nose was previously so blocked that the patient Quack," we commented upon some abominable documents could not breathe through it. But if he persevered nasal sent out by a person calling himself at that time the Rev. respiration became established and the irritation passed David Jones who vended a nostrum known as the Corrassa away rapidly. In most of the cases Dr. Heath had precompound. We concluded our annotation by commending viously tried various recent remedies for hay fever with little Mr. Jones "to the notice of the police as a man who is success. : Some of the patients had obtained considerable attempting to obtain money under false pretences." At relief at night by putting a wet handkerchief over their length the law (Pede poencz claudio) has overtaken Jones, faces and trying to breathe through this. This fact sugwhose real name appears to be Hawkins, and his son, for gested to Dr. Heath the appliance now described. He they were committed on Sept. 30th by the Brighton magis- usually made the rings of German silver, sometimes of trates for trial at the assizes on a charge of conspiracy tocork and hard rubber. It is not necessary that the two obtain money by fraudulent representations. On Nov. 26thrings should be connected by a bridge but this facilitates the elder Hawkins, who had pleaded guilty, was sentenced their introduction and removal. The bridge passes across The younger prisoner wasthe to three months’ hard labour. septum at its junction with the upper lip and is discharged, no evidence being offered against him. Mr. ]hardly noticeable. The filtering fabric is put on in the Justice Lawrence in passing sentence is reported as saying same way as linen is put on embroidery hoops by women that the case might be regarded as a test case. He hoped, and can be changed whenever desired. It soon becomes however, that the punishment which he inflicted would notmoist, but this increases its filtering power. be taken as an indication of what was necessary in such cases. The false pretences were two : firstly, prisoner repreTHE INTERNATIONAL SOCIETY FOR THE PREthat sented the powders were remedies for certain disorders ; VENTION OF TUBERCULOSIS. and secondly, he pretended that two persons, whom he deAT the meeting of the Societe Internationale de la Tuberscribed as clergymen, had been to some part of Africa and had learned the secret of this remedy. (See a detailed accountculose held on Nov. 6ch in Paris, under the presidency of He wished the Crown success in undertaking Professor Lancereaux, the subject of the compulsory notificaon p. 1565.) of this kind, as it was most desirable in thetion of tuberculosis was under discussion. A paper was prosecutions interest that such frauds should be brought to lightread by Dr. Samuel Bernheim and Dr. Louis Dieupart, who public and put a stop to. These are admirable words ; we. hopereferred to the conclusions of the recent international conbefore long that the Public Prosecutor will turn his atten-ference on tuberculosis (at the Hague in October of this tion to some of the other disgraceful quacks who fill theiryear), and also to the report of the committee of the pockets and those of the proprietors of sundry magazines andAcademy of Medicine (June, 1906). These observers mainpapers by trading on the credulities of weak-minded persons.tained that the prophylaxis of tuberculosis could not be A glance at the advertisement pages of any popular monthlyimade real and efficacious unless the compulsory notification (of the disease was legally enforced. They further exmagazine will give him plenty of material. pressed their conviction that with such a formidable enemy A SIMPLE CONTRIVANCE FOR THE TREATMENT no half measures would avail; they considered that compulsory notification of tuberculosis could be made without OF HAY FEVER. any shock to humanity and pointed out that certain IN the Journal of the American Medical Association of countries had adopted this system and found the advantage Oct. 20th Dr. A. C. Heath has reported some ingenious ex- oof it. It is, of course, understood that compulsory notificaperiments performed during the hay fever season of 1905 totion t involves, ipso facto, compulsory disinfection. We have prove that the atmosphere was laden with some irritating on 0 previous occasions drawn attention to the arguments He used substance which could be removed by filtration. which have been advanced in favour of, and against, coman ordinary water-bottle of the chemical laboratory fitted and voluntary notification of tuberculosis, and in a p pulsory with two glass tubes to one of which was attached rubber leading article in THE LANCET of August llth, 1906, tubing. The bottle was half filled with water and when p. p 380, we laid stress on the importance of distinguishsuction was made through the rubber tubing the air inhaled between cases of "open" and "closed " tubering passed through the water. The apparatus worked on the cculosis when considering the advisability of notifying principle of the Turkish pipe. By this means it was hopedthe t As we have indicated, Dr. Bernheim and disease. that any material suspended in the air would be removedI Dr. Dieupart are firmly impressed with the necessity in its passage through the water. In the experiments o of resorting to the strict régime of compulsory notifithe subjects inspired through the nose, which was con0 cation ; we note with satisfaction, however, that they nected with the apparatus, and expired through the mouth. suggest that during the lifetime of the patients notification should only apply to manifest tuberculosis in which tubercle 1 Guy’s Hospital Reports, 1856, vol. ii., p. 250.
chest as follows. The wall of the posterior aneurysm became weaker, permitting its enlargement and causing pressure on the trachea and oesophagus. As this was the nearer aneurysm to the left ventricle it received the force of the ventricular systole and permitted the subsidence of the anterior aneurysm. Only one other case of bronchooesophageal fistula due to aneurysm appears to have been recorded. Habershon reported1 the case of a man, aged 23 years, suffering from traumatic aneurysm of the arch off the aorta which proved fatal by perforation into the peri. cardium. For a week preceding death there was considerable dysphagia. At the necropsy a fistula was found in exactly the same position as in the case now recorded.
c
ii
s,
impossible to ignore the beneficial effect of this important factor in public health administration, having special regard to the exceptional decline in London where hospital isolation has been so successfully developed under the Metropolitan Asylums Board. No fewer than 16,958 cases of scarlet fever were admitted to the hospitals of that Board during last year, considerably exceeding the number in any previous year since the Board commenced its operations in 1871; the nearest approach to so high a number occurred in 1896, when 15,982 cases were admitted. It is true that a constantly increasing proportion of this disease in London now receives hospital isolation, but the statistics quoted above seem to suggest that while the type of the disease has in recent years assumed a milder form, its prevalence does not appear to have declined notably. This theory of a milder type of disease is somewhat supported by the marked decline in the case-mortality of the patients treated in the Asylums Board hospitals, after due allowance for the larger proportion of the total cases of the disease now treated therein. The case-mortality among scarlet fever patients treated in those hospitals averaged 12’6 per cent. during the ten years 1874-83, whereas the mean percentage in the last ten years has not exceeded 3’ 5; the decline of case-mortality, indeed, has been almost steadily maintained during the whole period. As indicating, however, a possible decline in the prevalence as well as of the fatality of this disease in London, it should be pointed out that while the annual number of notified cases averaged 22,177 during the eight years 1890-97, the average annual number during the more recent eight years 1898-1905 had declined to 16,356. On the whole there seems little ground for doubting that hospital isolation has been one of the most influential factors in the recent remarkable decline in fatality of scarlet fever, at any rate in London.
the A
DANGER THE
OF
ELECTRIC SUSPENSION
LAMPS.
they are technically termed " the leads," lamp are frequently made to serve two purposes-namely, to carry the current to the lamp and to suspend it from the ceiling. As a rule all goes well so long as the insulating material covering the wires is intact. But this material, especially in certain atmospheres, tends to rot or to wear out. By the continual kinking also of the wire, as by doubling it or looping it up in order to reduce the distance of the lamp from the ceiling, a similar effect may easily be produced. The two naked wires may thus become in dangerous proximity to each other and occasionally contact results, and therefore short circuiting, and The support the wires for some length are destroyed. and is thus withdrawn it falls to of the lamp suddenly the ground. If a person happens to be immediately underneath the lamp at the moment he may receive severe injury. The results might easily be serious-as, for example, when the lamp is inclosed in a weighty globe or is fitted with a heavy shade. The vacuum bulb, as everybody ends in a knows, quite sharp point, and if this point with the weight of a heavy shade above it should happen to strike anybody’s head a very serious injury might be inflicted. The event of an electric suspension lamp falling in this way is no figment of the imagination. of
a
wires,
or as
suspension
We have
seen
electric
such
an occurrence on
several occasions,
though luckily without personal injury, simply because no one happened to be under the lamp at the time of the accident. Apart from such an undesirable result the fall of the lamp is preceded by a sharp terrifying flash, then the lamp comes to the ground with a crash, the bulb itself ’’imploding," and the result is an unpleasant shock to most persons All this could, of course, be avoided by for one function-that is, of conthe wires setting apart the current. They should not be trusted as a means veying
of
support for the lamp.
It would
surely be quite a simple
matter to provide cords or special wires not connected with the current and used exclusively for suspending the lamp from the ceiling. -
BRONCHO-ŒSOPHAGEAL FISTULA DUE TO AORTIC ANEURYSM. IN the University of Pennsylvania Med’ical Bulletin for October Dr. A. 0. J. Kelly and Dr. R. S. Lavenson have reported the following case. A woman, aged 37 years, was admitted into hospital on Nov. 13th, 1905. About two and a half months previously she began to suffer from pain in the right chest which became worse on exertion. About six weeks before admission a pulsating lump was noticed on her chest. There were also dyspnoea, palpitation, cough, and huskiness. The apex beat was visible in the fifth interspace almost in the anterior axillary line. To the right of the sternum from the first to the third interspace was a globular pulsating tumour about one and a half centimetres high. It showed expansile pulsation, systolic and diastolic thrill, and diastolic shock, and a double murmur was heard over it. At the cardiac apex was a blowing systolic murmur. The pulse was less marked in the right carotid and radial arteries than in the left. The left pupil was larger than the right. On the left side the respiratory murmur was very faint and expansion was defective. There was impaired resonance from the third to the seventh ribs in both interscapular spaces. The patient was comfortable only when propped up and leaning forward. On the 23rd she complained of a lump rising in her throat when she tried to swallow. On the 24th the dysphagia had increased and solid food could not be swallowed. There was pain in the back, the prxcordium, and over the aneurysm. On the 25th the bulging had subsided almost to the level of the chest but posteriorly the right side was prominent and the interscapular space was dull from the third to the eighth rib. Over the dull area breath sounds and vocal fremitus were absent. The patient rapidly lost strength and weight. On Dec. 9th expansile pulsation was no longer visible to the right of the sternum and the murmurs were less loud. The dysphagia and cough increased and there was considerable expectoration of thick lumps of mucus. On the llth swallowing produced such severe paroxysms of coughing that it was necessary to resort to rectal feeding. At times the respiration was harsh and noisy as if the bronchi were compressed. On the 15th the patient was cyanosed and loud bronchial rules could be heard at a distance of some feet from the bed. She could no longer swallow and complained of pain over the whole chest. She suddenly became extremely cyanosed and fell back dead. The necropsy showed an aneurysm arising from the junction of the ascending and transverse portions of the aortic arch and adherent to the sternum It con. at the junction of the second costal cartilage. tained greyish-red laminated clot which projected into the left ventricle and was attached to the musculi pectinati. On the posterior wall of the ascending arch was a second aneurysm which extended posteriorly and compressed the trachea at the level of the bifurcation. The tracheal rings were broken down and the pressure on the posterior wall had produced necrosis with a resulting fistula between the left bronchus and œsophagus. The perforation was half a centimetre in diameter and its edges were necrotic and foulsmelling. Above the level of the fistula the trachea was filled with a milky substance presenting the characters of liquid food. The mucous membrane of the trachea was intensely congested. The bronchi were partially filled with a similar fluid to that contained in the trachea. Throughout the lungs were areas of consolidation which were Dr. Kelly and Dr. confluent in the right lower lobe. Lavenson explain the subsidence of the tumour in the
1530 Two persons who were so sensitive to golden rod that they suffered from paroxysms of sneezing when near it inspired air taken from the midst of a bunch of golden rod. In a few minutes after breathing the filtered air they became comfortable and the irritation ceased. Dr. Heath then made an appliance consisting of two rings to fit the nostrils connected by a bridge. Over the rings he stretched fine "grass linen " or silk chiffon. To get the best results a fine mesh (at least 100 to the inch) was necessary. The rings were placed in the nostrils at a distance of about half an inch from the orifice, so that all inspired air had to pass through the fine netting covering them. They did not interfere with respiration and were worn comfortably. One man wore them continuously for 24 hours, at business and during sleep. The rings were used in a number of severe cases of hay THE CORRASSA COMPOUND. fever and in every one relief was apparent in from 15 NEARLY ten years ago, or, to be exact, in THE LANCET of minutes to an hour. Sometimes the appliance was difficult Dec. 19th, 1896, in an annotation headed "An Infamous to use if the nose was previously so blocked that the patient Quack," we commented upon some abominable documents could not breathe through it. But if he persevered nasal sent out by a person calling himself at that time the Rev. respiration became established and the irritation passed David Jones who vended a nostrum known as the Corrassa away rapidly. In most of the cases Dr. Heath had precompound. We concluded our annotation by commending viously tried various recent remedies for hay fever with little Mr. Jones "to the notice of the police as a man who is success. : Some of the patients had obtained considerable attempting to obtain money under false pretences." At relief at night by putting a wet handkerchief over their length the law (Pede poencz claudio) has overtaken Jones, faces and trying to breathe through this. This fact sugwhose real name appears to be Hawkins, and his son, for gested to Dr. Heath the appliance now described. He they were committed on Sept. 30th by the Brighton magis- usually made the rings of German silver, sometimes of trates for trial at the assizes on a charge of conspiracy tocork and hard rubber. It is not necessary that the two obtain money by fraudulent representations. On Nov. 26thrings should be connected by a bridge but this facilitates the elder Hawkins, who had pleaded guilty, was sentenced their introduction and removal. The bridge passes across The younger prisoner wasthe to three months’ hard labour. septum at its junction with the upper lip and is discharged, no evidence being offered against him. Mr. ]hardly noticeable. The filtering fabric is put on in the Justice Lawrence in passing sentence is reported as saying same way as linen is put on embroidery hoops by women that the case might be regarded as a test case. He hoped, and can be changed whenever desired. It soon becomes however, that the punishment which he inflicted would notmoist, but this increases its filtering power. be taken as an indication of what was necessary in such cases. The false pretences were two : firstly, prisoner repreTHE INTERNATIONAL SOCIETY FOR THE PREthat sented the powders were remedies for certain disorders ; VENTION OF TUBERCULOSIS. and secondly, he pretended that two persons, whom he deAT the meeting of the Societe Internationale de la Tuberscribed as clergymen, had been to some part of Africa and had learned the secret of this remedy. (See a detailed accountculose held on Nov. 6ch in Paris, under the presidency of He wished the Crown success in undertaking Professor Lancereaux, the subject of the compulsory notificaon p. 1565.) of this kind, as it was most desirable in thetion of tuberculosis was under discussion. A paper was prosecutions interest that such frauds should be brought to lightread by Dr. Samuel Bernheim and Dr. Louis Dieupart, who public and put a stop to. These are admirable words ; we. hopereferred to the conclusions of the recent international conbefore long that the Public Prosecutor will turn his atten-ference on tuberculosis (at the Hague in October of this tion to some of the other disgraceful quacks who fill theiryear), and also to the report of the committee of the pockets and those of the proprietors of sundry magazines andAcademy of Medicine (June, 1906). These observers mainpapers by trading on the credulities of weak-minded persons.tained that the prophylaxis of tuberculosis could not be A glance at the advertisement pages of any popular monthlyimade real and efficacious unless the compulsory notification (of the disease was legally enforced. They further exmagazine will give him plenty of material. pressed their conviction that with such a formidable enemy A SIMPLE CONTRIVANCE FOR THE TREATMENT no half measures would avail; they considered that compulsory notification of tuberculosis could be made without OF HAY FEVER. any shock to humanity and pointed out that certain IN the Journal of the American Medical Association of countries had adopted this system and found the advantage Oct. 20th Dr. A. C. Heath has reported some ingenious ex- oof it. It is, of course, understood that compulsory notificaperiments performed during the hay fever season of 1905 totion t involves, ipso facto, compulsory disinfection. We have prove that the atmosphere was laden with some irritating on 0 previous occasions drawn attention to the arguments He used substance which could be removed by filtration. which have been advanced in favour of, and against, coman ordinary water-bottle of the chemical laboratory fitted and voluntary notification of tuberculosis, and in a p pulsory with two glass tubes to one of which was attached rubber leading article in THE LANCET of August llth, 1906, tubing. The bottle was half filled with water and when p. p 380, we laid stress on the importance of distinguishsuction was made through the rubber tubing the air inhaled between cases of "open" and "closed " tubering passed through the water. The apparatus worked on the cculosis when considering the advisability of notifying principle of the Turkish pipe. By this means it was hopedthe t As we have indicated, Dr. Bernheim and disease. that any material suspended in the air would be removedI Dr. Dieupart are firmly impressed with the necessity in its passage through the water. In the experiments o of resorting to the strict régime of compulsory notifithe subjects inspired through the nose, which was con0 cation ; we note with satisfaction, however, that they nected with the apparatus, and expired through the mouth. suggest that during the lifetime of the patients notification should only apply to manifest tuberculosis in which tubercle 1 Guy’s Hospital Reports, 1856, vol. ii., p. 250.
chest as follows. The wall of the posterior aneurysm became weaker, permitting its enlargement and causing pressure on the trachea and oesophagus. As this was the nearer aneurysm to the left ventricle it received the force of the ventricular systole and permitted the subsidence of the anterior aneurysm. Only one other case of bronchooesophageal fistula due to aneurysm appears to have been recorded. Habershon reported1 the case of a man, aged 23 years, suffering from traumatic aneurysm of the arch off the aorta which proved fatal by perforation into the peri. cardium. For a week preceding death there was considerable dysphagia. At the necropsy a fistula was found in exactly the same position as in the case now recorded.
c
ii
s,