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FURTHER OBSERVATIONS ON STERTOR ; ITS PATHOLOGY AND TREATMENT.
971 end of the wire stitches, draw them out, and so allow the slip of rubber to come away by the rectum with the usual motions. A week after this the fistula is noted as ,"healing 28th.-Some tenderness and some headache. Temperature 99’3°. Forceps came away in the afternoon, bringing away quickly," and a fortnight later as "nearly closed." After this it required to be touched two or three times with lunar caustic to stimulate, its deeper parts, On June 29th, or and twice with Paquelin’s - cautery. within eight weeks of the last operation, the wound was quite closed. The patient now rose every day, and soon went to the country. He returned some two months later to show himself, when the scar was found by myself and colleagues to be perfectly secure, and he himself in rude health. He volunteered the remark that since the operation he Lad lost all that sensation of "internal straining " about the seat of interruption in the gut which had troubled him , First portion removed Second portion removed formerly as the contents forced themselvesagainst the between blades. of between blades of narrowed spot on their way to the anal portion. He -also forceps. (Nat. size forceps. (Nat. size when dried.) when dried.) said that he felt as well as ever he had felt in his life, and had now no abnormal sensation at all in the abdomen. a portion of mucous membrane between the blades, of the It appears to me probable that whatever part this valve :size given in Fig. 2. may have played in effecting this very complete cure of a very troublesome fistula, it may be found useful in other similar cases. I think in another similar case 1. should employ somewhat thinner rubber, and perhaps also modify the shape of the valve somewhat. I cannot conclude without thanking, my colleague, Mr. Berkeley Hill, for kindly transferring this case to my care. Harley-.street.
27th.-Slight tenderness
ture 99-60.
in
right iliac region. Tempera-
FURTHER OBSERVATIONS ON STERTOR ; ITS PATHOLOGY AND TREATMENT.1 BY ROBERT L.
(Communicated by
Diagram (about
half natural size) showing condition of a a, Abdominal wall. b, External orifice of fistula in latter. c, Internal ditto. dd, Intestine. e, " Spur" in latter directing contents into fistula. Arrows indicate the direction of flow of faeces.
BOWLES, M.D.
CÆSAR HAWKINS,
F.R.S.)
parts before operation.
IN the forty-eighth volume of the Transactions of the Royal Medical and Chirurgical Society is a, paper entitled Observations on Stertor." Since the publication of that 29th.-Feels as yesterday. 30th.-Very well; all tenderness gone from iliac region; paper, if I except a paragraph in the article " ’Chloroform," in Holmes’s System of Surgery, I know of nothing which tongue clean. Temperature 98 ’8°. May 6th.-Yesterday afternoon, having patient under the has been contributed to medical literature on this subject. influence of ethedene, I inserted an india-rubber valve In my first paper only three forms of stertor are defined, (Fig. 4,.t) within the intestine in such a manner as to lap Palatine, Pharyngeal, and Mucous Stertor. Professor, Lister refers to a "laryngeal stertor," as occurring during a "
certain stage of the inhalation of chloroform, but as it has practical connexion, so far as I am, aware,, with the apoplectic and its allied conditions, we will at present dismiss it from further, consideration. The forms of stertor, then, which have a direct connexion with the apoplectic state are-the palatine, arising from the vibrations of the soft palate; the pharyngeal, ,from’ the gravitation of-the tongue into the back of the pharynx, and the mucous stertor, from the presence of mucus or other fluids in the larger air-tubes. These three varieties;. whatever their remote cause, are the immediate result of a local mechanical condition-a condition which may always and at once be changed, to the great relief of the patients, and sometimes to their permanent recovery. Since adopting this method of management many other points have developed themselves of the utmost practical importance both to the surgeon and to the physician. CASE 1.-In October, 1863, Mrs. S- was seized with apoplexy. On my arrival there was a partial return to consciousness, and the left side was found to be paralysed. There was pharyngeal stertor when in the recumbent posture, and she appeared uneasy when placed on her tight side, so she was placed on her left, when the stertor, ceased. A blister was applied to the nape of the neck, and she -remained in this position for nine days. She was now,better, and spoke to me. Fearing a bedsore, I desired the nurse to change her position by turning her from her left to her right side. Soon after this was done she was distressed for breath, and the countenance became livid. On my arrival Ifound the difficulty of breathing gradually increasing, the blistered surface and the ear upon which she had lain of a dark-purple hue, and the pulse, which had before been weak and, irregular, full and bounding. There were large ’mucous tales no
.Diagram (lettered as’Fig: 3) -showing condition of:,,parts after
operation.
e, Remainder of
"spur’! after removal
by forceps. f, India-rubber valve in situ, closing internal orifice of fistula., gg, Silver stitches holding valve by both ends in situ.
up against the internal orifice of the fistula. It was fastened
in this position to the skin by a single wire-stitch at each end (g g), passing through the. latter in such a way as to The pressure of the faeces against this valve was secure it. relied upon to make it fit still more closely to the curves of the opening. The valve itself was thin ,and flexible, about one and a half inches long by five-eighths of an inch broad, and was inserted with the double object of giving the fistula rest, on the one.hand by preventing the faeces from escaping that way, and, on the other hand, of keeping the, newly-notched spur of mucous membrane from recontraction: by directing the full stream of faeces against it until it was’ soundly healed. The first of these objects was attained fox several days, but at last a little gas and faeces escaped undei the lower edge of the rubber valve, -and at the end of a week the fistula seemed to be enlarging a little at its lower: border. I therefore removed the rubber slip through the opening.My intention had been to allow it to remain untill 1 A; paper the tistula had closed over it, and then simply to cut oneMay 10th.
read at the
Royal Medical and, Chirurgical. Society,
972 over the whole chest; she was quite unconscious, and death The following case would, I believe, have terminated .from suffocation was imminent. Finding that these sym- fatally but for the careful management of position. CASE 4.-Mrs. S- was seized on Sept. 24th, 1867, with ptoms supervened upon the change of position, I had her replaced upon her lett side, and immediately the pulse sank, left hemiplegia. She was unable to speak or to masticate, the mucous stertor ceased, the breathing was relieved, the and could only swallow liquids with much difficulty ; the lividity of countenance passed away, and the blistered pulse was 80, and very feeble. She was placed on her left surface, which had been almost black, resumed a bright side. On Sept. 28th (four days after) the respiratory murmur cherry-red colour. This additional shock, however, proved on the left side was shallow and feeble, there weie some too much for her, and she died the same day, peaceful and rates, and the percussion sounds were dull. She was turned on her right side, when immediately great distress of breath. conscious. The silient points of this interesting case are : (1) That ing and mucous stertor supervened ; this gradually disappharyngeal stertor ceased when the patient was placed on peared on replacing her on her left side. When turned on her side ; (2) that there was a slow but gradual improvement her back, for the use of the bed-pan, mucous stertor comsubsequent to this; (3) that mucous stertor and imminent menced, and it was noticed that in this position the interdeath supervened when she was placed on the opposite costal muscles and the diaphragm acted more feebly than on side; (4) the instant relief on resuming her original position; the unparalysed side. On Sept. 29th there was a little more and (5) thit a return to consciousness was coincident with power, and she was less excitable. The respirations, which the cessation of tertor; in other words, on the removal of had been 56, were now 44. She was able to remain half an hour on the right side before the difficult breathing comthe respiratory difficulty. On a careful examination of the chest after she became menced. The following day she was still better; and the quiet, I found all râles slowly fade away from the right side, dribbling of saliva, which had been very great, ceased, but she still had no control over her bladder or rectum.-Oct. 6th: or that which was uppermost, and the natural breathing return ; hut the left lung, which had been dependent During the last week she has slowly improved. Several exthroughout, was dull on percussion and deficient in respira- periments of change of position have been made, and it was tory murmur. The explanation now became clear-viz., found that as her power returned she could remain longer on that the dependent lung had become filled with some mucous the right side before the difficulty of breathing commenced, fluid, and that on changing the side the fluid, by gravitation, and now can remain an hour and a half in this position. She speaks better, eats and sleeps better. Tongue is cleanwas finding its way across the trachea to the opposite lung, but in doing so it had been churned into foam by the ingoing ing ; bowels open, but she is still unable to retain her water. air,giving rise to mucous stertor, and that this foam, by Pulse 80, respiration quiet and natural; on the right side the filling up the larger bronchial tubes, was quickly causing respiratory murmur is natural, on the left there are still a few suffocation with all its usual results. râles, but the resonance is good, and the air enters more As a point of management, then, in a case of apoplexy, it freely. Power is returning to the hand and face.-March, would appear necessary to keep the patient on one side, 1870:The patient is still alive and well, but has a good and not to change it ; but which side should this be ? deal of weakness on the left side. Remarks.-In its early stage this case was most critical; Healthy people when lying on their side breathe chiefly with the side which is uppermost; for the intercostal and had a little extra strain been put upon her, she must have other thoracic muscles of the lower side are fixed between died, and no strain could have been worse than the perthe weight of the body and the bed, and the breathing of sistence of a condition (stertorous breathing) which would this side is almost entirely diaphragmatic. indirectly cause obstruction in the jugulars. In the supine CASE 2.--Dr. Fitzgerald during his attendance on a case posture, from the paralysed and insensible condition of the of cancer of the brain finding the breathing much oppressed pharynx, much of the saliva which dribblfd away in the by mucus in the air-passages, at my suggestion placed the lateral position would have entered the trachea, and added patient on his side, when he became suddenly so much to the trouble. Sir James Simpson, in writing of the treatworse that he thought he would have died instantly. Dr. ment of phlegmasia dolens, says: "Position is one of the Fitzgerald repeated the experiment with exactly the same most powerful means in the treatment of many diseases; results, and he found that the difficulty arose from mucus attention to this point is frequently of more importance, and in the trachea and larger air-tubes. It was afterwards dis- affords more satisfactory results, than the use of any kind or covered that the paralysed side was placed upwards. Un- quantity of drugs." In no case is this opinion of Sir James so aptly illustrated as in certain affections of the fortunately, only the head was examined after death ; but I have reason to believe that in hemiplegia from progressive brain and air-passages. Dr. Bence Jones, in writing to me disease of the brain a low form of inflammatory action takes on this subject, sas :"The case I mentioned to you was place in the lung of the affected side from disturbed innerva- one of extreme hemiplegia of the right side, for the first few hours with perfect clearness of mind, passing in twelvehours tion of the pneumogastric nerves. In a recent case of tubercular mass in the centre of the into complete coma, with the most intense and distressing brain, which was under my care, this was the case, and stertor, lasting for many hours. This was immediately precisely the same distress as above-mentioned occurred from stopped by changing the position of the patient to one side. It But it had no known effect on the progress of the case. The mucus when the paralysed side was placed upwards. The must be remembered, too, that in placing the paralysed side total duration, I think, was not forty-eight hours. downwards the injured side of the brain is upwards, and gentleman was about sixty-two, pale and rather sickly, and therefore relieved from congestion, a condition always liable had always feared apoplexy." Mr. Reid of Canterbury, and many other of my friends, to occur when an injured part remains dependent. Apoplexy, with much mucous stertor, is, I believe, have reported to me cases of apoplexy in which, on the always of the most dangerous character, for it change of position, stertor has ceased, and the patients have indicates, as well as muscular paralysis, loss of function of died peacefully and quietly, to the great relief of the dissuch vital nerves as the pneumogastric, and, I believe, the tressed and sorrowing relatives. I have never in my own time will soon come, now that cases can be so simplified by practice failed to do away with stertor by position and the removal of stertor, that by a careful consideration of the management. functions of the various nerves a very accurate diagnosis CASE 5.-At a medical meeting in May, 1862, after urging and prognosis will be arrived at even in the early stage of my views on stertor, Mr. Francis of Boughton stated that he had just left an old lady dying from apoplexy, who had apoplexy. CASE 3.-Mrs. W- was found lying on her back been in a state of stertor for many hours. At the November breathing stertorously and with great difficulty ; the trachea meeting in the same year he informed us that the old lady was still alive and well. was filled with frothy mucus, and she was almost in a state On his return home he found her of collapse. She was turned on her right side, when the just as he had left her, dying as he believed. He changed stertor and difficulty of breathing ceased. Seventeen hours her position, the stertor ceased, and she gradually but perafterwards she was lying quiet and comfortable; the depend- fectly recovered. CASE 6.-Mr. Eustace Carver of Melbourne, a former ing cheek was dusky and congested, the upper cheek pale. She was now turned on her left side; the difficult breathing house-surgeon at the Middlesex and Nottingham hospitals, immediately returned, and both sides of the face became and a careful observer, was called to Captain B-, in deep
Simpson
grave and
the breathing was shallow and large stertor and moribund. Life was evidentty more a question present in both sides of the chest ; on re- of minutes than hours. The position was changed, the suming the orignal position all difficulty ceased. She died stertor ceased, and the old gentleman lived nine months.
highly congested ;
moist rales
the next
were
morning.
CASE 7.-Dr. Lewis of Folkestone
was
sent for to Mrs.
973 ’
F-, aged sixty-seven.
He found her in bed in the apo-
plectic condition. There was total loss of consciousness, the pupils were fixed, but there was slight reflex action on touching the eyeball, the face was turgid, the cheeks were and there was deep pharyngeal puffed out on expiration, on her side the stertor ceased and stertor. On being placed she gradually improved. In twelve hours she had perfectly recovered consciousness, the respiration was normal, the face very pale, the pulse quick and feeble ; there was no paralysis. The action of the heart was feeble, but there was no murmur. CASE 8.-I was called in August, 1859, to a boy who had fallen on his head from a height. I found him lying on his back snoring, senseless, and collapsed ; pulse irregular and pupils alternately contracting and dilating. The mouth On turning him on his was half full of vomited matter. side the snoring (palatine stertor) ceased, he was sick several times with comparative ease. Presently he began snoring whilst he was on his side, his chin was bent upon the sternum; on straightening the neck he was quiet. The boy slowly recovered. On three different occasions in my own practice I have been summoned to cases of apoplexy with stertor, in which the patients recovered, two with and one without paralysis. Case 4 demonstrates that as power returns to the brair the pneumogastric and probably also the sympatheti< regain their power, and effusion into the lung ceases ; and, moreover, that the, lung is not injured by remaining in. active and filled with mucus for a long period. (To be concluded.)
NOTE ON THE DIAGNOSIS OF CAVITY IN THE LUNG. BY SOLOMON CHARLES
SMITH,
SURGEON TO THE HALIFAX INFIRMARY.
I HAVE recently met with a peculiar physical sign of deepseated cavity in the lung, of which I can find no mention in any of the books within my reach, and which seems worthy of being placed on record. It is a sound synchronous with the cardiac systole, not necessarily heard over the lung, but distinctly audible in the trachea, and even without the stethoscope when merely standing opposite the patient, and obviously produced by the impact of the contracting ventricle against a neighbouring cavity, expelling such a puff of air as to produce a sound in the bronchus and trachea. My first patient was a man suffering from cough, expectoration, and shortness of breath. While watching the expansion of his lungs I heard a bruit synchronous with the first sound of the heart; it was short and soft, but plainly audible when we were about eighteen inches apart. On applying the stethoscope over the heart nothing abnormal was heard, but over the lung to the left the bruit was easily perceived. Systolic bruit over the left upper lobe is, however, no strange thing in phthisis, but on tracing it up it was loudly audible in the trachea, and on careful observation it was plain that the sound was conveyed outwards through the air-passages. Easy respiration did not interfere with its production, but on breathing deeply or quickly it was in-
terrupted during inspiration. The other physical signs were dulness, diminished respiration, and expansion, with moist clicks over the upper five inches of the left lung, and some tubular cough sound at the third interspace. In my next case the physical sign I have described was not so well marked-that is, it was more easily interrupted by inspiration, and could not be heard quite so far from the patient; but, on the other hand, its connexion with a cavity was more completely demonstrated, the presence of a vomica being proved by a concurrence of many physical signs. I do not at all wish to add another to the many sounds which have been described as occurring in cavities in the lung ; if this were audible only over the position of the vomica it would be a matter of no great interest. Any importance it may possess arises from its being transmitted to the ear through the air-passages rather than through the chest walls, and thus being audible even when the disease is deeply placed. I may add that in auscultation of the trachea and larynx a flexible stethoscope is of great service. Halifax.
AN UNUSUAL CASE OF CONGENITAL SYPHILIS. BY M.
PRICKETT, M.D.
THE following case appears to me of so much interest both from its rarity and its importance as to deserve publication; especially so as I am unable to find any records of precisely similar symptoms. Mr. contracted syphilis three years ago ; a chancre developed, and in due course of time mild secondary symptoms followed. These soon disappeared under treatment, which was continued for about six weeks, and the disease appeared eradicated. He remained in good health until his marriage a year ago; shortly after which, however, a skin eruption of doubtful nature developed itself. This was treated without avail by a large variety of remedies, amongst which were mercury and iodide of potassium; but I am unable to learn how long they were persevered with. As the eruption got considerably worse a specialist was consulted, who pronounced the disease to be psoriasis, but of a non-specific character. In spite of his treatment the eruption spread until, three months ago, his legs and arms were covered with it and patches also appeared upon the trunk. About a year after his marriage Mrs. was confined with a female child under my care ; the labour was natural and easy and the mother recovered without developing any symptoms of syphilitic infection. The infant appeared perfectly healthy and was suckled by its mother; it fed regularly, the motions were normal in colour and frequency, and it slept soundly. On the night of the fourteenth day after birth it refused the breast and was observed by the nurse to be drowsy and feeble; at 1 A.M. she found it cold, blue, and gasping for breath. When I arrived an hour later it was in a state of semi-collapse, dusky, pulse running and almost imperceptible, and so weak it could scarcely cry or move. The temperature was 99 5°. It was ordered some brandy and a warm bath. Next morning a few mulberry-colonred spots were visible on the face, arms, and buttocks, which did not fade on pressure and were scarcely raised above the surface, but became as the day passed darker in colour and more prominent. Some fresh spots also appeared upon the legs. The temperature was now 102° ; the child had been sick several times and the motions were somewhat slimy; otherwise the child appeared better ; the pulse was stronger and skin less dusky.’- Suspecting that the child might be suffering from variola, it was weaned and separated from the mother for the next three days. The child rapidly improved in its condition, but the spots, about ten in number, grew hard, raised, and black, much resembling the spots of hæmorrhagic variola. In about three days time it appeared quite well, the spots remaining as before. On the after the first attack it was seized in the same way again. It became rigid, cold, dusky, the respirations became gasping, and, according to its nurse,"it seemed convulsed." I saw it about an hour afterwards it had partially recovered ; the heart sounds were normal and so was the temperature. It fed as usual and the motions were healthy. It was ordered bromide of potassium and ammonia together with a little brandy at short intervals. In the night it had two or three similar attacks followed by much larger extravasations of blood beneath the skin. The next morning it was much weaker; it could scarcely cry, and did not take notice of anything about it, although it continued to take its food regularly and the motions remained healthy. The subcutaneous extravasations, three or four in number, took the form of bluish rounded lumps about one and a half inches in diameter, and there -were also some small petechiae upon the legs and buttocks. From this time the child gradually sank ; cerebral respiration supervened, and it died on the fourth day of the second attack. No post-mortem examination was made. The child was never treated mercurially because the syphilitic character of the disease was not suspected, partly owing to my not being aware at the time of the father’s previous history, nor of the existence of his skin affection, and partly to my ignorance of -
-
fifth day
When
1
Careful examination of the heart elicited
ever.
no
signs of disease what-
27th.-Slight tenderness
ture 99-60.
in
right iliac region. Tempera-
FURTHER OBSERVATIONS ON STERTOR ; ITS PATHOLOGY AND TREATMENT.1 BY ROBERT L.
(Communicated by
Diagram (about
half natural size) showing condition of a a, Abdominal wall. b, External orifice of fistula in latter. c, Internal ditto. dd, Intestine. e, " Spur" in latter directing contents into fistula. Arrows indicate the direction of flow of faeces.
BOWLES, M.D.
CÆSAR HAWKINS,
F.R.S.)
parts before operation.
IN the forty-eighth volume of the Transactions of the Royal Medical and Chirurgical Society is a, paper entitled Observations on Stertor." Since the publication of that 29th.-Feels as yesterday. 30th.-Very well; all tenderness gone from iliac region; paper, if I except a paragraph in the article " ’Chloroform," in Holmes’s System of Surgery, I know of nothing which tongue clean. Temperature 98 ’8°. May 6th.-Yesterday afternoon, having patient under the has been contributed to medical literature on this subject. influence of ethedene, I inserted an india-rubber valve In my first paper only three forms of stertor are defined, (Fig. 4,.t) within the intestine in such a manner as to lap Palatine, Pharyngeal, and Mucous Stertor. Professor, Lister refers to a "laryngeal stertor," as occurring during a "
certain stage of the inhalation of chloroform, but as it has practical connexion, so far as I am, aware,, with the apoplectic and its allied conditions, we will at present dismiss it from further, consideration. The forms of stertor, then, which have a direct connexion with the apoplectic state are-the palatine, arising from the vibrations of the soft palate; the pharyngeal, ,from’ the gravitation of-the tongue into the back of the pharynx, and the mucous stertor, from the presence of mucus or other fluids in the larger air-tubes. These three varieties;. whatever their remote cause, are the immediate result of a local mechanical condition-a condition which may always and at once be changed, to the great relief of the patients, and sometimes to their permanent recovery. Since adopting this method of management many other points have developed themselves of the utmost practical importance both to the surgeon and to the physician. CASE 1.-In October, 1863, Mrs. S- was seized with apoplexy. On my arrival there was a partial return to consciousness, and the left side was found to be paralysed. There was pharyngeal stertor when in the recumbent posture, and she appeared uneasy when placed on her tight side, so she was placed on her left, when the stertor, ceased. A blister was applied to the nape of the neck, and she -remained in this position for nine days. She was now,better, and spoke to me. Fearing a bedsore, I desired the nurse to change her position by turning her from her left to her right side. Soon after this was done she was distressed for breath, and the countenance became livid. On my arrival Ifound the difficulty of breathing gradually increasing, the blistered surface and the ear upon which she had lain of a dark-purple hue, and the pulse, which had before been weak and, irregular, full and bounding. There were large ’mucous tales no
.Diagram (lettered as’Fig: 3) -showing condition of:,,parts after
operation.
e, Remainder of
"spur’! after removal
by forceps. f, India-rubber valve in situ, closing internal orifice of fistula., gg, Silver stitches holding valve by both ends in situ.
up against the internal orifice of the fistula. It was fastened
in this position to the skin by a single wire-stitch at each end (g g), passing through the. latter in such a way as to The pressure of the faeces against this valve was secure it. relied upon to make it fit still more closely to the curves of the opening. The valve itself was thin ,and flexible, about one and a half inches long by five-eighths of an inch broad, and was inserted with the double object of giving the fistula rest, on the one.hand by preventing the faeces from escaping that way, and, on the other hand, of keeping the, newly-notched spur of mucous membrane from recontraction: by directing the full stream of faeces against it until it was’ soundly healed. The first of these objects was attained fox several days, but at last a little gas and faeces escaped undei the lower edge of the rubber valve, -and at the end of a week the fistula seemed to be enlarging a little at its lower: border. I therefore removed the rubber slip through the opening.My intention had been to allow it to remain untill 1 A; paper the tistula had closed over it, and then simply to cut oneMay 10th.
read at the
Royal Medical and, Chirurgical. Society,
972 over the whole chest; she was quite unconscious, and death The following case would, I believe, have terminated .from suffocation was imminent. Finding that these sym- fatally but for the careful management of position. CASE 4.-Mrs. S- was seized on Sept. 24th, 1867, with ptoms supervened upon the change of position, I had her replaced upon her lett side, and immediately the pulse sank, left hemiplegia. She was unable to speak or to masticate, the mucous stertor ceased, the breathing was relieved, the and could only swallow liquids with much difficulty ; the lividity of countenance passed away, and the blistered pulse was 80, and very feeble. She was placed on her left surface, which had been almost black, resumed a bright side. On Sept. 28th (four days after) the respiratory murmur cherry-red colour. This additional shock, however, proved on the left side was shallow and feeble, there weie some too much for her, and she died the same day, peaceful and rates, and the percussion sounds were dull. She was turned on her right side, when immediately great distress of breath. conscious. The silient points of this interesting case are : (1) That ing and mucous stertor supervened ; this gradually disappharyngeal stertor ceased when the patient was placed on peared on replacing her on her left side. When turned on her side ; (2) that there was a slow but gradual improvement her back, for the use of the bed-pan, mucous stertor comsubsequent to this; (3) that mucous stertor and imminent menced, and it was noticed that in this position the interdeath supervened when she was placed on the opposite costal muscles and the diaphragm acted more feebly than on side; (4) the instant relief on resuming her original position; the unparalysed side. On Sept. 29th there was a little more and (5) thit a return to consciousness was coincident with power, and she was less excitable. The respirations, which the cessation of tertor; in other words, on the removal of had been 56, were now 44. She was able to remain half an hour on the right side before the difficult breathing comthe respiratory difficulty. On a careful examination of the chest after she became menced. The following day she was still better; and the quiet, I found all râles slowly fade away from the right side, dribbling of saliva, which had been very great, ceased, but she still had no control over her bladder or rectum.-Oct. 6th: or that which was uppermost, and the natural breathing return ; hut the left lung, which had been dependent During the last week she has slowly improved. Several exthroughout, was dull on percussion and deficient in respira- periments of change of position have been made, and it was tory murmur. The explanation now became clear-viz., found that as her power returned she could remain longer on that the dependent lung had become filled with some mucous the right side before the difficulty of breathing commenced, fluid, and that on changing the side the fluid, by gravitation, and now can remain an hour and a half in this position. She speaks better, eats and sleeps better. Tongue is cleanwas finding its way across the trachea to the opposite lung, but in doing so it had been churned into foam by the ingoing ing ; bowels open, but she is still unable to retain her water. air,giving rise to mucous stertor, and that this foam, by Pulse 80, respiration quiet and natural; on the right side the filling up the larger bronchial tubes, was quickly causing respiratory murmur is natural, on the left there are still a few suffocation with all its usual results. râles, but the resonance is good, and the air enters more As a point of management, then, in a case of apoplexy, it freely. Power is returning to the hand and face.-March, would appear necessary to keep the patient on one side, 1870:The patient is still alive and well, but has a good and not to change it ; but which side should this be ? deal of weakness on the left side. Remarks.-In its early stage this case was most critical; Healthy people when lying on their side breathe chiefly with the side which is uppermost; for the intercostal and had a little extra strain been put upon her, she must have other thoracic muscles of the lower side are fixed between died, and no strain could have been worse than the perthe weight of the body and the bed, and the breathing of sistence of a condition (stertorous breathing) which would this side is almost entirely diaphragmatic. indirectly cause obstruction in the jugulars. In the supine CASE 2.--Dr. Fitzgerald during his attendance on a case posture, from the paralysed and insensible condition of the of cancer of the brain finding the breathing much oppressed pharynx, much of the saliva which dribblfd away in the by mucus in the air-passages, at my suggestion placed the lateral position would have entered the trachea, and added patient on his side, when he became suddenly so much to the trouble. Sir James Simpson, in writing of the treatworse that he thought he would have died instantly. Dr. ment of phlegmasia dolens, says: "Position is one of the Fitzgerald repeated the experiment with exactly the same most powerful means in the treatment of many diseases; results, and he found that the difficulty arose from mucus attention to this point is frequently of more importance, and in the trachea and larger air-tubes. It was afterwards dis- affords more satisfactory results, than the use of any kind or covered that the paralysed side was placed upwards. Un- quantity of drugs." In no case is this opinion of Sir James so aptly illustrated as in certain affections of the fortunately, only the head was examined after death ; but I have reason to believe that in hemiplegia from progressive brain and air-passages. Dr. Bence Jones, in writing to me disease of the brain a low form of inflammatory action takes on this subject, sas :"The case I mentioned to you was place in the lung of the affected side from disturbed innerva- one of extreme hemiplegia of the right side, for the first few hours with perfect clearness of mind, passing in twelvehours tion of the pneumogastric nerves. In a recent case of tubercular mass in the centre of the into complete coma, with the most intense and distressing brain, which was under my care, this was the case, and stertor, lasting for many hours. This was immediately precisely the same distress as above-mentioned occurred from stopped by changing the position of the patient to one side. It But it had no known effect on the progress of the case. The mucus when the paralysed side was placed upwards. The must be remembered, too, that in placing the paralysed side total duration, I think, was not forty-eight hours. downwards the injured side of the brain is upwards, and gentleman was about sixty-two, pale and rather sickly, and therefore relieved from congestion, a condition always liable had always feared apoplexy." Mr. Reid of Canterbury, and many other of my friends, to occur when an injured part remains dependent. Apoplexy, with much mucous stertor, is, I believe, have reported to me cases of apoplexy in which, on the always of the most dangerous character, for it change of position, stertor has ceased, and the patients have indicates, as well as muscular paralysis, loss of function of died peacefully and quietly, to the great relief of the dissuch vital nerves as the pneumogastric, and, I believe, the tressed and sorrowing relatives. I have never in my own time will soon come, now that cases can be so simplified by practice failed to do away with stertor by position and the removal of stertor, that by a careful consideration of the management. functions of the various nerves a very accurate diagnosis CASE 5.-At a medical meeting in May, 1862, after urging and prognosis will be arrived at even in the early stage of my views on stertor, Mr. Francis of Boughton stated that he had just left an old lady dying from apoplexy, who had apoplexy. CASE 3.-Mrs. W- was found lying on her back been in a state of stertor for many hours. At the November breathing stertorously and with great difficulty ; the trachea meeting in the same year he informed us that the old lady was still alive and well. was filled with frothy mucus, and she was almost in a state On his return home he found her of collapse. She was turned on her right side, when the just as he had left her, dying as he believed. He changed stertor and difficulty of breathing ceased. Seventeen hours her position, the stertor ceased, and she gradually but perafterwards she was lying quiet and comfortable; the depend- fectly recovered. CASE 6.-Mr. Eustace Carver of Melbourne, a former ing cheek was dusky and congested, the upper cheek pale. She was now turned on her left side; the difficult breathing house-surgeon at the Middlesex and Nottingham hospitals, immediately returned, and both sides of the face became and a careful observer, was called to Captain B-, in deep
Simpson
grave and
the breathing was shallow and large stertor and moribund. Life was evidentty more a question present in both sides of the chest ; on re- of minutes than hours. The position was changed, the suming the orignal position all difficulty ceased. She died stertor ceased, and the old gentleman lived nine months.
highly congested ;
moist rales
the next
were
morning.
CASE 7.-Dr. Lewis of Folkestone
was
sent for to Mrs.
973 ’
F-, aged sixty-seven.
He found her in bed in the apo-
plectic condition. There was total loss of consciousness, the pupils were fixed, but there was slight reflex action on touching the eyeball, the face was turgid, the cheeks were and there was deep pharyngeal puffed out on expiration, on her side the stertor ceased and stertor. On being placed she gradually improved. In twelve hours she had perfectly recovered consciousness, the respiration was normal, the face very pale, the pulse quick and feeble ; there was no paralysis. The action of the heart was feeble, but there was no murmur. CASE 8.-I was called in August, 1859, to a boy who had fallen on his head from a height. I found him lying on his back snoring, senseless, and collapsed ; pulse irregular and pupils alternately contracting and dilating. The mouth On turning him on his was half full of vomited matter. side the snoring (palatine stertor) ceased, he was sick several times with comparative ease. Presently he began snoring whilst he was on his side, his chin was bent upon the sternum; on straightening the neck he was quiet. The boy slowly recovered. On three different occasions in my own practice I have been summoned to cases of apoplexy with stertor, in which the patients recovered, two with and one without paralysis. Case 4 demonstrates that as power returns to the brair the pneumogastric and probably also the sympatheti< regain their power, and effusion into the lung ceases ; and, moreover, that the, lung is not injured by remaining in. active and filled with mucus for a long period. (To be concluded.)
NOTE ON THE DIAGNOSIS OF CAVITY IN THE LUNG. BY SOLOMON CHARLES
SMITH,
SURGEON TO THE HALIFAX INFIRMARY.
I HAVE recently met with a peculiar physical sign of deepseated cavity in the lung, of which I can find no mention in any of the books within my reach, and which seems worthy of being placed on record. It is a sound synchronous with the cardiac systole, not necessarily heard over the lung, but distinctly audible in the trachea, and even without the stethoscope when merely standing opposite the patient, and obviously produced by the impact of the contracting ventricle against a neighbouring cavity, expelling such a puff of air as to produce a sound in the bronchus and trachea. My first patient was a man suffering from cough, expectoration, and shortness of breath. While watching the expansion of his lungs I heard a bruit synchronous with the first sound of the heart; it was short and soft, but plainly audible when we were about eighteen inches apart. On applying the stethoscope over the heart nothing abnormal was heard, but over the lung to the left the bruit was easily perceived. Systolic bruit over the left upper lobe is, however, no strange thing in phthisis, but on tracing it up it was loudly audible in the trachea, and on careful observation it was plain that the sound was conveyed outwards through the air-passages. Easy respiration did not interfere with its production, but on breathing deeply or quickly it was in-
terrupted during inspiration. The other physical signs were dulness, diminished respiration, and expansion, with moist clicks over the upper five inches of the left lung, and some tubular cough sound at the third interspace. In my next case the physical sign I have described was not so well marked-that is, it was more easily interrupted by inspiration, and could not be heard quite so far from the patient; but, on the other hand, its connexion with a cavity was more completely demonstrated, the presence of a vomica being proved by a concurrence of many physical signs. I do not at all wish to add another to the many sounds which have been described as occurring in cavities in the lung ; if this were audible only over the position of the vomica it would be a matter of no great interest. Any importance it may possess arises from its being transmitted to the ear through the air-passages rather than through the chest walls, and thus being audible even when the disease is deeply placed. I may add that in auscultation of the trachea and larynx a flexible stethoscope is of great service. Halifax.
AN UNUSUAL CASE OF CONGENITAL SYPHILIS. BY M.
PRICKETT, M.D.
THE following case appears to me of so much interest both from its rarity and its importance as to deserve publication; especially so as I am unable to find any records of precisely similar symptoms. Mr. contracted syphilis three years ago ; a chancre developed, and in due course of time mild secondary symptoms followed. These soon disappeared under treatment, which was continued for about six weeks, and the disease appeared eradicated. He remained in good health until his marriage a year ago; shortly after which, however, a skin eruption of doubtful nature developed itself. This was treated without avail by a large variety of remedies, amongst which were mercury and iodide of potassium; but I am unable to learn how long they were persevered with. As the eruption got considerably worse a specialist was consulted, who pronounced the disease to be psoriasis, but of a non-specific character. In spite of his treatment the eruption spread until, three months ago, his legs and arms were covered with it and patches also appeared upon the trunk. About a year after his marriage Mrs. was confined with a female child under my care ; the labour was natural and easy and the mother recovered without developing any symptoms of syphilitic infection. The infant appeared perfectly healthy and was suckled by its mother; it fed regularly, the motions were normal in colour and frequency, and it slept soundly. On the night of the fourteenth day after birth it refused the breast and was observed by the nurse to be drowsy and feeble; at 1 A.M. she found it cold, blue, and gasping for breath. When I arrived an hour later it was in a state of semi-collapse, dusky, pulse running and almost imperceptible, and so weak it could scarcely cry or move. The temperature was 99 5°. It was ordered some brandy and a warm bath. Next morning a few mulberry-colonred spots were visible on the face, arms, and buttocks, which did not fade on pressure and were scarcely raised above the surface, but became as the day passed darker in colour and more prominent. Some fresh spots also appeared upon the legs. The temperature was now 102° ; the child had been sick several times and the motions were somewhat slimy; otherwise the child appeared better ; the pulse was stronger and skin less dusky.’- Suspecting that the child might be suffering from variola, it was weaned and separated from the mother for the next three days. The child rapidly improved in its condition, but the spots, about ten in number, grew hard, raised, and black, much resembling the spots of hæmorrhagic variola. In about three days time it appeared quite well, the spots remaining as before. On the after the first attack it was seized in the same way again. It became rigid, cold, dusky, the respirations became gasping, and, according to its nurse,"it seemed convulsed." I saw it about an hour afterwards it had partially recovered ; the heart sounds were normal and so was the temperature. It fed as usual and the motions were healthy. It was ordered bromide of potassium and ammonia together with a little brandy at short intervals. In the night it had two or three similar attacks followed by much larger extravasations of blood beneath the skin. The next morning it was much weaker; it could scarcely cry, and did not take notice of anything about it, although it continued to take its food regularly and the motions remained healthy. The subcutaneous extravasations, three or four in number, took the form of bluish rounded lumps about one and a half inches in diameter, and there -were also some small petechiae upon the legs and buttocks. From this time the child gradually sank ; cerebral respiration supervened, and it died on the fourth day of the second attack. No post-mortem examination was made. The child was never treated mercurially because the syphilitic character of the disease was not suspected, partly owing to my not being aware at the time of the father’s previous history, nor of the existence of his skin affection, and partly to my ignorance of -
-
fifth day
When
1
Careful examination of the heart elicited
ever.
no
signs of disease what-