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ON THE PRACTICAL VALUE OF PRONE RESPIRATION IN DISEASE.
the first
instance,
with the
exception of
five
or
six soft
frag- ceptible,
and in less than
ments, which, though recognisable, did not amount in weight ratory efforts
as much as 4 grammes." With regard to the pancreatic infusion: "After remaining four hours in the stove, the quantity of solid albumen which had disappeared amounted to 45 grammes of the albumen originally employed;" and further, it is stated that " before the albumen was used, the infusion displayed to litmus or turmeric papers of great tenacity no noticeable traces either of acidity or alka-
to
now
ceased,
minute and the
a
was
not to be felt. Respito all appearance
man was
dead.
Hopeless as the case seemed, I was unwilling to leave withdoing something. I first tried to excite respiration by irri. tating the back of the fauces, but without the slightest effect; then,turning the body to the prone position, and the head being held by one of the nurses present, I performed artificial respiration for some time, during which the pulse could just at times out
be felt. linity." The artificial respiration caused air to go in and out of the The weight attaching to the researches of M. Meissner urges me to solicit most earnestlyfor further investigations, which, lungs. During this time it now and then excited a natural doubtless, will not fail-to be productive of some explanation of respiratory effort. At the end of a quarter of an hour, the skin the cause of the discrepancy to which this special point has of the patient had become decidedly warmer, much mucus had been expelled from the mouth, and the pulse had become given rise between us. stronger and more regular. A teaspoonful of brandy was now occasionally tried by the mouth, but with more harm than good; ON THE for the turning the patient from the prone position each time to be worse, and the reflex action of the PRACTICAL VALUE OF PRONE RESPIRA- caused the breathing pharynx being still absent, the liquid could not be swallowed, TION IN DISEASE. but caused choking. In about half an hour, I gradually ceased artificial respiBY CHARLES HUNTER, ESQ., M.R.C.S. ration, as natural breathing gradually returned, still maintainthe prone position; for each attempt to sit him up, or turn No ONE can call attention to posture an unimportant subject him on the back, made the face darker, and caused choking. had still to be assisted by pressure on the back.since the Marshall Hall Method of Postural Respiration was Expiration minutes: The Forty-five respiration was now natural and given to the world, and its value established beyond doubt by free from rhonchus, but still the prone position was found the numerous cases recorded in quick succession in the pages oj necessary; the pulse was considerably stronger, the colour and THE LANCET. temperature of the face were again normal, but the man was The Marshall Hall Method consists of two parts-firstly, not yet sensible. At the end of an hour an epileptic attack came on, with constant grinding of the teeth, biting of the attention to posture; secondly, the performance of artificial and rigidity of the intercostal muscles and those of tongue, respiration. The attention to posture is the all-important part, the extremities. the essence of the plan of treatment. Hitherto the adoption The effect of this attack was to cause lividity of the face, of the Marshall .Hall Method has been in cases of still-birth, laboured respiration, and diminished strength of pulse; and it and of apnma from accidental causes. It is, however, appli- was some time before these symptoms passed off. One hour and a half: Breathing still very laboured (but now cable in a far wider range; I allude especially to apncea which of the supine, or sitting-up posture); face still dark; allowing may at any time threaten in the course of disease, as I shall temperature of body good; pulse of good strength; pupils conshow immediately. tracted and insensible. As the symptoms now were evidently those of non-oxydized Prone respiration, or, as it has been named by Marshall Hall, Prenopnœa,"* is as important, if not more so, as I can show, blood in the system, and the pulse was good, my colleague,Mr. to save or prolong life in the course of disease. This is a new E. D. Tomlinson, bled the man to eight ounces. The state of application of the Marshall Hall Method, and of its modifica- the breathing and the countenance was a little improved by the venesection. tion, prenopnœa.† There are numerous diseases in the course of which the Nov. 29th.--Two A.M. : Pulse 100, quiet; respiration quiet, bronchial tubes are apt to get loaded with secretion, or so filled with very slight rhonchus; face slightly dusky; sensibility reo with fluid as to endanger the life of the patient. Chronic turning. -Ten A.M.: Perfectly sensible, and able to talk; bronchitis, the rapid effusion of fluid into the bronchial tubes sitting up in bed, breathing with but little effort. It is intein the course of Bright’s disease, the accumulation of bronchial resting that he made his will to-day, which he had not done secretion which so rapidly takes place in cerebral apoplexy, before. The man lived about ten days after the above event, may serve as instances. during which time he had numerous attacks of dyspnoea, after No case can more strikingly show the value of attention to one of which he sank. In the post-mortem examination it was postural respiration in disease than the following, which came found that the lungs were much congested, and the kidneys under my care whilst house-surgeon to St. George’s Hospital :- diseased.
ing
"
CASE 1. -On Nov. 28th, 1858, at a quarter to eleven P.M., I called to the Fitzwilliam ward to see one of the patients, who had suddenly been seized with great difficulty of breathing. He had been admitted for some affection of the hand, under the care of Mr. H. C. Johnson, and was so far improved that he was shortly to have gone out. I found the patient sitting up in bed, making the most laborious efforts to breathe, with the face dusky, and each respiration giving evidence of much fluid being collected in the bronchial tubes. The pulse was 80, strong, and full. Havingordered an emetic immediately, I left the ward, but was sent for in about five minutes with the message that the emetic was too late-the man was dying or dead. Hastily returning, I found the patient leaning back in bed against pillows. The face was now cold, purple, and clammy to the touch; occasional gasping efforts were being made to breathe, but with little or no effect; the pulse was now scarcely perwas
*
"
I conclude by observing that the principle of prone respiration is of suet as to demand a new designation to impress it on the attention ani the memory. I propose to term it Prenopnœa."-THE LANCET, Feb. 7th 1857. tIt was about two years ago, and during,-the life of Dr. Marshall Hall, thav my attention was first drawn to the value of prone respiration in disease, at ! time when I was making observations on enlargement of the thyroid gland I must here observe, that the attention of Mr. R. L. Bowles (who, like myself helped to work out " the problem of postural respiration") has also beer drawn to prone respiration in disease, especially with regard to stertor, as hE
importance
mentioned to me by letter fifteen months ago. Since the announcement ir THE LANCET that this paper should shortly appear, I have learnt that Mr
608
Remarks.-l. There seemed
present that life
no
doubt in the minds of those
prolonged in the above case, humanly speaking, by artificial respiration and attention to posture. 2. It also appeared evident that any attempt to remove the patient from the prone position, either during the time artificial respiration was being carried on, or for some time after, was to endanger the life of the patient. 3. Considered physiologically, the case was, primarily, apncea, from a mechanical cause-viz., effusion into the lungs and bronchia, impeding lung action, and the due circulation of the blood through the lungs. Secondarily, asphyxia, produced probably in two ways-1st, and chiefly, by the mechanical obstruction the state of the lungs offered to the circulation of£ the blood; 2nd, and towards the close, to the effect of the unoxydized blood on the nerves of the heart. Nor must the state of the nervous system pass unnoticed. There was a progressive diminution of nervous power, loss of sensation, and absence of reflex action; and, after a time, a comatose state of the brain, with occasional spasms of the muscles of an epileptic character. Had the narcotized state of the brain continued longer than it did, death from apncea.might have been expected;but, in this case, secondary apncea from was
absence of nervous power was the result.** CASE 2.-On the 24th November, 1858, at a quarter to one P.M., a man was brought into St. George’s Hospital in a state of insensibility from a blow on the head, occasioned by a fall of * See a well-marked case of secondary apncea, in which artificial respiration and prenopncea were found necessary.-Medical Gazette, Nov. 6th, 1858,
bricks; there was general bruising of the scalp, but no fracture to be felt, and no bleeding from the ears. Soon after admission he became partly sensible, noisy, and restless. At ten P.M. he was comatose; pupils contracted; respiration 20, with difficulty, and slight stertor; pulse 80, full and strong; sensibility of skin almost absent.-Twelve hours after admission, the man appeared dying; the face was almost black; respiration 16, or less, a minute, each act being made with the greatest difficulty, the air having to pass through much frothy mucus, which it did with a slow gurgling sound; pulse still 80, full and strong; pupils quite insensible. Whilst he was in this state I bled him to sixteen ounces; the face improved whilst he was being bled, and for a few minutes the breathing was better, but no longer. Speedy death from apnœa again threatened. I then turned the patient well over towards the prone position. The effect of this change in position was striking; the breathing was immediately and decidedly relieved; the number of respirations a minute became 20, instead of 16 or less; all stertor ceased. The breathing was as of one asleep; but the chief point of interest was, that with each expiration a large quantity of frothy mucus rolled from the mouth. At the end of half an hour the respiration was 24, quiet, full, and strong ; no sterter, no gurgling. All the lividity of the face had disappeared, but its temperature was not quite restored; the pupils A certain degree of consciousness returned were contracted. for a few minutes about this time. The patient lived from seven to eight hours after the prone position was adopted. Remarks.-I believe the respiration is always more or less affected in cases of coma, especially if it lasts any length of time. In the case just given, death would, in all probability, have occurred about seven hours before it ultimately did had no change been made in the position-had, in fact, the supine in position did this : position been continued. The it got rid of the secretion accumulated in the lungs and airpassages ; it kept the larynx open; it delayed death. There are cases of partial compression of the nervous system, where coma exists, in which "we know from physiology," says Alison, ’’ that the part of the nervous system which must be specially affected in these cases, where the failure of respiration is the immediate cause of death, must be at the sides of the medulla oblongata ; but the part visibly injured is often considerably distant from this."* In such cases as these, prone respiration may save life. In conclusion, prenopnœa, or prone respiration, is as important, prophylactically, in threatening apncea from injury or disease, as the Marshall Hall Method is where that stage of apncea has set in requiring artificial respiration. Wilton-place, Belgrave-square, June, 1859.
alteration
ON A CASE OF PUTRID SORE-THROAT. WITH REMARKS.
BY WM. THOS.
FERNIE, ESQ., M.R.C.S., Hursley.
AT the
present time
a measure
of
general professional
in.
terest, and perhaps instruction, is attached to every detailec instance of malignant sore-throat; so that, without further I am induced to transmit notes of the following case which has recently occurred in my own house, under my con. tinued personal observation .In February last, my groom, a remarkably steady, sobe] young man, aged twenty years, of a thin, spare habit, palE complexion, and bilious temperament, was attacked with ulcerated sore-throat, which, though more than ordinarily persistent in duration, was superficial, and characterized by nc
apology,
This yielded unusual symptoms. with chlorate of
after six or seven days tc potash, astringent gargles, beef-tea, and other tonic treatment, leaving the patient in somewhat weak and impaired health. However, he quickly resumed his ordinary occupation, and continued, apparently convalescent, on restorating regimen until the middle of April, when, being questioned about his again looking ill, he complained that the soreness of his throat had returned. At this time I observed that the entire posterior fauces, tonsils, and uvula, were highly congested, of a livid, angry appearance, and coated with a viscid, tenacious secretion over their general surface. A small, yellow, ragged slough also appeared on the anterior aspect of the right amygdala. To this the caustic
quinine, with wine,
*
Alison’s Outlines of Pathology and Practice of Medicine, vol. i. p. 9.
pencil was at once freely applied underneath and around its margin. A gargle of sulphate of zinc with muriatic acid was ordered to be frequently used, and twenty minims of muriated tincture of iron, with two grains of quinine, were exhibited in water every four hours. The pulse at this time was quick, but feeble and thready, with much general languor and depression. A liberal allowance of beef-tea, with port wine, was directed to be supplied, and an alternate succession of mustard poultice): and hot fomentations was applied to the throat. On the next morning I found that the size of the slough had increased with dire rapiditv, almost the entire right tonsil, with its pillars, being involved, while the uvula presented an ugly ash-coloured spot; the viscid secretion had become more copious and tenacious, being foetid, and of a darker tinge. Likewise an offensive muco-purulent discharge not began to issue from both nostrils, and increased in quantity during the day. The tongue had become dry, brown, and thickly coated, whilst the pulse indicated an increased degree
already
of
general asthenic prostration. In conjunction with my brother,.then staying with me (from the Reading Hospital), I thoroughly applied with a probang to the whole of the affected surface a strong solution of nitrate of silver (one drachm to an ounce of distilled water), having first mopped away all the loose slough and clinging secretion. Onedrachm doses of the concentrated liquor cinchonæ cordifolise were alternated with those of the tincture of iron, with quinine, every three hours; brandy, with egg, was administered at frequent intervals, in addition to the beef-tea and wine. Chlorine was evolved about the chamber, the muriate and gargle being continued; also a dose of castor oil was given to carry off whatever foetid sputa might have been swallowed, no action of the bowels having taken place for two days previously. The patient was placed in a large, airy, and otherwise empty room. Towards evening, confusion of mind and low muttering delirium began to supervene ; meanwhile the act of swallowing remained practicable, without much apparent difficulty ; neither did any external swelling of the throat or glandular enlargement impede ready respiration. The semi-conscious condition continued during the night, with some intermissions of troubled sleep.
On the morning of the third day matters were still worse: the slough had now involved nearly all the textures of the throat; the pulse told of circulatory powers more and more enfeebled. On being raised in bed, that the throat might be examined, the patient immediately fainted. The extremities now assumed a cold, livid, and shrunken character. Mr. Butler, surgeon to the County Hospital, very kindly came over to see the case, but could suggest no further treatment than the constant pouring in of powerful stimulants, which, though taken to the last, tended in no degree to resuscitate the failing powers. As the function of swallowing remained available, stimulating enemata did not seem to be called for. Towards evening, through excess of exhaustion, the patient quietly died. I assume that some specific cause must have originated these two attacks, so quickly consecutive in a subject to whom such an affection had been hitherto unknown-a cause, too, not to be ascribed, in a healthy country village, to any local noxious malaria, or to an enervating social position. Before coming to me, ten months since, this servant had resided for six years in uninterrupted good health with my next-door neighbour. His habits of life were singularly regular, and free from all excess. I would rather regard the case as one of those said by Dr. Barlow (vide" Practice of Medicine") to occur as an occasional form of "scarlatina maligna." This author teaches us that " cases now and then appear of putrid sloughing of the throat without any rash whatever, tending rapidly to death by sinking, the true nature of which is rendered manifest by subsequent cases of scarlatina obviously traceable to communication with the patient so affected." I am led thus to look upon the case now -under notice-not, indeed, because scarlatina has since indubitably appeared inmy house, but because both before and during the interval between the two attacks of sore-throat experienced by my late patient I was continuously engaged in close attendance on a family in a neighbouring hamlet, numerous members of which were severely affected with scarlet fever; this attendance must have necessarily entailed the repeated infection of my personal attire with the active fomites of that disease, and their consequent importation into my own house. Nor is it unwarrantably hypothetical to suppose that my servant, being constitutionally liable to engender the malady, became an unfortunate nidus for prompt propagation of the virus, a second (and perhaps larger) dose of which directly laid prostrate his whole
609
instance,
with the
exception of
five
or
six soft
frag- ceptible,
and in less than
ments, which, though recognisable, did not amount in weight ratory efforts
as much as 4 grammes." With regard to the pancreatic infusion: "After remaining four hours in the stove, the quantity of solid albumen which had disappeared amounted to 45 grammes of the albumen originally employed;" and further, it is stated that " before the albumen was used, the infusion displayed to litmus or turmeric papers of great tenacity no noticeable traces either of acidity or alka-
to
now
ceased,
minute and the
a
was
not to be felt. Respito all appearance
man was
dead.
Hopeless as the case seemed, I was unwilling to leave withdoing something. I first tried to excite respiration by irri. tating the back of the fauces, but without the slightest effect; then,turning the body to the prone position, and the head being held by one of the nurses present, I performed artificial respiration for some time, during which the pulse could just at times out
be felt. linity." The artificial respiration caused air to go in and out of the The weight attaching to the researches of M. Meissner urges me to solicit most earnestlyfor further investigations, which, lungs. During this time it now and then excited a natural doubtless, will not fail-to be productive of some explanation of respiratory effort. At the end of a quarter of an hour, the skin the cause of the discrepancy to which this special point has of the patient had become decidedly warmer, much mucus had been expelled from the mouth, and the pulse had become given rise between us. stronger and more regular. A teaspoonful of brandy was now occasionally tried by the mouth, but with more harm than good; ON THE for the turning the patient from the prone position each time to be worse, and the reflex action of the PRACTICAL VALUE OF PRONE RESPIRA- caused the breathing pharynx being still absent, the liquid could not be swallowed, TION IN DISEASE. but caused choking. In about half an hour, I gradually ceased artificial respiBY CHARLES HUNTER, ESQ., M.R.C.S. ration, as natural breathing gradually returned, still maintainthe prone position; for each attempt to sit him up, or turn No ONE can call attention to posture an unimportant subject him on the back, made the face darker, and caused choking. had still to be assisted by pressure on the back.since the Marshall Hall Method of Postural Respiration was Expiration minutes: The Forty-five respiration was now natural and given to the world, and its value established beyond doubt by free from rhonchus, but still the prone position was found the numerous cases recorded in quick succession in the pages oj necessary; the pulse was considerably stronger, the colour and THE LANCET. temperature of the face were again normal, but the man was The Marshall Hall Method consists of two parts-firstly, not yet sensible. At the end of an hour an epileptic attack came on, with constant grinding of the teeth, biting of the attention to posture; secondly, the performance of artificial and rigidity of the intercostal muscles and those of tongue, respiration. The attention to posture is the all-important part, the extremities. the essence of the plan of treatment. Hitherto the adoption The effect of this attack was to cause lividity of the face, of the Marshall .Hall Method has been in cases of still-birth, laboured respiration, and diminished strength of pulse; and it and of apnma from accidental causes. It is, however, appli- was some time before these symptoms passed off. One hour and a half: Breathing still very laboured (but now cable in a far wider range; I allude especially to apncea which of the supine, or sitting-up posture); face still dark; allowing may at any time threaten in the course of disease, as I shall temperature of body good; pulse of good strength; pupils conshow immediately. tracted and insensible. As the symptoms now were evidently those of non-oxydized Prone respiration, or, as it has been named by Marshall Hall, Prenopnœa,"* is as important, if not more so, as I can show, blood in the system, and the pulse was good, my colleague,Mr. to save or prolong life in the course of disease. This is a new E. D. Tomlinson, bled the man to eight ounces. The state of application of the Marshall Hall Method, and of its modifica- the breathing and the countenance was a little improved by the venesection. tion, prenopnœa.† There are numerous diseases in the course of which the Nov. 29th.--Two A.M. : Pulse 100, quiet; respiration quiet, bronchial tubes are apt to get loaded with secretion, or so filled with very slight rhonchus; face slightly dusky; sensibility reo with fluid as to endanger the life of the patient. Chronic turning. -Ten A.M.: Perfectly sensible, and able to talk; bronchitis, the rapid effusion of fluid into the bronchial tubes sitting up in bed, breathing with but little effort. It is intein the course of Bright’s disease, the accumulation of bronchial resting that he made his will to-day, which he had not done secretion which so rapidly takes place in cerebral apoplexy, before. The man lived about ten days after the above event, may serve as instances. during which time he had numerous attacks of dyspnoea, after No case can more strikingly show the value of attention to one of which he sank. In the post-mortem examination it was postural respiration in disease than the following, which came found that the lungs were much congested, and the kidneys under my care whilst house-surgeon to St. George’s Hospital :- diseased.
ing
"
CASE 1. -On Nov. 28th, 1858, at a quarter to eleven P.M., I called to the Fitzwilliam ward to see one of the patients, who had suddenly been seized with great difficulty of breathing. He had been admitted for some affection of the hand, under the care of Mr. H. C. Johnson, and was so far improved that he was shortly to have gone out. I found the patient sitting up in bed, making the most laborious efforts to breathe, with the face dusky, and each respiration giving evidence of much fluid being collected in the bronchial tubes. The pulse was 80, strong, and full. Havingordered an emetic immediately, I left the ward, but was sent for in about five minutes with the message that the emetic was too late-the man was dying or dead. Hastily returning, I found the patient leaning back in bed against pillows. The face was now cold, purple, and clammy to the touch; occasional gasping efforts were being made to breathe, but with little or no effect; the pulse was now scarcely perwas
*
"
I conclude by observing that the principle of prone respiration is of suet as to demand a new designation to impress it on the attention ani the memory. I propose to term it Prenopnœa."-THE LANCET, Feb. 7th 1857. tIt was about two years ago, and during,-the life of Dr. Marshall Hall, thav my attention was first drawn to the value of prone respiration in disease, at ! time when I was making observations on enlargement of the thyroid gland I must here observe, that the attention of Mr. R. L. Bowles (who, like myself helped to work out " the problem of postural respiration") has also beer drawn to prone respiration in disease, especially with regard to stertor, as hE
importance
mentioned to me by letter fifteen months ago. Since the announcement ir THE LANCET that this paper should shortly appear, I have learnt that Mr
608
Remarks.-l. There seemed
present that life
no
doubt in the minds of those
prolonged in the above case, humanly speaking, by artificial respiration and attention to posture. 2. It also appeared evident that any attempt to remove the patient from the prone position, either during the time artificial respiration was being carried on, or for some time after, was to endanger the life of the patient. 3. Considered physiologically, the case was, primarily, apncea, from a mechanical cause-viz., effusion into the lungs and bronchia, impeding lung action, and the due circulation of the blood through the lungs. Secondarily, asphyxia, produced probably in two ways-1st, and chiefly, by the mechanical obstruction the state of the lungs offered to the circulation of£ the blood; 2nd, and towards the close, to the effect of the unoxydized blood on the nerves of the heart. Nor must the state of the nervous system pass unnoticed. There was a progressive diminution of nervous power, loss of sensation, and absence of reflex action; and, after a time, a comatose state of the brain, with occasional spasms of the muscles of an epileptic character. Had the narcotized state of the brain continued longer than it did, death from apncea.might have been expected;but, in this case, secondary apncea from was
absence of nervous power was the result.** CASE 2.-On the 24th November, 1858, at a quarter to one P.M., a man was brought into St. George’s Hospital in a state of insensibility from a blow on the head, occasioned by a fall of * See a well-marked case of secondary apncea, in which artificial respiration and prenopncea were found necessary.-Medical Gazette, Nov. 6th, 1858,
bricks; there was general bruising of the scalp, but no fracture to be felt, and no bleeding from the ears. Soon after admission he became partly sensible, noisy, and restless. At ten P.M. he was comatose; pupils contracted; respiration 20, with difficulty, and slight stertor; pulse 80, full and strong; sensibility of skin almost absent.-Twelve hours after admission, the man appeared dying; the face was almost black; respiration 16, or less, a minute, each act being made with the greatest difficulty, the air having to pass through much frothy mucus, which it did with a slow gurgling sound; pulse still 80, full and strong; pupils quite insensible. Whilst he was in this state I bled him to sixteen ounces; the face improved whilst he was being bled, and for a few minutes the breathing was better, but no longer. Speedy death from apnœa again threatened. I then turned the patient well over towards the prone position. The effect of this change in position was striking; the breathing was immediately and decidedly relieved; the number of respirations a minute became 20, instead of 16 or less; all stertor ceased. The breathing was as of one asleep; but the chief point of interest was, that with each expiration a large quantity of frothy mucus rolled from the mouth. At the end of half an hour the respiration was 24, quiet, full, and strong ; no sterter, no gurgling. All the lividity of the face had disappeared, but its temperature was not quite restored; the pupils A certain degree of consciousness returned were contracted. for a few minutes about this time. The patient lived from seven to eight hours after the prone position was adopted. Remarks.-I believe the respiration is always more or less affected in cases of coma, especially if it lasts any length of time. In the case just given, death would, in all probability, have occurred about seven hours before it ultimately did had no change been made in the position-had, in fact, the supine in position did this : position been continued. The it got rid of the secretion accumulated in the lungs and airpassages ; it kept the larynx open; it delayed death. There are cases of partial compression of the nervous system, where coma exists, in which "we know from physiology," says Alison, ’’ that the part of the nervous system which must be specially affected in these cases, where the failure of respiration is the immediate cause of death, must be at the sides of the medulla oblongata ; but the part visibly injured is often considerably distant from this."* In such cases as these, prone respiration may save life. In conclusion, prenopnœa, or prone respiration, is as important, prophylactically, in threatening apncea from injury or disease, as the Marshall Hall Method is where that stage of apncea has set in requiring artificial respiration. Wilton-place, Belgrave-square, June, 1859.
alteration
ON A CASE OF PUTRID SORE-THROAT. WITH REMARKS.
BY WM. THOS.
FERNIE, ESQ., M.R.C.S., Hursley.
AT the
present time
a measure
of
general professional
in.
terest, and perhaps instruction, is attached to every detailec instance of malignant sore-throat; so that, without further I am induced to transmit notes of the following case which has recently occurred in my own house, under my con. tinued personal observation .In February last, my groom, a remarkably steady, sobe] young man, aged twenty years, of a thin, spare habit, palE complexion, and bilious temperament, was attacked with ulcerated sore-throat, which, though more than ordinarily persistent in duration, was superficial, and characterized by nc
apology,
This yielded unusual symptoms. with chlorate of
after six or seven days tc potash, astringent gargles, beef-tea, and other tonic treatment, leaving the patient in somewhat weak and impaired health. However, he quickly resumed his ordinary occupation, and continued, apparently convalescent, on restorating regimen until the middle of April, when, being questioned about his again looking ill, he complained that the soreness of his throat had returned. At this time I observed that the entire posterior fauces, tonsils, and uvula, were highly congested, of a livid, angry appearance, and coated with a viscid, tenacious secretion over their general surface. A small, yellow, ragged slough also appeared on the anterior aspect of the right amygdala. To this the caustic
quinine, with wine,
*
Alison’s Outlines of Pathology and Practice of Medicine, vol. i. p. 9.
pencil was at once freely applied underneath and around its margin. A gargle of sulphate of zinc with muriatic acid was ordered to be frequently used, and twenty minims of muriated tincture of iron, with two grains of quinine, were exhibited in water every four hours. The pulse at this time was quick, but feeble and thready, with much general languor and depression. A liberal allowance of beef-tea, with port wine, was directed to be supplied, and an alternate succession of mustard poultice): and hot fomentations was applied to the throat. On the next morning I found that the size of the slough had increased with dire rapiditv, almost the entire right tonsil, with its pillars, being involved, while the uvula presented an ugly ash-coloured spot; the viscid secretion had become more copious and tenacious, being foetid, and of a darker tinge. Likewise an offensive muco-purulent discharge not began to issue from both nostrils, and increased in quantity during the day. The tongue had become dry, brown, and thickly coated, whilst the pulse indicated an increased degree
already
of
general asthenic prostration. In conjunction with my brother,.then staying with me (from the Reading Hospital), I thoroughly applied with a probang to the whole of the affected surface a strong solution of nitrate of silver (one drachm to an ounce of distilled water), having first mopped away all the loose slough and clinging secretion. Onedrachm doses of the concentrated liquor cinchonæ cordifolise were alternated with those of the tincture of iron, with quinine, every three hours; brandy, with egg, was administered at frequent intervals, in addition to the beef-tea and wine. Chlorine was evolved about the chamber, the muriate and gargle being continued; also a dose of castor oil was given to carry off whatever foetid sputa might have been swallowed, no action of the bowels having taken place for two days previously. The patient was placed in a large, airy, and otherwise empty room. Towards evening, confusion of mind and low muttering delirium began to supervene ; meanwhile the act of swallowing remained practicable, without much apparent difficulty ; neither did any external swelling of the throat or glandular enlargement impede ready respiration. The semi-conscious condition continued during the night, with some intermissions of troubled sleep.
On the morning of the third day matters were still worse: the slough had now involved nearly all the textures of the throat; the pulse told of circulatory powers more and more enfeebled. On being raised in bed, that the throat might be examined, the patient immediately fainted. The extremities now assumed a cold, livid, and shrunken character. Mr. Butler, surgeon to the County Hospital, very kindly came over to see the case, but could suggest no further treatment than the constant pouring in of powerful stimulants, which, though taken to the last, tended in no degree to resuscitate the failing powers. As the function of swallowing remained available, stimulating enemata did not seem to be called for. Towards evening, through excess of exhaustion, the patient quietly died. I assume that some specific cause must have originated these two attacks, so quickly consecutive in a subject to whom such an affection had been hitherto unknown-a cause, too, not to be ascribed, in a healthy country village, to any local noxious malaria, or to an enervating social position. Before coming to me, ten months since, this servant had resided for six years in uninterrupted good health with my next-door neighbour. His habits of life were singularly regular, and free from all excess. I would rather regard the case as one of those said by Dr. Barlow (vide" Practice of Medicine") to occur as an occasional form of "scarlatina maligna." This author teaches us that " cases now and then appear of putrid sloughing of the throat without any rash whatever, tending rapidly to death by sinking, the true nature of which is rendered manifest by subsequent cases of scarlatina obviously traceable to communication with the patient so affected." I am led thus to look upon the case now -under notice-not, indeed, because scarlatina has since indubitably appeared inmy house, but because both before and during the interval between the two attacks of sore-throat experienced by my late patient I was continuously engaged in close attendance on a family in a neighbouring hamlet, numerous members of which were severely affected with scarlet fever; this attendance must have necessarily entailed the repeated infection of my personal attire with the active fomites of that disease, and their consequent importation into my own house. Nor is it unwarrantably hypothetical to suppose that my servant, being constitutionally liable to engender the malady, became an unfortunate nidus for prompt propagation of the virus, a second (and perhaps larger) dose of which directly laid prostrate his whole
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