63

LECTURESON THE

PROGNOSIS AND TREATMENT OFCERTAIN ACUTE DISEASES,

WITH

SPECIAL REFERENCE TO THE INDICATIONSAFFORDED BY THE GRAPHIC STUDY

OF THE PULSE.

Delivered at the Royal College of Physicians of London.

BY FRANCIS E. ANSTIE, M.D. LOND.,FELL. ROYAL COLL. OF PHYSICIANS,

SENIOR ASSISTANT-PHYSICIAN TO THE WESTMINSTER HOSPITAL.

LECTURE I.-(Continued.)EVEN more important than the degree of <licroi;ism,m a,!

.prognostic point of &middot;view,.is’the height 6f,the,,febrilepalse-i’.curve, taken in eonju-netion, with’,the f01’m c,())f, its ,-.apex. ’The,atterial tension is, ex. Jtyp&otilde;thesi, ’l’Ow;’a.nd,the 1’esi tothe heart-force is therefore small. If, then, the ventricle actin such a way as to indicate a good reserve of power, the leverwill be thrown up brusquely to a considerable height by thepercussion-waves of’the bloocl-column. According to thenumber and form of these oscillations, the "simple typhoid’curve, already explained, will be, formed ; or more commonly’there is one lofty percussion-wave, which occupies the wholesystolic part of the curve, which is twice or three times theheight of the wave which follows the aortic notch, and theapex of which is sharp.Such is the’ HOEma.1 st&te. of thBtgs the !itebt bf 1,pyro-xia,

When the heart power is good.the other hand, is that in which, at the height of the pyrexial!stage, the pulse-curve is small, the primary ascent not vertical,,and the apex blunt, and wither -sq:lifa.re’<3r,’seftlyrolmtied. I

cean hardly better illustrate the oppasite prognostic indicationsi0f the high, sharp-peaked curve, -and :the low, blunt apexes curve, than by exhibiting, side by side, the tracings, -from, dayto day, of a benign and of a malignant case, so to speak, ofpericarditis. I call the one case "benign" because, thoughthe patient was seriously ill, his heart never showed threat-enings of an approaching cot-lapse; and’I I ea.11 the other ’ ’ma-lignant" because the tracings from the first and throughout in-dicated that the ventricle acted with difficulty.

Figures 8 to 14 are the successive pulse-forms in the case ofa boy whose story is as follows:&mdash;His age was fifteen. He

presented himself to me, in the out-patient department ofWestminster Hospital, looking very ill, and with a facies atonce suggestive of pericarditis. He had only felt ill sincethe day before. I examined his heart, and found a friction-sound over the base. He entered the hospital, under mycare, the same day. Fig. 8 is the tracing of his pulse aboutone hour after he had got to bed. On the following day the rest and quietude of the hospital had toid - upon him. greatly:there was scarcely any sign of fever, the friction-sound wasmuch fainter, and the pulse gave a trace (Fig. 9) which onlydiffers from that of health in being weak and ill.developed.Two days afterwards he unluckily got chilled by an exposureof his chest ; and on the next morning the tracing had taken the form of Fig. 10, in which there is something suspicious inthe shape of the apex. The pulse had not yet quickened;and though he seemed uneasy and restless, the patient wasnot perceptibly feverish. He got worse during the night; and the following day the tracing had assumed the full dicroti(type seen in Fig. 11. It remained in this form for two days;the patient’s general condition continuing much the same,

loud friction-sound being audible at the base. An unfortunateincident now.occurred. A man suffering from cholera wasbrought into the hospital, and placed in the next bed to the boy, who was disturbed and terrified by his groans during a- whole night. The next day he was much worse ; the pulse ’was very rapid,; and hyperdicrotic (fig 12). Tor sevee&Mayshe continued in this state, the pulse always presenting this type at the usual hour for examination. Under the influenceof morphia, and a moderate amount of stimulants, however,he somewhat suddend experienced a great improvement,’1andthe pulse dropped into the form seen in Fig. 13. On tf1ej foI-lowing day convalescence had fairly commenced the teatpera-ture was down to a normal level, and the pulse had assumedthe form of Fig. 14, which is quite apyrexial. The boy madea. good, and, quick recovery.

Contrast, - mow, with, this case the following. A little girl.aged thirteen, who ’was - known tto have previously suffered aeute rheumatism and to have a mitral regurgitant bruit, was admitted to Westminster Hospital suffering from slight ana-sarca, and complaining of increased cardiac distress. As she layin bed, her pale and puffed features suggested nothing of peri-carditis ; and thourgh the pulse was weak and quick, this wasnet unllikely to have been oaiased. by the mere flurry of removal. The tracing seen in! Fig. 15 was taken, however, and roused the suspicion of an inflammatory affection by its rapidity and its dicrotic character : an examination of the heart detected a .

faint commencing friction-sound over and above the old endo-cardial murmur at the apex. A few hours -brought the friction-sound -into full relief. Twenty-four ’hours ’after the -firstexamination of the pulse, the tracing Fig. 16 was taken. Thepatient’s general state was now considerably better, and ac-

cordingly we find that the size of the curve: is greater ; it still retains the feature, however, to the evil augury of which Iwish’to direct your attention&mdash;the apex is blunt, and indicates a difliclllt and prolonged systole, while the moderate height ofthe first ascent of the lever shows that the power of the heartis small {seeing that arterial tension-resistance is known to bevery low). Dn each successive day, down to the period when

tracing Fig. 21 was taken, these charaters were maintenedand another peculiarity appeared in the trace (simultaneouslywith the development of extensive liquid effusion), which we-

shall have to speak of presently as of specially evil omen-L viz., an irregular ttndulation of the general line of the tracing.’On the day, however, on which the tracing Fig. 20 was taken,

11 the general symptoms had somewhat improved ; -the liquideffusion seemed slightly diminishing, and the undulation hadnearly disappeared. On the following day-some friends had an

agitating interview with the patient, who was found shivering1 slightly, and the curious tracing Fig. 21 was taken shortly

afterwards. The next day there was greatly increased debility,and now the pulse had become slow, irregular, and extremelyweak, as shown in Fig. 22. The day following she seemedreally at the point of death ; the pulse could not be felt withthe finger, but the sphygmograph (with the spring weakenedto the utmost, in a manner which I shall have to describehereafter) gave, two or three times over, the kind of trace ofwhich Fig. 23 is an example. The free administration of brandy,however, revived her wonderfully; and next day the pulse hadassumed the form shown in Fig. 24, in which we perceive thatthere is a distinct, though an abnormal, rhythm. On the dayfollowing, the improvement in the general symptoms, and in

. the sphygmographic pulse-form (Fig. 25), was even greater.; Still, however, the small size of the curve and the bad shape of’.

the apex persist. On the day after this it was manifest that’

the patient was somewhat weaker, and now the tracing(Fig. 26) reveals a state of things yet more dangerous than,.thegeneral symptoms would have led one to infer. The pulse-

r curve is altogether very small, and the systolic portion pre-,

sents the extreme development of that square, flat-topped.. type which indicates difficult ventricular contraction. In cor-J

respondence with the indications of great difficulty attendingsystole is the fact that the dicrotic wave is almost non-existent;

1 the whole of the expansile force has been used up in over-; coming the arterial resistance, feeble though that is, and theres is no stored-up energy to resume the expansile movement after1 the interruption caused by the aortic closure. [The cutter hasaccidentally exaggerated the dicrotic waves. In the originaltracing they scarcely rise at all.] A few hours after the taking’ of this last tracing, the patient sank. The liquid effusion had,a, increased to a great a,mount by this time.

64

No one can fail to be struck, in studying these two con-trasted series of tracings. -with the persistent way in which thefavourable signs in one case, and the unfavourable signs inthe other, as regards the heart’s action, maintain themselves,and reappear day after day, notwithstanding material fluctua-tions in mere pulse f-recluency--fluctuations which, I may say,were often accompanied by apparently important changes inthe general symptoms. Fortified by my present much largerexperience, I should now not hesitate to place very high prognostic importance on the persistence of the one or theother type of pulse in any pyrexial disease, unless, indeed, allthe other clinical features of the case were in blank oppositionto the sphygmographic indications. But this seems all butimpossible. The rationalp of the particular features in thepulse-curve on which we have j LLst been dwelling is particularlyplain and free from doubt ; and I may add that in the largernumber of cases, with such great rapidity of pulse, it is im-

possible for any but the very few consummate masters of theart to obtain any indications with the finger which even ap-proach the delicacy of these graphic representations. A most

important formula of prognosis in the pyrexise results from theobservations which have been made. In all cases the main-tenance of the high, moderately sharp apex, save at the periodwhen defervescence might be expected, is pro tarato of goodaugury; and in all cases the appearance of the blunt apex,with a small maximum height of the curve, while the pulse israpid and the aortic notch deep, is extremely ill-omened, andevery hour during which it persists adds to the gloominess ofthe prospect. It is even probable that from the conditionshadowed forth by the tracing (Fig. 26), no patient could everrecover.

65

At this point I must diverge for a moment to describe cer-tain precautions which are requisite to ensure accuracy intaking the tracings of fever-pulses. It is necessary very care-

fully to graduate the strength of the tactile spring of the sphyg-mograph, which receives the pulsations of the artery. A pulseof medium power of resistance to pressure will not require anymodification of the spring. If the pulse be highly unyielding,the spring must be strengthened by screwing down the button inthe centre of the instrument. This is hardly ever the case in-the diseases we are considering. Very generally the springneeds to be weakened for pyrexial pulses ; this can be done byputting cork pads of various thicknesses beneath the brass-work at the end of the instrument nearest the hand, and thenscrewing down the free end of the spring.

[In the report of the first part of this lecture, in last week’sLANCET, a mistake occurred in the author’s manuscript whichunfortunately escaped correction in proof. In the descriptionof the formation of the " simple typhoid curve" it was statedthat the sphygmograph spring could not follow completely thedeep and rapid oscillations of the "lever." It should havebeen, " oscillations of the blood-column." The passage, as itstood, was of course unintelligible.]

(To be continued.)

CLINICAL PAPERS ON THE SURGERY OFCHILDHOOD.

BY THOMAS SMITH, F.R.C.S.,ASSISTANT-SURGEON TO ST. BARTHOLOMEW’S AND THE CHILDREN’S HOSPITALS.

N&AElig;VUS.

UNDER this term I propose to include only those growths,spots, and stains that are either formed entirely of bloodvessels,or at all events owe their colour to abnormal vascularity; andare therefore in colour either bright scarlet, a deep dull purple,or some intervening shade. Moles and other pigmentary stainsI shall describe under the term of "Mother’s Marks." A N&aelig;vus is either a separate growth formed of bloodvessels;

or an area where bloodvessels so predominate over the naturaltissues of the part as to communicate to it an abnormal andpermanent vascular stain.

N&aelig;vi may be composed chiefly or entirely of arteries, chieflyor entirely of veins, or of capillaries; being on this accounttermed respectively "arterial," "venous," or "capillary."The microscopic structure of a venous n&aelig;vus&mdash;the ordinarykind that belongs to childhood-may be seen in the specimensunder the microscope on the table. The growth is formed ofa congeries of veins and venous capillaries running a mosttortuous and irregular course in loops and tufts; the wholegrowth being generally surrounded by a capsule of areolartissue. The blood to a growth of this kind is supplied by oneor more large veins which may be called afferent, and is carriedoff by one or more efferent veins; so that the vascular systemof such a n&aelig;vus is just after the plan of the portal circulation,being carried on by two sets of veins with intermediate venouscapillaries. This is the structure of a subcutaneous venousn2evus-the only kind of child’s nasvus that I have had anopportunity of examining after its removal from the body.

N&aelig;vi may occur in almost every part and in almost everytissue of the body; having been found in the liver, lungs,bones, and tongue, as well as in their more common seats, theintegument and subcutaneous cellular tissue. M. Guersantrelates a case where, in one child, he found the disease in thelungs and liver, besides over a considerable portion of the headand face.For practical purposes, and since n&aelig;vi are generally situated

either on or in the common integument, these growths are oftenclassified as cutaneous, subcutaneous, and mixed; the lastbeing partly in the skin and partly under it.

There is no part of the external surface that is exempt froma liability to naevus, though certain localities show a greatertendency to the disease than others. Thus, the hairy scalpand face are, perhaps, the chosen seats of the affection, nextthe trunk, and lastly, the extremities. They may, however,be met with in the vagina, in the rectum, or in the interior of

the mouth ; on the gums, the tongue, and on the conjunctiva.But in these cases they are, for the most part, in connexionwith, and are prolongations from, n&aelig;vous growths affectingthe skin in the immediate neighbourhood.

In looking over the cases that I have noted as occurring inthe out-patient room, I find a singular predominance of femalesover males in those suffering from naevi. Since the month ofJuly, 18Gl, I have seen 140 cases of n&aelig;vus, of which I havekept some record : 95 were females, 42 were males, and in 3the sex is not stated. This difference is too considerable to beaccidental, especially when the aggregate number is taken intoconsideration ; we may, therefore, safely conclude that femaleinfants are far more liable to the disease than males, though Iconfess I was quite unaware of this circumstance until I thusreckoned up some of my own cases.

In referring to the symptoms of n&aelig;vus, one may shortly sayof the arterial, that the only symptom distinctive of thisvariety is pulsation ; if any n&aelig;vus does not pulsate in a livingchild it is not arterial. These n&aelig;vi are but rarely seen inadults, and are scarcely ever met with in children; it has neverfallen to my lot to see one in a child.

Subcutaneous venous n&aelig;vus is generally a lobular, puffyswelling, about the consistence of a fatty tumour, soft andvery slowly elastic; that is, if compressed firmly, it collapsesconsiderably, and but slowly regains its shapp. and consistenceon pressure being relaxed. It is situated at various depths inthe subcutaneous tissue; if very near the skin it generallycommunicates a bluish tinge to the surface.Here is a little girl, about two years old, with a subcutaneous

nasvus; on the side of the trunk it extends from the navel tothe spine in one direction, and from the ribs to the crest of theilium and Poupart’s ligament in another. It is seemingly twoor three inches thick, and is as large as a good-sized plate.Until lately it was unconnected with the skin, which, as yousee, is tinged of a bluish purple colour. This growth is nowundergoing spontaneous cure, and the skin is dimpling downover it and forming connexions to it as the vascular tissuebeneath shrivels up.These subcutaneous naevi may be confounded with cystic,

glandular, and fatty tumours, and lastly, and most fatally,with meningocele. The diagnosis between subcutaneous n&aelig;viand congenital cystic tumours, in doubtful cases, may befacilitated, and the ignominious, though sometimes necessary,resort to a grooved needle may be avoided, by observing theeffect of firmly grasping the tumour, a proceeding that muchdiminishes the size of a nsevus, while it produces no impressionon a cystic tumour; and this manoeuvre is often absolutelynecessary in order to distinguish between these tumours, sincethe blueness of deep vascularity over a subcutaneous n&aelig;vus

’ almost exactly resembles the blueness of translucency seenover congenital cystic growths.

Large subcutaneous n&aelig;vi, when deeply situated in the sub-maxillary region, bear some resemblance to glandular tumours,

. and mistakes of this kind have been committed. Moreau re-lates the case of a surgeon, an author on n&aelig;vi, who made thismistake. In this case, also, the employment of pressure wouldbe a valuable means of settling the question; while the exist-ence of any vascular tinting of the skin over the part, or thepresence of nasvi elsewhere on the body, would be almost de-cisive in favour of the growth being n&aelig;vus in structure in adoubtful case. The same may be said of the diagnosis betweenn&aelig;vi and fatty tumours, though the latter are comparativelyrare in infants.The following case, given by M. Guersant, illustrates the

fatal resemblance the subcutaneous n&aelig;vus may bear to menin-

gocele :-A child had on the internal angle of the right orbit a small

swelling, which bore all the characters of a subcutaneous erec-tile tumour. Many Fellows of the Surgical Society of Parissaw this case, and agreed with M. Guersant that the tumourshould be treated by thread setons. Shortly after this hadbeen carried into effect, the child was seized with cerebralsymptoms, and quickly died.On post-mortem examination, the growth was found to be

an encephalocele; the sac of which, the size of a pea, passedthrough the fronto-ethmoidal suture, and protruded at theinner angle of the orbit. The protrusion was formed of asmall portion of cerebral substance, covered by the membranesof the brain.Such a tumour I myself have seen on the bridge of the nose

in an infant. The real nature of this swelling was only de-cided by a puncture with a grooved needle-a proceeding whichproved it to be a meningocele, that must have protruded throughthe fronto-ethmoidal suture. This conjecture has not, I am