Stertorous breathing in apoplexy and the management of the apoplectic state / by Robert Bowles.

  • Bowles, Robert.
Date:
1881
Catalogue details

Licence: Public Domain Mark

Credit: Stertorous breathing in apoplexy and the management of the apoplectic state / by Robert Bowles. Source: Wellcome Collection.

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    mortality. Those only who have observed the extraordinary change on the removal of suffocative stertorous breathing, can judge how the diagnosis and prognosis are affected by it, and, not less so, the treat* merit and morbid anatomy. Most modern writers on apoplexy adopt the general views of Dr. Abercrombie, and naturally, from the broad division of cases into sthenic and asthenic, are disposed to bleed in the former, and to avoid it in the latter; whereas, if we look upon the hard slow pulse as the result of the heart labouring to overcome an obstruction in the lungs (suffocation), we shall at once see that our first duty is to remove this obstruction, and thus simplify the case. Heberden and Fothergill were opposed to bleeding in any case, and the latter has made some curious suggestions which pertain to the sub¬ ject of this paper. He says that “even the hard, full, and irregular pulse, which seems imperatively to call for a very free use of the lancet, is often an insufficient guide, since it may be that struggle which arises from an exertion of the vires vitce to restore health”. From what has already been said, you will readily guess that I should say: “This strong pulse arises from an exertion of the vires vitce to overcome vascular obstruction caused by gradually increasing suffocation.” Niemeyer, more than others among recent authors, has attempted to be systematic, and to clear away the confusion attached to apoplexy; but, like others, he fails, from not discriminating between the apoplexy and the suffocation. He believes that the shock and oppression of the apoplectic state arise from anaemia of the brain-substance, from sudden compression of the cerebral capillaries; this anaemia is always seen after death, and is shown during life by the very symptom which has always had a contrary interpretation—“a remarkable pulsation of the carotids”. This, instead of being a sign of increased pressure of blood to the head, eally indicates that the flow of blood into the skull is obstructed “by he space”, he says, “in the skull being affected, so as to prevent the scape of blood from the afferent vessels”; throwing the blood back, as it were, into the carotids. As a consequence of this view, under the head of treatment, he says: “It is evident that, under some circumstances, venesection is a very useful remedy; under others, it is very injurious, and the indications for it may be very exactly given. In order that as much arterial blood as possible may enter the brain, we must try to facilitate the escape of venous blood, without, however, diminishing the propelling power too much” (what a plea is this for removing suffocation); then he con¬ tinues: “If the impulse of the heart be strong, and its sounds loud; if the pulse be regular, and no signs of commencing cedema of the lungs exist, we should bleed without delay. If, on the contrary, the heart’s impulse be weak, the pulse irregular, and the rattling in the trachea has already begun, we may be almost certain that bleeding would only do harm, since the action of the heart, which is always weakened, would be still more impaired, and the amount of arterial blood going to the brain would thus be still more decreased.” The simple relation of some of my early cases will best .illustrate what usually happens in a case of apoplexy, and how it may best be managed. Case I.—In October 1863. Miss B. 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 re¬ cumbent posture, and she appeared uneasy when placed on her right side; she was therefore placed on her left, when the stertor ceased. A blister