10th. His bowels continue open-has some pain in his head-he continues cheerful-his tongue this morning, for the first time, furred-his pulse is not so full as yesterday, and 80-his skin is rather dry, and he feels, he says, slightly feverish there is a free discharge from the wound. Mr. T. considered it advisable to increase the nutrition of his diet, which had hitherto consisted of, as I have before observed, light pudding, sago, arrow-root, &c. He, therefore, ordered him to have daily a beef-steak or mutton chop; this the patient appeared gratified to hear. He took the former to day with a relish he had also pint of porter; but this, it was found, stimulated him too much, and he afterwards had the table beer of the hospital. He was ordered a fever draught to take occasionally-his urine had been drawn off twice in the night (pint and each time)—it was also drawn off this morning and the bladder injected with warm water as before. The urine was more ammoniacal, and was mixed with a small quantity of thick mucus-there was also a very small portion of blood-continues to have the "darting and prickling" feel (as he describes it) in his legs and thighs -sensation is not quite so low down as last evening. Vesp. His bowels have not been open since the morning-complains of considerable pain in the wound-sensation is not lower than the crista of the ilium -his pulse more full than in the morning -he also complains of soreness in the chest, and some difficulty of breathing from his position. Mr Tyrrell in consequence changed it, placing him on his back with a firm pillow on each side of the wound in the direction of the spine, so as to prevent pressure. He expressed himself very warmly as to the immediate relief this afforded him in his breathing, &c. but as he still complained of soreness, he was examined, and a slight redness was perceived in the part. His aperient draught was repeated. The surface of the wound was covered with a slough. more mucus mixed with it, but not any blood. Merid. Enjoyed his mutton chopcontinues to take plentifully of arrow root, &c. Vesp. Pulse 90, rather harder than in the morning-bowels open-rather more restless-dull pain in the bowels, with some soreness of the integuments-his breathing appears a little more hurried than natural-wound still looks rather foul-sensation is not lower than yesterday-there is more mucus mixed with a little blood in the urine this evening-it also emits a stronger ammoniacal odourordered to continue the fever mixture and to have tinct. opii gtt. xx. hora somni. Bladder injected as usual. 12th. Slept for a few hours last night, but became more restless towards morning-complains of more pain in the bowels which are open-his pulse is as last evening, and his countenance had not the placid appearance it had hitherto borne-there was an expression of pain in it-there was some pain (he did not however complain much of it) in his chest, on the right side, where he had complained of pressure in his first position-sensation is not so low by six inches as yesterday-there is no darting in the legs and thighs nor any pain in the head. The urine is strongly ammoniacal, and has more thick mucus (with a little blood) than yesterday-there is not much pain in the wound-the slough is separated and it looks more healthy. Vesp. Urine is plentiful-on the bladder being injected with warm water, much mucus came away-it also smelt very ammoniacal-bowels open-fæces dark coloured-his countenance expresses more anxiety, and he is not so confident as to his recovery, as he has hitherto been has still slight pain in the chest-pulse 90, sharper than in the morning-wound dressed looks as well as in the morningsensation is not lower than the umbilicus. 13th. There is this morning an evident alteration in his appearance-his countenance expresses considerable anxiety-has not slept-pulse 100 and hard —has considerable pain in right side of the chest, with cough, which increases the pain-bowels open-urine plentifulhaving, as before, ammonia-thick mucus and some blood-the wound looks more unhealthy than last evening, having a RR 2 11th. Has slept well-feels more easy in his present position-pulse 80 and full -has not so much pain in the head-has still pain in the back, though not so violent as yesterday-tongue white-bowels freely open-has more of the prickling in his legs and thighs-urine plentiful-still ammoniacal-bladder injected with water slough on the surface-sensation not lower than last evening. Ordered.-V. S. ad vj. vel viij. ozs. and if this does not afford relief, 12 leeches to be applied to the seat of pain. The meat and beer are to be omitted, but to be still allowed sago, arrow-root, or broth. R. Calomel, gr. j. opii, gr. ss. nocte et mane. R. Sodæ subcarbonat, 3iij. mucil. g. acaciæ, 3ss. R; Tinct. hyosciam. 3j. syr. papav. alb. 3j. aq. menth. 3vj. m. The patient was directed to take a dessert spoonful of this when the cough was troublesome. Merid. ix. of blood were taken, which presents a buffy appearance-immediately after the bleeding, the pulse became more expanded and soft, but the pain and difficulty of breathing not being relieved, the 12 leeches were applied, which are now bleeding very freely, but his breathing is still laborious-his pulse is 100, though not so hard as in the morning-bowels open-urine drawn and bladder injected. Continues very restless, and his temper which has, till now, been comparatively mild, is very irritable. 10 o'Clock P.M. The leeches have continued to bleed very freely-but all his symptoms have now assumed a most alarming aspect. His pulse is 120, full and bounding-has excruciating pain in the side-much greater anxiety of the countenance-great restlessness frequent cough, with greater difficulty of breathing-pain in the wound, which looked unhealthy-no sensation below the displaced vertebrææ. A much greater evolution of ammoniacal odour from the urine, which contained at least 3 ozs. of mucus mixed with blood. V. Sectio ad 3xvj. this had a considerable effect for a time on his pulse, but did not relieve the difficulty of breathing, and but very slightly the pain. 2 o' Clock A. M. The pulse has risen to 130, but more feeble-pain and difficulty of breathing much more considerable. V. S. ad 3vj. produced but temporary relief, and at 4 o'clock A. M. he died. He was perfectly sensible till within a short time of his death, when he became delirious, and expressed a wish to get out of bed, but did not attempt it. I mention this as a curious coincidence with Mr. Tyrrell's former case, and also in confirmation of Mr. Bell's statement.. It is to be regretted that no post mortem examination could be obtained, as the poor man's Irish friends interfered, and nothing could induce them to consent to it-application was made to the Coroner for an order, but without effect. Remarks. Although this case has terminated unfavourably, still, on looking to the immediate cause of death, which, as far as the symptoms inform us, without having the confirmation of a post mortem inspection, was evidently seated in the pleura and lungs; where, it appeared, on enquiry, he had before had an inflam matory attack; we must acknowledge, that as this attack was not a necessary consequence either of the accident or treatment, (which is proved by Mr.Tyrrell's former case) it affords, in this point of view, no argument against the mode adopted for the relief of the patient. But it becomes a question whether it is not almost certain, from the symptoms, that death must have eventually, and at no distant period, terminated the case, from the disorganization evidently going on in the bladder, if the fatal attack of pneu monia had not supervened?-Mr. Tyrrell has, in his remarks on his former case in Sir A. Cooper's Lectures, Vol. 2nd. stated "My patient died of inflammation of the bladder, occasioned by the irritation of the urine, which, I believe, might have been prevented; and I should have taken steps for that purpose, had I known some circumstances connected with Mr. Cline's experiments relative to injuries of the spine." "He invariably found, that,after complete paraplegia was produced by the injury which he inflicted on the spinal marrow of dogs-the bladder became affected from the action of the urine on its mucous coat." "This organ," he continues, having lost its nervous power, it appears that the urine becomes decomposed in it, as it does after it is voided under ordinary circumstances, and thus acts as an irritant on the mucous surface." "This" says Mr. T. "might probably be obviated by frequently emptying the blad der with a syringe, and injecting a fuid to protect its mucous coat." It is, however, necessary that these changes should be further investigated: the present case entirely disproving the above conclusions-Ist, "That the urine is decomposed in the bladder"-2dly, That For, in the first place, the urine was drawn off so frequently in the present case, as not to allow sufficient time for the decomposition; but, to place the matter beyond a doubt the following method was adopted :—After the bladder had been emptied of the urine, by means of Read's syringe, (which is admirably adapted to the purpose) warm water was several times injected and withdrawn, till no trace of ammonia could be perceived. A small quantity of clear water was then injected, and allowed to remain about 15 or 20 minutes, when it was allowed to pass off, and the odour of ammonia could be distinctly perceived. Now, supposing urine to have been in stantly mixed with the water after its injection into the bladder, and that under the "loss of nervous power," it will decompose as quick in as out of it; still, every one is aware, that more time, than was allowed, is required, under "ordinary circumstances," out of the bladder, for its decomposition. It must, therefore, be concluded, that in whatever way the ammonia is formed, it takes place before the urine arrives in the bladder. 2ndly. The same argument is equally applicable to this position, the urine not having probably in this case been allowed to remain sufficiently long to produce the disorganization-but 3rdly. In whatever way the disorganization is effected, it is very evident that the means recommended and employed in this case, are perfectly inadequate to the prevention of it; and, as this appears a sine qua non in the successful treatment of these accidents, it still remains an interesting subject for investigation; for it is evident, from the symptoms, that the present case must, ere long, have terminated fatally from the disorganization in the bladder (which it will be seen gradually increased from the 3d or 4th day up to his death) if the fatal attack of pneumonia had not supervened. An occasional instance may, however, occur where this is not the case. This is exemplified by an interesting case which has within the last few weeks been spoken of at the Borough schools. In this instance, the patient survived a fracture with displacement of the superior lumbar vertebræ, causing paralysis of the lower extremity, 14 years; it was found, on inspecting the body after death, that the spinal chord was completely divided, with the exception of the dura mater. The case is, however, I am told, shortly to be published. 2. Case of Injury to the Spine. W. Stephens, æt. 24, was admitted into St. Thomas's Hospital, under Mr. Tyrrel, on the same day as the case before related, Feb. 5th, with total loss of motion and sensation in the lower extremities, and partial loss of motion in the upper, occasioned by being violently thrown, in a scuffle, against the edge of a board, on his back. There was considerable pain between the shoulders, extending down his arms, with some pain in the head. After minute examination, no irregularity could be perceived in the spinous process. Mr. Tyrrell did not, therefore, consider himself justified in proposing an operation. His pulse was 80, and full-ordered to be cupped to 16 ounces, at the back of the neck, after which, a dose of castor oil. The catheter to be introduced. Vesp. The pain was somewhat relieved by the bleeding. Feb. 6th. Restless night-countenance rather anxious-pulse 85, full-some pain in the head-tongue rather furred, with some thirst-fæces pass involuntarily. Vesp. Urine plentifully secreted, did not smell ammoniacal-pulse 95, rather sharp-more pain and restlessness-cupping repeated, which again produced temporary relief; the pulse also became softer. 7th, Mane. Slept for a short time after the bleeding last evening, but has since been restless-the lower part of the abdomen tense, somewhat tender on pressure, and slightly distended-the urine was plentifully secreted-did not smell ammoniacal-there was more anxiety of countenance, and greater difficulty of breathing than yesterday:—the latter symptom was, indeed, now the most urgent; it was, therefore, considered probable, that the injury extended to the cervical vertebræ-his pulse was more feeble. Vesp. Countenance livid, and very anxious-pulse more feeble-bowels evacuated. 8th. Was in every respect worsepulse more feeble-respiration very difficult-anxiety of countenance and restlessness much increased-urine smelt slightly ammoniacal-no mucus mixed with it. He gradually sunk during the day, and in the evening expired. Sectio Cadaveris. Before removing the arches of the vertebræ, after having made an incision upon them, considerable effusion of blood was found, and slight displacement of the 7th cervical vertebra forward was perceptible. Having removed the arches, considerable effusion of a bloody serum was found between the pia and dura mater-extending principally from the 5th cervical to the 4th dorsal vertebra. When the spinal cord was removed and examined more accurately, it was found that at the part opposite to the displaced vertebra, it presented a pulpy, homogeneous mass, containing many bloody points. The pia mater was turgid with blood. The remaining parts of the vertebræ, at the seat of injury, were then removed, when it was found that the 7th cervical was dislocated forward, with fracture of the left inferior oblique process, the right inferior process being dislocated from the corresponding one on the 1st dorsal vertebra-the intervertebral substance between the 7th cervical and 1st dorsal was torn through transversely the anterior part adherent to the vertebra above, the posterior to that below-there was also a longitudinal fracture through the body of the 3rd dorsal vertebra. The cavities were not examined. II. CASE OF VENEREAL LEPRA, FOLLOWING GONORRHEA AND SUPERFICIAL ULCE KATION. TREATED BY F. TYRBELL, ESQ. ST. THOMAS'S HOSPITAL. JAMES BIRBECK, æt. 20, was admitted into Lazarus' ward, Feb. 1st, 1827. Had gonorrhoea 8 months since, of which he soon recovered; after which, he had superficial ulcers on the glans, which healed in a few days without mercury-took merely six aperient pills. About a month since, he first found his throat slightly sore, and at the same time had an eruption over the whole body, except the face; it came out at first, he states, "with an itching." Had never any eruption before. Feb. 1st. There is now superficial ulceration on the tonsils, the right being rather the worst—the eruption is in distinct red patches, somewhat elevated, and covered with scales-if these scales are rubbed off, they will form again in a few hours-on the scale being removed, the red base is rather tender, but no appearance of ulceration. He has also a slight excoriation on the glans-penishas been under medical treatment three weeks before his admission—taking sulphur, and anointing the eruption with sulph. ointment, but without any benefit. Ordered.-Pil. Plummer. gr. v. om. nocte-decoct. sarsæ, c. 3xij. in die→ mist. aper. pro re natâ. Under this plan the excoriations on the penis were removed in two days, and the superficial ulcers on the tonsils were healed in four or five. The scales also separated in about the same period, and they did not re-form, leaving the red patches, which, however, soon became level with the surrounding skin; by continuing the medicine, the eruption became gra dually paler, and on the 5th of March they are scarcely visible. He is to continue the medicine a few days. Not the slightest effect has ever been produced on his gums. III. CASES OF INTERMITTENT FEVER. DR. BROWN, in his work on Intermittent Fever, has stated that "the practice of waiting for the paroxysm, and exercising powers to arrest its progress on its first approach, has never been established." Now, as far as the recommendation of a respectable physician, founded on and supported by cases, which were related, illustrating the efficacy of this practice, can be said to establish it, Dr. B.'s assertion is disproved; I allude to the recommendation, by Dr. Ridgway, of this plan, in the Number of the Medical and Physical Journal, for April, 1825. His attention was first directed to this mode of administering the bark, by a patient taking, at one dose, 1 oz. instead of in divided ones, as ordered it prevented the expected fit, and produce nothing unpleasant. "Since this period," says Dr. R. "I have never thought of giving the Peruvian bark in divided doses between the paroxysms; but, where I thought it necessary to use this medicine, have uniformly ordered it in one efficient dose, as near as possible to the approaching_parorysm." Dr. R. adds, that he considers an ounce as a sufficient dose in most instances, to avert the paroxysm this being accomplished, half-ounce 'doses were afterwards given. Bark did nutes before the fit came on. 10th. Pergat.-no return of paroxysm, Feb. 8th. Had ague six months-severe cough, does not expectorate-no pain in chest-bowels lax-pulse 80— type, quotidian. Ordered. Dr. R. twice R. Pulv. cinchon. 3ss. p. zing. gr. xxv. Took it an hour before the paroxysm came on; it was very slight." No sickness from bark. cured himself in this manner. Thus we see the principle of Dr. Brown's practice has been before recommended, but he has had the advantage of possessing the bark in a much more convenient form for fulfilling his object; this preparation having, since Dr. Ridgway first adopted the plan under consideration, been brought more under the notice of the profession; and, in availing himself of it, Dr. B. has, in some measure, altered the mode of fulfilling the object which both have in view, viz. preventing or repelling," as Dr. B. calls it, the approaching paroxysm, by giving several smaller, in lieu of one efficient dose, immediately before the paroxysm; but still it will be seen the principle is the same. Whether this alteration in the mode of administering the bark is an improvement, on the one recommended by Dr. R. remains to be proved. The following are, however, the results of several cases treated in St.Thomas's Hospital, by Drs. Williams and Roots, they having, with their usual kindness,consented to try the experiment. It will be seen that only half the dose recommended by Dr. Ridgway was found necessary. Case 1. Treated by Dr. Williams. WM. CUFF, ÆT. 35. Feb. 8th. Had intermittent fever since Christmas-type quotidian. Bowels regular-slight pain and fulness in left side. Ordered. R. Pulv. cinchon. 3ss. p. zingiber. gr. xxv. m. This was ordered to be taken about an hour before the expected paroxysm. Attack not so severe, and much shorter than it had hitherto been-had not, however, taken the bark more than five mi 9th. Pergat-very slight chill to day.' 25th. Not any return of the paroxysms.' March 1st. Discharged, cured. Case 3.-TIMOTHY FLYNN, ÆT. 27. Feb. 8th. Had ague three weeks-health otherwise good-type quotidian. The dose as in former casess-felt but a slight trembling. 9th. Pergat-scarcely any cold feel. 10th. No attack. 11th. The medicine omitted this morning, and he has had an attack of chill. 12th. Pergat-no attack. 13th. Re jected the medicine, and had a more severe attack than the last. 25th. Has not had any symptom of ague since. March 1st. Discharged, cured. In the following case the old plan was adopted, to contrast the effects. Case 4.-JOHN KELLEY, ÆT. 30. Feb 8th. Has had intermittent fever two months, daily-bowels regular-some cough at night-pulse 75. R. Pulv. cinchon. 3j. 4tis horis,sumend. inter paroxys. opii, gr. j. om. nocte. 8th. Shook 1 hour and a half. 9th. Pergat-paroxysm came on three hours later, and cold stage lasted an hour. 10th. Pergat same as yesterday. 11th. Pergat-continues the same. 12th. Somewhat better-pergat. 16th. Had an attack every day, but not so violent-pergat. 19th. Is still better-pergat. 25th. Has a very slight trembling-pergat-he continued the bark for another week, and was discharged cured. |