Gambar halaman

quarter of an hour. During the following forty-eight hours liver and spleen seemed to be slightly enlarged. Her bowels the fits were frequently repeated, and three days afterwards were opened twice a day. There were signs of slight con(June 12) the child was admitted into the East London solidation of the right apex, and all over the right back the Children's Hospital. The temperature on the evening of respiration was weaker than on the opposite side. Large admission was 102.84. On examination of the chest on the bubbling rhonchus was heard all over the chest. The evening following day, signs of consolidation were found at the upper temperature at first varied between 99' and 100', the pulse part of the right lung, and the respiration in the right axilla was small and rapid (120), and the breathing hurried (40). .Was tubular.

The child remained very fretful until December 14, when The fits continued, and were very violent. During the she became more composed, hier appetite improved, and she attacks both sides of the face twitched, the tongue was bitten, seemed generally better. She coughed less, and the bronchitis and all the limbs became rigid and were convulsed. Between from which she had been suffering appeared to be subsiding. the fits, consciourne:8 was not restored; the eyeballs oscillated, Her weight on this date (December 14) was exactly the same and the eyes were often turned upwards. There was no squint. as on the day of her admission into the hospital. The convulsions continued with short intervals until the During the next fortnight the temperature varied between evening of June 16, when they ceased. The temperature all 99' and 101', and the child seemed growing daily weaker. this time was over 102', both morning and evening. The pulse Her cough, too, returned and was very troublesome. On was quickenel, but remained regular, 140 to 150; and the December 29 much consolidation was found on the right side. breathing was hurried and irregular, with deep sighs.

In addition, however, she had begun to squiut with the right June 17.—No fit since yesterday evening. Child quite un- eye, and had occasionally slight twitchings of the muscles of conscious; face pale; nares act; eyeballs oscillate, turned rather the face. The temperature rose, and both the pulse and the upwards ; pupils contracted, but act slowly with light; tongue respiration became quickened. ulcerated from being bitten during the fits. Breathing very On December 31, 8 a.m., temperature 103°, pulse 150, rapid (75), but not laborious; intercostal spaces sink in rather respirations 60; 6 p.m., temperature 103-2°, pulse 150. deeply during inspiration. Pulse 157, regular. Skin wet with On the following day she seemed about the same; the squint, perspiration; very little flushing on irritation of the skin. however, had ceased, and the pupils were equal. The temperaOn examination of the chest, dulness was found at the upper ture remained high (1030 at 6, and the fontanelle was half of the right side. The respiration in the axilla was

much elevated. intensely tubular; elsewhere on that side it was covered by a On January 3 cho had a violent convulsive fit early in the fine crisp bubbling rhonchus, which was heard all over both morning, after which the left pupil was noticed to be larger sides of the chest. There was also dulaess at the lower half than the right. In the evening the fits returned, and the child of the left back, and the respiration was blowing, becoming died in the course of the night. The evening temperature tubular at the base. 9 a.m.: Temperature 104.8'; pulse 174 ; during the last three days was 103°, 103, and 102-8'. respirations 75. 7 p.m.: Temperature 105". The child died A post-mortem examination showed the body to be the seat quietly the next day. Temperature, a few hours before death, of acute general tuberculosis. The lungs were studded with 105.8.

grey granulations, and there was pneumonic consolidation of the On examination of the body, numerous small grey granula- right lung, which had softened into a small cavity towards thetions were found in the pia mater, the lungs, and the spleen. base. Numerous grey granulations were also found in the The pia mater was much injected at the base of the brain, and heart, kidneys, intestines, and in the meninges of the brain. a patch of effused lymph was seen on the left side. The whole The lateral ventricles were full of fluid, and there was besides brain seemed softened, and the lateral ventricles contained a a yellowish nodule the size of a small pea in the white matter large amount of fluid. Both lungs were the seat of pneumopic of the brain near the lateral ventricle of one side. consolidation, and in the right were several small cavities. The two preceding cases furnish very good examples of the

In this case the occurrence of a convulsive attack was the way in which the earlier symptoms of acute hydrocephalus are. first alarming symptom noticed by the mother. Before this obscured when the disease occurs in the course of an attack of event took place, although the child was no doubt feverish, acute tubercular phthisis. In such cases the occurrence of and was, as we know, troubled with cough and some oppression marked brain symptoms is a sign that the disease is about to of breathing, there was yet nothing in its condition which run a rapid downward course, and that the end is not far distant. appeared sufficiently urgent to require medical advice.

The case of Louisa P. is interesting as showing that the On admission, the obstinate recurrence of the fits, the con- emaciation does not always proceed with regularity, for during tinuance of insensibility between the attacks, the oscillation the first fortnight of the child's residence in the hospital her of the eyeballs, and the other symptoms, made it evident that weight remained stationary. The patient's appetite was good, the convulsions were not merely sympathetic with the condition and the quiet, and the better food she was taking at the time, of the lung. In certain forms of pulmonary disease in the no doubt contributed to this result. child, sympathetic convulsions are not uncommon. Thus in

(To be continued.) the course of acute capillary bronchitis they are often observed, especially if that disease be complicated by collapse of the lung. They are also not unfrequent at the close of

ORIGINAL COMMUNICATIONS. acute catarrhal pneumonia; and at the beginning of many acute diseases in the child convulsions may occur, taking the place of the rigor which often ushers in an acute disease in the

TUMOUR OF LATERAL adult; but it is very rare for sympathetic convulsions to appear PORTIONS OF THE LOWER JAW REMOVED first in the course of an acute pulmonary consolidation. Where this happens we should always, as in the present case, suspect

WITHOUT EXTERNAL WOUND. the existence of some complication. All the symptoms here

By C. F. MAUNDER, pointed to meningeal inflammation, and the history of the

Surgeon to the London Hospital. attack, combined with the pulmonary symptoms, made it evident that the case was one of acute general tuberculosis. Where, as in the present instance, the first symptoms pointing to the

So far as I am aware, the instructions usually given by authors brain are those of the third stage, it is rare to find a slow to guide surgeons in the removal of portions comprising more or pulse. In the third stage of acute hydrocephalus, the pulse, as a

less of the whole depth of the lower jaw, when the seat of tumour rule, has become rapid and often regular, the period during is not merely the symphysis, involve section of the skin. which it is slow and intermittent having gone by.

Some advise certain incisions to be traced so as to form a flap; Louisa P., aged six months, born of a healthy family, had in one case to be turned up, in the other to be turned down, in been herself a healthy child up to the age of five months, order to expose the condemned piece of bone. Some, in making when, after a severe attack of acute diarrhæa, she began to

the flap, carry the incision into the mouth, either at its angle waste, and for the following month seemed low and ailing. or some point of the lower lip, and thus deform this feature. She was then (December 1) admitted into the East London Others are content with incision of the cheek, leaving the Children's Hospital. The child was thin and weakly-looking,

mouth untouched. Some of the instructions, if followed, weighing only twelve pounds three ounces. The fontanelle must disfigure the patient very seriously. Free incision of was rather depressed, and she was very peevish and fretful. the cheek, as is recommended, entails free bleeding and delay The cervical glands were enlarged and also those of the axilla in arresting it, the formation of unsightly scars, and an and groing. The abdomen was very firm and tense, and the unnecessary interference with the nervous supply to the muscles of expression. The mode of proceeding which I have practised piece of necrosed bone came away from the sawn surface of in two instances is here described, and the result illustrated. the remnant of the base.

Examination of Bone.—My colleague, Mr. Barrett, examined Case 1.Myeloid Tumour of the Lower Jaw.

the diseased bone, and discovered a misplaced second bicuspid The patient, C., ten years of age, referred to me by tooth; it was lying at right angles to 'its natural position. Mr. Owen, of Leatherhead, is a female. The left base of the This malplaced organ may have been the cause of the growth; jaw was enlarged to the size of a hen's egg, the swelling but inasmuch as the corresponding tooth was also absent, the projecting outwards, and inwards to the floor of the mouth, fact was comparatively valueless from an etiological point displacing the tongue somewhat, and deforming the lower of view. part of the face. The tumour had a history of two years, Remarks.—The patient was recumbent during the operation, was painless, smooth on the surface, and hard and resistant to but no sign of danger from blood passing into the larynx was the touch, and gave one the impression that a growth within exhibited. Bleeding was comparatively trifling, the blood was expanding the jaw. It had enlarged rather quickly of coming chiefly from the tumour when this had been broken into, late. The teeth usually found at that age were present. I but this was arrested at once by the introduction of a piece of did not pretend to make a diagnosis beyond suggesting that sponge. A groove in the gum having been made with a scalpel it was probably benign. I thought it possible that I might 80 as to admit the end of the raspatory, the periosteum and have to deal either with a cyst or with a fibrous or cartilaginous chief muscular attachments, such as those of the masseter and growth, and, if so, that I might be able to evacuate the one internal pterygoid, were separated, and the bone being bared, and enucleate the other, and, at the same time, preserve the awaited section only. By this proceeding a very large piece line of the jaw unbroken ; this I was disappointed.

of the lower jaw (Fig. 1.), containing a growth of the size Operation (March 9, 1870). — The child being under the of a hen's egg was removed through the mouth, without any influence of chloroform, recumbent, with the head well for- section whatever of skin, with trifling bleeding, and without wards, I penetrated the tumour at the most resilient spot with division either of the facial artery or of branches of the facial a drill by way of exploration. A little blood only flowed. nerve. And what is of great importance in the female, at all With a chisel and mallet I perforated the thin, bony wall at events, there is no scar. Fig. 1 shows on the healthy jaw, inthis spot, and extracted a small portion of a growth. This cluded by the dotted lines, the extent of bone removed. (By was at once submitted to a microscopic examination by Dr. an error of the artist the right instead of the left side of the Sutton and Mr. Tay, and pronounced to be myeloid. The jaw is represented.) bleeding from the growth, now increasing, was checked by the

Fig. 1. introduction of a bit of sponge. I determined to remove the portion of bone containing the growth, and if possible through the mouth, and without cutting the skin of the cheek and lip at all. Standing somewhat behind, and on the right side of the patient, the integuments of the chin, including muscular attachments and periosteum, were first turned down off the symphysis, partly with a scalpel and partly with a raspatory, so as to expose the right side of the jaw opposite the right canine tooth (which was then extracted by Mr. A. W. Barrett) to the action of the saw and cutting forceps. At the back of this position the soft parts were also detached from the bone, and the floor of the mouth was perforated so as to admit of the introduction of a narrow spatula passed behind the bone to protect the soft parts from injury by the saw. The section here being completed, the mucous membrane and periosteum covering the tumour both in front of and behind the alveolus, as well as along the lower half of the anterior edge of the ramus, were severed down to the bone; and a raspatory introduced separated the periosteum, and with it the muscular Postscript (April 19, 1874).–To-day, in company with Mr. attachments to the required extent. By a little manquvring Owen, I visited the child, the subject of the above remarks, the end of the raspatory was made to pass round the base of and who had been operated upon rather more than four years the jaw and to appear under the floor of the mouth, and with ago (March 19, 1870). I found her wonderfully grown, being the aid of the forefinger similarly introduced, the soft parts unusually tall for her age, but thin. Although possessed of on the deep surface of the bone were detached from it. It only three teeth in the remnant of the right half of the lower was found to be possible to turn the soft parts covering the jaw, she masticates tolerably well, and enjoys good health. chin literally inside out. While the bone was being cut by the She works at her needle many hours daily; and notwithstand. forceps the thin shell containing the tumour cracked, and so ing this cramped position she carries herself well, being very the condemned fragment came away in two portions. This upright. Twenty months subsequent to the operation, when fracture did not facilitate the operation. The next step con- her photograph was taken, of which the woodcut (Fig. 2) is sisted in cutting across the ramus about its middle, and this

FIG. 2. was effected with forceps alone (guided into position by the point of the left forefinger), but not without some longitudinal splintering. During the operation the mouth was kept open by a gag. Before detaching the frænum linguæ and muscles at the back of the symphysis, the tongue was secured by a ligature passed through it near the tip, and held by an assistant to prevent the possibility of the organ falling back upon the larynx. Also before the patient left the theatre the tongue was firmly secured with its raw surface in apposition with the raw surface of the integuments of the chin by a harelip-pin, and also by fastening the ends of the ligature previonsly passed through the tip of the organ on either side to either end of the pin. Bleeding was trifling, no ligature being requisite.

Progress of Case.-During the early days following operation there was a good deal of swelling about the mouth, with fetid discharge. The child was sustained in a semi-recumbent posture with the head well forwards. The buccal cavity was repeatedly syringed with Condy's fluid and water, and liquid nourishment was plentifully administered. The case progressed favourably throughout; and before three weeks had elapsed, she could protrude her tongue tolerably well and articulate; a copy, the deformity was comparatively slight; but now, by and was running about the ward. Subsequently a very small lapse of time, growth, and development, the upper part of


Under atropine, H=ă diagnosed with oph


the face has become enlarged in all directions, while the frag- The treatment adopted is as follows :-Having diagnosed ment of the lower jaw has probably remained nearly stationary. myopic astigmatism by the ophthalmoscope, the patient is The immediate effect of the operation was (two-thirds of the ordered to use a strong solution of atropine, as detailed under semicircle of bone being removed) to allow the remnant to fall the first class of cases. The accommodation being paralysed, in towards the centre of the mouth, and to make the chin the myopic astigmatism, with any existing myopia, is accusomewhat pointed. Now, by reason of her growth, the pointed rately neutralised, and the proper glasses ordered for all near chin is more marked, as though she were the subject of a work. If a proper correction is obtained, the result is most congenital want of development of the lower jaw, whilst when satisfactory both to the patient and the surgeon. If the the muscles about the mouth are in a state of repose, the mouth asthenopia return, we may rest assured that the defect in falls away to the left. Her mother says this is especially refraction has not been accurately neutralised, and must be evident during sleep. The maximum of deformity will be worked out again. In this plan of treatment by paralysis of reached when the patient is full-grown, which may be expected the accommodation, it is interesting to notice how many cases if the operation be performed in early life ; while the minimum of mixed astigmatism are met with, which, without the use of will accrue to an adult submitted to a similar operation. atropine, appear to be cases of simple myopic astigmatism (To be continued.)

both by examination with the ophthalmoscope and by trial with lenses-showing that a certain tonic contraction of the

ciliary muscle must exist, sufficient to mask in some instances NOTES ON SOME ANOMALIES OF even a considerable amount of hypermetropia. REFRACTION.

Subjoined are notes of a few illustrative cases :-

Case 1.-Extreme Hypermetropia.
Assistant Ophthalmic Surgeon, Guy's Hospital ; Surgeon, Central London

G. W., aged 25. Eyes have always been troublesome; has Ophthalmic Hospital.

had many different glasses ordered, all of which gave relief

1 THERE are two anomalies of refraction of the eye, which,

for a time.

6 although recognised by ophthalmologists, appear not to have received sufficient attention as regards treatment, which, if

thalmoscope, and also by means of convex lenses. Right eye

12 properly carried out at first, will save the surgeon endless with convex -V= Left eye extremely amblyopio; most

6 12
trouble, and will spare his patient much inconvenience, and in
many cases prevent considerable suffering.

cyl. 18
improved by + Ordered convex

for both eyes. The anomalies alluded to are—first, high degrees of hyper

sph. 6 metropia ; secondly, the astigmatism which is met with in by

Seen four months later, could read or do any kind of near far the greater number of cases of the distressing asthenopia

work for any time without the least inconvenience. The left of short sight. The treatment to be presently described, of

eye had somewhat improved. the first of these, is insisted on by Mr. John Couper in his

Case 2.- Extreme Hypermetropia. clinical teaching, and was, I believe, mentioned by him in his Edwin T., aged 9. Has always been thought to be nearOration before the Hunterian Society. The second has received sighted; has learned to read, but with great difficulty, and by no notice that I am aware of. Under the first class are holding print close to the eyes. Can make out Snellen 6} at

1 included cases of hypermetropia above which, if treated

about four inches with either eye. Extreme hypermetropia 12'

diagnosed with ophthalmoscope. Under atropine, hypermein the ordinary way (that is, by neutralising the manifest


15 hypermetropia), will give no trouble for a time; but sooner

not improved beyond by any lens. When

30 or later the asthenopia returns, and the glasses ordered are seen a fortnight later, could read Snellen 2 at about eighteen found too weak. Patients thus affected go from one oculist to another, getting stronger glasses ordered by each, but with

inches without difficulty. Ordered to use convex

for all the like result—that the asthenopia returns and the glasses become useless.

purposes for six months, and then to report himself. The treatment I adopt in these cases is as follows :- Having

Case 3.High Degree of Hypermetropia. diagnosed a high degree of hypermetropia with the ophthal- S. K., needlewoman. Always had more or less difficulty in moscope, a solution of atropine gr. iv. ad 3j. is ordered to be doing near work. Has worn glasses, but they never appeared used three times a day for four or five days. The accommoda- to suit. Under atropine right eye

20 tion being thoroughly paralysed, the defect in refraction is

c. + 9V=

100 accurately neutralised, whether it be simple hypermetropia


20 or complicated by astigmatism, vision being, if possible,

left eye V = c. + 14 V = Ordered to use con

70 made =


The proper glass having been ascertained, is vex 12 for both eyes. Seen two months later, could do near 20

work for any time, and read small print (S. 11) easily. ordered be used at first for all purposes; but when the accommodation is restored only for near work, if the two eyes are

Case 4.-Compound Myopic Astigmatism— Much Asthenopia. alike, or nearly alike, a glass of the same description is given

William L., aged 23, a compositor. Has suffered from more for both. If there is any considerable difference, a different

or less pain in eyeballs and forehead for some years. Pain glass is ordered for each.

much increased by close application to his work. Has worn There is one difficulty which patients complain of when

glasses, and had them frequently changed, but without relief. first the accommodation returns-viz., that they have to hold

With the ophthalmoscope, myopia in the left eye, with myopia objects too close. This is caused by inability to relax the

and astigmatism in the right, were diagnosed. Left eye with accommodation, which the patient was before accustomed to



; right eye under atropine with constrain to the utmost : he must be told to wear the glasses

30 15 persistently, and in course of time all will come right. I cyl. 30 15


30 for left eye, have now carried out this plan of treatment for some two sph. 9

sph. 9 years, and with the most satisfactory results.

for right eye-to be used for near work, and also for going The second class includes many, if not all, of the cases of so- about, if he likes. Seen six weeks later, says his eyes have not. called "apparent asthenopia" of myops. The uneasiness, and been so comfortable for years. in some instances severe pain, in these cases is most distressing to the patients. The asthenopia does not show itself until

Case 5.-Compound Myopic Astigmatism-Much Asthenopia.. after the eyes have been constantly used on near work for

Elizabeth B., aged 18, a bookfolder. Suffers great pain, more some considerable period—often two or three years ; but, when especially at night, in eyeballs and forehead, getting

gradually once it has manifested itself, it increases so as to preclude all worse for the last eighteen months. Is slightly near-sighted. possibility of the patient continuing work. The pain would

15. Both

cyl. 40 under atropine-Left, with concave,

eyes appear to be due to irregular and spasmodic contraction of


15 the ciliary muscle. As a rule, the patients are only slightly

right, with concave,

cyl. 60 15

The pain was so commyopic-in fact, many of them do not complain of near sight

sph. 40

15 20 at all, and have V

pletely removed by the atropine and rest that this patient 50

objected to wearing glasses. Accordingly, none were ordered,

tropia a





concave =




-cyl. 30








care cyl. 36



and her eyes will no doubt become as bad as ever in the course absent--that is to say, the function of the median nerve is of a few weeks.

perhaps abolished, that of the musculo-spiral, musculoCase 6.--Compound Myopic Astigmatism.

cutaneous, and ulnar more or less complete. There is power in Emma S., aged 23, needlewoman. Has suffered for some the muscles of the neck. There is complete retention of urine ; time from much pain in forehead over left eye and in left the bowels acted slightly yesterday, to-day not at all. There temple; pain always worse after doing near work. Right is no absolute loss of sensibility anywhere, but in the legs it is

20 eye emmetropic; left eye under atropine, V =

with con

decidedly less than natural, the deficiency increasing down. 200

wards, so that on the dorsum of each foot, though he can Ordered to use this glass for left eye,

localise firm pressure, he scarcely feels a prick with the tips of sph. 36 20

the nails. He complains of scarcely any pain, but there is a and plain glass for right. Seen three weeks later; could work

little tenderness opposite the middle and lower cervical vertebræ for any time without inconvenience.

and in left shoulder. At eleven o'clock his body was gently raised and propped up at about an angle of 25° from the

horizontal, when he expressed himself relieved from the REPORTS OF HOSPITAL PRACTICE suffocation produced by the mucus; however, the cyanosis is

markedly increasing. Catheter tied in and arranged as a

syphon, with a vessel placed underneath the bed. Urine MEDICINE AND SURGERY.

coming by no means freely.

23rd.— Yesterday afternoon, about 3 p.m., three ounces of UNIVERSITY COLLEGE HOSPITAL.

blood were taken from the arm, as choking appeared imminent. Artificial coughing was also practised by compressing the

chest-walls and abdomen simultaneously with the effort of the FRACTURE OF BODY OF SIXTH CERVICAL VERTE- patient ; this gave him great relief. The loud rhonchal fremitus BRA-COMPRESSION OF CORD-PARALYSIS OF

felt in the morning disappearing. Urine acid, sp. gr. 1027; MUSCLES SUPPLIED BY PART OF BRACHIAL

no albumen; a very little ropy mucus; rather high-coloured. PLEXUS-PLEURISY, WITH EFFUSION-DEATH

Bowels not having acted since the day before yesterday, enema FROM EXHAUSTION AND ASPHYXIA.

administered. Tourniquets were also applied to the femorals

alternately, with a view to reducing the amount of blood in (Under the care of Mr. BERKELEY HILL.)

circulation. The artificial coughing was continued through GEORGE S., aged 23, carpenter, was admitted on December 20, the night. He slept for half an hour at a time. This morn1873. At half-past six in the evening of that day, patient was ing he seems more comfortable than yesterday; much less in the act of conveying a heavy box upstairs, and on the third cyanosis. Breathing quiet, 32 per minute ; skin moist ; step from the bottom fell backwards, striking, as he thinks, temperature 101°; tongue clean; abdomen not distended; the upper part of his neck and the back of his head. He was urine still acid. There is no improvement in the paralysis or brought to the hospital at seven o'clock.

in the numbed sensation of the limbs and body. Catheter The following is a report of his condition soon after taken out and passed every two hours. 4 p.m. : Urine acid, admission :-Lies on back, and takes no notice of anything but more mucus observable. round him, but can easily be aroused. Face cool. Pulse 24th.—The patient was sick last night very frequently, but staall, but compressible. Skin of right upper limb and of feels somewhat more settled to-day. Cyanosis almost disright side of chest markedly cooler than that of left. Tem- appeared, and breathing easier. Temperature this morning at perature of left lower limb higher than is natural-much 6.30 a.m., 102.2°; pulse 82. Temperature, 11 a.m., 102-6°; higher than that of right. Can raise both arms, bring them pulse 80, rather irregular. Feverish and thirsty ; seems across in front of him, and bend and extend the forearm, but frequently half-choked by phlegm, which, however, he is able cannot grasp at all; can extend wrist a very little. Can move to get rid of by the artificial coughing. Urine acid on passing, the right leg, but there is some loss of power. Has no power with no albumen. Abdomen quite as tympanitic as before. over left leg at all. Sensation entirely lost in right leg and No change in paralysis. 3.15 p.m. : Both feet distinctly and on right half of trunk as far as about the level of the nipple. much inverted, apparently from excessive relaxation of peroneal Sensation normal in left leg. Says arms and hands feel numb; muscles. Some ædema of both feet, especially the right. can feel the prick of a needle. No irregularity can be felt Interrupted current applied to peronei longi shows that the along spines of vertebræ. Has pain at lower part of back of irritability on right side is less than that on left. The neck and between shoulders. Says he feels as if his irritability of tibiales antici is almost equal. The current neck were coming off. Breathing 13 per minute, almost applied over the course of peroneal nerve shows a distinct entirely diaphragmatic; lower ribs appear to move slightly, deficiency of irritability on the right side. Optic discs examined: but upper ones are not raised at all in inspiration, while upper veins large and dark; no optic neuritis. Pain in left shoulder half of chest falls in. There is great rigidity of muscles at increasing. Pupils small and equal. Catheter tied in as back of neck; can rotate the head slightly. Some amount of before, by Mr. Hill's orders. priapism. Fæces appear to have passed involuntarily,

25th.--Temperature, 5 a.m., 101°; at 11 a.m. 101°, pulse December 21.-Patient says that one hour ago he could 80; temperature at 10 p.m. 101•3°. Urine acid ; no albumen; move his right leg, but now cannot at all; can now feel the light-coloured; ropy mucus. Enema. Has been sick often prick of a pin in it. Sensation remains in the left leg, but less through the night after anything that he has taken. The acute than it was last night. Intercostals do not act, and tympanites is now very considerable. Pulse quiet; skin upper part of chest falls in during inspiration. Sensation and moist. No increase of ædema in feet, which retain the same power remain about the same in upper limbs. Has no power inverted position. No alteration in paralysis. to expectorate, while bronchial tubes are apparently loaded 26th.-11 a.m.: Temperature 100°; pulse 84. Galvanism with mucus; feels as though he should choke; pain remains applied ; one sponge at anus, the other over abdomen. Flatus about the same. Has not passed any fæces.

escaped four or five times; distension of abdomen less; breathing 22nd.-Patient, when first seen by the registrar, Mr. easier. Has not been sick since morning. Godlee (to whom we are indebted for these notes), was in a 27th.— Temperature, 6 a.m., 102°; pulse at 11 a.m. 72, recumbent position, breathing entirely diaphragmatic, and respirations 32. Temperature at 6.40 p.m. 101o. Incoherent considerably cyanotic. There was evidently a considerable in his talk: this state of things began on the night of the 25th. collection of mucus in the trachea and bronchi. Skin very hot; Was sensible yesterday, but incoherency came on during the equally so on both sides, moist. Temperature in both axillæ, night, and continues this morning. Tympanites relieved by 102:30 ; pulse 96, rather hard and bounding. There is com- galvanism. No vomiting since the morning of the 25th. plete paralysis of the lower ribs, of apparently all the inter- Irritability of left peroneus longus greater than on the right costals, and of various branches of the brachial plexus, as side-as per battery register, 113 to 6; peroneal nerves about follows:-The deltoid, biceps, brachialis anticus, and triceps all equal. Patient had a slight rigor at 6.30, but has not been act, though the biceps only feebly. In the forearm, supination sick. Urine acid; no albumen ; small quantity of mucus. and extension of the wrist and fingers are apparently complete; 29th.—Temperature at 10.30, 99.9°; at 12, 99.4°; pulse at pronation can only be conducted so far as to bring the thumb 10.30, 64; respirations 32. Patient was not sick at all yesterupwards, probably performed by the supinator longus. Flexion day, and feels better this morning; was not galvanised of the wrist is very imperfect, and is apparently performed by yesterday. Was moved this morning for the purpose of putting the flexor carpi ulnaris only. Flexion of the fingers is altogether clean sheets on the bed, and suffered a good deal of pain in

the neck during the process. The left foot has now assumed the natural position of rest—viz., slight eversion. The posi. tion of the right is unaltered. The sensibility is distinctly less in the right foot than in the left; in the latter the power of localising sensation is pretty complete, in the former very imperfect. Pulse and respiration still quiet. Sputa as before, muco-purulent; power of coughing increases. Paralysis of arms no less ; pain in neck more severe; bowels acted twice without assistance yesterday and this morning ; no cyanosis now; odour of patient peculiar and fetid; urine acid.

30th.— Temperature 99.4°; pulse 64, rather feeble; respirations 32. Bowels open; passed some flatus this morning. No distension of abdomen; no change in position of feet, nor any in degree of paralysis in feet. He appears to have lost all extension movement in arms, and flexion muscles assume some rigidity on passive extension. Urine acid ; no albumen. Tongue furred and dirty; appetite good; sleep pretty good, considering the frequent interruptions.

January 1, 1874.—Urine: Yesterday morning, as the catheter had not been acting, a full beaker of urine was obtained immediately it was passed. It was acid to test-paper, and had a faintly disagreeable smell. On microscopical examination, it was found to teem with motionless bacteria of large size. Besides that, there were a considerable number of pus corpuscles. It was slightly turbid. Temperature 100·4°; pulse 72. This morning the man's condition is much the same as yesterday-namely, there is no increase or diminution in the paralysis. The left foot is now everted, and carries with it the leg, producing rotation outwards of the thigh. The right foot is still strongly inverted, producing a corresponding rotation inwards of the thigh. The arms, if left alone, assume a flexed position, the elbows being raised, and the hands touching the shoulders. The patient is emaciating rapidly. His skin is dry and rough, and he gives off an odour that is peculiarly disagreeable. His cough is becoming less troublesome; pulse still full, and fairly strong; tongue furred. Temperature 101.2°; pulse 76; respiration 36. Urine still acid; not so thick as yesterday.

2nd.—Skin dry and hot; temperature 101:4°; pulse 64, very strong and hard. Sleep much disturbed last night by coughing. Bowels open, but tongue dirty; has not been sick. Urine acid, and somewhat clearer; not so much mucus. No change in paralysis. Galvanism applied as before. Distension of abdomen decreased. Emaciation continues.

3rd.–Foot inverted again, though not quite so much as before. Temperature 100:4°. Bowels open; smell of the patient most disagreeable. Slept somewhat better last night, and looks more lively this morning. Artificial coughing still has to be kept up, though he is much better able than before to expel the mucus.

5th.-On Saturday afternoon the patient passed a motion just as Mr. Hill made his round in the afternoon, and said that, for the first time since his accident, he was conscious of passing it-i.e., actually felt the fæces passing. This morning he is not so feverish-temperature 99.2°,—but seems more uncomfortable. For the first time since admission he was regularly lifted off his bed while it was made comfortable. His left foot has again become everted, though not absolutely, and his left knee slightly flexed; in the latter he has sensation of pain. His bowels have been open this morning, but his smell is still abominable, though he is in his clean bed—even worse than before. He reports that during the last week he has been subject to occasional twitchings of his lower limbs. When this began he finds it impossible to specify; but on last Tuesday being suggested to him, he states that that was about the right day. His urine is still tolerably clear, acid, with a faintly disagreeable smell. The catheter was taken out this morning, cleaned, and replaced. He has a very small attempt at a bedsore, half-way down the left side ; otherwise his skin is perfectly whole.

7th.—Both feet extremely inverted to-day. Patient complains of great pain over his left shoulder. Left wrist and elbow and fingers are all in the position of extreme flexion.

8th.-Much difficulty in bringing up the mucus. Patient feels much more difficulty in breathing. Left leg is quite straight this morning; right leg extremely inverted. Early this morning the house-surgeon was called up on account of the patient's extreme difficulty in breathing.

9th.-Faradisation was applied by means of one pole up the rectum and the other over the surface of the abdomen. The patient has much more difficulty in getting up the

phlegm, even with the assistance of artificial coughing. Botha feet in position of extreme inversion.

10th.-Both legs extremely inverted. Complains of his legs “jumping” frequently in the day and night; no twitchings of the arms. Temperature 103.4°; respirations 32; pulse 72.

13th.-When the catheter is out, the urine runs away involuntarily. Temperature 102-2°. No change in paralysis, but emaciation becoming more and more prominent. Tongue so dry that it cracks and bleeds. Urine is still acid, fairly clear, and of only faintly nasty smell. Some roughness of skin can be felt on the back (about the middle), which feels. something like a coming bedsore.

14th.Patient died at a quarter-past seven yesterday evening.

Post-mortem, twenty hours after Death.—The head was first. opened, and the brain was found pale and anæmic, and excess. of fluid under the arachnoid. Nothing abnormal to the naked eye about the brain. On cutting down on the spine it was thought that the sixth cervical vertebra was more movable than natural. The spines of the vertebræ were removed; there was no blood outside the dura mater, unless perhaps a little in the lumbar region; there was some extravasation in the muscles of the lower cervical region. On removing the spinal cord it was seen that there was a prominence opposite the sixth cervical vertebra, which proved to be caused by the splitting of this vertebra in a vertical direction. The neural arch is split obliquely and on the left side behind the transverse process. On slitting up the dura mater, no blood was. found between the membranes; there was a distinct depression of the spinal cord opposite the projection mentioned. The veins below this point were much gorged; those above it of natural size. On cutting the cord transversely at seat of injury, it was found to be very soft and pulpy; a narrow line of extravasation ran from the anterior course of left side obliquely forwards and outwards. Above and below the seat. of injury the cord presented a natural appearance, except in. lower dorsal region, where it was soft. The fourth, fifth, sixth, and seventh vertebræ were then removed, and it was. found that the lower part of the body of the sixth and the intervertebral substance between that and the seventh were impacted one into the other. Before opening the chest the left side was seen to be greatly bulged, and on opening it the left pleura was found to be entirely filled with slight opaque

ellowish serum, containing flakes of recent lymph. The left lung was completely collapsed, and coated with a layer of lymph; it presented no sign of pneumonia. There was no fluid the right pleura. The right lung was somewhat congested, but presented no sign of pneumonia. Heart was rather large, and substance pale. Liver weighed 88 oz.; appearance normal, except that it was considerably congested. Spleen very soft, large, dark red colour; weight 18 oz. Right kidney congested and of rather large size; weight not taken. Left kidney : Pelvis much dilated, not inflamed-in fact, a good example of a sacculated kidney; kidney-substance being in some places not more than one-eighth of an inch in thickness, in others as much as an inch. Left ureter much dilatedlarge enough to admit the forefinger. Just behind the bladder a hard lump was felt, which proved to be a calculus. of spindle-shape, of black colour, with an accumulated yellow tip directed upwards ; on it were one or two minute prominences; round it the ureter lay with a sharp turn, and was probably pretty completely obstructed. Bladder showed signs of recent subacute cystitis. On the right thigh were two deep sloughs on the inner and outer sides, probably caused by the tourniquet which was applied on his first day in the hospital.

WE regret to hear that Mr. Baker, a surgeon, of Junction-road, Holloway, died on Sunday morning from the effects of a dose of carbolic acid taken, by mistake, a short time previously, for a composing draught.

SOCIETY OF APOTHECARIES v. ANDERTON.-A penalty of £20, and costs amounting to £5 ls. 6d., have been recovered through the Halifax County Court from the defendant, a. homeopathic chemist in Halifax, for illegally practising as an apothecary. This Mr. Anderton, some few years ago, was in business as a grocer in Halifax, and is, or was until quite lately, in some way connected with Mr. Ainley, the Medical Officer of Health for the borough of Halifax. The bills for Mr. Anderton's attendance were sent out in Mr. Ainley's name.

« SebelumnyaLanjutkan »