No. 974.

LONDON, SATURDAY, APRIL 30, 1842.

CLINICAL LECTURE

DELIVERED AT

KING’S COLLEGE HOSPITAL,BY R. B. TODD, M.D., F.R.S.,

Prof. of Anat. and Phys. in King’s College,and Physician to the Hospital.

Case of poisoning by oxalic acid; recovery.Poisoning by sulphate of copper ; symptomsand treatment. Convulsions from teething ;effect of the application of cold; the warm-bath.

DR. ToDD remarked, first, that in his lastclinical lecture* he had called the attentionof the students to a case of poisoning byoxalic acid ; another case had since occurredprecisely similar. The young woman whowas the subject of it bought the acid, as shestated, at a medical man’s shop, and swal-lowed it in a wineglassful of water ; thequantity was a pennyworth ; it burned herthroat severely, and tasted exceedingly sour.For three-quarters of an hour after havingtaken the poison she suffered intensely fromviolent pain in the throat, and griping pains inthe belly, which quite drew her double, vio-lenttremors, intense frontal headach ; she feltvery hot, and had pain in swallowing, andburning in the course of the oesophagus. Inan hour from the time of taking the poisonshe had medical assistance, and two or threepints of chalk mixture were administered :she was shortly afterwards admitted into thehospital (January 30th), still complaining ofsevere abdominal pain, but not showing anysigns of collapse ; she got an emetic of sul-phate of zinc, and afterwards chalk mixture,whilst the vomiting was encouraged bycopious draughts of hot water. This womanhad no bad symptom : on the night of the30th she had cramps in the legs, and nextday suffered from muscular soreness in theepigastric and lumbar regions, which, doubt-less, were only the effects of the efforts of

vomiting.

See LANCET, vol. i., 1841-42, p. 607.

POISONING BY SULPHATE OF COPPER.

It was so important for the medical prac-titioner to be always prepared in cases of

emergency, that Dr. Todd thought it wellbriefly to notice another case of poisoningwhich was admitted into the hospital a fewdays before the last. A young woman,aged eighteen, was admitted on the 24th ofJanuary on account of having swallowed asolution of what she called copperas ; on in-quiry it was found to be blue copperas, orsulphate of copper.

In this case the after-symptoms only hadto be treated ; she had swallowed the poisonon the 18th, a week before ; five minutesafterwards she vomited; she then took alarge quantity of salt and water, by whichthe vomiting was considerably promoted ;her throat became very painful and felt burnt,and the abdomen became swollen, tender,and painful ; she passed a good night. Nextday she had constant pain in the region ofthe stomach, and vomited everything, solidand liquid; she had also some diarrhoea.The vomiting, diarrhoea, and abdominal

pain, continued till the day of her admis-sion.On admission she was suffering chiefly

from exhaustion ; she had some pain in theabdomen, an unpleasant coppery taste in themouth, nausea, without vomiting, and dial"rhoea ; tongue white and furred; generalexsanguined state of the surface ; pulse 150.One-third of a grain of hydrochlorate of

morphia was given directly, and an efferves-cing draught, containing five minims of tinc-ture of opium, every three hours; to havealso a common enema,containing twenty 4ropsof tincture of opium. The opium readily con-trolled the diarrhoea, the taste in the mouthbecame less distinct, the pain in the abdo-men disappeared, and she was able to takewine and beef-tea. On the 27th she com-pletely recovered her appetite, and lost all

pain, except some headach. She was nowordered middle diet, and one grain of sulphateof quinine three times a-day.

In this case there were some of the irri-tant effects of the sulphate of copper. Thispoison, said the lecturer, acted very muchin the same way as arsenic and corrosive

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sublimate ; it irritated, inflamed, and killedthe mucous membrane of the oesophagus andstomach with which it came in contact; andit not only produced these local effects, butlikewise, and especially when taken in a

large dose, or in a concentrated form, itaffected the nervous system, causing insen-sibility, convulsions, tetanic spasms, or

palsy.This patient suffered chiefly from the local z,

symptoms ; the dose, the exact amount ofwhich could not be ascertained, was not suf-ficient to produce the effects upon the ner-vous system. She exhibited a symptomwhich seemed characteristic of copper poi-soning, namely, a coppery taste in the

mouth, lasting for several days. They hadnot here, however, the jaundice, which, ac-cording to Orfila, occasionally followed poi-soning by cupreous salts.Had this patient have come into

hospital immediately after taking the poison,what should they have done? They couldnot have done better than promote vomit-ing by large draughts of warm water, torid the stomach of the salt as soon as pos-sible, having previously administered whiteof egg, or milk, in order that the albumen byforming an insoluble compound with it

might disarm it of its irritating qualities.Sugar, ferrocyanate of potash, and iron,were extolled as antidotes ; but white of eggand milk were always to be had, and werewithin the reach of all. The treatment ofthis case was entirely directed to allay irri-tation, and remove the exhaustion underwhich the patient laboured, and this theysaw was speedily accomplished by opiates,followed by nutritious diet.

CONVULSIONS CONSEQUENT UPON DENTITION,TREATED BY THE APPLICATION OF ICE TO

THE SPINE.

The third case to which he would call theattention of the students, one of infantileconvulsions, likewise came into the class ofwhat one might call diseases of emergency.It was certainly one of those cases in thetreatment of which the medical man espe-cially required to keep in view correct prin-ciples, and should carefully avoid adoptinga routine practice. Convulsions were symp-toms of disease, to which, indeed, they stoodin the same relation as the vomiting occa-sioned by an incarcerated hernia did to theobstructing cause. The first and main pointwhich they would have to decide whencalled to a case of convulsions was theircause. I

Convulsions could not occur without someaffection of the medulla oblongata or spinalcord direct or indirect ; mechanical pressureon the fontanelle, as in parturition, mightoccasion convulsive movements; pressureon the tumour of the acephalous foetus didthe same. Irritation of the nervous centre

itself, then, might cause convulsions, as weknew often resulted in children from tuber.cular disease, and in adults, too, from menin-geal disease irritating the brain. But theirritation of the nervous centre might resultfrom some distant irritation propagated to itby an excitor nerve ; and in children, infantsespecially, this was most commonly the case.The excitement occasioned by the teethslowly making their way through the gums,or some derangement of the stomach or

bowels, not unfrequently reacted on the ner-vous centres, exciting an irritation there- which proclaimed itself by giving rise toconvulsions. The case which led him tomake these remarks was that of a child,Edward Brookes, aged eighteen months,who was admitted into hospital on the 23rdof January of the present year. The child’smother, who was a young woman of twentyyears of age, earned her livelihood as a

hawker in the streets. The infant, therefore,must have been much exposed and ill-at.tended to, ill-fed, and half clothed: for thefirst month after birth the child had frequentattacks of convulsive twitchings of the limbs,with drawing of the head backwards, and

starting of the eyes ; he was often awokefrom sleep by these attacks.On the 23rd of January in the morning

he was seized with a convulsive attack,having previously passed an uncomfortablenight, and apparently suffering pain in the

right side of the head, as indicated by hisfrequently placing his hand there. The fitlasted ten minutes, but after it had ceasedthe right hand shook violently ; at one o’clocka second fit occurred, and as it did not seem

likely to cease readily the mother applied tothe hospital.

The child was admitted at two, p.m,;at that time the following symptoms pre.sented themselves :-Total absence of con.

sciousness powerful convulsive twitchingof the flexor muscles of the right side, andalso of the muscles of the face on the sameside ; internal squinting pupils natural;respiration heaving and difficult; degluti-tion impossible ; action of the heart veryrapid. Such were the symptoms, they weresymptoms of irritation, and the first inquiryof the medical man should be, What is thesource of the irritation ? Dentition, as waswell known, was a very fruitful source ofirritation to infants, and so frequently gaverise to convulsions, that the practitionerwould be guilty of an unpardonable over.sight who did not first carefully examine thegums to ascertain whether any teeth were

struggling to come forward, and if so, todivide the membrane which retarded theirprogress.Mr. Pincott, the excellent resident assist.

ant to the physicians, having found the gumsswollen, scarified them freely ; and here,lethim (the lecturer) remark, that in the ma-

nagement of cases like the present they must

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not be content with a simple incision of thegum, they must take care to divide it freely,so as to cut through all the coverings of thetooth, and thus to remove every obstacle toits protrusion.

The scarification of the gums in this

case, however, was not followed by any im-provement in the symptoms; the child wasthen immersed in a warm-bath at the tem-

perature of 100° for ten minutes. There wasstill no improvement. In half an hour after-wards, with the view of removing any irri-tating matter which might have accumulated,in the bowels, an enema, consisting of fourounces of gruel and two drachms of spiritsof turpentine, was administered, but withoutgood effect. Cold sponging of the head wasnext tried, and two leeches were applied tothe right temple; these bled freely, and inhalf an hour the convulsive twitchings gra-dually left the right side, but consciousnessdid not return ; the muscles of the left sideof the face became slightly convulsed, andthe twitchings gradually extended to thewhole of the left side ; the extremities of theright side remained powerfully flexed, andcould not be extended. The child was inthis state at six o’clock, p.m., five hoursfrom the commencement of the fit. It thenoccurred to Mr. Pincott to adopt the expe-dient which they had, not long since, foundto produce such marked effects in a case of

hydrophobia, namely, of applying ice alongthe back of the neck and spine, with a viewof calming, by the sedative’ agency of cold, Ithe irritable state of that portion of the

cerebro-spinal axis which he rightly judgedto be affected, the medulla oblougata andspinalis, and the happiest results followed.Ice was applied in an ox-gullet along thecourse of the spine, extending from the occi-put to the sacrum. Immediately on its ap-plication the breathing became easier, thechild sighed several times, the pulse fellrapidly, and in ten minutes the convulsionshad entirely ceased. Consciousness was

not immediately restored, but as soon as theconvulsions were over, the child fell into asound sleep. Next morning the child wasquite conscious, but irritable ; he was freelypurged with a little calomel and jalap, andleft the hospital quite well in the fourth dayfrom his admission.The result of this case was highly satis-

factory, as affording a clear example of thegood effects resulting from the sedative in-fluence of cold. He would, however, im-press upon them that an application thusmade to the region of the irritated nervouscentre was less likely to be useful, if theoriginal irritant was not removed or dimi-nished ; and, therefore, it would not havebeen good practice to have applied the ice, un-less the gums had been previously freely sca-rified, and means used to clear out the bowels.Of the value of leeching and the warm-bathm the convulsions of children, he could not

speak so favourably. He thought, as a gene-ral rule, depletion in convulsive affectionswas bad; it tended to impoverish the blood,and to render the system more susceptible toirritating influences; it was only admissiblewhere there were decided indications of in-flammatory action. The warm-bath was apopular remedy, and was, he thought, almostalways used empirically, and without anydefinite object. Sometimes it seemed tosoothe the patient ; at other times, and hethought more frequently, it either did nogood at all, or did positive mischief, relaxingand increasing debility. It was, however,an expedient which now and then theymight try, and even with benefit; and in suchcases it possibly acted by soothing the ex-ternal sentient surface, whence the calminginfluence was communicated to the centres.

It had been assumed in this case that thesymptoms under which the child laboured,were the result only of a temporary irritationof the nervous centres. What evidence wasthere that the brain, medulla oblongata, orspinal cord, or their membranes, did notsuffer from actual inflammatory disease,tubercular irritation, or other chronic affec-tion ? The evidence appeared to him to be, derived mainly from the history of the case;the child had been in good health for severalmonths up to the day of his seizure ; the

seizure was perfectly sudden, and unaccom-panied by any marked premonitory symp-toms. After the first fit the child enjoyed afreedom from suffering for a little time, andthen the convulsions recurred with the samesuddenness as before; there was no greatdegree of febrile movement, nor heat of head,no vomiting, which was so frequent a symp-tom in children’s head affections ; and thespeedy result of the treatment certainly con-firmed this view, for it could not be sup-posed that, had actual disease existed, thechild would have become convalescent sorapidly.

ON THE

HÆMORRHAGIC DIATHESIS.

By JOHN COCHRANE, M.D., Surgeon.

HowEVLR similar animal structures mayappear to each other, they are verydiffer-ently constituted in respect of vital action.No two beings of the same species are

organised alike ; close resemblances in ge-neral arrangement no doubt exist, but strictidentities seem to be incompatible withnature’s endless, yet harmonious, variety.It is in the minute disposition of those im-portant parts where life is generated anddeveloped, that the organic distinctionsoccur which graduate the scale of vital

power, and furnish the individual suscep-tibility to be operated upon by the common