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Clinical Lectures ON DISEASES OF THE SPINE
NOVEMBER 19, 1864. It is to the antero. posterior curvatures and their modificatione that I wish to call your attention to-day. On your early re- cognition and true diagnosis of this disease, and your judicious treatment of it, may depend the earthly happiness and health of your patient-the form and stature of the man-the difference between a hunchbacked cripple and that especial attribute of man, the erect posture. I have no case in the hospital at this moment which exactly illustrates these observations, but they are dictated by the re., membrance of a case 1 have lately had in private practice, the account of which is drawn up by Dr. 1BI’Donnell, of Stobe Newington. I give it in his own wo ds, merely appendmg a commentary for your instruction. running " Mrs. -’s child (the sixth, all the others healthy), a fine healthy boy, was born June 30th, 1862. He continued to thrive until the December following, when he had a slight attack ofbronchitis, which was subdued by the usual remedies : he required attendance for four or five days only. He was vaccinated when twomonths old, successfully, and no unpleasant consequence ensued. A slight cough resulted from the attack in December, but no advice was sought. The general health began to suffer, which was attributed to a scanty supply of breast-milk : he was less lively, and not so well nourished in appearance. About the beginning of February, 1863, his nurse noticed an unusual projection in the back, and had remarked it to the mother, but no uneasiness was felt by the parents at that time. The strength of his legs had begun to fail, and he did not move them as before. I visited him on the llth of
Clinical Lectures ON
DISEASES
OF THE
Delivered at St. Thomas’s
BY SAMUEL
SPINE
Hospital,
SOLLY, ESQ., F.R.S.,
SURGEON TO THE HOSPITAL.
GENTLEMEN,—Last session I called your attention to the important subject of diseases of the spine, and I propose to do Its importance cannot be overrated. It so again this session. is a disease which pervades all classes, but it is more prevalent
among the poor than the rich. I think I may safely say that there is not one among those whom I now see before me who will be many months engaged in private practice before he is called upon to treat some form of this distressing malady. As many of your faces are new to me, I must repeat’what I have often had occasion to say before, that spinal disease may be ranged under two heads; the crowning type of one class being the lateral, producing in its most complete form terrible deformity and distress. You have all heard the expression, in February, and found a alight curvature present in the centre of speaking of a young lady, 11 poor thing ! she is as crooked as a the dorsal vertebrse, with little power in the limbs. He was fretful, failed to be amused, and had fallen off considerably rams’s-horn." In lateral curvature, the spine, when viewed more from behind, instead of presenting a straight perpendicular line, in flesh and good looks. A wet-nurse was advised, but not assented to; then, in absence of this, that the child be weaned, waves from side to side. In its aggravated form it is as painful and well supported by all the means suitable to infancy, and to look at as it is lamentable in its result; but it is not indica- be freely sponged daily in the tepid salt-water bath. Thecom. tive of disease of bone, nor, with rare exceptions, is it produc- plaint progressed, when, on the 23rd of March, he was seen, tive of paralysis. again. The curvature had increased, was more angular, limited The other form is the angular curvature, seen, when viewed to four or five central dorsal vertebrsa. and projected directly backwards. There was now not the power over th-6,, laterally, changing the graceful § like curves of the whole’ lower limbs, which were usually cold,slightest while the body was hot. spinal column into an abrupt angle at one particular point. So’ Sudden movements would cause him to scream, and indications abrupt is this deviation from the natural curve, so acute is thisI of pain were elicited on suddenly tapping in the neighbourhood angle, that if you look at the natural structure of the spinall -i.e., on either side of the projection of the spine. He could not column shown by a central perpendicular section, you see at; suffer to be amused as children of his age usually are, preferring quietude and immobility, as also the horizontal position in the once that some portion of the bodies of the vertebrae must have’ nurse’s arms. A hacking cough was present. There was no been removed to admit of such a falling forward of the columnL paralysis of the sphincter ani et vesicas. The expression of the and such a hunchback projection behind. countenance was anxious and pitiful; the eyes were brilliant;9 This broad line of division is something like that adoptedl the whole body was wasted. Mr. Solly was consulted on the by the geologist when he divides the terrestrial rocks into two) 24th of March." grand classes, the stratified and unstratified : the cause which I The appearance of the spine in this child, the history of th& produces the two being, water in the former, fire in the latter. case, the pain and suffering from pressure on the curvature, a11 So in the spine, the lateral curvature is the result of weakness, rather pointed to the conclusion that there was disease of the without any lesion of tissue ; the angular is the result of lesion bodies of one or more vertebrae, and that the child was doomed to be a hunchback for life. Further examination, however, caused by disease. The lateral curvature depends on a feeble condition of the convinced me thd.t it was not a true case of angular curvature, muscles and ligaments, just as the upright figure and the erect but an exaggerated stoop or curved back, without carious disspine are due to the proper action of the muscles of the back ease of the bodies, but in all probability with a partial absorp and the ligaments thereof : the muscles of the back, the pons tion of them. That the spinal canal was encroached upon, and asinorum of the juvenile anatomist. Yes, gentlemen, there are the spinal cord more or less compressed, was clear from the amount of paralysis which existed in the lower extremities. seven layers of muscles in the back, including in these layers With this view of its pathology the first step in the remedial fifteen muscles on each side and four sets. The origin, insertion, relative position, and action are difficult to learn and ’, agency to be set at work appeared to me-rest, entire rest, tc. hard to remember ; but when you have once learned them and the vertebral column, support to the spinal column, to do by thoroughly understand them, then also will you be able to mechanical means what the muscles could no longer do, prevent understand the pathology of lateral curvature. Remember this the spine bending unduly forwards. Not to make any attempt when you dissect them, and do not regard them as a piece of to straighten it forcibly or suddenly, but quietly and gradually, I advised the application of a leathern splint, carefully moulded mere dry uninteresting anatomy, to be learned for the College, but for nothing else. If these muscles become feeble, then the to the back and lower extremities. I extended it to the lower spine sinks into unnatural lateral curves; or it arches forward, extremities because I knew that in so young a child sufficient and that which is at first a mere occasional stoop becomes ulti- support could not be obtained by limiting it to the spine. This plan was carried out most efficiently by Mr. Millikin, instrumately a confirmed deformity. This brings me to the point where I must explain that this ment maker to St. Thomas’s Hospital. The splint was composed of three pieces-1st, a piece of aggravated stoop, this antero-posterior curvature, is of the leather moulded accurately to the back, embracing the sides, same genus and arises from the same cause as the lateral curvature, though it differs from it in form. It is the curve of feeble- and nearly meeting in front, softly padded at the back, and ness, not of disease. It is most important that you should fastened over the chest by an elastic lacing piece ; 2nd and 3rd., distinguish between this antero posterior curvature and the two pieces of leather moulded to the thighs and legs, and contrue angular curvature, which it resembles so much in outward nected to the body-piece by steel hinges or joints, which could appearances. Each can be recognised by looking at the spine be secured at any angle by screws. The leg-pieces were alac sideways. The outward difference is, that in the antero- softly padded. The child being placed in this splint, and the posterior deformity the curve is never quite lost, though it elastic laced over the chest, there were straps buckled round forms part of a very small circle ; whereas in the other, as its the thighs and legs too each, so that there was perfect rest enname implies, there is really an acute angle. forced to all narts. with the execution of the neck and arma, No. 2151 .
_
568 I’a the course of a week the splint was applied, and at first was believe, is since dead,-who told him he would correct his devery irksome to the child, and especially at night ; no sleep formity by degrees without any doubt whatever. About three was obtained for a night or two when it was worn. " It was times a week he used to smooth down the chest, as he called decided to leave it off for obvious reasons, and it was not again it, in order to correct the unnatural protrusion. He ordered resumed at night. Phosphate of iron with lime-water was sug- him to lie upon his back, and then pretended to extend it, and gested as medicine, and every support to be given. After a few thus make straight the breast. The extension was partly carweeks benefit was apparent from the use of the instrument. It ried on by manual force, and partly by fixing the upper part was very difficult to manage the urine, and prevent it spoiling the of the chest and attaching weights to the legs. I need hardly instrument and making it offensive. It was found after a time ’, that I expressed my horror and disgust at the treatment to say that this mischief was best guarded against by freely padding which the poor fellow had been subjected-treatment which, the lower parts of the body-piece and the thigh-pieces with if it had been continued with any effect, must have rendered cotton wool, and by oiling daily the steel joint. The bowels him paralysed for life. were easily managed ; the child’s wants were anticipated, and It was not, however, so easy to convince the patient; and its infantile language of expression interpreted in due time. he desired that I should be shown two casts of his chest which He had the benefit of the sea-side for two months in the had been taken, the one when he was first placed under treatsummer, and returned greatly improved in appearance, and ment, and the other after he had been subjected to it for about had grown as much as was natural. The curvature still re- a month. He called my attention to the difference in the promained, though less prominent, and some power was now had jection of the chest-the deformity which was most apparent 6fM’ the lower limbs. Two or three teeth had been cut at to him, and concerning which he was most anxious. At the Worthing; since his return two more. He has gradually im- first glance I could not quite understand it, as there certainly proved. and the power over the limbs increases; the curvature was some difference in the form; but in a few minutes I disgradually lessening. He is well nourished; is a fine child for covered the mystery. The two casts were really identical; but the facet oh which the casts stand had been altered in one of his age, and is now playful." On the 26th of July I received the following report :-"The spinal affection of Mrs. -’s child, a sketch of whose case I seat you some months ago, has been quite recovered from. He e8 been well for several months, and has discontinued the enpporting apparatus about three months. The spine is perfeetity straight, and he is full grown, vigorous, and looks remarkably well. I am firmly of opinion that but for the timely interference of the support afforded at your suggestion and upon *your advice, this child would have been a hunchback, with all its. attendant miseries to himself and to his family. No cure would be more perfect." The result of the case proved the correctness of the diagnosis. If there had been ulceration of the bodies of the bone, such as you may see in the preparations of this disease in our museum, 1Ihe child’s life might have been saved by the support given to the spine, but the deformity could not have been corrected. The very cure which Nature effects in this disease consists in arresting the destructive process set up in the bodies of the vertebrse, healing the osseous wound, uniting the separated bones, archylosing one or more bones together, strengthening the union by supplementary bands of bony tissue, but not filling up the chasm, or correcting the deformity. If, gentlemen, you understand, as I trust you do, the pathology of angular curvature, you may think it a work of supererogation to warn you against any attempt to straighten the spine, or correct the accompanying deformity of the thorax. I say accompanying deformity of the chest. I will explain what I them (Fig. 2). Fig. 3 represents the amount that had been reIf the angular deformity is great, the capacity of the moved, throwing the whole rather backwards, and thus lessenmean. thoracio cavity is encroached upon; and in order to get room ing the lower part .of the chest. The revelation of the fraud for the lungs and heart, Nature thrusts out the sternum, raising rather astonished my patient, but it did not quite convince it, and the whole chest assumes permanently something like him; so it was agreed that Sir Benj. Brodie should be called the form which I am now producing in my chest by taking a in for consultation. After that all went on well. very forced inspiration. You will, I am sure, hardly believe that in the present day any medical man could be found so ignorant or such a knave as to pretend that he could correct such deformity, and that it was the duty of the surgeon to do so; I had, however, a case a few years ago in private practice which was an illustration of this form of ignorance or knavery. The patient, who was about twenty-five years of age when he first consulted me, had a decided angular curvature in the dorsal region, with a compensating curve in the lumbar. There The was no stoop, but considerable projection of the back. sternum was thrust forward, and thus the whole chest projected considerably. The arrangement of the chest, though not very sightly, was very essential to the comfort and wellbeing of the patient, as thereby allowing a fair amount of spt-ce four the action of the heart and lungs. The most formidable symptom of disease was unmistakable signs of impending paraplegia, or paralysis of the lower ex. tremities. He complained of a feeling of pins and needles dowr the thighs, some numbness in the feet, occasional cramps, anc The brief history some loss of power in walking and standing. Mthe case was that the deformity was of long-standing, nol attended with much inconvenience; indeed, the more receni and serious symptoms were induced by carrying his gun in the fp-44 for rather a long day. This over-exertion produced grew pMn in his back and the other symptoms of threatened para lysis which I have detailed. On my inquiring into the amoun and kind of medical treatment that he had been subjected to I waa6bliged to con6ne my friend to a couch f6T about t8 I vas told that he was under the care of a surgeon,—who, months, in order by entire rest to check the iniammaliott
569 action which had been induced in the first instance by walking and shooting, and afterwards by pulling and rubbing. He ultimately recovered, and is now tolerably well and strong. Though still nnable to keep in an erect posture for any length of time, he has been benefited by ajudiciously-applied spinal
sapport,
made of cow-hide,
carefully
moulded to the
led to a class of cases hitherto altowhich may be now diagnosed with as much certainty as phthisis or valvular disease of the heart. In a,lJ those I am about to relate, a correct diagnosis wns eastly arrived at-first, from the character of the bronzing, and especiaHy its occurrence coincidently with the commencement of illness; deand secondly, from such illness being characterized bility and prostration, unaccounted for by any ascertained
legitimate bounds,
spine.
by
organic lesion.
BRONZING OF THE SKIN IN CONNEXION WITH DISEASED SUPRA - RENAL
Wm. S-, aged seventeen, a tall lad, who had much the appearance of having outgrown his strength. He was a saddler’ workman. For the last four months he was noticed to hav been weakly and ih, and losing flesh ; but he would not ad.OH that he had anything the matter with him, andw ent on wit)4 his work until ten days before admission, when vomiting came on, accompanied by some degree of mental wandering. When he came to the hospital he was extremely lean, and bad 4 general slight tint cf jaundice about the skin ; the conjunctive, however, were perfectly white. There was constant vomitipg; the belly was depressed; no enlargement was detected in the hepatic region. Nothing unnatural was discovered by auscul tation. When questioned, he showed a hesitating, uncertain manner. He complained of pain across the loins, and a bUf1,B.ing sensation at the lower part of the sternum. The skin W,49 cool, or rather cold ; pulse 96, very feeble; tongue c’eap, m4. urine natural. On the day before his death (he wes under pbt servation in the hospital five days in all) the sickness subsided, he was more emaciated, and the yellow tint of the skin remained ; the skin was cool; pulse 100, small and weak; he complained of feeling " awfully low," and at times was a little delirious. The next day found him lying with half shut eyes, cold and pulseless, with tranquil respiration, and usually regardles3 of passing things. He died in the afternoon. Post morte,m examination. - Body emaciated ; skin universally somewhat discoloured, of a dirty yellowish hue, approaching to bronze only on the parts which would be exposed to the A white clot was in the right ventricle of the heart. sun. There was a small collection of crude tubercle at the apex of the right lung. Much bile was found in the gall-bladder. The supra-renal capsules were of large size, especially the left; they were occupied by a mass of tubercular deposit, so that no portion of the healthy gland appeared to be left. The mesenteric The solitary and were enlarged by tubercular deposit. agminate glands were much enlarged at the lower part of th.9 ileum. No ulceration or inflammation existed.
BODIES. OCTAVIUS
BY
STURGES,
MEDICAL REGISTRAR
TO ST.
GEORGE’S
M.B.
CANTAB.,
HOSPITAL.
of Addison’s disease having lately I have been at the pains to refer back to the records of that institution for other similar I find two other such, neither of which, so far as I cases. know, has been published. T-nese cases are valuable, because in all three the supra renal bodies alone were the seat of disease of any extent likely to interfere with life, and in all the bronzing of the skin was coincident with the first notice of impaired health. In the case of G. P-,tndeed, the gradual darkening of the integument could be watched almost from day to day as the disease advanced, till, near the patient’s death, some parts of the body were almost black. There is a fourth case, not in the records of the hospital, inasmuch as the subject of it died at his own home in Bath. This I have been enabled to complete by the kindness of Dr. Bagshawe. relating these cases, and referring to some others published at various times by the Pathological Society, I may just recall the illustrations of the disease given by Dr. Addison. They are eleven in number. Of these four only appear to have died directly of the disease (2, 4, 5, and 6); one (No. 1) was cut off by acute pneumonia ; the remaining six were the subjects of morbid deposits involving the supra renal capsules in common with other organs. Of these last, three (7, 10, and 11) are cases without history. In Case 10 the bronzing is mentioned as "slight," and in Case 11 the face is described as " of dingy hue." No portrait is given of either. Case 5 is taken from Dr. Bright’s reports, where that author, having described the patient as " of very dark complexion," goes on to say, " The oply marked disease was in the supra-renal capsules." These Were enlarged, and the seat of scrofulous deposit. From such scanty materials Dr. Addison deduces the description of the disease which has since gone by his name. He says tat it occurs generally beyond middle life, chiefly in persons of a large and somewhat bulky frame, with a strongly marked tendency to the formation of fat ; that it is so insidious in its approach that the patient cannot accurately date it. The face gets pale in the first instance, and the conjunctives pearly; the general frame becoming flabby rather than wasted ; the whole surface blanched, smooth, and waxy; the lips, gums, and tongue bloodless. Slight oedema probably occurs about the ankles. The general symptoms are, extreme debility, with a prostrate, half torpid mental state, often irritability of the stomach and feeble cardiac action; the frame the while often
A
we are
gether overlooked,
STRBMNG
example
occurred at St. George’s
Hospital,
]?efore
glands A
George P--, aged thirty-two, admitted April 3rd, 1862. costermonger, af light complexion ’up to three months before
admission. He t4an observed the scrotum, chest, insides of thighs, and face suacessively become dark, so that he attained the colour of a Hindoo. At the same time he rapidly lost strength. He had formerly been very muscular, and able, he said, to carry Ii cwt. from Billingsgate to Chelsea. Debility came upon him very rapidly, so that a month after the first symptom of it he had to discontinue work altogether; at the same time he lost appetite, and complained of thirst ; the urine became pale, and much more abundant than in health, and was frequently passed. On admission his face was the colour of a Red Indian’s as far as the junction of the neck and trunk. There were -dark areolse round the nipples. Thescrotum and
penis were the darkest parts. The skin elsewhere than in the places named was like that of a very dark person. He was much emaciated, and extremely weak. The urine had a specific gravity of 1013, and contained a trace of albumen. He grew darker day by day. Vomiting commenced on the 8th, and could not be controlled before he had become drowsy He was conscious and exhibited obvious signs of sinking.
remaining obese.
In these observations
we have a description, accurate in the of a disease which, when uncomplicated, is more uniform im its manifestations than almost any other. In diagnosis, however, it is not allowable to fix upon every debilitated per- throughout. Post-mortem .examination.-The supra-renal capsules wme son with a brown face as the subject of Addison’s disease ; nor enlarged, and occupied by tubercular looking deposit, which is it at all necessary or safe to ascribe the disease to patients was not microscopically examined. The scrotum and perineum when their conthe colour of their from skins, merely general dition is manifestly dependent on the presence of easily recog- were almost black. There was a good deal of subcutaneous niaed disease elsewhere than in the supra-renal capsules. A fat. A hydatid cyst was connected with the liver. patient, for instance, with-cirrhosed liver need not be suspected Joseph P-,aged twenty-three, admitted Feb. 5th, 1863; of diseased capsules only because the jaundice in his case is an engine cleaner, of temperate habits and dark complexion mere brown than usual. Still less are we to take all brown or (which was natural to him), who had never had syphilis. Be btonzed people indiscriminately, and refer every obscure com- had had strong health till some three years before admifiplaint they may suffer to this disease. In short, the point sion, when he noticed his skin getting darker and yellowish. contended for at present may be put in this form : That in Eighteen months ago he vomited bile, and has been subject to cases where symptoms of debility arise and persist which are vomiting ever since ; debilitv had come on at the same time. inexplicable by reference to the condition of any other part ofFor six months he has been able to do very little, and has give4 the organism, and which are accompanied by bronzing of theup labour altogether for ten days, having once fallen on his akin, the supra-renal capsules are diseased. way to work and been unconscious for a minute or two. For Guided by this-discovery, and not stretching it beyond itsnine months he has had frequent diarrhoea, and very abundant
main,
,
,
,
Clinical Lectures ON
DISEASES
OF THE
Delivered at St. Thomas’s
BY SAMUEL
SPINE
Hospital,
SOLLY, ESQ., F.R.S.,
SURGEON TO THE HOSPITAL.
GENTLEMEN,—Last session I called your attention to the important subject of diseases of the spine, and I propose to do Its importance cannot be overrated. It so again this session. is a disease which pervades all classes, but it is more prevalent
among the poor than the rich. I think I may safely say that there is not one among those whom I now see before me who will be many months engaged in private practice before he is called upon to treat some form of this distressing malady. As many of your faces are new to me, I must repeat’what I have often had occasion to say before, that spinal disease may be ranged under two heads; the crowning type of one class being the lateral, producing in its most complete form terrible deformity and distress. You have all heard the expression, in February, and found a alight curvature present in the centre of speaking of a young lady, 11 poor thing ! she is as crooked as a the dorsal vertebrse, with little power in the limbs. He was fretful, failed to be amused, and had fallen off considerably rams’s-horn." In lateral curvature, the spine, when viewed more from behind, instead of presenting a straight perpendicular line, in flesh and good looks. A wet-nurse was advised, but not assented to; then, in absence of this, that the child be weaned, waves from side to side. In its aggravated form it is as painful and well supported by all the means suitable to infancy, and to look at as it is lamentable in its result; but it is not indica- be freely sponged daily in the tepid salt-water bath. Thecom. tive of disease of bone, nor, with rare exceptions, is it produc- plaint progressed, when, on the 23rd of March, he was seen, tive of paralysis. again. The curvature had increased, was more angular, limited The other form is the angular curvature, seen, when viewed to four or five central dorsal vertebrsa. and projected directly backwards. There was now not the power over th-6,, laterally, changing the graceful § like curves of the whole’ lower limbs, which were usually cold,slightest while the body was hot. spinal column into an abrupt angle at one particular point. So’ Sudden movements would cause him to scream, and indications abrupt is this deviation from the natural curve, so acute is thisI of pain were elicited on suddenly tapping in the neighbourhood angle, that if you look at the natural structure of the spinall -i.e., on either side of the projection of the spine. He could not column shown by a central perpendicular section, you see at; suffer to be amused as children of his age usually are, preferring quietude and immobility, as also the horizontal position in the once that some portion of the bodies of the vertebrae must have’ nurse’s arms. A hacking cough was present. There was no been removed to admit of such a falling forward of the columnL paralysis of the sphincter ani et vesicas. The expression of the and such a hunchback projection behind. countenance was anxious and pitiful; the eyes were brilliant;9 This broad line of division is something like that adoptedl the whole body was wasted. Mr. Solly was consulted on the by the geologist when he divides the terrestrial rocks into two) 24th of March." grand classes, the stratified and unstratified : the cause which I The appearance of the spine in this child, the history of th& produces the two being, water in the former, fire in the latter. case, the pain and suffering from pressure on the curvature, a11 So in the spine, the lateral curvature is the result of weakness, rather pointed to the conclusion that there was disease of the without any lesion of tissue ; the angular is the result of lesion bodies of one or more vertebrae, and that the child was doomed to be a hunchback for life. Further examination, however, caused by disease. The lateral curvature depends on a feeble condition of the convinced me thd.t it was not a true case of angular curvature, muscles and ligaments, just as the upright figure and the erect but an exaggerated stoop or curved back, without carious disspine are due to the proper action of the muscles of the back ease of the bodies, but in all probability with a partial absorp and the ligaments thereof : the muscles of the back, the pons tion of them. That the spinal canal was encroached upon, and asinorum of the juvenile anatomist. Yes, gentlemen, there are the spinal cord more or less compressed, was clear from the amount of paralysis which existed in the lower extremities. seven layers of muscles in the back, including in these layers With this view of its pathology the first step in the remedial fifteen muscles on each side and four sets. The origin, insertion, relative position, and action are difficult to learn and ’, agency to be set at work appeared to me-rest, entire rest, tc. hard to remember ; but when you have once learned them and the vertebral column, support to the spinal column, to do by thoroughly understand them, then also will you be able to mechanical means what the muscles could no longer do, prevent understand the pathology of lateral curvature. Remember this the spine bending unduly forwards. Not to make any attempt when you dissect them, and do not regard them as a piece of to straighten it forcibly or suddenly, but quietly and gradually, I advised the application of a leathern splint, carefully moulded mere dry uninteresting anatomy, to be learned for the College, but for nothing else. If these muscles become feeble, then the to the back and lower extremities. I extended it to the lower spine sinks into unnatural lateral curves; or it arches forward, extremities because I knew that in so young a child sufficient and that which is at first a mere occasional stoop becomes ulti- support could not be obtained by limiting it to the spine. This plan was carried out most efficiently by Mr. Millikin, instrumately a confirmed deformity. This brings me to the point where I must explain that this ment maker to St. Thomas’s Hospital. The splint was composed of three pieces-1st, a piece of aggravated stoop, this antero-posterior curvature, is of the leather moulded accurately to the back, embracing the sides, same genus and arises from the same cause as the lateral curvature, though it differs from it in form. It is the curve of feeble- and nearly meeting in front, softly padded at the back, and ness, not of disease. It is most important that you should fastened over the chest by an elastic lacing piece ; 2nd and 3rd., distinguish between this antero posterior curvature and the two pieces of leather moulded to the thighs and legs, and contrue angular curvature, which it resembles so much in outward nected to the body-piece by steel hinges or joints, which could appearances. Each can be recognised by looking at the spine be secured at any angle by screws. The leg-pieces were alac sideways. The outward difference is, that in the antero- softly padded. The child being placed in this splint, and the posterior deformity the curve is never quite lost, though it elastic laced over the chest, there were straps buckled round forms part of a very small circle ; whereas in the other, as its the thighs and legs too each, so that there was perfect rest enname implies, there is really an acute angle. forced to all narts. with the execution of the neck and arma, No. 2151 .
_
568 I’a the course of a week the splint was applied, and at first was believe, is since dead,-who told him he would correct his devery irksome to the child, and especially at night ; no sleep formity by degrees without any doubt whatever. About three was obtained for a night or two when it was worn. " It was times a week he used to smooth down the chest, as he called decided to leave it off for obvious reasons, and it was not again it, in order to correct the unnatural protrusion. He ordered resumed at night. Phosphate of iron with lime-water was sug- him to lie upon his back, and then pretended to extend it, and gested as medicine, and every support to be given. After a few thus make straight the breast. The extension was partly carweeks benefit was apparent from the use of the instrument. It ried on by manual force, and partly by fixing the upper part was very difficult to manage the urine, and prevent it spoiling the of the chest and attaching weights to the legs. I need hardly instrument and making it offensive. It was found after a time ’, that I expressed my horror and disgust at the treatment to say that this mischief was best guarded against by freely padding which the poor fellow had been subjected-treatment which, the lower parts of the body-piece and the thigh-pieces with if it had been continued with any effect, must have rendered cotton wool, and by oiling daily the steel joint. The bowels him paralysed for life. were easily managed ; the child’s wants were anticipated, and It was not, however, so easy to convince the patient; and its infantile language of expression interpreted in due time. he desired that I should be shown two casts of his chest which He had the benefit of the sea-side for two months in the had been taken, the one when he was first placed under treatsummer, and returned greatly improved in appearance, and ment, and the other after he had been subjected to it for about had grown as much as was natural. The curvature still re- a month. He called my attention to the difference in the promained, though less prominent, and some power was now had jection of the chest-the deformity which was most apparent 6fM’ the lower limbs. Two or three teeth had been cut at to him, and concerning which he was most anxious. At the Worthing; since his return two more. He has gradually im- first glance I could not quite understand it, as there certainly proved. and the power over the limbs increases; the curvature was some difference in the form; but in a few minutes I disgradually lessening. He is well nourished; is a fine child for covered the mystery. The two casts were really identical; but the facet oh which the casts stand had been altered in one of his age, and is now playful." On the 26th of July I received the following report :-"The spinal affection of Mrs. -’s child, a sketch of whose case I seat you some months ago, has been quite recovered from. He e8 been well for several months, and has discontinued the enpporting apparatus about three months. The spine is perfeetity straight, and he is full grown, vigorous, and looks remarkably well. I am firmly of opinion that but for the timely interference of the support afforded at your suggestion and upon *your advice, this child would have been a hunchback, with all its. attendant miseries to himself and to his family. No cure would be more perfect." The result of the case proved the correctness of the diagnosis. If there had been ulceration of the bodies of the bone, such as you may see in the preparations of this disease in our museum, 1Ihe child’s life might have been saved by the support given to the spine, but the deformity could not have been corrected. The very cure which Nature effects in this disease consists in arresting the destructive process set up in the bodies of the vertebrse, healing the osseous wound, uniting the separated bones, archylosing one or more bones together, strengthening the union by supplementary bands of bony tissue, but not filling up the chasm, or correcting the deformity. If, gentlemen, you understand, as I trust you do, the pathology of angular curvature, you may think it a work of supererogation to warn you against any attempt to straighten the spine, or correct the accompanying deformity of the thorax. I say accompanying deformity of the chest. I will explain what I them (Fig. 2). Fig. 3 represents the amount that had been reIf the angular deformity is great, the capacity of the moved, throwing the whole rather backwards, and thus lessenmean. thoracio cavity is encroached upon; and in order to get room ing the lower part .of the chest. The revelation of the fraud for the lungs and heart, Nature thrusts out the sternum, raising rather astonished my patient, but it did not quite convince it, and the whole chest assumes permanently something like him; so it was agreed that Sir Benj. Brodie should be called the form which I am now producing in my chest by taking a in for consultation. After that all went on well. very forced inspiration. You will, I am sure, hardly believe that in the present day any medical man could be found so ignorant or such a knave as to pretend that he could correct such deformity, and that it was the duty of the surgeon to do so; I had, however, a case a few years ago in private practice which was an illustration of this form of ignorance or knavery. The patient, who was about twenty-five years of age when he first consulted me, had a decided angular curvature in the dorsal region, with a compensating curve in the lumbar. There The was no stoop, but considerable projection of the back. sternum was thrust forward, and thus the whole chest projected considerably. The arrangement of the chest, though not very sightly, was very essential to the comfort and wellbeing of the patient, as thereby allowing a fair amount of spt-ce four the action of the heart and lungs. The most formidable symptom of disease was unmistakable signs of impending paraplegia, or paralysis of the lower ex. tremities. He complained of a feeling of pins and needles dowr the thighs, some numbness in the feet, occasional cramps, anc The brief history some loss of power in walking and standing. Mthe case was that the deformity was of long-standing, nol attended with much inconvenience; indeed, the more receni and serious symptoms were induced by carrying his gun in the fp-44 for rather a long day. This over-exertion produced grew pMn in his back and the other symptoms of threatened para lysis which I have detailed. On my inquiring into the amoun and kind of medical treatment that he had been subjected to I waa6bliged to con6ne my friend to a couch f6T about t8 I vas told that he was under the care of a surgeon,—who, months, in order by entire rest to check the iniammaliott
569 action which had been induced in the first instance by walking and shooting, and afterwards by pulling and rubbing. He ultimately recovered, and is now tolerably well and strong. Though still nnable to keep in an erect posture for any length of time, he has been benefited by ajudiciously-applied spinal
sapport,
made of cow-hide,
carefully
moulded to the
led to a class of cases hitherto altowhich may be now diagnosed with as much certainty as phthisis or valvular disease of the heart. In a,lJ those I am about to relate, a correct diagnosis wns eastly arrived at-first, from the character of the bronzing, and especiaHy its occurrence coincidently with the commencement of illness; deand secondly, from such illness being characterized bility and prostration, unaccounted for by any ascertained
legitimate bounds,
spine.
by
organic lesion.
BRONZING OF THE SKIN IN CONNEXION WITH DISEASED SUPRA - RENAL
Wm. S-, aged seventeen, a tall lad, who had much the appearance of having outgrown his strength. He was a saddler’ workman. For the last four months he was noticed to hav been weakly and ih, and losing flesh ; but he would not ad.OH that he had anything the matter with him, andw ent on wit)4 his work until ten days before admission, when vomiting came on, accompanied by some degree of mental wandering. When he came to the hospital he was extremely lean, and bad 4 general slight tint cf jaundice about the skin ; the conjunctive, however, were perfectly white. There was constant vomitipg; the belly was depressed; no enlargement was detected in the hepatic region. Nothing unnatural was discovered by auscul tation. When questioned, he showed a hesitating, uncertain manner. He complained of pain across the loins, and a bUf1,B.ing sensation at the lower part of the sternum. The skin W,49 cool, or rather cold ; pulse 96, very feeble; tongue c’eap, m4. urine natural. On the day before his death (he wes under pbt servation in the hospital five days in all) the sickness subsided, he was more emaciated, and the yellow tint of the skin remained ; the skin was cool; pulse 100, small and weak; he complained of feeling " awfully low," and at times was a little delirious. The next day found him lying with half shut eyes, cold and pulseless, with tranquil respiration, and usually regardles3 of passing things. He died in the afternoon. Post morte,m examination. - Body emaciated ; skin universally somewhat discoloured, of a dirty yellowish hue, approaching to bronze only on the parts which would be exposed to the A white clot was in the right ventricle of the heart. sun. There was a small collection of crude tubercle at the apex of the right lung. Much bile was found in the gall-bladder. The supra-renal capsules were of large size, especially the left; they were occupied by a mass of tubercular deposit, so that no portion of the healthy gland appeared to be left. The mesenteric The solitary and were enlarged by tubercular deposit. agminate glands were much enlarged at the lower part of th.9 ileum. No ulceration or inflammation existed.
BODIES. OCTAVIUS
BY
STURGES,
MEDICAL REGISTRAR
TO ST.
GEORGE’S
M.B.
CANTAB.,
HOSPITAL.
of Addison’s disease having lately I have been at the pains to refer back to the records of that institution for other similar I find two other such, neither of which, so far as I cases. know, has been published. T-nese cases are valuable, because in all three the supra renal bodies alone were the seat of disease of any extent likely to interfere with life, and in all the bronzing of the skin was coincident with the first notice of impaired health. In the case of G. P-,tndeed, the gradual darkening of the integument could be watched almost from day to day as the disease advanced, till, near the patient’s death, some parts of the body were almost black. There is a fourth case, not in the records of the hospital, inasmuch as the subject of it died at his own home in Bath. This I have been enabled to complete by the kindness of Dr. Bagshawe. relating these cases, and referring to some others published at various times by the Pathological Society, I may just recall the illustrations of the disease given by Dr. Addison. They are eleven in number. Of these four only appear to have died directly of the disease (2, 4, 5, and 6); one (No. 1) was cut off by acute pneumonia ; the remaining six were the subjects of morbid deposits involving the supra renal capsules in common with other organs. Of these last, three (7, 10, and 11) are cases without history. In Case 10 the bronzing is mentioned as "slight," and in Case 11 the face is described as " of dingy hue." No portrait is given of either. Case 5 is taken from Dr. Bright’s reports, where that author, having described the patient as " of very dark complexion," goes on to say, " The oply marked disease was in the supra-renal capsules." These Were enlarged, and the seat of scrofulous deposit. From such scanty materials Dr. Addison deduces the description of the disease which has since gone by his name. He says tat it occurs generally beyond middle life, chiefly in persons of a large and somewhat bulky frame, with a strongly marked tendency to the formation of fat ; that it is so insidious in its approach that the patient cannot accurately date it. The face gets pale in the first instance, and the conjunctives pearly; the general frame becoming flabby rather than wasted ; the whole surface blanched, smooth, and waxy; the lips, gums, and tongue bloodless. Slight oedema probably occurs about the ankles. The general symptoms are, extreme debility, with a prostrate, half torpid mental state, often irritability of the stomach and feeble cardiac action; the frame the while often
A
we are
gether overlooked,
STRBMNG
example
occurred at St. George’s
Hospital,
]?efore
glands A
George P--, aged thirty-two, admitted April 3rd, 1862. costermonger, af light complexion ’up to three months before
admission. He t4an observed the scrotum, chest, insides of thighs, and face suacessively become dark, so that he attained the colour of a Hindoo. At the same time he rapidly lost strength. He had formerly been very muscular, and able, he said, to carry Ii cwt. from Billingsgate to Chelsea. Debility came upon him very rapidly, so that a month after the first symptom of it he had to discontinue work altogether; at the same time he lost appetite, and complained of thirst ; the urine became pale, and much more abundant than in health, and was frequently passed. On admission his face was the colour of a Red Indian’s as far as the junction of the neck and trunk. There were -dark areolse round the nipples. Thescrotum and
penis were the darkest parts. The skin elsewhere than in the places named was like that of a very dark person. He was much emaciated, and extremely weak. The urine had a specific gravity of 1013, and contained a trace of albumen. He grew darker day by day. Vomiting commenced on the 8th, and could not be controlled before he had become drowsy He was conscious and exhibited obvious signs of sinking.
remaining obese.
In these observations
we have a description, accurate in the of a disease which, when uncomplicated, is more uniform im its manifestations than almost any other. In diagnosis, however, it is not allowable to fix upon every debilitated per- throughout. Post-mortem .examination.-The supra-renal capsules wme son with a brown face as the subject of Addison’s disease ; nor enlarged, and occupied by tubercular looking deposit, which is it at all necessary or safe to ascribe the disease to patients was not microscopically examined. The scrotum and perineum when their conthe colour of their from skins, merely general dition is manifestly dependent on the presence of easily recog- were almost black. There was a good deal of subcutaneous niaed disease elsewhere than in the supra-renal capsules. A fat. A hydatid cyst was connected with the liver. patient, for instance, with-cirrhosed liver need not be suspected Joseph P-,aged twenty-three, admitted Feb. 5th, 1863; of diseased capsules only because the jaundice in his case is an engine cleaner, of temperate habits and dark complexion mere brown than usual. Still less are we to take all brown or (which was natural to him), who had never had syphilis. Be btonzed people indiscriminately, and refer every obscure com- had had strong health till some three years before admifiplaint they may suffer to this disease. In short, the point sion, when he noticed his skin getting darker and yellowish. contended for at present may be put in this form : That in Eighteen months ago he vomited bile, and has been subject to cases where symptoms of debility arise and persist which are vomiting ever since ; debilitv had come on at the same time. inexplicable by reference to the condition of any other part ofFor six months he has been able to do very little, and has give4 the organism, and which are accompanied by bronzing of theup labour altogether for ten days, having once fallen on his akin, the supra-renal capsules are diseased. way to work and been unconscious for a minute or two. For Guided by this-discovery, and not stretching it beyond itsnine months he has had frequent diarrhoea, and very abundant
main,
,
,
,