REPORT OF A CASE OF CHOLERA MALIGNA. COLLAPSE OF NINE HOURS' DURATION : RECOVERY.

94 so than the other voluntary muscles. Why they had not so far wasted and degenerated as to lose their contractile power. But how is it, it will be asked, that no account has been is to be explained, I think, by the frequent motions into which given of the mind in the case I have described as gradually mental excitement threw them, for let us consider the long enfeebled by the disease ? It so happened that I had no duration of the paralysis, which had lasted seven years and a opportunity of examining the child from the time of my notes half. Anything which moves nourishes a muscle; emotion being printed, (THE LANCET, July, 1840,) until a short while therefore nourishes it. And it is plain that in health it must previous to her death. At that time, her age could not have have a great indirect influence as a nutrient power, both as been told by the appearance of the body, so stunted was it; acting alone and blending with volition. What it mayacthe mind was nothing but a miserable wreck; quick hearing, complish in disease, let the case I have recorded suffice partly ’extreme restlessness, and great desire for food, were all the to show. When the facial muscles are paralyzed as to mental phenomena which I was able to discover; but I learn, will, but yet actively respond to passion, emotion may keep that for a long time subsequent to her blindness she seemed them duly nourished, and be of great use in this way. It would be out of place here to enter at any length into the as quick as other children, indicated her wants intelligently, and not only knew the members of her own family by the consequences of very protracted rest to the muscular fibresound of their voices, but recollected strangers by the same a subject on which Hunter has most emphatically dwelt; and means. It must be remembered, however, that it is difficult I may refer to a graphic passage, wherein he speaks of the to ascertain how far a mind is impaired, especially if no pale state of the muscles of new-born animals, contrasting it searching inquiry be instituted for the purpose; and in a case with that of their heart, which has been active before their so distressing as that detailed, any sign of intelligence is more birth; and to our being able to keep the muscles of an animal likely to strike the mind than usual, and even to be exaggerated, pale by compulsory rest, taking exception to the diaphragm, in spite of every effort to judge calmly of it. It happens the movements of which must persist in spite of us.* He from such reason that patients who have lost their intelligence ipoints to a truth most evident; but it remains for us to apply - for awhile from some head affection or other, do, when they it fully. Paralyzed limbs should be forced into action, that begin to show a return of it, more astonish their friends by one effect of volition may be preserved to them-their due the simplest answers to the simplest questions than ever they nutrition. Dr. John Reid has shown, by his experiments on astonished them before their illness by their chief feats of infrog, how galvanism keeps a limb from wasting. I have how it nourishes limbs in paralysis, as many who tellect. There are two points to which I would advert shortly before have used it in cases of that affection must have done also. concluding—the hypertrophy of the cranium, and the condi- I have enforced its employment, as a means of nutrition, in a few sentences which Dr. Marsliall Hall did me the honour of tion of the muscles of the paralyzed limbs. The hypertrophy of the cranium was very well marked in inserting in the first volume of his "Observations in Medicine;" this case, and it is a point of great interest in all those cases of and I suggested, in the same place, the excitement of reflex ’cerebral atrophy in which it is found. We may distinguish actions with the intent of producing nutrition also. But by means of it, as Cruveilhier says, between congenital galvanism is the chief remedy for paralytic atrophy - the atrophy of the brain and that which happens after birth. The most universally applicable, the most easily regulated; it skull enlarges not externally, but grows inwards, so that the serves us when no involuntary action can be excited otherincrease of its thickness is formed entirely at the expense of wise-when none other is known to occur. Other means, its cavity. Moreover, the diploe is the part which increases however, areof value; and with respect to the provoking of and hence the cranium, though so much thicker, gains not in reflex actions, I must refer to a case, in which Mr. Paget, led weight, as it would do if the enlargement more involved the by his thoughts on Dr. Reid’s experiments, recommended tables. This, however, is not invariable. " The deposit of their excitement in a paralytic affection, with the direct view bone" (says Dr. Sims) " frequently takes place on the inner of preventing atrophy, and, as he has reason for thinking, with surface of the cranium." It sometimes happens that one good result. I have known a limb, which was well nourished ,hemisphere of the brain becomes wasted, to the complete ex- so long as there were reflex actions, become leanofand diminuclusion of the other: and then the skull has been seen to tive when those movements ceased. All kinds involuntary hypertrophy on the diseased side only, as Cruveilhier has movements deserve to be considered in the light of indirect beautifully depicted, so that it might be inferred, from a view nourishers of paralyzed parts. A very interesting case of ,of the cranium, which hemisphere of the brain had suffered, hysterical paralysis is referred to by a writer in the April just as the same fact might be conjectured from a comparison number of the British and Foreign Medico-Chirurgical Review. of the crura cerebri. It is not to be supposed that this state The legs were paraplegic; one was affected by violent cramps, of the cranium is a necessary attendant on cerebral atrophy; the other not. Let the difference between them be well for, as I need not say, there are many forms of this affection remarked. " The former measured an inch more in circumwhich impair the structure, without obviously diminishing the ference than the latter." But when volition returned, and volume of the brain; forms wherein the weight of the organ the cramps ceased, and they were both exercised alike, they gives great assistance to the inquirer, as may be proved by the gradually became of the same size. In this form of paralysis, cases described by Dr. Sims. Again, there may be degenera- then, it is very important, as the narrator remarks, to attend tion, without either loss of size or weight, and yet atrophy so to the nutrition of the limb. But perhaps the most important ,far as the proper cerebral structure is concerned. It has been case of all, for attention to this point, is the paralysis of a observed by Mr. Paget, that there is a greater thickening of child, when the affection involves one side of the body, or the cranium in those parts at which ossification commences in one leg alone. In this instance, as Dr. West observes, and the feetal state than elsewhere, an observation too interesting shows by his own experience, the unused limb ceases to to be passed over. He says, too, " I believe that at what- lengthen; whilst the other, exercised always, and ever growof ever age, after the complete closure of the cranial sutures, ing, lengthens fast. The result is, a permanent shortening " the limb Dr. the of of of the the brain paralytic extremity. Copland speaks may happen, hypertrophy shrinking skull may be its consequence. I lately examined a re- of a child being joined to the body of an adult." He has markable case, showing the same conditions in a person seen such instances as the result of palsy. If there be a way less than thirty years old, in whom the thickening of the of preventing them, it is by forcing the unused limb into inskull must have begun in early life. The case was that of voluntary action during the paralysis. a lady of remarkable personal attractions, but of slenderly developed intellect, whose head did not externally appear below the average female size. Yet her cranial cavity was singularly contracted; the skull had adapted itself to an im- REPORT OF A CASE OF CHOLERA MALIGNA. COLLAPSE OF NINE HOURS’ DURATION : RECOVERY. perfectly grown brain, by the hypertrophy of its diploe, which was nearly half an inch thick at and near the centres of ossiBY JOHNSON K. BAINES. ESQ., Surgeon. Aldgate. fication of the frontal and parietal bones. With regard to the remaining point, I would advert to the I WAS called, at six A.M. on the morning of the 28th of Decem·. fact. that the paralytic muscles—paralytic so far as volition is ber, to visit Mrs. R-, aged thirty-three, living in Savilleconcerned—maintained their contractile power to the last, buildings, High-street, Aldgate. I found her complaining of quivering whenever the mind was agitated, and it was so very agonizing cramps in the calves of the legs, and in the body, often. Ill nourished they were, but not much, if any, more more especially referred to the lower part of the abdomen, accompanied with continuous purging and vomiting. She was. * Medico-Chirurgical Transactions, vol. xix. pp. 364, 366. * Works of t See Lectures on Nutrition, Hypertrophy, and Atrophy, delivered in the Hunter, (by Palmer,) vol. iv. p. 219. theatre of the Royal College of Surgeons, May 1847, p. 29. (From the t See Lectures on Atrophy &c., p. 44, to which I must refer for many .London Medical Gazette.) other valuable observations on the value of exciting motion in paralysis.

-,amongst its symptoms.*

I must refrain from

pursuing

this

part of the subject further.

the noticed

95 speak above a whisper, and articulates with Pulse 135;somewhat stronger on the right side, not so perSays she is cold, "like a piece of ice;" seems ceptible on the left. Hands and feet warm. Cramps less very restless; countenance anxious, of a bluish leaden hue; frequent, and much diminished in intensity. Complains of but has only vomited once, (about an hour after eyes sunken, and turned upwards; conjunctivae of the same colour as countenance; nose pinched, of a darkish red appear- taking the medicine.) No motion except that which passes under ance about an inch around the apex, and very cold; cheeks the clothes. Thirst still continuing, ordered to drink freely sunken; lips compressed, and livid; hands livid, slirivelled, of weak brandy-and-water, (a wine-glass of brandy to two pints and conveying to the touch a feeling as of handling cold and a half or three pints of water.) During the cramps, JDetal; tips of fingers and nails, dark blue; tongue shrunken, legs to be rubbed with spirits of turpentine; if cramps should and covered with a white fur, and very cold. Pulse, hardly return in the abdomen, ordered to apply a large mustard to be felt in right wrist, 130; not perceptible on the left side; poultice to cover the whole of abdomen; calomel, two grains; respiration feeble and laboured, about eighteen, or twenty, in potassio-tartrate of antimony, one-third of a grain. To be the minute; matter vomited very copious, dark yellow, with given every half-hour. (Six sent.) At half-past two r.M. she was still much easier. Counsemifluid lumps of same colour floating in it. Dejections very copious, consisting of light coloured fluid, with a sediment of tenance regaining its natural colour and expression. Skin white shreds, resembling boiled rice, or tapioca; very tena- warm throughout the whole body. ’No dejections since last cious; the cramps in legs and body recurring every two or report. Has vomited a quantity of brown fluid, intermixed three minutes; and each paroxysm lasting for a period of from with currants. Pulse fuller, 110. Of the pills last ordered, forty to sixty seconds; surface of body covered with a cold, four have been taken, but only one retained on stomach; complains of ‘‘ soreness of the mouth." Gums red and tumid; clammy sweat; feet slightly warm. The following particulars were gathered from those con- slight mercurial odour from breath; of two pills remaining, one was ordered to be taken every hour, and the following mix-nected with and residing with her. She was represented to be of a delicate constitution, and turo every hour, first dose to commence half an hour after the frequently subject to "bilious attacks :’ Was attacked last pill:-Sesquicarbonate of ammonia, a scruple; bicarbonate of Tuesday week, (December 19th, 1848,) with vomiting and soda, half a drachm; chlorate of potass, a scruple; spirit of purging; pains in the body, referred to the umbilical region, nitric ether, aromatic spirit of ammonia, of each two drachms; Of so violent a character as to confine her to her bed for some compound tincture of rhubarb, a drachm; tincture of opium, few days, till Friday, December 22nd, at which period the diar- twenty minims; peppermint-water to six ounces. Mix. rhœa and vomiting left her, though the pains continued. She Half-past eleven P.M. Greatly improved. Features had reremained in this state of health till yesterday morning, the covered their natural appearance. Hands very slightly livid; 27th ultimo, when, after having been engaged for some time ends of fingers and nails not 11 eyanosed." Tongue warm, still in cleaning out a drain, running beneath the floor of her covered with white fur. Expresses herself much relieved; house, she was seized, about eleven A.31., with severe rigors, attributes it to mixture, each dose of which has been retained followed bv diarrhoea and nausea, though no vomiting. Is on the stomach; but the pills were rejected as soon as swalstated to have passed from this time up to the period when lowed. No dejection or vomiting since last report. I saw her, more than fifty motions. About ten, on the night Half-past two: feels that she has the power to retain her of the 27th of December, she went a short distance to see her motions. Has passed about three ounces of urine, highdaughter, whose mistress persuaded her (Mrs. R ) to par- coloured, and smelling like sweet-brier. Pulse 90 to 95, soft, take of a piece of plum-pudding, and balf-a-glass of gin. She full, and compressible. To continue the mixture. It, was returned home, and complaining of being very ill, retired to mentioned in the last report that neither of the pills were rebed at eleven P.M., when she was almost immediately attacked tained, they were thereforeentirely discontinued. I saw her twice on the 29th of December, when she was with vomiting; diarrhoea very much increased; cramps in lower extremities and abdomen; rigors, succeeded by a feel- rapidly improving. Pulse 65 to 70, quite soft and full; skin ing of coldness throughout the whole body. These symptoms warm; countenance free from any expression of anxiety, continued increasing, without any cessation, up to the time I though represented to be darker than natural. Tongue still first saw her, at six A.:r.r.,28th of December. Ordered hot whitish. Has passed one motion, consisting of a small quantity bottles to be placed to the feet; hot fomentations of salt-and- of dark-coloured scybala, with a greenish tint; also passed water to be applied to the abdomen; and the following medi- more than a pint of urine, presenting the same character as eines: potassio-tartrate of antimony, one grain; ipecacuanha, that of yesterday. I ordered her intusion of cinchona, with fifteen grains, to be taken directly; and vomiting to be excited gentle aperient, to be taken four or five times a day. She was by warm water, with salt. Afterwards, to take two pills com- able, on the 1st of January, to sit up in bed, and is recovering posed of eight grains of chloride of mercury, and two grains as fast as one could expect any patient would do after so of opium ; and the following mixture: sesquicarbonate of severe an attack. I do not report the above as a case presenting any very ammonia, a scruple; bicarbonate of soda, half a drachm; corndifference from other cases of the same disease, but pound tincture of senna, spirit of nitric ether, aromatic spirit of ammonia, of each two drachms; caraway-water to six suggest it as an instance of the efficacy of a certain kind of ounces : mix; a fourth part to be taken every two hours. treatment, which I need not say is that which is recommended. I saw her again at-half-past nine A.-51. Owing to some care- by all the medical men who have written upon this disease, lessness on the part of those attending upon her, neither the and who have witnessed its ravages in the East. From the mixture nor pills were given. The emetic acted freely a short effect, evidently produced by the tartarized antimony in time after being taken. Features much the same. Pulse just this case, while the patient was in a state of collapse, I should perceptible in both wrists, 130 to 140, small, thready, and ir- be inclined to recommend its employment in all similar cases. regular. Complains of thirst, which she attributes to the salt- A curious circumstance connected with this case was, the and-water. Hands warmer; not so livid. Slight tenderness rapidity with which the patient was affected by the mercury, Has vomited four times, followed only twelve grains of which could have been retained on the on pressure over abdomen. each time by a dejection, a great part of which passes in- stomach. Judging from this case, considering the small voluntarily. Urine stated to pass with each motion. (?) (As quantity of opium taken, I think we can place but little conthe dejection, consisting chiefly of fluid, was passed under the fidence in that drug. bed-clothes, and on the sheets laid under her, this could not be Something might be gathered from this case also, in inculperfectly ascertained; the patient, when questioned, was unable cating thenecessity of a proper attention being paid to the to say positively whether she passed the fluid from the bladder ’ drains and sewerage, in such narrow, confined places, as courts In the buildings" in which this case or bowels.) Respiration more free. Cramps less in intensity and " buildings," &c. and frequency. Has had the hot bottles to the feet, and hot occurred,I was informed that all " the privies" were in the fomentations, as ordered, to the abdomen, from both of which cellars; and that there was no sewerage in the court. I exaapplications she had derived great relief. Ordered bags of mined one of thee houses, and found " the privy," as reported, in hot salt to abdomen; to take the medicine as ordered, and to the cellar, and certainly the stench arising from it was suffihave two pills composed as follows, of chloride of mercury, cient to breed the most virulent diseases. This ought to be ten grains; powdered opium, two grains; potassio-tartrate of attended to: if we are to keep the cholera as much as possible antimony, one-third of a grain. To be taken as soon as pos- from ravaging this country, we cannot be too particular about sible. Extra blankets to be put on the bed, and the patient such nuisances being quickly removed. to be kept as warm as possible. Aldgate, February, 1849. == At a quarter to twelve I again visited her; when I entered

unable to

difficulty.

retching,

marked

good

"

THE CHOLERA IN FRANCE.—In Lille and the vicinity there she stated that she was easier. Features less eyes brighter in colour and expression. Skin of have been, from the 15th of November to the 21st of Decemhands and face presented the same colour as last reported ber, 246 cases, 142 deaths, and 57 recoveries.

the

room

shrunken;