Page images
PDF
EPUB

communicating, for aught I knew, with the inner surface. Next, I thought that it might occur from some deposit of calcareous substance on the pericardial surface; and, in fact, I was embarrassed as much with doubts and fears, as any practitioner, in an imminent and doubtful case, can well be. At last, the true explanation of the phenomenon presenting itself, these anxieties were all cleared away; and now the diagnosis of this special auscultatory sound is to my ear as definite and as simple as that of any much more commonly met with. To make others equally and readily conversant with the sound is the simple object of this essay; and as the phenomenon described is one, the verbal account of which is almost sufficient to lead to its immediate recognition, I hope I have succeeded in rendering it familiar even to the novice in auscultation,

133

ESSAY VI.

ON URÆMIC COMA.

THERE is no one class of symptoms grouped together in our modern nosologies under a specific name, of greater or wider import than that which we are accustomed to recognise under the term uræmia. Bearing in many instances a close analogy to other symptoms produced by known narcotic poisons, as well as to the symptoms of apoplexy and even of epilepsy, the pure indications of uræmic coma cannot be too early learned by the student, nor too carefully studied and recast by the matured practitioner. In the present essay, it is my object to speak only of the uræmic condition as it absolutely presents itself in its most marked representation. As the patient appears, when, comatose and convulsed, he lies the prostrated victim of uræmic toxæmia, I write of him; of his symptoms, of his pathology, of the immediate cause of his malady, and of the treatment which promises most certain and effectual relief.

OBSERVED FACTS AND ANALYSES.

A man, sixty-five years of age, who had been many years a letter-carrier, was seized on November

3rd, 1851, with drowsiness whilst delivering his evening letters. He went home and to bed, where he fell into a profound coma, preceded, however, by severe pain over the right hypochondrium. He had for some time before suffered from constipation, and had been passing albuminous urine. On the morning of the 4th, he was seen by a medical friend of mine, who found him typhoid and comatose: he sank rapidly, and died at half-past seven in the evening of that day.

The friends of the patient being of opinion that he had taken, either on his own account or by maladministration, some narcotic poison, I was retained to make a post mortem examination. This was conducted fourteen hours after death.

The body was still warm; the limbs were flaccid. On opening the chest, I found some slight old-standing adhesions between the visceral and the parietal pleural membranes on the right side. In the apex of the right lung were two small cavities; but there were no signs of tubercular deposit. The heart was loaded with fat externally, although there was great emaciation in all other parts of the body, and hardly a trace of adipose deposit. The heart was soft in structure, but not fatty. The right ventricle contained a soft fibrinous coagulum, which sent ramifications into the pulmonary artery. The liver was healthy. The spleen was shrunken, and very firm in its structure. The small intestines were normal, except at the lower part; here, for a space six inches in length, the ileum was reddened and injected on the

inner surface: the mucous surface of the cæcum was also much injected, and the surface of the ascending and transverse colon was in the same condition. There was no obstruction anywhere in the canal, and the tube contained nothing except mucus. There was no ulceration of the intestinal glands. The kidneys were disorganised; the pelvis of each was filled with a soft fat; the organs were large, soft, and white; the tubular structure was entirely degenerated, and the cortical soft and greasy to the fingers. The other parts of the body were natural. I could find no indication of poison, mineral or vegetable, in any of the tissues.

The succeeding history is more interesting in that, owing to the circumstances by which it was surrounded, it led to a coroner's inquest, and to an important medico-legal investigation.

A woman, aged thirty-four years, who was given to the free use of alcoholics, and had recently been treated for primary syphilis, was seized on the 18th November, 1859, with rigors. She was attended by a neighbouring chemist, who on November 22nd gave her a mixture, which he said contained quinine, dilute nitric acid, nitrate of potassa, syrup of buckthorn, sulphate of magnesia, and water.* I proved afterwards that these were

*The formula supplied was as follows.

R Quinæ disulphatis gr. vj; acidi nitrici dilut. 3iss; potassæ nitratis 3 ss; solutionis magnesiæ sulphatis 3j; syrupi rhamni cathartici 3iij; aquæ ad 3vj.

Two tablespoonfuls to be taken every four hours.

the constituent parts of a remaining portion of the mixture. The medicine was sent in to the woman on the evening of the 22nd; and, after taking a large quantity of beef-tea, she swallowed one dose of the mixture. Five minutes after this event she became hysterical and convulsed, and the friends, believing the woman to have been poisoned, called in the druggist, who in alarm tried to get her to take some ipecacuanha, but without avail. In the course of the night, Mr. Harris, of Windmill Street, was summoned: he found the woman in a state of typhoid coma, with the pupils slightly dilated and immovable, and the body at times convulsed, the convulsions assuming an epileptiform type. Mr. Harris called to his assistance my friend Mr. Peter Marshall, of Bedford Square they carried out every available means of treatment; but the coma became more profound, and, seventy hours after the administration of the mixture already named, death closed the scene. By the coroner's warrant the body was examined, and a chemical inquiry instituted. Mr. Marshall, Mr. Harris, and myself were engaged in this research: Mr. Callender was present to watch the case on the part of the accused druggist, together with Mr. Morgan.

The autopsy was conducted thirty hours after death. There was no cadaveric rigidity at that time; there were no marks of external violence; there were evidences of the specific disease under which the patient had suffered, viz. warty excrescences on the pudenda.

There were post mortem ecchymoses on the back, and marks of a recent blister at the nape of the neck.

« PreviousContinue »