SECTION VI.

ON AFFECTIONS OF THE SPINE, &c.

CHAPTER I.

Diseased Spine.

DISEASE of the spine is said to be of very frequent occurrence. It may be so; but I feel persuaded that it does not occur half so frequently as is imagined. A delicate female cannot now complain of pain in the back, but a Surgeon is immediately sent for, to examine the spine. If after thumbing it, and striking it with his knuckles from occiput to coccyx for half an hour, one part is discovered to be, or has been rendered by the examination more tender than the rest, it is very gravely pronounced to be diseased. Incarceration, for three months, or sometimes for three years, is immediately directed, and setons or issues made in the back. If by this judicious treatment, aided by confinement, the health of the patient be not destroyed, in a reasonable time she is declared to be cured of the disease, and allowed to get up. I have known cases of this description kept "in durance vile" three years, and ultimately recover; the recovery, however, did not take place till after they had escaped from under the hands of the Surgeon. Imposition, under any disguise, I detest; wherever I see it, I will expose it.

Treatment.

When the spine is actually diseased, absolute rest is requisite. Leeches should be frequently applied in the vicinity of the diseased vertebræ, and every possible means employed to improve the constitution. Bark, with carbonate of ammonia, or muriate of lime, will be eminently useful.

Psoas Abscess.

I have never examined psoas abscess, without finding it connected with disease of the vertebra; and I am inclined to think that it ought to be treated as such.

For an account of the appearances usually met with on dissection, see CASE V.

CHAPTER II.

Fracture of the Spine.

CASE XXXIII.

JAMES PALMER, aged sixty-three years, was admitted into the Infirmary, on Wednesday, June 19th, 1812, at ten o'clock at night. He stated, that about seven o'clock, he fell from a load of hay, backwards, and that he struck the back of his neck violently against the ground.

When the head was elevated, he complained of excruciating pain. There appeared to be a slight depression in the integuments above the spinous process of the fifth cervical vetebra; but whether it was the natural conformation of the part, or the consequence of the injury, could not at that time be determined. His mental faculties were not at all impaired, but his speech was rather indistinct. His upper and lower extremities were completely paralysed and destitute of sensation. Various parts of his body were pinched, without his being at all conscious of the violence committed upon them. His pulse was full and slow; it did not beat more than fifty times in the minute. Twelve ounces of blood were directed to be taken from his arm, and afterwards a cathartic powder was given him.

20th. He appeared somewhat better; his articulation was more distinct; his pulse eighty, and regular; he slept a little during the night. As he was incapable of

expelling his urine, a catheter was directed to be passed twice a day. The cathartic powder produced no faecal evacuation. Half an ounce of castor oil was directed every four hours.

21st. In the same state as yesterday. He once felt an inclination to go to the closet; but, when there, was unable to expel any thing from the intestinal canal.

22. Pulse diminished in frequency, not more than forty-eight in the minute, and was weaker than upon his first admission. Voice feeble and indistinct. He died about nine o'clock at night.

Examination.

Upon making an incision along the spinous processes of the cervical vertebræ, blood, in considerable quantities, was observed to have been extravasated. The spinous process of the fourth cervical vertebra, reckoning from the atlas, with that portion of the vertebra constituting the back part of the medullary canal, was broken off from the body of the vertebra. It was quite loose, and only required to be dissected from the surrounding muscular substance to be removed. Its inferior edge was advantageously situated for making compression upon the medulla spinalis, and probably was driven upon it at the time the blow was inflicted. The medulla was not at all lacerated, nor did it exhibit any mark of long-continued compression. Upon puncturing its investing membrane, a quantity of serous fluid escaped. It could not be discovered that the body of the vertebra was injured.

Observations.

The most remarkable circumstance in this case is the length of time the patient lived after the accident. It has been stated that a fracture of the cervical vertebræ, for the most part, proved instantly fatal; whereas this man lived seventy-one hours. The case warrants the

conclusion, that an operation would have saved the patient. Where the medulla spinalis is simply compressed, and without having sustained any laceration or other injury, I can see no reason why the removal of the compression should not relieve as effectually as elevating a portion of depressed bone from the cerebrum.

It may, perhaps, be urged against an operation, that it is impossible to determine whether the medulla be torn or not. It is a common practice, to destroy animals by dividing the medulla. They die almost instantaneously after the operation. Almost as sudden will be the death of a patient, where the medulla (as it is passing along the cervical vertebræ) is wounded; but where it is simply compressed, the patient may survive hours, or even days, as in the case above related.

A force sufficient to fracture the body of one of the superior cervical vertebræ, would inevitably destroy life at the same time; but a less degree of force would be capable of breaking off the processes of the vertebræ, and driving them upon the medulla. If they be suffered to remain there, the patient will inevitably die; if they be elevated, he may live. Whenever, therefore, a superior dorsal or cervical vertebra is fractured, an examination of the parts should be made, if the patient survives a few hours. It cannot possibly do harm, and affords a prospect of success. The immense mass of muscular fibre which must be cut through, to expose the vertebræ completely, ought not to deter us from making an incision through it. No part of importance can be wounded, even though the incision were to be carried through the whole length of the spine. Generally, an incision of five inches in extent will be sufficient.

In a work professedly medical, perhaps I have erred, by introducing a surgical case. I have, however, so frequently seen patients with injuries of the spine suffered to perish, without a single effort being made for their relief, that I trust the irregularity will be forgiven.

SECTION VII.

CHAPTER I.

Theory of Fever.

In what fever essentially consists, has baffled the powers of the most distinguished medical philosophers to explain. If it were possible to discover it, perhaps it would not enable us to treat it more successfully. It is of greater importance that we should be aware of its exciting causes, and that we should be able to moderate their baneful influence.

Mental anxiety, the exposure of the body to a great increase or diminution of temperature; and vegetable and animal effluvia, are the most frequent exciting causes of fever. Mental anxiety produces a great determination of blood to the brain. The exposure of the head to the rays of an intense sun, has the same effect. If a great abstraction of caloric take place from the surface of the body, an undue quantity of blood will be propelled upon the brain, lungs, liver, or some other viscus. The application of effluvia is productive of the same effect; more powerfully, and to a greater certainty, however, when the animal powers have been previously impaired by mental anxiety, or violent and long-continued exertions, and a subsequent exposure to a great increase or diminution of temperature.

I have never observed fever of any description, without being able to trace a determination of blood to some particular organ. Examination after death, whenever it has been resorted to, has confirmed the observation. The uniformity of the occurrence has taught me to think, with some other men, that fever is an effort of the vis medicatrix naturæ, to free the oppressed organ from the superabundant blood. In other words, by the ap