1861 The Lancet  
29 abdominal walls became much softer; he could breathe freely, and had natural and refreshing sleep. The last I heard of him was, that the abdominal parietes had decreased to their natural limits, with obscure sense of fluid in small quantity. I have had no opportunity of examining this patient since my first visit to him. I am indebted for these particulars to Mr. Whitmarsh, who tells me that the patient is able to employ himself in some light occupation with advantage, and that he feels
more » ... r than he has done for years. I have mentioned this case to you, less for the purpose of explaining the pathology or symptoms of cirrhosis with dropsy, than for illustrating what may be done, even in unpromising cases, by a well-directed and persevering plan of treatment. Had this man been tapped, he could never have reached his present state of improvement. PHYSICIAN TO THE SAMARITAN FREE HOSPITAL. TnE particulars of the following case are not detailed with that minuteness which, if sometimes irksome to the reader, is undeniably of great advantage to the progress of Medicine as a science. I highly respect the conscientious work now being done by those disciples of the school of elaborate pathology, who labour so assiduously in the collection of data, and record so minutely whatever they recognise as aids to diagnosis. But I here only desire to relate, as simply as possible, the particulars of an individual case; in the belief that by so doing, I may add to that stock of provisions in emergency which every practitioner desires to have in store, and may direct attention to a source of serious public danger, the continuance of which is unpardonable, because easily prevented. CASE.—A year and a half ago I was summoned into Hampshire to visit the daughter of a clergyman. Her age was seven years; the history as follows:-She had been favourably recovering from a slight attack of scarlet fever, and taking some simple and almost colourless saline medicine, twice a day. In the confusion of a parish-school fête, on July 5th, 1859, the head nurse delegated to her assistant the duty of administering one dose of the mixture. A bottle of Sir William Burnett's (also almost colourless) solution of chloride of zinc stood beside the medic;ne bottle. From the former the dose was poured out. The " white medicine" was to be taken, and the little girl had been taught to get rid of her dose bravely by throwing it to the back of her mouth, and swallowing it at a gulp. In this way, therefore, she took about a drachm and a half of the corrosive poison on an empty stomach. The immediate symptoms were those described as occurring in the numerous recorded cases of a similar mistake. Warm water was given, and she vomited freely. Under medical direction albumen and demulcents were subsequently administered, and with such good effect, that in a few days the child appeared to be recovering. The corroded mucous membrane of the pharynx separated in patches; no of pain was made, nor were any symptoms noticed of serious injury having been done to the stomach. The little patient ate well, was only moderately thirsty, was merry and active as before the accident. The urine was safficieat, the bowels regular, but the character of the motions was not observed. I note all these things as indicating how necessary is a guarded opinion in such cases. For, ten days after swallowing the poison, and without any remembered cause, she was suddenly seized with violent retching, and vomited a mass of black blood, followed by several smaller clots, all dark in colour. From this time she gradually pined away, refusing food, or only swallowing it after great persuasion, and invariably rejecting it in about an hour and a half, slightly altered (as by partial digestion), and sometimes mixed with a little blood. She manifested no ,symptoms of nervous irritation, was cheerful, and evinced no tenderness on examination. She slept restlessly, lying always on the right side, with her legs drawn up, and ground her teeth during sleep. The throat was clear, but the tongue gradually became coated, and the skin dry and harsh, as the child wasted. Nutrient enemata were tried, but almost immediately rejected, and the medicinal remedies applicable were judiciously administered, but without benefit. It was late in the evening of July 26th, (when these symptoms had continued eleven days,) that I paid my visit. She presented a woeful spectacle, one seldom seen except by those who have witnessed the effects of starvation in famine times, and amongst young children of the abjectly poor who lurk in great cities : the skin drawn tightly across the face, and thinning off towards the mouth in place of filling out to form the lips; the pulse like a vibrating thread; the skin harsh and dingy in hue, exhaling that peculiar odour which is almost distinctive of starvation, and moderately warm to the touch, though she constantly complained of cold, notwithstanding that the heat of the weather was intense. The tongue was coated with a thin white fur; the abdomen was shrunken, and the edge of the liver sharply traceable. There was no tenderness on an examination as minute as it was safe to attempt. There was constant thirst, but an intense aversion to swallowing any fluids. The mind was clear, and the eyes very bright. She had not slept for two days, only restlessly dozing, and waking with a start. The child was, in fact, in that condition occasionally witnessed in the last stage of exhaustive disease, where the body requires all the voluntary as well as involuntary energies for even the simple maintenance of life-cases wherein it is so important that stimulants should be freely administered, and that the patient should not be allowed to sleep too long without another fillip to the life-sustaining powers. It happened, luckily, that a number of cows, kept for dairy purposes, had been milked shortly before my visit. I advised that the child should be immediately immersed in a bath of the new milk, slightly warmed. The effect was remarkable, allaying the intense thirst, soothing the constant restlessness, and affording great pleasure to the patient. She remained in the bath for twenty minutes, was carefully removed to bed, and fell tranquilly asleep, with the skin moist and supple. I woke her in two hours to give a little soup thickened with tragacanth. She then slept on till morning without sickness, when the bath was repeated, and its continuance, night and morning, for half an hour each time, with cautious administration of small quantities of soup and wine, (always with the addition of tragacanth,) formed the whole of the treatment I advised. From this time the child gradually improved. The sickness recurred at intervals, but there was always, I think, some effort (so difficult to prevent in children) causing sudden contraction of the abdominal muscles, or some irregularity in diet, to account for it. The baths were continued about ten weeks, and gradually omitted as the child regained her strength. I urged the necessity for restricting the food to fluids and pultaceous substances, writing a diet 1 st. But those who know the weariness of long and constant watching, and how hard it is for servants to refuse the appeal of a child whom they consider as half-starved to order, well understand how it came to pass that indigestible things were sometimes given; that the healing ulcer, which I believe existed at the pyloric end of the stomach, became irritated, and a relapse followed; daily sickness, with ejection of pellets of dark blood, and the further complication of small black clots passing with the motions. This had continued for five weeks, and the child appeared to be gradually fading away, when she was brought to London to be under my care. I ordered absolute rest, and, observing that the abdominal muscles appeared to suddenly start into action with a kind of jerk on every movement of the body, I applied to the surface overlapping strips of thick chamois leather spread with adhesive plaster. This gave great comfort. The diet was restricted to asses' milk mixed with lime-water and sucked through a straw, and subsequently beef-tea, jelly, eggs, and wine were added, and a little almond-oil, as she took it readily. The only medicine was a few grains of mercury-withchalk, and a little of the solution of morphia. The sickness entirely ceased during her stay in London; the bowels acted naturally, without blood ; she slept well, and improved visibly-. Three weeks after her return home, some matters just vomited were sent to me, with expressions of anxiety as to certain round dark bodies, believed to be blood, but which were actually currants. A surreptitious spoonful of sweet pudding had done the mischief. Exercise of greater watchfulness was followed by the best results; and though the sickness recurred at intervals, the child gradually recovered her strength, became plump and rosy, and is now reported well. Re?7zark-s.-I. This case makes up thirteen of which I have found record, or obtained the particulars, where life has been endangered or destroyed by swallowing this corrosive poison. In eleven instances it was certainly taken by mistake; and
doi:10.1016/s0140-6736(02)41242-1 fatcat:5ks7mm2lrfa4rnnr5nzgnbk6e4