cervical vertebræ) is of considerable interest. The patient, I hope, will shortly be admitted into one of the Borough Hospitals, so that we shall have an opportunity of watching and reporting the progress of her malady.

Case 1. A child, æt. 4 months, previously healthy, was attacked with hooping cough, which continued for a fortnight, not very violent, for which a blister was applied to the chest by a neighbouring practitioner, to whom it was taken, and some aperient powders, to relieve the confined state of the bowels. At the termination, however, of this period, the child was attacked with convulsions, which invariably, from this time, preceded and ushered in each attack of the cough, and which now became more urgent; this continued, regardless of the aperients freely administered, for about three weeks, when the patient expired. I was requested to examine the body, which was done 36 hours after death.

I first carefully examined the larynx, trachea, bronchia, and lungs; but not the slightest deviation from healthy structure could be perceived. The pleura covering the lungs, and that lining the parietes of the thorax and covering the diaphragm, was perfectly healthy. The stomach and intestines, with the remainder of the chylopoietic viscera, were then carefully examined, but all possessed their natural appearance. The mucous membrane of the stomach was more particularly the object of my attention, as a physician, for whose opinion I entertain the greatest respect, believes this to be the seat of the disease, having come to this conclusion from cases which he has dissected, and in which the villi were turgid with blood, the lungs and air-passages being healthy; but he did not examine the brain: in this case, however, no such appearance was present. On removing the calvarium, the vessels of the dura mater were found turgid with blood, on removing which, it was found that the pia mater was also highly injected, with effusion of serum between the membranes. A great many bloody points were found on cutting into the brain, and at least two ounces of bloody serum in the ventricles.

Case 2. H. C. about three months since fell from the top of a stage coach

on the side of her head, which " stunned" her for a time, and, on recovering her senses, it was found that the head was immoveably fixed to the left side, with considerable pain in the neck, and, on examining the spinous processes of the cervical vertebræ, that of the (?) 4th was very distinctly felt to the left of the one below it; forming not an inconsiderable angle, evidently shewing, in conjunction with the fixed state of the head towards the left side, that lateral partial dislocation, most probably conjoined with fracture, had taken place. The pain in the neck entirely subsided in a few hours, but the head still remained fixed in the same position, which it still retains. There was no paralysis or diminished sensation in the extremities for two months-her respiration natural, as were also the secretions. About three weeks since, she first felt a slight coldness and numbness in the left side, without any increase of pain in the neck, or other symptoms-this numbness continued for a few days, but did not prevent her taking her usual exercise ; when, in about a week, she was attacked with spasmodic twitchings of the muscles of both the upper and lower extremities. She now applied to an eminent physician in the Borough, who found, in addition to the above symptoms, that the mouth was slightly drawn to the left side-there' was inability to raise the left arm far from the side-some pain inthe shoulder and left side of the chest-pulse natural-spasmodic twitchings every five or ten minutes-general health good.

Feb. 17th. Twenty leeches were applied to the neck-pil. coloc. c. si opus sit. 22d. Symptoms much the same.

Cont. pil. Empl. belladon. ad nuch. 28th. Patient not able to attend-is reported to be much the same, as regards the twitchings-has some cough.

March 3d. Twitchings worse-cough more severe, with some difficulty of breathing-some pain in the head.

Rept. empl. bellad. Cont. pil. Mist. emulg. pro re nata.

Murch 7th. Cough relieved, but there is more pain in the neck, twitchings of the muscles more frequent. Some numbness in the left arm and leg.

Ordered.-A small blister to be applied on each side of the spinous process near the seat of injury.

March 10th. More inability to raise the

arm-some swelling of the glands in the neck-in other respects as last report.

March 14th. The patient was admitted into Guy's Hospital to-day, under Mr. Morgan, No. 8, Mary Ward. Symptoms as last report-ordered to be cupped on the neck to 12 ounces-an issue to be formed on each side of the apparently displaced spinous process.

R. Ferr. carbon. 3ss. per diem sumend. Here our account must close, but we shall give the sequel of the case in our next Number.

VI.

CASE OF TETANUS, FOLLOWING INJURY TO THE FINGERS, TREATED BY F. TYRRELL, ESQ. ST. THOMAS'S HOSPITAL.

1827,

Feb. 24th. Thomas Lee, æt. 45, a stonemason, was admitted into Edward's ward, with compound fracture of three of the fingers of the left hand-two of them (the ring and little finger) comminuted; the nails were also nearly separated from two of the fingers of the right hand. The wounds bled very freely, and the surface looked tolerably even, more resembling a cut than a contused wound, although it was caused by the fall of a stone. The man was, at the time of his admission, somewhat intoxicated; but his constitution did not, as far as could be judged from his apparent muscular strength, seem to have suffered much from drinking. Mr. Tyrrell, therefore, determined to endeavour to save the fingers. Accordingly, the wounds were carefully cleansed-several small spicule of bone were removed -the sores covered with lint, which was kept in its situation by slight strapping; -the fingers being, lastly, kept straight by pasteboard splints, nicely adjusted. A spirit-wash was afterwards applied, and the limb so placed, as to best favour the return of the blood. The bowels to be kept open by aperient mixture.

He suffered but little pain for several days, but (March 4th) feeling some additional uneasiness, the dressings were removed, and it was found that the ringfinger of the left hand had separated between the second and third phalanx-the first phalanx of the fourth finger was also nearly separated-suppuration was very

free-the matter appeared healthy, and he again felt comparatively easy.

March 5th. Free discharge from wounds some healthy granulations—and he continued the same till March 6th, at 7 o'clock, A. M. when he first felt a slight rigidity of the muscles of the neck, and those moving the jaw-his pulse became quickened-wounds suppurating freely.

11 o'clock, A.M. Every symptom increased in violence-pulse 110, and intermitting; being, for a few beats, hard, full, and bounding,-then small and feeble-bowels not open.

R. Ext. coloc. c. gr. xx. Stat. sumend. 4 o'clock. Mr. Tyrrell saw him. The rigidity of the muscles connected with the lower jaw is increased-the pulse is still very irregular-his bowels but slightly open-fæces of a dark colour.

Mr. Tyrrell enquired particularly if he had been accustomed to drink hard. He admitted taking several pots of porter daily, with an occasional dram of gin; but not, he said, to excess. He was ordered to have beef tea, bij. in die. Porter, Bj. Repr. pil. aper. duæ. R. Calom. gr. ij. opii, gr. j. nocte maneque. Mr. Tyr

Vesp. Bowels freely open. rell being engaged, Mr. South has seen the patient, and, “the pulse having risen," he directed the porter not to be given. The rigidity of the muscles is now, however, much greater; and so great is the difficulty of swallowing, that but very little of the beef tea has been taken. Sometimes spasms of all the voluntary muscles are produced by the attempt at deglutition.

March 7th. Took the pills with some difficulty last evening; but the trismus is so much increased, as also is the difficulty in deglutition, that he could not take them this morning. Bowels relieved early this morning-motion dark-coloured.

Spasmodic twitchings of the muscles of the trunk and extremities now very frequent-pulse 120, irregular. At 11 o'clock A. M. tinct. opii, gtt. 1. were attempted to be given by the apothecary, but without success. Even the sight of a liquid, or the thought of swallowing, now caused violent spasmodic twitchings.

Mr. Tyrrell saw him at 12 o'clock. The muscles of the abdomen were now rigid, and the mouth was nearly closed.

Mr. T. pressed firmly along the spinal column, but not the slightest pain was

produced. He complained of no pain, except at the scrobiculus cordis ;-but, willing to grant the patient every chance, he was ordered to be cupped to 12 ozs. from the back, and afterwards blisters to be applied to the neck and between the shoulders.

4 o'Clock, P.M. The respiration is more hurried-pain in the scrobiculus cordis more severe-spasmodic twitchings more frequent. He gradually became worse, but his intellects remained unimpaired-and at 9 o'clock, P. M. he expired.

Mr. T. learnt from his friends, after his death, that the patient had been a very hard drinker- not having been satisfied with an "occasional dram," he had, on an average, taken a dozen per diem. Sect. Cad. 40 hours after death.-On cutting down upon the spinous processes, (in order to examine the spinal cord) a considerable turgescence of the vessels, with, apparently, some effusion of lymph into the cellular tissue, was found under the part where the cupping-glasses had been applied. (I mention this, not having been able to learn whether this is the usual appearance presented by parts under such circumstances-if it is, what is the inference?) The arches of the vertebræ were then removed, and a small quantity of bloody serum was found external to the dura mater; on a puncture being made into this membrane, a considerable quantity (perhaps 3iij. or more) of fluid, presenting the same character, escaped.

It was said, by a very minute and accurate morbid anatomist present, that the "fat found under the ligamentum subflavum was fluid, and the cellular tissue highly vascular."

The whole cord, before removing the dura mater, was of a reddish colour, presenting, particularly about the dorsal vertebræ, a number of dark blue or purple spots.

The dura mater being removed, the pia mater was found turgid with blood, and having on it a number of small bony patches, or scales, which did not adhere very firmly.

On removing the calvarium, the dura mater was found very little more than usually turgid with blood-the tunica arachnoides presented, in many parts, a milky appearance, in streaks or lines, and under this membrane a more than usual

accumulation of serum. The brain did not otherwise present any thing unusual.

A gentleman present requested that the other cavities might not be opened; it was, therefore, only possible to examine the oesophagus and larynx, which was done by removing the bodies of the vertebræ.

The oesophagus presented its usual appearance. The membrane lining the larynx was unusually vascular-there was also some oedema at the root of the epiglottis.

There appeared, on examining the fingers, to be a free exit for the matter.

Clinical Remarks. Mr. Tyrrell, in a clinical lecture on the above case, (on the 12th March) took a comprehensive view of tetanus, and examined the opinions of several writers on the subject, but I shall confine myself to the observations which were given as the result of his own experience, and those bearing on the case related.

Mr. T. has more frequently seen traumatic tetanus follow injury to the fibrous and nervous textures, than to any other parts-hence,its frequent occurrence after injuries to the fingers (as in the present case) or to the toes.

In reviewing the symptoms of acute tetanus, Mr. T. stated, that he usually finds the muscles of the back or abdomen first affected, after trismus-then those of the lower, and, lastly, (of the voluntary muscles) those of the upper extremity; and, when the last become affected" death is not far distant ;” for the involur tary muscles, and those of a mixed character, as the diaphragm and other muscles of respiration, become involved, and terminate the scene. It is worthy of attention, that the symptoms will frequently very closely resemble those of hydrophobia, as was the case in this patient. Even the sight of water or any fluid caused violent spasms. Taking, therefore, the word in its literal sense, the patient had "a dread of water."

Mr. T. has seen it occur at all ages, except the very old; and in all constitu tions, but more especially the young and robust. He particularly referred to the case of a delicate girl, who died at Guy's, from tetanus following injury to the fingers; and that of a boy, equally delicate, from injury to the toes-proving that those of a robust constitution are not the only sufferers-though the most frequent.

Sometimes Mr. T. has seen considerable pain in the wound precede or accompany the tetanic symptoms; but frequently (as in the present case) no pain or uneasiness existed.

In one case, which occurred last year, pain was complained of in the cervical vertebræ, but frequently, and such was the case in the present instance, none was present; nor is there ever any cerebral disturbance.

Mr. T. now reviewed the post mortem appearances in these cases, in order to ascertain if these will furnish any clue to the successful treatment.

It has been lately attributed by some to inflammation of the spinal chord; and, in five or six cases which Mr. T. has examined, he has found, as in this case, effusion into the theca, and the vessels of the pia mater turgid with blood. But the spinal cord is so seldom examined, that it is impossible (with our present imperfect knowledge of its healthy appearance, coupled with the fact, that the fluids will, of course, after death, gravitate to the most dependent part) to say how far the appearance found depended on inflammation. With respect to the bony deposits which were found in this case (and which is most beautifully seen in a preparation in St. Thomas's museum, taken from a patient who died from tetanus), Mr. T. has found the same in a case of hydrophobia, and also in a case of chorea. It does not appear to him to be the product of acute inflammation, nor to have been formed in the short time the patient was affected; for, previous to a deposition of bone, it is well known that a cartilaginous deposit must take place. Mr. T. was inclined to believe, that little light has hitherto been thrown on the pathology of this disease, by post mortem examinations.

How, then, are we to treat it? Are we to bleed, as some have recommended, or should we stimulate, and give antispasmodics, as others have as strongly advised? Mr. T. thinks that each plan is adapted to particular cases, but that it is impossible to legislate for all.

The state of the wound will naturally first claim the surgeon's attention, and if there be pain, examine it attentively, as probably some spicule of bone or collection of pus may be keeping up an irritation. if it is found impossible, as in a

severe comminuted compound fracture, to remove the spiculæ, amputate the limb. But it will, as the following case illustrates, sometimes be in our power to remove the cause of irritation, without resorting to this measure.

A patient was brought to St. Thomas's Hospital, and admitted under Mr Tyrrell, with compound dislocation of the great toe. The end of the bone protruded. This was reduced; but trismus came on, and he could not swallow without difficulty. Dr. Elliotson saw him, and ordered, fer. carb. 3ss. 2nda. vel 3tia. quaq. hora. He continued this for eight days

the disease gradually increased—and at this time the muscles of the abdomen had become rigid. Fluctuation was now felt on the dorsum of the foot; a free incision was made, and about Ziij. of a fetid pus escaped. The patient quickly became better, but the iron was continued in smaller doses for some time.

Some may be inclined to attribute the cure to the iron; but Mr. T. thinks it probably prevented the disease proceeding more rapidly; yet, until the matter was evacuated, the disease gradually increased.

Sometimes the discharge from the wound is altered, or stopped altogether; in this case, Mr. T. recommends counterirritation in a neighbouring part, which will, in a few hours, restore it. This is founded on experience. He finds blistering the best mode of counter-irritation.

The bowels will frequently be constipated, as was the case in this patient; these must first be relieved the other secretions and excretions must also be attended to.

Mr. T. considers it a most important point in the treatment of these cases, and of injuries generally, to ascertain the previous habits of the patient. Although this man appeared stout and muscular, still, had he been aware of his previous habits, he would have allowed him a much greater quantity of stimuli. To illustrate this proposition, he related the two following cases.

A man was brought to the hospital, somewhat intoxicated, with considerable injury to the knee-joint. Mr. T. recommended amputation, but the patient would not then consent. On the following day, however, the operation was performed, and the stump was dressed in the usual

manner. He became delirious, and his pulse was irregular. Mr. T. now learnt that he was accustomed to drink largely. Some porter was immediately sent for, and, although delirious, the man was permitted to drink freely. He went to sleep-his pulse became calm and regular-and he recovered.

Another patient, from injury to the elbow, had diffuse cellular inflammation. He became delirious. It was found, as in the former case, that he was accustomed to drink freely. He was allowed porter-the delirium subsided-and he recovered.

Thus, in short, Mr. T. recommends the surgeon to be guided by the constitution and state of the patient. If robust and young, bleed freely, open the bowels, and afterwards give opium, or perhaps camphor and musk. If he has been accustomed to stimuli, give that to which he has been most accustomed, combined with antispasmodics-attending, in all cases, to the secretions and excretions.

VII.

OPERATIONS.

of thin pus, mixed with a curdy matter, escaped. The semilunar cartilages were destroyed by ulceration, as was also the ligamentous structure covering the condyles of the femur, and the articulating surfaces of the patella. The extremities of the femur and tibia were not enlarged; but were of a softer texture than natural, The synovial capsule was thickened.

GEORGE POCOCK, æt. 35, was admitted (August 24th, 1826) Into Isaac's ward, under Mr. Travers, with chronic inflammation of the knee, which had existed several years, and was first induced by a fall, for which he had been under the care of various practitioners, during nearly the whole period since the receipt of the injury.

The same plan of treatment, with the exception of pressure, was employed in this, as in the former case, with apparently some benefit. But, after submitting to a confinement of more than six months, the patient became extremely anxious for the removal of the limb; feeling, he said, but little hope of ever again being able to use it; as, even now, the slightest pressure on the foot caused considerable pain, although none was felt in the recumbent posture. Atlength, Mr. Travers, with the concurrence of Mr. Green, con

VERS, Esq.

JOHN LINGARD, æt. 20, was admitted under Mr. Travers with chronic inflammation of the knee-joint.

The patient's strength being supported by nourishing food, with decoct. cinchon. c. acid sulph. leeches were repeatedly applied, with fomentations and poultices, to the knee. After this, counter-irritation, by the ung. ant. tart. was tried, which relieved the pain, but the swelling continued. An attempt was made to relieve this by pressure, which is said sometimes to have succeeded. Rollers and splints were applied; but without affording any relief. The swelling, indeed, increased --the patient's constitution began materially to suffer-and, on March 2nd, the limb was removed by the circular incision. On examining the joint, after its removal, the surrounding integuments, &c. were found indurated and thickened. On opening the joint, a considerable quantity

VOL. VI. No. 12.

same manner, and on the same day, as the case above.

It was found necessary, in this case, to take up the femoral vein.

March 15th. The patient is going on well.

On examining this joint, it was found to exhibit a beautiful specimen of incipient anchylosis. The crucial ligaments were removed by ulceration and absorption, as was also the central part of the semilunar cartilages, so as to form a deeper cavity to receive the articulating surfaces of the femur, the form of which had become so modified, as to be more accurately adapted to the tibia. A callus had been thrown out, uniting the extre mities of these bones, in which ossification had commenced at several points, on the posterior part, where there was also one spot of ulceration remaining. The patella had become similarly attached to the femur.

2 S