798

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

ST. GEORGE’S HOSPITAL.

A CASE OF TETANUS FOLLOWING COMPOUND FRACTURE

OF THE ARM ; RECOVERY.(Under the care of Mr. TATUM.)

Nulla antem est alia pro certo noscendi via, nisi quarnplurirnas et rnorborurn ! i

et dissectionum historias, turn aliorum, turn proprias collectas habere, at inter Iae oompara.re.—MoBtM.tHfl De 8’ad. et Ca". Morb., lib. iv. Proaemium.

THE following very interesting case illustrates the successfultreatment of traumatic tetanus by the subcutaneous injectionof atropine and morphia. For notes of it we are indebted toMr. E. C. Ring, late surgical registrar to the hospital.George B-, aged forty, a cab-driver, was admitted into

the hospital, having fallen from his cab whilst drunk. Thelower end of the right t humerus was fractured in several places,one fracture apparently running into the joint. On the innerside of the arm, a short distance above the inner condyle, therewas a wound an inch long, communicating with the fragments.The limb, which was much bruised and swollen, was put up ’,in an angular splint, and the patient was placed upon ordinarydiet and a pint of porter. He went on well until the fifteenthday, when he complained of pain in the arm and stiffness ofthe jaws, which gradually increased; and two days later-namely, on January 30th-he was unable to open the jawsmore than half way. There was, however, no stiffness of theneck, or pain in the epigastrium; and his countenance anddemeanour were tranquil. The bowels being confined, a tur-pentine enema was administered.The patient continued in much the same state until the

2nd February, when his appetite began to fail, and the trismusslightly increased. He was ordered wine and eggs, and at10 P.M. was injected with gr. of sulphate of atropine.On the following day the jaws were firmly closed ; the arm

"jumped" a great deal, and he had slight vertigo. The pupilswere somewhat dilated. The injection was repeated at 10 A.M.and 10 P.M., a blister applied to back of neck, and nutrientenemata ordered.

Feb. 4th.-The arm still " jumps ;" has twitchings of allthe limbs, and pain in the epigastrium. The jaws will allowthe protrusion of the tip of the tongue, which is clean andmoist. Pupils less dilated; pulse 72, weak; respiration 20;temperature in axilla 7 ’7". At 3 r. M., .1-6. grain was injected,and at seven P. M., 2;- grain.5th.-Has had a very restless night; the trismus remained,

and deglutition was difficult; the mouth drawn to the rightside; pulse 84, soft; respiration 24; temperature 981°. -,]0 gr.was injected at 1 A.M. and 10 A M., and lv gr. at 2.20 P. M.The turpentine injection was repeated.

6th.—Was very restless during the night; the trismus con-tinues, rendering it difficult to get anything into the mouth,but there is no pain in swallowing. Still has pain in the armand twitching of the limbs ; tongue rather coated ; pulse 104,soft and small; respiration 22 ; temperature 98’2°. At 10 A.M.and 10 r.m. the injection of ,16 gr. was repeated; brandy, fourounces; beef-tea, four pints.7th.-Passed a less restless night; the spasms are more fre-

quent and severe ; trismus same; tongue coated ; no appetite ;pulse 112, soft; respiration 24; temperature 981°. Sulphateof atropine, gr.; bimeconate of morphia, gr.; distilledwater, six minims. Mix ; send two drachms of this solution.At 10 P.M. seven minims of solution were injected.8th.-Patient slept during the greater part of the day, and

he was not disturbed for the purpose of taking notes ; spasmsreported to be less frequent and severe. Brandy, eight ouncesdaily. The injection was repeated at 10.30 A.M., 4.15 r.nz.,and 10 r. M.9th.--The severity of the spasms has decreased, and there

is less twitching of the limbs. The trismus is well marked,and the sterno-mastoid muscles are rigid, but there is no opis-thotonos or pain in the epigastrium. Skin cool and moist ;

bowels open; pulse 112, soft; respiration 21; temperature99.4O.At 10 P.M. the injection was repeated.1oth.-Has had a restless night; occasionally has sharp pain

in the left side of the abdomen. The arm aches a great deal,but there is less trismus and rigidity of the sterno-mastoids,and the spasms generally are much less distressing; sweatacid ; bowels open.11th.-The arm and elbow are a good deal swollen ; tetanic

symptoms improved.12th.-The arm is more swollen ; the spasms are diminish-

ing ; deglutition fairly easy; pupils normal; pulse 96; tem-perature S9°. At ten A.M. and ten P.M. the injections wererepeated.During the next two days the symptoms continued about

the same. The extensors of the thighs were chiefly affected,and the slightest touch would bring on spasms. The swellingof the arm increased. The injections were repeated morningand evening. A turpentine enema was administered.15th.-An abscess was opened on the inner side of the

elbow, from which a considerable amount of fetid pus escaped.Pulse 92, weak; respiration 20; temperature 993°. Injectionsrepeated as before.The next day patient was much the same ; and on the 17th

the trismus had almost gone ; there was no risus, the musclesof the neck were lax, and there was but little spasm of thelimbs ; appetite good ; skin cool and moist; tongue clean;bowels open ; pulse 112 ; respiration 24; temperature 100 3°.Injection repeated at midnight.On the following day there was an increase of the spasms,

and there was slight trismus; pulse 100, weak; respiration 20;temperature 98°. At 12 P.M. the injection was repeated.On the next day the spasms had ceased, and from this date

the patient gradually improved. The muscles of the limbs,however, were occasionally attacked by spasm, more especiallythe extensors of the thighs ; and there was more than once arecurrence of trismus, with rigidity of the muscles of theneck. By degrees all these symptoms subsided, and on the25th the patient was able to sit up in bed. Several timesat about 3 A.M., he suffered from slight pain in the elbowand front of the thighs. On the 28th there was a totalabsence of all tetanic symptoms, and there was no recurrenceof them after this date. On March 13th the patient was dis-charged, with his general health fairly good.There was a great deal of thickening of the lower end of the

humerus, and slight shortening of the arm; but there wassome amount of motion of the elbow-joint.

LONDON HOSPITAL.

A CASE OF MERCURIAL TREMOR.

(Under the care of Dr. RAMSKILL.)WE lately saw an Italian, aged forty-two years, affected

with mercurial tremor, to whom Dr. Ramskill had givenolive oil with advantage. The man told us that he had sil-vered mirrors for twenty-one years. He believed that the

mercury entered the system by the palms of the hands andunder the finger-nails, its vapour also l-eing inhaled. Thiswas his third attack of tremor, the first having occurred seven ears ago. During the attacks be would work half time, butlatterly he had knocked-off altogether. He had been admittedin July for the present attack. He was then affected withgeneral tremor, the head being involved as well as his limbs,and the arms so much agitated that he could not cut up hisdinner. At first he used to shake most at night. He did notsuffer any pains in his limbs. His spirits were greatly depressedby the attack. He was treated at first with ten grains ofiodide of potassium with one drachm of tincture of hyoscyamusin decoction of bark, three times a day. After two months,half an ounce of olive oil was given three times daily, and thedose gradually increased to one ounce. At the time of onrvisit the patient had nearly lost his tremor. He told us thathe felt dreadfully nervous at times, especially during changeof weather. His gums had never been very sore, nor his teethloose; nor had his bowels been in any way affected. He saidthere were great differences in the symptoms produced in menexposed to mercurial poison. Some would never have tremor,but would always "feel loaded at the chest;" others wouldsuffer severely from salivation, and lose their teeth. He hadtried all sorts of masks and respirators, but they do not act.Moreover a great deal of the mercury, he thought, got inthrough the skin; and it was impossible to work in gloves.