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A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

GUY’S HOSPITAL.

Idiopathic Tetanus; Recovery.(Under the care of Dr. GULL.)

Nulla est alia pro certo noscendi via, nisi quam plurimas et morborum, etdissectionum historias, tam aliorum proprias, collectas habere et inter secomparare.-MORGAGNI. DeSed.etCaus.Morb.,lib.14. Prooomium. I

CASES of idiopathic tetanus are not often received in thewards of our hospitals; but the traumatic variety is unfor-

tunately but too frequently seen in these institutions. Weneed hardly say how obscure is the pathology of tetanus, Iwhether it be connected with some bodily injury or not; butthis very obscurity materially endows all the cases of thisfearful malady with a considerable share of interest. The

symptoms and effects of treatment are then carefully watched,post-mortem appearances are accurately noted, and it is notimprobable that by this study of nature, and by such experi-ments as those of Dr. Marshall Hall, some light may even-tually be thrown on the actual nervous lesions which give riseto the fearful tetanic spasms.The case of idiopathic tetanus, lately under the care of Dr.

Gull, confirmed some of the remarks made by various authorson the subject; among these we may mention that in idio-pathic tetanus the spasmodic contractions take place moreslowly; that the paroxysms do not increase in violence andrapidity of recurrence, as they are apt to do in the traumaticvariety of the disease, &c. (Miller’s " Principles of Sur-gery.") Much stress has been laid on the predisposing causes,and we think with very good reason: a man may be exposedto cold-to sudden alternations of temperature-he may beunder the influence of intestinal irritation, from worms orotherwise, &c., but he will not be attacked with idiopathictetanus, if there is not in him that unexplained peculiarity called Ipredisposition. Though this last appellation is certainly not Ias lucid as could be Wished, if may confidently be asserted ithat most of the diseases to which the human race is subjectare likely to depend on predisposition, either hereditary oracquired; and it may be surmised that the exanthemata andcontinued fevers have a large charge in creating the acquiredpredisposition.Every one agrees that the organic changes causing

tetanus are but imperfectly known; but sufficient has beenlearned to leave no doubt as to the spinal origin of thedisease, this portion of the nervous system being centricallyor eccentrically affected. We may, in fact, say, in the wordsof Dr. Watson, the assertions being founded on Dr. MarshallHall’s experiments, and on clinical observation,-

" We are not advancing any wild theory, then, respectingthe controverted pathology of this disease (tetanus) when welay down the following propositions: that it is essentially adisorder of the excito-motory apparatus; that it results fromirritation of a peculiar kind affecting that part of the nervoussystem; that the irritating cause may be centric-within thespinal canal itself; and that it may also be, and often is,eccentric-situated at the extremity, or somewhere in thecourse, of one or more of the aiferent spinal nerves; and thata certain predisposition of the body is for the most partnecessary to render it susceptible of the disease under theoperation of the exciting irritation."The details of the following case are founded upon the

notes of Mr. Gooddy, one of Dr. Gull’s clinical clerks:-George R-, aged twenty-three years, a labourer, re-

siding in Bermondsey, was admitted, June 8th, 1853. Thepatient enjoyed good health until two years ago, when hehad scarlatina, from which he suffered for nine days. Lastwinter he had hoarseness, but no cough, and five weeksbefore admission, after severe purging, his jaws became stiff,and he was unable to eat solid food. This was followed, intwo days, by a puin in the left side, and in another day bytightness around the chest, radiating from the painful part.Three days after the appearance of these symptoms the manwas attacked by a pain in the back, and he was obliged totake to his bed. Blisters and sinapisms were applied to the

back by the order of a surgeon, and the gums were madesore by mercury. At this juncture the patient applied atthis hospital, and was admitted.

No history of any recent injury or exposure to cold couldbe obtained. On examination, the man was found of middlestature, sandy hair, and fair complexion, with a peculiar-tetanic-like risus sardonicus. Pulse 90, strong, and full;-respiration abdominal; bowels regular; tongue moist and red)at the edges; urine healthy. The muscles of the back and.abdomen are very hard and rigid, as well as the adductormuscles of the thighs, and his head is drawn upon his chest bythe rigidity of the sterno-cleido-mastoid muscles. He isalso unable to open his mouth, and complains of sudden

twitching pains in all the voluntary muscles. There is im-

perfect power of the legs and arms, still the patient can go,across the room, but cannot raise his legs to walk up stairs..

Dr. Gull ordered three grains of quinine in port wine, tobe taken three times a day; wine, three ounces; two eggs;and beef-tea.Second day.-He is much easier, the muscular spasm is

not so great, and he can open his mouth. Pulse 72; bowels?confined.Third day.-He is much better, and is able to eat a Kttle

bread and butter without much pain. He had a little startingin the night, but not in the morning. Bowels only movedonce since his admission. Continue the medicines; eightounces of port wine per diem. Has had no headache andno dreams. The patient states that he passed a lumbricussix years ago. Pulse 80; appetite good. The muscles of theright side of the back are not so rigid; the left much thesame.

Sixth day.-Bowels regular; pulse 80; appetite good. Heis able to open his mouth wide, and to eat his food with verylittle pain; but the muscles of the abdomen and left side arestill very rigid.Eighth day.-He is still gradually improving, but there is -

no very marked change in any of his symptoms. Dr. Gullordered small doses of mercury-with-chalk, combined with frhubarb and ipecacuanha. The sterno-mastoid muscles arenot near so rigid, nor the muscles of the back, but those ofthe abdomen remain much the same. Bowels regular; pulse80. He is gradually improving in every respect.Fourteenth day -The muscles of the abdomen are still s

rigid; pulse 75. He gradually improved, and was discharged*in good health twenty days after admission.

It will be perceived that in this case the patient hadsuffered an attack of scarlatina two years before he wasseized with tetanus; that his throat had remained obnoxiousto inflammation; that he had purging just before the tetanicsymptoms supervened. No doubt but the system had under-gone peculiar modifications, which created the predisposition.Among the spasmodic symptoms, it may be noted that themuscles both of back and front of the body were stronglyaffected; nor should it be passed unobserved that the patientcould walk, though unable (through an imperfection of thespinal influence) to raise his legs sufficiently as to ascendsteps. The treatment was essentially of the sthenic character,and the good results obtained are encouraging as to theadoption of this line of treatment.

ST. BARTHOLOMEW’S HOSPITAL.

Acute Ulceration of the Aortic Valves, of Three Weeks’ Duration;Death; Autopsy.

(Under the care of Dr. BURROWS.)IT has, doubtless, struck those who see much of medical

practice in hospitals, that disease of the heart is met with ina rather large proportion; and yet such a circumstance shouldhardly excite their surprise, when it is considt-red how veryobnoxious to disease the central organ of circulation must ofnecessity be. This fact is alluded to by Dr. Bellingham, inhis lately-published work on diseases of the heart, in thefollowing manner:-"The machinery which carries on the functions of the

animal economy in which life consists is, we know, not destinedto last for ever; it contains within itselt the elements of decay,and this applies with peculiar force to the heart, no otherorgan performing such unceasing duties;-functions whichcannot be disturbed without every other organ sympathising,and motions whidl cannot be interrupted, even for a fewseconds, without death ensuing. In addition, the heart, aboveall other orgcu.a, is iiio.,t readily acted upon by mental im-pressions; ciiiotioits (,f the mind the most opposite, the ex-citing as well as the depressing passions, hurrying, increasing,

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or otherwise disturbing its action. lIenee we ought ratherto be surprised (as Corvisart remarks) that the heart is notmore frequently diseased than it is." (Part 1., p. 242.)Among the many cases of heart disease seen in hospitals, it

may perhaps be said that the " extrinsic" class forms themajority-viz.: first, acute or chronic inflammation of certaintextures of the organ connected with rheumatism; secondly,the same resulting from intemperance, long-continued or

occasional muscular exertions, or from powerful mentalemotion, whether of an exciting or depressing nature. Wehave this day to bring before our readers a case of thekind alluded to, which seems to be clearly connected withhabits of intemperance, but in which the pathological altera-tions appear to have taken place in a very short time, thesebeing no less than acute ulceration of portions of the aorticvalves, and enormous hypertrophy. It should, however, bementioned that cases of this sort are by no means frequentlyseen in hospitals, the chronic form of disease being the morefrequently met with. In the present instance the affectionproved quickly fatal, and this will be easily understood whenthe amount of valvular destruction, consequent embarrassment tin heart and lungs, and the broken-down constitution of thepatient are considered. The details of the case were notedby Mr. Nesbitt, one of Dr. Burrows’ clinical clerks.John M———, aged twenty-four years, was admitted July

7th, 1853. The patient is a strong, well-built, muscular man,with brown liair, blue eyes, and fair complexion; his counte-nance is rather languid and anxious, his face pale, skin warmand moist, and the eyes surrounded by a slightly dark areola.Pulse 112, sharp, full, and soft; respirations forty in a minute,but a deep breath can be taken without exciting pain. The

patient has a hollow cough, and expectorates phlegm mixed withblood. Tongue fissured, with a dry red stripe down the centre,and a rough, yellowish fur laterally. The man is very thirsty;he has no appetite, and his bowels have been moved from sixto seven times a day for a fortnight up to his admission; themotions are reported slimy; there was but one evacuationwith much griping pain on the day previous to his coming intothe house. The urine passes freely, but is of deep colour.The patient complains of a sinking pain about the sternum’after coughing, and frontal headache produced by the samecause. The ankles are cedematous, and the legs swollen andvaricose; on the right leg are several scars, some produced byinjury, others by ulcers ; the cough prevents the patient fromsleeping at night; the abdomen is full, soft, resonant, andtolerant of pressure.-Auscultation of the Heart: Diffusedrubbing sound at the apex over the left ventricle, and also asystolic murmur; no increased dulness On the anterior partof the chest the resonance is good, and the respiratory mur-mur natural, both anteriorly and posteriorly.History.-The patient is a steward of a river steam-boat,

and of very intemperate habits. His illness commenced threeweeks before admission, when he awoke, while sleeping ondeck, with a feeling of severe stabbing pain across the chestextending to the arms, sickness, shivering, and pain in thelimb. Cough came on five days before admission, and therigors continued up to the time of his coming to the hospital.He applied as an out-patient to one of the hospitals of themetropolis, where lie was so severely purged that he wasafraid of returning. He was subsequently treated at thishospital as an out-patient by Dr. Jeaffreson for a few days,until he was admitted into John’s ward, under the care of Dr.Burrows. The patient had never had rheumatism or syphilis,and the health had generally been pretty good. He was-ordered a blister to the epigastrium, one grain of opium im-mediately, and another at bed-time; beef-tea, and six ouncesof wine.Second day.-The patient slept very little in the night,

’t)eing kept awake by the pain, and by his being unable to liedown; the blister rose well; countenance somewhat haggard;face blanched and a.nsemic; conjunctivae pale and bloodless; lipsand gums in the same state; respiration hurried and panting,56 per minute. When the patient attempts to lie down the

pain shoots from the chest to his right scapula, and down thearm on the same side; he coughs a great deal, and expectoratesa quantity of viscid, frothy, bloody mucus; the latter lookedas if some blood had been intimately mixed with it, air havingbeen freely admitted.; pulse 102, of moderate volume, sharp,and very weak; tongue cleaning and moist; great thirst; hetakes his nourishment well, and the bowels have been openedonce freely; urine evacuated without uneasiness, specificgravity 1005, clear, amber-coloured, unaffected by heat ornitric acid; the stabbing pain across the front of the chest isworse, and does not allow him to lie down.--Auscultation ofthe heart: Loud, harsh, double murmur, clearly endocardial,

as the action is too tranquil for it to be a friction-sound. Chestposteriorly: Clear, good respiration throughout the right lung;on the left side loud, coarse breathing above, abundant crepi-tation limited in extent below, and dull on percussion at thebase. It is supposed that the expectoration, though resemblingthat of pneumonia, is not bonr1.fide such, but that its characteris dependent on engorgement, as a result of aortic regurgita-tion, and perhaps the commencement of pulmonary apoplexy.The regurgitation is not supposed to be mitral because thepulse is of moderate volume, and not small, thready, and in-termittent.-Three P.M.: The poor man is very restless; he istossing himself about, demanding more air; respirationsheaving, 60 per minute; cough rather loud and ringing; paindiminished. He died at seven o’clock on the same evening,being sensible to the last; he had no convulsions, and got upto go to the closet a few minutes before lie expired.’ Post-mortem Exagniiiation, eighteen hours after death.-General condition of the body: Not much oedema; face pale;vessels of the head and neck not congested; rigidity general;scalp tough; skull heavy and thick; adhesions between duramater and bone, the latter looking as if worm-eaten.-Mem-branes of the brain: Arachnoid rather milky and spotted;excess of fluid in the subarachnoid tissue. The cerebralventricles contained about twenty ounces of fluid. Vesselsof the brain healthy; brain pale and soft; ventricles granular.-Chest: The pericardium contained from four to six ouncesof turbid fluid; a white patch of lymph, evidently of oldformation, was observed on its anterior and inner surface.Heart twice its natural size; fatty degeneration of its tissue;aorta much diminished in calibre; all the valves healthy, withthe exception of the aortic, which were attacked by destructiveulceration, the outer half of the middle valve, and the innerhalf of the outer, being destroyed. The other valves were

healthy, but vascular, and the ulceration extended throughthe coats of the aorta as far as the endocardium. Some wartymasses of fibrine were deposited on the ulcerated surface.

(See the annexed engraving.) Each pleura contained about a

pint of fluid, there being here and there scattered adhesions.Lungs cedematous; lower lobe of the right lung congested;bronchi very vascular. Liver large, and gorged with blood.Both kidneys were enlarged and nodular, but not lobulated;the nodules were pale and bloodless, and the capsule waseasily stripped off. There was only a rim of cortical substance,the medullary extending to the parietes.The question might now be raised, whether the amount of

hypertrophy observed in this case had taken place in thethree weeks which followed the acute seizure. This is notprobable; but it is likely that some hypertrophy alreadyexisted in consequence of warty excrescences upon thevalves, which excrescences were attacked with the acute in-flammation, which led to ulceration, and to considerableinefficiency of the valvular apparatus. Another reason fornot supposing the changes to have been so sudden is the factof fatty degeneration of the substance of the heart. On thislatter subject (adipose transformation) we would fain dilate,but must postpone our remarks to a future occasion, when weshall have to report another case of degeneration of theorgan. -

KING’S COLLEGE HOSPITAL.

Chronic Rheumatism; Cardiac complication; Albuminuria;Anasarca and Ascites; Good effects of Elaterium.

(Under the care of Dr. TODD.)

IT would be well if physicians, and all engaged in the practice of the medical art, were to turn their earnest attentionto incurable diseases, and use their best efforts to relieve thesymptoms (both slight and distressing) of the patients affectedwith such maladies. Sufficient importance is, perhaps, notattached to this point, and a wide door is thus opened to theimpositions of quackery. It is unfortunately but too true thatwe meet in practice with a great number of affections, of theincurability of which we are deeply and painfully convinced;but although we cannot cure, we have at our command meanswhich will afford the sufferers considerable relief, cheer themon in the sad struggle between the vis conservalriae of the