This practice consists mainly in the antiphlogistic plan of treatment, modified according to circumstances. "It admits of the mildest practice in the mild cases, as well as of the most active treatment in severe cases." In whatever form the disease begins, in the advanced stages it becomes occasionally marked by "adynamic spasmodic nervous symptoms, with a black or blackish tongue, and a very peculiar alteration of countenance." Under these circumstances, indications arise which require all the mental resources of the practitioner.

"The Methodus Antiphlogistica, is to be employed not only in a very mitigated manner, but it must be combined with, and often superseded by antispasmodic, antinervous, diffusively stimulating and tonic remedies. As in the class of tonic medicines, cinchona holds a prominent station, I think it right to observe that this article is scarcely ever useful, and is often injurious in continued Fever during the existence of a hot skin, a quick pulse, and a loaded tongue; cases of gangrene excepted, where indeed the temperature is in general any thing but high, and where cinchona aided by camphorated mixture, good wine, and a suitable position of the body, is an extremely valuable curative agent. I have already noticed the great efficacy of this bark in Erysipelas, after the previous subtraction of some blood from the arm."

The opinion of every man, grounded on such a field of experience as a Fever Hospital, is entitled to respect, especially when it is accompanied by the salutary modifications and precautions contained in the foregoing extracts. On this account we shall

not append any comments on the report, but allow the arguments of the Reporter to acquire all the weight to which they may be found entitled.

LXVI.

HOPITAL DU MANS. TRAUMATIC TETANUS-PATHOLOGY OF.

We are inclined to think, that if ever the true pathology of traumatic tetanus be discovered, it will be found, that the nerves leading from the injured part will exhibit symptoms of inflammation, and that this inflammation will extend to the spinal marrow. In a former Number* we alluded to some researches made by M. Lepelletier, surgeon of the HÔPITAL DU MANS, on the subject of tetanus traumaticus. He had scarcely published his paper, when the following interesting case occurred, confirmatory of this gentleman's doctrines.

Case. Peter Crepon, aged 15 years, feeble in constitution, and miserable in circumstances, had been affected with a tumour on the left heel, from the age of three years, which, gradually increasing, ulcerated, assumed a malignant character, and, finally led to amputation, at the Hospital of Mans, on the 28th of Dec. 1827. Nothing particular occurred till the 5th Jan. 1828, when he complained of convulsive twitchings in the stump. On the 6th, symptoms of tetanus came on and were soon unequivocal. It was remarked, that the temporal and masseter muscles of the left side only were affected with trismus. This corresponded with the amputated limb. We shall not detail the daily treatment and symptoms. Repeated venesections were performed, and, in almost every instance, they relieved the tetanus for a time; but nothing could arrest the progress of the disease, and death took place on the 9th January.

Dissection. A small depôt of purulent matter was found in the stump, on the head of the fibula, with traces of inflammation in the neighbourhood. The sciatic nerve at

* See No. XVI. April, 1828, p. 439.

this place was found so much injected as to be of a violet hue, while the same nerve, in the other limb, was of its natural colour. This discolouration continued, with some interruptions, up to the hip. The patient, during life, complained of pain in the track of this nerve, when pressed by the handand that for some days previous to the developement of the trismus. The discoloration could be traced in some branches of the sciatic nerve distributed to the crural muscles. The pulpy substance of the nerve was found to be somewhat softened. The pia mater of the spinal marrow was decidedly injected; especially towards the middle of the dorsal region, where the medulla itself was softened and degenerated in structure. Some reddish effusion was also found under the membranes of the medulla spinalis. -JOURNAL DE PROGRES.

The narrator thinks that the evidence of the inflammation of nerve from the stump to the spine, as the cause of the tetanus, is here complete. We do not think that the deduction can be denied, as far as this case is concerned; but, unfortunately, there are other cases of traumatic tetanus, where the most careful dissection cannot detect any inflammation of nerve between the seat of injury and the encephalon. A case occurred at St. George's Hospital, where the spinal marrow, and the nerves of the limb were carefully examined, but without success. These conflicting facts prove that tetanus may be induced by the local injury, with or avithout evident change in the spinal marrow

or nerves.

LXVII.

GLASGOW ROYAL INFIRMARY.*

1. COMPOUND FRACTURES.

An instance of severe compound fracture of the superior maxillary, nasal, and malar bones, was treated by pressing them, as nearly as possible, into their natural situation, and dressing the wounds with adhesive plaster. By these means, with liberal bleeding, general and local, abstinence, and

* Glasgow Medical Journal, No. IV.

"The limb was placed in the straight position, the wounds dressed with oiled lint, and splints and a bandage applied. During five weeks, these dressings were allowed to remain undisturbed, the patient suffering no pain in the limb, and not the slightest derangement of the general health; at the end of that time, on removal of the bandages, the bones were found completely united, the wound in the integuments still admitted the point of the little finger, but no bone could be felt either with the finger or a probe. The integuments above, and to outer side of wound, were undermined to the extent of about three inches, and, when pressed, discharged about two teaspoonfuls of healthy pus. About the same quantity of pus was found in the bandages. Immediately after this first dressing, pus was formed in such quantity, that the leg required to be dressed every day, or every second day, and many weeks elapsed before the undermined integuments became sound.

The second case is far more conclusive than the first. A boy was admitted on the 2d of April, with oblique fracture of the tibia, a little above its inferior third. The inner margin of the bone projected obliquely through a wound of the soft parts, and the integuments were detached for an inch around the wound. The limb was placed in the straight position, the wound dressed with dry lint

and adhesive plasters and a bandage and splints applied over all. The apparatus remained undisturbed till the 30th of April, when the bandage was removed, the integuments discovered to be sound, the bone united, the external wound the size of the base of a split pea. During the treatment no pain was experienced, and the health was undisturbed. A slight attack of dysentery detained the patient in the house till the end of the sixth week.

The above, though certainly instructive cases, are hardly, we think, fair illustrations of the absolute value of the practice pursued. Both were young patients, one, only eight years of age, and in these it is notorious that fractures are far less likely to produce those extensive suppurations and sloughings of the cellular membrane which constitute the harrassing and fatal sequela of compound dislocations and fractures in adults. The fact is, that the surgeon should be guided by the pain and the general disturbance produced. If these are inconsiderable, the less that the limb is meddled with the better; if great, the surgeon is a confident or careless man, who would suffer the dressings to remain undisturbed.

Case 1. A weaver, fifty years of age, was admitted on the 7th of November, 1827, with dyspnoea, and difficult deglutition. The voice was much impairedthe air during inspiration produced in its passage through the upper part of the larynx, a loud, moving noise, and, at times, a ringing sound-occasional paroxysms of violent cough, with copious but difficult expectoration of tough and yellowish sputum-parts in front, and at the side of the thyroid cartilage swollen and tender upon pressure, the swelling extending in a less degree towards the cricoid cartilage and os hyoides-no discoloration of the skin-nothing unusual in the fauces or the epiglottis-pulse 120, feeble, and thready-skin cold-aspect pale and

haggard-strength much reduced. These were the symptoms, and it seemed that six weeks before, without obvious cause, the complaint began by swelling around the thyroid cartilage, followed by throbbing pain in the part. In the course of seven days the pain was relieved, but difficulty of breathing and swallowing commenced, and during the last eight days had been urgent.

Leeches, and after them a blister were immediately applied over the larynx, and a grain of calomel and the same amount of opium ordered to be taken every third hour. At nine, p. m. he was suddenly seized with dyspnoea so severe as to threaten immediate suffocation, and this was still so urgent when Dr. C. arrived, that he forthwith proceeded to open the windpipe. On account of the swelling above the larynx, the opening was made below the cricoid cartilage, which procured instantaneous relief for the dyspnœa. The wound was kept open by a bit of curved wire. No further difficulty of breathing took place, excepting that once a severe fit of coughing was caused by a little milk escaping through the wound. On another occasion, also, accidental derangement of the wire produced a slight paroxysm, but further than these, not the slightest inconvenience was felt after the operation. After a few weeks the wire was exchanged for a curved silver tube, about two and a half inches long, and one fourth of an inch in diameter, provided with two small rings, through which a piece of tape was passed, and tied round the neck, to retain the tube in situ.

"On the supposition that the contraction of the cavity of the larynx depended on thickening of its lining membrane, a mercurial course was prescribed, but apparently without benefit; for, although the patient continued to breathe easily, so long as the wound was kept open, yet all attempts to make him breathe through the mouth alone, proved ineffectual. On various occasions the wound was closed with adhesive plaster, to ascertain if any improvement had taken place, but it was invariably found necessary at the end of a few minutes to open the wound, and replace the tube, on account of increasing dyspnoea. At one time I entertained hopes of being able to dilate the contracted larynx, by bougies passed upwards through

it from the wound; but the extreme irritability of the parts, rendered this proposal impracticable. The introduction of even a probe through the wound into the larynx, was found to excite such a paroxysm of cough, that it was absolutely necessary to desist."

After remaining in the hospital above five months, the patient was dismissed, suffering no inconvenience except the necessity of breathing through the tube, a circumstance which habit had rendered very tolerable. By stopping up the tube with the point of his finger, he could speak in a hoarse, but audible tone. In the month of August last, he appeared at the Infirmary, and was perfectly free from all complaint,

Case 2. This was a tobacco-pipe maker, aged 28, who was seen by Dr. Couper, thirteen days after the commencement of the laryngeal inflammation. He had been bled pretty freely at different times, blistered, and treated with diaphoretic medicines, but still, though at times apparently relieved, the disease had proceeded on its march. When examined by Dr. C. he was just recovering from a fit of alarming orthopnoea, and presented these symptoms. Incapability of assuming the horizontal posture-inspiration laborious and wheezing-fauces red and swollen-epiglottis enlarged, tense, and shaped like a glans penis during erection-uneasiness decidedly referred to the larynx.

"Laryngotomy was immediately agreed upon. In making the incision through the integuments, a small artery was cut, and bled very freely. At the same instant the dyspnoea became greatly increased; the patient's face became livid, his limbs quivered, and his urine was ejected involuntarily. Without waiting to secure the artery, I immediately perforated the thyrocricoid membrane, and the transition from the state now described to easy respirawas nearly instantaneous. The patient's body being inclined forward, no inconve nience was felt from the bleeding, which was speedily stopt by the pressure of the wire employed to dilate the aperture. From this time he continued to breathe easily, partly by the wound and partly by the mouth, and swallowed without diffi culty."

Four days after the operation the wire was withdrawn, and on the 15th, the

wound was so very nearly healed, that even during coughing no air escaped by it. Nine days after this, the patient had a rigor, followed by urgent orthopnoea, and a little pain and swelling of the right side of the larynx. After vainly employing a full dose of laudanum and antimonial wine, without relief, the larynx was opened a second time. In the course of ten days, the wire was changed for a silver tube which was kept in the wound for upwards of a month, and then withdrawn, shortly after which, the wound was healed. A few days after this, he was discharged, affected with only a glandular swelling on the left side of the neck, which soon disappeared on his leaving the hospital.

"Both of these cases appear important; the former is an example of contraction of the larynx produced by chronic inflammation, and the latter as an instance of the same effect arising from acute cedematous laryngitis. The important fact, that the dyspnoea, in cases of laryngeal disease, is liable to sudden and dangerous exacerbations, is well illustrated by both. Such paroxysms may cease, after the irritability of the parts is exhausted, but they will cer tainly recur again and again, until suffocation is produced, unless an artificial opening is made into the windpipe, to allow a free access of air to the lungs. When the necessity for it ceases, the aperture can be easily healed up; and even should the contraction of the larynx prove permanent, as in the case of Limpitiaw, it must be allowed, that the inconvenience arising from breathing through a tube inserted into the windpipe during the remainder of life, is small, when compared with loss of a limb, to which few refuse to submit as a mean of prolonging life."

LXVIII.

SANTA MARIA HOSPITAL OF FLORENCE.

SUCCESSFUL CASE OF CESAREAN OPERATION. BY SIGNIOR TASSINARI.

Eg. Zanobini, 23 years of age, of weak constitution, ricketty, and deformed, entered on the holy state of matrimony, contrary to the advice of her medical

and other friends. Six months after marriage, she became pregnant, and on the 11th of May, 1827, being near the completion of the ninth month of utero-gestation, she was seized with labour-pains, but unaccompanied by any expulsive efforts. In 24 hours the waters burst; but the midwife delayed sending for a surgeon, thinking the protraction of delivery was owing to the circumstance of its being a first accouchment. At the expiration of 48 hours, Dr. Lotti was summoned, and found that the superior aperture of the pelvis was too small to permit the descent of the head. The patient was therefore conveyed to the SANTA MARIA HOSPITAL, at 10 o'clock in the forenoon of May 13th, and placed in the ward of St. PHILIPPE. Professor Andrini examined the parts, and came to the conclusion that nothing but the Cæsarian operation offered any chance of success. Several other professors and surgeons came into consultation, and were of the same opinion. The operation being determined on, the head-dresser of the hospital, (le premier eléve interne en chirurgie,) M. Tassinari, proceeded to the task.* An incision directly over the linea alba was made, between the umbilicus and pubes, and then the tendinous fibres were divided, till the peritoneum was exposed. This last was opened by means of scissors, and the opening in it enlarged by tearing the membrane with the fingers, to the extent of the internal incision.t The uterus was next incised, from the fundus to near the cervix. The

* This is a plan adopted in several foreign schools; but which, we suppose, John Bull would not permit. In this country, students have few opportunities of putting the knife upon the living body, till, in private practice, they have the whole responsibility on their heads, and none to direct their trembling hands! The continental rule of permitting students to operate under the direction of their masters, is assuredly better calculated for sending forth into private life men capable of operating, than the plans here prevailing.

The operator gives no reason for this tearing of the peritoneum, instead of making a clean incision with the bistoury-nor can we conceive any good reason why the above process was employed. The issue was successful; but this does not justify, in our opinion, the measure pursued.

fœtus was then seized by the feet, and readily extracted. A very slight traction

At

Next

on the umbilical cord served to remove the placenta. The wound was brought together, secured by sutures, and covered with lint. The patient was put to bed, and an anodyne draught exbibited. six in the evening, there were signs of approaching reaction and inflammation, and twelve ounces of blood were abstracted, which was repeated at midnight. morning, (14th of May,) the pulse was very high, and a third venesection was employed. At 2 P. M. vomiting came on, but was stopped by the exhibition of iced drink. At 11 o'clock, the abdomen was much swelled, and the fever very high, with sanguineous discharges from the vagina, and suppression of urine. Bled again, to six ounces-catheter introduced, but no water drawn off-laxative enema. 15th. The constipation and ischuria continue-fever intense-enemata-another venesection. 16th. The symptoms are improved-the fever reduced-the abdomen less tense-the lochia flowing copiously. The urine has again appearedand the patient has slept. 17th. An aggravation of the general and local symptoms-another venesection The symp

toms now became more favourable. On the 21st, the dressings were removed, in the presence of all the professors who had assisted at the operation, and the whole line of incision was found to be united, except a very small portion at the inferior angle, where a piece of lint had been introduced between the lips. On the 7th of June, the patient was able to get out of bed, and was discharged from the hospital cured on the 16th of the same month.

The foregoing operation, authenticated as to its success, beyond the slightest doubt or cavil, does great credit to the juvenile operator. It appears that this was the first successful operation of the kind, which was performed in the hospital above-men tioned.