WORCESTER INFIRMARY.
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279 to the last. The total duration of the attack was about seventeen days. CASE 2. S. C-, labourer, aged forty-eiglit, was admitted into the infirmary urder Dr. Tuckwell’s care on May 8th, 1875. He was reported to have been attacked seven days before admission, after prolonged exposure to wet and cold, with stiff neck, followed by spasm in the muscles of the neck and chin, which had gradually extended to the muscles of the belly, back, and limbs. He had enjoyed re- markable health, and had not received hurt or injury of any kind. He was a well-made, strong, and muscular man. He lay on his back with well-marked risus, tetanic rigidity of all the muscles of the neck, extreme spasm of the abdominal muscles, and permanent opisthotonos. Every few minutes this was violently intensified by a paroxysm of general tetanic cramp. Pulse 100 ; evening temperature 100°. Ordered to have his bowels well opened with calomel and jalap pill, followed by black draught, and then to take twenty grains of chloral every three hours. May 9th.-His bowels had acted freely, and he had taken five doses of chloral, but the cramps were not relieved. It was now resolved, bearing in mind the previous case, and in consideration of the good result that had followed a similar plan of treatment in severe chorea, to discontinue all medicine, and trust to nursing and nourishment. He was ordered to be kept perfectly quiet, and take, at regular intervals, milk, beef-tea, eggs beaten up in milk, and light puddings, but no medicine or stimulant. 10th.—He had taken nourishment well, the mouth being only partly closed by the tetanus. The tetanus was un- changed, the spasm of opisthotonos being very severe. 11th.—He had been quieter, and had slept at intervals through the night. He expressed himself as feeling better. There was the same permanent rigidity of the muscles, but the paroxysms of cramp were less severe. Pulse 108. Even- ing temperature, 1004°. Tongue moist, but coated. 12th.-He had dozed through the night. The cramps had been less severe, not recurriug more than every hour ; the permanent rigidity remaining. 13th.—Had had a quiet night ; the spasms still shorter in duration and at longer intervals. Pulse 100. Evening temperature, 99°. 14th.—Much the same. Pulse 108. Evening temperature 100’2° ; skin profusely sweating. 15th.—Much the same. Pulse 106. Temperature 994°. Same profuse sweating. 16th.-The spasms had been more severe in the night, but he was quieter again this morning. The face was still drawn, but less than at lirst. The sterno-mastoids were now relaxed. The abdominal muscles were as hard as a board, and the spinal muscles persistently rigid, keeping up a constant slight opisthotonos. Pulse 108. Evening temperature 992°. Tongue moist, but foul. 17th.-He had passed a better night, and had had less spasm. Pulse 88. Temperature 98’8°. 19th.-The spasms had recurred at much longer intervals, and he was in less pain. The belly was still board-like. The permanent opisthotonos was gone, and he could move freely both arms and legs. He could open the mouth wider, and put out the tip of the tongue. Pulse 88 ; temperature 98 4°. 20th.-Had passed a restless night. During the visit he had a short but sharp spasm of opisthotonos, and contraction of the extensors of the legs, but as soon as the spasm was over these muscles relaxed. Pulse 96; temperature 98°. His expression was quiet and calm. He could protrude the tongue half-way. The abdominal muscles were still board- like. 24th.-Had had very slight spasms at long intervals. The abdominal muscles were still rigid. Pulse 80 ; temperature 98°. He had taken yesterday, for the first time, a little minced meat and mashed potato. 31st.-All spasms had ceased. Slight rigidity of the abdominal muscles remained. He had slept well at night, and was quite cheerful. He could pull himself up in bed and sit upright. On June 7th, the thirty-eighth day of the attack, he could walk up and down the ward. All pain was gone. Slight rigidity of the abdominal muscles remained till June 18th, when he was discharged cured. CASE 3.-E. M—, brewer’s man, aged forty-seven, was admitted into the infirmary, under Mr. Winkfield’a care, on May 23rd, 1878, suffering from an injury to the thumb and commencing tetanus. Ten days before admission his left thumb had been partially crushed between some casks. He had been treated with water-dressing, and had gone on favourably till three days before admission, when he had begun to feel pain about his jaw and difficulty in swallowing. He had continued at his work till the day before admission, the stiffness and pain in moving the jaw having gradually increased. On admission there was a ragged slough on the injured thumb. The jaw was so far closed that he could only open his mouth about three-quarters of an inch, and there was stiffness about the muscles of his neck. His abdomen was soft. Tongue furred, breath rather fetid. Pulse 66; tem- perature in axilla, 98’4°. His bowels were reported to have been regularly and freely open. He was ordered, for diet, broth, milk, and a little minced meat ; and for medicine, haustus menthæ sulphuricus, one ounce three times a day. May 24th.-His bowels had acted naturally. The stiff. ness of his jaw had increased, and risus sardonicus was beginning. His other symptoms were much the same. This condition lasted for some days, the jaw becoming closed, so that he could only open his mouth half an inch wide, with stiffness in the neck and the muscles of the back; but he managed to take his food well. The symptoms then gradually abated, and he was discharged on June 12th, his thumb being healed, and all tetanic symptoms gone. He is now well, and doing his work as usual. WORCESTER INFIRMARY. A CASE OF FRACTURE OF THE FEMUR FROM SPASMODIC MUSCULAR CONTRACTION. (Under the care of Mr. THOMAS W. WALSH.) JAMES Y-, aged forty, was admitted on Oct. 23rd, 1878. Seven years before he was kicked by a horse on the left thigh, but his leg was not broken, and he was able to work afterwards. Subsequently, at different times, abscesses, attended with much pain, formed in his thigh. These abscesses burst, and some months after small pieces of bone were passed through the sinuses, which never healed. For some time previous to admission the man had suffered much pain from spasm of the muscles of the thigh, but he was able to get about, and even followed the plough a fortnight before the accident. At that period, however, the leg became so weak, and the spasms so frequent and severe, that he was obliged to take to his bed ; and on Oct. 20th, in one of those violent spasms, he heard his thigh snap. On admission the leg was manifestly broken at the junc- tion of the lower with the middle third. It was much shortened, and the foot was everted. There were several old cicatrices and two sinuses, one on either side of the thigh opposite to the fracture. The whole limb was brawny.. On passing a probe, it struck dead bone, and the opinion arrived at by Mr. Walsh and his colleagues was that there was necrosis, with a deficient formation of new bone. The, slightest manipulation gave extreme pain. The thigh was placed on a splint, with sand-bags on each side. Opiates and a liberal diet were ordered. Notwithstanding this, the spasmodic twitchings were frequent and most painful, and, as he did not improve, Mr. Walsh, with the approbation of his colleagues, decided to amputate, which was done on Nov. 5th by Carden’s single skin flap. Nothing very particularly noteworthy occurred in the later progress of the case, except the formation of one or two small subcutaneous abscesses, which somewhat delayed his recovery until Feb. 14th, when he was discharged with a sound and useful stump. On examining the limb the fracture, which was deeply and irregularly serrated, was found at the locality before men- tioned. There was no sequestrum, nor was any new bone formed. The medullary canal for about two inches in either fragment was much distended, and the bony structure con- sequently much attenuated. It would seem that the man had been suffering from medullary abscess. The specimen is preserved in the museum of the infirmary. THE Witham Union is to be dissolved from Lady-day next, and the seventeen parishes of which it is comprised are to be added to the Maldon, Lexden and Winstree and BraintTee Unions,
Transcript of WORCESTER INFIRMARY.
279
to the last. The total duration of the attack was aboutseventeen days.CASE 2. - S. C-, labourer, aged forty-eiglit, was
admitted into the infirmary urder Dr. Tuckwell’s care onMay 8th, 1875. He was reported to have been attackedseven days before admission, after prolonged exposure to wetand cold, with stiff neck, followed by spasm in the musclesof the neck and chin, which had gradually extended to themuscles of the belly, back, and limbs. He had enjoyed re-markable health, and had not received hurt or injury of anykind.He was a well-made, strong, and muscular man. He lay
on his back with well-marked risus, tetanic rigidity of allthe muscles of the neck, extreme spasm of the abdominalmuscles, and permanent opisthotonos. Every few minutesthis was violently intensified by a paroxysm of generaltetanic cramp. Pulse 100 ; evening temperature 100°.Ordered to have his bowels well opened with calomel andjalap pill, followed by black draught, and then to taketwenty grains of chloral every three hours.May 9th.-His bowels had acted freely, and he had taken
five doses of chloral, but the cramps were not relieved. Itwas now resolved, bearing in mind the previous case, and inconsideration of the good result that had followed a similarplan of treatment in severe chorea, to discontinue allmedicine, and trust to nursing and nourishment. He wasordered to be kept perfectly quiet, and take, at regularintervals, milk, beef-tea, eggs beaten up in milk, and lightpuddings, but no medicine or stimulant.
10th.—He had taken nourishment well, the mouth beingonly partly closed by the tetanus. The tetanus was un-changed, the spasm of opisthotonos being very severe.
11th.—He had been quieter, and had slept at intervalsthrough the night. He expressed himself as feeling better.There was the same permanent rigidity of the muscles, butthe paroxysms of cramp were less severe. Pulse 108. Even-ing temperature, 1004°. Tongue moist, but coated.12th.-He had dozed through the night. The cramps had
been less severe, not recurriug more than every hour ; thepermanent rigidity remaining.
13th.—Had had a quiet night ; the spasms still shorterin duration and at longer intervals. Pulse 100. Eveningtemperature, 99°.
14th.—Much the same. Pulse 108. Evening temperature100’2° ; skin profusely sweating.
15th.—Much the same. Pulse 106. Temperature 994°.Same profuse sweating.16th.-The spasms had been more severe in the night, but
he was quieter again this morning. The face was still drawn,but less than at lirst. The sterno-mastoids were now relaxed.The abdominal muscles were as hard as a board, and thespinal muscles persistently rigid, keeping up a constantslight opisthotonos. Pulse 108. Evening temperature992°. Tongue moist, but foul.17th.-He had passed a better night, and had had less
spasm. Pulse 88. Temperature 98’8°.19th.-The spasms had recurred at much longer intervals,
and he was in less pain. The belly was still board-like.The permanent opisthotonos was gone, and he could movefreely both arms and legs. He could open the mouth wider,and put out the tip of the tongue. Pulse 88 ; temperature98 4°.20th.-Had passed a restless night. During the visit he
had a short but sharp spasm of opisthotonos, and contractionof the extensors of the legs, but as soon as the spasm wasover these muscles relaxed. Pulse 96; temperature 98°.His expression was quiet and calm. He could protrude thetongue half-way. The abdominal muscles were still board-like.24th.-Had had very slight spasms at long intervals. The
abdominal muscles were still rigid. Pulse 80 ; temperature98°. He had taken yesterday, for the first time, a littleminced meat and mashed potato.31st.-All spasms had ceased. Slight rigidity of the
abdominal muscles remained. He had slept well at night,and was quite cheerful. He could pull himself up in bedand sit upright.On June 7th, the thirty-eighth day of the attack, he could
walk up and down the ward. All pain was gone. Slightrigidity of the abdominal muscles remained till June 18th,when he was discharged cured.CASE 3.-E. M—, brewer’s man, aged forty-seven, was
admitted into the infirmary, under Mr. Winkfield’a care, onMay 23rd, 1878, suffering from an injury to the thumb and
commencing tetanus. Ten days before admission his leftthumb had been partially crushed between some casks. Hehad been treated with water-dressing, and had gone onfavourably till three days before admission, when he hadbegun to feel pain about his jaw and difficulty in swallowing.He had continued at his work till the day before admission,the stiffness and pain in moving the jaw having graduallyincreased.On admission there was a ragged slough on the injured
thumb. The jaw was so far closed that he could only openhis mouth about three-quarters of an inch, and there wasstiffness about the muscles of his neck. His abdomen wassoft. Tongue furred, breath rather fetid. Pulse 66; tem-perature in axilla, 98’4°. His bowels were reported to havebeen regularly and freely open. He was ordered, for diet,broth, milk, and a little minced meat ; and for medicine,haustus menthæ sulphuricus, one ounce three times a day.May 24th.-His bowels had acted naturally. The stiff.
ness of his jaw had increased, and risus sardonicus wasbeginning. His other symptoms were much the same.This condition lasted for some days, the jaw becoming
closed, so that he could only open his mouth half an inchwide, with stiffness in the neck and the muscles of the back;but he managed to take his food well. The symptoms thengradually abated, and he was discharged on June 12th, histhumb being healed, and all tetanic symptoms gone. He isnow well, and doing his work as usual.
WORCESTER INFIRMARY.A CASE OF FRACTURE OF THE FEMUR FROM SPASMODIC
MUSCULAR CONTRACTION.
(Under the care of Mr. THOMAS W. WALSH.)JAMES Y-, aged forty, was admitted on Oct. 23rd, 1878.
Seven years before he was kicked by a horse on the leftthigh, but his leg was not broken, and he was able to workafterwards. Subsequently, at different times, abscesses,attended with much pain, formed in his thigh. Theseabscesses burst, and some months after small pieces of bonewere passed through the sinuses, which never healed. Forsome time previous to admission the man had suffered muchpain from spasm of the muscles of the thigh, but he was ableto get about, and even followed the plough a fortnightbefore the accident. At that period, however, the legbecame so weak, and the spasms so frequent and severe,that he was obliged to take to his bed ; and on Oct. 20th, inone of those violent spasms, he heard his thigh snap.On admission the leg was manifestly broken at the junc-
tion of the lower with the middle third. It was muchshortened, and the foot was everted. There were severalold cicatrices and two sinuses, one on either side of the thighopposite to the fracture. The whole limb was brawny.. Onpassing a probe, it struck dead bone, and the opinionarrived at by Mr. Walsh and his colleagues was that therewas necrosis, with a deficient formation of new bone. The,
slightest manipulation gave extreme pain. The thigh wasplaced on a splint, with sand-bags on each side. Opiatesand a liberal diet were ordered. Notwithstanding this, thespasmodic twitchings were frequent and most painful, and,as he did not improve, Mr. Walsh, with the approbation ofhis colleagues, decided to amputate, which was done onNov. 5th by Carden’s single skin flap.Nothing very particularly noteworthy occurred in the
later progress of the case, except the formation of one or twosmall subcutaneous abscesses, which somewhat delayed hisrecovery until Feb. 14th, when he was discharged with asound and useful stump.On examining the limb the fracture, which was deeply and
irregularly serrated, was found at the locality before men-tioned. There was no sequestrum, nor was any new boneformed. The medullary canal for about two inches in eitherfragment was much distended, and the bony structure con-sequently much attenuated. It would seem that the manhad been suffering from medullary abscess. The specimenis preserved in the museum of the infirmary.
THE Witham Union is to be dissolved fromLady-day next, and the seventeen parishes of which it is
comprised are to be added to the Maldon, Lexden andWinstree and BraintTee Unions,
