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A CASE OF TRAUMATIC TETANUS TREATED WITH NICOTINE.
577 I
Amply to the carrying into practice of a passing thought which constantly kept in a state of unpleasant are applied to the limb. claims simplicity as its greatest merit. I have somewhere seen it stated, that the criteria of a useiul apparatus for the treatment of fractures are-1st, that it should be efficient; 2nd, that it should be cheap; and, 3rd, that it should be readily obtainable. All these advantages I think I may claim for the instrument I am about to describe : the conditions of the first clause it especially fulfils; and those ofthe second and third not less so than any other apparatus in
moisture when lotions
perm its an examination of the limb to be made withremoving the splints.
4th. It
out
5th. Its comfort must be obvious to the most casual observer. ’
,E
Gth. It is
light, and can be obtained for a very small sum.
general use.
The main feature in my
plan is the substitution
of
a
water
pad exactly adapted to the splint upon which the leg reclines, the lateral pressure being applied by means of cushions capable of being distended by air or water, as may be deemed advisable; and the way in which it has been applied at the Royal Free Hospital (through the kindness of Mr. de Meric and Mr. Weeden
Cooke)
presents
a
may be described as follows:—AB water bed made to fit an ordinary back
(Fig. 1) resplint ; an
In some future number I hope to give some details of its application to fractures of other limbs, to all of which it is easily adapted, more especially to those of the forearm. The apparatus may now b0 seen in use at the Royal Free Hospital. October, 1867.
A
CASE OF TRAUMATIC TETANUS TREATED WITH NICOTINE. BY REGINALD
HARRISON, F.R.C.S. ENG.,
SURGEON TO THE LIVERPOOL NORTHERN HOSPITAL, AND LECTURER ON ANATOMY AT THE LIVERPOOL ROYAL INFIRMARY SCHOOL OF MEDICINE.
being left at c for the heel, and beyond this the bed aperture to iit the understood This is turns
up by easily foot-piece. reference to the diagram =D E, which represents a side view of the two together in sitic. G G is a diagram of the two lateral cushions. They are made of caoutchouc, aud are sufficiently long to extend from a little above the knee to the sole of the foot. Their two feeding tubes unite at H, and thus the amount of air sent to either of them is equalised. I I represents them in a distended condition. The leg then having been securely placed upon the back splint, and extension being made to reduce the fracture, the cushions, which are accurately adapted to two slightly convex lateral splints, are loosely adjusted to the limb by means of two webbing straps (Fig. 2). The mouth is then applied to the tube H, and air steadily driven into the pads. These soon become distended to the extent to which the lateral splints will admit of, and at once adapt themselves to the limb so closely as to form an admirably equable support in all directions, effectually preventing any displacement, and that without being irksome or painful to the patient (Fig. 3). At first I imagined that an air-pump would be necessary to produce the amount of tension required; but I find that my own respiratory effort is sufficient to produce any amount short of what would be absolutely injurious.
AMONGST the very numerous remedies used in the treatment of tetanus, tobacco in some form has frequently been resorted to for many years past; and since the publication of the Rev. Prof. Haughton’s paper on the Counteractive Effects of Strychnia and Nicotine, an additional interest has been given to this plan. A recent case under my care where nicotine was used may not prove uninteresting, as generally corroborative of the conclusions drawn by Professor Haughton from somewhat similar cases under his observation, and which are recorded in the thirty-fourth volume of the Dublin Quarterly Journal. I am iudebted to Mr. Woods, who was my dresser at the time, for the notes of this case. R. D-, a labouring boy, aged eleven, was admitted into the Liverpool Northern Hospital, under my care, on Jan. 6th, 1857. Exactly five weeks before admission, he fell on the back of his head, producing a ragged scalp wound about an inch in length. The wound was not inclined to heal, and three days before admission he complained of stiffness about the neck and difficulty in opening his mouth. The wound was suppurating and the bone bare. The muscles about the face I will then briefly enumerate the advantages which are to and neck were rigid, the tongue could not be protruded, and be derived from the instrument whose claims I advocate. the ?"i8’118 8a1’don icU8 was unmistakable. There was a slight lst. It produces an even and equable pressure on all parts degree of opisthotonos and rigidity of the flexors of the foreof the limb, adapting itself to all its curves and undulations. arm. These symptoms gradually increased in severity. A 2nd. This pressure can be regulated with a nicety unattain- quart8r of a grain of morphia in solution was injected subcutftable by any other process. neously every three or four hours. Beef tea and juice were in small quantities at frequent intervals. 3rd. It avoids the necessity of pads, of tow, lint, or any other J1,n. 7th.-The general symptoms were much the same. The material, which absorb discharges, harbour vermin, and are
given
578 opisthotonos rather more marked. He had slept several hours effects as an external application, in the form of a poultice to after the morphia. The morphia to be continued. Pulse about the wound by which the tetanic symptoms were produced. From the observation of many cases of this distressing disease 100. The bowels opened after an enema. 8th.-The symptoms are more marked. The opisthotonos I should certainly feel more confidence in again adopting the . is extreme. The voluntary muscles generally are rigid. He treatment that I have recorded than any other I have seen tried. was extremely restless; and though the morphia was increased, Liverpool, 1867. it failed to give relief. Pulse 104. 9th.-General rigidity of muscles increased. He was constantly crying out, being in great pain. He had not slept "THE TURTLE WOMAN" OF DEMERARA. during the night. The muscles in the perineum were extremely rigid, and it was necessary to remove the urine with the catheter. BY IZETT W. ANDERSON, M.D. EDIN. Though the muscular spasm was continuous, it was greatly increased in intensity on anyone touching him, or even approachI LATELY received from my brother-Dr. F. H. Andersor, ing him to alter his position. There was great pain about the diaphragm, with hiccough. Skin hot and dry; bowels only of Demerara-a photograph (from which the accompanying er.acting after an enema ; pulse 120, and thready. There was a graving is taken) of a case of congenital deformity. It apsmall collection of matter near the wound, which was opened, and about a drachm of pus evacuated.-Quarter to five P.M.: One- peared to me one of such interest and comparative rarity that twelfth of a drop of nicotine was administered, the pulse being I obtained further particulars regarding it, and the permission 120.-Quarter past five P.M.: The dose was repeated; pulse of the Surgeon-General and my brother to bring it before the 108.-Quarter past seven: Pulse 112. One-eighth of a drop profession in any way I might think fit. of nicotine was given. -Nine P.m.: The pulse was 68, and The subject of this case was a black girl, aged twenty-four. slightly intermittent. He was sweating profusely. There was much less muscular rigidity, and he was enabled to pass his She was commonly called " the turtle woman," from, I supurine naturally, which he had not done for thirty hours. The pose, the peculiar malformation of the lower extremities, and nicotine was discontinued for the night. also from the fact that her mother, when pregnant of her, was 10th.-Nine A.M.: The pulse had risen to 110. He had frightened by a turtle; and to this misfortune attributed the slept comfortably for several hours. Muscular rigidity cer- condition of her child. The girl has generally been healthy, tainly less than on the previous day. Skin moist and perspir- and has never suffered from rickets or any disease of the bones; ing. No nicotine was administered during the day; but in the and her as regards the malformation, has existed a the noted one-twelfth of was condition, evening drop given, pulse being at 132. unchanged since her birth. None of her relations are deformed. llth.-Passed a tolerably good night, and remained com- She was able to move about a little, and could do needlework fortable during the day. Pulse 110. One-eighth of a drop of by holding the cloth between the right arm and the body, and using the needle with the left hand. About two years ago she nicotine to be given at night. 12th.-Had slept for several hours. Pulse 92, and regular. gave birth to a full-grown child free from deformity, but it Towards the evening of this day he did not appear so well. died the next day. The labour was natural in every respect. The general muscular rigidity was much increased, and it was In the early part of last April she miscarried of a four months’ Pulse 115. The foetus. On the 13th of the same month she was admitted into twice during the the Colonial Hospital, suffering from syphilis, and she died on the 10th of July. night. i He several eleven A. -iV.1. : hours, My brother writes me that he could only examine the bones 13th.-Half-past had slept for and was decidedly better. Pulse 100. He was again able toi of one leg. The femur was only six inches long, but was articulated in the usual way, there being an acetabulum, with a pass his water naturally. Without going more into detail, I may say that from this strong capsule, and a ligamentum teres. " The foot is put on date his improvement was uninterrupted, and he left the hos- sideways, there being no tibia or fibula. The foot altogether consists of only six bones, four of these being toe bones-viz., pital quite well in six weeks. The nicotine was given occa- the and second phalanges of the big and second toes. sionally, being invariably followed with relief. During the The first femur articulates inferiorly with one long bone, which whole course of the disease a generous fluid diet was given, seems to be the prolonged metatarsal bone of the great toe. without stimulants. In this case, although symptoms did not show themselves The sixth bone is the second metatarsal. The right arm contill the thirty-second day after the injury, yet they were of a sists of a humerus, with the condyles well developed." sufficiently aggravated character to lead me to apprehend a fatal result. The morphia in the first instance appeared to give relief; but on its failing, I fell back upon the tobacco treatment as a last resource. In administering the nicotine (which was procured for me with great promptness by Messrs. Clay and Abraham), I found that one-twelfth of a drop was quite sufficient to produce a decided effect, and at no time was it increased to more than one-eighth, dissolved in alcohol and water. An hour always intervened between the doses. I mention these points for the guidance of those who feel disposed to try the plan of treatment. The effect of nicotine on the system is of so depressing a nature, especially in the case of those unused to tobacco, that it is most important not to necessary. give the least quantity more than is absolutely The effects of the nicotine, as observed in this case, may be summed up as follows:1st. A diminution in the frequency of the heart’s action. On the 9th of January, in four hours and three quarters, the was most marked on the first pulse fell from 120 to 68. Thismore or less invariably observed day; but the same effect was consequent upon its administration. 2ndly. The muscular spasm was invariably diminished. This was generally evident, but more especially by the voluntary discharge of urine, and by the breathing becoming easy and necessary again to make
nicotine
was
use
of the catheter.
repeated (one-eighth of
a
drop)
I
unaccompanied with diaphragmatic pain. 3rdly. A tranquilising effect on the nervous system generally. 4thly. It promoted the action of the skin, though I never detected the " snuffy odour" of the excretion as mentioned by others.
Although it is to be regretted that, owing to various circum. stances, the post-mortem examination was not more complete, I yet I think these rough notes may be of interest to the pro-
Such are the more prominent particulars in this case. find there are many recorded cases where a recovery followed the use of tobacco; and some speak highly of its beneficial
fession. Kingston, Jamaica, Sept. 23rd, 1867.
Amply to the carrying into practice of a passing thought which constantly kept in a state of unpleasant are applied to the limb. claims simplicity as its greatest merit. I have somewhere seen it stated, that the criteria of a useiul apparatus for the treatment of fractures are-1st, that it should be efficient; 2nd, that it should be cheap; and, 3rd, that it should be readily obtainable. All these advantages I think I may claim for the instrument I am about to describe : the conditions of the first clause it especially fulfils; and those ofthe second and third not less so than any other apparatus in
moisture when lotions
perm its an examination of the limb to be made withremoving the splints.
4th. It
out
5th. Its comfort must be obvious to the most casual observer. ’
,E
Gth. It is
light, and can be obtained for a very small sum.
general use.
The main feature in my
plan is the substitution
of
a
water
pad exactly adapted to the splint upon which the leg reclines, the lateral pressure being applied by means of cushions capable of being distended by air or water, as may be deemed advisable; and the way in which it has been applied at the Royal Free Hospital (through the kindness of Mr. de Meric and Mr. Weeden
Cooke)
presents
a
may be described as follows:—AB water bed made to fit an ordinary back
(Fig. 1) resplint ; an
In some future number I hope to give some details of its application to fractures of other limbs, to all of which it is easily adapted, more especially to those of the forearm. The apparatus may now b0 seen in use at the Royal Free Hospital. October, 1867.
A
CASE OF TRAUMATIC TETANUS TREATED WITH NICOTINE. BY REGINALD
HARRISON, F.R.C.S. ENG.,
SURGEON TO THE LIVERPOOL NORTHERN HOSPITAL, AND LECTURER ON ANATOMY AT THE LIVERPOOL ROYAL INFIRMARY SCHOOL OF MEDICINE.
being left at c for the heel, and beyond this the bed aperture to iit the understood This is turns
up by easily foot-piece. reference to the diagram =D E, which represents a side view of the two together in sitic. G G is a diagram of the two lateral cushions. They are made of caoutchouc, aud are sufficiently long to extend from a little above the knee to the sole of the foot. Their two feeding tubes unite at H, and thus the amount of air sent to either of them is equalised. I I represents them in a distended condition. The leg then having been securely placed upon the back splint, and extension being made to reduce the fracture, the cushions, which are accurately adapted to two slightly convex lateral splints, are loosely adjusted to the limb by means of two webbing straps (Fig. 2). The mouth is then applied to the tube H, and air steadily driven into the pads. These soon become distended to the extent to which the lateral splints will admit of, and at once adapt themselves to the limb so closely as to form an admirably equable support in all directions, effectually preventing any displacement, and that without being irksome or painful to the patient (Fig. 3). At first I imagined that an air-pump would be necessary to produce the amount of tension required; but I find that my own respiratory effort is sufficient to produce any amount short of what would be absolutely injurious.
AMONGST the very numerous remedies used in the treatment of tetanus, tobacco in some form has frequently been resorted to for many years past; and since the publication of the Rev. Prof. Haughton’s paper on the Counteractive Effects of Strychnia and Nicotine, an additional interest has been given to this plan. A recent case under my care where nicotine was used may not prove uninteresting, as generally corroborative of the conclusions drawn by Professor Haughton from somewhat similar cases under his observation, and which are recorded in the thirty-fourth volume of the Dublin Quarterly Journal. I am iudebted to Mr. Woods, who was my dresser at the time, for the notes of this case. R. D-, a labouring boy, aged eleven, was admitted into the Liverpool Northern Hospital, under my care, on Jan. 6th, 1857. Exactly five weeks before admission, he fell on the back of his head, producing a ragged scalp wound about an inch in length. The wound was not inclined to heal, and three days before admission he complained of stiffness about the neck and difficulty in opening his mouth. The wound was suppurating and the bone bare. The muscles about the face I will then briefly enumerate the advantages which are to and neck were rigid, the tongue could not be protruded, and be derived from the instrument whose claims I advocate. the ?"i8’118 8a1’don icU8 was unmistakable. There was a slight lst. It produces an even and equable pressure on all parts degree of opisthotonos and rigidity of the flexors of the foreof the limb, adapting itself to all its curves and undulations. arm. These symptoms gradually increased in severity. A 2nd. This pressure can be regulated with a nicety unattain- quart8r of a grain of morphia in solution was injected subcutftable by any other process. neously every three or four hours. Beef tea and juice were in small quantities at frequent intervals. 3rd. It avoids the necessity of pads, of tow, lint, or any other J1,n. 7th.-The general symptoms were much the same. The material, which absorb discharges, harbour vermin, and are
given
578 opisthotonos rather more marked. He had slept several hours effects as an external application, in the form of a poultice to after the morphia. The morphia to be continued. Pulse about the wound by which the tetanic symptoms were produced. From the observation of many cases of this distressing disease 100. The bowels opened after an enema. 8th.-The symptoms are more marked. The opisthotonos I should certainly feel more confidence in again adopting the . is extreme. The voluntary muscles generally are rigid. He treatment that I have recorded than any other I have seen tried. was extremely restless; and though the morphia was increased, Liverpool, 1867. it failed to give relief. Pulse 104. 9th.-General rigidity of muscles increased. He was constantly crying out, being in great pain. He had not slept "THE TURTLE WOMAN" OF DEMERARA. during the night. The muscles in the perineum were extremely rigid, and it was necessary to remove the urine with the catheter. BY IZETT W. ANDERSON, M.D. EDIN. Though the muscular spasm was continuous, it was greatly increased in intensity on anyone touching him, or even approachI LATELY received from my brother-Dr. F. H. Andersor, ing him to alter his position. There was great pain about the diaphragm, with hiccough. Skin hot and dry; bowels only of Demerara-a photograph (from which the accompanying er.acting after an enema ; pulse 120, and thready. There was a graving is taken) of a case of congenital deformity. It apsmall collection of matter near the wound, which was opened, and about a drachm of pus evacuated.-Quarter to five P.M.: One- peared to me one of such interest and comparative rarity that twelfth of a drop of nicotine was administered, the pulse being I obtained further particulars regarding it, and the permission 120.-Quarter past five P.M.: The dose was repeated; pulse of the Surgeon-General and my brother to bring it before the 108.-Quarter past seven: Pulse 112. One-eighth of a drop profession in any way I might think fit. of nicotine was given. -Nine P.m.: The pulse was 68, and The subject of this case was a black girl, aged twenty-four. slightly intermittent. He was sweating profusely. There was much less muscular rigidity, and he was enabled to pass his She was commonly called " the turtle woman," from, I supurine naturally, which he had not done for thirty hours. The pose, the peculiar malformation of the lower extremities, and nicotine was discontinued for the night. also from the fact that her mother, when pregnant of her, was 10th.-Nine A.M.: The pulse had risen to 110. He had frightened by a turtle; and to this misfortune attributed the slept comfortably for several hours. Muscular rigidity cer- condition of her child. The girl has generally been healthy, tainly less than on the previous day. Skin moist and perspir- and has never suffered from rickets or any disease of the bones; ing. No nicotine was administered during the day; but in the and her as regards the malformation, has existed a the noted one-twelfth of was condition, evening drop given, pulse being at 132. unchanged since her birth. None of her relations are deformed. llth.-Passed a tolerably good night, and remained com- She was able to move about a little, and could do needlework fortable during the day. Pulse 110. One-eighth of a drop of by holding the cloth between the right arm and the body, and using the needle with the left hand. About two years ago she nicotine to be given at night. 12th.-Had slept for several hours. Pulse 92, and regular. gave birth to a full-grown child free from deformity, but it Towards the evening of this day he did not appear so well. died the next day. The labour was natural in every respect. The general muscular rigidity was much increased, and it was In the early part of last April she miscarried of a four months’ Pulse 115. The foetus. On the 13th of the same month she was admitted into twice during the the Colonial Hospital, suffering from syphilis, and she died on the 10th of July. night. i He several eleven A. -iV.1. : hours, My brother writes me that he could only examine the bones 13th.-Half-past had slept for and was decidedly better. Pulse 100. He was again able toi of one leg. The femur was only six inches long, but was articulated in the usual way, there being an acetabulum, with a pass his water naturally. Without going more into detail, I may say that from this strong capsule, and a ligamentum teres. " The foot is put on date his improvement was uninterrupted, and he left the hos- sideways, there being no tibia or fibula. The foot altogether consists of only six bones, four of these being toe bones-viz., pital quite well in six weeks. The nicotine was given occa- the and second phalanges of the big and second toes. sionally, being invariably followed with relief. During the The first femur articulates inferiorly with one long bone, which whole course of the disease a generous fluid diet was given, seems to be the prolonged metatarsal bone of the great toe. without stimulants. In this case, although symptoms did not show themselves The sixth bone is the second metatarsal. The right arm contill the thirty-second day after the injury, yet they were of a sists of a humerus, with the condyles well developed." sufficiently aggravated character to lead me to apprehend a fatal result. The morphia in the first instance appeared to give relief; but on its failing, I fell back upon the tobacco treatment as a last resource. In administering the nicotine (which was procured for me with great promptness by Messrs. Clay and Abraham), I found that one-twelfth of a drop was quite sufficient to produce a decided effect, and at no time was it increased to more than one-eighth, dissolved in alcohol and water. An hour always intervened between the doses. I mention these points for the guidance of those who feel disposed to try the plan of treatment. The effect of nicotine on the system is of so depressing a nature, especially in the case of those unused to tobacco, that it is most important not to necessary. give the least quantity more than is absolutely The effects of the nicotine, as observed in this case, may be summed up as follows:1st. A diminution in the frequency of the heart’s action. On the 9th of January, in four hours and three quarters, the was most marked on the first pulse fell from 120 to 68. Thismore or less invariably observed day; but the same effect was consequent upon its administration. 2ndly. The muscular spasm was invariably diminished. This was generally evident, but more especially by the voluntary discharge of urine, and by the breathing becoming easy and necessary again to make
nicotine
was
use
of the catheter.
repeated (one-eighth of
a
drop)
I
unaccompanied with diaphragmatic pain. 3rdly. A tranquilising effect on the nervous system generally. 4thly. It promoted the action of the skin, though I never detected the " snuffy odour" of the excretion as mentioned by others.
Although it is to be regretted that, owing to various circum. stances, the post-mortem examination was not more complete, I yet I think these rough notes may be of interest to the pro-
Such are the more prominent particulars in this case. find there are many recorded cases where a recovery followed the use of tobacco; and some speak highly of its beneficial
fession. Kingston, Jamaica, Sept. 23rd, 1867.