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non-plastic lymph. This mischief in the longitudinal sinusdid not extend forwards beyond the point of entrance of theveins, which returned the blood from the seat of the abscessin the convolutions of the right hemisphere. On removingthe coagulum from the lateral sinuses, by drawing it out withthe forceps, several small collections of pus were noticed occu-pying its surface ; and on making clean and defined cuts intothe coagulum of blood, several small collections of pus (asshown by the microscope) were discovered in the centre of theclot, isolated and completely surrounded by the coagulum ofblood. The muscles exposed on making the post-mortemexamination were occupied by the trichinia spiralis to animmense extent, so as to give all the muscles a speckledappearance, rendering the latter of a pale red colour; 180were counted on the surface of a portion of the pectoralismajor, less than an inch square.* * The same condition waspresent throughout all the voluntary muscles examined, and thediaphragm was crowded with them, but not any could be de-tected in the stomach or intestines. Recent and isolated pleuriticpatches, glueing the lung to the walls of the chest, were foundin the right side, occupying the lower lobe and subjacent tissue.There were also phlebitic abscesses in the pulmonary substance,and several other purulent deposits in the interior of theleft lung, as well as in the right.-Heart: The right auricleand ventricle, and the pulmonary artery and its branches,were occupied by a firm clot of blood, such as is often observedin persons dying a slow death. -Abdomen: No evidence ofrecent inflammation was observed, either in the form of serouseffusion or of adhesions; but the coecum and ascending colon,small portion of the transverse colon, and the portion ofduodenum seen between the colon and liver, were all of a darkleaden hue, and the adjoining peritoneum, extending on to theabdominal parietes, were also of the same colour, but not inany way decomposed. This appeared to be the result of

ecchymosis, or subserous effusion of blood, or possibly of thestaining effect of the blood which escaped from the laceratedliver at the time of the accident. Some parts of this dark sur-face were mottled with small, black, pigment-like spots, andhere and there were seen some small, shrivelled, leechbite-likelooking clots of blood adhering to the free surface of this por-tion of the peritonaeum. The exposed and dark portion of theduodenum presented at its most convex part an attenuatedappearance, bounded by two defined lines of its muscularfibre, and the peritoneum over it was slightly flocculent inappearance, (not smooth, even, and shining, like the surround-ing peritoneum); it seemed as if the blow had produced aforcible separation of the circular muscular fibres, and probablya slight tearing of the peritoneum covering this part, andwhich, if so, had become repaired; but the muscular fibreshad not readjusted themselves. The mucous membrane cor-

responding to this injury had a well-defined, unhealthyappear-ance, the surface spread out interrupting the continuity of twoof the valvulae conniventes. Upon examining this portion ofthe duodenum by transmitted light, it was distinctly recognisedas much thinner than the structure of the surrounding portionof the same intestine.-Liver: The minute structure of theliver did not present - anything pathological, (no secondaryabscess,) but there was complete evidence of the right lobe ofthe organ over the duodenum having been torn or broken onits convex surface, the tear extending from the acute marginnear the fundus of the gall-bladder obliquely backwardstowards the left side, to the length of about three inches; apart of this was adherent to the diaphragm by recent but firmadhesions. At that part of the laceration nearest the acutemargin, the edges of the wound were separated from each otherto the extent of about three quarters of an inch, and not uponthe same level; this separation gradually diminished until itbecame a mere crack or fissure, losing itself in the substanceof the liver. In the gap of the broadest fissure an insular portionof liver structure seemed to have been detached from the

surrounding parts at the time of the injury, and to have re-mained, forming a rounded and abrupt elevation detachedfrom the neighbouring textures except at its base, where it restedTipon the subjacent liver structure. The lacerated surface wasclosed in and covered over by recent false membrane, but therough edge of the laceration separating it from the smoothconvex surface of the liver was very strongly and satisfactorilymarked. Kidneys large and coarse ; there appeared to havebeen some inflammatory condition of the pelves, as these partscontained some muco-purulent fluid.

* Mr. Hilton first drew attention in this country, many years ago, to the,dL,eased condition of the voluntary muscles, which i., now known to dependon the existence of the tricliiiiia spiraiis in them. Several of the bodies inwhich this entozoon was found came from Woolwich; and the present, whose;case is above described, was from the same neighbourhood.

ST. BARTHOLOMEW’S HOSPITAL.Tetanus at first supposed to have arisen from a Blow on the

Back, and subsequently found to depend on a puncturedWound of the Foot made by treading on a rusty Nail.

(Under the care of Mr. STANLEY.)A CASE involving a serious medico-legal question lately

occurred at this hospital. By the details of the same it willbecome clearly apparent how extremely guarded we should berespecting the evidence given before a court or coroner. Cautionis so much the more necessary, as it will sometimes happen,as actually took place in the present case, that very importantfacts are concealed from the surgeon, or else overlooked, andhe is left to grapple with exceptional phenomena, in which theassistance afforded by analogy is entirely wanting. Such wasthe situation in which Mr. Callender, house-surgeon to Mr.Stanley, found himself respecting the cause of death of theboy who is the subject of the case. It is to Mr. Callender thatwe are indebted for the following particulars :-

William 0-, aged fifteen years, a norid-complexionedlad, was admitted into Kenton ward, Sept. 22, 1853, at half-past nine A.M., stating that two days previously he had reoceived a blow on the back from a boy’s fist, followed by a kickon the same spot, but not of a severe character. He furtherstated that he was sitting down at the time, and that theassault was consequent upon a quarrel which had arisen

between himself and assailant. He was able to get up and towalk home, when, in about two hours, he began to complainto his mother of stiffness about the jaw. Having passed a

restless night, he awoke on the morning before admission withincreased stiffness about his jaw, accompanied by pain. The

boy remained in much the same condition during the day, buttowards night the pain increased, and he complained of diffi-

culty in swallowing.When admitted, the patient’s aspect was natural, but he

still referred to the neck as being stiff and painful, though hetook some tea without any apparent di-fnculty. On inquiringfurther into the history of the case, it was ascertained that sixdays prior to the first appearance of the symptoms described,the boy had run a rusty nail into his foot, and that the suppu-rating wound which resulted from this injury only closed onthe day on which the blow was inflicted. This circumstance

’ was not ascertained until the mother gave her evidence at theinquest, the father having, as he said, in the flurry of themoment, forgotten all about it when interrogated at the time

, of his child’s admission. The pain and stiffness gradually in-creased, and became paroxysmal, the patient was unable toraise his head from the pillow, and the jaw became partiallyfixed, though he could still swallow powders and fluids. Ateleven A.M., the boy began to perspire profusely, his aspectgrew anxious, and the angles of the mouth were drawn down,

, giving to his countenance a ghastly smile; respirations quickand laboured, mostly abdominal; pulse 110, small and soft;

bowels costive; urine passed in small quantity, clear, acid,specific gravity 1025. Ordered, five grains of calomel and four

, of jalap, to be continued at intervals until the bowels were re-lieved. At two P.M., the patient for the first time had a

decided spasm of the muscles of the back, the opisthotonosbeing well marked. During the intervals of the spasms, themuscles about the trunk remained rigid, those about the neckbecoming relaxed. At three P.M., the symptoms increased inseverity; pulse rising in frequency and volume; the spasmsrecurring every three or four minutes. The patient wasordered to be bled to ten ounces; after which the pulsesuddenly sank, but soon rose when the flow of blood had beenarrested. He was free from the muscular contractions duringthe bleeding, but they returned shortly afterwards. He nowlay from choice upon his abdomen, and took a dose of chloricether, (one drachm;) but the act of swallowing excited suchpowerful spasms, accompanied by intense pain, that themedicine was not repeated.The pain of which the poor boy chiefly complained he

described as running up and down the spine, the slightestexertion, even speaking, inducing a recurrence of the mostsevere symptoms. Repeated doses of calomel and of crotonoil (the latter in the form of injections, as well as by themouth) failed to produce any action of the bcwels, and theapplication of extract of belladonna to an extensively blisteredsurface of the back was not followed by the slightest ameliora-tion of this condition. He sank rapidly, and died at half-pasttwo A.M. on the 23rd of September, about seventeen hoursafter admission.

Autopsy, twelve hours after death.-No bruise or fracturewas discovered, but on examining the ball of the great toe o

the left foot, a small puckered cicatrix, such as would result

551

from the healing of a punctured wound, was found connectedwith a slight vascularity in the subcutaneous tissues, pene-trating to a depth of half an inch, but not communicating withany nerve or tendon. On examining the dorsal region of thecord, there was seen an appearance of effused blood outside thedura mater, on opening which the arachnoid opposite to theseventh and eighth dorsal vertebra appeared ecchymosed. Thecord was softened throughout its substance in the whole dorsalregion. A small quantity of blood was effused about themiddle of the psoas muscle on the right side. All the organsof the body were apparently healthy, though the seat of muchpost-mortem congestion. Scarcely any faeces in the intestinalcanal. The bladder held about six ounces of urine, which con-tained epithelial scales and a great number of blood-corpuscles.Now it is plain that, according to all probability, the

tetanic seizure was caused by the wound of the foot; for casesare unfortunately very numerous in which tetanus (almostalways fatal) was caused by injuries as slight and of the samedescription. Indeed we well recollect reporting a case of thiskind which occurred in this hospital, and was placed underthe care of Dr. Burrows. The fact of the injury which hadcaused the tetanic symptoms was, in that case, quite unknownat first; and it was only after the patient (a young woman)had been in the hospital for some days, that the physicianlearned that such a palpable exciting cause of the tetanicaffection as a wound about the foot had existed, (THE LANCET,vol. i. 1852, p. 591.)But in Mr. Stanley’s case, which is related above, not only

did the actual cause remain for a little while unknown, but itwas confidently stated by the friends that a blow on the backhad been the origin of the mischief. Now this cause, thoughrare, has, if we mistake not, been recorded once or twice; itwas therefore natural to suppose that violence suffered by thecord, an organ well known to be mainly concerned in tetanicsymptoms, could be followed by the fearful affection of whichthe poor boy died. Nor could a surgeon have been blamed if,under these circumstances, he had, with due caution and re-strictions, stated that the patient had indirectly been thevictim of the playmate who had struck him on the back.Further evidence has, however, proved that, in all probalility,the spasmodic affection was caused by the wound in the foot,and cicatrized when the subject of the case was admitted.But one point is nevertheless to be examined.—viz., the

effusion of blood under the dura mater of the cord, and thesoftening of that organ, which morbid changes were discoveredon the post-mortem examination. Was such a state of partsthe result of the blow, or was, on the contrary, the conditionof the cord the result of changes connected with tetanus!Without pretending to solve the problem, we would merelyventure to say that softening of the cord and extravasation ojblood have not in general been found when patients, who haddied of tetanus, were inspected; nay, in the majority of cases,no tangible changes have been noticed in any of the greatnervous centres. The important questions raised by this casehave induced us to give it publicity, as the record of the factsconnected with it may serve the purpose of making medicalmen pause before they are induced to give evidence in cases o;the kind, surrounded as the latter are with most perplexingdoubts and fallacies.

Reviews and Notices of Books

On Lithotrity and Lithotomy.With numerous Woodcuts. ByWILLIA-11 COULSON, Surgeon to St. Mary’s Hospital, &c.London: Churchill. 1853. pp. 388.

THE readers of THE LANCET will be familiar with the sub-stance of the present work, the greater portion of which

appeared in this journal in the form of lectures in the courseof last year. In the volume now before us, the lectures havebeen carefully revised, certain points which appeared to re-quire further elucidation have been treated in a fuller manner,and several lectures not hitherto published have been added. Theadditional matter chiefly relates to the subjects of lithotomy,and lithotrity in the female, the parallel between the differentmethods of lithotomy, and to the extraction of calculi fromthe urethra. In the present review, we shall direct the atten-tion of our readers chiefly to the new matter which has beenadded in Mr. Coulson’s work.

Up to the present time, the statistics of the operation oflithotomy in the female have been very scanty. Mr. Coulson

has collected a large mass of valuable information upon thissubject. The principal results of his inquiry are embodied inthe following passage :-

" The mortality of lithotomy in the female does not varymaterially from that shown by Cheselden’s tables for the male.Let us take the best of our English tables, that of the late Mr,Crosse, of Norwich. Of 704 patients operated on, 35 werefemales, and of these 2 died, giving a mortality of 1 in 17 1B2.This is nearly the same proportion as the one furnished by aFrench table, the elements of which were collected by M.Civiale. Here out of 93 operations we find 7 fatal, giving amortality of 1 in 13 2B7. In another table, given by the sameauthor, and comprising 173 cases, we find 19 deaths, or about1 in 9. In the 44 operations mentioned in Dupuytren’s tables,to which I have already alluded, no less than 5 deaths occurred,.giving a mortality of 1 in 9. The reports from the LunevilleHospital, however, show a much more favourable result. Outof 2834 calculous patients admitted into that establishment,112 were females, of whom 93 were operated on. Only 4 easesproved fatal, which gives a mortality of 1 in 23. Nor can it besaid, that the mortality in any of these returns arose from thecircumstance of the knife having been used; for the method-adopted, in the majority of cases, was extraction by dilatingonly. Lithotomy in the female, then, is not the harmless

operation which many writers assert it to be, since if 10 percent. of males die, 5 per cent. of females, if not more, fallvictims to the operation."The kind of operation which should be adopted for the

removal of stone from the female bladder has long been asubject of discussion with practical surgeons. On this topicMr. Coulson is very clear and precise. For small calculi he

would employ dilatation alone, and very large calculi he wouldeither extract by dilatation, combined with incision, or bybreaking them up into small fragments, and then extractingeach fragment separately. All intermediate cases, with few

exceptions, he would submit to lithotrity; and he concludesthe chapter relating to this subject by a description of theoperation.

Mr. Coulson next enters upon the parallel between thedifferent methods of lithotomy. This, however, as far asit relates to the high operation and the recto-vesical operation,

’ is now matter rather of historical interest than practical value,as these methods of operating are not entirely abandoned. The

bi-lateral operation, which was introduced by Dupuytren,deserves greater consideration. This eminent surgeon was led,

to entertain the hope that the danger inseparable from allattempts to extract the stone below the pubis might be

’ avoided. After examining the various ways in which the’

prostate might be divided, Dupuytren conceived the idea ofcutting through the gland on both sides, and of thus avoiding

the risk of free incision when practised on one side only. We; quote the remarks of Mr. Coulson on this point :-

" The advantages which Dupuytren attributes to thismethod are the following. It is quicker and more easythan most other methods, and just as safe. The incisions aremade at the widest part of the outlet of the pelvis. It takesthe most direct route from the surface of the perinaeum to the.cavity of the bladder, and thus facilitates the introduction and

. working of the forceps, the extraction of the stone, and thedischarge of the urine. It enables the operator to make his

_ incisions proportionate to the size of the stone, better than anyother method. The lateral incision gives an opening whichallows a spheroidal body, thirty-four lines in circumferenee,to pass out; the bilateral incisions give one which admits the

s passage of a sphere forty-eight lines in circumference, besides- the gain of dilatation on both sides instead of one. Hence the

chance of contusion, laceration, &c., and their evil consequences’ are more surely avoided. It is exempt from the danger of

haemorrhage, and it avoids in a certain manner the seminal’ ducts and the rectum.t " This is a brilliant picture, but it has been drawn by thei inventor of the method, and surgeons, like other men, are not_ exempt from the failing of looking with admiration on their1

own works. We must, I fear, abate somewhat from Dupuy-tren’s estimate.

" I do not believe that the bilateral method is either easierf or quicker, under ordinary circumstances, than the laterali operation. I have myself, more than once, extracted a good