16

little power over the muscles of the leg, and the feet fall.When the front of, say, the left leg is rubbed, can tell which;if the right be then rubbed also with the other, does notdetect any difference; then when the right is continued tobe rubbed and the left is let alone, is not aware of thechange. Has all along, with the improvement, sufferedfrom painful sensations over her body, which she has spokenof as " fidgets " ; these were almost continuous, but havenow changed into paroxysms, more severe while they last,but with intervals of ease. Along with the bodily improve-ment her mind has become alienated, and her dispositionentirely changed. She screams at the top of her voicefrequently through the night and day, and when told howseriously this interferes with other people’s comfort, saysshe does not care; it is nothing to her if they are kept awakeall night by her noise. As she has become able to move herhands, &c., they have become subject to fits of uncontrollablemovement after voluntary effort. There has throughoutbeen no tendency to bedsores; very great care has beentaken to guard against this.March, 1886.-Has had a long, weary time of it. Can now

walk about her room ; at tirst with assistance, now without.Can feed herself, and write letters with great effort. Hasstill pain after movement, and general feeling of distress allover her body. Disposition again natural. Bowels usuallymoved without enema, with a pill every other night. Hassevere pain after passing urine. Small quantities of puscome from the vagina (there had been symptoms of a smallpelvic abscess which burst through the vagina). Legs areplump again; pain in the joints, knees especially, much less.There had been considerable redness about the right patella.The patient subsequently went on improving. Great care

was taken with the muscles to prevent degeneration-bymovement, rubbings, galvanism, &c. The medicines duringthe later period of convalescence were nux vomica, arsenic,iron, and valerian. Went away to the seaside and elsewherefor change of air, and returned home by midsummer well.My patient had the advantage of first-rate trained nurses

. from the Leeds Nursing Institution, and I wish to acknow-ledge their care and faithful discharge of their duties, with-out which she could hardly have escaped the variousacsidents which are liable to occur in such a case. Fromtime to time I reported her condition to Dr. Allbutt,and he has kindly favoured me with the followingcriticism:-" As the later history of this remarkable caseunfolded itself, of course I gave up the idea of peripheralneuritis. Ascending paralysis (so-called Landry’s palsy) wasset aside for several reasons, among others the profoundanaesthesia, the palsy of rectum and bladder with cystitis,and the age of the patient. It is clear that the disease in-volved the whole thickness of the cord, including the greymatter, and was probably a myelitis-either an ascendingdiffused myelitis, or a myelitis ascending in patches. In

any case the recovery is very remarkable. The symptoms ofreturning health in the cord are full of interest."

"

Dr. Gowers, who has seen my notes, has kindly favouredme with the following criticism of the case founded uponthem, which is too interesting and valuable to be omitted.Dr. Gowers remarks on the absence from the report of"some information as to the electric irritability of themuscles at various stages, because this is an importantelement in the diagnosis." "The diagnosis rests betweentrue acute ascending paralysis and acute ascending dissemi-nated myelitis, and I should incline to the latter, partlyon the ground of the cerebral complication, which pointsto either meningitis or to disseminated inflammation of thecortex. Coincident cerebral and spinal inflammation is notrare, while the brain functions are usually-it is said always-unimplicated in true ascending paralysis. At the same timeno malady is sharply defined, and aberrant forms are metwith, differing more or less widely from the customary type."

AN UNHEALTHY HOUSE. - At the Nottingham ’,

County Court a woman was recently sued for the rent of acottage in which she had resided. The defendant admittedthe debt, but alleged that, owing to defective sanitaryarrangements, the place was unfit to live in, and she pre-sented a counter-claim for medical charges and funeralexpenses in respect of a child whose death was proved tohave been caused by an illness arising from defective drain-age. The judge gave judgment for the rent due, andallowed the counter-claim, on the ground that the cottagewas not reasonably fit for habitation.

WOUND DIVIDING THE TENDO ACHILLISAND OPENING THE ANKLE-JOINT.

SUTURE OF TENDON; RESULT.

BY A. G. P. GIPPS, M.R.C.S., &c.

F. S--, a carpenter, was working with an adze onJuly 30th last, when the tool slipped and struck him overthe posterior and inner portion of the left ankle-joint. Theresult was a transverse wound of about 1 in. long, dividingthe tendo Achillis immediately above its insertion into theos calcis, "nicking" the edge of the tendon of the flexorlongus pollicis, and the corner of the adze entering theankle-joint. There was also considerable bleeding from abranch of the posterior tibial artery, divided close to itsjunction with the main artery. The patient was a verymuscular man and the cut tendon at once receded somedistance into the calf of the leg. He was as soon as possibleplaced under the influence of chloroform, and, the parts havingbeen thoroughly examined, I made an incision twoinches and a half long at right angles to the wound,and parallel to the edge of the cut tendon, this being re-quired before it was possible to catch hold of the upper endof the tendon. When this could be grasped by the fingers,it was forcibly pulled down till it was almost in contactwith the lower end, when three silver sutures were passedthrough both ends and secured by twisting. The woundedvessel had previously been secured by torsion; the silversutures were cut off long. The whole wound and

joint were now freely syringed out with a solution ofperchloride of mercury (1 in 1000) ; the skin wounds werebrought together with silver wire, leaving only the lowestportion of the wound open, through which were broughtthe ends of the wires used to unite the tendon, and whichserved for drainage purposes. The whole wound was welldusted with iodoform, covered with a pad of lint wrung outin the mercurial solution, and the joint surrounded withabsorbent wool. The limb was placed on a metal backsplint extending above the knee, and the foot secured to thefoot-piece in a state of extreme extension, and the patientput to bed.

. Aug. 6th: Wound dressed for the first time since theoperation (a week). The lint over it was found dry, thewound quite aseptic, and no discharge of any kind present.The upper part of the wound was healed, and all the wiresin position. The solution of perchloride of mercury wasagain used, the wound dusted with iodoform, and the wholereplaced as before.-13th: Wound re-dressed. No dischargeof any kind. Except at the spot where the inner suturesproject, both wounds have united entirely. The skinsutures were removed, and as any attempts to get at thesutures in the tendon only produced a good deal ofbleeding from the newly-formed material, these werepulled out as far as possible and cut off I short,the small unhealed point being dressed as before.-17th : As the ship was going to sea, the foot was takendown and readjusted, the foot being flexed in order tostretch the tendon. Patient can move the joint himself,and the reunited tendon can be felt in continuity as heextends his foot. There is but little stiffness in the jointitself.---25th: The cicatrix being now firm, everything wasremoved from the joint, and the patient told to’work itfreely in bed.-31st: Patient up to-day, and commenced towalk about. He has complete use of the joint as far asmovement goes in all directions, and complains only of someweakness and a feeling at present of insecurity.-Sept. 9th :Patient can now walk fairly well, go up and downladders, &c.

jReMCM’.—With regard to the temperature, the first twonights it went up to 100°, being normal in the mornings.On the third day it was normal, and remained so for therest of the time. The bowels were opened on the eighth,tenth, eighteenth, and twenty-fourth days, to avoid all pos-sible disturbance; after that they were allowed to act

naturally. With regard to the silver sutures cut off andleft in the tendon, so far no effect has been felt from them ;firm pressure gives no sensation of "pricking," so they areprobably completely buried. The tendon has complete andfree play, and the wounded ankle-joint its natural mobility.The treatment by means of the solution of the perchlorideof mercury and iodoform proved completely antiseptic, its

17

simplicity and easy preparation being a great boon in a

ship. During the patient’s confinement to bed he was keptin a canvas swinging cot by an open port.

Clinical Notes :MEDICAL, SURGICAL, OBSTETRICAL, AND

THERAPEUTICAL.

NOTE ON THE CAUSE AND CURE OF A FORMOF BACKACHE.

BY SIR JAMES SAWYER, KNT., M.D. LOND., F.R.C.P.,SENIOR PHYSICIAN TO THE QUEEN’S HOSPITAL, AND PROFESSOR OF

MEDICINE IN QUEEN’S COLLEGE, BIRMINGHAM.

EARLY in the year 1881, in a note which was published in aweekly professional journal, I asked the attention of mybrethren to a form of backache which had not, so far as I know,been described before.l I desire now to refer to this subjectagain, and to-record that my further experience in practicehas confirmed my previous remarks upon the point in ques-tion.

Subjective symptoms are always important diagnosticsigns, and they are often clear therapeutic indications,Amongst such sensations backache is frequently a leadingsymptom, and also one which is pressingly dwelt upon bypatients. Of backache there are divers forms. Dr. GeorgeJohnson, in an able clinical lecture, and Mr. WilliamSquire, in a practical memorandum, have drawn the atten-tion of the profession to many of these.2 But they havenot mentioned a variety of backache in which the cause ofthe pain is traceable to the condition of the large bowel. Ifind that some patients complain of a pain, aching, dull, andheavy in character, and extending "right across the back."When asked to point out its position, they indicate this bycarrying a hand behind the trunk and drawing the extendedthumb straight across the back, in a transverse line, abouthalf-way between the inferior angles of the scapulas and therenal region. This pain I venture to attribute to a loadedcolon; I conclude I have correctly found its proximate causein foetal accumulation in the large intestine. I have found itdisappear after the exhibition of an efficient cathartic. Thisform of backache is a concomitant of habitual constipation,and is especially significant of the alvine sluggishness ofsedentary persons. In such a condition, as I have statedelsewhere, I find aloes, given in combination with iron, toyield the best results.3 We owe the valuable suggestionof combining iron with aloes, when aloes is given for laxa-tive purposes, to the late Sir Robert Christison. He showedthat the cathartic property of aloes is much increased byits combination with sulphate of iron. Dr. Neligan, Dr.Kent Spender, and Dr. David Bell have confirmed this ex-perience. I prefer socotrine aloes, and I give of it one, two,or three grains in a pill, combined with a quarter of a grainof sulphate of iron and one grain of extract of hyoscyamus.This pill should be taken every night. We must aim atproducing a full alvine evacuation after breakfast. Whena saline cathartic is indicated, I usually employ the old-fashioned Rochelle salt. This "goes well with tea, coffee,or cocoa. One or two teaspoonfuls may be taken at breakfast,dissolved in a large cupful of one of these beverages.Birmingham.

____

CASE OF COCAINE POISONING.1

BY C. S. KILHAM, L.R.C.P., &c.

ON Nov. 9th, 1886, at 12.10 noon, John B- accidentallytook 4t grs. of cocaine hydrochlorate in the form of solution.At 12.30 he was seized with severe cramps in the stomach,nausea, throbbing and feeling of bursting in his head,failure of eyesight, loss of use of his legs, incoherence ofspeech and confusion of ideas, and drowsiness, but couldalways answer questions if roused. No delirium; appeared

1 British Medical Journal, Feb. 19th, 1881.2 Loc. cit., Feb. 12th, 1881.

3 Contributions to Practical Medicine, p. 48. Cornish Brothers, 1886.4 Read before the Sheffield Medico-Chirurgical Society, Nov. 25th, 1886.

L as if drunk, and got quite helpless. Brandy was given tohim, and he vomited after it, but only the remains offood. About 12.50 he commenced sweating most profusely,shirt &c. being soaked through, perspiration streamingdown his face and body, and his head steaming. Pupilswere normal and equal. No loss of taste. The sweatinglasted some time, and was succeeded by very severe pros-tration, shivering, and feeling of impending death. Atintervals the patient had severe cramps in the stomach, withretching and vomiting of a quantity of clear mucus, whichrelieved the pain. About 1.15 P.M. the pulse became inter-mittent (missing every fifth beat). This was accompanied bycyanosis of the face, and intense feeling of suffocation overthe cardiac region. Relief was afforded by sinapisms. Thepulse varied from 80 to 8G, never more, and became graduallyregular. About 1.45 P.M. he began to have cramps in thelegs and feet (especially on dorsal surface of right foot), andtingling and numbness in both hands. Later on the pupilsbecame dilated. The vomiting and cramps ceased about4 P.M. (unless food was taken), but the drowsiness, throbbingof head, and prostration continued up to 6 P.M., when thepatient began to get warm and feel relieved. The improve-ment continued, and he could be moved at 8,30 P.M. Therewas great weakness, with swimming of head all night.Next day there was still weakness, continual vomiting,

a dry leathery feeling in the mouth, with loss of taste,partial loss of power in the legs, and tingling and numb-ness of the fingers, especially of the right hand. These sym-ptoms commenced nearly thirty-six hours after taking thecocaine, and most of them disappeared in twenty-four hours.The loss of power in the legs lasted three days, and thetingling and numbness of fingers longer. Ile was not ableto write a letter until the sixth day, as he could not feel thepen between his fingers before. An emetic was at first given,with sinapisms over the heart and stomach ; afterwardswarmth and stimulants (principally compound spirit ofammonia).Remarks.-The solution of cocaine had been made at

least twelve months, but appeared all right. The patientwas in the habit of taking gr. of cocaine for neuralgia ofthe stomach. The dose taken was 4t gr. of hydrochlorateof cocaine. The official dose is up to 1 gr. Martindale, inhis book on " Coca and Cocaine, &c.," mentions two caseswhere larger doses were taken. In one case (of attemptedsuicide) 23 grs. of cocaine were taken without "seriouslyinjurious effect." In the other case 32 grs. of cocaine weretaken within three hours, but the symptoms varied con-siderably from those in the case under notice. The mostremarkable symptoms were the severe sweating, the intenseprostration, and the intermittent pulse. The last symptom1 have not seen mentioned before.

Sheffield. _______________

A CASE OF RETRO-ŒSOPHAGEAL ABSCESS, CAUSINGDEATH BY PRESSURE ON THE TRACHEA.

BY PHILIP D. TURNER, M.B. LOND.,LATE HOUSE-SURGEON, VICTORIA HOSPITAL FOR CHILDREN.

I AM indebted to Dr. Julian Evans for permission topublish this case, which occurred at the Victoria Hospitalin April last.

T. II. 11i an infant, aged three months, had beenattending the hospital as an out-patient for some weeks forcongenital syphilis. It first came towards the end of Marchwith a strongly marked syphilitic eruption, which wasfollowed in the beginning of April by the appearance ofmultiple subcutaneous phlegmons in the limbs. On April19th there was an attack of dyspnoea, which passed off in afew minutes. On the 22nd, as the mother was bringing itto the hospital, the child was seized, according to her

account, quite suddenly with dyspnoea, and became of avery dusky colour. She hurried to the hospital, where itwas at once admitted. There was, on admission, greatdyspnoea, with considerable retraction of the thorax; colourvery dusky; pulse rapid and feeble; voice not at all hoarse.Hot fomentations were applied to the neck, and the childplaced in a steam tent. An hour after admission the re-spirations became more unfrequent and gasping, the colourvery bad, and the pulse scarcely perceptible. Tracheotomywas therefore at once performed. After the operation thechild rallied considerably. The recession almost ceasedand the colour improved. About three hours later, howeverthe breathing got worse, the recession increasing again, and