A CASE OF ANESTHETIC LEPROSY.

DR. W. S. HEDLEY ON TRIGEMINAL NEURALGIA. were Ttrse

then

passed between serous surfaces in direction, and s? the opening in the

a

trans.

cut

was

closed. The intestine was then washed and The abdominal wound returned into the abdomen. closed in the usual manner. That night the patient was

completely

fairly comfortable, passing flatus. The temperature was 100° F. There was no vomiting, he had a little morphia, and was not distended or tender. The 100. On llth he had a fair night, being Apxil pulse rather under opium. The bowels acted freely several times, and there was no abdominal distension or pain. The temperature was 996°, and the pulse 95. The tongue was moist, and there was no vomiting. From that time the bowels acted well daily, and there were no important symptoms to narrate. On the 16th, as he complained of rectal discomfort, on

micturated. The abdomen was

11’ra 3

v

examination an impaction of fasces was found, which was relieved by an oil enema. A few days later he had a small dose of castor oil, and the bowels were freely opened. On the 200h all the sutures were removed from the abdominal wound, as it was nicely healed. By the 29th the abdominal wound was soundly healed, and the patient had been up some days. The bowels were acting comfortably each day, sometimes assisted by a little castor oil. No resistance or induration about the sigmoid flexure was to be felt, and the abdomen was quite soft. The patient was free from all pain, his aspect was good, and he ate and lept well. On May 20th I saw him again, and he was perfectly well in every respect. Pie7tiarks -1 selected the operation of enteroplasty for these reasons : (1) It is much simpler than any methods of resection of a stricture, and, the stricture being an innocent one, there was no occasion to resect it ; and (2) I was greatly to perform enteroplasty, having seen what excellent result I had with the case narrated above. Grosvmor.street, W.

tempted

an

THE TREATMENT OF TRIGEMINAL NEURALGIA. BY W. S.

HEDLEY, M.D. EDIN., M.R.C.S. ENG.

No one who has read Professor Rose’s paper in a recent number of THE LANCET/descriptive of two operations for the relief of trigeminal neuralgia, can have failed to be struck by their brilliancy and success. It is one more instance of an increasing class of cases where surgery steps in to do what medicine has failed to accomplish. It may be freely conceded that in these two cases nothing short of surgical interference would have proved effectual ; the results, however, will be satisfactory in proportion to the assurance felt that the unsuccessful remedies had in the first instance been fully and fairly tried. Electricity is one of these. "The application of the constant current (from five to ten cells) to the face was recommended." To my mind these words point to what may be considered a crude and insufficient procedure, inasmuch as (1) by such a measurement no adequate idea is conveyed either to the operator or reader of the current-strength ("intensity") passed through the patient ; and (2) the application of even a known and measured quantity of electrical energy in this form by no means in such a case exhausts the resources of electro-therapeutics. The former of these points is obvious to anyone possessing any electrical knowledge; the second it ill proposed to illustrate by the following case. A man aged fifty-tbree had for about four years suffered 1

THE LA CET, March 17th, 1894.

1553

from severe paroxysmal neuralgia of the second and third divisions of the fifrh nerve. In September of last year he was, as he expressed himself at the time, "desperate " from it. It was relieved by five milliamperes of galvanic anodethe details of which application need not here be entered upon. On several subsequent occasions the same proceeding had been successful, and at other times the pain had disappeared under the administration of Indian hemp. After some months of complete freedom from pain he again (on April 5lh) presented himself for electrical treatment. He said that for the past three weeks he had suffered-,, night and day." A variety of medicines, including Indian hemp, had been used without, benefit. He described the pain as "plunging like knives," "stabbing," "seizing the roots of the tongue," and he altogether bore an expression of great suffering. During a paroxysm the face became fixed in spasm, and he vigorously grasped the left side of the lower jaw, exercising powerful pressure with his thumb on the point of emergence of the mental branch of the inferior dental. Having examined the mouth without result for a probable I I offending tooth," five milliampbres of continuous current were locally applied for five minutes-viz., the anode (an electrode of 4 cm. diameter) over the seat of pain, and the kathode (14 by 8 cm.) at the nape of the neck. This was without effect. By the simple expedient, however, of insulating the patient and "taking sparks " over the points of greatest pain it completely disappeared, and he went away smiling. A short lived smile. Scarcely had he reached home when, within half an hour of the application, things Next day a similar application were as bad as ever. was followed by an hour’s relief and a night’s rest, but there was an immediate return of pain on getting out of bed next morning. Both as to symptoms and treatment this represents the history of the case for the next few days. On April 15th, besides the electrical application, a tooth (third left lower molar) was extracted at the patient’s request on the chance that there might be exostosis or other After half an hour undiscoverable condition of the root. the pain returned with much increased violence. On the 17 ch, the condition of the patient having in no way improved, and despairing of results from localised applications or drugs, the hydro-electric bathwas administered at a temperature of 98° F. for fifteen minutes-the current being obtained from an alternating light circuit having a potential of 100 volts and 8000 alternations a minute. Its strength was regulated simply by means of a sponge rheostat, with a The effect was sixteen candle-power lamp in circuit. striking and immediate. From a condition of intense suffering on entering the bath the patient found himself on emergence absolutely free from pain. Seven such baths were given on the same number of successive day?—but from the first, with the exception of a slight "bruised" feeling for a few days, the freedom from pain has been lasting and complete. The patient says that he has fdt from the first " a different man," and stoops down to lace his boots without misgiving—a position which before would inevitably have induced a paroxysm of pain. Now, if instead of the above treatment this patient had been subjected to operation, the operation would with justice have claimed the result. As it is, this may be fairly credited to the electrical treatment. It is idle to talk of "cure" in such cases. The important questions are, How long will immunity from pain continue,.and how far will the same procedure be successful on recurrence? It is more than possible that this patient may eventually have to be sent for operation, but in the meantime it is at least satisfactory to think that, before the more heroic remedy is resorted to, there are yet other weapons in the varied armoury of electro-therapeutics. Western-terrace, Brighton.

A CASE OF ANESTHETIC LEPROSY. HEATH, M.D., L.R.C.P. LOND.,

BY A. DOUGLAS

M.R.C.S.ENG.,

&c.

ON account of the rarity of the development of this disease novo in natives of this country I have thought it might be worth while to place the following case, which has recently come under my care, on record, as it presents several points of interest. The patient, a male fifty-six

de

2

Dipolar.

MR. DE SANTI ON TERTIARY ULCERS OF THE PHARYNX.

1554 years of age,

Bombay healthy,

was born in England, but went to reside in when thirty-two years of age. His parents were and no member of his family had suffered from this

disease. During his residence in Bombay, which lasted twenty years, he had very few illnesses of importance, except that he went through a rather severe attack of dysentery about twelve months before the commencement of his present affection. The onset of the leprous neuritis first showed itself in a feeling of numbness and tingling in the left hand and foot in August, 1889, a year before the patient left Bombay for England. Little notice was, however, taken of these sensations, and no medical advice was obtained. Within a few months similar feelings were complained of in the other hand and foot, and a few dull red blotches were observed on the forearm and leg. No actual pain was felt in the limbs, and the muscular power remained good, the patient being able to take prolonged walking exercise without fatigue. During the next three years, whilst living in England, the numbness and tingling gradually increased in all four limbs, and a few nodules appeared on the dorsal surfaces of the hands and feet, and in the lobes of the ears. Throughout the period during which these symptoms were occurring there does not seem to have been any noticeable indisposition or malaise. When the patient first consulted me in July, 1893, the facial aspect was very characteristic, the large size of the ears and the large, fiat nose being very striking, especially when the features were compared with photographs taken six and eight years ago, before the onset of the disease. The tint of the skin was everywhere of a dusky, earthybrown hue, but no skin eruptions, scarring, or pale patches could be seen on the trunk and were only visible on the extremities. The hands and feet were slightly enlarged, smooth, pale, and glistening. The hair was almost entirely absent over the feet and hands, and that which remained was very pale and devoid of pigment. Over the feet and hands there was almost complete loss of sensation to touch, pain, and temperature, and this anaesthesia and analgesia extended some distance up the legs and forearms. Sensation to touch and pain was, however, perfect above the knees and elbows, and no isolated patches of anesthesia could be detected above the level of these joints. Slight feelings of numbness and " pins and needles " were felt in the feet and hands. The voice was natural and the appetite good. Present state (June, 1894).-The disease is now in a far more advanced stage. Ulceration has begun in the feet and hands, and is especially noticeable along the ulnar border of the left hand, where there are several small indolent ulcers, which discharge a thin, scanty pus. Under the finger-nail of the ring finger of the left hand a pale mass of granulation tissue forces up the nail. The hands and feet have greatly increased in size, and the soles of the feet are covered with thick white flakes of dried epidermis. Both ears are considerably enlarged, and the nodules in the lobes have broken down and are discharging pus. The voice has become more weak and high-pitched, but his strength is well maintained and his appetite continues to be good. On examination of the chest and abdomen no abnormal physical signs could be detected. The urine is light yellow in colour, slightly acid, of specific gravity 1014, and contains no albumen or sugar. Nervous system.-No paralysis of any cranial nerve. Sensation to touch, pain, and temperature perfect over head and neck. No ansesthesia to be detected over pharynx, palate, mouth-cavity, or tongue. Senses of smell and taste unimpaired. The optic discs appeared to be normal when examined ophthalmoscopically, and no corneal opacities could be seen. The remarks made with regard to the anaesthesia and analgesia in the upper and lower limbs in July, 1893, still hold good, except that the loss of sensation is now still more profound. The prick of a needle cannot be felt anywhere on the feet, and, except for a few small sensitive patches on the legs, there is almost complete loss of sensation to touch and pain below the knees. One or two small areas of ansesthesia can also be detected on the extensor surfaces of the thighs. In the hands the loss of sensation to touch is almost complete, and the patient experiences great difficulty in feeding himself, owing to his inability to feel accurately any object he grasps. From the same cause also his writing is getting very shaky and bad. Owing to the large size of the feet progression is a little clumsy, but the muscular power remains exceedingly good, and the patient is still able to walk two or three miles a day without much discomfort. Ankle flexion is strong, and the grip of the hands, though interfered with in consequence of their swelling, is fairly good.. The deep reflexes seemed

The external popliteal and ulnar on both sides. where they become superficial can be well felt on two sides; but they do not seem to be very appreciably thickened, and no nodular infiltrations can be felt on them. Treatm.ent.-Tonics and chaulmoogra oil combined with good food have been tried, but have not met with much success. Nerve stretching and splitting seem, according to Dr. K.. McLeod in a recent paper,l in which he sums up the latest results, to be often beneficial. The ulcerations heal, and the general atrophic condition of the limbs at all events becomes temporarily ameliorated, the explanation being that the leucocytes thrown out by the operation cause a disappearance of the infiltrating growth. - BMMM*.—As is so commonly the case, no cause can be found for the onset of the disease. I could obtain no evidence whatever regarding the possibility of contagion, and it does not seem that the patient was accustomed to indulge largely in a fish diet. The attack of dysentery was perhaps a predisposing cause. It will be seen that in this case the macular and nodular eruptions have not been prominent features, and that the nervous symptoms greatly predominate. Removal to England from India does not seera to have had any effect in retarding the progress of the disease. It is remarkable what a profound sensory disturbance exists with such a very small deficiency on the motor side. This may, perhaps, be accounted for either by supposing that the disease first starts around the fine ramifications of the sensory nerves to the skin, and thence spreads up the nerve trunks, or that the fibres transmitting efferent impressions in the mixed nerve trunks show greater resistance to the infiltrating normal nerves

growth. Finally, the last noticeable feature which strikes one in this very distressing case is the extensive ulceration of the skin of the left hand in the region supplied by the cutaneous branches of the ulnar

nerve.

Edgbaston, Birmingham.

A NOTE ON THE TREATMENT OF TERTIARY ULCERS OF THE PHARYNX BY THE TOPICAL APPLICATION OF SULPHATE OF COPPER. BY PHILIP R. W. DE L.R.C.P.

SANTI, F.R.C.S. ENG., LOND.,

SURGICAL REGISTRAR TO WESTMINSTER HOSPITAL MEDICAL SCHOOL; SENIOR CLINICAL ASSISTANT, THROAT AND NOSE DEPARTMENT, WESTMINSTER HOSPITAL.

THE following five cases, which occurred in the clinic of Dr. de Havilland Hall in the throat department of Westminster Hospital, illustrate very well the excellent results to be obtained by the application of sulphate of copper of the strength of twenty grains to the ounce to bad tertiary syphilitic ulcers of the pharynx. There is nothing new in this method of treatment, for it was much recommended and extensively used by the late Sir Morell Mackenzie years ago ; but, having found it so much more efficacious than other forms of treatment, such as the application of tincture of iodine, nitrate of silver, and acid nitrate or cyanide of mercury recommended by some authorities, I have thought it worth while recording the results obtained by it in five bad cases that I have lately come across in Dr. de Havilland Hall’s throat department. Some authorities-e.g., Mr. Lennox Browne2advise the use of the galvano-cautery and state that by its application these tertiary deep ulcers heal very rapidly and

show no tendency to recurrence. In my own experience I have seen equally good results from the application of sulphate of copper, and to the majority of practitioners this method will, I think, recommend itself more particularly, because the galvano-cautery can only be available to the few. The tertiary ulcers found in the pharynx are generally of two kinds-viz., (1) superficial, and (2) deep perforating. The superficial are most frequently located on the palate, less often on the pillars of the fauces and the tonsils ; they extend with great rapidity and, like other tertiary ulcerations, are often serpiginous ; their base is pale and smooth, with

fungous-looking granulations. The deep or perforating ulcers are usually due to the breaking down of gummata, and, as 1

Proceedings of the Royal 17th, 1894. LANCET, Feb. 2

Medical and

THE

Diseases of the Throat and Nose,

Chirurgical Society; p. 207.