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CASE OF SPASMODIC TORTICOLLIS; SECTION OF SPINAL ACCESSORY NERVE; RECOVERY.
1184
MR. A. G. FRANCIS ON SPASMODIC TORTICOLLIS. the administration of bromides. As there seemed to beconnexion between his employment and the recurrence of twitching, I suggested that he should learn to play an instrument which entailed the use of different muscles; he selected the bass viol, soon became proficient, and finally discontinued the trombone. From that date to the present time he has continued quite well, both as regards the wryneck and his mental aberration. There has been no appreciable wasting of either the trapezius or sterno-mastoid, and no sign of spasm in any other muscle. 7i’e)K.
on
CASE OF SPASMODIC TORTICOLLIS; SECTION OF SPINAL ACCESSORY
NERVE; RECOVERY. BY ALFRED G. FRANCIS, B.A. CANTAB., M.B., B.S. LOND., F.R.C.S. ENG. A TROMBONE PLAYER aged twenty-nine, suffering from spasmodic wryneck, was placed under my care by Mr. A. Legge Hoe in December, 1891. As to his family history, The disease had none was obtainable of insanity or epilepsy. been present for eight months ; the spasms began first in the affected muscles and remained confined to them ; at first they were slight in character and were only noticed when he was tired after a long evening’s work as first trombone player at a music-hall ; they gradually increased in frequency and severity to such an extent that he was obliged to discontinue his employment, and for the last two months he had been scarcely free from spasms, which occurred not only during the day, but at night also, frequently waking him up.
He was under continuous treatment in the hands of several medical men for six months, but stated that he was steadily becoming worse ; the remedies adopted included counterirritants, galvanism, bromides, belladonna, Indian hemp, morphia, and atropine. There was no history or evidence of the disease originating in exposure to cold or injury, rheumatism, gout, syphilis, or malaria. The patient was a highly nervous and excitable individual. For some weeks he had suffered from delusions to the effect that he was ill-used, laughed at, and followed in the streets by persons who mockingly called the attention of people passing by to his wryneck. There was no facial spasm or spasm of any other muscles than the right sterno-mastoid and right trapezius. These muscles were in a constant state of tonic spasm, which prevented the head from being placed straight, its usual position being inclined towards the right shoulder. Every few minutes they were affected by severe clonic spasms, by which the head was drawn strongly There was severe cramp-like towards the right shoulder. pain in the muscles during the clonic spasms, which occurred throughout the whole day and night and even during sleep. They were most severe and frequent when the patient was tired or excited, and were found to occur during the slighter stages of chloroform narcosis. There were almost complete The heart, lungs, and urine were anorexia and insomnia. natural. Medical treatment in competent hands having been fairly, though unsuccessfully, tried, I suggested that he should submit to division of the spinal accessory nerve and obtained his ready assent. On Dec. 20th, 1891, I divided the right spinal accessory nerve at the point where it was about to enter the sterno-mastoid through a three-inch incision along the upper part of the anterior border of that muscle. The wound healed by first intention, the stitches and dressings being removed on the third day, and a flannel bandage was applied to the neck. During the first six days after the operation the patient was sensible and comfortable and completely free from the slightest spasm. On the 26th a slight twitching of the sterno-mastoid was noticed, but unattended by any pain ; this lasted for a few hours. On this day his mental condition became worse, his manner was wild and excitable, the old delusions returned and fresh ones were noticed ; he was possessed of the most extraordinary notions as to the intentions of his present and former medical attendants and armed himse:f with a carving knife for his protection, with which he walked about the house and garden ; he was quite unmauageable and four days later ’was removed to the Borough Asylum in a maniacal condition. After a few days in the asylum he completely recovered. On Jan. 7th, 1892, a slight twitching of the right sterno-mastoid was noticed on making the patient look steadily at an object held above the level of his eyes. He complained that his neck felt stiff at the end of the day. The head could be placed quite straight, but there was some slight rigidity of the right sterno-mastoid. A few weeks later he returned to his work, and after a short time he noticed some return of the slight twitching in the right sterno-mastoid. He gave up the trombone-playing and In the went for a long holiday and completely recovered. autumn of 1892 he commenced work again, but in November the slight twitching returned ; this time it soon disappeared
some
Albion-street, Hull.
_______
1
THE LANCET, April 19th, 1879. 2 THE LANCET, Oct. 11th, 1873. 3 Dr. Gowers : Diseases of the Nervous System. 4 Mr. Noble Smith (Spasmodic Wryneck. 1891) has collected siderable number of cases demonstrating this fact.
a con
NEW LUNATIC ASYLUM, SUNDERLAND. - The Mayor of Sunderland and the vice-chairman of the ’Asylum. Committee performed on the 2nd inst., in the presence of a large assembly, the ceremony of laying the foundation-stone of a new asylum at Ryhope, Sunderland. The cost is estimated at upwards of .680,000, and accommodation will be provided for 300 patients. PRESENTATION.-Dr. J. D. Adams and Mrs. Adams, of Martock, have been the recipients, on the occasion, of their silver wedding, of a set of silver entrée dishes, bearing the following inscription:—"Presented to Dr. and Mrs. Dixoru Adams in commemoration of their silver wedding, with theesteem and best wishes of their friends and neighbours. "’ Dr. Adams has been a practitioner at Martock for a pericd’ covering thirty-five years.
CLINICAL NOTES
Clinical
Notes:
MEDICAL, SURGICAL, OBSTETRICAL, AND THERAPEUTICAL.
1185
brim after the passage of the body. 5. Forceps were not applied to the after-coming head, as the pulsation of the cord had ceased and any pressure applied to the head anteroposteriorly would tend to increase the bi-temporal diameter and hence retard delivery. 6. The child was a large fullterm male. Extensive bruising was seen on the right temple, evidently caused by the promontory of the sacrum, and a good deal of head moulding had taken place during the first stage before turning, as seen by the following diameters :
A CASE OF BROW PRESENTATION IN RICKETY PELVIS, CONJUGATE THREE AND A QUARTER mento-occipital diameter, 6J2- in.; fronto-occipital diameter, 62 in.; bi-temporal diameter, 3- in. The scalp was cedematous, INCHES ; TURNING TWENTY-SEVEN HOURS with a well-marked caput succedaneum over the left frontal AFTER RUPTURE OF MEMBRANES. bone. BY CHARLES S. PATTERSON, M.B. EDIN., M.R.C.S. ENG. Highbury-place, N. _______________
Sept. 2nd at 8.30 A.M. by Dr. W. J. multipara. This was her second labour. Her first was premature (seven and a half months) and the .child was stillborn. On asking about the progress I was I WAS called
Opettigue to
on
see a
A
CASE OF ASCITES; RECOVERY. BY J. M. WALKER, M.B., C.M. EDIN.
EXTENSIVE accumulations of fluid within the peritoneal away at 5 A.M. on the cavity so frequently resist the best directed efforts to propreceding day. The high forceps had been applied, after mote their absorption and necessitate a recourse to paradigital dilatation of the os, at 11 P. M. and again at 6 A. M. but centesis that a short account of the following case, in which without any result. On examination, the os was found to be complete recovery-as far as the dropsy was concernedwidely dilated, the promontory was very marked, and the resulted from purely medical treatment, may prove to be ,occiput hitched against it, causing a brow presentation; the interesting to the readers of THE LANCET. occiput lay to the right posteriorly. The patient had A man aged forty-eight consulted me on Aug. lst last in passed into a condition of powerless labour. Dr. Spettigue consequence of his abdomen having recently become .administered a little chloroform, and as the head had not enormously distended, and a very slight examination sufficed properly engaged at the brim an endeavour was made to to prove that he was suffering from ascites, a history of bring down the occiput by the use of the axis traction forceps many years’ excessive indulgence in alcohol leaving little - and to press up the forehead and thus convert the case into room for doubt that cirrhosis of the liver was the cause. ., vertex right occipito-posterior one, but the endeavour was There was no oedema of the legs or other part of the body. futile. Further measurement showed the conjugate to be The urine, of which only three or four ounces were passed in ,only three and a quarter inches, and as the child was alive the twenty-four hours, was loaded with lithates and conit was decided to endeavour to turn and deliver alive if tained some bile, but was free from albumen. The heart and possible, the only other alternative being craniotomy. lungs were healthy, and the abdominal girth measured fortyChloroform was then administered to the full surgical five inches. I prescribed a mixture containing acetate of ,degree. The hand could not at first be passed owing to potassium, spirit of nitrous ether, tincture of squills, tincture tonic spasm of the uterus, but as the patient became deeply of digitalis, and decoction of scoparius, a considerable inanaesthetised this passed away, and a knee, the left, was crease in the flow of urine (from which the lithates and bile .seized and brought down. Version was easily effected. The disappeared by degrees) taking place in the course of a day patient was then allowed to come to, good strong pains came I or two. In addition to this the abdomen gradually became on at once, and the body of the feetus passed slowly through softer, and its girth was reduced to forty-three inches. The aided by traction during the pains. The cord was pulled improvement, however, did not continue, notwithstanding down a little and placed to the left side of the promontory ; that other diuretics and an electuary of compound jalap it pulsated freely and regularly until the head entered the powder and confection of senna were subsequently tried. !brim and became arrested, when it at once stopped. Traction The patient strongly objected to paracentesis being perby the feet, and later by the feet and neck and lower jaw, formed, and I saw him on Aug. 29th in consultation was tried for some minutes, and just as perforation of the with Sir James Sawyer, who prescribed the following: iodide after-coming head was decided upon the head commenced to of potassium, one scruple ; muriated ammonia, four scruples ; The child carbonate of ammonia, one move and was extracted as qaickly as possible. scruple; bicarbonate of soda, one was completely asphyxiated and could not be made to drachm ; liquid extract of taraxacum, half an ounce; dill lTespond to any of the means of resuscitation employed. As water to eight ounces. One ounce with half an ounce of the uterus failed to contract upon the placenta, it was lime-juice to be taken three times a day. The electuary to iirmly grasped in the left hand, and one drachm of liquid be continued. Within a week of commencing the above the The placenta came away by amount of fluid had sensibly diminished, and extract of ergot was given. by Sept. 27th expression in twenty minutes. A carbolic douche (1 in 40) was it had completely disappeared, the abdominal girth measuring ,at once administered ; this was ordered to be repeated twice a thirty-five inches. The patient, who had become greatly day. At 6 P.M. the temperature was 99’4° F. and the pulse emaciated during the course of his illness, rapidly gained was 96 ; at 10 A. M. the temperature was 98 8° and the pulse flesh and strength, and in a little more than two months from was 90. The temperature was never above 100° during the the date of my first seeing him was actively engaged in the whole puerperium, which was indeed most uneventful. pursuit of his business, and was able to walk several miles The chief points of interest in the case are : 1. The ease daily. The case is an instructive one as showing what may with which the tonic contraction, or rather the tetanic condi- be accomplished by persevering with suitable remedies and tion of the uterus, was overcome by chloroform and turning the advantage to be gained by varying the latter should one accomplished twenty-seven hours after the escape of the class fail to bring about the desired result. Attention also amniotic fluid. 2. The child being alive (as proved by may be drawn to the value of chloride of ammonium in such auscultation and pulsation of the cord) towards the end of cases, which drug Dr. MurchisonI speaks of as holding a "presuch a prolonged second stage. 3. The possibility that the eminent place " in the treatment of hepatic derangements life of the child might have been saved if the cord had been and as "exercising a powerful influence in relieving the placed to the right side of the promontory-i.e , the side portal circulation." unoccupied by the large occipital portion of the head of the Belgrave-road, Birmingham. Jcetus, as the stoppage of the pulsation took place just as the I base of the head was engaging the brim. 4. The amount of LEAD POISONING FROM TEA. pressure and manipulative interference that the soft parts of the mother tolerated without injury-viz., digital dilatation BY J. P. WILLIAMS-FREEMAN, M.D. DURH., D.P.H. ,of the os followed by three distinct applications of the forceps, with strong prolonged traction on each occasion, and finally BETWEEN the months of October and March last winter the great traction required to bring the head through the five cases of undoubted lead poisoning amongst cottagers came under my notice, besides about half a dozen cases in 1 Dr. Matthews Duncan held
informed that the waters had
come
that this was due to asphyxia of the child and infarction of the air passages from detachment of placenta. Transactions of the Obstetrical Society, vol. xx., p. 63.
1
Lectures
on
Diseases of the Liver.
MR. A. G. FRANCIS ON SPASMODIC TORTICOLLIS. the administration of bromides. As there seemed to beconnexion between his employment and the recurrence of twitching, I suggested that he should learn to play an instrument which entailed the use of different muscles; he selected the bass viol, soon became proficient, and finally discontinued the trombone. From that date to the present time he has continued quite well, both as regards the wryneck and his mental aberration. There has been no appreciable wasting of either the trapezius or sterno-mastoid, and no sign of spasm in any other muscle. 7i’e)K.
on
CASE OF SPASMODIC TORTICOLLIS; SECTION OF SPINAL ACCESSORY
NERVE; RECOVERY. BY ALFRED G. FRANCIS, B.A. CANTAB., M.B., B.S. LOND., F.R.C.S. ENG. A TROMBONE PLAYER aged twenty-nine, suffering from spasmodic wryneck, was placed under my care by Mr. A. Legge Hoe in December, 1891. As to his family history, The disease had none was obtainable of insanity or epilepsy. been present for eight months ; the spasms began first in the affected muscles and remained confined to them ; at first they were slight in character and were only noticed when he was tired after a long evening’s work as first trombone player at a music-hall ; they gradually increased in frequency and severity to such an extent that he was obliged to discontinue his employment, and for the last two months he had been scarcely free from spasms, which occurred not only during the day, but at night also, frequently waking him up.
He was under continuous treatment in the hands of several medical men for six months, but stated that he was steadily becoming worse ; the remedies adopted included counterirritants, galvanism, bromides, belladonna, Indian hemp, morphia, and atropine. There was no history or evidence of the disease originating in exposure to cold or injury, rheumatism, gout, syphilis, or malaria. The patient was a highly nervous and excitable individual. For some weeks he had suffered from delusions to the effect that he was ill-used, laughed at, and followed in the streets by persons who mockingly called the attention of people passing by to his wryneck. There was no facial spasm or spasm of any other muscles than the right sterno-mastoid and right trapezius. These muscles were in a constant state of tonic spasm, which prevented the head from being placed straight, its usual position being inclined towards the right shoulder. Every few minutes they were affected by severe clonic spasms, by which the head was drawn strongly There was severe cramp-like towards the right shoulder. pain in the muscles during the clonic spasms, which occurred throughout the whole day and night and even during sleep. They were most severe and frequent when the patient was tired or excited, and were found to occur during the slighter stages of chloroform narcosis. There were almost complete The heart, lungs, and urine were anorexia and insomnia. natural. Medical treatment in competent hands having been fairly, though unsuccessfully, tried, I suggested that he should submit to division of the spinal accessory nerve and obtained his ready assent. On Dec. 20th, 1891, I divided the right spinal accessory nerve at the point where it was about to enter the sterno-mastoid through a three-inch incision along the upper part of the anterior border of that muscle. The wound healed by first intention, the stitches and dressings being removed on the third day, and a flannel bandage was applied to the neck. During the first six days after the operation the patient was sensible and comfortable and completely free from the slightest spasm. On the 26th a slight twitching of the sterno-mastoid was noticed, but unattended by any pain ; this lasted for a few hours. On this day his mental condition became worse, his manner was wild and excitable, the old delusions returned and fresh ones were noticed ; he was possessed of the most extraordinary notions as to the intentions of his present and former medical attendants and armed himse:f with a carving knife for his protection, with which he walked about the house and garden ; he was quite unmauageable and four days later ’was removed to the Borough Asylum in a maniacal condition. After a few days in the asylum he completely recovered. On Jan. 7th, 1892, a slight twitching of the right sterno-mastoid was noticed on making the patient look steadily at an object held above the level of his eyes. He complained that his neck felt stiff at the end of the day. The head could be placed quite straight, but there was some slight rigidity of the right sterno-mastoid. A few weeks later he returned to his work, and after a short time he noticed some return of the slight twitching in the right sterno-mastoid. He gave up the trombone-playing and In the went for a long holiday and completely recovered. autumn of 1892 he commenced work again, but in November the slight twitching returned ; this time it soon disappeared
some
Albion-street, Hull.
_______
1
THE LANCET, April 19th, 1879. 2 THE LANCET, Oct. 11th, 1873. 3 Dr. Gowers : Diseases of the Nervous System. 4 Mr. Noble Smith (Spasmodic Wryneck. 1891) has collected siderable number of cases demonstrating this fact.
a con
NEW LUNATIC ASYLUM, SUNDERLAND. - The Mayor of Sunderland and the vice-chairman of the ’Asylum. Committee performed on the 2nd inst., in the presence of a large assembly, the ceremony of laying the foundation-stone of a new asylum at Ryhope, Sunderland. The cost is estimated at upwards of .680,000, and accommodation will be provided for 300 patients. PRESENTATION.-Dr. J. D. Adams and Mrs. Adams, of Martock, have been the recipients, on the occasion, of their silver wedding, of a set of silver entrée dishes, bearing the following inscription:—"Presented to Dr. and Mrs. Dixoru Adams in commemoration of their silver wedding, with theesteem and best wishes of their friends and neighbours. "’ Dr. Adams has been a practitioner at Martock for a pericd’ covering thirty-five years.
CLINICAL NOTES
Clinical
Notes:
MEDICAL, SURGICAL, OBSTETRICAL, AND THERAPEUTICAL.
1185
brim after the passage of the body. 5. Forceps were not applied to the after-coming head, as the pulsation of the cord had ceased and any pressure applied to the head anteroposteriorly would tend to increase the bi-temporal diameter and hence retard delivery. 6. The child was a large fullterm male. Extensive bruising was seen on the right temple, evidently caused by the promontory of the sacrum, and a good deal of head moulding had taken place during the first stage before turning, as seen by the following diameters :
A CASE OF BROW PRESENTATION IN RICKETY PELVIS, CONJUGATE THREE AND A QUARTER mento-occipital diameter, 6J2- in.; fronto-occipital diameter, 62 in.; bi-temporal diameter, 3- in. The scalp was cedematous, INCHES ; TURNING TWENTY-SEVEN HOURS with a well-marked caput succedaneum over the left frontal AFTER RUPTURE OF MEMBRANES. bone. BY CHARLES S. PATTERSON, M.B. EDIN., M.R.C.S. ENG. Highbury-place, N. _______________
Sept. 2nd at 8.30 A.M. by Dr. W. J. multipara. This was her second labour. Her first was premature (seven and a half months) and the .child was stillborn. On asking about the progress I was I WAS called
Opettigue to
on
see a
A
CASE OF ASCITES; RECOVERY. BY J. M. WALKER, M.B., C.M. EDIN.
EXTENSIVE accumulations of fluid within the peritoneal away at 5 A.M. on the cavity so frequently resist the best directed efforts to propreceding day. The high forceps had been applied, after mote their absorption and necessitate a recourse to paradigital dilatation of the os, at 11 P. M. and again at 6 A. M. but centesis that a short account of the following case, in which without any result. On examination, the os was found to be complete recovery-as far as the dropsy was concernedwidely dilated, the promontory was very marked, and the resulted from purely medical treatment, may prove to be ,occiput hitched against it, causing a brow presentation; the interesting to the readers of THE LANCET. occiput lay to the right posteriorly. The patient had A man aged forty-eight consulted me on Aug. lst last in passed into a condition of powerless labour. Dr. Spettigue consequence of his abdomen having recently become .administered a little chloroform, and as the head had not enormously distended, and a very slight examination sufficed properly engaged at the brim an endeavour was made to to prove that he was suffering from ascites, a history of bring down the occiput by the use of the axis traction forceps many years’ excessive indulgence in alcohol leaving little - and to press up the forehead and thus convert the case into room for doubt that cirrhosis of the liver was the cause. ., vertex right occipito-posterior one, but the endeavour was There was no oedema of the legs or other part of the body. futile. Further measurement showed the conjugate to be The urine, of which only three or four ounces were passed in ,only three and a quarter inches, and as the child was alive the twenty-four hours, was loaded with lithates and conit was decided to endeavour to turn and deliver alive if tained some bile, but was free from albumen. The heart and possible, the only other alternative being craniotomy. lungs were healthy, and the abdominal girth measured fortyChloroform was then administered to the full surgical five inches. I prescribed a mixture containing acetate of ,degree. The hand could not at first be passed owing to potassium, spirit of nitrous ether, tincture of squills, tincture tonic spasm of the uterus, but as the patient became deeply of digitalis, and decoction of scoparius, a considerable inanaesthetised this passed away, and a knee, the left, was crease in the flow of urine (from which the lithates and bile .seized and brought down. Version was easily effected. The disappeared by degrees) taking place in the course of a day patient was then allowed to come to, good strong pains came I or two. In addition to this the abdomen gradually became on at once, and the body of the feetus passed slowly through softer, and its girth was reduced to forty-three inches. The aided by traction during the pains. The cord was pulled improvement, however, did not continue, notwithstanding down a little and placed to the left side of the promontory ; that other diuretics and an electuary of compound jalap it pulsated freely and regularly until the head entered the powder and confection of senna were subsequently tried. !brim and became arrested, when it at once stopped. Traction The patient strongly objected to paracentesis being perby the feet, and later by the feet and neck and lower jaw, formed, and I saw him on Aug. 29th in consultation was tried for some minutes, and just as perforation of the with Sir James Sawyer, who prescribed the following: iodide after-coming head was decided upon the head commenced to of potassium, one scruple ; muriated ammonia, four scruples ; The child carbonate of ammonia, one move and was extracted as qaickly as possible. scruple; bicarbonate of soda, one was completely asphyxiated and could not be made to drachm ; liquid extract of taraxacum, half an ounce; dill lTespond to any of the means of resuscitation employed. As water to eight ounces. One ounce with half an ounce of the uterus failed to contract upon the placenta, it was lime-juice to be taken three times a day. The electuary to iirmly grasped in the left hand, and one drachm of liquid be continued. Within a week of commencing the above the The placenta came away by amount of fluid had sensibly diminished, and extract of ergot was given. by Sept. 27th expression in twenty minutes. A carbolic douche (1 in 40) was it had completely disappeared, the abdominal girth measuring ,at once administered ; this was ordered to be repeated twice a thirty-five inches. The patient, who had become greatly day. At 6 P.M. the temperature was 99’4° F. and the pulse emaciated during the course of his illness, rapidly gained was 96 ; at 10 A. M. the temperature was 98 8° and the pulse flesh and strength, and in a little more than two months from was 90. The temperature was never above 100° during the the date of my first seeing him was actively engaged in the whole puerperium, which was indeed most uneventful. pursuit of his business, and was able to walk several miles The chief points of interest in the case are : 1. The ease daily. The case is an instructive one as showing what may with which the tonic contraction, or rather the tetanic condi- be accomplished by persevering with suitable remedies and tion of the uterus, was overcome by chloroform and turning the advantage to be gained by varying the latter should one accomplished twenty-seven hours after the escape of the class fail to bring about the desired result. Attention also amniotic fluid. 2. The child being alive (as proved by may be drawn to the value of chloride of ammonium in such auscultation and pulsation of the cord) towards the end of cases, which drug Dr. MurchisonI speaks of as holding a "presuch a prolonged second stage. 3. The possibility that the eminent place " in the treatment of hepatic derangements life of the child might have been saved if the cord had been and as "exercising a powerful influence in relieving the placed to the right side of the promontory-i.e , the side portal circulation." unoccupied by the large occipital portion of the head of the Belgrave-road, Birmingham. Jcetus, as the stoppage of the pulsation took place just as the I base of the head was engaging the brim. 4. The amount of LEAD POISONING FROM TEA. pressure and manipulative interference that the soft parts of the mother tolerated without injury-viz., digital dilatation BY J. P. WILLIAMS-FREEMAN, M.D. DURH., D.P.H. ,of the os followed by three distinct applications of the forceps, with strong prolonged traction on each occasion, and finally BETWEEN the months of October and March last winter the great traction required to bring the head through the five cases of undoubted lead poisoning amongst cottagers came under my notice, besides about half a dozen cases in 1 Dr. Matthews Duncan held
informed that the waters had
come
that this was due to asphyxia of the child and infarction of the air passages from detachment of placenta. Transactions of the Obstetrical Society, vol. xx., p. 63.
1
Lectures
on
Diseases of the Liver.