TWO CASES OF PUERPERIUM COMPLICATED WITH SCARLET FEVER ; RECOVERY.

1260 the category of mere coincidence. It consists in a peculia] admitted to the hospital on March lst, 1897. Her mother’s affection of the toes, which in the majority of the cases; sister had paralysis agitans. Four years previously, a fortin which I have met with it was one of the earliesl5 night after her last confinement, the patient noticed tremor symptoms of the disease, and is therefore, I think, oJ, of the fingers of the left hand on movement. Stiffness of It is as follows. Th(i the left arm and later of the left leg had since developed. considerable diagnostic value. patient complains, when walking, that the toes of one fooiJ Within the last two years the right side had become stiff, occasionally become spontaneously strongly flexed and curleèl the arm being affected before the leg. For about two years up under the sole in a cramp-like fashion, causing difficulty she had noticed in walking that the toes of both feet in walking. This "curling up"of the toes is often scI occasionally curled under the soles, except the big toes, and uncomfortable that the patient has to stand still for a she had to stand still for a few minutes until this passed off. minute or two until he can get his toes to relax and spread She had had great difficulty in turning in bed for the past out flat again. All the toes, with the exception of the great six months. On admission she had the typical face of toe, participate in this flexor contracture ; the hallux, on the paralysis agitans, "interosseal" attitude of the hands, other hand, usually becomes hyperextended at the same stooping head, festinant shuffling gait, and marked retrotime; sometimes, however, it may become flexed like the pulsion. The speech was monotonous and festinant. All other toes. In some cases the contraction may spread to the the voluntary movements were slow and stiff, especially on anterior tibial muscles, causing an inversion of the ankle as the left side. She had difficulty in doing her hair herself; well. For permission to publish my notes I am indebted to she could not use her left hand easily to "gather"" the hair. the courtesy of Dr. Hughlings Jackson, Dr. Buzzard, Dr. There was very slight tremor in the left hand, this occurring Ferrier, and Dr. Ormerod. only on holding it out, not when it was at rest. CASE 1.-The patient, a man, fifty-four years of age, was CASE 5.-A man, fifty-three years of age, was admitted to admitted to the hospital on Dec. 13th, 1896. Six months the hospital on Dec. 4th, 1896. He was left-handed. For before his admission, when walking, he began to feel the four years he had noticed that the toes cf his right foot toes of both feet become occasionally hyperextended, this occasionally became stiffly flexed into the sole ; the hallux, movement passing on at once to one of plantar flexion. however, became hyperextended. About two years previous His ankles also became dorsiflexed, so that he had to take to his admission he began to have slowness and tremor in Two writing with the right hand, and about a year afterwards his a step or two backwards until the cramp passed off. months after the onset of this symptom his hands became right leg began to shake, especially in walking. On admisstiff and weak and his handwriting became abnormally slow. sion he had the typical symptoms of paralysis agitans in On admission he had the typical facies of paralysis agitans- the right face, arm, and leg, there being both tremors and the starched expression, the stooping of the head, the rigidity. The gait was shuffling but not festinant. He could elbows slightly flexed, the fingers in the "interosseal" voluntarily stop the tremors for a moment. In 3 of the above 5 cases the "toe-curling"symptom was position, no tremor either at rest or on movement, and all the earliest to appear, preceding the other symptoms by voluntary movements slow and stiff. CASE 2.-A man, forty-two years of age, was admitted to intervals of four months (Case 1), a year (Case 2), and two the hospital on Feb. 9th, 1897. For four years before his years (Case 5) respectively. admission he noticed that the toes of his right foot would Since the above paper was written I have been kindly occasionally become strongly flexed when he walked so that favoured by Dr. Ormerod (to whom I had mentioned this he had to stand still until his toes relaxed. Later his right symptom) with the notes of another corroborative case in leg became stiff and weak and his right hand became slow in which the patient, after having had the"toe-curling " symits movements so that he could not cut his food readily nor ptom for five years, developed symptoms of paralysis agitans. could he write so easily or so rapidly as usual. Within the CASE 6.-The patient, a man, aged forty-four years, last three or four months he had developed slight tremor of consulted Dr. Ormerod in March, 1892, for a "drawthe right foot when fatigued. On admission he had slight ing under of the toes of the left foot. This came weakness and rigidity of the right face, arm, and leg, with on chiefly after walking, all the toes becoming flexed, marked " starchedexpression. The right hand was held in beginning with the big toe and then the ankle becoming the "interosseal"attitude and the right elbow was inverted. The symptom had been present since 1890. Dr. habitually semi-flexed. All movements of the right arm and Ormerod writes : "At that time I do not think there was leg were slower and stiffer than on the left side. He dragged anything in his symptoms or general appearance to make me his right foot a little in walking ; there were no tremors on suspect that he had paralysis agitans. In May, 1895, he admission. He complained of difficulty in turning in bed came there was doubt that he now had and no again and in finding a comfortable posture when in bed. There were characteristic tremors of agitans. paralysis CASE 3.-A married woman, aged fifty years, was both hands and the facies was that of paralysis agitans; admitted to the hospital on June 14th, 1898. For three the gait was not very characteristic. The affection of the years she had had trembling of the left hand and arm left foot still continues; it looks shorter and more humpy followed, some six months later, by trembling of the right than the right." hand, which she first noticed when putting pegs on a Queen-square, W.C. ,clothes-line. For two years she had had difficulty in turning in bed and had been unable to get into or out of bed without assistance owing to stiffness of her legs. About a year before admission she began to feel her toes curling up under her soles inside her shoes when she was sitting down. AND This made her get up and walk about for a few minutes until the symptom passed off. She had been unable to sing THERAPEUTICAL. for a year ; within the last month or so her jaw began to tremble and her articulation became less distinct. On admission she was seen to have severe paralysis agitans with TWO CASES OF PUERPERIUM COMPLICATED WITH the typical "starched"face, the typical attitude of the SCARLET FEVER ; RECOVERY. limbs and trunk, and tremors of the face, jaw, tongue, and BY J. GAWLER MURRAY, L.R.C.P., L.R.C.S. EDIN., limbs, synchronous, the rate of tremor being 6 per second. L.F.P.S. GLASG. The tremors affected the limbs equally on the two sides. Her articulation was markedly festinant and her voice was THE following cases may be of interest, showing that monotonous and plaintive. All voluntary movements of the trunk and limbs were slow and stiff and the tremor persisted pregnant women seldom develop scarlet fever (Haultain). CASE 1.-I attended the patient on May 24th. The child in spite of voluntary movement. The gait was slow and shuffling and there was no festination ; she could not turn was born on my arrival and the placenta came away quite round without holding on to the furniture. She could not easily. I visited the patient on the 26th, 27th, and 28th, her feed herself owing to tremors. She was unable to lie down temperature never being above 992° F. On the 29th I found in bed herself. When trying to do so she put one knee on her looking very ill and with a temperature of 105°. I the edge of the bed and then fell heavily on to the bed in a immediately douched out the uterus with iodine and water semi-prone posture, from which she was unable to move and ordered the nurse to give a vaginal douche of weak without assistance. She perspired excessively and would not Condy’s fluid every two hours as the discharge was very allow herself to be covered by more than a single sheet. foul-smelling. I called in the afternoon to repeat the intraCASE 4.-A married woman, aged fifty years, was uterine douche and found the patient’s temperature to be ,

,

,

Clinical Notes:

MEDICAL, SURGICAL, OBSTETRICAL,

1261 105’8°. On calling in the evening her temperature

was found but I repeated the douche of iodine. The temperature on the next morning was 1024° and the patient was found to be covered with a typical scarlatinal rash and she complained of sore-throat. My father (Dr. Ivor Murray), whom I called in, confirmed my diagnosis and notified scarlet fever. On making inquiries I learnt that two children of the previous tenant of the house had had scarlet fever there in the previous October; the patient and her husband came into the house in November. This was the ’ only clue to contagion which I could get, as the patient had not been near any scarlet fever cases and I had not myself seen any for six months previously. This, I think, points to the indefinite incubation period of scarlet fever in pregnant The baby also took the infection, but both mother women. and child made uninterrupted recoveries, both desquamating

to have fallen to

103’4°,

freely.

The result of the operation was extremely satisfactory, the patient recovering with a sound stump, which was afterwards

artificial limb and bore pressure well. Encouraged by Mr. Hutchinson’s success I advised my patient, a male, aged forty-nine years, to submit to amputation of the leg below the knee-joint, and to this he readily consented, being anxious to be rid of the foot, which, though it caused him no pain, had become a great inconvenience to him. Since then I have performed the same operation in three other patients, all males between forty and fifty years of age, for a similar condition, the ankle-joint being affected in one case and the tarsal joints in the other two. In all four patients the result has been most satisfactory, the stumps healing quickly without suppuration and without any tendency to sloughing of the soft tissues or necrosis of the end of the bone, as might have been expected from the nervous origin of the disease. It is somewhat strange that in most works on surgery little or no reference is made to the question of operation in cases of locomotor ataxy when a joint has become completely disorganised. In a recent text-book the following paragraph, however, appears : " In the later stages, where the joint is entirely disorganised, some form of fixed apparatus may be applied to render the limb more 2useful, since no operative treatment can be undertaken." A similar opinion is expressed in one of the most recent German works on nervous diseases, for it is there stated that though the joint affections may require some mechanical support surgical treatment is seldom necessary, operative interference being avoided by most surgeons.3 fitted with

an

/

CASE 2.-A sister-in-law of the above patient who was in daily expectation of being confined and who lived next door had, of course, seen her sister and the baby before I had any suspicion of anything being wrong, but when the temperature of the first patient rose I forbade her sister-in-law to enter the house, and at the confinement of the latter on June 5th I took every precaution and was careful to put on fresh clothes. On June 8th, however, the patient’s temperature ran up to 104° F., and she had a strawberry tongue and sore-throat, but there was no definite rash. Knowing that she had been exposed to contagion I treated her as for scarlet fever. In spite of diaphoretics, quinine, Warburg’s tincture, &c., her temperature oscillated between 101° and Manchester. 104° for fourteen days, when it went down to 99°. Owing to sleepless nights I had given trional (20 gr.) with good result, but on the 23rd I found that she had taken a violent NOTES ON A CASE OF PERSISTENCE OF dislike to nursing her baby and to her husband and that she HYMEN; NON-RUPTURE. fancied herself to be a feather and that she would blow BY N. CULLINAN, M.D. BRUX. away. On the 25th she complained of her left arm being swollen and on examination I found a hard lump in the axilla. I wrapped the arm in wool and kept her quiet, but it THE following case having come under my notice may be swelled to twice its size till under massage it gradually of interest to the readers of THE LANCET from a medicodecreased. Her urine contained a slight amount of albumin and her legs were slightly swollen, but as she recovered legal point of view as well as on account of the obstruction strength her urine became normal. She desquamated very which may be caused during the second stage of labour. On March 13th, 1898, I was called to attend a primipara, slightly. The mania lasted about a fortnight and she is now This case I think aged twenty-five years. On making my visit and questioning as strong and well as ever she was. interesting because of the number of complications which the midwife I found that the patient had been in labour for had to be contended against. nine hours, the pains then recurring about every seven minutes. On attempting to make a vaginal examination I Scarborough. found that an obstruction existed and the parts were tender to the touch, which latter sensation lasted a conA NOTE ON AMPUTATION FOR CHARCOT’S siderable time. Having determined the position of the JOINT DISEASE. foetus by an abdominal examination I resolved to await results. The labour progressed naturally until a fulness BY F. A. SOUTHAM, M.B. OXON., F.R.C.S. ENG , could be noticed in the perineum. A visual examination. SURGEON TO THE MANCHESTER ROYAL INFIRMARY ; LECTURER ON OPERATIVE SURGERY, OWENS COLLEGE. now confirmed the conclusion which I had previously arrived at; the membrane was intact except for a small opening which would allow the escape of the menstrual fluid, ABOUT six years ago a case of Charcot’s joint disease came situated in the antero-posterior line about one-third under my care in which the ankle-joint had become so com- from the anterior and two-thirds from the posterior pletely disorganised that the foot was displaced upwards edge of the vaginal opening, the aperture being of suffiThe clitoris and outwards, the internal malleolus projecting prominently cient size to admit an ordinary slate-pencil. was of abnormal length and sensitive. On attempting in the in an the fact, skin ; through opening appearance to enlarge the opening in the hymen with the tip of the was not unlike that met with in an unreduced compound little finger the patient complained of intense pain and Pott’s fracture. Removal of the foot was the obvious treat- I decided to desist. I then used a hernia knife, making a. ment, but in the absence of any definite information on the crucial incision, and the succeeding pain caused the protruquestion of amputation in patients suffering from Charcot’s sion of the membranes well into the opening made. After joint disease, and, bearing in mind the unsatisfactory results making a vaginal examination and allowing the liquor amnii which often follow amputation for perforating ulcer in to escape the labour terminated naturally, no laceration. tabetic subjects, I was hesitating somewhat as to the taking place. The patient made a good recovery. advisability of adopting this course, when a short article by The points of interest in this case are as follow : (1) the Alr. Jonathan Hutchinson, published a few months preof the membrane although the patient had been non-rupture viously in the Archives of Surgery,’ attracted my notice. married for eleven months ; (2) the membrane itself was of a Mr. Hutchinson wrote as follows:"Ihave recently had fibro-elastic consistence and extremely dense; (3) the small an opportunity of observing the process of repair opening allowing impregnation to take place; (4) the after amputation in a state of advanced locomotor abnormal sensitiveness of the parts ; (5) an unusually large ataxy. It may be of interest to record the result, clitoris ; and (6) the obstruction caused during the second since, owing to absence of any experience on the point, I stage of labour with the amount of force necessary felt some misgivings in recommending the measure." to cause rupture. From a medico-legal point of view cases Details were then given of the performance of Teale’s of this sort are of much importance showing that imamputation in a middle-aged subject who for ten years had pregnation can take place without rupture of the hymen, suffered from locomotor ataxy accompanied by perforating that the presence of the membrane is not a positive proof’ ulcer and disease of the bones of the foot and ankle-joint. ___________

___

1

Archives of

Surgery,

Oct.

1891, p. 137.

3

2 Rose and Carless : A Manual of Surgery, p. 585. Oppenheim: Lehrbuch der Nervenkrankheiten, vol. ii., p. 145.

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