1744 As to which direction is the best for making the section in order to divide the stricture it is difficult to lay down any fixed rule, but I think in the majority of cases it will be safest to make it either directly inwards or forwards and inwards. But should any branch of the obturator artery be injured the double operation will probably render it comparatively easy to secure the bleeding point.
A CASE OF INTERMITTENT HEMIPLEGIA.
(Under the care of Dr. A. DAVIDSON.) THE only condition in which transitory recurring attacks of hemiplegia occur is uræmia, as in a case recorded by Boinet in which a man, aged thirty-seven years, suffered from five attacks of uræmia within a short time ; in the first two there were only localised convulsions, in the third he had unilateral convulsions followed by hemiplegia, and in the fourth and fifth attacks the hemiplegia occurred alone. In the following case there seems no reason to suspect a renal origin of the hemiplegia. Dr. Davidson’s explanation is extremely in. genious, and is no doubt possible; in its favour is the fact that ultimately the hemiplegia became permanent. Should the case finally prove fatal, it is very desirable that the local lesion should be early and carefully examined. A watchman, aged seventy-three years, was admitted into ward 10 of the Royal Infirmary, Liverpool, under the care of Dr. Davidson on Jan. 18th, 1897, suffering from left hemiplegia. He had worked on a farm till fifteen years previously, when he came to Liverpool. He always enjoyed very good health. On the afternoon of Jan. 18th, after arranging his lamps, he sat down in his sentrybox before the fire. On trying to get up again he
found himself unable to do so ; so he called for assistTwo policeman raised him; he was unable to ance. stand alone, but had no loss of consciousness, either’, then or at any time. An ambulance was procured and he was brought to the hospital at 6-30 P.M. On admission he was quite conscious. His left side was completely paralysed. The pupils were equal and reacted to light ; the upper part of the face was partially weakened on the left side; at the lower part the mouth was drawn to the right side, the articulation was imperfect and mumbling, and the tongue was protruded slightly to the left side. The left arm I, and leg were totally paralysed. Sensation seemed everywhere normal. The pulse was 76 and regular. Two hours after admission he had regained complete power in his face and limbs. He passed urine without trouble. He seemed somewhat excited, but otherwise was quite well. During the night he had four or five hemiplegic attacks similar to the first, each lasting from about fifteen to thirty minutes, all without loss of consciousness. On the morning of the 19th he was free from any sign of paralysis of the face, arm, or leg. The dynamometer showed the grasp of the right hand as 50 and the left as 40. As regards his general condition, he was a hale-looking old man; the tongue was coated, the teeth were very defective, the appetite was good, the pulse was 76 and regular, the arteries were thickened and tortuous, the heart-sounds were normal ; the chest was emphysematous, there were slight cough and expectoration, and the urine was normal. At 12.30 P.M. he was again found to have complete paralysis of the face, arm, and leg of the left side. About 1.15 P.M. Dr. Davidson saw him for the first time. He had paralysis of the left side. He could wrinkle the brow on both sides, and close both eyelids together, but he could not close the left eyelid without the right. The leftside of the mouth was immobile. Articulation was only slightly affected. The left
night of Jan. 20th the hemiplegia became almost permanent, and remained so till his removal from the hospital by his friends on the 28th. Remarks by Dr. DAVIDSON.-I have seen the patient twice since at his own home, the last time in the beginning of June. He remains in good general health and spirits. The pulse is 72 and regular. The arm is completely paralysed, he can just move the fingers ; there is no rigidity and no pain except in the shoulder (rheumatic) ; the leg and face are rather better. He can lift the leg off the bed. There is some tenderness in the thigh. The tongue is protruded straight. The bladder is normal. This interesting case is unique so far as my experience and reading go. When I related the history lately at a meeting of the Liverpool Medical Society, one of the members, Dr. Kennan, referred to a case of a man with complete left hemiplegia, which disappeared in a quarter of an hour only to return half an hour later and become permanent. One used to hear of "spasm"of cerebral arteries as being a possible cause of temporary hemiplegia; and one can con. ceive such an explanation reasonable in cases of urasmia, &c. There was nothing to point to that here, or to embolism from the valves of the heart. The explanation which I gave at the time and still adhere to is that a thrombus in the atheromatous cerebral artery became partially detached, and flapped to and fro in the current of blood, occasionally blocking the artery and occasionally leaving the current free. Or, if it was entirely detached and arrested at the next bifurcation of the artery, it might there sway to and fro like a ball valve, until by continued growth it became fixed and a permanent block of the vessel resulted.
Medical Societies. OPHTHALMOLOGICAL SOCIETY. Filaria
Loa. Sympathetic Ophthalmitis, Blindness following Blows on the Head.-Exhibition of Cases. AN ordinary meeting of this society was held on June 10th, Mr. E. NETTLESHIP, President, being in the chair. -
Dr. ARGYLL ROBERTSON gave an account of Filaria Loa in continuation of a description furnished by him two years previously in the same patient, who had returned to Old Calabar and immediately suffered a return of her former symptoms. There were itching behind the eyes and swellings in the arms, as described by Miss Kingsley as almost universal in the Gaboon district. On one occasion at night the patient felt a bite in the flank, and forthwith extracted a portion of a worm. Movement of a similar parasite was felt under the conjunctiva, and twice incisions were made in the knuckles in quest of one felt moving to and from the arm. Sandflies and mosquitos were sent home and examined by Dr. Robertson and Dr. Manson with a view to finding the intermediate form, but without success. Finally, the patient herself returned, invalided with dysentery and anasmia. Nausea and headache occurred while the parasites were moving about, associated with puffy swellings in the arms. All parts of the body were affected, but especially the scalp ; as recently as May 15th, 1897, the parasite was perceived moving near the umbilicus, but could not be secured. The blood, excreta, saliva, and nasal mucus were carefully examined for embryos, but without success. Since the former account of this case was given two instances had been described on the continent, and two were at present under the treatment of Dr. Manson. Mr. RICHARDSON CROSS read a paper on Sympathetic In the left leg there was only a i Ophthalmitis, especially in connexion with Mules’s operation arm was quite powerless. very slight ability to move the hip and knee. Sensation was of evisceration. He cited several instances in which symnormal. While he was still under examination (1.45 P.M.) he pathetic irritation, or ophthalmitis, had followed the operadrew Dr. Davidson’s attention to the gradual return of power tion, the proportion being as high, he said, as 13 per cent. in his left hand, and presently the paralysis entirely One patient in particular was under treatment of the most disappeared. He could now close the left eye independently watchful and sustained kind for seven months before he as well as the right. He was ordered to have a dose of happily recovered. In another a black mass at one corner calomel, and eight grains of bromide of potassium three of the stump was mistaken for melanotic sarcoma, but on times a day. During the next twenty-four hours several closer examination proved to be an artificial vitreous of alternations of paralysis and recovery took place, but the silver which had been inserted ten years previously. Many remissions by degrees became shoiter and slighter. On the cases certainly appeared to do well for a time, but sooner or later trouble generally supervened.-Mr. ADAMS FROST referred to the fact that there was a committee at present 1 Revue de Médecine, December, 1892.
considering the whole subject of sympathetic ophthalmitis. BARBOUR. They found it very difficult to say whether it was He thought unsuccessful cases-that is, cases in which sym- a case of interstitial gestation or of rupture of the pregnant pathetic trouble followed-were often those in which delay uterus. The clinical history suggested the former, while the had occurred between the original injury and the eviscera- situation of the rent, the marked hypertrophy of the uterine tion, giving time for infection to take place before the wall, and the appearance of the Fallopian tube were in operation, or else those in which a fistula persisted leaving favour of the latter view. He cited Dr. F. W. N. HAULTAIN read a paper on the Culture, the channels open for subsequent infection. twelve cases of four years’ standing, and others of Diagnosis, and Serum Treatment of Puerperal Fever. He eight and nine years, without any after-trouble ; in one gave detailed accounts of three cases. The first was a there developed nystagmus in the sound eye after five primipara where help was needed in the labour by the appliyears, and this was perfectly represented in the artificial cation of low forceps. The puerperium for the first ten days one.-Mr. BICKERTON declared his experience in favour of was normal, except that the strength was not regained with Mules’s operation, and referred to published and collected the usual rapidity. On the twelfth day she fainted on cases, which showed a percentage of 15 sympathetic attempting to rise, and for a fortnight her pulse was quick ophthalmitis after complete enucleation. (rhese, however, and there was a rise of temperature to about 100° F. On the were shown to be picked and more than ordinarily severe twenty-sixth day she first complained of severe pain and cases collected from ’the point of view of sympathetic swelling in the right thigh, this rapidly passed off ; four ophthalmitis, and not representing the true proportion of days afterwards pain occurred in the left thigh and the disease following simple enucleation.) He cited a case calf, associated with considerable swelling and severe in which, though the disturbance occurred, it subsided in constitutional symptoms ; vomiting, sweating, and faintness. about ten days, the eye recovering perfectly.-Mr. SNELL Dr. Haultain then saw her. Pelvic examination revealed questioned whether sympathetic ophthalmitis occurred as nothing abnormal except a subinvoluted uterus and frequently as formerly. His experience led him to believe it a slight swelling in the left broad ligament. The lochia did not, and he attributed the improvement to the greater were a little offensive, and a culture was made of the care exercised. Though dealing with many cases of injury discharge from the interior of the cervical canal ; one was he enucleated fewer eyes. He thought the percentage of sub- also made from the blood drawn from the finger. The former sequent sympathetic change indicated in the paper a very showed a typical pure culture of the Löffler bacillus ; 10 c.c. high one.-Mr. CRITCHETT, Dr. ARGYLL ROBERTSON, and of the diphtheritic antitoxin were injected with marked the PRESIDENT all spoke as to the rarity of sympathetic beneficial results. On two successive days a similar quantity ophthalmitis after complete enucleation. The President said of serum was injected as the temperature again slowly rose. it was an important question in pathology whether the disease After the third dose the temperature fell to normal and she occurred in a less intense form after Mules’s operation or had an uninterrupted recovery. No case of diphtheria was not.-Mr. TREACHER COLLINS inquired whether the stumps present in the neighbourhood and the attending practitioner had been carefully examined after removal to see if had not seen a case of diphtheria for some weeks previously, evisceration had been complete. (Of this there was no but the drains were found to be in an insanitary state. record.)-Mr. RICHARDSON CROSS, in reply, said he was sure The second case showed marked signs of fever forty-eight The medical man had used many cases occurred after Mules’s operation even with the hours after the labour. strictest antiseptic precautions and often after many years. intra-uterine douches, but without benefit. Dr. Haultain saw He preferred enucleation. her on the fifth day. She then showed signs of marked Mr. S. SNELL read a paper on Blindness following Blows septic infection, the face had a leaden appearance, and there on the Head. Loss of vision was attributed to fracture were erythematous patches on the abdomen. A culture of extending into the foramen rotundum, and was the result the discharge, similarly taken, was again made, and exgenerally of injuries to the front of the cranium ; but amination showed a mixed growth of streptococcus and Mr. Snell showed that a similar condition not infrequently bacillus coli. Anti - streptococcic serum (10 c.c.) was from to and cited several followed any injected, injuries by a similar quantity the next day, and part, resulted of blows on different of the skull which led to 30 c.c. on the third day, but no beneficial effect resulted. parts instances immediate loss of vision in this way.-Mr. BICKERTON spoke The patient developed an intractable diarrhoea ; her left of the remote as well as the immediate effects of injury to knee-joint became extremely painful ; pulmonary comthe head in producing blindness, and referred to the interest plications and parotitis set in, and she died on the tenth A culture was made from the blood of the connected with cycling accidents and insurance. He men- day. tioned the case of one man who compounded with an finger twenty hours before death, and a pure growth insurance company for £50 as compensation for such an of the bacillus coli was found, which from its reactions Mr. was found to be extremely active and virulent. accident which later led to complete blindness. The LINDSAY JOHNSON spoke of the effects of injury to patient was a coachman’s wife and was confined in a the head in animals followed by blindness, and quoted room immediately above the stable. The third case had instances in a crane, a leopard, a bear, and a kangaroo been attended by an unskilled woman, and showed signs of in which he had subsequently observed white atrophy fever on the third day. Dr. Haultain saw her four days -
of the disc.-Mr. CEITCHETT mentioned an instance in afterwards. The vaginal discharge was offensive. The which a heavy blow above the nose was followed by a reduc- culture showed many streptococci. Anti-streptococcic serum tion of vision to 20/70, and subsequently to bare perception of (10 c.c.) was injected; the uterus was washed out with a light. The case was the subject of a lawsuit. In a case 1 in 40 carbolic lotion and packed with gauze soaked in recorded at the time in "Holmes’s System of Surgery the the antitoxin. On the next day a further 10 c.c. were opinion was expressed that loss of vision might follow lateinjected. The temperature fell on both occasions. No from such an injury.-The PRESIDENT discriminated betweenfurther rise of temperature occurred, though the cervical immediate and remote loss of vision in connexion with headdischarge showed many streptococci. The uterus was injuries ; of the first there could be no doubt, but the second washed out on the two succeeding days, and further was liable to great difference of opinion and interpretation. examination showed the discharge to be free from septic The following cases were shown :organisms. On reviewing the cases, the first one was eviMr. J. R. LUNN: Bilateral Facial Palsy, Deafness, and (dently a case of intra-uterine diphtheria, and the diagnosis Ulceration of the Corneæ. would have been impossible except for the bacteriological Mr. LuNN and Mr. C. D. MARSHALL: Foreign Bodiesexamination. The second case showed features of interest embedded in the Orbit. :in the presence of mixed infection in the culture from the cervix and in the pure culture of the bacillus coli from the blood. Clinically, the violent diarrhœea, the erythematous patches and the absolute inefficiency of the antistreptococcic EDINBURGH OBSTETRICAL SOCIETY. serum, were of value. The third case was one of those simple cases of toxin poisoning which usually yield to antiseptic Report on Specimen-Culture, Diagnosis, and Serum Treat- intra-uterine douching, the focus of the disease being thus ment of Puerperal hever-Morphology of the Vaginal removed. Still it must be noted that intra-uterine douching Segment of the Genital Tract. had almost no effect until combined with the serum treatA meeting of this socieiy was held on June 9th, Dr. ment. In all cases of puerperal fever the culture method of ALEXANDER BALLANTYNE, President, being in the chair. diagnosis was much to be preferred to all others. The microThe specimen shown at last meeting by Dr. KYNOCIi was scope alone was helpful, but no idea could be obtained of the reported upon by Dr. HART, Dr. HAULTAIN, and Dr. vitality or virulence of the organisms. In the prognosis, a