FrancisE. Marston
1886 The Lancet  
442 not too for advanced; good food, fresh air, and as much rest as possible, with a radical change in the construction of the boot. The toe and heel should change places, or, what amounts to the same thing, a good laced boot should be worn, with the sole quite an inch thick in front, fining off to a line or two at the heel. By these means the normal inclination of the os calcis would be maintained, and the weight of the body properly disposed of. THE following interesting case has recently
more » ... under my notice :-Harriet B-, aged ten years, had measles, scarlet fever, and whooping-cough before she was three years old. At the age of five she was in the Infirmary for Children suffering from rheumatism and chorea. She was admitted into the infirmary on the 21st of April of this year. Her mother stated that three weeks previously she began to suffer from rheumatic pains in her joints, and that one week before she was brought to the infirmary chorea set in. On admission the patient complained of pain in the right knee and right wrist. She was also suffering from a well-marked attack of chorea, most marked on the right side. The choreic movements were more violent during the night, when awake, than in the daytime. The heart's apex beat in the fourth and fifth interspaces, internal to the nipple line. There was slight epigastric pulsation. A rough systolic thrill could be felt over the apex. There was a loud grating systolic murmur heard most distinctly over the axilla. There was no cedema or albuminuria. A few days after admission she had clonic twitching of the right side of the face, accompanied by incoordmated movements (described by the house-surgeon as being like an infant's convulsion). The patient improved considerably, and on May 25th she was sent to our convalescent home at Waterloo. She remained there for three weeks, and seemed to be improving in health and benefiting by the sea air. On her return (June 14th) to the infirmary, it was noticed that there was much greater impulse over the cardiac region, and that the apex was now outside the nipple line. The chorea had disappeared, and she was allowed to be up and about the ward. A few days after her return she was noticed to have a slight rise of temperature at night (101°), and she was ordered back to bed. On July 2nd the heart symptoms became much more marked, and her face and feet became cedematous. From this time she became rapidly worse, and died on the morning of July llth. Post-mortem ezaminction.-Therewas slight cedema of the legs and eyelids. Heart very much enlarged, displacing the lungs, especially the left, and extending, partially covered by the thin edge of the lung, about half an inch to the right of the sternum and to the lower border of the second left rib. Pericardium: A patch of thick, firm, white adhesion, about the size of a sixpence, situated over the right ventricle near its apex, attached the two layers of pericardium; there were no other signs of pericarditis. On the surface of the aortic, mitral, and tricuspid valves, minute vegetations about the size of a pin's head were to be seen grouped in clusters. The aortic and mitral valves were both incompetent. The lungs were congested and oedematous all over; the left pleura was slightly adherent at the back. The liver was most typical nutmeg, and a large and apparently recent infarct was found on section. Remarks.-This case, taken with others which have been reported, help to strengthen the opinion' held by many, that rheumatism and heart disease are responsible for chorea; and the fact that in chorea we frequently cannot find evidence of heart disease is no proof that there is no valvular disease. This was very well illustrated in a case which I brought before the members of the British medical Association at their meeting in Liverpool in 1883. It just happened that many of my colleagues were examining cases in order to supply information to the Collective Investigation Committee, and a patient who was under my care at that time was frequently examined with the view of detecting heart disease. No cardiac bruit could be detected, and there was no apparent hypertrophy; yet, notwithstanding, after death, 'n'hich occurred unexpectedly during the chorea from exhaustion, vegetations about the size of pin's heads were found to fringe the aortic and mitral valves. In both these instances the vegetations were very small, and were very readily detached from the valves. In two other fatal cases of chorea which I have had under my care, the patients being of the ages of seven and eleven respectively, one had vegetations on the aortic and mitral valves, while the other had well-marked pericarditis and nodular rheumatism as described THE following cases of strychnine poisoning, one homicidal and the other suicidal, having come under my observation during the last seven months, may not be without some interest to the readers of THE LANCET. s I was called to see W. M— at 6.35 in the evening of June 14th, 1886. The patient was lying on his shop floor, complaining of great pain over the epigastrium, a feeling of suffocation, and of being very thirsty; he was very restless, and his face wore a somewhat anxious expression. On being questioned, he replied that he had drunk some porter from a jug which had been given him. The jug was handed to me, and found to contain about a drachm of porter, with some small white crystals at the bottom and some clinging to the sides of the vessel; they had a very bitter taste. Thirty grains of sulphate of zinc were administered, and a stomach-pump was sent for. After the lapse of ten minutes from my arrival the patient was seized with convulsions of a tetanic character, which left no doubt as to the poison taken. Mr. Herbert Hawksworth, who had arrived on the scene, assisted in introducing the stomach-pump, and the stomach was thoroughly washed out with water, the washings being nearly colourless. The patient had two more violent convulsive spasms, with only a slight intermission. There was great lividity of the face; and the lips were retracted, showing the teeth firmly closed. He was quite conscious during the intervals of the fits, and requested to be turned over on his side. During the second spasm?, which were of increased severity, the patient died (6.55 P.M.). The emetic acted only slightly. Probably about fifty-five minutes elapsed from the poison being taken until the time of death. Mr. Hawksworth and myself made a necropsy twenty-one hours after death, when the following notes were recorded :-The whole of the body was extremely rigid, the upper extremities being slightli flexed and the hand clenched; feet markedly arched; no opisthotonos; the mouth tightly closed, and the face wearing a somewhat agonised expression. The membranes of the brain, and the substance of the br.ain itself, were congested; the medulla and upper part of the spinal cord were slightly congested, but otherwise appeared healthy. The stomach showed a few patches of congestion, and contained about five ounces of thick grumous straw-colo'lued fluid, consisting of partially digested particles of food, and smelling ot alcohol. The duodenum and upper part of the small intestines were healthy, and contained fluid similar in appearance to that in the stomach. Lungs intensely congested, and engorged with blood. Heart of natural size; its muscular substance soft and flabby; cavities nearly empty, the little blood they contained being fluid and very dark. Here and in every other part of the body the blood was not coagulated. The rest of the organs appeared healthy. Bladder empty and strongly contracted. The trowsers contained anevacuation of fseces. The stomach and its contents were sent to Mr. T. Blunt of Shrewsbury, the county analyst. One-tenth of a grain of commercial strychnine was found in the contents, and the washings obtained by the stomach-pump contained a little more than one-tenth of a grain. In the jng from which W. M— drank the porter six grains of btrychnine were found. Fifteen grains of strychnine is the quantity supposed to have been thrown into the jug.
doi:10.1016/s0140-6736(02)13274-0 fatcat:earhum5cffbhpiylq2ma3l77xu