Henry C., 23, labourer, was admitted into this asylum on December 18, 1888. Has had epileptic fits since age of 13. Grandfather had fits. Fits increasing in severity during last two years. He was admitted in a state of acute mania, rolling and throwing himself about, and generally in a state of raving incoherence. He was treated in a single room, but would not stay in bed, standing for whole nights on his bare feet and shouting vigorously. This continued for eight nights. On the 25th December his feet were noticed to be slightly swollen, but not discoloured. His mental condition considerably improved, and on the 4th January he was able to sit up near the fire. Had a relapse, however, on the 11th, and, after spending a restless night, his feet were noticed to be again swollen, and he complained of great pain. On careful examination the toes of both feet presented a bluish-purple tint, especially on the plantar aspect; they felt cold, and there was slight cutaneous anæsthesia, patient experiencing subjective sensations of excruciating pain, referable to the anæsthetic regions. The pulsation in the tibial and dorsalis pedis arteries could scarcely be detected. There was considerable constitutional disturbance. Patient felt a sense of constriction all over his body; intense frontal headache, with severe pain of a spasmodic character in his lumbar region and great tenderness over the region of the kidneys. In addition there were several small hæmorrhagic extravasations on his buttocks and thighs. His vision was also materially affected. He complained of dimness and inability to read. On ophthalmic examination the fundus was seen to be unusually pale, while the vessels were blanched and almost indistinct. The urine was scanty and of a very smoky appearance, specific gravity 1,028, neutral in reaction; contained a deposit of phosphates, slight trace of albumen, and a large quantity of blood. Blood was also present in his expectoration. He was placed in a warm bed near the fire, and the feet carefully wrapped in cotton wool. The discoloration became more intense, and a large bleb formed under the epidermis of the plantar surface of three toes. On opening these a quantity of sanguineo-purulent fluid escaped, and a distinct line of demarcation was seen round the base of the terminal phalanges, which were gangrenous. Charcoal poultices were freely applied, and every endeavour made to check the spread of the disease. The result being that three of the terminal phalanges of the right foot, viz., second, fourth, and fifth, and one of the left foot, viz., the great toe, sloughed off, leaving a healthy granulating surface. His constitutional symptoms only lasted about a week; the pain in the back disappeared. Blood was only observed in the urine and expectoration for three days, and then quite disappeared. Vision was perfectly restored, and the optic discs appeared normal. The toes have healed up nicely, leaving very little deformity or inconvenience to the patient.
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