CASE OF CEREBRO-SPINAL MENINGITIS; DEATH AND AUTOPSY.

612 and favourable surroundings generally attain these them for a small sum-a system of "farming out" not as yet averages. But what of children that fall below the standard? known, I am sorry to say, in this country. I find that there is a 71b. margin of safety, and that children The medical inspection of schools which has been instifalling more than 71b. below this standard are devoid of tuted in the department of the Seine is a step in this direcreserve capital on which to draw, and consequently they tion which might be imitated in this country with advantage, succumb quickly to many constitutional diseases. This, and I would strongly urge the triennial use of the scales and therefore, may be called the preventive medicine margin, measure as the most trustworthy indicators of the physical welfare of the rising population. There is little doubt that beyond which lies the dangerous land of cachexia. Arrest of growth, or loss of weight, precedes so many dis- the mental pressure which is now so common in elementary eases that it may be looked upon as a danger signal, and if schools causes an excessive waste of nerve force for mental the " caution"is noticed before the disease point is reached work, which should be subservient to bodily growth and catastrophe may frequently be prevented, and so childhood development. Mental overstrain is most common amongst may be worked on a kind of "block system." It is thus the poor who stilfer from want of food and bad hygienic sur. that it becomes of such value in preventive medicine. roundings, but it is not uncommon amongst the growing In pulmonary consumption loss of weight generally children of the rich; and it is important that parents should precedes cough, and, according to Dr. Dobell’s table No. 4, be aware of the possibility of sacrificing physical to mental haemoptysis only occurred 8 times out of 100 cases before development. The reverse may certainly occur, the result loss of weight had been noticed. Moreover, while cough is being a fine but not very intellectual animal; and therefore a symptom at once recognised and noticed, loss of weight is in this, as in most things, it is the " happy medium" that is the best and safest. so insidious that it is apt to go some time unnoticed. The number of cases in which loss of weight began before cough Seymour-street, W. is sure to be understated. These remarks apply more strongly to the cases in which loss of weight preceded first haemoptysis-a symptom never overlooked. CASE OF CEREBRO-SPINAL MENINGITIS; I have been glad to notice that lately there have been DEATH AND AUTOPSY. evidences in various quarters that this subject is attracting attention. At the International Congress at Amsterdam BY TOM ROBINSON, L.R.C.P. LOND., &c. Professor Donders in his most eloquent address said, that " the principal aim of hygiene is contained in the factorsA. G-, aged eight, was a cheerful and intelligent the desire to raise man to the full perfection of his physical Father and mother both living and healthy; schoolboy. and moral being, the principles of gymnastics, that are yet but little known, the doctrine of heredity, the influence of have four other children all living and well. On July Dr. Zeeman, of Amsterdam, in 21st whilst at school the mistress noticed that he was dull consanguinity," &c. speaking of the best methods for measuring public health, and sleepy, but he got through his lessons in the morning dwelt on "the physical development of infants and youths, and the results which have partly been obtained, or will be and came home crying with pains in his head. His mother obtained in the future, by a series of careful investigations, gave him castor oil, after which he vomited. On July 22nd he was quite delirious, complaining of in. which are classified under the name of anthropometry." At the meeting of the British Medical Association at Cork Dr. tense pain in his head. On the evening of this day I saw Rabagliati touched on the same subject. the boy and found him lying in bed and on his back. He As a practical example of what has been done through the knowledge of a physical standard, let me instance what was rolling his head about and complaining of great pain. occurred at the Boys’ Home, Regent’s-park. In 1875 it was I did not distinguish any irregularity of pupils or paralysis found at that institution that the boys had not increased on of muscles of eyeball or elsewhere. He was extremely irrian average two inches a year, so in January, 1876, a revised table. No evidence of any disease or eruption. Tempedietary was used, and it was found, after one year, that by rature 102-2"; pulse 126; respiration 32. this simple change the average increase amongst the boys July 23rd.-His right eye attracted my attention on going had been over two inches in stature, and 6¼ lb. in weight. to his bedside. The pupil was very dilated, insensible to is in It not possible this paper to go into the question how the standard is likely to be more generally attained ; but, light, and the cornea looked steamy. He was still lying on speaking broadly, the principles of sanitary science, food, his back, moaning and complaining of pain in his head, parclothing, work, rest, pure air-in short, the proper bringing ticularly when moved about. He said he could see a up of children is the foundation. It is merely stating a truism to say that suitable food and surroundings are neces- candle, but he could not count my fingers or tell those sary for the healthy development of every living thing ; and around him. Temperature 1022°; pulse 103; respiration 31. 24th.-Mr. Hutchinson saw the case with me. On his that overwork of the young, whether mental or bodily, illfeeding, sickness, hereditary diseases, and the like, cause first visit the patient was lying on his back with the knees children to be puny and fall below their proper averages. drawn up, almost touching the chin, very delirious, and Diseased and diminutive parents are apt to procreate under- screamed violently on being disturbed. The steaminess of sized and unhealthy off’spring, which nothing will make the right eye had become opacity, and from the evidence grow up to a typical standard, for the embryo receives a we concluded he was blind on this side. There was marked stamp at the time of conception which would baffle all our increased tension of the globe. Temperature 103°; pulse subsequent efforts for its welfare. But children born of 124 ; respiration 30. 25th.-Head thrown back and very fixed. His gums were healthy parents are constantly being added to the roll of the! weedy and undersized owing to want of care during the inflamed from repeated doses of calomel. His eye was much growing years. For all such the scales and measure offer the same. Temperature 1022°; pulse 128 ; respiration 30. indications of no mean value. Much might be done by 27th.—Quite conscious. Slept well during the night. His homes, left eye was normal, but with the right he was totally blind, sanitary, medical, and general inspection of and by establishing child-colonies, as in Switzerland, Ame- and the iris was invisible. Temperature 100°; pulse 120; rioa, and Saxony. respiration 30. 31st. - His condition had not much changed. He had Our school boards might become a great power for the physical improvement of our rising population, if some of slept for long periods both night and day. Complained of the monstrous sum expended in teaching our labourers and great pain when he was moved. Could lie on either side, servants of the future the rudiments of science, mathematics, but his head was always drawn back, and he resisted any and German were utilised during school vacation in sending; effort to flex it. Temperature 99°; pulse 120; respiration 30. Feb. 2nd. -I made the following notes: "On the right the undersized to the country under the care of their teachers, and opportunity were afforded them to become physically eye there is marked bulging on the upper aspect, which strengthened by judiciously regulated diet, plenty of exer- bulging is brown. I can now see through the cornea, and cise in the fresh air, &c.; if, in short, a little less were done! discern the iris distinctly, but there is an opaque patch on for the mens sana and a little more for the corpore sano. It the cornea which obscures the pupil. He is conscious, does is perfectly wonderful what only three weeks of change to not like to be disturbed, and says his legs pain him. Temthe country has been found to do for town children thus! perature 100°; pulse 120; respiration 24." 10th. treated in Saxony. In Switzerland and America the childWasting very rapidly, but more cheerful. The the cornea is more transparent; ren are placed in the families of farmers, who take charge ofE bulging on the globe is

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613 the pupil is triangular. The vision of the left eye remainst good. Temperature 96’2°; pulse 110; respiration 20.

strate the connexion between nerve changes and several forms of skin disease. In the museum of St. Bartholomew’s 14th. Dr. Wilks saw the case in consultation with me. (Series 9, No. 9) is a case of penetrating ulcer of the cornea, On our visit the boy was cheerful, was lying on his left side, which occurred in a case of tumour near the pons, which and had no pain or difficulty in turning from side to side, but. tumour destroyed the trunk of the trigeminal. And Sir moved his head and shoulders as if fixed. He complained James Paget writes in his work on Surgical Pathology, "It of pain in his neck. When he sat up his head seemed toe is well-known that when the trigeminal nerve is divided the heavy for his body, and he begged of us to put him on hisI eyeball innames, so that within a few days its textures may injured, or even destroyed, by the inflammation." pillow. With the exception of the right eye, there were beIgreatly have under my care at the present time a young lady no other discoverable physical signs. 97’8°;; whose fingers and toes are an indigo blue, which blueness pulse 108; respiration 20. of and conscious. Often 21st. cold, disappears on pressure, is not changed by position, but Quite complains when he docs so his cheeks look like goosellesh. When passes away when she has been near the fire for some time. asked to sit up he says he cannot. If an attempt is made to Her fingers are very painful and she cannot feel the pricking lift him he cries, but his head may be rotated and extended of a pin. This patient has cherry-coloured lips and is free without any resistance. Vomits after food. Complains offrom organic disease of heart; so we must believe she has, from the slightest noise. Temperature 98’; pulse 107 ; respiraparalysis of those nerves which govern the arteriotion 21. capillary venous network, which vessels are simply, as Dr. March 2nd.—Has not slept all night, and was wandering W. H. Stone has shown, closed cells. So that I think I am incessantly, lying on his right side, with his legs drawn up. justified in stating that the destructive inflammation which The right eyeball isgetting smaller, but is quite sightless. took place in my patient’s eyeball was due to the destruc. tion, or partial destruction, of the trigeminal nerve by the Temperature 102’8°; pulse 110; respiration 22. 12th.—Since the last note he has been very irritable and inflammatory process which took place at the base of hiq restless. Has complained much of pain in his head, and brain ; and I apprehend his herpes zoster and his cutaneous asks to be left alone. He vomited at frequent intervals. gangrene were attributable to the same action, involving Is delirious at times. Picks his face, and chatters a great other nerves. In the absence of any history of an injury, or growth, or deal incoherently. Temperature 98.4°; pulse 100 ; respirafracture of skull, one is compelled to accept this as a case of tion 20. 19th. - Seems very much better. Answers questions idiopathic cerebro-spinal meningitis, such as is described by rationally. His hearing and sight of left eye seem quite Niemeyer under the term epidermic, and by many other normal. He takes his food, and does not vomit. Still writers, and it is found that isolated cases have been reported looks extremely ill. Temperature 99° ; pulse 98 ; respira- from time to time. Thus Dr. B. W. Richardson saw an tion 22. unquestionable case at Mortlake in 1843 (Social Science 26th.-Since the last note his right eye has given way in Review, May, 1865, p. 398). Dr. Wilks has reported cases the upper aspect, and is discharging pus. Complains bitterly which he has met with during each of the three years 1856, of his head, particularly when moved. Temperature 99° ; 1858, and 1859, in London, and I remember a case occurring in the London Hospital during the year 1870. The diffipulse 110; respiration 24. April 10th.—He has not exhibited any material alteration culty arises as to whether the case I have ventured to make since the last note was made. lIe looks very careworn and public is a true example. It certainly presented all the old. Has ilicontillence of urine and fæces, and is terriblv objective symptoms, and the pathological evidence would thin. There are some aphthous patches in his mouth. He demonstrate that it was a cerebro-spinal meningitis. will answer questions, but the response is slow and monoGuilford-street, Russell-square. syllabic. Temperature 98° ; pulse 124 ; respiration 22. 16th.-There is a band of herpes over the sixth right f)nrsa1 nerve. There are on his abdomen a. number of purple spots, which do not disappear on pressure. The saliva dribbles FIVE YEARS’ SURGICAL WORK IN THE from his mouth, and over his body in such positions as the CARDIFF INFIRMARY. helix the skin is dead, but only the skin. When he is raised his head falls back, and he cannot move it without BY ALFRED SHEEN, M.D., assistance, at least he does not. Temperature 99-2° ; pulse SURGEON TO THE INFIRMARY. 126; respiration 24. (Continued from p. 533.) 21st.-He goes scarlet in his face at times. Is absolutely unconscious to reflex action or questioning. Breathing in short rapid gasps, which are irregular. Sweats on the least Dislocations.—Under this heading there are but few exertion. Swallows with great difficulty. He died during entries, chiefly because dislocations as a rule are dealt with the night. Temperature 99 8°; pulse 144; respiration G8. as out-patients. The elbow case had a stiff bandage Autopsy, twenty-four hours after decctlz.-The body was applied in ten and was made an out-patient. It was days, very much wasted, and the muscles about the neck appeared more so than any other part of the body, the transverse a dislocation backwards, complicated by fracture. The processes of the vertebrae standing out in relief as the body shoulder cases were both of some standing-one being thirty lay on the table. The abdominal and thoracic viscera were days, and the other nine months. The first was in a man healthy. Head : The pia mater on the surface of the brain aged fifty-four, and was reported in THE LANCET at the was shining and normal, but as you looked towards the base of the brain this membrane became greasy, which greasiness time.l On admission, there was flattening of the left gradually became opacity, and on the under surface, matting shoulder, prominence of the acromion, lessened mobility of together the optic commissure and other structures, was an the arm, which was somewhat from the side, and pain on opaque covering, which was firm. This opacity was con- trying to raise it. No swelling or crepitus ; slight protinued on each side into the Sylvian fissures. The convolu- minence in front of the joint; head of the bone to be felt in tions of the brain were flattened. The lateral ventricles the axilla. The patient was placed fully under the influence were much distended by about six ounces of thick fluid. to break down any of chloroform, the limb was There was no evidence of tubercle or injury to the skull. I adhesions which had and reduction attempted, but formed, was forbidden any examination of the spinal cord. without success. A further examination of the limb was The points of interest in this case are three. then made, and on rotating the arm with my fingers placed 1. The destructive process which so suddenly attacked on the head of the bone the latter was found not to move. the eyeball. was : original accident, fracture of the neck The 2. The cutaneous conditions which arose during the boy’s with diagnosis and now disturbance of fractured ends. dislocation, illness. In Guy’s Hospital Reports for 1875, p. 132, I find a some3. The want of evidence as to the cause of the meninwhat similar case thus recorded :-‘ " Mr. Howse attempted to gitis. of the right The first two, I think, must be attributed to alteration in reduce an unreduced subcoracoid dislocation the humerus of one month’s standing. With under patient nerve-function. I have seen cases where, after affections of the brachial plexus, either from injury or other causes, the chloroform, Mr. Howse attempted to violently break down adhesions, and in doing so fractured the humerus, pro. fingers have become withered and glazed, and one need scarcely say how much modern pathology has done to demon. 1 Vol. i. 1876, p. 211. -

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