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CEREBRAL TUMOUR; OPERATION; DEATH FOURTEEN HOURS LATER WITH SYMPTOMS OF IMPLICATION OF MEDULLA.
1306 the whole of the back and down the ta.ka of the thighs condition after sixteen months on the Weet Coast as it was and legs ; and there is often pain in all theoints. The onset on the day it arrived. A typical malarial fever chart is appended. is always sudden. Some patients struggle against the malaise ; many give in at once and go to bed. There is often Oxford and Cambridge-mansions, Hyde Park, W. great fear of death (especially in the case of new arrivals) ; others become frightened when they notice the urine discoloured or when the vomiting is severe, the latter causing The skin is severe spasms over the abdominal region. CEREBRAL TUMOUR; OPERATION; DEATH the There harsh to touch. is and dry nearly always FOURTEEN HOURS LATER WITH but this the fever. In generally precedes constipation, has come under I seizure that notice have my nearly every SYMPTOMS OF IMPLICATION used the treatment to be presently described, and have found OF MEDULLA. it absolutely successful except in the case of the patient marked No. 14 in Table II., who had been about three BY E. N. NASON, M.B. CAMB,, M.R.C.S. ENG. weeks on the coast when first attacked by fever, and was a healthy, full-blooded man twenty-one years of age. On my A MAN aged forty-three years, while walking in the Selde. arrival his temperature was about 102’F. All the drugs which were considered useful were tried, but none seemed to in July, 1894, thought he felt something in his left boot. have any effect. He took slops well, but after a few days While taking the boot off twitching began in the left hee, was inclined to be despondent. This condition lasted for fully and extended up the leg to the thigh. The twitching lasted fourteen days, his temperature varying from 100° to 103°A month later he had a second similar seldom lower, but never higher-and his skin remaining harsh about ten minutes. and attacks became more frequent, some. afterwards attack, and dry all the time. As his condition was now becoming There was temporary He was sponged three times two occurring in one day. worse more stimulants were given. and four times daily with the coolest water procurable (which paresis of the left leg after each attack, but no per. is not very cold in Warri), and I cheered him up to the best manent trouble except some stiffness and a tendency to of my ability. This stimulating treatment was continued for catch the toes when walking. He had no loss of conseveral days; his temperature fell, and he was at his work sciousness and no headache, but suffered occasionally from again in less than a week. I "’ what he called biliousness." On one occasion, just before The treatment observed with all the other patients was as follows. If there was much vomiting or pain, from a quarter Christmas, the left arm became affected in a similar way, to half a grain of morphia was given either by the mouth or and in January, 1895, the muscles on the left side of thehypodermically, and when this had taken effect from two trunk also. The face was never affected until Feb. 2nd, oc. and a half to five grains of calomel with colocynth and a quarter of a grain of podophyllin, together or singly, were which day, while travelling by train, he had a very severe administered. The patient being in bed, a hot-water bottle attack affecting the whole of the left side and accompanieda or bag was applied to his feet and another over the spleen, by cyanosis and loss of consciousness lasting some mmtes. and he was then well covered with blankets. As soon as the It was after this attack that he first came under my care. stomach had settled itself (generally within half an hour The following conditions were then noted. On Feb. 10th after taking the morphia) from ten to fifteen grains of anti- there was paresis of the left leg, the extensors of the foot -pyrin were taken, followed by a large cup of weak tea. being most affected. There was no loss of power in the left. Sometimes this dose was repeated, either in consequence of arm or left side of the face or tongue. There was no affecbeing vomited or if in twenty or thirty minutes the patient tion of speech, no headache, and the mind was quite did not sweat. In every case the action of the skin took clear. The left knee-jerk was much exaggerated and place after the first or second dose. Ten-grain doses of the right perhaps more easily obtained than natural. sulphate of quinine were administered three, four, or five Ankle-clonus was well marked on the left side, but times daily till the patient felt symptoms of cinchonism. was absent on the right. Plantar reflexes were present. In some cases the antipyrin treatment had to be repeated The urine was free from albumen. There was no optic for a day or two when the temperature rose at all and neuritis, but the retinal veins seemed fuller than natural. the skin refused to act well, but this seldom happened. He denied the possibility of syphilis, but admitted a previous He was put upon iodide of As the temperature fell the quinine was reduced. Stimulants, occasional alcoholic excess. unsweetened condensed milk (the climate is too deadly potassium, fifteen grains three times a day. By the end of for cows), and meat extracts were the diet. The patient the month there was further loss of power in the left leg:, was generally at work again under a week, unless it had been there had been several convulsive attacks, limited almost a very severe case and there was much weakness. The entirely to the left arm and left side of the trunk, and highest temperature I have registered was 106.80, but this is there was distinct paresis of the left shoulder muscles, an exception ; in most of my patients it has seldom risen above with a feeling of clumsiness in the left hand. The grasp 105°. In a few cases delirium appeared. I have noticed it of the left hand, however, remained strong. Early is on the first or second night, but it is doubtful whether this March he began to suffer from more or less constant was due to a high temperature, as it has occurred when the headache, vertical in position, but slightly more marked temperature was only from 100° to 102 5°, and one patient on the right side. There was no area of superficial tenderhad delirium when his temperature was slightly subnormal. ness. Vision remained gocd, and there was no paresis of theThe fever runs its course in from two to thirty days, during ocular muscles, though much difficulty in fixing the eyes during and after which time there may be kidney, liver, and spleen examination. The pupils were equal and reacted to light. complications requiring treatment according to their respective The head constantly rotated to the left while the eyes weresymptoms. The drugs which to me seem to have given the heing examined. There was slight facial paresis. Or best results are calomel, morphia, antipyrin, and quinine. March 80h complete paralysis of the left arm was found, The after-treatment consists in administering arsenic, having come on almost suddenly. The paralysis of the left strychnia, some dilute acid, iron in its different forms, and arm, now found for the first time, was absolute, while that the hypophosphites, Cod-liver oil is a most useful tonic; of the leg, though of much longer duration, was not quite to take it well, and good results are obtained. complete. Slight tenderness on pressure over the head OD patients seem Fajrish’s "chemical food " made up as a pill is a useful drug the right side of the vertex was noticed, otherwise the and is easily taken in this form. patient’s condition remained unaltered until March ltb, The hot, moist climate of Warri acts injuriously on the when he complained of a little wheeziness and expectorateà drugs, especially on the liquid ones, and I therefore order some frothy mucus. He thought he bad "caught cold." them as solids. I have tried them in tabloid, gelatine, and but there was no other indication of catarrh.’ He was atilt palatinoid form, and prefer the last because they are easily taking iodide of potassium. On March 20th the patient showed swallowed, because they leave no disagreeable taste in the signs of general cerebral compression, as indicated by mental mouth, because, not being compressed, they act quickly, hebetude (once), involuntary micturition, and deep, almost because they are easily dispensed, and because, when sent stettorous, breathing. The expectoration of frothy macns out in glass-stoppered bottles, they keep better than any still continued. There was no rise in temperature. On other form of drugs in the West African climate. One drug in particular which I have bad to use in so many cases1 This may have been an indication of interference with the vagi was in as perfect a morphia quarter-grain palatinoids through compression of the nuclei in the medulla.
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1307 March 21st the symptoms of general compression were much The patient discussed the question of operation rationally, and asked that something might be done at once. The right optic disc showed slight swelling not noticed AND before; the left remained unaltered. On March 22nd Mr. MEDICAL, surgical, OBSTETRICAL, THERAPEUTICAL. Gilbert Barling examined the patient with me, and agreed both as to the diagnosis of cerebral tumour and its locality and the advisability of operation. The patient, having A CASE OF INSOMNIA. been prepared the night before in the usual way, was ansesthetised with chloroform, and a horseshoe - shaped By M. CHARTERIS, M.D., PROFESSOR OF MATERIA MEDICA. AND THERAPEUTICS IN THE flap, including pericranium, was turned down, exposing UNIVERSITY OF GLASGOW. the bone over the region of the right fissure of Rolando. After the hsemorrhage had been controlled and the A MAN aged thirty years consulted me on Oct. 15th, 1893, flap wrapped in hot cyanide gauze, two discs of bone The discs were in. were removed with a 1 in. trephine. from insomnia. He told me that he had always suffering apart and situated on either side (horizontally) of what was been a light sleeper, but to this he paid no particular attenjudged to be a point immediately over the upper limit of the centre for the left arm. The two holes were united by tion ; but owing to an unhappy circumstance he began to Hoffmann’s forceps and the opening in the bone increased by suffer from sleeplessness, which grew upon him to such an the same means till it measured 3 in. bv 2 in. There was extent that it had been common for him, during a period of free oozing from the diploë at the anterior edge of the eight months, to have no sleep for a week at a time. In the divided bone, but little elsewhere. This was checked by month of May, 1892, he was advised to take sulphonal, of pressure with a pad of gauze. The dura mater, which looked which he took in all from thirty to forty capsules of five unduly dark, bulged into the opening, felt very tense, and grains each. His condition did not improve, and, acting on exhibited only a very faint pulsation. The dura mater was medical advice, he tried, during June, July, and August, divided, and a flap turned up exposing the cortex, which bromide of potassium every night in a dose of twenty grains, bulged into the opening thus made and pulsated but feebly. but obtained only from one to three hours’ sleep. The Two large veins, much distended with dark blood, crossed effect of the bromide seemed to be wearing off. He disthe exposed cortex, and between these an incision was continued its use and went to the for ten days. country made which, a quarter of an inch beneath the surface, these ten days, although free from all business, During opened a large tense cyst without any definite wall. he had only one night’s sleep of four hours’ duration, and The cyst or cavity was situated immediately beneath the on to business in the beginning of September Rolandic area, and contained some three or more ounces his returning condition became very serious. "By this time," of clear amber-coloured fluid, free from blood. The cavity he stated, head had become strange and work was a "my passed deeply in the direction of the right lateral ventricle, matter of At night my heart beat so loudly that but no solid growth or thickening could be felt. After the no matter difficulty. in what position I lay I could hear it. During the evacuation of the fluid the space appeared to close comday I was dizzy and full of morbid fears. Something ticked pletely, and the pulsation of the brain became distinct. The in the left temple and the eyes felt hot and fiery. At the end cavity was kept free to drain itself by means of a strand of of September I had sunk into a state of depression, and, cyanide gauze; one stitch was placed in the dura mater, dreading to go to bed, wandered about the streets, had lost and the external flap replaced and fixed by silkworm-gut hope and formed resolutions of which I do not like to think sutures and the wound dressed with cyanide gauze and now, and for which I can offer no very satisfactory explanawood-wool wadding. The operation (at which Mr. Barling tion, yet they were as real and natural as sober and sensible very kindly assisted) occupied one hour and six minutes, thoughts are to a person in good health." When I saw him and was well borne. After being conveyed to bed the he was certainly in a very depressed and morbid state of patient soon began to regain consciousness, and in- mind, but he promised to follow my injunctions. These were timated that he wished to pass water, which he did as follows : to take an alterative pill of mercury and podonaturally. Up to 6 . M. he seemed to be going on very phyllum at 4 P.M. on one day and on the following night six satisfactorily. The dressings had twice become saturated drachms of chlorobrom at bedtime. He was requested to with cerebro-spinal fluid, and the outer portions were changed return at the end of a week and to bring with him by the nurse. The pulse was steady and between 60 and 70 notes of his case. This he did, and I found that a per minute. The respiration was 20 and natural, and the six-drachm dose had each night secured a sleep of temperature 99’40 F. Quite suddenly, at 6 P.M., the character five hours’ duration. He continued to take this dose of the respirations changed, some cyanosis was noticed, and for five weeks, and each night had the same average the temperature rose to 1034° in the left and 1022° in the amount of At the end of five weeks I considered it sleep. right axilla. At half-past seven mucus began to collect, and advisable to decrease the dose to four drachms nightly. He the temperature rose to 105° in the left and 104° in the right took this dose for four weeks, and the average amount of axilla, and the respiration to 43 per minute. There was no sleep remained the same. Then for four weeks the dose was vomiting or any sign of convulsion, but unconsciousness had reduced to one drachm, and with this small dose he had returned. At 10 P.M. breathing became still further embar- from five to six hours’ sleep. On Jan. 19th, 1894, he saw me rassed, and the intercostal muscles, which had previously again, and gave me a tabulated statement of his doses been inactive, suddenly began to act vigorously. The tem- for three months. This, though interesting and instructive, perature had risen to just short of 1060 and 105° on thei would be too lengthy for insertion, but it bore out comleft and right side respectively and the respirations to 54 per. pletely his verbal statements. In the month of June last he minute. There was but little change from this condition tilll called again. He was then able to secure refreshing 4.25 A.M., when the pulse, which was being taken at thei sleep without the hypnotic and his physical and mental contime, gave a bound and stopped suddenly. The respirationl dition was perfect. Work was again a pleasure to him and continued one minute after cessation of the pulse. Thelife was worth living. temperature registered 106° and 105° after death on the left’ Note.—In a similar way I have treated successfully less and right side respectively. The habit of taking the solucases of insomnia. It seems probable that the course of events in this case pronounced tion does not grow on the patient, and its exhibition is was the following. First, the slow development of a simple attended by no depression or derangements of digestion. cyst in the right cerebral hemisphere with increase of intraGlasgow. cranial pressure ; that this gave way into, or formed a connexion with, the right lateral ventricle on Feb 2nd, occasioning POISONING BY EXALGINE. the very severe convulsive seizure accompanied by cyanosis and unconsciousness, &c. ; that a communication with the BY F. GRAHAM CROOKSHANK, M.R.C.S.ENG., ventricles subsequently existed, keeping up an increased intraL.R.C.P.LOND. ventricular pressure, which was present until relieved by the operation; and that the sudden relief of pressure was followed A SINGLE woman aged thirty, extremely thin, was under by oedema of the centres located in the floor of the fourth my care for severe asthma and consequent insomnia. On ventricle, with a consequent interference with their action, May 3rd of this year she was given by a friend, without my leading to the fatal result recorded. knowledge, five grains of exalgine Within five minutes "she Nuneaton, Warwickshire.
less marked.
Clinical Notes:
,
.
.
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over
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1307 March 21st the symptoms of general compression were much The patient discussed the question of operation rationally, and asked that something might be done at once. The right optic disc showed slight swelling not noticed AND before; the left remained unaltered. On March 22nd Mr. MEDICAL, surgical, OBSTETRICAL, THERAPEUTICAL. Gilbert Barling examined the patient with me, and agreed both as to the diagnosis of cerebral tumour and its locality and the advisability of operation. The patient, having A CASE OF INSOMNIA. been prepared the night before in the usual way, was ansesthetised with chloroform, and a horseshoe - shaped By M. CHARTERIS, M.D., PROFESSOR OF MATERIA MEDICA. AND THERAPEUTICS IN THE flap, including pericranium, was turned down, exposing UNIVERSITY OF GLASGOW. the bone over the region of the right fissure of Rolando. After the hsemorrhage had been controlled and the A MAN aged thirty years consulted me on Oct. 15th, 1893, flap wrapped in hot cyanide gauze, two discs of bone The discs were in. were removed with a 1 in. trephine. from insomnia. He told me that he had always suffering apart and situated on either side (horizontally) of what was been a light sleeper, but to this he paid no particular attenjudged to be a point immediately over the upper limit of the centre for the left arm. The two holes were united by tion ; but owing to an unhappy circumstance he began to Hoffmann’s forceps and the opening in the bone increased by suffer from sleeplessness, which grew upon him to such an the same means till it measured 3 in. bv 2 in. There was extent that it had been common for him, during a period of free oozing from the diploë at the anterior edge of the eight months, to have no sleep for a week at a time. In the divided bone, but little elsewhere. This was checked by month of May, 1892, he was advised to take sulphonal, of pressure with a pad of gauze. The dura mater, which looked which he took in all from thirty to forty capsules of five unduly dark, bulged into the opening, felt very tense, and grains each. His condition did not improve, and, acting on exhibited only a very faint pulsation. The dura mater was medical advice, he tried, during June, July, and August, divided, and a flap turned up exposing the cortex, which bromide of potassium every night in a dose of twenty grains, bulged into the opening thus made and pulsated but feebly. but obtained only from one to three hours’ sleep. The Two large veins, much distended with dark blood, crossed effect of the bromide seemed to be wearing off. He disthe exposed cortex, and between these an incision was continued its use and went to the for ten days. country made which, a quarter of an inch beneath the surface, these ten days, although free from all business, During opened a large tense cyst without any definite wall. he had only one night’s sleep of four hours’ duration, and The cyst or cavity was situated immediately beneath the on to business in the beginning of September Rolandic area, and contained some three or more ounces his returning condition became very serious. "By this time," of clear amber-coloured fluid, free from blood. The cavity he stated, head had become strange and work was a "my passed deeply in the direction of the right lateral ventricle, matter of At night my heart beat so loudly that but no solid growth or thickening could be felt. After the no matter difficulty. in what position I lay I could hear it. During the evacuation of the fluid the space appeared to close comday I was dizzy and full of morbid fears. Something ticked pletely, and the pulsation of the brain became distinct. The in the left temple and the eyes felt hot and fiery. At the end cavity was kept free to drain itself by means of a strand of of September I had sunk into a state of depression, and, cyanide gauze; one stitch was placed in the dura mater, dreading to go to bed, wandered about the streets, had lost and the external flap replaced and fixed by silkworm-gut hope and formed resolutions of which I do not like to think sutures and the wound dressed with cyanide gauze and now, and for which I can offer no very satisfactory explanawood-wool wadding. The operation (at which Mr. Barling tion, yet they were as real and natural as sober and sensible very kindly assisted) occupied one hour and six minutes, thoughts are to a person in good health." When I saw him and was well borne. After being conveyed to bed the he was certainly in a very depressed and morbid state of patient soon began to regain consciousness, and in- mind, but he promised to follow my injunctions. These were timated that he wished to pass water, which he did as follows : to take an alterative pill of mercury and podonaturally. Up to 6 . M. he seemed to be going on very phyllum at 4 P.M. on one day and on the following night six satisfactorily. The dressings had twice become saturated drachms of chlorobrom at bedtime. He was requested to with cerebro-spinal fluid, and the outer portions were changed return at the end of a week and to bring with him by the nurse. The pulse was steady and between 60 and 70 notes of his case. This he did, and I found that a per minute. The respiration was 20 and natural, and the six-drachm dose had each night secured a sleep of temperature 99’40 F. Quite suddenly, at 6 P.M., the character five hours’ duration. He continued to take this dose of the respirations changed, some cyanosis was noticed, and for five weeks, and each night had the same average the temperature rose to 1034° in the left and 1022° in the amount of At the end of five weeks I considered it sleep. right axilla. At half-past seven mucus began to collect, and advisable to decrease the dose to four drachms nightly. He the temperature rose to 105° in the left and 104° in the right took this dose for four weeks, and the average amount of axilla, and the respiration to 43 per minute. There was no sleep remained the same. Then for four weeks the dose was vomiting or any sign of convulsion, but unconsciousness had reduced to one drachm, and with this small dose he had returned. At 10 P.M. breathing became still further embar- from five to six hours’ sleep. On Jan. 19th, 1894, he saw me rassed, and the intercostal muscles, which had previously again, and gave me a tabulated statement of his doses been inactive, suddenly began to act vigorously. The tem- for three months. This, though interesting and instructive, perature had risen to just short of 1060 and 105° on thei would be too lengthy for insertion, but it bore out comleft and right side respectively and the respirations to 54 per. pletely his verbal statements. In the month of June last he minute. There was but little change from this condition tilll called again. He was then able to secure refreshing 4.25 A.M., when the pulse, which was being taken at thei sleep without the hypnotic and his physical and mental contime, gave a bound and stopped suddenly. The respirationl dition was perfect. Work was again a pleasure to him and continued one minute after cessation of the pulse. Thelife was worth living. temperature registered 106° and 105° after death on the left’ Note.—In a similar way I have treated successfully less and right side respectively. The habit of taking the solucases of insomnia. It seems probable that the course of events in this case pronounced tion does not grow on the patient, and its exhibition is was the following. First, the slow development of a simple attended by no depression or derangements of digestion. cyst in the right cerebral hemisphere with increase of intraGlasgow. cranial pressure ; that this gave way into, or formed a connexion with, the right lateral ventricle on Feb 2nd, occasioning POISONING BY EXALGINE. the very severe convulsive seizure accompanied by cyanosis and unconsciousness, &c. ; that a communication with the BY F. GRAHAM CROOKSHANK, M.R.C.S.ENG., ventricles subsequently existed, keeping up an increased intraL.R.C.P.LOND. ventricular pressure, which was present until relieved by the operation; and that the sudden relief of pressure was followed A SINGLE woman aged thirty, extremely thin, was under by oedema of the centres located in the floor of the fourth my care for severe asthma and consequent insomnia. On ventricle, with a consequent interference with their action, May 3rd of this year she was given by a friend, without my leading to the fatal result recorded. knowledge, five grains of exalgine Within five minutes "she Nuneaton, Warwickshire.
less marked.
Clinical Notes:
,
.
.
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