MEMORANDA RELATIVE TO SOME CEREBRAL AFFECTIONS OF CHILDREN.

34 operation is to form two flaps, one of the latter being one-third MEMORANDA RELATIVE TO SOME CEREBRAL longer than the other, the long one having the narrowest base. AFFECTIONS OF CHILDREN. Mr. Wakley explainshis operations mathematically: thus, if the circumference of the limb be twelveinches, the anterior flap BY W. HUGHES WILLSHIRE, M.D. EDIN., should be three inches, and the posterior six inches long, the PHYSICIAN TO THE ROYAL INFIRMARY FOR CHILDREN, &c. knife having transfixed the soft parts so as to make the anterior or shorter flap seven inches at its base, and the posterior or No. IV. longer flap fiveinches. By this method the measured cut surface of the anterior is exactly the sameas the posterior flap; 1. Abscess of the Cerebellum, &c.—R. Ta,little girl, both, consequently, lie together without strain or puckering, three months old, and of a fair, strumous appearance, was and the divided surface of the bone or bones is not in contact brought to the Infirmary on the 22nd of September. According to the mother her child was suddenly taken ill two days before. with the cicatrizing soft parts. The following cases, of which casts have been made, clearly She then had a wild look, rolling of the eyes, and some diffishow that union is very much assisted, rapidity of cure effected, i culty of breathing. A leech was applied to the chest, which relieved the latter disturbance, but there had remained a stiffand an useful stump formed by this mode of amputating. Eliza C-, aged thirty-three years, was admitted under ness of the neck, and inclination to keep the head bent back the care of Mr. Wakley, being sent to the hospital from Hert- ever since. When seen by me the head was thrown back very fordshire to have her thigh amputated, on account of extensive stimy, the mouth kept half open, appearing as if tightly reo disease of the knee-joint. Every means were attempted to tained so by the depressor muscles. The fingers were strongly excite healthy action in the affected knee-joint, but without iiiflexed, and the thumbs firmly doubled under them. The The disease rapidly increased, and disorganization of cranial bones did not appear loose atthe sutures, nor was there success. the articulation supervened, with the accompanying dangerous any overlapping of the occipital bone by the parietals, or pres. deterioration of her general health. The thigh was removed sure inwards on the brain by the former. The anterior fomaat its lower third, by the double flap operation. The parts nelle was not elevated. The respiration was peculiar, not united almost entirely by the first intention, and in six weeks easily describable; for a few seconds it seemed to stop sud. the patient left the hospital with a very excellent stump. denly, then as if by a voluntary determination on the part of James M—, an Irish brickmaker’s labourer, was admitted the child, very quick respiratory efforts were carried on fora with a compound fracture of the leg and extensive laceration few seconds longer. There had been no shrill screaming, nor of the soft parts. The haemorrhage at the time of admission anv convulsions, but the child stared in a strange manner, and was profuse, but checked in the usual way. The parts were had not slept, according to the mother, for an hour during the brought together and carefully retained so, but in six weeks past night. There was often a low whining or moaning great sloughing and profuse discharge commenced, no attempt sort of cry, and the child sucked with difficulty. There had at union taking place. The man was evidently sinking by been no vomiting, and the bowels were moved once or twice the wasting consequent upon the unsuccessful attempt at during the day. The mother had had five children, and apreparation. The leg was amputated immediately below the peared healthy. She was doubtful if the present was not born knee by the double flap operation. For some days afterwards before the full period of gestation; from the look of the child ’ the patient was in danger, but eventually was discharged, the mother’s idea that it was so would be corroborated. The treatment mainly consisted in leeches to the temples, blisters fully evidencing the valuable stump made by this operation. Eliza P-, aged five years, a very healthy-looking child, behind the ears, purgatives and salines. The little patient was admitted with a severe laceration of the right forearm, continued much in the above condition for six days. On the comminuted fracture of both bones in the upper third, and sixth day, soon after I had seen it, convulsions supervened, anel complete disorganization of the wrist-joint. Mr. Wakley there was some faint screaming. When I saw it on the 7th, it amputated the forearm within an inch of the elbow-joint, by appeared much in the same state as before, except that the the double-flap operation. Fever and delirium followed the countenance was paler, and there was a trembling of the lower operation; these, however, subsided under the influence of jaw. A blister was now applied to the nucha, as high up as it citrate of ammonia in effervescence, and the child was dis- could be placed, and the surface of the sore ordered to be kept charged with an excellent stump, six weeks after the opera- discharging by savine ointment. Half a grain of calomel was tion. It was an interesting fact connected with this case, that desired to he given every two hours. This was not so exhibited although the amputation was performed in such close proximity at first by some mistake, but was regularly given afterwards. to the joint, the latter has retained all its normal movements. Improvement appeared to ensue from this treatment. On the Ellen R-, aged thirty-one years, of intemperate habits, 3rd of October it was noted down that the child was evidently was admitted, under the care of Mr. Wakley, with a compound better; that there had been no convulsions for two days; that comminuted fracture of the right arm. She stated that whilst there was far less rigidity of the neck, or stiff recurvity of the staggering along she fell from the pavement, and an omnibus head; that it took the breast far more readily than it had done since first seen by us, and that in tine the little thing appeared over her arm immediately above the elbow-joint, the braehial artery being much lacerated. After an examination far more comfortable. The calomel was gradually reduced to of the arm, it was determined to attempt saving the limb; but every four, six, and eight hours, when on the 6th of October the next day gangrene of the forearm and hand commenced, the patient was put on cod-liver oil, as the only symptoms and the arm was amputated by the double-flap operation, just were those of emaciation and debility. On the 9th, untoward below the shoulder-joint. The woman was discharged with an symptoms again appeared, the child was uneasy, rolled the head from side to side; there was vomiting, but the bowels excellent stump, seven weeks after the accident. Jane A-, aged seventy-six, was admitted, under the care were regular. The next day convulsions came on, the head of Mr. Wakley, with a compound comminuted fracture of the was much shaken, or rolled at intervals, the eyes again had tibia and crushed knee-joint. Amputation at the lower third their peculiar stare, and the stiffening of the neck, and bending of the thigh was performed, and the patient is now conva- back of the head returned. During the afternoon of this day it lescent, with a very good stump, notwithstanding her ad- was evident that the child could not see-a fact about which there had been some doubts before. Towards the evening vanced age. Charles C-, aged fifteen years, a sickly and debilitated death closed the scene. At the autopsy, about forty hours after death, the following lad, a telegraph-runner atthe Northern Railway, was admitted with his left foot crushed by the passing over it of an express lesions were observed by iair. Tucker and myself: - Body engine. The mutilated foot was removed at the ankle-joint, greatly emaciated; the flngers and toes strongly incurved; a flap being formed from the external malleolar integument, skull thin, but could not be cut by the scissors; meninges which was tolerably sound. Three days afterwards the soft somewhat congested, but not much so. On the convexities of£ parts about the ankle-joint had sloughed, leaving the lower the cerebrum some slight amount of yellowish semi-purulent portions of the bones of the leg exposed. Amputation at the matter was observed here and there in the sulci, and alongthe lower third of the leg was then performed by the double-flap course of one or two vessels. Nogranulations to be seen along operation. The boy, under the influence of generous and the margin of the hemispheres. The brain matter felt soft. On attempting to remove the brain from the skull, before nourishing diet, is now convalescent. S. W—, aged ten years, was admitted with both legs cutting down upon the ventricles, the former began to yield crushed by a railway engine passing over him. In the absence and tear from softness, and as much as two ounces of green of Mr. Wakley, Mr. Lane, the house-surgeon, amputated botb sero-purulent fluid apparently ran out from the spinal canal, as legs, the right at the lower third, and the left at its middle. the brain, &c., were being held forward whilst dipping down This boy has been the subject of a very rapid cure, and the to cut them off at the medulla oblongata. On the contents of the cranium being removed it was discovered that the greater stumps do the young operator great credit.

passed

35

portion of this

fluid had been pressed by the hand from out an abscess in the cerebellum, the whole central part of which was hollowed out, and still contained some bright green pus in its cavity. The medulla oblongata was soft and rough on its anterior surface, as if acted on by the purulent matter which invested it. There appeared to Mr. Tucker and myself to be On a thin cystic lining to the cerebellar abscess. away the brain to get to the ventricles from above downwards pure and green purulent matter poured from each cavity. It was thought as much as three ounces must have been present in each ventricle. The lining membrane was thickened and very vascular; the choroid plexi thickened, firmly glued down by the lymph, and covered by a false membrane, easily raisable with the forceps. The spinal cord, as far as it was examined, (cervical and upper dorsal portions,) was healthy, at least there was no effusion or exudation found upon it, nor was it softened in the least. There was congestion of the rachidian meninges, assumed to be due to position and cadaveric change. The lungs were free from tubercular deposit. I am not aware of abscess in the cerebellum having been recorded of one so young as in the above case. Mauthner relates all example of what he calls " cerebellitis" in a boy four years of age; and Abercrombie alludes to abscess " of the medulla oblongata where it is crossed by the pons Varolii" in a child sixteen months old. Its association in the present case with ventricular abscess, the want of any very marked lesion of the convexities, and the absence of granular and tuberculous deposit in any organ examined, are points permitting of particular mention. The stiffness of the muscles and recurvity of the neck, the staring expression of the eyes, and peculiarity about the mouth, were to me the marked phenomena, whilst more stress was laid upon rolling of the head by the relatives than personal observation warranted me in doing. The diagnosis formed was somewhat at variance with the necroscropic phenomena. It was thought the cerebrum and ventricles were not engaged in the mischief, that the base of the brain 1ni{Jht be involved, but that undoubtedly the upper part of the spinal cord or its membranes were affected. No consideration was paid separately to the cerebellum. If there had been more pyrexia when the child was first seen, a suspicion might possibly have arisen that I had a case before me simply of remittent fever, in which that affection of the neck and upper part of the spine noticed by Heberden, Underwood, Joy, and myself, existed in a delusive intensity; but the want of any pyrexia, idiopathic or reactional, the stare of the eyes, the appearance of the mouth, and peculiar anxiety of the countenance, together with the flexure of the toes and fingers, dismissed this view of the matter. The opisthotonic signs and the affection of the mouth led me to the spinal cord. On noticing the latter, I was reminded of the peculiar look and contraction of the mouth to a point given as a diagnostic sign of trismus nascentium by Verson and Manthner, and for whose alliance with apoplectic conditions of the spinal cord and its membranes much may be related, (vide West and Weber.) The right interpretation of the rigidity of the muscles of the neck sometimes met with in remittent fever, and before alluded to, I am now not satisfied of, at any rate so far as applies to that variety marked by unmistakeable recurvity or throwing back of the head. It may be asked, in reference at least to these latter cases, which occasionally occur, if we have not mistaken a reactional or symptomatic fever for a primary or idiopathic one? or, if such are not in truth examples of some primary affection, however slight, (perhaps rheumatic,) of the base of the brain or upper part of the spinal cord, instead of being instances of remittent fever, with rheumatism of the cervical muscles? Had it been observed that these cases of remittent fever, with cervical muscular stiffness and recurvity, were usually witnessed together at a particular time, as if in the same epidemic, some support might, I think, undoubtedly be given to such a view of the matter. A perusal of the interesting papers of Drs. Derby and Mayne on the "Epidemic Cerebro-spinal Meningitis " occurring to children in Ireland, of the observations of appeared at Schélestadt, (Bas-Rhin,) and in particular of the memoir of Dr. Ames (Montgomery, U.S.) on a like affection also attacking adults, -will render one the less disposed to deny that it is possible such cases as we have alluded to may be examples of some slight irritation of the meninges at the base of the brain or upper part of the cord, with marked symptomatic fever. Dr. Darby’s cases, though fatal, were regarded by him as the expression of an epidemic constitution, which might at a future period giverise to a less dangerous type of disease as its influence became more generally diffused. Now, it may be that

slicing

Mistier uponan epidemic which

this

"

less dangerous type of disease" already existed, and had. and still is, confounded with remittent fever, complicated with affection of the neck and spine ? Dr. Ames specifically notices the " remissions of fever, as if the meningitis were engrafted on an ordinary endemic fever." (See also Ranking’s Reports, vols. iii., iv., vi., x.) It may be replied that the cases under discussion are nothing but remittent fever, with some slight congestion of the vessels, or irritation at the base of the brain or rachis, of a secondary character, giving rise to the muscular contractions ; and, on the other hand, great stress may be placed on the fact of a rheumatismal and a very painful affection of the muscles, especially of the upper part of the trunk, most undoubtedly forming a very frequent complication of primary remittent fever in children. A further discussion of this matter, however, would be here out of place; and I shall only remark that I have known one of the resident surgeons of the Infirmary-a person by no means of superficial acquirement in pœdiatrics—maintain that it was often impossible to say whether the symptoms we have been dwelling on might not turn out to be those of true tubercle of the substance of the cerebrum. C. F-, a girl, eleven years of age, living near the Infirmary, became a patient under my care on the 15th September, 1853. When first seen, the symptoms were those of simple fever, indicating, from the dryness of the tongue, and some anxiety of countenance, the approach to a low or typhoid character. She complained most bitterly of pain over the brow. There was some sickness, and which had been before rather troublesome, but there was no constipation. There was a slight purulent discharge from both ears, which, according to her mother, had existed with intervals of cessation for two or three years. Leeches were applied behind the ears, a blister to the nape of the neck, the hair was cut shorter, and a mixture of soda, hydrocyanic acid, and calumba, given. She continued much in the same way until the 18th, when the discharge from the ears ceased, the bowels became costive, and the pain in the head was still more complained of. The head was shaved, a blister applied to the vertex, a bladder of ice to the brow, and purgatives administered, in addition to the previous internal remedies. Poultices were directed to be applied to the For four days matters continued in the same state. On ears. the 23rd the strong tartar-emetic ointment was freely applied to the blistered surface of the vertex. Much irritation was produced by it, and it was evident that a considerable slough would be the result; still this was little heeded, as between the 23rd and the 26th such improvement ensued that it was thought the patient was rescued. The tongue became clean, then moist; the pain of head greatly diminished, and at last was scarcely alluded to; some amount of appetite returned, and the quiet submissive little patient expressed a desire to get up. On the 28th she was not so well; the tongue became dry, and somewhat glazed, and she complained much of her head, and insisted upon having the ice put to it. On the 29th she was still worse; she lay on her back, frequently crying out in a somewhat low voice, "my poor head,""my poor head,"and requested those near her to press it hard. She had full possession of her mental faculties, and showed great feeling towards her mother, calling her endearing names, while she requested her not to cry so, as if it added to her own sufferings. There was a remarkably copious secretion of urine; the tears were secreted also, and the bowels were regular; the slough on the scalp was separating. On the 30th the tongue was still drier and more glazed; the pulse had a peculiar and methodically slow pulsation of from 50 to 55 beats per minute; the headache was not complained of, but she said that she felt so funny that she did not know how she felt. On October 1st the patient was evidently worse; the countenance was very anxious; the brows were knitted ; the pupils appeared more dilated than before, though her mother said (on its being pointed out and explained) that her daughter always had large pupils, and she has such herself. She kept saying ’’what shall I do?" the pulse scarcely was equal to what it was yesterday, and was of the same methodically slow yet decisively marked character. The intellect was entire ; the bowels moved thrice in the twentyfour hours, and there had been some vomiting. The next day my interesting and patient little sufferer was evidently sinking. The pulse was scarcely 50, and much weaker; the brows were now not knitted, and the countenance was less anxious, and less expressive of acute suffering, but more subdued and oppressed. She sighed and moaned deeply at intervals. There was no vomiting, no action of the bowels, and her mother stated that she had complained since I saw her yesterdav of loss of sight occasionally. There had been no strabismus; she took nothing. On the 3rd of October the only additional symptoms noted

been,

"

36 what her mother called "three fainting fits." Death pill, and to be taken at bedtime. To use ablutions of soap occurred at four the next morning. Most unfortunately no and water, and to throw half a pint of cold water up the bowel after each stool. post-mortem examination could be obtained. I assume this case to have been one of abscess of the central March 10th.—The pill acted freely. Has less uneasiness portions of the hemispheres, and in connexion with the long- this morning. To take three grains of blue pill, and two of standing disease of the organs of audition. It may be parallel- extract of centum, every second night; and a draught every ized with the case I related in my first paper, (The LANCET, morning of compound infusion of gentian, half an ounce; comvol. ii. 1853, p. 348,) under "Abscess of theBrain." It may pound infusion of senna, an ounce; Rochelle salts, a drachm also not be without instruction when viewed in association and a half.Tocontinue enemata and ablutions. with Abercrombie’s remarks (sect. i.) on the deceptive remis22.nd.-Hehas continued the remedies. All the symptoms sion of some forms of cerebral disease; and it may likewise have subsided, and his general health has greatly improved. aerve as an illustration of some of the therapeutic views proTo omit the pill, and to take the draught twice a week, ana mulgated in regard to counter-irritation by antimony on the to use the soap and water. vertex in the late work of M. Hahn, "Sur la Meningite April 5th.—Has had no return of the hæmorrhoidal affecTuberculeuse." tion; the mucous membrane of the bowel perfectly healthy in appearance. Internctl Hæmorrhoids; much 10s8 of Blood, attended with REPORTS OF Giddiness and Drowsiness.—R. R—, aged thirty-eight, wa.s CASES OF DISEASES OF THE RECTUM. advised to consult me by my friend Mr. Bennett, surgeon to the Dioimsbury Infirmary. About fourteen years since, he BY T. J. ASHTON, ESQ., M.R.C.S.E., have continued to first suffered from external were

piles,which

BLENHEIM DISPENSARY, AND FORMERLY HOUSE-SURGEON, AT UNIVERSITY COLLEGE HOSPITAL.

trouble him more or less up to the present time. Eight years he experienced pain within the anus. and a sensation of ago, (Continued from page 162, vol. ii., 1853.) the presence of a foreign body. Defecation was difficult, with increase of pain and haemorrhage; and that period he has continued to lose a considerable quantity of HEMORRHOIDS. blood at intervals; lie has also been annoyed by a constant THE cases narrated, in THE LANCET of August 20, 1853, were discharge of mucus from the bowel. He has alwaysbeen or those covered the by examples of external haemorrhoids, and suffered from flatulence, pains in thin integument of the anus, and situated superficially to the subject to constipation, the abdomen, giddiness of the head, and depression of spirits. external sphincter muscle. Others differing in situation and habits of life are temperate. in the tissues involved, arising from various causes, are of fre- His ! He came to me on the 10th of November, 1832. His counthan the are more constantly annoying quent occurrence; they tenance was sallow; eyes dull; lips and gums pale; tongue external form of the disease, and when they have existed some furred; pulse frequent and irritable; bowels acting scantily length of time react powerfully on the system generally. and irregularly; has little power in retaining the faeces during Mucous the attended Membrane of Congestion of the Rectzzan, the bladder is irritable, and he has some 2cillz great pain.-A. S-, ageci thirty-two, a carver, of any violent exertion; in difficulty micturatiug. The analorifice is surrounded by ordinary stature and conformation, bilious temperament. Some a margin of loose skin. evidently collapsed external piles; the since he suffered of from the bowels; latterly years irregularity ani is relaxed. On introducing the finger within the sphincter he has been very costive. In the early part of November, two large internal haemorrhoids were felt; these were 1852, he experienced great pain at stool, also aching and ex- intestine, a very slight effort of straining; the mucous memextruded by treme discomfort at the fundiment while at work; this was brane was then seen in a granular state. He informed me that. sometimes so severe as to compel him to go home. Slight the hæmorrhoidal tumours descended by walking, or riding In bleeding from time to time took place. He applied at the any vehicle that shook him much. Totake six grains cf extract Blenheim Dispensary, December 1852, complaining of of taraxacum and three of blue pill every night, and in grains at the fundiment. great pain the morning a teaspoonful of an electuary, ccnnpouncied of cc.nEXamination.—On separating the margins of the anus, the fection of senna, sulphur, bitartrate of potash, jalap, copaiba. mucous membrane was observed to be congested, and the hæmorrhoidal veins turgid. Digital examination revealed no ginger, and a sufficient quantity of syrup. To use ablutions of distinct tumours. The speculum ani showed the whole mucous soap and water night and morning. Nov. 14th.—Has taken the medicines ordered; the bowels membrane within the limits of the internal sphincter in the have acted every day, but not freely; passed some clots of same condition as at the margin of the anus. His tongue was blood yesterday, and this morning a tablespoonful of bright coated and notched; the countenance heavy and anxious; blood. To continue the medicines. more than bowels had not been moved natural; pulse frequent 17th.-Has had very little pain, and passed but a small the last two days. Fivegrains of grey powder and one drop of blood; still complains of drowsiness and giddiness. of croton oil to be taken every night; to wash the anus night quantity Examination of the urine demonstrated an excess of urea, and and morning with yellow soap and water, and to use half a under the microscope numerous crystals of oxalate of lime were pint of cold water as an enema after each dejection. To take an ounce of the following mixture twice a day: seen. He took one of the pills prescribed on the three following infusion of ten ounces; sulphate of magConlpound nights; the bowels were freely acted on, and he felt much less nesia, one oance; dilutegentian, acid, a drachm and a halil sulphuric fullness and aching in the rectum. Ordered to omit the pill, To inject half a pint of water containing sixteen grains of and to take a teaspoonful of a laxative confection every night; of zinc after each evacuation of the bowels. to continue the ablutions, and to use the enemata ofcold sulphate Dec. 1st.—He hastaken the medicines regularly, andused water. the enemataas directed. Feeling so much better he did not In three weeks he was free from all disease, and by having think it necesuary to see me at an earlier period; has had no recourse to the electuary occasionally, if the bowels were at all sanguineous discharge the last twelve days; a slight mucous well. he has continued confined, perfectly discharge continues; he can now retain his faeces during exerInternal Hæmorrhoidal Tumours in an early stage cured.— tion. He was drowsy on one occasion since his previous visit J. S-, aged nineteen, a shoemaker, came under my care at to me, but is not so now; his eyes are bright; countenance the Blenheim Dispensary last year, affected with svphilitic clear; pulse 76; the irritability of the urinary organs hass lepra, for which a solution of bichloride of mercury and arsenic ceased. was ordered, and he progressed favourably. On the 8th of 15th.—Has continued the medicines, and expresses himself March, 1853, he complained of having for three or four days ex- as feeling better than he has for many years; his countenance perienced pain, weight, and throbbing in the rectum, increased is clear and healthy; pulse regular; appetite good; he does at stool, and attended with the discharge of a small quantity not suffer from flatulence; has gained strength, and does not of blood. For several weeks his bowels have been constipated, feel fatigue after an ordinary amount of exercise. To inject and he has sat at work from an early hour in the morning till cold water only after each stool. late at night. His eyes are dull; the sclerotic conjunctiva This patient visited me a few weeks since he has continued slightly tinged yellow; tongue furred, and the teeth indented to take the medicine occasionally, and has not omitted the ininto the pulse quicker than natural; skin hot and dry. jection of cold water; the only annoyance he experiences is a On examining the rectum, the mucous membrane was observed mucous discharge from the anus. I examined the bowel; the to be congested, and several small purple lumps were seen internal piles were still 1,,i,rge, but not turgid ; the mucous memimmediately within the margin of the sphincter. Five grains brane in a much healthier condition. Removal of the piles of grey powder and one drop of croton oil to be made into a was advised in the first instance, but his occupation prevented

SURGEON TO

THE

attended

7th,

edges;

fror.f