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THE TREATMENT OF FRACTURES OF THE BASE OF THE SKULL BY REPEATED LUMBAR PUNCTURE.
1026
feeding on materials which contain pathogenic organisms assizes. It is to be observed, therefore, that although the practically in pure culture. It would, he adds, be premature "throwing out " of a bill of indictment by a grand jury is to conclude that these experiments and observations often treated as an emphatic declaration of a prisoner’s described in the report do more than indicate that under innocence, and although it spares him the painful ordeal exceptionally favourable conditions certain bacteria can be of trial by a petty jury, it may operate as a hardship. recovered from the contents of the alimentary canal and faecal deposits of infected flies for some days after infection, and that these flies are capable for several days of infecting certain materials on which they may feed. The experiments with tubercular sputum and anthracic blood alone afford evidence as to the duration of life, in the contents of the alimentary canal, of pathogenic bacteria taken up under natural conditions. After quoting a number of instances recorded by other observers, at home and abroad, in which flies have been shown to have become grossly infected under natural conditions, it is pointed out that even these observations only prove that cultures of pathogenic organisms may occasionally be obtained from naturally infected flies ; they do not afford conclusive evidence that such flies are a frequent source of disease in man by infecting his food. We are glad to learn that Dr. Graham-Smith hopes to continue these valuable investigations with naturally infected materials, not only with musca domestica, but with other non-biting flies. Appended to Dr. Graham-Smith’s report is a summary of literature relating to the bionomics of the parasitic fungus of flies (Empusa muscse) by Dr. J. M. Bernstein ; and also a note by Dr. S. M. Copeman as to the work in hand, but not yet published, and as to proposed further work in reference to flies as carriers of infection.
THE CASE OF SURGEON-MAJOR BRINGHURST.
FARMAR
WE have been favoured with a statement from SurgeonFarmar Bringhurst, a retired member of the Army Medical Staff, who was recently indicted at the Guildford Assizes upon the grave charge of manslaughter based upon allegations of neglect upon his part, and arising out of the death of his wife at Egham. The grand jury, before whom the indictment was laid, declined to find a true bill upon the evidence adduced by the prosecution, and a verdict of " Not guilty" was formally returned by the direction of the Lord Chief Justice upon the coroner’s inquisition, with the result that Surgeon-Major Farmar Bringhurst was discharged without having the opportunity to give evidence in his own behalf and to corroborate it by that of other medical men. This he was prepared to do, the gist of the testimony at his disposal being that the treatment which he applied upon his own responsibility, and particularly the use of morphia, were proper in view of the symptoms He was, moreover, evinced by Mrs. Farmar Bringhurst. desirous of establishing on oath the fact that it was through yielding to his wife’s urgent wish that he abstained from obtaining the services of a trained nurse, undertaking himself the duties which would have been assigned to her The difficult and performing them devotedly to the end. circumstances in which the husband is placed in a case in which his wife is the patient, and in which alcoholism and the drug habit have induced her condition or contributed to render it almost hopeless, will be borne in mind. We have referred to the accused as not having had the opportunity of tendering evidence owing to the case not coming to trial
Major
because, although
we
are
aware
that, strictly speaking,
have done so when before the magistrates, counsel permits his client to we realise how seldom go into the witness-box at this early stage of the proceedings, if committal is likely to take place in any event, and how impossible it is, owing to the expense, for a person of moderate means to call witnesses before the aoroner, before the magistrates, and yet a third time at the he
might
The accused person may welcome the grand jury’s opinion that there is not a sufficient primd-faaie case againlit him to justify his being put upon his trial, but at the same time may feel aggrieved that as the accusation has been publicly brought, has resulted in his being committed, and has been kept hanging over his head until the assizes, he has not been allowed to do his utmost to establish his complete innocence. Surgeon-Major Bringhurst is entitled to every sympathy in his regret that this opportunity should not have been afforded to him, and we are glad to record that he was willing and ready to make the fullest use of it.
THE TREATMENT OF FRACTURES OF THE BASE OF THE SKULL BY REPEATED LUMBAR PUNCTURE. A FRACTURE of the base of the cranium is
universally
regarded as a very serious condition, one in which the prognosis must of necessity be guarded. According to Chudovszky the mortality in fractures of the cranial vault is 45’3per cent. and in fractures of the base 64’22 per cent. More recent figures furnished by Maclaren are 20’2 per cent. for the former lesion, and 60 per cent. for the latter. It is true that within the last few years surgeons have advocated active interference in such cases to a greater extent : Cushing of Baltimore, for instance, recommends trephining subtemporally, and subarachnoid draining has also been employed. In the hands of skilful surgeons no doubt such procedures arejustified, and in some published cases have been attended with remarkable success. Unfortunately, however, the condition of the patient is frequently so desperate that surgical measures only add to the shock from which he is suffering. A much more simple method, preferable to the pure passivity of medical treatment on the one hand and to the severity of surgical treatment on the other, consists in the reduction of the hasmorrhagic effusion by repeated lumbar puncture. Both in England and abroad cures by this means have been reported. Of course, in the case of cranial fractures the interpretation of statistics is a delicate manner, for among the " cures " it is difficult to exclude the possibility of spontaneous recovery whatever be the therapeutic measures adopted. It can scarcely be doubted, however, that the haemorrhage accompanying the fracture, both from its volume and from the chemical phenomena associated with its absorption, constitutes the chief danger for the patient, and it is precisely this danger which is minimised by recourse to In La Presse Medicale for August 10th lumbar puncture. Dr. Apostolos G. Apostolides, physician to the Ottoman civil hospital in Smyrna, has published the details of two cases of fracture of the cranial base in each of which a complete cure was effected, the credit for which seems to be due to repeated lumbar puncture. The first of these concerned a young man, aged 22 years, who fell a distance of about 36 feet on to his head, and was picked up unconscious, bleeding freely though slowly from the nose, and presenting all the features of fracture of the base. His condition remained so grave that lumbar puncture was suggested more as a palliative than as a remedial measure. Forty cubic centimetres of cherry red sanguineous fluid were withdrawn under considerable pressure, the result being an immediate improvement in the patient’s condition. During the next few days the procedure was repeated three times, the cerebro-spinal fluid being perfectly clear on the last occasion. The patient made an uninterrupted recovery. The other case was somewhat similar, and the success was equally striking. Whatever be
1027 the verdict of the future, cases such as these are sufficiently encouraging to warrant recourse to lumbar puncture instead of the adoption of a waiting policy merely, thus allowing time for the development of infection of the meninges. Hasmorrhagic effusions are excellent media for bacterial germination. -
FAMILIAL HYPERTROPHIC
NEURITIS.
usual and the myelin sheath also is reduced. Degeneration in the posterior columns of the spinal cord, and to a less extent in the lateral columns, is described by Dr. Boveri.
PRECOCIOUS
PARENTAGE.
OUR correspondent in China writes as follows: "The enclosed photograph is of a young couple whose precocious assumption of parentage has created some stir even among the Chinese. The characters round the photograph state that the mother is 8 years and the father 9 years old, but as a child is always reckoned in China as 1 year old at its birth this makes the parents each a year younger. Their names and village are given and the notice also states that in the first month of this year a child was born to them. In the photograph the mother can be seen suckling her child which measured one foot long at birth. The Governor
IN La Semaine Medieale Dr. Boveri of Pavia has described comparatively rare disease to which the term progressive hypertrophic interstitial neuritis " has been applied. In 1889 Gombault and Mallet published an account of a curious case, under the title 11 A Case of Tabes dating from Childhood," concerning a man aged 58 years who presented what were considered to be characteristic symptoms of tabes, but the anomalous feature was that the disease commenced almost in infancy and was associated with muscular wasting of the Aran-Duchenne type. In 1893 Dejerine and Sottas described the cases of a brother and sister who showed the classical symptoms of tabes in the shape of myosis, Argyll-Robertson pupil, ataxia, lightning pains, marked disturbance of sensibility, and loss of deep reflexes, to which, moreover, were added nystag-I The result of mus, scoliosis, and gross amyotrophy. a post-mortem examination in one of these cases was quite unexpected : the peripheral nerves were found to be greatly thickened, as were the spinal roots, especially those of the cauda equina. Evidently a new morbid entity had been discovered. Clinically, there appeared to be an of tabes and muscular atrophy, the underlying amalgam stratum of which was hypertrophic interstitial pathological neuritis. In 1908 Professor Pierre Marie described a family of six, no fewer than four of whom were afflicted with hypertrophic neuritis, but in a special form. The symptoms of tabes were not present to the same extent; the muscular atrophy was practically confined to the lower extremities; intentional tremor was noted, and a staccato articulation not unlike what is found in disseminated sclerosis. Otherwise, the clinical symptoms and signs were the same-scoliosis, wasting of the legs, with the 11 tabetic foot" well marked (a combination of pes equinovarus of Shansi, the province in which the birth took place, sent and pes cavus), absent deep reflexes, loss of sensiofficial particulars to Peking, but in order to make more sure bility, and in particular palpable enlargement of the super- made further inquiries through a Chinese friend who lives I ficial branches of peripheral nerves. That these cases may in the neighbouring city of Tai-yuan-fu. He reports that the be more common than is usually supposed is to be inferred facts are as stated and that the boy is the father of the from the fact that Dr. Boveri mentions another which bad child, but I have been unable to obtain particulars of the been diagnosed as one of Friedreich’s ataxia until the disdevelopment of his or her generative organs, whether the covery that the peripheral nerves were greatly thickened mother had previously menstruated, &c. In Taylor’s Medical revealed the true nature of the condition. From both the Jurisprudence’ a case is mentioned of a mother 9 years old, clinical and the pathological aspect the disease is remarkbut there is no record of so juvenile a father." able. Hypertrophic neuritis is a definitely familial disease that may occur in either of two types (the CHRONIC ECZEMA FOLLOWED BY FATAL Dejerine and the Marie variety). The features common to GANGRENE. both are loss of deep reflexes, gross defect of sensibility, a
IN the British Journal of Dermcctology for July Dr. G. H. amyotrophy of the distal type, scoliosis, club-foot, and the underlying pathological condition. In the Dejerine type, Lancashire has reported a very rare sequel of eczemahowever, further symptoms analogous to those of tabes are pre- gangrene of the skin. A married woman, aged 54 years, was sent-viz., lightning pains, myosis, Argyll-Robertson pupil, admitted into the Manchester and Salford Hospital for Skin true ataxia, also nystagmus and fibrillary contractions. All Diseases in December, 1909, suffering from acute weeping these are absent in the Marie type, but there are found, on eczema of the cruro-genital regions extending over the hypothe other hand, intention tremor, dysarthria, and a muscular gastrium and inner and upper parts of the thighs. On the atrophy which is limited to the feet and legs, not generalised face and neck there was a subacute seborrhoeic dermatitis. as in the first form. Pathologically the peripheral nerves A chronic aural discharge was present. The patient was are enormously thickened-in one case the sciatic nerve, well nourished and did not appear to have lost strength. 5 centimetres below its point of exit from the pelvis, was She had been treated for the eczema for over a year, during there had 19 millimetres in transverse diameter. The increase is due almost entirely to great overgrowth of the sheath of few days after Schwann ; there is less actual interstitial change, while from the upper the axis-cylinders themselves seem to be more slender than genital region it
which
been improvement and exacerbations. A admission the eczema had disappeared part of the body, but in the cruroremained obstinate. On Dec. 31st there
feeding on materials which contain pathogenic organisms assizes. It is to be observed, therefore, that although the practically in pure culture. It would, he adds, be premature "throwing out " of a bill of indictment by a grand jury is to conclude that these experiments and observations often treated as an emphatic declaration of a prisoner’s described in the report do more than indicate that under innocence, and although it spares him the painful ordeal exceptionally favourable conditions certain bacteria can be of trial by a petty jury, it may operate as a hardship. recovered from the contents of the alimentary canal and faecal deposits of infected flies for some days after infection, and that these flies are capable for several days of infecting certain materials on which they may feed. The experiments with tubercular sputum and anthracic blood alone afford evidence as to the duration of life, in the contents of the alimentary canal, of pathogenic bacteria taken up under natural conditions. After quoting a number of instances recorded by other observers, at home and abroad, in which flies have been shown to have become grossly infected under natural conditions, it is pointed out that even these observations only prove that cultures of pathogenic organisms may occasionally be obtained from naturally infected flies ; they do not afford conclusive evidence that such flies are a frequent source of disease in man by infecting his food. We are glad to learn that Dr. Graham-Smith hopes to continue these valuable investigations with naturally infected materials, not only with musca domestica, but with other non-biting flies. Appended to Dr. Graham-Smith’s report is a summary of literature relating to the bionomics of the parasitic fungus of flies (Empusa muscse) by Dr. J. M. Bernstein ; and also a note by Dr. S. M. Copeman as to the work in hand, but not yet published, and as to proposed further work in reference to flies as carriers of infection.
THE CASE OF SURGEON-MAJOR BRINGHURST.
FARMAR
WE have been favoured with a statement from SurgeonFarmar Bringhurst, a retired member of the Army Medical Staff, who was recently indicted at the Guildford Assizes upon the grave charge of manslaughter based upon allegations of neglect upon his part, and arising out of the death of his wife at Egham. The grand jury, before whom the indictment was laid, declined to find a true bill upon the evidence adduced by the prosecution, and a verdict of " Not guilty" was formally returned by the direction of the Lord Chief Justice upon the coroner’s inquisition, with the result that Surgeon-Major Farmar Bringhurst was discharged without having the opportunity to give evidence in his own behalf and to corroborate it by that of other medical men. This he was prepared to do, the gist of the testimony at his disposal being that the treatment which he applied upon his own responsibility, and particularly the use of morphia, were proper in view of the symptoms He was, moreover, evinced by Mrs. Farmar Bringhurst. desirous of establishing on oath the fact that it was through yielding to his wife’s urgent wish that he abstained from obtaining the services of a trained nurse, undertaking himself the duties which would have been assigned to her The difficult and performing them devotedly to the end. circumstances in which the husband is placed in a case in which his wife is the patient, and in which alcoholism and the drug habit have induced her condition or contributed to render it almost hopeless, will be borne in mind. We have referred to the accused as not having had the opportunity of tendering evidence owing to the case not coming to trial
Major
because, although
we
are
aware
that, strictly speaking,
have done so when before the magistrates, counsel permits his client to we realise how seldom go into the witness-box at this early stage of the proceedings, if committal is likely to take place in any event, and how impossible it is, owing to the expense, for a person of moderate means to call witnesses before the aoroner, before the magistrates, and yet a third time at the he
might
The accused person may welcome the grand jury’s opinion that there is not a sufficient primd-faaie case againlit him to justify his being put upon his trial, but at the same time may feel aggrieved that as the accusation has been publicly brought, has resulted in his being committed, and has been kept hanging over his head until the assizes, he has not been allowed to do his utmost to establish his complete innocence. Surgeon-Major Bringhurst is entitled to every sympathy in his regret that this opportunity should not have been afforded to him, and we are glad to record that he was willing and ready to make the fullest use of it.
THE TREATMENT OF FRACTURES OF THE BASE OF THE SKULL BY REPEATED LUMBAR PUNCTURE. A FRACTURE of the base of the cranium is
universally
regarded as a very serious condition, one in which the prognosis must of necessity be guarded. According to Chudovszky the mortality in fractures of the cranial vault is 45’3per cent. and in fractures of the base 64’22 per cent. More recent figures furnished by Maclaren are 20’2 per cent. for the former lesion, and 60 per cent. for the latter. It is true that within the last few years surgeons have advocated active interference in such cases to a greater extent : Cushing of Baltimore, for instance, recommends trephining subtemporally, and subarachnoid draining has also been employed. In the hands of skilful surgeons no doubt such procedures arejustified, and in some published cases have been attended with remarkable success. Unfortunately, however, the condition of the patient is frequently so desperate that surgical measures only add to the shock from which he is suffering. A much more simple method, preferable to the pure passivity of medical treatment on the one hand and to the severity of surgical treatment on the other, consists in the reduction of the hasmorrhagic effusion by repeated lumbar puncture. Both in England and abroad cures by this means have been reported. Of course, in the case of cranial fractures the interpretation of statistics is a delicate manner, for among the " cures " it is difficult to exclude the possibility of spontaneous recovery whatever be the therapeutic measures adopted. It can scarcely be doubted, however, that the haemorrhage accompanying the fracture, both from its volume and from the chemical phenomena associated with its absorption, constitutes the chief danger for the patient, and it is precisely this danger which is minimised by recourse to In La Presse Medicale for August 10th lumbar puncture. Dr. Apostolos G. Apostolides, physician to the Ottoman civil hospital in Smyrna, has published the details of two cases of fracture of the cranial base in each of which a complete cure was effected, the credit for which seems to be due to repeated lumbar puncture. The first of these concerned a young man, aged 22 years, who fell a distance of about 36 feet on to his head, and was picked up unconscious, bleeding freely though slowly from the nose, and presenting all the features of fracture of the base. His condition remained so grave that lumbar puncture was suggested more as a palliative than as a remedial measure. Forty cubic centimetres of cherry red sanguineous fluid were withdrawn under considerable pressure, the result being an immediate improvement in the patient’s condition. During the next few days the procedure was repeated three times, the cerebro-spinal fluid being perfectly clear on the last occasion. The patient made an uninterrupted recovery. The other case was somewhat similar, and the success was equally striking. Whatever be
1027 the verdict of the future, cases such as these are sufficiently encouraging to warrant recourse to lumbar puncture instead of the adoption of a waiting policy merely, thus allowing time for the development of infection of the meninges. Hasmorrhagic effusions are excellent media for bacterial germination. -
FAMILIAL HYPERTROPHIC
NEURITIS.
usual and the myelin sheath also is reduced. Degeneration in the posterior columns of the spinal cord, and to a less extent in the lateral columns, is described by Dr. Boveri.
PRECOCIOUS
PARENTAGE.
OUR correspondent in China writes as follows: "The enclosed photograph is of a young couple whose precocious assumption of parentage has created some stir even among the Chinese. The characters round the photograph state that the mother is 8 years and the father 9 years old, but as a child is always reckoned in China as 1 year old at its birth this makes the parents each a year younger. Their names and village are given and the notice also states that in the first month of this year a child was born to them. In the photograph the mother can be seen suckling her child which measured one foot long at birth. The Governor
IN La Semaine Medieale Dr. Boveri of Pavia has described comparatively rare disease to which the term progressive hypertrophic interstitial neuritis " has been applied. In 1889 Gombault and Mallet published an account of a curious case, under the title 11 A Case of Tabes dating from Childhood," concerning a man aged 58 years who presented what were considered to be characteristic symptoms of tabes, but the anomalous feature was that the disease commenced almost in infancy and was associated with muscular wasting of the Aran-Duchenne type. In 1893 Dejerine and Sottas described the cases of a brother and sister who showed the classical symptoms of tabes in the shape of myosis, Argyll-Robertson pupil, ataxia, lightning pains, marked disturbance of sensibility, and loss of deep reflexes, to which, moreover, were added nystag-I The result of mus, scoliosis, and gross amyotrophy. a post-mortem examination in one of these cases was quite unexpected : the peripheral nerves were found to be greatly thickened, as were the spinal roots, especially those of the cauda equina. Evidently a new morbid entity had been discovered. Clinically, there appeared to be an of tabes and muscular atrophy, the underlying amalgam stratum of which was hypertrophic interstitial pathological neuritis. In 1908 Professor Pierre Marie described a family of six, no fewer than four of whom were afflicted with hypertrophic neuritis, but in a special form. The symptoms of tabes were not present to the same extent; the muscular atrophy was practically confined to the lower extremities; intentional tremor was noted, and a staccato articulation not unlike what is found in disseminated sclerosis. Otherwise, the clinical symptoms and signs were the same-scoliosis, wasting of the legs, with the 11 tabetic foot" well marked (a combination of pes equinovarus of Shansi, the province in which the birth took place, sent and pes cavus), absent deep reflexes, loss of sensiofficial particulars to Peking, but in order to make more sure bility, and in particular palpable enlargement of the super- made further inquiries through a Chinese friend who lives I ficial branches of peripheral nerves. That these cases may in the neighbouring city of Tai-yuan-fu. He reports that the be more common than is usually supposed is to be inferred facts are as stated and that the boy is the father of the from the fact that Dr. Boveri mentions another which bad child, but I have been unable to obtain particulars of the been diagnosed as one of Friedreich’s ataxia until the disdevelopment of his or her generative organs, whether the covery that the peripheral nerves were greatly thickened mother had previously menstruated, &c. In Taylor’s Medical revealed the true nature of the condition. From both the Jurisprudence’ a case is mentioned of a mother 9 years old, clinical and the pathological aspect the disease is remarkbut there is no record of so juvenile a father." able. Hypertrophic neuritis is a definitely familial disease that may occur in either of two types (the CHRONIC ECZEMA FOLLOWED BY FATAL Dejerine and the Marie variety). The features common to GANGRENE. both are loss of deep reflexes, gross defect of sensibility, a
IN the British Journal of Dermcctology for July Dr. G. H. amyotrophy of the distal type, scoliosis, club-foot, and the underlying pathological condition. In the Dejerine type, Lancashire has reported a very rare sequel of eczemahowever, further symptoms analogous to those of tabes are pre- gangrene of the skin. A married woman, aged 54 years, was sent-viz., lightning pains, myosis, Argyll-Robertson pupil, admitted into the Manchester and Salford Hospital for Skin true ataxia, also nystagmus and fibrillary contractions. All Diseases in December, 1909, suffering from acute weeping these are absent in the Marie type, but there are found, on eczema of the cruro-genital regions extending over the hypothe other hand, intention tremor, dysarthria, and a muscular gastrium and inner and upper parts of the thighs. On the atrophy which is limited to the feet and legs, not generalised face and neck there was a subacute seborrhoeic dermatitis. as in the first form. Pathologically the peripheral nerves A chronic aural discharge was present. The patient was are enormously thickened-in one case the sciatic nerve, well nourished and did not appear to have lost strength. 5 centimetres below its point of exit from the pelvis, was She had been treated for the eczema for over a year, during there had 19 millimetres in transverse diameter. The increase is due almost entirely to great overgrowth of the sheath of few days after Schwann ; there is less actual interstitial change, while from the upper the axis-cylinders themselves seem to be more slender than genital region it
which
been improvement and exacerbations. A admission the eczema had disappeared part of the body, but in the cruroremained obstinate. On Dec. 31st there