day. APPENDIX. No. 11. On The attacks have taken place at the following hours; viz,On the 24th and 25th at half-past three in the afternoon; on the 26th at 9.30 p.m.; on the 27th at 10.30 p.m.; and on the 28th at midnight. March 1st.-Pain in the nape and back; tongue slightly coated Cerebro-Spinal with white fur; pulse 108. Five grains of quinine were ordered to be taken daily in the afternoon, and a grain of opium at bedtime. March 5th.-For the first time the patient had no shivering; the quinine was discontinued. March 16th.-During the preceding night and this morning the patient again shivered, and vomited three times; pulse 108. ordered to take Seltzer's water ad libitum. He was March 17th.-In the morning the pulse was 80. In the afternoon there was a violent attack of shivering, with increased headache and pain in the back, and great hyperesthesia of the lower limbs down to the toes; pulse in the evening 120. He was ordered a grain and a half of hydrochlorate of quinine with one twelfth grain of morphia every three hours; 24 cupping glasses to be applied to the nape and spine, 16 to be without scarification; ice to be applied to the head. March 18th. The patient slept quietly during the night, and does not complain of much pain. There has been no shivering nor vomiting, but the skin perspired freely; pulse 76; bowels have not acted for the last 36 hours. March 20th.-General state satisfactory; perspiration increased; pulse 96. March 21st. The deafness, which was before almost complete, appears to decrease; pulse 80, respirations 16. April 12th. The patient is convalescent, but is not able yet to leave his bed, from excessive weakness and wasting of the limbs. His hearing improves gradually. Meningitis about the Lower Vistula, by Dr. Sanderson. No. 12.-SUBSTANCE of other COMMUNICATIONS relative to CEREBRO- (a.) From Dr. F. J. BROWN, Rochester, October 15, 1865, and Mr. T. P. ATKINSON, November 4, 1865. No. 12. Communications relative to Cerebro-Spinal Meningitis. Dr. Brown and I.-Case 1.-C. Card, æt. about 20, a domestic servant in the family of a drawing-master at St. Margaret's, Rochester (one of the highest Mr. Atkinson, parts of the city) was seized, on September 17th, 1865, with chills. Next day she had violent pains in the head and all over the body and extremities even to the tips of the fingers. For three days there was excessive vomiting. She was ill 8 or 10 days, and recovered without keeping her bed. Leeches applied over the spine gave very great relief. In this case the nucha was stiff and recurved. Case 2.-E. Jennings, æt. 38, wife of an artizan residing in John street, Rochester, a part of the city presenting indifferent hygienic arrangements, was seized with chills on September 30th, 1865. She attributed the seizure to exposure in a hop-garden on the foggy evening of September 25th. When first seen by a medical man (Dr. J. D. Brown, brother to Dr. F. J. Brown) on October, 3 she had violent pains in the nape of the neck and in the back and limbs. Dr. F. J. Brown saw her on the 6th: she was then sitting downstairs in a chair, curved over to one side, with the neck stiff and recurved. On October 7th she took to her bed. On the 9th she was seized with severe headache and APPENDIX. No. 12. tions relative to - Dr. Brown and Mr Atkinson. vomiting. On the 10th, when seen again by Dr. F. J. Brown, she was lying diagonally across the bed upon her left side, with her fore-arms flexed on the elbows and rigid, occasionally jerking spasmodically. The Communica- pupils were dilated and fixed: there was no strabismus. She was talking Cerebro-Spinal now and then to imaginary auditors, but when loudly spoken to turned Meningitis. her eyes without turning her head, and she tried to put out her tongue when directed so to do. The tongue was red, with some yellowish fur, and bare portions. The pulse was uncertain, from 110 to 120, without The faces (dark and offensive) escaped in the bed. The urine power. was retained, and the catheter required. No rose-coloured spots and no rash. Her sister stated that the respiration became catching occasionally, and that swallowing appeared likely to cause choking. On October 11th she died at 7 A.M., having been comatose for several hours before death. On examination of the body, 36 hours after death, the skull was found extremely thick and dense [she had had inflammation of the brain when a girl] the membranes were very vascular and of a bright red colour : a large quantity of sero-purulent fluid gushed out on section of the tentorium: the spinal canal, as also the lateral and third ventricles, was full of this fluid, and of flakes of lymph: lymph was infiltrated from the cerebellum to the fissure of Sylvius: the base of the brain was soft and lacerable: the cerebellum of a violet red color and lacerable: the right corpus striatum was softened on its surface into an operculum upon a moderately firm subjacent portion: the pus in every situation looked more like softened lymph mixed with some pus. The spinal cord was not examined. The thorax was not examined. The liver when sliced was of the colour of red lead, and readily converted into soft pulp by scraping with the scalpel: the spleen was turgid, but not softened the kidneys intensely congested, and feeling crispy as if emphysematous: the small and large intestines healthy, except violetred injection of the ileum for about 18 inches of its length not far from the cæcum. The other organs were unaffected. II.-In the previous May and July three cases had occurred which were considered by Dr. Brown as exhibiting symptoms of cerebrospinal meningitis. Case 3. does not appear to have been seen by Dr. Brown. It occurred in the practice of Mr. Steddy, a surgeon of Chatham. A boy, believed to be under 14 years old, the child of working people, was seized suddenly, when witnessing the Volunteer Review on Chatham Lines, with symptoms, so far as Dr. Brown could ascertain, of inflammation of the nervous centres, and died with well marked opisthotonos. Case 4. occurred in St. Bartholomew's Hospital, Rochester, and is reported from the notes of Mr. T. P. Atkinson, resident surgeon to the hospital. The sense Agnes Gray, æt. 32, a widow, residing at Brompton (part of Chatham) was admitted into the hospital, May 25th, 1865, complaining of pains over the whole body and great debility. She appeared very dull and heavy, and her eyes had a very vacant expression. of hearing was much blunted, and the understanding evidently weakened. There was a loud chattering of the teeth about every five minutes, which seemed increased by any slight excitement. The tongue was covered with a moist whity-brown fur. The pulse was scarcely perceptible. She was first seized, she said, about a week before, with rigors, sickness. pain in the region of the heart, followed by pains over the whole body. On the 26th she was wandering: the teeth continually chattering though she appeared somewhat quieter on the whole she complained of pain in the neck and head the eyelids drooped: the axis of the Some indistinct roseseen on the abdomen. APPENDIX. No. 12. -Communications relative to eyes was unequal: the right eye turned in. coloured spots, fading under pressure, were Tenderness existed over the whole surface. The slightest touch caused convulsive twitchings of the arms and face. On the 27th she had still pain in the head: the pupils were equal in size: the eyes occasionally Cerebro-Spinal squinting and staring: she wandered occasionally. On the 28th she Meningitis. seemed better, the pain in the head was less, but there was still a good deal of nervous twitching: the eyes squinted occasionally. There were still a few spots about the abdomen. The skin was moist and perspiring. Mr. Atkinson. The pulse about 98. On the 30th she was not so well: had rigors: more pain of head: twitchings of head, lower jaw, and eyes occurred frequently the tongue protruded slightly to the left side: the mouth was drawn to the right. On June 1st she was much better, and she gradually improved, and was discharged well on the 21st. Dr. Brown observes of this case: "On her admission she appeared half"dead of some extraordinary illness, and it was not known whether it "was fever or brain-disease. But soon the diagnosis of typhoid fever, "with cerebro-spinal inflammatory complications, was established.". Case 5. also occurred in St. Bartholomew's Hospital, Rochester, and is reported chiefly from Mr. Atkinson's notes. Doubts existed whether the case was one of rheumatism affecting the sheaths of the spinal cord, or one of cerebro-spinal neuro-myalgia. Dr. Brown considered it to be the latter. Caroline White, æt. 63, the accident-nurse of the hospital, was admitted into Watts' Ward, July 11th, 1865, with severe pains all over the body. The wrists were somewhat swollen, but nothing in proportion to the pain experienced. She said they had been rather large for some long time past, though she thought they had increased in size the last week or so. She had had wandering pains for at least 3 weeks, caused, as she supposed, by the draughts to which she had been constantly exposed. The tongue was covered with a dryish whity-brown fur: the appetite bad: the bowels confined: the urine scanty and high-coloured. On the 17th she had slight rigors and sickness, flushed face, exquisite pain in the limbs. On the 18th, severe pain in the back of the neck, and in the left hypochondrium: the neck was thrown slightly backwards: the legs bent up to the abdomen: the brows knit. (She looked strange, with a constant frown. F.J.B.) On the 20th the pains which had been easier the day before were worse, but relieved by a small bleeding. (Violent pains in the back shooting through to the præcordia, F.J.B.) On the 22nd, some delirium is reported as having occurred during the night and early part of the morning. The pains were now very acute. Several small slightly elevated brown spots had appeared on the abdomen. (A measly rash appeared on the abdomen: notwithstanding which, the tongue, which was dry and furred at first, was now natural, F.J.B.) On the 23rd there was no delirium: and the pains which had been relieved the day before by leeches had become more severe. By the 26th she was better, though the pains were still very acute at times. August 2nd, she was going on well, but the pains had not by any means gone: the swelling of the joints was rather less. By September 6th she had very little pain, and desired her discharge. (Dr. Brown, in his account of the case, mentions the existence of insomnia, finally overcome by Dover's powders. He says that during the whole illness there was marked recurvation of the nucha, with tenderness : and that since her discharge she still complained of pain about the spine and of stiffness.) She had had no communication with Agnes Gray, and the accident-ward was in a separate portion of the building. Dr. Brown and APPENDIX. No. 12. Communica III.-Dr. Brown also met with two cases of fatal Idiopathic Tetanus in March and July 1865. Case 6.-A. Sage, æt. 27, residing at Borstal, 1 miles from tions relative to Rochester, having old ulcers on the legs, was seized March 25th, 1865, Cerebro-Spinal without assignable cause, with symptoms of tetanus, was admitted into Meningitis. St. Bartholomew's Hospital March 28th, and died on the 29th. Dr. Brown. Case 7.-Occurred in the practice of Dr. John D. Brown. A Labourer, æt. 59, residing in Delce Lane, Rochester, a place of bad hygienic conditions, was seized July 17, 1865, with trismus. He had lain out of doors at night, drunk, a short time previously. Opisthotonos set in July 21st, and for days he was curved on occiput and heels. He died July 30. Dr. F. J. Brown says that in the practice of several surgeons at Chatham and Rochester there were in the summer of 1865 numerous cases of persistent vertigo, with headache and pains in the nucha. He also reports that there had been several cases of congestion of the spine in its dorsal and lumbar portions: two of them threatening paraplegia. Dr. Clapton. (b.) From DR. CLAPTON, Assistant Physician of ST. THOMAS'S HosPITAL, Oct. 24th, 1865. I have endeavoured to call to mind some of the cases of cerebrospinal meningitis which have fallen under my immediate observation. In no instance did it occur idiopathically, but as a complication, usually fatal, during the progress of some zymotic affection. Of course I speak of those cases in which the meningitis was well marked; but for a period of at least two years I have noticed that very many diseases have been complicated with peculiar cerebro-spinal symptoms, such as I used not formerly to observe; and, in conversation with other medical men in the course of my practice, I have not unfrequently heard confirmatory remarks as to increasing tendency of diseases (principally exanthematous) to take on this peculiar type. The following are a few of the cases the particulars of which I distinctly remember : Case 1.-A child, aged 4, at Clapham Common, was attended by Dr. West, Mr. Taylor, and myself. Had a most severe attack of scarlet fever in February last. Became very delirious on the 15th day after the first appearance of the rash. Up to this time was not thought to be in danger. No albuminuria; no typhoid condition; no throat mischief. The delirium was attended with vomiting and much general excitement. In the course of the following day distinct and violent tetanic convulsions with opisthotonos occurred, in one of which the little girl died in my presence. Case 2.--A boy, æt. 12, at Blackheath, attended by Dr. Farre and myself (about a year ago). He was just recovering, seemingly without a single bad sign, from a mild attack of scarlet fever, when he was suddenly seized (about the 12th day) with intense headache, strabismus, and violent vomiting. These symptoms were speedily followed by general convulsions, which lasted a considerable time, and were succeeded by more or less unconsciousness, irregularity of pupils, retraction of head, slow and very irregular pulse, and hard and tense abdominal muscles. He unexpectedly recovered. There was only a trace of albumen in the urine throughout the entire illness. He has been subject ever since to headache, flushing of the face after the slightest excitement, and an irregular and intermitting pulse. APPENDIX. No. 12. Communications relative to Case 3.-A lady at New Cross, recently attended by Dr. Downing and myself. She was just recovering from a very mild attack of scarlet fever (which occurred a few weeks after confinement) when she was seized with violent maniacal delirium, vomiting, and occasional paroxysms of tetanic convulsions. No febrile symptoms or dyspnoea. Cerebro-Spinal Face very pale; eyes fixed; pupils contracted. Constipation, and Meningitis. retention of urine. When I last saw her (about a fortnight ago) I did not think she would recover, but I have heard to-day that she is still living, but, although in other respects well, there has been no cessation. of her maniacal state. Case 4.-A boy at Brixton, whom I saw about a year ago, but only once in consultation. He was then delirious, and I was since informed died the same night in an attack of opisthotonos. Case 5.-A railway porter's child, aged 5, was brought to me from Bermondsey. He was then affected with whooping-cough, but was brought in consequence of the head being drawn back, difficulty of swallowing, and occasional convulsions. The muscles of the neck were rigid, pupils contracted, and the limbs constantly drawn up in a jerking spasmodic manner. The little boy was very listless, but not unconscious. He died two days after, but I did not see him. From the symptoms as described I have little doubt that he suffered from active cerebro-spinal meningitis. Dr. Clapton has since (Jan. 8th, 1866) written further :-I inquired of several members of the West Kent Medico-Chirurgical Society, at one of their meetings, whether any cases of this disease were at that time under their care. I found that Dr. Mitchell of New Cross had two such cases, and I gained permission to see one of them with him the same evening. It was characterized by symptoms which left no doubt as to its nature. The patient died the next morning. Dr. Mitchell has since kindly supplied me with the brief notes of the cases which he took at the time. They are the following: Mrs. C., Deptford, age about 34. Was confined early in the morning of the 4th November 1865, and had some hæmorrhage from retained placenta. On the 9th complained of very stiff neck, and inability to swallow no tenderness: not worse in other respects: vomiting once or twice. 10th. Trismus: total inability to swallow: head drawn back: abdominal muscles tense. 11th. Became much worse at 4 a.m. Convulsions: back completely arched: mouth tightly closed: toes drawn toward the soles of feet: thighs bent on to abdomen. Died at 7.40 a.m. No post-mortem allowed. The second case was that of a young girl at Greenwich, who was just recovering from scarlet fever. There was more or less opisthotonos for 8 days, with occasional convulsions. The patient recovered, but has had strabismus ever since, and her intellect has been decidedly impaired. I have lately had 2 cases of idiopathic trismus ; one at the hospital, and one which I saw with Dr. Pocock at Brixton; but I do not think they had reference to the disease in question, although of unusual occurrence. Dr. Clapton. 13614. U |