CEREBRAL DISEASES OF CHILDREN.

circumstances and symptoms may have been passed over or slightly touched upon, which by others, may be supposed important.

595

be hoped the morbid action within the cranium has not made a fatal progress, the idea may be entertained that by the timely use of appropriate means, it is still possible to avert the threatened danger; but in too many instances, it is to be feared, that when this spmptom has made its appearance, irrevocable injury has been sustained by the brain or its membranes. Sickness and vomiting being such common occurences at all ages and particularly in childhood, and known to arise under very different circumstances, and from such a variety of causes, it is not perhaps a matter of surprise that its value in these cases should not have been duly estimated. With care and attention, however, to all the

it cannot be very difficult to distinguish the persisting sickness and vomiting of the early stage of hydrocephalus, either from that which occurs from teething or from ordinary gastric and intestinal disturbance. In all doubtful cases, it is safer to assume the existenee of cerebral disorder, since no evil can result from such an error of diagnosis. In the bilious remittent fever of children, the complaint most likely to be confounded with hydrocephalus, vomiting, though occasionally occurring, is not a prominent symptom. Whenever sickness takes place in a child, no trouble or time should be considered too great in investigating or searching after its cause or origin. We know that vomiting is one of the first symptoms that follow injuries of the head. It often happens, when a child falls on its head from a chair or table, that the accident is almost immediately succeeded by vomiting, after which it goes off into a heavy sleep, and this is so exactly like what happens in hydrocephalus, that the inference is abundantly clear, that the brain must be suffering either from congestion or more advanced

In the consideration of this subject, it is necessary that the mind of the practitioner should be duly impressed with the value of premonitory symptoms; they will efficiently assist him in appreciating those signs on which his diagnosis is subsequently to be founded. The premonitory symptoms are for the most part made up of some of those phenomena expressive general malaise,-such as languor; listlessness; erratic pains in various parts of the body and limbs; mental irritability; a tendency to constipation, with some form of gastric disorder, leading to imperfect assimila-existing symptoms, and the previous history of the patient, tion of food, and frequently to its sequence-loss of flesh. The complaint is often ushered in with pain of the head, heariness, and a disposition to lie down and doze, and generally with a great dislike to motion of every kind, fretting when disturbed. A due attention to the state of the pulse is of the first consequence; | on this symptom, as is well known, Dr. Whytt bases his division of hydrocephalus into three stages, the first and last being marked by a frequent pulse; the second by a slow and sometimes an irregular one. But all who are practically acquainted with the disease, know that the symptoms of arachnitis are by no means uniform, and that the stages are often remarkable for the great diversity in their duration; in some cases, the early stage of excitement is not observed, whilst in others it may last several days; occasionally the second stage does not appear, or is so slightly marked, as to escape notice. In the discrimination of hydrocephalus from the infantile remittent fever, the observation of the pulse may be made very available, as in the latter disease it is rarely ever slow, and never below the normal standard, even in the remissions from fever. In the slow pulse accompanying diseases of the brain, there is a peculiarity which I do not remember to have seen noticed,—which is, that it is remarkably quickened by the slightest exertion, as turning in bed, &c, immediately resuming its former frequency, as soon as a state of quiescence is obtained. This state of the pulse exists after concussion of the brain. The respiration in an early period of the disease is sometimes quick and irregular, but its general character is that of slowness and inaudibility, with occasional or frequent sighing Strabismus and double vision are common symptoms; but the former is rarely noticed before the case is passing into the third stage, and the patient all but in a hopeless condition, and the latter, either from the tender age of the patient, or the state of the intellect, can seldom be availed of as a means of diagnosis.

The one great and important symptom in distinguishing hydrocephalus from other diseases of children is sickness and vomiting. This symptom is not only important as being more pathognomonic than any other individual one, but occurring at a period when it may

disease.

The high interest with which the subject of the diagnosis of the cerebral diseases of children is invested, is scarcely more important with reference to the safety of the patient than the character of the medical attendant. Unhappily, as has already been observed, a great portion of these cases has a fatal issue, and should he be misled by the too frequently insidious progress of complaint, and thereby have failed to acquaint the parents with the precarious situation of their child, he has not only lowered himself in their opinion, but will have the mortification to reflect that he has let pass a rare opportunity for establishing his reputation for tact and discernment. Next to the kind feelings which are awarded to successful practice, the friends of the sick feel most grateful by being forewarned of the trouble that is to come upon them, and by shewing that no care or skill has been wanting, that might have brought about a more happy result.

4

NOTES ON THE EPIDEMIC FEVER OF RUGBY
AND ITS NEIGHBOURHOOD, DURING THE
AUTUMN OF 1846.

By JAMES PAXTON, M.D.

(Continued from page 535.)

It is usual, especially in large and populous places, and perhaps very justly, to connect continued fever with the idea of organic debility. With these views the chief object in the treatment has been to attempt

to maintain the circulation with wine, cordials, stimulants, and nutritious diet; at the same time, while suppressing relaxation of the bowels by opium, to relieve local determinations by leeches, and to meet morbid irritations by counter-irritation of sinapisms and blisters. With this plan, generally, saline medi

cines and doses of mercury were administered.

In considering the late fever of Rugby, such disadvantages as we have just referred to do not exist. Here the air is without carbon in excess, and altogether untainted by the fumes arising from factories. None of the poor are destitute; every one is living in a comparative state of comfort. It is the custom of those who move in the superior ranks of life to visit and relieve the poor, and in times of sickness they watch over them and administer to their temporal and spiritual necessities. Societies thus constituted have more of the moral and physical elements for maintaining their natural tone in the hour of trial, than is known to exist under circumstances which have lately been reported as prevailing in Scotland and Ireland. It is requested all this may be borne in mind, in accounting for results and deviations in practice, in this place, and for adopting a treatment the very opposite to that which has been recommended by practitioners of great experience and high standing in the profession else

where.

The successful treatment of our epidemic depended on the strictest attention to regimen: errors in diet were fatal. All kinds of stimuli had the effect of

"Whenever the circulation became feeble, wine and stimuli were used in such quantities that could not be supposed to be inert, and the pulse became less frequent and firmer under their use" "Wine is given for this one lesion of the circulation; the support of this peculiar function of circulation is your object all through :"+ with what success we may be able to increasing arterial action, congestions, and cerebral judge by the following statement:-"Several patients disturbance. It was only in the stage of perfect subwere brought into the hospital suffering from typhus, sidence of the malady, that wine could be taken with the tongue was natural, and the pulse 70 or 80, and impunity. I had often to regret the permission I yet the majority died." Other physicians of equal had given to use wine at too early a period. The eminence, have spoken more guardedly when recommost mild species of nutriment were the best for the mending wine, they have entertained suspicions of the patient. Time after time have I known a generous general expediency of wine in fevers, even among the diet, such as beef tea and wine, to derange the viscera, same classes as those just alluded to; observing, that and to have a direct tendency to excite organs already "wine should be given a little at a time, when the too much excited by febrile phenomena, and the consecond sound of the heart is wanting." There is an sequences were invariably a correspondent depression admirable direction given in these words-viz., "Wine of the vital powers. The principle which suggests should be administered when the skin is cold." The wine and the highest nutriment in low fever, in theory epidemics of Dublin, Edinburgh, and of the metropolis, is plausible enough. To oppose what was esteemed have been thought to differ from the epidemics of strength to weakness, is a theory which readily gains rural districts. They may. This much is certain, that an ascendency in the minds of those who are ignorant the constitutions of persons resident in confined situa- of the management of diseases. They are haunted by 'ations, are little prepared to encounter a struggle with the single perception of debility, but the exhibition of an aerial poison. "The very atmosphere of commerwine to counteract the debility, only involved the cial and manufacturing cities undoubtedly deteriorates patient in additional dangers. At the advanced stage the race of men." They are in an unfavourable of fever, wine is the medicinal extreme unction for the position to meet disease. Hence the great mortality patient's dismissal. In the earlier stages it may be of populous districts has been justly attributed to this symbolized by the golden cup filled with abominations. cause. In the London ferer hospitals one in seven There could be no compromise between wine and the die. When we know that there has been a low standard Rugby fever. It was not long before I found, that of health antecedent to the attack, the expectation of either the nature of the fever, or the peculiar habit of a successful issue under a malignant attack, of an persons in this locality, would not allow of the epidemic, is but a forlorn hope. I have gone out of administration of stimulants without decreasing the my way thus far in order that we may estimate the chances of recovery. To give an examplerelative condition of communities and persons becoming the subjects of fevers.

Dr. Alison. Dr. Corrigan. Ibid. Dr. Stokes.
Dr. Williams. Dr. Black, of Liverpool.

Mrs. P., aged 27, was seized with fever, attended by great prostration of strength, and a disordered state of the bowels. Her appearance was faded, and the pulse feeble and frequent. Wine, and afterwards brandy and water, were given in considerable quantities, which

⚫ ON THE EPIDEMIC FEVER OF RUGBY.

$597

The same plan of

reduced him to a mere skeleton.
treatment as before pointed out; was adopted with a
favourable result.

appeared to comfort the feelings and to suppress the diarrhoea. However, on the fifth day most of the symptoms became more serious. The typhoidal influences were fully manifested; the skin was dry and J. B., a boy aged 9, in addition to a severe form of burning; purple redness of the cheeks; tongue loaded typhus, had peritoneal tenderness, and abdominal with hæmotose brown mucus, the teeth and lips tumefaction, which continued seven weeks. Chloride having an incrustation of the same secretion; the of soda was exhibited with occasional doses of chloride pulse was increased in rapidity and diminished in of mercury. As there was a tendency to constipation, strength. I scarcely need observe, that with great tartrate of soda was also occasionally given. When thirst there was not the least appetite. She was aperients were required, this neutral salt or phosphate unable to converse with any one for many seconds; of soda were observed to act with mildness and good her words may be described as muttering and incohe-effect. This boy's diet was solely grapes, chocolate, rent; there was no voluntary control over the sphincters.whey, and toast water. He passed through the worst None could entertain a favourable impression as to the stages of the worst degree of the epidemic. In three result; a very different course of treatment therefore was months his health and strength returned. pursued. Hydrarg. cum Creta, gr. x., was directed; afterwards Liquor Soda Ch. M. xx., e Mist. Camphora, quartis horis. Broth was exchanged for chocolate; raspberry vinegar and water was substituted for port wine negus. The hands and feet were, several times a day, sponged with warm water. In twenty-four hours it became obvious that the system was returning to a more tranquil state. By the fifteenth day the sensorial faculties were clearer, the pulse had fallen to 120, and the tongue was moist and white at the margin. Still as she was complaining of much uneasiness in the cæcal region, with troublesome diarrhoea, the same dose of Hydrarg. cum Creta was repeated, the operation of which, though attended with much inconvenience to the nurse, was of decided advantage to the patient. On the 18th day, having been allowed beef tea, it occasioned an exacerbation of fever and increased disturbance of the bowels. Chocolate and milk was therefore resumed as the only nourishment that could be safely recommended. On the 22nd day a copious diaphoresis appeared critical. There remained indeed, extreme emaciation, but the tongue was gradually improving, (i.e.,) the brown receding from the margin

and apex. On the 25th day, quinine, with small quantities of hydrochloric acid were prescribed, and the patient was removed from a confined part of the town to a mile distance, where the house was situated in a garden surrounded by fields. This step immediately had the effect of improving her appetite. Her recovery was slow. Four months elapsed before she could return to her home and resume the duties of her family.

The mother-in-law who assisted in nursing this good woman took the fever and died. Three cases occurred in the house adjoining; two of great severity, but as soon as there was subsidence of fever, these likewise were removed into the country, where they recruited their strength in about five weeks. I might briefly observe of one of the last-named cases, a girl, aged 6, who, having the epidemic of the third degree, lost her flesh, had mulberry-coloured fur on the tongue, lips and teeth, with stupor and delirium. Now, tea and pure water constituted the whole of the dietetic treatment for fourteen days, when an inclination for food returning, she was allowed milk diet.

His sister took the same complaint, as well as a great number of persons resident in that part of the town, (the neighbourhood of Queen Street,) the disease occasioned great loss of mental and physical energy, but fatal terminations were rare. After giving the fairest trial of stimulants and the generous plan of treatment, under the notion of opposing debility, I found that stimulants and cordials were not only unnecessary, but positively injurious. Given by way of support they only occasioned supplimentary fevers. Tea, chocolate, and fruits, were sufficiently nutrient, and might be taken with greater safety than broths and jellies. I have learned to attach much importance to the dietetics of patients in fever. Unless there is a desire for food, the attendants of the sick are unwise in pressing it on the patient. In no case did they sink from want of nutrition, but from morbid actions.

E. H., a youth aged 17, for fourteen days took only soda water; it was grateful and refreshing, and he eagerly drank from six to twelve bottles a day; subsequently grapes and chocolate constituted his nourish

ment for about a week, and in five weeks he was able to walk out.

As a summary of my observations,-1st. The remote cause of this fever appeared to arise from the reception of an intoxicating poison invading the whole system, and often accompanied by local disorder. The innumerable varieties were dependent on temperature or predisposition. 2ndly. This disease, even in healthy subjects, was lingering; yet in its third degree, and when assuming the most formidable characteristics of typhus, if previous lesion did not exist, a favourable issue might be predicted. 3rd. The depression from the very commencement of the attack marked its asthenic type; it would not, consequently, admit of depletion, unless locally, by means of a few leeches, to relieve engorgement, or where inflammation co-existed with fever. On the other hand, an attempt to strengthen the system by strong animal infusions had a tendency to keep up febrile action.

The immediate cause of fever is now supposed to depend on depraved circulating fluids. There may be

Her brother, aged 10, had a similar attack which in addition, lesions of particular organs, prior or

bowels was acute, the local abstraction of blood by By GEORGE NORMAN, F.R.C.S., Senior Surgeon to leeches was preferable to taking blood by the arm.

Of this family, consisting of seven persons, four had with him the infection of the low fever, then prevailing