J. S. Bury
1902 BMJ (Clinical Research Edition)  
PARALYSIS OF LIMBS IN A CHILD. [MAY 24, 1902, stand questions and to frame answers. In some of the fits observed, the arms and head moved, but not the legs. He bit his tongue, but did not pass urine or faeces. The duration of the fits was from two to five minutes. In one fit, on December 22nd, movements of both legs took place. At a visit on December 23rd, while saying a few words about his case, I laid my finger lightly on the scar over the pulsating gap, on which he immediately turned his
more » ... tely turned his head and eyes to the right, becoming instantly unconscious, twitching his right lower lip and his fingers, but not otherwise moving either arm or leg. On December 24th at 9.30 a.m., he had a fit, in which he foamed at the mouth and bit his tongue. Other fits occurred every ten or fifteen minutes during the rest of the morning. The same morning, while his head was being shaved and otherwise prepared for operation, a gurgling cry prolonged into a moan accompanied the fits then and afterwards. Operation. Operation was undertaken the satne afternoon with a semicircular flap including the old scar, which was found adherent directly to the brain and dissected off it. The dura mater was found turned out along the margins of the bone aperture, adhering to it and to the outer surface by scar tissue. This was all stripped with a raspatory, and also freed from. the inner table for some distance all round the aperture, and laid down on the exposed brain, leaving a central portion uncovered. The hole in the bone was oval, measuring I in. or less in one direction and more in the other. On the exposed brain and dura mater, passing between the latter and the skull, were laid pieces of stiffish goldfoil, cut from Ash's No. 6o (a piece about 4 in. square that weighedoz.). It was found impossible to pass in a single oval piece a little larger than the bone aperture with anything approaching smoothness or neatness, so one smaller piece that broke off was laid on as well as could be done, followed by two more pieces, all by this time thoroughly crumpled. The skin flap was closed down by continuous mattress suture, without attempt at ligature of the numerous vessels, that now bled again on removing the compression forceps which had been applied to the cut edges. Finally, all was covered up under cyanide gauze and capelline bandage. After-Historty. He slept well the next night, but had a fit early the next morning. During the day he was at first depressed, then excited, and towards night became delirious and hysterical, and did not sleep. On December 26th he was very excited, and persisted in sitting up in bed, but slept well at night. On December 27th he was also excited, and only partially rational. Some diet which had been withheld was supplied to him this day, as he was hungry. The dressings also were loose, and so were changed, and the wound was found adhering throughout, and free from redness or swelling at the edges. On December 28th he had had another very good night, and was perfectly quiet and rational. On December 30th he was sitting up in bed reading and taking an intelligent interest in what went on around him. The stitches were removed on January ist, 1902, and the wound was found firmly healed throughout. He now said that he " never felt better in his life." No pulsation could be noticed over the gap in the skull, either now or at any. time since this operation. The clearness of his recollections, and the quickness and certainty of his perceptions and replies, were quite noteworthy. In every way he appeared in excellent health and spirits, and no fit has occurred since the one noticed the day after operation. Remar7;. On. the day of his last admission this patient looked like one stupefied by alcohol, and his dull, hesitating manner led me to make inquiries about his habits. His wife was with him, and supported his own statement that, as a matter of fact, he did not drink alcohol. I made further inquiries as to whether or no he was out of work, in view of some possible motive other than the necessity of illness, and found that he had a good and regular occupation, which was only interrupted by the fits. It was evident that he was genuinely in need of assistance, as the history shows. But at his previous stay in this hospital I was not so fully persuaded of the genuineness of his case. The history of previous recent fits lhad then a certain vagueness about it, and tile one fit reported after his admission was insufficiently corroborated for my own satisfaction. The operation then performed was not undertaken on account of the alleged fits, but simply to protect. him against injurious consequences, in case the thin protruding sear should give way and cerebral fluid escape in the absence of immediate surgical attention. If it had not been for the cystic distension of the scar, I should not have touched him; and I concluded that MIr. Horsley had refrained from interference for a similar reason-namely, that there seemed no occasion to do so for the convulsions' sake. When, therefore, the man left hospital shortly afterwards, to all appearance perfectly well and free from the repetition of any sort of fit, the impression left upon my mind was that before the operation he had probably exaggerated his own condition and requirements; had even been actuated by indolence, or perhaps malingering. I had not then sufficiently informed myself of the absence of all possible motive on his part, as the pathological evidences, partly second-hand, were both scanty and transitory. This time the condition was more markeci, and the analysis of his symptoms and motives placed their genuineness beyond all question for both occasions. The time, in fact, had arrived when interference was really called for. It is possible that the operation undertaken in 1895 may have unexpectedly served the purpose of removing his susceptibility to the fits, and of postponing for more than six years the necessity for interference so obvious on the last, occasion. As to pulsation,' when the skull is opened the brain pulsates at the orifice, unless its own substance or the dura mater be resistant enough to prevent it. For instance, a cerebral tumour which I removed in 1889 showed no pulsation when exposed through a large trephine hole.2 The growth was a gumma, adhering inseparably to the dura mater, and firm enough to resist the vascular expansion of the brain at each beat of the heart. But the moment the tumour was removed the exposed brain pulsated, and pulsation has continued to the present time through the unossified hole in the skull, the movement being imparted to the integument (that forms the only covering), to a visible extent, but without raising the parts appreciably from the level of the bone. When the patient coughs, however, the encephalon balloons the skin out, raising it about half an inch from the cranial level.3 In other cases of cranial operation, whether for compound fracture, or in trephining for other purpose, pulsation occurs on removal of portions of the bony case, and continues as long as the coverings remain unossified,' even when the bonefragments are replaced. The pulsation gets fainter as ossification proceeds, and usually ceases when the latter is completed. In the present instance the gold foil appears stiff enough to. resist the pulsation that naturally occurs where continuity of the bony case may be interrupted. The accompanying photographs show the seat of injury as it appeared before my first operation and after the last. NOTES AND REFERENCE. 1Written April 6th on preparing this report for the JOURNAL. 2BRITISH MEDICAL JOURNAL, November 30th, 1889. 3 Strange to say, this patient. called upon me the following morning. I had not seen him sinee-December. i83o, but found him in good health, and with clear recollectior of past events.
doi:10.1136/bmj.1.2160.1258 fatcat:npgo3mro6rb2zbxzgrbd6w5c6e