Imagens das páginas

at a small university only, and to some extent limited in his autopsies as regards number, in relation to that afforded to many of his brethren at larger schools, he has yet, by the kindness of Michaelis and his successor, Dr. Litzman of the Lying-in Hospital, been able to increase it to an extent otherwise impossible. The author refers, very modestly, in his preface, to his own labours, begging the reader to bear carefully in mind that he considers them merely, as his title-page indicates, "Contributions," and as making no pretension to an approach to a complete treatise on "the Pathological Anatomy of New-born Children."

As Dr. Weber gives no general sketch of what the work it to include when finished, we can but form our judgment from the portion of it now before us, and which treats of the "Head and Spine." From this it would appear that all monstrosities are to be excluded, and we thought at first all deformities and malformations as well, until we found several pages occupied with an account of club foot, and spina-bifida touched upon under affections of the spinal column. These being included, we are at a loss to account for the exclusion of many things which fall quite as much within the scope of Dr. Weber's inquiries as the above subjects, which, to speak the truth, really fall without it, seeing that they are not induced by the act of parturition, nor is their origin limited to the latter periods of intra-uterine existence.

When noticing the first part of Dr. Beduar's treatise, we expressed a hope that'it would not be long before we again had the pleasure of meeting with its author, considering how capable he was of illustrating the ' Morbid Anatomy of the Diseases of Children.'* We have now the second portion of his work upon our table, and are happy in bearing testimony to its value in relation to our present subject. The first part of his work related, as our readers will remember, to the pathology of the alimentary canal; the present embraces that of the cranium and spinal canal and their contents. No direct comparison can be fairly made between Dr. Bednar's and Dr. Weber's works, since the investigations of the latter are limited in most cases to quite the new-born child, whilst those of the former extend to patients several years old, although many of the children received into the Foundling Hospital of Vienna are admitted within fourteen days after birth. As it is within the walls of this institution that Dr. Bednar has prosecuted his labors, he has had considerable opportunity of investigating the pathology of what even Dr. Weber himself would designate the "newborn child," and hence touches upon many of the subjects more minutely dwelt upon by the latter writer. In passing Dr. Weber's work under view, we shall, as opportunity offers, make reference to that of Dr. Bednar, so that both treatises may be included under one head. We shall make the former, on this occasion, our point de depart, having already introduced Dr. Bednar to our readers (vol. vii. p. 107) ; the more especially, too, as the field within the limits he has chosen is so peculiarly his own, rendering our labours less critical than we might otherwise have made them. We pause for a moment, however, to^draw the attention of those interested in the pathology of the diseases of children to a name which has not hitherto received mention in these pages—a name to which much praise is due, as those who are acquainted with the work of Dr. Hiigel (reviewed in our fifth volume, p. 362) will be sufficiently aware. We allude to Dr. Schoepf-Merei, whose work is noticed at the head of this article. There may not be a few, however, to whom the intricacies of Viennese-German f are scarcely so familiar as to have permitted them to have made acquaintance with the writer in question; and for their information, and to the credit of Dr. Schoepf-Merei, we may here observe, that to this Hungarian physician is due the existence of the hospital for children at Pesth. This institution was projected by him immediately after the great inundation of the city by the Danube, about twelve years ago; and now, by the kind patronage of the Archduchess-Palatine, Mary Dorothea, it contains thirty if not more beds. Judging from Dr. Hugel's remarks, it would appear that the projector had very great difficulties to encounter ere he attained his purpose—difficulties so

• Vide No. XIII. p. 110, et seq.

f Even a German (the reviewer in the ' Journal fur Kinderkrankheiten') alludes to the "ensctzlich Iasg ftjliairte Perioden," which the preface to Dr. Hugel's work contains.

great, indeed, that those only who are acquainted with the peculiar condition of citizen-life in Hungary, induced by the high political excitement and party feelings there prevalent, can form an adequate notion of them. Dr. Schoepf-Merei has now become a voluntary exile from Hungary, and we believe permanently settled himself on English soil. He has already made himself known to the profession in this country by some able papers in one of the monthly and weekly serials; and we have no doubt will earn for himself here a repute in his specialize, as well deserved as that which he has for several years enjoyed in his natiie land. Some few years ago, Dr. SchoepfMerei published a yearly report on 'Practical Medicine and Surgery in Relation to Children.' This report has been followed by the systematic treatise now before us, which, however, is but the prelude to others, which we trust may follow, and these clothed in the garment of our mother tongue. On the present occasion, we fear that we can do but scanty justice to the author and his labours; but if, in the course of our remarks, we find opportunity for appealing to his acute observations and experience, we shall do so without further preamble.

We shall now refer to Dr. Weber, who thus commences his introduction:

"The corpse of the new-born child undergoes decomposition far less rapidly than that of the adult. Development of gases in the cellular tissue, deliquescence, and offensive odours, rarely make their appearance during the first week ; more frequently an imperfect dryness, with induration of the skin and fat, are seen. The cause of this delayed decomposition is, [ believe, to be found in the less frequent previous existence of those dyscrasic maladies in the child, which undoubtedly dispose the corpse of the adult to a more rapid putrefaction. In consequence of the protracted appearance of the latter, the corpse of the new-born child is longer available after death for many points of pathological investigation. Nevertheless, certain organs form an exception to the rule, and pass even more rapidly than in the adult into a state of putrefaction. No portions change more quickly, and yield, even twenty-four hours after death, more fallacious results relative to consistency, than the brain and spinal cord, particularly in those cases where both have been in contact with morbid effusions. But even when the latter have been absent, the consistency of each becomes markedly less a short time after death, the brain softening earlier than the spinal cord." (p. 7.)

In cases where the chief point for investigation in the autopsy will be the condition of these portions, Dr. Weber advises the body to be laid on the face as soon as possible after death; for although the dorsal position might produce no important alteration in the contents of the capillaries, yet the larger venous plexus covering the dura mater and the whole spinal canal, may become engorged from gravitation, leading, on the one hand, to false conclusions, and, on the other, preventing a perfect examination of the spinal marrow and its coverings. The whole of Dr. Weber's introductory remarks are worthy of careful perusal, but our limits oblige us to pass to the "Pathological Alterations in the Head." (p. 11.)

The author enters first upon the consideration of those cranial tumours which are the consequences of a stasis in the capillaries of the external covering of the skull, produced by the pressure to which the child is subjected in the lower pelvis. The capillary vessels can only imperfectly, or not at all, empty themselves, on account of the compression of the veins; they swell, and a serous fluid exudes through their delicate parietes, analogous to the effusionx)f dropsical swellings produced by pressure upon the venous canals. In some cases a limited rupture of the capillaries or veins ensues, and a slight extravasation of blood is the consequence. The situation and size of the tumour depend upon the position of the child's head during labour, and quite as much upon the degree, if not rather more than upon the duration, of the pressure to which it is subjected. These effusions and extravasations take place in the tissues above the periosteum of the cranium, producing a swelling constituting the caput succedaneum of many writers. But effusions, <fec, also ensue beneath the periosteum, giving rise to a tumour; such is the cephalhematoma of authors. In the latter also, blood constitutes the chief extravasation. The distinction here made, as insisted on by many pathologists, between the two classes of tumours, is to a certain extent maintained by Dr. Weber, and particularly so, as it appears to us, by Dr. Bednar; but it is doubtful whether there are not transitional forms which unite the two together, anatomically considered, however well the demarcation seems to be preserved between extreme forms of these affections. Dr. Weber thus writes—

"The third form of caput succedaneum (kopfgeschwuhl) differs from the other two varieties in this, that extravasation not only exists in the subcutaneous cellular tissue, as also in and beneath the galea, but the periosteum of the crania! bones is elevated to a greater or less extent by effusion of blood beneath it. I have had frequent opportunities of observing this in caput succedaneum, and view it as the commencement and lower grade of cephalhematoma, without however denying that the latter may also originate in another way." (p. 13.)

In one of the varieties of caput succedaneum alluded to by the author, such appearances of suggillation, or contusion, are occasionally seen, on dividing the subcutaneous cellular tissue and aponeurosis, that suspicion may arise that external force, as a blow, has been applied, and the matter become a subject for the medical jurist. A case in point is recorded by Dr. Weber as having occurred in Germany, though no criminal intent was attributed to the mother, as ii was thought likely, from the circumstances of the case, that the child was born very suddenly, and fell upon the ground whilst the ■woman was standing before the bed. Without denying that such appearances of contusion corresponding to the tumour above it, as in the example given, might be produced in the manner asserted, Dr. Weber urges attention to the fact, that—

"Every extravasation of blood in the cellular tissue beneath the scalp is not to be'ascribed to external violence. Its formation during birth, and as a complication of caput succedaneum, must not be lost sight of in medical jurisprudence." (p. 12.)

According to Bednar ^p. 178), where there is extravasation of blood in the scalp and subcutaneous cellular tissue, there is generally effusion of it between the meninges, and often in the substance of the brain itself.

Cephalhematoma is by most writers usually regarded under two forms; 1st, the ordinary form in which an effusion of blood exists between the periosteum and external surface of the skull,—c. externum, or sub-pcricranial ceph.; 2dly, where blood is effused between the dura mater and the cranium,—c. internum, or sub-cranial cephalhematoma. The latter may, or may not, be accompanied by the former; but under any circumstances it is very uncommon. Bednar does not appear to have met with a single instance of it. Dr. Weber is not satisfied with the above classification, but prefers the following: 1st, cephalhaematomic tumours which occur under a healthy condition of the vessels and bones of the locality affected; 2ndly, those connected with a primitive diseased state of the vessels or bones, or of both. (p. 17.) The immediate cause of the latter form is, in the majority of cases, identical with that of the first— viz., pressure during labour hindering the return of the blood, consequently producing a rupture of vessels. Of the first form, three varieties are alluded to by the author. The simplest is characterized by the existence of a thin layer of blood beneath the periosteum, corresponding to the locality of an overlying caput succedaneum of that description, in which extravasation of blood, along with the ordinary serous effusion, is formed in the cellular tissue under the scalp. It is non-fluctuating, and according to Dr. Weber, more frequently to be met with than the larger and fluctuating varieties. Both the fluctuating and non-fluctuating tumours depend for their production upon the rupture of vessels between the bone and periosteum. In some cases rupture also ensues in the vessels of the substance of the bone, giving rise to the extravasation; whilst in others the walls of the superior longitudinal sinus suffer, and blood is poured out in the vicinity of the sagittal suture, between the periosteum and cranial bones. An example of the former is detailed by Dr. Weber; and of the latter he remarks—

"In this instance also a so-called cephalhematoma internum waa found, easily explainable by the inordinate distension and consequent rupture Of the capillaries which connect the dura mater with the inner surface of the skull. I must here observe, that I have had but rarely opportunity of seeing this; but where it occurred, similar rupture of capillary vessels and effusion existed at other spots, namely, above the orbit between the dura mater and skull. Although such may be of the same nature as the former, yet the term c. internum is scarcely applicable toil." (p. 17.)

Dr. Bednir writes—

"Once only have I seen the veins between the parietal bones and dura mater gorged with blood, and effusion between the latter on the left side; therefore, of the so-called internal thrombus I can say nothing." (p. 174.)

To return to Dr. Weber:

"It has been maintained that cephalhematoma arises at the spots where the skull, in its transit through the lower pelvis, is particularly exposed to the pressure of the protuberances of the bones, and especially to that of the promontory. In itself, this appears not improbable; for if we reflect upon how great the pressure often is upon the child's skull and its coverings, when the conjugate diameter is small, injury to vessels by bruising will not seem unlikely to happen. Nevertheless, my experience does not confirm this mode of causation. I never witnessed at those spots, where the scalp through injury to the integuments showed bruising to have happened, nor even where the bones had suffered from the promontory, nor where the marks of the forceps were seen upon the skin, cephalhematoma arise. On the contrary, where t observed the latter, the above-mentioned causes did not exist We must adopt therefore, provisionally, the opinion, if the experience of others does not gainsay it or prove the existence of other causes, that the origin of many ceplialhaematomata is to be found in the obstruction to the return of the blood produced by pressure over the whole periphery of the child's head, and the consequent rupture of vessels." (p. 17.)

The author thus appears to participate in the views of Valleix, who considers that the "ecchymosis" is due to a circular pressure, which can only be exerted by the neck of the uterus; M. Valleix admitting, however, the existence of exceptional cases, in which the intervention of the osseous walls of the pelvis may act in producing the tumour. That the latter must be very rarely the case, this writer considers, is proved by the fact of cephalhematoma almost always being observed after easy labours only. On the other hand, from this very circumstance, M. Pauli has sought to establish the influence of the bones of the pelvis, since the tumour only then occurs from the head of the infant being exposed to shocks and brusque pressure in rapid labours.* Again, in reference to the opinions of Valleix, it has been asked: How is it, the cause being constant and inevitable, that eephalhaematomata are not more frequently met with? The answer is, that the cases which are most favourable for their production are those in which a very large extent of the parietal surface of the head presents at the neck of the uterus, to the exclusion of other portions of the cranium, and such cases are sufficiently rare. Out of 74 examples, Bednar (p. 175) found the tumour 40 times over the right, 22 over the left parietal bone, and 6 over each; 4 times over the occipital, once over both parietals and the occipital, and once over the frontal bone. The tumour reached its largest circumference over the parietal, and its smallest over the frontal bone.

It was the opinion of many of the older writers, that cephalhematoma was always connected with a primitive disease of the cranial bones. Such opinion had its origin in the following facts. On examining the tumour during life, soon after it appears, a hard and apparently bony ridge is felt running round and limiting its base, and onpostmorlem inspection the surface of the bone beneath it is found in many cases to present appearances very different from usual or healthy structure. This ridge was assumed by many (Michaelis, Paletta, Dzondi, <fec.) to be the limit or edge of the external table of the bone, deficient from vice of conformation, or destroyed by caries. We believe that Naegele, in 1819 (vide Graetzer), was the first to dispute the necessary connexion of the tumour with lesion of the bone, having seen cases in which the bones were quite sound and smooth." In later times, different views have been held upon the matter. The existence of the ridge, in most cases, if not in all, an unusual condition of the upper surface of the bone in some, and a healthy state of it in other instances, are now generally admitted to occur. But what is the nature of this ridge, and what are the relations of cause and effect between the appearance of the surface of the bone and the sanguinolent or other extravasation or tumour? Opposing themselves to the views of the earlier observers before alluded to (Michaelis, &c), Zeller and Pignd regard the

* Vido Fabre, Maladies des Enlans, t. ii. p. 220.


ridge as resulting from the pressure of the effused fluid on the bone within its circle, Dubois considers it formed by indurated or diseased periosteum; Carus, as the reflected edge of the latter; Krause believes it to be a true osseous ring; Valleix, an osseous pad or cushion (bourrelet); whilst Busch, Wokurka, and Bartsch, refer it to " une pure hallucination de toucher !"* Finally, M. Dcepp.f from observations made on 255 children, asserts that in the vast majority of cases the ridge in question has its origin in coagulation of the blood, precisely at that spot where the periosteum, elevated by the effusion, begins to separate itself from the cranial bone. M. Dcepp, however, admits that in certain and rare cases, where the tumour has remained in existence a long time, the superior table of the skull disappears from absorption, or is destroyed by caries, and that in such instances the ridge may indicate the limits between the locality of the deficient bone and that which remains in a sound condition. A modification of M. Dcepp's views is now received by many pathologists as the true explanation of the matter. It is admitted that the blood in the tumour quickly coagulates, and that the edge of the coagulum imparts to the touch the sensation of a peripheral ring; but that the firm and hard ring, felt as the tumour gets older, is the result of a reparative process, in the course of which a fibrinous exudation is poured out, and heaped up in great abundance at the place before indicated; in some cases, also, bony matter is deposited in this fibrinous ridge, so as really to cause it to be an osseous circle.J Admitting that there are cases in which an original abnormal condition of the bone exists, predisposing to the formation of a sanguinolent tumour, yet it appears to he the fact, that in a very great majority the appearances of osseous disease are truly the effect of the extravasation and not its cause; an effect seen in the destruction of the surface of the bone by pressure in one set of cases, and in another evinced by an attempt at reparation being made, " bony plates " being formed at the spot where extravasation existed, causing the surface of the bone to appear as if roughened by ulceration or caries.§ Upon some of the foregoing points, Dr. Weber thus expresses himself:

"There are, however, cephalhaematomata, towards whose production a diseased state of the bones and vessels may be said to dispose. Ammon, in his ' Congenital Surgical Diseases,' speaks of cephalhematoma in connection with which the vascular system of the pericranium, of the bones, and of the dura mater, were abnormally altered, the veins of the cranium especially being enlarged. Langenbeck, of Gottingen, also observed beneath the tumour highly-dilated vena: diploeliac. having the appearance of v. emissdritc. These observations, coupled with some afterwards to be mentioned, and which I myself had an opportunity of making, appear to me to substantiate the existence of the second class of cephalha;matoma. I believe that here the immediate cause of the rupture of the vessels is identical with that of the first class—namely, hindrance by pressure to the return of the blood. The rupture ensues with so much the more facility as the vessels are enlarged, and hence, probably, their walls diseased, and more easily tearable. I cannot participate in the opinion of Langenbeck, that cephalhasmatoma may also be a vitium prima formationis, depending as it does for its support upon the absence of the tabula externa of the corresponding portion of the cranial bones; for, so far as I know, cephalha:matomata have never been observed in the early uterine periods. The primitive want of a tabula externa, when such happens, particularly when the vessels are at the same time enlarged, cannot be denied to be a predisposing cause, as a following case will show. The case reported by Ammon, where the parietal bone was completely perforated at a small spot, and where a c. internum existed, I am inclined to refer to a secondary process for production." (p. 18.)

"Ammon, in one place mentions, that cephalha:matomata with pulsation have been seen. Such cases cannot, in my opinion, be numbered amongst cephalhaematomata, without extension of the meaning of the term; for, until now, the escape of blood from the vessels has been implied as its signification, or we must assume that the tumour experiences vibration from underlying pulsating vessels." (p. 19.)

When we reflect, that the extravasated blood lies between the bone and periosteum, and is present in such quantity that weeks are needed for its complete resorption, or even are insufficient for the purpose,—that consequently a large extent of bone (covered on its surface with periosteum, which is connected to it by capillaries, a sur

• Fabrc, op. cit. t Annates de la Chirurg. Franc, et Etrang., t. x. 1844.

X Vide Lectures by I>r. West, second edition, p. 39, and his paper in the Medioo-Chirurgical Transaatioue, Tol xxviii. § Ibid.

« AnteriorContinuar »