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A CASE OF PUNCTURED FRACTURE OF THE SKULL COMPLICATED WITH OTHER SEVERE INJURIES; RECOVERY.
1824 the greater proportion. If we obtain this comparative analysis then the treatment is easy, but if the practitioner be unable to obtain this data then I should advocate the simpler
came to my knowledge the source of mischief pointed only too plainly to the nurse who was dismissed on May 4th. On the 14th the temperature was 103 6°, falling methods-first, diuretics, diaphoretics, bromide, chloral, by the 17th to 100.4°. On the 19th it was 102 4°, when and chloroform-before resorting to morphine or hypodermo- Dr. H. B. Carter saw the patient with me and we decided to clysis, keeping in mind the safety of the patient above all try anti-streptococcic serum, which I procured from the other things, and the particular treatment as of secondary Jenner Institute, and at 8 P.M. 20 cubic centimetres were importance. If the eclampsia appears in the first injected, the temperature falling to 100.4° at noon on months of pregnancy forcible measures in emptying the 20th, when I injected 10 cubic centimetres. On the the uterus should be avoided even under chloroform, as 21st the temperature was 1016°, so at 11 P.M. I injected 30 cubic centimetres of serum. Half an hour afterwards the one never knows how much damage may be caused to the uterus by this means. Nature is, as a rule, gentle in her temperature was 103.6°, but on the next morning it was methods, therefore the bougie is more likely to act bene- 1004°, rising on the 23rd to 1017°. The patient died at ficially than is forcible emptying of the uterus. It should noon on May 24th. The respiration rose gradually from be kept in 8itu so long as to produce powerful and regular 20 to 60 per minute, latterly with moist râles. From the contractions. and then withdrawn, to be re-inserted if the 18th strychnia and brandy were necessary. pains lag. Venesection is a valuable form of treatment if Having been probably fortunate in this being the only the patient is plethoric, but to bleed indiscriminately is, in case of puerperal fever which I have had to encounter in my own practice I desire to call attention to the rise of 2’ my judgment, bad treatment. after the injection on May 21st. I, however, cannot be Blandford-street, W.
Clinical Notes : MEDICAL, SURGICAL, OBSTETRICAL,
AND
facts which
certain that this was due to the anti-streptococcic serum, and consider that bleeding and the injection of saline solution would not have been of benefit under the circumstances and that the combination of iron and quinine was on the whole preferable. New-cross, S.E. ______
THERAPEUTICAL. A CASE OF PUERPERAL FEVER TREATED WITH ANTI-STREPTOCOCCIC SERUM ; DEATH. BY F. W. THURNAM, M.B., C.M. EDIN. A MARRIED woman,
aged
34 years, the mother of four
children, and who had had three miscarriages, was safely delivered by me, after a normal labour, at 6 P.M. on April 27tb, 1901. All appeared to be going on satisfactorily till the fourth day (May lst) when her temperature, which had been 99° F. the previous day, was 1034°, and the lochia were scanty and offensive. Quinine and uterine
injections of 2 per cent. solution of creolin reduced the temperature one degree on the following day, but it rose again till on May 4th it was 103°. Doses of five grains of quinine with 20 minims of solution of perchloride of iron given every four hours brought it down to 100.4° on the 6th, and, after an intervening rise to 101.8°, to 99.8° on the 9th. After this date there was thrombosis of the left leg and subsequently of the arm on the same side and of the other leg. There was some thickening, probably perimetritis, mostly on the left side. There was diarrhoba from May 7th to 19th, which was checked to some extent by chalk mixture and benzo-naphthol with port wine. A troublesome crop of boils formed on the buttocks and one of them went on to a bedsore, after some
A CASE OF PUNCTURED FRACTURE OF THE SKULL COMPLICATED WITH OTHER SEVERE INJURIES; RECOVERY. BY EDWARD A.
PIGGOTT, L.R.C.P. & S. EDIN., L.S.A. LOND.
ON August 30th, 1900, I was called by telegraph some nine miles from my residence to attend the subject of this note. The patient, a builder and contractor by occupation,. aged 46 years, in the course of his duties had been unfortunate enough to fall down a deep well; but I cannot do better than quote the following account of the accident from theBrick and Pottery Trades Journal :" In August last Mr. J. was engaged in carrying out extensive works at the Manor, Cowlinge, Suffolk. He had employed an experienced well engineer to sink a new welb for the water-supply, and being desirous of personally examining the work he requested the well foreman to let him down to the bottom. Unfortunately, Mr. J. went a good deal quicker than he anticipated, for a man employed on the surface to manage the tackle discovered when too late, that Mr. J. bad got It. into the large bucket before everything was ready. appeared that the man who had charge of the handle had not attached it to the roller in a proper manner, and Mr. J. was dropped no less a distance than 102 feet. His fall was broken by becoming impaled on the bore iron which happened to be still standing in the well. It spiked him through the thigh and held him there until assistance was forthcoming. He was taken to the top, where it was discovered that the thigh was torn open for a considerable distance, and his skull severely fractured." The patient was removed to his residence from the scene of the accident as soon as practicable, and a careful examination made at 4 A.M. on the 31st revealed the following injuries. There was a wound of the scalp some two and a half inches square exposing the bone, situated a little posterior to the left parietal eminence and encroaching on the position of the lambdoid suture. There was no sign of depression or fissure of the external table of the skull, but in the centre of the wound there was a distinct puncture which penetrated the diploe. On the inner side of the right thigh, some threeinches above the knee-joint, was a lacerated wound measuring four inches transversely and extending along the innerborder of the rectus femoris, beneath the sartorius, and terminating deeply amongst the muscles in the neighbourhood of the apex of Scarpa’s triangle ; from this wound there was profuse venous haemorrhage. Fortunately the femoral
artery escaped injury. The right lumbar region, the right buttock, and the whole of the right thigh were one continuous track of ecchymosis-in fact, black with efEused incontinence of urine, which was albuminous. The rigors and there was more or less delirium, though the tongue remained clean throughout. The pulse and respiration did not correspond with the temperature. From were numerous
blood. The pelvic bones and femur were free from lesion. The condition of the patient at 11 A.M. on August 3lsts was as follows. He was perfectly unconscious ; his breathing was laboured and at times was inclined to be stertorous. The
1825
pupils were unequal, the pulse
was 120, and the temperature the afferent and contraction of the efferent blood-vessels of urine had been passed since the acci- the kidney. The patient, then, with the kidneys engorged dent on the previous afternoon a catheter was passed and the with blood exposed himself to a thorough cooling of the bladder was emptied. The head was shaved and an ice-bag surface of the body. The mode of production of the What is not so clear is its was applied; small quantities of milk and soda-water and hsematuria seems plain enough. beef-tea were ordered to be given at intervals. The patient transient character. Apparently, a train had been well laid lead to an explosion of Fin acute nephritis, but ended, was placed upon a water-bed as soon as one could be to in a mere fizzle. The patient himself is, for his in a For the next few he remained happily, days procured. violent with most of etate semi-consciousness, alternating years, remarkably active, both in mind and body. Of spare attacks of delirium, requiring at times two men in habit and small stature he enjoys, as a rule, excellent health, addition to the nurses to control him. The catheter beyond occasional slight "uricacidity"manifestations. He had to be employed night and morning until Sept. 5’.h, on exhibits a degree of arterio-sclerosis not uncommon at his which date the bladder resumed its normal action. On the age, but of chronic interstitial nephritis no symptoms at evening of Sept. 7th the temperature suddenly rose to all. The moral appears to be that exposure to a chill after 100’8° F. The whole day the patient was more or less indulgence in asparagus is not without its dangers. delirious, the symptoms indicating irritation of the brain ; Hampstead, N.W. the next morning the temperature fell to the normal point, and during the remainder of the treatment never rose above 100 4°—the point attained on Oct. 4th and 6th, its usual The pulse-rate was range being from 97 4° to 99°. generally between 80 and 96 ; the hightest rate recorded was OF 120 on the evening of Sept. 7th. The respiration rate between and The wound in the was 20 24. Tanged thigh very HOSPITAL tedious in its progress and necessitated a hypodermic injection of morphine (a quarter of a grain of bi-meconate) each BRITISH AND FOREIGN. night when dressed. A considerable amount of sloughing of integument and fascia was unavoidable; it eventually healed by granulation and was systematically dressed for Nulla autem est alia pro certo noscendi via, nisi quamplurimas et the last time on Oct. 31st, the patient leaving home for the morborum et dissectionum historias, tum aliorum tum proprias collectas habere, et inter se comparare.—MORGAGNI De Sed. et Caus. sea-coast on Nov. 6th. Morb., lib. iv., Proœmium. Remarks.-The cae is remarkable, more especially as regards the depth of the fall. There were never any BEDFORD COUNTY HOSPITAL. decided symptoms of compression, those of irritation being A CASE OF PANCREATIC CYST OR EFFUSION INTO THE most marked. Abscess and the trephine I most dreaded, but the brain mischief gradually and steadily improved. Great LESSER PERITONEAL CAVITY ; DRAINAGE ; RECOVERY. credit was due to a man working on a platform at the bottom - of the well at the time of the accident, who, although of Dr. R. H. COOMBS and Mr. W. the care (Under suffering from three fractured ribs and a laceration of the GIFFORD NASH.) face caused by the falling gear, managed by means of the THE diagnosis between true cysts of the pancreas and tackle to send his more severely-injured companion to the surface. I must express my indebtedness to Mr. R. H. effusions into the lesser peritoneal cavity is very difficult Wilkin of Wickhambrook who saw the patient with me even after a laparotomy has been performed. In the followimmediately after the accident, and also to Mr. R. W. ing very interesting case the arguments certainly appear to Waring of Cavendish, who met me several times in con- be in favour of the cyst being an effusion into the small sac sultation. of the peritoneum, and much may be said on behalf of Mr. Clare, Suffolk. Gifford Nash’s contention that the absence of a history of trauma is a fairly trustworthy criterion that a doubtful cystic ASPARAGUS AND HÆMATURIA. swelling in this situation is a cyst of the pancreas rather than BY J. S. MACKINTOSH, M.R.C.S. ENG., L.R.C.P. LOND. a peritoneal effusion. A girl, aged four years, was admitted into the Bedford ON May 25th last an old gentleman, aged 73 years, sent to County Hospital on Feb. 3rd, 1900, under the care of Dr. me a bottle of his urine, passed between 11 P.M. and 4 A.M. R. H. Coombs. In the summer of 1899 she had whoopingon the previous night, which had alarmed him by its dark cough and at the end of October began to suffer from attacks "colour. On testing it gave reactions for albumin and blood of abdominal pain and vomiting. These attacks continued and under the microscope plenty of blood-corpuscles and a and she lost flesh. An attack of abdominal pain on Feb. lst was the cause of her being taken to the hospital. There was few blood-casts could be seen. This, together with the no obtainable of any injury to the abdomen. On history smoky colour of the urine, pointed clearly to the kidney admission the abdomen was found to be slightly distended but itself as the source of the hsemorrhage. On calling to see the not tender, and by some it was thought to contain a little patient I found him busy in his study, looking and feeling free fluid. There was some resistance to be felt below the quite well. The history he gave was that he was very fond left costal margin. Mr. Gifford Nash saw the child a few of asparagus and that two days previously he had had a fine after admission and found some tenderness and bundle sent to him from the country, which he had consumed days resistance in the left deep epigastric and hypochondriac at luncheon and dinner on each of the two days, taking below the edge of the ribs (Fig. 1). No just regions at each meal "about as much as he could grasp with one hand." He owned an astronomical telescope, and FIG. 2. FIG. 3. FIG. 1. after dinner on the second before the
was
normal.
As
no
A Mirror
PRACTICE,
___________
day (the evening
hsematuria took place) he went out to give a demonstration of the moon to some friends. The day had been warm, but the evening, with the strong east wind prevalent at that date, became very cold. The patient did not notice the cold until the end of the demonstration, when he felt that he had got chilled. About midnight he had a desire to urinate and he passed the urine of which he sent to me a specimen. In the evening he sent to me another specimen of the urine passed during the day after I had seen him. In this there was no trace whatever of albumin, blood, or casts. There has been no abnormality of the urine since. The patient had a prejudice against drugs, so, as there had been no symptoms whatever of an acute nephritis beyond the condition of the urine, he was recommended to confine his diet to slops and to keep himself under observation. Asparagus is a stimulant diuretic causing dilatation of
condition from Feb. 3rd to 12th. Fig. 2, condition on Feb. 13th. Fig. 3, condition on Feb. 20th. The shaded portion shows the extent øf the tumour,
Fig. 1,
came to my knowledge the source of mischief pointed only too plainly to the nurse who was dismissed on May 4th. On the 14th the temperature was 103 6°, falling methods-first, diuretics, diaphoretics, bromide, chloral, by the 17th to 100.4°. On the 19th it was 102 4°, when and chloroform-before resorting to morphine or hypodermo- Dr. H. B. Carter saw the patient with me and we decided to clysis, keeping in mind the safety of the patient above all try anti-streptococcic serum, which I procured from the other things, and the particular treatment as of secondary Jenner Institute, and at 8 P.M. 20 cubic centimetres were importance. If the eclampsia appears in the first injected, the temperature falling to 100.4° at noon on months of pregnancy forcible measures in emptying the 20th, when I injected 10 cubic centimetres. On the the uterus should be avoided even under chloroform, as 21st the temperature was 1016°, so at 11 P.M. I injected 30 cubic centimetres of serum. Half an hour afterwards the one never knows how much damage may be caused to the uterus by this means. Nature is, as a rule, gentle in her temperature was 103.6°, but on the next morning it was methods, therefore the bougie is more likely to act bene- 1004°, rising on the 23rd to 1017°. The patient died at ficially than is forcible emptying of the uterus. It should noon on May 24th. The respiration rose gradually from be kept in 8itu so long as to produce powerful and regular 20 to 60 per minute, latterly with moist râles. From the contractions. and then withdrawn, to be re-inserted if the 18th strychnia and brandy were necessary. pains lag. Venesection is a valuable form of treatment if Having been probably fortunate in this being the only the patient is plethoric, but to bleed indiscriminately is, in case of puerperal fever which I have had to encounter in my own practice I desire to call attention to the rise of 2’ my judgment, bad treatment. after the injection on May 21st. I, however, cannot be Blandford-street, W.
Clinical Notes : MEDICAL, SURGICAL, OBSTETRICAL,
AND
facts which
certain that this was due to the anti-streptococcic serum, and consider that bleeding and the injection of saline solution would not have been of benefit under the circumstances and that the combination of iron and quinine was on the whole preferable. New-cross, S.E. ______
THERAPEUTICAL. A CASE OF PUERPERAL FEVER TREATED WITH ANTI-STREPTOCOCCIC SERUM ; DEATH. BY F. W. THURNAM, M.B., C.M. EDIN. A MARRIED woman,
aged
34 years, the mother of four
children, and who had had three miscarriages, was safely delivered by me, after a normal labour, at 6 P.M. on April 27tb, 1901. All appeared to be going on satisfactorily till the fourth day (May lst) when her temperature, which had been 99° F. the previous day, was 1034°, and the lochia were scanty and offensive. Quinine and uterine
injections of 2 per cent. solution of creolin reduced the temperature one degree on the following day, but it rose again till on May 4th it was 103°. Doses of five grains of quinine with 20 minims of solution of perchloride of iron given every four hours brought it down to 100.4° on the 6th, and, after an intervening rise to 101.8°, to 99.8° on the 9th. After this date there was thrombosis of the left leg and subsequently of the arm on the same side and of the other leg. There was some thickening, probably perimetritis, mostly on the left side. There was diarrhoba from May 7th to 19th, which was checked to some extent by chalk mixture and benzo-naphthol with port wine. A troublesome crop of boils formed on the buttocks and one of them went on to a bedsore, after some
A CASE OF PUNCTURED FRACTURE OF THE SKULL COMPLICATED WITH OTHER SEVERE INJURIES; RECOVERY. BY EDWARD A.
PIGGOTT, L.R.C.P. & S. EDIN., L.S.A. LOND.
ON August 30th, 1900, I was called by telegraph some nine miles from my residence to attend the subject of this note. The patient, a builder and contractor by occupation,. aged 46 years, in the course of his duties had been unfortunate enough to fall down a deep well; but I cannot do better than quote the following account of the accident from theBrick and Pottery Trades Journal :" In August last Mr. J. was engaged in carrying out extensive works at the Manor, Cowlinge, Suffolk. He had employed an experienced well engineer to sink a new welb for the water-supply, and being desirous of personally examining the work he requested the well foreman to let him down to the bottom. Unfortunately, Mr. J. went a good deal quicker than he anticipated, for a man employed on the surface to manage the tackle discovered when too late, that Mr. J. bad got It. into the large bucket before everything was ready. appeared that the man who had charge of the handle had not attached it to the roller in a proper manner, and Mr. J. was dropped no less a distance than 102 feet. His fall was broken by becoming impaled on the bore iron which happened to be still standing in the well. It spiked him through the thigh and held him there until assistance was forthcoming. He was taken to the top, where it was discovered that the thigh was torn open for a considerable distance, and his skull severely fractured." The patient was removed to his residence from the scene of the accident as soon as practicable, and a careful examination made at 4 A.M. on the 31st revealed the following injuries. There was a wound of the scalp some two and a half inches square exposing the bone, situated a little posterior to the left parietal eminence and encroaching on the position of the lambdoid suture. There was no sign of depression or fissure of the external table of the skull, but in the centre of the wound there was a distinct puncture which penetrated the diploe. On the inner side of the right thigh, some threeinches above the knee-joint, was a lacerated wound measuring four inches transversely and extending along the innerborder of the rectus femoris, beneath the sartorius, and terminating deeply amongst the muscles in the neighbourhood of the apex of Scarpa’s triangle ; from this wound there was profuse venous haemorrhage. Fortunately the femoral
artery escaped injury. The right lumbar region, the right buttock, and the whole of the right thigh were one continuous track of ecchymosis-in fact, black with efEused incontinence of urine, which was albuminous. The rigors and there was more or less delirium, though the tongue remained clean throughout. The pulse and respiration did not correspond with the temperature. From were numerous
blood. The pelvic bones and femur were free from lesion. The condition of the patient at 11 A.M. on August 3lsts was as follows. He was perfectly unconscious ; his breathing was laboured and at times was inclined to be stertorous. The
1825
pupils were unequal, the pulse
was 120, and the temperature the afferent and contraction of the efferent blood-vessels of urine had been passed since the acci- the kidney. The patient, then, with the kidneys engorged dent on the previous afternoon a catheter was passed and the with blood exposed himself to a thorough cooling of the bladder was emptied. The head was shaved and an ice-bag surface of the body. The mode of production of the What is not so clear is its was applied; small quantities of milk and soda-water and hsematuria seems plain enough. beef-tea were ordered to be given at intervals. The patient transient character. Apparently, a train had been well laid lead to an explosion of Fin acute nephritis, but ended, was placed upon a water-bed as soon as one could be to in a mere fizzle. The patient himself is, for his in a For the next few he remained happily, days procured. violent with most of etate semi-consciousness, alternating years, remarkably active, both in mind and body. Of spare attacks of delirium, requiring at times two men in habit and small stature he enjoys, as a rule, excellent health, addition to the nurses to control him. The catheter beyond occasional slight "uricacidity"manifestations. He had to be employed night and morning until Sept. 5’.h, on exhibits a degree of arterio-sclerosis not uncommon at his which date the bladder resumed its normal action. On the age, but of chronic interstitial nephritis no symptoms at evening of Sept. 7th the temperature suddenly rose to all. The moral appears to be that exposure to a chill after 100’8° F. The whole day the patient was more or less indulgence in asparagus is not without its dangers. delirious, the symptoms indicating irritation of the brain ; Hampstead, N.W. the next morning the temperature fell to the normal point, and during the remainder of the treatment never rose above 100 4°—the point attained on Oct. 4th and 6th, its usual The pulse-rate was range being from 97 4° to 99°. generally between 80 and 96 ; the hightest rate recorded was OF 120 on the evening of Sept. 7th. The respiration rate between and The wound in the was 20 24. Tanged thigh very HOSPITAL tedious in its progress and necessitated a hypodermic injection of morphine (a quarter of a grain of bi-meconate) each BRITISH AND FOREIGN. night when dressed. A considerable amount of sloughing of integument and fascia was unavoidable; it eventually healed by granulation and was systematically dressed for Nulla autem est alia pro certo noscendi via, nisi quamplurimas et the last time on Oct. 31st, the patient leaving home for the morborum et dissectionum historias, tum aliorum tum proprias collectas habere, et inter se comparare.—MORGAGNI De Sed. et Caus. sea-coast on Nov. 6th. Morb., lib. iv., Proœmium. Remarks.-The cae is remarkable, more especially as regards the depth of the fall. There were never any BEDFORD COUNTY HOSPITAL. decided symptoms of compression, those of irritation being A CASE OF PANCREATIC CYST OR EFFUSION INTO THE most marked. Abscess and the trephine I most dreaded, but the brain mischief gradually and steadily improved. Great LESSER PERITONEAL CAVITY ; DRAINAGE ; RECOVERY. credit was due to a man working on a platform at the bottom - of the well at the time of the accident, who, although of Dr. R. H. COOMBS and Mr. W. the care (Under suffering from three fractured ribs and a laceration of the GIFFORD NASH.) face caused by the falling gear, managed by means of the THE diagnosis between true cysts of the pancreas and tackle to send his more severely-injured companion to the surface. I must express my indebtedness to Mr. R. H. effusions into the lesser peritoneal cavity is very difficult Wilkin of Wickhambrook who saw the patient with me even after a laparotomy has been performed. In the followimmediately after the accident, and also to Mr. R. W. ing very interesting case the arguments certainly appear to Waring of Cavendish, who met me several times in con- be in favour of the cyst being an effusion into the small sac sultation. of the peritoneum, and much may be said on behalf of Mr. Clare, Suffolk. Gifford Nash’s contention that the absence of a history of trauma is a fairly trustworthy criterion that a doubtful cystic ASPARAGUS AND HÆMATURIA. swelling in this situation is a cyst of the pancreas rather than BY J. S. MACKINTOSH, M.R.C.S. ENG., L.R.C.P. LOND. a peritoneal effusion. A girl, aged four years, was admitted into the Bedford ON May 25th last an old gentleman, aged 73 years, sent to County Hospital on Feb. 3rd, 1900, under the care of Dr. me a bottle of his urine, passed between 11 P.M. and 4 A.M. R. H. Coombs. In the summer of 1899 she had whoopingon the previous night, which had alarmed him by its dark cough and at the end of October began to suffer from attacks "colour. On testing it gave reactions for albumin and blood of abdominal pain and vomiting. These attacks continued and under the microscope plenty of blood-corpuscles and a and she lost flesh. An attack of abdominal pain on Feb. lst was the cause of her being taken to the hospital. There was few blood-casts could be seen. This, together with the no obtainable of any injury to the abdomen. On history smoky colour of the urine, pointed clearly to the kidney admission the abdomen was found to be slightly distended but itself as the source of the hsemorrhage. On calling to see the not tender, and by some it was thought to contain a little patient I found him busy in his study, looking and feeling free fluid. There was some resistance to be felt below the quite well. The history he gave was that he was very fond left costal margin. Mr. Gifford Nash saw the child a few of asparagus and that two days previously he had had a fine after admission and found some tenderness and bundle sent to him from the country, which he had consumed days resistance in the left deep epigastric and hypochondriac at luncheon and dinner on each of the two days, taking below the edge of the ribs (Fig. 1). No just regions at each meal "about as much as he could grasp with one hand." He owned an astronomical telescope, and FIG. 2. FIG. 3. FIG. 1. after dinner on the second before the
was
normal.
As
no
A Mirror
PRACTICE,
___________
day (the evening
hsematuria took place) he went out to give a demonstration of the moon to some friends. The day had been warm, but the evening, with the strong east wind prevalent at that date, became very cold. The patient did not notice the cold until the end of the demonstration, when he felt that he had got chilled. About midnight he had a desire to urinate and he passed the urine of which he sent to me a specimen. In the evening he sent to me another specimen of the urine passed during the day after I had seen him. In this there was no trace whatever of albumin, blood, or casts. There has been no abnormality of the urine since. The patient had a prejudice against drugs, so, as there had been no symptoms whatever of an acute nephritis beyond the condition of the urine, he was recommended to confine his diet to slops and to keep himself under observation. Asparagus is a stimulant diuretic causing dilatation of
condition from Feb. 3rd to 12th. Fig. 2, condition on Feb. 13th. Fig. 3, condition on Feb. 20th. The shaded portion shows the extent øf the tumour,
Fig. 1,