A CASE OF DEPRESSED FRACTURE OF THE SKULL.

1395 In every case which could be considered clinically typical of Mediterranean fever a reaction was obtained. There remained a certain number of cases of uncomplicated fever

lasting from

six to ten

days,

not at all uncommon in

Malta,

In Case 5 no serum reaction showed on the fourth day, 1 but it did so on the eighth day. On the ninth day 30 c.c. I of antitoxin were injected and the temperature, which had already shown a tendency to come down but continued between 100° and 102°, reached and remained normal from the third day after the injection. The recorded temperatures in Case 5 were as follows, two observations being taken each day, the first in the morning and the second in the evening:-Tbird day of the disease, 105-00 F. and 101-0° ; fourth, 103’00 and 103’0° ; fifth, 102-4° and 103-0°; sixth, 101’40 and 102-4°; seventh, 100-4° and 102-2° ; eighth, 100-2° and 102-0° ; ninth, 100-0° and 102’60 (antitoxin was injected); tenth,100’0° and 101-2°; eleventh, 100-4° and 99’40; twelfth, 98’40 and 99’0° ; thirteenth, 98’20 and 99’00; fourteenth. 98’00 and 97’60; fifteenth, 978° and 98-4; and sixteenth, 97’60 and 98-4°, In coming to any conclusion as to the benefit resulting from the antitoxic serum a great difficulty lies in the fact that whereas from analogy with the use of similar serums in diphtheria and tetanus and also experimental inoculations the best results are to be expected in recent cases, yet diagnosis during the first week is very difficult, for besides enteric and other causes of fever there is a form of slight fever, already referred to, common in Malta. This lasts from about six to ten days and is apparently different from Mediterranean fever but only distinguishable from it by its short duration and by the serum test. Now this test does not seem to occur until the end of the first week and is itself of no value after the injection of antitoxin, which presumably will produce the reaction in the blood. The cultivations used in these experiments were from Dr. T. Zammit’s laboratory, with whose assistance much of the work was carried out.

which did not give the reaction at any time during their course or after the fever had subsided. Four cases of enteric fever were also tested with negative results, but gave a reaction with the bacillus typhosus. The course of the "disease confirmed these results and in two of them postmortem appearances also. Three cases during part of their course closely resembled enteric fever. Two of these were, in fact, so diagnosed at first, but no clumping was obtained with the bacillus typhosus, whereas the reaction with the micrococcus Melitensis was immediate, and in each case the after history left no doubt as to its nature; in two the usual relapses and"rheumatic " pains recurred for several weeks, and in the third a necropsy confirmed the diagnosis. As regards the date at which the reaction first appears the number of cases examined during the first week has been very few. The fifth day was the earliest on which it was obtained and in no case which ultimately showed the reaction was it found absent after this. The cases were at first all tested with a dilution of 1-10 and the reaction in almost every case occurred immediately-that is, the micrococci were found clumped when the slide was put under the microscope, though a few could often be seen free ; in from The a quarter to half an hour these, too, were clumped. reaction was also well marked in greater dilutions up to 1-100, though with such a rather longer time was generally required up to half an hour. If a considerable quantity of the micrococci be added in putting up the specimen the clumping can be recognised with the naked eye. Five cases were treated with the antitoxic plasma prepared Malta. by Professor Wright of Netley. Of these 2 cases which were in their sixth and ninth week of disease did not appear to be affected in any way by the injection. The third case was a very severe one with great prostration, in which the fever had lasted seven weeks with only one partial remission; 30 c.c. of the antitoxin were injected and a marked improvement commenced from the following day. The tongue, MEDICAL, SURGICAL, OBSTETRICAL, AND which had been dry and brown, and the breath, which had THERAPEUTICAL. been very fostid, improved very markedly; the collapse became less, and the temperature came down and remained normal from the eighth day after the injection (see Fig. 1). Another relapse occurred after three weeks and A CASE OF DEPRESSED FRACTURE OF THE SKULL. the temperature again decreased three days after another BY CLAYTON A. LANE, M.D. LOND., injection of 15 c.c. of the antitoxin, but this improvement SURGEON-LIEUTENANT, INDIAN MEDICAL SERVICE. was not maintained and no more of the antitoxin was available. ABOUT noon on Aug. 17th, 1897, while the 18th Bengal The two other cases were recent ones and uncomplicated. In Case 4 30 c.c. of antitoxin were injected on the fifth day. Lancers were encamped at Kuahalgarh on their way to The temperature, which had reached 106°, gradually fell till it Kohat, a sowar was kicked on the head by his horse and was ranged between normal and 101° ; but on the fourteenth day, brought to the hospital tent. He was insensible, answering as it showed a tendency to rise again, another similar dose His pulse was irregular and very easily comno questions. was given and was followed again by a fall of temperature, pressible ; his pupils were neither contracted nor dilated Fn.. 2. and were equal. Crossing the centre of the lefteyebrow and running upwards and inwards for an inch was a wound leading down to the periosteum. Above and inside the upper end of this wound a depression could be seen and felt through the skin and on putting a finger into the wound a fracture was felt starting near the middle of the upper edge of the orbit and curving upwards and finally outwards across the temporal ridge, where it was lost. The curve had a radius of about an inch and the portion of bone in its concavity was depressed, the greatest depression being along the line of fracture, where it amounted to -31- in. The man’s condition seemed to me to be so critical as not to justify my waiting to operate till water could be boiled and cooled, though the water I should have to use came from a dirty tank near the camp. Accordingly I began the operation at once, using carbolised water (1 in 40) for lotion and using the instruments provided in the field surgical pannier. On starting to enlarge the wound upwards the patient began to struggle, so the hospital assistant gave him chloroform. After trephining and inserting the elevator the depressed bone sprang at once into position and remained there. The bleeding vessels were twisted, not tied, and Chart in illustration of the course of temperature in Case 4. the skin was sewn up with silver wire without any drain. After the twentieth day the temperature remained pracDuring the operation he stopped breathing, the pulse being tically normal. still felt at the wrist, but after artificial respiration bad been which did not rise above 100° from the third day afterwards continued for some minutes he began to breathe again. With (see Fig. 2). This case did not show the serum reaction on the thermometer at over 100° F. in the shade the cessation the fourth day, but did so on the ninth, which, however, of artificial respiration was an even greater pleasure than was after the first injection of antitoxin. usual. 20 minims of spirit of ether were injected after _________

Clinical Notes :

x 3

1396 the his

operation and he shortly revived. In the evening temperature was normal and his pulse was 100. The patient was sensible and had no pain. The question of after-treatment was a most anxious one as the

to march next day, but after grave consideration I determined to have the patient carried with us on the two marches to Kohat, 30 miles in all, for at that time the chances of his obtaining efficient medical aid at Kushalgarh were more than remote. He was carried in a doolie by Kahars, starting at 4.30 A.M. each day and getting into camp before the heat from the sun was great. On the evening of Aug. 18th his temperature was 100° F. but the wound looked perfectly healthy. On the 19th his temperature was normal and he was quite free from any pain. I left him at Kohat and subsequently heard from Surgeon-Captain

regiment was

Bamfieldth%the

had

bad symptom. He rejoined the In February last, six months after the operation, the patient told me that he had been quite well since he rejoined the regiment and had had no headache. He had been doing his duty satisfactorily and had not been ailing in any way. There was a slight scar 12 in. in length above his left eyebrow and on the site of the fracture was a prominence giving the impression that the previously depressed bone had been too much elevated. Where the bit of bone had been removed there was a slight depression and its area, too, was small. The fact that the wound remained aseptic was probably due to the following reasons, at least in part. So far as the water went either the carbolic acid was effectual in sterilising it sufficiently to enable the leucocytes to do their work easily or the micro-organisms it must have contained were not pathogenic, or if they were so they were not educated to virulence. The silk supplied in the field equipment is not kept in an antiseptic solution and cannot be kept surgically clean, and I do not believe that silk can be sterilised by a few minutes’ soaking in carbolic solution. I accordingly avoided it, twisting all vessels. Before using the silver wire for suturing I rubbed it thoroughly with a clean cloth, hoping that in this way I might be able to get it almost surgically clean, just as one can clean the outside of a catheter. The measures used to cleanse it were probably effectual for no stitch-abscess resulted. The case seems to show with particular force the wellknown fact that when in the field and away from a contaminated hospital building (as all hospital buildings tend to become) operations can be successfully performed without all the precautions necessary in a fixed hospital; and though that, of course, is no cause for not taking every precaution which can be taken, still it shows that under these circumstances the risk of septic infection is less than it appears to be, and that it is justifiable, if not an actual duty, to make an attempt to save life even though the surroundings may appear far from favourable. never

a

regiment about six weeks later.

Jullunder.

RUPTURE

OF GALL-BLADDER; LAPAROTOMY TWENTY-FOUR DAYS AFTER INJURY ; RECOVERY. BY J. M. H. MARTIN, M.D. VICT., F.R.C.S. ENG.,

SENIOR HONORARY SURGEON TO THE BLACKBURN AND KAST LANCASHIRE INFIRMARY.

complained of pain in the abdomen, which was slightly distended but not very tender to the touch. Nothing else was made out by physical examination of the

and

abdomen. His pulse was 100 and his temperature was 980. His tongue was furred; there was no sickness. Nothing in the way of local treatment seemed indicated and milk with lime-water was the only food given. At 10 P.M. the temperature rose to 1018°. Once during the afternoon there was vomiting of curdled milk. Next morning the abdominal tenderness had almost disappeared and the boy looked much better. He complained’ of being hungry. From this time till Dec. 2nd (six days), when he was sent home; improvement was very rapid ; in fact, two days before dis. charge he was found running about the ward during the nurse’s absence for a short time. He was discharged as being "well" and was taken home to Accrington by an uncle wh() carried him most of the way. The uncle states that in the train the boy complained of feeling ill and when he was seen the same evening by his former medical attendant he was " complaining of pain in the abdomen and vomiting bilious fluid." The abdomen had become distended again. He remained at home for twenty-one days and during this time the stools were clay-coloured. He was sick occasionally during this time and the abdomen remained swollen. On admission to the infirmary for the second time a great change was evident in the boy. He had lost a great dea} of flesh; the abdomen was full of fluid of some kind but was not tender. The temperature was 98° and the pulse was 110. The tongue was furred ; there was no jaundice, neither was bile present in the urine; the stools were clay-coloured. The temperature remained normal during the second twenty-four hours after admission. On the third day the abdomen was opened in the middle line above the umbilicus by an incision 2 in. long. Nearly five pints of fluid escaped. This fluid, which was deeply bilestained, was in the general peritoneal cavity and not in any way limited by adhesions. The coils of intestine in the neighbourhood of the liver were matted together with lymph. The gall-bladder was empty and was thought on digital exploration to be adherent to the parietal peritoneum. A drainage-tube was left in the wound and a, bulky dressing was applied. The boy bore the operation well and there was no rise of temperature afterwards. The dressing was removed on the second day and found to be soaked with bile-stained fluid. The boy’s general condition had improved, his tongue being moist and his pulse better. The after, history is only remarkable for the rapidity of recovery. The temperature never reached 100°, the discharge became less each day, and the tube was discontinued on the seventh day. The total quantity of fluid absorbed by the dressing would almost equal the first amount removed. Bile was noticed for the first time in the forces on the third day after the operation. The urine was examined each day for bile but it was never detected. The daily average quantity of urine was only 20 cz, The patient was discharged on Jan. lst, 1898, and when seen on March 21st was quite well. Blackburn.

A

CASE OF INCARCERATED RETROFLEXED PREGNANT UTERUS WITH ENORMOUSLY DISTENDED BLADDER.

IN THE LANCBT of March 12th, 1898, Mr. Whipple records BY WILLIAM SIMPSON, M.B., B.S. DURH., of cyst in connexion with the liver apparently due to RESIDENT MEDICAL OFFICER OF THE UNION HOSPITAL, NEWCASTLE-ON-TYNE. the rupture of a hepatic duct. In the following case the bile escaped into the peritoneal cavity from a ruptured gallA SINGLE woman, thirty-two years of age, was admitted bladder. Such an injury is generally considered fatal, but, into the Union Hospital, Newcastle-on-Tyne, on April 5th, as this case shows, not necessarily so. A boy, aged nine years, was admitted to the Blackburn 1898, complaining of great pain in her abdomen. Two weeks and East Lancashire Infirmary on Nov. 26th, 1897. h’our previously she began to have difficulty of micturition which days before admission his abdomen had been run over by a gradually increased. For three days previously to admission cart weighing 15 cwt. After the injury he was carried, she had been unable to pass urine and only a very small’ The or rather dragged, a quarter of a mile to his home. had escaped involuntarily; her bowels had been medical man who then saw him reported that "he was quantity confined since April 1st. suffering from shock and pain in the right side of the belly not specially confined to the liver." Next On examination the abdomen was very much distended and’ day his symptoms were distinct abdominal swelling, slight tense and a swelling, which was dull on percussion and on discolouration over the region of the gall-bladder, and first consideration appeared like a large ovarian cyst, exa temperature of 101° F. ; there was no vomiting. On tended from the pubes to 2 in. above the umbilicus. Both the 24th there was retention of urine and his 11 bowels legs and the vulva were cedematous. On vaginal examinaø were moved, the motion giving marked evidence of blood." tion the fundus of the uterus was felt to be enlarged; it On admission to the infirmary the by leoked very ill occupied Dougla&’s pouch and the ceivix was felt to be a case