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HOSPITAL FOR SICK CHILDREN, GREAT ORMOND STREET.
HOSPITAL MEDICINE AND SURGERY.
89
eruption and sound condition of all teeth and by the fact of was no extradural haemorrhage. The dura mater bulged the tumour first appearing at the temporo-maxillary articula- tense and blue into the opening and on incising it there was tion and thence extending downwards, the case was diagnosed a gush of thin unclotted blood which continued to flow for The right arm was immeas probably one of myeloid sarcoma, and an operation was per- some minutes and then ceased.
by Lieutenant-Colonel W. H. Quicke, I.M.S., senior diately moved voluntarily and the leg movements soon No bleeding point was found and the wound in the surgeon of the hospital. An exploratory incision was first made when the ramus was seen to be expanded from within. dura mater was closed except for a small gauze drain. The bone being cut open with a chisel and hammer a cyst Within an hour of the operation the child was quite conwas revealed filled with soft epithelial-like flakes. The scious and there was no trace of paralysis. The dressings flakes were all removed and the cyst wall, which was partly were repeatedly soaked with cerebro-spinal fluid in spite of head being raised. At 11.30 P.M. the temperature had adherent to and lining the bony cavity, was thoroughly scraped off and removed. The cyst growing inside had also risen to 103°, the respirations were fast and irregular, and to some extent expanded the body of the mandible where pulse was feeble and rapid. About 6 A.az. on the followThe fang ing morning, as the child was unconscious, the gauze drain one of the fangs of the third molar was seen. The bony cavity was then cleaned and removed and some dark blood escaped. The child died was quite normal. 7.30 A.M. stuffed with iodoform gauze, and it finally healed by granulation, the healing taking a long time, and the patient was Neoropsy.-At the post-mortem examination no fracture of the skull, gross lesion of the brain, or rupture of bloodultimately discharged cured on June 14th. The case is of interest on account of the unusual site vessels was found. There was a marked scarcity of cerebroselected by the dermoid. A dermoid within the structures spinal fluid and between the dura mater and the brain on the of a bone and at a place where during embryonic life there side of the operation was a thin film of blood-quite insuffiis no union between two skin-covered surfaces is a surgical cient to produce symptoms. CASE 2. Fracture of the skull nitlt cerebral symptoms.-A anomaly and one which I venture to explain as follows. At birth the mandible is a mere shell of bone containing the boy, aged four years and three months, was admitted to the sockets of the temporary teeth and covered by the mucous Hospital for Sick Children on August lst, 1906. 20 minutes membrane of the gums. Probably by some accident-and before admission he fell off the steps of a tramcar on to the perhaps due to the very accident above referred to-a street, a height of about six feet, landing on his head. He portion of the mucous membrane got into this shell-like bone seemed dazed by the fall, but did not lose consciousness and remained confined therein, only awaiting some irritation and was able to walk. Ten minutes later the left arm and to determine its development into a cyst in the same way as left side of the face were noticed to twitch and later the the other so-called implantation dermoids are formed. right side also twitched. He vomited and became drowsy Another marked feature of the case was the difficulty ex- and was at once taken to the hospital. On admission he perienced in diagnosis. The only diagnosis which could be was quite unconscious and was having clonic convulsions of arrived at was that of a myeloid sarcoma, and indeed the all the limbs and face as much on one side as on the other. appearance of the tumour was quite typical of that disease. Ten minutes later the convulsions had entirely passed off and The cyst growing inside had expanded the bone in the the limbs were quite flaccid. The breathing was stertorous. fashion of a myeloid sarcoma, and in fact there was some The pupils varied constantly in size, being at one moment at one part of the dilated, at the next contracted, but always remaining equal. obscure sensation of egg-shell tumour. The hardness and innocency of the tumour were The pupils reacted sluggishly to light. The head and eyes accounted for by assuming that the sarcoma had undergone deviated first to one side and then to the other. There were a happy termination, viz., ossification, and indeed chondrifino facial paralysis and no squint. The knee-jerks were present cation and ossification of sarcoma are not uncommon. and a flexor response was obtained in the right foot but none I am indebted to Lieutenant-Colonel Quicke for permitting in the left. There was a hsematoma above the right ear. me to report this case. No depressed fracture was made out. Bombav. Operation was performed about 50 minutes after the accident. No anaesthetic was given during the initial stages of operation. A little chloroform was administered later. A flap of scalp was turned down above and in front of the right ear. A fissured fracture was found running horizontally backwards from the external angular process of the frontal OF bone and extending beyond the limits of the wound which measured two and a half inches across. There was no depression of fragments. The skull was trephined just below the BRITISH AND FOREIGN. anterior part of the fissure. There was no extradural hoemorrhage and the dura mater pulsated feebly. On enlarging the Nulla autem est alia pro certo noscendi via, nisi quamplurimas et trephine hole backwards a local bulging of the dura mater, morborum et dissectionum historias, tum aliorum tum proprias somewhat dusky in colour, was exposed. A small incision collectas habere, et inter se oomparare.—McssAHM De Sed. et Cazss. was made through the dura mater at this spot but no blood Morb., lib. iv., Prooemium. was found within reach of the puncture. The dura mater was closed by a couple of stitches and the flap sutured in plac<:. HOSPITAL FOR SICK After the operation the boy was restless and even violent, GREAT ORMOND STREET. but after about seven hours he regained consciousness. From that time he made an uninterrupted recovery. TWO CASES OF INJURY OF THE HEAD IN CHILDREN. Remarks by Mr. FAIRBANK.-Grave cerebral symptoms (Under the care of Mr. H. A. T. FAIRBANK.) which are the result of traumatism and which call for CASE 1. Traumatic subduraz Acemorphage without any surgical interference are so rarely met with in children that lesion of the skull.-The patient was a healthy girl, aged the above cases seem worthy of publication. In the first case one year and nine months. On May 19th, 1906, at 11 A.M. the indications for treatment were sufficiently clear, though she fell off a chair on to her head. For 15 minutes she seemed want of experience of such injuries in young children all right and ate some bread and butter, then "the eyes rendered the diagnosis of the source of the blood doubtful. became fixed"" and she rapidly became unconscious. At The disappointing termination after the symptoms had been 2.30 P.M. she became convulsed on the right side, the head entirely relieved by operation was probably the result of the being turned towards the left shoulder. On admission to loss of cerebro-spinal fluid. Yet it did not seem to be a wise the Hospital for Sick Children at 3.30 P.z. there was twitch- procedure to close the dura mater entirely without drainage, ing of the right arm and leg and the right side of the face since the source of the haemorrhage had not been discovered. The head and eyes deviated to the left. The pupils were The procedure was justified by the occurrence of the second dilated, equal], and did not react to light. Twitching was small hoemorrhage. The result of the post-mortem examination showed that it would have been useless to hunt for the soon followed by paralysis of the whole of the right side. There was slight response to pinching but the deep and ruptured vessel. In the second case the localisation of the lesion would cutaneous reflexes were absent. With the onset of paralysis the pupils became smaller and remained equal. There was no have been difficult but for the presence of the haematoma over the right motor area, the region of the brain which squint. The pulse was 110 and the temperature was 97- F. At 4.15 P.M. the skull was trephined over the left middle the symptoms seemed to indicate as involved in the meningeal artery and the hole enlarged backwards. There injury. The operation only revealed the presence of a
formed
returned. the the
was at
crackling
__
A Mirror
HOSPITAL
PRACTICE,
-
CHILDREN,
90
HOSPITAL MEDICINE AND SURGERY.
fissured fracture, so the cause of the cerebral symptoms The presence of minute boemormust be left in doubt. rhages into the cerebral cortex may be suggested as an explanation. Since the incision made in the dura mater was minute and the hole in the skull not very extensive, it is difficult to see how intracranial tension can have been relieved to any extent by the operation. Unless the trephining did some good in this way it necessarily follows that probably the child would have recovered with equal rapidity had nothing surgical been done.
dressed. Vomiting had ceased, but the cough was troublesome. Bronchitis was present all over the chest and there wasfriction at the right base posteriorly. The temperature went up to 101°. From this date the patient’s condition improved daily : his chest cleared up, the temperature became normal, the wound was dressed every second day, and the convalescence was uneventful except for another attack of pleurisy and bronchitis which lasted for about a week. A blood count early in October showed 3,967,480 red cells and 6758 white cells per cubic millimetre. The patient went to. town quite well on Nov. 20th. The spleen was a shade larger than usual at the time of removal ; it was somewhat collapsed and there were two LIVERPOOL WORKHOUSE HOSPITAL. holes in its surface through which blood was seen oozing before the pedicle was clamped. RUPTURE OF THE SPLEEN; SPLENECTOMY ; RECOVERY. Remarks by Dr. ALEXANDER.-There are several points in the care of Dr. W. ALEXANDER.) (Under this case that are of interest to the profession. The history FOR the notes of the case we are indebted to Mr. John of the case, though not reliable owing to the partial intoxiT. Moore, resident medical officer. cation of the patient, points to a fall over a form and the The patient, aged 34 years, a labourer and an ex-soldier, injury to the spleen would probably not have occurred but was admitted into the Liverpool workhouse hospital on for the adherent condition of that organ. Its convex surface August 5th, 1906, complaining of pain in the left side of was fixed to the diaphragmatic peritoneum and had to beHe stated that upon the night before peeled off by the fingers at the operation. It could not the abdomen. admission, while under the influence of drink, in the move to avoid the crush and so was injured when a moveable course of a row with another man, he fell over a form spleen would probably have escaped. Again, the hsemorrhage and hurt his side. After the injury he went to bed and was at first undoubtedly inside the capsule and had the slept. The next morning he arose at the usual time and patient been able to rest it might never have gone beyond went to his work, which consisted in wheeling a heavy that position. But after a good night’s rest he had to get up barrow. He commenced work at 5 A.M. and struggled on and work "wheeling a barrow." Even when he came into till noon. During this time he felt bad and had two pints hospital the same afternoon he was not in an alarming conof beer, part of which he vomited. He then sought admis- dition, nor did he show urgent symptoms until the next sion to the hospital. morning. The rupture of the splenic capsule probably did On admission the patient complained of severe pain in the not take place until some time after he was in bed in the left hypochondrium. His temperature was normal. There hospital, as at the operation the blood was entirely confined were no signs of injury or fracture of the ribs. Opium stupes to the left hypochondrium. This would hardly have occurred were ordered and later he said that he felt better and slept had bleeding been going on whilst the patient was moving fairly well. On the evening of the next day, August 6th, the about, as blooi would in that case have trickled down into pain in his side became intense ; he vomited three times, the lower abdomen. It was especially noticed that this had his respirations became frequent and chiefly thoracic, the not occurred. The next point is that we did not operate on account of a pulse was small and frequent, and the temperature fell to The abdomen was retracted and the liver dulness ruptured spleen. We did not know what had taken place 97’ 6° F. It was evident that some but the symptoms indicated grave internal lesions and the was apparently diminished. serious internal injury existed. An exploratory operation operation was at first exploratory only. The retraction of was proposed and agreed to by the patient. The abdomen the abdomen and the lessened liver dulness pointed rather to was opened at 8.30 the same evening by a median incision. an injury of a hollow viscus than of a solid organ. The The left hypochondrium was found full of blood clot and the collapse, the rapidly failing pulse, the shallow breathing, &c., spleen ruptured. The vertical incision was now prolonged all called urgently for an exploration, and as an exploration to the left just below the costal margin. The blood was in itself is not dangerous, nor does it add materially to the confined to the left hypochondrium and the colon was dis- gravity of the case, we performed it, although we had no idea. tended, which accounted for the diminished liver dulness. at the time of the nature of the injury. An important point in the case is the great and manifest. Bright blood was gushing up from the left. The spleen was at once brought into view, having to be scraped off the value of adrenalin and saline transfusions. After the spleen parietes owing to old adhesions. It was found to be was removed the condition of the patient became alarming, surrounded by firm clots and to be ruptured in two places. and the feeling of my anaesthetist and of some of my The pedicle was clamped, the spleen was excised, the stump assistants was that the patient was dying. Dr. Donaldson ligated, and the blood clot was removed. The patient at this rapidly inserted the transfusion needle into the usual vein stage became extremely collapsed. An intravenous injec- in the arm and passed one drachm of adrenalin solution tion of 30 ounces of normal saline solution containing one! mixed with one and a half pints of normal saline solutiondrachm of 1 in 1000 adrenalin solution was given by Dr. R. into the circulation. The effect was immediate and enabled Donaldson whilst the operation was rapidly completed. me to finish the operation satisfactorily. The value of After the removal of blood and clots the cavity was swabbedL adrenalin was also shown in its effect on the oozing from out with saline solution containing adrenalin, and as therethe bleeding surfaces from which the ruptured spleen had was some oozing and the patient was much collapsed the been removed. The oozing ceased as if by magic when we large cavity was packed with sterile gauze and two largepressed on the bleeding surface gauze soaked with adrenalin gauze drains in split rubber tubes were placed in the lowerrsolution, and we were then able to place our gauze drains The incision in the abdominal wall1 in position comfortably. corner of the wound. was closed in the usual three-tier way. He was removed to On August 10th I left for Canada and Mr. Moore took bed, the lower end of which was well raised. He had small1 entire charge of the case. The credit of piloting the patientr rectal salines and fluids by the mouth every two hours,, through various pulmonary complications is entirely due tostrychnine hypodermically (th of a grain) every four hours, his care and skill. When I came back the patient was conand a th of a grain of morphine to check the intense rest- valescent, his blood count was practically normal, and there lessness. The temperature remained at 970 and the pulsee were no signs that such an important organ had been was very small, 130 during the night. The shock continuedremoved. to a considerable extent all the next day, the pulse being from 130 to 136. At 4 P.M. the temperature rose to 100’4°, PRIVATE ASYLUMS FOR THE INSANE IN ST. PETERS-gradually coming down to normal towards morning. The patient was fed with small quantities frequently, meat juice BURG.-At a recent sitting of the St. Petersburg town beef-tea, chicken broth, and egg flip alternately, and four government it was decided to make an experiment by sub-hourly rectal nutrients were administered. On the 8th thl sidising private homes to the initial extent of R1000 for shosk had passed off, the gauze and drainage tubes wer4 patients of weak mind, so as to relieve the pressure on the removed, and small gauze drains were applied. During tb4 hospitals. Although some members argued that the step day he vomited three times and the bowels were moved ; a was calculated to encourage " angel making" the decision. held that night he had a troublesome cough which was relieved b: was given in favour of the argument of others who people to whom the jacket poultices and a steam tent. On the 9th his condition there were many wholly trustworthy cara of insane persons might be given. On the 10th the wound was agai was about the same. .
.
.
,
-
__________________________________-
89
eruption and sound condition of all teeth and by the fact of was no extradural haemorrhage. The dura mater bulged the tumour first appearing at the temporo-maxillary articula- tense and blue into the opening and on incising it there was tion and thence extending downwards, the case was diagnosed a gush of thin unclotted blood which continued to flow for The right arm was immeas probably one of myeloid sarcoma, and an operation was per- some minutes and then ceased.
by Lieutenant-Colonel W. H. Quicke, I.M.S., senior diately moved voluntarily and the leg movements soon No bleeding point was found and the wound in the surgeon of the hospital. An exploratory incision was first made when the ramus was seen to be expanded from within. dura mater was closed except for a small gauze drain. The bone being cut open with a chisel and hammer a cyst Within an hour of the operation the child was quite conwas revealed filled with soft epithelial-like flakes. The scious and there was no trace of paralysis. The dressings flakes were all removed and the cyst wall, which was partly were repeatedly soaked with cerebro-spinal fluid in spite of head being raised. At 11.30 P.M. the temperature had adherent to and lining the bony cavity, was thoroughly scraped off and removed. The cyst growing inside had also risen to 103°, the respirations were fast and irregular, and to some extent expanded the body of the mandible where pulse was feeble and rapid. About 6 A.az. on the followThe fang ing morning, as the child was unconscious, the gauze drain one of the fangs of the third molar was seen. The bony cavity was then cleaned and removed and some dark blood escaped. The child died was quite normal. 7.30 A.M. stuffed with iodoform gauze, and it finally healed by granulation, the healing taking a long time, and the patient was Neoropsy.-At the post-mortem examination no fracture of the skull, gross lesion of the brain, or rupture of bloodultimately discharged cured on June 14th. The case is of interest on account of the unusual site vessels was found. There was a marked scarcity of cerebroselected by the dermoid. A dermoid within the structures spinal fluid and between the dura mater and the brain on the of a bone and at a place where during embryonic life there side of the operation was a thin film of blood-quite insuffiis no union between two skin-covered surfaces is a surgical cient to produce symptoms. CASE 2. Fracture of the skull nitlt cerebral symptoms.-A anomaly and one which I venture to explain as follows. At birth the mandible is a mere shell of bone containing the boy, aged four years and three months, was admitted to the sockets of the temporary teeth and covered by the mucous Hospital for Sick Children on August lst, 1906. 20 minutes membrane of the gums. Probably by some accident-and before admission he fell off the steps of a tramcar on to the perhaps due to the very accident above referred to-a street, a height of about six feet, landing on his head. He portion of the mucous membrane got into this shell-like bone seemed dazed by the fall, but did not lose consciousness and remained confined therein, only awaiting some irritation and was able to walk. Ten minutes later the left arm and to determine its development into a cyst in the same way as left side of the face were noticed to twitch and later the the other so-called implantation dermoids are formed. right side also twitched. He vomited and became drowsy Another marked feature of the case was the difficulty ex- and was at once taken to the hospital. On admission he perienced in diagnosis. The only diagnosis which could be was quite unconscious and was having clonic convulsions of arrived at was that of a myeloid sarcoma, and indeed the all the limbs and face as much on one side as on the other. appearance of the tumour was quite typical of that disease. Ten minutes later the convulsions had entirely passed off and The cyst growing inside had expanded the bone in the the limbs were quite flaccid. The breathing was stertorous. fashion of a myeloid sarcoma, and in fact there was some The pupils varied constantly in size, being at one moment at one part of the dilated, at the next contracted, but always remaining equal. obscure sensation of egg-shell tumour. The hardness and innocency of the tumour were The pupils reacted sluggishly to light. The head and eyes accounted for by assuming that the sarcoma had undergone deviated first to one side and then to the other. There were a happy termination, viz., ossification, and indeed chondrifino facial paralysis and no squint. The knee-jerks were present cation and ossification of sarcoma are not uncommon. and a flexor response was obtained in the right foot but none I am indebted to Lieutenant-Colonel Quicke for permitting in the left. There was a hsematoma above the right ear. me to report this case. No depressed fracture was made out. Bombav. Operation was performed about 50 minutes after the accident. No anaesthetic was given during the initial stages of operation. A little chloroform was administered later. A flap of scalp was turned down above and in front of the right ear. A fissured fracture was found running horizontally backwards from the external angular process of the frontal OF bone and extending beyond the limits of the wound which measured two and a half inches across. There was no depression of fragments. The skull was trephined just below the BRITISH AND FOREIGN. anterior part of the fissure. There was no extradural hoemorrhage and the dura mater pulsated feebly. On enlarging the Nulla autem est alia pro certo noscendi via, nisi quamplurimas et trephine hole backwards a local bulging of the dura mater, morborum et dissectionum historias, tum aliorum tum proprias somewhat dusky in colour, was exposed. A small incision collectas habere, et inter se oomparare.—McssAHM De Sed. et Cazss. was made through the dura mater at this spot but no blood Morb., lib. iv., Prooemium. was found within reach of the puncture. The dura mater was closed by a couple of stitches and the flap sutured in plac<:. HOSPITAL FOR SICK After the operation the boy was restless and even violent, GREAT ORMOND STREET. but after about seven hours he regained consciousness. From that time he made an uninterrupted recovery. TWO CASES OF INJURY OF THE HEAD IN CHILDREN. Remarks by Mr. FAIRBANK.-Grave cerebral symptoms (Under the care of Mr. H. A. T. FAIRBANK.) which are the result of traumatism and which call for CASE 1. Traumatic subduraz Acemorphage without any surgical interference are so rarely met with in children that lesion of the skull.-The patient was a healthy girl, aged the above cases seem worthy of publication. In the first case one year and nine months. On May 19th, 1906, at 11 A.M. the indications for treatment were sufficiently clear, though she fell off a chair on to her head. For 15 minutes she seemed want of experience of such injuries in young children all right and ate some bread and butter, then "the eyes rendered the diagnosis of the source of the blood doubtful. became fixed"" and she rapidly became unconscious. At The disappointing termination after the symptoms had been 2.30 P.M. she became convulsed on the right side, the head entirely relieved by operation was probably the result of the being turned towards the left shoulder. On admission to loss of cerebro-spinal fluid. Yet it did not seem to be a wise the Hospital for Sick Children at 3.30 P.z. there was twitch- procedure to close the dura mater entirely without drainage, ing of the right arm and leg and the right side of the face since the source of the haemorrhage had not been discovered. The head and eyes deviated to the left. The pupils were The procedure was justified by the occurrence of the second dilated, equal], and did not react to light. Twitching was small hoemorrhage. The result of the post-mortem examination showed that it would have been useless to hunt for the soon followed by paralysis of the whole of the right side. There was slight response to pinching but the deep and ruptured vessel. In the second case the localisation of the lesion would cutaneous reflexes were absent. With the onset of paralysis the pupils became smaller and remained equal. There was no have been difficult but for the presence of the haematoma over the right motor area, the region of the brain which squint. The pulse was 110 and the temperature was 97- F. At 4.15 P.M. the skull was trephined over the left middle the symptoms seemed to indicate as involved in the meningeal artery and the hole enlarged backwards. There injury. The operation only revealed the presence of a
formed
returned. the the
was at
crackling
__
A Mirror
HOSPITAL
PRACTICE,
-
CHILDREN,
90
HOSPITAL MEDICINE AND SURGERY.
fissured fracture, so the cause of the cerebral symptoms The presence of minute boemormust be left in doubt. rhages into the cerebral cortex may be suggested as an explanation. Since the incision made in the dura mater was minute and the hole in the skull not very extensive, it is difficult to see how intracranial tension can have been relieved to any extent by the operation. Unless the trephining did some good in this way it necessarily follows that probably the child would have recovered with equal rapidity had nothing surgical been done.
dressed. Vomiting had ceased, but the cough was troublesome. Bronchitis was present all over the chest and there wasfriction at the right base posteriorly. The temperature went up to 101°. From this date the patient’s condition improved daily : his chest cleared up, the temperature became normal, the wound was dressed every second day, and the convalescence was uneventful except for another attack of pleurisy and bronchitis which lasted for about a week. A blood count early in October showed 3,967,480 red cells and 6758 white cells per cubic millimetre. The patient went to. town quite well on Nov. 20th. The spleen was a shade larger than usual at the time of removal ; it was somewhat collapsed and there were two LIVERPOOL WORKHOUSE HOSPITAL. holes in its surface through which blood was seen oozing before the pedicle was clamped. RUPTURE OF THE SPLEEN; SPLENECTOMY ; RECOVERY. Remarks by Dr. ALEXANDER.-There are several points in the care of Dr. W. ALEXANDER.) (Under this case that are of interest to the profession. The history FOR the notes of the case we are indebted to Mr. John of the case, though not reliable owing to the partial intoxiT. Moore, resident medical officer. cation of the patient, points to a fall over a form and the The patient, aged 34 years, a labourer and an ex-soldier, injury to the spleen would probably not have occurred but was admitted into the Liverpool workhouse hospital on for the adherent condition of that organ. Its convex surface August 5th, 1906, complaining of pain in the left side of was fixed to the diaphragmatic peritoneum and had to beHe stated that upon the night before peeled off by the fingers at the operation. It could not the abdomen. admission, while under the influence of drink, in the move to avoid the crush and so was injured when a moveable course of a row with another man, he fell over a form spleen would probably have escaped. Again, the hsemorrhage and hurt his side. After the injury he went to bed and was at first undoubtedly inside the capsule and had the slept. The next morning he arose at the usual time and patient been able to rest it might never have gone beyond went to his work, which consisted in wheeling a heavy that position. But after a good night’s rest he had to get up barrow. He commenced work at 5 A.M. and struggled on and work "wheeling a barrow." Even when he came into till noon. During this time he felt bad and had two pints hospital the same afternoon he was not in an alarming conof beer, part of which he vomited. He then sought admis- dition, nor did he show urgent symptoms until the next sion to the hospital. morning. The rupture of the splenic capsule probably did On admission the patient complained of severe pain in the not take place until some time after he was in bed in the left hypochondrium. His temperature was normal. There hospital, as at the operation the blood was entirely confined were no signs of injury or fracture of the ribs. Opium stupes to the left hypochondrium. This would hardly have occurred were ordered and later he said that he felt better and slept had bleeding been going on whilst the patient was moving fairly well. On the evening of the next day, August 6th, the about, as blooi would in that case have trickled down into pain in his side became intense ; he vomited three times, the lower abdomen. It was especially noticed that this had his respirations became frequent and chiefly thoracic, the not occurred. The next point is that we did not operate on account of a pulse was small and frequent, and the temperature fell to The abdomen was retracted and the liver dulness ruptured spleen. We did not know what had taken place 97’ 6° F. It was evident that some but the symptoms indicated grave internal lesions and the was apparently diminished. serious internal injury existed. An exploratory operation operation was at first exploratory only. The retraction of was proposed and agreed to by the patient. The abdomen the abdomen and the lessened liver dulness pointed rather to was opened at 8.30 the same evening by a median incision. an injury of a hollow viscus than of a solid organ. The The left hypochondrium was found full of blood clot and the collapse, the rapidly failing pulse, the shallow breathing, &c., spleen ruptured. The vertical incision was now prolonged all called urgently for an exploration, and as an exploration to the left just below the costal margin. The blood was in itself is not dangerous, nor does it add materially to the confined to the left hypochondrium and the colon was dis- gravity of the case, we performed it, although we had no idea. tended, which accounted for the diminished liver dulness. at the time of the nature of the injury. An important point in the case is the great and manifest. Bright blood was gushing up from the left. The spleen was at once brought into view, having to be scraped off the value of adrenalin and saline transfusions. After the spleen parietes owing to old adhesions. It was found to be was removed the condition of the patient became alarming, surrounded by firm clots and to be ruptured in two places. and the feeling of my anaesthetist and of some of my The pedicle was clamped, the spleen was excised, the stump assistants was that the patient was dying. Dr. Donaldson ligated, and the blood clot was removed. The patient at this rapidly inserted the transfusion needle into the usual vein stage became extremely collapsed. An intravenous injec- in the arm and passed one drachm of adrenalin solution tion of 30 ounces of normal saline solution containing one! mixed with one and a half pints of normal saline solutiondrachm of 1 in 1000 adrenalin solution was given by Dr. R. into the circulation. The effect was immediate and enabled Donaldson whilst the operation was rapidly completed. me to finish the operation satisfactorily. The value of After the removal of blood and clots the cavity was swabbedL adrenalin was also shown in its effect on the oozing from out with saline solution containing adrenalin, and as therethe bleeding surfaces from which the ruptured spleen had was some oozing and the patient was much collapsed the been removed. The oozing ceased as if by magic when we large cavity was packed with sterile gauze and two largepressed on the bleeding surface gauze soaked with adrenalin gauze drains in split rubber tubes were placed in the lowerrsolution, and we were then able to place our gauze drains The incision in the abdominal wall1 in position comfortably. corner of the wound. was closed in the usual three-tier way. He was removed to On August 10th I left for Canada and Mr. Moore took bed, the lower end of which was well raised. He had small1 entire charge of the case. The credit of piloting the patientr rectal salines and fluids by the mouth every two hours,, through various pulmonary complications is entirely due tostrychnine hypodermically (th of a grain) every four hours, his care and skill. When I came back the patient was conand a th of a grain of morphine to check the intense rest- valescent, his blood count was practically normal, and there lessness. The temperature remained at 970 and the pulsee were no signs that such an important organ had been was very small, 130 during the night. The shock continuedremoved. to a considerable extent all the next day, the pulse being from 130 to 136. At 4 P.M. the temperature rose to 100’4°, PRIVATE ASYLUMS FOR THE INSANE IN ST. PETERS-gradually coming down to normal towards morning. The patient was fed with small quantities frequently, meat juice BURG.-At a recent sitting of the St. Petersburg town beef-tea, chicken broth, and egg flip alternately, and four government it was decided to make an experiment by sub-hourly rectal nutrients were administered. On the 8th thl sidising private homes to the initial extent of R1000 for shosk had passed off, the gauze and drainage tubes wer4 patients of weak mind, so as to relieve the pressure on the removed, and small gauze drains were applied. During tb4 hospitals. Although some members argued that the step day he vomited three times and the bowels were moved ; a was calculated to encourage " angel making" the decision. held that night he had a troublesome cough which was relieved b: was given in favour of the argument of others who people to whom the jacket poultices and a steam tent. On the 9th his condition there were many wholly trustworthy cara of insane persons might be given. On the 10th the wound was agai was about the same. .
.
.
,
-
__________________________________-