14

found to be empty, and on everting it the lining of itswalls had the appearance of pulpy granulation tissue. Nocanal could be made out at its cæcal extremity.

It is now a year since the operation. The patient hasenjoyed perfect health, and is quite free from any feeling ofweakness in the region of the cicatrix. The diagnosis ofcatarrhal appendicitis proved correct, and so, also, wouldseem the treatment. Whether this patient would, by con-servative measure?, have reached a period when no furtherrepetition of his troubles would have taken place, or whetherthe time might have come for opening an abscess in the

region of the appendix, or even graver measures, it is impos-sible to say. The operation can hardly be said to havecarried any risks with it, and its result was and has beento relieve him completely of his trouble.Glasgow.

________ __

PARTIAL ASPHYXIA FROM IMPACTION OF FALSETEETH IN THE ŒSOPHAGUS DURING AN

EPILEPTIC FIT; RECOVERY.BY A. STANHOPE DAWSON, L.R.C.P., L.R.C.S. ED.

CALLED suddenly to W. E-, aged seventy-eight, I foundthe patient suffering from stertorous breathing, cyanotic,and in a severe epileptic seizure. On opening his mouth toexamine the tongue I found the top plate and false teethhad been swallowed. After considerable difficulty I hookedup the plate ; but the patient being a chronic bronchiticsubject, an alarming accumulation of tenacious phlegm hadtaken place, due mainly to the pressure of the tooth-plateon the epiglottis. I asked for strong hen feathers, and bytheir aid for half an hour removed the phlegm, my patientbreathing more easily, but the pulse becoming intermittent,I administered twenty drops of sulphuric ether hypodermi-cally ; this, with brandy followed by a stimulating expecto-rant, caused the patient to rally, subsequent soreness of mouthand throat being relieved by ice and ehampagne. I firmlybelieve the removal of phlegm by the feathers saved mypatient’s life. I was called in on June 7th, and to-day(June 14th) he has taken bread and milk freely. My reasonfor reporting the case is to suggest that surgeons should notforget that "a feather may turn the scale." In future I shallkeep one or two brushes at hand, such as are sold bv musicalinstrument vendors for cleaning the flute, which, I ventureto believe, would be of more use than the feathers. Thesebrushes being mounted on wire, they may be bent to a con-venient angle, like the throat brushes in ordinary use.Cockermouth.

______________

A CASE OF PLACENTA PRÆVIA IN A PATIENTSUFFERING FROM MITRAL VALVULAR

DISEASE.

BY PHILIP E. HILL, M. R. C. S. ENG., L. S. A. LOND.

ON May 31st, at 11 P.M., I was called toMrs. E-, twenty-eight years of age, the subject of mitral disease, eight monthsadvanced in her fifth pregnancy. Immediatelyprevious to mybeing sent for, the patient was surprised by a sudden gush ofblood from the uterus, without any shock or violent exertionto account for it ; she was in bed and at perfect rest. Bythe time I arrived the haemorrhage had moderated. Uponexamination per vaginam, I found the os slightly dilated,but not sufficiently so to enable me to make out thepresentation; the cervix, however, felt more spongyuhan usual. The case, to my mind, peculiarly pointed toa placental presentation. For the present, therefore, mychief care was to arrest the discharge, and for this purposeI directed the patient to be kept cool, quiet, and in therecumbent position, and ordered fifteen minims of dilutesulphuric acid every three hours. After explaining to thefriends myopinion as to the probable nature of the case, I left,giving instructions that should pain occur or the haemorbagereturn I was to be at once sent for. About an hour subse-quently I was again summoned, when I found the boemorrhagehad returned and uterine action commenced. Upon exami-nation, the os was sofit and dilatable, the head presenting,and the placenta partially so, the mass being felt detachedand to the left side. During a pain a torrent of florid bloodgushed from the uterus, which at orca placed the patient in

extreme danger. I now felt that I must immediately deter,-mine the course to pursue for the rescue of the mother fromimpending death, as well as the possible preservation of thechild. I therefore passed two fingers inside the os, anddetached as much of the placenta as I could. I then cuttwo V-shaped notches in the nail of the index finger of myright hand, and with it sawed through the tough andreceding membranes. This being done, the liquor amniiescaped, the head at once descended, all haemorrhageceased, and the child was delivered at 1.15 A.M., but.it was dead. After remaining for two hours, I left,the patient feeling much stronger, more comfortable,the radial pulse 72, of fair strength and volume. At8A.M.I was again hastily summoned, when I found the followingcondition of things. The pulse was failing, being weak, small,and intermittent; the patient was blanched and coveredwith a cold, clammy sweat; vomiting, with restlessness,impairment of vision, and delirium. The uterus was wellcontracted, firm, and there was no hæmorrhage. I immediatelygave her brandy and ether, applied a mustard leaf over theheart, hot-water bottles to the extremities, and prescribed thefollowing mixture : Twenty minims of tincture of digitalis,half a drachm of spirit of cajuput, camphor mixture to oneounce, to be taken every three hours. Gradually the heartregained tone and steadiness, but she lapsed almost intothe same condition periodically upon the slightest move-ment or attempt at sleep. The above symptoms slowly dis-appeared, and the patient is now making a gradual anduninterrupted recovery.CrickhowelI.

A MirrorOF

HOSPITAL PRACTICE,BRITISH AND FOREIGN.

MIDDLESEX HOSPITAL.SOME RECENT CASES OF INJURY TO THE HEAD.

(Under the care of Mr. HULKE.)

Nulla autem est alia pro certo noscendi via, nisi quamplurimas et mor-borum et dissectionuin historias, tmn aliorum tum proprias collectashabere, et inter se comparare.—MORGAGNI De Sed. et Ca1tS. hqorb.,lib. iv. Proœmium. THESE cases of injury to the cranium present features

which render them of considerable interest. In the firstthe severity of the injury to the vault of the skull appearedto produce but little impression in the way of shock on thepatient, and the case presents another example of thaamount of injury which may occasionally be inilicted andthe sufferer quite unable to realise it, because able to walkabout without much inconvenience or local pain. Thetreatment of the case by the application of the trephinewas successful, and there is nothing beyond the copiouswatery discharge from the wound, a rare occurrence afterfracture of the vault, to attract attention in the subsequentprogress of the case. The second patient, who had receiveda punctured wound of the orbit, probably accompanied by-fracture of the orbital roof, recovered from a conditionwhich (if the bone was indeed fractured) is so frequentlyfatal that it should be placed on record. The reason forthis statement will be more evident to our readers when weremind them that the results of such injury have beenestimated as fatal in seventeen out of eighteen ofthose injured. The third case presents features veryuncommon as the result of contusion of the skull.Mr. Hulke considers the paralyses to have beenof peripheral origin, and in a clinical lecture re-

marks : " The supposition of syphilis suggested by the earlydeath of all the patient’s children is conaistent with thecourse of her disorder, and it is supported by the results oftreatment. When she first entered the hospital the questionof syphilis was considered, and it was thought, upon the whole,at that time, before we had had much opportunity of observ-ing her, that probably she was suffering from traumatic peri-cranitis. Later, the presence of a syphilitic factor gainedground, and she was given iodide of potassium, but withoutobvious benefit. After her return the dose of iodide ofpotassium was increased from five to fifteen grains three

15

times a day, and this was followed by improvement. Her buried itself between the eyeball and the orbital roof. Onheadaches became very much less severe, and though no seizing the object with a forceps it was found to be sodiminution in the bulk of the temporal and post-mastoid tightly fixed as to strongly suggest that it had pierced andswellings was observable, they became less tender. Upon was grasped by bone. With some effort, by traction in aobserving this, the dose of iodide of potassium was increased forward and downward direction, the foreign body wasfrom fifteen to twenty grains, and apparently with advantage. extracted entire, and it proved to be the vulcanite mouth-The ocular palsies disappeared." Mr. Hulke also pointed piece of a pipe, 4-5 centimetres long, 1-4 centimetres

out that a later extension of the disorder whilst under the across at its base, and slightly tapering to the free end.iodide treatment did not exclude the hypothesis of a In the upper eyelid was a superficial lacerated wound,syphilitic origin. which did not communicate with that made by the foreignCASE 1. Compound, comminuted, depressed fracture Of body. He was stated to have been struck by a man who

- skull trep7ining; recovery -On Nov. 19th last, soon had a pipe in his hand, and he was brought to the hospitalafter 9 A.M., E. F——, aged thirty-six, a builder’s labourer, directly aft er the injury. This was regarded as so trivialwas hit on the head by a brick which fell out of a bucket by himself and his friends that he was with difficulty per-aome twenty feet above him, whilst this was being hoisted suaded to remain. Conspicuous symptoms of cerebralto a scaffold. He fell on the ground, was dazed for a few injury have throughout been absent, yet we are not leftmoments, then rose and resumed his work for an hour, completely without warning that such an injury may havewhen his mates, noticing his face bloody, sent him to the occurred, for his temperature and pulse-rate until the lasthospital. He walked into the surgery to have his head day or two have been slightly subnormal. The externaldressed. As he could not take off his cap because it seemed wounds quickly closed, and he soon felt so little ill that hetightly fastened to his head the casualty house surgeon re- rebelled against being kept in bed and the moderate dietmoved it by cutting through its lining, and then found which was allowed him. He left the hospital a few daysa scalp wound crossing the parietal region in a nearly afterwards, much against the wish of Mr. Hulke, and withsagittal direction, about two inches long, exposing a de- a full explanation of the risks he was incurring by thispressed comminuted fracture of the vault. At each end course.

of this depression pieces of the cap lining were entangled and CASE 3. Contusion of head followed by a widely dis-tightly held between the fragments. The man, a very tributed pericranitis.-On Oet. llth, 1890, C. P-, agedstolid fellow, would not believe his hurt to be serious; he twenty-six, was admitted into Bird Ward for the effects of,refused to stay and be an in-patient, and insisted on being an injury of the head alleged to have been occasioned four-allowed to go home, which he did, a distance of about teen days previously by the patient striking her cheek with’half a mile. He was perfectly conscious, he walked with- the handle of a saucepan. Below the right eye, involvingout difficulty, and no one could have inferred from his the lower eyelid and the malar region, were traces of a fadingappearance and manner that he had sustained a very ecchymosis, and here, and in the adjoining temple, right,grave injury. Two hours later the house surgeon, temporal region, the subcutaneous tissues were cedematouslyrealising the great risks to which the ignorant fellow puffy, occasioning obvious swelling, most prominent in thewas exposing himself, went to his lodgings, and with temple just over the zygoma, and ceasing below thesome trouble persuaded him to return to the hospital, curved line, limiting the temporal fossa superiorly.where Mr. Hulke saw him at 1.30 P.M., about four hours Quite distinct from this, a prominent, obviously fluctuatingafter the occurrence of the accident, and confirmed the swelling was present over the right parietal bone, the limits.existence of the injuries above mentioned. As the exami- of which, though not accurately definable, seemed not tonation hurt him, he readily fell in with the idea of taking transgress the area of this bone. This swelling was not.chloroform. This having been given him, the scalp wound particularly tender or painful, nor was the scalp over itwas enlarged, the depressed fragments, tightly impacted, hotter than elsewhere, nor was it discoloured. She had awere raised, one loose piece was taken away, and all the very ansemic, feeble appearance, suggestive of chronic ill-bits of cap lining were removed. To accomplish this it was ness, of privations, and of work beyond her strength. Hermecessary to apply a trephine at each end of the depression, statement that until the accident she had always enjoyedwhich was boat shaped, with sides falling in steeply to the excellent health was discredited by the fact that not one ofkeel, and also meeting at each end. It was estimated her children (four) had survived its infancy. She had head-approximately to be about six centimetres long and aehe, a furred tongue, and her temperature was 1030 F.two centimetres wide at its middle. Its position was With the exception of an interval of one week spent at home,’nearer the upper than the lower border of the parietal bone. she has remained in the hospital up to the present time;From the posterior end of the depression a fissure, at its com- and throughout this period her temperature has continuedmencement about two millimetres wide, ran almost directly high. It has not again reached 103°, but it has a few times’backwards, its extent was not ascertained Theduramater exceed 102°, very frequently passed above 101°, has com-.under the depressed bone, so far as it was apparent, and monly oscillated about 100’, and on one occasion only wasthat corresponding to the trephine holes, was coated with it found to have fallen to the normal line, 98 4°. Headacheblood-cloh, and mingled with this, at the posterior of the has been constant, variable in degree and in seat, nowtwo openings, were pieces of a soft, greyish substance very chiefly frontal, then occipital, often general. On Nov. 10thdike brain tissue. The wound having been irrigated with a slight inequality of the pupils was observed, the righta watery solution of mercuric perchloride (1 in 2000), the pupil appearing to be slightly larger, and a tender andscalp was united with sutures, drainage provided for, and a puffy swelling of the scalp behind the left mastoidlight, dry, antiseptic dressing applied. Restlessness, which process was noticed. On the llth the right foreheadset in the same evening, was treated with morphia, after was puffy. On the 13th there was increased swellingwhich he slept. There continued for several days a copious of the right temple and an elastic puffiness withoubwatery discharge through the drain. Primary union took great tenderness; no heat or redness of integument. Head-place throughout nearly the entire length of the divided ache very severe. On the 17th the right cheek was swollen.scalp. The case ran an afebrile course. The patient was An alveolar abscess connected with carious roots of rightsoon able to leave his bed, and for several weeks he has molar teeth was detected and opened, giving escape to aboutappeared convalescent ; but he was detained in the hospital two drachms of very fetid pus. This occasioned no furtherbecause a small sinus persisted at each end of the wound, trouble, and soon closed under local treatment. In theand through one of these a small area of bare bone is early part of December a puffy swelling appeared behindfelt, and until this has exfoliated and cicatrisation is com- the right mastoid region, resembling that on the left side,pleted, it would be imprudent to let him expose himself to which continued without obvious change, and a chain ofthe vicissitudes of his calling. He has been recently seen, slightly swollen and tender lymph-glands was discoveredperfectly well, the wound soundly healed. along the posterior border of the right sterno-mastoidCASE 2. P1.tnctured wound of orbit, with lodgment oj muscle. About this time the fluctuating swelling over the

<.f. foreign body.. perhaps pmforation of orbital roof. right parietal bone and the ecchymosis of the right cheek(From notes taken by tne dresser.)-At 10.45 P.M. on had quite disappeared. Her condition continued the sameMay 9th, 1891, W. B-, aged thirty-six, a tailor, drunk with little notable change until Dec. 22nd, except that theand noisy, was brought to the hospital. He had, he said, puffy swellings in both temples had become perceptiblypain in the right eye. The house surgeon, Mr. Soulby, larger. Frightened by the apprehension of an operation,on examining this found the eyeball pressed down from which had been spoke of in her presence, she now went home.its central position by a hard, oval, perforated object, On Dec. 30th she sought readmission, finding herself quitewhich had pierced the upper sinus of the conjunctiva and unable to discharge her domestic duties. On Jan. 1st last

16

this note was taken of her condition on that day : Face pale,waxy, its integument smooth, shiny, devoid of wrinkles,and puffed. Bight temporal fossa, its lower part just abovethe zygoma distinctly prominent, the prominence fadingout insensibly upwards, but traceable nearly to the curvedline running backwards from the external process of thefrontal bone above the temporal fossa. The integumenthere cannot be pinched up in a fold, but it and the under-lying fatty tissue are soft, and both these are readilymovable upon the deep temporal fascia. The contractions ofthe temporal muscle, when the teeth are tightly clenched, arescarcely perceptible to the finger-tip placed on the muscle,they appear hampered by the presence of a deepsweDing firmerthan the superficial puffiness. She cannot separate her jawswidely owing apparently to a loss of extensibility of thetemporal muscles. The left temporal fossa is occupied by asimilar but rather less prominent swelling. The posteriormargin of the lefb mastoid process with the immediatelyadjoining occipital region and the posterior border of theright sterno-mastoid present similar swellings, and theenlarged lymph glands already mentioned along theposterior border of this muscle persist. No trace ofparietal swelling remains, except a trace perhaps at theright limit of the lambdoidal suture. There is completepalsy of all muscles of the right side of the face. Deafness(absolute ?) of right ear; watch tick not heard even whenthe watch touches the side of the head, and tuning forkinaudible. The meatus externus clear. A small defect isapparent at the lower and front part of the membranatympani, where there is a bunch of granulations. Nodischarge. Temperature 1002&deg;; pulse 102 -Jan. 4th: Shecomplained to the ward sister that she saw two or threethings where she knew there should be only one. Oninvestigating this next day diplopia was found limitedto the left half of the visual field, with increasing horizon-tal separation of the images towards the left, and obliquelyvertical separation of them, increasing upwards. Her in-telligence is not great, and her statements as to the relativepositions of the two images sometimes seemed contra-dictory. No absolute loss of range of mobility of the lefteye, tested separately, was discernible, but in the con-sensual upward movement and in that towards left theleft eye seemed to lag a trifle behind the right eye. OnJan. 5th some deafness of left ear; watch tick inaudiblebeyond nine inches. This deafness increased rapidly tothe extent that on the llth she failed to recognise wordsunless spoken very loudly and close to the ear. On the12th. she said the double sight had gone, and this wasverified on the following day. Notwithstanding the deaf-ness of the left ear, there has recently occurred a distinctthough slight improvement in the patient’s condition. Shenow sleeps well, her headaches are less, her diplopia isgone, but her extreme deafness has somewhat depressedher mind. She became very desponding, and in Februaryleft the Middlesex Hospital, and soon after entered Charing-cross Hospital.

ROYAL PORTSMOUTH HOSPITAL.A CASE OF GUNSHOT WOUND OF THE SPINAL CORD;

NECROPSY ; REMARKS.

(Under the care of Mr. J. WARD COUSINS. )IT is comparatively rare to meet with gunshot injuries Iof any severity, especially in other regions than the head,

in the surgical practice of this country ; o that the fulldescription of a recent case, in which the cervical cordwas injured, is important. In the Surgeon-General’saccount of his department during the American Warthere are said to have been 642 cases under treatment forgunshot wound of the spine; of these, in 91 the cervicalregion was wounded and G3 died. The recoveries werenearly always of patients in whom the bullet had strucka spinous or a transverse process of one of the vertebrae, andthe cord had escaped. The notes of this large number ofcases are admittedly imperfect, but it is stated that priapismwas observed in three patients only, all of them treated forwounds of the cervical region. The account of one patientis especially interesting, for after an injury to the third cer-vical vertebra, in which, however, the cord was probablyonly contused, he suffered from paralysis of all the limbsRecovery to a great extent ensued, in spite of necrosis ofthe body of the bone injured, but with atrophy and paralysis

of the right shoulder and arm. For the account of this!case we are indebted to Mr. J. Watson, senior housesurgeon.

G. T-, aged twenty-two, a painter by trade, wasadmitted into the Royal Portsmouth Hospital on the even-ing of Saturday, April 25th, 1891, siifyeriiig from a wouncin the neck produced by a revolver bullet. On admissionhe was quite conscious, and gave a clear account of hip.injury, even to the minuteat details. He complainedonly of pain in the neck and back and of intense thirst.The breathing was even. quiet, and regular, and the,pulse normal in rate. He was unable to stand or ever..to support himself without assistance, having lost entirepower over the lower extremities ; sensation and refiex,action were also absent entirely in these parts. Markedpriapism was present from the outset, with loss of control’over the bladder. On placing him in bed the entranceaperture of the bullet was seen four inches above the leftclavicle and an inch and a half to the left of the medianline of the neck in front, the edges being slightly raggedand depressed and stained with gunpowder; fine grains ofgunpowder were also embedded in the skin on the leftside of the neck and in the skin overlying the ramus ofthe lower jaw and left cheek, showing that the weaponmust have been fired at close range. There was a

little oozing of blood from the wound at the timeof admission, and the friends who brought him statedthat he had not lost any considerable quantity before’admission. The neck was very carefully examined ex-

ternally to see whether any trace of the bullet could be-felt subcutaneously, but without any result, and a smallprobe being gently passed in failed to touch the bullet or to.show any trace of its whereabouts ; it, however, passedinwards and somewhat backwards, and it was surmised that.the ball was lodged high up in the spinal column. Therewas complete paraplegia and anesthesia of the lower extremities, no sensation whatever being experienced on deep.pinching with the finger, or on inserting pins deeply intothe skin of the part. The superficial reflexes were entirelyabolished, and, as before stated, priapism was present in amarked degree. The line of anaesthesia extended up to.about an inch below the nipples, and was a trifle higher onthe right than on the left side of the trunk. Thebreathing was markedly diaphragmatic, though therewas some costal movement towards the upper partof the chest, but none in the lower. The tongue was,dry. The patient was ordered perfect quietude in bed, withmilk, eggs, and beef-tea as diet; the wound was thoroughlycleansed with perchloride of mercury solution (1 in 1000),dredged over with iodoform, and covered with a pad of sal-alembroth wool and a bandage. Four hours after admission,the urine was drawn off by a ilexible catheter, the priapismbeing still present as on admission. The man was still’quite conscious and collected, and talked quite rationallyabout his affairs; he still complained greatly of pains inthe back, and of numbness and tingling pains at the ends.of the fingers and in the palms of the hands ; he had, how--ever, dozed for about half an hour since admission. Intense-thirst was still one of his most distressing symptoms.It was deemed advisable at this stage to take his deposi-tions before a magistrate, owing to the serious nature of hisinjury, and the likelihood of fatal symptoms superveningsuddenly. This was accordingly done, and the patient gavea perfectly lucid description of all that had occurred, statingthat his brother (who fired the shot) and a friend had hadthe revolver to inspect and had snapped off two of thechambers without any result, when he (the patient) rosefrom his chair to leave the room, thereby bringing himselfwithin the line of fire, when his brother snapped off" a.third chamber (which, quite unknown to everybody present,was loaded), and the bullet struck him in the left side of theneck at about three yards’ distance. He was unable to signthe deposition owing to the numbness and loss of powerin his fideeis, but made a feeble cross mark to indicate hisassent to it. At 7 AM. on April 26th he was still perfectlyconscious, and conversed with his friends. Priapism wasstill present. The urine was drawn oil by the catheter.Temperature 99&deg;; pulse 105. At 2 r M. on the same day thepains in the back and arms began to lessen in severity, andwith it some further loss of power was noticed in these limb?.The priapism, which had begun to subside about 9 o’clockin the morning, had now become markedly diminished ; thepatient was, however, more flushed in the face, and was alittle less inclined for conversation than he had been. Tem-