89HOSPITAL MEDICINE AND SURGERY.

eruption and sound condition of all teeth and by the fact ofthe tumour first appearing at the temporo-maxillary articula-tion and thence extending downwards, the case was diagnosedas probably one of myeloid sarcoma, and an operation was per-formed by Lieutenant-Colonel W. H. Quicke, I.M.S., seniorsurgeon of the hospital. An exploratory incision was firstmade when the ramus was seen to be expanded from within.The bone being cut open with a chisel and hammer a cystwas revealed filled with soft epithelial-like flakes. Theflakes were all removed and the cyst wall, which was partlyadherent to and lining the bony cavity, was thoroughlyscraped off and removed. The cyst growing inside had alsoto some extent expanded the body of the mandible whereone of the fangs of the third molar was seen. The fangwas quite normal. The bony cavity was then cleaned andstuffed with iodoform gauze, and it finally healed by granu-lation, the healing taking a long time, and the patient wasultimately discharged cured on June 14th.The case is of interest on account of the unusual site

selected by the dermoid. A dermoid within the structuresof a bone and at a place where during embryonic life thereis no union between two skin-covered surfaces is a surgicalanomaly and one which I venture to explain as follows. Atbirth the mandible is a mere shell of bone containing thesockets of the temporary teeth and covered by the mucousmembrane of the gums. Probably by some accident-andperhaps due to the very accident above referred to-aportion of the mucous membrane got into this shell-like boneand remained confined therein, only awaiting some irritationto determine its development into a cyst in the same way asthe other so-called implantation dermoids are formed.Another marked feature of the case was the difficulty ex-perienced in diagnosis. The only diagnosis which could bearrived at was that of a myeloid sarcoma, and indeed theappearance of the tumour was quite typical of that disease.The cyst growing inside had expanded the bone in thefashion of a myeloid sarcoma, and in fact there was someobscure sensation of egg-shell crackling at one part of thetumour. The hardness and innocency of the tumour wereaccounted for by assuming that the sarcoma had undergonea happy termination, viz., ossification, and indeed chondrifi-cation and ossification of sarcoma are not uncommon.

I am indebted to Lieutenant-Colonel Quicke for permittingme to report this case.Bombav.

__

A MirrorOF

HOSPITAL PRACTICE,BRITISH AND FOREIGN.

HOSPITAL FOR SICK CHILDREN,GREAT ORMOND STREET.

TWO CASES OF INJURY OF THE HEAD IN CHILDREN.

(Under the care of Mr. H. A. T. FAIRBANK.)

Nulla autem est alia pro certo noscendi via, nisi quamplurimas etmorborum et dissectionum historias, tum aliorum tum propriascollectas habere, et inter se oomparare.—McssAHM De Sed. et Cazss.Morb., lib. iv., Prooemium.

-

CASE 1. Traumatic subduraz Acemorphage without anylesion of the skull.-The patient was a healthy girl, agedone year and nine months. On May 19th, 1906, at 11 A.M.she fell off a chair on to her head. For 15 minutes she seemedall right and ate some bread and butter, then "the eyesbecame fixed" " and she rapidly became unconscious. At2.30 P.M. she became convulsed on the right side, the headbeing turned towards the left shoulder. On admission tothe Hospital for Sick Children at 3.30 P.z. there was twitch-ing of the right arm and leg and the right side of the faceThe head and eyes deviated to the left. The pupils weredilated, equal], and did not react to light. Twitching wassoon followed by paralysis of the whole of the right side.There was slight response to pinching but the deep andcutaneous reflexes were absent. With the onset of paralysisthe pupils became smaller and remained equal. There was nosquint. The pulse was 110 and the temperature was 97- F.At 4.15 P.M. the skull was trephined over the left middle

meningeal artery and the hole enlarged backwards. There

was no extradural haemorrhage. The dura mater bulgedtense and blue into the opening and on incising it there wasa gush of thin unclotted blood which continued to flow forsome minutes and then ceased. The right arm was imme-diately moved voluntarily and the leg movements soon

returned. No bleeding point was found and the wound in thedura mater was closed except for a small gauze drain.Within an hour of the operation the child was quite con-scious and there was no trace of paralysis. The dressingswere repeatedly soaked with cerebro-spinal fluid in spite ofthe head being raised. At 11.30 P.M. the temperature hadrisen to 103°, the respirations were fast and irregular, andthe pulse was feeble and rapid. About 6 A.az. on the follow-ing morning, as the child was unconscious, the gauze drainwas removed and some dark blood escaped. The child died

at 7.30 A.M.Neoropsy.-At the post-mortem examination no fracture ofthe skull, gross lesion of the brain, or rupture of blood-vessels was found. There was a marked scarcity of cerebro-spinal fluid and between the dura mater and the brain on theside of the operation was a thin film of blood-quite insuffi-cient to produce symptoms.CASE 2. Fracture of the skull nitlt cerebral symptoms.-A

boy, aged four years and three months, was admitted to theHospital for Sick Children on August lst, 1906. 20 minutesbefore admission he fell off the steps of a tramcar on to thestreet, a height of about six feet, landing on his head. Heseemed dazed by the fall, but did not lose consciousnessand was able to walk. Ten minutes later the left arm andleft side of the face were noticed to twitch and later theright side also twitched. He vomited and became drowsyand was at once taken to the hospital. On admission hewas quite unconscious and was having clonic convulsions ofall the limbs and face as much on one side as on the other.Ten minutes later the convulsions had entirely passed off andthe limbs were quite flaccid. The breathing was stertorous.The pupils varied constantly in size, being at one momentdilated, at the next contracted, but always remaining equal.The pupils reacted sluggishly to light. The head and eyesdeviated first to one side and then to the other. There wereno facial paralysis and no squint. The knee-jerks were presentand a flexor response was obtained in the right foot but nonein the left. There was a hsematoma above the right ear.No depressed fracture was made out.

Operation was performed about 50 minutes after theaccident. No anaesthetic was given during the initial stagesof operation. A little chloroform was administered later.A flap of scalp was turned down above and in front of theright ear. A fissured fracture was found running horizontallybackwards from the external angular process of the frontalbone and extending beyond the limits of the wound whichmeasured two and a half inches across. There was no depres-sion of fragments. The skull was trephined just below theanterior part of the fissure. There was no extradural hoemor-rhage and the dura mater pulsated feebly. On enlarging thetrephine hole backwards a local bulging of the dura mater,somewhat dusky in colour, was exposed. A small incisionwas made through the dura mater at this spot but no bloodwas found within reach of the puncture. The dura mater wasclosed by a couple of stitches and the flap sutured in plac<:.After the operation the boy was restless and even violent,but after about seven hours he regained consciousness. Fromthat time he made an uninterrupted recovery.Remarks by Mr. FAIRBANK.-Grave cerebral symptoms

which are the result of traumatism and which call forsurgical interference are so rarely met with in children thatthe above cases seem worthy of publication. In the first casethe indications for treatment were sufficiently clear, thoughwant of experience of such injuries in young childrenrendered the diagnosis of the source of the blood doubtful.The disappointing termination after the symptoms had beenentirely relieved by operation was probably the result of theloss of cerebro-spinal fluid. Yet it did not seem to be a wise

procedure to close the dura mater entirely without drainage,since the source of the haemorrhage had not been discovered.The procedure was justified by the occurrence of the secondsmall hoemorrhage. The result of the post-mortem examina-tion showed that it would have been useless to hunt for the

ruptured vessel.In the second case the localisation of the lesion would

have been difficult but for the presence of the haematomaover the right motor area, the region of the brain whichthe symptoms seemed to indicate as involved in the

injury. The operation only revealed the presence of a

90 HOSPITAL MEDICINE AND SURGERY.

fissured fracture, so the cause of the cerebral symptomsmust be left in doubt. The presence of minute boemor-rhages into the cerebral cortex may be suggested as anexplanation. Since the incision made in the dura mater wasminute and the hole in the skull not very extensive, it isdifficult to see how intracranial tension can have beenrelieved to any extent by the operation. Unless thetrephining did some good in this way it necessarily followsthat probably the child would have recovered with equalrapidity had nothing surgical been done.

LIVERPOOL WORKHOUSE HOSPITAL.RUPTURE OF THE SPLEEN; SPLENECTOMY ; RECOVERY.

(Under the care of Dr. W. ALEXANDER.)FOR the notes of the case we are indebted to Mr. John

T. Moore, resident medical officer.The patient, aged 34 years, a labourer and an ex-soldier,

was admitted into the Liverpool workhouse hospital on

August 5th, 1906, complaining of pain in the left side ofthe abdomen. He stated that upon the night beforeadmission, while under the influence of drink, in thecourse of a row with another man, he fell over a formand hurt his side. After the injury he went to bed andslept. The next morning he arose at the usual time andwent to his work, which consisted in wheeling a heavybarrow. He commenced work at 5 A.M. and struggled ontill noon. During this time he felt bad and had two pintsof beer, part of which he vomited. He then sought admis-sion to the hospital.On admission the patient complained of severe pain in the

left hypochondrium. His temperature was normal. Therewere no signs of injury or fracture of the ribs. Opium stupeswere ordered and later he said that he felt better and sleptfairly well. On the evening of the next day, August 6th, thepain in his side became intense ; he vomited three times,his respirations became frequent and chiefly thoracic, thepulse was small and frequent, and the temperature fell to97’ 6&deg; F. The abdomen was retracted and the liver dulnesswas apparently diminished. It was evident that someserious internal injury existed. An exploratory operationwas proposed and agreed to by the patient. The abdomenwas opened at 8.30 the same evening by a median incision.The left hypochondrium was found full of blood clot and thespleen ruptured. The vertical incision was now prolongedto the left just below the costal margin. The blood wasconfined to the left hypochondrium and the colon was dis-tended, which accounted for the diminished liver dulness.Bright blood was gushing up from the left. The spleen wasat once brought into view, having to be scraped off the

parietes owing to old adhesions. It was found to besurrounded by firm clots and to be ruptured in two places.The pedicle was clamped, the spleen was excised, the stumpligated, and the blood clot was removed. The patient at thisstage became extremely collapsed. An intravenous injec-tion of 30 ounces of normal saline solution containing onedrachm of 1 in 1000 adrenalin solution was given by Dr. R.Donaldson whilst the operation was rapidly completed.After the removal of blood and clots the cavity was swabbedout with saline solution containing adrenalin, and as therewas some oozing and the patient was much collapsed thelarge cavity was packed with sterile gauze and two largegauze drains in split rubber tubes were placed in the lowercorner of the wound. The incision in the abdominal wallwas closed in the usual three-tier way. He was removed tobed, the lower end of which was well raised. He had smallrectal salines and fluids by the mouth every two hours,strychnine hypodermically (th of a grain) every four hours,and a th of a grain of morphine to check the intense rest-lessness. The temperature remained at 970 and the pulsewas very small, 130 during the night. The shock continuedto a considerable extent all the next day, the pulse beingfrom 130 to 136. At 4 P.M. the temperature rose to 100’4&deg;,gradually coming down to normal towards morning. The

patient was fed with small quantities frequently, meat juicebeef-tea, chicken broth, and egg flip alternately, and fourhourly rectal nutrients were administered. On the 8th thlshosk had passed off, the gauze and drainage tubes wer4removed, and small gauze drains were applied. During tb4day he vomited three times and the bowels were moved ; anight he had a troublesome cough which was relieved b:jacket poultices and a steam tent. On the 9th his conditionwas about the same. On the 10th the wound was agai

dressed. Vomiting had ceased, but the cough was trouble-some. Bronchitis was present all over the chest and there was-friction at the right base posteriorly. The temperature wentup to 101&deg;. From this date the patient’s condition improveddaily : his chest cleared up, the temperature became normal,the wound was dressed every second day, and the con-valescence was uneventful except for another attack ofpleurisy and bronchitis which lasted for about a week. Ablood count early in October showed 3,967,480 red cells and6758 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 twoholes in its surface through which blood was seen oozingbefore the pedicle was clamped.Remarks by Dr. ALEXANDER.-There are several points in

this case that are of interest to the profession. The historyof the case, though not reliable owing to the partial intoxi-cation of the patient, points to a fall over a form and theinjury to the spleen would probably not have occurred butfor the adherent condition of that organ. Its convex surfacewas fixed to the diaphragmatic peritoneum and had to be-peeled off by the fingers at the operation. It could notmove to avoid the crush and so was injured when a moveablespleen would probably have escaped. Again, the hsemorrhagewas at first undoubtedly inside the capsule and had thepatient been able to rest it might never have gone beyondthat position. But after a good night’s rest he had to get upand work "wheeling a barrow." Even when he came into

hospital the same afternoon he was not in an alarming con-dition, nor did he show urgent symptoms until the nextmorning. The rupture of the splenic capsule probably didnot take place until some time after he was in bed in thehospital, as at the operation the blood was entirely confinedto the left hypochondrium. This would hardly have occurredhad bleeding been going on whilst the patient was movingabout, as blooi would in that case have trickled down intothe lower abdomen. It was especially noticed that this hadnot occurred.The next point is that we did not operate on account of a

ruptured spleen. We did not know what had taken placebut the symptoms indicated grave internal lesions and theoperation was at first exploratory only. The retraction ofthe abdomen and the lessened liver dulness pointed rather toan injury of a hollow viscus than of a solid organ. Thecollapse, the rapidly failing pulse, the shallow breathing, &c.,all called urgently for an exploration, and as an explorationin itself is not dangerous, nor does it add materially to thegravity of the case, we performed it, although we had no idea.at the time of the nature of the injury.An important point in the case is the great and manifest.

value of adrenalin and saline transfusions. After the spleenwas removed the condition of the patient became alarming,and the feeling of my anaesthetist and of some of myassistants was that the patient was dying. Dr. Donaldson

. rapidly inserted the transfusion needle into the usual veinin the arm and passed one drachm of adrenalin solution

! mixed with one and a half pints of normal saline solution-. into the circulation. The effect was immediate and enabled. me to finish the operation satisfactorily. The value ofL adrenalin was also shown in its effect on the oozing fromthe bleeding surfaces from which the ruptured spleen hadbeen removed. The oozing ceased as if by magic when wepressed on the bleeding surface gauze soaked with adrenalinrsolution, and we were then able to place our gauze drains1 in position comfortably. On August 10th I left for Canada and Mr. Moore took1 entire charge of the case. The credit of piloting the patientr, through various pulmonary complications is entirely due to-

, his care and skill. When I came back the patient was con-- valescent, his blood count was practically normal, and theree were no signs that such an important organ had beenremoved.

__________________________________-

PRIVATE ASYLUMS FOR THE INSANE IN ST. PETERS--BURG.-At a recent sitting of the St. Petersburg towngovernment it was decided to make an experiment by sub--sidising private homes to the initial extent of R1000 forpatients of weak mind, so as to relieve the pressure on thehospitals. Although some members argued that the stepwas calculated to encourage " angel making " the decision.was given in favour of the argument of others who held thatthere were many wholly trustworthy people to whom thecara of insane persons might be given.