ARTIFICIAL PNEUMOTHORAX IN FRACTURED RIBS
Journal of the American Medical Association (JAMA)
The patient was removed to the Misericordia Hospital, and a simple mastoid operation was performed. The cells were numerous and extensive, especially in the middle fossa and overlying the temporal bone, where they were more super¬ ficial. Free pus was found in these with granulations, but very little in the mastoid tip. The cells were thoroughly curetted to the plate, but neither sinus nor dura was exposed. Next day the temperature receded to normal and remained normal, and the patient was
... he patient was apparently making an uneventful recovery. The mastoid wound was looking fine, with a diminution of discharge and no discharge from the canal. However, March 4, that is, ten days from the date of the operation, I was informed that the patient was having a con¬ vulsion. When I arrived at the hospital an hour later, the boy was still in convulsions. He was in a deep coma, with respiration only at great intervals, and then a convulsion, which was more or less generalized. The patient had been in good condition until about an hour previous to the attack, when he tried to ask for the urinal bottle, which he seemed to recognize but could not name. There had not been chills or headache. The respiration and pulse rates were normal. There was some difference of opinion as to whether the con¬ vulsions in the beginning were more right sided than left sided. There was no history of any former attacks of epilepsy, and the family history was negative. Oxygen was given while the operating room was being put in readiness. With the history of the word aphasia symptom and the con¬ vulsions probably due to a local meningeal edema, I per¬ formed a decompression. There were no adhesions of the dura, but a slight discoloration ; my light was poor at this time, but the case was urgent. The middle fossa was uncovered and the temporal plate removed, about an inch in diameter, extending directly over the ear. A vertical linear incision was made through the dura about an inch in length. This released what appeared to me as coffee-ground blood, with a small piece of organized clot or slough. A grooved director was passed forward, inward and backward in the brain substance in the various directions in the effort to locate an abscess, but with no success. A cigaret drain was inserted and the wound left open. In the afternoon of the same day the patient had apparently regained his normal self. His reflexes were normal and equal. His conversation was coherent and rational. There was no aphasia or ocular nys¬ tagmus. At this time Drs. D'ench and Garretson were called in consultation. The fundi were negative. There was no nystagmus. All reflexes were normal. Those of both upper and lower extremities were slightly exaggerated, but normal. Abdominal and cremasteric reflexes were normal and equal. The muscle tonus was normal throughout. Sensation (tactile, pain, temperature and muscle sense) was normal. On exami¬ nation, the right ear at this time proved to be normal. Urinalysis was negative. Examination of the spinal fluid and blood gave a normal cell count and negative Wassermann reaction. At the end of four days the patient continued nor¬ mal with no elevation of temperature. The drain was com¬ pletely removed at this time, having previously been shortened or successive dressings. There was no pus or exúdate coming from the wound. March 10, in the morning, there was a distinct hesitation in the patient's speech, rather stumbling in character, with irrelevent and monotonous phrases. He spoke of seeing his father, who had died shortly after the boy's birth. There was no nystagmus, over pointing or stiffness of the neck. The reflexes were normal. There was no deviation of the tongue or twitching of the mouth. The condition remained about the same during the day except for continued motor aphasia with an inclination to vomit. However, at 6 o'clock the same even¬ ing they informed me that he was again having convulsions. I reached his bedside, about forty-five minutes later, when the patient was having convulsions at intervals, but was not in the deep comatose state that he had been in at the previous attack. His contractions were evidently right sided, involving the face and the limbs. He was immediately removed to the operating room, where I extended the removal of the temporal bone on a line with the supra-orbital ridge and about 1 inch in front of the ear. A new vertical linear incision was made, and a grooved director passed forward and downward about an inch toward the frontal'convolutions. At the second passing, a teaspoonful of rather blood-stained pus was exacuated. A cigaret drain was placed. The next day the temperature was about 101 to 102. The reflexes were normal and the patient was fully oriented. The second day the tem¬ perature was still at 102. In the morning, when the drain was removed, a considerable amount of thick exúdate was found behind it. . Instead of replacing the cigaret drain, I rolled and inserted a small piece of rubber at the base of the abscess. Following this the rubber drain was removed twice daily and the patient's temperature dropped to about 99. About this time he developed pain in the eye. Dr. Conrad Berens, Jr., reported vision 20/15 and normal fundi. Two days later the patient developed another slight rise in temperature, which was due to the development of an abscess beneath the tem¬ poral muscle. This was readily drained, and the tempature dropped to normal and remained so until his complete resolu¬ tion, April 19. No hernia had developed in this case, and the hearing was 20/20. Up to about a week ago when I last heard from this patient he was in good health and apparently quite normal. COMMENT Acute brain abscess cases rarely complicate acute otitis media, and even less so the epileptiform attacks. If an abscess has been located and drainage established and maintained, resolution is the natural course, if located early enough. Of course, there is always the possibility of the abscess ruptur¬ ing, inundating the ventricles or the subarachnoid space, and causing a suppurative meningitis. At the first" decompression the symptoms pointed more to an abscess or pressure of the sensory speech center of the left temporosphenoidal lobe, while the distinct motor speech symptoms prior to the second attack made it evident that further involvement existed, farther forward in the frontal lobe. It seemed to me that the simple rolled rubber drain proved most effective in maintaining the drainage. This, of course, was gradually shortened, allowing granulations to fill in from the bottom and to wall off the meninges.