Report of an Epidemic of Influenza (140 Cases) Occurring at the Royal Asylum, Morningside, Edinburgh

G. M. Robertson, F. A. Elkins
1890 BMJ (Clinical Research Edition)  
Mt place where I looked for the pus was in the temporosphenoidal lobe. The subsequent progess of the wound showed that I had over-estimated the danger c s epsi from contamination from the ear. It has been a constant source of regret to me that I was out of town on the Saturday evening when the symptoms supervened and therefore could not operate at once. It is also a source of regret to me that the case occurred during the holiday season, when all the physicians, except one, were awvay, and the
more » ... essage which I sent asking him to see the case never reached him; I was, therefore, left to my own unaided resources. The question which is of chief importance in these cases, and that on which I hope we shall have the opinion of some of the Fellows present is, What is the minimum of symptoms which justifies exploratory trephining ? One word also as to the position of the trephine opening, a point about which there has been a good deal of controversy. It seems to me that it is not possible to indicate one point which will suit al' cases. In this particular instance I selected the position indicated by Mr. Barker, because, from the entire absence of symptoms localising the abscess, I concluded that it was most probably situated about the middle of the temporo-sphenoidal lobe. The cause of the rigors is not by any means clear. I naturally at first concluded that pymemia had set in, but the further progress of the case negatived this view. There was no evidence at any time of thrombosis of the lateral sinus. The diagnosis was made still more perplexing by the swelling of the scalp whiclh followed the application of the alembroth gauze, and to some wlho saw the case this swelling seemed to indicate a suppurative periostitis or osteomyelitis extending from the trephine hole. This was a view which I could not, however, accept, for the swelling of the scalp was coextensive witlh the dressing from the first, that is, occu ied about half the scalp, while I should have ex;pected an osteomye itis to be limited to the temporal bone; and further the dermatitis which was evidently present exactly resembled what one had previously seen from the action of sal alembroth on the skin in other parts of the body. The meaning of the temporary paralysis is also obscure. At first It seemed to point to a purulent leptomeningitis, biut the ultimate recovery of the patient seems to preclude that view, and I presume it must have been due to some temporary congestion of the cortex of the brain, probably in connection with the formation of the second collection of pus, or possibly the result of probing the brain with the view of linding pus. Lastly we have to note the formation of a second collection of pus, which might either have been reaccumulation in some diverti-. culum of the original abscess, which was not perfectly drained, or an entirely fresh formation in the neighbourhood of the original collection. I am inclined to take the latter view, because the second abscess was situated distinctly further back and higher up than the first, and it seems to me that therigors, relapse, and other symptoms which afterwards developed were mainly connected with the formation of this second abscess. In connection with the opening of this second abscess there is one practical point to which I think it is worth while to call attention. I searched the situation of the abscess a few days before it was opened with a hollow needle and failed to lind pus; a few days later I introduced sinus forceps and on expanding the blades, pus at once welled out. Now I have found on several occasions, and also in this case, that when a hollow needle is passed througlh healtlhy brain tissue it at once becomes filled with a plug of brain material, and even though it enters a collection of fluid, unless that fluid is under high tension, this plug is not forced out, and the fluid may remain undetected. On the other hand by using fine sinus forceps much less injury is done to the brain and, by expanding the blades from time to time, if fluid is reached it will certainly appear at the surface. I venture therefore to recommend the use of long sinus forceps in place of hollow needles when one wishes to search for collections of fluld in the brain. DR. ALEXANDER MACGREGOt, Assistant Physician to the Aberdeen Hlospital for Sick Children, has commenced the publication of a series of demonstrations in clinical medicine. They are intended for students attending his clinique, and are given to them gratis. Their issue is promised at regular intervals. The first is a demonstration of a case of hemiplegia, with illustrated diagrams and clinical commentary. There appears to be a general desire among students that teachers might publish more fully in this form.
doi:10.1136/bmj.1.1518.228 fatcat:uz4woru4uzbgfastjxzm6j2ghu