514
"The peri-
grazing the upper border of the seventh rib. It had then burrowed up into the axilla. cardium contained about ten ounces of defibrinated blood and both surfaces of the pericardium were thickly covered with fibrin deposited on the serous membrane. Left pleura contained some sero- purulent fluid and left lung was almost completely collapsed." The heart had the same "graze” upon it post mortem which I felt with my little finger half an hour after the accident. Had I known of or even suspected the pericardial fluid conditions soon after the injury it is just possible we might have been able to pull him through.
Such an injury is rare where the patient can after its infliction do as this man did. He retained hold of his prisoner until help reached him (about five or ten minutes afterwards), then walked about fifty yards to the nearest chair and was carried to the Charge Rooin where he gave particulars to the Inspector in charge, and was then carried to Hospital where he survived his injuries for six days.
This tragedy gave us another operative case. The man who inflicted the injuries on the police- man was shot in the hip by one of his comrades, and in this case I was able to extract the bullet from his hip at once and he got well only to meet his fate on the scaffold along with another of his col- leagues in crime.
"2
Two deaths occurred after operative interference necessitated by severe head injuries. One of these was the subject of important medico-legal proceedings. A private of marines from H. M. S. Tamar went into the Hongkong Hotel bar for refreshinent and had a quarrel with one of the "boys who promptly jumped over the counter with a big stick in his hand and hit the sailor on the head about un inch and a half above the right eye. The sailor fell on the back of his head on the tiled floor and he was then brought up to Hospital. As he had evidently been drinking heavily his stomach was washed out after his general state had been examined. His pupils were equal and dilated whilst his pulse was slow between 60 and 72. He remained comatose for about twenty minutes when he sud- denly ceased breathing-10 p.m. A careful examination of the head had revealed no more of note than small swelling on the posterior left parietal region. A needle inserted at the site of bruise on forehead failed to discover a fracture and no blood came from nose or ears. From 10 p.m. till 6 a.m. the following morning artificial respiration was kept up during which time the pulse remained good, unless of course when the artificial respiration was left off. When left off, it took from one minute and forty seconds to two minutes and a half for the pulse to disappear at the wrist, when on resuming operations it again returned. At 6 a.m. with daylight to assist I again made a careful examination of his head and detected by a needle a fracture at the site of the swelling over the left parietal region and, resolving to trephine, sent for Deputy Inspector General KNOTT to see the case with me. How- ever, before he came the inan's pulse began to flag and it was evidently necessary to trephine at once if any good was to be done. This was not an easy matter seeing that artificial respiration and all its difficulties had to be reckoned with. Trephining over the spot revealed the presence of a large blood clot, about an ounce of which was removed after incising the dura mater. Notwithstanding the relief of pressure the pulse continued to get worse and he died about thirty-five minutes after. Another hæmorrhage was found at the base of the brain with another fracture separate from that at site of operation. Interesting medico-legal discussion ensued; but the prisoner was set free through want of identification. By the mail the following week came Professor VICTOR HORSLEY's paper on head injuries wherein he stated that in many cases of head injury artificial respiration is the proceeding necessary to keep the heart going, and the above case certainly bears this out. Whether an earlier trephination would have done any good in this case is extremely doubtful, but by keeping up artificial respiration there is no doubt that occasionally valuable time may be gained for operative procedures to be undertaken. The period taken for the pulse to become imperceptible is also notable. Although of the nature of an experiment it was not so in the first instance, as when I was called to see him on one occasion his heart could not be heard, though effective manipulation soon brought back its action and the usual good pulse. The variations in time of disappearance of pulse I expect were dependent on the previous effectiveness of the artificial respiratory process.
One case of abscess of liver died which was operated on in extremis. Post mortem it was found that the liver was not enlarged but was merely a sack of pus, the actual amount of liver tissue remain- ing being very small indeed. This normal size of area of dulness together with absence of tenderness. and other signs of abscess had led to operation being delayed till too late. The other case of abscess of liver recovered rapidly after resection of about three inches of rib when efficient local medication could be applied. Many cases of liver abscess improve rapidly when this can be done, and I often wonder why some of our surgeons who have had or should have large experience of this matter do not give their views in a succinct manner. We have lengthy dissertations on the local medicinal treatment of ulcerated throats, suppurating knee joints, empyæmas, ozona, &c., but few (if any) have given opinions on the local medication of liver abscess. Perhaps most people think it useless. It generally is, unless properly done. Iodine, cresol and a dozen other drugs are injected and useless because often all they touch is simply necrosed and broken down tissue. Few people would dream of applying nitric acid to a bad phagodenic penis until they had removed sloughs by a Volkman's spoon, yet it is very nearly the same condition which holds good in many liver abscesses where the necrosis of tissue goes on in a very similar manner, as is found out by those who take the trouble to make a post mortem examination of the case. In addition to the above two cases operated
prove