PLAGUE ERADICATION AND PREVENTION.
Authors: MARK J. WHITE
Journal: JAMA (1907)

the way to the hospital the patient's breathing ceased to be stertorous and he reached up with the left hand and unbut- toned undershirt.On being pinched, movements of the face were apparently equal.On arrival at the hospital he reacted slightly to painful stimuli in the right leg, but not as freely as in the left leg.The pupils were at this time equal.March 8 (hospital notes).-Unconsciousnesscomplete; right hemiplegia; right pupil dilated and would not react to light; left pupil normal.Pulse slow (from 65 to 80), full and of moderate tension; respiration slightly labored.Temperature between 99 F. and 100 F. Bowels and bladder acted involuntarily.Patient was able to swallow.March 9.-Condition about the same except that pulse showed slightly more tension and the temperature was about 0.5 de- gree higher.Operation.-OnMarch 9 at 12:30 p. m. operation by Dr. Rudolph Matas was performed under chloroform anesthesia; very little anesthetic was necessary.A curvilinear incision was made in the right parietal region, with the base down- ward; periosteum was elevated and the bone trephined over the middle meningeal artery.The dura was exposed, artery was found intact and on slightly enlarging the opening no clot was visible.The dura was incised and the brain found fairly normal and slightly bulged into wound; felt tense on pressure.Hemorrhage was controlled during operation by manual pressure at base of flap.The wound was closed with interrupted sutures of silkworm gut and pressure was applied.The head was now turned and a similar operation performed on the left side; when the dura was reached no clot was found, the middle meningeal artery and its posterior branch were exposed, with the trephine and the intervening bridge of bone removed, making an opening between 2*4 and 3 inches long.The condition of the dura was the same as on the right side; brain was markedly congested, edematous and under con- siderable tension.No clot was found.The wound was closed, as on the opposite side, and a pressure bandage applied to the head.Postoperative History.-March 10, condition the same.On the afternoon of March 11 the patient's temperature went from 99.4 F. to 103.5 F. and the pulse from 96 to 130.The respiration was labored and irregular; large mucus rales over both lungs.The patient was restless and continuously moved the extremities of the left side.Strychnin, digitalis and alcohol were given for stimulation and bromids for restlessness.• March 12.-Condition slightly improved, dressing changed and wounds found healthy, with no evidence of infection.March 13 to IS.-Condition had slowly improved; the tem- perature dropped from 102 F. to 100 F. Right pupillary con- dition had slowly changed, the pupil reacted slightly to light, but did not contract equally with the left.Slight movement had been noticed in the right leg, but no change in the condi- tion of the right arm; the patient had shown some evidence of consciousness, taking notice when fed, but making no effort to speak.March 19 to 28.-Slow but progressive improvement, tem- perature dropped to nearly normal and pulse maintained at from 70 to 80. Returning consciousness more evident every day, but no effort made to speak.Right pupil reacted to light, but was not entirely normal.Bowel and bladder movements were still involuntary.March 31.-Spokedistinctly for the first time.April 2.-Patient able to talk intelligently and to under- stand what others said.Could recognize friends, but his mind was still cloudy.Some resistance could be felt on moving the right arm and there were voluntary movements of the right leg.April 10.-Mental condition and speech had slowly im- proved; fair control of bladder and bowels.April 15.-Patient was dressed and helped out of bed; was unable to stand on right leg; was kept in reclining chair.May 1.-Could stand on right leg, speech fairly good, mind slightly cloudy and still unable to use right arm.May 20.-Patient left hospital able to walk with stick.Movements still defective in right leg and right arm com- pletely flaccid, with no movements.