GLASGOW ROYAL INFIRMARY.
Injuries of the Head.
D. M'Millan, æt. 40, seaman;—while he was employed in the hold of a vessel, a heavy iron block, of a round form, fell from the rigging, a height of 20 feet, and struck him on the head. He was knocked down and stunned, but was able to rise and to walk with a little support. He was brought about a mile and a half in a hackney-coach to the hospital, and admitted by Mr. Cowan at one o'clock P.M., half an hour after the accident. At this time he had a stupified look, but was quite collected, and was able to walk across the ward; breathing and pupils both natural; pulse 75, of moderate strength. There was a wound in the scalp, commencing nearly over the centre of the sagittal suture, and running about three inches backwards and towards the left; along this a portion of skull, corresponding to the wound in size, was felt fractured, detached, and irregularly depressed. His right arm was benumbed and nearly powerless, but no mark of injury was observed on it.
It was determined to remove the detached piece of bone, and the original wound being extended lengthwise in both directions, an incision was made through the scalp at right angles to it over the left parietal bone, thus bringing the fractured portion into view. This was found to be broken down into several fragments, some of which were firmly impacted under the surrounding cranium, and one spiculum, driven through the dura mater, had penetrated the brain. The trephine was applied a little to the left of the fracture, and the intermediate part removed with Hey's saw; the detached pieces of bone, ten in number, of various sizes and irregular shapes, were removed with the forceps, the scalp replaced and retained in position by a stripe of adhesive plaister and very light dressings. During the operation one artery required ligature, and about ℥v.
v. of blood were lost: he had lost perhaps as much before. He remained quite sensible, bore it well, and shortly afterwards had half a glass of port wine in warm water.
Ten P.M.—Has been tolerably easy; complains of pain of fore-part of head; pulse 82, firm.
Fiat V. S. ad ℥xviii.
xviii.
Sumat statim Submur. Hydr. gr. viii. Pulv. Antimon. gr. vi.
Applic. Capiti Lotio ex Alcohol. et aq. calcis.
Second day.—After bleeding, thought feeling of numbness of right arm somewhat lessened, and to-day has rather more power of it. Passed a tolerable night; a little head-ache; countenance pretty natural; tongue slightly loaded; thirst; no stool.
Sum. stat. Sulph. Magnesiæ ℥j.
j. et rep. vesp. si opus.
Third day.—From an aversion to use the bed pan, he rose to stool last night, and fell forwards on the floor, seemingly from having entangled himself in the bed clothes; he got into bed without assistance; had a shivering fit shortly after, but has had a pretty good night; bowels freely opened; head-ache slight; pulse 84, soft; tongue dry in middle. Towards the evening of this day he appeared drowsy; and on the fourth day he is reported as seeming confused and uneasy; countenance anxious; articulation difficult; the right arm was more paralysed, and indeed the whole right side seemed now to partake in the paralysis; a small part of the wound had adhered, the remaining part was flabby, discharging thin serum. In the evening the difficulty of articulation and drowsiness had increased. Twelve leeches were applied to each temple, and in a short time he seemed a little livelier.
Fifth day.—Much in the same state; took a little beef tea.
Sixth day.—Paralytic symptoms increased; breathing laborious. Blister to the neck. It may be worthy of remark, that in the few words he now spoke he never made use of the English language, but of the Gaelic, which was his native tongue; and even when told that he was not understood, he persisted in repeating the Gaelic phrase.
Seventh day.—A small fungus was observed in upper part of wound, to which lint dipped in lime water was applied, and moderate pressure. The fungus continued to increase.
On the eleventh and twelfth days he had slight bleedings from the scalp, which stopped spontaneously. Stupor, &c. greatly increased, but he still recognised his friends; took a very little chicken soup or beef tea daily, with lemonade, &c. for drink.
On the evening of the thirteenth day bleeding to the extent of ℥iv.
iv. or v. took place from fungus: it was checked by application of saturated solution of alum, but he sunk rapidly, and died that night.
Inspection 36 hours after death.—The fungus protruded considerably beyond the scalp, and was rather larger than a hen's egg, of a dirty brown colour, and a soft spongy consistence; it completely filled up the opening made in the skull by the trephine and removal of detached bone. The pericranium to the inferior side of this opening was found detached from the bone, to the extent of a crown piece, and beneath it the bone was rough, and covered with thin purulent matter. The dura mater, for two inches around the fungus, was covered with pus; this membrane, by sloughing, had allowed the fungus to protrude, and its edges adjacent to the aperture were thickened. On removing the dura mater, the fungus was observed to arise, partly from the middle, but chiefly from the posterior lobe of the left cerebral hemisphere: it occupied a space about three inches in length, and an inch and a half in breadth, extending to within a line or two of the roof of the ventricle; at its anterior part was an abscess, containing ℥ss.
ss. of pus. The fungus seemed to be a degeneration of the cerebral substance; sections of it showed the cerebral matter first dotted with an unusual number of bloody points, then assuming a greyish colour, which gradually passed into a dirty brown. With the exception of these bloody points, the brain presented no unusual vascularity: it was quite firm, except in the immediate neighbourhood of the fungus, where it gradually became softer as the colour of the cerebral substance became deeper, till in the centre of the fungus it was nearly of a broken down consistence. A quantity of serum was found in each ventricle.
Another man who had been struck by the piece of iron which fractured M'Millan's skull was brought up to the hospital at the same time. He had received the blow on the vertex of his head. On admission he was in a state of fury, requiring the efforts of several men to hold him. His head was bruised out of all shape, quite depressed behind, and a fracture also of the frontal bone; there were evident symptoms too of fracture of the base of the skull. The case was hopeless. Several large depressed and detached pieces of bone were removed, but he died a few minutes after the operation.
During the same week an old woman was brought up to the infirmary, who, the day previously, had fallen headlong down a stone staircase. She laboured under the severest symptoms of concussion, and besides had a comminuted fracture of the humerus into the elbow joint, and of the radius into the wrist joint of left arm. She was past all treatment, and died on the second day. The case is mentioned chiefly to remark, that although no external injury of the head could be observed, on inspection a fracture was found extending completely across the anterior part of base of cranium.
There are no dispensaries in Glasgow, but such of the poor as are unable to obtain admission into the Royal Infirmary, and those who are not so ill as to submit to the confinement of an hospital, or for other reasons prefer remaining in their own houses, are prescribed for, and, if necessary, visited at the public expense. For this purpose the city is divided into districts, and a surgeon appointed to each. The "district shop" thus resembles a dispensary, where the surgeon prescribes in the presence of his pupils, who indeed, under his superintendance, have the management of many of the cases, both among the patients who receive advice at the "shop," and those who are visited at home. Although under the care of a surgeon, the diseases treated are both medical and surgical, for there is little distinction made between the two branches of the profession here.
The following case occurred under the care of Mr. Stirling:—
W. M. æt. 28, while returning home during the night in a state of intoxication, fell from a height of ten feet, into a court paved with stone. He was rendered insensible for some time, but on recovering was able to crawl to the nearest door, and was conveyed home. Medical assistance was immediately procured. On the forehead, about an inch above the nasal process of the frontal bone, was a cut an inch and a half in length, extending obliquely downwards from the right side; through this a triangular fracture was felt, the base of which was in the direction of the external wound, and the apex pointing downwards; the fractured portion of the bone was slightly depressed; the bones of the nose were also fractured, and there was great discharge of blood from the nostrils. One third, or nearly, of the upper lip was cut off, and a good deal of blood had been lost from the labial artery; the lower jaw at the symphysis was fractured and comminuted, and several pieces were perceived to be loose. Was quite sensible, remembering every thing up to the period of the accident. Pulse 80; has vomited frequently. Wound of forehead was dressed with adhesive plaister; the loose pieces of bone were removed from the lower jaw, and it was afterwards retained in juxta-position by a chin bandage.
Early next morning he was bled to ℥xii.
xii. and had a purge of jalap and calomel, by which his bowels were freely opened. That night he felt considerable pain of head; pulse 90, full, and strong. He was bled again to ℥xxv.
xxv. Blood first drawn had the buffy coat. After the bleeding the pain of head diminished, and he continued to do well. When the swelling and tenderness of face had subsided, it was observed that the fracture communicated with the frontal sinus. On holding his nose and attempting to blow it, matter and air escaped by the fracture. The man was anxious for a speedy cure, and for this purpose an operation to remove the depressed piece of bone was at one time thought of; there was no constitutional disturbance, however, and the case was left to nature. The discharge gradually diminished, and the wound healed up in about a month. The bones of the nose retained their position, and the broken ends of the jaw, after the swelling had subsided, were kept in their proper situation by a pasteboard splint till re-union took place. The lip also healed easily, and no deformity is now observable.