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:—