_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. 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.
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. 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. 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. 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.