HOSPITAL REPORTS.

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.

GUY'S HOSPITAL.

Inflammation of Hernial Sac.

The previous report of this case (Gazette, No. 51) conducted it to Nov. 18th, the tenth day from the operation, and the third on which fæces had been discharged from the wound; that discharge continued on the 19th, but on the 20th pus only was seen.

Nov. 22.—Yesterday the dresser, Mr. King, observed a portion of solid fæces make its escape, and to-day a similar discharge, in the fluid form, is manifest.

Nov. 26.—Since the 22d, nothing but healthy pus has been seen; the wound is rapidly healing, and the patient's general condition as good as can be desired.

Dec. 4.—He has begun to wear a truss, and is to-day allowed to leave his bed.

Dec. 8.—As regards his original complaint, the man is perfectly convalescent, but he now discloses a small abscess in the scrotum, which has been gradually forming, and will detain him in the house some time longer.

If it be a sound surgical maxim that, in strangulated hernia, the patient's safety depends upon an early operation, it is also a maxim no less sound, that where the evidence and symptoms of strangulation are imperfect, or dubious, the benefit of the doubt should be given to the operation, and it should be performed: for it is better that buboes should be laid open, or inflamed sacs cut into, twenty, aye, fifty times in succession, than that in one case a man should be suffered to die with strangulation of the intestine unrelieved.

These remarks apply strikingly to this case of Mr. Key's, in which, although no hernia was found, they perfectly justify the operation. No case of strangulation could be more distinctly marked, or more clearly call for the knife, than did this; and had Mr. Key refused to use it, he would have deserved the scoff which, by a contemporary, has so preposterously been thrown on the "no hernia case." But, more than this, the operation was not only justifiable, but beyond a doubt beneficial—beneficial inasmuch as it at once relieved the distress of the patient, secured him from more extensive suppuration, from farther sloughing of intestine, and probably from extravasation of fæces into the abdomen; rendering also the process of reparation more easy and rapid.

Hereditary Hare-Lip.

Dec. 4th, Mr. Key performed the operation for hare-lip on a child a few months old, whose case was remarkable only as it afforded an instance of hereditary malformation. The father of the child had congenital hare-lip, for which no operation had been performed, and of his six children two were born with the same malformation.

Queries.—1. If the father's lip had, in his infancy, been restored to the natural form, would the malformation in that case have descended to his children?

2. Is the casualty in these cases to be traced directly from the father to the incipient embryo, or indirectly, through the medium of the mother's imagination—It has been said that paternal resemblances are produced in the latter mode.

G.

PARIS HOSPITALS.

Hôtel Dieu.

Cases of Gangrene of the Lungs.

Some interesting cases of gangrenous suppuration of the lungs were published by Dr. Chambers, about eighteen months ago, in which he particularly pointed out the horrible fœtor of the breath as a diagnostic mark of the disease. The following cases which recently occurred at the Hôtel Dieu are good illustrations of more extensive destruction of the lung by a similar disease.

Case I.—A man, aged 32, of good constitution, laboured under bronchitis for some weeks, to which he paid little attention, when he was suddenly seized with pain in left side, dyspnœa, considerable cough, and a rigor, followed by fever. He was admitted into the Hôtel Dieu next day. Crepitation was perceptible over the whole extent of the left lung, posteriorly, and reaching to the site of the pain in the side, which was increased by percussion; great oppression, with frequent cough, and expectoration of violet-red colour, mixed with mucus; pulse frequent and small; constant chilliness; cheeks flushed.

Next day the symptoms remained unabated, and fœtor of the breath was observed. Two days after it is stated that the expectoration maintained the same appearance, but was now fœtid; the breath was, however, still more offensive, and during the fits of coughing particularly so. In the evening the breath is said to have become gangrenous.

21.—The cough was small, difficult, and painful, producing an expectoration of violet-coloured matter, approaching to chocolate, with a characteristic odour.

22 to 25.—Expectoration and breath emit an intolerable stench. On the latter day the patient died.

Examination.—The body not emaciated. Strong adhesions of the left lung to pleura costalis. At its posterior part a large gangrenous layer, occupying the two superior thirds of the lung, covered at some points by a false membrane. The lower third, and the parts round the gangrenous portion, in different degrees of inflammation, and hepatised; the putrid mass was in great part black or violet-coloured, containing fragments of the pulmonary texture; the smell gangrenous, but less so than that of the breath during life; pus might be squeezed from the adjacent part of the lung.

Case II.—A man, aged 55, enjoyed good health till the beginning of May, at which time he experienced pain in the left side of the thorax after exposure to cold. During the next few days the cough was frequent, and the expectoration tinged with blood. A rigor now came on, followed by a distinct exacerbation of fever, and he came to the Hôtel Dieu. At this time he presented symptoms of inflammation of the lungs, and was bled with relief; he left the hospital in twelve days, being sufficiently well to resume his occupation. Scarcely had he done this, however, when he had a relapse, accompanied by great lassitude, oppression of breathing, and frequent cough. At the end of a week he returned. He was now at the twenty-first day of the attack. His skin was yellowish; face pale or of leaden hue, and greatly altered; his cough frequent, with abundant expectoration of matter like chocolate, with small specks resembling pus, and little bodies about the size of peas, which appeared to be portions of the lung. This putrid mass exhaled a gangrenous odour, and the expired air was impregnated in a high degree with an equally disgusting smell, which surrounded the patient's bed with a contaminated atmosphere. Percussion gave a clear sound over the whole extent of the chest; auscultation did not discover the pulmonary expansion on the right side. The pulse was weak, but not frequent; the patient was in a state of extreme prostration. Next day the odour of the breath and expectoration was, if possible, more dreadful. He lingered two days longer, during which time the fœtid smell somewhat diminished, and the proportion of pus in the expectoration increased.

Examination.—The left lung had contracted firm adhesions, particularly above and behind. It was torn in attempting to remove it, and there issued from the middle and posterior part a large quantity of dark-coloured matter, similar to what had been expectorated. An incision was made along the back part of the lung, and laid open a large cavity, occupying all the extent of the pulmonary organ, and still in part filled with the same kind of dark putrid matter. On washing out the cavity it was perceived that it was lined with a smooth and white membrane, to which were still adherent, at some points, dark filamentous shreds; these were removed by the least touch, and left the surface smooth beneath. The boundary was formed by a false membrane, about a line in thickness, which separated the mortified from the sound parts. The lung was reduced to a kind of bag, the parietes of which were on an average about an inch thick. In the upper part of the lung, which was hepatized, an incision discovered a number of smaller tubercles, which in the centre were in a crude state; and at one point several had suppurated, forming a cavity large enough to contain a nut.

[The Editors of the Journal Hebdomadaire, from which these cases are abridged, add, in a note, that although the fœtor of the expectoration, such as above described, is usually dependent on gangrene of the lungs, yet that this is not invariably the case. In confirmation of this assertion they refer to three instances of fœtid expectoration—in the first, the patient is still alive; in the second, there was chronic bronchitis, with considerable dilatation of numerous bronchi; and in the third, bronchitis with some appearances of chronic pneumonia. Laënnec gives a case of dilatation of the bronchi, with remarkably fœtid expectoration. The argument derived from the first patient having survived we consider to be altogether erroneous, as patients more frequently recover from this than other forms of purulent expectoration.—Ed.]