Pg. 346

Admin_LH

November 2, 2020

¶ 1 Leave a comment on paragraph 1 0 346

¶ 2 Leave a comment on paragraph 2 0 THE PROVINCIAL PRACTICE OF MEDICINE AND SURGERY.

¶ 3 Leave a comment on paragraph 3 0 better. Pulse 60, and soft. During the day he had several convulsive fits.

¶ 4 Leave a comment on paragraph 4 0 14th.—Gums sore. He has passed his water for the first time involuntarily. The fits continue. There is some puffiness of the left temporal region and at one spot on the forehead. Incisions were made down to the bone in these situations, but no unhealthy appearance was found. Omit calomel.

¶ 5 Leave a comment on paragraph 5 2 For several days no change of any importance occurred; the fits continued up to the 17th, when they ceased. He now began to pass both his urine and faeces involuntarily; he became more stupid, and lay in a perfectly quiescent state. Paralysis of the right side was first observed on the 18th. During all this time he was easily roused to consciousness would protrude his tongue when told to do so, and regularly took his food. The predominant symptoms were, an impaired state of intellect, with paralysis of the muscles of articulation and of the right side. On the 21st calomel was again given, and was continued up to the 26th. He became more conscious for the next two days, took his food better, and appeared to be in every respect improved; On the 28th he was more unconscious. Pulse weak, 108. He gradually sank into a state of perfect coma, and died on the 30th, at one a.m.

¶ 6 Leave a comment on paragraph 6 2 Autopsy.:-Cranium.—On removing the scalp, a portion of the frontal bone, about the size of a two-shilling piece, was found denuded of its pericranium. At the centre of the denuded portion there was a narrow spot, about an inch in length, where the bone had ulcerated ; arid a Very small opening existed leading into the cavity of the cranium. On removing the calvarium, no pus was found between the bone and dura mater ; but under the seat of ulcerated bone, at one spot, the dura mater was adherent to the inner table of the skull, and a portion of it came away with the latter, and thus an Opening was established into the cavity of the arachnoid ; that portion of the dura mater which thus adhered to the bone was covered on its arachnoid surface with pus, On opening the cavity, of the arachnoid, pus was found existing between its layers, and coating the visceral surface of the upper and anterior parts of the anterior and middle lobes of the brain. A similar deposit of purulent matter existed also in the sulcus between the hemispheres of the brain on the left side, but it did not pass to the opposite side; the lateral surface of the left hemisphere was also coated with it. No deposit was found at the base of the brain. In the substance of the anterior lobe of the left hemisphere, there existed a cavity filled with greenish yellow fetid matter, mixed with pus, having the appearance of gangrenous brain; this cavity extended backwards into the middle lobe, and communicated at its upper and back part with another cavity, containing matter of a similar character. Both these cavities were circumscribed, and had a distinct sac in the substance of the brain itself. The upper wall of these cavities was formed by the dura mater, but in this situation, they were not so distinct and circumscribed. The right hemisphere presented a healthy appearance.

¶ 7 Leave a comment on paragraph 7 0 The viscera of the thorax and abdomen were healthy.

¶ 8 Leave a comment on paragraph 8 0 During the progress of this case, the propriety of trephining the skull at the Seat of injury was on two or three occasions considered; but, as the symptoms did not indicate any great amount of pressure on the brain, and as there was no external appearance indicating the seat of any deposition of matter beneath the bone, the operation was deemed unadvisable, and the condition of the brain, as revealed by the autopsy, fully justified, I think, the course that was adopted ; for, although in some cases, the dura-mater has been punctured,  and an abscess of the brain has been opened with satisfactory result, yet, probably, these have been cases in which but little of the structure of the brain has been involved; Whereas, in the case before us, a large portion of one hemisphere was the subject of suppurative inflammation, as well as the membranes investing it; operative interference, in such a case, in all probability, would only have tended to hasten deaths

¶ 9 Leave a comment on paragraph 9 0 John G—, aged 25, Was admitted into the infirmary bn the 13th February, 1854. While engaged unhooking some wagons from an engine on the London and North Western Railway, the part of the engine on which he was supporting himself with one hand, gave way, and he fell on the rails; the wheels of twelve wagons passed over his left arm, arid his head was struck by some of them. When picked up he was quite insensible, and he states, that the first thing he distinctly recollects, is finding himself in bed at the infirmary. This was after the performance of the operation, which will be Subsequently detailed.

¶ 10 Leave a comment on paragraph 10 0 When admitted he was partially sensible, and answered questions put to him. On examination he was found to have sustained the following extensive injuries. The left forearm, about three inches above the wrist, was completely smashed, so that

¶ 11 Leave a comment on paragraph 11 0 the lower part was only connected with the upper by a few shreds of tissue; the wheels of the wagons had evidently passed over this part. The humerus was fractured about three inches below the shoulder-joint, and a small opening existed on the outside of the arm, which communicated with the fracture, which was comminuted. Further examination revealed a dislocation of the head of the humerus into the axilla. On ascertaining the condition of the head, if was found that a large portion of the scalp, at the posterior aspect, had been torn from the cranium, and was but slightly connected at one spot with the remaining portion of the scalp. The laceration had taken place from below upwards. The cranium was exposed to the extent of several square inches, and the lambdoid suture was seen in the centre of the denuded part.

¶ 12 Leave a comment on paragraph 12 0 Treatment, etc. -Chloroform having been administered, amputation at the shoulder-joint was at once performed. A flap was first made by transfixing the deltoid muscle, and the cavity of the joint was opened. The dislocated head of the humerus was now replaced, and the knife being passed behind it the under flap was made. The subclavian artery was compressed by the finger above the clavicle, and but little blood was lost during the operation. The flaps were secured in the ordinary way. The Wound of the scalp was carefully cleaned, the parts replaced, and water-dressing applied.

¶ 13 Leave a comment on paragraph 13 0 As it is chiefly with reference to the progress of the scalp- wound that it is desired to direct attention, it will be sufficient, as regards the stump, to] say, that it healed almost entirely by adhesion, and did well.

¶ 14 Leave a comment on paragraph 14 1 General Progress of Case.—A few days after the operation the pulse became somewhat slow and irregular, but this soon subsided. No symptoms indicating any mischief going on within the cavity of the cranium occurred. On the 22nd February, viz., nine days after admission, a portion of the scalp that had been torn sloughed, and exposed a piece of bone about half the size of the palm of the hand. A few days subsequently the remaining portion of the lacerated scalp sloughed, so that the whole extent of bone originally laid bare was exposed. The bone was for the most part pale in colour, but yet at some spots it presented a pink appearance. On the 2nd of March I find the following notes entered:—The bone is exposed to the extent of several square inches, granulations have sprung up in the line of the lambdoid suture, and are also shooting across from the integuments surrounding the denuded bone. Appetite good. He takes a chop daily; pulse quiet. The scalp is dressed with water dressing, and a weak solution of chlorinated soda, the discharge being of a somewhat fetid character.

¶ 15 Leave a comment on paragraph 15 0  March 6 th.—There is a large Collection of matter beneath the scalp, contiguous to the exposed bone. This was evacuated by incision. The granulations look flabby. To take a pint of ale and two mutton-chops daily.

¶ 16 Leave a comment on paragraph 16 0 9th.—There is but little discharge from the abscess of the Scalp; granulations healthy; discharge natural.

¶ 17 Leave a comment on paragraph 17 0  13th.—In the evening he complained of pain in the head; pulse 50 and irregular; tongue clean. No other symptoms

¶ 18 Leave a comment on paragraph 18 0 14th.—The pulse has resumed its natural state. The pain in the head is gone.

¶ 19 Leave a comment on paragraph 19 0 16th.—The granulations have increased in the line of suture ; they are somewhat exuberant at the sides of the wound, and are repressed with caustic.

¶ 20 Leave a comment on paragraph 20 0 The wound progressed favourably from this date, under the treatment already mentioned, (the chlorinated soda wash being omitted as the suppuration became healthy,) and no symptom of any importance occurred till the 15th of April, when a portion of the denuded bone, which for some time had looked pale, and seemed deprived of its vitality, exfoliated. It was a thin shell, rough on its under surface. Healthy granulations appeared beneath it.

¶ 21 Leave a comment on paragraph 21 0 April 30.—He is progressing favourably. The remaining portion of denuded bone, which had been getting loose for some days, was removed; and, bn examination, it was found that at one spot the whole thickness of the cranium had exfoliated, to the extent of nearly a square inch; the pulsation of the brain was distinctly visible where this had taken place. Healthy granulations appeared beneath the exfoliated bone.

¶ 22 Leave a comment on paragraph 22 0 May 25.—No symptom requiring any remark has occurred since the last report. Cicatrisation is going oh round the circumference of the sore. The pulsation of the brain is still visible, but it is more circumscribed. His health continues good. He was made an out-patient this day.

¶ 23 Leave a comment on paragraph 23 0 At the present time (June 18) he still attends as an outpatient. He has improved since he left the Infirmary. The wound is cicatrising slowly. The pulsation of the brain is much less visible, and is more circumscribed.