NOTES OF CASES TREATED IN THE MEDICAL COLLEGE HOSPITAL. Repoeted
by
Baboo GOPAL CIIUXDEB ROY, House Suegeox.
I.?FRACTURE OF THE
SKULL, WITH SUPPURATION.
Hindoo girl, aged 10 years, a resident of Burra Bazaar, was admitted on the 21st August, 1865, at p. m. She had a fall from the roof of a two-storied house at 6 p. m. that day, and remained insensible for an hour after the accident. When she was brought to the hospital she had rallied and was complaining of pain in both the forearms. On examination, Colles' fracture was detected on both sides. There was a contused wound on the scalp, opposite the left parietal eminence. It There was a good deal of was an inch long and semi-lunar. swelling around the wound itself. The arms were put on pistol shaped splints, and bandaged; water dressing to the head. The next day she had fever, which subsided in the night, but recurred next morning. Bowels were well opened, and salines given internally, when the fever soon abated. For the next twelve days she remained pretty well, taking her food regularly, walking about in the ward, complaining of no pain in the wound on the head, which was healing. On the 4th September, she had an attack of fever with shivering, and the wound on the head became inflamed. The fever continued from that day, with irregular exacerbations attended with shivering. Bowels continued loose, being moved four or five times in 24 horns. Did not complain of any headache, and was not drowsy. There was some discharge from the wound, the margins of which were sloughlylooking and painful. The following was prescibed :?
Gouka,
a
Pulv. antimon.
Hyd.
c.
creta
co.
..
..
..
..
gr. ?
v.
i-
Soda sesq. carb. V. ? One powder every six hours. Poultice to the wound; milk and soojee diet. This was continued till the 8th, the above described symptoms continuing mere or less. A crucial incision was made in the wound down to the bone, and the margins painted with nitrate of silver lotion. On the 9th the pulse was quick, full, and bounding; was delirious and occasionally drowsy ; was very irritable,, and shrieked ; alarmed when touched ; vomited several times, and the bowels continued loose as before; could answer questions slowly. The shiverings were irregular and frequent, and she did not take her food well. The former medicine omitted, and dec. einchonae, with a little nitric ether, was given every four hours; soup, and a measure of port wine, added to the diet. The same train of symptoms continued till the 12th, when the pulse was quick and thrilling, and disappearing under slight pressure ; suppuration had extended under the pericranium anteriorly, and passed to the.left eyelid, which was swollen. On extending the former crucial incision, a little of the parietal bone, about half a rupee in size, was found denuded of its periosteum. On the cenlre of this denuded portion there was a depressed fracture, involving only the outer table of the skull. On trephining the portion of bone just noted, some thick pus, about a drachm in quantity, gushed out. The seat of the ..
..
12
THE INDIAN MEDICAL GAZETTE.
suppuration, however, being higher up, another semi-circular piece was trephined anteriorly to the former. The cancellous structure of the diplcB was infiltrated with pus. The pus was between the bone and the dura-mater, which was healthy. Some manifest improvement was observed in the symptoms after the operation. She became quite conscious, and in the evening took her food well; was neither drowsy nor irritable. The same treatment with cold to the head was persevered in. But the improvement was temporary. Next morning she was found lying drowsy on one side in a flexed position, with pupils dilated. Her couutenance was quite changed. Shiverings continued as irregularly as before ; drowsiness merged gradually into profound stupor. Pulse 140? and weak. Beef tea was injected with port wine every six hours to keep up the failing strength. She died on the 15th, three days after the operation, and eleven days after the first manifestion of the head symptoms. On a post mortem examination being made, the bone around the trephined portion was found divided to the extent of half an inch, There was a layer of pus between the dura-mater and brain, beneath the wound as well as around it; the right lung was adherent to the thoracic wall anteriorly. There was some
collection of fluid in the left side of the chest. There were gangrenous patches in both lungs at their posterior surface, not bounded by any indurated margin; no other collection of pus; liver and spleen healthy. Fracture of the skull is commonly believed to be a serious accident, but fracture of its base is inevitably fatal. I have seen fractures of the vertex, involving the outer and inner plates of the bone, extending down to the dura-mater, and leaving a gap through which the pulsation of the brain could be distinctly seen, The fracture recover without any constitutional disturbance. was due to direct violence on the part by the fall of a heavy brick. On another occasion there was a depression of one side of the skull in an adult man, who recovered, though after some suffering. In a little boy, with fracture of the frontal bone, there was protrusion of the brain, but still the recovery was perfect. In the case under consideration, the fracture was a very trivial one, especially when it had involved the outer table only. The patient would have recovered from the direct inj ury, had not its sequel proved fatal. Such alarming results aro always expected, even in cases of slight contusion of the head, in which the pericranial inflammation extends inwards to the dura-mater, and there gives rise to suppuration. Therefore, in cases of injury of the head, rest and cold to the head are the main points in the treatment; when suppuration has fully formed underneath the cranial bones or underneath the dura-mater, the expectant system of treatment is to be followed. No internal medicine will absorb the purulent effusion, but we must wait and observe nature. If symptoms of compression supervene, the pus must be liberated by trephining. But that symptoms nd, according as it presses on one fibre or another, the sensation in the periphery of those begins to change till the continuous pressure destroys the nervous fibres entirely, and the part is irreparably deprived of its ulnar
nerve
sensibility.
In the above case, the circumstances worthy of note are the gradual recovery, though the disease was of eleven months' duration, the rapid ptyalism by 12 grains of grey powder after potass, iod., and no subsequent salivation with 30 grains of the same.
IT.?ABSCESS.
Bukshoo, aged 30 years, a Mussulman beggar, was admitted He on the 6th October, 1865, with a large abscess on the back. had a weak, emaciated look, with a congenital malformed leg.
Stated that he was following his avocation regularly until ten days before admission, when he felt some pain in the right lumbar region. A swelling then appeared on that spot and continued to increase steadily. Had no fever or shivering from
the commencement. The swelling extended from the iliac crest of the right side to the posterior surface of the ninth rib, and occupied a region from the spines of the vertebrae to a line drawn vertically downwards from the posterior fold of the axilla. It bulged out considerably, was soft and fluctuating, and very painful. Pulse was weak and slow, skin of natural temperature, and bowels regular. I drew out some 16 ounces of pus by a valvular opening about It was thick and quite healthy. A pad and one inch long. bandage were applied, and stimulants were given to support the
strength.
On the 7th, the abscess filled up again ; the skin was drawn the opening, which had closed up. It was opened out again with a probe, and 10 ounces of thin pus escaped. Pulse still weak; no fever. Same treatment followed. On the 8th the abscess had filled up to the same extent; discharge was somewhat foetid and thinner. I thought now of enlarging the opening, instead of remaining ignorant as to the state of the cavity of the abscess, but postponed the operation. About a drachm of pus flowed out next morning, and since then the abscess commenced to heal. He was discharged on the 19th perfectly cured. Though this case is a very trifling one, yet the rapidity with which the abscess healed, considering the worn and debilitated constitution of the patient, is really worthy of observation. over
BY C. MACNAMARA.
13
by
Baboo GOPAL CIIUXDEB ROY, House Suegeox.
I.?FRACTURE OF THE
SKULL, WITH SUPPURATION.
Hindoo girl, aged 10 years, a resident of Burra Bazaar, was admitted on the 21st August, 1865, at p. m. She had a fall from the roof of a two-storied house at 6 p. m. that day, and remained insensible for an hour after the accident. When she was brought to the hospital she had rallied and was complaining of pain in both the forearms. On examination, Colles' fracture was detected on both sides. There was a contused wound on the scalp, opposite the left parietal eminence. It There was a good deal of was an inch long and semi-lunar. swelling around the wound itself. The arms were put on pistol shaped splints, and bandaged; water dressing to the head. The next day she had fever, which subsided in the night, but recurred next morning. Bowels were well opened, and salines given internally, when the fever soon abated. For the next twelve days she remained pretty well, taking her food regularly, walking about in the ward, complaining of no pain in the wound on the head, which was healing. On the 4th September, she had an attack of fever with shivering, and the wound on the head became inflamed. The fever continued from that day, with irregular exacerbations attended with shivering. Bowels continued loose, being moved four or five times in 24 horns. Did not complain of any headache, and was not drowsy. There was some discharge from the wound, the margins of which were sloughlylooking and painful. The following was prescibed :?
Gouka,
a
Pulv. antimon.
Hyd.
c.
creta
co.
..
..
..
..
gr. ?
v.
i-
Soda sesq. carb. V. ? One powder every six hours. Poultice to the wound; milk and soojee diet. This was continued till the 8th, the above described symptoms continuing mere or less. A crucial incision was made in the wound down to the bone, and the margins painted with nitrate of silver lotion. On the 9th the pulse was quick, full, and bounding; was delirious and occasionally drowsy ; was very irritable,, and shrieked ; alarmed when touched ; vomited several times, and the bowels continued loose as before; could answer questions slowly. The shiverings were irregular and frequent, and she did not take her food well. The former medicine omitted, and dec. einchonae, with a little nitric ether, was given every four hours; soup, and a measure of port wine, added to the diet. The same train of symptoms continued till the 12th, when the pulse was quick and thrilling, and disappearing under slight pressure ; suppuration had extended under the pericranium anteriorly, and passed to the.left eyelid, which was swollen. On extending the former crucial incision, a little of the parietal bone, about half a rupee in size, was found denuded of its periosteum. On the cenlre of this denuded portion there was a depressed fracture, involving only the outer table of the skull. On trephining the portion of bone just noted, some thick pus, about a drachm in quantity, gushed out. The seat of the ..
..
12
THE INDIAN MEDICAL GAZETTE.
suppuration, however, being higher up, another semi-circular piece was trephined anteriorly to the former. The cancellous structure of the diplcB was infiltrated with pus. The pus was between the bone and the dura-mater, which was healthy. Some manifest improvement was observed in the symptoms after the operation. She became quite conscious, and in the evening took her food well; was neither drowsy nor irritable. The same treatment with cold to the head was persevered in. But the improvement was temporary. Next morning she was found lying drowsy on one side in a flexed position, with pupils dilated. Her couutenance was quite changed. Shiverings continued as irregularly as before ; drowsiness merged gradually into profound stupor. Pulse 140? and weak. Beef tea was injected with port wine every six hours to keep up the failing strength. She died on the 15th, three days after the operation, and eleven days after the first manifestion of the head symptoms. On a post mortem examination being made, the bone around the trephined portion was found divided to the extent of half an inch, There was a layer of pus between the dura-mater and brain, beneath the wound as well as around it; the right lung was adherent to the thoracic wall anteriorly. There was some
collection of fluid in the left side of the chest. There were gangrenous patches in both lungs at their posterior surface, not bounded by any indurated margin; no other collection of pus; liver and spleen healthy. Fracture of the skull is commonly believed to be a serious accident, but fracture of its base is inevitably fatal. I have seen fractures of the vertex, involving the outer and inner plates of the bone, extending down to the dura-mater, and leaving a gap through which the pulsation of the brain could be distinctly seen, The fracture recover without any constitutional disturbance. was due to direct violence on the part by the fall of a heavy brick. On another occasion there was a depression of one side of the skull in an adult man, who recovered, though after some suffering. In a little boy, with fracture of the frontal bone, there was protrusion of the brain, but still the recovery was perfect. In the case under consideration, the fracture was a very trivial one, especially when it had involved the outer table only. The patient would have recovered from the direct inj ury, had not its sequel proved fatal. Such alarming results aro always expected, even in cases of slight contusion of the head, in which the pericranial inflammation extends inwards to the dura-mater, and there gives rise to suppuration. Therefore, in cases of injury of the head, rest and cold to the head are the main points in the treatment; when suppuration has fully formed underneath the cranial bones or underneath the dura-mater, the expectant system of treatment is to be followed. No internal medicine will absorb the purulent effusion, but we must wait and observe nature. If symptoms of compression supervene, the pus must be liberated by trephining. But that symptoms nd, according as it presses on one fibre or another, the sensation in the periphery of those begins to change till the continuous pressure destroys the nervous fibres entirely, and the part is irreparably deprived of its ulnar
nerve
sensibility.
In the above case, the circumstances worthy of note are the gradual recovery, though the disease was of eleven months' duration, the rapid ptyalism by 12 grains of grey powder after potass, iod., and no subsequent salivation with 30 grains of the same.
IT.?ABSCESS.
Bukshoo, aged 30 years, a Mussulman beggar, was admitted He on the 6th October, 1865, with a large abscess on the back. had a weak, emaciated look, with a congenital malformed leg.
Stated that he was following his avocation regularly until ten days before admission, when he felt some pain in the right lumbar region. A swelling then appeared on that spot and continued to increase steadily. Had no fever or shivering from
the commencement. The swelling extended from the iliac crest of the right side to the posterior surface of the ninth rib, and occupied a region from the spines of the vertebrae to a line drawn vertically downwards from the posterior fold of the axilla. It bulged out considerably, was soft and fluctuating, and very painful. Pulse was weak and slow, skin of natural temperature, and bowels regular. I drew out some 16 ounces of pus by a valvular opening about It was thick and quite healthy. A pad and one inch long. bandage were applied, and stimulants were given to support the
strength.
On the 7th, the abscess filled up again ; the skin was drawn the opening, which had closed up. It was opened out again with a probe, and 10 ounces of thin pus escaped. Pulse still weak; no fever. Same treatment followed. On the 8th the abscess had filled up to the same extent; discharge was somewhat foetid and thinner. I thought now of enlarging the opening, instead of remaining ignorant as to the state of the cavity of the abscess, but postponed the operation. About a drachm of pus flowed out next morning, and since then the abscess commenced to heal. He was discharged on the 19th perfectly cured. Though this case is a very trifling one, yet the rapidity with which the abscess healed, considering the worn and debilitated constitution of the patient, is really worthy of observation. over
BY C. MACNAMARA.
13
