Pioneering surgery at town hospital

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The Lancet of July 14, 1900, carries an article headed: “Morpeth Cottage Hospital — A case of fracture of the left side of the skull with complete right hemiplegia; operation; recovery (under the care of Dr E.F.L. de Jersey).”

Dr de Jersey was the House Surgeon at Morpeth Dispensary.

After a brief technical introduction, the article goes on: “The harmlessness and the value of modern treatment of even extensive fractures of the skull could not be better illustrated than in the case recorded below.

“A man, aged 45 years, was admitted into the Morpeth Cottage Hospital on Feb. 22, 1900, having been struck on the left side of the head on the 17th with a pole six feet in length and from six to nine inches in diameter.

“There was complete unconsciousness with right-sided hemiplegia (i.e. paralysis of one side of the body but not the other) and retention of urine and faeces. The temperature was 102F.

“On the day before the patient’s admission... slight crepitation was detected over the right parietal bone at about its centre. There was no external wound or discolouration over the site of the injury, only slight pitting on pressure.

"There was a slight effusion of blood a little above and in front of the left ear. There were also two black eyes produced by fist-blows.

"On firm pressure on the site of the fracture spasm of the whole right side of the face and body was produced."

Dr de Jersey began operating at 3.30pm on February 22, making a rectangular, three-sided incision, 4½ in by 5½ in, over the fracture.

“On raising the flap just formed an extensive stellate, depressed, fissured, and comminuted fracture was found.

“On raising the depressed and comminuted fragments both the internal and external tables of bone were found to be involved, fragments of bone projecting in all directions into the brain substance, tearing to shreds the dura mater, the arachnoid, and the pia mater lying over the convolutions of the brain.

“After removal of the fragments of bone an area of brain two-and-a-half inches by three-quarters of an inch was exposed.”

He describes seeing two fissures in the bone, one of them a quarter of an inch wide. There was also “a large haematoma (blood clot), which was left undisturbed”. Behind the left ear “was a cavity extending right into the substance of the brain large enough to admit the little finger quite easily”.

"This cavity, no doubt, was produced by the injury, but degenerative changes had already set in, as the brain matter round the orifice was quite pulpy and friable.

“The fracture covered most of the motor area, there being complete right-sided hemiplegia and motor aphasia, showing that the left inferior frontal convolution must have been damaged as well as the parietal convolutions.

“Some of the difficulty of speech was due to paralysis of the tongue... The patient stated when he got the use of his tongue that he could hear everything that was said to him and wished to answer but he could not get his words out.

“Part of the whole thickness of the parietal bone (top of the skull) was replaced, a gauze plug was inserted into the cavity in the brain and brought out under the flap, which was sutured, and a dry dressing was put on. The plug was removed on March 3 and the wound healed without suppuration.

“Before operation the pulse was 40, the breathing was very quiet, almost inaudible, and deep coma was setting in. At 9pm on the evening of the operation the patient was still unconscious but he raised his right leg every now and again.

"The pulse was quicker and the breathing was stronger. The temperature was 97.5F. He had taken nourishment, and this he had not done before since the injury.

“He was very restless and kept raising himself from the pillow. Shoulder bands were put on which kept him still, they being tied to the head of the bed.

“On Feb. 23 (the day following the operation) the patient had had a pretty good night though he had been very restless at times. He had said the word ‘No’ and had made signs for a drink. The urine and faeces were passed involuntarily. The temperature was 98.2F.

“From the operation the patient steadily improved and never once did the temperature rise above the normal. On Feb. 24 the right arm could be raised slightly. On the 25th the right arm could be moved freely and consciousness was returning.

“On the 28th the patient tried hard to speak but could not get the words out. He opened his mouth when asked to do and said small words like ‘Yes’ and ‘No,’ but usually he used the latter to questions which were put to him. Consciousness had almost completely returned.

“On March 7 the patient put out his tongue for the first time. It deviated much to the right. He carried on a little disconnected conversation, there being much motor aphasia. He started taking light solids on this day.

“On the 12th he gave a statement to the police as to the cause of his injury quite rationally, but with difficulty at times owing to the aphasia. He said that he had a bad memory and could not remember names so well as he could before the injury.

“On April 2 he walked about the ward quite well and was able to carry on conversation with very little difficulty. The paralysis had completely disappeared, but there was slight weakness of the right side, specially noticeable with the clench of the two hands. On the 10th he was dismissed from the hospital.”

The article concludes with Remarks by Dr de Jersey.

“The order in which the paralysis disappeared was very prominent. Almost directly after the pressure over the motor area had been relieved movement of the paralysed side returned, starting with the leg, then followed by the upper extremity, the face, and lastly by the tongue.

"The shoulder movements returned before those of the elbow, and those of the elbow before those of the hand — viz, the finer movements.

“The upper face being only slightly affected returned to its normal state long before the lower face. The return of the paralysed side to normal brought out very well the fact that the parts which rarely act independently of their fellows on the opposite side are the parts that are usually the least paralysed and consequently are the parts that recover the most quickly.

“The interesting points in the case are the rapid recovery after the pressure on the brain had been relieved, the signs of relieved pressure appearing before those of shock began to pass off, and consciousness returning comparatively late.

“Another interesting point is the fact that a piece of bone, including both the external and internal table, completely deprived of its periosteum, was replaced and has become firmly adherent to the adjacent bone. It was nearly half an inch square.”

Dr de Jersey does not say what anaesthetic he used, but it was probably chloroform, it being less dangerous than some others.