Part 32
A man fell down stairs and received an injury on the head from the fall which rendered him nearly insensible at the moment. There were no signs or appearances on the outside of the head indicative of any serious mischief, nor were any found on examination after death. The pulse was quick, and rose to 140; the left side was paralytic; the breathing not stertorous, but accompanied by a little puff on the right side of the mouth; the pupils somewhat dilated; he could not speak, convulsions supervened, and he died the day afterward. On dissection, the peculiar flatness of the convolutions of the brain on the right side was so remarkable, when compared with that of the left, as to leave little doubt of its having been occasioned by something which had pressed them forcibly upward against the inside of the cranium; and, on slicing off a portion of the brain, a larger coagulum of blood was found below than is usually observed to exist without the almost immediate death of the patient. The same thing has been so distinctly marked in other instances that no doubt can be entertained of those convolutions of the brain which were situated between the coagulum and the cranium having undergone a considerable degree of compression. It is worthy of remark that the pulse of this person was always regular and remarkably quick from the first examination after the receipt of the injury until the period of his death, showing, perhaps, that the action of the heart is not affected directly by pressure acting only on the upper surface of the brain.
256. Convulsive actions of the muscles, or positive convulsive fits, are always important symptoms; yet they seem in some persons to be dependent on idiosyncrasy, particularly when they appear early, and after the loss of blood, in which case they are less dangerous. They occur at different periods after the receipt of the injury, and have been supposed to depend in general upon laceration of the substance of the brain, although experiments on animals would seem to show that they may be caused directly by irritation of the cerebro-spinal axis within the skull, in which case the patients are more likely to recover. They have been observed particularly on the side opposite to that which is paralytic, so as to give rise to the idea that the paralysis is dependent on injury of one side of the cerebrum, and convulsions on injury of the other. When the effect of the mischief is so great as to cause complete paralysis, convulsive twitches do not take place, although they frequently precede, and may in many cases be considered as premonitory signs, while the evil which gives rise to the paralysis is gradually accumulating. When the paralysis is not complete, the side so affected suffers sometimes from slight convulsive twitches, while well-marked spasms prevail in the other, leading to the belief that, while paralysis is an affection of only half the brain of the opposite side, or of half the spinal marrow of the same side, convulsions are the effect of a more general irritation, capable, however, of being confined to a part; for partial convulsive motions do very frequently occur without any paralysis accompanying them on the opposite side. Several cases have occurred in which the convulsions have ceased, and the patients recovered after the removal of a portion of bone which was irritating the brain; but convulsions have generally been the forerunners of death when the seat of injury was unknown and effective relief could not be given. When they occur in cases apparently of pure concussion, accompanied by inflammation of the brain or of its membranes, and the patient recovers after many days of the strictest antiphlogistic treatment, it is possible that the brain may have been lacerated, and the cure have been effected by adhesion. Convulsions, it must be remarked, are among the most common symptoms of inflammation of the membranes of the brain, without any such lesion of its substance, although they are frequently wanting. They may be expected to take place about and after the fifth day in injuries of the head, when inflammation of the brain or of its membranes is about to extend to or to become continuous with the neighboring parts, and may be more or less severe, varying from a state of partial trembling of a limb to that of general agitation and restlessness of the body generally--from a slight, irregular movement of the eyelids, or of the muscles of the face, to the more marked spasmodic startings of the whole of one side, grinding of the teeth, and contraction of the limbs. It is far different with those convulsive movements which, at a late period, become nearly permanent, or with rigid spasms, resembling tetanus, in which the body is drawn in different directions, forward, backward, or to one side. These are for the most part forerunners of death. Examination after death, in such cases, has frequently shown nothing discoverable beyond inflammation of the pia mater, and an effusion of fluid, generally purulent, on the surface of the brain, or in its ventricles, or between the pia mater and the tunica arachnoides.
The three following cases are intended to show the different forms of paralysis that ensue after injuries accompanied by compression or irritation of the brain:--
Charles Murray, private in the 2d battalion of 1st Foot Guards, aged thirty-three, was wounded on the 18th of June, at Waterloo, by a piece of shell which struck him on the superior part of the _left_ parietal bone. He remained insensible about half an hour, and on recovering from that state, was affected with nausea and some bleeding from the left ear, and found himself unable to move his _right_ arm and _right_ leg, which hung as if they were dead, and had lost their feeling. Admitted into the Minimes General Hospital at Antwerp on the 29th; he suffered much from pain in the head, which was relieved by his being twice bled. The paralytic affection having remained without change from the moment he was wounded, a piece of the parietal bone, about three-fourths of an inch long, and several smaller fragments, were extracted four days after admission into the hospital, two perforations with the trephine having been necessary. Immediately after the removal of the bone he recovered the use of his right arm and leg, so far as to be able to move them, and to be sensible of their being touched. He gradually recovered by the 14th of August, so as to be sent to the General Hospital at Yarmouth, never having had a bad symptom, the only defect remaining on the right side being an inability to grasp anything in his hand with force. The pulsation of the brain was still visible at the bottom of the wound for about the space of half the circumference of the crown of the trephine. September 16th, 1815: the wound has filled up with healthy granulations, and has nearly cicatrized. A small sinus remains at the superior part, through which the edge of the bone can be felt. His health has been invariably good, although he has suffered a good deal of pain twice previously to the coming away of little pieces of bone, and toward evening he has been generally subject to slight vertigo. Discharged cured.
William Mitchel, of the Royals, aged forty, was wounded by a musket-ball on the 18th of June, at Waterloo; it struck the side of the head near the vertex, and, passing across through the sagittal suture, fractured and depressed _both_ parietal bones. When he had recovered his senses he suffered great pain in the part, and found that he had lost the use of BOTH his legs, and was benumbed even from the loins and lower part of the chest; he was often sick, and felt low and ill. On the 28th, ten days after the battle, the trephine was applied in two places, and the whole of the detached and depressed portions of bone were removed. The sickness, lowness of spirits, and general illness immediately subsided, and the loss of power in the lower extremities gradually began to diminish, but he was not able to walk without assistance until the first week in August. On the 10th he arrived at Yarmouth, not having had a bad symptom after the depressed bone had been removed; and by the end of September he was discharged, able to walk well with the assistance of a stick.
Mr. Keate has mentioned to me a case, in which the injury and the paralysis were apparently on the same, or the right side. The paralysis, although positive, was not so complete as to render the patient quite incapable of moving the arm and leg, which were frequently convulsed, but the convulsions, which were observable in both, were more marked on the opposite or left side. On examination after death, the most serious injury was found to be a fracture of the right parietal and temporal bones, extending to the petrous portion of the latter, and beyond it; this, with a rather large extravasation of blood under and in the course of the fracture, appeared to be sufficient not only to destroy life, but to have caused paralysis of the left side, which, however, it did not do. Another extravasation, rather less in quantity, had, however, taken place under the upper and anterior portion of the left parietal bone, which enabled Mr. Keate fully to account for the paralysis which took place on the right side. According to the surgery of the French Academicians of the beginning of the eighteenth century, this man would have been trephined or trepanned on the left side of the head in search of an extravasation by contre-coup; but accident or chance alone could have led to the right spot, as it was by no means opposed to that on the other side.
257. A simple fissure or fracture of the skull is of no more importance than a fracture of any other bone in the body, unless it implicate the brain; it should be managed according to the ordinary principles of surgery. These principles, however, involve a treatment diametrically opposite to that practiced by many surgeons, almost unto the present day.
If the integuments or scalp be divided, and the bone fissured, these principles should be carried out, by endeavoring to procure the union of the divided parts, as was generally done during the war in all such injuries from sabre-cuts as did not quite penetrate the skull--a practice that was found to be eminently successful, even when union did not take place. The general treatment should be similar to that insisted on in concussion, of which the following may perhaps be considered a sufficient example:--
A soldier in Lisbon, partly in liquor, received a blow from a spade which cut the upper part of the head across the sagittal suture, and rendered him senseless. He soon got better, and a slight fissure or fracture without depression was discovered. His head was shaved, kept raised, wet and cold, and the divided parts brought together by sticking-plaster; he was bled to twenty-four ounces, purged, starved, and kept quiet in a dark room. Slept well, but said that his head felt painful, as if something tight was tied around it. Pulse 96, small and hard; bowels not open. Blood was taken from the arm to the amount of forty ounces, when he appeared about to faint. Calomel and jalap, followed by infus. sennæ cum magnes. sulphate, were given, and acted well, and he was greatly relieved. The calomel was continued every six hours. In the evening, however, the pain and tightness of the head returned, with a pulse of 110, hard and full; these symptoms were removed by the loss of twenty-four ounces of blood. He remained easy until the evening of the next or the third day, when the pulse quickened to 120, became small and hard, and he complained of severe pain in the head. It was evident that inflammation of the brain or of its membranes had commenced, and that it must be subdued; he was therefore bled until he fainted, forty ounces having been taken away. This entirely relieved him, and calomel and jalap, senna and salts were again administered with great effect. On the fourth day he was easy, the pulse 94, soft and full, the mouth being tender from the mercury. The wound did not heal by adhesion, but by granulation; and under the continuance of the starving and purging system he gradually got well without any more bad symptoms, having been saved by the loss of one hundred and twenty-eight ounces of blood in three days.
The vigorous and decided abstraction of blood saved the man, and, with the mercury, in all probability prevented the occurrence of those evils which our predecessors sought to obviate by removing a portion of bone. They believed the bone could not be fractured without an extravasation taking place beneath; and some took credit to themselves for placing wedges between the broken edges, in order to allow the escape of the blood or of the matter which might be formed below it. That blood may be effused, and matter may be formed, is indisputable, even under the most active treatment; but that an operation by the trephine will anticipate and prevent these evils, cannot be conceded in the present state of our knowledge; and the rule of practice is at present decided, that no such operation should be done until symptoms supervene distinctly announcing that compression or irritation of the brain has taken place. It is argued that when these symptoms do occur, it will be too late to have recourse to the operation with success. This may be true, as such cases must always be very dangerous; but it does not follow, and it never has been, nor indeed can it be shown, that the same mischief would not have taken place, if the operation had been performed early.
258. When a simple fracture, which in its slightest form is called a capillary fissure, takes place, the dura mater must be separated from it at that part to a certain extent, and some small vessels must be torn through. It does not follow, however, that blood must necessarily be poured out in such a quantity that it will not be absorbed. Dissection, on the contrary, has established the fact that it will be absorbed even in cases of fracture of greater extent, where it has been seen that a larger quantity had been extravasated. As the effusion of a larger, or of so large a quantity of blood as to prove eventually mischievous, does not _usually_ take place, except under other circumstances than those of a simple fracture, the ordinary practice ought not to be to seek for that which is not likely to be found. The dura mater is rarely separated beyond the limits of the fracture, and it is more likely to recover without any further exposure or interference than with it. The dura mater, however, may be separated to a considerable extent from the bone in more severe injuries, and a quantity of blood is often extravasated upon it. When this does occur, the commotion or shock which occasioned the fracture, the separation of the dura mater, and the extravasation will generally have caused other more important although less perceptible derangements. These show themselves after the lapse of a few days, by giving rise to inflammation of the brain or of its membranes, of which such patients more usually die, than of the separation of the dura mater, or of the extravasation of a small quantity of blood. The case is no longer one of simple fissure or fracture of the cranium, and the nature and severity of the symptoms which have supervened must regulate the practice to be pursued.
259. After the receipt of a severe blow, or of a gunshot fracture of the head, which has not even stunned the person at the moment, he may walk to the surgeon, the wound be dressed, and he may converse with his fellows as if nothing had happened; yet in a short time he may become heavy, stupid, drowsy, and unwilling to move, with a slow pulse and a pallid countenance. Inflammation has not yet had time to set in, and extravasation has not always taken place. If the loss of a moderate quantity of blood should relieve such a person, it shows that congestion had occurred, perhaps on the surface of the brain under the injured spot, on recovering from which, by the unassisted efforts of nature, he would still be liable to inflammation. I have repeatedly seen a sharp bleeding from an incision made to allow a complete examination of the part in such a case, cause the restoration of the patient to his natural state. A return of untoward symptoms during the progress of the case does not always indicate essential mischief; they will be removed, if of a temporary nature, by a further moderate bleeding, by purgatives, and by greater restriction in diet, through irregularities in which these secondary attacks most usually occur. If the loss of blood should not relieve the symptoms, the case is probably complicated by a separation of the dura mater, or by an extravasation having taken place between the dura mater and the bone, or even in or on the surface of the brain.
260. When a fracture takes place at the anterior inferior angle of the parietal bone, or in any part of the course of the middle meningeal artery, it often gives rise to a more serious injury, which nothing but an operation can remove. The artery is always in a groove, and is often even imbedded in the bone at its lower part, and may be torn at the moment of fracture, giving rise to a gradual extravasation of blood on the surface of the brain, which can be borne to a considerable extent without causing any particular symptoms, although a sudden and considerable effusion causes immediate insensibility. When the extravasation is gradual, the patient walks away after the accident, and converses freely, becoming oppressed slowly, and in the end insensible, as the last drops of blood which are effused render the compression effective. When these symptoms occur after a wound in this particular part, the bone should be immediately examined; if there be no obvious fracture, and relief cannot be obtained by the abstraction of blood, the trephine should be resorted to as a last resource; for if there be truth in the statements so confidently made of fracture of the inner table of the bone from concussion of the outer without fracture, it is here especially that we may be permitted to look for it. The hemorrhage in the greater number of these cases takes place slowly, and the effused blood depresses the brain by separating the dura mater from the neighboring bone--a process, however, which can hardly occur unless the injury has been so violent as to rupture its attachments to the bone; for the brain generally yields rather than the attachments of the dura mater, and is depressed, the hollow or cavity thus formed being filled up by the coagulum, which becomes thicker and thicker until insensibility is induced. Blood effused between the dura mater and the bone readily fills up in the first instance all the space formed by the disruption of the membrane; for the force with which the blood is poured out from the artery overcomes the resistance offered by the brain, which gradually yields and sinks unto that point at which its natural functions can no longer be carried on. If the attachments of the dura mater be strong, and the separation which has taken place between it and the bone be small, the blood effused is compressed by the bone on one side, on which it can exert no influence, and is resisted by the dura mater, which will recede no further on the other. The wounded artery in such a case is soon compressed by its own coagulum, and the effusion is comparatively trifling, giving rise, according to its nature, either to the primary symptoms of compression from extravasation, or to the secondary ones dependent in all probability on inflammation and suppuration of the part, and of irritation and compression of the brain beneath. If, on the contrary, the separation of the dura mater from the bone be extensive, the quantity of extravasated blood may be considerable and the brain will be greatly depressed. Experience has demonstrated that persons have recovered after large coagula have been removed; but in all these cases the brain had not lost its resiliency, and was seen to regain its natural level on the removal of the depressing cause, the person often opening his eyes and recognizing and speaking to those about him; but this does not take place when the brain remains depressed after the blood has been removed.
A French artillery driver was knocked off his horse by a musket-ball, which struck him on the anterior and inferior portion of the right parietal bone, during a charge made by General Brennier, at the battle of Vimiera, on the British infantry under the command of the late Sir Ronald Fergusson. I took him under my care, thinking from his freedom from bad symptoms and the slightness of the fracture that he would probably do well. The next morning I found him apparently dying. A portion of bone being removed, a thick coagulum of blood appeared beneath, apparently extending in every direction. Three more pieces of bone were taken away and the coagulum, which appeared to be an inch in thickness, was removed with difficulty with the help of a feather. The brain did not, however, regain its level, and the man shortly after died. The middle meningeal artery was torn across on the outside of the dura mater; the wound did not pass through to the inside, and there was no blood beneath the dura mater. The convolutions of the brain were depressed and flattened by the pressure.
A soldier of the 29th Regiment was struck on the right parietal bone in a similar manner, shortly after daylight, at the battle of Talavera, during the first attack on the hill, the key of the British position. He walked to me soon afterward to the place where the wounded of the evening before had been collected in the rear. Being otherwise employed, I heard his story but could not attend to him at the moment, and found him some time afterward insensible, with a slow, intermitting pulse, breathing loudly, and supposed to be dying. The fractured parts were sufficiently broken to admit of the introduction of two elevators, by means of which they were gradually removed, together with a large coagulum of blood which had depressed the brain. When this had been done the brain regained its level, the man opened his eyes, looked around, knew and thanked me. The pulse and breathing became regular; he said he suffered only a little pain in the part, and should soon get well. He died, however, on the third day.
During the battle of Salamanca a soldier of the 27th Regiment was brought to me, who had walked to the rear, and had fallen down insensible within a few yards of the hospital station. I found a considerable fracture, with depression at the inferior part of the parietal bone before and above the ear. The end of the elevator having been introduced, a small piece of bone was first raised, then another, and a third, when a thick coagulum was exposed and removed. The dura mater was not separated from the bone around to any extent, and the coagulum, although thick, was not large. The brain, which had been depressed, regained its level immediately; the man recovered his senses, and was cured of his wound, but remained unfit for service. The artery did not bleed after it had been exposed.
The rule in surgery, to remove the bone in such cases, is absolute.
261. Fractures of the skull are stated, from almost the earliest records of surgery, to occur on one _side_ of the head in consequence of blows received on the _other_. The facts which ancient authors have collected and related on this point are so numerous and so well attested that it appears almost more than skeptical to doubt their accuracy, however seldom they may be now observed.