Part 34
A British soldier received a wound at the affair of El Boden, in front of Ciudad Rodrigo, from a sword, on the top of the head; he accompanied me to Alfaiates, on the retreat of the army. The bone was apparently only cut through, yet the inner table was depressed, and felt rugged when examined with the probe. The symptoms of inflammation increasing on the fourth day, and not being relieved by copious bleeding, I removed a central portion of the cut bone by one large crown of the trephine, and took away several small pieces which were sticking into the dura mater, after which all the symptoms gradually subsided.
266. The whole of the French wounded, who remained on the ground or were taken prisoners after the battle of Salamanca, were under my care, and among them there were several severely wounded by sword-cuts received in the charges of heavy cavalry made by Generals Le Merchant and Bock. The cerebellum was laid bare in two cases without any immediate bad effect. In one particular case, which recovered, (after the battle of Waterloo,) the brain was seen pulsating for several weeks; and the statements made to me by the different officers at Brussels and Antwerp, and afterward at Yarmouth and Colchester, entirely confirmed the observations I had made, and the recommendations I have inculcated on this particular point as resulting from the practice of the Peninsular war.
267. It would appear that too much stress is laid upon a difference which is supposed to exist in the danger of trephining a man on the first or on the seventh day after an accident; and that an error may be committed in believing that the trephine is a more dangerous instrument on the first day than on the seventh. The question is not whether the man is to be trephined or not, but which will be the best and safest day or time to do the operation. I do not hesitate to say the first, believing the violence to be greater when done on parts already in a state of inflammation, than when they are sound. When the inner table has pierced the membranes and gone into the brain itself, the individual will in most cases ultimately die miserably of the accident if not relieved by art. It is less safe to let him designedly run the certain risk of cerebral irritation, which when once excited is often indomitable, than to remove the cause, and endeavor to prevent the evil. If the cerebral irritation only manifested its effects on the surface of the dura mater by causing suppuration there, delay might be admitted; but as it usually gives rise under these circumstances to the formation of matter on the surface, and even in the substance of the brain, where it is deadly, “la chirurgie expectante” cannot be allowed. Lastly, there is not more danger of a hernia cerebri, as has been supposed, when the operation is done early, than when it is done at a later period; on the contrary, the patient has a much better chance of escape from hernia cerebri, and from all other evil, when the local and the general treatment are decided and efficient.
If, on attempting to remove a fragment buried in the brain, serious convulsive movements should be excited, it would be proper to desist from all further attempts to extract the splinters until the brain has become more quiescent.
It is necessary to recollect that the brain appears to be insensible, or nearly so, when first exposed; and it has rarely occurred that a serious convulsion or anything beyond vomiting has taken place on the removal of a piece of bone from the brain; nor will any difficulty be found in removing such small fragments as can be seen with a pair of forceps duly adapted for the purpose. It is impossible to say at what period of time the brain may become irritable, and no longer admit of its being touched without convulsive movements ensuing; but when this state of irritation has commenced, and its existence is proclaimed by the excitement which takes place on touching the fragment of bone, the surgeon should at once desist from all attempts to remove the foreign body. The brain under ordinary circumstances is much more likely to recover from an injury, all foreign or irritating matters having been removed, than when suffering from their presence.
268. The establishment of the principles which ought to regulate the practice of surgery in cases of fracture with depression of the inner table of the skull, is of the greatest importance. The principle being laid down that it is right and proper to examine all such wounds with a blunt, flat probe, in order to ascertain if possible whether the inner table be depressed and broken, the question necessarily arises, what is to be done when such depression and breaking down of the inner table have been ascertained to have taken place? There can be no hesitation in answering, that in all such cases the trephine should be applied, although no symptoms should exist, with the view of anticipating them. The old doctrine, it may be said, in regard to fractures generally, is revived in these cases, but on a principle with which our predecessors were not sufficiently acquainted. A patient very often survives a mere depression of the skull; he may, and occasionally does survive, a greater depression of the inner than of the outer table; but it has not been shown that he ever does survive and remain in tolerable health, after a depression with fracture of the inner table, when portions of it have been driven into the dura mater. If cases could be advanced of complete recovery after such injuries, they would not supersede the practice recommended, unless they were so numerous as to establish the fact that injuries of the dura mater and brain by pieces of bone sticking in them are curable without an operation, and without leaving any serious defects. There are great objections to the trephine being applied in ordinary cases of fracture, not attended by symptoms of further mischief; but the nature of the cases particularly referred to having been ascertained, the practice should be prompt and decisive in every instance in which the surgeon is satisfied that there is not merely a slight depression or separation of the inner table, but that several points of it have been driven into the dura mater. If one trephine will suffice, the central point being applied close to the edge of the middle of the wound in the bone, it should be applied there; but if the cut be longer, and the spiculæ of bone extend upward and downward in its length, a small trephine should be applied as near each end as may be judged advisable, and one edge of the cut bone should be removed by the straight saw, of which Paré and Scultetus made such use in ancient times, and which Mr. Hey of Leeds revived in modern surgery; or the small straight saw may be used alone, if the object of removing a portion of bone can be attained without the trephine. By these means sufficient room will be obtained to remove the broken pieces of bone which are irritating the dura mater and brain. The danger resulting from the application of the trephine, in such cases, bears no proportion to the risk incurred by leaving the broken portions of bone as a constant cause of irritation.
269. There is an essential difference between a depression of the skull in a CHILD and in an ADULT. In the child the inner table is not brittle--it bends equally and does not break; it very often does little mischief when depressed, and gradually recovers its level. The brain in young persons is softer and less consistent, and can accommodate itself more readily to pressure for a limited time, without ultimate mischief, than the brain of an adult; so that a continuance of the most urgent symptoms can alone authorize the application of the trephine in children, and in young persons under fifteen or sixteen years of age. A similar bending of the long bones in young children is often observed at an early period in life.
270. The propriety of dividing the scalp in an adult, in order to examine the state of the bone beneath, when evidently depressed, thus rendering a simple although comminuted fracture a compound one, is a matter of very great importance, the decision of which rests upon the still more essential point--viz., whether a depressed portion of bone ought or ought not to be removed? This again must depend upon the nature and extent of the depression, for many persons who have suffered from such a misfortune have recovered without the depressed portion being raised. It is a question of degree or extent, upon which every surgeon must form a judgment from his own observation and experience.
The difference between a simple and a compound fracture of the leg is often considerable; it is more often dependent on degree. When the fracture is nearly transverse, and the skin is cleanly divided, the difference between it and a simple fracture of the same part is little more than one of time. This may be the case with an injury of the head; the difference between the two states in fractures of the skull has, however, been much exaggerated; so much so, that no reliance can be placed on the supposition that there is more real danger in a case of fracture with depression in which the scalp has been divided, than when it has been only bruised, and not divided. I admit that theoretically it ought to be otherwise, but theory and practice do not always correspond. In all cases in which a fracture with _marked_ depression is known to have occurred in an ADULT, it is good practice to ascertain the nature and extent of the depression. It is imperatively necessary if accompanied by symptoms of compression.
If the result of a great number of comparative trials should be in favor of never, under any circumstances, raising a depressed portion of bone in an adult, but of leaving it to the efforts of nature, an incision in order to ascertain the state of parts below ought not to be made; but as such a result is not likely to be obtained, the practice recommended appears to be the best.
The scalp should be divided, in such cases as may require the operation, by a straight, crucial, or such other shaped incision as may be found most convenient to the surgeon; but no part should be removed which can be preserved with the hope of maintaining its life.
271. The cranium, together with the fracture and depression, being exposed, the question whether the trephine should be applied or not is next to be determined. If the operation by the trephine, or that of sawing a piece of bone out of the head, were not in itself dangerous, there could be no hesitation about its use; but it is a dangerous operation, especially in crowded hospitals, and ought not to be resorted to when it can be avoided. If any ten healthy persons were trephined in a hospital, one would in all probability die from the effects of the operation, and three or four more might have a narrow escape from the inflammation of the brain and its membranes, or the other consequences which would probably ensue. It is not the admission of air, which has been even lately supposed to do mischief, that is to be dreaded in these cases, but the same kind of irritation which often follows the abstraction of a piece of bone under other and more ordinary circumstances at a later period of time.
The following cases are illustrative of many important points:--
William Rogers, aged nineteen, of the 32d Regiment, was wounded on the 16th of June by a musket-ball, which entered at the inferior angle of the left parietal bone, knocked him down, and for a few minutes rendered him insensible. On recovering his mental powers, he found that he was unable to speak, not so much (as he said afterward) from the want of power to form words, as from the incapacity of giving them sound. He was conscious of everything passing around him, and reasoned correctly. He retired out of the reach of shot, and then lay down for the night. On the following morning, he went to Brussels, where he was examined and dressed. On the morning of the 18th he reached Antwerp on horseback, very giddy, and overwhelmed with fatigue, fasting, and watching; he was admitted into the Minimes General Hospital and put to bed, when he soon fell into a sound sleep, which with some tea refreshed him much.
June 19th. The ball was found to have passed obliquely upward and backward at least two inches, and could be distinctly felt with a probe. It gave more the idea of having raised the outer table than that of having depressed the inner. The defect in speech was in some measure diminished, and this with giddiness were the only symptoms of compression. A poultice was placed over the wound, a brisk purgative given, and spoon diet ordered.
20th. The pain and giddiness having increased, with annoyance from noise and exposure to light, twenty-six ounces of blood were taken from the arm. The following day the purgative was repeated, and the patient was much relieved. Everything went on well, the wound was nearly healed, and he was considered almost fit to be discharged, when, on the 16th of July, the wound began to open; on the 18th it was dilated and a portion of the cranium removed by the forceps; this was soon followed by symptoms of inflammation of the brain; twenty ounces of blood were taken immediately from the arm, purgatives and diaphoretics were ordered, and the strictest abstinence enjoined. 23d. Venesection was repeated, as well as the other means usually adopted to reduce high action. 24th. Completely relieved. 26th. Another portion of the cranium removed, the dura mater being fully exposed; the general health in the best state.
August 3d. Doing remarkably well; the wound healthy; the pulsation of the brain evident; the power of speech perfectly restored. The ball yet remains in, according to the opinion of the patient, (who is a fine, intelligent lad,) and he thinks it has gradually descended toward the petrous portion of the left temporal bone. Sent to England at the end of the month, the wound being healed.
When I saw this man at Antwerp I gave my opinion, without hesitation, that the bone and the ball ought to have been removed in the first instance, when he would have had a better chance for perfect recovery. The operation, when afterward performed for the removal of the loose pieces of bone, placed his life in great jeopardy. He was discharged the service with the ball lodged, and it is more than probable that he did not long survive, which he might have done if the ball had been removed when it was first felt within the skull.
In the following case the ball could not perhaps have been removed in the first instance with propriety; it might, however, have been lying on the dura mater, or near it, within reach, and the actual state of things ought to have been ascertained, the surgeon afterward deciding whether any further operation were necessary.
Thomas O’Brien, 28th Regiment, aged twenty-three, was wounded by a musket-ball on the 16th of June at Quatre Bras; the bullet penetrated the occipital bone below and to the right of the junction of the lambdoidal and sagittal sutures. On his arrival at Colchester, the wound was healthy in appearance and healing rapidly. It appeared from his own account that for some hours after the injury he was totally deprived of sight; since that time he has been constantly more or less affected with headaches, for which he has been prescribed occasional cathartics and low diet. He has also been affected with pain and weakness in both eyes, but more particularly in the right. While at Brussels, and during his progress to Ostend, he lived very irregularly, and was frequently intoxicated. The external wound was entirely healed on the 20th of July, and no suspicion existed that the ball was lodged in the brain. On the 25th matter was perceived under the scalp, and was evacuated yesterday. To-day, the 27th, he complains of increase of headache; pulse small and quick. V. S. ad ℥vj. Haust. cathart. statim. 28th. In the course of this day his symptoms have become very urgent; he is restless, with a very quick pulse; an extensive crucial incision was made in the site of the original wound, and now for the first time it was discovered that the ball had penetrated the brain; several loose pieces of bone were extracted; a considerable quantity of arterial blood was suffered to flow from the small vessels divided in the incision. His bowels had been well opened by the cathartic. The most vigorous treatment was continued, but the symptoms notwithstanding increased, and he died on the morning of the 29th of July.
The ball was found lodged nearly two inches deep in the substance of the right posterior lobe of the brain; a considerable quantity of pus surrounded it; some inflammation of the brain and its membranes was observed, but much less than might have been expected.
A. Clutterbuck, 61st Regiment, aged twenty-five, was wounded in the back of the head by a musket-ball at the battle of Toulouse, on the 10th of April, 1814. He felt little inconvenience from the wound during the first two days. On the 14th he complained of severe pain in the head, giddiness, and dimness of sight; the face was flushed, pulse hard and frequent. Twenty ounces of blood were taken from the arm, and the wound enlarged so as to expose the cranium. The upper part of the os occipitis was found fractured by the ball, and a circular portion of it, about the size of a shilling, was depressed and fractured. 15th. Pain in the head much abated; no giddiness, dimness of sight, or any unfavorable symptom; pulse still hard. V. S. ad ℥xx. To be well purged. 19th. He was bled again this day to the extent of twelve ounces, as a matter of precaution. 23d. Continues free from any bad symptom. May 8th. The wound is now much contracted, and he feels no inconvenience. A small portion of the bone still feels bare to the probe, but the greater portion of the depressed piece is covered with healthy granulations. No exfoliation has taken place. May 24th. The wound is nearly healed; he is in good health and spirits, and without inconvenience.
This case may be properly contrasted with that of O’Brien, as showing by the result the difference between an uninjured and an injured brain. If the fractured and depressed bone had not been at the back part of the head, it is probable the depressed portion would have been removed in the first instance, as it certainly would have been after the 15th, if the unfavorable symptoms had not yielded to the general treatment; but the bone would then have been removed under much more unfavorable circumstances than at first.
The following case is related to show the extent to which blood-letting may frequently be carried to preserve life. There having been no reason to believe that the symptoms depended on fractured and depressed bone, the scalp was not divided; and as the symptoms were coeval with and not consecutive to the injury, they were therefore supposed to depend on concussion rather than on compression of the brain. If the trephine had been applied on the fourth day because the insensibility continued, the additional injury would in all probability have proved fatal. If the depletion of all kinds had been less effective, the inflammation of the brain or of its membranes would certainly have terminated in the effusion of lymph or the formation of matter, which the use of the trephine would not have prevented nor removed.
George Mills, an artillery driver, aged twenty-eight, was admitted into the Dépôt de Mendicité Hospital, Toulouse, May 29, 1814, in consequence of having been thrown from his horse on his head against the ground. He had fallen on the right side of the os frontis, immediately above the eye, where the surface of the skin appeared to be scratched and bruised, but the bone was not depressed: he was bled freely, but remained insensible. The next morning he was again bled to twenty ounces, which operation was repeated in the evening. On the 29th, the temporal artery was opened, and a vein in his arm at the same time, the breathing being strong and sonorous, the eyes closely shut, and he lying quite insensible; the pulse before the bleeding was quick and small; after he had lost about eight ounces of arterial and eight ounces of venous blood, it became fuller, and the breathing was somewhat relieved; the slightest touch gave him pain, and he shrunk from pressure made directly above the eye. The temporal artery was again opened in the evening, and ten ounces of blood were taken away. A purgative and a stimulating enema were ordered, and cold was constantly applied to the head.
30th. He has been freely purged and appears more collected; the pulse is still quick and small; breathing very free; the irritability continues and he complains of pain on pressing the head. The purgative and the enema were repeated, and ten ounces of blood were drawn from the temporal artery, after which he attempted to speak. 31st. Passed a good night; the pulse is quick and small; pain in the head still great; was again bled to twelve ounces, and the purgative was repeated. June 1st. Pulse quick; there is not so much pain in the injured part, and he appears more sensible; was bled to twenty-four ounces, and the purgative was repeated. 3d. Was again bled to ten ounces. From this time until the 20th, he gradually improved, and was then discharged cured.
The treatment in these cases was the same, although in one there was no fracture, and in the other two there was fracture with depression. The broken portions of bone did not, in Clutterbuck, appear to press unequally on the dura mater, and it was presumed that the moderate degree of pressure which ensued from the depression might be borne with impunity, as it did not seem likely to be accompanied by the projection inward of any pointed pieces which might irritate the brain. The result confirmed the supposition and justified the treatment. If the examination of the depressed part had led to the apprehension that such points of bone did exist, and were sticking into and irritating the dura mater or brain, they would have been removed, in the belief that although they might not at the moment have given rise to any other symptoms than those which depended on the blow, the time would come when they would scarcely fail to cause those which usually accompany the formation of matter within the skull. If this danger should also be avoided, the subsequent evils which have been noticed as occurring at a later period, and which ultimately require the same operation for the relief of the patient after months of acute suffering, might be encountered; for although a person may temporarily recover from an injury in which a portion of bone has been allowed to remain a source of irritation to the brain, it does not follow that such recovery should be permanent. If there be a doubt on the mind of the surgeon, whether there be or be not any pieces of bone depressed and irritating the brain or its membranes, he should wait; this is the real difference between the surgery of the latter part of the Peninsular war and that of the olden time.
272. When a fracture is accompanied by depression, and the broken portion or portions of bone would seem to be driven into the dura mater or the brain, or to press so unequally upon them that as much mischief is likely to ensue from leaving as from removing them, especially in an adult or a middle-aged man, less harm will in general follow from ascertaining the fact by dividing the scalp and removing the broken pieces than by doing nothing, more particularly when the presence of a foreign body has been ascertained. If there be no symptoms indicative of mischief below the fractured part, the surgeon must then decide, after the best estimate he is able to make, of the probable evil which will occur from allowing the broken or depressed portions of bone to remain.