Part 35
A French grenadier was brought to the field hospital the second day after the battle of Salamanca; he had received a blow on the left side of the head, probably from a piece of shell, which had caused a contusion and swelling on the left parietal bone, with a graze of the scalp, but without any opening communicating with the bone. This swelling, on examination, was so soft, and the feeling of depressed bone beneath so distinct, combined with the fact of the continued lethargic state of the patient, that an incision was made into it, when the bone beneath was found broken into several small pieces. On clearing away the blood, two pieces which were loose were readily raised and removed by the elevator and forceps, and egress given to an ounce or two of blood, which were extravasated beneath, apparently from the rupture of the vessels passing between the dura mater and the bone. The patient regained his senses in the course of the night and morning of the third day, and under a strictly antiphlogistic regimen gradually recovered, some other small pieces of bone coming away, one or two others apparently reuniting to the uninjured parts, showing that it is not always necessary to remove every portion of bone which may be broken, provided any bond of union remains, and principally that which exists between it and the dura mater.
These different cases stand out in bold relief as eminently successful and opposed to those said to have been equally so under _la chirurgie expectante_. They tend to show that however good a general rule may be, it may admit of many and important exceptions; and they prove that experience, aided by sound and correct observation, is essentially necessary for the formation of a scientific surgeon.
273. In young persons the brain will bear a greater degree of pressure and of irritation with impunity than it will in persons of mature age. By far the greater number of cases in which recovery has taken place after fracture and depression of the skull with injury of the brain, and even loss of its substance, have occurred in children or in persons _under the adult age_; greater reliance may therefore be placed on the powers of nature in them; and recourse may be had less frequently to the aid of operative surgery in order to prevent mischief than in older persons, even when the bone is fractured as well as depressed. It will be found, and the remark is important, that the cases of fracture and depression reported to have been successfully treated without operation, have occurred principally in young persons.
The result of my experience has rendered it imperative to remove at once all portions of bone or foreign substances which have materially injured the dura mater in adults, although no symptoms of compression should be observed. If the wound in the dura mater should not be sufficiently large to allow the offending body to be extracted through it, the opening must be enlarged to enable it to be withdrawn without further laceration.
274. Depressed portions of bone, accompanied by fracture at the _back_ part of the head, need not necessarily be removed in the first instance. When the fractured and depressed bone is accompanied by symptoms of compression in an adult, which continue after the usual antiphlogistic means and remedies have been employed in vain, and appear to increase rather than to diminish, the broken and depressed portion should be raised; for although the brain will bear and accommodate itself to pressure in many persons in a manner which could not be either foreseen or expected, it will not do so in all; and the removal of the bone offers the best chance for relief, whether the mischief has arisen from the pressure made by it or occurs from the extravasation of blood beneath. When the principal symptom of compression is a severe fixed pain in the part, although the state of the fracture and depression would not alone have rendered the removal of the bone positively necessary, it is advisable to do so when this symptom is present.
The greatest discrimination is required in cases where the extent of the injury is not so manifest and in which there is more room for doubt. In most cases in which a slight or moderate degree of fracture and depression of the skull has taken place, the symptoms of concussion are present as well as those of compression. The symptoms of concussion are, however, coeval with the injury, and although those of compression may take place almost instantaneously, they more usually occur at a later period of time. The symptoms of concussion may nevertheless continue for days, more particularly the insensibility, or that state which is approaching to it, complicating the case and embarrassing the practitioner. In a child or young person the symptoms of compression or irritation, when they appear even at a secondary period, may pass away under further moderate depletion; but in an adult any undue delay in giving the necessary relief, by the removal of the depressed portion of bone, will in general be destructive to the patient. It is the irritation caused by the depressed bone on the dura mater, and communicated to the brain, which gives rise to the unfavorable symptoms and to the formation of matter which follows them.
A gentleman received a blow on the side of the head, which knocked him down and deprived him of his senses, from which state he partially recovered, and vomited; some stupefaction, however, remained, although he could be made to answer by a little importunity. Pulse 62, irregular, breathing slow, the pupils contracting under the influence of light; the integuments where the blow was received were soft and swollen, in all probability from an extravasation of blood beneath. The next day the pulse was full and regular, the pupils were dilated, vomiting had taken place several times, and the patient answered correctly on being sharply questioned. He was bled largely, purgatives were administered, and cold was steadily applied to the head. He was bled the next day; on the third the left arm became paralytic, the pupils continued dilated, and on the fifth day paralysis implicated the left leg as well as the arm. There could now be no doubt that the brain was suffering from compression; but as the nerves of the excito-motory system were unaffected, and the functions of ingestion and egestion were satisfactorily accomplished, it was thought advisable to trust to the efforts of nature. The swelling of the scalp was painful.
A week afterward the general symptoms were the same, or only slightly augmented by fever; but, as the swelling of the scalp was more painful, it was opened, and a quantity of matter was evacuated, the bone beneath being fractured and depressed. As this operation gave some relief, it was thought advisable to wait, with the hope that the benefit thus obtained might prove permanent. The patient did not improve, however; and as the symptoms of fever increased, and were accompanied at last by rigors and great pain in the head, the depressed portions of bone were removed, and about half an ounce of purulent matter escaped from between the dura mater and the bone. The relief given this time was effective, and the patient perfectly recovered. “La chirurgie expectante” placed this man’s life in the greatest jeopardy. It was only saved at the last moment by the aid of that surgery which ought not to have been withheld when the paralysis, by affecting the leg as well as the arm, demonstrated the extension of the mischief within the head. In this instance the operation was successful, but it is not in general so serviceable when delayed to so late a period. It is in cases of this serious nature often a means of prevention rather than of cure.
275. When a severe blow, accompanied by a shock, as from a fall, has been received on the head, and the skull is so thick and strong as to be able to resist the violence thus offered without being broken, or is only slightly fractured, the vibration or _trémoussement_ is directly communicated to the brain, giving rise to laceration or bruising of its structure in various situations, to the rupture and separation of the vessels of the dura mater from the bone to which they are attached, and to derangement of other parts, which will in all probability be followed by inflammation, and may even terminate in the formation of matter under the dura mater as well as above it, and even in the brain itself. It is said to take place by “contre-coup” when the mischief occurs in any other part of the head than that which is struck, numerous instances of which are given by the older French authors. They were probably cases of laceration, the consequence of concussion of the brain, and not relievable by the art of surgery; but the injury which the older surgeons particularly distinguished as by “contre-coup” was where the blow was on one side, and a fracture took place or matter was formed in a circumscribed spot on the other; these cases did sometimes, they say, although rarely, admit of relief by operative surgery. These cases, unaccompanied by fracture, do not appear to take place under the improved method of treatment by larger depletion, by antimony, and by the early use of mercury. In the event, however, of their occurring, there is no surgeon of the present day who would attempt an operation of exploration on the opposite side of the head to the injury, without some sign of mischief existing at that part; although such operation, if done, might accidentally be followed by success.
LECTURE XIX.
TUMORS OF THE SCALP, ETC.
276. When the periosteum covering the bone is bruised, or the bone is merely deprived of this membrane, it does not follow that it should die or exfoliate. In many instances the wound will gradually close up and heal, as if no such accident had happened. A blow or bruise on the head often gives rise to a swelling or tumor, from the rupture of the small vessels passing into the cellular membrane between the scalp and the pericranium; the tumor in these cases appears _immediately_ after the receipt of the injury as a soft swelling, and is usually found to contain blood, which in most instances is removed by absorption in the course of from two to three weeks. In some cases inflammation supervenes, and one part becomes tender and appears to point; into this a small incision should be made to allow the blood and matter to escape, when gentle compression should be resorted to in order to induce the parts to unite. Swellings of this kind in new-born infants, occurring from pressure during delivery, may be readily mistaken for deficiencies of the occipital and parietal bones, if it were not for the absence of all motion, which under such circumstances would be communicated to them from the brain. The blood effused in the cellular membrane raises the border of the swelling, which becomes harder than the neighboring parts, while the center remains soft and yielding, giving a sensation to the finger as if the bone beneath were wanting, or, after a blow, the idea that the bone beneath is depressed. If such a swelling be unnecessarily opened, considerable inflammation and suppuration will often follow, to the great inconvenience of the patient; this will in general be avoided by the use of a moderately stimulating cold lotion.
277. In other cases of tumors, which are called secondary in contradistinction to the preceding, the patients go on well for eight, nine, or more days, at the end of which time they complain of headache, giddiness, nausea, restlessness, thirst, and generally of fever. A few days more, frequently from the thirteenth to the fifteenth day, rigors, sometimes severe, are superadded, and a swelling, if not observed before, is now perceived on the spot where the injury had been received, if the integuments have not been divided; or, if there be a wound, it loses its healthy red appearance, and assumes a yellowish, unhealthy color, which is accompanied by a thinner and more acrid discharge. From this time the symptoms gradually increase, the patients become delirious, convulsed, comatose, and die; and matter is found between the skull and the dura mater, or in or on the substance of the brain. If this secondary swelling be divided, and the fluid evacuated, which is not good pus, the pericranium will be found detached and the bone bare.
It has been stated that a bone so circumstanced would not be found to bleed on being scraped, and that, by attending to the want of hemorrhage from the outside of the cranium, the extent of the evil might be ascertained, and that so long as a denuded, discolored bone will bleed on being scraped, it may be considered that the dura mater is attached below, and that no operation should be performed.
The essential difference between the primary and the secondary swellings is to be found in the fact that, although the bone be exposed, and even in some degree may have changed its color in the primary swelling when matter has formed, the febrile symptoms will subside after its evacuation, healthy granulations will spring up, and little or no exfoliation will take place. In the secondary swelling none of these favorable symptoms or appearances will take place, for the bone is incapable of maintaining its life, and must die. If the outer table only be implicated, it may exfoliate; but if there be reason to believe that matter has collected beneath, on the dura mater, the bone should be removed by the trephine.
Inflammation of the dura mater proceeding to suppuration, or the formation of matter between it and the bone, appears to have been a much more common consequence of injuries of the head in former times than at present. It is not now of frequent occurrence in London hospitals.
As blows on the head and the structure and functions of the brain are the same at present as formerly, the difference in regard to such cases can only depend on the difference of treatment. It is, in fact, infinitely more depletory now, and therefore less operative. Blood is taken away in larger quantities, although to this there are exceptions, depending on the constitution of the patient, which will not always admit of it, while the potassio-tartrate of antimony and mercury are by most surgeons administered at an early period.
Suppuration, or the formation of pus on the surface of the dura mater, not being, under the strictly antiphlogistic and mercurial system, so common as formerly, sufficient attention has not perhaps been paid to another evil which frequently accompanied it in former times, viz., suppuration on the surface and in the substance of the brain itself; for the greater number of those who died with fracture and depression of the skull, and whose cases are recorded, suffered also from alteration of the structure or substance of the brain, and the formation of matter within it or upon its surface. This termination might not have taken place in a large proportion of the cases in which it occurred if the depressed bone had been raised to its level, and the irritation arising from undue or unequal pressure had been avoided. It must be admitted, however, that an internal part of the brain may receive such a shock at the moment of injury, as well as an external part, that no treatment can arrest the progress of the mischief, although it may be delayed; and when the patient dies, after four, five, or more weeks of alternate hope and suffering, matter may be found in some part of the brain where an injury was not suspected.
Purulent matter may be formed beneath the dura mater in a confined spot, or it may be diffused generally over the surface of the brain, in which case the sufferer has no chance of relief.
278. The operation of incising the dura mater, to admit of the discharge of blood or matter from beneath, and even of puncturing the brain, has not been much resorted to in England; this may be an error. The records of surgery supply many cases where it might have been done with advantage, and some in which it was done with the greatest benefit to the patient. It is not an operation which ought to be performed without signs sufficiently demonstrative of the necessity for doing it.
I have seen, on the removal of a portion of bone by the trephine, the dura mater rise up rapidly into the opening so as to attain the level of the surface of the skull, totally devoid, however, of that pulsatory motion which usually marks its healthy state. An opening into it, under these circumstances, has allowed a quantity of blood or of purulent matter to escape, proving that the unnatural elevation of the dura mater was caused by the resiliency of the brain when the opposing pressure of the cranium was removed. This tense elevation, its abnormal color, and the absence of pulsation are positive signs of there being a fluid beneath, requiring an incision into the dura mater for its evacuation. It is a point scarcely noticed in English surgery--one which was not in the slightest degree understood at the commencement of the war in the Peninsula.
A. Monro, of the 42d Regiment, was wounded on the 10th of April, at Toulouse, by a musket-ball, which fractured the left parietal bone slightly, without depressing any part of it. No symptoms followed requiring more than ordinary attention until the 23d, up to which time he had been kept on low diet, for the most part in bed, and had been bled and purged. On the evening of that day he became feverish, and hasty and odd in manner, and the pulse quickened; he declared himself, however, to be quite well, and submitted to be bled and physicked with great reluctance, calomel combined with opium being given him at short intervals. On the 24th he complained of pain in the head, which he said was very slight, and that upon the whole he was quite well, and would not be bled nor have anything done. He was bled largely by force, which lowered the strength of the pulse, but did not relieve any of the symptoms of irritation of the brain. On the 25th he was evidently worse, although he declared himself to be quite well; he talked a little incoherently; the pupils were dilated; the pulse quick but regular; the countenance was changed; he was sensible, apparently, upon all points except that of being much worse, which he resolutely denied, saying he was better and would soon be well. Satisfied that matter was forming, or had formed, in or on his brain, I desired that the trephine might be applied on the fractured part and the bone removed. This, however, he would not permit the officers in charge to do, and they awaited my return in the afternoon, when, finding him much worse, I directed it to be done by force, three of his own regiment with others attending to assist the surgeons. He called upon these men by name not to allow him to be murdered in cold blood, declared he was getting well, and would get well if let alone, and prayed them to avenge his death on the doctors if they meddled with him. The surgeons were dismayed, and requested that the operation, which they said required great care, should be performed by me, their chief. I therefore removed the bone; and the moment it was taken away the dura mater rose up in the opening to the level of the surrounding bone, and remained without any pulsatory motion. I had no doubt of matter being beneath, and that, from his general state, the man would die. I did not therefore think it prudent, under all the circumstances, to do more than warn his comrades that, when dead, they would see the whole brain beneath in a state of suppuration. He died that night; and the next day they saw the whole of the left hemisphere soft, yellow, and covered with matter, to their great surprise and satisfaction at the accuracy of the diagnosis.
Absalom Lorimer, of the 42d Regiment, was wounded by a musket-ball on the 10th of April, 1814, at the battle of Toulouse, which carried away a small portion of the scalp just above the right temple, fracturing the bone slightly, but without any depression. No symptoms occurred demanding more than ordinary attention for the first fortnight, during which period he had been bled once, purged, and kept on low diet. On the 25th, he complained of pain in his head around the wound, shooting to the back part; pulse 60; pupils dilated. An incision having been made to the bone, the pericranium was found detached, and the bone fractured, but without any obvious depression. V. S. ad ℥xx, calomel and colocynth: as the pain continued, the bleeding was repeated in the evening. 26th. Pain in the head greatly relieved; pulse 60; bowels torpid. Ten ounces of blood were taken from the temporal artery, and the calomel and colocynth, salts and senna were repeated. On the morning of the 29th, the symptoms of compression having increased, the trephine was had recourse to, and the fractured portion of bone was removed: a layer of coagulated blood was found on the dura mater, which puffed up into the opening. In the evening he became convulsed, the pulse intermitted, and he died. On examination, a large abscess was found in the right hemisphere of the brain, having the ventricle for its base, with some matter on the surface of the brain, and between the dura mater and the bone at the base of the cranium.
On the morning of the day that I performed this operation, I had done another of the same kind at the Hôpital des Minimes; the dura mater rose up in a similar manner without pulsation into the opening made by the removal of the circular piece of bone by the trephine; on puncturing it a considerable quantity of pus oozed out. The opening was enlarged; and the flow of matter was daily encouraged, until it gradually diminished, and ceased with the formation of granulations, and the drawing in and cicatrization of the part.
279. It has been supposed theoretically that a wound through the dura mater was particularly dangerous, in consequence of the tunica arachnoides which lines it being a serous membrane; and that, if the inflammation which ensued did not cease at the adhesive stage, by the consolidation of the surface which covered the pia mater with that which lined the dura mater, a diffuse inflammation would necessarily follow, which might spread over its whole extent. This has not been found practically to be the case; and if a simple wound of the dura mater be a danger that ought to be avoided, the risk run cannot be put in comparison with that which accompanies the continuous irritation depending on the presence of a spicula of bone, which has passed through the dura mater, and is irritating the brain beneath. It has also been supposed theoretically that the danger would be diminished if the pia mater were wounded also, as the brain would project and fill the wound; but the accuracy of this opinion may be doubted. If the dura mater were injured through error or design, I should not think the evil lessened by adding to it a wound of the pia mater, and perhaps also of the brain.
By those who have been accustomed to the terrible injuries which occur in military warfare, in which large portions of the brain are sometimes exposed, and even lost, without much inconvenience following, the exposure of or the opening into the dura mater is not considered of so much importance as it is by those who have had fewer opportunities of seeing such awful cases; while the formation and retention of matter below the bones of the cranium is, on the other hand, more dreaded by those who have often seen their ill effects than by those who have not had many occasions for observing them; by whom, however, they are often considered, when they do take place, to be irremediable by art.