Part 37
It has been proposed to destroy protrusions of the brain with escharotics, and by ligature; and more faith has sometimes been placed in the knife for their early removal than in the more deferred operations of nature. Greater reliance may, however, be placed on the efforts of nature, assisted by a methodical treatment of the low inflammatory state of the brain, and by such pressure at a later period as can be borne with comfort, and persisted in with propriety.
286. It has been supposed that abscess of the liver followed injuries of the head in a more peculiar manner than injuries of other parts of the body, an opinion upon which too much reliance should not be placed; for experience has induced me to think that unless the liver be really injured by a fall or blow, it only becomes affected in a secondary manner, in a similar way to the lungs or other viscera, or to the joints or other parts. The new disease in these cases is always insidious in its nature and progress, and for the most part fatal in its result, as has been explained at length, (Aph. 59, p. 62, et seq.)
287. When a person has received a serious blow on the head, which has given rise to an exfoliation of the bone, or to a very slight depression of the skull, he is rarely restored to his previous healthy and natural state. The scalp adheres firmly to the bone beneath, instead of sliding loosely over it, and a deep hollow is formed, which would imply that greater mischief had been done and a greater loss of bone had been sustained than had actually occurred. This is the more remarkable when pieces of bone have been removed. Major D., of the Indian army, was wounded on the left side of the forehead, at its upper part, by a musket-ball, at the assault of Maheidpoor. Several pieces of bone were removed, and the pulsation of the brain was evident under the discharge. The point of a little finger passes into the hole left by the cicatrization of the wound, to a greater extent than might be expected. This officer suffers from headaches, augmented or brought on by any exertion of body or mind. He cannot bear exposure to the heat of the sun. He can scarcely drink three glasses of wine without feeling their effect. Persons so afflicted can bear no great exertion of any kind. They fall down under exposure to heat. They are easily inebriated, rendered furious by a small quantity of liquor, and often become stupefied, comatose, or even die suddenly. In addition to these evils, which may be avoided by care, many are subjected to fits, which are apparently epileptic; and others suffer from such intolerable pain in the part injured, as well as in the head generally, as to be desirous of seeking relief by an operation, even at the risk of life.
These injuries are often accompanied during their progress by mental defects which time does not always remove. The memory is very often much impaired; it is frequently defective as to things as well as to persons. The sight of one or of both eyes may be impaired, or even lost. Ptosis, or a falling of the upper lid, is not an uncommon although a more curable defect. Speech is not only difficult, but the power of uttering certain words is often lost; a language is occasionally for a time forgotten, and a sort of conventional one has even been adopted, under my own observation. The more serious evils which befall these unfortunate sufferers are aberrations of mind, rendering some degree of restraint necessary, or a state of fatuity, which is not less distressing. These intellectual defects are often accompanied by various states of lameness or debility, from which there is but little hope of recovery. Pathologists have supposed that concussion of the brain is frequently accompanied by, and may indeed be essentially dependent on, small extravasations of blood in various parts of or throughout the brain, not larger than the point or head of a small pin, constituting, in fact, a derangement which, when general, is destructive of life, and, when partial, may sometimes be the cause of the various defects which follow injuries of the head.
288. It is an interesting fact that a person who has been shot in the head, or has fallen from the top of a house, so as to become insensible, has no knowledge of the circumstance; and when, after several days or weeks, he regains his senses, he has no recollection of the injury, or of having received the wound; or if he should have fallen from a height, he only remembers that he was aware he was about to fall, but of the actual descent, or of the injury, he knows nothing.
289. The trephine, which is worked by turning the hand, and makes therefore only a half turn, necessarily saws unequally; but the operator has the advantage of being able to press with it on any particular part as the sawing of the bone draws to a close, and can thus cut any portion of the bone which is thicker than the rest without wounding the dura mater. The division and yielding of the last layer of bone is very sensibly felt by the hand, and when sawing, the surgeon can use the trephine as a slight lever with great effect, by pressing on a particular part, or from side to side, and the inner layer of the vitreous table may be in this manner as much broken as sawn through. The piece to be removed should never be brought away in the crown of the trephine, but should be raised by the forceps and lever; whenever a rough edge of the inner table remains, it should be carefully rounded off with the lenticular or blunt-ended instrument commonly used for that purpose.
290. Whenever there has been a loss of the integuments or scalp, so that this part cannot be brought over the opening made by the removal of the bone, some fine soft cotton should be laid on the dura mater, so that a slight degree of support may be given to that membrane, more particularly when it is thought that it may not be necessary to examine it for two or three days. When circumstances appear to render a daily inspection necessary, the cut portions of the scalp should be brought over the opening, and retained by a slight compress and bandage kept constantly wet and cold. The dura mater usually changes color and becomes more red; a layer of lymph is seen adhering to it, from which granulations arise and spring up until they touch the scalp, to which they unite, or cicatrization takes place. When the patient dies early from other causes, and the calvarium has been raised, the discolored spot on the dura mater marks the place from over which the bone was removed. I have seen this in a state of slough, and the only apparent discoverable mark of disease.
One of the improvements in modern surgery is to be found in the restriction which has gradually been placed on the repeated use of the trephine on the same person, and on the removal of large portions of the skull. Cases are not, however, wanting in the older authors which would appear to justify the proceeding, although it may perhaps be said that they only show how great an extent of injury may sometimes be committed with impunity.
Saviard trepanned one person twenty times. Russ Martel and Le Gendre, surgeons to the King of Navarre, say that in the year 1686 they took away nearly both parietal bones, and the patient recovered and lived for thirty years afterward, half his body, however, being paralyzed. Marechal applied the trephine twelve times successfully, Gooch thirteen times, Desportes twelve times. Saviard says that he had under his care a woman whose parietal bones, together with a great part of the occipital and frontal, separated at the end of two years after a blow; the bones thus separated resembled a calvarium sawn off a dead person. No fungus or hernia took place, and she lived for several years afterward.
Dr. Drummond, deputy inspector-general of hospitals, has published the case of a seaman belonging to H.M.S. “Mutine,” who in 1845 fell down some stone steps at Sierra Leone, receiving a contused wound on the scalp, for which he was admitted into the Royal Naval Hospital at Plymouth in October of the same year. The bone, which was not supposed to have been injured, was then found to be denuded of its pericranium to some extent, (left side of occipital.) After an attack of erysipelas, followed by numerous purulent deposits under the scalp, necrosis went on rapidly; there was oozing of pus from beneath the diseased bones, and gaping of the coronal and sagittal sutures, the brain pulsating very distinctly in the spaces. In July, 1846, he was removed to Melville Naval Hospital at Chatham. During the six years he has been under observation, there have been repeated attacks of erysipelas, followed by profuse suppuration. Both tables of the bones have suffered in some places; in others only the external. About five square inches have been lost from the right side of the frontal, right parietal, and squamous part of the right temporal. The whole of the occipital to within a short space of the foramen magnum is deficient, with the exception of about two inches in the center of the bone, which are now undergoing the process of separation. On the left side, Dr. Drummond adds, there has been less destruction of the bones, but extensive caries was going on there, and fetid pus was being discharged from several openings at the date when the case was reported, (April, 1851.) At no point was there any tendency to reproduction of bone, or arrest of the disease.
291. The removal of a large portion of the skull may be necessary where the broken portions are deprived of their natural support and connections, but as little should be taken away as possible. When the loss of sense and motion is accompanied by fracture, and continues to increase rather than to diminish, after the necessary and usual means have been adopted for its relief, a piece of bone should be removed. If blood should be found in any quantity on the dura mater, it may be necessary to take away more bone to admit of its free discharge; for although the gradual pressure of the brain from within will tend to expel it, this object may not be attained in sufficient time, and the patient may be lost. The older surgeons in these cases were anxious to ascertain how far or to what extent the dura mater was separated from the skull, and they often removed large portions of bone accordingly; although their practice should not be implicitly followed, repeated observation has shown that modern surgeons have often fallen too much into the opposite extreme of doing nothing. When blood has been evacuated in this manner, the parts must pass from a state of inflammation into that of suppuration before the dura mater can again adhere to the superincumbent bone, and care must be taken that the matter shall have a free discharge. If symptoms of fever, followed by those of commencing compression, should supervene from the granulations arising from the dura mater filling up the opening and preventing its exit, they should be excised; or if the matter should have gravitated in a direction which does not admit of its being discharged, the opening in the skull should be increased so as to remove the impediment, and thereby lessen the danger.
A layer of blood is often extravasated very thinly over the whole surface of the brain and cannot be removed, although it may be absorbed. It is, on the other hand, often collected in larger quantity on the basis of the cranium, whence it will not be absorbed and cannot be removed. It may be extravasated without reference to the part on which the blow has been received, giving rise in the end to symptoms of epilepsy or apoplexy, for the relief of which no surgical operation can avail; but when a blow has been undoubtedly received on a part of the skull, and any sign of mischief can be perceived on or in that part, the removal of the bone is permissible.
292. The wind of a cannon-ball has been supposed to exert some influence on the brain when passing close to the head; there is, however, no valid foundation for the opinion. An officer of the fifth division was struck by a cannon-shot, during the assault of Badajos, on the right side of the head and face. It carried away the right eye and the whole face, the left eye hanging in the orbit, the floor of which was destroyed. A part of the lower jaw remained on the left side, but a great part of the tongue was gone. He had lost a large quantity of blood, but was quite sensible. In the middle of the next day he suffered much from the want of water to moisten his throat, which could not be procured. After a distressing delay of three or four hours under a hot sun, a small quantity was obtained, the arrival of which he observed; and while I was giving directions relative to its distribution, I felt a gentle tap on my shoulder, and on turning round saw this unfortunate man standing behind me, a terrific object, holding out a small cup for water, not one drop of which he could swallow. Alone among strangers, he felt that every kindness in our power to offer was bestowed upon him, and he contrived to write his thanks with a pencil, which he gave me when he pressed my hand at parting at eleven at night. I was glad at sunrise to find he had just expired.
293. When a portion of bone is as it were sliced off with the scalp and adheres to it firmly, the scalp and bone should be reapplied; and the cure will often be effected without difficulty. When the portion of bone cut off and hanging to the scalp, which is turned down, has but little adherence, it should be removed.
A German dragoon was brought to me in front of Madrid, who had received a slicing cut of this kind on the top and side of the head, which caused a portion of the scalp and parietal bone to be turned down over the ear, uncovering the dura mater. Replaced and retained in its situation, the flap and bone appeared to adhere, and the man recovered. In the case of a Portuguese soldier cut down by the French cavalry in a sortie during the second investment of Badajos, a portion of bone cut off with a flap was quite loose, and was removed. The patient did equally well.
In the museum of the Royal College of Surgeons there are ten skulls which have suffered from very severe slicing cuts. They appear to have been collected from the burial-place of some establishment for invalid soldiers in Germany. The portions of bone thus sliced, and they are large pieces, were once detached, and afterward reunited a little out of their proper places, so that the points of separation and of union can be distinctly seen. These fissures are all in a certain state of progress toward being filled up by bone, and the patients must have lived some months, if not years, after the receipt of their respective injuries; for bone is deposited apparently with difficulty and most carefully in all such cases, so as not to irritate the membranes of the brain. The opening in the first instance is filled up by granulations, over which a thin skin is formed; this afterward becomes firmer and harder, being in some cases, where the trephine had been used, a thin but strong membranous expansion extending from one edge of bone to the other. In others it is thicker and more solid, and in a few instances osseous matter is deposited in its circumference, so as in part to fill up the opening, the edges of the bony circle made by the trephine becoming gradually thinner as they appear to grow inward. It is common for an exfoliation to take place in such cases from the edges of the cut bone, and from the circle made by the trephine. It has been occasionally observed, after death, that the circular cut edge of the bone does not become thin in the manner described, but that a sort of ridge forms around and within it.
When the scalp is torn down without being much bruised, and a large flap extending from the occiput to the forehead falls down on the shoulder, covered with blood or dirt, the flap should be cleansed and restored to its place. When it is large, two or three sutures may be necessary to keep it in its proper situation. The flap may not entirely adhere under any management, but it will do so in parts; and care should be taken to evacuate at an early period any matter which may form by small but sufficient incisions made where required; this will in general be above and about the ear. When the flap is much bruised, the attempt at adhesion by close apposition will be useless until after suppuration has taken place, when a well-regulated pressure will do much toward expediting the cure.
294. Erysipelas occurs in two forms: when the skin has the ordinary redness characteristic of the complaint, and when the color of the skin is not altered or is whiter than natural, but puffed, tense, and shining, the inflammation being seated beneath the tendinous expansion of the occipito-frontalis muscle.
The general treatment should be regulated by the powers of the patient and the state of the constitution, (Aph. 24, page 39.) The local treatment of the first form essentially depends on puncturing the red and inflamed skin all over with the point of a lancet, assisting the flow of blood by warm fomentations. The punctures should be repeated, if necessary. The second form is to be treated by incisions, perhaps the greatest improvement of the surgery of the Peninsular war.
The scalp in such cases is in a state of general puffiness, causing the head to look considerably larger than usual, but without redness; it retains the impression of the finger. Incisions are to be made in the scalp from two to four or six inches in length, united by others, if necessary. The scalp will often be upward of an inch in thickness, and filled with a fluid partly serous, partly purulent. The small arteries bleed freely, and should be allowed to do so as long as may be desirable, when the hemorrhage should be arrested by pressure. The head should be fomented. The essential points are, to take off tension, and to allow the free discharge of any fluid which may be secreted. The moment the parts around a wound have become puffy, the surface of the wound changing from a red to a yellowish color, with a thin discharge instead of good pus, an incision should be made through them, and repeated, if necessary. It relieves the tension and the irritative fever, and prevents the delirium which would follow; which neither bleeding, purging, nor the other constitutional remedies which the state of fever may indicate will remove. If it should be neglected, suppuration and sloughing will extend under the tendon of the occipito-frontalis, or the fascia of the temporal muscle, and the greatest danger will be incurred from this additional cause.
LECTURE XX.
WOUNDS OF THE CHEST.
295. Wounds penetrating the wall of the chest, and implicating any part or portion of its cavity or contents, are among the most dangerous of injuries. They require in their treatment a more careful attention and a greater extent of knowledge than most others which befall mankind. The means which the improved methods of auscultation have afforded cause the progress of the symptoms which follow to be less obscure, and lead to a less doubtful practice than formerly; while they render a knowledge of this branch of medical science an essential part of the education of a surgeon.
296. _Incised_ or _punctured wounds_, from swords, lances, bayonets, or knives, require a treatment _essentially distinct_ on many points from that of _gunshot_ wounds, especially in the commencement. On this early treatment so much depends, that details of the more serious or more important cases are rarely found among the records of injuries sustained on the field of battle, where so much is often to be done, and so few are to be found to do it.
The simplest of the more serious results from injuries not penetrating the chest is the occurrence of inflammation, either of its lining membrane, giving rise to what is called _pleuritis_, or of the substance of the lung, termed _pneumonia_, or of both, constituting what has been named _pleuro-pneumonia_; but many severe blows on the chest are not followed by such serious consequences.
On the 17th August, 1808, in the act of leaving the village of Colombeira to ascend the heights of Roliça, a soldier was shot in the leg: he jumped up three or four feet, and made a considerable outcry. A second was struck at the same time by a ball on the shoulder, which did not penetrate, but gave him great pain. A third received a ball on his buff-leather belt, on the right breast. The noise made by these two blows was unmistakable. I saw this man fall, and supposed he was killed: the ball, however, had only gone through his belt, and made a mark on his chest, over the cartilage of the fourth rib, the hardness and elasticity of which had prevented further mischief. He recovered in a short time, spat a little blood in the night, and after a large bleeding was enabled to accompany me on the 20th to Vimiera, ready for the fight next morning.
A soldier was struck on the hill of Talavera,[4] on the breast-plate by a ball, which, as he believed, had gone through his body. He was as white as a sheet, and desperately frightened. On opening his coat, I found the ball had indented the breast-plate, and made a round, red mark on the skin, without going deeper. I did not see him again for several days, until after crossing the bridge of Arzobispo, on the retreat to Truxillo. He was then engaged in disemboweling a fine fat wild hog, among a herd of which we had, unluckily for them, just fallen. He recognized me at once; said that, as I told him, he had been more frightened than hurt; that he had been bled largely and well physicked, and after two or three days had thought no more of it. I am bound to add that, in gratitude, he offered me a leg of the pig, which, having nothing to eat, I could not but accept. It supplied a dinner for three others who are now no more.
[Footnote 4: The Duke of Wellington received a blow from a spent ball at the same time, near the left clavicle.]