253. Compression of the brain means a diminution of the size of certain
parts of it, resulting from the pressure of an extraneous body, whether
it be fluid or solid, in consequence of which particular symptoms
are generally known to ensue. When they occur, it is said that the
sufferer is laboring under symptoms of compression of the brain, and
apoplexy from the rupture of a blood-vessel may be considered as the
best form or illustration of the complaint. These symptoms sometimes
take place from the presence of a foreign substance, such as a point
or piece of bone, which from the smallness of its size can hardly
compress, although it may displace; and it is then said that the
symptoms arise from irritation of the brain. Many of them have also
been found to occur from loss of blood, or the absence of pressure, or
from insufficient pressure arising from changes in the circulation;
and several different opinions have been entertained on all the points
connected with these subjects. It has been argued that as the brain
is incompressible, no compression can take place. There is no proof,
however, of the fact of its being incompressible as a whole, although
it has been stoutly maintained by Monro secundus, Sir C. Bell, and
others.
The brain is surrounded by membranes capable of secreting a halitus
or a fluid whenever it may be necessary to fill up space; it is
intersected by partitions apparently for the prevention of jar and
pressure, and is permeated in every part by vessels of various sizes,
both venous and arterial. It has been presumed that it contains at
all times the same quantity, or nearly the same quantity, of blood,
in consequence of its freedom from atmospheric pressure, through the
intervention of the bones of the skull. If this conjecture be correct,
the quantity cannot be materially increased, unless something be
displaced to make room for the addition; nor can it be essentially
diminished without something being added to supply its place. The
question turns, however, very much on the words “materially increased
or diminished;” for a very small additional quantity may be the cause
of serious mischief, and the subtraction of even less may give rise
to great cerebral disturbance; but there can be little doubt that the
actual quantity contained in the head is less at one time than at
another, the deficiency being usually on the side of the arteries;
when congestion takes place, it is for the most part venous. When a
person is about to faint on the first passage of a catheter through the
urethra, the blood deserts his face, he feels sick, his pulse nearly
ceases, and he would faint if he were allowed to remain in the erect
position. Let his head now be bent down between his knees for a minute;
his face fills with blood, his brain does the same, and he recovers
almost immediately. Young ladies, when about to faint, are prevented
from doing so by these means being adopted, which they declare,
nevertheless, to be very unladylike, although they may be doctorial and
effective.
254. The motions of the brain covered by the dura mater are but little
observable under ordinary circumstances when a circular portion of bone
has been removed by the trephine; the surface of the dura mater remains
in general perfectly LEVEL; it is of a reddish-silvery color, and is
firmly attached to the cut edge of the bone. The surface is raised,
however, on a full expiration, and it falls on a deep inspiration.
Fluid secreted or placed upon it is seen to move synchronously with
the pulse; but the dura mater never rises up into the hole made by
the removal of the bone, unless some fluid be retained beneath it. If
the quantity of fluid extravasated or collected under it be large, it
rises immediately on the removal of the bone; but the protrusion of
this membrane does not always take place for some hours afterward if
the fluid be more diffused. The motions of the brain, when the dura
mater is thus protruded into the opening, become very indistinct, even
if they can be perceived. These two points, viz., the protrusion into
the opening and the absence of pulsation, are important facts, little
noticed by surgical writers, to be borne in mind in connection with the
practice to be pursued.
If we sometimes see the natural and ordinary size of the brain
diminished under pressure, and that certain symptoms, such as
insensibility, syncope, convulsions, and paralysis, are consequent
on this state, and are relieved by the removal of the pressure and
the restoration of the compressed brain to its ordinary state, we may
safely conclude that some derangement takes place in its integral
parts, which may be best understood by the word compression. If we
further consider that compression can rarely exist without irritation,
and that sometimes of a formidable nature, there does not appear to
be so much difficulty in the subject as is frequently represented,
although the physiological explanation may not be so simple. In the
present state of our knowledge, we apprehend that in many cases
approaching to apoplexy, in which the symptoms are similar to those
arising from compression, all, or nearly all, the vessels, as far as we
can ascertain, are actually full of blood, instead of being partially
empty and containing less than the natural quantity. When we see a
patient, lying in a state of insensibility with a fracture of the
cranium, immediately recover his senses after the application of the
trephine and the removal of a large coagulum of blood, we are apt to
suppose that the coagulum of blood and the insensibility stand in the
relation to each other of cause and effect. It is not unreasonable to
conclude that the pressure of the extravasated blood confined by the
bone had occasioned the insensibility, and that this did not depend
alone upon some few vessels containing less blood than usual; for
the brain must be considered as a whole in all these investigations,
and reference should not be made to its vascular structures only in
explanation of the cause of its derangements.
255. When compression of the brain is caused by an extravasation of
blood, the patient is insensible, breathes slowly, loudly, and in
a heavy, labored manner, or with stertor, and cannot be awakened,
although the noisy breathing may be for a time suspended. The breath is
sometimes emitted from the corner of the mouth, like a whiff or puff of
smoke, and with something of a similar noise: this, when permanent,
is a more dangerous symptom than the common snoring or stertorous
breathing. He sometimes froths at the mouth, and occasionally appears
convulsed, but neither hears nor sees, nor takes the least notice of
those about him. The countenance is generally flushed if the shock
or blow has been slight, pale or livid if it should have been great.
The pulse is usually slower than natural, sometimes irregular or
intermitting, occasionally quick, even from the receipt of the injury.
The pupils of the eyes may be contracted or dilated, being dependent
for their condition more perhaps on the part of the brain affected
than on the degree of injury. They are generally more contracted
in the first instance than dilated; they may afterward pass into a
medium or doubtful state; one may be even dilated, and the other not.
In general, as the mischief is continued and augmented, they become
dilated and immovable. The eyes may be turned upward, or may be fixed
in the center, or be drawn irregularly outward or inward, causing
strabismus, which is, however, a more rare occurrence. If the eyelids
should be partially open, tickling the cilia or the conjunctiva of
the ball with a straw or a feather will cause them to close, if the
spinal cord be sound. The mouth and lips are more or less compressed,
and fluids run out at the corners, unless placed on the very back
of the tongue by a long, narrow spoon, when they are swallowed with
difficulty. Paralysis of one side of the face and hemiplegia are
common; paraplegia is more rare. In both kinds of palsy one part in one
limb may be more completely affected than another, in which convulsive
twitchings are sometimes present, as well as a frequent drawing up of
the limb of the unaffected side. Tickling the soles of the feet or
the palms of the hands will sometimes cause retraction of the toes or
fingers when the limbs are apparently motionless; pricking them gently
with a pin will often give rise to convulsive startings and tremblings
of all the muscles of the extremity when tickling fails, showing that
the capability to move the part remains, although the will to do so
is wanting. The leg or arm is sometimes drawn toward the body when
separated from it; it more often falls from the hand as if it belonged
to the body of a dead person; the muscles are occasionally more stiff
and rigid, and some power of motion remains, although but little of
sensation; sometimes sensation is perfect when motion is lost, and
sensation may be lost on one side and motion on the other. The urine
at first retained may ultimately pass involuntarily, as well as the
feces; nevertheless, irritating the verge of the anus will excite
motion and contraction in the sphincter ani, if the functions of the
spinal cord be not destroyed. The action of the involuntary muscles
is little impaired in general, and the secretions are but slightly
affected; when it is otherwise, the injury must have extended to
the ganglionic system, and the whole of the nervous centers must be
materially implicated.
The loss of motion, or of the power of moving parts of the body, is
either perfect or imperfect according to the degree of injury which
has been inflicted, varying from a sense of feebleness to an almost
utter incapability of moving the part. It is accompanied in general by
defective sensation, or numbness, or by the complete loss of sensation
and of the power of resisting heat and cold; the whole side, or one
extremity, or a part only of an extremity may be affected, and not the
whole. The mischief which gives rise to the loss of motion usually
occurs on the side of the brain opposite to that part of the body
which is paralytic. This was known and stated by Hippocrates, and the
subject has been pursued to the most complete demonstration by modern
anatomists.
The pathological proofs are not less complete. Desault and Bichat
were by no means satisfied that the paralysis which followed an
injury always took place on the opposite side; and some pathologists
since their time, while admitting the fact, have shown that there may
be exceptions. It is acknowledged, although it is not clearly and
satisfactorily accounted for as to the face, that an extravasation of
blood into one hemisphere of the cerebrum, or even of the cerebellum,
can cause paralysis of the complete half of the body on the opposite
side. It has been demonstrated that the right side of the body and
the left side of the face may be paralytic at the same time and from
the same injury apparently of the left side of the head, the mischief
which caused the paralysis of the right side being found, in by far
the greater number of instances, on the left side of the brain, and
that which gave rise to the paralysis of the left side of the face to
have been caused by an injury in the course of the portio dura of the
seventh pair of nerves when about to leave, or after it had left, the
brain.
Burdach found, in 268 cases of lesion of one side of the brain, that
10 presented paralysis on both sides of the body, and 250 of one
side; in 15 of these the paralysis was on the same side as the injury.
Convulsions took place in 25 cases on the same side as the disease; in
3, on the opposite side. In cases of lesion of one corpus striatum,
there were, in 36 instances, paralysis of the opposite side, and 6 with
convulsions of the same side, and in no instance convulsions of the
opposite side. In 28 cases of cerebral lesion of one side, the muscles
of the opposite side of the face were paralyzed; in 10, those of the
same side. Paralysis of the eyelid was in 6 cases on the same side,
in 5 on the opposite side. Paralysis of the muscles of the eyeball
occurred in 8 cases on the same side, in 4 on the opposite; paralysis
of the iris, in 5 cases on the same side and in 5 on the opposite, the
tongue being generally drawn toward the paralyzed side of the face.
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.
A counter-fracture or fissure of one parietal or temporal bone, caused
by a blow on the opposite one, is of such rare occurrence that it is
in general unnoticed by later writers on injuries of the head. It is
not so, however, with respect to a fracture at the base of the cranium
from a blow on the vertex, or on the back part of the head--a kind
of accident which occurs more frequently perhaps than any other in
civil life--because persons who suffer from fractures of the skull do
so more generally by falling from a height, or from being pitched on
their heads, than by direct blows or other injuries. This accident
principally depends on the superincumbent weight of the body pressing
on the unsupported flat and thin base of the skull, and is but little
connected with the unyielding nature of the spine; for it occurs to as
great an extent in consequence of falls from a short distance without
any impetus, as from falls from a great height. Some of the worst
cases take place by the sufferer having been thrown from the back of a
horse by the sudden starting of the animal, without any running away.
Although in these cases a fissure may often be traced to the foramen
magnum, the great fracture is essentially distinct, extending from the
petrous portion of the temporal bone on each side, across, and between
the sphenoid bone and the os frontis, and even separating the edges of
the coronal suture nearly to the opposite side.
A noted gambler was thrown from his horse, and pitched on the top of
his head at the door of the Westminster Hospital, late at night; he
was taken up insensible, and died shortly afterward. The skull was
fractured quite round from the vertex to the base, and from side to
side, so that the fore and back parts might have been easily separated
into halves, if the soft parts had been removed. Fractures of the base
of the cranium are generally fatal, but not always so; for some persons
live a considerable time afterward, and appear to die from other
causes; so that partial, if not perfect recovery is possible.
H. Cochrane, forty-five years of age, fell a distance of twenty feet
upon his head, and was taken up apparently lifeless, bleeding largely
from the ears, nose, and mouth, but more particularly from the ears.
He was seen within half an hour of the accident. He was then quite
insensible; the surface of the body cold; pulse about 68, and very
feeble; in three hours after the accident he was bled to sixteen
ounces, when his pulse rose to 76, and the breathing, which before
was rather oppressed, became more free. He was ordered six grains of
calomel, followed by moderate doses of senna, till the bowels should be
relieved.
He continued progressively mending, but in a state of stupidity,
accompanied by extreme listlessness; answered questions sullenly, and
frequently rested upon one arm without appearing conscious of pain;
the mouth was drawn to the left side, to which there had been a slight
tendency for some days; the tongue not at all affected.
He continued under treatment for three weeks longer, soon after which
he was permitted to resume his employment, the mouth being still
drawn in some degree to the left side. His habits became silent and
solitary, but he performed his task with the greatest exactness. He was
occasionally subject to vertigo, particularly in hot weather, after
any violent exertion or taking a small quantity of beer; a pint of ale
would render him stupid or insensible. Six months afterward he was
found dead, lying in a ditch.
_Sectio cadaveris._--The nasal bones were fractured by a blow which
had made a transverse incision in the upper part of the face. The
femur was found fractured upon the right side, and the scalp puffy
and ecchymosed on the left. On removing the skull-cap, the dura mater
appeared perfectly healthy, without any sign of extravasated blood upon
the surface. Beneath the pia mater on the left side the sulci of the
brain were filled with black blood, apparently very recently effused.
The brain was removed without the least violence, when a lesion was
found upon its inferior surface, corresponding to the petrous portion
of the right temporal bone. The dura mater in this situation was
externally of its natural structure, and adhered with its usual degree
of firmness to the bone beneath. The arachnoid and pia mater were here
deficient; the lesion consisted of a cavity about fifteen lines in
length, nine in breadth, and three in depth, coated with a light-yellow
lining, which also adhered to the corresponding portion of the inner
surface of the dura mater, which completed the walls of the cavity
inferiorly; it contained a turbid serum, in which were seen floating
numerous but exceedingly minute white globules. The portion of the
brain in this situation did not appear to have been disturbed by the
recent violence, except that from the upper part of the cavity a probe
was admitted without any resistance into the descending horn of the
right lateral ventricle, which, with the one on the opposite side, was
filled with a large quantity of bloody serum, none of which, however,
had escaped into the cavity beneath. The brain generally appeared
perfectly healthy, and not more vascular than usual. Even within a line
of the yellow deposit above mentioned there appeared not the slightest
change of structure. On removing the dura mater from the base of the
skull, indications of a former fracture were discovered, leading
vertically down through the squamous portion of the temporal bone,
whence it appeared to have been continued along the anterior part of
the petrous portion into the Vidian canal; the edges of this fracture,
both internally and externally, had been rounded by absorption; it was
met at right angles by another which ran across the base of the petrous
portion of the temporal bone. The direction of the last fracture was
marked by numerous small, rough particles of bone, which adhered so
slightly to the rest that they separated on maceration. The transverse
ligament of the second vertebra was ruptured, and the atlas forced
forward. The connection between the articular processes of the second
and third cervical vertebræ on the right side had also been separated
by the fall which had caused death.
William Clayton, forty-four years of age, was admitted on the 31st of
July, 1841, into the Westminster Hospital, having received a blow on
the RIGHT side of his head from the handle of a windlass, by which his
skull was fractured. The fracture extended downward from the parietal
bone across the temporal, and in all probability through its petrous
portion, as blood flowed freely from the ear for the first six hours;
he was stunned for a few minutes at first, but became sensible by the
time he was brought to the hospital. The bleeding from the ear was
followed by the discharge of a fluid resembling water--which is a very
dangerous symptom, as it usually flows from the sac of the arachnoid
membrane--and afterward at intervals by a discharge of blood and
matter, particularly, he said, on coughing; he was also quite deaf,
with a little pain on the right side of the head. The bowels were well
opened, and he lost sixteen ounces of blood. On the evening of the
third of August, the fourth day after the accident, paralysis of the
muscles of the RIGHT side of the face supplied by the portio dura came
on, or was first observed. Pulse 80. He was well purged, but lost no
blood, as he was apparently weak and the pulse soft; it fell next day
to 72. Mercury was now administered twice a day until the mouth became
sore. On the eighteenth of September he was discharged, cured of the
paralysis, the wound on the head being open, and a piece of bone bare
and likely to exfoliate. October 8. Readmitted in consequence of great
headache after drunkenness, with numbness of the toes and fingers; he
was well purged, and felt relieved. He remained in the hospital for a
month, his mouth being again slightly affected, occasionally drinking
in spite of all remonstrance; he then returned to his work on the piers
of Westminster bridge. On the eighth of June several small pieces of
bone came away; and the wound nearly healed. The course of the fracture
can be traced, in consequence of the scalp having adhered to the bone,
causing a slight depression and hardness, which can be felt by the
finger, extending down to the ear.
An hostler was thrown on his head from a horse, and was carried to
the Westminster Hospital late at night in a state of stupefaction; no
other injury could be discovered. The next morning he could answer
questions, although not always correctly; complained of pain in his
head, had bled from the ears all night, and had vomited some blood
two or three times. Pupils dilated, but they contracted on bringing a
lighted candle near them; the left eyelid more open than the right;
pulse 52; very restless, and constantly turning in bed. V. S. ad ℥xxiv.
Calomel and colocynth: salts and senna. Cold to the head. The pulse
rose to 60 after the loss of blood. 2d day. Is delirious; bleeding from
the ears but trifling; complains of pain in the head; bowels open;
passes urine freely; pulse 54, a little irregular. Y. S. ad ℥xvj gave
relief. Continue calomel, and salts and senna. 3d day. Restless all
night; headache and thirst; bowels open. V. S. ad ℥xiv relieved the
pain in the head. Pulse 56. 4th day. Restless and delirious at night;
pulse 60, regular; bowels open; headache. V. S. ad ℥xiv. No discharge
from the ears. 6th day. Slightly paralytic on the left side of the
face, tongue drawn to that side; headache, restless, delirious; feces
and urine passed unconsciously; pulse 80. V. S. ad ℥xx. Pulse rose to
100, and was weaker. Calomel, gr. iii every six hours. 7th day. Pulse
88, compressible; restless at all times, delirious at night; bowels
open, but he is more conscious of everything. 8th day. Pulse 80, small,
intermitting; occasionally slept a little, and is generally better;
bowels well purged; paralysis of the face continues. Has taken a little
farinaceous food. Continue calomel and inf. sennæ. 10th day. Improved;
slept tolerably well. 12th day. Continues to improve. Omit the calomel,
but continue the infus. sennæ. 16th day. Is better. Paralysis lessened.
Recollects he was thrown from a horse, but nothing else. Is free from
pain, but very weak. Mouth a little sore.
After this time he gradually recovered, but was for a long time unable
to work, or to undergo any exposure. A very little more mischief, and
he would have gradually sunk, and died after the seventh day, instead
of slowly recovering.