William Rogers, aged nineteen, of the 32d Regiment, was wounded on the
16th of June by a musket-ball, which entered at the inferior angle
of the left parietal bone, knocked him down, and for a few minutes
rendered him insensible. On recovering his mental powers, he found
that he was unable to speak, not so much (as he said afterward) from
the want of power to form words, as from the incapacity of giving them
sound. He was conscious of everything passing around him, and reasoned
correctly. He retired out of the reach of shot, and then lay down for
the night. On the following morning, he went to Brussels, where he was
examined and dressed. On the morning of the 18th he reached Antwerp
on horseback, very giddy, and overwhelmed with fatigue, fasting, and
watching; he was admitted into the Minimes General Hospital and put
to bed, when he soon fell into a sound sleep, which with some tea
refreshed him much.
June 19th. The ball was found to have passed obliquely upward and
backward at least two inches, and could be distinctly felt with a
probe. It gave more the idea of having raised the outer table than
that of having depressed the inner. The defect in speech was in some
measure diminished, and this with giddiness were the only symptoms of
compression. A poultice was placed over the wound, a brisk purgative
given, and spoon diet ordered.
20th. The pain and giddiness having increased, with annoyance from
noise and exposure to light, twenty-six ounces of blood were taken from
the arm. The following day the purgative was repeated, and the patient
was much relieved. Everything went on well, the wound was nearly
healed, and he was considered almost fit to be discharged, when, on
the 16th of July, the wound began to open; on the 18th it was dilated
and a portion of the cranium removed by the forceps; this was soon
followed by symptoms of inflammation of the brain; twenty ounces of
blood were taken immediately from the arm, purgatives and diaphoretics
were ordered, and the strictest abstinence enjoined. 23d. Venesection
was repeated, as well as the other means usually adopted to reduce high
action. 24th. Completely relieved. 26th. Another portion of the cranium
removed, the dura mater being fully exposed; the general health in the
best state.
August 3d. Doing remarkably well; the wound healthy; the pulsation of
the brain evident; the power of speech perfectly restored. The ball yet
remains in, according to the opinion of the patient, (who is a fine,
intelligent lad,) and he thinks it has gradually descended toward the
petrous portion of the left temporal bone. Sent to England at the end
of the month, the wound being healed.
When I saw this man at Antwerp I gave my opinion, without hesitation,
that the bone and the ball ought to have been removed in the first
instance, when he would have had a better chance for perfect recovery.
The operation, when afterward performed for the removal of the loose
pieces of bone, placed his life in great jeopardy. He was discharged
the service with the ball lodged, and it is more than probable that he
did not long survive, which he might have done if the ball had been
removed when it was first felt within the skull.
In the following case the ball could not perhaps have been removed in
the first instance with propriety; it might, however, have been lying
on the dura mater, or near it, within reach, and the actual state of
things ought to have been ascertained, the surgeon afterward deciding
whether any further operation were necessary.
Thomas O’Brien, 28th Regiment, aged twenty-three, was wounded by a
musket-ball on the 16th of June at Quatre Bras; the bullet penetrated
the occipital bone below and to the right of the junction of the
lambdoidal and sagittal sutures. On his arrival at Colchester, the
wound was healthy in appearance and healing rapidly. It appeared from
his own account that for some hours after the injury he was totally
deprived of sight; since that time he has been constantly more or less
affected with headaches, for which he has been prescribed occasional
cathartics and low diet. He has also been affected with pain and
weakness in both eyes, but more particularly in the right. While at
Brussels, and during his progress to Ostend, he lived very irregularly,
and was frequently intoxicated. The external wound was entirely healed
on the 20th of July, and no suspicion existed that the ball was lodged
in the brain. On the 25th matter was perceived under the scalp, and
was evacuated yesterday. To-day, the 27th, he complains of increase
of headache; pulse small and quick. V. S. ad ℥vj. Haust. cathart.
statim. 28th. In the course of this day his symptoms have become very
urgent; he is restless, with a very quick pulse; an extensive crucial
incision was made in the site of the original wound, and now for the
first time it was discovered that the ball had penetrated the brain;
several loose pieces of bone were extracted; a considerable quantity
of arterial blood was suffered to flow from the small vessels divided
in the incision. His bowels had been well opened by the cathartic. The
most vigorous treatment was continued, but the symptoms notwithstanding
increased, and he died on the morning of the 29th of July.
The ball was found lodged nearly two inches deep in the substance of
the right posterior lobe of the brain; a considerable quantity of pus
surrounded it; some inflammation of the brain and its membranes was
observed, but much less than might have been expected.
A. Clutterbuck, 61st Regiment, aged twenty-five, was wounded in the
back of the head by a musket-ball at the battle of Toulouse, on the
10th of April, 1814. He felt little inconvenience from the wound during
the first two days. On the 14th he complained of severe pain in the
head, giddiness, and dimness of sight; the face was flushed, pulse
hard and frequent. Twenty ounces of blood were taken from the arm, and
the wound enlarged so as to expose the cranium. The upper part of the
os occipitis was found fractured by the ball, and a circular portion
of it, about the size of a shilling, was depressed and fractured.
15th. Pain in the head much abated; no giddiness, dimness of sight,
or any unfavorable symptom; pulse still hard. V. S. ad ℥xx. To be
well purged. 19th. He was bled again this day to the extent of twelve
ounces, as a matter of precaution. 23d. Continues free from any bad
symptom. May 8th. The wound is now much contracted, and he feels no
inconvenience. A small portion of the bone still feels bare to the
probe, but the greater portion of the depressed piece is covered with
healthy granulations. No exfoliation has taken place. May 24th. The
wound is nearly healed; he is in good health and spirits, and without
inconvenience.
This case may be properly contrasted with that of O’Brien, as showing
by the result the difference between an uninjured and an injured brain.
If the fractured and depressed bone had not been at the back part of
the head, it is probable the depressed portion would have been removed
in the first instance, as it certainly would have been after the 15th,
if the unfavorable symptoms had not yielded to the general treatment;
but the bone would then have been removed under much more unfavorable
circumstances than at first.
The following case is related to show the extent to which blood-letting
may frequently be carried to preserve life. There having been no reason
to believe that the symptoms depended on fractured and depressed bone,
the scalp was not divided; and as the symptoms were coeval with and
not consecutive to the injury, they were therefore supposed to depend
on concussion rather than on compression of the brain. If the trephine
had been applied on the fourth day because the insensibility continued,
the additional injury would in all probability have proved fatal. If
the depletion of all kinds had been less effective, the inflammation
of the brain or of its membranes would certainly have terminated in
the effusion of lymph or the formation of matter, which the use of the
trephine would not have prevented nor removed.
George Mills, an artillery driver, aged twenty-eight, was admitted
into the Dépôt de Mendicité Hospital, Toulouse, May 29, 1814, in
consequence of having been thrown from his horse on his head against
the ground. He had fallen on the right side of the os frontis,
immediately above the eye, where the surface of the skin appeared to
be scratched and bruised, but the bone was not depressed: he was bled
freely, but remained insensible. The next morning he was again bled
to twenty ounces, which operation was repeated in the evening. On the
29th, the temporal artery was opened, and a vein in his arm at the
same time, the breathing being strong and sonorous, the eyes closely
shut, and he lying quite insensible; the pulse before the bleeding was
quick and small; after he had lost about eight ounces of arterial and
eight ounces of venous blood, it became fuller, and the breathing was
somewhat relieved; the slightest touch gave him pain, and he shrunk
from pressure made directly above the eye. The temporal artery was
again opened in the evening, and ten ounces of blood were taken away. A
purgative and a stimulating enema were ordered, and cold was constantly
applied to the head.
30th. He has been freely purged and appears more collected; the pulse
is still quick and small; breathing very free; the irritability
continues and he complains of pain on pressing the head. The purgative
and the enema were repeated, and ten ounces of blood were drawn from
the temporal artery, after which he attempted to speak. 31st. Passed
a good night; the pulse is quick and small; pain in the head still
great; was again bled to twelve ounces, and the purgative was repeated.
June 1st. Pulse quick; there is not so much pain in the injured part,
and he appears more sensible; was bled to twenty-four ounces, and the
purgative was repeated. 3d. Was again bled to ten ounces. From this
time until the 20th, he gradually improved, and was then discharged
cured.
The treatment in these cases was the same, although in one there was
no fracture, and in the other two there was fracture with depression.
The broken portions of bone did not, in Clutterbuck, appear to press
unequally on the dura mater, and it was presumed that the moderate
degree of pressure which ensued from the depression might be borne
with impunity, as it did not seem likely to be accompanied by the
projection inward of any pointed pieces which might irritate the brain.
The result confirmed the supposition and justified the treatment. If
the examination of the depressed part had led to the apprehension that
such points of bone did exist, and were sticking into and irritating
the dura mater or brain, they would have been removed, in the belief
that although they might not at the moment have given rise to any other
symptoms than those which depended on the blow, the time would come
when they would scarcely fail to cause those which usually accompany
the formation of matter within the skull. If this danger should also
be avoided, the subsequent evils which have been noticed as occurring
at a later period, and which ultimately require the same operation
for the relief of the patient after months of acute suffering, might
be encountered; for although a person may temporarily recover from an
injury in which a portion of bone has been allowed to remain a source
of irritation to the brain, it does not follow that such recovery
should be permanent. If there be a doubt on the mind of the surgeon,
whether there be or be not any pieces of bone depressed and irritating
the brain or its membranes, he should wait; this is the real difference
between the surgery of the latter part of the Peninsular war and that
of the olden time.
272. When a fracture is accompanied by depression, and the broken
portion or portions of bone would seem to be driven into the dura mater
or the brain, or to press so unequally upon them that as much mischief
is likely to ensue from leaving as from removing them, especially in
an adult or a middle-aged man, less harm will in general follow from
ascertaining the fact by dividing the scalp and removing the broken
pieces than by doing nothing, more particularly when the presence of a
foreign body has been ascertained. If there be no symptoms indicative
of mischief below the fractured part, the surgeon must then decide,
after the best estimate he is able to make, of the probable evil which
will occur from allowing the broken or depressed portions of bone to
remain.
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.