Chapter XV: Part 15

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.

LECTURE XVIII.

INJURIES OF THE HEAD.

262. A fracture of the inner or vitreous table of the skull, as it has been termed from its peculiar brittleness, as opposed to the greater toughness of the outer, is a rare occurrence without some signs of depression or fracture of the outer table, or detachment of the pericranium.

Mr. S. Cooper says: “One case of this kind, attended with urgent symptoms of compression, I trephined at Brussels. A large splinter of the inner table was driven more than an inch into the brain, and on its extraction the patient’s senses and power of voluntary motion instantly returned. The part of the skull to which the trephine was applied did not indicate externally any depression, although the external table came away in the hollow of the trephine, leaving the inner table behind.”

The records of eighteen centuries have produced but little information on this most interesting subject: and if the cases were collected which have been overlooked by authors, as well as those which have been altogether omitted, little would be gained; it may be concluded, therefore, that although such things have happened, they are of rare occurrence. I have never, in the great number of broken heads I have had under my care on many different and grand occasions, actually known the inner table to be separated from the outer, without positive marks of an injury having been inflicted on the bone or pericranium. Although it is not possible to doubt the fact of fracture of the inner table having occurred, without apparent injury to the outer, it is very desirable in a practical point of view not to bear it too strongly in mind; for if a surgeon should be prepossessed with the idea that the inner table may be so readily fractured and separated from the diploe placed between it and the outer table, and thus cause irritation or pressure on the brain, few persons who had received a knock on the head, followed by any serious symptoms, without fracture or depression, would escape the trephine, and the worst practice would be again established. An operation should never be performed under the expectation that such an accident may have happened, unless it be apparently required by the urgency of the symptoms indicating compression or irritation of the brain, which cannot be relieved by other means, and are about to prove fatal.

It is by no means intended to imply by these remarks that a blow on the head will not frequently detach the dura mater from the inner table by rupturing its vessels, and thus give rise to compression or irritation of the brain from the effusion of blood or the formation of matter; or that the inner table may not from the same cause become diseased, and thus lead to ulterior mischief; but these are altogether different states of injury, and require a different consideration.

Mr. Deane, of Chatteris, in Cambridgeshire, had occasion to examine the head of a young man after death from a blow on the left side, just below the parietal protuberance, there being only a _slight detachment_ of the pericranium, but no fracture. On removing the skull-cap, a very distinct fracture of the inner table, about three-quarters of an inch long, was seen corresponding to the external part injured, extending outwardly as far as the diploe, but no farther. The dura mater adhered firmly everywhere, except at this part, and for some distance around, a quantity of fluid blood being interposed between it and the bone. If this man had outlived the first symptoms, he would not, in all probability, have recovered without an operation for the removal of the extravasated blood.

263. Severe effects do not always take place in such cases in the course of the first treatment, but occur afterward; or the unfavorable symptoms, never having been entirely removed, increase so much at a later period as to render the aid of operative surgery necessary for the removal of the bone, in order to save life.

M. A. Farnham, aged twenty-three, a stout, healthy-looking girl, received a blow, two years before, from a stone falling from a door-way under which she was passing; it struck her upon the left side of the head at a spot an inch anterior to the parietal prominence, the weight of the stone and the space through which it fell making the estimated force with which it struck the head equal to sixteen pounds. The immediate effect of the blow was insensibility, followed by acute fixed pain in the head, which has ever since continued to mark the seat of injury. A week after the receipt of the blow she began to lose the power of moving the right arm, there being, however, no loss of sensation or any disturbance of the cerebral functions.

During the following twelve mouths the symptoms remained unchanged; this period was spent in several London hospitals; not having derived any relief while in any of these institutions, she became an out-patient of the Westminster Hospital.

The arm and leg of the right side were quite paralytic, the former, which had previously been flaccid, having now become remarkably rigid, its temperature being below that of the opposite side; vision, particularly of the left eye, imperfect, the pupils, however, acting naturally; hearing on that side also affected; memory bad; respiration frequently slow and almost stertorous; the countenance had assumed a dull, heavy expression, and she manifested an unusual tendency to sleep.

April 1st, 1841.--Mr. Guthrie this day removed a disk of bone from the exact point in the parietal region to which she referred the pain. The portion of bone presented no evidence of disease; its thickness varied from two and a half to four lines, the latter measurement corresponding to the part most distant from the sagittal suture; the vessels of the diploe bled freely, the dura mater was quite healthy, and without any very evident motion.

On visiting her _an hour_ after the operation, she raised the previously paralytic arm several inches from the bed, and was able to bend and extend the fingers. The pain in the head was considerably less, and her countenance, before dull and heavy, was now remarkably animated. Sensation had returned in the arm, and partially in the leg. Her pulse was calm, and the skin cool.

Ten hours after the operation she was attacked with rigors, followed by pyrexia and all the symptoms of commencing inflammation of the brain. By the immediate abstraction of blood, which was three times repeated during the succeeding twelve hours, whenever the pain in the head or the force of the circulation increased, every bad symptom was removed. In the course of three days the paralysis had completely disappeared, sight and hearing again became perfect, and after passing through a speedy convalescence, she quitted the hospital completely recovered.

She has since had some relapses of pain and uneasiness in the head, but is altogether a different person, although of a very hysterical temperament. The cicatrix on the head is firm, and she considers herself to have been cured by the operation.

264. The inner table is sometimes broken in a peculiar manner, and to this attention was first drawn in my lectures, since trepanning has ceased to be the rule of practice in all cases of fractures. It occurs from the blow of a sword, hatchet, or other clean-cutting instrument, which strikes the head perpendicularly, and makes one clean cut through the scalp and skull into the brain. This kind of cut is usually considered as a mere solution of continuity, and not as a fracture, the bone being apparently only divided, with scarcely any crack or fissure extending beyond the part actually penetrated by the instrument. When the outer table alone has been divided, the wound in the scalp should be treated as a simple incised one, and united as quickly as possible, a practice of which I have seen several successful instances. When the instrument even penetrates to the diploe, the same course should be pursued; for although the external wound may not unite by the adhesive process, and some small exfoliations may occur, it is not common for serious consequences to ensue under that strictly antiphlogistic plan of treatment to which all persons with such injuries should be subjected.

265. When the sword or ax has penetrated the inner table, the case is of a much more serious nature; for this part will be broken almost always to a greater extent than the outer table. It may be separated from it, and driven into the membranes, if not into the substance of the brain itself, the surface of the bone showing merely a separation of the edges of the cut made into it. These cases should all be examined carefully. The length of the wound on the top, or side, or any part of the head which is curved and not flat, will readily show to what depth the sword or ax has penetrated. A blunt or flat-ended probe should in such cases be carefully passed into the wound, and being gently pressed against one of the cut edges of the bone, its thickness may be measured, and the presence or absence of the inner table may thus be ascertained. If it should be separated from the diploe, the continued but careful insertion of the probe will detect it deeper in the wound. A further careful investigation will show the extent in length of this separation, although not in width; and will in all probability satisfy the surgeon that those portions of bone which have thus been broken and driven in are sticking in or irritating the brain. In many such cases there has not been more than a momentary stunning felt by the patient; he says he is free from symptoms, that he is not much hurt, and is satisfied he shall be well in a few days.

An officer was struck on the head, in Halifax, Nova Scotia, by a drunken workman with a tomahawk, or small Indian hatchet, which made a perpendicular cut into his left parietal bone, and knocked him down. As he soon recovered from the blow, and suffered nothing but the ordinary symptoms of a common wound of the head with fracture, it was considered to be a favorable case, and was treated simply, although with sufficient precaution. He sat up, and shaved himself until the fourteenth day, when he observed that the corner of his mouth on the opposite side to that on which he had been wounded was fixed, and the other drawn aside; and that he had not the free use of the right arm so as to enable him to shave. He was bled largely, but the symptoms increased until he lost the use of the right side, became comatose, and died. On examination, the inner table was found broken, separated from the diploe, and driven through the membranes into the brain, which was at that part soft, yellow, and in a state of suppuration.

Mr. B., of the 29th Regiment, when in Halifax, Nova Scotia, was struck, in a drunken frolic, on the anterior part of the left parietal bone, with his own sword, which was a straight, heavy one, and a wound about two inches long was made in the side of his head through the bone. His little finger was cut at the same time, and it was not until the finger had been dressed that I was asked to look at the head, which he declared had nothing the matter with it. He was vomited, and purged, and the next morning bled, and as symptoms of inflammation of the membranes of the brain came on or increased, the bleedings were repeated, the quantity taken at each time being gradually diminished. He lost 250 ounces of blood in five days, after which he gradually although slowly recovered, some small spiculæ of bone coming away during the cure. Returning to England, the vessel was taken off the Scilly Islands, and he was sent to Verdun, where he remained several years, until liberated by the peace of 1814, when he rejoined his regiment, which had served in the Peninsula, and had returned to North America. It was soon found that he became outrageous on drinking a very little wine, and was odd in his manner, and had a great propensity to set out walking for hours without apparently knowing what he was about, or where he was going. When his regiment came immediately in front of the enemy, he was found going over to their lines, without being aware of what he was doing; and he was at last obliged to be sent to England, having evidently become deranged. This gentleman has ever since been confined in a private mad-house. His brother offered to allow the bone to be removed; but after thirty years of derangement a recovery could not be expected, and it was declined. If the examination I have since learned to be proper in such cases, had been made at the time, the inner table of the bone would have been found broken and depressed; and he might now have been in health both of mind and body.

I removed, in Lisbon, in the hospital appropriated to the wounded French prisoners in 1812, a portion of bone by the trephine, which had been fractured by a sword some months before: the wound had not healed, and some pieces of bone were depressed. One piece, in particular, of the inner table, was sticking in and irritating the dura mater, and was in all probability the immediate cause of the fits from which the patient had been suffering. He recovered.

A British soldier received a wound at the affair of El Boden, in front of Ciudad Rodrigo, from a sword, on the top of the head; he accompanied me to Alfaiates, on the retreat of the army. The bone was apparently only cut through, yet the inner table was depressed, and felt rugged when examined with the probe. The symptoms of inflammation increasing on the fourth day, and not being relieved by copious bleeding, I removed a central portion of the cut bone by one large crown of the trephine, and took away several small pieces which were sticking into the dura mater, after which all the symptoms gradually subsided.

266. The whole of the French wounded, who remained on the ground or were taken prisoners after the battle of Salamanca, were under my care, and among them there were several severely wounded by sword-cuts received in the charges of heavy cavalry made by Generals Le Merchant and Bock. The cerebellum was laid bare in two cases without any immediate bad effect. In one particular case, which recovered, (after the battle of Waterloo,) the brain was seen pulsating for several weeks; and the statements made to me by the different officers at Brussels and Antwerp, and afterward at Yarmouth and Colchester, entirely confirmed the observations I had made, and the recommendations I have inculcated on this particular point as resulting from the practice of the Peninsular war.

267. It would appear that too much stress is laid upon a difference which is supposed to exist in the danger of trephining a man on the first or on the seventh day after an accident; and that an error may be committed in believing that the trephine is a more dangerous instrument on the first day than on the seventh. The question is not whether the man is to be trephined or not, but which will be the best and safest day or time to do the operation. I do not hesitate to say the first, believing the violence to be greater when done on parts already in a state of inflammation, than when they are sound. When the inner table has pierced the membranes and gone into the brain itself, the individual will in most cases ultimately die miserably of the accident if not relieved by art. It is less safe to let him designedly run the certain risk of cerebral irritation, which when once excited is often indomitable, than to remove the cause, and endeavor to prevent the evil. If the cerebral irritation only manifested its effects on the surface of the dura mater by causing suppuration there, delay might be admitted; but as it usually gives rise under these circumstances to the formation of matter on the surface, and even in the substance of the brain, where it is deadly, “la chirurgie expectante” cannot be allowed. Lastly, there is not more danger of a hernia cerebri, as has been supposed, when the operation is done early, than when it is done at a later period; on the contrary, the patient has a much better chance of escape from hernia cerebri, and from all other evil, when the local and the general treatment are decided and efficient.

If, on attempting to remove a fragment buried in the brain, serious convulsive movements should be excited, it would be proper to desist from all further attempts to extract the splinters until the brain has become more quiescent.

It is necessary to recollect that the brain appears to be insensible, or nearly so, when first exposed; and it has rarely occurred that a serious convulsion or anything beyond vomiting has taken place on the removal of a piece of bone from the brain; nor will any difficulty be found in removing such small fragments as can be seen with a pair of forceps duly adapted for the purpose. It is impossible to say at what period of time the brain may become irritable, and no longer admit of its being touched without convulsive movements ensuing; but when this state of irritation has commenced, and its existence is proclaimed by the excitement which takes place on touching the fragment of bone, the surgeon should at once desist from all attempts to remove the foreign body. The brain under ordinary circumstances is much more likely to recover from an injury, all foreign or irritating matters having been removed, than when suffering from their presence.

268. The establishment of the principles which ought to regulate the practice of surgery in cases of fracture with depression of the inner table of the skull, is of the greatest importance. The principle being laid down that it is right and proper to examine all such wounds with a blunt, flat probe, in order to ascertain if possible whether the inner table be depressed and broken, the question necessarily arises, what is to be done when such depression and breaking down of the inner table have been ascertained to have taken place? There can be no hesitation in answering, that in all such cases the trephine should be applied, although no symptoms should exist, with the view of anticipating them. The old doctrine, it may be said, in regard to fractures generally, is revived in these cases, but on a principle with which our predecessors were not sufficiently acquainted. A patient very often survives a mere depression of the skull; he may, and occasionally does survive, a greater depression of the inner than of the outer table; but it has not been shown that he ever does survive and remain in tolerable health, after a depression with fracture of the inner table, when portions of it have been driven into the dura mater. If cases could be advanced of complete recovery after such injuries, they would not supersede the practice recommended, unless they were so numerous as to establish the fact that injuries of the dura mater and brain by pieces of bone sticking in them are curable without an operation, and without leaving any serious defects. There are great objections to the trephine being applied in ordinary cases of fracture, not attended by symptoms of further mischief; but the nature of the cases particularly referred to having been ascertained, the practice should be prompt and decisive in every instance in which the surgeon is satisfied that there is not merely a slight depression or separation of the inner table, but that several points of it have been driven into the dura mater. If one trephine will suffice, the central point being applied close to the edge of the middle of the wound in the bone, it should be applied there; but if the cut be longer, and the spiculæ of bone extend upward and downward in its length, a small trephine should be applied as near each end as may be judged advisable, and one edge of the cut bone should be removed by the straight saw, of which Paré and Scultetus made such use in ancient times, and which Mr. Hey of Leeds revived in modern surgery; or the small straight saw may be used alone, if the object of removing a portion of bone can be attained without the trephine. By these means sufficient room will be obtained to remove the broken pieces of bone which are irritating the dura mater and brain. The danger resulting from the application of the trephine, in such cases, bears no proportion to the risk incurred by leaving the broken portions of bone as a constant cause of irritation.

269. There is an essential difference between a depression of the skull in a CHILD and in an ADULT. In the child the inner table is not brittle--it bends equally and does not break; it very often does little mischief when depressed, and gradually recovers its level. The brain in young persons is softer and less consistent, and can accommodate itself more readily to pressure for a limited time, without ultimate mischief, than the brain of an adult; so that a continuance of the most urgent symptoms can alone authorize the application of the trephine in children, and in young persons under fifteen or sixteen years of age. A similar bending of the long bones in young children is often observed at an early period in life.

270. The propriety of dividing the scalp in an adult, in order to examine the state of the bone beneath, when evidently depressed, thus rendering a simple although comminuted fracture a compound one, is a matter of very great importance, the decision of which rests upon the still more essential point--viz., whether a depressed portion of bone ought or ought not to be removed? This again must depend upon the nature and extent of the depression, for many persons who have suffered from such a misfortune have recovered without the depressed portion being raised. It is a question of degree or extent, upon which every surgeon must form a judgment from his own observation and experience.

The difference between a simple and a compound fracture of the leg is often considerable; it is more often dependent on degree. When the fracture is nearly transverse, and the skin is cleanly divided, the difference between it and a simple fracture of the same part is little more than one of time. This may be the case with an injury of the head; the difference between the two states in fractures of the skull has, however, been much exaggerated; so much so, that no reliance can be placed on the supposition that there is more real danger in a case of fracture with depression in which the scalp has been divided, than when it has been only bruised, and not divided. I admit that theoretically it ought to be otherwise, but theory and practice do not always correspond. In all cases in which a fracture with _marked_ depression is known to have occurred in an ADULT, it is good practice to ascertain the nature and extent of the depression. It is imperatively necessary if accompanied by symptoms of compression.

If the result of a great number of comparative trials should be in favor of never, under any circumstances, raising a depressed portion of bone in an adult, but of leaving it to the efforts of nature, an incision in order to ascertain the state of parts below ought not to be made; but as such a result is not likely to be obtained, the practice recommended appears to be the best.

The scalp should be divided, in such cases as may require the operation, by a straight, crucial, or such other shaped incision as may be found most convenient to the surgeon; but no part should be removed which can be preserved with the hope of maintaining its life.

271. The cranium, together with the fracture and depression, being exposed, the question whether the trephine should be applied or not is next to be determined. If the operation by the trephine, or that of sawing a piece of bone out of the head, were not in itself dangerous, there could be no hesitation about its use; but it is a dangerous operation, especially in crowded hospitals, and ought not to be resorted to when it can be avoided. If any ten healthy persons were trephined in a hospital, one would in all probability die from the effects of the operation, and three or four more might have a narrow escape from the inflammation of the brain and its membranes, or the other consequences which would probably ensue. It is not the admission of air, which has been even lately supposed to do mischief, that is to be dreaded in these cases, but the same kind of irritation which often follows the abstraction of a piece of bone under other and more ordinary circumstances at a later period of time.

The following cases are illustrative of many important points:--

William Rogers, aged nineteen, of the 32d Regiment, was wounded on the 16th of June by a musket-ball, which entered at the inferior angle of the left parietal bone, knocked him down, and for a few minutes rendered him insensible. On recovering his mental powers, he found that he was unable to speak, not so much (as he said afterward) from the want of power to form words, as from the incapacity of giving them sound. He was conscious of everything passing around him, and reasoned correctly. He retired out of the reach of shot, and then lay down for the night. On the following morning, he went to Brussels, where he was examined and dressed. On the morning of the 18th he reached Antwerp on horseback, very giddy, and overwhelmed with fatigue, fasting, and watching; he was admitted into the Minimes General Hospital and put to bed, when he soon fell into a sound sleep, which with some tea refreshed him much.