Commentaries on the Surgery of the War in Portugal, Spain, France, and the Netherlands / from the battle of Roliça, in 1808, to that of Waterloo, in 1815; with additions relating to those in the Crimea in 1854-55, showing the improvements made during and since that period in the great art and science of surgery on all the subjects to which they relate.

by G. J. Guthrie

LECTURE XIX.

TUMORS OF THE SCALP, ETC.

276. When the periosteum covering the bone is bruised, or the bone is merely deprived of this membrane, it does not follow that it should die or exfoliate. In many instances the wound will gradually close up and heal, as if no such accident had happened. A blow or bruise on the head often gives rise to a swelling or tumor, from the rupture of the small vessels passing into the cellular membrane between the scalp and the pericranium; the tumor in these cases appears immediately after the receipt of the injury as a soft swelling, and is usually found to contain blood, which in most instances is removed by absorption in the course of from two to three weeks. In some cases inflammation supervenes, and one part becomes tender and appears to point; into this a small incision should be made to allow the blood and matter to escape, when gentle compression should be resorted to in order to induce the parts to unite. Swellings of this kind in new-born infants, occurring from pressure during delivery, may be readily mistaken for deficiencies of the occipital and parietal bones, if it were not for the absence of all motion, which under such circumstances would be communicated to them from the brain. The blood effused in the cellular membrane raises the border of the swelling, which becomes harder than the neighboring parts, while the center remains soft and yielding, giving a sensation to the finger as if the bone beneath were wanting, or, after a blow, the idea that the bone beneath is depressed. If such a swelling be unnecessarily opened, considerable inflammation and suppuration will often follow, to the great inconvenience of the patient; this will in general be avoided by the use of a moderately stimulating cold lotion.

277. In other cases of tumors, which are called secondary in contradistinction to the preceding, the patients go on well for eight, nine, or more days, at the end of which time they complain of headache, giddiness, nausea, restlessness, thirst, and generally of fever. A few days more, frequently from the thirteenth to the fifteenth day, rigors, sometimes severe, are superadded, and a swelling, if not observed before, is now perceived on the spot where the injury had been received, if the integuments have not been divided; or, if there be a wound, it loses its healthy red appearance, and assumes a yellowish, unhealthy color, which is accompanied by a thinner and more acrid discharge. From this time the symptoms gradually increase, the patients become delirious, convulsed, comatose, and die; and matter is found between the skull and the dura mater, or in or on the substance of the brain. If this secondary swelling be divided, and the fluid evacuated, which is not good pus, the pericranium will be found detached and the bone bare.

It has been stated that a bone so circumstanced would not be found to bleed on being scraped, and that, by attending to the want of hemorrhage from the outside of the cranium, the extent of the evil might be ascertained, and that so long as a denuded, discolored bone will bleed on being scraped, it may be considered that the dura mater is attached below, and that no operation should be performed.

The essential difference between the primary and the secondary swellings is to be found in the fact that, although the bone be exposed, and even in some degree may have changed its color in the primary swelling when matter has formed, the febrile symptoms will subside after its evacuation, healthy granulations will spring up, and little or no exfoliation will take place. In the secondary swelling none of these favorable symptoms or appearances will take place, for the bone is incapable of maintaining its life, and must die. If the outer table only be implicated, it may exfoliate; but if there be reason to believe that matter has collected beneath, on the dura mater, the bone should be removed by the trephine.

Inflammation of the dura mater proceeding to suppuration, or the formation of matter between it and the bone, appears to have been a much more common consequence of injuries of the head in former times than at present. It is not now of frequent occurrence in London hospitals.

As blows on the head and the structure and functions of the brain are the same at present as formerly, the difference in regard to such cases can only depend on the difference of treatment. It is, in fact, infinitely more depletory now, and therefore less operative. Blood is taken away in larger quantities, although to this there are exceptions, depending on the constitution of the patient, which will not always admit of it, while the potassio-tartrate of antimony and mercury are by most surgeons administered at an early period.

Suppuration, or the formation of pus on the surface of the dura mater, not being, under the strictly antiphlogistic and mercurial system, so common as formerly, sufficient attention has not perhaps been paid to another evil which frequently accompanied it in former times, viz., suppuration on the surface and in the substance of the brain itself; for the greater number of those who died with fracture and depression of the skull, and whose cases are recorded, suffered also from alteration of the structure or substance of the brain, and the formation of matter within it or upon its surface. This termination might not have taken place in a large proportion of the cases in which it occurred if the depressed bone had been raised to its level, and the irritation arising from undue or unequal pressure had been avoided. It must be admitted, however, that an internal part of the brain may receive such a shock at the moment of injury, as well as an external part, that no treatment can arrest the progress of the mischief, although it may be delayed; and when the patient dies, after four, five, or more weeks of alternate hope and suffering, matter may be found in some part of the brain where an injury was not suspected.

Purulent matter may be formed beneath the dura mater in a confined spot, or it may be diffused generally over the surface of the brain, in which case the sufferer has no chance of relief.

278. The operation of incising the dura mater, to admit of the discharge of blood or matter from beneath, and even of puncturing the brain, has not been much resorted to in England; this may be an error. The records of surgery supply many cases where it might have been done with advantage, and some in which it was done with the greatest benefit to the patient. It is not an operation which ought to be performed without signs sufficiently demonstrative of the necessity for doing it.

I have seen, on the removal of a portion of bone by the trephine, the dura mater rise up rapidly into the opening so as to attain the level of the surface of the skull, totally devoid, however, of that pulsatory motion which usually marks its healthy state. An opening into it, under these circumstances, has allowed a quantity of blood or of purulent matter to escape, proving that the unnatural elevation of the dura mater was caused by the resiliency of the brain when the opposing pressure of the cranium was removed. This tense elevation, its abnormal color, and the absence of pulsation are positive signs of there being a fluid beneath, requiring an incision into the dura mater for its evacuation. It is a point scarcely noticed in English surgery—one which was not in the slightest degree understood at the commencement of the war in the Peninsula.

A. Monro, of the 42d Regiment, was wounded on the 10th of April, at Toulouse, by a musket-ball, which fractured the left parietal bone slightly, without depressing any part of it. No symptoms followed requiring more than ordinary attention until the 23d, up to which time he had been kept on low diet, for the most part in bed, and had been bled and purged. On the evening of that day he became feverish, and hasty and odd in manner, and the pulse quickened; he declared himself, however, to be quite well, and submitted to be bled and physicked with great reluctance, calomel combined with opium being given him at short intervals. On the 24th he complained of pain in the head, which he said was very slight, and that upon the whole he was quite well, and would not be bled nor have anything done. He was bled largely by force, which lowered the strength of the pulse, but did not relieve any of the symptoms of irritation of the brain. On the 25th he was evidently worse, although he declared himself to be quite well; he talked a little incoherently; the pupils were dilated; the pulse quick but regular; the countenance was changed; he was sensible, apparently, upon all points except that of being much worse, which he resolutely denied, saying he was better and would soon be well. Satisfied that matter was forming, or had formed, in or on his brain, I desired that the trephine might be applied on the fractured part and the bone removed. This, however, he would not permit the officers in charge to do, and they awaited my return in the afternoon, when, finding him much worse, I directed it to be done by force, three of his own regiment with others attending to assist the surgeons. He called upon these men by name not to allow him to be murdered in cold blood, declared he was getting well, and would get well if let alone, and prayed them to avenge his death on the doctors if they meddled with him. The surgeons were dismayed, and requested that the operation, which they said required great care, should be performed by me, their chief. I therefore removed the bone; and the moment it was taken away the dura mater rose up in the opening to the level of the surrounding bone, and remained without any pulsatory motion. I had no doubt of matter being beneath, and that, from his general state, the man would die. I did not therefore think it prudent, under all the circumstances, to do more than warn his comrades that, when dead, they would see the whole brain beneath in a state of suppuration. He died that night; and the next day they saw the whole of the left hemisphere soft, yellow, and covered with matter, to their great surprise and satisfaction at the accuracy of the diagnosis.

Absalom Lorimer, of the 42d Regiment, was wounded by a musket-ball on the 10th of April, 1814, at the battle of Toulouse, which carried away a small portion of the scalp just above the right temple, fracturing the bone slightly, but without any depression. No symptoms occurred demanding more than ordinary attention for the first fortnight, during which period he had been bled once, purged, and kept on low diet. On the 25th, he complained of pain in his head around the wound, shooting to the back part; pulse 60; pupils dilated. An incision having been made to the bone, the pericranium was found detached, and the bone fractured, but without any obvious depression. V. S. ad ℥xx, calomel and colocynth: as the pain continued, the bleeding was repeated in the evening. 26th. Pain in the head greatly relieved; pulse 60; bowels torpid. Ten ounces of blood were taken from the temporal artery, and the calomel and colocynth, salts and senna were repeated. On the morning of the 29th, the symptoms of compression having increased, the trephine was had recourse to, and the fractured portion of bone was removed: a layer of coagulated blood was found on the dura mater, which puffed up into the opening. In the evening he became convulsed, the pulse intermitted, and he died. On examination, a large abscess was found in the right hemisphere of the brain, having the ventricle for its base, with some matter on the surface of the brain, and between the dura mater and the bone at the base of the cranium.

On the morning of the day that I performed this operation, I had done another of the same kind at the Hôpital des Minimes; the dura mater rose up in a similar manner without pulsation into the opening made by the removal of the circular piece of bone by the trephine; on puncturing it a considerable quantity of pus oozed out. The opening was enlarged; and the flow of matter was daily encouraged, until it gradually diminished, and ceased with the formation of granulations, and the drawing in and cicatrization of the part.

279. It has been supposed theoretically that a wound through the dura mater was particularly dangerous, in consequence of the tunica arachnoides which lines it being a serous membrane; and that, if the inflammation which ensued did not cease at the adhesive stage, by the consolidation of the surface which covered the pia mater with that which lined the dura mater, a diffuse inflammation would necessarily follow, which might spread over its whole extent. This has not been found practically to be the case; and if a simple wound of the dura mater be a danger that ought to be avoided, the risk run cannot be put in comparison with that which accompanies the continuous irritation depending on the presence of a spicula of bone, which has passed through the dura mater, and is irritating the brain beneath. It has also been supposed theoretically that the danger would be diminished if the pia mater were wounded also, as the brain would project and fill the wound; but the accuracy of this opinion may be doubted. If the dura mater were injured through error or design, I should not think the evil lessened by adding to it a wound of the pia mater, and perhaps also of the brain.

By those who have been accustomed to the terrible injuries which occur in military warfare, in which large portions of the brain are sometimes exposed, and even lost, without much inconvenience following, the exposure of or the opening into the dura mater is not considered of so much importance as it is by those who have had fewer opportunities of seeing such awful cases; while the formation and retention of matter below the bones of the cranium is, on the other hand, more dreaded by those who have often seen their ill effects than by those who have not had many occasions for observing them; by whom, however, they are often considered, when they do take place, to be irremediable by art.

280. Gunshot wounds of the skull are attended by certain peculiarities. In ordinary circumstances there is usually an external wound and a fracture more or less comminuted, with depression; this wound will almost always require to be enlarged by a simple incision, so as to show the extent of the depression or the size of the broken and depressed portions of bone. When the bone is scarcely injured, and the periosteum is only bruised, or when the bone is even deprived of this covering, it does not follow that it should die or even exfoliate. In many instances the wound will gradually close in and heal, as if no such evil had occurred; and in those which do not terminate so favorably, the cure may only be delayed by the exfoliation of a layer or scale of bone from its outer surface, unless the mischief should have implicated the parts beneath.

A musket-ball striking directly against a bone sometimes makes a hole not larger than itself, with or without any radiating fracture; and one large trephine, if properly applied, will often embrace the whole of the mischief, and admit of the removal of the broken pieces. As a center-pin cannot be used, the trephine may be made to turn very well in most cases in a flat but thick bar of iron, having a hole in the middle, of such a size only as will allow the polished outside of the trephine to turn in it. Sufficient support for the instrument will be obtained by this means until it has made a groove in the bone for itself, when the operation may be continued as it would be in an ordinary case after the removal of the center-pin.

When a musket-ball ranges along the side or top of the head, it may break the outer, and depress and fracture the inner table to a considerable extent, for the space even of three or more inches. The broken portions of bone may in general be removed by means of good forceps and a straight saw; and no good reason can be given for delaying the operation unless the nature of the injury be doubtful, when it may be as well to wait for symptoms. It sometimes happens, although rarely, that a ball sticks so firmly in the bone that it cannot be extracted by working round it in any ordinary way with a pointed instrument. The difficulty usually arises from the ball having half buried itself in the diploe, so little of it being exposed as not to admit of a firm hold being taken of it. The large trephine, used in the way pointed out, has several times overcome this difficulty. The removal of the outer table has been sufficient where the inner one has not been driven into the dura mater; when any doubt is entertained on this point both should be removed.

281. A ball or other foreign substance may penetrate the brain directly or obliquely. When the ball penetrates the brain directly, it is not often that it can be removed, and the sufferer very rarely survives beyond a few days, even if the ball has been extracted; more particularly if the injury have occurred in the anterior part of the substance of the brain; several persons, however, have recovered, in whom the injury occurred toward the back part of the head, the ball being allowed to remain. It will be better in all such cases to allow the ball to remain, which it will often do for many days, until circumstances render it necessary to endeavor to find it. When it can be felt immediately under the surface of the brain, it ought to be removed like any other foreign substance.

Dr. Rogers relates the history of an excellent case, in which a young man aged nineteen received a wound on the frontal bone, just above the center of the left superciliary ridge, from the bursting of a gun on the 10th of July. It was not until the 4th of August that he discovered a piece of iron lodged within the head, in the bottom of the wound, (from which a considerable quantity of brain had come away,) which he extracted the next day. It proved to be the breech-pin of the gun, three inches in length, and three ounces in weight. By the tenth of December his patient was perfectly cured.

When a ball strikes the head obliquely, it may enter and pass out or lodge. Nearly all these cases die, but one occasionally escapes, and none should be allowed to die without assistance. When the entrance and exit of the ball are obvious, and not far distant from each other, the splinters of bone should be removed; and if the little bridge between the openings should be injured, the whole should be taken away by the straight saw; an operation which cannot, however, be necessary in the first instance, if the portion of bone be apparently sound.

At the battle of Talavera, a soldier of the 48th Regiment was brought to me in a state of insensibility; he had received a musket-ball on the upper part of the right side of the frontal bone, where it had entered, and had evidently passed backward; it could be followed by the probe rubbing against the bone for nearly four inches. The scalp over this point was soft, as if blood were effused below; and on dividing it, a fracture was seen bulging rather outward. The trephine was applied forthwith, and the bone removed, together with the ball, which only wanted a little more impetus to have come through. The brain was injured, and the man died two days afterward.

A French grenadier was wounded at the battle of Salamanca by a musket-ball, which struck him on the right side of the head, penetrated the temporal muscle, and lodged in the bone beneath, giving rise to symptoms of compression. On dividing the parts, I found that the ball had fractured and driven in a part of the temporal bone, one portion of the ball being above, and the other below the broken bone. The upper half of the ball was readily removed, but several small portions of bone were raised by the elevator and forceps before the remaining portion of the ball could be drawn from under the bone, which was not depressed, the ball having been cut in two by its edge. The dura mater was bruised, but not torn through. The wound suppurated freely; several pieces of bone exfoliated, and the patient was ultimately discharged in progress toward a cure.

A small ball sometimes becomes so flattened by striking against the skull as to remain undiscovered when care is not taken in the examination. A soldier was wounded at the storming of San Sebastian by a ball on the side of the head, which was supposed not to have lodged. The wound did not heal, a small opening remaining, although no exfoliation took place, and the bone did not seem to be bare. On dividing the scalp to ascertain the cause of the delay in healing, a small ball, quite flat, was found; it had sunk down a little below the hole left for the discharge to which by its irritation it had given rise.

When a larger ball or a piece of a shell strikes the head, the fracture is usually extensive, and portions of bone, or a piece of the shell itself, are often lodged in the substance of the brain. There is nothing peculiar in the management of these cases, which are for the most part unfortunate.

282. A suture may be separated by a musket-ball, which impinges with a moderate degree of force directly upon it, but not without great danger. It can, however, only happen in young persons in whom the sutures are not obliterated as they are in elderly ones; in general it takes place when the ball happens to lodge as it were between the bones concerned in the formation of the suture. The first case of the kind which came under my observation occurred at the taking of Oporto. I met with a second at Albuhera, a third at Salamanca, and a fourth in a slighter degree at Orthez.

A heavy dragoon was wounded at the battle of Salamanca by a musket-ball in the body, which caused him to fall from his horse, injuring the top of his head. Little attention was paid to him until mischief was suspected from the lethargic state into which he fell, which could only be attributed to the blow on the head, where a tumor was observable. This, on being divided, showed a separation of the edges of the sagittal suture, from which some blood flowed. Two crowns of the trephine were applied on the twelfth day, in order to admit of the free discharge of some blood which had been extravasated from a wound in the longitudinal sinus, after which the symptoms subsided, and the patient gradually recovered.

A ball may pass apparently through the fore part of the head from side to side without doing much mischief beyond depriving the sufferer of sight. It does not in these cases injure the brain, but passes immediately below it and through the back part of both orbits. In four such cases the recovery was rapid, but the blindness was irremediable.

283. The danger of injury to the frontal sinuses has been greatly exaggerated, and vanishes in a great degree when attention is paid to their structure. The uncertainty of the depth of the cavity between the tables of the bone, and the irregularity of the exposed surface of the inner table, which may through carelessness be mistaken for depression, should be remembered.

A soldier of the 29th Regiment was wounded at the battle of Talavera by a ball, which struck him on the lower part of the right side of the forehead, fracturing the external wall of the frontal sinus. On examination, the ball could be felt lodged in the sinus, whence it was readily removed by enlarging the opening, and the man recovered without any bad symptoms.

At the storming of Badajos, a soldier of one of the regiments engaged at the little breach was struck by a small ball about the size of a swan-shot; it penetrated the frontal sinus of the right side, and stuck in the inner table, the outer being considerably injured and splintered by the blow. The splinters having been removed, the small ball could be seen sticking in the inner table of the bone, whence it was easily extracted, leaving the dura mater bare beneath. He was sent to Elvas, and recovered with a good and firm cicatrix.

After a wound of the frontal sinus has healed, the air has been known to raise up the integuments of the forehead into an elastic crepitating swelling whenever the patient blew his nose, so that a compress and bandage on the part were required for its relief; but these cases are very rare.

284. Wounds of the bony parts within the orbit are often attended by the most serious consequences. A boy, nine years of age, was struck by his playfellow with the end of a thick iron wire on the right eye, which blackened it. There was no external wound; but as there was some bloody chemosis at the upper part and the inside, there was a probability of the wire having penetrated deeply, although the opening could not be discovered by the probe. The accident had happened two days before, but he did not think himself ill. He was well purged, and cold water was applied externally. Two days after, he complained of sickness, headache, and some pain over the brow. He was bled freely from the temple of that side by leeches, and well purged by calomel and jalap. On the sixth day his mother reported him as having been delirious and restless all night. He was found stupefied, answering with difficulty and incoherently; pulse very quick, skin hot and dry, with some convulsive twitches of the face and arms; pupils slightly obeying the influence of a strong light, but not dilated. He was again bled freely from the temple, but his breathing became more difficult, he fell into a comatose state, and died in the night. On examining the head, the stiff iron wire was found to have passed under the upper eyelid, between it and the eye, through the posterior part of the orbitar plate of the frontal bone and into the anterior lobe of the brain, which was softened at that part, and bedewed with matter.

A woman, who had been struck by her husband on the left eye with a tobacco-pipe, while preparing her frying-pan for cooking, knocked him down with the pan, and ruptured his right eye, which was lost. She then pulled out a piece of the pipe which was sticking in the orbit, between the lid and upper and inside of her own eye, which was uninjured. She complained of little but the bruise, and rather brought her husband than herself for advice. Bled and purged, she did not complain of anything for several days, when she said she had been very ill all night, with nausea, headache, and shivering; with hot and dry skin, pulse very quick, the upper eyelid paralytic; she looked very ill, became delirious at night, and died two days after the first complaint of serious illness. On examination, half an inch of the red waxed end of the tobacco-pipe was found to have gone through the sphenoid bone, by the side of the sella turcica, and to have lodged in the brain, whence it was removed bedewed with pus, the brain being yellow and softened around it.

A wound of the longitudinal or lateral sinuses, allowing a free discharge of the blood poured out, is of comparatively little consequence. It is, on the contrary, a very fatal injury when the blood is permitted to accumulate.

285. A protrusion of the brain, often improperly called a fungus cerebri, is of two kinds, and occurs at different periods of time. The first kind is principally composed of coagulated blood, usually appears immediately after, or within two days after, the injury, and is generally fatal. The second takes place at a later period, although it has occurred on the third or fourth day, and is formed for the most part of brain. These protrusions rarely take place when a considerable portion of the skull has been lost or removed, the brain then being able to expand to such an extent as the inflammatory impulse from within may render necessary. When the opening is small, and the dura mater has not been injured, it has seldom been observed. It is then principally when the opening in the skull has been of greater extent than the size of one piece of bone removed by the trephine, the dura mater having yielded either in consequence of the injury or by ulceration, that this evil takes place; it is not, under proper treatment, a fatal, although it is always an extremely dangerous occurrence.

In the first kind of protrusion, the dura mater must necessarily be torn to some extent, and the tumor which comes through it is of a dark-brown color, glazed and covered in general by the pia mater. These protrusions were accompanied, in every case I have seen, by delirium and other symptoms of inflammation of the brain and of its membranes, and not by coma, until near the fatal termination of the disease. I have seen them torn off by the patients themselves during life, or before death; and satisfied myself that they all arose from hemorrhage into the substance of the brain, probably immediately below its surface, which became more elevated as the inflammation proceeded, and was gradually protruded at the part where there was the least opposition. When the tumor was torn off, little hemorrhage ensued, but a dark-brown blood cavity was seen in the substance of the brain; and when cut off and examined, the protruded part seemed to be covered by the pia mater, with or without a layer of cerebral matter, and was made up generally of coagulated blood. No case of this kind recovered.

In the second kind of protrusion, or that which usually although not necessarily takes place when the first or active inflammatory symptoms are on the decline, the tumor is formed of the substance of the brain. It has been supposed that in whatever manner a case of hernia cerebri may arrive at a favorable termination, there must inevitably be a loss of brain proportionate to the extent of the protrusion—a conclusion which the experience of the Peninsular war did not confirm, while it may lead to the establishment of an erroneous practice for the too early removal of the protrusion. The loss of a portion of one of the hemispheres of the brain is now known to occasion little or no inconvenience in many instances, either to the intellectual or corporeal faculties; nevertheless, as the precise quantity of brain which a person may lose with impunity has not been ascertained, it may be as well not to deprive a patient of any, provided its removal can be dispensed with; and that it may be so dispensed with, the practice of that war gave positive proof in several instances, by the protruded part being gradually withdrawn within the skull, the wound having afterward healed by the ordinary processes of nature.

There were three cases of recovery from a protrusion of the brain after the battle of Toulouse.

Bernard Duffy, 40th Regiment, aged twenty-four, was wounded on the 10th of April, and admitted into the Caserne de Calvete Hospital, on the 13th, with fracture and depression of the upper part of the os frontis. Some portions of detached bone were removed; he was largely bled and purged.

On the 14th, he complained of severe pain in the head, giddiness, dimness of sight, and drowsiness. The pupils were much dilated; pulse 60, and full. An incision was made down to the bone, and the divided arteries were allowed to bleed freely. One perforation was made by the trephine, and the whole of the detached and depressed pieces of bone, which were of considerable size, were removed, one of them having penetrated the dura mater.—15th. Has less pain in the head; pulse full and slow; pupils dilated, with a tendency to coma, but he is sensible when spoken to. V. S. ad ℥xxiv. Continue the purgatives.—18th. Is less drowsy; pupils more contracted. The surface of the dura mater is sloughy, and a small, dark-colored excrescence is rising up through the opening in the cranium.—22d. The fungus cerebri has considerably increased in size during the last few days; in other respects he is doing well.—24th. The wound looks clean; the discharge is healthy. The fungus increases in size, and is rather above the edges of the wound; some sloughs have separated from it, and it has now a red and tolerably clean appearance.—26th. The wound granulates regularly; the excrescence seems to enlarge rather at the base than at the upper part; it was touched slightly with lunar caustic without any pain or unpleasant symptom being produced.—30th. Continues doing well. The pupils are still somewhat dilated, but contract readily on the admission of light; appetite good; bowels regular; and the patient says he has no complaint. Discharge from the wound healthy; the fungus is prevented from increasing by a slight application of the argenti nitras every second day. He has not required any medicine for some time past.—May 6th. The wound has closed around the fungus, which is a little above its edges; it is touched slightly every day with lunar caustic or the sulphate of copper. The pulsation of the brain elevating and depressing the fungus is perfectly distinct; no constitutional derangement. Was discharged cured to Bordeaux.

William Donaldson was admitted, on the 13th of April, 1814, into the Dépôt de Mendicité Hospital, having received a gunshot wound in the head on the 10th of April, which fractured the right parietal bone to a considerable extent. The brain protrudes; pulse quick and small; bowels open. V. S. ad ℥xvi.—14th. The pulsation of the brain is evident, and the protrusion increases; he complains of no particular pain; the discharge is profuse, and of a thin, black, watery quality; pulse 90; bowels freely open. V. S. ad ℥xvi. Continue the purgatives.—15th. The pulse and bowels natural, the protrusion has scarcely increased; discharge profuse, and still gleety; a small compress was laid over the dressings, and a bandage was lightly applied.—16th. Pulse and secretions natural; the wound looks more healthy; the discharge something better in appearance; the fungus does not increase.—19th. Is doing well, and does not complain of pain; functions natural; the protrusion somewhat less; discharge good. A small quantity of cloth has come away.—21st. Discharge improved. Continue the purgatives.—26th. The protrusion evidently diminishes, and begins to heal at the edges.—30th. The hernia cerebri has considerably diminished; secretions natural; a small quantity of bone has come away; discharge diminished.—May 4th. The wound is healing rapidly; the patient is now permitted to get out of bed, and has half diet. Another very small piece of bone has come away.—10th. The wound is now nearly healed.—Between the 15th and the 25th several small pieces of bone came away.—On the 26th, on introducing the probe, a small piece of bone followed it; and on further examination a large piece was felt quite loose, and was removed by incision. Discharged cured to Bordeaux.

Gentle pressure was made on the protrusions, according to the feelings of the individuals, in both these cases; when made too firmly, it gave rise to swimmings and pain in the head, retardation of the pulse, a sense of sickness and fainting, and on one occasion to syncope. Pressure could only be borne when very lightly applied while the protrusion was increasing, but could be gradually augmented when it became stationary, and during its diminution and secession. The pressure was continued until after the wound had healed.

I had occasion, at Santander, to remove a portion of bone, including the upper part of the lambdoidal suture of the right side, from the head of a soldier of the Light Division, in consequence of symptoms of irritation having come on after an irregularity in drinking. He had been wounded by a musket-ball on the heights of Vera, which had fractured and depressed the skull at that part some weeks before. A piece of bone was depressed, and had irritated the dura mater at the part; the membrane had some matter upon its surface, and was evidently abraded. The operation gave relief, but a tumor soon sprang up, evidently composed of brain. The patient was again bled, purged, and starved; calomel and opium were given in moderate doses, and the protrusion ceased to increase; about the same time it changed color, became yellow, fetid, softer, and soon wasted away, pieces of dead matter separating at each dressing, until it sunk within the level of the skull; after which healthy granulations sprung up, and the wound healed.

In the fatal cases, paralysis, accompanied by stupor and other symptoms of compression of the brain, invariably supervened before death.

The preceding cases prove that persons may recover after having had a protrusion of the brain, without as well as with the loss of a portion of its substance, the difference in all probability between the cases being dependent on the degree of mischief which gave rise to them. In the fatal cases I have seen, the protrusion was manifestly a part of the substance of the brain, and firmer than the hemisphere beneath, which was soft, pulpy, and of a yellow and sometimes of a reddish color, the lateral ventricle being filled with a sero-purulent matter, pus being also spread over the surface and intermingled with the pulpy structure, into which the brain had been changed. The protrusion was the consequence of low inflammation of the brain; and greater caution had been necessary during the progress of the mischief than had been enforced. It was the observation of this, and of other circumstances not less important, which led me to enjoin that rigid system of management insisted upon in all cases of injury of the head. There can be no doubt that the formation of many of these protrusions was aided by the opening made in the dura mater, which would have restrained their growth if it had been sound. The dura mater therefore should never be opened if it can be avoided.

It has been proposed to destroy protrusions of the brain with escharotics, and by ligature; and more faith has sometimes been placed in the knife for their early removal than in the more deferred operations of nature. Greater reliance may, however, be placed on the efforts of nature, assisted by a methodical treatment of the low inflammatory state of the brain, and by such pressure at a later period as can be borne with comfort, and persisted in with propriety.

286. It has been supposed that abscess of the liver followed injuries of the head in a more peculiar manner than injuries of other parts of the body, an opinion upon which too much reliance should not be placed; for experience has induced me to think that unless the liver be really injured by a fall or blow, it only becomes affected in a secondary manner, in a similar way to the lungs or other viscera, or to the joints or other parts. The new disease in these cases is always insidious in its nature and progress, and for the most part fatal in its result, as has been explained at length, (Aph. 59, p. 62, et seq.)

287. When a person has received a serious blow on the head, which has given rise to an exfoliation of the bone, or to a very slight depression of the skull, he is rarely restored to his previous healthy and natural state. The scalp adheres firmly to the bone beneath, instead of sliding loosely over it, and a deep hollow is formed, which would imply that greater mischief had been done and a greater loss of bone had been sustained than had actually occurred. This is the more remarkable when pieces of bone have been removed. Major D., of the Indian army, was wounded on the left side of the forehead, at its upper part, by a musket-ball, at the assault of Maheidpoor. Several pieces of bone were removed, and the pulsation of the brain was evident under the discharge. The point of a little finger passes into the hole left by the cicatrization of the wound, to a greater extent than might be expected. This officer suffers from headaches, augmented or brought on by any exertion of body or mind. He cannot bear exposure to the heat of the sun. He can scarcely drink three glasses of wine without feeling their effect. Persons so afflicted can bear no great exertion of any kind. They fall down under exposure to heat. They are easily inebriated, rendered furious by a small quantity of liquor, and often become stupefied, comatose, or even die suddenly. In addition to these evils, which may be avoided by care, many are subjected to fits, which are apparently epileptic; and others suffer from such intolerable pain in the part injured, as well as in the head generally, as to be desirous of seeking relief by an operation, even at the risk of life.

These injuries are often accompanied during their progress by mental defects which time does not always remove. The memory is very often much impaired; it is frequently defective as to things as well as to persons. The sight of one or of both eyes may be impaired, or even lost. Ptosis, or a falling of the upper lid, is not an uncommon although a more curable defect. Speech is not only difficult, but the power of uttering certain words is often lost; a language is occasionally for a time forgotten, and a sort of conventional one has even been adopted, under my own observation. The more serious evils which befall these unfortunate sufferers are aberrations of mind, rendering some degree of restraint necessary, or a state of fatuity, which is not less distressing. These intellectual defects are often accompanied by various states of lameness or debility, from which there is but little hope of recovery. Pathologists have supposed that concussion of the brain is frequently accompanied by, and may indeed be essentially dependent on, small extravasations of blood in various parts of or throughout the brain, not larger than the point or head of a small pin, constituting, in fact, a derangement which, when general, is destructive of life, and, when partial, may sometimes be the cause of the various defects which follow injuries of the head.

288. It is an interesting fact that a person who has been shot in the head, or has fallen from the top of a house, so as to become insensible, has no knowledge of the circumstance; and when, after several days or weeks, he regains his senses, he has no recollection of the injury, or of having received the wound; or if he should have fallen from a height, he only remembers that he was aware he was about to fall, but of the actual descent, or of the injury, he knows nothing.

289. The trephine, which is worked by turning the hand, and makes therefore only a half turn, necessarily saws unequally; but the operator has the advantage of being able to press with it on any particular part as the sawing of the bone draws to a close, and can thus cut any portion of the bone which is thicker than the rest without wounding the dura mater. The division and yielding of the last layer of bone is very sensibly felt by the hand, and when sawing, the surgeon can use the trephine as a slight lever with great effect, by pressing on a particular part, or from side to side, and the inner layer of the vitreous table may be in this manner as much broken as sawn through. The piece to be removed should never be brought away in the crown of the trephine, but should be raised by the forceps and lever; whenever a rough edge of the inner table remains, it should be carefully rounded off with the lenticular or blunt-ended instrument commonly used for that purpose.

290. Whenever there has been a loss of the integuments or scalp, so that this part cannot be brought over the opening made by the removal of the bone, some fine soft cotton should be laid on the dura mater, so that a slight degree of support may be given to that membrane, more particularly when it is thought that it may not be necessary to examine it for two or three days. When circumstances appear to render a daily inspection necessary, the cut portions of the scalp should be brought over the opening, and retained by a slight compress and bandage kept constantly wet and cold. The dura mater usually changes color and becomes more red; a layer of lymph is seen adhering to it, from which granulations arise and spring up until they touch the scalp, to which they unite, or cicatrization takes place. When the patient dies early from other causes, and the calvarium has been raised, the discolored spot on the dura mater marks the place from over which the bone was removed. I have seen this in a state of slough, and the only apparent discoverable mark of disease.

One of the improvements in modern surgery is to be found in the restriction which has gradually been placed on the repeated use of the trephine on the same person, and on the removal of large portions of the skull. Cases are not, however, wanting in the older authors which would appear to justify the proceeding, although it may perhaps be said that they only show how great an extent of injury may sometimes be committed with impunity.

Saviard trepanned one person twenty times. Russ Martel and Le Gendre, surgeons to the King of Navarre, say that in the year 1686 they took away nearly both parietal bones, and the patient recovered and lived for thirty years afterward, half his body, however, being paralyzed. Marechal applied the trephine twelve times successfully, Gooch thirteen times, Desportes twelve times. Saviard says that he had under his care a woman whose parietal bones, together with a great part of the occipital and frontal, separated at the end of two years after a blow; the bones thus separated resembled a calvarium sawn off a dead person. No fungus or hernia took place, and she lived for several years afterward.

Dr. Drummond, deputy inspector-general of hospitals, has published the case of a seaman belonging to H.M.S. “Mutine,” who in 1845 fell down some stone steps at Sierra Leone, receiving a contused wound on the scalp, for which he was admitted into the Royal Naval Hospital at Plymouth in October of the same year. The bone, which was not supposed to have been injured, was then found to be denuded of its pericranium to some extent, (left side of occipital.) After an attack of erysipelas, followed by numerous purulent deposits under the scalp, necrosis went on rapidly; there was oozing of pus from beneath the diseased bones, and gaping of the coronal and sagittal sutures, the brain pulsating very distinctly in the spaces. In July, 1846, he was removed to Melville Naval Hospital at Chatham. During the six years he has been under observation, there have been repeated attacks of erysipelas, followed by profuse suppuration. Both tables of the bones have suffered in some places; in others only the external. About five square inches have been lost from the right side of the frontal, right parietal, and squamous part of the right temporal. The whole of the occipital to within a short space of the foramen magnum is deficient, with the exception of about two inches in the center of the bone, which are now undergoing the process of separation. On the left side, Dr. Drummond adds, there has been less destruction of the bones, but extensive caries was going on there, and fetid pus was being discharged from several openings at the date when the case was reported, (April, 1851.) At no point was there any tendency to reproduction of bone, or arrest of the disease.

291. The removal of a large portion of the skull may be necessary where the broken portions are deprived of their natural support and connections, but as little should be taken away as possible. When the loss of sense and motion is accompanied by fracture, and continues to increase rather than to diminish, after the necessary and usual means have been adopted for its relief, a piece of bone should be removed. If blood should be found in any quantity on the dura mater, it may be necessary to take away more bone to admit of its free discharge; for although the gradual pressure of the brain from within will tend to expel it, this object may not be attained in sufficient time, and the patient may be lost. The older surgeons in these cases were anxious to ascertain how far or to what extent the dura mater was separated from the skull, and they often removed large portions of bone accordingly; although their practice should not be implicitly followed, repeated observation has shown that modern surgeons have often fallen too much into the opposite extreme of doing nothing. When blood has been evacuated in this manner, the parts must pass from a state of inflammation into that of suppuration before the dura mater can again adhere to the superincumbent bone, and care must be taken that the matter shall have a free discharge. If symptoms of fever, followed by those of commencing compression, should supervene from the granulations arising from the dura mater filling up the opening and preventing its exit, they should be excised; or if the matter should have gravitated in a direction which does not admit of its being discharged, the opening in the skull should be increased so as to remove the impediment, and thereby lessen the danger.

A layer of blood is often extravasated very thinly over the whole surface of the brain and cannot be removed, although it may be absorbed. It is, on the other hand, often collected in larger quantity on the basis of the cranium, whence it will not be absorbed and cannot be removed. It may be extravasated without reference to the part on which the blow has been received, giving rise in the end to symptoms of epilepsy or apoplexy, for the relief of which no surgical operation can avail; but when a blow has been undoubtedly received on a part of the skull, and any sign of mischief can be perceived on or in that part, the removal of the bone is permissible.

292. The wind of a cannon-ball has been supposed to exert some influence on the brain when passing close to the head; there is, however, no valid foundation for the opinion. An officer of the fifth division was struck by a cannon-shot, during the assault of Badajos, on the right side of the head and face. It carried away the right eye and the whole face, the left eye hanging in the orbit, the floor of which was destroyed. A part of the lower jaw remained on the left side, but a great part of the tongue was gone. He had lost a large quantity of blood, but was quite sensible. In the middle of the next day he suffered much from the want of water to moisten his throat, which could not be procured. After a distressing delay of three or four hours under a hot sun, a small quantity was obtained, the arrival of which he observed; and while I was giving directions relative to its distribution, I felt a gentle tap on my shoulder, and on turning round saw this unfortunate man standing behind me, a terrific object, holding out a small cup for water, not one drop of which he could swallow. Alone among strangers, he felt that every kindness in our power to offer was bestowed upon him, and he contrived to write his thanks with a pencil, which he gave me when he pressed my hand at parting at eleven at night. I was glad at sunrise to find he had just expired.

293. When a portion of bone is as it were sliced off with the scalp and adheres to it firmly, the scalp and bone should be reapplied; and the cure will often be effected without difficulty. When the portion of bone cut off and hanging to the scalp, which is turned down, has but little adherence, it should be removed.

A German dragoon was brought to me in front of Madrid, who had received a slicing cut of this kind on the top and side of the head, which caused a portion of the scalp and parietal bone to be turned down over the ear, uncovering the dura mater. Replaced and retained in its situation, the flap and bone appeared to adhere, and the man recovered. In the case of a Portuguese soldier cut down by the French cavalry in a sortie during the second investment of Badajos, a portion of bone cut off with a flap was quite loose, and was removed. The patient did equally well.

In the museum of the Royal College of Surgeons there are ten skulls which have suffered from very severe slicing cuts. They appear to have been collected from the burial-place of some establishment for invalid soldiers in Germany. The portions of bone thus sliced, and they are large pieces, were once detached, and afterward reunited a little out of their proper places, so that the points of separation and of union can be distinctly seen. These fissures are all in a certain state of progress toward being filled up by bone, and the patients must have lived some months, if not years, after the receipt of their respective injuries; for bone is deposited apparently with difficulty and most carefully in all such cases, so as not to irritate the membranes of the brain. The opening in the first instance is filled up by granulations, over which a thin skin is formed; this afterward becomes firmer and harder, being in some cases, where the trephine had been used, a thin but strong membranous expansion extending from one edge of bone to the other. In others it is thicker and more solid, and in a few instances osseous matter is deposited in its circumference, so as in part to fill up the opening, the edges of the bony circle made by the trephine becoming gradually thinner as they appear to grow inward. It is common for an exfoliation to take place in such cases from the edges of the cut bone, and from the circle made by the trephine. It has been occasionally observed, after death, that the circular cut edge of the bone does not become thin in the manner described, but that a sort of ridge forms around and within it.

When the scalp is torn down without being much bruised, and a large flap extending from the occiput to the forehead falls down on the shoulder, covered with blood or dirt, the flap should be cleansed and restored to its place. When it is large, two or three sutures may be necessary to keep it in its proper situation. The flap may not entirely adhere under any management, but it will do so in parts; and care should be taken to evacuate at an early period any matter which may form by small but sufficient incisions made where required; this will in general be above and about the ear. When the flap is much bruised, the attempt at adhesion by close apposition will be useless until after suppuration has taken place, when a well-regulated pressure will do much toward expediting the cure.

294. Erysipelas occurs in two forms: when the skin has the ordinary redness characteristic of the complaint, and when the color of the skin is not altered or is whiter than natural, but puffed, tense, and shining, the inflammation being seated beneath the tendinous expansion of the occipito-frontalis muscle.

The general treatment should be regulated by the powers of the patient and the state of the constitution, (Aph. 24, page 39.) The local treatment of the first form essentially depends on puncturing the red and inflamed skin all over with the point of a lancet, assisting the flow of blood by warm fomentations. The punctures should be repeated, if necessary. The second form is to be treated by incisions, perhaps the greatest improvement of the surgery of the Peninsular war.

The scalp in such cases is in a state of general puffiness, causing the head to look considerably larger than usual, but without redness; it retains the impression of the finger. Incisions are to be made in the scalp from two to four or six inches in length, united by others, if necessary. The scalp will often be upward of an inch in thickness, and filled with a fluid partly serous, partly purulent. The small arteries bleed freely, and should be allowed to do so as long as may be desirable, when the hemorrhage should be arrested by pressure. The head should be fomented. The essential points are, to take off tension, and to allow the free discharge of any fluid which may be secreted. The moment the parts around a wound have become puffy, the surface of the wound changing from a red to a yellowish color, with a thin discharge instead of good pus, an incision should be made through them, and repeated, if necessary. It relieves the tension and the irritative fever, and prevents the delirium which would follow; which neither bleeding, purging, nor the other constitutional remedies which the state of fever may indicate will remove. If it should be neglected, suppuration and sloughing will extend under the tendon of the occipito-frontalis, or the fascia of the temporal muscle, and the greatest danger will be incurred from this additional cause.