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 XVII.

WOUNDS OF THE HEAD.

253. Compression of the brain means a diminution of the size of certain parts of it, resulting from the pressure of an extraneous body, whether it be fluid or solid, in consequence of which particular symptoms are generally known to ensue. When they occur, it is said that the sufferer is laboring under symptoms of compression of the brain, and apoplexy from the rupture of a blood-vessel may be considered as the best form or illustration of the complaint. These symptoms sometimes take place from the presence of a foreign substance, such as a point or piece of bone, which from the smallness of its size can hardly compress, although it may displace; and it is then said that the symptoms arise from irritation of the brain. Many of them have also been found to occur from loss of blood, or the absence of pressure, or from insufficient pressure arising from changes in the circulation; and several different opinions have been entertained on all the points connected with these subjects. It has been argued that as the brain is incompressible, no compression can take place. There is no proof, however, of the fact of its being incompressible as a whole, although it has been stoutly maintained by Monro secundus, Sir C. Bell, and others.

The brain is surrounded by membranes capable of secreting a halitus or a fluid whenever it may be necessary to fill up space; it is intersected by partitions apparently for the prevention of jar and pressure, and is permeated in every part by vessels of various sizes, both venous and arterial. It has been presumed that it contains at all times the same quantity, or nearly the same quantity, of blood, in consequence of its freedom from atmospheric pressure, through the intervention of the bones of the skull. If this conjecture be correct, the quantity cannot be materially increased, unless something be displaced to make room for the addition; nor can it be essentially diminished without something being added to supply its place. The question turns, however, very much on the words “materially increased or diminished;” for a very small additional quantity may be the cause of serious mischief, and the subtraction of even less may give rise to great cerebral disturbance; but there can be little doubt that the actual quantity contained in the head is less at one time than at another, the deficiency being usually on the side of the arteries; when congestion takes place, it is for the most part venous. When a person is about to faint on the first passage of a catheter through the urethra, the blood deserts his face, he feels sick, his pulse nearly ceases, and he would faint if he were allowed to remain in the erect position. Let his head now be bent down between his knees for a minute; his face fills with blood, his brain does the same, and he recovers almost immediately. Young ladies, when about to faint, are prevented from doing so by these means being adopted, which they declare, nevertheless, to be very unladylike, although they may be doctorial and effective.

254. The motions of the brain covered by the dura mater are but little observable under ordinary circumstances when a circular portion of bone has been removed by the trephine; the surface of the dura mater remains in general perfectly LEVEL; it is of a reddish-silvery color, and is firmly attached to the cut edge of the bone. The surface is raised, however, on a full expiration, and it falls on a deep inspiration. Fluid secreted or placed upon it is seen to move synchronously with the pulse; but the dura mater never rises up into the hole made by the removal of the bone, unless some fluid be retained beneath it. If the quantity of fluid extravasated or collected under it be large, it rises immediately on the removal of the bone; but the protrusion of this membrane does not always take place for some hours afterward if the fluid be more diffused. The motions of the brain, when the dura mater is thus protruded into the opening, become very indistinct, even if they can be perceived. These two points, viz., the protrusion into the opening and the absence of pulsation, are important facts, little noticed by surgical writers, to be borne in mind in connection with the practice to be pursued.

If we sometimes see the natural and ordinary size of the brain diminished under pressure, and that certain symptoms, such as insensibility, syncope, convulsions, and paralysis, are consequent on this state, and are relieved by the removal of the pressure and the restoration of the compressed brain to its ordinary state, we may safely conclude that some derangement takes place in its integral parts, which may be best understood by the word compression. If we further consider that compression can rarely exist without irritation, and that sometimes of a formidable nature, there does not appear to be so much difficulty in the subject as is frequently represented, although the physiological explanation may not be so simple. In the present state of our knowledge, we apprehend that in many cases approaching to apoplexy, in which the symptoms are similar to those arising from compression, all, or nearly all, the vessels, as far as we can ascertain, are actually full of blood, instead of being partially empty and containing less than the natural quantity. When we see a patient, lying in a state of insensibility with a fracture of the cranium, immediately recover his senses after the application of the trephine and the removal of a large coagulum of blood, we are apt to suppose that the coagulum of blood and the insensibility stand in the relation to each other of cause and effect. It is not unreasonable to conclude that the pressure of the extravasated blood confined by the bone had occasioned the insensibility, and that this did not depend alone upon some few vessels containing less blood than usual; for the brain must be considered as a whole in all these investigations, and reference should not be made to its vascular structures only in explanation of the cause of its derangements.

255. When compression of the brain is caused by an extravasation of blood, the patient is insensible, breathes slowly, loudly, and in a heavy, labored manner, or with stertor, and cannot be awakened, although the noisy breathing may be for a time suspended. The breath is sometimes emitted from the corner of the mouth, like a whiff or puff of smoke, and with something of a similar noise: this, when permanent, is a more dangerous symptom than the common snoring or stertorous breathing. He sometimes froths at the mouth, and occasionally appears convulsed, but neither hears nor sees, nor takes the least notice of those about him. The countenance is generally flushed if the shock or blow has been slight, pale or livid if it should have been great. The pulse is usually slower than natural, sometimes irregular or intermitting, occasionally quick, even from the receipt of the injury. The pupils of the eyes may be contracted or dilated, being dependent for their condition more perhaps on the part of the brain affected than on the degree of injury. They are generally more contracted in the first instance than dilated; they may afterward pass into a medium or doubtful state; one may be even dilated, and the other not. In general, as the mischief is continued and augmented, they become dilated and immovable. The eyes may be turned upward, or may be fixed in the center, or be drawn irregularly outward or inward, causing strabismus, which is, however, a more rare occurrence. If the eyelids should be partially open, tickling the cilia or the conjunctiva of the ball with a straw or a feather will cause them to close, if the spinal cord be sound. The mouth and lips are more or less compressed, and fluids run out at the corners, unless placed on the very back of the tongue by a long, narrow spoon, when they are swallowed with difficulty. Paralysis of one side of the face and hemiplegia are common; paraplegia is more rare. In both kinds of palsy one part in one limb may be more completely affected than another, in which convulsive twitchings are sometimes present, as well as a frequent drawing up of the limb of the unaffected side. Tickling the soles of the feet or the palms of the hands will sometimes cause retraction of the toes or fingers when the limbs are apparently motionless; pricking them gently with a pin will often give rise to convulsive startings and tremblings of all the muscles of the extremity when tickling fails, showing that the capability to move the part remains, although the will to do so is wanting. The leg or arm is sometimes drawn toward the body when separated from it; it more often falls from the hand as if it belonged to the body of a dead person; the muscles are occasionally more stiff and rigid, and some power of motion remains, although but little of sensation; sometimes sensation is perfect when motion is lost, and sensation may be lost on one side and motion on the other. The urine at first retained may ultimately pass involuntarily, as well as the feces; nevertheless, irritating the verge of the anus will excite motion and contraction in the sphincter ani, if the functions of the spinal cord be not destroyed. The action of the involuntary muscles is little impaired in general, and the secretions are but slightly affected; when it is otherwise, the injury must have extended to the ganglionic system, and the whole of the nervous centers must be materially implicated.

The loss of motion, or of the power of moving parts of the body, is either perfect or imperfect according to the degree of injury which has been inflicted, varying from a sense of feebleness to an almost utter incapability of moving the part. It is accompanied in general by defective sensation, or numbness, or by the complete loss of sensation and of the power of resisting heat and cold; the whole side, or one extremity, or a part only of an extremity may be affected, and not the whole. The mischief which gives rise to the loss of motion usually occurs on the side of the brain opposite to that part of the body which is paralytic. This was known and stated by Hippocrates, and the subject has been pursued to the most complete demonstration by modern anatomists.

The pathological proofs are not less complete. Desault and Bichat were by no means satisfied that the paralysis which followed an injury always took place on the opposite side; and some pathologists since their time, while admitting the fact, have shown that there may be exceptions. It is acknowledged, although it is not clearly and satisfactorily accounted for as to the face, that an extravasation of blood into one hemisphere of the cerebrum, or even of the cerebellum, can cause paralysis of the complete half of the body on the opposite side. It has been demonstrated that the right side of the body and the left side of the face may be paralytic at the same time and from the same injury apparently of the left side of the head, the mischief which caused the paralysis of the right side being found, in by far the greater number of instances, on the left side of the brain, and that which gave rise to the paralysis of the left side of the face to have been caused by an injury in the course of the portio dura of the seventh pair of nerves when about to leave, or after it had left, the brain.

Burdach found, in 268 cases of lesion of one side of the brain, that 10 presented paralysis on both sides of the body, and 250 of one side; in 15 of these the paralysis was on the same side as the injury. Convulsions took place in 25 cases on the same side as the disease; in 3, on the opposite side. In cases of lesion of one corpus striatum, there were, in 36 instances, paralysis of the opposite side, and 6 with convulsions of the same side, and in no instance convulsions of the opposite side. In 28 cases of cerebral lesion of one side, the muscles of the opposite side of the face were paralyzed; in 10, those of the same side. Paralysis of the eyelid was in 6 cases on the same side, in 5 on the opposite side. Paralysis of the muscles of the eyeball occurred in 8 cases on the same side, in 4 on the opposite; paralysis of the iris, in 5 cases on the same side and in 5 on the opposite, the tongue being generally drawn toward the paralyzed side of the face.

A man fell down stairs and received an injury on the head from the fall which rendered him nearly insensible at the moment. There were no signs or appearances on the outside of the head indicative of any serious mischief, nor were any found on examination after death. The pulse was quick, and rose to 140; the left side was paralytic; the breathing not stertorous, but accompanied by a little puff on the right side of the mouth; the pupils somewhat dilated; he could not speak, convulsions supervened, and he died the day afterward. On dissection, the peculiar flatness of the convolutions of the brain on the right side was so remarkable, when compared with that of the left, as to leave little doubt of its having been occasioned by something which had pressed them forcibly upward against the inside of the cranium; and, on slicing off a portion of the brain, a larger coagulum of blood was found below than is usually observed to exist without the almost immediate death of the patient. The same thing has been so distinctly marked in other instances that no doubt can be entertained of those convolutions of the brain which were situated between the coagulum and the cranium having undergone a considerable degree of compression. It is worthy of remark that the pulse of this person was always regular and remarkably quick from the first examination after the receipt of the injury until the period of his death, showing, perhaps, that the action of the heart is not affected directly by pressure acting only on the upper surface of the brain.

256. Convulsive actions of the muscles, or positive convulsive fits, are always important symptoms; yet they seem in some persons to be dependent on idiosyncrasy, particularly when they appear early, and after the loss of blood, in which case they are less dangerous. They occur at different periods after the receipt of the injury, and have been supposed to depend in general upon laceration of the substance of the brain, although experiments on animals would seem to show that they may be caused directly by irritation of the cerebro-spinal axis within the skull, in which case the patients are more likely to recover. They have been observed particularly on the side opposite to that which is paralytic, so as to give rise to the idea that the paralysis is dependent on injury of one side of the cerebrum, and convulsions on injury of the other. When the effect of the mischief is so great as to cause complete paralysis, convulsive twitches do not take place, although they frequently precede, and may in many cases be considered as premonitory signs, while the evil which gives rise to the paralysis is gradually accumulating. When the paralysis is not complete, the side so affected suffers sometimes from slight convulsive twitches, while well-marked spasms prevail in the other, leading to the belief that, while paralysis is an affection of only half the brain of the opposite side, or of half the spinal marrow of the same side, convulsions are the effect of a more general irritation, capable, however, of being confined to a part; for partial convulsive motions do very frequently occur without any paralysis accompanying them on the opposite side. Several cases have occurred in which the convulsions have ceased, and the patients recovered after the removal of a portion of bone which was irritating the brain; but convulsions have generally been the forerunners of death when the seat of injury was unknown and effective relief could not be given. When they occur in cases apparently of pure concussion, accompanied by inflammation of the brain or of its membranes, and the patient recovers after many days of the strictest antiphlogistic treatment, it is possible that the brain may have been lacerated, and the cure have been effected by adhesion. Convulsions, it must be remarked, are among the most common symptoms of inflammation of the membranes of the brain, without any such lesion of its substance, although they are frequently wanting. They may be expected to take place about and after the fifth day in injuries of the head, when inflammation of the brain or of its membranes is about to extend to or to become continuous with the neighboring parts, and may be more or less severe, varying from a state of partial trembling of a limb to that of general agitation and restlessness of the body generally—from a slight, irregular movement of the eyelids, or of the muscles of the face, to the more marked spasmodic startings of the whole of one side, grinding of the teeth, and contraction of the limbs. It is far different with those convulsive movements which, at a late period, become nearly permanent, or with rigid spasms, resembling tetanus, in which the body is drawn in different directions, forward, backward, or to one side. These are for the most part forerunners of death. Examination after death, in such cases, has frequently shown nothing discoverable beyond inflammation of the pia mater, and an effusion of fluid, generally purulent, on the surface of the brain, or in its ventricles, or between the pia mater and the tunica arachnoides.

The three following cases are intended to show the different forms of paralysis that ensue after injuries accompanied by compression or irritation of the brain:—

Charles Murray, private in the 2d battalion of 1st Foot Guards, aged thirty-three, was wounded on the 18th of June, at Waterloo, by a piece of shell which struck him on the superior part of the left parietal bone. He remained insensible about half an hour, and on recovering from that state, was affected with nausea and some bleeding from the left ear, and found himself unable to move his right arm and right leg, which hung as if they were dead, and had lost their feeling. Admitted into the Minimes General Hospital at Antwerp on the 29th; he suffered much from pain in the head, which was relieved by his being twice bled. The paralytic affection having remained without change from the moment he was wounded, a piece of the parietal bone, about three-fourths of an inch long, and several smaller fragments, were extracted four days after admission into the hospital, two perforations with the trephine having been necessary. Immediately after the removal of the bone he recovered the use of his right arm and leg, so far as to be able to move them, and to be sensible of their being touched. He gradually recovered by the 14th of August, so as to be sent to the General Hospital at Yarmouth, never having had a bad symptom, the only defect remaining on the right side being an inability to grasp anything in his hand with force. The pulsation of the brain was still visible at the bottom of the wound for about the space of half the circumference of the crown of the trephine. September 16th, 1815: the wound has filled up with healthy granulations, and has nearly cicatrized. A small sinus remains at the superior part, through which the edge of the bone can be felt. His health has been invariably good, although he has suffered a good deal of pain twice previously to the coming away of little pieces of bone, and toward evening he has been generally subject to slight vertigo. Discharged cured.

William Mitchel, of the Royals, aged forty, was wounded by a musket-ball on the 18th of June, at Waterloo; it struck the side of the head near the vertex, and, passing across through the sagittal suture, fractured and depressed both parietal bones. When he had recovered his senses he suffered great pain in the part, and found that he had lost the use of BOTH his legs, and was benumbed even from the loins and lower part of the chest; he was often sick, and felt low and ill. On the 28th, ten days after the battle, the trephine was applied in two places, and the whole of the detached and depressed portions of bone were removed. The sickness, lowness of spirits, and general illness immediately subsided, and the loss of power in the lower extremities gradually began to diminish, but he was not able to walk without assistance until the first week in August. On the 10th he arrived at Yarmouth, not having had a bad symptom after the depressed bone had been removed; and by the end of September he was discharged, able to walk well with the assistance of a stick.

Mr. Keate has mentioned to me a case, in which the injury and the paralysis were apparently on the same, or the right side. The paralysis, although positive, was not so complete as to render the patient quite incapable of moving the arm and leg, which were frequently convulsed, but the convulsions, which were observable in both, were more marked on the opposite or left side. On examination after death, the most serious injury was found to be a fracture of the right parietal and temporal bones, extending to the petrous portion of the latter, and beyond it; this, with a rather large extravasation of blood under and in the course of the fracture, appeared to be sufficient not only to destroy life, but to have caused paralysis of the left side, which, however, it did not do. Another extravasation, rather less in quantity, had, however, taken place under the upper and anterior portion of the left parietal bone, which enabled Mr. Keate fully to account for the paralysis which took place on the right side. According to the surgery of the French Academicians of the beginning of the eighteenth century, this man would have been trephined or trepanned on the left side of the head in search of an extravasation by contre-coup; but accident or chance alone could have led to the right spot, as it was by no means opposed to that on the other side.

257. A simple fissure or fracture of the skull is of no more importance than a fracture of any other bone in the body, unless it implicate the brain; it should be managed according to the ordinary principles of surgery. These principles, however, involve a treatment diametrically opposite to that practiced by many surgeons, almost unto the present day.

If the integuments or scalp be divided, and the bone fissured, these principles should be carried out, by endeavoring to procure the union of the divided parts, as was generally done during the war in all such injuries from sabre-cuts as did not quite penetrate the skull—a practice that was found to be eminently successful, even when union did not take place. The general treatment should be similar to that insisted on in concussion, of which the following may perhaps be considered a sufficient example:—

A soldier in Lisbon, partly in liquor, received a blow from a spade which cut the upper part of the head across the sagittal suture, and rendered him senseless. He soon got better, and a slight fissure or fracture without depression was discovered. His head was shaved, kept raised, wet and cold, and the divided parts brought together by sticking-plaster; he was bled to twenty-four ounces, purged, starved, and kept quiet in a dark room. Slept well, but said that his head felt painful, as if something tight was tied around it. Pulse 96, small and hard; bowels not open. Blood was taken from the arm to the amount of forty ounces, when he appeared about to faint. Calomel and jalap, followed by infus. sennæ cum magnes. sulphate, were given, and acted well, and he was greatly relieved. The calomel was continued every six hours. In the evening, however, the pain and tightness of the head returned, with a pulse of 110, hard and full; these symptoms were removed by the loss of twenty-four ounces of blood. He remained easy until the evening of the next or the third day, when the pulse quickened to 120, became small and hard, and he complained of severe pain in the head. It was evident that inflammation of the brain or of its membranes had commenced, and that it must be subdued; he was therefore bled until he fainted, forty ounces having been taken away. This entirely relieved him, and calomel and jalap, senna and salts were again administered with great effect. On the fourth day he was easy, the pulse 94, soft and full, the mouth being tender from the mercury. The wound did not heal by adhesion, but by granulation; and under the continuance of the starving and purging system he gradually got well without any more bad symptoms, having been saved by the loss of one hundred and twenty-eight ounces of blood in three days.

The vigorous and decided abstraction of blood saved the man, and, with the mercury, in all probability prevented the occurrence of those evils which our predecessors sought to obviate by removing a portion of bone. They believed the bone could not be fractured without an extravasation taking place beneath; and some took credit to themselves for placing wedges between the broken edges, in order to allow the escape of the blood or of the matter which might be formed below it. That blood may be effused, and matter may be formed, is indisputable, even under the most active treatment; but that an operation by the trephine will anticipate and prevent these evils, cannot be conceded in the present state of our knowledge; and the rule of practice is at present decided, that no such operation should be done until symptoms supervene distinctly announcing that compression or irritation of the brain has taken place. It is argued that when these symptoms do occur, it will be too late to have recourse to the operation with success. This may be true, as such cases must always be very dangerous; but it does not follow, and it never has been, nor indeed can it be shown, that the same mischief would not have taken place, if the operation had been performed early.

258. When a simple fracture, which in its slightest form is called a capillary fissure, takes place, the dura mater must be separated from it at that part to a certain extent, and some small vessels must be torn through. It does not follow, however, that blood must necessarily be poured out in such a quantity that it will not be absorbed. Dissection, on the contrary, has established the fact that it will be absorbed even in cases of fracture of greater extent, where it has been seen that a larger quantity had been extravasated. As the effusion of a larger, or of so large a quantity of blood as to prove eventually mischievous, does not usually take place, except under other circumstances than those of a simple fracture, the ordinary practice ought not to be to seek for that which is not likely to be found. The dura mater is rarely separated beyond the limits of the fracture, and it is more likely to recover without any further exposure or interference than with it. The dura mater, however, may be separated to a considerable extent from the bone in more severe injuries, and a quantity of blood is often extravasated upon it. When this does occur, the commotion or shock which occasioned the fracture, the separation of the dura mater, and the extravasation will generally have caused other more important although less perceptible derangements. These show themselves after the lapse of a few days, by giving rise to inflammation of the brain or of its membranes, of which such patients more usually die, than of the separation of the dura mater, or of the extravasation of a small quantity of blood. The case is no longer one of simple fissure or fracture of the cranium, and the nature and severity of the symptoms which have supervened must regulate the practice to be pursued.

259. After the receipt of a severe blow, or of a gunshot fracture of the head, which has not even stunned the person at the moment, he may walk to the surgeon, the wound be dressed, and he may converse with his fellows as if nothing had happened; yet in a short time he may become heavy, stupid, drowsy, and unwilling to move, with a slow pulse and a pallid countenance. Inflammation has not yet had time to set in, and extravasation has not always taken place. If the loss of a moderate quantity of blood should relieve such a person, it shows that congestion had occurred, perhaps on the surface of the brain under the injured spot, on recovering from which, by the unassisted efforts of nature, he would still be liable to inflammation. I have repeatedly seen a sharp bleeding from an incision made to allow a complete examination of the part in such a case, cause the restoration of the patient to his natural state. A return of untoward symptoms during the progress of the case does not always indicate essential mischief; they will be removed, if of a temporary nature, by a further moderate bleeding, by purgatives, and by greater restriction in diet, through irregularities in which these secondary attacks most usually occur. If the loss of blood should not relieve the symptoms, the case is probably complicated by a separation of the dura mater, or by an extravasation having taken place between the dura mater and the bone, or even in or on the surface of the brain.

260. When a fracture takes place at the anterior inferior angle of the parietal bone, or in any part of the course of the middle meningeal artery, it often gives rise to a more serious injury, which nothing but an operation can remove. The artery is always in a groove, and is often even imbedded in the bone at its lower part, and may be torn at the moment of fracture, giving rise to a gradual extravasation of blood on the surface of the brain, which can be borne to a considerable extent without causing any particular symptoms, although a sudden and considerable effusion causes immediate insensibility. When the extravasation is gradual, the patient walks away after the accident, and converses freely, becoming oppressed slowly, and in the end insensible, as the last drops of blood which are effused render the compression effective. When these symptoms occur after a wound in this particular part, the bone should be immediately examined; if there be no obvious fracture, and relief cannot be obtained by the abstraction of blood, the trephine should be resorted to as a last resource; for if there be truth in the statements so confidently made of fracture of the inner table of the bone from concussion of the outer without fracture, it is here especially that we may be permitted to look for it. The hemorrhage in the greater number of these cases takes place slowly, and the effused blood depresses the brain by separating the dura mater from the neighboring bone—a process, however, which can hardly occur unless the injury has been so violent as to rupture its attachments to the bone; for the brain generally yields rather than the attachments of the dura mater, and is depressed, the hollow or cavity thus formed being filled up by the coagulum, which becomes thicker and thicker until insensibility is induced. Blood effused between the dura mater and the bone readily fills up in the first instance all the space formed by the disruption of the membrane; for the force with which the blood is poured out from the artery overcomes the resistance offered by the brain, which gradually yields and sinks unto that point at which its natural functions can no longer be carried on. If the attachments of the dura mater be strong, and the separation which has taken place between it and the bone be small, the blood effused is compressed by the bone on one side, on which it can exert no influence, and is resisted by the dura mater, which will recede no further on the other. The wounded artery in such a case is soon compressed by its own coagulum, and the effusion is comparatively trifling, giving rise, according to its nature, either to the primary symptoms of compression from extravasation, or to the secondary ones dependent in all probability on inflammation and suppuration of the part, and of irritation and compression of the brain beneath. If, on the contrary, the separation of the dura mater from the bone be extensive, the quantity of extravasated blood may be considerable and the brain will be greatly depressed. Experience has demonstrated that persons have recovered after large coagula have been removed; but in all these cases the brain had not lost its resiliency, and was seen to regain its natural level on the removal of the depressing cause, the person often opening his eyes and recognizing and speaking to those about him; but this does not take place when the brain remains depressed after the blood has been removed.

A French artillery driver was knocked off his horse by a musket-ball, which struck him on the anterior and inferior portion of the right parietal bone, during a charge made by General Brennier, at the battle of Vimiera, on the British infantry under the command of the late Sir Ronald Fergusson. I took him under my care, thinking from his freedom from bad symptoms and the slightness of the fracture that he would probably do well. The next morning I found him apparently dying. A portion of bone being removed, a thick coagulum of blood appeared beneath, apparently extending in every direction. Three more pieces of bone were taken away and the coagulum, which appeared to be an inch in thickness, was removed with difficulty with the help of a feather. The brain did not, however, regain its level, and the man shortly after died. The middle meningeal artery was torn across on the outside of the dura mater; the wound did not pass through to the inside, and there was no blood beneath the dura mater. The convolutions of the brain were depressed and flattened by the pressure.

A soldier of the 29th Regiment was struck on the right parietal bone in a similar manner, shortly after daylight, at the battle of Talavera, during the first attack on the hill, the key of the British position. He walked to me soon afterward to the place where the wounded of the evening before had been collected in the rear. Being otherwise employed, I heard his story but could not attend to him at the moment, and found him some time afterward insensible, with a slow, intermitting pulse, breathing loudly, and supposed to be dying. The fractured parts were sufficiently broken to admit of the introduction of two elevators, by means of which they were gradually removed, together with a large coagulum of blood which had depressed the brain. When this had been done the brain regained its level, the man opened his eyes, looked around, knew and thanked me. The pulse and breathing became regular; he said he suffered only a little pain in the part, and should soon get well. He died, however, on the third day.

During the battle of Salamanca a soldier of the 27th Regiment was brought to me, who had walked to the rear, and had fallen down insensible within a few yards of the hospital station. I found a considerable fracture, with depression at the inferior part of the parietal bone before and above the ear. The end of the elevator having been introduced, a small piece of bone was first raised, then another, and a third, when a thick coagulum was exposed and removed. The dura mater was not separated from the bone around to any extent, and the coagulum, although thick, was not large. The brain, which had been depressed, regained its level immediately; the man recovered his senses, and was cured of his wound, but remained unfit for service. The artery did not bleed after it had been exposed.

The rule in surgery, to remove the bone in such cases, is absolute.

261. Fractures of the skull are stated, from almost the earliest records of surgery, to occur on one side of the head in consequence of blows received on the other. The facts which ancient authors have collected and related on this point are so numerous and so well attested that it appears almost more than skeptical to doubt their accuracy, however seldom they may be now observed.

A counter-fracture or fissure of one parietal or temporal bone, caused by a blow on the opposite one, is of such rare occurrence that it is in general unnoticed by later writers on injuries of the head. It is not so, however, with respect to a fracture at the base of the cranium from a blow on the vertex, or on the back part of the head—a kind of accident which occurs more frequently perhaps than any other in civil life—because persons who suffer from fractures of the skull do so more generally by falling from a height, or from being pitched on their heads, than by direct blows or other injuries. This accident principally depends on the superincumbent weight of the body pressing on the unsupported flat and thin base of the skull, and is but little connected with the unyielding nature of the spine; for it occurs to as great an extent in consequence of falls from a short distance without any impetus, as from falls from a great height. Some of the worst cases take place by the sufferer having been thrown from the back of a horse by the sudden starting of the animal, without any running away. Although in these cases a fissure may often be traced to the foramen magnum, the great fracture is essentially distinct, extending from the petrous portion of the temporal bone on each side, across, and between the sphenoid bone and the os frontis, and even separating the edges of the coronal suture nearly to the opposite side.

A noted gambler was thrown from his horse, and pitched on the top of his head at the door of the Westminster Hospital, late at night; he was taken up insensible, and died shortly afterward. The skull was fractured quite round from the vertex to the base, and from side to side, so that the fore and back parts might have been easily separated into halves, if the soft parts had been removed. Fractures of the base of the cranium are generally fatal, but not always so; for some persons live a considerable time afterward, and appear to die from other causes; so that partial, if not perfect recovery is possible.

H. Cochrane, forty-five years of age, fell a distance of twenty feet upon his head, and was taken up apparently lifeless, bleeding largely from the ears, nose, and mouth, but more particularly from the ears. He was seen within half an hour of the accident. He was then quite insensible; the surface of the body cold; pulse about 68, and very feeble; in three hours after the accident he was bled to sixteen ounces, when his pulse rose to 76, and the breathing, which before was rather oppressed, became more free. He was ordered six grains of calomel, followed by moderate doses of senna, till the bowels should be relieved.

He continued progressively mending, but in a state of stupidity, accompanied by extreme listlessness; answered questions sullenly, and frequently rested upon one arm without appearing conscious of pain; the mouth was drawn to the left side, to which there had been a slight tendency for some days; the tongue not at all affected.

He continued under treatment for three weeks longer, soon after which he was permitted to resume his employment, the mouth being still drawn in some degree to the left side. His habits became silent and solitary, but he performed his task with the greatest exactness. He was occasionally subject to vertigo, particularly in hot weather, after any violent exertion or taking a small quantity of beer; a pint of ale would render him stupid or insensible. Six months afterward he was found dead, lying in a ditch.

Sectio cadaveris.—The nasal bones were fractured by a blow which had made a transverse incision in the upper part of the face. The femur was found fractured upon the right side, and the scalp puffy and ecchymosed on the left. On removing the skull-cap, the dura mater appeared perfectly healthy, without any sign of extravasated blood upon the surface. Beneath the pia mater on the left side the sulci of the brain were filled with black blood, apparently very recently effused. The brain was removed without the least violence, when a lesion was found upon its inferior surface, corresponding to the petrous portion of the right temporal bone. The dura mater in this situation was externally of its natural structure, and adhered with its usual degree of firmness to the bone beneath. The arachnoid and pia mater were here deficient; the lesion consisted of a cavity about fifteen lines in length, nine in breadth, and three in depth, coated with a light-yellow lining, which also adhered to the corresponding portion of the inner surface of the dura mater, which completed the walls of the cavity inferiorly; it contained a turbid serum, in which were seen floating numerous but exceedingly minute white globules. The portion of the brain in this situation did not appear to have been disturbed by the recent violence, except that from the upper part of the cavity a probe was admitted without any resistance into the descending horn of the right lateral ventricle, which, with the one on the opposite side, was filled with a large quantity of bloody serum, none of which, however, had escaped into the cavity beneath. The brain generally appeared perfectly healthy, and not more vascular than usual. Even within a line of the yellow deposit above mentioned there appeared not the slightest change of structure. On removing the dura mater from the base of the skull, indications of a former fracture were discovered, leading vertically down through the squamous portion of the temporal bone, whence it appeared to have been continued along the anterior part of the petrous portion into the Vidian canal; the edges of this fracture, both internally and externally, had been rounded by absorption; it was met at right angles by another which ran across the base of the petrous portion of the temporal bone. The direction of the last fracture was marked by numerous small, rough particles of bone, which adhered so slightly to the rest that they separated on maceration. The transverse ligament of the second vertebra was ruptured, and the atlas forced forward. The connection between the articular processes of the second and third cervical vertebræ on the right side had also been separated by the fall which had caused death.

William Clayton, forty-four years of age, was admitted on the 31st of July, 1841, into the Westminster Hospital, having received a blow on the RIGHT side of his head from the handle of a windlass, by which his skull was fractured. The fracture extended downward from the parietal bone across the temporal, and in all probability through its petrous portion, as blood flowed freely from the ear for the first six hours; he was stunned for a few minutes at first, but became sensible by the time he was brought to the hospital. The bleeding from the ear was followed by the discharge of a fluid resembling water—which is a very dangerous symptom, as it usually flows from the sac of the arachnoid membrane—and afterward at intervals by a discharge of blood and matter, particularly, he said, on coughing; he was also quite deaf, with a little pain on the right side of the head. The bowels were well opened, and he lost sixteen ounces of blood. On the evening of the third of August, the fourth day after the accident, paralysis of the muscles of the RIGHT side of the face supplied by the portio dura came on, or was first observed. Pulse 80. He was well purged, but lost no blood, as he was apparently weak and the pulse soft; it fell next day to 72. Mercury was now administered twice a day until the mouth became sore. On the eighteenth of September he was discharged, cured of the paralysis, the wound on the head being open, and a piece of bone bare and likely to exfoliate. October 8. Readmitted in consequence of great headache after drunkenness, with numbness of the toes and fingers; he was well purged, and felt relieved. He remained in the hospital for a month, his mouth being again slightly affected, occasionally drinking in spite of all remonstrance; he then returned to his work on the piers of Westminster bridge. On the eighth of June several small pieces of bone came away; and the wound nearly healed. The course of the fracture can be traced, in consequence of the scalp having adhered to the bone, causing a slight depression and hardness, which can be felt by the finger, extending down to the ear.

An hostler was thrown on his head from a horse, and was carried to the Westminster Hospital late at night in a state of stupefaction; no other injury could be discovered. The next morning he could answer questions, although not always correctly; complained of pain in his head, had bled from the ears all night, and had vomited some blood two or three times. Pupils dilated, but they contracted on bringing a lighted candle near them; the left eyelid more open than the right; pulse 52; very restless, and constantly turning in bed. V. S. ad ℥xxiv. Calomel and colocynth: salts and senna. Cold to the head. The pulse rose to 60 after the loss of blood. 2d day. Is delirious; bleeding from the ears but trifling; complains of pain in the head; bowels open; passes urine freely; pulse 54, a little irregular. Y. S. ad ℥xvj gave relief. Continue calomel, and salts and senna. 3d day. Restless all night; headache and thirst; bowels open. V. S. ad ℥xiv relieved the pain in the head. Pulse 56. 4th day. Restless and delirious at night; pulse 60, regular; bowels open; headache. V. S. ad ℥xiv. No discharge from the ears. 6th day. Slightly paralytic on the left side of the face, tongue drawn to that side; headache, restless, delirious; feces and urine passed unconsciously; pulse 80. V. S. ad ℥xx. Pulse rose to 100, and was weaker. Calomel, gr. iii every six hours. 7th day. Pulse 88, compressible; restless at all times, delirious at night; bowels open, but he is more conscious of everything. 8th day. Pulse 80, small, intermitting; occasionally slept a little, and is generally better; bowels well purged; paralysis of the face continues. Has taken a little farinaceous food. Continue calomel and inf. sennæ. 10th day. Improved; slept tolerably well. 12th day. Continues to improve. Omit the calomel, but continue the infus. sennæ. 16th day. Is better. Paralysis lessened. Recollects he was thrown from a horse, but nothing else. Is free from pain, but very weak. Mouth a little sore.

After this time he gradually recovered, but was for a long time unable to work, or to undergo any exposure. A very little more mischief, and he would have gradually sunk, and died after the seventh day, instead of slowly recovering.