An officer was struck on the head, in Halifax, Nova Scotia, by a drunken workman with a tomahawk, or small Indian hatchet, which made a perpendicular cut into his left parietal bone, and knocked him down. As he soon recovered from the blow, and suffered nothing but the ordinary symptoms of a common wound of the head with fracture, it was considered to be a favorable case, and was treated simply, although with sufficient precaution. He sat up, and shaved himself until the fourteenth day, when he observed that the corner of his mouth on the opposite side to that on which he had been wounded was fixed, and the other drawn aside; and that he had not the free use of the right arm so as to enable him to shave. He was bled largely, but the symptoms increased until he lost the use of the right side, became comatose, and died. On examination, the inner table was found broken, separated from the diploe, and driven through the membranes into the brain, which was at that part soft, yellow, and in a state of suppuration.
Mr. B., of the 29th Regiment, when in Halifax, Nova Scotia, was struck, in a drunken frolic, on the anterior part of the left parietal bone, with his own sword, which was a straight, heavy one, and a wound about two inches long was made in the side of his head through the bone. His little finger was cut at the same time, and it was not until the finger had been dressed that I was asked to look at the head, which he declared had nothing the matter with it. He was vomited, and purged, and the next morning bled, and as symptoms of inflammation of the membranes of the brain came on or increased, the bleedings were repeated, the quantity taken at each time being gradually diminished. He lost 250 ounces of blood in five days, after which he gradually although slowly recovered, some small spiculæ of bone coming away during the cure. Returning to England, the vessel was taken off the Scilly Islands, and he was sent to Verdun, where he remained several years, until liberated by the peace of 1814, when he rejoined his regiment, which had served in the Peninsula, and had returned to North America. It was soon found that he became outrageous on drinking a very little wine, and was odd in his manner, and had a great propensity to set out walking for hours without apparently knowing what he was about, or where he was going. When his regiment came immediately in front of the enemy, he was found going over to their lines, without being aware of what he was doing; and he was at last obliged to be sent to England, having evidently become deranged. This gentleman has ever since been confined in a private mad-house. His brother offered to allow the bone to be removed; but after thirty years of derangement a recovery could not be expected, and it was declined. If the examination I have since learned to be proper in such cases, had been made at the time, the inner table of the bone would have been found broken and depressed; and he might now have been in health both of mind and body.
I removed, in Lisbon, in the hospital appropriated to the wounded French prisoners in 1812, a portion of bone by the trephine, which had been fractured by a sword some months before: the wound had not healed, and some pieces of bone were depressed. One piece, in particular, of the inner table, was sticking in and irritating the dura mater, and was in all probability the immediate cause of the fits from which the patient had been suffering. He recovered.
A British soldier received a wound at the affair of El Boden, in front of Ciudad Rodrigo, from a sword, on the top of the head; he accompanied me to Alfaiates, on the retreat of the army. The bone was apparently only cut through, yet the inner table was depressed, and felt rugged when examined with the probe. The symptoms of inflammation increasing on the fourth day, and not being relieved by copious bleeding, I removed a central portion of the cut bone by one large crown of the trephine, and took away several small pieces which were sticking into the dura mater, after which all the symptoms gradually subsided.
266. The whole of the French wounded, who remained on the ground or were taken prisoners after the battle of Salamanca, were under my care, and among them there were several severely wounded by sword-cuts received in the charges of heavy cavalry made by Generals Le Merchant and Bock. The cerebellum was laid bare in two cases without any immediate bad effect. In one particular case, which recovered, (after the battle of Waterloo,) the brain was seen pulsating for several weeks; and the statements made to me by the different officers at Brussels and Antwerp, and afterward at Yarmouth and Colchester, entirely confirmed the observations I had made, and the recommendations I have inculcated on this particular point as resulting from the practice of the Peninsular war.
267. It would appear that too much stress is laid upon a difference which is supposed to exist in the danger of trephining a man on the first or on the seventh day after an accident; and that an error may be committed in believing that the trephine is a more dangerous instrument on the first day than on the seventh. The question is not whether the man is to be trephined or not, but which will be the best and safest day or time to do the operation. I do not hesitate to say the first, believing the violence to be greater when done on parts already in a state of inflammation, than when they are sound. When the inner table has pierced the membranes and gone into the brain itself, the individual will in most cases ultimately die miserably of the accident if not relieved by art. It is less safe to let him designedly run the certain risk of cerebral irritation, which when once excited is often indomitable, than to remove the cause, and endeavor to prevent the evil. If the cerebral irritation only manifested its effects on the surface of the dura mater by causing suppuration there, delay might be admitted; but as it usually gives rise under these circumstances to the formation of matter on the surface, and even in the substance of the brain, where it is deadly, “la chirurgie expectante” cannot be allowed. Lastly, there is not more danger of a hernia cerebri, as has been supposed, when the operation is done early, than when it is done at a later period; on the contrary, the patient has a much better chance of escape from hernia cerebri, and from all other evil, when the local and the general treatment are decided and efficient.
If, on attempting to remove a fragment buried in the brain, serious convulsive movements should be excited, it would be proper to desist from all further attempts to extract the splinters until the brain has become more quiescent.
It is necessary to recollect that the brain appears to be insensible, or nearly so, when first exposed; and it has rarely occurred that a serious convulsion or anything beyond vomiting has taken place on the removal of a piece of bone from the brain; nor will any difficulty be found in removing such small fragments as can be seen with a pair of forceps duly adapted for the purpose. It is impossible to say at what period of time the brain may become irritable, and no longer admit of its being touched without convulsive movements ensuing; but when this state of irritation has commenced, and its existence is proclaimed by the excitement which takes place on touching the fragment of bone, the surgeon should at once desist from all attempts to remove the foreign body. The brain under ordinary circumstances is much more likely to recover from an injury, all foreign or irritating matters having been removed, than when suffering from their presence.
268. The establishment of the principles which ought to regulate the practice of surgery in cases of fracture with depression of the inner table of the skull, is of the greatest importance. The principle being laid down that it is right and proper to examine all such wounds with a blunt, flat probe, in order to ascertain if possible whether the inner table be depressed and broken, the question necessarily arises, what is to be done when such depression and breaking down of the inner table have been ascertained to have taken place? There can be no hesitation in answering, that in all such cases the trephine should be applied, although no symptoms should exist, with the view of anticipating them. The old doctrine, it may be said, in regard to fractures generally, is revived in these cases, but on a principle with which our predecessors were not sufficiently acquainted. A patient very often survives a mere depression of the skull; he may, and occasionally does survive, a greater depression of the inner than of the outer table; but it has not been shown that he ever does survive and remain in tolerable health, after a depression with fracture of the inner table, when portions of it have been driven into the dura mater. If cases could be advanced of complete recovery after such injuries, they would not supersede the practice recommended, unless they were so numerous as to establish the fact that injuries of the dura mater and brain by pieces of bone sticking in them are curable without an operation, and without leaving any serious defects. There are great objections to the trephine being applied in ordinary cases of fracture, not attended by symptoms of further mischief; but the nature of the cases particularly referred to having been ascertained, the practice should be prompt and decisive in every instance in which the surgeon is satisfied that there is not merely a slight depression or separation of the inner table, but that several points of it have been driven into the dura mater. If one trephine will suffice, the central point being applied close to the edge of the middle of the wound in the bone, it should be applied there; but if the cut be longer, and the spiculæ of bone extend upward and downward in its length, a small trephine should be applied as near each end as may be judged advisable, and one edge of the cut bone should be removed by the straight saw, of which Paré and Scultetus made such use in ancient times, and which Mr. Hey of Leeds revived in modern surgery; or the small straight saw may be used alone, if the object of removing a portion of bone can be attained without the trephine. By these means sufficient room will be obtained to remove the broken pieces of bone which are irritating the dura mater and brain. The danger resulting from the application of the trephine, in such cases, bears no proportion to the risk incurred by leaving the broken portions of bone as a constant cause of irritation.
269. There is an essential difference between a depression of the skull in a CHILD and in an ADULT. In the child the inner table is not brittle—it bends equally and does not break; it very often does little mischief when depressed, and gradually recovers its level. The brain in young persons is softer and less consistent, and can accommodate itself more readily to pressure for a limited time, without ultimate mischief, than the brain of an adult; so that a continuance of the most urgent symptoms can alone authorize the application of the trephine in children, and in young persons under fifteen or sixteen years of age. A similar bending of the long bones in young children is often observed at an early period in life.