When I saw this man at Antwerp I gave my opinion, without hesitation, that the bone and the ball ought to have been removed in the first instance, when he would have had a better chance for perfect recovery. The operation, when afterward performed for the removal of the loose pieces of bone, placed his life in great jeopardy. He was discharged the service with the ball lodged, and it is more than probable that he did not long survive, which he might have done if the ball had been removed when it was first felt within the skull.
In the following case the ball could not perhaps have been removed in the first instance with propriety; it might, however, have been lying on the dura mater, or near it, within reach, and the actual state of things ought to have been ascertained, the surgeon afterward deciding whether any further operation were necessary.
Thomas O’Brien, 28th Regiment, aged twenty-three, was wounded by a musket-ball on the 16th of June at Quatre Bras; the bullet penetrated the occipital bone below and to the right of the junction of the lambdoidal and sagittal sutures. On his arrival at Colchester, the wound was healthy in appearance and healing rapidly. It appeared from his own account that for some hours after the injury he was totally deprived of sight; since that time he has been constantly more or less affected with headaches, for which he has been prescribed occasional cathartics and low diet. He has also been affected with pain and weakness in both eyes, but more particularly in the right. While at Brussels, and during his progress to Ostend, he lived very irregularly, and was frequently intoxicated. The external wound was entirely healed on the 20th of July, and no suspicion existed that the ball was lodged in the brain. On the 25th matter was perceived under the scalp, and was evacuated yesterday. To-day, the 27th, he complains of increase of headache; pulse small and quick. V. S. ad ℥vj. Haust. cathart. statim. 28th. In the course of this day his symptoms have become very urgent; he is restless, with a very quick pulse; an extensive crucial incision was made in the site of the original wound, and now for the first time it was discovered that the ball had penetrated the brain; several loose pieces of bone were extracted; a considerable quantity of arterial blood was suffered to flow from the small vessels divided in the incision. His bowels had been well opened by the cathartic. The most vigorous treatment was continued, but the symptoms notwithstanding increased, and he died on the morning of the 29th of July.
The ball was found lodged nearly two inches deep in the substance of the right posterior lobe of the brain; a considerable quantity of pus surrounded it; some inflammation of the brain and its membranes was observed, but much less than might have been expected.
A. Clutterbuck, 61st Regiment, aged twenty-five, was wounded in the back of the head by a musket-ball at the battle of Toulouse, on the 10th of April, 1814. He felt little inconvenience from the wound during the first two days. On the 14th he complained of severe pain in the head, giddiness, and dimness of sight; the face was flushed, pulse hard and frequent. Twenty ounces of blood were taken from the arm, and the wound enlarged so as to expose the cranium. The upper part of the os occipitis was found fractured by the ball, and a circular portion of it, about the size of a shilling, was depressed and fractured. 15th. Pain in the head much abated; no giddiness, dimness of sight, or any unfavorable symptom; pulse still hard. V. S. ad ℥xx. To be well purged. 19th. He was bled again this day to the extent of twelve ounces, as a matter of precaution. 23d. Continues free from any bad symptom. May 8th. The wound is now much contracted, and he feels no inconvenience. A small portion of the bone still feels bare to the probe, but the greater portion of the depressed piece is covered with healthy granulations. No exfoliation has taken place. May 24th. The wound is nearly healed; he is in good health and spirits, and without inconvenience.
This case may be properly contrasted with that of O’Brien, as showing by the result the difference between an uninjured and an injured brain. If the fractured and depressed bone had not been at the back part of the head, it is probable the depressed portion would have been removed in the first instance, as it certainly would have been after the 15th, if the unfavorable symptoms had not yielded to the general treatment; but the bone would then have been removed under much more unfavorable circumstances than at first.
The following case is related to show the extent to which blood-letting may frequently be carried to preserve life. There having been no reason to believe that the symptoms depended on fractured and depressed bone, the scalp was not divided; and as the symptoms were coeval with and not consecutive to the injury, they were therefore supposed to depend on concussion rather than on compression of the brain. If the trephine had been applied on the fourth day because the insensibility continued, the additional injury would in all probability have proved fatal. If the depletion of all kinds had been less effective, the inflammation of the brain or of its membranes would certainly have terminated in the effusion of lymph or the formation of matter, which the use of the trephine would not have prevented nor removed.
George Mills, an artillery driver, aged twenty-eight, was admitted into the Dépôt de Mendicité Hospital, Toulouse, May 29, 1814, in consequence of having been thrown from his horse on his head against the ground. He had fallen on the right side of the os frontis, immediately above the eye, where the surface of the skin appeared to be scratched and bruised, but the bone was not depressed: he was bled freely, but remained insensible. The next morning he was again bled to twenty ounces, which operation was repeated in the evening. On the 29th, the temporal artery was opened, and a vein in his arm at the same time, the breathing being strong and sonorous, the eyes closely shut, and he lying quite insensible; the pulse before the bleeding was quick and small; after he had lost about eight ounces of arterial and eight ounces of venous blood, it became fuller, and the breathing was somewhat relieved; the slightest touch gave him pain, and he shrunk from pressure made directly above the eye. The temporal artery was again opened in the evening, and ten ounces of blood were taken away. A purgative and a stimulating enema were ordered, and cold was constantly applied to the head.
30th. He has been freely purged and appears more collected; the pulse is still quick and small; breathing very free; the irritability continues and he complains of pain on pressing the head. The purgative and the enema were repeated, and ten ounces of blood were drawn from the temporal artery, after which he attempted to speak. 31st. Passed a good night; the pulse is quick and small; pain in the head still great; was again bled to twelve ounces, and the purgative was repeated. June 1st. Pulse quick; there is not so much pain in the injured part, and he appears more sensible; was bled to twenty-four ounces, and the purgative was repeated. 3d. Was again bled to ten ounces. From this time until the 20th, he gradually improved, and was then discharged cured.
The treatment in these cases was the same, although in one there was no fracture, and in the other two there was fracture with depression. The broken portions of bone did not, in Clutterbuck, appear to press unequally on the dura mater, and it was presumed that the moderate degree of pressure which ensued from the depression might be borne with impunity, as it did not seem likely to be accompanied by the projection inward of any pointed pieces which might irritate the brain. The result confirmed the supposition and justified the treatment. If the examination of the depressed part had led to the apprehension that such points of bone did exist, and were sticking into and irritating the dura mater or brain, they would have been removed, in the belief that although they might not at the moment have given rise to any other symptoms than those which depended on the blow, the time would come when they would scarcely fail to cause those which usually accompany the formation of matter within the skull. If this danger should also be avoided, the subsequent evils which have been noticed as occurring at a later period, and which ultimately require the same operation for the relief of the patient after months of acute suffering, might be encountered; for although a person may temporarily recover from an injury in which a portion of bone has been allowed to remain a source of irritation to the brain, it does not follow that such recovery should be permanent. If there be a doubt on the mind of the surgeon, whether there be or be not any pieces of bone depressed and irritating the brain or its membranes, he should wait; this is the real difference between the surgery of the latter part of the Peninsular war and that of the olden time.