272. When a fracture is accompanied by depression, and the broken portion or portions of bone would seem to be driven into the dura mater or the brain, or to press so unequally upon them that as much mischief is likely to ensue from leaving as from removing them, especially in an adult or a middle-aged man, less harm will in general follow from ascertaining the fact by dividing the scalp and removing the broken pieces than by doing nothing, more particularly when the presence of a foreign body has been ascertained. If there be no symptoms indicative of mischief below the fractured part, the surgeon must then decide, after the best estimate he is able to make, of the probable evil which will occur from allowing the broken or depressed portions of bone to remain.
A French grenadier was brought to the field hospital the second day after the battle of Salamanca; he had received a blow on the left side of the head, probably from a piece of shell, which had caused a contusion and swelling on the left parietal bone, with a graze of the scalp, but without any opening communicating with the bone. This swelling, on examination, was so soft, and the feeling of depressed bone beneath so distinct, combined with the fact of the continued lethargic state of the patient, that an incision was made into it, when the bone beneath was found broken into several small pieces. On clearing away the blood, two pieces which were loose were readily raised and removed by the elevator and forceps, and egress given to an ounce or two of blood, which were extravasated beneath, apparently from the rupture of the vessels passing between the dura mater and the bone. The patient regained his senses in the course of the night and morning of the third day, and under a strictly antiphlogistic regimen gradually recovered, some other small pieces of bone coming away, one or two others apparently reuniting to the uninjured parts, showing that it is not always necessary to remove every portion of bone which may be broken, provided any bond of union remains, and principally that which exists between it and the dura mater.
These different cases stand out in bold relief as eminently successful and opposed to those said to have been equally so under la chirurgie expectante. They tend to show that however good a general rule may be, it may admit of many and important exceptions; and they prove that experience, aided by sound and correct observation, is essentially necessary for the formation of a scientific surgeon.
273. In young persons the brain will bear a greater degree of pressure and of irritation with impunity than it will in persons of mature age. By far the greater number of cases in which recovery has taken place after fracture and depression of the skull with injury of the brain, and even loss of its substance, have occurred in children or in persons under the adult age; greater reliance may therefore be placed on the powers of nature in them; and recourse may be had less frequently to the aid of operative surgery in order to prevent mischief than in older persons, even when the bone is fractured as well as depressed. It will be found, and the remark is important, that the cases of fracture and depression reported to have been successfully treated without operation, have occurred principally in young persons.
The result of my experience has rendered it imperative to remove at once all portions of bone or foreign substances which have materially injured the dura mater in adults, although no symptoms of compression should be observed. If the wound in the dura mater should not be sufficiently large to allow the offending body to be extracted through it, the opening must be enlarged to enable it to be withdrawn without further laceration.
274. Depressed portions of bone, accompanied by fracture at the back part of the head, need not necessarily be removed in the first instance. When the fractured and depressed bone is accompanied by symptoms of compression in an adult, which continue after the usual antiphlogistic means and remedies have been employed in vain, and appear to increase rather than to diminish, the broken and depressed portion should be raised; for although the brain will bear and accommodate itself to pressure in many persons in a manner which could not be either foreseen or expected, it will not do so in all; and the removal of the bone offers the best chance for relief, whether the mischief has arisen from the pressure made by it or occurs from the extravasation of blood beneath. When the principal symptom of compression is a severe fixed pain in the part, although the state of the fracture and depression would not alone have rendered the removal of the bone positively necessary, it is advisable to do so when this symptom is present.
The greatest discrimination is required in cases where the extent of the injury is not so manifest and in which there is more room for doubt. In most cases in which a slight or moderate degree of fracture and depression of the skull has taken place, the symptoms of concussion are present as well as those of compression. The symptoms of concussion are, however, coeval with the injury, and although those of compression may take place almost instantaneously, they more usually occur at a later period of time. The symptoms of concussion may nevertheless continue for days, more particularly the insensibility, or that state which is approaching to it, complicating the case and embarrassing the practitioner. In a child or young person the symptoms of compression or irritation, when they appear even at a secondary period, may pass away under further moderate depletion; but in an adult any undue delay in giving the necessary relief, by the removal of the depressed portion of bone, will in general be destructive to the patient. It is the irritation caused by the depressed bone on the dura mater, and communicated to the brain, which gives rise to the unfavorable symptoms and to the formation of matter which follows them.
A gentleman received a blow on the side of the head, which knocked him down and deprived him of his senses, from which state he partially recovered, and vomited; some stupefaction, however, remained, although he could be made to answer by a little importunity. Pulse 62, irregular, breathing slow, the pupils contracting under the influence of light; the integuments where the blow was received were soft and swollen, in all probability from an extravasation of blood beneath. The next day the pulse was full and regular, the pupils were dilated, vomiting had taken place several times, and the patient answered correctly on being sharply questioned. He was bled largely, purgatives were administered, and cold was steadily applied to the head. He was bled the next day; on the third the left arm became paralytic, the pupils continued dilated, and on the fifth day paralysis implicated the left leg as well as the arm. There could now be no doubt that the brain was suffering from compression; but as the nerves of the excito-motory system were unaffected, and the functions of ingestion and egestion were satisfactorily accomplished, it was thought advisable to trust to the efforts of nature. The swelling of the scalp was painful.
A week afterward the general symptoms were the same, or only slightly augmented by fever; but, as the swelling of the scalp was more painful, it was opened, and a quantity of matter was evacuated, the bone beneath being fractured and depressed. As this operation gave some relief, it was thought advisable to wait, with the hope that the benefit thus obtained might prove permanent. The patient did not improve, however; and as the symptoms of fever increased, and were accompanied at last by rigors and great pain in the head, the depressed portions of bone were removed, and about half an ounce of purulent matter escaped from between the dura mater and the bone. The relief given this time was effective, and the patient perfectly recovered. “La chirurgie expectante” placed this man’s life in the greatest jeopardy. It was only saved at the last moment by the aid of that surgery which ought not to have been withheld when the paralysis, by affecting the leg as well as the arm, demonstrated the extension of the mischief within the head. In this instance the operation was successful, but it is not in general so serviceable when delayed to so late a period. It is in cases of this serious nature often a means of prevention rather than of cure.
275. When a severe blow, accompanied by a shock, as from a fall, has been received on the head, and the skull is so thick and strong as to be able to resist the violence thus offered without being broken, or is only slightly fractured, the vibration or trémoussement is directly communicated to the brain, giving rise to laceration or bruising of its structure in various situations, to the rupture and separation of the vessels of the dura mater from the bone to which they are attached, and to derangement of other parts, which will in all probability be followed by inflammation, and may even terminate in the formation of matter under the dura mater as well as above it, and even in the brain itself. It is said to take place by “contre-coup” when the mischief occurs in any other part of the head than that which is struck, numerous instances of which are given by the older French authors. They were probably cases of laceration, the consequence of concussion of the brain, and not relievable by the art of surgery; but the injury which the older surgeons particularly distinguished as by “contre-coup” was where the blow was on one side, and a fracture took place or matter was formed in a circumscribed spot on the other; these cases did sometimes, they say, although rarely, admit of relief by operative surgery. These cases, unaccompanied by fracture, do not appear to take place under the improved method of treatment by larger depletion, by antimony, and by the early use of mercury. In the event, however, of their occurring, there is no surgeon of the present day who would attempt an operation of exploration on the opposite side of the head to the injury, without some sign of mischief existing at that part; although such operation, if done, might accidentally be followed by success.