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

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.