Chapter XVI: Part 16

June 19th. The ball was found to have passed obliquely upward and backward at least two inches, and could be distinctly felt with a probe. It gave more the idea of having raised the outer table than that of having depressed the inner. The defect in speech was in some measure diminished, and this with giddiness were the only symptoms of compression. A poultice was placed over the wound, a brisk purgative given, and spoon diet ordered.

20th. The pain and giddiness having increased, with annoyance from noise and exposure to light, twenty-six ounces of blood were taken from the arm. The following day the purgative was repeated, and the patient was much relieved. Everything went on well, the wound was nearly healed, and he was considered almost fit to be discharged, when, on the 16th of July, the wound began to open; on the 18th it was dilated and a portion of the cranium removed by the forceps; this was soon followed by symptoms of inflammation of the brain; twenty ounces of blood were taken immediately from the arm, purgatives and diaphoretics were ordered, and the strictest abstinence enjoined. 23d. Venesection was repeated, as well as the other means usually adopted to reduce high action. 24th. Completely relieved. 26th. Another portion of the cranium removed, the dura mater being fully exposed; the general health in the best state.

August 3d. Doing remarkably well; the wound healthy; the pulsation of the brain evident; the power of speech perfectly restored. The ball yet remains in, according to the opinion of the patient, (who is a fine, intelligent lad,) and he thinks it has gradually descended toward the petrous portion of the left temporal bone. Sent to England at the end of the month, the wound being healed.

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.

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.

LECTURE XIX.

TUMORS OF THE SCALP, ETC.

276. When the periosteum covering the bone is bruised, or the bone is merely deprived of this membrane, it does not follow that it should die or exfoliate. In many instances the wound will gradually close up and heal, as if no such accident had happened. A blow or bruise on the head often gives rise to a swelling or tumor, from the rupture of the small vessels passing into the cellular membrane between the scalp and the pericranium; the tumor in these cases appears _immediately_ after the receipt of the injury as a soft swelling, and is usually found to contain blood, which in most instances is removed by absorption in the course of from two to three weeks. In some cases inflammation supervenes, and one part becomes tender and appears to point; into this a small incision should be made to allow the blood and matter to escape, when gentle compression should be resorted to in order to induce the parts to unite. Swellings of this kind in new-born infants, occurring from pressure during delivery, may be readily mistaken for deficiencies of the occipital and parietal bones, if it were not for the absence of all motion, which under such circumstances would be communicated to them from the brain. The blood effused in the cellular membrane raises the border of the swelling, which becomes harder than the neighboring parts, while the center remains soft and yielding, giving a sensation to the finger as if the bone beneath were wanting, or, after a blow, the idea that the bone beneath is depressed. If such a swelling be unnecessarily opened, considerable inflammation and suppuration will often follow, to the great inconvenience of the patient; this will in general be avoided by the use of a moderately stimulating cold lotion.

277. In other cases of tumors, which are called secondary in contradistinction to the preceding, the patients go on well for eight, nine, or more days, at the end of which time they complain of headache, giddiness, nausea, restlessness, thirst, and generally of fever. A few days more, frequently from the thirteenth to the fifteenth day, rigors, sometimes severe, are superadded, and a swelling, if not observed before, is now perceived on the spot where the injury had been received, if the integuments have not been divided; or, if there be a wound, it loses its healthy red appearance, and assumes a yellowish, unhealthy color, which is accompanied by a thinner and more acrid discharge. From this time the symptoms gradually increase, the patients become delirious, convulsed, comatose, and die; and matter is found between the skull and the dura mater, or in or on the substance of the brain. If this secondary swelling be divided, and the fluid evacuated, which is not good pus, the pericranium will be found detached and the bone bare.

It has been stated that a bone so circumstanced would not be found to bleed on being scraped, and that, by attending to the want of hemorrhage from the outside of the cranium, the extent of the evil might be ascertained, and that so long as a denuded, discolored bone will bleed on being scraped, it may be considered that the dura mater is attached below, and that no operation should be performed.

The essential difference between the primary and the secondary swellings is to be found in the fact that, although the bone be exposed, and even in some degree may have changed its color in the primary swelling when matter has formed, the febrile symptoms will subside after its evacuation, healthy granulations will spring up, and little or no exfoliation will take place. In the secondary swelling none of these favorable symptoms or appearances will take place, for the bone is incapable of maintaining its life, and must die. If the outer table only be implicated, it may exfoliate; but if there be reason to believe that matter has collected beneath, on the dura mater, the bone should be removed by the trephine.

Inflammation of the dura mater proceeding to suppuration, or the formation of matter between it and the bone, appears to have been a much more common consequence of injuries of the head in former times than at present. It is not now of frequent occurrence in London hospitals.

As blows on the head and the structure and functions of the brain are the same at present as formerly, the difference in regard to such cases can only depend on the difference of treatment. It is, in fact, infinitely more depletory now, and therefore less operative. Blood is taken away in larger quantities, although to this there are exceptions, depending on the constitution of the patient, which will not always admit of it, while the potassio-tartrate of antimony and mercury are by most surgeons administered at an early period.

Suppuration, or the formation of pus on the surface of the dura mater, not being, under the strictly antiphlogistic and mercurial system, so common as formerly, sufficient attention has not perhaps been paid to another evil which frequently accompanied it in former times, viz., suppuration on the surface and in the substance of the brain itself; for the greater number of those who died with fracture and depression of the skull, and whose cases are recorded, suffered also from alteration of the structure or substance of the brain, and the formation of matter within it or upon its surface. This termination might not have taken place in a large proportion of the cases in which it occurred if the depressed bone had been raised to its level, and the irritation arising from undue or unequal pressure had been avoided. It must be admitted, however, that an internal part of the brain may receive such a shock at the moment of injury, as well as an external part, that no treatment can arrest the progress of the mischief, although it may be delayed; and when the patient dies, after four, five, or more weeks of alternate hope and suffering, matter may be found in some part of the brain where an injury was not suspected.

Purulent matter may be formed beneath the dura mater in a confined spot, or it may be diffused generally over the surface of the brain, in which case the sufferer has no chance of relief.

278. The operation of incising the dura mater, to admit of the discharge of blood or matter from beneath, and even of puncturing the brain, has not been much resorted to in England; this may be an error. The records of surgery supply many cases where it might have been done with advantage, and some in which it was done with the greatest benefit to the patient. It is not an operation which ought to be performed without signs sufficiently demonstrative of the necessity for doing it.

I have seen, on the removal of a portion of bone by the trephine, the dura mater rise up rapidly into the opening so as to attain the level of the surface of the skull, totally devoid, however, of that pulsatory motion which usually marks its healthy state. An opening into it, under these circumstances, has allowed a quantity of blood or of purulent matter to escape, proving that the unnatural elevation of the dura mater was caused by the resiliency of the brain when the opposing pressure of the cranium was removed. This tense elevation, its abnormal color, and the absence of pulsation are positive signs of there being a fluid beneath, requiring an incision into the dura mater for its evacuation. It is a point scarcely noticed in English surgery--one which was not in the slightest degree understood at the commencement of the war in the Peninsula.

A. Monro, of the 42d Regiment, was wounded on the 10th of April, at Toulouse, by a musket-ball, which fractured the left parietal bone slightly, without depressing any part of it. No symptoms followed requiring more than ordinary attention until the 23d, up to which time he had been kept on low diet, for the most part in bed, and had been bled and purged. On the evening of that day he became feverish, and hasty and odd in manner, and the pulse quickened; he declared himself, however, to be quite well, and submitted to be bled and physicked with great reluctance, calomel combined with opium being given him at short intervals. On the 24th he complained of pain in the head, which he said was very slight, and that upon the whole he was quite well, and would not be bled nor have anything done. He was bled largely by force, which lowered the strength of the pulse, but did not relieve any of the symptoms of irritation of the brain. On the 25th he was evidently worse, although he declared himself to be quite well; he talked a little incoherently; the pupils were dilated; the pulse quick but regular; the countenance was changed; he was sensible, apparently, upon all points except that of being much worse, which he resolutely denied, saying he was better and would soon be well. Satisfied that matter was forming, or had formed, in or on his brain, I desired that the trephine might be applied on the fractured part and the bone removed. This, however, he would not permit the officers in charge to do, and they awaited my return in the afternoon, when, finding him much worse, I directed it to be done by force, three of his own regiment with others attending to assist the surgeons. He called upon these men by name not to allow him to be murdered in cold blood, declared he was getting well, and would get well if let alone, and prayed them to avenge his death on the doctors if they meddled with him. The surgeons were dismayed, and requested that the operation, which they said required great care, should be performed by me, their chief. I therefore removed the bone; and the moment it was taken away the dura mater rose up in the opening to the level of the surrounding bone, and remained without any pulsatory motion. I had no doubt of matter being beneath, and that, from his general state, the man would die. I did not therefore think it prudent, under all the circumstances, to do more than warn his comrades that, when dead, they would see the whole brain beneath in a state of suppuration. He died that night; and the next day they saw the whole of the left hemisphere soft, yellow, and covered with matter, to their great surprise and satisfaction at the accuracy of the diagnosis.

Absalom Lorimer, of the 42d Regiment, was wounded by a musket-ball on the 10th of April, 1814, at the battle of Toulouse, which carried away a small portion of the scalp just above the right temple, fracturing the bone slightly, but without any depression. No symptoms occurred demanding more than ordinary attention for the first fortnight, during which period he had been bled once, purged, and kept on low diet. On the 25th, he complained of pain in his head around the wound, shooting to the back part; pulse 60; pupils dilated. An incision having been made to the bone, the pericranium was found detached, and the bone fractured, but without any obvious depression. V. S. ad ℥xx, calomel and colocynth: as the pain continued, the bleeding was repeated in the evening. 26th. Pain in the head greatly relieved; pulse 60; bowels torpid. Ten ounces of blood were taken from the temporal artery, and the calomel and colocynth, salts and senna were repeated. On the morning of the 29th, the symptoms of compression having increased, the trephine was had recourse to, and the fractured portion of bone was removed: a layer of coagulated blood was found on the dura mater, which puffed up into the opening. In the evening he became convulsed, the pulse intermitted, and he died. On examination, a large abscess was found in the right hemisphere of the brain, having the ventricle for its base, with some matter on the surface of the brain, and between the dura mater and the bone at the base of the cranium.

On the morning of the day that I performed this operation, I had done another of the same kind at the Hôpital des Minimes; the dura mater rose up in a similar manner without pulsation into the opening made by the removal of the circular piece of bone by the trephine; on puncturing it a considerable quantity of pus oozed out. The opening was enlarged; and the flow of matter was daily encouraged, until it gradually diminished, and ceased with the formation of granulations, and the drawing in and cicatrization of the part.

279. It has been supposed theoretically that a wound through the dura mater was particularly dangerous, in consequence of the tunica arachnoides which lines it being a serous membrane; and that, if the inflammation which ensued did not cease at the adhesive stage, by the consolidation of the surface which covered the pia mater with that which lined the dura mater, a diffuse inflammation would necessarily follow, which might spread over its whole extent. This has not been found practically to be the case; and if a simple wound of the dura mater be a danger that ought to be avoided, the risk run cannot be put in comparison with that which accompanies the continuous irritation depending on the presence of a spicula of bone, which has passed through the dura mater, and is irritating the brain beneath. It has also been supposed theoretically that the danger would be diminished if the pia mater were wounded also, as the brain would project and fill the wound; but the accuracy of this opinion may be doubted. If the dura mater were injured through error or design, I should not think the evil lessened by adding to it a wound of the pia mater, and perhaps also of the brain.

By those who have been accustomed to the terrible injuries which occur in military warfare, in which large portions of the brain are sometimes exposed, and even lost, without much inconvenience following, the exposure of or the opening into the dura mater is not considered of so much importance as it is by those who have had fewer opportunities of seeing such awful cases; while the formation and retention of matter below the bones of the cranium is, on the other hand, more dreaded by those who have often seen their ill effects than by those who have not had many occasions for observing them; by whom, however, they are often considered, when they do take place, to be irremediable by art.

280. Gunshot wounds of the skull are attended by certain peculiarities. In ordinary circumstances there is usually an external wound and a fracture more or less comminuted, with depression; this wound will almost always require to be enlarged by a simple incision, so as to show the extent of the depression or the size of the broken and depressed portions of bone. When the bone is scarcely injured, and the periosteum is only bruised, or when the bone is even deprived of this covering, it does not follow that it should die or even exfoliate. In many instances the wound will gradually close in and heal, as if no such evil had occurred; and in those which do not terminate so favorably, the cure may only be delayed by the exfoliation of a layer or scale of bone from its outer surface, unless the mischief should have implicated the parts beneath.

A musket-ball striking directly against a bone sometimes makes a hole not larger than itself, with or without any radiating fracture; and one large trephine, if properly applied, will often embrace the whole of the mischief, and admit of the removal of the broken pieces. As a center-pin cannot be used, the trephine may be made to turn very well in most cases in a flat but thick bar of iron, having a hole in the middle, of such a size only as will allow the polished outside of the trephine to turn in it. Sufficient support for the instrument will be obtained by this means until it has made a groove in the bone for itself, when the operation may be continued as it would be in an ordinary case after the removal of the center-pin.

When a musket-ball ranges along the side or top of the head, it may break the outer, and depress and fracture the inner table to a considerable extent, for the space even of three or more inches. The broken portions of bone may in general be removed by means of good forceps and a straight saw; and no good reason can be given for delaying the operation unless the nature of the injury be doubtful, when it may be as well to wait for symptoms. It sometimes happens, although rarely, that a ball sticks so firmly in the bone that it cannot be extracted by working round it in any ordinary way with a pointed instrument. The difficulty usually arises from the ball having half buried itself in the diploe, so little of it being exposed as not to admit of a firm hold being taken of it. The large trephine, used in the way pointed out, has several times overcome this difficulty. The removal of the outer table has been sufficient where the inner one has not been driven into the dura mater; when any doubt is entertained on this point both should be removed.

281. A ball or other foreign substance may penetrate the brain directly or obliquely. When the ball penetrates the brain directly, it is not often that it can be removed, and the sufferer very rarely survives beyond a few days, even if the ball has been extracted; more particularly if the injury have occurred in the anterior part of the substance of the brain; several persons, however, have recovered, in whom the injury occurred toward the back part of the head, the ball being allowed to remain. It will be better in all such cases to allow the ball to remain, which it will often do for many days, until circumstances render it necessary to endeavor to find it. When it can be felt immediately under the surface of the brain, it ought to be removed like any other foreign substance.

Dr. Rogers relates the history of an excellent case, in which a young man aged nineteen received a wound on the frontal bone, just above the center of the left superciliary ridge, from the bursting of a gun on the 10th of July. It was not until the 4th of August that he discovered a piece of iron lodged within the head, in the bottom of the wound, (from which a considerable quantity of brain had come away,) which he extracted the next day. It proved to be the breech-pin of the gun, three inches in length, and three ounces in weight. By the tenth of December his patient was perfectly cured.

When a ball strikes the head obliquely, it may enter and pass out or lodge. Nearly all these cases die, but one occasionally escapes, and none should be allowed to die without assistance. When the entrance and exit of the ball are obvious, and not far distant from each other, the splinters of bone should be removed; and if the little bridge between the openings should be injured, the whole should be taken away by the straight saw; an operation which cannot, however, be necessary in the first instance, if the portion of bone be apparently sound.

At the battle of Talavera, a soldier of the 48th Regiment was brought to me in a state of insensibility; he had received a musket-ball on the upper part of the right side of the frontal bone, where it had entered, and had evidently passed backward; it could be followed by the probe rubbing against the bone for nearly four inches. The scalp over this point was soft, as if blood were effused below; and on dividing it, a fracture was seen bulging rather outward. The trephine was applied forthwith, and the bone removed, together with the ball, which only wanted a little more impetus to have come through. The brain was injured, and the man died two days afterward.

A French grenadier was wounded at the battle of Salamanca by a musket-ball, which struck him on the right side of the head, penetrated the temporal muscle, and lodged in the bone beneath, giving rise to symptoms of compression. On dividing the parts, I found that the ball had fractured and driven in a part of the temporal bone, one portion of the ball being above, and the other below the broken bone. The upper half of the ball was readily removed, but several small portions of bone were raised by the elevator and forceps before the remaining portion of the ball could be drawn from under the bone, which was not depressed, the ball having been cut in two by its edge. The dura mater was bruised, but not torn through. The wound suppurated freely; several pieces of bone exfoliated, and the patient was ultimately discharged in progress toward a cure.

A small ball sometimes becomes so flattened by striking against the skull as to remain undiscovered when care is not taken in the examination. A soldier was wounded at the storming of San Sebastian by a ball on the side of the head, which was supposed not to have lodged. The wound did not heal, a small opening remaining, although no exfoliation took place, and the bone did not seem to be bare. On dividing the scalp to ascertain the cause of the delay in healing, a small ball, quite flat, was found; it had sunk down a little below the hole left for the discharge to which by its irritation it had given rise.

When a larger ball or a piece of a shell strikes the head, the fracture is usually extensive, and portions of bone, or a piece of the shell itself, are often lodged in the substance of the brain. There is nothing peculiar in the management of these cases, which are for the most part unfortunate.

282. A suture may be separated by a musket-ball, which impinges with a moderate degree of force directly upon it, but not without great danger. It can, however, only happen in young persons in whom the sutures are not obliterated as they are in elderly ones; in general it takes place when the ball happens to lodge as it were between the bones concerned in the formation of the suture. The first case of the kind which came under my observation occurred at the taking of Oporto. I met with a second at Albuhera, a third at Salamanca, and a fourth in a slighter degree at Orthez.

A heavy dragoon was wounded at the battle of Salamanca by a musket-ball in the body, which caused him to fall from his horse, injuring the top of his head. Little attention was paid to him until mischief was suspected from the lethargic state into which he fell, which could only be attributed to the blow on the head, where a tumor was observable. This, on being divided, showed a separation of the edges of the sagittal suture, from which some blood flowed. Two crowns of the trephine were applied on the twelfth day, in order to admit of the free discharge of some blood which had been extravasated from a wound in the longitudinal sinus, after which the symptoms subsided, and the patient gradually recovered.

A ball may pass apparently through the fore part of the head from side to side without doing much mischief beyond depriving the sufferer of sight. It does not in these cases injure the brain, but passes immediately below it and through the back part of both orbits. In four such cases the recovery was rapid, but the blindness was irremediable.

283. The danger of injury to the frontal sinuses has been greatly exaggerated, and vanishes in a great degree when attention is paid to their structure. The uncertainty of the depth of the cavity between the tables of the bone, and the irregularity of the exposed surface of the inner table, which may through carelessness be mistaken for depression, should be remembered.

A soldier of the 29th Regiment was wounded at the battle of Talavera by a ball, which struck him on the lower part of the right side of the forehead, fracturing the external wall of the frontal sinus. On examination, the ball could be felt lodged in the sinus, whence it was readily removed by enlarging the opening, and the man recovered without any bad symptoms.

At the storming of Badajos, a soldier of one of the regiments engaged at the little breach was struck by a small ball about the size of a swan-shot; it penetrated the frontal sinus of the right side, and stuck in the inner table, the outer being considerably injured and splintered by the blow. The splinters having been removed, the small ball could be seen sticking in the inner table of the bone, whence it was easily extracted, leaving the dura mater bare beneath. He was sent to Elvas, and recovered with a good and firm cicatrix.

After a wound of the frontal sinus has healed, the air has been known to raise up the integuments of the forehead into an elastic crepitating swelling whenever the patient blew his nose, so that a compress and bandage on the part were required for its relief; but these cases are very rare.

284. Wounds of the bony parts within the orbit are often attended by the most serious consequences. A boy, nine years of age, was struck by his playfellow with the end of a thick iron wire on the right eye, which blackened it. There was no external wound; but as there was some bloody chemosis at the upper part and the inside, there was a probability of the wire having penetrated deeply, although the opening could not be discovered by the probe. The accident had happened two days before, but he did not think himself ill. He was well purged, and cold water was applied externally. Two days after, he complained of sickness, headache, and some pain over the brow. He was bled freely from the temple of that side by leeches, and well purged by calomel and jalap. On the sixth day his mother reported him as having been delirious and restless all night. He was found stupefied, answering with difficulty and incoherently; pulse very quick, skin hot and dry, with some convulsive twitches of the face and arms; pupils slightly obeying the influence of a strong light, but not dilated. He was again bled freely from the temple, but his breathing became more difficult, he fell into a comatose state, and died in the night. On examining the head, the stiff iron wire was found to have passed under the upper eyelid, between it and the eye, through the posterior part of the orbitar plate of the frontal bone and into the anterior lobe of the brain, which was softened at that part, and bedewed with matter.

A woman, who had been struck by her husband on the left eye with a tobacco-pipe, while preparing her frying-pan for cooking, knocked him down with the pan, and ruptured his right eye, which was lost. She then pulled out a piece of the pipe which was sticking in the orbit, between the lid and upper and inside of her own eye, which was uninjured. She complained of little but the bruise, and rather brought her husband than herself for advice. Bled and purged, she did not complain of anything for several days, when she said she had been very ill all night, with nausea, headache, and shivering; with hot and dry skin, pulse very quick, the upper eyelid paralytic; she looked very ill, became delirious at night, and died two days after the first complaint of serious illness. On examination, half an inch of the red waxed end of the tobacco-pipe was found to have gone through the sphenoid bone, by the side of the sella turcica, and to have lodged in the brain, whence it was removed bedewed with pus, the brain being yellow and softened around it.

A wound of the longitudinal or lateral sinuses, allowing a free discharge of the blood poured out, is of comparatively little consequence. It is, on the contrary, a very fatal injury when the blood is permitted to accumulate.

285. A protrusion of the brain, often improperly called a fungus cerebri, is of two kinds, and occurs at different periods of time. The first kind is principally composed of coagulated blood, usually appears immediately after, or within two days after, the injury, and is generally fatal. The second takes place at a later period, although it has occurred on the third or fourth day, and is formed for the most part of brain. These protrusions rarely take place when a considerable portion of the skull has been lost or removed, the brain then being able to expand to such an extent as the inflammatory impulse from within may render necessary. When the opening is small, and the dura mater has not been injured, it has seldom been observed. It is then principally when the opening in the skull has been of greater extent than the size of one piece of bone removed by the trephine, the dura mater having yielded either in consequence of the injury or by ulceration, that this evil takes place; it is not, under proper treatment, a fatal, although it is always an extremely dangerous occurrence.

In the first kind of protrusion, the dura mater must necessarily be torn to some extent, and the tumor which comes through it is of a dark-brown color, glazed and covered in general by the pia mater. These protrusions were accompanied, in every case I have seen, by delirium and other symptoms of inflammation of the brain and of its membranes, and not by coma, until near the fatal termination of the disease. I have seen them torn off by the patients themselves during life, or before death; and satisfied myself that they all arose from hemorrhage into the substance of the brain, probably immediately below its surface, which became more elevated as the inflammation proceeded, and was gradually protruded at the part where there was the least opposition. When the tumor was torn off, little hemorrhage ensued, but a dark-brown blood cavity was seen in the substance of the brain; and when cut off and examined, the protruded part seemed to be covered by the pia mater, with or without a layer of cerebral matter, and was made up generally of coagulated blood. No case of this kind recovered.