A Collection of Chirurgical Tracts

Chirurgical Remarks ON A Wound of the Head RECEIVED

SIR,

I do not question but you have had the Curiosity to read over a very remarkable Case in Surgery, not only upon Account of the Recommendation the Name of the Author2 gives it, but partly because I know you have been for a long time of opinion, That this Age wou’d distinguish it self by the Advances that Medicine has, and will receive; I need not observe, to a Man of your Capacity, how just, according to my Opinion, our Author has been in relating all the Particulars of the Case he gives us the History of: Nor need I intimate to you how peculiarly the Prescriptions were adapted to the several alterations that were observable in that little Patient: I will only take the freedom to make some Remarks on a considerable Circumstance, which perhaps we shall find obstructed so methodical a Procedure, in order for a Cure.

Our Author is of opinion, That his Death was owing to the effused Blood from some Vessel upon the Pia Mater, which had been ruptured by the Concussion or Shock of the said Vessel, from the Force of the Blow; which Blood pent in (for want of a Discharge) had formed an Abscess, thereby deluging the Surface of the Brain with Matter: And this, tho’ continually draining off thro’ the Orifice in the upper Membrane, yet some part thereof lying beyond the Elastic Power of the said Membrane to raise up, and out of the Reach of Medicine to deterge and mundifie, was at length imbibed by the Vessels, where missing the Salutary Crisis, sometimes observed in the Empieme and Pleuritic Cases, it was conveyed by the Circulation to the Heart, and at length, we are to suppose, somehow effected the Nervous System, bringing on the fatal Spasm.

Thus you see, Sir, how plain and consequential the Account of the Child’s Death is; but even here, I hope, I shall do no Injustice to the Author, if I inform you, I cannot perswade my self that the Matter was imbibed by the Vessels, purely because some part thereof lay beyond the Elastic Power of the Dura Mater to raise up, and out of the Reach of Medicine to deterge and mundifie, as our Author’s Words are; but that it is reasonable to believe, that some part of it was reassumed by the Vessels, when it could no longer discharge it self as before; for if you will give your self the trouble of looking back to the 32d Page, you will find, that no sooner was the Orifice choaked up by a caked Matter, but the mischievous Effects of the Suppression of the Discharge soon began to discover themselves by the Rigours the Child was attended with; and we find our Author soon after fearful of such a thing.

By this we may see how circumspect we ought always to be, lest we interrupt the Design of Nature when she is about to expel any morbifick Matter, the ill Effects that attend it oftentimes discovering themselves after different Manners; We look upon a continued Discharge of Matter to be, as it were, a natural Evacuation, and that it’s immediate Stoppage, without other Means, being made use of to divert and evacuate it, to be succeeded by a greater Fulness and Distention of all the Vessels, as is observable upon the Suppression of the Menses, Hemorrhoides, or insensible Transpiration, there is this Difference to be observed that the ill Accidents that attend the Stoppage of the Discharge of Matter are not so much owing to the Distention and Plenitude of the Vessels, but according to the ill Quality of it, ’tis disposed to render the Patient feverish more or less, which is generally ushered in by Rigours, and sometimes succeeded by Spasmodic Contractions.

For a further Illustration of this, we will take the liberty to relate the Case of a Man of about Forty Years of Age, who was for a considerable time incommoded in his Business, by reason of a violent Contusion he had received on the Upper-part of his Left Arm, a little below the Shoulder: After some time it was succeeded by an Apostemation, upon the opening of which I was informed, a considerable Quantity of Matter discharged, which was not of any ill Colour or Smell, the Matter continuing to make its Exit the same way for several Weeks, at length formed a Sinus, which might be easily traced to the Upper and Fore-part of the Os Humeri. The external Orifice of this was endeavoured to be dilated, but it not only put the Patient to a great deal of Pain, but pent in the Matter, and caused the contiguous Parts to tumifie very much. About this time the Axillary Glands began to swell and pain him, and by their Pressure on the Limphaticks the whole Arm became Oedematous; soon after some part of the Matter made it’s way out under the Arm, upon which it almost ceased to flow from the Sinus on the upper-part of it. In short, upon this the Patient found himself very much indisposed, he lost his Appetite, was attended with Shiverings, became feverish, and at length died violently convulsed.

On Dissection we found the Surface of the Lungs to be interspersed with blackish Specks, the left Lobe adhered to the Pleura, and the Pericordium contained a much greater Quantity of Liquor than usual, though its Colour was natural. The Right Auricle and Ventricle of the Heart were very much distended, and the Diameter of the Arteria Pulmonaris considerably enlarged: on the Division of the Integuments of the Abdomen, a very large Quantity of yellowish fœtid Matter discharged it self, which was somewhat viscid; we found that the Intestines floated in this, for the Abdomen was full of it. In the lower-part of the Concave Side of the Liver there was a very large Abscess discovered, which contained a Fluid of the same Colour and Consistence with that which we took notice of before. There was an Orifice in the lower part of the Abscess capable of admitting the End of one’s Finger; by which, without doubt, Matter discharged it self into the Abdomen. The Spleen was of a very odd Figure: On it’s convex Side there were a Multitude of Streaks, that proceeded from all Parts of it, and centered in one Point, which proceeded only from the Disposition of the Fibres of it’s internal Membrane. It was almost full of Blood, which in the middle was corrupted, and stank abominably. After it was cleared from the contiguous Parts to which it adhered, and taken out of the Body, it weighed four Pounds and a half.

There might have been something more observable upon the Dissection of this Body, but the short time that was allotted for it did not give us an Opportunity of making that strict Enquiry as seemed to be necessary. Blancard. in his Anat. Pract. Rationalis, p. 252. has much such an Observation as this which we have related. See likewise Schenckius, Lib. 3. Obs 26. But I do not doubt, Sir, but you have made some curious Remarks on Cases of this Nature, tho’ I am pretty positive you will agree with me in this, That the immediate Cause of the Death of the Person we have been speaking of, was the giving a sudden Check to the Discharge of the Matter. It was the Work of Nature in this Case (and what she was endeavouring to perform) to disburden herself of those disproportionate and offensive Particles, which by their Continuance in the Body would but have occasioned an irregular Motion of the Fluids, and consequently a Discomposure of it’s whole Frame: For the animal Body being nothing else but a Congeries of Canals, filled with different Liquors, it must necessarily suffer very much, and it’s Actions be irregular, if any Heterogeneous Particles become incorporated therewith. We must here allow, that in Discharges of Matter of a long Continuance, sometimes the Diameters of the Fibres and Vessels may be so much enlarged, that the nutritious Juices may be thrown out with the other, and so occasion a general Emaciation: But this may be easily rectified at the Beginning, without Detriment to the Patient, by making use of some spirituous and moderately astringent Remedies, to recover the natural Tone of the too lax Fibres and Vessels, and give the Matter a proper Consistence. It is to be observed in such Cases as these are, that the Part from whence the Matter discharges, if it be the Leg or Thigh, first loses it’s former Fulness and Dimensions, tho’ soon after there appears an Emaciation of the whole Body. Such an Abscess as we discovered in the Liver of the Person before mentioned, we are inclined to believe might have been found in the Child, had the Abdomen been dissected; for several Authors have assured us, it has frequently been observed to be the Consequent of Fractures of the Skull, tho’ I am apt to believe it never happens, but when the Matter has received a Check in it’s Discharge.

I shall now take the Liberty to observe, that the imprudent Application of Repellents to some Tumours, and inconsiderate Healing of old Ulcers, with the unhappy Method of Procedure, in order to the Cure of some Diseases, very often discover themselves, by their being succeeded by very ill Effects. Non tamen in omnibus Huxionibus repellentia adhibere licet, (says Sennertus) Partibus ignobilibus, præcipue iis, ad quas natura interdum humores protrudere solet, ut sunt Glandulæ post aures, & in collo, sub axillis, in inguinibus adhibenda non sunt, ne humor ex iis repulsus ad partes principes & nobiles feratur.

The same Author informs us in his Paralipom. ad lib. 5. Pract. Med. of a Boy, fourteen Years of Age, that died upon the Accession of an Epileptic Fit, which was caused by the striking in of the Scab by the imprudent Use of Liniments. And Baglivi allows, that the irregular Cure of the same Disease may be succeeded by a Spitting of Blood, an Apoplexy, Dropsy, lingering Fevers, &c. The Healing of old Ulcers, without having a Respect to those Circumstances that ought to precede such an Undertaking, generally lays the Foundation for a Train of mischievous Accidents; for the Patient soon begins to be sensible of an Unactiveness of the whole Body, is sleepy, has a weak Digestion, Head-ach, and is feverish, which is attended with very profuse Night-Sweats; and these we have several times observed to be the Forerunners of the Patient’s Death, though sometimes all these ill Accidents may be prevented by an Imposthumation in some part of the Body or other.

Now to account for such remarkable Alterations, in such Subjects, we are obliged to take notice, that here is the Suppression of the Evacuation of a Humour, that had been constantly discharged for a long time; and this, we have before observed, will cause a greater Fulness and Distention of all the Vessels. Now the Quantity of the Blood being very much encreased by the Addition of this viscid Juice, the Celerity of its Motion must be considerably abated, upon which Account it will enlarge the Diameters of the Vessels, by relaxing their Coats, and pass with so great a Difficulty through the Capillary Vessels, that if it arrive at any Part where the Fibres have lost their due Tensity and Spring, it is disposed to stagnate, and produce an Imposthumation. If this does not happen, as the Motion of the Blood continues to be very languid, the Quantity of Spirits filtrated in the Brain will be less upon two Accounts: First, Because as the Blood moves more slowly, all the Parts of the Body through which it circulates, will receive a much less Quantity of it in a given Time, than they must have done, had it moved with a greater Celerity. Secondly, The Viscidity of the Blood, together with it’s Motion diminished will lessen the Quantity of Spirits, according to the 20th and 22d of Dr Wainright’s Propositions of Animal Secretion.

Now this being so, it is no wonder to observe such an Inactivity of the Parts, Sleepiness, weak Digestion, &c. to attend a Person under such Circumstances: For the Quantity of Spirits being so much diminished, the Parts can never be sufficiently influenced by them to perform their respective Functions with that Force as usual. To this we may add, that they are in a great measure deprived of their Power and Spring, and Sensation in general is not near so strong and lively. From hence it is evident, that when Nature has found a Passage whereby she may disburden herself of any excrementitious Humours, we ought for a considerable time to give proper Internals, and make use of some other Method, as by Issues, or such like, whereby we may divert the Course of the Matter, which, if I may so say, has been so long together determined to pass the same way. Beside this Advantage which will accrue by that Method, there may be near the same Quantity of Humours evacuated; and so those unhappy Accidents, will be prevented, and the Ulcer cured.

I am perswaded, that it is not without a great deal of Difficulty that we can sometimes divert the Tendency of Humours to a Part; and I can bring several Instances of Sores that have been healed, where the suppressed Matter has discovered it self, by an Aposthume near the Place where the Sore was, a short time after it had been healed.

Fælix Wurtz, who was a very judicious Surgeon, informs us, That it sometimes happens, that in a little time after a Patient has been cured of a Wound of the Head, he feels violent Pains there, which indicates that Matter is collected in the Part. He adds, That many die of it, by reason the Cause is not understood by some Surgeons. This Remark proves, that the Wounds were not kept open long enough, or else that the Surgeon acted imprudently in not making use of proper Means to divert the Tendency of the Humours to that Part; not but it will abundantly more easily happen to those Parts that are depending, and where the Weight of the viscid Fluid will incline it to settle.

I knew a lusty Fellow, about twenty five Years of Age, that had an Ulcer on the internal Ancle of his left Leg near twelve Years: It had been cured three or four times, but he always found himself very much indisposed after it, till it broke out again, and the Matter had a free Discharge: At length, upon his coming from Sea, it was healed again, upon which he was seized with a violent Pain in his Head, Loss of Appetite, which the next Day was succeeded by a violent Fever and Looseness. His Physician ordered, among other Things, a large Blister-Plaister, to be applyed to the Leg on which the Ulcer had been. The Patient recovered; but what was very observable, was, that the Sore the Blister-Plaister had made terminated in an ugly Ulcer, which would not heal, though various Applications were made use of. If Nature had been in this Case compelled, as it were, and forced to a Compliance in the healing of this Ulcer, it is probable the Matter would have been thrown upon another Part, and so occasioned a Disease there.

By this we may see how cautious we ought to be not to proceed in a Method contrary to the Dictates of Nature; for if we do, we consequently disturb her regular Motions, upon which she oftentimes commences a new Work, which, if it does not tend to the Subversion of the whole Oeconomy, there ensues a Permutation of the Disease, by the Translation of the Matter from one Part to another.

It would be impossible to recount all the obscure Motions Nature makes use of to accomplish such Ends: We will only mention some where the Disease has been perfectly changed from what it was before by such Methods. Mear gives us an Instance of a Dropsie of the Breast, which succeeded an ill-cured Hydrocele. Hildanus observes, that an inveterate Ulcer of the left Leg being unhappily healed up, the Patient died of a Pleurisy some Months after.

To this I may add an Observation of a Man that had an old Ulcer on each Leg, which being attempted to be cured, as the Matter gradually lessened, he was deprived of his Sight. There was no Alteration to be observed in the Eyes of this Person, but only a Dilatation of the Pupils, as is generally observed in a Gutta Serena, which was judged to be his Case. In short, upon the running of the Sores, though he had been perfectly blind, he effectually recovered his Sight again.

I will not tire you, Sir, with the Recital of any more Cases of this Nature. What has been hitherto said, I hope is sufficient to incline you to believe, that the immediate Cause of the Death of the Child I spoke of in the former part of the Letter was the Suppression of the Matter, which had continued to discharge in such large Quantities so long together. And that such a sudden Stoppage of a Discharge of Matter may procure a Patient’s Death, though the Symptoms that proceed may be different. I have likewise shewn the Difficulty there is in Diverting the Tendency of the Matter to a Part, and mentioned how one Disease is sometimes converted into another: But of what Use these Remarks may be I leave you to judge. To me it seems reasonable enough to suppose, that as a regular Method of Practice is not the Effect of a Man’s Sagacity, but the Product of repeated Experiences, every thing that occurs may tend, by a proper Application, to the Illustration of the Art. What else has made some Men so famous for their Prognosticks? Had not our great Master Hippocrates a Respect to the Suppression of the Discharge of Matter from Ulcers, when he expressed himself thus, Ulcus lividum & siccum, aut cum virore pallidum lethale est? And this we have known to be true in several Cases.

Well then, does not this sufficiently prove, that where we have Cause to fear a Suppression of the Discharge, we ought to remove any Impediment that may embarass Nature in her Work, and advise a proper Method to promote the precipitating the morbific Matter? For so shall we, by joining our Forces with those of Nature, still keep her in due Course; and that when she is grown languid, and departing from her former Measures.

You must excuse me, if I digress a little to take notice of an Observation that some Authors have made, viz. That from a dangerous Fracture of the Skull, after Death the Liver has been often found impostumated. They have been likewise very sollicitous to know which way the Matter could be conveyed to so remote a Viscus; but it would be needless for me to offer what has been said in this Case, because it seems to be evident enough, that a Part of it is reassumed by the Vessels; which, with that should have been discharged from the Mass of Blood, is by the Circulation deposited in that Part. But here we may start a considerable Problem, which is, How comes it to pass that the Morbific Matter if it’s Discharge is suppressed, is thrown upon the Liver rather than any other Part? In order to the Solution of this, we ought to consider, That the Spleen is subservient to the Liver in performing its Office, by giving the Blood a Check in it’s Progress, whereby it’s Velocity is lessened; otherwise so thick a Juice as the Bile could not be separated from it. Now the Motion of the Blood being rendered abundantly slower in this Part, it is no wonder that the Morbific Particles separate themselves from it, while the Filtration is carrying on, and by their Assemblage form an Abscess in the Part.

You may perhaps expect, Sir, that I should make an Apology to excuse the Length of my Letter; but I assure you, the Pleasure I have taken in writing it would oblige me to make it of a larger Extent, if I did not find I should be forced to take notice of some things, which may perhaps have a Place elsewhere. I have only this to add, that if through the little time I have taken to write it in, I have in any part omitted to pay that Respect as is due to you, I shall very readily ask your Pardon. In the mean time I must own my self to be,

Southwark,

Aug. 22, 1709.

IF you remember, Sir, in the History of the Child’s Case, which I have before mentioned, it was observed, that notwithstanding the violent Pressure upon the Brain, by the depressed Pieces of the fractured Skull; yet the little Patient laboured under no worse Symptom, than a Head-ach, and was in a Condition to walk about the Chamber. This was really very remarkable; but if you will be pleased to give your self the Trouble of reading the following Account, I do not question but you will meet with something much more surprizing.

On November the 4th, 1707, it happened, that during an Engagement between a small English Vessel and a French Privateer, near Margate, one of our Men was unfortunately wounded by a Bullet, which past through the middle of the Os Frontis. The Surgeon aboard the Ship immediately enlarged the Wound, by making an Incision through the Integuments, but could not discover the Bullet; whereupon he dressed him up, and the same Day being set ashore, he was dispatched for London. On Thursday the 6th Day of the same Month, he arrived, having walked much the greater part of the way in that time, which is about 66 Miles; the same Day his Surgeon endeavoured to extract some Pieces of the Bone, which discovered themselves through that Aperture which was made by the Bullet, but without Success; for they consisted chiefly of the internal Table, which were much larger than the Hole in the external: Upon this the Wound was immediately drest up, and a second Attempt was made a Day or two after; but it proved as successless as the former. In the mean time, the Patient continued to be very hearty and well, and seemed to be no more indisposed than if he had only received a slight Wound of the Head. The opening the Skull with the Trepan was proposed, and which would probably have been put in Practice in a Day or two’s time: But on the Sabbath-Day Morning following, after he had rested well all Night, he was seized with such violent convulsive Motions as were very surprizing; during which he expired. The Body being laid on a Table to be dissected, all it’s Parts appeared so prodigiously inflated, that the Person, when a live, being one of the largest Stature, it seemed perfectly monstrous. A Puncture being made in any Part through the Integuments, there was nothing discharged but a subtile Matter or Air; immediately after which the Part subsided, though before on a Compressure of the Fingers it would receive such an Impression as is observed in Oedematous Tumours; but it would suddenly return to it’s former State. The Surface of several of the Parts appeared livid and vesicated. The Skull being opened, the Bullet dropped out of the Brain, all the Fore-part of which was corrupted, and abounded with a thick yellowish Juice, of a very offensive Smell; there were two or three very large Pieces of the inner Table of the Skull, with some smaller that were found among the lacerated Membranes, and lodged in the corrupted Brain.

This Case is so particular, that it may not be amiss if we make some Reflections on it.

We are very well assured, Sir, that it has been a Matter of very great Surprize to several ingenious Men, to consider how the various Operations of the Body have continued to be performed, when those Parts which were so absolutely necessary to the Well-being of the Animal, have been naturally or accidentally disordered to such a degree, as to suffer a perfect Confusion of their Parts: And of this we find Variety of Instances in those Authors, who have very obligingly applied themselves to relate the Histories of deceased morbid Bodies. But that the Brain it self, which is the very Source and Principle of all Animal Functions, should, after it has undergone such a Violation as we have observed, continue several Days without incommoding the Person in the least respect, is really very remarkable; for if we do but consider what an absolute Necessity there is for a constant Supply of Animal Spirits, to empower the Parts to perform their mechanical Actions, and at the same time reflect on the Disorder and Corruption of that Part, whose Office it was to secrete a sufficient Quantity of those Spirits, we might very reasonably expect a considerable Alteration in the whole Body. One might very well think, that from the Deficiency of Spirits that would ensue, the Parts could no longer continue to perform their Actions, but must gradually lose their Power and Spring, and at length become in a manner destitute of Motion: For we can scarce perswade our selves, that Nature in this Case is so provident as to suffer the Cerebellum and Medulla Spinalis to filtrate the Spirits in a greater Quantity, that they might supply the Exigencies of the Body.