Suppuration within the meninges of the brain, with uncommon symptoms cured by the trepan

Excerpt from:

Essays and cases in surgery: the whole illustrated with copper-plates.

By John Aitken, Surgeon, Fellow of the College of Surgeons, and one of the Surgeons of the Royal Infirmary, Edinburgh.

London.  1775

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Diana Foreman, a girl aged 7 years, was struck with an arrow falling perpendicularly, upon the crown of the head, a little to the left side of the saggital suture; it penetrated the cranium so as to remain erect. After drawing it out, she went home crying; her father, a shoemaker, regarding the wound as a very slight scratch, applied over it a little of the wax he employs in his business; her mother then ordered her on a little errand; but after going a few steps, she staggered and fell to the right side; she then placed her on a seat, from which she likewise fell to the same side; as a further trial, she made her stand on a chair, from which she fell to the floor, still inclining to the same side; she was then put to bed, she lost her appetite for food, but thirst increased in proportion; she was often seized with retchings, so that what she drank was immediately returned; except when drinking or vomiting, she lay very quiet.

The paralytic affection of her left side increased so as to render her incapable of using her right arm or leg in the smallest degree. She was attended by an Apothecary of this place, who treated her as in a common fever, without paying any farther regard to the wound than applying a little ointment, by which it was twice superficially healed. After continuing in this way about 10 days, her father desired me to visit her, he said she was ill of a fever and palsy. Attending a Lady in child-bed, I declined visiting the girl till next morning; I found her labouring under great stupor so as to require to be roused by loud speaking, before she would give any answer to questions put; her face was flushed, the pupils dilated, the pulse exceedingly irregular, beating from 50 to 60 strokes in a minute.

Above: Late 18th-century trepanning instruments. Engraving by J. H. Savigny. Image courtesy of the Wellcome Library, London.

The father not having informed me of the foregoing accident, from the analogy of some of the symptoms to those of the hydrocephalus internus, I accidentally asked if she had complained of pain in the crown of the head; he then told me the story of the arrow as above narrated, but added, that the Apothecary had healed the wound with ointment. A purulent matter was, however, still issuing from it; with a probe I perceived a small circular space of the skull bare; searching more attentively, the probe-point sunk into a hole quite through the parietal bone; after this discovery, the ratio symptomatum was no longer a mystery. I convinced her father, that, in order to save the child’s life, there was a necessity of giving free vent to the matter that was oppressing the brain; I accordingly, that day, in presence of two Fellows of the College of surgeons, applied the trepan on the bare portion of the skull, after laying aside the teguments, the perforation made by the point of the arrow serving to fix the centre of the saw; the dura mater appeared closely applied to the interior surface of the cranium in the ordinary way; in the middle of its exposed part, there was a small hole which corresponded to that in the skull; this being dilated, above two ounces of well concocted pus issued out; more might have been forced out at that time; but fearing the consequences of too sudden and great an evacuation, I dressed the wound superficially, recommending to her father to keep her head so inclined during the night as to favour its gradual exit.

She rested well the following night, about two ounces of a thick matter, similar to the foregoing, was discharged by next dressing, with remarkable relief of the stupor and other symptoms. At a following dressing, I observed a small portion of the cortical substance of the brain mixed with the ordinary matter: a fungous excrescen rose from the dura mater, a very constant phaenomenon after the trepan, especially if this membrane is wounded.

In six days from the operation, she could sensibly squeeze my finger with the paralytic hand, in a day or two more was able to raise this hand to her head; the cure went on most successfully. She has been about four years in perfect health, and has had no attack of a periodical asthma, to which she was formerly subjected.