No. 1446.

MAY 17, 1851.

Clinical LectureDelivered at St. George’s Hospital,

BY CÆSAR HAWKINS, ESQ.,SURGEON TO THE HOSPITAL,

AND VICE-PRESIDENT OF THE ROYAL COLLEGE OF SURGEONS.

Caries and Necrosis of the Parietal Bone; Epilepsy.—Caries ofthe Temporal Bone; Abscess of Brain; Hæmorrhage, &c.

IT is the province of your systematic course of lectures toteach you the general principles of surgery, while in clinicallectures these principles are shown you more in detail; and into-day’s lecture I propose to explain to you something of thesubject of inflammation of the bones of certain parts of thebody.You have learned, regarding this texture, that in healthy

-inflammation the inflammatory secretions are organized inthe form of hard periosteal or osseous nodes, while in un-’healthy inflammation there are formed soft nodes, containinga .glairy transparent fluid, or pus. You know that caries is

analogous to unhealthy ulceration in the soft parts,-it maybe weak or phagedsenic, strumous or syphilitic,-and, finally, I

that with or without caries there may be the death of theinflamed parts, which exfoliate, or separate in larger pieces,onstituting necrosis.You are familiar with the subject of caries, as it is seen in

the cancellous structure of the carpus or tarsus, or in theheads of the long bones, whence the joints so often becomediseased, and also as you witness it in the disease of the

spinal column; but there are some parts in which caries andnecrosis are more rare, and of much importance, and in nopart of greater interest than in the bones of the cranium,which I will first bring under your notice in two cases now inthe hospital.The first case for our consideration is that of Elizabeth

M——.aged 51, admitted November 13th, who tells us thatlast May twelvemonth she began to suffer from violent painin the right temple, whence it extended to the top of the headon the same side, and that she had previously been labouring,as she called it, under debility, without apparent cause. Abouta month afterwards, she perceived a swelling near the seat ofpain, which was opened at the Chelsea Dispensary in thefollowing October, and some thin fluid escaped, the pain beingthen relieved. Last May she had a fit of epilepsy, and hascontinued to have fits ever since, and that more frequently ’,in the last two or three months, the fits occurring at intervalsof about a fortnight, and lasting from a few minutes to nearlyhalf an hour, but without the convulsions being very severe;and they are unattended with much stupor. She has nearlylost the use of the left or opposite arm to the seat of disease,and says she had some numbness in it previous to the first fit;but on examination, it appeared that there is no palsy of thelimb, but that the hand and wrist are stiff and useless frominflammation-perhaps rheumatic-in the carpal joints. Shesuffered much from a cough, but says she has had it for twentyyears; she is thin and emaciated, with a feeble and rapidpulse, without fever, and not much pain in the head. Twoulcers in the scalp led down to the same part of bone, theupper and anterior border of the right parietal, a narrowbridle of skin separating them; the bone was dead, and had athin, black, and very foetid discharge from around it.

I requested Dr. Nairne to see her at first for her cough,which slowly improved, but has never left her, and appears tobe only bronchitis, though her aspect is a very suspicious one.’On the 18th, five days after her admission, she had a slight

fit, and I divided the band of skin across, which it is alwaysright to do in cases of necrosis of the cranium; it takes awaysome tension, and so far relieves irritation, and by dividingthis band you also save some skin to fill up the hole, for it issure to be ulcerated away if left, and when divided the twoends retract to a certain degree, and are preserved.Dec. 6th.-She had another fit, her cough being now less,

and her health a little better. On the 17th, finding the boneapparently loose, I removed it; it was worm-eaten on the out-side and smooth on the inside, where it had been attached tothe dura mater, and was about an inch long, and as broad asthe end of the forefinger. I did this, you may remember, with

great gentleness, inserting the end of an elevator under one,4idle and another under the other, moving them alternatelyand slightly, lest the edge of bone should be tilted in uponthe dura mater; and yet you may have learned a lesson ofcaution in the case as to meddling with dead bone of thehead whenever force is required; for our notes of the nextday remark that she had two fits on the evening of the day inwhich the bone was taken out-one at seven o’clock, the otherat ten-partly, no doubt, from a little fright, but in part also=probably from the operation, slight as it seemed, for she alsosuffered from pain in the head.On the 20th she was perfectly quiet, the pulse natural, and

the dura mater granulating healthily.Jan. 6th.-She again had two slight fits. But why, you

may ask, should this take place after the removal of the deadbone? The cause was evident on looking to the exposed durarmater; for a little yellow, unhealthy ulcer appeared in themiddle of it, the size of a small pea. It got well again underthe use of solution of caustic, and by giving a little wine, with

sarsaparilla and iodide of potassium, her health also improved,and she was able to get up from her bed.At the end of the month she was weakened by an attack of

diarrhoea, and from this cause on the 30th she again had a fit,and a similar spot of ulceration was observed, whilst the restwas cicatrizing, the new skin passing from the scalp down-wards over the surface of the dura mater. Now it is againmore healthy.

In such cases as these, then, the danger arises from theeffects on the brain, and hence they are most frequently seenunder the physician’s care, unless some injury has been knownto have been the cause, or the bone requires surgical attend-ance, as in M-.Sometimes there is pretty acute inflammation of the brain.

A man, for example, was admitted under the physician someyears ago, who had been ill with pain in the head for eightmonths, and three times he had had epilepsy, and for a weekbefore I saw him he had been nearly in a state of coma. It,then appeared that his attack followed a blow on the head,and I was asked to attend him; he was insensible, with dilatedpupils, and a perfectly passive state of his limbs, and his pulsewas under 50. Finding some little swelling over the rightparietal bone, I made an incision down to the bone, which hadthe effect of rousing him to look up, though not to answerquestions. I bled him, and administered calomel, and in afew days he was much better. He had one relapse, thoughnot to the extent of becoming comatose, and bleeding andcalomel again restored him. A fortnight after this he againbecame ill, but it was with delirium and half mania, for whichthree or four grains of morphia were given daily, and in a.short time he got well, and continued so a year afterwards.More often, however, the inflammation of the bone is of a

chronic character, and the symptoms of cerebral affectionsare those of irritation or congestion rather than of inflam-mation. The effect of the bone itself is seen in this cranium,which is covered with small ulcerated depressions inside andout, over its whole extent, some parts having apertures throughthe bone; it is probably the the result of syphilis. In thiscranium again a nearly similar condition has been producedby a blow, and an attempt was made by the surgeon to re-lieve the symptoms by an incision at one part, but matterwas found after death below the bone at another part. Youcannot wonder that operations are of little avail in such casesas these, where hardly a portion of all the cranium is unaffected.But at the same time, the fatal effects of confined matterare seldom seen, especially if any of the bone dies, for littleperforations generally take place in different places aroundit, through which the pus within the bone escapes, and inwhich you may see it rising at every pulsation of the arteriesof the brain, or at every cough or deep expiration. In stru-mous cases you may see the caries in circular spots, as in thiscranium, which was taken from a patient of mine, who diedof disease of the hip-joint; the deposit was in complete tuberclesboth on the inside and the outside; one or two were even inthe sphenoid bone, radiated depressions marking where thetubercular matter had been deposited.The symptoms of inflammation of the cranium may be

either entirely local and external; or they may influence thenerves in their passage through the bone without any cerebralaffection; or, thirdly, the brain may be affected with or with-out local pressure on the nerves in their course.A child, about ten years old, was admitted into the hospital

under my care, with an immense collection of pus without anypain, in contact with the bone or pericranium over the wholehead, completely distending the occipito-frontalis muscle from.

540the occipital ridge to the forehead, and from one ear to theother, which was the consequence of a fall some time before.I made a small opening on one side, and pressed the mattergently from all parts to this opening, and used a bandageafterwards to keep the parts in contact. The case was suffi-ciently healthy to have adhesion take place very shortly, andno part whatever of the bone exfoliated, except a verysmall piece just under the lancet puncture. Frequentlyyou may find the probe touch the surface of the bonefor several inches, and yet if you do not expose it more thanyou can help, the pericranium will again come in contact withand adhere to the bone, without any exfoliation.In the next place, as to the effect upon the nerves alone: a

man was in the hospital with chronic disease of the sphenoidand temporal bones, without any cerebral affection, in whomcomplete loss of sensation and of motion on one side of theface marked the affection of the fifth and seventh nerves,while some ulceration of the Schneiderian membrane, and ofthe conjunctiva, showed the effects of loss of sensibility inthe delicate surfaces. I remember a man, whom I saw manyyears ago in the Middlesex Hospital, in whom all the firstseven nerves of one side of the head were affected by syphiliticinflammation of the bones; he had neither smell, nor sight,nor taste, nor hearing, nor feeling in any part whatever of theleft side, while these senses were perfect in the other half;the eye was immovable and fixed from palsy of the third,fourth, and sixth nerves; and the whole face and the musclesof the lower jaw were paralyzed, and the face cedematous;the eighth and ninth nerves alone were unaffected, the cerebralfunctions having up to that time been unimpaired.

Generally, however, the brain becomes affected at sometime or other,-sometimes only producing epilepsy, as inM- ; but often the mental functions are weakened;there is general torpor of mind and body; the memory fails,and the speech is imperfect; or complete coma indicatesmore complete compression by temporary congestion, orpermanent and fatal pressure.A woman, who probably had chronic inflammation from

syphilis, was under my care, having a curiously misshapenhead, from lymph and serum in the front of the right side ofthe head, and in the back part of the left. One day she wassuddenly attacked with insensibility and paralysis of the leftside of her body and face, and loss of sight, for a time, in botheyes, and of hearing in both ears. She was very near dyingin this attack, but recovered from it, and went out well,except having nearly complete deafness of both ears still re-maining.A Jew dentist was under my care, more or less for about

eight years, who had a small hole in the palate, and a carious

spot in one clavicle, from a node; he had once some dischargefrom the ear, with palsy of the portio dura, and deafness ofthat side permanently. When I first saw him he was sufferingfrom incessant sickness, which had on several occasions, in theprevious year and a half, lasted for two or three weeks at atime, and had been treated as dyspeptic. His friends weremuch astonished when I ordered a bladder of ice to be appliedto his head, which, however, relieved the vomiting, for it wasa cerebral symptom, accompanied by much pain of the head,arising from chronic inflammation of the cranium, not only ofone temporal bone, but of many other parts of the skull, bothwithin and on its outer surface, in which, after death, rough-ness and depressions marked where the disease had been, withthickness of the bones and of the dura mater. In the courseof his illness he had at one time partial loss of power overthe lower limbs and bladder, but not of long duration; andbecoming reduced in circumstances, he finally died in thishospital of abscess in the hip-joint, which lasted about sixmonths. There had been no disease going on in the headfor a considerable time before he died.

I have already mentioned something of the treatment ofthe more acute form of disease; but venesection and mercury,to affect the system, are of course not to be thought of forchronic cases, as far as the bone itself is concerned, particu-larly when caries and necrosis are present; nor is it often thateven cerebral symptoms require such active measures. Farmore often, cupping or a few leeches afford all the depletionthat is requisite; and blisters to the nape of the neck, or nowand then a seton, are more frequently required than any lossof blood at all. The treatment is, on the whole, not unsatis-factory, if the affection is tolerably limited in extent; andiodide of potassium, with bark or sarsaparilla, offers you themost efficacious remedy, whether the case be syphilitic or notin adults, for the original cause is not of much importance, astate of cachexia being present in all, otherwise the diseasewould not exist. Sometimes, however, a few grains of Plum-

mer’s pill may be added to, or substituted for, the iodide; andsometimes small doses of bichloride of mercury are of service,with a tonic, as an alterative, taking care not to salivate thepatient. When nodes are present, the firmer they are intexture, the more likely is a mercurial to be useful; and it isscarcely ever desirable when soft nodes are formed, or the-suppuration is accompanied by caries. If much irritation is:present, moderate doses of opiates are of service, and thisremedy, with blisters, are to precede the use of iodide ortonics, if the pulse is quick and irritable, with flushing of faceand excitement of the nervous system. The diet is of courseto accord with either of these different states; and complete.rest in the horizontal posture, with the head raised, or goingout in the air as much as possible, may each be necessary atdifferent times in the same case. I am not now speaking ofscrofulous caries which occurs in young persons for the mostpart, for whom cod-liver oil, steel, air, and good living, are byfar the most appropriate treatment.Your local measures must vary according to the state of the

parts. Suppose there are hard periosteal nodes in the inflamedbone; you may have the part shaved, and apply blisters, if theconstitutional treatment does not check their increase; and ifthe pain is very great, an incision gives very great relief, butis seldom required. If there are soft nodes of moderate ex-tent you need do little locally; it is surprising how quicklyseveral apparent abscesses will have the fluid absorbed, andthe pericranium again fixed to the bone, in a few days afteryou have given iodide of potassium, with some tonic, especiallyif there is a syphilitic poison still in the system: so also willsome scrofulous nodes, if the cheesy matter is not very abun-dant. If the fluid is slow in being absorbed, you may oftenhasten the cure by the local application of iodine and iodideof potassium lotion, painted over the swelling, or hydrochlorateof ammonia lotion. Do not open the collection of fluid hastily,for, if exposed, the inflamed or carious bone will die. If, how-ever, the fluid is rapidly formed, it will separate the pericra-nium from the bone to a great extent, which you can avoid byremoving the tension by means of a small puncture, which youallow to heal again. If, again, the swelling is tense, and theskin is beginning to redden, a similar small puncture takesaway irritation, while your medicine is acting on the system.If, however, the proportion of pus to the glairy fluid secretedunder inflamed periosteum is considerable, you cannot avoid apermanent opening as long as the bone remains diseased.The separation of dead bone in the cranium is generally a slow

process, and you cannot do much to hasten it. It is, as we haveseen, not often that the pus secreted by the dura mater is con-fined, but if symptoms indicate such an occurrence, it would ofcourse be right to employ the trephine. It is astonishing tosee how little irritation of the brain is excited by very largepieces of dead bone, even when almost the whole frontal andboth parietal bones are dead, as I have myself seen, and thatfor many years together.

I have already spoken of the caution to be observed inforcibly removing the necrosed bones, the effect of which youcan understand, from seeing how little interference occasionedsome irritation in M-, although the bone was so small.But in some cases, you can do much good by dividing the deadbone by a cutting forceps, or Hey’s saw, or cutting off any edgeof bone by which it is imprisoned. A woman was in the sameward as this patient, whose arm I was obliged to amputate onaccount of disease of the elbow; she also had necrosis of two-thirds of the frontal bone, and four years afterwards, the deadbone appearing insulated, though quite fixed by its irregu-larities, I got a bone forceps between it and the dura materand divided it across. I remember it was so hard that onepiece flew off over one or two adjoining beds when it wasdivided; probably some years’ inconvenience was thus saved.I have only one more remark to make at present-namely,that the dura mater is thickened in these cases of chronic in-flammation, so that there is no fear of hernia cerebri from itsexposure as in cases of recent injury.M- has since left the hospital, with very little tendency

to epilepsy, for-several weeks.

One of the cranial bones, the temporal bone, requires someseparate consideration, as it is very often attacked by caries,which is occasioned in many instances by inflammation of thelining membrane of the meatus and tympanum, to which theseparts are peculiarly liable from contact with the atmosphericair.Of this you have an example in the case of William W-,

twenty-three years of age, in Winchester ward, who was ad-mitted Feb. 5th. It seems that he has been subject from hischildhood to some purulent discharge from the right ear, vary-

541

ing in amount, but never absent entirely. Three years ago, axabscess formed, which burst into the meatus, having beeIsituated probably beneath the mucous membrane only, fo]

, such abscesses are very common in these cases of chroni(inflammation, as you might expect. A week ago he perceiveca swelling behind the ear, which extended upwards and downwards to some distance, giving him much pain, so that hEcould not sleep at night, till some morphia was given himafter his admission. He is a pale, thin, consumptive-lookingyoung man, but has no cough, and has had no fits or cerebralaffection, and is quite deaf on the affected side, except to theticking of a watch held close to the ear.

The abscess was punctured by the house-surgeon the nextday, and when I saw him on the following day, I enlarged theorifice, as the pus, which was very foul and offensive, did notreadily escape. The bone was felt exposed, and the probepassed deeply into the ear, and probably into the tympanum;but I did not examine the ear minutely, for fear of irritating it.Here then you have a good deal of suppuration, separating

the auditory tube from the bone, which is itself diseased, ifnot dead at some part. He was directly relieved from muchsuffering, and already, in four days, there is hardly anydischarge from the abscess behind the ear, and the periosteumbeing now allowed to come in contact with the bone, willagain adhere to the part which is not diseased, though sepa-rated from it by the pressure of the pus.The inflammation he has so long been subject to is of a

scrofulous nature, as you would suppose from his appearance.The discharge, in such cases, is partly purulent, partly ceru-minous and epithelial, while the bone is unaffected, and isexceedingly offensive in many cases; and in scrofulous familieswhen no other symptom is present, you will often see parentsand children, alike complaining from time to time of ear-ache,and abscess, or discharge. I know an instance in which alady died of abscess of the brain connected with the ear, andno less than seven of her children have had discharge fromthe ears, the membrani tympani being perforated by ulcera-tions in, I think, four of them, and in one, very alarmingcerebral symptoms have been sometimes present.

The disease is to be checked and cured chiefly by internalremedies,—cod-liver oil, steel, and such remedies more parti-cularly. You should, if there is much discharge, inject warmwater very gently, daily, or on alternate days, as the thicksecretions lodging in the ear are themselves irritating to thesurface. Do it very cautiously, however, for intense pain forseveral hours may easily be excited by using any force withthe syringe. I do not feel the same fears which some personsentertain, from endeavouring to check the discharge, while itis perfectly tree from acute symptoms, and while your alter-ative and tonic medicines are exerting a beneficial influenceon the system. Doubtless you may see alarming or fatalsymptoms succeed the sudden stoppage of the discharge, andastringents improperly used may do harm; but in many cases,where blame is attributed to mild injections, a diminishedsuppuration is the consequence and not the cause of internalmischief, just as a wound of the scalp dries up, if suppurationtakes place below the cranium. A solution of a grain ofsulphate of zinc to an ounce of water may be dropped intothe ear, or two grains of lunar caustic, with much advantage,when the internal ear is not affected, or the inflammationactive.What the ultimate result of so long continued a disease

may be in reference to our patient, it is impossible to say; butlooking to his apparent constitution, it may easily terminateas in this preparation on the table.

In this case, the patient, twenty-seven years of age, nearlythe same as in Bviz, was admitted under my care onFebruary 26th, a few years ago, with purulent discharge fromthe right ear, deafness, pain in the head, and other symptomsof inflammation of the brain, of moderate severity, which com-menced six months previously. The discharge became inMarch very copious and foetid, and mixed with blood, bothfrom the ear and Eustachian tube, and at the end of the monththere was some oppression of the brain, with local paralysis ofthe muscles supplied by the right portio dura. In April themalleus and stapes came away entire, and on June 7th, copioushaemorrhage from the ear was the immediate cause of hisdeath, phthisical symptoms having in the meantime much re-duced his strength.You may see the upper surface of the right temporal bone

carious and cribriform; it was dark coloured, and the duramater was adherent to it, inflamed and sloughy, and in partabsorbed. Just above this the under surface of the cerebrumwas sloughy, and the cerebral substance around softened, witha small quantity of foul pus. On the posterior surface of the

: petrous portion was a small quantity of ivory deposit. The. groove for the lateral sinus was partially carious, and the sinus

at that part was inflamed, and almost sloughy, but withoutany opening in its coats. Around the carotid artery, where itascends by the side of the sella turcica, was a small quantity ofeffused blood, but whence it had proceeded could not be ascer-tained. The bony floor of the meatus and tympanum wasabsorbed, and there was a large quantity of foul bloody matterin the cavity which was thus formed, which communicatedwith the joint of the lower jaw, the condyle of which wasalmost wholly absorbed. The lungs were filled with tubercles;some forming abscesses, and there was recent lymph in themediastinum, and old adhesions of the pleura. The peritonaeumwas also studded with tubercles, and the intestines adheredtogether. The state of the lateral sinus shows you the dangerof absorption of matter, and formation of secondary abscesses,and in another preparation on the table you may see the sinuscompletely obliterated by inflammation.Some gentlemen present may perhaps remember the case

from which this preparation was taken, a patient of Mr.Tatum, September 6th, 1848, aged sixteen, in whom inflamma-tion had begun two months previously, which soon produceddeafness, for which the membrana tympani had been twicepunctured without relief. The portio dura became affected,and numerous abscesses formed, having dead bone exposed inthem in the situation of the mastoid process. She becamevery weak and restless, and on January llth had a fit, fol-lowed by delirium, altered voice, and dilated pupil, and shedied on the 19th.The caries is the most extensive I have ever seen, affecting

the squamous, mastoid, and petrous portions of the temporalbone. The anterior portion of the mastoid process is quitedestroyed, as also were the styloid, vaginal, and auditory pro-cesses of this bone; no trace of the stylo-mastoid foramencould be observed; the ulceration did not encroach on theoccipital bone; that portion of the mastoid element whichforms the floor of the lateral sinus was ulcerated to the extentof an inch in length and three-quarters of an inch in breadth,the sinus itself being almost impervious from effusion of lymphinto its cavity. Nearly the whole of the base of the petrousportion was destroyed, and the cavity of the tympanum laidopen. The back part of the glenoid cavity, the commence-ment of the zygomatic process, and the lower part of thesquamous portion, were also very extensively ulcerated. Thedura mater covering the bone was very vascular; the rightmiddle lobe of the brain was more vascular, and softer thannatural; lymph was found in the cavity of the arachnoid, andin the subarachnoid areolar tissue at the base of the brain.

Observe how rapid the progress of this remarkable casewas as compared with our patient Wiz, and notice therecent characters of the cerebral inflammation, and contrastwhat I have just read with the appearance of the cyst of thislarge abscess of the brain, the size of an apple, which com-municated with the tympanum, in a boy eight years of age,the thickness of which shows you that it must have been longformed, being firm and tough, and lined with a blackishsloughy membrane; it followed discharge from the ear ofseveral years’ duration, and you may examine the carious con-dition of the bone corresponding to it in the Museum.You may find many such cases as these in Dr. Abercromby’s

work, or Dr. Bright’s, and in other medical writings, and insome of these cases perhaps a chronic abscess in the brainmay have itself caused perforation and caries of the temporalbone in trying to make its way outwards; but in almost all theear is first affected, and the brain secondarily. Where sucha complication as this exists, the patient is necessarily exposedto sudden danger from any injury or impairment of the health,and a fatal result rapidly follows the previously chronic formof disease.For example, a man was admitted many years ago under

my care, three weeks after a blow, which he received byknocking his own head against a door while endeavouring tostrike another man, with whom he was quarrelling. This wasfollowed by intense pain over the head and delirium, in whichhe made several attempts to destroy himself. He died threedays after his admission, having become comatose a few hoursbefore his death. A large sloughy abscess occupied theanterior and middle lobes of the brain, communicating withthe carious openings into the tympanum, which you may heresee. He had, as in the other cases I have related, been sub-ject for several years to discharge from one ear, which occa-sionally ceased, and when stopped he became very deaf.Doubtless, the abscess had existed for some time, and dis-charged itself through the bone, but was suddenly inflamedby the blow, and made quite gangrenous on its inner surface.