Traumatic Cerebral Edema: Its Pathology and Surgical Treatment — A Critical Study

J. W. COURTNEY
1899 Boston Medical and Surgical Journal  
was a case which, having all the clinical aspects of hypertrophy, was suitable for prostatectomy aud not for orchidectomy. In three cases (13, 14 and 16) out of the four that had a prostatectomy after orchidectomy the restoration of function after the obstructing tissue was fiually cut away was marked and satisfactory. The fourth patient (case 15), profoundly uremic before operation, died before the effect on urination was clear. In my former paper another conclusion, drawn from a study of the
more » ... rom a study of the statistics then available, was, that " the functional results of the two operations seem at present to be as nearly equal as possible, and tbe tendency to relapse shows itself in about the same proportion of cases after either operation." This conclusion, which seemed true in the light of eventB up to 1896, is not borne out by my personal experience as embodied in the above report. My present feeling is, that prostatectomy offers a distinctly better prospect of relief than orchidectomy, and is especially applicable in the cases where the obstruction is due to tbe growth into the bladder of prostatic projections which encroach on the urethral orifice. In Cases 3 and 4 it is probable that the result would have been better had the lateral lobes of the prostate been thoroughly removed, either through the bladder or by the perineal route in the manner advocated by Alexander. The following cases cited by Walton are, if we admit the possibility for motor symptoms to result from local collections of serum after trauma, beautifully corroborative of the evidence already adduced in demonstration of tho power of the brain, under favorablo circumstances, to rid itself of such local collections. Case I. A boy of six years was struck by a bicycle at noon one day, was restless and drowsy, and on the following day became unconscious, with unilateral paralysis, including the face. Operation was considered but postponed. The paralysis disappeared within four days. Case II. A child, three and a half years old, fell from a swing, striking the head. It was drowsy after-Ward, and the next day one arm was paralyzed. The paralysis began to lessen on the third day, aud rapidly disappeared. A case cited by Prince80 is interesting in this connection. It was the case of a child who, after a head injury, developed absolute paralysis of the right side, with partial coma, preceded by a period of consciousness. As the child could be aroused, Prince advised postponement of operation, and on the following morning every sign of paralysis had disappeared and the child's mental condition was normal. An important observation in connection with the class 1 An essay to which was awarded the William H. Thorndike Prize (Harvard) for 1898. m Princo, Morton : Boston Medloal and Surgical Journal, vol, cxxxvl, No. 13, p. 312. under discussion is that of White and the writer.81 In this case, which was that of a man who was thrown from a carriage, striking on tho right parietal region, there was nothing, outside of a primary loss of consciousness and a continued subnormal temperature, to indicate tbe serious nature of the case up to the fourteenth day. On this day the patient was suddenly, and without prodromata of any sort, seized with a trembling of his entire body, lasting about fifteen minutes. After this he became unconscious and was found about two hours later iu the following condition : " The patient was lying on the left side, unconscious, and breathing stertorously. The face was cyanosed and the facial veins congested ; the carotids pulsated forcibly, the eyes were closed. Temperature in right axilla 103°, in left 102.5°. The pupils were equal in size, dilated, but reacted to light. No ocular or facial palsy was apparent. The mouth was open and tho tongue retracted. The right arm and both legs were in constant motion, but the left leg was not moved as vigorously as the right. The left ¡land and arm were extremely paretic, but were moved when forcibly pricked witli a pin. Both deep and superficial reflexes were abolished on the left, lively on the right. " Operation was undertaken within two hours, the point selected for trephining being over the arm centre on the right side. On removing the trephine button the dura bulged somewhat into the opening and did not pulsate. On opening the dura the brain pushed out moderately, but without pulsation. Tho pial veins were much distended. There was no evidence of fracture of either table in the region of operation. A probo swept round between the dura and pia showed au excess of edema in all directions, but a director passed first into the substance of tbe brain directly under the arm centre and then into the ventricle failed to disclose anything further. With rongeur forceps the trephiue opening was enlarged and the dura opened more freely. For a few moments pulsations returned, only to disappear before completion of the operation." Only slight improvement was noted in the paralyzed arm alter tbe operation and the patient died two days later, without having at any time regained consciousness. Every feature of this case is in harmony with the view of a generalized contusiou, and the writer feels justified in making the positive assertion that the edema found on operation was not tbe underlying cause of the paralysis which was present. In fact, it seems probable that exactly the same conditions would have been found if the skull had been opened at random ou either side. The two following cases, selected from the records of the City Hospital, are further valuable evidence against the cortical edema theory of the production of paralysis. They are not cited as absolutely uncomplicated cases of contusion : Cash I. Patient, male adult, fell several feet, striking bead. He became immediately unconscious, but could be partially roused, relapsing, however, when left to himself. The pupils were equally dilated but responded to light. Pulse on entrance was 112, gradually rising, with temperature, to 160. Temperatsl Wlilte, H. Warron and Courtney,
doi:10.1056/nejm189904271401702 fatcat:canokcacfbeqrhldky5elqf6zy