Trepanation and surgical infection in the 18th century

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<ul><li><p>REVIEWARTICLE - HISTORY OF NEUROSURGERY</p><p>Trepanation and surgical infection in the 18th century</p><p>Jeremy C. Ganz</p><p>Received: 22 August 2013 /Accepted: 23 September 2013 /Published online: 8 October 2013# Springer-Verlag Wien 2013</p><p>AbstractBackground It is widely believed that trepanation prior tomodern surgical hygiene was dangerous because of surgicalinfection, especially in the hospital. There has been a widevariability in the success and risks of different historical studiesPurpose To obtain a more accurate assessment of the risks ofpost-operative infection following 18th-century cranial traumaand to note what factors were of prognostic significance.Material and methods Seven 18th-century texts on head injuryare reviewed and analyzed.Results Infection was the commonest cause of death (in over60% of patients) in five series but not in the other two. Hospitaladmission did not appear to be a major factor influencingmortality from infection. Delayed infection was the indicationfor patient referral and trepanation in more than two patients intwo series. In one series, the patients were helped by theprocedure, in the other they were not. The reasons for thedifference are discussed. The most striking finding was thatpatients treated in rural areas had a much better prognosis.Conclusions The risks of suffering a surgical infectionfollowing head injury and trepanation are multifactorial. Admis-sion to hospital seems to have been less risky than has beenpreviously thought. It seems that the greatest risk factor for alethal infection for these patients was living in an urbanenvironment.</p><p>Keywords Head injurymanagement . Trepanation .</p><p>Infection . Urbanization . 18th century</p><p>Introduction</p><p>It is a truism that prior to the invention of antisepsis andasepsis post-operative infections were much more of a risk</p><p>than since. One operation which was known to be riskierbecause of such infection was trepanation. There was andremains a widespread belief that hospitals could increase therisk. This was mentioned contemporaneously by Quesnay[34] and Desault [6] in France. Quesnay quotes the view ofa surgeon called Mr. Boudon writing: Mr. Boudon howeverwould not upon these conjectures...hazard the trepan, whichseldom succeeded at the hospital, on account of the unwhole-some state of the air [34]. Recent reviews confirm thecontinuation of this notion in the current literature [13, 17, 18].</p><p>However, a review of surgical series from the 18th centuryhad led the author to realize that while infection associatedwith trepanation was common in that century, it is not at allcertain that these were mostly hospital or surgical infections[16]. Nor is it clear that infection was so dangerous that it wasa genuine contraindication to trepanation. Moreover, there isan additional element to consider; something of a mystery.This is a remark of Arbosellius, mentioned by Kellett in theintroduction to the now out-of-print head injury text by G. F.Rowbotham and quoted by Dr. Teo Forcht Dagi in his chapterThe Management of Head Injuries in the AANS publishedreference work A History of Neurosurgery. The quotationruns as follows. Arbosellius was wont to tease Vesalius andhis fellow surgeons asking them Why is it that those whoreceive a head injury in Verona, no matter how slight cannotbe cured, and the unfortunate patient, forsaken by his physi-cians, dies miserably, but, as I have often seen, he is cured inPadua and Venice? [13] It would be interesting to know thesolution to this inconsistency.</p><p>The 18th century saw the beginnings of the evolutionwhich led neurosurgery away from Galenic mythologytowards the acquisition of knowledge on which current prac-tice is based. The purpose of this paper is to present the patternof infection in the seven available English language seriesfrom that century. The influence of surgical hospital infectionwill be examined as will the value of trepanation in cases withestablished infections. Reasons for the variation of result withlocation will also be analyzed.</p><p>J. C. Ganz (*)53 Market Street, Ulverston, Cumbria LA12 7LT, UKe-mail: jcganz@gmail.com</p><p>Acta Neurochir (2014) 156:615623DOI 10.1007/s00701-013-1900-0</p></li><li><p>Background</p><p>At the beginning of the 18th century, there was considerableawareness of the processes now known to be due to infectionwhich are both local and systemic. The local components wereinflammation and pus. The components of inflammation,rubor, tumor, dolor and calor had been known since Celsusdescribed them [11]. This was understood in the same waythen as now, when applied to tissues which could be seen ortouched. However, in 18th-century texts the term inflamma-tion needs to be interpreted with caution when used withregard to invisible tissues such as the brain. A good exampleis provided by Sylvester OHalloran, who mentions that Nowevery one knows, that inebriety, which is a kind of temporaryinflammation of the brain, is most sensibly relieved by strongtea or coffee; and is it not surprizing, that such obvious effectsare not applied to practical cases [30]. This is obviously notcurrent usage. In addition, the term sepsis was used. It isderived from the Greek word [] meaning decomposi-tion of animal or vegetable organic matter [8]. It includes theprocesses of necrosis as registered by changes in the color andconsistency of the tissues. Moreover, there was the evidenceof unpleasant odors. There was also awareness of at least twodifferent kinds of pus; white thick laudable pus thought toassist healing by secondary intention and runny thin oftenbrown foul smelling fluid called sanies. It is seems unlikelythat sepsis and laudable pus were seen as related phenomena.The systemic features of sepsis included fever, fatigue andlistlessness. The full picture specific for infected cranialwounds was best described by Percivall Pott [32]. It consistedof deterioration following an initial improvement usuallyafter a latent interval of several days. Characteristically,there would be delirium, fever, fatigue, vomiting and oftenfocal and subsequently spreading headache. These reportedfindings are taken to indicate infection even though theoriginal authors did not use that term.</p><p>Twelve major English language texts were written on headinjuries in the 18th century. In addition, two French bookswritten in the 18th century and translated into English in the19th century made a significant contribution. These 14 textsare tabulated in Table 1. Of these writings, seven includesubstantial numbers of patients, making them suitable foranalysis in this article.</p><p>Spontaneous separation of the pericranium</p><p>One phenomenon which was of great concern in this contextwas separation of the pericranium from the skull. Separationof pericranium from the bone as a result of the mechanicaltrauma itself was not considered a cause for concern. However,it was believed that spontaneous separation of the pericraniuminterrupted or occluded the small blood vessels that passedthrough the cranium from the pericranium on the outside to the</p><p>dura on the inside. This led to damage of the bone with asimilar separation of the dura from the craniumwith the risk ofsecondary inflammation and putrefaction [32].</p><p>Management of sepsis associated with cranial trauma</p><p>The seven contributors had varying attitudes about appropriatesurgical management as outlined below.</p><p>Henri-Franois Le Dran (16851770)Le Dran was an enthusiastic proponent of trepanation</p><p>for depressed fractures and fissures because he believedthat the risk of inflammation and putrefaction of the duracould be avoided by this means. He also considered smallfissures more dangerous since wider fractures wouldpermit the escape of fluids trapped under the bone. Despitehis encouragement to perform trepanation whenever afracture was present, his actual practice was at variancesince he only trepanned four of his 14 patients, or 28.6 %.There were five fractures in his series and only two weretrephined. One patient refused surgery but the remainingtwo with fractures were simply not operated. Thus, LeDrans teaching and practice were somewhat at odds.</p><p>Table 2 shows the distribution of infections in the sevenseries. It may be seen that infection was the commonestcause of death in all but two series, underlining its impor-tance. In Le Drans material, infection accounted forover 60 % of a total mortality of nearly 36 %. Five ofthe six patients who died from infections had openwounds, making it impossible to be sure of the sourceof the infection, which could have come from theoriginal wound, the wound toilet or subsequent woundmanagement. The sixth patient had a closed injury butthe skin was incised and skull inspected a short timeafter the injury. Thus, in essence all the injuries weretechnically open. There were two infected cases whosurvived. Table 3 shows the relationship between infec-tions and wound status.</p><p>Of the patients who died from infections one sufferedan accident and the other five were victims of assault.Francois Quesnay (1694 1784)</p><p>Quesnay was later to arouse the wrath of, amongstothers, John Bell of Edinburgh [5] for his advice to tre-phine any patient with a fissure or a depressed fracture. Headmitted that there were cases where trepanation could beavoided but they were rare and required experience andjudgment. He admitted other surgeons had a different viewbased on the perceived risks of trepanation. However,Quesnay argued that the risks of the operation were sub-stantially less than the risks of the unoperated injury. In hisseries, however, only 13 of 37 patients were trephined, or35 %. Quite a few patients did not require trepanation</p><p>616 Acta Neurochir (2014) 156:615623</p></li><li><p>because the injury required bone removal to gain access.Three cases with fractures were not trephined. Thus, thereis again a mismatch between advice and practice.</p><p>In Quesnays material, infection accounted for over70 % of the 30.5 % mortality (Table 2). In three lethalopen injuries, the fracture fragments had penetrated brainsubstance while the fourth was a superficial open injury.Four cases with closed injuries died from infections. Allwere opened by the surgeon within 24 h of the injury; inone case to treat an epidural hematoma (EDH) and in threeto lay open or inspect the damage under the skin. Thus, inall these patients who died from infection, the skin had</p><p>been breached prior to infection, as happened in the seriesof Le Dran . However, while these eight patients with openwounds or primary wound toilet died, a further 11 withopen wounds survived. In one further case (as quoted inthe introduction), the surgeon refused to perform a trepa-nation because he was worried that the dirty air of thehospital would damage the patient. That patient also sur-vived. With such a disparate material, statistical analysis isnot possible. Of the eight patients who died, three hadsuffered an accident and five had been assaulted.</p><p>Table 2 Overview and mortality rates of the seven series. The numbersof patients and the mortality rates vary widely. The contribution ofinfection to mortality is very similar in four series. The lower rates inthe series of Hill and OHalloran may be due to their more rural andcleaner environment. The high rate of infection in Deases material has noclear cut explanation but could be due to poverty and poor diet in theDublin of the day</p><p>Author No. Cases Deaths and(Mortality)</p><p>Infection deathsand (Mortality)</p><p>Deaths frominfection</p><p>Le Dran 14 8 (57.1 %) 5 (35.7 %) 62.5 %</p><p>Quesnay 36 11 (30.5 %) 8 (22.2 %) 72.7 %</p><p>Pott 43 22 (51.1 %) 15 (34.9 %) 68.2 %</p><p>Hill 18 3 (16/7 %) 1 (5.6 %) 33.3 %</p><p>OHalloran 71 21 (29.5 %) 8 (11.3 %) 38.1 %</p><p>Dease 24 13 (54.1 %) 13 (54.1 %) 100 %</p><p>Abernethy 20 8 (40.0 %) 5 (25 %) 62.5 %</p><p>Table 3 Death rates from infection and the impact of open and closedwounds. There is a clear tendency in most series for open wounds to beassociated with a higher mortality from infection. This is expected anddeath and could be due either from contamination in the environment orfollowing wound toilet in the hospital. However, a proportion of Pottsand all of Deases patients developed their infections before coming tohospital. This indicates that hospital infections may be less important thanhas been previously thought. OHallorans text is not precise enoughconcerning the parameters in this table so his series is not included</p><p>Author No. cases Cases withinfection (Died)</p><p>Infection withopen wound(Died)</p><p>Infection withclosed wound(Died)</p><p>Le Dran 14 8 (6) 5 (5) 1 (1)a</p><p>Quesnay 36 14 (8) 9 (4) 5 (4)a</p><p>Pott 43 29 (15) 15 (7) 14 (8)</p><p>Hill 18 1 (1) 1 (1) 0</p><p>Dease 24 15 (13) 15 (13) 0</p><p>Abernethy 20 7 (5) 5 (4) 2 (1)</p><p>a These closed cases were opened surgically to inspect</p><p>Table 1 18th-century texts on head injury. The 12major 18th-century English texts on head injury are arranged in order of the year of the authors birth.Series were analysed if there were an adequate number of patients as indicated. There are also two translated French texts included</p><p>Author Title No. cases Included</p><p>Daniel Turner (16671741) The art of surgery[38] Only 4 cases No</p><p>Lorenz Heister (16831758) A general system of surgery in three parts [20] No cases No</p><p>Henri-Franois Le Dran (16851770) Observations in surgery [25] 14 analyzable cases Yes</p><p>Franois Quesnay (16941774) Observations on surgical diseases of the head and neck [34] 39 analyzable cases Yes</p><p>Samuel Sharp (ca. 17001779) A treatise on the operations of surgery [37] No cases No</p><p>William Bromfield (17121792) Sudorific opiates recommended in concussions of the brain [9]. Only 3 cases No</p><p>Percivall Pott (17141788) Observations on the nature and consequences of those injuries towhich the head is liable from external violence [32]</p><p>43 analyzable cases Yes</p><p>James Hill (17031776) Cases in surgery [21] 18 analyzable cases Yes</p><p>Sylvester OHalloran (17281807) A New Treatise on the Different Disorders Arising from ExternalInjuries of the Head [30]</p><p>81 analyzable cases Yes</p><p>Pierre-Joseph Desault (17381795) The surgical works of PJ Desault by X Bichat [6] Only 6 cases No</p><p>Benjamin Bell (17491806) A system of surgery [4] No cases No</p><p>William Dease (17501798) Observations on wounds of the head [14] 24 analyzable cases Yes</p><p>James Latta (17541804) A practical system of surgery [24] Only 3 cases No</p><p>John Abernethy (17641831) Surgical observations on injuries of the head [3] 20 analyzable cases Yes</p><p>Acta Neurochir (2014) 156:615623 617</p></li><li><p>Percivall Pott (1714 1788)Pott was very aware of the dangers of secondary</p><p>inflammation and putrefaction and described them andpondered their pathogenesis at length. The observedchanges included a swelling where there was pericranialseparation, discolored bone, and epidural and duralputrefaction associated with fever, headache listlessnessand drowsiness. Pott advocated prophylactic trepanationto avoid these problems, again arousing the ire of JohnBell [5]. However, while there were 29 out of 43 caseswith trepanation in his series or 67 % of all cases, yet, henever actually recorded that he himself undertook a pro-phylactic trepanation. Once again there is a...</p></li></ul>

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