Severe Head Trauma

June 9, 2012 7:47 AM

Subdural hematoma in the 19th Century. Dead on the feet, or treatable?

We saw a movie last night where a character fell and struck his head during a fight. The character got up in a daze, wandered back to his hotel room and lay down, and died overnight. There was a hint of blood running from one ear, to indicate the severity of the injury. The movie takes place in mid-to-late 19th Century Britain.

Out of curiosity, was this a survivable injury in that time period, given medical technology and knowledge? There was a physician living in that hotel who came this next day to verify the character's death. If he had been there the night before, could the character have lived?

posted by chengjih to science & nature (7 answers total)

The range of severity is very wide. I had a subdural hematoma and had no medical intervention, only diagnostics (it was small and not getting any worse as time went on. So, sure, i would have totally survived it no matter what the era.
posted by Stonestock Relentless at 7:52 AM on June 9, 2012 [1 favorite]

Trepanation has been used as primitive surgical relief of the pressure caused by a subdural hematoma since primitive times (when a club to the head was perhaps a more common happening). Not sure what sort of luck an attending physician would have with that sort of surgical procedure in a Hotel in GB in the 1800s, but the medical know-how existed then.
posted by carsonb at 7:53 AM on June 9, 2012

@Stonestock, Hmm, severity was such that the character died overnight, so I guess that was relatively severe; this would have been worse than, say, Natasha Richardson.
posted by chengjih at 8:01 AM on June 9, 2012

The big problem with any surgical procedure in the early-to-mid 19th century was infection. Any time a surgeon cut into your skin, you were as likely as not to end up dead from septicemia. By the late 19th century the germ theory of disease had taken hold, and surgeons were becoming more careful about cleanliness.
posted by Chocolate Pickle at 8:56 AM on June 9, 2012

Subdural/epidural brain bleeds kill the person by putting a volume of blood into a closed and rigid space (the skull) and resulting in physically compressing the spongy brain tissue, sometimes actually pushing the brain through the opening in the bottom of the skull.

Natasha Richardson actually died from an epidural bleed (a bleed between the skull and the dura mater, a tough membrane overlying the brain). Epidural bleeds tend to be more dangerous than subdural bleeds because they're usually caused by damage to arteries, which pump blood rapidly into the space. Subdurals (between the dura and the brain), on the other hand, are usually caused by injuries to smaller bridging veins and are typically smaller.

The primary treatment for a subdural hematoma in the 19th century was rest and watchfulness. For small bleeds that aren't showing any signs of brain compression the same is true today. I've had more than one patient come into the hospital, get a head scan for some other reason, and discover that they have old/healing subdural bleeds that no one ever knew about, which don't need any additional treatment.

Trephination is certainly something that was practiced back then and a high-tech version of it is still the way life-threatening bleeds are managed (albeit now with the additional benefit of aseptic technique, intracranial pressure monitors, and CT scans). Most doctors probably would have been trained to do it, although I imagine that the skill level would vary widely.
posted by The Elusive Architeuthis at 9:56 AM on June 9, 2012 [1 favorite]

See also Patrick O'Brian's Master and Commander (or better yet, read the book). Trepanning is a speciality of Dr. Maturin.

No, wait. I take that back. Maturin actually takes off a piece of the gunners skull to relieve the swelling and replaces it with a hammered out coin.
posted by SLC Mom at 10:20 AM on June 9, 2012 [1 favorite]

I love old medical textbooks, and an excuse to peruse google books. A Manual of Military Surgery suggests trephination as a last resort, first trying to reduce the pressure indirectly by bloodletting and purgatives, and "The trephine is not thought of unless the unconsciousness obstinately persists and there is reason to believe from the nature of the phenomena especially the existence of a wound or contusion on the head that the blood may be reached by the instrument".

One of the big issues would be that this is a "talk and die" injury. People die of them in exactly this way today because they don't seek medical attention. Today we can CT heads to see if there is an underlying haemorrhage; back then, you're relying on severity of symptoms and your suspicion regarding the injury. So the doctor would have to have been alert to the possibility of haemorrhage, so the patient could have been observed in hospital, and surgeons on hand to operate swiftly as the patient deteriorated.

Lack of antibiotics meant that sepsis was much more likely and much more dangerous; however, it wasn't inevitable. Going later into the 19th century you have antiseptic and then aseptic surgery which greatly increased chances of survival. I'd give the patient more than a 50/50 chance of surviving if the surgery went well.
posted by Coobeastie at 3:16 PM on June 9, 2012