Acute-on-chronic subdural hematoma: the death of the famous XIX century soprano Maria Malibran-a study of the sources.

Maria Malibran (1808-1836) is one of the most famous sopranos of the nineteenth century. In 1825, along with her father, the renowned tenor Manuel Garcia, she introduced the Italian opera in America for the first time. The European debut in Paris (1828) definitively crowned her as a star. Thus, she was requested by the most famous European theaters. In July 1836, during an equestrian excursion in London, she fell from her horse dashing her head against the ground, resulting in a state of insensibility. Since that accident, she had suffered from continual headache and nervous attacks, but she continued to work. In September 1836, she attended a music festival in Manchester, but her health rapidly worsened: episodes of nervous attacks, headache, and fainting occurred with higher frequency. At the end of a representation, she was attacked by violent convulsions. In the following days, she was laid in a kind of stupor. Afterward, she died at the age of 28. The hypothesis that prolonged efforts during her performance could have provoked a rebleeding of a pre-existent chronic subdural hematoma should be taken into account as a possible cause of death.

Formas clínicas de presentación del hematoma subdural crónico en el adulto mayor en el Hospital de Quelimane(Mozambique, 2009–2013) / Clinical presentation forms of chronic subdural hematoma in elderly persons assisted in Quemaline Hospital (Mozambique, 2009–2013)

OBJETIVO: Describir el comportamiento de las formas clínicas de presentación del hematoma subdural crónico en el adulto mayor.MÉTODOS: Se realizó un estudio retrospectivo en el Hospital Provincial de Quelimane (Mozambique) en un periodo de 4 años (junio 2009 a junio 2013) de todos los casos diagnosticados como hematoma subdural crónico con el uso de la tomografía axial computarizada. Se estudiaron las variables: sexo, edad, lado del hematoma, factores de riesgo y formasclínicas de presentación.RESULTADOS: La muestra del estudio estuvo constituida por doce pacientes en edades comprendidas entre 60 y 82 años.El 58,3 Por ciento de los hematomas diagnosticados se localizaron en el lado izquierdo. La mayoría de los pacientes eran del sexo masculino (75 Por ciento). Dentro de los factores de riesgo que antecedieron a la enfermedad se presentó el traumatismo cranealcomo el de mayor frecuencia (66,6 Por ciento). El antecedente de alcoholismo se recogió en 6 de los enfermos (50 Por ciento) y el uso de los anticoagulantes orales en 5 pacientes (41,6 Por ciento). La cefalea progresiva fue la forma clínica de presentación más frecuenteen los pacientes (41,6 Por ciento). Fue menor la frecuencia de casos presentados con confusión mental (25 Por ciento), déficit motor (16,6 Por ciento) y con el síndrome de herniación uncal (16,6 Por ciento).CONCLUSIONES: Las formas clínicas de presentación del hematoma subdural crónico pueden ser variables. Elreconocimiento de las formas clásicas y los antecedentes de riesgo favorecen de manera positiva el diagnostico precoz delos pacientes(AU)

OBJECTIVE: To describe presentation clinical forms of chronic subdural hematoma in elderly persons.METHODS: A retrospective study was conducted at the Provincial Hospital of Quelimane (Mozambique) in a period of four years (June 2009 to June 2013) of all cases diagnosed as chronic subdural hematoma with axial CT scan. The variables studied were: sex, age, hematoma side, risk factors and presentation clinical forms.RESULTS: The study sample consisted of twelve patients with age between 60 and 82 years old. 58.3 Per cent of cases have hematomas located in the left side. Most patients were male (75 Per cent). Among the risk factors that preceded the disease head Formas clínicas de presentación del hematoma subdural crónico en el adulto mayor en el Hospital de Quelimane (Mozambique,2009–2013)trauma was the most frequent (66.6 Per cent). Alcoholism was detected in six patients (50 Per cent) and oral anticoagulants treatment infive patients (41.6 Per cent). Progressive headache was more frequent in chronic subdural hematomas clinical presentation (41.6 Per cent). Less frequency was detected of mental confusion (25 Per cent), motor deficit (16.6 Per cent) and uncal herniation syndrome (16.6 Per cent).CONCLUSIONS: The clinical presentations of chronic subdural hematoma can be variable. Recognition of classical forms and risk factors can influence in a positive way in early diagnosis of these patients(AU)

Biographical sketch: John Caffey, MD (1895-1978).

This biographical sketch on John Caffey corresponds to the historic text, The Classic: Multiple Fractures in the Long Bones of Infants Suffering From Chronic Subdural Hematoma (1946), available at DOI 10.1007/s11999-010-1666-0 .

A historical vignette (19). An orbital trauma in the 16th century.

An orbital trauma in the 16th century. On 30 June 1559, during a jousting tournament, King Henri II of France incurred an injury to the eye from a shattered lance, dying ten days later. Trepanation was discussed briefly before being rejected. The autopsy on the King confirmed that it would have been justified. Even though there was no skull fracture, there was a secondary rebound trauma resulting in a subdural haematoma in the occipital area. This paper examines why the trepanation option was rejected (Figure 1).

Nonaccidental head injury in children. Historical vignette.

Our current understanding of nonaccidental head injury in children is the result of decades of effort and the tireless work of numerous physicians. In 1860 Auguste Ambroise Tardieu, a French forensics expert, recognized important patterns of injury in children and identified nonaccidental trauma as the cause of these injuries. His work was ignored. In the years that followed, physicians continued to report these patterns of injury but were unable to identify the etiology. A fundamental misunderstanding of the usual cause of subdural hematoma (SDH) contributed to the confusion at that time. Early in the 20th century, neurosurgeons such as Wilfred Trotter recognized that SDHs were traumatic in origin. However, even Trotter's efforts to expose faults in the theories that SDHs primarily resulted from inflammatory or infectious processes were not accepted immediately. Eventually, the pattern of injuries in children was again recognized both by neurosurgeons, who began to identify an association between trauma-induced SDHs and retinal hemorrhages, and by radiologists, who began to note SDHs in conjunction with osseous lesions. Not until the 1950s and 1960s, however, did physicians begin to routinely identify nonaccidental trauma as the cause of these injuries. Following the recognition of child abuse, a pattern of injuries in conjunction with shaking was identified and is currently known as shaken baby syndrome. Since its identification, our understanding of this syndrome has been modified as a result of new medical research, legal challenges, and popular media forces.

The skull and cervical spine radiographs of Tutankhamen: a critical appraisal.

BACKGROUND AND PURPOSE: Tutankhamen, the last pharaoh of the XVIIIth dynasty, died unexpectedly at approximately age 18 years. A cause of death has never been established, but theories that the young king was murdered by a blow to the head have been proposed based on skull radiographs obtained by a team from the University of Liverpool in 1968. We recently had the opportunity to evaluate the skull and cervical spine radiographs of Tutankhamen. The purpose of this study was to report our critical appraisal of the radiographs of Tutankhamen regarding the findings alleged to indicate traumatic death. METHODS: Copies of lateral, anteroposterior, and submental vertex skull radiographs of Tutankhamen were reviewed with special attention to the claims of a depressed skull fracture, intracranial bone fragments, and calcified membrane of a posterior fossa subdural hematoma. A phantom skull was radiographed to reproduce the appearance of the floor of the posterior fossa in the lateral projection. RESULTS: The skull radiographs of Tutankhamen show only postmortem artifacts that are explainable by an understanding of the methods of mummy preservation used at the time of his death. Some findings also relate to trauma inflicted by an autopsy performed in 1925. The alleged calcified membrane of a posterior fossa subdural hematoma is easily reproduced with a skull phantom. CONCLUSION: Our critical review of the skull and cervical spine radiographs of Tutankhamen does not support proposed theories of a traumatic or homicidal death.

Did Pope Boniface die of a subdural?

At the age of 68, Pope Boniface the VIII was hit in the face with a heavy mailed fist and then imprisoned, where he neither ate nor drank for 48 hours. Rescued, he was alert and rational but a few days later unable to appear in public. In Italy he is sa id to have died of shame at being hit. He died 5 weeks after the blow, probably with alternating periods of drowsiness and delirium. It is suggested he died of a subdural haematoma.

[Chronic subdural hematoma: historical studies]. / Hématome sous-dural chronique: données historiques.

The first description of a chronic subdural hematoma was made in 1658 by J.J. Wepfer, followed in 1761 by Morgagni. A possible case was described by Honoré de Balzac in 1840 including its traumatic origin and surgical treatment. Virchow, in 1857, denied a traumatic origin, and gave the name of "pachymeningitis hemorrhagica interna" to this pathology which he explained by inflammatory processes. The traumatic etiology of chronic subdural hematoma was recognized in the XXth century, especially by Trotter in 1914. Pathophysiology was considered later on in the XXth century.

The Whiplash Shaken Infant Syndrome: has Caffey's syndrome changed or have we changed his syndrome?

OBJECTIVE: The aim of this study is to examine the data used by John Caffey in his description of the Whiplash Shaken Infant Syndrome and compare it with recent data in an attempt to determine whether the syndrome that he described has changed, or if we have changed his syndrome into what we now call The Shaken Infant Syndrome. METHOD: This study examined recent literature describing the Shaken Infant Syndrome, and compared it to Caffey's descriptions. In addition, a retrospective review of 71 children under the age of 3 years identified as having a subdural hematoma caused by other than accidental means during 54 months was done. This data was compared to data from the 27 case examples offered by Caffey in 1972 and his other descriptions in 1974 and 1946. RESULTS: A review of recent literature shows that our definition of Shaken Infant Syndrome today includes cases where impact trauma was involved. In contrast to Caffey's descriptions, we found the perpetrator to be more often male, fractures to be more often to ribs rather than long bones, and admissions of shaking and other trauma more often made. CONCLUSIONS: Our findings demonstrate that not only have we changed the diagnostic parameters from Caffey's original Whiplash Shaken Infant Syndrome, but the syndrome has also changed to reflect changes in medical diagnosis and in our society.

The last days of Alessandro Manzoni.

Alessandro Manzoni died on 22 May 1873 at the age of 88. On the morning of 6 January 1873, on his way to Mass in the Milanese church of San Fedele, he fell and hit his head on the church steps. From the newspaper accounts of the day, it appears that this apparently banal accident was fatal for the old writer. It seems likely that his death was caused by a chronic subdural hematoma.

Mozart's chronic subdural hematoma.

No commemoration of the bicentennial of Mozart's death would be complete without some consideration of that premature yet predictable demise. Mozart's premonitions of death are well known and apparently played a role in the composition of the K.626 Requiem and perhaps other works. His death has traditionally been ascribed to infectious causes, chiefly rheumatic fever or post-streptococcal glomerulonephritis, exacerbated by intemperance and chronic penury. Pathology has been difficult because of his supposed burial in a pauper's grave, the location and contents of which were later supposedly lost. Mozart's burial place in St. Mark's Cemetery in Vienna was known and, in the parlance of the day, "reorganized" a decade later, as the occupants of plots were disinterred to make room for the more recently decreased. A skull believed to the Mozart's was saved by the successor of the gravedigger who had supervised Mozart's burial, and then passed into the collections of the anatomist Josef Hyrtl, the municipality of Salzburg, and the Mozarteum museum (Salzburg). Forensic reconstruction of soft tissues related to this skull reveals substantial concordance with Mozart's portraits. The skull suggests premature closure of the metopic suture, which has been suggested on the basis of his physiognomy. A left temporal fracture and concomitant erosions raise the question of chronic subdural hematoma, which would be consistent with several falls in 1789 and 1790 and could have caused the weakness, headaches, and fainting he experienced in 1790 and 1791. Aggressive bloodletting to treat suspected rheumatic fever could have decompensated such a lesion to produce his death on December 5, 1791.

Hematomas subdurales crónicos / Chronic subdural hematomas

Se revisan los conceptos clásicos sobre la fisiopatogenia de los hematomas subdurales crónicos y se confrontan con los nuevos que cuestionan la existencia del espacio subdural como tal, y con la nueva evidencia, la cual demuestra que el crecimiento de los hematomas subdurales crónicos se debe a hemorragias repetidas dentro de la cápsula, secundarias a alteración de la coagulación, como había sido propuesto por Putman y Cushing en 1925, y producidas por aumento de actividad fibrinolítica, según se ha demostrado recientemente. Se revisaron las historia clínicas de los pacientes con hematomes subdurales crónicos operados en la Fundación Santafé de Bogotá. De los 69 hematomas crónicos, 21 (30.43 por ciento) fueron bilaterales y 48 (69.56 por ciento) unilaterales; 51 (74 por ciento) ocurrieron en pacientes de sexo masculino y 18 (26 por ciento) en el femenino. El promedio de edad fue de 58 años; 56 para los hombres y 63 para las mujeres. Soló el 75 por ciento tenían antecedentes de traumatismo y el promedio de tiempo entre éste y el diagnóstico fue de 38 días; el 9 por ciento de los pacientes no presentaron síntomas orgánicas y se hace énfasis en que algunos pacientes con hematomas la sintomatología puede simular afecciones psiquiátricas, lo cual dificulta el diagnóstico; 38 de nuestros pacientes presentaron síntomas mentales. El examen de elección para el diagnóstico es la escanografía cerebral, pero en algunos casos, cuando el hematoma es isodenso y bilateral, puede ser interpretado erróneamente. Uno de los problemas en el tratamiento de los hematomas subdurrales crónicos es la posibilidad de reproducción, que fluctúa entre el 5 y el 37 por ciento; en nuestra serie fue del 10 por ciento.

Balzac's 'Pierette'. An early description of chronic subdural hematoma.

In his novel Pierrette, written in 1840, Balzac describes a case of chronic subdural hematoma, including its traumatic origin and surgical treatment. The description was written at a time when subdural hematoma was not seen as a separate clinical entity, and was generally thought to be the result of inflammation.

Child abuse before Kempe: an historical literature review.

This literature review traces the recognition of child abuse and ends where many texts begin with the publication of Henry Kempe's paper in 1962, where the term, "battered child syndrome," was used for the first time. Starting with the first known treatise in pediatrics, the review examines evidence produced throughout the centuries on the recognition of physical child abuse. Many of the references are medical and show how while the early physicians found it easy to accept that those caring for children might injure them, by the end of the 19th century, more obscure diagnoses were being sought to explain the lesions. However, even during the time some physicians were pursuing "scientific" etiologies, there are publications that demonstrate a continuing acknowledgment of the problem of child abuse. No review of this type can claim to be complete, and the author hopes others will be sufficiently interested to seek out further historical references.