The principles and practice of modern surgery

THE SCALP.

ERYSIPELAS AND CELLULITIS.

Erysipelas and cellulitis of the scalp are the result of the same infections and conditions as when encountered in other regions, but are peculiarly prone to occur here because of the liability to infection from the hair with the material concealed in and upon the surface. They frequently lead to suppuration, in which case abscesses form that may extend inside the cranium, or into the frontal or other sinuses. These are common about the orbit and in the upper eyelid, and unless speedily incised may lead to gangrene. Multiple abscesses are also common. Disturbances of sight and hearing as sequels of these infections occasionally occur. The principal danger from these purulent collections pertains to intracranial infection or general sepsis, usually of pyemic type.

GASEOUS TUMORS OF THE SCALP.

The most common of these tumors is ordinary emphysema, which may result from injury to the upper and lower air passages. Thus fractures of the nasal bones or of the base of the skull may permit of distention of the subcutaneous cellular tissue by forcible inspiration of air. Emphysema of the scalp may be a valuable diagnostic feature in certain instances, as after fractures of the upper bones of the face. When connected with a wound it should be enlarged in order to permit the escape of contained air. Otherwise these puffy swellings disappear spontaneously by absorption of air into the veins. In cases of malignant or gangrenous emphysema early and numerous incisions are necessary, after which antiseptic solutions, etc., should be used.

Pneumatocele.

—A pneumatocele is a chronic gaseous tumor, being a cavity distended with air which has escaped from the cells of the underlying bone, bounded on the outside by the scalp and beneath by the cranium. They are found about the mastoid or the frontal regions. Not more than three dozen cases are on record. In consistency these tumors are elastic, while the escape of air upon pressure is sometimes heard on auscultation. Their explanation is usually a defect of the inner wall of the mastoid cells, through which air may be forced from the pharynx through the middle ear by violent effort, or similar defect in the ethmoidal cells by which air is forced anteriorly. Bony defects which might permit this condition are seen in a small percentage of craniums.

Treatment.

—The best results in the way of treatment have been achieved by puncture, with the injection of weak iodine solution (Fig. 366).

TUMORS OF THE SCALP.

Tumors of the scalp may be divided into the congenital and the acquired, as well as into the benign and malignant.

Of the congenital tumors the dermoids are of most interest. Originally the dura and the skin were in contact, and the cranial bones develop later between them. This explains the occurrence of dermoids either beneath or outside of the bone or their simultaneous appearance and possible connection. Many of the so-called atheromatous cysts or wens are of dermoid origin. Those which are extracranial need only antiseptic incision or excision. It will often be sufficient to split such a cyst with a bistoury, after which each half of the sac can be detached from the bed in which it has lain. Should intracranial connection be discovered the bone chisel and sharp spoon will be necessarily called into employment. Some of these dermoids perforate into the orbit, and may have to be followed into that location.

Most varieties of tumors, benign or malignant, may be met with in this region. Subcutaneous collections of fat are not so common, nor are fibromas. Various bony growths may be met, while in certain cases the signs of brain pressure are to be explained only by their extension within the cranium.

Malignant tumors are common about the scalp and the cranium; they assume, however, no conventional appearance, and are seen in any shape or form, those of the scalp alone occurring either as carcinoma or epithelioma from its epithelial elements, or as sarcoma from its mesoblastic elements. Tumors primary in the periosteum or bone are necessarily of sarcomatous nature, while those of the type which perforate to the surface may be either sarcoma or possibly endothelioma. The general character of these growths has been referred to previously. In regard to their extirpation (for there is no other treatment than this) operations of varying degrees of severity may be required. (See Cysts and Tumors and Tumors of Bone.)

The superficial epithelioma should be attacked before it has become adherent, in which case everything should be removed down to the underlying periosteum, after which a plastic operation will permit the repair of the defect, so that primary union of the whole surface may be secured. Any malignant growth which is adherent to the underlying cranial bone calls not only for removal of its own substance, but for that of the bone to which it is attached. To fail in this is to invite recurrence. This may necessitate more or less extensive osteoplastic resections of the bone, but the condition permits of no middle course. Extensive resections of bone have been made with success, and need not be abstained from unless there be good reason to fear involvement of the dura or cortex. In this case the advantages and dangers should be carefully weighed before proceeding to operation. During operations on the bone great care should be taken, especially in certain regions, to avoid injury to the intracranial sinuses, although it has been learned that these may be ligated and intervening portions removed. But the wounding of the sinus by the point of an instrument or spicule of bone may lead to a hazardous and annoying complication, and is to be prevented when possible. A small wound in a sinus may be plugged with gauze, which may remain for two or three days. There is always a possibility of air embolism (see pp. 38 and 363) when the sinuses are opened, as their walls do not easily collapse. Hemorrhage from the soft parts may be almost entirely controlled by the use of an elastic tourniquet stretched around the skull. Oozing veins in the diploë or in the bone may often be secured by pressing the tables of the skull together with bone forceps, while at other times an antiseptic wax can be forced into the interstices of the bone and hemorrhage thus checked. In certain cases where it seems impracticable to slide flaps and cover defects the desired end may be obtained by skin grafts, after Thiersch’s method.

A rare and specialized form of blood tumor, seen only on or within the cranium, is the so-called hernial dilatation of the superior longitudinal sinus. It may present through openings in the bone; sometimes pressure upon it will cause vertigo and perhaps greater prominence of adjoining veins, even of the jugulars.

NON INFLAMMATORY DISEASES AND CONGENITAL CONDITIONS OF THE SKULL.

Incomplete Formation of Bone (Aplasia Cranii).

—Incomplete formation of bone is occasionally met with. The bone is a secondary formation in the skull, the dura and skin being originally in contact; consequently this condition can be easily explained as a failure to develop bone where it is normally produced. These defects are most common in the frontal and temporal regions. The bone may fail also to develop to ordinary thickness, and may be found as thin as paper or ossifying only in certain directions. Supernumerary bones may also develop, apparently to take the place of those previously lacking. Aplasia may also be a unilateral defect and contribute toward the formation of meningocele. Atrophy or anostosis—i. e., complete disappearance of cranial bones—is occasionally observed. It may be an interstitial or an eccentric process, and may happen at any point or at several spots. Up to a certain extent it is the rule in the skulls of the aged, when the bones become reduced to the thinness of paper or may in certain places completely disappear. Senile atrophy, in other words, is a normal process, and is to be expected after the sixtieth year of life, its possibility being not forgotten when operations are undertaken upon the skulls of those advanced in years. Eccentric atrophy may also occur from pressure of soft or hard tumors, among them the so-called Pacchionian bodies. It is also stated that increasing hydrocephalus may produce an internal and eccentric anostosis.

Craniotabes, or Cranial Rickets.

—It is particularly in the skull that the manifestations of rickets are most common, the bone becoming unduly thick and the general shape being changed. Usually there is a flattened vertex with delayed ossification, with an abnormally firm union along the suture lines. In spite of these changes, the bone often becomes affected by pressure to such an extent that a rachitic or hydrocephalic child, confined to bed and moving little or not at all, will develop a skull showing the effect of such pressure. Many rachitic skulls show areas of atrophic thinning, dispersed irregularly, while the inner surface may show the markings of the convolutions impressed upon it by the softness of the bone (Fig. 368). (See Rachitis.)

SURGICAL AFFECTIONS OF THE CRANIAL BONES.

The acute affections of bones have been considered in Chapter XXXII. Acute periostitis is, in the main, due either to syphilis or to an infection following injury. In the latter case it proceeds from the margin of the wound, and may spread to a considerable distance. It is in some instances secondary to deeper infection extending from the middle ear, and then is found posteriorly to the ear and externally to the mastoid cells. Congenital openings or defects of the sutures about the mastoid seem to have much to do with the travelling of infectious lesions in these localities.

Acromegaly and Leontiasis

have been considered on pages 437 and 438.

Acute Osteomyelitis.

—Acute osteomyelitis is due to essentially the same causes as those just discussed. In this case it is especially in the diploë that the principal ravages occur. Unless promptly recognized and relieved by surgical measures this is likely to lead to sepsis of the pyemic type and at a relatively early period, the venous arrangement of the diploë favoring such type of disease.

Necrosis of the Skull.

—Necrosis of the skull is ordinarily the result, directly or indirectly, of injury, in which case it is usually of the acute form, a fragment, which has been too much separated from its surroundings to live, giving evidence of early and easily recognizable death. This necrosis is mainly confined to the external table. Necrosis of slow origin is due either to tuberculosis or syphilis, perhaps more often to the latter. Under a cold abscess of the scalp or subperiosteal abscess will often be found a small area of dead external table which needs complete removal. Necrosis has also been observed to follow severe burns of the scalp. It is usually combined with caries of adjoining bone. The caries produced by syphilis is illustrated in Fig. 371.

INJURIES TO THE HEAD PREVIOUS TO AND DURING BIRTH.

In utero the head is surrounded by amniotic fluid and is well guarded against injury. Nevertheless as the result of penetrating wounds or of falls on the part of the mother real injuries do occasionally occur. Most of the cases of skull fracture reported as occurring before birth have occurred during delivery. Multiple fractures of the skull of either character have been observed.

During the process of parturition there nearly always appears a tumor of the scalp in the newborn, known as the caput succedaneum, at the point where pressure upon the head has been least. It usually disappears quickly after birth. It is due to a collection of blood, partly an extravasation, as the result of compression or injury. It is composed also of edematous soft tissues of the surface. If incised, blood-stained serum is poured out. When this fails to rapidly resorb during the first days of the infant’s existence, and especially if it fluctuate, it may be incised under antiseptic precautions and blood clot be turned out. In rare cases it suppurates, by which is produced an acute abscess, which should be promptly evacuated.

A collection of fluid blood between the periosteum and the bone is known as the cephalhematoma neonatorum, such a lesion occurring on an average once in two hundred cases. It is generally found over the fissures, and appears to be produced by the sliding of the bones. This collection also usually promptly disappears. In case of failure it may be aspirated or incised. Before resorting to any operative procedure it would be well to make a careful distinction between a possible meningocele or encephalocele, as a congenital defect, and cephalhematoma as an accident of delivery.

A depression in the skull of a newborn child which does not quickly right itself or yield to expanding influences from within should not be allowed to go uncorrected, as serious lesions ordinarily of paralytic type may result therefrom. In these days of aseptic surgery there is no reason why such operation as may be necessary to elevate a fragment or an entire bone should not be performed, with the usual precautions.

IMPORTANT POINTS IN THE SURGICAL ANATOMY OF THE SKULL.

The young and the aged have no distinction of tables of the skull, but the diploë which separates the two tables is an affair of middle age, develops slowly, and disappears after the same fashion—sometimes to such an extent as to leave the skull of almost paper-like thinness. In all operations, then, upon the young and the old the surgeon should proceed with extreme caution, as if expecting to find the skull quite thin. The lower limit of the squamous bone proper is the so-called mastosquamosal suture, and operations confined to the squamous plate alone are safe from injuring the sigmoid sinus on its inner side. The ridge at the posterior root of the zygoma indicates, by its lower border, the level of the mastoid antrum. A few lines above this is the level of the base of the brain. The mastoid is present at birth and appears externally by the second year. Its antrum is present also at birth, though its air cells do not develop until after puberty, their location being previously occupied by cancellous tissue. Most of these cells open into the antrum, a few directly into the tympanum. They are not always separated from the sigmoid sinus by bone. The partition between them is perforated by minute veins, forming an easy communication between the sinus and the antrum. Air escaping from the mastoid cells into the overlying tissue may cause emphysema from a basal fracture. In all operations upon the mastoid antrum the operator should keep to its outer side, and the higher and the more closely to the posterior zygomatic ridge he makes the first opening the more sure is he to escape injuring the facial nerve. The groove for the sigmoid sinus extends to the jugular foramen from a point on the outside corresponding to the asterion. The lateral sinus may be indicated externally by a line from the superior border of the mastoid to the inion—i. e., from the asterion to the inion.

The frontal sinuses are usually separated by a septum, which is often incomplete or wanting. They are variable in size and outline, and do not develop until after the seventh year. The infundibulum, by which they empty into the nasal cavity, is often so small that when the lining membrane is involved it becomes closed, and retention, with its accompanying symptoms—pain, tenderness, swelling, etc.—may ensue. Ulceration and erosion, however, may cause perforation internally through the supra-orbital plates, so that pus may penetrate through the inner half of the orbit.

Aside from its direct communication the superior longitudinal sinus connects with the basal sinuses through the middle cerebral and the Sylvian veins, while communications with the middle meningeal veins are abundant. Where the frontal and diploëtic veins enter the longitudinal sinus there frequently are dilatations in which marasmic thromboses often originate. This sinus is also connected with the veins of the nasal septum, so that a septic phlebitis may be propagated from the nose. So much of the lateral sinus as is contained in the sigmoid groove is known as the sigmoid sinus, which connects directly with the exterior through the mastoid and the posterior condyloid veins. In sinus thrombosis this mastoid vein is likewise affected. One or more condyloid veins accompany the hypoglossal nerve through the anterior condyloid foramen, and may also serve for the propagation of infection or exit of pus.

While septic particles may be carried from any part of the lateral or sigmoid sinuses—usually through the internal jugular—they may also be carried by way of the other veins above mentioned or the occipital sinus, all of which empty directly into the subclavian without passing through the internal jugular. These sinuses are all rigid tubes, always open, while the veins are thin and flexible, their caliber constantly varying with inspiration and expiration. The sinuses contain no valves, and these are very rare in the cerebral veins.

So far as the lymphatics are concerned there is free and easy communication between the internal and external plexuses and nodes. Into the superficial nodes, along the external jugular, outside of the deep fascia, empty all the external lymphatics of the head. Intracranial infection shows itself in swelling of the deep cervicals beneath the deep fascia. Lymphatics are abundant in the dura, and pathogenic organisms, once housed within the dura, find it easily open to invasion. The potential interval between the dura and the arachnoid is termed the subdural space, when considerable effusion may occur without marked symptoms, owing to its easy diffusion, while blood here poured out may travel even to the lowest parts of the spine and cause death by pressure upon remote points.

The arachnoid bridges over the convolutions and does not extend into the sulci. It is not vascular; at certain points it is adherent to the pia, at others it does not touch it. The subarachnoid space is formed in the latter way, and within it most of the cerebrospinal fluid is contained. This space is unevenly distributed over the brain surface, most prominently beneath the posterior two-thirds of the brain, where there is a wide interval between the arachnoid and the pia, extending forward around the medulla and pons and as far forward as the optic nerves. This space connects with the ventricles by the foramen of Magendie, as well as with the sheaths of the cranial nerves. Where these nerves escape from the brain or cord they are covered by all three membranes, the layers being most distinct along the optic nerves. Fluid injected into the subdural space may pass along the spinal nerves as far as the limbs. It is essential to realize this in order to appreciate how extensive is the surface exposed in leptomeningitis.

Internal hydrocephalus is often the result of closure of the foramen of Magendie. The cerebrospinal fluid is rapidly reproduced after traumatic escape. External hydrocephalus or accumulation in the subarachnoid space, is a condition frequently due to tuberculous infection.

The pia is the vascular coat of the brain, supplied with an extensive network of fine nerve fibers derived from the sympathetic and the cranial nerves, having intimate relations with the brain, to such an extent that leptomeningitis and encephalitis are almost inseparable. The nerve supply to the cerebral membranes explains the severe pain of meningitis.

INJURIES TO THE SOFT PARTS OF THE CRANIUM.

In direct connection with what has been stated above it is well to emphasize that the venous communications between the exterior and interior of the cranium are numerous, and that the frequency of these anastomoses explains the ease with which extracranial infections are propagated within; in other words, these explain the frequency of septic mischief in the brain after external injuries.

Penetrating and Incised Wounds.

—Penetrating and incised wounds are frequent about the head, their prognosis per se, as well as their proper treatment, varying but little from that of such wounds in other parts, so long as the skull proper and its contents escape injury. Hemorrhage from scalp wounds may be profuse and even fatal. The most dangerous hemorrhages occur from the temporal vessels. Penetrating wounds are short, and the periosteum and underlying bone are usually also injured. Such small articles as blades of penknives, particles of dirt, etc., will often be found when the parts are carefully inspected, a measure never to be neglected. Contusions of the scalp and skull are spoken of as subcutaneous, subaponeurotic, or subperiosteal, and are most frequent in the frontal and lateral regions. Ecchymoses following them may be extensive and discoloration may spread over a large area. In traumatic hematomas resulting from various injuries incision should be an early resort should blood clot fail to resorb.

INJURIES TO THE CRANIAL BONES.

All conceivable degrees of injury to the bones, from a trifling division of the periosteum down to most extensive denudation or mangling of the external table or the entire thickness of the bones, may be encountered. These lesions may be spread over a large area or may be the result of penetrating wounds. In other words, we may have linear, penetrating, or large surface wounds, with such injury to the scalp as perhaps to amount to a total loss of covering for the same. All of these, moreover, may be complicated by fractures of the bone at the point of injury, with or without brain lesions, or by other and more remote lesions.

In regard to most of these, it may be said that non-penetrating injuries, when promptly and properly attended to, have, in most cases, a favorable prognosis. Every penetrating wound of the cranium is a condition justifying grave prognosis, on account of the great danger of infection incurred. Other features of these wounds, with more in regard to prognosis and treatment, will be given under the head of Compound Fractures of the Skull, etc.

It is necessary, however, to say in this place that penetrating wounds of the cranium are often received in a way which does not permit actual diagnosis, as, for instance, when received through the nose or the orbit. Every wound whose history and appearance indicate that penetration may have occurred should be subjected to the most rigid scrutiny and care. Points of fencing foils, umbrella tips, etc., have been forced into the brain cavity through the orbit and elsewhere in ways which left little external evidence of the severity of the injury.

FRACTURES OF THE SKULL.

Following the anatomists, and for general convenience, these are divided into fractures of the vertex, of the lateral region, and of the base, the former being the most frequent as the vertex is the most exposed. A fracture in a given region may be confined to that locality or may radiate widely or extend nearly around the cranium. Of all the fractures of the bony skeleton those of the skull constitute about 2 per cent.

Fractures of the Vertex of the Skull.

Fractures of the vertex are, in most instances, due to actual violence, the force being often expended at the point of application or producing radiating fractures. Those which are limited to the neighborhood of the injury are referred to as direct fractures, in distinction to which we have indirect or radiating, often producing remarkable results. Fractures may vary between the simplest crack or fissure, accompanied by but trifling brain symptoms and never recognized, to the most extensive comminution and destruction of cranial bones which can be imagined.

Splintered or Comminuted Fractures.

—Splintered or comminuted fractures refer to the formation of numerous bony fragments, which are often more or less loosened, sometimes completely so, occasionally dovetailed together, and often driven in or depressed. Such fractures are direct. It is possible to have comminution without depression; the latter makes it the more grave condition.

Fractures with absolute loss of substance may be made by gunshot injuries or by any extensive splintering or by a penetrating body. It is possible to have fracture of one table without that of the other, this being often true of the external table. In isolated fractures of the inner table there is often dislodgement of small fragments which may injure the dura and possibly produce later epileptic or irritative disturbance. When the external table is chipped off the diploë is exposed, and this with its wonderfully fine venous communications opens up a wide area to infection and subsequent pyemia.

Gunshot Fractures.

—Gunshot fractures are always depressed and almost invariably comminuted. The bullet of the modern army rifle possesses a great initial velocity, and the cranium struck by it will probably be disrupted into fragments, causing instant death. The majority of gunshot fractures of the skull seen in ordinary civil practice are due to revolver or pistol bullets from weapons of the prevailing type. In these instances there will usually be penetration, perhaps with perforation of the skull, and the formation thus of one or of two compound fractures, the wound of entrance being always comminuted and depressed, while fragments of bone may be scattered along the course of the bullet, which may also carry infectious material from without, such as hair, particles of hat, and the like (Figs. 373 and 374). (See also Figs. 52, 53 and 54.)

Whatever may be the wisdom of operating in other cases where there is room for doubt as to the proper course there rarely is uncertainty as to the proper treatment of gunshot wounds of the skull, which should be invariably subjected to operation.

It will thus be seen that fractures of the skull may be simple or compound, or complicated with other injuries, or depressed, without any reference to whether they are simple fissures or more extensive injuries. On the other hand, depressed and comminuted fractures may occur without being compound in a surgical sense, and with each one of these injuries there may be accompanying disturbance of the brain of any degree of severity, from the mildest concussion or shock up to rapidly fatal compression. Any imaginable complication of these head injuries is not beyond the bounds of possibility.

The essential features in explaining the mechanism of fractures of the vertex are the area involved and the violence of the impact. The skull is often surprisingly elastic, even in the oldest individuals, and fractures occur ordinarily when the natural limits of elasticity have been exceeded and bone cohesion overcome. Children particularly suffer from depression without fracture, which formerly was never operated upon, but which is now regarded as requiring operation. On the other hand, certain skulls are abnormally fragile (see Fragility of the Bones, Chapter XXXII), and among the insane may be found so porous and yielding as to be easily pressed out of shape. In injuries of slight extent it is sufficient that the skull be regarded as composed of an elastic substance, while for injuries produced by greater violence the skull is to be considered rather as a globe or arch possessed of high resistance and elasticity, whose shape will probably yield more or less before a fracture results. Much may be learned from such experiments as those of Félizet, who filled skulls with paraffin and dropped them from varying heights, and then divided the bone, to note in numerous instances that, although the bone had not been fractured, it had yielded at the point of impact to a degree producing a marked depression in the paraffin beneath. After various injuries, especially to the top of the head, the shape of the skull may be altered and its diameters affected. Many fractures, then, are the result of a bursting force, which may be shown by the fact that hair has been found included within apparently closed fissures, and even on the dura. Moreover, particles of bullets have been found within the skull without any visible opening through which they could have entered, showing that the bone has yielded under impact for a fraction of a second. In certain injuries to the head, as when a man is struck to the ground, there is injury at two points nearly opposite.

Fractures of the skull, especially of the vertex, possess surgical interest mainly as they are accompanied by more or less evidence of intracranial complications. So long as there is no evidence of hemorrhage or laceration within they are ordinarily regarded as a feature of the external wound with which they are usually found, and unless there be comminution, depression, or some other good reason for operating they are covered over as the wound is closed and are left to the natural process of repair by formation of minute callus or by the ossification of granulation tissue.

It is unfair to contrast the results of the surgery of today with those of the pre-antiseptic era. Rules then enforced are now abrogated. One respect in which we violate precedent is in our disregard of the periosteum or pericranium. This is sacrificed without hesitation when found to be infected or torn or lacerated beyond repair. A flap of scalp will adhere as readily to denuded bone as to periosteum, and skin grafts can be applied and will adhere to this same bone—if not upon the first day, a little later when granulations have appeared. In the various plastic operations necessitated about the head we may also transplant flaps upon otherwise uncovered bone without the slightest hesitation. Fractures should be treated mainly in accordance with intracranial complications, or through what can be seen either through the wound or through an opening intentionally made under antiseptic precautions for purposes of exploration. It is conceded to be better policy to remove fragments of bone whose vitality is uncertain and to sacrifice tissue injured or lacerated to such an extent that sloughing would probably follow or be so exposed as to have become infected.

Diagnosis of Fractures of the Vertex.

—In the absence of an open wound, and unless incision be made, diagnosis of fractures of the vertex is necessarily conjectural. In the presence of a wound diagnosis is usually easy. In case of a small puncture it will be better to enlarge it sufficiently to permit the introduction at least of the finger. With the finger and the eye we seek to detect differences in level, depressions, fissures, etc. Mistakes arise from the formation of an exudate or a clot, by which a depression of the soft parts may be regarded as depression of the bone. Error occasionally arises from the existence of previous atrophy of the bone or any congenital defects in ossification of the skull; also in the skulls of syphilitic patients where disappearance of a gumma is often followed by absorption of the underlying bone. In case of doubt exploratory incisions should be made under aseptic precautions. These should not be made, however, unless the attendant is ready—i. e., has the facilities immediately at hand—for carrying out any further operative procedure that may be necessary, as elevation of fragments, removal of foreign bodies, etc. Error also may arise from mistaking for fracture a deceptive circular effusion of blood which frequently occurs beneath the scalp after injury. Areas of bloody infiltration often have abrupt margins which are calculated to easily deceive. In children, more especially, we often have a circumscribed bloody tumor which may contain cerebrospinal fluid rather than pure blood. In some of these cases after exploration there will be found material resembling brain matter, which, however, is not always such, although real brain substance may escape, caused by rupture of the overlying membranes. Should it be noted that the fluid used for irrigating and cleansing such a wound begins to pulsate, it will imply connection with the cranial cavity, and, obviously, fracture. A suture should not be mistaken for a line of fracture. This mistake is more easy when Wormian bones are present. Blood may be wiped away from a suture line, but not from that indicating fracture. It is not often possible to diagnosticate an isolated fracture of the inner table. It happened, however, once to Stromeyer to notice that so soon as an injured patient assumed the horizontal position he began to vomit, and that nausea subsided when he was placed in the upright position. On autopsy it was found that there had occurred a depressed splintering of the inner table with perforation of the dura—less irritation was produced in the upright position than when the patient was lying down, which accounted for his vomiting when in the horizontal posture. When a comminution has been produced it is always of prognostic value if an unbroken dura be found. Prolapse of brain substance is a serious complication. Escape of cerebrospinal fluid is relatively rare. Rising temperature after these injuries is always a sign of danger.

Treatment.

—Treatment comprises attention to the local injury and the suitable dealing with the condition of the brain within when injured. The treatment of simple fractures is expectant. In the absence of indication for operation it should be simple, and should consist of physiological rest, aseptic dressings, ice applications to the head, the administration of such laxatives, diuretics, antacids, etc., as may be necessary to favor free excretion and to guard against autointoxication. Whenever there is reason to suspect a depression, exploratory incision should be made. Actual depression, whether the fracture be compound or not, requires operation. This course is justified by the numerous instances in which later consequences have been noted, such as traumatic epilepsy, insanity, etc.

Compound injuries should always be operated upon in some manner, which includes the removal of loosened splinters, the elevation of depressed bone, the removal of foreign matter, the checking of hemorrhage, the excision of bruised and lacerated tissue, and the proper closure of the wound, with or without drainage.

In serious and lacerated cases it is inadvisable to close the wound with the view of attempting primary union. It should be packed with gauze and temporarily closed with secondary sutures. These measures should be seconded by physiological rest (quietude of the head, which may even be enforced by the posterior plaster-of-Paris splint to the head and neck), attention to the primæ viæ, the avoidance of transportation, the prevention of auto-intoxication, etc. The surgeon should use discrimination as to the amount of bone to be removed, the wisdom of opening the dura when not lacerated, of examination of the brain with the exploring needle, the matter of drainage, and the time during which it shall remain. With reference to all these matters exact rules cannot be given. When drainage is made in recent cases it is usually sufficient to drain the scalp wound. Only in cases where there is probability of meningeal infection is it advisable to attempt to drain the dural cavity. This is better accomplished with gauze, catgut, or folded rubber tissue than with drainage tubes.

Skull fractures where the injury is limited to a small area are treated according to a bolder method than was in vogue a number of years ago. There should be careful and judicious operating in every case where distinct depression can be made out, as well as in every case where indications point to injury of parts within the bone. The statistics of trephining in the pre-antiseptic era are valueless as arguments in this consideration. If done according to aseptic precautions, and if good surgical judgment be used in every respect, the operation is per se almost devoid of mortality and should not be regarded as a last resort, but rather in such cases as a first one. I have seen so many instances of later untoward consequences resulting from delay, which corroborate the experience of others, that I would not be misunderstood in this matter. My advice might perhaps be summed up in the following words: Where there are no brain symptoms and no skull symptoms, in fractures of the vertex, let the case alone; when either of these are present, especially the former, it will always be advisable to operate.

Fractures of the Base of the Skull.

In the majority of these fractures the violence is applied at some more or less distant point, and, by transmission through the arch-like structure of the skull, expends itself in fissuring or comminuting the base. The most frequent location of the indirect injury is upon the convexity. The mechanism of these fractures has been a problem for many centuries, but has been cleared up mainly within the past three decades. Félizet has shown, for instance, how the handle of a hammer may be forced into its head by striking it in either one of two different ways, and has compared the mechanism of basal fractures to this fact. The secret of these fractures probably resides in the elasticity of the skull, which varies within wide limits in different individuals, and which breaks, as do the ribs and the pelvis, at points more or less distant from that at which the injury occurred. Were the skull everywhere equally thick and elastic, there would be much less variation in these fractures, but lacerations frequently extend between the most resistant parts; and when violence is applied upon the forehead we find that the resulting fissure extends between the crista and the wings of the sphenoid, upon the same side, in its course toward the base; that when the lateral region of the skull is injured the fissure extends between the sphenoidal wings and the occipital bone; and that when the occipital region receives the first injury the fracture lies between the pyramid and the occipital crests. The analogy between fractures of the skull and cracks made in nutshells (cocoanuts, etc.) when struck with a hammer is too self-evident to be disregarded. Many years since the French introduced the term fracture by contre-coup (counter-stroke)—a practical admission of the occurrence of fracture at a point more or less opposite to that struck.

There is, however, no certainty about these fractures. Extensive fissures of the vertex are almost always extended to the base of the skull, while the reverse is seldom true. There are doubtless also many cases in which a bursting force compromises the bone rather than mere radiation of unexpended violence; but so long as skulls conform to no fixed mathematical figures nor proportions, and are composed of bones varying in shape, density, and strength, it will be impossible to formulate any laws which are sufficiently comprehensive to be satisfactory. Fractures in the posterior fossa occur most often through violence applied posteriorly and from below. There is a ring form of basal fracture produced mainly by the impact of the vertebral column, as when an individual falls upon his head the weight of the body forcing the cranial base in upon the brain.

Fractures of the anterior fossa may involve the roof of the orbit; even facial bones may participate in the injury. These considerations are not without importance, for if a patient presents symptoms of injury of the petrous bone, and if these be accompanied by injury to the lateral region of the skull, we are in a position to make a diagnosis of fracture of the middle fossa. (See Plate XLII, and Figs. 375 and 376.)

By all means the majority of basal fractures are mere fissures which open and close instantly upon their production—close so quickly, in fact, as scarcely even to include blood between the broken bony surfaces.

Prognosis.

—The majority of basal fractures are fatal, either because of injuries to the brain, or of hemorrhage or violence along the nerve trunks, or from infection extending along the newly opened paths. Other things being equal, the longer the fissure the greater the danger, particularly so when it takes its origin in the vertex, and because of greater ease of infection. Air infection may occur in any basal fracture by fissures extending into the various air-containing cavities—nose, ears, sinuses, etc. They are then practically compound, though invisibly so. The general prognosis will depend, first, upon the injury to the cranial contents; second, upon the possibility of infection. Statistics are absolutely unreliable, although always possessing interest. Numerous museum specimens show the perfection with which bony repair may occur and the admirable way in which compensation is afforded for defects. Suppuration after basal fractures is mainly that due to purulent basal meningitis, in which case the brain symptoms dominate in the clinical picture, while the appearance of a single drop of pus in the ear or upon the surface is of the greatest significance. The conversion of a serous outflow (e. g., from the ear) into purulent fluid is also pathognomonic. Various paralyses, principally of the cranial nerves, may follow this injury and prove temporary or permanent. Diagnosis is often made by a study of these special nerve lesions.

Diagnosis.

—The most significant diagnostic features are:

1. Spread of blood from the point of fracture until it appears as an ecchymosis at certain points beneath the skin: This will occur early in some cases and late in others. It may appear beneath the skin or beneath the conjunctiva or other mucous membranes, even in the pharynx. Occurring about the mastoid, it implies fracture of the middle or posterior fossa; about the eyelids, of the anterior fossa. Beneath the bulbar conjunctiva it means extravasation along the optic sheath, probably from within the dura. In fractures of the posterior fossa it will come to the surface of the neck, but only after two or three days. The ecchymoses about the lids or orbits occurring after two or three days mean more than those occurring within these days, for the latter may be caused by external bruising. The globe of the eye may be pushed forward by blood accumulating within the orbit. Exophthalmos thus produced is therefore most significant, though not common.

2. Escape of serous fluid, blood, or brain substance from the cavities of the skull: Hemorrhages from this cause occur most often from the ear, the petrous bone being tunnelled with various canals through which blood may thus escape. The surgeon should, however, assure himself in every instance that the blood is escaping from the ear and not from some trifling wound of the external soft parts, the soft walls of the meatus, or the tympanum. Profuse hemorrhage can probably only come from a basal fracture. Escape of serous fluid is usually noted as a sequel to hemorrhage, although it may begin almost immediately after an injury. Rarely more than twenty-four hours elapse before it begins to flow. The quantity of fluid discharged is sometimes considerable. It may occur in frequent drops or during expulsive efforts, like coughing, or may ooze in such a way as to be insensibly collected by the absorbent dressings. In average cases the amount in twenty-four hours is from 100 Cc. to 200 Cc.; 800 Cc. have been noted in occasional instances, and in a very few still more. Occasionally violent expiration will increase the flow.

In some cases the fluid may escape through the Eustachian tube into the pharynx, whence it may escape by the nostrils or be swallowed.

The escape of brain substance is rarely noted, but obviously implies such serious injury as to make the prognosis of the worst.

3. Disturbance of function along particular cranial nerves, paralysis of which is often produced by fractures of the base, especially those involving the foramen of exit of the nerve involved: The nerve may be lacerated or injured in such case by the fragment of bone.

In addition to these distinctive features there will be in the majority of instances brain symptoms, either of contusion or compression, varying in severity within all possible limits, but adding their weight to the value of the testimony.

Other and unusual signs of basal fracture may occur, such as communication between the cavities of the petrous bone and the mastoid cells, leading to the formation of pneumatocele (see page 545), or emphysema of the overlying soft parts, observed mostly about the orbits, when the nasal cavity is involved.

Treatment.

—The treatment of basal fractures is mainly symptomatic. The first effort should be to make antiseptic all those parts of the skull involved, which means to shave the scalp; to thoroughly cleanse and irrigate the external ear and the auditory meatus, using a head mirror and ear speculum for this purpose; to tampon the meatus with antiseptic cotton; to provide a copious absorbent dressing for such fluid as may escape and to change this frequently; to cleanse the nasal cavity as well as the conjunctival sac, for all of which the peroxide of hydrogen is serviceable. All of this should be done promptly, while at the same time studying the patient for evidence of brain injury or of involvement of special nerves. By the time these measures are thoroughly performed a decision as to the necessity for immediate operation should have been reached. Evidence of brain compression wanting, and in the absence of external or compound injury the patient may be left at rest, with cold applications to the head and active purgation. In many of these instances benefit follows the application of a number of leeches to the mastoid region and to the occiput. Operation is necessary later only when brain symptoms supervene, these consisting of evidences of compression, either from blood or from pus, as compression from other causes should have been acting at the time of the first examination, and should have been recognized at that time. When direct fractures are evident the possibility of the entrance of foreign bodies should be also remembered. Thus penetrating fractures of the base have occurred through the orbit as the result of accident or assault, and such weapons or implements as foils, ramrods, drumsticks, canes, umbrella points, etc., have been known not only to penetrate into the brain, but perhaps to leave some portion of their substance—e. g., a foil tip or an umbrella tip—within the cranium after their withdrawal.

Separation of sutures, known also as diastasis of the same, is the occasional result of injury instead of, or complicated with, fissures or other fractures. It is the result of violence, and is virtually a specific form of fracture, from which it differs in no essential particular. Diastasis can only take place along lines of previous suture, but it is possible that Wormian bones may be thus loosened. Sutures thus separated ordinarily heal by fibrous repair rather than osseous union. Diagnosis is possible only as they are exposed to view, although displacement in the middle line or along known suture lines may be regarded as diastasis. The treatment differs in no respect from that of other fractures.

Injuries to the frontal sinuses occasionally complicate fractures of the skull. These sinuses vary in different individuals, are rarely truly symmetrical, and are not found in the young. They connect with the nose in such a way that emphysema of the frontal region is quite possible, while air may be blown beneath the periosteum or may communicate with the interior of the cranium. In wounds of the frontal region the sinuses are occasionally opened—a fact of importance, for infection of the Schneiderian membrane may occur and endanger life, mainly because of the retention of infectious products within its cavities. Moreover, by such wounds the ethmoid may also be injured. Pus which escapes from these sinuses and from the ethmoidal cells is usually thin and bad-smelling. Long continuation of suppuration after such injuries probably means necrosis and formation of sequestra.

INJURIES TO THE BRAIN AND ITS ADNEXA.

By better acquaintance with certain portions of the brain whose function is now generally recognized and described, as well as with the more exact knowledge regarding the entire encephalon, the outcome of many recent studies, the teaching of the past in regard to the nature of various brain lesions has been essentially modified. Especially is this true in regard to the distinction formerly emphasized as between concussion and compression. In discussing brain injuries we should, first of all, distinguish between traumatic disturbances of the entire endocranium and localized injuries to the brain or particular vessels and nerves entering into its composition. In regard to the first, it is possible that the entire blood or lymphatic circulation within the cranium may be affected in such a way as to influence its nutrition and function, by which means activity and function are mildly or seriously perverted. The immediate effect of severe injury to any part of the body is reflex vasomotor spasm, which constitutes the essential feature of the condition known everywhere as shock. It is this condition, with its marked local expressions, which was formerly known as concussion of the brain. When studied upon its merits it is found to be indistinguishable from shock produced by injuries to other parts. The condition for so many years taught and recognized as concussion is but shock following injury to the head. This makes no further demands upon the question of pathology than those prompted by any traumatic disturbance.

Through the mechanism of the cerebrospinal fluid rapid alterations of pressure and of the volume of the brain are produced. There is an easy path between the inelastic cranial cavity and the exceedingly elastic and accommodating spinal canal, which latter serves as a reservoir for the fluid which may be pressed out of the cranium when brain pressure is increased. While the subdural and subarachnoid spaces are each of them absolutely closed sacs and do not communicate one with the other, there is ample accommodation within each to permit a constant equilibrium of pressure under ordinary circumstances, as between the spinal canal and the cranial cavity. The brain expands in volume with every systole of the heart, while with every diastole it contracts. Its size is, moreover, modified by the motions of respiration. Under these extremely accommodating conditions it is scarcely credible that external injuries which leave no internal evidences of violence should do anything more than disturb the equilibrium of fluid distribution.

“CONCUSSION” OF THE BRAIN.

We inherit this term concussion from the earlier masters of our art, by whom, however, it was used in a much broader sense than of late. Its modern significance was given to it by Boirel, who made it apply to a group of cerebral symptoms the result of injuries not accompanied by fracture or perceptible laceration of vessels, symptoms varying in intensity and duration.

Our present position is practically this: The possibility of pure concussion of the brain—i. e., disturbance of brain function without gross mechanical lesions—is admitted, but its general frequency is denied. When present it should either pass away quickly, the condition being equivalent to that called “stunning,” or, if it assume distinct form, its signs and symptoms are indistinguishable from those of shock, consisting essentially of rapid and feeble pulse, quick and shallow respiration, pallor of the skin, copious perspiration, complete or partial unconsciousness, muscle incoördination, with lack of sphincter control, occasional vomiting, the pupils usually reacting in light.

Treatment.

—The treatment for this condition is essentially that for shock, and whatever may be called for in the way of attention to injuries about the head—e. g., sewing up a scalp wound, etc. (See Chapter XVIII, on Blood Pressure.)

CONTUSION OF THE BRAIN.

The condition of shock (cerebral concussion), when of pure type, passes away with reasonable promptness, especially when aided by surgical treatment. Anything which persists in the way of muscle paralysis, disturbance of function of nerves of special sense, or other sign of importance, indicates something more than mere vibratory disturbance: it implies mechanical lesion which could be perceived by the eye were the parts exposed, and constitutes the condition known as contusion. This implies the existence of trifling exudates, or hemorrhages, which lead not only to absorption but even cicatrization. Contusion pure and simple differs from ordinary laceration as a contusion elsewhere may differ from a wound. It cannot be separated, however, from conditions in which there are minute separations of continuity and actual lacerations. It may be divided into three postmortem forms—general hyperemia, with or without edema; punctate or miliary hemorrhages; and thrombosis of minute vessels, which may occur separately or together. Moreover, there may exist similar lesions in the meninges, constituting meningeal contusion. Ordinarily minute vessels of the pia are ruptured and blood is effused in small and thin patches over various parts of the brain. The so-called compression apoplexies of certain authors are inseparable from the conditions above described. Such minute blood clots are only to be distinguished upon very careful sectioning of the brain, and are found most often in the region of the medulla and along the floor of the fourth ventricle. They are probably caused by the forcing into the fourth from the lateral ventricles of the fluid contained in the latter.

Symptoms.

—When the ordinary symptoms of shock, which follow all severe injuries to the head, especially when the deep lesions are not too severe, fail to disappear in a short time under proper treatment, and when new and irregular symptoms are superadded to those of shock alone, it is reasonable to suppose that the intracranial condition is one of contusion rather than of shock. When mental agitation changes into delirium, when the rapid, feeble pulse becomes stronger and slower, the respiration deeper, the limbs move in incoördinate ways, the speech disturbed from muscle incoördination, the patient selects wrong words, or when the mental condition becomes more serious and stupor or coma take place of the delirium, while external irritants have less and less effect, and when the pupils gradually enlarge while failing to respond to light, it may be said that the condition of contusion is making itself apparent. If along with muscle uncertainty there is also muscle spasm or rigidity, with fixation of the fingers in the athetoid position, the evidence to this effect is increasing. If with all this the thermometer fails to show that an active inflammatory condition—i. e., meningitis—is prevailing the diagnosis may be regarded as certain. Error may possibly arise when there are evidences of alcoholism. Coma following head injury ought not to be ascribed to the alcoholic condition except by the strictest process of exclusion. Temperature alone will be of the greatest service in this direction, since in alcoholism it is usually subnormal. In apoplexy and non-traumatic hemorrhages it is also usually subnormal at the commencement of the attack, rising to normal, and remaining there if the patient recover, but continuing to rise in cases where the prognosis is bad.

Treatment.

—The treatment of brain contusion should be managed largely in response to special symptoms. Physiological rest, attention to scalp wounds, fractures, etc., shaving of the scalp, application of ice to the head, with such stimulation to the heart as may be necessary in extreme cases by subcutaneous administration of adrenalin, atropine, etc., by local fomentations over the epigastrium, or by immersion in a hot bath when surroundings permit it—these in a general way constitute most of the methods of treatment in contusion. When only symptoms of diffuse and minute lacerations can be recognized the use of the trephine is impracticable except when indicated by some external marking—i. e., compound fracture or the like. When localizing symptoms are present the trephine is, of course, indicated. When the skull injury is recognized as a basal fracture, venesection or the application of leeches behind the ears will be most serviceable. In every such case there is the greatest necessity for regulating the excretions and preventing auto-intoxication. For this purpose diuretics and laxatives should be used, often in conjunction with intestinal antiseptics. The catheter should be employed whenever indicated by the condition of the bladder, which should be carefully watched. As the days go by, and patients lie more or less helpless and inert, the greatest care should be exercised for the prevention of bed-sores. When mental inertness, muscle rigidity, etc., fail to disappear, potassium iodide should be used internally.

BRAIN PRESSURE OR COMPRESSION.

That the cranial contents—brain, blood, lymph, and cerebrospinal fluid—completely fill the cranial cavity has been already amply shown, as well as that there is no room for anything in the shape of a foreign body without seriously affecting the equilibrium between the brain and the contents of the spinal canal. When, however, any foreign substance exerts pressure upon the brain the results are invariably the same, be this substance what it may, and compression signs are always the same, no matter what the compressing cause. Reduction in capacity of the cranial cavity (i. e., compression) may be produced—