Part 31

It has been said that we must be regulated in our proceedings very much by the existence or not of external wound; that we must be cautious in cutting down upon fractures of the cranium where there is no wound, and so converting a simple into a compound fracture. In fact, so much is the danger increased, it is alleged, by the existence of wound, that the symptoms must be very urgent indeed which would demand division of the integuments in order to admit of examination of the fracture, the application of the trephine, or the elevation of the bone; whilst, on the contrary, if the fracture is exposed by the accident, very slight symptoms will fully warrant performance of the operation of trephine. In other words, it is said that simple fractures should be left to nature, unless under very urgent and alarming circumstances, and that compound ones ought almost always to be interfered with. But the facts are otherwise. The greatest danger of compound fractures of the cranium does not arise from the admission of air. It is not the wound of the scalp, but the mechanical irritation of the brain and its membranes that proves dangerous. Injuries of the cranium inflicted by sharp bodies, such as divide the scalp and cause compound fractures, are generally attended with splintering of the internal table, and require the trephine. The existence of this sort of fracture of itself, without a single bad symptom, without any present disturbance of the sensorial functions, is a sufficient warrant for the application of the trephine, so as to permit the removal of the detached portions of the inner table: and this should be done before inflammatory symptoms have shown themselves. The brittleness of the internal layer of the skull is well known. In fractures inflicted with sharp and pointed instruments, as a bayonet or pike, the corner of a sharp stone, or the heel of a horse’s shoe, the external opening is often very small, it is a mere puncture; in the bone there is a central depression, from which fissures proceed around in a radiated form, and hence the injury has been termed punctured, or starlike fracture. But though the external wound is apparently insignificant, the vitreous table is extensively separated, and, perhaps, broken into innumerable minute and sharp spicula. These sharp portions are driven down upon the dura mater, and by them the membrane is often severely lacerated. If these be not removed soon after the accident, inflammatory action is almost invariably lighted up on the surface of the brain; and we cannot expect to allay or avert such action by general antiphlogistic means, however energetically applied, so long as their exciting cause remains. It is in such cases, I repeat, that the operation of trephining is imperiously called for. Sometimes, however, patients are found to recover from punctured fracture of the cranium, without the operation having been performed, as in the following case, the only one so terminating with which I have met:—On the 4th September, I was consulted by a gentleman, aged 35, who had received a punctured fracture of the cranium, on the 29th of August; a heavy dung fork had fallen from the top of a haystack, and struck him on the upper part of the head. Immediately after the accident he became confused, but not insensible; he lost the power of motion in the right lower extremity, but almost instantly regained it. Next day the right arm became weak, and when I saw him, he was almost wholly unable to move it: he could not bend his fingers, nor raise the arm, and he retained the power of exercising but very slight motion in the elbow-joint. There was a small wound of the scalp, nearly healed, over the posterior part of the left parietal bone, close to the sagittal suture, and nearly midway between its two extremities. A probe passed down to, and through, the bone; and there was slight swelling of the scalp around the wound. He had felt pain in the right ear, and in the forehead, whilst stooping, for some days after the accident. No blood had ever escaped from the ear. A fit of shivering occurred on the night following the injury, but never returned. He soon recovered completely.

I subjoin a case of an opposite description. A coachman was knocked down, late on a Saturday night, and fell with his head on the corner of a stone on which masons had been recently working. After being carried to his lodgings, he recovered from the stupor produced by the combined causes of liquor and blows; and next morning he went to have his head dressed by an apothecary, who with difficulty extracted a fragment of the stone from the wound of the head. The patient then drove a party to church, and probably drank some more whiskey during the day. He afterwards felt indisposed, and was seized with sickness and shivering in the afternoon. On Monday he was in a violent fever, and I saw him in the evening. He had been delirious, but was now lying in a state of stupor. There was a hole in the right parietal bone, capable of admitting the point of the little finger, and many loose fragments of bone were felt lying on the dura mater; a trephine was applied, and numerous spicula were removed. Afterwards, the circulation became much excited, he was bled copiously, and antimony was exhibited in nauseating doses; but he died early on Wednesday morning. On dissection, there were found marks of violent inflammatory action on the surface of the hemispheres. The vessels were unusually numerous and highly engorged, and lymph and pus were effused in considerable quantity, the arachnoid was opaque, and the cerebral substance was somewhat softened. Had the operation been performed at an earlier period, there is every probability that the inflammation, which proved fatal, would have been averted, as in the following instance:—A quarryman received a blow from a sharp stone of considerable size, which rolled down a precipitous bank, and struck him on the vertex. He lay insensible for half an hour, but recovered, and followed his occupation during the rest of the day. In the evening he came for advice. There was a small wound in the scalp, and the subjacent bone was fractured exactly in the same manner as in the former instance, but he felt no uneasy symptoms whatever. The consequences likely to result from such an injury, and the necessity for trephining, were represented to him; he agreed, and the operation was performed on the spot. Many sharp fragments of the inner table were extracted; he proceeded home, never had a bad symptom afterwards, and consequently required no treatment save dressing of the wound.

The operation, if undertaken early, will, in all probability succeed in averting future evil, more especially if the dura mater be not wounded. As a proof of the unfavourable nature of this latter circumstance, I give the following case:—A young man, aged 18, received a kick on the forehead from a horse, September 9th. He remained perfectly sensible, and did not fall to the ground. Shortly after, he was seized with vomiting, which recurred at intervals; his pulse was regular, but feeble; pupils dilated. On the centre of the forehead, there was an irregular wound, which extended to the root of the nose; and on introducing the finger, the os frontis was found fractured, and a small portion of it comminuted and depressed. The trephine was applied, and several detached portions were removed, with some difficulty, from beneath the undepressed portion of the bone. A spiculum had lacerated the dura mater, and penetrated the substance of the brain, to the depth of half an inch; on removing it, a small portion of cerebral matter escaped. The fracture extended apparently in the direction of the right orbit. In the afternoon, the pulse was sixty-four, of good strength, and the pain in the wound had slightly increased. He was bled to fourteen ounces, and ordered an antimonial solution. Afterwards, the pain of the head increased, the pulse rose, the scalp around the wound became the seat of puffy swelling, and several small abscesses formed: the antiphlogistic regimen was rigorously followed, and the abscesses were freely opened as soon as they began to form. On the 21st, a portion of the brain had sloughed, and there was some appearance of fungus cerebri; an incision was made into a swelling over the right temporal muscle, and ℥viii. of blood allowed to flow. On the 22d, several portions of brain were discharged, the pulse was 100, and intermitting. Next day, he was delirious, and a hernia cerebri protruded, of sloughy appearance, and considerable size; pulse 142. Soon afterwards he became comatose; and died early in the morning of the 23d. On dissection, the integuments and pericranium surrounding the aperture, in the frontal bone, were found much thickened, and infiltrated with pus and serum. The dura mater at the wound had a sloughy appearance. There was great effusion of purulent matter, under the dura mater, investing the right hemisphere of the brain; the corresponding tunica arachnoidea was thickened and opaque; and between it and the pia mater there was considerable deposition of lymph and pus. The fungus was collapsed, of a dark colour, soft consistence, and connected with the anterior lobes; the surrounding cerebral matter was much softened, and mixed with pus. The fracture extended through the orbitar plate of the right os frontis, over which lay two small spicula of bone; and a similar fragment was situated over the right optic nerve.

Many cases illustrating the danger of punctured fracture might be related, but are unnecessary, inasmuch as they would lead to the mere repetition of such facts as have been already stated.

Fracture of the external table alone must be rare, but we occasionally see in museums specimens exhibiting a small portion of the outer table driven into the subjacent cancelli, without any fracture of the inner table. This kind of injury belongs entirely to that period of life in which the diploe is of considerable thickness. The treatment would of course be simply that adapted to contusion or concussion.

It is also possible for a blow on the head to produce fracture of the brittle inner table, the outer table remaining entire. However uncommon such a form of injury may be, as its effects may possibly be very serious, it is right to bear it in mind. A splinter of the inner table thus driven into the dura mater might cause violent symptoms and even death.

_Wounds of the Brain._—Laceration of this organ to a slight extent, with more or less extravasation of blood, often takes place, without external wound, and when the patient has symptoms of concussion only. In such cases, the blood may be absorbed, and the læsion repaired, without permanent impairment of the sensorial functions. Wounds of it, along with fracture of the skull, are often very extensive; and portions of its substance may be either severely injured, or entirely separated. Loss of substance, even to a considerable extent, in the upper part of the hemispheres, may occur, without bad symptoms or consequences ensuing. The exposed surface of the brain granulates, and is healed as other parts of soft structure. Generally, however, untoward symptoms result sooner or later in such cases. Hemorrhage occurs from the injured part, and a clot protrudes from the external wound. Or the cerebral substance in the neighbourhood of the wound softens, and becomes converted into a semifluid mass, often mixed with pus; and a fungous growth, connected with the disorganised matter, gradually protrudes through the aperture in the cranium, and is repressed with difficulty. If removed by knife or ligature, it is rapidly reproduced. Pressure is the only means left by which to attempt its retardation; and this, too, is generally ineffectual; for if not very moderate, the effects of compression extend from the fungus to the whole of the brain, and an impairment of the sensorial functions in a greater or less degree necessarily results. The formation of such a growth is generally attended with shivering, sickness, and fever, by a weak, rapid, and irregular pulse; the strength declines, convulsions and delirium supervene, and coma terminates the symptoms.[26]

_Perforation of the Cranium_ is not often resorted to since the treatment of injuries of the head has become better understood. In former times, the operation of trepan was performed frequently, and many seemed to rate the dexterity and science of a surgeon by the number of holes which he was able to bore in the skull of an unfortunate patient. It ought never to be performed, unless the necessity for, and the propriety of, the proceeding be clearly indicated. It used to be practised in a most unlimited manner for fissure: cracks were sought for with the greatest care, rules were propounded to enable the surgeon to distinguish fissures from the cranial sutures, and from furrow made in the bone by periosteal vessels; and the trepan was frequently applied over each part of the fissure, however extensive it might be, the only apparent end of the operation being to widen very materially the solution of continuity in the cranium. It was also resorted to in cases of compression without fracture, with the view of discovering the effused fluid, and removing it; but, as was already stated, it is unwarrantable in such cases; and much more so in concussion, for which latter accident, however, it has been occasionally performed. I met with a case some years since, in which the patient was certainly not much benefited by such active practice. The operation is of itself attended with danger, and likely, under many circumstances, to aggravate the patient’s symptoms, and diminish his chance of recovery.

The cranium must be perforated, however, when the existence and site of abscess under the bone is distinctly marked: and in such cases the practitioner is much to blame if he does not give his patient a chance of recovery by the operation: many are lost by its not being performed, and the following case is a striking example of such negligent practice. A young female fell from a great height amongst some rubbish, and sustained a severe blow on the left side of the os frontis, a considerable portion of which was thereby denuded. She seemed to be doing well for some time; but about the eighth day after the accident, pain in the head, with vertigo, rigors, and sickness, febrile excitement, and a white and dry state of the bare portion of the bone, supervened. She was depleted copiously, but notwithstanding all the symptoms indicating formation of matter under the exposed bone were present, the operation of trephine was deemed inadvisable. Severe rigors continued; she became affected with spasmodic twitchings of the muscles of the face, and stiffness of the jaw, neck, back, and breast, and was, in short, allowed to die. On the dissection, the dura mater below the diseased bone was found separated to a very considerable extent, and the cavity was filled with thin purulent matter; the abscess extended along the superior longitudinal sinus, and communicated with this vessel through an ulcerated aperture; the canal was filled with pus, as far as its junction with the transverse sinus, near which point its cavity was obstructed, and the abscess limited by a firm plug of lymph. A small abscess had formed between the bone and pericranium, above the extensive collection within; the internal table of the diseased bone was fractured and slightly depressed, and its fractured edge was rough, sharp, and projecting.

But the operation may sometimes fail to prove beneficial; the brain may have become diseased, as well as its membranes, or the patient may not recover from the irritation caused by the abscess, and the depressing tendency of the antiphlogistic treatment which may have been put in force, previously to the formation of matter. But still there is a probable chance, after the collected matter has been evacuated by the operation, of the dura mater granulating, the cavity filling up, the membrane becoming adherent to the cranium around the aperture, and the patient regaining his former health and vigour.

If, after removing a portion of bone on account of symptoms of suppuration in that situation, the dura mater be found adherent, and of a healthy appearance, the surgeon is scarcely justified in going deeper in search of effused fluid: the evils liable to result from wounds of the dura mater have been already mentioned, and illustrated by an example.

The operation of trephine must also be resorted to in cases of punctured fracture. One perforation will generally be sufficient to enable the surgeon to remove the detached fragments of the inner table.

In fractures with depression, when the brain is oppressed and its functions suspended, means must be taken to elevate the displaced portion or portions to their natural level, and so remove the pressure. For the accomplishment of this purpose, it may or may not be necessary to divide the integuments. If they are entire, which is rarely the case, a crucial incision must be made, or one in the form of the letter T, and the flaps raised so as to show the extent of depression. No portion of the integuments ought to be cut away; the preparatory process of scalping, formerly in use, has been abandoned as cruel and unnecessary. If a wound already exists, but is not sufficiently large, it may be dilated in such a direction as appears most likely to facilitate the after part of the proceedings. The elevation can often be then effected by the judicious application of the lever, its point being carefully placed under the depressed portion, and the sound part of the bone being made the fixed point on which the instrument acts. Those depressed portions which are completely detached, must be removed; but those which adhere, either to the dura mater or to the scalp, ought to be left after having been raised to their former sites, as they will furnish a large contribution towards the filling up of the deficient parietes. Reparation of the skull, when a small portion is removed, or when a single narrow fracture exists, is effected by bone; but when the opening is large, the deficiency is always repaired by a dense ligament, to which the dura mater and integuments adhere. By employing a small saw—represented in both ancient and modern surgical works—so as to widen the fracture, or remove a projecting corner of bone, sufficient room may be obtained for the introduction of the lever and the removal of splinters. In old subjects, the bones are brittle, and a small corner may be readily removed by pliers, or cutting forceps, so as to allow the depression to be raised.

But it may be necessary, in order to elevate portions that are wedged under the sound part of the cranium, to take away a considerable portion of the latter. One or more circular pieces must be removed by the trephine, and it may, perhaps, be necessary to cut out the parts between these apertures by means of the straight-edged saw. The size of the crown of the trephine must be varied according to the object which is in view. The trepan is now disused, and the trephines best suited to the purpose are those fluted on the side of the crown, with the perforator made to slide and fix by means of a proper screw. The centre pin, or perforator, is fixed on a sound and firm part of the bone, and the edge of the crown made to project slightly over the fractured margin. A few turns will suffice to fix the instrument. The saw is then made to turn steadily and lightly, pressure being made when the instrument is moving from left to right, until a pretty deep sulcus is made. The centre pin is then withdrawn, the saw being sufficiently retained by its own groove. The centre pin can scarcely be used at all in children, the cranium being at that age soft and thin. I once had occasion to operate with an old-fashioned trepan, at a distance from town, on a child with abscess under the bone, occasioned by a punctured wound from the point of a spinning top. The centre pin was long, very sharp, and screwed in; and, if it had been used, would have perforated skull, dura mater, and nearly half an inch of the brain, before the saw could come in contact with the bone. I was obliged to use the crown of the trepan, without a centre pin.

In patients at the middle period of life, a different feeling and sound is communicated to the operator after having cut through the outer table of the skull. Whether this change is experienced or not after getting to some depth, he ought to proceed cautiously, moving the saw lightly, quickly, and sharply, in the direction of the teeth, and using no pressure. The operator should not be hurried, for he is apt to do harm if he is; there is no inducement to make great haste, for the patient does not suffer much, if any pain. After every two or three turns of the saw, it is prudent to examine the track with the flat end of a probe, or with a toothpick. If the perforation is found to be completed at any point, then the instrument is to be inclined to those which are undivided; and the fluted crown allows of this being done with great facility. After the circle of bone is separated on all sides, it is to be removed by forceps, or by means of the lever; and the sharp points ought to be taken from the edge of the perforation by means of the latter instrument, otherwise the dura mater may be fretted and torn when following the natural motions of the brain. The lever must be strong, and simple in its construction. And after a sufficient space of bone has been removed, its point is to be introduced cautiously under the part that requires elevation; the edge of the sound bone at various points affords a fulcrum, and by persevering and steady efforts, the object of the operation will be accomplished. The dressing of the wound should be simple; the integuments are made to cover the aperture, or as much of it as possible, and due support is given by compress and bandage. The after-treatment must be varied, and conducted according to circumstances. It may become necessary to repress the granulations, or else to soothe the wound and abate inflammatory action in the surrounding parts. Perhaps incisions may be required, to prevent the formation of matter, and destruction of the cellular tissue, and of the tendinous expansion, or to evacuate fluid already secreted. The patient’s strength may require support. He may stand in need of stimulants; or, on the contrary, the most active means may be required to subdue vascular action, and to prevent the evil consequences which would result to the important parts within the cranium from such over-action.