CHAPTER XXXVI

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INJURIES AND SURGICAL DISEASES OF THE HEAD.

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.

[Illustration: FIG. 366

Pneumatocele of cranium. (Warren’s Surg. Obs., 1867.)]

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.)

[Illustration: FIG. 367

Osteosarcoma of the temporal region. Metastatic tumor in the arm and thyroid. (Parker.)]

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.)

[Illustration: FIG. 368

Craniotabes (rachitis). (Bruns.)]

SURGICAL AFFECTIONS OF THE CRANIAL BONES.

The acute affections of bones have been considered in