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.
[Illustration: FIG. 375
Fracture of base of skull. (Bruns.)]
[Illustration: FIG. 376
Fracture of base by fall on vertex. Both condyles broken off and driven in. Vertex was fissured.]
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.
[Illustration: PLATE XLII
Fractures of the Base of the Skull. Illustrative lines of fissure or fracture are printed in red.]
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
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