the following case:—The patient, a boy, æt. 11, received a blow on
the vertex, after which a puffy tumour formed in the injured scalp,
and was freely incised. He afterwards became subject to epileptic
fits, which were relieved by copious evacuation of matter from the
wound. Exfoliation of the cranium occurred; one small sequestrum
was separated, which involved the whole thickness of the bone, and
a collection of matter between the dura mater and skull-cap was
thereby exposed. The contained matter was evacuated, and the wound was
carefully dressed, with the view of procuring adhesion between the
membrane and bone, but without effect. The dura mater was ascertained
to be extensively detached around the opening; it was found necessary
to remove a large portion of bone by means of the trephine and cutting
pliers, and then the dura mater soon became united with the integuments
of the head. Many months afterwards, the patient complained of severe
pain in the back of the neck; an abscess formed in that situation, and,
pointing under the right scapula, was opened. Weakness of the right
arm and of the inferior extremity suddenly supervened, and the patient
gradually sunk. On examination after death, the cervical portion of the
spinal chord was found much softened, with infiltration of purulent
matter into its substance. The deficiency in the cranium was supplied
by a ligamentous expansion, to which the dura mater and scalp adhered
intimately.
_Of Compression of the Brain._—Compression is produced by extravasation
within the cranium of blood or other fluid, by the lodgement of a
foreign body on the surface of the brain, or in its substance, or
by displacement inwards of portions of the cranial bones; and these
causes are usually the effects of external injury. It may either
follow the injury instantaneously, or supervene some time thereafter.
Many examples have occurred of a patient, at first insensible, with
symptoms of concussion, having had the functions of the brain restored
almost entirely, and again having relapsed very quickly into a
comatose state, in consequence of extravasation of blood. The whole
circulation is at first lowered by the shock of the commotion, and the
blood scarcely flows in the cerebral vessels; but on its restoration,
blood is poured out from the lacerated vessels, or from those which
have been so injured in their coats as to be unable to withstand the
increasing impulse of their contents. As was already observed, the
symptoms of compression are often mixed up with those of commotion,
but, when an interval of sensibility has occurred, mistake in diagnosis
can scarcely occur. Compression is attended with slow, stertorous
breathing; a distinct slow pulse; a relaxed state of the limbs,
features, and sphincters; and dilated pupil. Total insensibility to
external impressions attends compression of the brain, whatever the
cause of it may be. These symptoms may, and do sometimes, gradually
disappear after a time. But they may continue unabated, and the patient
may gradually sink under them. Or, again, his dissolution may be
preceded by excited circulation and furious delirium, the vital powers
recovering from their first depression, only to become roused into
violent and destructive action, again to sink to a still lower ebb,
and be ultimately annihilated. Extravasation is most commonly met with
on the lateral parts of the brain in the situation here indicated; the
coagulum is perhaps extensive, reaching to the base of the skull, in
consequence of rupture of the middle meningeal artery, with or without
fracture of the parietal bone.
[Illustration]
Little or nothing can be done in cases of compressed brain from
extravasation. We possess no means of preventing the effusion, and
though we did, the mischief has generally taken place before the
patient can receive assistance. Again, the site of the extravasation
can seldom be ascertained; and, should that objection to the propriety
of surgical interference not exist, still the coagulated blood cannot
be evacuated even after extensive removal of the bone. If the coagulum
is small, it may be gradually and wholly absorbed, or the brain may
become accustomed to the pressure of what remains. It is the surgeon’s
duty to take means for averting inflammatory action, and to subdue
or moderate it when it has been excited. The symptoms arising from
displaced bone may be relieved by surgical operation; but we must
premise some observations on fracture, before speaking of the treatment
necessary in such cases.
FRACTURES OF THE CRANIAL BONES.
At an early period of life the bones are soft and elastic; they yield
readily under external violence, and it requires a great and direct
force to produce fracture of them. Late in life, when the diploe
disappears, the external and internal tables come in contact; the bone
is brittle, and solution of continuity in it is easily effected. And
it is wisely so arranged, for thus in the recklessness of childhood
and youth, severe blows on the cranium, which are then of so frequent
occurrence, are seldom attended or followed with danger; whilst the
aged are taught by experience to avoid the unfortunate consequences so
apt to result from even a slight blow on the then brittle cranium, by
cautiously preserving themselves from exposure to violence.
Solutions of continuity in the cranium, caused by external force,
are either attended with depression or not. Fissures, mere capillary
rents in the bone, may take place at the part of the cranium which is
struck, or on the side opposite to that to which the force is applied.
They will be found either short and limited by sutures, or extending
in different directions through several sutures, as from the vertex to
the base of the skull, and terminating perhaps in the foramen magnum.
Fissures in the upper part of the cranium are of themselves attended
with comparatively little danger; they produce of themselves no claim
to attention, and really require none. But the force which gave rise
to the injury of the bone may have disturbed the internal parts; and
though the patient may have recovered from the first shock and the
immediate effects of the violence, severe and dangerous consequences
often result, and at a late period from the infliction of the injury.
Fractures of the base of the skull are the result of great force
applied to the lateral parts of the head, to the vertex, or to the base
itself through the spinal column. A blow inflicted by an obtuse body
on the top of the head, whilst it is at rest and fixed—by producing
expansion of the lateral parietes, and forcing the base down upon the
upper part of the spinal column—may have the effect of breaking up the
connections of the bones at the base, which is the weakest part of the
cranium, and splintering them to a greater or less extent. Again, if
a person falls from a height, he perhaps alights on some part of his
trunk, as the buttocks, and this coming to a state of rest, whilst
the head is still in projectile motion, the spinal column is driven
towards the cavity of the cranium, and the same effects are thereby
produced as in the preceding instance. Or the patient alights on his
head, and the base of the cranium is then impinged upon by the weight
of the whole trunk, as well as by the force of the projecting power,
and in this case also the base is frequently broken up. In the sketch
here given, showing extensive fracture of the occipital and sphenoid
bones into the foramen magnum, the patient, a brick-layer, fell from
a ladder on the vertex. He lay comatose for some days before death:
there was found extensive extravasation over the middle lobes and
cerebellum. Concussion has resulted from falls when the person has
alighted on his nates or feet; but the symptoms attendant on fracture
of the base are more generally those of compression of the brain. In
this accident the bones are seldom displaced to any great extent; the
dura mater is generally lacerated, its bloodvessels, and frequently its
sinuses, are wounded, and blood is consequently effused at the base
of the brain, where injury is most fatal. The upper part of the brain
may bear pressure to a considerable degree without bad consequences
ensuing, but compression at the origins of the nerves is always highly
dangerous and generally fatal. Bleeding from the nose, mouth, and ears,
when attended with other circumstances and symptoms evincing a violent
injury and consequent cerebral disturbance, has been considered as
decisive of fracture at the base having occurred. But we find that such
bleeding happens in slight injuries unattended with any circumstances
or consequences to induce a belief that so serious an injury has taken
place: and again, in cases where dissection has shown most extensive
fracture in the temporal, sphenoid, and æthmoid bones, no blood had
issued from their external openings. Fracture of the base of the skull
generally proves fatal, but many cases are met with in which there is
reason to believe that it had taken place, and yet the patients have
recovered with perhaps partial paralysis. Of this I lately met with
a good example in the case of a girl seven years of age, whose head
had been squeezed between a wall and the back of a cart, and thereby
considerably flattened. She lay insensible for several days, with all
the symptoms of compression, and with blood flowing in small quantity
from the nose, mouth, and right ear. An extensive abscess formed
over the right temporal bone. She ultimately recovered, but remained
affected with paralysis of the right side of the face and amaurosis of
the left eye; sensation in the paralysed parts being quite perfect.
[Illustration]
Fractures of the upper part of the cranium are generally attended
with displacement to a greater or less extent, and with wound of the
cranial coverings. The size of the depressed portion, the depth to
which it is displaced, and the extent of wound, will depend upon the
nature and intensity of the force applied. When both tables are broken,
the fracture of the inner is almost always more extensive than that of
the outer one, as fissures will extend furthest in the most brittle
part. A broken fragment, comprehending the entire thickness of the
skull, presents generally a much larger portion of the inner than of
the outer table, so much so that the piece would sometimes not admit of
removal, though perfectly detached, without enlarging the opening in
the outer table. Fractures, with depression of a considerable portion
of one of the flat bones, are sometimes unattended with any alarming
symptoms. The effects of the injury soon disappear, and even in cases
where the depression has been very considerable, and where, from the
escape of brain, it was evident that both this organ and its membranes
had been seriously injured, no bad symptoms have occurred to retard
the patient’s recovery. Symptoms of compressed brain, however, may
generally be expected to attend depression of any considerable portion
of bone below its natural level. Still the brain may become accustomed
to the pressure, and the symptoms may gradually subside without
surgical interference. And if the indications of compression are not
very alarming, the coma not very profound, a little delay is allowable,
means being taken to avert inflammatory action: for danger is not
imminent, the cure may not be expedited by operative aid, and there is
chance of injury resulting from rash interference.
But it is in general necessary to remove the cause of the symptoms, to
elevate the depressed bone, and take away those portions which may be
detached.
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]