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.
_Inflammation of the Scalp_ occurs either spontaneously, or in
consequence of external injury, though slight; and is generally met
with in those who have lived freely and irregularly, and are of a bad
habit of body. It is more dangerous than inflammation of any other
part of the surface, on account of the sympathy and connection which
exists between the parts affected and those situated internally:
frequently, at an early stage of the affection, delirium occurs, with
violent fever. In slight cases, in which the external surface merely
is affected, there is little swelling, and but little pain or fever.
But when all the pericranial coverings are involved, the symptoms are
uniformly severe. The swelling is elevated and puffy, and extends to
the eyelids, to the face, and, in some cases, even to the neck: the
constitutional symptoms run high, and there is considerable risk of the
patient dying comatose. If he recover, and if the disease is little
interfered with, but allowed to take its own course, much sero-purulent
fluid is infiltrated into the cellular tissue, which generally
perishes, along with a greater or less portion of the tendinous
expansion lost by sloughing. Often, in neglected cases, a large abscess
forms, separating perhaps one-half of the scalp, and bulging over the
ear.
The constitutional treatment must vary according to the nature of
the symptoms which present themselves; in some cases they show great
vascular excitement, and in others they bear unequivocal evidence
of general debility from the first. In slight cases of the local
affection, it is sufficient to relieve the tension, and abstract blood
and effused serum by means of a few punctures, and afterwards to use
warm fomentation. More violent cases require free incision in the
direction of the fibres of the occipito-frontalis muscle, and thus only
can destruction of the parts be averted; the incision must necessarily
be deep, for the scalp is often swollen to the thickness of one or more
inches. When a depôt of matter has formed, it must be evacuated early,
otherwise there is a risk of the bone becoming extensively denuded and
exfoliation ensuing.
_Chronic thickening of the Scalp_ is a consequence, by no means
unfrequent, of slight injuries in those of strumous habit, but may also
occur without any assignable cause. In delicate subjects it is often
attended with chronic periostitis of other bones besides those of the
cranium. The patient perhaps complains of pains about the shoulders,
in the tibiæ, femora, the tuberosities of the ischia, the sternum,
the cervical vertebræ, or in the clavicles and ribs. He cannot bear
pressure on some points without suffering the most excruciating agony.
The pain is also much increased by motion of the parts, as by coughing
when the ribs are affected. Such painful affections of parts external
to cavities are often mistaken for diseases of the internal organs, and
are treated as such by violent bleedings, purgings, and starvation,
to the still farther impairment of the patient’s constitution. The
symptoms are frequently and correctly attributed to exposure to cold
and moisture, sleeping in a damp bed, sitting with wet clothes or on
the cold ground; but such affections are very apt to occur in those
whose constitution has degenerated into that peculiar cachectic state
formerly mentioned, after mercurial courses, whether short or severe;
or in those who for some real or fancied derangement of the digestive
organs have persevered in swallowing, for months or even years, the
universal panacea of some practitioners, Plummer’s or blue pill. The
bones and their coverings, of even the best constituted, can scarcely
resist a perseverance in such a course.
The swelling of the scalp is often general, and is slightly œdematous;
some points are more elevated than others, feel soft, and are the seat
of extreme pain when pressed upon. But such affections frequently
flit from one part to another; what was most unsound, at one time,
recovering itself, and painful swellings attacking that which was
comparatively free of disease. The same holds true in regard to the
other bones at the commencement of the affection; but when much change
of structure takes place, then the pain and swelling become fixed. The
pains are most severe during the night, being then so violent as to
deprive the patient of rest, and even prevent him from placing his head
on the pillow: they abate towards morning, and remain tolerable during
the day. They are always aggravated by change in the atmosphere from
dryness to moisture, and the prevalence of easterly winds is peculiarly
distressing to patients afflicted with such diseases. The swelling
is composed of thickened and vascular periosteum with œdematous
integuments. The bone too is often increased in size, and condensed,
from continuance of increased vascular action; and its surface is
roughened in consequence of its texture being opened out, and new bone
having been deposited. Death of portions of the bone often follows,
either spontaneously, or after slight bruises received during the
continuance of the disease. A few accidental blows on the head, and a
perseverance in the use of mercurial alteratives for a series of years,
gave rise to the state of matters represented in the accompanying
illustrations. The large dead portion represented was removed some
months before death. Here the deficiency in the cranial bones is partly
owing to ulceration, partly to death of portions of them. The patient’s
health becomes undermined by want of sleep and continual suffering; and
he may at the same time have relaxation of the mucous surfaces, with
increased discharge from them, produced by the same cause as occasioned
the affection of the coverings of the bones. He may be subject to a
relaxed or ulcerated state of the throat, increased or caused by the
slightest exposure; and may have hemorrhage from the nostrils, copious
expectoration, mucous stools, &c. The periosteal affection alone is a
troublesome and serious complaint.
[Illustration]
[Illustration]
When the pains are fixed and violent, we are sometimes obliged to
give small doses of the bichloridum hydrargyri at first, even though
there is reason to think that mercurial medicines, perhaps imprudently
or carelessly administered, have brought the constitution into its
present morbid condition. The good effects of this medicine are well
marked and speedy. The patient is freed from the nocturnal pain, gains
flesh, and the swellings subside. It ought not to be resorted to,
however, unless in severe cases, when the disease cannot otherwise be
successfully combated; and when used, it should not be continued longer
than is necessary for the removal of the more urgent symptoms: when the
pains begin to yield, it is time to discontinue the medicine. Great
care is necessary on the part of the patient; he must industriously
avoid exposure to moist atmosphere, and ought to be well and warmly
clothed, wearing flannel, chamois leather, or both, on the trunk and
extremities. A patient treated with the corrosive sublimate of mercury
is perhaps more subject to recurrence of the affection, after imprudent
exposure, for a considerable time afterwards, than if simple and less
powerful means had been employed. A cure can often be effected by the
exhibition of the compound decoction of the woods, with or without
antimony. Moderate diet and strict abstinence from wine and other
internal stimulants should be enjoined; the patient, soon experiencing
the good effects of temperance, is exceedingly willing to restrict
himself to a somewhat antiphlogistic regimen.
In cases of violent fixed pains, with swelling and threatening of
matter forming, incision may be sometimes practised with relief to the
patient, but is not to be had recourse to unless there is a risk of the
bone suffering. Local abstraction of blood is advantageous, and may,
if necessary, be followed by counter-irritation, as the application of
blisters or sinapisms. Friction with stimulating substances, or with
opiate liniments, is often useful when the disease begins to yield,
the pain and puffiness of the parts being thereby dispelled. The hair
should be kept short during the cure, and ought not to be allowed to
grow till the scalp is firm and sound.
The disease is often so far advanced that, in spite of the most active
treatment, abscess forms in one or more points; and, on the matter
being evacuated, the bone is found denuded. Exfoliation is then very
likely to take place.
Exfoliation generally follows denudation of the bone by accident, but
not uniformly. When the periosteum is stripped off by violent injury,
the bone in some cases does not lose its natural colour; granulations
arise from the exposed part, and it again becomes covered without any
part of its substance having been destroyed. Again, careful removal
of the periosteal covering, as in excising a tumour or ulcer by the
knife, may be followed by death of the outer table of the skull; small
portions only separating in some cases, whilst in others a large part
of the bone, and of considerable thickness, perishes. The cranial
bones may in part become dead throughout their entire thickness,
and separate, either after a severe bruise, or in consequence of
inflammatory action following injury or arising from disease. The
process of separation is either speedy or tedious, according to the
vigour of the constitution. The deficiency is repaired, in a great
measure, from the subjacent bone, when its whole thickness is not
thrown off. But when the breach is complete, the surrounding parts
assume the reparative action; the granulations from the dura mater and
integuments coalesce, and a dense membrane fills up the space.
The denuded bone should be kept covered and moist, and for this
purpose lint frequently wetted with tepid water is the best dressing:
spirituous or greasy applications can do no good. A free discharge
for the matter should be afforded, and the wound kept clean. If the
exfoliation goes on slowly, perforation in the dead bone may be made at
different points down to the living parts, with the view of expediting
the process. Exfoliations are sometimes retained by surrounding
granulations overlapping their edges and confining them in their
situation; or are fixed by atmospheric pressure, after separation has
taken place from the parts underneath by the action of the absorbents,
in the same way as a boy’s leathern sucker becomes firmly fastened
to the stone to which it is applied. In such circumstances a small
screw may be fixed into a perforation carefully made in the bone,
and thus the dead part may be lifted out without pain or difficulty,
when otherwise it might have lain for many weeks, keeping up the
discharge. In this way the large sequestrum, represented at p. 240, was
extracted from its bed. The powdered red precipitate of mercury may
be occasionally sprinkled on the parts surrounding the dead portion,
in order that the granulations embracing it may be destroyed, and the
part more completely detached. The general health must be all along
carefully attended to. Sarsaparilla with guaiac, sassafras, mezereon,
&c., is often useful, more especially if pains in other parts continue
to annoy the patient. Under such medicines he in general improves very
rapidly in appetite, flesh, and strength.
The scalp is sometimes, though rarely, the seat of malignant ulcer.
In the early stage the ulceration is not of great extent, and affects
only the soft parts; perhaps it is confined at first to the common
integument, but is extremely apt to extend to the deeper layers which
invest the cranium, and even to the bone itself. It is by no means
uncommon to find the cranium very extensively diseased, though the
affection originated in the superimposed soft parts. Such ulceration of
the bone is of a peculiarly destructive nature; it is a disease of the
osseous tissue, corresponding to the most malignant ulceration of the
soft parts. The bone around the ulcerated cavity is spongy and soft,
its margin is irregular, and bristles with numerous spiculæ; the centre
is composed of soft morbid deposit, entangling small portions of bone
which have become detached, and flabby, almost lifeless granulations
shoot from the distempered mass. Such disease, when the patient does
not soon succumb to its virulence, advances to a frightful extent,
affecting a large surface, destroying the whole thickness of the bone,
and even exposing the internal parts. In a case of this description,
which occurred in the Royal Infirmary under my care, the anterior half
of the cranium was totally destroyed, the left orbit contained a putrid
mass, consisting of the disorganised eye mixed with pus and bloody
fluid; the dura mater was exposed, and sloughed at several points,
and the unhealthy discharge from the parts lodged on the surface of
the brain. In malignant diseases of scalp, as of other parts, the
lymphatics become secondarily affected: the absorbents feel hard and
thickened, the glands in the neighbourhood enlarge and ulcerate,
and the sore thereby formed soon assumes the characters of decided
malignancy,—hard everted edges, an angry surface, and fetid thin
discharge.