Reduction is more or less easily accomplished by traction with an easy

movement, by which the upper end of the forearm shall be directed

toward its proper position.

_Lateral displacements_ result also from falls in extreme positions.

Lateral dislocations are rare and the result of violence, and may

compel amputation. In these cases the lateral diameter of the joint is

markedly increased, while the normal relation of the condyles to the

olecranon is greatly altered. In these cases movement is painful and

limited.

[Illustration: FIG. 350

Backward dislocation of both bones. (Lejars.)]

[Illustration: FIG. 351

Outward displacement of both bones. (Lejars.)]

The _ulna alone_ may be dislocated backward, in which case the

orbicular ligament must be lacerated and the upper ends of the

adjoining bones forcibly separated. The olecranon will present back of

its proper position, while the head of the radius will rotate where it

belongs.

[Illustration: FIG. 352

Dislocation forward and outward of head of radius. (Lejars.)]

_Anterior dislocation of both bones_ is exceedingly rare unless

complicated by fractures of the olecranon. When thus injured the

forearm is lengthened and fixed. The posterior surface of the humerus

here has only a skin covering, the condyles are bulging, the olecranon

fossa empty, and the upper ends of the forearm bones felt in front of

the elbow.

The _head of the radius_ alone may be displaced in any direction save

toward the ulna. The _forward_ dislocation is the most common, which

may be produced by a fall upon the overextended and pronated hand.

The orbicular ligament here is lacerated or the head of the radius is

slipped out of it. In the latter case it may be difficult to replace

it. When dislocated _backward_ the capsule is torn posteriorly as well

as the orbicular ligament (Fig. 353).

[Illustration: FIG. 353

Position of the bones in an old unreduced dislocation forward of the

radius. (Erichsen.)]

=Treatment.=--The treatment of elbow dislocations is based upon general

and but slightly differing principles. It consists of a combination

of traction with sufficient force, made with one hand, while with the

other pressure should be made upon one or both bones in the desired

direction; at the same time by a combination of swaying and rotary

movements more or less massage may be given to the parts, by which

complete reduction may be more easily effected. Anesthesia is nearly

always necessary, not alone for the relief of pain, but to produce

muscular relaxation, by which manipulation is materially assisted.

A peculiar form of dislocation of the head of the radius in young

children has received considerable attention. It is produced by a firm

pull upon the wrist or forearm, as in lifting or jerking a child by

the forearm or hand. Pronation of the hand is usually a feature of

the injury. It is probable that the head of the bone is pulled out of

the orbicular ligament and displaced forward. The forearm is slightly

flexed, movements of the elbow are very free, except that supination of

the forearm meets with resistance. The displacement is rectified by a

forced supination with traction. An epiphyseal separation of the head

may simulate this injury. Such cases necessitate a few days’ rest in

a splint, with the arm flexed and supinated, although recovery often

occurs without particular restraint.

DISLOCATIONS OF THE WRIST AND HAND.

Wrist dislocations are rare, the _posterior_ being more frequent than

the _anterior_. It simulates the deformity of a Colles fracture, and is

produced in a similar way. The deformity is more marked, the outlines

of the various bones more distinct, except in front, where they may be

masked by the flexor tendons. There is no alteration in the relations

of the styloid processes. The _forward_ dislocation may possibly

simulate Smith’s fracture, the symptoms being the reverse of those

above mentioned.

Firm traction, with pressure in the proper direction upon the carpus,

will suffice for reduction of these cases. The subsequent dressing may

be practically that of a Colles fracture.

The _lower ends of the ulna and radius_ are sometimes dislocated from

their proper relations. Reduction is easy, but rest and restraint are

required for some time until the ligaments have recovered their tonus.

Of the _carpus_ the _os magnum_ is the only one likely to be displaced,

it being occasionally forced backward so that it forms a projection

on the dorsum of the hand. It requires extreme force to displace the

carpal bones, enough frequently to produce other injuries at the

same time, some of which may be compound. A carpal bone which cannot

be reduced to position by pressure may be safely removed through an

incision.

Of the carpometacarpal dislocations, the _thumb_ is the most frequently

displaced, usually in a backward direction. Traction and pressure

suffice for its reduction. When the bone is forced forward it is

usually as the result of direct violence. Wherever the base of the bone

may rest it is easily detected, while pressure with traction suffices

for its replacement.

Of the dislocations of the _phalanges_ upon the metacarpus those of

the thumb are the more frequent. This may occur as the result of

a fall, by which the thumb is forced backward into a position of

hyperextension. Nearly all of these dislocations are accompanied by a

rupture of capsule. Those of the thumb are difficult of reduction; this

appears to be due to the tendons of the short flexor, which surround

the head of the metacarpal bone. The sesamoid bones also furnish a

source of difficulty, while the long tendons, when contracted by their

respective muscles, increase it (Fig. 354).

[Illustration: FIG. 354

Metacarpophalangeal dislocation.]

Treatment, especially of the thumb dislocations, is facilitated by

first exaggerating the abnormal position, then making traction and

pressure in the proper direction at the same time. Special forceps have

been devised for seizing and holding the digits, or a clove-hitch can

be thrown over the thumb or finger. Extension should not be first made

in the axis of the metacarpal bone, but rather _at an abrupt angle to

it_ in order to relieve the expanded phalangeal end. The majority of

writers concede that in some cases reduction is practically impossible.

When effort has proved futile the parts should be sterilized and

incised, the incision being utilized for open reduction or for

excision, as deemed best.

Dislocations of the other phalanges are usually easily recognized and

treated by traction and pressure.

DISLOCATIONS OF THE HIP.

Hip dislocations constitute about 5 per cent. of the total. As they

are produced by violence they are much more frequent in men, and occur

mostly between the ages of twenty and fifty years. Before the twentieth

year epiphyseal separations often take place, while after the fiftieth

year violence will usually break the neck of the femur. Nevertheless

dislocations may occur at any age. The hip is a ball-and-socket joint,

with a deep socket still further extended by cartilage, in which the

head of the bone is not only retained by the ligamentum teres, but by

atmospheric pressure, which in the natural state furnishes a factor

of perhaps one hundred pounds. The strongest muscles and tendons of

the body envelop the joint. When dislocation occurs the capsule is

usually torn along its inferior aspect. The limb is usually in an

extreme position, or it would require more violence to tear the head

from the socket. The anterior dislocations occur during abduction

without outward rotation; posterior dislocations occur during flexion.

Thus when a person is stooping over in work and a heavy weight falls

upon the back the head of the bone is more easily pushed backward,

especially if the feet be close together.

While hip dislocations are classified for convenience, and because

of their final form, the head of the bone may rest upon almost any

segment of the margin of the acetabulum, though within a short time

it will assume a position justifying a designation as _anterior_ or

_posterior_, meaning thereby in front of or behind Nélaton’s line.

This is, moreover, a convenient distinction, as the symptoms vary

between the two groups. Another classification is into the _forward_,

the _backward_ or _backward and upward_, and the _downward_, which

are again referred to as _iliac_, _ischiatic_, _dorsal_, and

_supracotyloid_ among the posterior, and _perineal_, _obdurator_,

_suprapubic_, etc., among the anterior (Fig. 355).

Allis, however, has simplified the subject by showing that all forms

of dislocation escape primarily from the lower segment, shifting their

position later either upward or downward. He classifies them as follows:

1. Lower thyroid. } All present the general characteristics of

2. Middle thyroid.} adduction and rotation outward.

3. High thyroid. }

1. Low dorsal. } All present the general characteristics of

2. Middle dorsal. } abduction and rotation inward.

3. High dorsal. }

The relation of the so-called Y-ligaments to the successful reduction

of these dislocations, as well as to their formation, is of

considerable importance.

[Illustration: FIG. 355

Upward and somewhat backward on dorsum ilii.

Backward toward sciatic notch.

Downward into foramen ovale.

Forward and upward on the pubic bone.

Dislocations of the head of the thigh bone, according to Astley

Cooper’s classification. (Erichsen.)]

Fig. 356 illustrates the manner in which this ligament receives its

name, it being simply a reduplication of fibers which strengthen the

capsule and which are arranged in the shape of an inverted Y. No

matter how serious the injury it is seldom entirely detached. While it

prevents too great displacement it is of special service in that it

may be made to serve as a fulcrum for the leverage required in certain

manipulations. American surgeons are entitled to the credit for the

establishment of the importance of this ligament in this consideration,

and while Bigelow’s name is most prominently mentioned, the names of

Gunn, of Chicago, and Reid and Moore, of Rochester, New York, deserve

almost equal prominence, not only for their anatomical studies, but

for working out the entire method of manipulation which has completely

supplanted the old and more violent methods in which the use of pulleys

and tackle was not infrequent. The Jarvis “adjuster,” a powerful

mechanism, which was formerly employed for this purpose, is not now

seen except in museums.

[Illustration: FIG. 356

Inverted Y-ligament.]

=Symptoms and Signs.=--These vary decidedly in the different forms.

In every case where the head of the bone rests on a higher level than

the acetabulum there will be shortening. In nearly every instance a

certain degree of flexion is present. In anterior displacements there

is generally abduction and outward rotation. When the head of the

bone is beneath the pubes or in the obturator foramen the limb may

be lengthened as well as flexed, while the trochanter is shifted to

a correspondingly lower position. In most instances the head of the

bone can be felt in its abnormal position, and muscle spasm is always

a pronounced feature, especially when there is actual elongation and

muscles are really stretched. In the backward displacements adduction

and inward rotation are the conspicuous features, the reverse of those

of forward dislocation. When the head of the bone is actually in the

ischiatic notch, and even when it is on the dorsum of the ilium, the

limb is the more flexed, while the trochanter will be found above

Nélaton’s line. Figs. 357 and 358 illustrate the two types of anterior

and posterior displacement, with the usual and predominating postural

features, while Figs. 359, 360, 361 and 362 (from Lejars) portray the

anatomical features of the four principal types in graphic form. By

these can be determined the class to which the dislocation belongs.

[Illustration: FIG. 357

Anterior dislocation of head of femur. (Lejars.)]

[Illustration: FIG. 358

Posterior dislocation of head of femur. (Lejars.)]

This classification into the anterior and posterior seems to the

writer to simplify the general subject and to be serviceable for its

particular purpose and place. Inasmuch as anesthesia is nearly always

required for these injuries it may be expected to clear up difficulties

in diagnosis by its aid.

=Treatment.=--Through the anatomical researches of the surgeons above

named, as well as those of Allis and others, the method of reduction

of hip dislocations is practically always that by _manipulation_,

and is in nearly every instance commenced with _flexion_. In fact a

considerable number of backward dislocations can be reduced almost

alone by flexion and rotation with traction, the patient being upon his

back, preferably upon the floor, and the surgeon standing over him.

While anesthesia is not necessary in all cases it affords sufficient

assistance to justify its general employment.

In the backward dislocations, the patient and surgeon being in position

as above, it is well to employ the Kocher method, which consists of (1)

inward rotation, by which the capsule is relaxed and the head of the

bone carried from the pelvic surface; (2) flexion to a right angle,

preserving the existing adduction and inward rotation; (3) traction, by

which the capsule is made tense and the head of the bone raised to the

level of the socket; (4) outward rotation, by which the posterior part

of the capsule and the outer band of the Y-ligament are tightened and

the head turned forward into the socket.

[Illustration: FIG. 359

FIG. 360

FIG. 361

FIG. 362

Illustrating various types of dislocation at the hip. (Lejars.)]

During the practice of this or any other method the pelvis should be

firmly held in place by assistants, who may seize it with the hands

and hold it down. If the patient lay upon the table the pelvis may be

bound to it. The surgeon may need help in making a sufficient degree

of traction. This can be furnished by a strong loop passed under

the patient’s knee and over the surgeon’s shoulders, the hands thus

remaining free for manipulation, traction being the most important

feature.

Stimson accomplishes the same purpose by placing the patient, face

downward, upon a table, the dislocated limb hanging downward as

represented in Fig. 363. Traction is here partly affected by the weight

of the limb, while in some instances the surgeon has to wait only for

the muscles to relax and the bone to resume its place without much

further effort than a slight rocking or rotation. Stimson claims that

this often succeeds without anesthesia, and sometimes so quietly that

there is scarcely any jar or sound to indicate the effection of the

reduction.

[Illustration: FIG. 363

Reduction of dorsal dislocation of the hip by the weight of the limb.

(Stimson.)]

In those forms of dorsal dislocation which are accompanied by _eversion

instead of inversion_ it is necessary only to convert them into the

ordinary dorsal type before proceeding as above.

In high displacement of the head of the bone traction should be made in

the extended position, by which the head will be brought back of the

acetabulum, and then proceed as above.

Of the _anterior_ dislocations the obturator is perhaps the more

common, while for its reduction the following directions usually

suffice: The limb is flexed toward the perpendicular to disengage the

head of the bone, then rotated inward and adducted while the knee is

carried to the floor. As Bigelow suggested, in this maneuver we may

need the aid of a towel passed around the upper part of the thigh, an

assistant making upward and outward traction while the operator is

bringing the limb downward. Inward rotation is likely to transform the

dislocation into a posterior one. On account of this fact, Kocher would

give the following advice: (1) Flex the thigh to a right angle with the

pelvis, preserving abduction and outward rotation until (2) traction is

made, by which the posterior part of the capsule is tightened and the

head brought nearer the socket; then (3) forcible outward rotation is

made, which should bring the head upward and backward into place.

A _perineal_ dislocation is usually accompanied by laceration of the

capsule. This will permit of easy reduction, which can probably be

effected by traction in the axis of the limb in its abnormal position

and by direct pressure, with some rotation or rocking.

The _pubic and suprapubic_ dislocations require forcible flexion with

traction in the axis of the limb, followed by inward rotation and

circumduction of the knee. Some of these maneuvers are illustrated in

Figs. 364 and 365.

So of the other dislocations of the hip; an application of principles

similar to the above, coupled with such assistance as may be afforded

by manipulation, practised by the operator, or by traction, with the

help of an assistant, will usually suffice.

If a general rule could be formulated covering all cases it would be

of great assistance. I have been in the habit of quoting a rule of

this character, which I first saw mentioned in the American edition

of Bryant’s _Surgery_, edited by Roberts, to the following effect:

(1) Flex the leg on the thigh and the thigh on the body; (2) carry

the knee as far as it will go in the direction in which it already

points; (3) carry the knee to the extreme in the opposite direction and

combine this movement with circumduction and traction. In the backward

dislocations these manipulations should be accompanied by traction

made with one of the operator’s hands in the popliteal space. In the

anterior displacement backward pressure instead of traction can be

made by pressing upon the knee. I have found this an admirable working

direction.

[Illustration: FIG. 364

Reduction of a dorsal dislocation of the hip by traction. (Erichsen.)]

[Illustration: FIG. 365

Reduction of a dislocation by rotation. The thigh is flexed, slightly

adducted and rotated inward, as in the first stage of reduction of a

dorsal dislocation. (Erichsen.)]

The _after-treatment_ of hip dislocations consists mainly in rest

and quiet. These should be enforced, at least by a binder around the

pelvis, and, if necessary, a starch or plaster-of-Paris protection. The

anterior suspension splint affords a comfortable and efficient method

of treating these cases after the first few days. (See Fig. 322.) Very

little liberty should be allowed the patient until the expiration of

the first month.

=Ancient and Unreduced Dislocations.=--The longer a hip dislocation

is allowed to go unreduced the more difficult is its replacement.

The expiration of six weeks will usually make a hip reduction very

difficult, while after a lapse of three or four months it becomes

wellnigh impossible. The longer a limb is disused the more do its

osseous structures atrophy. Therefore a fracture of the neck of the

femur or upper end of the shaft may occur in attempting to reduce

an old luxation. The most marked obstacles are offered by formation

of adhesions about the femoral head in its new position, and the

shrivelling or change in shape of the capsule, whose opening may be

distorted or obliterated, so as to make reëntrance impossible within it

of the head of the bone.

Other things being equal, then, more force and wider range of motion

are necessary in reducing the older dislocations, while success may be

attained only by the expenditure of wellnigh all the muscular energy

of a powerfully built man. Attempts prolonged too far produce serious

laceration, with hemorrhages, which tend to encourage new adhesions

in case of failure. If a dislocated hip cannot be reduced by any

apparently safe procedure the operator should decide whether to leave

it, in the hope of securing a false joint, or to cut down the parts

and make such further division of tissues as may be necessary. Should

this be contemplated it implies, of course, that each case should be

adjudged upon its merits.

DISLOCATIONS OF THE PATELLA.

By various contractions of the quadriceps muscles the patella may be

displaced _outward_, it being practically slipped over the external

condyle. The same result may be produced by a blow from the inward

direction and in the extended position of the limb. These displacements

may be _complete_ or _incomplete_; in the former case the flat plane

and inner edge of the bone are directed forward instead of sidewise.

_Inward_ displacements are unusual and usually produced by direct

violence. Such previous disease as shall have weakened the capsule,

or caused its distention, permits these dislocations to occur with a

minimum of violence. In fresh cases the capsule is usually torn.

_Reduction_ is easily effected by lifting the limb, thus relaxing the

quadriceps muscle and making pressure and manipulation in the indicated

direction. An anesthetic may be given if thought admissible.

When the limb is partially flexed, and a blow is received on the edge

of the patella directly from the front, it is occasionally rotated

on its tendinous axis, so that without being displaced from its

position in front of the condyles its articular surface looks inward

and it rides the knee upon its edge. This is referred to as _vertical

rotation_. It is relieved and replaced by suitable manipulation, a

feature of which may be sudden and forcible flexion with external

pressure.

The patella once displaced the joint structures are left more or

less permanently impaired, and recurrence of the lesion is by no

means uncommon. Some individuals, the young especially, have the

habit of “slipping the knee-pan,” this implying that at least partial

displacement occurs easily with comparatively slight provocation.

Sometimes children become so accustomed to this that they learn how to

care for it themselves.

=Treatment.=--After every knee dislocation protection should be

afforded for a considerable period. In habitual dislocations it may

be justifiable to make lateral incisions and to excise an elliptical

portion of the capsule, by which its dimensions may be reduced and its

undue laxity abolished.

DISLOCATIONS OF THE KNEE.

The _head of the tibia_ is occasionally displaced as the result of

accident, though frequently this is the result of joint lesions. A

traumatic dislocation can scarcely occur without considerable injury

and internal derangement of the joint structures proper. _Anterior_

dislocation may occur when the femur is forced backward or the leg

forward in severe accidents. Here the popliteal vessels may undergo

such pressure and injury as to constitute a serious complication. The

_backward_ dislocations are less common, though likewise the result of

violence. It matters not whether the thigh be fixed and the leg forced

in either direction, or whether the leg be caught and fixed while the

body is made to displace the femur; such injuries are not likely to be

mistaken. They are likely, also, to be accompanied by _displacement of

the semilunar cartilages_. _Lateral_ dislocations are practically the

result of force, often combined with torsion. Injury to the lateral

ligaments, usually extensive laceration, should accompany them.

Dislocations of the knee are more or less easily reduced, in theory at

least, by forcible traction and manipulation, and with the aid of an

anesthetic. Absolute rest, preferably in a plaster-of-Paris splint, is

requisite.

The _semilunar cartilages_ are occasionally torn loose and more or less

displaced, either toward the notch or toward the exterior of the joint.

A cartilage so displaced will project, as a rule, at the upper margin

of the tibia. These injuries may occur alone or as a complication of

more serious forms described above.

=Symptoms.=--These displaced cartilages produce symptoms simulating

those of movable bodies in the joint--that is, disability depending

upon the extent of the original injury and the direction of the

displacement. The movable cartilage may be either pulled into place

by flexion or manipulated until it returns there, but will frequently

reappear when the leg is straightened. It sometimes becomes so

entangled in the joint as to cause almost complete disability. When

movable anteriorly it may be recognized along the upper border of the

tibia. The same sudden disability may be produced here as when there

are other loose or movable bodies in the joint. The patient may be able

to indicate that there is something movable in the joint.

=Treatment.=--Non-operative treatment consists in sufficient limitation

in the motion of the joint with abstention from use of it. In cases

not amenable to non-operative measures the joint may be opened and

the cartilage fastened in place to the head of the tibia either with

absorbable or non-absorbable sutures.

=The Fibula.=--The upper end of the fibula, although firmly bound to

the tibial head, may be dislodged by direct or indirect violence.

Forcible inward rotation of the foot, in full extension, will sometimes

displace it _forward_, while forcible traction on the biceps may

dislocate it _backward_. Displacements at this joint may occur when

the leg bones are broken, while when the tibia alone is broken and

shortened _upward_ displacement may occur in consequence. Should

displacements be discovered it will not be difficult by traction

upon the foot and leg, in the normal direction, and by pressure to

replace them. The backward displacement is the more unstable of the

two. The _lower end_ of the fibula is by itself rarely dislocated or

distorted except in connection with violent sprains, accompanied by the

laceration of ligaments or fracture of one or both bones.

DISLOCATIONS OF THE FOOT.

_Backward_ and _forward_ displacements of the foot are possible without

fracture; as, for instance, when violence is applied to the leg after

the foot is caught and fixed. Even here, however, the lateral ligaments

must suffer partial or complete laceration, while one or both malleoli

may be broken. The most frequent displacements of the foot are those

which accompany and are permitted by fractures of the lower part of the

leg, notably that originally described by Pott, with its troublesome

form of bone lesions. An _inward_ dislocation of the foot is described

as produced by extreme supination and adduction.

It is necessary in studying these injuries to the ankle region to make

out the existence of fracture, if any be present, as the treatment

hinges largely upon such complication.

The _astragalus_ may be dislocated from its relations with the lower

ends of the leg bones, as the result of wrenches or twists or of

violent injuries, as falls or blows upon the feet. When displaced it is

nearly always forward. A backward dislocation is exceedingly rare. The

rest of the foot itself is sometimes dislocated backward beneath the

astragalus, although some portion of its lower surface still remains

in contact with the upper surface of the calcis. These displacements

occur in consequence of combined torsion and excessive violence. The

foot here will be shortened anteriorly. No matter in what direction the

astragalus may be displaced it is easily recognized.

=Treatment.=--Reduction of ankle-and-foot dislocations accompanied by

fracture is not a difficult matter, although their retention may be;

but astragalus dislocations which are complicated are usually difficult

of replacement. They will require relaxation of muscle tension by

anesthesia or tenotomy and forced manipulations. When accomplished good

function results. Better results may be obtained by exsection.

Many of these more serious forms of dislocation are _compound_. In such

cases removal of the astragalus, or a more or less typical resection of

the ankle-joint, may be judicious. In crushing injuries, either primary

or secondary amputation may be necessary.

In general it may be said of the bones of the foot that one which

resists reasonable effort at reduction, when displaced, should be

removed. Various displacements of the tarsal bones, as the result of

direct violence, may occur, as well as of the metatarsal and phalanges.

Many of them may be reduced by judicious pressure and manipulation,

but the violence which inflicts the displacement will frequently make

the injury so compound that excision or partial amputation may be

necessary.

PART VI.

SPECIAL OR REGIONAL SURGERY.

CHAPTER XXXVI.

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 Chapter XXXII.

_Acute periostitis_ is, in the main, due either to syphilis or to an

infection following injury. In the latter case it proceeds from the

margin of the wound, and may spread to a considerable distance. It is

in some instances secondary to deeper infection extending from the

middle ear, and then is found posteriorly to the ear and externally to

the mastoid cells. Congenital openings or defects of the sutures about

the mastoid seem to have much to do with the travelling of infectious

lesions in these localities.

[Illustration: FIG. 369

Osteoma of skull. (Mudd.)]

[Illustration: FIG. 370

Same as Fig. 369, seen from below.]

=Acromegaly and Leontiasis= have been considered on pages 437 and 438.

=Acute Osteomyelitis.=--Acute osteomyelitis is due to essentially the

same causes as those just discussed. In this case it is especially in

the diploë that the principal ravages occur. Unless promptly recognized

and relieved by surgical measures this is likely to lead to sepsis

of the pyemic type and at a relatively early period, the venous

arrangement of the diploë favoring such type of disease.

=Necrosis of the Skull.=--Necrosis of the skull is ordinarily the

result, directly or indirectly, of injury, in which case it is usually

of the acute form, a fragment, which has been too much separated

from its surroundings to live, giving evidence of early and easily

recognizable death. This necrosis is mainly confined to the external

table. Necrosis of slow origin is due either to tuberculosis or

syphilis, perhaps more often to the latter. Under a cold abscess of the

scalp or subperiosteal abscess will often be found a small area of dead

external table which needs complete removal. Necrosis has also been

observed to follow severe burns of the scalp. It is usually combined

with caries of adjoining bone. The caries produced by syphilis is

illustrated in Fig. 371.

[Illustration: FIG. 371

Syphilitic caries of cranium. (Bruns.)]

INJURIES TO THE HEAD PREVIOUS TO AND DURING BIRTH.

_In utero_ the head is surrounded by amniotic fluid and is well guarded

against injury. Nevertheless as the result of penetrating wounds or of

falls on the part of the mother real injuries do occasionally occur.

Most of the cases of skull fracture reported as occurring before birth

have occurred during delivery. _Multiple fractures_ of the skull of

either character have been observed.

During the process of parturition there nearly always appears a tumor

of the scalp in the newborn, known as the _caput succedaneum_, at

the point where pressure upon the head has been least. It usually

disappears quickly after birth. It is due to a collection of blood,

partly an extravasation, as the result of compression or injury. It is

composed also of edematous soft tissues of the surface. If incised,

blood-stained serum is poured out. When this fails to rapidly resorb

during the first days of the infant’s existence, and especially if it

fluctuate, it may be incised under antiseptic precautions and blood

clot be turned out. In rare cases it suppurates, by which is produced

an acute abscess, which should be promptly evacuated.

A collection of fluid blood between the periosteum and the bone is

known as the _cephalhematoma neonatorum_, such a lesion occurring on

an average once in two hundred cases. It is generally found over the

fissures, and appears to be produced by the sliding of the bones.

This collection also usually promptly disappears. In case of failure

it may be aspirated or incised. Before resorting to any operative

procedure it would be well to make a careful distinction between a

possible meningocele or encephalocele, as a congenital defect, and

cephalhematoma as an accident of delivery.

[Illustration: FIG. 372

Fracture of right frontal bone in a newborn infant; fracture extending

into orbit. (Bruns.)]

A depression in the skull of a newborn child which does not quickly

right itself or yield to expanding influences from within should not be

allowed to go uncorrected, as serious lesions ordinarily of paralytic

type may result therefrom. In these days of aseptic surgery there is no

reason why such operation as may be necessary to elevate a fragment or

an entire bone should not be performed, with the usual precautions.

IMPORTANT POINTS IN THE SURGICAL ANATOMY OF THE SKULL.

The young and the aged have no distinction of tables of the skull, but

the diploë which separates the two tables is an affair of middle age,

develops slowly, and disappears after the same fashion--sometimes to

such an extent as to leave the skull of almost paper-like thinness. In

all operations, then, upon the young and the old the surgeon should

proceed with extreme caution, as if expecting to find the skull quite

thin. The lower limit of the squamous bone proper is the so-called

mastosquamosal suture, and operations confined to the squamous plate

alone are safe from injuring the sigmoid sinus on its inner side. The

ridge at the posterior root of the zygoma indicates, by its lower

border, the level of the mastoid antrum. A few lines above this is the

level of the base of the brain. The _mastoid_ is present at birth and

appears externally by the second year. Its _antrum_ is present also

at birth, though its air cells do not develop until after puberty,

their location being previously occupied by cancellous tissue. Most of

these cells open into the antrum, a few directly into the tympanum.

They are not always separated from the sigmoid sinus by bone. The

partition between them is perforated by minute veins, forming an easy

communication between the sinus and the antrum. Air escaping from the

mastoid cells into the overlying tissue may cause emphysema from a

basal fracture. In all operations upon the mastoid antrum the operator

should keep to its outer side, and the higher and the more closely to

the posterior zygomatic ridge he makes the first opening the more sure

is he to escape injuring the facial nerve. The _groove for the sigmoid

sinus_ extends to the jugular foramen from a point on the outside

corresponding to the asterion. The _lateral sinus_ may be indicated

externally by a line from the superior border of the mastoid to the

inion--_i. e._, from the asterion to the inion.

The _frontal sinuses_ are usually separated by a septum, which is often

incomplete or wanting. They are variable in size and outline, and do

not develop until after the seventh year. The _infundibulum_, by which

they empty into the nasal cavity, is often so small that when the

lining membrane is involved it becomes closed, and retention, with its

accompanying symptoms--pain, tenderness, swelling, etc.--may ensue.

Ulceration and erosion, however, may cause perforation internally

through the supra-orbital plates, so that pus may penetrate through the

inner half of the orbit.

Aside from its direct communication the superior longitudinal sinus

connects with the basal sinuses through the middle cerebral and the

Sylvian veins, while communications with the middle meningeal veins are

abundant. Where the frontal and diploëtic veins enter the longitudinal

sinus there frequently are dilatations in which marasmic thromboses

often originate. This sinus is also connected with the veins of the

nasal septum, so that a septic phlebitis may be propagated from the

nose. So much of the lateral sinus as is contained in the sigmoid

groove is known as the _sigmoid sinus_, which connects directly with

the exterior through the mastoid and the posterior condyloid veins. In

sinus thrombosis this mastoid vein is likewise affected. One or more

condyloid veins accompany the hypoglossal nerve through the anterior

condyloid foramen, and may also serve for the propagation of infection

or exit of pus.

While septic particles may be carried from any part of the lateral or

sigmoid sinuses--usually through the internal jugular--they may also

be carried by way of the other veins above mentioned or the occipital

sinus, all of which empty directly into the subclavian without passing

through the internal jugular. These sinuses are all rigid tubes, always

open, while the veins are thin and flexible, their caliber constantly

varying with inspiration and expiration. The sinuses contain no valves,

and these are very rare in the cerebral veins.

So far as the _lymphatics_ are concerned there is free and easy

communication between the internal and external plexuses and nodes.

Into the superficial nodes, along the external jugular, outside of

the deep fascia, empty all the external lymphatics of the head.

Intracranial infection shows itself in swelling of the deep cervicals

beneath the deep fascia. Lymphatics are abundant in the dura, and

pathogenic organisms, once housed within the dura, find it easily open

to invasion. The potential interval between the dura and the arachnoid

is termed the _subdural space_, when considerable effusion may occur

without marked symptoms, owing to its easy diffusion, while blood here

poured out may travel even to the lowest parts of the spine and cause

death by pressure upon remote points.

The _arachnoid_ bridges over the convolutions and does not extend into

the sulci. It is not vascular; at certain points it is adherent to the

pia, at others it does not touch it. The _subarachnoid space_ is formed

in the latter way, and within it most of the cerebrospinal fluid is

contained. This space is unevenly distributed over the brain surface,

most prominently beneath the posterior two-thirds of the brain, where

there is a wide interval between the arachnoid and the pia, extending

forward around the medulla and pons and as far forward as the optic

nerves. This space connects with the ventricles by the foramen of

Magendie, as well as with the sheaths of the cranial nerves. Where

these nerves escape from the brain or cord they are covered by all

three membranes, the layers being most distinct along the optic nerves.

Fluid injected into the subdural space may pass along the spinal nerves

as far as the limbs. It is essential to realize this in order to

appreciate how extensive is the surface exposed in leptomeningitis.

Internal hydrocephalus is often the result of closure of the foramen of

Magendie. The cerebrospinal fluid is rapidly reproduced after traumatic

escape. External hydrocephalus or accumulation in the subarachnoid

space, is a condition frequently due to tuberculous infection.

The _pia_ is the vascular coat of the brain, supplied with an extensive

network of fine nerve fibers derived from the sympathetic and the

cranial nerves, having intimate relations with the brain, to such an

extent that leptomeningitis and encephalitis are almost inseparable.

The nerve supply to the cerebral membranes explains the severe pain of

meningitis.

INJURIES TO THE SOFT PARTS OF THE CRANIUM.

In direct connection with what has been stated above it is well to

emphasize that the venous communications between the exterior and

interior of the cranium are numerous, and that the frequency of these

anastomoses explains the ease with which extracranial infections are

propagated within; in other words, these explain the frequency of

septic mischief in the brain after external injuries.

=Penetrating and Incised Wounds.=--Penetrating and incised wounds are

frequent about the head, their prognosis _per se_, as well as their

proper treatment, varying but little from that of such wounds in other

parts, so long as the skull proper and its contents escape injury.

Hemorrhage from scalp wounds may be profuse and even fatal. The most

dangerous hemorrhages occur from the temporal vessels. Penetrating

wounds are short, and the periosteum and underlying bone are usually

also injured. Such small articles as blades of penknives, particles of

dirt, etc., will often be found when the parts are carefully inspected,

a measure never to be neglected. Contusions of the scalp and skull are

spoken of as subcutaneous, subaponeurotic, or subperiosteal, and are

most frequent in the frontal and lateral regions. Ecchymoses following

them may be extensive and discoloration may spread over a large area.

In traumatic hematomas resulting from various injuries incision should

be an early resort should blood clot fail to resorb.

INJURIES TO THE CRANIAL BONES.

All conceivable degrees of injury to the bones, from a trifling

division of the periosteum down to most extensive denudation or

mangling of the external table or the entire thickness of the bones,

may be encountered. These lesions may be spread over a large area or

may be the result of penetrating wounds. In other words, we may have

linear, penetrating, or large surface wounds, with such injury to the

scalp as perhaps to amount to a total loss of covering for the same.

All of these, moreover, may be complicated by fractures of the bone at

the point of injury, with or without brain lesions, or by other and

more remote lesions.

In regard to most of these, it may be said that _non-penetrating

injuries_, when promptly and properly attended to, have, in most cases,

a favorable prognosis. Every _penetrating wound_ of the cranium is a

condition justifying grave prognosis, on account of the great danger of

infection incurred. Other features of these wounds, with more in regard

to prognosis and treatment, will be given under the head of Compound

Fractures of the Skull, etc.

It is necessary, however, to say in this place that penetrating wounds

of the cranium are often received in a way which does not permit

actual diagnosis, as, for instance, when received through the nose

or the orbit. Every wound whose history and appearance indicate that

penetration may have occurred should be subjected to the most rigid

scrutiny and care. Points of fencing foils, umbrella tips, etc., have

been forced into the brain cavity through the orbit and elsewhere in

ways which left little external evidence of the severity of the injury.

FRACTURES OF THE SKULL.

Following the anatomists, and for general convenience, these are

divided into _fractures of the vertex_, of the _lateral region_, and

of the _base_, the former being the most frequent as the vertex is the

most exposed. A fracture in a given region may be confined to that

locality or may radiate widely or extend nearly around the cranium. Of

all the fractures of the bony skeleton those of the skull constitute

about 2 per cent.

Fractures of the Vertex of the Skull.

Fractures of the vertex are, in most instances, due to actual violence,

the force being often expended at the point of application or producing

radiating fractures. Those which are limited to the neighborhood of the

injury are referred to as _direct_ fractures, in distinction to which

we have _indirect_ or _radiating_, often producing remarkable results.

Fractures may vary between the simplest crack or fissure, accompanied

by but trifling brain symptoms and never recognized, to the most

extensive comminution and destruction of cranial bones which can be

imagined.

=Splintered or Comminuted Fractures.=--Splintered or comminuted

fractures refer to the formation of numerous bony fragments, which are

often more or less loosened, sometimes completely so, occasionally

dovetailed together, and often driven in or depressed. Such fractures

are direct. It is possible to have comminution without depression; the

latter makes it the more grave condition.

Fractures with absolute loss of substance may be made by gunshot

injuries or by any extensive splintering or by a penetrating body. It

is possible to have _fracture of one table without that of the other_,

this being often true of the external table. In isolated fractures of

the inner table there is often dislodgement of small fragments which

may injure the dura and possibly produce later epileptic or irritative

disturbance. When the external table is chipped off the diploë is

exposed, and this with its wonderfully fine venous communications opens

up a wide area to infection and subsequent pyemia.

=Gunshot Fractures.=--Gunshot fractures are always depressed and almost

invariably comminuted. The bullet of the modern army rifle possesses

a great initial velocity, and the cranium struck by it will probably

be disrupted into fragments, causing instant death. The majority of

gunshot fractures of the skull seen in ordinary civil practice are due

to revolver or pistol bullets from weapons of the prevailing type.

In these instances there will usually be penetration, perhaps with

perforation of the skull, and the formation thus of one or of two

compound fractures, the wound of entrance being always comminuted and

depressed, while fragments of bone may be scattered along the course of

the bullet, which may also carry infectious material from without, such

as hair, particles of hat, and the like (Figs. 373 and 374). (See also

Figs. 52, 53 and 54.)

[Illustration: FIG. 373

FIG. 374

Gunshot fracture of skull. (Helferich.)]

Whatever may be the wisdom of operating in other cases where there is

room for doubt as to the proper course there rarely is uncertainty as

to the proper treatment of gunshot wounds of the skull, which _should

be invariably subjected to operation_.

It will thus be seen that fractures of the skull may be _simple_ or

_compound_, or _complicated_ with other injuries, or _depressed_,

without any reference to whether they are simple fissures or more

extensive injuries. On the other hand, depressed and comminuted

fractures may occur without being compound in a surgical sense, and

with each one of these injuries there may be accompanying disturbance

of the brain of any degree of severity, from the mildest concussion or

shock up to rapidly fatal compression. Any imaginable complication of

these head injuries is not beyond the bounds of possibility.

The essential features in explaining the _mechanism of fractures_ of

the vertex are the area involved and the violence of the impact. The

skull is often surprisingly elastic, even in the oldest individuals,

and fractures occur ordinarily when the natural limits of elasticity

have been exceeded and bone cohesion overcome. Children particularly

suffer from depression without fracture, which formerly was never

operated upon, but which is now regarded as requiring operation.

On the other hand, certain skulls are _abnormally fragile_ (see

Fragility of the Bones, 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

Chapter XVIII, on Blood Pressure.)

CONTUSION OF THE BRAIN.

The condition of _shock (cerebral concussion)_, when of pure type,

passes away with reasonable promptness, especially when aided by

surgical treatment. _Anything which persists_ in the way of muscle

paralysis, disturbance of function of nerves of special sense, or

_other sign of importance_, indicates something more than mere

vibratory disturbance: it implies mechanical lesion which could be

perceived by the eye were the parts exposed, and constitutes the

condition known as _contusion_. This implies the existence of trifling

exudates, or hemorrhages, which lead not only to absorption but even

cicatrization. _Contusion pure and simple_ differs from ordinary

_laceration_ as a contusion elsewhere may differ from a wound. It

cannot be separated, however, from conditions in which there are

minute separations of continuity and actual lacerations. It may be

divided into three postmortem forms--_general hyperemia_, with or

without edema; _punctate_ or _miliary hemorrhages_; and _thrombosis

of minute vessels_, which may occur separately or together. Moreover,

there may exist similar lesions in the meninges, constituting

_meningeal contusion_. Ordinarily minute vessels of the pia are

ruptured and blood is effused in small and thin patches over various

parts of the brain. The so-called _compression apoplexies_ of certain

authors are inseparable from the conditions above described. Such

minute blood clots are only to be distinguished upon very careful

sectioning of the brain, and are found most often in the region of the

medulla and along the floor of the fourth ventricle. They are probably

caused by the forcing into the fourth from the lateral ventricles of

the fluid contained in the latter.

=Symptoms.=--When the ordinary symptoms of shock, which follow all

severe injuries to the head, especially when the deep lesions are not

too severe, fail to disappear in a short time under proper treatment,

and when new and irregular symptoms are superadded to those of shock

alone, it is reasonable to suppose that the intracranial condition is

one of contusion rather than of shock. When mental agitation changes

into delirium, when the rapid, feeble pulse becomes stronger and

slower, the respiration deeper, the limbs move in incoördinate ways,

the speech disturbed from muscle incoördination, the patient selects

wrong words, or when the mental condition becomes more serious and

stupor or coma take place of the delirium, while external irritants

have less and less effect, and when the pupils gradually enlarge while

failing to respond to light, it may be said that the _condition of

contusion is making itself apparent_. If along with muscle uncertainty

there is also muscle spasm or rigidity, with fixation of the fingers in

the athetoid position, the evidence to this effect is increasing. If

with all this the thermometer fails to show that an active inflammatory

condition--_i. e._, meningitis--is prevailing the diagnosis may be

regarded as certain. Error may possibly arise when there are evidences

of alcoholism. Coma following head injury ought not to be ascribed to

the _alcoholic condition_ except by the strictest process of exclusion.

Temperature alone will be of the greatest service in this direction,

since in _alcoholism_ it is usually _subnormal_. In _apoplexy and

non-traumatic hemorrhages_ it is also usually _subnormal at the

commencement of the attack_, rising to normal, and remaining there

if the patient recover, but _continuing to rise in cases where the

prognosis is bad_.

=Treatment.=--The treatment of brain contusion should be managed

largely in response to special symptoms. Physiological rest, attention

to scalp wounds, fractures, etc., shaving of the scalp, application of

ice to the head, with such stimulation to the heart as may be necessary

in extreme cases by subcutaneous administration of adrenalin, atropine,

etc., by local fomentations over the epigastrium, or by immersion

in a hot bath when surroundings permit it--these in a general way

constitute most of the methods of treatment in contusion. When only

symptoms of diffuse and minute lacerations can be recognized the use of

the trephine is impracticable except when indicated by some external

marking--_i. e._, compound fracture or the like. When _localizing

symptoms_ are present the trephine is, of course, indicated. When

the skull injury is recognized as a basal fracture, venesection or

the application of leeches behind the ears will be most serviceable.

In every such case there is the greatest necessity for _regulating

the excretions_ and preventing auto-intoxication. For this purpose

diuretics and laxatives should be used, often in conjunction with

intestinal antiseptics. The catheter should be employed whenever

indicated by the condition of the bladder, which should be carefully

watched. As the days go by, and patients lie more or less helpless

and inert, the greatest care should be exercised for the prevention

of bed-sores. When mental inertness, muscle rigidity, etc., fail to

disappear, potassium iodide should be used internally.

BRAIN PRESSURE OR COMPRESSION.

That the cranial contents--brain, blood, lymph, and cerebrospinal

fluid--completely fill the cranial cavity has been already amply shown,

as well as that there is no room for anything in the shape of a foreign

body without seriously affecting the equilibrium between the brain and

the contents of the spinal canal. When, however, any foreign substance

exerts pressure upon the brain the results are invariably the same, be

this substance what it may, and _compression signs are always the same,

no matter what the compressing cause_. Reduction in capacity of the

cranial cavity (_i. e._, compression) may be produced--

[Illustration: PLATE XLIII

FIG. 1.

FIG. 2.

FIG. 1. Compound Fracture of Cranium, with Depression; Fracture of

Bones of Face; Extradural Clot from Rupture of Middle Meningeal Artery.

FIG. 2. Horizontal Section of same, showing Depressed Fracture of Bone.

(Anger.)

C, extradural clot; D, laceration of brain substance, with extensive

intracerebral clot; F, same condition produced by contrecoup. Punctate

hemorrhages and minute lacerations at numerous points, characteristic

of contusion of the brain.]

1. By reducing the dimensions of its enclosing walls (_e. g._,

depressed fractures or by direct pressure);

2. By increase in the quantity of cerebrospinal fluid or of the volume

of the brain, which latter may be produced by edema, by serous exudate,

or by actual hypertrophy;

3. By foreign bodies, which may enter the skull from without;

4. By pathological conditions--collections of blood or pus, tumors,

etc., which may be produced either from the brain substance, its

containing bone or membranes, or its vessels.

In every one of these conditions the size and tension of the brain

are affected. _The cerebrospinal fluid is mainly involved in acute

not in chronic conditions._ A slow reduction of the diameters of the

skull produces such slow alterations of pressure as to cause a minimum

of disturbance. So far as compression from traumatic influences is

concerned we distinguish mainly between compression--

1. By extravasation of blood (see Plate XLIII);

2. By fractures of the skull with depression, or by foreign bodies

penetrating from without;

3. By products of acute infectious inflammation due to septic infection

from without.

The result common to all of these is _increase of intracranial

tension_, and its consequence is a less rapid flow of blood and an

altered blood supply to the brain and its membranes.

Experiment has established that in compression of the brain

cerebrospinal fluid is forced by pressure into the spinal canal, whose

membranes are more elastic, and which thus help to accommodate it; it

has been also established that compression of the brain by one-sixth of

its volume, by any material, is fatal, and that much less is at least

serious. That fractures with depression produce sometimes serious, at

other times trifling, symptoms is due to the varying accommodation

of the spinal canal. Both experiment and observation seem to confirm

the view that consciousness pertains to the cortex as a whole, and

that unconsciousness is an inhibitory or paralytic condition which is

produced in compression.

_Temperature_ is a matter of great importance in studying compression

and foretelling its consequences. Elevation of temperature is an

early, continuous, and constant symptom in these cases. If temperature

be subnormal and subsequently rise, prognosis is bad. Variations of

temperature are more reliable guides than conditions of consciousness.

As Phelps has remarked, in no condition except sunstroke is temperature

so uniformly high as in cases of serious encephalic lesions.

=Symptoms.=--As indicated above, the symptoms and signs of compression

are practically identical, no matter what the compressing cause.

When this cause acts instantly there is no time afforded for

differentiation, but when it occurs slowly we note the following

symptoms, and about in the order here presented: Irritability or

restlessness; visceral disturbances; pain; intense cephalalgia;

congestion of the face; narrow pupils; augmented pulse, often seen

in the carotids. If compression occur more rapidly, torpor quickly

succeeds erethism, after which patients vomit, have convulsions or at

least convulsive motions, speech is disturbed, and stupor comes on,

from which they neither awake nor can be awakened until the compression

is relieved. All of these indications refer to involvement of the

cortex, which is generally regarded as the seat of consciousness as

well as of projection and imagination. During the night, of the senses

produced by pressure upon the cortex only the automatic basal apparatus

and that of the spinal cord continue in more or less disturbed

operation. Of all the general functions consciousness vanishes first

and returns among the last. When intracranial pressure has reached a

certain point, epileptiform convulsions result, varying in intensity,

affecting all the limbs, and terminating perhaps with rigidity. These

form an expression of high pressure. Similar convulsions occur in

various head wounds, explanation for which is the result of pressure,

which, though not extensive, may produce alteration in the circulation,

with its disastrous consequences. The later and _constant evidences

of compression, and those which in aggravated cases supervene

at once_, are reduction of pulse rate, due to the action of the

pneumogastric, which suffers first an irritation and later a paralysis.

The pulse becomes not only slackened but full; the respiration rate

is correspondingly reduced, so that breathing during coma is deep,

slow, and often stertorous. This feature of stertor is an expression

of paralysis of the palatal and pharyngeal muscles, which flap, as

it were, in the air current. Vomiting, which may occur before brain

tension has risen high, does not occur in the most serious cases. Coma

is absolute.

Along with these signs the most important other indications are

the _paralyses_, which may consist of monoplegia, hemiplegia, or

paralysis of individual muscle groups, according as pressure is made

upon a limited area or upon an entire hemisphere. By the division of

the cranial cavity by the falx and the tentorium it is divided into

chambers, in any one of which pressure may be more manifest than in

the others. Nevertheless a serious compressing cause will affect the

tension of the cerebrospinal fluid and produce general expression of

pressure. The _pupils_ often vary, and responsiveness to light is

occasionally noted. Nystagmus and ocular rotation may be occasionally

seen. Choking of the optic disk is also a frequent phenomenon, to be

recognized only by ophthalmoscopic examination. This is due to pressure

in the subdural and subarachnoid prolongations along the optic nerve.

In milder cases of chronic compression disturbances of vision are of

very great clinical importance. These pertain especially to diagnosis

of hydrocephalus and of brain tumors. When they occur immediately after

injury and remain, they depend upon laceration or other severe injury

of the optic nerve. Those which quickly disappear depend mainly upon

pressure of blood, which is reabsorbed, while those which are later

in their appearance depend upon later intracranial complications. A

unilateral lesion of the optic nerve depends most often upon injuries

to it within the optic canal. When the lesion is bilateral the cause

lies deep. General paralysis may be of the type of hemiplegia, single

or double--_i. e._, by “double” I mean paralysis of the entire

voluntary musculature of the body, which necessarily implies serious

and often fatal hemorrhage.

=Prognosis.=--This depends in large degree upon the nature of the

compressing cause and of the possibility of its removal. While the

nature of the same may ordinarily be determined, how much can be

accomplished by way of removal may often not be foretold before the

operation at which this should be attempted. In every acute case it

is desirable to make this attempt early, for high pressure, which may

be borne for a short time, is fatal if continued. Compression to any

serious degree is usually fatal. So soon as paralysis of circulatory

and respiratory centres is apparent the beginning of the end is at

hand. Another reason for hastening operation is that acute softening of

brain tissue comes on promptly, as well as _general cerebral edema_,

which has destroyed many a patient during the second to the fourth day

after injury.

=Treatment.=--The treatment of compression is summed up in one

phrase--_i. e._, to remove the cause when possible. The only cases

in which this rule may be safely disregarded are those where the

attempt to remove the cause means more danger than to leave it

unremoved. This is not true, however, in the ordinary cases of bone

depression, meningeal hemorrhage, etc. Before operation, however, or

as a substitute for it in cases of minor severity, it may be well to

assist venous outflow by _venesection_, by which blood pressure is

reduced. In these cases this may be done from the temporal veins or

external jugulars, with the patient in the semi-upright position.

Drastic purgatives may also be employed in order to utilize intestinal

outpour as a stimulation to resorption of cerebrospinal fluid. The

physiological action of cold (ice-bags) may also be secured for the

purpose of contracting the cerebral arteries. But all these measures

are only to be resorted to when there is uncertainty as to the

wisdom of operating, since when operation is indicated it should be

done at once, and _should take precedence of everything else_. This

operation means ordinarily the procedure to which the now general term

_trephining_ has been, by common consent applied, and comprises any

measure by which the skull is opened at a suitable place and the dura

or the underlying cortex exposed to such extent as to permit removal

of the compressing cause. Whether the opening be made with trephine

(annular saw) or with the straight or revolving saw, with bone chisel,

with bone forceps, or with anything else, is a matter of choice on the

part of the operator. So, too, removal of the compressing cause should

include the elevation of depressed bone, the removal of dislodged

particles as well as of all foreign bodies, the cleaning out of blood

clot, the checking of hemorrhage, and the closure of the wound, with

or without drainage or counteropening at some other part of the skull,

as may seem desirable in special cases. This entire procedure comes

now under the name of trephining, and should in most instances be

painstakingly followed.

The operative maneuvers will be discussed in another portion of this

chapter.

INJURIES OF INTRACRANIAL VESSELS AND SINUSES.

Intracranial hemorrhages may occur--

(_a_) From internal sources through the broken bone or between it and

the dura (extradural);

(_b_) Beneath the dura, between or into the membranes (subdural);

(_c_) Into the brain substance proper or the ventricles (subcortical or

intraventricular).

The vessels whose injuries are most often under consideration are

the _meningeal arteries_, the _sinuses_, the _small vessels of the

membranes_, and the _internal carotid_. The arteries, like the sinus

walls, may be ruptured either by substances forced in from without or

by sheer laceration. The _longitudinal sinus_ is most liable to injury

from without. When this sinus is exposed, it may be dealt with either

by suture if the wound be small, or by ligation, or by tamponing with

prepared gauze. Hemorrhage from this source is ordinarily not difficult

to check. Fatal air embolism has resulted through an opened sinus not

properly plugged. The other sinuses are more rarely injured, as by

gunshot wound, fracture of the base, etc. The sinuses have also been

injured by compression of the skull during parturition. Bleeding from a

sinus is usually indistinguishable from that from a meningeal artery,

except that the former occurs more slowly.

=Injuries to the Middle Meningeal Artery.=--Injuries to the middle

meningeal artery naturally occur in the immediate neighborhood of

this vessel, which is not infrequently ruptured by contre-coup. The

artery runs sometimes in a groove of the bone, sometimes in the

dura, and sometimes entirely in the bone. The more it lies within

the bone the more likely it is to be ruptured when this part of the

skull is fissured. Basal fractures often follow the groove for this

artery. The anterior branch is more often injured than the posterior.

Extravasations from this source are more common than from all others

combined, the amount of blood varying within wide limits. 240 Gm. of

blood clot have been known to collect and the dura to be separated

down to the base of the skull. I have repeatedly taken away a small

teacupful of blood clot in such cases (Fig. 377 and Plate XLIII).

[Illustration: FIG. 377

Compression following hemorrhage from the middle meningeal artery.

(Helferich.)]

=Symptoms.=--The symptoms of this hemorrhage are those of compression,

while extravasation may be rapid and quickly fatal, delayed for some

time, or may take place in two stages, the first but slight and

producing no coma. New clots are always dark and disk-shaped, thick

in the middle, with a definite margin. As the clots become older they

become more adherent and difficult to remove. The symptoms of meningeal

hemorrhage consist of an interval of consciousness or lucidity after

injury, followed by epileptic or spastic symptoms, alterations in the

pupils and pulse, unconsciousness passing into coma, and stertorous

respiration. There may or may not be external evidence of head injury.

The character of the _paralysis_ (hemiplegia) may indicate that the

clot is really upon the side opposite to that of the skull which shows

evidence of injury. In this case arterial laceration is the result of

_contre-coup_. According to the rapidity of the symptoms is the extent

of the primary lesion. Meningeal hemorrhages involve immediately the

motor area, which makes diagnosis all the easier.

=Injuries to the Carotid.=--Injuries to the carotid within the cranium

are exceedingly rare. Still, it has been injured in basal fractures and

penetrating wounds.

=Arteriovenous Aneurysm.=--Development of arteriovenous aneurysms after

basal injuries is occasionally noted. They will occasionally give rise

to pulsating exophthalmos. Pulsating tumors within the orbit which push

the eye forward not infrequently occur after serious head injury. Of 77

cases collected by Rivington, 41 had a traumatic origin.

=Subdural Hemorrhages.=--Subdural hemorrhages are not infrequent in

the skulls of the newborn, and constitute the so-called _apoplexia

neonatorum_. They may occasion convulsions and paralyses of irregular

type, while if the extravasations become infected multiple abscess may

result.

In adults subdural hemorrhages are most commonly connected with brain

lesions which have been already spoken of as contusions. They may be

the starting points for pachymeningitis. Their most common results

are disturbances of consciousness and mentality. Paralytic dementia

follows in some of these cases. Extensive subdural hemorrhage may give

a clinical picture corresponding to extradural. Disseminated minute

ecchymoses constitute minute focal lesions, which are, however, usually

so distributed as to confuse and prevent accurate diagnosis. Apoplexy

or intraventricular hemorrhages, especially from the lenticulostriate

artery (Charcot’s “artery of hemorrhage”), have until very recently

never been regarded as warranting surgical interference. Of late,

however, especially in the ingravescent or progressive forms, ligature

of the common carotid has been of some service, though in order to

render this effective ligation should be done early.

=Traumatic Intraventricular Hemorrhage.=--Traumatic intraventricular

hemorrhage occurs in much the same way as meningeal, by contre-coup.

Individuality of symptoms is lost in the general comatose condition of

the patient, but when operation is performed, as it is usually best

to perform it, if no extradural clot be found and if brain tension

be evidently increased, the dura should be opened; after which, if

no subdural clot be seen, the ventricles should be tapped with an

exploring instrument. In this case, if blood be removed by aspiration,

a knife should be passed directly into the ventricle, after which

blood, if present, will promptly escape. Dennis was the first to

diagnosticate the presence of intraventricular clot and to deliberately

incise into it, and I have myself repeatedly imitated this procedure,

both with and without success.

In every case in which superficial or cortical hemorrhage can be

recognized--or even suspected--or intraventricular hemorrhage as well,

one should insist upon exploration. This means trephining, with perhaps

aspiration of the ventricular contents. Tapping of the ventricle is

described under Treatment for Hydrocephalus, while trephining is

described at the end of this chapter.

LACERATIONS AND INJURIES TO THE BRAIN SUBSTANCE.

These have been mentioned under _contusion of the brain_. They may

be divided into those which occur with or without fracture of the

cranial bones. The term contusion was first suggested by Dupuytren.

The condition comprises all degrees of injury, from the most minute

local disturbances to lesions involving the entire hemisphere. The

milder forms show a sprinkling of punctate hemorrhages, numerous in the

centre of the injured area, the surrounding tissue taking on a more or

less diffuse tint, which fades out toward the periphery, discoloration

being due to the imbibition of the coloring matter of the blood. In

more extensive injuries clots as large as peas, or larger, are embedded

at various points, each surrounded by its area of discoloration. When

foreign bodies have been driven into the brain the tissue is also

discolored, while various foreign materials may be met. In instances

of great violence there may occur absolute rupture of brain tissue

extending from cortex to ventricle.

=Prognosis.=--Prognosis depends in large degree upon escape from or

occurrence of infection. In infected cases the principal dangers are

from blood pressure and from later edema or acute softening as well as

from meningitis. Brain lacerations may heal by cicatricial repair, but

usually with some perversion of function.

The possibility of _cystic degeneration of large or small clots_ is

one of great importance. (See Cysts of New Formation in Chapter XXVI,

page 264.) A blood clot within the cranium which fails to resorb is

essentially a hematoma, in whose interior softening and conversion into

a cyst may easily occur. These cysts make room for themselves at the

expense of surrounding brain tissue, and when located in the motor area

give rise to localizing symptoms as well as to epileptic convulsions.

They may be often diagnosticated with certainty after an accurate

history of the case and a study of the phenomena which it presents. As

they grow older their walls become firmer, and it is often possible to

dissect them out.

That _foreign bodies may be encapsulated_ and remain without producing

disturbance is now well known. This is particularly true of bullets.

As a rule, however, though encapsulated, they produce symptoms like

headache, vertigo, etc. (See Plate XLIII.)

=Symptoms.=--The general features of brain lacerations are those of

_contusion_. So long as the disturbances are minute, even if multiple,

or the foreign body small, compression symptoms are not produced, or

at least in very incomplete degree. Minute diagnosis is not easily

obtained. The most essential thing is to decide upon the question

of operative interference. In the absence of distinctly localizing

symptoms or other external markings it is not usually performed.

Upon the other hand a lesion which can be localized is probably due

to extravasation sufficiently large to be easily reached by opening

the skull; and, unless there be other and sufficient reason to the

contrary, this should be done (Fig. 378).

In many instances, however, contractures or paralyses of muscle groups

occur later, and are followed by spastic conditions which may be

permanent. More can be done in these cases by massage, by internal

medication, perhaps with external counterirritation, than by distinctly

surgical procedures. Tendoplastic or neuroplastic measures for their

relief may also be considered. Both albuminuria and glycosuria are

known to be the result of injuries herein described, as well as bulbar

paralysis and disturbances of special senses. More immediate dangers

after these head injuries are those of bronchopneumonia or hemorrhagic

or edematous infiltration of the lower lobes of the lungs--conditions

often spoken of as _hypostatic pneumonia_, much resembling those

produced experimentally in bilateral division of the pneumogastrics.

Some of them are produced by paralysis of the glottis, the result of

which is incomplete closure, with aspiration of fluids and solids

from the mouth, whose decomposition sets up an infection within the

lungs, and is often referred to as _aspiration pneumonia_. Some form of

pulmonary disturbance follows in perhaps one-third of the cases of the

injuries above alluded to, and should be anticipated and prevented.

[Illustration: FIG. 378

Bullet embedded in anterior fossa. (U. S. Army Med. Museum.)]

GUNSHOT WOUNDS OF THE HEAD.

These have already been extensively considered in a previous chapter,

so that but little more need be said of them here. Such wounds in

the scalp are likely to be followed by sloughing. So far as gunshot

fractures of the skull are concerned, there is frequently a marked

discrepancy between the wounds of the inner and outer tables, that last

perforated by the bullet being almost splintered. Penetrating wounds of

the cranium by Mauser and similar bullets are not necessarily fatal.

Many men were shot through the head during the Cuban and South African

wars and yet did not die as a result of the wound. (See Chapter XXII.)

=Treatment.=--So far as treatment is concerned, gunshot injuries of

the skull necessitate trephining or exploration, for checking of

hemorrhage, disinfection of the bullet track when possible, often for a

counterdrainage opening with through drainage either by tube or gauze.

The _bullet_, if it can be found, should be removed. In searching for

it the old porcelain-tipped probe of Nélaton has almost completely

given way to Fluhrer’s aluminum probe, which is larger and longer

and when rightly directed will by slight weight usually glide gently

along a bullet track, thus leading often to the missile, and at the

same time indicating by its direction where the counteropening should

be made. Two other methods of detecting bullets are now in vogue.

Girdner, some years ago, invented a telephone probe, by which, so soon

as the instrument touches the missile, a telephone circuit is completed

and the operator with a telephone receiver applied over his own ear

hears the tell-tale “click” indicating the fact. This has been further

improved by the substitution of a bell or “buzzer,” which tells its own

tale when the probe touches the bullet.

A still more ingenious application of electricity for the purpose is

that afforded by Röntgen’s discovery, and during the American and

English campaigns of the past few years skiagrams of skulls showing

bullets in various locations have become quite common. (See Plate

XIII., p. 229.)

PROLAPSUS AND HERNIA CEREBRI.

_Escape of brain matter beyond its normal level_ is not uncommon in

connection with compound fractures or their sequels. It may be primary,

escaping with the blood at the time of the accident, or secondary,

occurring during the ensuing days. Any lesion of this kind in which the

brain appears or can be handled is entitled to the term _prolapsus_, in

contradistinction to _hernia_, which implies that, though escaping from

the proper cavity, it is nevertheless covered by other textures--_e.

g._, the dura or scalp.

The protrusion may vary in size from a small tumor to one the size

of a fist. It is always the result of uncontrolled intracranial

tension, and may be produced by hemorrhage, by serous imbibition, or

as the result of brain abscess. When immediate it is of the first

variety; when later, of the second or third. When abscess is present

it usually delays protrusion, which is produced by degrees. Prolapse

occurs through large openings, such as those made by gunshot wounds,

the trephine, etc. Prolapse proper implies laceration of the dura. It

pertains obviously to the convexity of the skull, occurring, however,

in exceedingly rare cases into the orbit (Fig. 379).

[Illustration: FIG. 379

Prolapsus cerebri. (Bryant.)]

=Prognosis.=--The prognosis is generally unfavorable. There is always

risk of edema or infection, either of which may prove fatal.

Infiltration, gangrene, suppuration, or repair by granulation may so

disfigure and disguise the real brain substance as to lead to _error

of diagnosis_. It by no means follows that every tumor presenting

through an opening in the skull is of this character. When gangrene

and spontaneous separation occur, spontaneous recovery may follow,

the stump being covered by granulations and finally roofed over by

connective tissue.

=Treatment.=--Treatment in the primary cases should include the most

rigid asepsis with removal of all foreign particles. Localized pressure

does some good, especially in those cases where it can be tolerated.

Signs of abscess should always be watched for, and deep exploration is

often justified or indicated. While excision or cauterization are often

heralded as successful, they are by no means without their dangers.

Nevertheless in selected and suitable cases excision may be freely

practised. Cases that admit of it should wear a protective shield

properly molded to the part. Skin transplantation, or even osteoplastic

repair of the defect, may give good results in favorable cases.

SEPTIC INFECTIONS WITHIN THE CRANIUM.

Under the general term _septic infection_ are included:

_A._ Abscess;

_B._ Thrombosis;

_C._ Sinus phlebitis;

_D._ Meningitis;

_E._ Encephalitis.

These are different manifestations of infection, the clinical picture

differing according to the tissues and localities involved. For the

production of these infectious conditions no special bacteria other

than those already catalogued in Chapter III are comprehended. Their

method of activity is there discussed at sufficient length, and we

need here only consider the various _paths of infection_. These may

lie along the _bloodvessels_, the _lymphvessels_, _nerve sheaths_, and

prolongations of the _membranous sacs_ which extend from the cranial

cavity proper.

The most common of all the paths of infection is afforded by the

_middle ear_, especially when involved in a chronic suppurative lesion,

which is by no means necessarily connected with a patulous tympanic

membrane, and which may consequently be undiscovered, though in more or

less constant activity.

A. =Abscess of the Brain.=--This may be _traumatic_ or _non-traumatic_.

The former variety is most often due to the direct result of injury,

infection displaying its consequences promptly or sometimes not until

long periods have elapsed. The ordinary form occurs within the first

two weeks, usually as an acute cortical abscess beneath a more or

less compromised membrane, surrounded by a zone of red softening, and

this by another of brain edema. The _chronic_ traumatic abscesses are

less often cortical, but are deeper. They are marked by prolonged

suppuration of the external wound, but may occur through some mechanism

not understood. Only the chronic abscesses show _encapsulation_, the

capsule partaking of the character of the pyophylactic membrane,

elsewhere described. (See Chapter VIII.) It may cover a long period--to

my personal knowledge at least nine years, while others have mentioned

twenty and more. The _non-traumatic abscesses_ are in the main due

to _middle-ear disease_. When the roof of the tympanum breaks down

it is the middle fossa of the skull which is infected; when the

posterior wall, naturally the posterior fossa. The most common result

of perforation of the tympanic roof is involvement of the mastoid

antrum or the sigmoid groove and sinus. In the former case we have

temporosphenoidal abscess; in the latter, cerebellar, if any. Previous

to actual perforation there is thinning of bone with thrombosis along

the minute veins connected with the sinuses. When the dura is exposed

by the carious process, granulation tissue often protects it against

further inroads, while masses of the same projecting into the tympanum

have been mistaken for prolapse. If the sigmoid groove be the site

of the first disturbance, extradural abscess may form between the

sinus and the remaining bone, the granulating process then involving

the whole bony groove. Its later consequence is _sinus phlebitis_,

_sinus thrombosis_, or _intradural infection_. If there be adhesion

between the dura and the cortex we have actual brain ulceration without

formation of a true abscess; but if once the perivascular sheaths

have carried infection to the substance of the brain there is a rapid

purulent disintegration of the same, and formation of a true subpial

or deep abscess, which latter is in effect a purulent encephalitis.

Macewen has shown how important it is not merely to evacuate such

abscesses, but to eradicate the path of infection from the point of

origin, which is rarely easy.

_Extradural pus_ may escape into the mastoid cells by erosion of their

inner walls. Such pus may escape suddenly, and serious symptoms thus

be mitigated. Even abscess of the bone may thus empty itself by the

process of adhesion and pointing toward the surface. Pus from the

mastoid cells may perforate the temporomaxillary joint or escape along

the digastric groove and form deep cervical abscesses.

When the arachnoidal tissue is involved, both subdural and

subarachnoidal spaces participate in the infection, and the brain

floats upon a pus-bed rather than a water-bed. _Leptomeningitis_ under

these circumstances becomes quickly diffused and fatal. Serous fluid

may accumulate so quickly as to produce death by mere obstruction to

the cerebral bloodvessels, while distention of the ventricles and an

acute infectious internal hydrocephalus is possible. Leptomeningitis

may be propagated wherever anatomical paths may carry it, even to the

cauda equina and along the spinal nerve sheaths.

The pus within cerebral abscesses is often discolored, sometimes

offensive. A greenish color is usually imparted by the Bacillus

pyocyaneus, while the offensive odor comes mostly from the Bacillus

coli. Around such an abscess is a zone of inflamed cerebral tissue. If

within this zone a pyophylactic membrane is produced by condensation

the abscess may become encapsulated and life be prolonged. When a

capsule fails to form, the process being too acute or rapid, death is

the speedy termination of such a case. These abscesses are generally

single, but may be multiple. There is also a metastatic expression of

abscess formation, seen in typical cases of pyemia, where numerous

miliary abscesses are found within the brain. Pressure symptoms are

less likely from abscess than from a tumor of the same bulk, while

there is much greater liability to edema and sudden infection.

Gradually extending paralysis implies pathological activity around the

abscess. Large collections of pus are often met in the least vital

parts of the brain, as in the frontal or temporosphenoidal lobes.

=Symptoms.=--Aside from causal indications (_e. g._, injury to the

head, middle-ear disease, recent operations upon the air-containing

cavities, etc.) the first symptoms may be slight. They consist usually

of headache, often ascribed to cold or trifling injury, becoming

exaggerated, rarely definitely located, radiating widely. In time it

is spoken of as “excruciating,” and may be continuous or intermittent.

Vomiting is not infrequent, rarely accompanied by nausea. Chills come

on early in the history of the case, varying in intensity, duration,

and frequency. The more frequent, the more likely is it that the

abscess results from some general infection. Temperature is seldom much

elevated; it is often subnormal. When exalted it is in proportion to

the degree of meningeal involvement. If pressure symptoms become marked

we get the usual slow pulse due to increased tension. After evacuation

of pus pressure symptoms may subside, but temperature rise. Such

discharge from the middle ear as may have been previously noted usually

diminishes. A history of cessation of discharge and of increased pain

and fever occurring at irregular intervals is very characteristic.

These patients seldom come under the surgeon’s notice until the

condition is serious. If they are still conscious, pain is the

dominating complaint. This may be aggravated by percussion over the

affected region. Rigidity of the sternomastoid on the affected side is

a sign of lesion of the sigmoid sinus. Pain elicited by deep pressure

in the posterior cervical triangle is also significant. There is mental

hebetude, with progressive failure of mental and physical power, as the

stupor increases, or coma becomes marked.

_Abscess_ may be often distinguished from _infectious thrombosis_, as

in the latter respirations are quickened and vomiting occurs when the

patient is in the upright position.

_Vomiting accompanied by cephalalgia is always indicative of

intracranial mischief._ If it be a special feature throughout the case

it may indicate cerebellar lesion. Convulsions are also frequent, but

rarely distinctive. They are the result in most cases of secondary

irritation of motor areas. Paralysis is the consequence of destructive

rather than of irritative lesions.

The ear should be examined, and the use of a probe may give much

information.