Encyclopaedia of the medical sciences ... forming a portion of the Encyclopaedia Metropolitana.

Date:
1847
Catalogue details

Licence: Public Domain Mark

Credit: Encyclopaedia of the medical sciences ... forming a portion of the Encyclopaedia Metropolitana. Source: Wellcome Collection.

Provider: This material has been provided by Royal College of Physicians, London. The original may be consulted at Royal College of Physicians, London.

    483/590 (page 847)
    Surgery. Fracture of the skull Cracks or ,fissures. •Starred ractures jVith epression f bone. even more in their complications and general effects in different cases. Cracks Of fissures are usually extensive when they occur alone, and commonly prove fatal by the internal disorganization that accompanies them. Tliey are occasioned by obtuse blows, as by falls from a great height; the violence must be very great in order to produce them, and this is the cause of the frequency with which they are conjoined with severe lacerations of the cerebral substance, and with large extravasations of blood. All this amount of injury fre- quently occurs without anything on the surface to point out the seat or existence of such an injury, and it can only be surmised. Bleeding from the ears or nose is a common symptom of a fissure running through the base of the Skull, and it may be suspected in cases where the symptoms of laceration are present. When a fissure crosses the course of one of the venous sinuses, as of the lateral sinus, this canal may be ruptured and pour out a large quantity of blood ; and a similar thing may happen when the great meningeal artery is impli- cated. Fissures usually take a more or less transverse direction, and run across sutures as though the whole vault were a continuous piece. Starred fractures are the effect of great violence applied to a small part of the surface ; the force is more spent upon the bone at one spot, and the internal hurt is commonly less severe. These fractures may be classed with several other varieties as local fractures. Their particular nature will differ with the kind of instrument which inflicted them, with the protective covering worn, and other circumstances too numerous to be specified. These local fractures are those so often attended with depression, and in which the aid of surgery can be most effectively employed. When the depression is obvious and the principal cause of the symptoms, the early elevation of the piece will speedily remove the most urgent of them, and frequently be the undoubted means of saving the patient's life. From the very common conjunction of the complications al- ready spoken of, and from the further fact of even local mischief that an operation might remedy being ob- scured by the unbroken state of the soft coverings of the Skull, the surgeon's course is continually beset with difficulties in these unfortunate cases. In circumstances apparently hopeless it will sometimes be his duty to proceed with an explorative operation, which the result may prove to have been, in its very nature, utterlyuseless. But it becomes him on no occasion to refuse the pos- sible resources of his art to a suffering fellow-creature, from a dread lest the result, if untoward, may bring discredit on himself or the operation. If there exist a compound fracture with depression of bone or fragments driven in upon the brain, the course to be pursued is plain. The displaced pieces are to be raised, and if isolated, or nearly so, they are to be removed altogether. Loose pieces are sometimes thrust between the bone and the dura mater, and admit of removal with ordinary forceps; but in general special means have to be resorted to for the elevation of sunken bone. A lever has to be insinuated beneath them to prise them up. If there be an aperture already- large enough to admit this instrument, it may be in- troduced, and the piece raised by making a fulcrum of the sound bone at its border ; if no opening suffi- ciently large have been made by the injury, it is requi- site that the surgeon should make one. In this consists the operation of trepanning or trephining, as it now ordinarily denominated. The trephine is a circular Surgery, saw, of a size varying from that of a sixpence to that v—m*Sm— of a shilling, with a projecting centre pin, removable TrePhin' at pleasure. The patient being conveniently laid with ln?* his head on a firm pillow, and the integuments turned aside from over the seat of fracture, the instrument is to be placed just so far on the border of the sound bone that the centre pin may be planted upon it. It is then to be rotated backwards and forwards, by quick mo- tions of the fore arm, until the saw has made its way into the surface of the bone. The centre-pin is now to be removed and the rest of the perforation to be com- pleted by the saw, a probe being introduced into its track from time to time, and great care being taken that it do not penetrate beyond the inner table. A nar- row lever will now be sufficient to loosen and extract it, and the subsequent steps of the operation will consist in the removal of all detached fragments, and the ele- vation of such as are bent in upon the brain. If any spiculae project across the opening they are to be care- fully removed, and for this and other purposes, the small saws, named after Mr. Hey, will be found of essential service. The flaps of integument have then to be brought together over the aperture, and a light compress and bandage applied. If it can be avoided, the trephine should not be applied over the course of the longitudinal sinus, or of the middle meningeal artery, as these vessels, and especially the latter, may be torn by the saw, in consequence of their lying in grooves on the inner surface of the skull. In some instances the existence of a depression of bone can be detected by the fingers, even though the integuments are themselves untorn. The discrimina- tion, however, is liable to be obscured by effusions of blood into the sub-aponeurotic areolar tissue of the scalp, which, pitting on pressure, may even give a feeling of sunken bone, particularly if sufficient time has elapsed to allow of the walling in of the ecchymosis by lymph. But even if there be no doubt of the ex- istence of a slight depression, this may be nothing more than an indentation of the outer table upon the diploe, while the inner, compact, and hard table of the Skull has altogether escaped injury. This, however, can only occur in adults of middle age, as the diploe' does not exist either in children or in old persons. The treatment under these circumstances will be determined more by the cerebral symptoms than by the external conditions. If compression be evidently present no doubt can exist as to the propriety of the surgeon's cutting down on the suspected part to explore the bone. If he find depression he will proceed to trephine and raise the bone ; if there be merely a fissure, he should yet trephine, as the inner table may be depressed though the outer is not, and especially in the hope of meeting with a clot of blood between the bone and dura mater, which may admit of extraction through his opening. Mr. Abernethy even advocated a still bolder procedure in case this external clot were not found, and the dura mater had a dark hue and bulged up into the wound: we allude to his proposal to cut into this membrane in expectation of discovering the sanguineous effusion in the arachnoid cavity. In seve- ral instances this has been actually effected, and the sufferer's life thereby saved, but it is comparatively a rare lesion, and when it does occur, the blood but too often spreads over the hemisphere, or diffuses itself at the base of the Skull, and is besides in too great quan- 5 q 2