SECT. XC.—ON FRACTURES OF THE BONES OF THE HEAD.
In particular, then, a fracture in the head is a division of the cranium, sometimes simple and sometimes complex, occasioned by some external violence. The differences of fractures of the head are these: a fissure, an incision, an expression, a depression, an arched fracture, and, in infants, a dent. A fissure, then, is a division of the skull, either superficial or deep, when the inward bone is not removed out of its place. An incision, or slash, (ἐγκοπὴ) is a division of the skull with refraction of the fractured bone (if the injured bone be broken off some call the affection deasciatio, i. e. as if done by a hatchet). An expression is a division of a bone into many parts, with a sinking down of the fractured pieces upon the membrane of the brain. A depression (ἐγγίσωμα) is a division of a bone with a sinking downwards of the fractured bone from its natural position towards the meninx. An arched fracture (καμάρωσις), as Galen says, is a division of the skull attended with elevation of the fractured pieces in the middle, and depression around the edges of the sound parts, like as in expression. Such is his opinion. Some enumerate also the capillary fracture, but it is a very narrow fissure which eludes the senses, and therefore, being often overlooked owing to the symptoms of it not being obvious, it occasions death. An indentation is not a division of a bone, and, therefore, such an injury is not properly called a fracture, but is, as it were, a protrusion and bending of the skull inwardly, forming a hollow without a solution of continuity, as when vessels made of copper, or the raw hide of an ox, are struck on the outside. There are two different kinds of indentation, for either the bone is depressed through its whole thickness, so that often a separation of the membrane of the brain takes place, or it is pressed upon by the skull throughout; or sometimes the indentation does not affect the skull through its whole thickness but only its outer plate down to the diploe. To these differences some also add that by repercussion, which happens, say they, when a fracture of the cranium takes place opposite to the part which received the blow. But they are in a mistake, for what happens to glass vessels does not, as they say, happen here; for, this happens to them from their being empty, but the skull is full and otherwise strong. But when many other parts of the head have been struck, as in a fall, and a fissure of the skull takes place without a solution of continuity of the skin, an abscess afterwards forms in it, and being opened, this fissure is discovered, which appears to them to have been occasioned by the blow on the opposite side; and this is to be cured like the fissure first mentioned. If a fracture, then, occur in the head, it is discovered by the sharpness, weight, hardness, or violent force of the body which struck it, and by the symptoms which supervene upon the person who has been struck, such as vertigo, loss of speech, and sudden prostration, more particularly if it be a fracture with depression, or contusion, or expression, or the internally-arched fracture, owing to the compression of the brain. It is also discovered by its appearances to the senses; for if there be a considerable division of the skin we ascertain the occurrence readily thereby; but if there be no division, or a very narrow one, and we suspect a fracture, we make an incision in the skin and ascertain it by the sight, or by probing it with an instrument. If then it be any of the other kinds of fracture it will readily be apparent, but if it is only a narrow capillary fissure which eludes the sense, having poured on the part some black liquid medicine, or the common writing ink, we scrape the bone, for the fissure appears black, and we must go on scraping until the symptoms of the fissure disappear; but if it extend to the membrane we must desist from the scraping, and endeavour to ascertain whether the membrane has separated from the bone or remains fixed. For if it remain, the inflammation of the wound continues moderate, the patient gets gradually freed from the fever, and the pus appears concocted. But if the membrane has separated, the pains increase and the fever in like manner, the bone changes colour, and then unconcocted pus is discharged; and if the person who has the charge of it neglect the case, and has not recourse to perforation, still more grievous symptoms will come on, vomiting of bile, convulsions, disorder of intellect, and acute fever, under which circumstances one must decline operating. But if these are not present, and the membrane has not separated, and if the fracture be a mere fissure, it may be cured by scraping alone, although it be of considerable depth. If it extend to the diploe only it is to be scraped down to it, or the broken bone removed, as will be described. If broken into small pieces, these also are to be extracted with a convenient instrument. And if the membrane separate, and you have treated the patient from the commencement, and if it be winter, endeavour by all means to effect the removal of the bone before the fourteenth day; but, if in summer, before the seventh, while the afore-mentioned symptoms have not come on you may operate in this way:
The Operation.—Having first shaved the head about the wound, we make two incisions intersecting one another at right angles like the Greek letter Χ, one of them being the wound already existing; then dissecting the four angles at the top, so that the bone about to be perforated may be wholly laid bare, if there be bleeding we apply pledgets moistened in oxycrate, but if not dry ones; and then applying a compress out of wine and oil, we use a proper bandage; and next day, if no new symptom supervene, we proceed to perforate the affected bone. Wherefore, having placed the patient on a seat, or in a reclining posture suitable to the wound, and stuffed his ears with wool in order to avoid the noise of the perforation, we loosen the bandage from the wound, and having removed all the dressings and sponged it, we direct two assistants with small twisted bands to retract the four angles of the parts lying over the fracture, and if the bone be weak, either naturally or from the fracture, we cut it out with counter-perforators, beginning first with the broader ones and changing to the narrower, and then using those which are of the form of a specillum, striking gently with the mallet to avoid shaking the head. But if the bone be strong it is to be first perforated with that kind of perforators called abaptistæ, which have certain eminences projecting a little above the point that prevent them from sinking down to the membrane, and then, by using the chisels, we remove the fractured bone not at once, but by pieces, if possible with the fingers, or otherwise with a tooth forceps, or bone forceps, or hair-nippers, or some such instrument. The space between the perforations should be as great as the breadth of the largest head of a specillum, and its depth should be until it is near the inner surface of the bone, taking care that the perforator (trepan?) do not touch the membrane. Therefore, in order to suit the thickness of the bone with the size of the perforator, several ought to be previously prepared for the purpose. But if the fracture extend only to the diploe the perforation should be carried no farther. After the removal of the bone, having cleared away any asperity that remained after the cutting of the bone with a carving instrument, or the extremity of a perforator, using the meningo-phylax as a protector, and bringing away carefully the small bones and spiculæ which remain, we proceed to the application of the dressings. This is the more common, and at the same time the easiest and least dangerous mode of operating; but the method of performing it with a sort of incisor called lenticular is greatly praised by Galen, being performed without perforation after the part has been scraped all round with hollow chisels (κυκλίσκοι). Wherefore he says thus: “If you have once laid bare the place, then applying the incisor, which has a projection at the extremity like a lenticular, blunt and smooth, but sharp longitudinally, when you apply the broad part of the lenticular to the meninx, divide the cranium by striking with the small hammer. For we have all that we require in such operations; for the membrane, even if the operator were half asleep, could not be wounded being in contact only with the broad part of the lenticular, and if anything adhere to the cranium, the round part of the lenticular removes its adhesion without trouble. And behind it follows the incisor, or knife itself, dividing the skull; so that is impossible to discover another mode of operating more free from danger or more expeditious.” But the mode of operating with saws and the instruments called chœnicides or modioli (trepans?) is condemned by the moderns as a bad one, and the operation may be done as we described for fissure. The same mode of removing bones will be applicable in the other fractures of the cranium. But regarding the amount of bones requiring extraction Galen informs us, writing thus plainly: “What parts of a fractured bone are to be removed I will now explain to you in order. When it is greatly bruised it is to be taken out entire, but if certain fissures extend from it farther, as sometimes they appear to do, we must not pursue them to their termination, well knowing that no harm will result from them if everything else be properly done.” After the operation, having dipped a simple linen rag of the size of the wound in oil of roses, we lay it over the membrane as a cover, and in like manner, having dipped a small ball of wool in oil of roses, we put it over the aforesaid rag, and then having moistened a doubled compress in wine and oil, or in the same oil of roses, we apply it to the whole wound, taking care that they be not too heavy for the meninx. We then have recourse to a broad bandage, which also must not be made tight, but so as merely to preserve the pledgets. And the regimen is to be what is called anti-inflammatory and such as is applicable for fevers, frequently bathing the membrane with oil of roses. After the third day loosing them and sponging the part we pursue the treatment applicable for recent wounds and the anti-inflammatory; sprinkling upon the meninx some of the powders called cephalics until it incarnate, and sometimes scraping the bone, if it require it, on account of certain projecting spiculæ, or for the sake of incarnation itself. And we may apply medicines of the ingredients recommended for wounds.
On inflammation of the membrane of the brain. Often after the operation the membrane is inflamed, so as not only to rise above the skull but likewise above the skin, and is attended with hardness, and obstructs the natural pulsatory motion of the brain, in which case convulsions and other severe symptoms, or death, for the most part supervene. It becomes inflamed either from the irritation of some sharp projecting piece of bone, or from the weight of the dressings, or from cold, or from eating too much, or from drinking wine, or some other cause not apparent. If then the cause be obvious it is to be speedily removed, or, if it is not, it will be proper to contend strenuously against it, either by having recourse to venesection, if nothing prohibit it, or to a diet suitable for inflammation. We must also use topical remedies, such as warm embrocations with hot rose-oil, and bathing the part with the decoction of marshmallows, or of fenugreek, of linseed, of camomile, and such like, and cataplasms of raw barley flour, or of linseed with the aforementioned decoction and the grease of a fowl; and irrigations with wool to be poured upon the head and occiput, and some anti-inflammatory oil is also to be poured into the meatus auditorius. The viscera also are not to be neglected, but suitable cataplasms are to be applied to them. And care is to be taken of the whole body, putting the patients into warm baths and anointing them. If the inflammation continues and nothing else prohibit, Hippocrates directs us to purge them with cholagogue medicines.
On blackness of the meninx. When the meninx turns black, if the blackness be superficial, and has been brought on by medicines which have that property, we may remove it by applying three parts of honey with rose-oil upon pledgets, along with the other suitable treatment. But if the blackness has come on spontaneously, more particularly if deep-seated, and be attended with other dangerous symptoms, then we must refrain from using them, for these appearances indicate a dissolution of the natural heat. I knew a person who had his skull trephined a year after the accident, and recovered. The fracture was from a weapon, and was situated on the bregma, and the discharge having an outlet, the meninx was thereby preserved free from injury.
Commentary. Hippocrates very properly lays it down as a rule that no injuries of the head are to be considered as trifling, since wounds affecting only the integuments will sometimes prove dangerous if neglected. He treats distinctly of fissures, contusions, and fractures of the cranium, which is an excellent arrangement of these accidents. Our limits, however, will not allow of our entering minutely into an explanation of his modes of treatment. In fractures of the head he forbids liquid applications, especially wine. He calls the trephine by the name of τρύπανον; and makes mention of a raspatory (ξυστὴρ). It would appear that his object in applying the trepan was altogether preventive; that is to say, that he had recourse to the operation in order to prevent inflammation and swelling of the brain, and not to remove the effects of them. He holds that severe contusions without fracture and fissures are more dangerous than injuries attended with depression and considerable separation of the fractured portions, and it is in the former class of cases that he recommends trepanning. When the bone is broken into several pieces, he says it stands in no need of the trephine. One of the varieties of fracture, which he describes with surprising accuracy, is the separation of the bones at a suture. It, he adds, seldom requires the use of the trephine. He remarks, that convulsions often occur in consequence of injuries of the head, and that the convulsions are in the opposite side to that in which the injury of the brain is seated. He gives an excellent account of erysipelas of the face supervening upon injury of the head, and recommends it to be treated with cholagogues. Altogether, his work ‘On Injuries of the Head’ bespeaks extensive acquaintance with the subject, and we need have little hesitation in pronouncing it to be one of the most valuable relics of antiquity. In one of his aphorisms, he states that concussion of the brain occasions loss of speech; that is to say, as Galen explains his meaning, superinduces apoplectic symptoms.
Galen mentions three sorts of instruments for operating upon the cranium, namely the cyclisci, the lenticulars, and the narrow raspatories. Fractures are classed by him into those which extend only to the diploe, and those which penetrate to the inner surface of the bone. He likewise divides them into simple fissures, contusions, and depressions inflicted by the body, which occasioned the injury. When the fissure extends down only to the diploe, he directs us to scrape down the bone with raspatories, and then to apply the medicines called cephalics, consisting of Illyrian iris, the farina of tares, manna, birthwort, and panacea. Of the fractures which extend to the meninx, if a simple fissure, it may be treated in the same manner by raspatories; but if attended with contusion, by perforating it all round with an auger (trepan?), and then using the scalpel, or by means of the cyclisci at once. Some, he says, instead of these instruments, use the abaptista, which had a circular border projecting a little above the sharp extremity of the perforator. Some, he says, from timidity, use only the instrument called chœnix (modiolus). Of all modes, however, he prefers that by the lenticular, as stated by our author. He then defines the engeisoma and camerosis, which we have translated the depressed and the arched fractures, the former being attended with depression, and the latter with elevation in the middle of the fracture. These are to be taken out entire by means of a lenticular or bone forceps. This, by the way, was the practice of the celebrated Heliodorus, of whose opinions on this subject we will give a short abstract below. (Nicetæ Collectio.) Such is Galen’s general treatment of fractures of the skull. In a word, he lays it down as a rule, that parts which are greatly comminuted, must be entirely removed; but that fragments, which extend far, must not be followed to their extremities. He forbids the use of bandages. He mentions having trepanned the head occasionally, but states that he generally left this task to the Roman surgeons. Sprengel remarks, that Galen was averse to the use of the trepan, and preferred the two instruments called by him φακωτὸς and κυκλίσκος. The latter, he remarks, was, properly speaking, a hollow chisel (un ciseau creux), which he drove in with a hammer. The former was a true lenticular-knife, resembling that described by Petit and Bell (Hist. de la Méd., 18.)
We will now attempt an abstract of Celsus’s lengthy account of these accidents. When the skull has been struck, he recommends us in the first place to inquire whether the person has vomited bile, has experienced dimness of vision, with loss of speech, or a discharge of blood from the nose and ears; whether he fell down at the time, and if he lay in a comatose and senseless state. These symptoms, he says, indicate a fracture of the bone, and the accident is to be looked upon as serious. But if torpor has come on, with mental aberration, paralysis, or contraction of the tendons, it is probable that the membrane of the brain has been injured, and little hopes of recovery need be entertained. In order to ascertain whether or not the bone be fractured, nothing answers better, he says, than making an examination with a specillum (sound), that is neither too sharp nor too blunt. If the bone is felt to be everywhere smooth, we are certain that it is sound; but if roughness is detected, we know that it is occasioned by a fracture. He warns us, however, not to mistake a suture for a fissure, as was once done by Hippocrates, upon whom he bestows a merited eulogium for this frank confession of his own blunder. When this method of inspection does not succeed, he advises us to pour writing ink on the part and to scrape the bone, which will appear black when there is a fissure. Sometimes, however, he adds, the blow has been sustained on one part of the skull, and the fissure occurs in another. This is the case of fracture by repercussion, of which we will make further mention afterwards. Celsus says, we ought to suspect the existence of it when symptoms of fracture have occurred without our being able to detect one in the part which received the blow. He also recommends us, if softness and swelling be detected in any part, to examine it, as it is likely that a fissure of the bone may be found there. (By the softness and swelling, of which he speaks, he probably meant the puffy tumour, described by Mr. Pott, in his work on ‘Injuries of the Head.’) Sometimes, he adds, but rarely, although the skull be safe, a vessel in the membrane of the brain bursts and pours forth much blood, which, becoming coagulated, occasions great pain and dimness of sight. In such a case, he says, the pain will point out the seat of the extravasation, and if an incision be made in the skin, the bone will be found to be pale—“eo loco cute incisâ, pallidum os reperitur.” (Heliodorus, in like manner, states that when extravasation has taken place within the cranium, the bone will be found to be pale—Nicetæ Collectio.) The fact that in cases of extravasation below the skull the bone is pale, that is to say, does not bleed, is pointed out by Mr. Abernethy as an unerring guide to practice in such cases. He says, “unless one of the large vessels of the dura mater be wounded, the quantity of blood poured out will probably be inconsiderable; I believe that a bone so circumstanced will not be found to bleed.” Celsus then proceeds to the description of the operation. If the injured portion of the bone is not sufficiently exposed, he directs us in the first place to enlarge the wound of the integuments. The periosteum is then to be scraped away with a raspatory. The form of the incision, if made solely by the operator, is to consist of two cross lines intersecting one another like the letter Χ, from the extremities of which the skin is to be dissected away. If there be a discharge of blood it is to be stopped by a sponge dipped in vinegar, or by compresses, while the head is elevated. In cases of fracture and fissure of the cranium, the ancient surgeons, he says, had immediate recourse to instruments for cutting out the part; but he recommends the surgeon, in the first place, to try the effect of applications for allaying the irritation, such as suitable plasters, with wool soaked in vinegar, proper bandages, and the like. This treatment is to be continued for five days, and on the sixth the part is to be fomented with a sponge soaked in warm water. If the skin begin to heal, and the fever to abate, and if the appetite return, with sound sleep, he recommends perseverance in the use of these applications. In this manner, he adds, fissures will often be filled with callus; thus, also, bones more extensively fractured may become united with callus, which forms a much better cover to the brain than the common integuments after a piece of bone has been cut out. But if, on the other hand, fever set in at the first with disturbed sleep, a copious discharge from the wound which shows no appearance of healing; if the glands of the neck swell, or if violent pain comes on, with loathing of food, the surgeon must proceed forthwith to the operation. Dangerous consequences, he adds, may arise either from a fissure or a depression. A fissure may allow fluids to descend to the membrane of the brain, and thereby give rise to pain and inflammation. A depression in like manner may occasion irritation, and spiculæ of bones by wounding the brain may prove particularly troublesome. As a general rule, he recommends as little of the bone as possible to be removed. If the one edge overtop the other, it will be sufficient to remove with a raspatory the prominent part; for when it is taken away there will be a sufficient opening for the cure. If the edges are firmly compressed together, a hole is to be bored with a wimble (terebra) on its side, at the distance of a finger’s breath, and from it two lines are to be cut to the fissure with a raspatory (scalpel), in the form of the letter V, so that its vertex may be at the hole, and its base at the fissure. If the fracture be long, more of these holes must be cut out. In cases of depression the whole depressed portion must be removed. In whatever way the pieces of bone are cut they are all to be removed by means of a suitable forceps. But we will not occupy more space in explaining his method of operating, as we have been already more than usually prolix. Enough has been said to show that the practice of Celsus was sensible, and in many respects not very different from that which is now followed in such cases. It will be seen that he was not forward to perforate the skull, and that many of the rules of treatment lately laid down as new discoveries are distinctly mentioned by him. For a description of the instruments used by him, namely, the modiolus, terebræ, and scalper excisorius, we must refer the reader to the original work. (viii, 3.)
The different kinds of fracture to which the skull is subject, and the treatment of them, are given very minutely in the Fragments of Heliodorus, published by Cocchi (Ch. Vet. 100, &c.); but as the views of the subject there laid down are nearly the same as our author’s, we shall only give a few specimens of the doctrines he inculcates. He describes very distinctly the species of fracture called diastasis, namely, the separation of two bones of the head at a suture. He directs that the head should be moulded into its former shape, and secured with compresses and tight bandaging. When matter forms he recommends it to be cut down upon. When depression of the bone without fracture occurs in children, it is not to be much interfered with, if no untoward symptoms come on. But if any collection take place, it is to be evacuated, even if trepanning should be required for this purpose. He says, in the treatment of simple injuries of the scalp, that the cure by the first intention is the quickest, but the suppurative the safest. In the same Collection there are a few fragments of Archigenes, containing some curious and important matter. He describes diastasis of the bones with more minuteness than any other ancient author, but does not touch upon the treatment. He appears to treat of hernia cerebri under the name of hypersarcosis, and recommends the excrescence to be removed, with septic medicines or the scalpel, down to the membrane (dura mater); after which a light dressing dipped in rose-oil is to be applied, and the part surrounded with a circular bandage. (Chirurg. Vet. p. 119.) Effusion of blood within the cranium is indicated by fevers coming on with chills, inordinate heat, disturbed sleep, eyes glossy, muddy, and red, loss of flesh, &c. In such cases, he remarks, if operated upon speedily, they exhibit promises of recovery, but generally soon die. (Ibid. 117.)