270. The propriety of dividing the scalp in an adult, in order to examine the state of the bone beneath, when evidently depressed, thus rendering a simple although comminuted fracture a compound one, is a matter of very great importance, the decision of which rests upon the still more essential point—viz., whether a depressed portion of bone ought or ought not to be removed? This again must depend upon the nature and extent of the depression, for many persons who have suffered from such a misfortune have recovered without the depressed portion being raised. It is a question of degree or extent, upon which every surgeon must form a judgment from his own observation and experience.
The difference between a simple and a compound fracture of the leg is often considerable; it is more often dependent on degree. When the fracture is nearly transverse, and the skin is cleanly divided, the difference between it and a simple fracture of the same part is little more than one of time. This may be the case with an injury of the head; the difference between the two states in fractures of the skull has, however, been much exaggerated; so much so, that no reliance can be placed on the supposition that there is more real danger in a case of fracture with depression in which the scalp has been divided, than when it has been only bruised, and not divided. I admit that theoretically it ought to be otherwise, but theory and practice do not always correspond. In all cases in which a fracture with marked depression is known to have occurred in an ADULT, it is good practice to ascertain the nature and extent of the depression. It is imperatively necessary if accompanied by symptoms of compression.
If the result of a great number of comparative trials should be in favor of never, under any circumstances, raising a depressed portion of bone in an adult, but of leaving it to the efforts of nature, an incision in order to ascertain the state of parts below ought not to be made; but as such a result is not likely to be obtained, the practice recommended appears to be the best.
The scalp should be divided, in such cases as may require the operation, by a straight, crucial, or such other shaped incision as may be found most convenient to the surgeon; but no part should be removed which can be preserved with the hope of maintaining its life.
271. The cranium, together with the fracture and depression, being exposed, the question whether the trephine should be applied or not is next to be determined. If the operation by the trephine, or that of sawing a piece of bone out of the head, were not in itself dangerous, there could be no hesitation about its use; but it is a dangerous operation, especially in crowded hospitals, and ought not to be resorted to when it can be avoided. If any ten healthy persons were trephined in a hospital, one would in all probability die from the effects of the operation, and three or four more might have a narrow escape from the inflammation of the brain and its membranes, or the other consequences which would probably ensue. It is not the admission of air, which has been even lately supposed to do mischief, that is to be dreaded in these cases, but the same kind of irritation which often follows the abstraction of a piece of bone under other and more ordinary circumstances at a later period of time.
The following cases are illustrative of many important points:—
William Rogers, aged nineteen, of the 32d Regiment, was wounded on the 16th of June by a musket-ball, which entered at the inferior angle of the left parietal bone, knocked him down, and for a few minutes rendered him insensible. On recovering his mental powers, he found that he was unable to speak, not so much (as he said afterward) from the want of power to form words, as from the incapacity of giving them sound. He was conscious of everything passing around him, and reasoned correctly. He retired out of the reach of shot, and then lay down for the night. On the following morning, he went to Brussels, where he was examined and dressed. On the morning of the 18th he reached Antwerp on horseback, very giddy, and overwhelmed with fatigue, fasting, and watching; he was admitted into the Minimes General Hospital and put to bed, when he soon fell into a sound sleep, which with some tea refreshed him much.
June 19th. The ball was found to have passed obliquely upward and backward at least two inches, and could be distinctly felt with a probe. It gave more the idea of having raised the outer table than that of having depressed the inner. The defect in speech was in some measure diminished, and this with giddiness were the only symptoms of compression. A poultice was placed over the wound, a brisk purgative given, and spoon diet ordered.
20th. The pain and giddiness having increased, with annoyance from noise and exposure to light, twenty-six ounces of blood were taken from the arm. The following day the purgative was repeated, and the patient was much relieved. Everything went on well, the wound was nearly healed, and he was considered almost fit to be discharged, when, on the 16th of July, the wound began to open; on the 18th it was dilated and a portion of the cranium removed by the forceps; this was soon followed by symptoms of inflammation of the brain; twenty ounces of blood were taken immediately from the arm, purgatives and diaphoretics were ordered, and the strictest abstinence enjoined. 23d. Venesection was repeated, as well as the other means usually adopted to reduce high action. 24th. Completely relieved. 26th. Another portion of the cranium removed, the dura mater being fully exposed; the general health in the best state.
August 3d. Doing remarkably well; the wound healthy; the pulsation of the brain evident; the power of speech perfectly restored. The ball yet remains in, according to the opinion of the patient, (who is a fine, intelligent lad,) and he thinks it has gradually descended toward the petrous portion of the left temporal bone. Sent to England at the end of the month, the wound being healed.