The Surgery of the Skull and Brain

by Louis Bathe Rawling

On the evidence supplied by symptoms dependent on injury to the intracranial contents.

The various intracranial lesions are discussed elsewhere (see [Chapters III] and [IV]).

Evidence supplied by local examination.

A compound fracture will be most readily determined by digital examination, previous to which the scalp-wound must be carefully cleansed. Digital examination is greatly preferable to investigation with the aid of the probe. In any case care must be taken to avoid mistaking one of the sutures of the skull for a fissured fracture.

In simple fractures the diagnosis is frequently obscured by an extensive subaponeurotic or subpericranial hæmatoma. Irregularities of surface are more or less diagnostic of a solution in the surface of the bone, and a linear hæmatoma is of corresponding clinical value. In any case, the presence of an extensive hæmatoma must be regarded as of so suggestive a nature that exploration is called for, more especially when prolonged concussion or compression are co-existent. Such treatment is imperative when the hæmatoma—whether diffuse, localized, or linear—pulsates, such a condition implying a breach in the surface of both bone and dura with communication between the extra-cranial and some intra-cranial hæmorrhage.

Pringle[24] lays stress on the value of percussion as an aid to diagnosis.

‘The patient’s head must be supported beneath the occiput, the mouth either open or shut—it matters not, so long as it is the same throughout the examination—and the skull is struck sharply with the finger. When a fracture is present, two changes in note may be elicited. Either a note lowered in pitch over the fracture zone, or, in addition, a definite crack-pot sound. The note elicited is most typical when comminution is present, and some fragments loose. A fracture of a T or L or V-shape gives the best crack-pot sound, and the crack quality is always most pronounced when the percussing finger comes over the angular portion of the bone. Hæmorrhage into the subaponeurotic region blurs the note.’

Fig. 42. A Comminuted Fracture of the Skull.

If time and occasion permit, an X-ray photograph will clinch the matter.