Elements of Surgery

by Robert Liston

preceded by excited circulation and furious delirium, the vital powers recovering from their first depression, only to become roused into violent and destructive action, again to sink to a still lower ebb, and be ultimately annihilated. Extravasation is most commonly met with on the lateral parts of the brain in the situation here indicated; the coagulum is perhaps extensive, reaching to the base of the skull, in consequence of rupture of the middle meningeal artery, with or without fracture of the parietal bone.

Little or nothing can be done in cases of compressed brain from extravasation. We possess no means of preventing the effusion, and though we did, the mischief has generally taken place before the patient can receive assistance. Again, the site of the extravasation can seldom be ascertained; and, should that objection to the propriety of surgical interference not exist, still the coagulated blood cannot be evacuated even after extensive removal of the bone. If the coagulum is small, it may be gradually and wholly absorbed, or the brain may become accustomed to the pressure of what remains. It is the surgeon’s duty to take means for averting inflammatory action, and to subdue or moderate it when it has been excited. The symptoms arising from displaced bone may be relieved by surgical operation; but we must premise some observations on fracture, before speaking of the treatment necessary in such cases.

FRACTURES OF THE CRANIAL BONES.

At an early period of life the bones are soft and elastic; they yield readily under external violence, and it requires a great and direct force to produce fracture of them. Late in life, when the diploe disappears, the external and internal tables come in contact; the bone is brittle, and solution of continuity in it is easily effected. And it is wisely so arranged, for thus in the recklessness of childhood and youth, severe blows on the cranium, which are then of so frequent occurrence, are seldom attended or followed with danger; whilst the aged are taught by experience to avoid the unfortunate consequences so apt to result from even a slight blow on the then brittle cranium, by cautiously preserving themselves from exposure to violence.

Solutions of continuity in the cranium, caused by external force, are either attended with depression or not. Fissures, mere capillary rents in the bone, may take place at the part of the cranium which is struck, or on the side opposite to that to which the force is applied. They will be found either short and limited by sutures, or extending in different directions through several sutures, as from the vertex to the base of the skull, and terminating perhaps in the foramen magnum. Fissures in the upper part of the cranium are of themselves attended with comparatively little danger; they produce of themselves no claim to attention, and really require none. But the force which gave rise to the injury of the bone may have disturbed the internal parts; and though the patient may have recovered from the first shock and the immediate effects of the violence, severe and dangerous consequences often result, and at a late period from the infliction of the injury.

Fractures of the base of the skull are the result of great force applied to the lateral parts of the head, to the vertex, or to the base itself through the spinal column. A blow inflicted by an obtuse body on the top of the head, whilst it is at rest and fixed—by producing expansion of the lateral parietes, and forcing the base down upon the upper part of the spinal column—may have the effect of breaking up the connections of the bones at the base, which is the weakest part of the cranium, and splintering them to a greater or less extent. Again, if a person falls from a height, he perhaps alights on some part of his trunk, as the buttocks, and this coming to a state of rest, whilst the head is still in projectile motion, the spinal column is driven towards the cavity of the cranium, and the same effects are thereby produced as in the preceding instance. Or the patient alights on his head, and the base of the cranium is then impinged upon by the weight of the whole trunk, as well as by the force of the projecting power,

and in this case also the base is frequently broken up. In the sketch here given, showing extensive fracture of the occipital and sphenoid bones into the foramen magnum, the patient, a brick-layer, fell from a ladder on the vertex. He lay comatose for some days before death: there was found extensive extravasation over the middle lobes and cerebellum. Concussion has resulted from falls when the person has alighted on his nates or feet; but the symptoms attendant on fracture of the base are more generally those of compression of the brain. In this accident the bones are seldom displaced to any great extent; the dura mater is generally lacerated, its bloodvessels, and frequently its sinuses, are wounded, and blood is consequently effused at the base of the brain, where injury is most fatal. The upper part of the brain may bear pressure to a considerable degree without bad consequences ensuing, but compression at the origins of the nerves is always highly dangerous and generally fatal. Bleeding from the nose, mouth, and ears, when attended with other circumstances and symptoms evincing a violent injury and consequent cerebral disturbance, has been considered as decisive of fracture at the base having occurred. But we find that such bleeding happens in slight injuries unattended with any circumstances or consequences to induce a belief that so serious an injury has taken place: and again, in cases where dissection has shown most extensive fracture in the temporal, sphenoid, and æthmoid bones, no blood had issued from their external openings. Fracture of the base of the skull generally proves fatal, but many cases are met with in which there is reason to believe that it had taken place, and yet the patients have recovered with perhaps partial paralysis. Of this I lately met with a good example in the case of a girl seven years of age, whose head had been squeezed between a wall and the back of a cart, and thereby considerably flattened. She lay insensible for several days, with all the symptoms of compression, and with blood flowing in small quantity from the nose, mouth, and right ear. An extensive abscess formed over the right temporal bone. She ultimately recovered, but remained affected with paralysis of the right side of the face and amaurosis of the left eye; sensation in the paralysed parts being quite perfect.

Fractures of the upper part of the cranium are generally attended with displacement to a greater or less extent, and with wound of the cranial coverings. The size of the depressed portion, the depth to which it is displaced, and the extent of wound, will depend upon the nature and intensity of the force applied. When both tables are broken, the fracture of the inner is almost always more extensive than that of the outer one, as fissures will extend furthest in the most brittle part. A broken fragment, comprehending the entire thickness of the skull, presents generally a much larger portion of the inner than of the outer table, so much so that the piece would sometimes not admit of removal, though perfectly detached, without enlarging the opening in the outer table. Fractures, with depression of a considerable portion of one of the flat bones, are sometimes unattended with any alarming symptoms. The effects of the injury soon disappear, and even in cases where the depression has been very considerable, and where, from the escape of brain, it was evident that both this organ and its membranes had been seriously injured, no bad symptoms have occurred to retard the patient’s recovery. Symptoms of compressed brain, however, may generally be expected to attend depression of any considerable portion of bone below its natural level. Still the brain may become accustomed to the pressure, and the symptoms may gradually subside without surgical interference. And if the indications of compression are not very alarming, the coma not very profound, a little delay is allowable, means being taken to avert inflammatory action: for danger is not imminent, the cure may not be expedited by operative aid, and there is chance of injury resulting from rash interference.

But it is in general necessary to remove the cause of the symptoms, to elevate the depressed bone, and take away those portions which may be detached.