Elements of Surgery

by Robert Liston

But the operation may sometimes fail to prove beneficial; the brain may have become diseased, as well as its membranes, or the patient may not recover from the irritation caused by the abscess, and the depressing tendency of the antiphlogistic treatment which may have been put in force, previously to the formation of matter. But still there is a probable chance, after the collected matter has been evacuated by the operation, of the dura mater granulating, the cavity filling up, the membrane becoming adherent to the cranium around the aperture, and the patient regaining his former health and vigour.

If, after removing a portion of bone on account of symptoms of suppuration in that situation, the dura mater be found adherent, and of a healthy appearance, the surgeon is scarcely justified in going deeper in search of effused fluid: the evils liable to result from wounds of the dura mater have been already mentioned, and illustrated by an example.

The operation of trephine must also be resorted to in cases of punctured fracture. One perforation will generally be sufficient to enable the surgeon to remove the detached fragments of the inner table.

In fractures with depression, when the brain is oppressed and its functions suspended, means must be taken to elevate the displaced portion or portions to their natural level, and so remove the pressure. For the accomplishment of this purpose, it may or may not be necessary to divide the integuments. If they are entire, which is rarely the case, a crucial incision must be made, or one in the form of the letter T, and the flaps raised so as to show the extent of depression. No portion of the integuments ought to be cut away; the preparatory process of scalping, formerly in use, has been abandoned as cruel and unnecessary. If a wound already exists, but is not sufficiently large, it may be dilated in such a direction as appears most likely to facilitate the after part of the proceedings. The elevation can often be then effected by the judicious application of the lever, its point being carefully placed under the depressed portion, and the sound part of the bone being made the fixed point on which the instrument acts. Those depressed portions which are completely detached, must be removed; but those which adhere, either to the dura mater or to the scalp, ought to be left after having been raised to their former sites, as they will furnish a large contribution towards the filling up of the deficient parietes. Reparation of the skull, when a small portion is removed, or when a single narrow fracture exists, is effected by bone; but when the opening is large, the deficiency is always repaired by a dense ligament, to which the dura mater and integuments adhere. By employing a small saw—represented in both ancient and modern surgical works—so as to widen the fracture, or remove a projecting corner of bone, sufficient room may be obtained for the introduction of the lever and the removal of splinters. In old subjects, the bones are brittle, and a small corner may be readily removed by pliers, or cutting forceps, so as to allow the depression to be raised.

But it may be necessary, in order to elevate portions that are wedged under the sound part of the cranium, to take away a considerable portion of the latter. One or more circular pieces must be removed by the trephine, and it may, perhaps, be necessary to cut out the parts between these apertures by means of the straight-edged saw. The size of the crown of the trephine must be varied according to the object which is in view. The trepan is now disused, and the trephines best suited to the purpose are those fluted on the side of the crown, with the perforator made to slide and fix by means of a proper screw. The centre pin, or perforator, is fixed on a sound and firm part of the bone, and the edge of the crown made to project slightly over the fractured margin. A few turns will suffice to fix the instrument. The saw is then made to turn steadily and lightly, pressure being made when the instrument is moving from left to right, until a pretty deep sulcus is made. The centre pin is then withdrawn, the saw being sufficiently retained by its own groove. The centre pin can scarcely be used at all in children, the cranium being at that age soft and thin. I once had occasion to operate with an old-fashioned trepan, at a distance from town, on a child with abscess under the bone, occasioned by a punctured wound from the point of a spinning top. The centre pin was long, very sharp, and screwed in; and, if it had been used, would have perforated skull, dura mater, and nearly half an inch of the brain, before the saw could come in contact with the bone. I was obliged to use the crown of the trepan, without a centre pin.

In patients at the middle period of life, a different feeling and sound is communicated to the operator after having cut through the outer table of the skull. Whether this change is experienced or not after getting to some depth, he ought to proceed cautiously, moving the saw lightly, quickly, and sharply, in the direction of the teeth, and using no pressure. The operator should not be hurried, for he is apt to do harm if he is; there is no inducement to make great haste, for the patient does not suffer much, if any pain. After every two or three turns of the saw, it is prudent to examine the track with the flat end of a probe, or with a toothpick. If the perforation is found to be completed at any point, then the instrument is to be inclined to those which are undivided; and the fluted crown allows of this being done with great facility. After the circle of bone is separated on all sides, it is to be removed by forceps, or by means of the lever; and the sharp points ought to be taken from the edge of the perforation by means of the latter instrument, otherwise the dura mater may be fretted and torn when following the natural motions of the brain. The lever must be strong, and simple in its construction. And after a sufficient space of bone has been removed, its point is to be introduced cautiously under the part that requires elevation; the edge of the sound bone at various points affords a fulcrum, and by persevering and steady efforts, the object of the operation will be accomplished. The dressing of the wound should be simple; the integuments are made to cover the aperture, or as much of it as possible, and due support is given by compress and bandage. The after-treatment must be varied, and conducted according to circumstances. It may become necessary to repress the granulations, or else to soothe the wound and abate inflammatory action in the surrounding parts. Perhaps incisions may be required, to prevent the formation of matter, and destruction of the cellular tissue, and of the tendinous expansion, or to evacuate fluid already secreted. The patient’s strength may require support. He may stand in need of stimulants; or, on the contrary, the most active means may be required to subdue vascular action, and to prevent the evil consequences which would result to the important parts within the cranium from such over-action.

Inflammation of the Scalp occurs either spontaneously, or in consequence of external injury, though slight; and is generally met with in those who have lived freely and irregularly, and are of a bad habit of body. It is more dangerous than inflammation of any other part of the surface, on account of the sympathy and connection which exists between the parts affected and those situated internally: frequently, at an early stage of the affection, delirium occurs, with violent fever. In slight cases, in which the external surface merely is affected, there is little swelling, and but little pain or fever. But when all the pericranial coverings are involved, the symptoms are uniformly severe. The swelling is elevated and puffy, and extends to the eyelids, to the face, and, in some cases, even to the neck: the constitutional symptoms run high, and there is considerable risk of the patient dying comatose. If he recover, and if the disease is little interfered with, but allowed to take its own course, much sero-purulent fluid is infiltrated into the cellular tissue, which generally perishes, along with a greater or less portion of the tendinous expansion lost by sloughing. Often, in neglected cases, a large abscess forms, separating perhaps one-half of the scalp, and bulging over the ear.

The constitutional treatment must vary according to the nature of the symptoms which present themselves; in some cases they show great vascular excitement, and in others they bear unequivocal evidence of general debility from the first. In slight cases of the local affection, it is sufficient to relieve the tension, and abstract blood and effused serum by means of a few punctures, and afterwards to use warm fomentation. More violent cases require free incision in the direction of the fibres of the occipito-frontalis muscle, and thus only can destruction of the parts be averted; the incision must necessarily be deep, for the scalp is often swollen to the thickness of one or more inches. When a depôt of matter has formed, it must be evacuated early, otherwise there is a risk of the bone becoming extensively denuded and exfoliation ensuing.

Chronic thickening of the Scalp is a consequence, by no means unfrequent, of slight injuries in those of strumous habit, but may also occur without any assignable cause. In delicate subjects it is often attended with chronic periostitis of other bones besides those of the cranium. The patient perhaps complains of pains about the shoulders, in the tibiæ, femora, the tuberosities of the ischia, the sternum, the cervical vertebræ, or in the clavicles and ribs. He cannot bear pressure on some points without suffering the most excruciating agony. The pain is also much increased by motion of the parts, as by coughing when the ribs are affected. Such painful affections of parts external to cavities are often mistaken for diseases of the internal organs, and are treated as such by violent bleedings, purgings, and starvation, to the still farther impairment of the patient’s constitution. The symptoms are frequently and correctly attributed to exposure to cold and moisture, sleeping in a damp bed, sitting with wet clothes or on the cold ground; but such affections are very apt to occur in those whose constitution has degenerated into that peculiar cachectic state formerly mentioned, after mercurial courses, whether short or severe; or in those who for some real or fancied derangement of the digestive organs have persevered in swallowing, for months or even years, the universal panacea of some practitioners, Plummer’s or blue pill. The bones and their coverings, of even the best constituted, can scarcely resist a perseverance in such a course.

The swelling of the scalp is often general, and is slightly œdematous; some points are more elevated than others, feel soft, and are the seat of extreme pain when pressed upon. But such affections frequently flit from one part to another; what was most unsound, at one time, recovering itself, and painful swellings attacking that which was comparatively free of disease. The same holds true in regard to the other bones at the commencement of the affection; but when much change of structure takes place, then the pain and swelling become fixed. The pains are most severe during the night, being then so violent as to deprive the patient of rest, and even prevent him from placing his head on the pillow: they abate towards morning, and remain tolerable during the day. They are always aggravated by change in the atmosphere from dryness to moisture, and the prevalence of easterly winds is peculiarly distressing to patients afflicted with such diseases. The swelling is composed of thickened and vascular periosteum with œdematous integuments. The bone too is often increased in size, and condensed, from continuance of increased vascular action; and its surface is roughened in consequence of its texture being opened out, and new bone having been deposited. Death of portions of the bone often follows, either spontaneously, or after slight bruises received during the continuance of the disease. A few accidental blows on the head, and a perseverance in the use of mercurial alteratives for a series of years, gave rise to the state of matters represented in the accompanying illustrations. The large dead portion represented was removed some months before death. Here the deficiency in the cranial bones is partly owing to ulceration, partly to death of portions of them. The patient’s