Penetrating and Incised Wounds.
—Penetrating and incised wounds are frequent about the head, their prognosis per se, as well as their proper treatment, varying but little from that of such wounds in other parts, so long as the skull proper and its contents escape injury. Hemorrhage from scalp wounds may be profuse and even fatal. The most dangerous hemorrhages occur from the temporal vessels. Penetrating wounds are short, and the periosteum and underlying bone are usually also injured. Such small articles as blades of penknives, particles of dirt, etc., will often be found when the parts are carefully inspected, a measure never to be neglected. Contusions of the scalp and skull are spoken of as subcutaneous, subaponeurotic, or subperiosteal, and are most frequent in the frontal and lateral regions. Ecchymoses following them may be extensive and discoloration may spread over a large area. In traumatic hematomas resulting from various injuries incision should be an early resort should blood clot fail to resorb.
INJURIES TO THE CRANIAL BONES.
All conceivable degrees of injury to the bones, from a trifling division of the periosteum down to most extensive denudation or mangling of the external table or the entire thickness of the bones, may be encountered. These lesions may be spread over a large area or may be the result of penetrating wounds. In other words, we may have linear, penetrating, or large surface wounds, with such injury to the scalp as perhaps to amount to a total loss of covering for the same. All of these, moreover, may be complicated by fractures of the bone at the point of injury, with or without brain lesions, or by other and more remote lesions.
In regard to most of these, it may be said that non-penetrating injuries, when promptly and properly attended to, have, in most cases, a favorable prognosis. Every penetrating wound of the cranium is a condition justifying grave prognosis, on account of the great danger of infection incurred. Other features of these wounds, with more in regard to prognosis and treatment, will be given under the head of Compound Fractures of the Skull, etc.
It is necessary, however, to say in this place that penetrating wounds of the cranium are often received in a way which does not permit actual diagnosis, as, for instance, when received through the nose or the orbit. Every wound whose history and appearance indicate that penetration may have occurred should be subjected to the most rigid scrutiny and care. Points of fencing foils, umbrella tips, etc., have been forced into the brain cavity through the orbit and elsewhere in ways which left little external evidence of the severity of the injury.
FRACTURES OF THE SKULL.
Following the anatomists, and for general convenience, these are divided into fractures of the vertex, of the lateral region, and of the base, the former being the most frequent as the vertex is the most exposed. A fracture in a given region may be confined to that locality or may radiate widely or extend nearly around the cranium. Of all the fractures of the bony skeleton those of the skull constitute about 2 per cent.
Fractures of the Vertex of the Skull.
Fractures of the vertex are, in most instances, due to actual violence, the force being often expended at the point of application or producing radiating fractures. Those which are limited to the neighborhood of the injury are referred to as direct fractures, in distinction to which we have indirect or radiating, often producing remarkable results. Fractures may vary between the simplest crack or fissure, accompanied by but trifling brain symptoms and never recognized, to the most extensive comminution and destruction of cranial bones which can be imagined.