In serious and lacerated cases it is inadvisable to close the wound with the view of attempting primary union. It should be packed with gauze and temporarily closed with secondary sutures. These measures should be seconded by physiological rest (quietude of the head, which may even be enforced by the posterior plaster-of-Paris splint to the head and neck), attention to the primæ viæ, the avoidance of transportation, the prevention of auto-intoxication, etc. The surgeon should use discrimination as to the amount of bone to be removed, the wisdom of opening the dura when not lacerated, of examination of the brain with the exploring needle, the matter of drainage, and the time during which it shall remain. With reference to all these matters exact rules cannot be given. When drainage is made in recent cases it is usually sufficient to drain the scalp wound. Only in cases where there is probability of meningeal infection is it advisable to attempt to drain the dural cavity. This is better accomplished with gauze, catgut, or folded rubber tissue than with drainage tubes.
Skull fractures where the injury is limited to a small area are treated according to a bolder method than was in vogue a number of years ago. There should be careful and judicious operating in every case where distinct depression can be made out, as well as in every case where indications point to injury of parts within the bone. The statistics of trephining in the pre-antiseptic era are valueless as arguments in this consideration. If done according to aseptic precautions, and if good surgical judgment be used in every respect, the operation is per se almost devoid of mortality and should not be regarded as a last resort, but rather in such cases as a first one. I have seen so many instances of later untoward consequences resulting from delay, which corroborate the experience of others, that I would not be misunderstood in this matter. My advice might perhaps be summed up in the following words: Where there are no brain symptoms and no skull symptoms, in fractures of the vertex, let the case alone; when either of these are present, especially the former, it will always be advisable to operate.
Fractures of the Base of the Skull.
In the majority of these fractures the violence is applied at some more or less distant point, and, by transmission through the arch-like structure of the skull, expends itself in fissuring or comminuting the base. The most frequent location of the indirect injury is upon the convexity. The mechanism of these fractures has been a problem for many centuries, but has been cleared up mainly within the past three decades. Félizet has shown, for instance, how the handle of a hammer may be forced into its head by striking it in either one of two different ways, and has compared the mechanism of basal fractures to this fact. The secret of these fractures probably resides in the elasticity of the skull, which varies within wide limits in different individuals, and which breaks, as do the ribs and the pelvis, at points more or less distant from that at which the injury occurred. Were the skull everywhere equally thick and elastic, there would be much less variation in these fractures, but lacerations frequently extend between the most resistant parts; and when violence is applied upon the forehead we find that the resulting fissure extends between the crista and the wings of the sphenoid, upon the same side, in its course toward the base; that when the lateral region of the skull is injured the fissure extends between the sphenoidal wings and the occipital bone; and that when the occipital region receives the first injury the fracture lies between the pyramid and the occipital crests. The analogy between fractures of the skull and cracks made in nutshells (cocoanuts, etc.) when struck with a hammer is too self-evident to be disregarded. Many years since the French introduced the term fracture by contre-coup (counter-stroke)—a practical admission of the occurrence of fracture at a point more or less opposite to that struck.
Fig. 375
Fracture of base of skull. (Bruns.)
Fig. 376
Fracture of base by fall on vertex. Both condyles broken off and driven in. Vertex was fissured.