Treatment.
—The treatment of basal fractures is mainly symptomatic. The first effort should be to make antiseptic all those parts of the skull involved, which means to shave the scalp; to thoroughly cleanse and irrigate the external ear and the auditory meatus, using a head mirror and ear speculum for this purpose; to tampon the meatus with antiseptic cotton; to provide a copious absorbent dressing for such fluid as may escape and to change this frequently; to cleanse the nasal cavity as well as the conjunctival sac, for all of which the peroxide of hydrogen is serviceable. All of this should be done promptly, while at the same time studying the patient for evidence of brain injury or of involvement of special nerves. By the time these measures are thoroughly performed a decision as to the necessity for immediate operation should have been reached. Evidence of brain compression wanting, and in the absence of external or compound injury the patient may be left at rest, with cold applications to the head and active purgation. In many of these instances benefit follows the application of a number of leeches to the mastoid region and to the occiput. Operation is necessary later only when brain symptoms supervene, these consisting of evidences of compression, either from blood or from pus, as compression from other causes should have been acting at the time of the first examination, and should have been recognized at that time. When direct fractures are evident the possibility of the entrance of foreign bodies should be also remembered. Thus penetrating fractures of the base have occurred through the orbit as the result of accident or assault, and such weapons or implements as foils, ramrods, drumsticks, canes, umbrella points, etc., have been known not only to penetrate into the brain, but perhaps to leave some portion of their substance—e. g., a foil tip or an umbrella tip—within the cranium after their withdrawal.
Separation of sutures, known also as diastasis of the same, is the occasional result of injury instead of, or complicated with, fissures or other fractures. It is the result of violence, and is virtually a specific form of fracture, from which it differs in no essential particular. Diastasis can only take place along lines of previous suture, but it is possible that Wormian bones may be thus loosened. Sutures thus separated ordinarily heal by fibrous repair rather than osseous union. Diagnosis is possible only as they are exposed to view, although displacement in the middle line or along known suture lines may be regarded as diastasis. The treatment differs in no respect from that of other fractures.
Injuries to the frontal sinuses occasionally complicate fractures of the skull. These sinuses vary in different individuals, are rarely truly symmetrical, and are not found in the young. They connect with the nose in such a way that emphysema of the frontal region is quite possible, while air may be blown beneath the periosteum or may communicate with the interior of the cranium. In wounds of the frontal region the sinuses are occasionally opened—a fact of importance, for infection of the Schneiderian membrane may occur and endanger life, mainly because of the retention of infectious products within its cavities. Moreover, by such wounds the ethmoid may also be injured. Pus which escapes from these sinuses and from the ethmoidal cells is usually thin and bad-smelling. Long continuation of suppuration after such injuries probably means necrosis and formation of sequestra.
INJURIES TO THE BRAIN AND ITS ADNEXA.
By better acquaintance with certain portions of the brain whose function is now generally recognized and described, as well as with the more exact knowledge regarding the entire encephalon, the outcome of many recent studies, the teaching of the past in regard to the nature of various brain lesions has been essentially modified. Especially is this true in regard to the distinction formerly emphasized as between concussion and compression. In discussing brain injuries we should, first of all, distinguish between traumatic disturbances of the entire endocranium and localized injuries to the brain or particular vessels and nerves entering into its composition. In regard to the first, it is possible that the entire blood or lymphatic circulation within the cranium may be affected in such a way as to influence its nutrition and function, by which means activity and function are mildly or seriously perverted. The immediate effect of severe injury to any part of the body is reflex vasomotor spasm, which constitutes the essential feature of the condition known everywhere as shock. It is this condition, with its marked local expressions, which was formerly known as concussion of the brain. When studied upon its merits it is found to be indistinguishable from shock produced by injuries to other parts. The condition for so many years taught and recognized as concussion is but shock following injury to the head. This makes no further demands upon the question of pathology than those prompted by any traumatic disturbance.
Through the mechanism of the cerebrospinal fluid rapid alterations of pressure and of the volume of the brain are produced. There is an easy path between the inelastic cranial cavity and the exceedingly elastic and accommodating spinal canal, which latter serves as a reservoir for the fluid which may be pressed out of the cranium when brain pressure is increased. While the subdural and subarachnoid spaces are each of them absolutely closed sacs and do not communicate one with the other, there is ample accommodation within each to permit a constant equilibrium of pressure under ordinary circumstances, as between the spinal canal and the cranial cavity. The brain expands in volume with every systole of the heart, while with every diastole it contracts. Its size is, moreover, modified by the motions of respiration. Under these extremely accommodating conditions it is scarcely credible that external injuries which leave no internal evidences of violence should do anything more than disturb the equilibrium of fluid distribution.
“CONCUSSION” OF THE BRAIN.
We inherit this term concussion from the earlier masters of our art, by whom, however, it was used in a much broader sense than of late. Its modern significance was given to it by Boirel, who made it apply to a group of cerebral symptoms the result of injuries not accompanied by fracture or perceptible laceration of vessels, symptoms varying in intensity and duration.
Our present position is practically this: The possibility of pure concussion of the brain—i. e., disturbance of brain function without gross mechanical lesions—is admitted, but its general frequency is denied. When present it should either pass away quickly, the condition being equivalent to that called “stunning,” or, if it assume distinct form, its signs and symptoms are indistinguishable from those of shock, consisting essentially of rapid and feeble pulse, quick and shallow respiration, pallor of the skin, copious perspiration, complete or partial unconsciousness, muscle incoördination, with lack of sphincter control, occasional vomiting, the pupils usually reacting in light.