SANOIEGO y 3 Ml D ATE DUE CAYLOBO WL 3S4 P5J& 1W0 UNIVERSITY OF CALIFORNIA SAN DIEGO B MINIMI Hill I 3 1822 01046 1069 u UN' C S < INJURIES OF THE BRAIN AND ITS MEMBRANES FROM EXTERNAL VIOLENCE WITH A SPECIAL STUDY OF 'PISTOL-SHOT WOUNDS OF THE HEAD IN THEIR MEDICO-LEGAL AND SURGICAL RELATIONS BY CHARLES PHELPS, M.D. SURGEON TO BELLEVUE AND ST. VINCENT'S HOSPITALS £econfc BMtion WITH FORTY-NINE ILLUSTRATIONS NEW YORK D. APPLETON AND COMPANY 1900 COPVKIOHT. 1897, iSqQ. 1900, By D. APPLETON AND COMPANY. PREFACE TO THE SECOND EDITION. This work is designed to be a concise and systematic exposition of the injuries which the brain suffers from external violence, a division of brain surgery which has th<3 greatest practical importance and has received the least careful attention. It is believed that it will not only be of interest to surgeons, but will meet the requirements of general practitioners in whose experience such injuries are infrequent, and who in exceptional instances have urgent need of the aid to be derived from a wider clinical obser- vation than their own opportunities have permitted. It has been based essentially, if not exclusively, upon an obser- vation of five hundred consecutive cases of recent oc- currence. These cases are so large in number, and so va- ried in character, and in so many instances are complete in the record of essential historic and necroscopic detail, as in themselves to afford material for a comprehensive history of intracranial traumatism. The picture they rep- resent is incomplete only in the illustration of secondary pyogenic infection involving the brain substance. In view of this clinical deficiency, the consideration given to cere- bral abscess has been supplemented by some account of the conditions of septic invasion and of the degenerative proc- esses which it occasions, derived from accepted authorities so far as necessitated by the limitations of the author's ex- perience. The generalizations which have been made, and the conclusions which have been reached, from clinical obser- vation, have been verified in each instance by necroscopic examination. IV l'RLFACE. In an appended series, all those cases in which necropsy was had, and a certain number of others which terminated in recovery or in which necropsy was otherwise impracti- cable, have been collated. This course has permitted the preservation of continuity in the text by the omission of interpolated illustrative cases, has afforded a means for the disproval of possible unwarranted or erroneous deductions, and has preserved much material for the use of indepen- dent observers hereafter. They have been classified sim- ply from their relation to cranial fractures, and this, though an imperfect method of classification, is, by reason of the multiplicity of lesions in individual cases, the only one which has seemed practicable. The lesions which attend pistol-shot wounds of the head have been considered apart from general injuries, as a method more clearly presenting their distinctive character- istics. Their complete history has necessitated an abstract of the results of a series of cadaveric experiments, instituted to determine for legal purposes the extent to which the conditions under which they have been inflicted can be predicated from the appearances they present. These observations have been sufficiently extensive to better define not only the positive value, but the limitations, of medical evidence in such cases than has been heretofore possible. This portion of the work which directly concerns medical jurisprudence is especially designed for the use of the legal profession in more precisely estimating the proper weight to be given to expert testimony in cases of this character. In this, the second edition of the work, only one essen- tial change has been made. The account of intracranial pyogenic inflammations, which in the first edition was summarized from the compendium of a Scotch surgeon, has been replaced by one which more directly relates to traumatisms, and in some degree differs in its conclusions. The additions made are few in number, and comprise PREFACE. V farther observations of lacerations of the frontal lobe and certain others made in connection with pistol-shot wounds. A general index has also been added. The continued observation of cases of intracranial in- juries during - the past two years has not necessitated any change in the deductions made or opinions expressed in the text of the earlier edition. The author has much pleasure in acknowledging his in- debtedness to his colleagues of the Fourth Surgical Divi- sion of Bellevue Hospital, and of the Surgical Service of St. Vincent's Hospital, through whose courtesy his oppor- tunities for clinical observation have been greatly extended ; and to successive house staffs of the same hospitals for the constant aid and cooperation which have made possible the collection of the great mass of facts which the nature of this work has involved. He is also under very great obligation to Dr. John D. Gorman, for assistance in the difficult and laborious task of cadaveric experimentation and to Dr. Carlin Phillips for assistance in bacteriological work. 34 West Thirty-seventh Street, January i, 1900. TABLE OF CONTENTS. PART I. General Traumatic Lesions. a preliminary consideration of cranial fracture. PAGE Classification of Injuries of the Head, i Cranial Fracture, 2 Classification 2 Fracture of the Cranial Base, 3 Direct and Indirect, ......... 4 Mechanism, .6 Complications of Cranial Fracture, 11 Symptomatology and Diagnosis 12 Fractures of the Vault, . . 12 Fractures of the Base, 13 External Hemorrhages of Cranial or Intracranial Origin ; . . 13 their Comparative Frequency in Different Forms of Basic Frac- ture 14 their Diagnostic Value, 18 Escape of Brain Matter, 21 Watery Discharges, 21 Oedema of the Mastoid Region, 23 Implication of the Cranial Nerves 24 Localized Pain, 26 Indirect Symptoms from Intracranial Complication, . . .27 Prognosis, . 2S Concomitant and Consecutive Complications, . . . .3° Treatment 32 Shock, 33 Fracture of the Base, 33 Fracture of the Vault 34 Incision, 35 Elevation of Depressed Bone, 3° Trephination, 39 Vlll TABLE OF CONTENTS. CHAPTER I. Pathology. Direct Lesions, Classification, . Hemorrhages, Epidural, .... Pial Cortical, .... Dangers of Hemorrhages, Shock, Exsanguination, and Diminu tion of Cranial Capacity, Terminations in Absorption and Cystic Degeneration, Thromboses of Dural Sinuses, Contusion, .... General Contusion of the Brain, Anatomical Conditions, . Duret's Theory of Displacement of the Cerebro-Spinal Fluid Concussion and Compression, Prescott Hewitt — Observations of Contusion Von Bergmann's Theory of Concussion and Compression, Structural Alteration Attends All Brain Injuries, Limited Contusion of the Brain, Anatomical Conditions, . Contusion of the Meninges, . Hemorrhage Subarachnoid Serous Effusion, Laceration of the Brain, Anatomical Conditions, . Terminations, . Indirect Lesions— Secondary Inflammations, Due to Accidental Infection of Primary Lesions, External or Distant Origin of Pathogenic Germs Infrequency of Occurrence Pachymeningitis Externa, Acute Arachnitis, Distant Infection, Acute Arachnitis, Subacute Arachnitis, Central Cerebral Abscess, Thrombosis of Dural Sinuses, Red, White, and Yellow Softening, Localization of Primary Lesion Determines the Alternat Meningitis or Abscess, Possibility of Intracranial Inflammation without Infection, Arachnitis a More Exact Term than Leptomeningitis. . PAGE 42 42 43 44 46 40 4 S 5i 52 53 53 53 55 56 56 57 58 59 59 61 62 62 63 63 66 6 9 69 7i 73 75 75 76 77 7S 80 33 83 ve o 84 84 86 TABLE OF CONTENTS. IX Encephalitis Always Pyogenic. Cirrhotic Inflammation — Atrophy, PAGE . 86 . 87 CHAPTER II. Symptomatology. Direct Lesions, .... Hemorrhages, .... Unconsciousness, Delirium, ..... Condition of the Pupils, . Temperature, .... Pulse, ..... Respiration — Marked Infrequency Medulla Tabulation of Cases, Cyanosis and Pulmonary CEdema, Psychical Disturbances, . Influence of Complications, General Contusion of the Brain, Variability of Symptoms, Severe Cases Mild Cases Cases Complicated by Hemorrhages Limited Contusion of the Brain, Laceration of the Brain, Temperature, .... Pulse and Respiration, Asymmetrical Radial Pulsation, Condition of the Pupils, . Loss of Consciousness, Psychical Disturbances, from Compression of the 89 90 9i 93 94 95 96 97 9 S 101 102 102 105 106 107 109 11 1 112 113 114 120 120 122 123 124 CHAPTER III. Symptomatology— Continued. Symptoms Indicative of the Localization of Lesions Mental Disorders in Cases of Laceration of the Frontal Lobes, . Differences in Symptomatology as the Right or the Left Frontal Lobe, or as the Superficial or Deeper Portion of the Left Lobe, is Involved — Tabulation of Cases, ...... Illustrated by Histories of Pistol-Shot Wounds Tabulation of a Series of Later Cases, Conclusions, ....... • • 12- [28 1 U 1 )6 133 x TABLE OF CONTENTS. PAGE Derangements of Muscular Action 138 Paralysis, 139 Incoordination, 139 Clonic and Tetanic Spasm 139 Symptoms from Lesion of Corpus Striatum, 14 1 Optic Thalamus 141 Fornix 142 Gyrus Fornicatus, 142 Pons M3 Temporal Lobe, 143 Conjugate Deviation '. . . . 146 Loss of Urinary and Faecal Control 147 Secondary Inflammations 148 Arachnitis, • 148 General Symptoms, 150 Abscess, 153 Superficial, 153 Deep i54 Analysis of General Symptoms 157 Localizing Symptoms 159 Progress and Terminations 161 CHAPTER IV. Diagnosis. Direct Lesions, Unconsciousness as a General Indication of Traumatic and Idiopathic Lesions, ..... Characteristics of Opium Narcosis, '* " Ursemic Coma, . " " Apoplectic Coma, " " Alcoholic Coma, 11 ii Traumatic Coma, Diagnosis of Traumatic from Alcoholic Coma, Coexistence of the Two Conditions, Temperature, Delirium, ....... Diagnosis of Traumatic from Apoplectic Coma, Coexistence of the Two Conditions. Diagnosis of Traumatic from Opium Narcosis or Uraemic Coma, 1 nfferentiation of Traumatic Lesions from Each Other, Comparative Symptomatology, Unconsciousness, Temperature, .... Respiration Pulse, 164 164 165 166 166 166 167 168 169 170 171 172 172 173 174 174 i75 176 177 177 TABLE OF CONTENTS. XI PAGE Condition of Pupils, 179 Mental Disturbances, 180 Muscular Disorders, . . 181 Loss of Urinary and Faecal Control, 1S2 Aphasia — Not from Hemorrhage, ■ 182 Unconsciousness, Temperature, Pulse, and Respiration, as the Essential Factors in Diagnosis of Intracranial Lesions, . . 185 Secondary Inflammations, 185 Arachnitis, 185 Abscess, ............ 188 Diagnosis, when of Early Formation, from Primary Contusion, . . 188 Diagnosis, when of Later Development, from Results of Vascular Le- sions and from Tumor 189 Symptoms Common to All Organic Diseases of the Brain, . . .190 Symptoms Common to Abscess and Tumor 190 Diagnosis of Abscess from Tumor, 19 1 CHAPTER V. Prognosis. Direct Lesions, *93 Statistical Results in Five Hundred Original Cases, . . . .193 Relative Danger of Fractures of Cranial Base and Vertex Dependent upon Complications, ......... 195 Relative Danger of Different Intracranial Complications, . . .195 Analysis of Recovering Cases 198 Prognostic Indications from Individual Symptoms, .... 201 Secondary Inflammations, 204 Arachnitis 204 Abscess 205 CHAPTER VI. Principles of Treatment. Direct Lesions, 206 Shock 206 Operation for Intracranial Injuries, 208 Epidural Hemorrhage, . 208 Conditions of Operation, . . . . . . . .210 Subdural Lesions 212 Pial and Cortical Hemorrhages • 212 General Contusion, 214 Laceration of the Brain, 21s Arachnitis, 2 "' Summary, . . . . . . . . • • -217 Late Pathic Conditions, 21.' Dangers of Operation 2211 Xll TABLE OF CONTENTS. General Conduct of Operation General Treatment, Secondary Inflammations, Arachnitis, Abscess, Superficial, Deep, PAGE . 222 . 223 . 227 . 227 . 228 . 228 . 230 PART. II. Pistol-Shot Wounds of the Head. chapter VII. Medico-Legal Relations. Observations Made upon the Cadaver 235 Extracranial Lesions 239 0.38 cal., Head, 239 0.38 cal., Body, .......... 250 0.32 cal., Head, .......... 254 0.44 cal., " 260 0.22 cal., " 266 Generalization of Results, ......... 276 Modifying Conditions, 286 Characteristics of Cutaneous Wound of Exit, 2SSc How far Wounds Inflicted during Life Differ from Those Produced in Cadaveric Experimentation, ....... .2SSd Comparative Importance of Different External Conditions Enumerated in Estimating Range and Calibre 292 Medico-Legal Importance of the Study of These Lesions, and the Ne- cessity of Sufficiently Extended Experimentation, Decisive in only a Limited Number of Cases, Cranial Lesions, Peculiarities Common to all Calibres of Ball, Cranial Penetration, .... 0.44 cal., Pistol of Most Efficient Type, Pistol of Inferior Type, 0.44 cal. 0.38 cal., .... 0.32 cal., .... 0.22 cal., .... Modifying Conditions. Dimensions of Cranial Wounds, 0.44 cal 0.38 cal., . 0.32 cal 0.22 cal 295 297 297 298 298 300 302 302 304 306 308 312 312 312 3i4 3i4 TABLE OF CONTENTS. Xlll Summary, .... Cranial Wounds of Exit, Cranial Comminution and Fissuring, 0.44 cal., . 0.38 cal., . 0.32 cal., . 0.22 cal., . Intracranial Lesions, PAGE • 314 • 315 . 320 . 320 . 322 • 324 • 324 . 326 CHAPTER VIII. Surgical Relations. Symptomatology. 334 Profundity of Unconsciousness, ....... 337 Immediate Subjective Symptoms, . 338 Diagnosis, 342 Fluhrer's Probe, 344 Nelaton's Probe, 344 Girdner's Telephonic Probe 345 Use of Rontgen Rays, 346 Acupuncture, . 348 Diversion of the Bullet, 349 Examination of the Eye and Orbit, 350 Examination of Cervical Region, 351 Treatment, 353 Shock, 353 Several Views as to Further Treatment, 354 Illustrations from Published Cases, ...... 355 Results of Expectant Treatment. ....... 356 Incision of Dura Mater 358 Operation with a View to Drainage only, ...... 3C0 Analysis of Published Cases with Reference to the Results of Reten- tion of Bullets within the Cranial Cavity, .... 360 Conclusions, ........... 366 Analysis of Published Cases with Reference to the Comparative Dan- ger of Retention and Removal of Bullets Deeply Situated within the Cranial Cavity, . 366 Conclusions, ........... 370 Treatment of Superficial Wounds of Entrance and Exit, . . . 371 Exaggerated Estimate of the Danger of Operation, .... 372 Details of Operation 375 Counter-Operation, 375 Circumstances Adverse to Counter-Operation, .... 382 Disinfection and Drainage, . . . . . . . . . 384 Prognosis 387 Statistics, ............ 387 Treatment, ........... 390 xiv TABLE OF CONTENTS. The Condensed Histories of Three Hundred Intra- cranial Traumatisms. cases verified by necropsy. PAGE Fractures of the Cranial Base, 395 Fractures of the Cranial Base from Pistol-Shot Wound, . . . 477 Fractures Confined to the Cranial Vertex 493 Fractures Confined to the Cranial Vertex from Pistol-Shot Wound. . 503 Encephalic Injuries without Cranial Fracture 513 CASES UNVERIFIED BY NECROPSY. Unclassified 537 Intracranial Lesions from Pistol-Shot Wounds with Recovery, . . 577 INJURIES OF THE BRAIN AND OF ITS MEMBRANES. PART I. GENERAL TRAUMATIC LESIONS. A PRELIMINARY CONSIDERATION OF CRANIAL FRACTURE. Injuries of the head may be topographically classified as superficial or extracranial, cranial, and intracranial. These may occur independently or may variously com- plicate each other. The external injuries may be excluded as of no import- ance in a consideration of intracranial lesions except as aids in diagnosis, and in the case of cutaneous wounds, as a possible means of infection in meningitis or in the course of cerebral abscess. The cranial injuries are contusion and fracture, and of these contusion followed by consequences of moment is in- frequent and has no closer relation to intracranial injury than have contusions of the more superficial parts. Frac- tures so usually complicate, or are complicated by, struc- tural changes in the brain or its meninges ; and are often so directly connected with the pathic results of intracranial lesions, either by osteal hemorrhage or by affording a channel for the invasion of septogenic germs, as to justify some particularity of attention to their peculiarities. 2 injuries of the brain and membranes. Fracture. The classification of fractures of the cranium is prima- rily the same as of fractures of other bones : I. Complete. Incomplete. II. Direct. Indirect. III. Simple. Compound. IV. Linear. Comminuted. Punctured. Depressed, which may- be either singly or doubly camerated. V. Complicated. Non-complicated. VI. Fractures of the vault. Fractures of the base. PRELIMINARY CONSIDERATIONS. 3 The last or regional subdivision is the only one of these peculiar to cranial fractures, and is not only that in most frequent use for purpose of designation but is of the most importance, aside from complication, in the. consideration of diagnosis and treatment. Fractures of either the vault or base may be simple, compound, or comminuted, punctured, linear, or depressed, direct or indirect, though the relative frequency of these subdivisions varies greatly in the two primary forms. Fractures of the base are ordinarily simple and linear, while those of the vault are not infrequently compound, comminuted, depressed, or punctured. Both are almost invariably caused by direct violence, and, while both may be either complicated or non-complicated, a complication in fracture of the base is more characteristic and often oc- casions not only differences in prognosis but in methods of diagnosis and requirements of treatment. The presence or absence of a complication is of essential importance, and as its recognition, probable result, and treatment may be influenced by the region of injury, the corresponding divisions of fracture, whether or not they are accepted as a formal basis of classification, must always be those of the greatest practical value. The other distinctions which may be made in the characters of a fracture, if not insig- nificant, are at least of minor importance ; whether the osteal wound be simple or compound, linear or depressed, or comminuted, is of little moment in view of the present resources of surgery ; and the simple one is often made compound in the course of preliminary examination. All fractures which involve the base, though originat- ing in the vault, are to be regarded as basic, because it is upon the implication of this region that their characteristic 4 INJURIES OF THE BRAIN AND MEMBRANES. conditions depend. In a certain number of cases, violence is inflicted through the eye, nose, or mouth, or inferior temporal region, by bullets or exceptionally by sharp- pointed instruments ; but exclusive of these there are few instances in which a fracture of the skull does not have its beginning in the vault. In the appended series of cases, as verified by necropsic examination, there are 146 frac- tures of the base, of which 18 were from pistol shot and 1 from another form of violence directly applied to the point of basic lesion ; there are 34 fractures confined to the vault, of which 14 were from pistol shot; in 147 fractures of the vault, therefore, not of pistol-shot origin, the base was im- plicated in 127. There existed in but 12 of the 127 a basic fissure independent of a fracture of the vault, and in sev- eral (6) of these another fissure extended from vault to base. These 12 cases in which force was indirect, that is to say, in which the fracture began and ended in the base, though the force was applied to the vault at a distance and transmitted through parts which maintained their in- tegrity, are instances of what has sometimes been called injury by contrecoup, and similar to what is much more frequently encountered in the brain. In each case by the history as well as by existent wound or contusion, it was proven that the force was primarily exerted upon the vault, nor was there in any one the slightest reason to suspect that the effect of violence had been conveyed through the spinal column. The concurrence of direct fracture was noted in 6 cases and there was intervening brain laceration in all but 2. The direct force in 6 cases was applied to the parietal region, and in 3 of these was transmitted to an orbital plate or to the crista galli and sphenoid surface; in 5 it was applied to the occiput, and PRELIMINARY CONSIDERATIONS. 5 in 3 of these also was transmitted to the orbital plates ; but in the others the indirect fracture was produced in the middle or posterior fossa or upon the surface of the inter- vening petrous portion. It is evident therefore that it is not always the most fragile portions of the cranium which give way. In 10 of the 12 cases the counterfracture was no more than a fine short fissure, which could have had no influence in the display of symptoms and could be of no real importance in contravening the general statement that fractures of the base are continuations of fissures which have their origin in the vault at the point of injury. In the 2 cases remaining the counterfracture was directly contributive to the death of the patient. In one the fis- sure widely curved through both orbital plates and the fractured edge of each was raised and tilted forward, and on the right side it deeply lacerated the base of the frontal lobe; the frontal sinus was also opened into the cranial cavity. In the other a smaller osseous lesion was no less disastrous; the fissure was fine and extended only from the anterior inferior angle of the parietal bone across the squamous portion of the temporal to the petrous junction, but a minute triangular portion of the inner table was de- tached and had lacerated the arteria meningea media at its bifurcation with resulting profuse and fatal hemorrhage. The conditions which govern the character and extent of cranial fractures are the violence of impact, the extent of surface involved, and the physical properties of the era nium, its elasticity, composite structure, degree of thick- ness or density, and its vaulted form. The concentration of force when the head is struck by an object of limited size and definite outline tends to the production of com- minuted and depressed fractures confined to the region of 6 INJURIES OF THE BRAIN AND MEMBRANES. impact. The diffusion of force when the head itself is the impinging object, as in falls from a distance, equally leads to extended fissures with or without crushing at the point of direct injury. The observation of cases, however, shows that the physical properties of the cranial vault are ordinarily such that even when force is concentrated, if the instrument of violence be other than a pistol shot or some sharp weapon, the effect is much more than likely to be diffused. A great degree and concentration of violence and a tenuity or brittleness of a part undoubtedly favor re- striction of fracture to the site of injury, as wider diffusion of force and the elasticity and average density of the skull account for its more frequent extension by fissure to a dis- tance. The precise mechanism of basic fracture has been ex- perimentally investigated by various surgeons, who have arrived at somewhat different conclusions. The recent summary of the opinions of these experimenters in various text-books of surgery precludes the necessity for their repetition. The usual basic fracture unquestionably extends be- tween the region in which primary injury is received and the corresponding basic fossa of the same side ; and the explanation of Aran, that force follows the shortest anatomi- cal route and in the direction in which there is least resistance, seems adequate. If the middle fossae, alone or in contiguity, suffer oftener than the others, it is because the middle region of the vault is most exposed to violence. If force is too great for its entire expenditure at the point of impact, or resistance too obstinate, it traverses the bone till exhausted; that it should be propagated in direct lines, modified only by inequalities of resistance, is as plainly in PRELIMINARY CONSIDERATIONS. 7 accordance with natural laws as the riving of wood or iron by the wedge. In some instances the force is too great to be restrained by any resistance which it may encounter, and transgresses the limits which may be set by " natural buttresses," or abandons the squamous to follow its direct course through the denser petrous portion. The theory of Hare, that the elastic skull, compressed between two poles, like a melon gives way in the middle, and that the fracture extends in both directions, seems far-fetched and not sub- stantiated by appearances which the fissures present when examined for corroboration. The comparison of the exact site of superficial contusion with the commencement of a linear fracture of the vault indicates that not infrequently force may be transmitted through the bone for a certain distance before disruption begins. The limited number of cases in which independent fractures, more or less trivial, occur at the base, with or without a fracture of the vault, are less readily explained by the direct propagation of force through the cranial wall. The brain substance and the bone have each been regarded as the medium of transmission. In the well-known case of the assassination of a president of the United States, in which a pistol-shot fracture of the occiput, with lodgement of the bullet near the corpus striatum, caused comminution of both orbital plates, Mr. Longmore believes that the or- bital fracture was due to "transmitted undulatory strokes or sudden impulse of the brain substance against these bony layers." This may be possible in so thin and fragile laminae as the orbital plates, but it is insufficient to explain the Assuring of bony parts so dense as the petrous portion of the temporal, or the floor of a middle or posterior basic fossa. There arc also the special defects in Mr. Long- 8 INJURIES OF THE BRAIN AND MEMBRANES. more's explanation of the counterfracture in the case quoted, that it ignores the fact that the direction of force was parallel to the orbital surfaces, and that it fails to account for the upward dislocation of the fragments. In simple counterfissure of the base, it would seem more probable that the distant lesion was due to the direct trans- mission of force through the bone. In view of the numer- ous instances in which force is transmitted for a limited distance through the lateral wall of the vault before cleav- age begins, it is not illogical to suppose that in others exceptionally noted its course should have been even longer continued before its eruption. In counterfissures confined to the petrous portion or to the contiguous basic fossae, it is scarcely possible to conceive, though the skull might be compressed to the point of bursting, that the rupture should have occurred in its most rigid if not abso- lutely inelastic portion. The effect of distant violence, in causing not only indirect fracture but limited osteal hyper- emia and extravasation, is illustrated in Case CXXV. of the appended series and represented in Fig. 44. There are occasional indirect basic fractures which are more readily explicable, or even necessarily dependent, upon the suppo- sition that the skull has been violently compressed. In Case CIV. of the appended series, the circumstances of in- jury and the effects which it produced concur to make this explanation inevitable. The head was struck upon the occiput by a descending elevator and forced forward, with the chin resting upon an iron railing as an approximately fixed point. Fracture was confined to the anterior basal fossae, and extended from the posterior border of the crib- riform plate upon the right side by a wide sweep outward and forward, and then inward through both orbital plates. PRELIMINARY CONSIDERATIONS. 9 The roof of the orbit was elevated and tilted forward, and the frontal sinuses were opened into the cranial cavity. Continued force and resistance acted at the extremities of the occipito-mental diameter, and violent disruption oc- curred in a vulnerable region at its centre. In a recov- ering case, No. CCLIX., in which force was similarly applied, fracture through the anterior and middle fossae into the petrous portion was doubtless produced by the same mechanism. It is impossible to believe that the mechanism of frac- ture is always the same. In a careful necropsic examina- tion of cranial fractures included in the appended series of cases, there are a rather limited number which immedi- ately involve the base, all but one from bullet wound, and a scarcely larger number which may be termed indirect and are of questionable origin. All the others, more than ninety per cent, of the entire number, are the result of violence inflicted upon the vault, and of these more than seventy-eight per cent, extend to the base. If pistol-shot fractures be excluded, the percentage of those which extend from vault to base is increased to eighty - five. The inspection of basic fractures of this predominating class has suggested nothing but an origin at the point of injury. They negative in their appearance Hare's opin- ion that diffuse blows produce their effect at a distance from the point of application, and, as such evidence is entitled to more weight than conclusions, which must be more or less theoretical, derived from experimentation upon the cadaver, these fractures must be regarded as in general the product of direct violence. The very small proportion of basic fissures which are obviously indirect are very likely of variable as well as questionable origin; IO INJURIES OF THE BRAIN AND MEMBRANES. apart from such unusual antecedent conditions as severe and demonstrable compression of the head between two fixed points, exemplified in Case CIV., they afford no positive etiological data; whether force is generated by insupportable distortion of the elastic vault, or is trans- mitted like the electric current without change in the osseous structure traversed to its point of discharge in some basic region, or is propagated by undulations in the brain substance, is a problem still confined for its solution to the domain of theory and of individual probability. These indirect fractures have been called contrccoup, since they are developed in a region directly or approximately opposite to that in which violence has been inflicted, and the term may be conveniently and allowably retained with- out involving a theory of their production; its application to fissures of the base which are continuous with fractures of the vault is unwarranted. A study of the one hundred and eighty cranial fractures in the appended series of original cases which were sub- jected to post-mortem examination discloses many facts concerning the details of their character and mechanism which are of interest and value, but are not essential to the discussion of intracranial lesions. The peculiarities of depressed, comminuted, or perfo- rating forms of cranial fracture are adequately described in general text-books of surgery. Simply as osseous le- sions they have been robbed of their significance by ad- vancements in the methods of surgical practice. In their greater liability to intracranial complication they retain their special importance ; a degree of violence sufficient to comminute the bone is likely to extend its effects to the subjacent structures; depressed fragments become new PRELIMINARY CONSIDERATIONS. I I sources of injury ; and perforating fractures almost neces- sarily involve cerebral or dural wound. Their results are more serious and their treatment demands more active intervention than do simple fissures, but it is by reason of the complication rather than by the greater injury which the bone has sustained. The necessity of removing com- minuted or of elevating depressed fragments of bone scarcely increases the gravity of prognosis. The most insignificant fissure may be associated with fatal in- tracranial hemorrhage, while the largest comminution, if uncomplicated, may be devoid of danger. It is the complication and not the fracture which dominates the case. The complications of cranial fracture are cerebral and meningeal, and in either one may be laceration, contusion, hemorrhage, or septic inflammation; and to these may be added hemorrhage from the osteal vessels. The septic inflammations are rather sequelae than complications, since they are not direct products of the same violence which causes the fracture, but the result of a later infection for which the fracture has afforded opportunity. All these conditions may equally occur in the absence of fracture, as primary and independent lesions, and as such will be given later consideration. Fractures which are practically uncomplicated may occur both in the vault and in the base, though some degree of cerebral contusion will probably attend even the most inconsiderable of simple fissures. If the symptoms of this contusion are trivial and transient, it may be properly disregarded in classification as well as in treatment. 12 injuries of the brain and membranes. Symptomatology and Diagnosis. The very frequent coincidence of fracture with intra- cranial lesion has led to much confusion in symptomatol- ogy and consequent prognosis. Loss of consciousness and variations in pulse, temperature, and respiration, with other undoubted indications of intracranial com- plication, are still enumerated among the symptoms of fracture. These inaccuracies are of consequence, since a lack of well-defined conception of the nature of lesions or of the significance of symptoms begets errors of treatment. The direct effects of fracture are few and usually not difficult to discover. It may be briefly stated that fracture of the vault is to be recogized by tactile or visual sense; that these methods are always practicable ; that no others are defensible; and that there is no justification for the neglect to resort to both when one is insufficient for exact diagnosis. If the fracture be compound, there can be no doubt of its existence, provided the wound be of sufficient size to disclose the osseous surface ; if the wound be too small for thorough exploration, the fracture may be re- garded as essentially of the simple variety. The simple fracture, if depressed, may be often recognized by palpa- tion through the layers of the scalp, but if doubt exists, or if from symptoms of intracranial complication suspicion arises, certainty should be reached by incision and direct inspection. This covers the whole ground of diagnosis — tactile or visual examination, and, if necessary to that purpose, unhesitating and sufficient incision down to the cranial surface. The diagnosis of fracture of the base is sometimes PRELIMINARY CONSIDERATIONS. 1 3 equally direct, but is oftener inferential, and it may be entirely conjectural. If continuous with a fracture of the vault which has attracted attention, it should be incident- ally discovered in the course of the examination necessi- tated at the site of immediate injury, as fissures are readily traceable to a point at which their implication of the base becomes assured. In a very large proportion of cases, however, the basic fracture begins as a simple fissure at the vertex, or upon the lateral aspect of the vault, and with an absence of conditions which suggest direct exploration. The indications of intracranial injury may then afford reasons for inferring the existence of basic -fracture, but not with absolute certainty, since the occurrence of inde- pendent traumatic lesions is not infrequent. There is one direct symptom of the fracture which when present may be almost pathognomonic: it is an osteal or intracranial hemorrhage which through some channel becomes visible at or beneath the surface. Its source may be the vessels of the diploe, of the meninges, or of the brain, and its escape may be from the ear, nose, or mouth, or into the subconjunctival or subcutaneous cel- lular tissue. The fracture very generally traverses some portion of the base which permits the appearance of the blood externally in one or the other of these situations. The comparative frequency with which different basic regions are involved, and the significance of various ex- ternal hemorrhages of internal origin, are suggested by a summary of these fractures included in the appended gen- eral series. 14 INJURIES OF THE BRAIN AND MEMBRANES. Fractures of the Base. I. Results. Recovered, ..... I 10 Died, ....... 176 II. Necropsies. Fractures continued from vault, 133 Fractures confined to base, 13 III. Hemorrhages. Fractures with e'xternal hemorrhage, 67 Fractures without external hemor- rhage, . . . . . .61 IV '. Regions of Fracture and External Site of Hemor- rhage (pistol-shot fractures excluded). . 1. Petrous Portion. Hemorrhage from ear, . . 5 No hemorrhage, .... 4 — 9 2. Petrous Portion and Middle Fossa. Hemorrhage from ear, . . 6 Hemorrhage from ear and nose, . 2 Hemorrhage from ear, nose, and mouth, 1 No hemorrhage, .... 3 — 12 3. Petrous Portion and Posterior Fossa. Hemorrhage from ear, . . 5 Hemorrhage, subcutaneous, mastoid, 1 Hemorrhage from ear and nose, . 3 No hemorrhage, .... 3 — 12 4. Petrous Portion ; — Middle and Posterior Fossa. Hemorrhage from ear. . . 6 Hemorrhage from nose, . . 3 Hemorrhage from ear and mouth, 1 PRELIMINARY CONSIDERATIONS. I 5 Hemorrhage from ear, mouth, and nose, .... 2 No hemorrhage, .... 2 — 14 5. Petrous Portion; Middle and Anterior Fossa. Hemorrhage from ear, . . i Hemorrhage from ear and nose, . 4 Hemorrhage from ear, nose, and mouth, 1 Hemorrhage from ear and nose and subconjunctival, . . 1 Hemorrhage, subconjunctival, . 1 — 8 6. Both Petrous Portions and All Basic Fossa. Hemorrhage from one ear, . . 1 Hemorrhage from both ears, nose, and mouth, .... 1 — 2 7. Petrous Portion and All Basic Fossa of the Same Side. Hemorrhage from ear, . . 1 Hemorrhage from ear, nose, and mouth, .... 1 — 2 8. Petrous Portion ; Anterior and Middle Fossa; Basilar Process. Hemorrhage from ear, nose, and mouth, . . . . 1 9. Anterior Fossa. Hemorrhage from nose, . . 2 Hemorrhage from nose and mouth, 1 Hemorrhage, subconjunctival, . 1 No hemorrhage, . . . . 5-9 10. Middle Fossa. Hemorrhage from nose, . . .} Hemorrhage, subconjunctival, . 1 l6 INJURIES OF THE BRAIN AND MEMBRANES. No hemorrhage, .... 13 — 17 1 1 . Posterior Fosses. No hemorrhage, . . . .21 12. Anterior and Middle Fossa. Hemorrhage from nose, . . 6 Hemorrhage, subconjunctival in both eyes, 1 Hemorrhage, subjunctival, in both eyes, nose, and mouth, . . 1 No hemorrhage, . . . . 5 — 13 1 3 . Posterior and Middle Fossce. Hemorrhage from nose, . . 1 No hemorrhage, .... 4 — -5 14. Posterior and Anterior Fossce. Hemorrhage, nose, 1 I 5 . Anterior, Middle, and Posterior Fossce. Hemorrhage from nose, . . 1 No hemorrhage, .... 1 — 2 V. Summary of External Sources of Hemorrhages. Hemorrhage from ear, . .26 Hemorrhage from ear and nose, . 9 Hemorrhage from ear and mouth, 1 Hemorrhage from ear, nose, and mouth, .... 6 Hemorrhage from ear, nose, and subconjunctival, 1 Hemorrhage from nose, . 17 Hemorrhage from mouth, . . 1 Hemorrhage from nose, mouth, and subconjunctival, . . 1 Subconjunctival hemorrhage, . 4 Subcutaneous, mastoid hemorrhage 1 — 67 PRELIMINARY CONSIDERATIONS. I 7 This study of hemorrhages has been confined to the first class of basic fractures, those in which fissure extends from a site of injury in some part of the vault. The cases in which fracture originates in the base are almost exclu- sively pistol-shot wounds, and are not often attended by distant hemorrhages and rarely involve a question of re- gional diagnosis. The inferences to be derived from the tabular analyses are so obvious as scarcely to call for explanatory comment. It will be observed that hemorrhage from the ear has oc- curred in more than one-third of the total number of cases, in all of which the petrous portion has been impli- cated ; that hemorrhage from the nose has occurred in more than one-fourth of all the cases, and when significant has followed fracture of an anterior fossa or of the ante- rior part of a middle fossa; that there has been subcon- junctival hemorrhage in six cases, in all of which the fracture traversed an anterior fossa ; that buccal hemor- rhage has been noted three times, twice in conjunction with cpistaxis; and that the subcutaneous hemorrhage resulted from an inclusion of the mastoid process in a fracture through the posterior fossa. The anatomical necessity which absolutely limits these external indications to fracture of positively definite regions is manifest. The causes of their frequent absence in fractures of the same arbitrarily defined basic fossae are not less obvious. If the fracture of the petrous portion does not involve the audi- tory cavities, or that of the middle fossa involve the sphe- noid bone, there can be no escape externally of the blood effused; if the fracture of the anterior fossae does not traverse the ethmoid bone, and the injury to the orbital plates is trivial, the slight hemorrhage which it occasions 18 INJURIES OF THE BRAIN AND MEMBRANES. still fails of outlet ; the only possible route by which blood extravasated in the posterior fossae can reach the surface is through the fascias of the neck, except when the mas- toid process is implicated, when it may force its way through the periosteum and be visible subcutaneously be- hind the ear. The amount of hemorrhage from an occip- ital fracture is usually insufficient to penetrate the deeper cervical fascias, unless it be from a pistol-shot wound, and its becoming subcutaneous is only a recognizable possi- bility. The occurrence of a visible hemorrhage as an in- dication of simple fracture of the base depends upon the implication of the mastoid or petrous portions of the tem- poral, the ethmoid or sphenoid, or the orbital processes of the frontal bone; and its undoubted value as a symp- tom, positive or negative, is dependent upon the relation, suggested by Aran, which these parts bear to the regions of the vault most exposed to injury. The apparent pro- portion of basic fractures attended by external hemor- rhage is somewhat diminished by the inclusion in the to- tality of cases of a certain number in which the early history was imperfect or absent, and in which the hemor- rhage might have been present but was not assumed. It is possible that these hemorrhages may occur as a coincidence rather than as a result of fracture, though their interpretation in such an event is not likely to be difficult. A hemorrhage from the ear accompanying a pistol-shot wound of the temporal fossa was found in Case CXXXVIII. to have resulted from a rupture of the tympanum by con- cussion, but extremities of violence by blows or falls upon the head, which have shattered the vault or base, have not incidentally produced a similar lesion, nor can such a re- sult be expected under any conceivable circumstances apart PRELIMINARY CONSIDERATIONS. 19 from the shock of an explosive at close contact. A wound of the external meatus may also occasion a moderate hem- orrhage, or blood from a wound of the scalp which has filled this canal may be momentarily deceptive, but such sources of error are eliminated in the preliminary exami- nation. If ordinary care be exercised in excluding these occasional non-essential hemorrhages, this direct symptom may be regarded as fairly pathognomonic. A failure to discover the wound of the tympanum is not material, since when linear it may be closed and invisible after hemor- rhage has ceased, but a lesion of the external meatus can- not be hidden from observation. The amount of blood which escapes from the ear, or the period at which hemorrhage occurs, its continuance, or its relation to serous discharges, while perhaps indicative of the extent of cranial or internal lesion, is not essential to the recognition of a petrous fracture. The simple knowl- edge that the hemorrhage exists, with exclusion of such possibilities of error as have been suggested, should be sufficient to establish the fact that this part has been frac- tured. The promptitude, freedom, and persistence of a hemorrhage from the ear which succeeds an injury to the head merely confirm the opinion which an otherwise in- explicable effusion has justified, and to this extent are fac- tors in the case. The subconjunctival, nasal, and buccal hemorrhages are less frequently positively diagnostic. Direct orbital contusions which involve the eye, or epistaxis from super- ficial injuries of the nose, may be coincident with basic fracture, and the estimate of the clinical value of a hemor- rhage in one of these situations may therefore require careful inquiry into the manner in which injury was re- 20 INJURIES OF THE BRAIN AND MEMBRANES. ceived, and a study of all the attendant symptomatic con- ditions. If the history shows, and the superficial lesions confirm, a limitation of the field of violence to a cranial region, and there is evidence of intracranial complication, the dependence of an ocular or nasal hemorrhage upon fracture can be properly inferred ; while the existence of a contusion of the nose or of an ecchymosis of the face or orbit will render its origin more or less uncertain. There are really few cases in which even this class of hemor- rhages cannot be correctly interpreted. The amount of blood lost or extravasated in this instance is of more im- portance than when the ear is the seat of discharge. An extensive subconjunctival effusion or a profuse flow from the nose at the outset, with perhaps subsequent hsema- temesis, affords a stronger presumption of fracture than trivial loss or discoloration, which might have been caused by trifling injury. After the lapse of twenty-four hours the beginning of a slow oozing from the nose or of a spreading discoloration beneath the subconjunctiva is more significant. The relative proportion of fractures of the base indi- cated by the external appearance of osteal or intracranial hemorrhage is greatly increased when comparison is ex- tended to the whole number of cases observed. In 115 cases in which fracture extended from vault to base, com- prising recoveries as well as deaths in which necropsy was unattainable, 99, or eighty-six per cent., were attended by external or superficial hemorrhage ; when no characteristic hemorrhage was present, diagnosis was made by incision. In the aggregate of this class of fractures, 224 recoveries, and deaths both with and without necropsic examination, 154, or seventy per cent., were associated with a visible PRELIMINARY CONSIDERATIONS. 21 hemorrhage which could be considered diagnostic. It is evident that the escape of blood externally, notwithstand- ing its obscurity in some instances and its failure of recog- nition in others, has in itself been sufficient to determine the existence of fractured base in a very large majority of cases included in the appended summary of observations. There are besides hemorrhage direct symptoms, of oc- casional or exceptional occurrence, which may be of great diagnostic value. The extrusion of brain matter from the ear is absolutely pathognomonic, not only of petrous frac- ture but of cerebral laceration. In one of two cases in the appended series, No. CCLIV., it followed profuse hemor- rhage and was delayed till the second day ; it was an in- termittent oozing for twenty-four hours, amounting to one drachm or more; it was not followed by serious effects of brain injury, and the patient recovered. In the second case it was accompanied by profuse hemorrhage from the nose and mouth, but by none from the ear; the patient died in a few hours and escaped necropsic examination. It is more frequently observed in fractures of the vault, and very rarely through the nose. Serous discharges from the ear are also infrequent. In the entire series of two hundred and eighty-six cases of deaths and recoveries, there are altogether thirteen in- stances, but in three it was undoubtedly a declining phase of hemorrhage which in each had continued for a week, gradually lessening and becoming serous before its cessa- tion; and in a fourth, an intermittent sero-sanguinolent discharge, which appeared on the eighth or ninth day, was clearly aural and inflammatory. In the nine in which it was an actual symptom, it was primary and independent in two only, Nos. LXXIII., CCXXX., and in one of these 22 INJURIES OF THE BRAIN AND MEMBRANES. was followed by recovery. In the recovering case it began suddenly and very profusely a short time after the pa- tient's fall from a considerable height, and continued for several days; the development of symptoms of intracranial complication was followed by a late mastoid inflammation, which was relieved by a trephination otherwise barren of result. The second case, in which the discharge was also profuse, proved fatal from pulmonary oedema in a few hours; the petrous portion was fissured and the brain ex- tensively lacerated subcortically, with only slight arachnoid hemorrhage in the frontal region. The discharge in both instances was probably cerebro-spinal, in view of its pro- fusion and almost immediate occurrence. In the seven cases remaining, the serous fluid, which was abundant and usually clear, was preceded in each by a free hemorrhage lasting from a few hours to the fourth day ; three were fol- lowed by recovery and four by death and necropsy. In two of the necropsic cases, death was caused by purulent meningitis and there had been no intracranial hemorrhage ; in one there was a large arachnoid serous effusion at the base, and in the other a moderate arachnoid effusion with excessive oedema of the brain substance ; in one the pos- terior surface of the petrous portion was comminuted and in the other a fissure traversed its central portion. In the other two necropsic cases, petrous fracture was accompanied by large and firm epidural and arachnoid clots in a con- tiguous basic fossa, and in one of them by thrombosis of the superior longitudinal, lateral, and petrosal sinuses and internal jugular vein, with a localized oedema in the pos- terior cerebral region confined to the meshes of the pia mater. The three recovering cases in which serous dis- charge followed hemorrhage were not of identical charac- PRELIMINARY CONSIDERATIONS. 23 ter; in one it was coincident with an extrusion of brain matter on the second day and continued twenty-four hours; in the other two it occurred on the second and fourth days and was of brief duration. All the sources to which these watery fluxes have been ascribed seem to have been exemplified in these few cases. In three it was demonstrably the final phase of hemor- rhage, and in one the outcome of aural inflammation ; in two it was no less positively the cerebro-spinal fluid, and in two an inflammatory arachnoid effusion; in one at least certainly, and in others presumably, it was the result of the coagulation of blood following an intracranial hemor- rhage. In this way it often happens that exclusive theories are disproved by the results of sufficiently extended observation. The diagnostic value of watery discharge is very lim- ited ; if it is primary and profuse, it is pathognomonic; if, as these observations seem to show, it usually follows a hemorrhage, when it occurs at all, it adds nothing to the already assured certainty of fracture. Another and still more infrequent symptom of basic fracture is an oedema of the mastoid region. In the single instance noted, No. LXII., it accompanied fracture of the posterior fossa which traversed the groove for the lateral sinus, with obstruction of that vessel by a thrombus. The occurrence of such a symptom must necessitate the joint condition of a venous obstruction to cause the oedema and of a fracture to permit its appearance in a cranial region. It could hardly be apparent at any point where the super- ficial tissues are thicker than those which so thinly cover this bony prominence. In one of the instances cited of secondary serous discharge from the ear, it is possible that 24 INJURIES OF THE BRAIN AND MEMBRANES. the same conjunction of thrombosis and fracture may have contributed to the result. The implication of a cranial nerve may disclose the existence of a fracture, even if otherwise unsuspected. It must be practicable, however, fairly to determine that functional disturbance or abeyance does not depend upon intracranial lesion before it can be attributed to structural injury of the nerve while within its bony conduit or fora- men. It is possible that any cranial nerve may be crushed or compressed in this manner, though, with the exception of the second and seventh pairs, it is in the highest degree improbable. In the appended series of cases, there are numerous instances in which each in turn has suffered functional loss or disturbance from intracranial lesion, but it is only in case of the second and seventh that similar conditions have been demonstrably due to implication of the nerve in the line of fracture. The frequency with which this complication occurs is probably overestimated. Facial paralysis in connection with head injuries is of con- stant occurrence, and fractures of the petrous portion in- volving the part through which the nerve passes constitute a large proportion of all those extending into the base; yet a cranial rather than an intracranial origin of this con- dition is rarely suspected, and is still more rarely disclosed on necropsic examination. There is in general neither osseous displacement nor retention of coagula to lacerate or compress the nerves, and only one or two examples can be found in the whole of the appended series. The lesion of the optic nerve at the optic foramen by compression from the osseous fragments is less exceptional than the injury to the facial, and is more readily discover- able, not only after death but during life. Callan published PRELIMINARY CONSIDERATIONS. 25 nine cases and has since increased the number of his obser- vations to seventeen. The appended series of cases in- cludes six, of which four were recognized only upon necropsy, and of these three had died without the recovery of consciousness and the fourth had suffered no loss of vision. In one only was the nerve implicated in the frac- ture. In the two cases in which life was preserved, the patient upon the restoration of intelligent consciousness discovered loss of vision. Ophthalmosopic examination made on the third day in the first was negative, though the pupil did not respond to direct exposure to light ; fifteen days later atrophy of the optic nerve had begun. In the second case the ophthalmoscopic examination was not made till the fourth week ; the pupil was then insensitive to light and atrophy of the nerve was in progress. Entire loss of vision was permanent in both cases. These six probably represent nearly if not quite the whole number of cranial injuries to the optic nerve in the series of two hundred and forty-five basic fractures. The necropsic examinations, when the anterior fossae were involved, were made with a view to the detection of this complication, and if the patient recovered it certainly could not have escaped observation ; if there were others, they must have been confined to the very few instances in which death occurred without previous restoration to con- sciousness, and in which opportunity was not afforded for post-mortem examination. The injuries to the nerve are much fewer even than the implications of the optic fora- men in the line of fracture. Callan gives this description of the lesion and its mani- festations: " It is due to a fracture of the sphenoid bone which compresses the optic nerve as it passes through the 26 INJURIES OF THE BRAIN AND MEMBRANES. optic foramen, and is more likely to happen if the blow is received upon the frontal bone, but may result from a fis- sure which extends from another cranial region. Monocu- lar blindness is immediate and generally with total loss of all light perception. The eyeball protrudes and diverges, and the pupil is enlarged and non-responsive to light. Optic-nerve atrophy begins within two weeks." The two cases cited conform to this description, except that hemorrhage chanced to be insufficient to cause ocular protrusion or divergence. In only one of the necropsic cases did the fracture involve the sphenoid body. The cases in which sight is destroyed by direct wound of the orbit, as from pistol shot or by profuse hemorrhage into the orbit or globus oculi in fracture propagated from the vault, are of less diagnostic interest, because the con- dition is obvious and readily apprehended. There is still another and perhaps final direct symptom of basic fracture which may suggest its existence and loca- tion in the absence of more positive indications. It is an acute localized pain, different from the frontal, occipital, or diffused headache which is common in all forms of in- tracranial lesion. Its limitation and intensity serve to distinguish it from the pain of internal injuries, while it is disproportionate to the amount of superficial contusion. In fracture limited to the posterior fossa, in which other direct symptoms are often wanting, it may afford the only ground for suspicion, and when it involves the mastoid process its import may be confirmed by the later appear- ance of subcutaneous hemorrhage. It has been often noted in the cases appended, and its significance often established in subsequent post-mortem examination. This symptom, which has been generally if not en- PRELIMINARY CONSIDERATIONS. 27 tirely overlooked, is sufficiently important to deserve attention. The evidences of intracranial complication which have been so often regarded as symptoms of basic fracture are indirectly diagnostic of that lesion, but only in so far as they explain or confirm its direct indications; they are of themselves insufficient, since all of the intracranial lesions may exist independently, just as fracture may occur with- out complication. The cranial and the intracranial lesions, however, concur in a large majority of cases, and while the direct symptoms are usually adequate to a diagnosis of the fracture, there are still cases in which an element of doubt remains, to be resolved, possibly, by the recognition of an internal injury. A profuse hemorrhage or serous dis- charge from the ear, with certain restrictions as to the conditions under which it occurs, or the extrusion of brain tissue, may render the existence of a petrous fracture cer- tain ; but a nasal hemorrhage or a localized pain, however characteristic, can hardly determine an ethmoid or sphe- noid or a mastoid fracture with equal certainty, and con- firmation is naturally sought in the fact of intracranial complication. The possible error in the use of this means of diagnosis has been in ascribing to it undue importance, and in a consequent depreciation of the value of direct symptoms. Some minor degree of cerebral contusion may exist in any case in which violence has been sufficient to produce fracture, but, if so, its indications are so often slight and transitory, and early histories are so often im- perfect, that this assumption is impossible of verification. The presence therefore of even trivial intracranial injury cannot be regarded as essential and much less as of pri- mary importance in the diagnosis of fracture, which really 28 INJURIES OF THE BRAIN AND MEMBRANES. occurs much oftener without complication than without the evidence of direct symptoms. Fractures of the base were for a long time regarded as shrouded in mystery, and, like the intracranial traumata, as problems to be satisfactorily solved only by necropsic examination. The means afforded for their diagnosis are certainly not unusually restricted; the possibility of trac- ing the fissure from its origin in the vault, the evidence of external hemorrhages, serous discharges, or extrusions of brain tissue, the localization of pain, and the concurrence of complicating intracranial lesions, suffice in by far the larger number of cases to remove them from the domain of obscurity and conjecture. Prognosis. The prognosis of cranial fracture demands some con- sideration. It concerns repair, the loss of function, and by a possibility the danger to life. The restoration of the bone in simple linear fracture is effected by a definitive callus and is perfect ; even a trace of its existence is eventually discoverable in only the most exceptional instances. At the base, in which fracture is almost invariably of this form when propagated from the vault, and in which frequency of occurrence and of recov- ery would presuppose frequency of disclosure in the dead- house if evidence of closed fissures remained, it is practi- cally unknown as an ancient lesion. A cranium discovered and lost in the morgue of Bellevue Hospital many years ago, by a student ignorant of its pathological value, exhib- ited a line of fracture across both middle fossae with slight displacement of the posterior segment upward, and with PRELIMINARY CONSIDERATIONS. 29 union long perfected. This specimen was perhaps unique. If the fissure is widely opened and the patient survives the complications with which it is likely to be attended, it will be approximately closed by the elasticity of the skull be- fore repair begins. In any event the process is slow and may extend over many months. An exception to the almost invariable closure of an open fissure occurs in one of the appended cases, in which, with a fracture through the median line of the frontal bone extending into an orbi- tal plate, perceptible separation and mobility of the seg- ments existed five years after a comminution of the vertex. The very unusual instances cited, the displacement of seg- ments of the base and the lack of union in fissure of the vault, are merely curiosities of surgical experience. The established rule as to the absence of displacement and the perfection of union in this class and variety of cranial frac- tures is unaffected. Fracture of the orbital processes of the frontal bone occur under special conditions, and dis- placement of fragments which sometimes directly lacerate the frontal lobes are not uncommon ; they are consequently allied to fractures of the vault rather than of. the base. The only dangers directly attributable to linear fracture are essentially confined to the orbital region, and are the laceration of the brain by elevation of an orbital fragment and implication of the optic nerve in its foramen of exit. Displacement elsewhere in the base or in the vault without comminution is practically impossible ; implication of other cranial nerves is very exceptional, and no subsequent harm can come from the simple process of repair. Depressed or displaced, and comminuted, fractures are limited to the vault and orbit, regions in which the bone is comparatively thin, and are often prolonged by simple fissures. If the 30 INJURIES OF THE BRAIN AND MEMBRANES. bone is composed of two tables, depression may be con- fined to either, and if the inner be the one depressed, the outer is usually but not invariably fissured ; and if both are depressed, the inner is likely to be the more exten- sively involved and often comminuted. These simple facts are of common acceptance. If the displaced frag- ments can be restored to their normal position without loss of substance, the lines of fracture only remain and will unite as readily and with as little incidental danger as primitive fissures. If loss of substance results from the displacement and necessary removal of fragments, the un- aided osteogenic properties of the pericranium, diploe, and dura are insufficient to replace the portion which is lost. The dense fibrous structures which then occupy the osse- ous hiatus imperfectly protect the cranial contents from external violence, and this structural weakness is a source of danger proportionate to the extent and situation of the enfeebled part. The detached fragments, when com- pletely separated and depressed, may become the source of additional dangers; they may be encapsulated in the dura and by irritative pressure lead to remote neuro-psy- chic disturbances, or they may be necrosed and occasion dural or peripheral abscess. The complications of depressed fracture are twofold : there are concomitant intracranial lesions, as general me- ningeal or cerebral contusions or distant lacerations pro- duced simultaneously by the same violence which causes the fracture, and common to all its varieties; and there are superadded the localized wounds inflicted by the dislo- cated fragments. The coincident injuries have no part in the prognosis of fracture ; the consecutive lesions consti- tute whatever elements of danger it possesses. Hence a PRELIMINARY CONSIDERATIONS. 3 I seeming paradox. The fissured fracture of the base is often followed by a fatal result, while the depressed and comminuted fractures of the vault generally end in recov- ery. The harmless fissure of the base is likely to be asso- ciated with grave concomitant lesions, and being in bad company is held responsible for the fatalities to which these complications directly lead ; the more dangerous fractures characteristic of the vertex are oftener compli- cated only by the direct and accessible injuries of their own production. The coincident lesions are in a majority of instances beyond remedy, though not equally beyond recovery; the consecutive injuries are in larger proportion amenable to treatment. In a minority of cases a wound of a dural sinus or of the middle meningeal artery may be irremediable, or a cerebral laceration made by an orbital fragment may be inacccessible, and it is possible that structural disorganization from crushing violence may be irreparable ; but ordinarily the hemorrhages and lacera- tions at the site of fracture are manageable and infection is preventible if surgical interference is sufficiently early and complete. It is therefore true that in themselves cranial fractures are important only in exceptional cases. Their prognosis is really the prognosis of their complications. Neither the shock of an uncomplicated fracture nor the hemor- rhage from the osteal vessels is ever fatal. Its methods of repair involve no subsequent dangers, and if it occasions loss of substance which necessarily fails of osteogenetic restoration it can only increase a bare chance of remote disaster from some future exposure to violence. The fatalities which follow in its train arc in the vast majority of cases due to concomitant lesions with which it has only 2,2 INJURIES OF THE BRAIN AND MEMBRANES. an accidental and innocent connection. The consecutive complications for which alone it is responsible are usually amenable to control, and there remains only a residuum of scattered cases beyond the pale of relief to justify its evil reputation. The tabulation of cases of fractured base or vault, with reference to the percentage of recoveries or its relation to the region involved, is useless, except it be to determine the probability of a fatal complication, or its more frequent occurrence in different parts. The fracture is rarely more than an incident. The generalization supposed to be jus- tified by the discovery that in a certain number of cases of fractured base recovery followed in all in which injury was survived for twenty-four hours, is a familiar illustra- tion of the idleness of purely arithmetical conclusions. It is well known that the issue of coincident intracranial le- sions is not usually determined in that length of time. An analysis of the results and conditions of fractures included in the appended series of cases will show a fatality in nearly two-thirds of those which involved the base and about one-third of those which were confined to the vault, but in the total of three hundred and fifty there are less than a score in which the fracture was the determining cause of death. Treatment. The treatment of cranial fracture is essentially local. If the osseous lesion is devoid of intracranial complication, there will be no general indications to meet, and if com- plicated, the general treatment will not be modified by the coexistence of fracture. The initiative of treatment in the presence of grave complication will be constitutional. PRELIMINARY CONSIDERATIONS. 33 Shock is the most urgent primary condition, and until re- action has been established, no local interference is per- missible except it be for the control of hemorrhage by the simplest possible means. If the hemorrhage is serious it may be proper to go farther, even to the extent of invad- ing the cranial cavity, since in emergencies even laws are held in abeyance — but always with discretion. The gen- eral principle that the resort to local measures must await the restoration of nervous and vascular force, except for the relief of hemorrhage by which depression is prolonged, is a fundamental law in surgery. The neglect of this pre- cept is one of the most frequent errors of inexperienced practitioners and hospital assistants, and seems especially to prevail in the case of injuries of the head; that life is often thus jeopardized or sacrificed at the outset is mani- fest not only from observation but in the published his- tories of cases. In the absence of shock or after reaction has been secured, the injury should receive immediate attention. If operative measures prove to be required, early conditions are more favorable than those presented after pathic changes have begun. The principles of sur- gical procedure are precisely the same as with complicated fractures of the extremities: the establishment of reaction and then, if interference be demanded, a resort to primary rather than to secondary operation. Fractures of the base rarely admit of direct interfer- ence, even for exploration. They are usually inaccessible, and of the linear type which neither involves danger nor requires rectification; it is only incidentally in an exami- nation of a fracture of the vault from which it takes its origin that a basic fissure may be justifiably exposed for inspection. 34 INJURIES OF THE BRAIN AND MEMBRANES. If a petrous fracture has been made compound by its implication of the internal auditory passage and a rupture of the tympanum, though the danger of infection may be slight, it should be repelled by careful aseptic protection of the external meatus. A similar external communi- cation of an ethmoid or a sphenoid fracture through the nasal cavities is anatomically less favorably situated for the exercise of aseptic precautions. Fractures of the orbit or of the ethmoid bone, the result of immediate violence, are allied to fractures of the vault not only in character and prognosis but in treatment; and the replacement or removal of osseous fragments and the observance of asep- tic care in the management of the osseous wound may be- come practicable and, if so, are no less imperative. The requirements of treatment in the case of fracture of the vault are more positive. There are simple uncom- plicated fissures which are often undiscovered and always unimportant, and which are better left without interfer- ence ; but complicated fissures and comminuted, depressed, and punctured fractures, even without apparent complica- tion, demand complete exploration, operative reduction to their simplest possible form, and rigid aseptic methods in the immediate and subsequent treatment of the wound. These conditions are absolute, and the particular measures which they necessitate are immaterial, but should be as simple as is compatible with the attainment of the ends in view. It is useless to discuss the propriety of one method of procedure, or the safety of another; it is the necessity of either to the fulfilment of essential indications which must be brought in question. Everything is proper which is indispensable, and anything is safe which can be pos- sibly required for the better comprehension and treatment PRELIMINARY CONSIDERATIONS. 35 of this very simple form of injury. If therefore the exist- ence of a hidden fracture of the vault can be ascertained by palpation, incision should be practised in order to de- termine its extent and characters; even a doubt in the presence of intracranial complication should be resolved by making direct inspection possible. If the cranial sur- face is precluded from digital examination by a large or well-defined haematoma, incision should still be made, though as yet there may be no indicaton of internal injury. So far diagnosis and treatment coincide. This method is justified not only by the necessity of exploration for the intelligent determination of treatment, but both by theo- retical considerations of safety and by the results of experi- ence. It has no conceivable dangers; the matter of infec- tion is within the control of the surgeon, and the amount of additional shock or hemorrhage involved in an explora- tive incision is inappreciable. This course has been gen- erally pursued in the conduct of cases in the series appended, and the issue has confirmed the opinion ex- pressed as to its propriety. The absence of shock, a fair constitutional condition, and the observance of ordinary precautions; the maintenance of asepsis, the careful re- pression of hemorrhage, and the restriction of the wound to the limits required for its purpose, are always to be assumed. If the incision reveals no fracture, or a fine fissure which is deemed unimportant, the wound can be closed and the patient will be none the worse for the means taken to ascertain the nature and extent of his local injury; but if a more pretentious fissure or some other form of frac- ture is disclosed, exploration and treatment, still conjoined, must be farther extended. The depressed fracture may 2,6 INJURIES OF THE BRAIN AND MEMBRANES. be said to include all the others, since it is the possibility of concealed depression which gives importance to cranial comminution or puncture, and removes the first from the class of mere multiple fissure, or the second from the con- dition of a wound left by trephination. It is the continued uncertainty as to the amount of injury done to the internal table which compels further exploration, even at the cost of operation when the external depression may seem un- important. The extensive and entirely disproportionate comminution of the internal table and the frequent serious laceration of the brain by its dislocated fragments, with simple fissure or trivial external depression, have been made notorious by reiteration and illustration in every surgical text-book. These conditions often are suggested by no primary general symptoms of complication, and, if unsought, must remain undiscovered at the peril of the patient. The unfortunate results of such neglected frac- tures have forced themselves upon the attention of every surgeon ; immediate septic infection or remoter effects of cerebral irritation or pressure from completely severed or partially detached osseous fragments resting upon or pene- trating the brain, including dural or cortical abscess, cere- bral necrosis, epileptiform convulsions, and multiform disturbances of functional control, have not yet ceased to be of common occurrence, though with improvement of practice they have notably diminished in frequency. Forty years ago, Dr. James R. Wood, who was often in advance of his time, was the only surgeon of eminence who taught the necessity of elevating depressed bone under all circum- stances when not specifically contraindicated. Since then Roberts, Nancrede, and other still more recent writers have advocated it as a general rule of treatment. The in- PRELIMINARY CONSIDERATIONS. 37 junction to refrain from interference with depressed frac- tures in the absence of complicating symptoms, however, is still widely upheld and respected in the profession, for no better apparent reason than the fact that many patients who are treated upon the expectant plan at least tempo- rarily recover, notwithstanding the recognized dangers to which they are exposed. The influence of tradition and a failure to apprehend the changed conditions of modern surgery often incline the general practitioner to an injudi- cious policy of inaction. There may be a slightly wider latitude of opinion allow- able when the bone is not obviously depressed, but the probabilities of depression when the vault is comminuted or traversed by an open fissure, or when the fracture is of the punctured variety, are sufficient to warrant a positive solution of the question when it arises. A comminution indicates great violence, limited or diffused, or else struc- tural weakness of the bone, and in either case makes prob- able greater injury of its deeper part than is apparent upon the surface. A punctured fracture almost invariably in- volves concealed injury of which the external lesion affords no means of estimate. The exposure of the inner table in both varieties is essential to safety, and should be made, almost without exception, when the general condition of the patient permits. There are sometimes numerous fine fissures, perhaps radiating from a point of impact, without mobility of the intervening parts, and the case is then to be regarded as one of multiple fissure rather than of com- minution. The proper course to pursue in the case of a fissure may in some instances seem difficult to decide; it is plain enough when the fissure is insignificant, appar- ently limited to the outer table, and has been made com- 38 INJURIES OF THE BRAIN AND MEMBRANES. pound only by incision, or, conversely, when it is wide and deep, and exposed by primary injury. The only rule which can be formulated is that hesitation is always to be ended by sufficient exploration to resolve whatever doubt exists. If the fissure is originally compound, its danger is enhanced by the possibility that infection has already occurred, since it is well known that even closed fissures may have been open in their inception. The concurrence of symptoms of intracranial injury gives additional force to the direct indications for deep exploration, by increas- ing the probability that the hurt has been sufficiently severe to comminute the inner table. The exploration and rectification of a fracture, of what- ever character, can ordinarily be effected by very simple operative measures, and by the use of correspondingly simple instruments. Depressed bone in a large propor- tion of cases can be raised by the periosteal elevator, the cranial opening can be sufficiently enlarged by the ron- geur, osseous fragments can be removed by any kind of forceps, and intracranial exploration made by the ordinary probe. If the elevator cannot be inserted, a sufficient opening can often be obtained with the burr drill. The use of the trephine is only occasionally required. Com- minuted fractures may be exposed and fragments removed with equal facility and by the aid of the same instruments. Even punctured wounds of the cranium may sometimes be enlarged by the rongeur. There is no objection to the resort to the trephine in any case in which it better or more conveniently serves the purposes of the opera- tion. The chisel is best adapted to the examination of fissures and can be supplemented by the trephine if reason is found to suspect internal comminution. The PRELIMINARY CONSIDERATIONS. 39 details of procedure are exemplified in text-books of general surgery. Trephination has been voluminously discussed, and large tabulations have been made of cases in which it has been a feature in treatment. Whatever of propriety or necessity may have existed heretofore for the marked attention which has been accorded this simple operative procedure, or whatever question may still exist as to its employment in the treatment of intracranial lesions, there can be no longer reason to give it special prominence or to individualize it among the other expedients utilized in the management of fractures. It is simply an incident in treatment, to be used or avoided as the exigencies of a case may suggest, not dangerous in itself, and no more respon- sible for the outcome than the choice of a knife for mak- ing the incision or of a forceps for the extraction of an osseous fragment. The statistical tables which have de- termined the rate of mortality in cases in which trephina- tion has been employed have also shown the infrequency with which the operation has contributed to the fatal re- sults recorded. It is the complication which kills, not the fracture, nor the means of treatment which the fracture requires. The percentage of deaths for which it is held responsible, three percent. (Amidon), is, in view of the fallibility of human judgment and the natural errors of inexperience, rather remarkable. It seems probable in the exceptional cases in which operation, whether trephination or some other procedure, and not the lesion, is justly chargeable with the death which follows, that the timidity or recklessness of the operator is likely to be in fault — a timidity which allows the case to drift till the development of symptoms compels interference under unfavorable cir- 40 INJURIES OF THE BRAIN AND MEMBRANES. cumstances, or a recklessness which impels to operation regardless of the constitutional condition of the patient. There is no apparent reason why trephination should in- volve peculiar dangers; it is not an operation in which shock need be excessive, nor in which a general anaes- thetic even need be employed if deemed unadvisable, or in which the danger of infection, whether from exposure of the diploe or of the cranial cavity need be greater than in the making of the external incision, if it need exist at all. The consideration of treatment in general has been advanced to a higher plane than it formerly occupied, and the proper fulfilment of indications has become of greater recognized importance than the selection of means for their accomplishment. It suffices if these are as simple as may be and devoid of unnecessary danger. Greater dis- crimination is also exercised in estimating the results of necessarily fatal injuries, and the effects of possibly un- successful measures taken for their relief. It is now recognized that trephination is in itself neither a formi- dable procedure nor necessarily of radical importance, and it has therefore come to be regarded as a less prominent factor in the prognosis and treatment of injuries of the head. The differentiation of cranial fracture from complicat- ing intracranial lesion defines the limit within which op- erations for its rectification are undertaken. They may be primarily explorative, but are ultimately prophylactic and not curative. The fracture of the bone is not directly a source of danger, but the lesions of the brain and me- ninges which its dislocated fragments, unless reduced or removed, may produce often lead to immediate or remote disaster. The traditional cases in which, by the elevation PRELIMINARY CONSIDERATIONS. 41 of a depressed fragment of bone and relief of " compres- sion," the patient in the twinkling of an eye springs from profound coma into consciousness and mental activity, seem to be extinct. Instances still occur in which by the opening of the cranial cavity and incidental elevation of encroaching bone for the relief of intracranial hemorrhage and removal of coagula, cerebral function is presently re- stored ; but these operations concern the treatment of con- secutive complication. Chapter I. PATHOLOGY. DIRECT LESIONS. The traumatic intracranial lesions, whether they occur independently or as complications or sequelae of cranial fracture, cannot be predicated upon the amount of violence apparently inflicted. Injuries received by falls upon the head from great distances, or from a mere stumble upon the street, may be in either event trivial or disastrous; force in the one case may be so broken in various ways that its final impact is minimized, as in the other it may be fully conserved or even exaggerated by attendant con- ditions. Their exact history is rarely attainable. The effect of a glancing blow differs from that of one which is direct, and the comparative elasticity, thickness, or density of the skull will modify the extent and character of intra- cranial injuries as well as of fracture. The study there- fore of different forms of violence, in the necessary absence of essential data, is of no practical utility. The intracranial traumatic lesions may be classified primarily as: Hemorrhages. Thromboses of sinuses. Contusions. Lacerations. And their sequelae as: Meningeal and parenchymatous inflammations, which are usually, if not invariably, of a septic character; and PATHOLOGY. 43 Atrophy. The primary conditions may occur as isolated lesions or in combination with each other, and the later inflamma- tions which may also coexist develop at any period during the persistence of the direct structural changes upon which they in part depend. The hemorrhages may be epidural, pial, cortical, or parenchymatous, and the contusions and lacerations may either be confined to the brain or meninges or may involve both structures with a predominance in one. As previously stated, when the intracranial lesions occur as complications of fracture they may be coincident or consecutive, and usually dominate the symptomatology, afford the indications for treatment, and determine the prognosis of the case. 1. Hemorrhages. Some confusion has arisen in the nomenclature of hem- orrhages as it relates to their nature and location. The use of the term " epidural" is anatomically correct, and as the sources of this hemorrhage are various it would be doubtless difficult or impossible to suggest another which would at the same time denote its origin. The terms "subdural" and "arachnoid" arc indefinite as to location, and imply nothing as to source, and are therefore objec- tionable. These deeper hemorrhages are derived from the vessels of the pia mater and from or through the cere- bral cortex, and are always originally situated beneath the visceral arachnoid membrane, though if the extravasation is sufficiently large it will secondarily break through into the arachnoid cavity. This extension has no clinical or 44 INJURIES OF THE BRAIN AND MEMBRANES. other importance, but to specialize them as subarachnoid rather than as subdural would somewhat more closely de- fine their anatomical position. The designations " pial" and "cortical," as the subarachnoid hemorrhage is of me- ningeal or visceral origin, are topographically exact and pathologically distinctive. If the prefix epidural is invari- ably used to characterize a hemorrhage which separates the dura from the cranial wall, "pial," to characterize a hemorrhage into that membrane from rupture of its ves- sels, and "cortical" to characterize a hemorrhage upon the surface of the brain from laceration of its substance, both the source and location of the hemorrhage will be ex- pressed in a single word with accuracy and conciseness, and the description of cases much shortened and fa- cilitated. a. Epidural hemorrhage, when derived from the diploic vessels, is usually inconsiderable in amount, and may ap- pear externally beneath the pericranium and in the situa- tions noted in connection with basic fractures. If it escape from the cranial cavity, its importancce in this form is mainly diagnostic, and if retained, is insufficient to occa- sion symptoms; but in exceptional instances of compound fracture of the vertex the loss of blood from this source has been excessive. The implication of the dural vessels increases the extent of hemorrhage in proportion to their size, and in case the arteria mcningea media or either of its primary branches is involved the danger to life be- comes imminent. The effusion from these large menin- geal vessels is usually rapid, with early coagulation, and may be as much as six or eight fluid ounces in volume. The lateral aspect of the corresponding cerebrum is some- times converted by compression into an oblique plane, and PATHOLOGY. 45 with the dura may remain for a time after the removal of the clot widely separated from the bone, both laterally and at the base. In one of the appended recovering cases the clot from a smaller meningeal branch in the squamous region measured four fluid ounces, and was one and a half inches in thickness in its central portion. The laceration may be occasioned by a wound inflicted by a fragment of the inner table, by rupture in the line of fracture, or by contrecoup, and may even occur without cranial lesion. These different forms of injury are all exemplified in the two hundred and twenty-five necropsic cases included in the appended series. The dural sinuses are a further source of large hemorrhages, possibly from direct rupture of their walls but more generally from wound by an osse- ous fragment. The accumulation of coagula is less than in the meningeal variety, since the fragment which causes the injury so often closes it till disturbed by manipulation. The profuse discharge of dark-colored fluid blood which at once follows the elevation or removal of a portion of bone from the vicinity of a sinus readily indicates the nature of the lesion. The greater longitudinal sinus is the one usually involved and is not infrequently lacerated in fractures of the vertex. The lateral sinus is occasion- ally wounded, but from its situation is somewhat more subject to rupture from transmitted force. The hemor- rhage is less manageable than that from the longitudinal sinus and is a far more serious accident. The wounding or rupture of the other sinuses must be of exceeding rarity except as it occurs in connection with crushing or disorga- nizing injuries in which all the adjacent structure.; are concerned. The several species of epidural hemorrhage may be 46 INJURIES OF THE BRAIN AND MEMBRANES. variously commingled, but it is likely to be essentially of one distinguishable and predominating character. b. Pial hemorrhage is occasioned by rupture of the vessels of the pia mater and is primarily confined to its meshes. It is one of the results of intracranial contusion and is independent of epidural extravasation. In its sim- plest form it consists of punctate extravasations analogous to those which occur in the brain substance. It more characteristically forms a thin sheet over the vertex ; if it is in larger quantity