Chapter XIII: Part 13

Fractures of the base of the skull are the result of great force applied to the lateral parts of the head, to the vertex, or to the base itself through the spinal column. A blow inflicted by an obtuse body on the top of the head, whilst it is at rest and fixed—by producing expansion of the lateral parietes, and forcing the base down upon the upper part of the spinal column—may have the effect of breaking up the connections of the bones at the base, which is the weakest part of the cranium, and splintering them to a greater or less extent. Again, if a person falls from a height, he perhaps alights on some part of his trunk, as the buttocks, and this coming to a state of rest, whilst the head is still in projectile motion, the spinal column is driven towards the cavity of the cranium, and the same effects are thereby produced as in the preceding instance. Or the patient alights on his head, and the base of the cranium is then impinged upon by the weight of the whole trunk, as well as by the force of the projecting power, and in this case also the base is frequently broken up. In the sketch here given, showing extensive fracture of the occipital and sphenoid bones into the foramen magnum, the patient, a brick-layer, fell from a ladder on the vertex. He lay comatose for some days before death: there was found extensive extravasation over the middle lobes and cerebellum. Concussion has resulted from falls when the person has alighted on his nates or feet; but the symptoms attendant on fracture of the base are more generally those of compression of the brain. In this accident the bones are seldom displaced to any great extent; the dura mater is generally lacerated, its bloodvessels, and frequently its sinuses, are wounded, and blood is consequently effused at the base of the brain, where injury is most fatal. The upper part of the brain may bear pressure to a considerable degree without bad consequences ensuing, but compression at the origins of the nerves is always highly dangerous and generally fatal. Bleeding from the nose, mouth, and ears, when attended with other circumstances and symptoms evincing a violent injury and consequent cerebral disturbance, has been considered as decisive of fracture at the base having occurred. But we find that such bleeding happens in slight injuries unattended with any circumstances or consequences to induce a belief that so serious an injury has taken place: and again, in cases where dissection has shown most extensive fracture in the temporal, sphenoid, and æthmoid bones, no blood had issued from their external openings. Fracture of the base of the skull generally proves fatal, but many cases are met with in which there is reason to believe that it had taken place, and yet the patients have recovered with perhaps partial paralysis. Of this I lately met with a good example in the case of a girl seven years of age, whose head had been squeezed between a wall and the back of a cart, and thereby considerably flattened. She lay insensible for several days, with all the symptoms of compression, and with blood flowing in small quantity from the nose, mouth, and right ear. An extensive abscess formed over the right temporal bone. She ultimately recovered, but remained affected with paralysis of the right side of the face and amaurosis of the left eye; sensation in the paralysed parts being quite perfect.

Fractures of the upper part of the cranium are generally attended with displacement to a greater or less extent, and with wound of the cranial coverings. The size of the depressed portion, the depth to which it is displaced, and the extent of wound, will depend upon the nature and intensity of the force applied. When both tables are broken, the fracture of the inner is almost always more extensive than that of the outer one, as fissures will extend furthest in the most brittle part. A broken fragment, comprehending the entire thickness of the skull, presents generally a much larger portion of the inner than of the outer table, so much so that the piece would sometimes not admit of removal, though perfectly detached, without enlarging the opening in the outer table. Fractures, with depression of a considerable portion of one of the flat bones, are sometimes unattended with any alarming symptoms. The effects of the injury soon disappear, and even in cases where the depression has been very considerable, and where, from the escape of brain, it was evident that both this organ and its membranes had been seriously injured, no bad symptoms have occurred to retard the patient’s recovery. Symptoms of compressed brain, however, may generally be expected to attend depression of any considerable portion of bone below its natural level. Still the brain may become accustomed to the pressure, and the symptoms may gradually subside without surgical interference. And if the indications of compression are not very alarming, the coma not very profound, a little delay is allowable, means being taken to avert inflammatory action: for danger is not imminent, the cure may not be expedited by operative aid, and there is chance of injury resulting from rash interference.

But it is in general necessary to remove the cause of the symptoms, to elevate the depressed bone, and take away those portions which may be detached.

It has been said that we must be regulated in our proceedings very much by the existence or not of external wound; that we must be cautious in cutting down upon fractures of the cranium where there is no wound, and so converting a simple into a compound fracture. In fact, so much is the danger increased, it is alleged, by the existence of wound, that the symptoms must be very urgent indeed which would demand division of the integuments in order to admit of examination of the fracture, the application of the trephine, or the elevation of the bone; whilst, on the contrary, if the fracture is exposed by the accident, very slight symptoms will fully warrant performance of the operation of trephine. In other words, it is said that simple fractures should be left to nature, unless under very urgent and alarming circumstances, and that compound ones ought almost always to be interfered with. But the facts are otherwise. The greatest danger of compound fractures of the cranium does not arise from the admission of air. It is not the wound of the scalp, but the mechanical irritation of the brain and its membranes that proves dangerous. Injuries of the cranium inflicted by sharp bodies, such as divide the scalp and cause compound fractures, are generally attended with splintering of the internal table, and require the trephine. The existence of this sort of fracture of itself, without a single bad symptom, without any present disturbance of the sensorial functions, is a sufficient warrant for the application of the trephine, so as to permit the removal of the detached portions of the inner table: and this should be done before inflammatory symptoms have shown themselves. The brittleness of the internal layer of the skull is well known. In fractures inflicted with sharp and pointed instruments, as a bayonet or pike, the corner of a sharp stone, or the heel of a horse’s shoe, the external opening is often very small, it is a mere puncture; in the bone there is a central depression, from which fissures proceed around in a radiated form, and hence the injury has been termed punctured, or starlike fracture. But though the external wound is apparently insignificant, the vitreous table is extensively separated, and, perhaps, broken into innumerable minute and sharp spicula. These sharp portions are driven down upon the dura mater, and by them the membrane is often severely lacerated. If these be not removed soon after the accident, inflammatory action is almost invariably lighted up on the surface of the brain; and we cannot expect to allay or avert such action by general antiphlogistic means, however energetically applied, so long as their exciting cause remains. It is in such cases, I repeat, that the operation of trephining is imperiously called for. Sometimes, however, patients are found to recover from punctured fracture of the cranium, without the operation having been performed, as in the following case, the only one so terminating with which I have met:—On the 4th September, I was consulted by a gentleman, aged 35, who had received a punctured fracture of the cranium, on the 29th of August; a heavy dung fork had fallen from the top of a haystack, and struck him on the upper part of the head. Immediately after the accident he became confused, but not insensible; he lost the power of motion in the right lower extremity, but almost instantly regained it. Next day the right arm became weak, and when I saw him, he was almost wholly unable to move it: he could not bend his fingers, nor raise the arm, and he retained the power of exercising but very slight motion in the elbow-joint. There was a small wound of the scalp, nearly healed, over the posterior part of the left parietal bone, close to the sagittal suture, and nearly midway between its two extremities. A probe passed down to, and through, the bone; and there was slight swelling of the scalp around the wound. He had felt pain in the right ear, and in the forehead, whilst stooping, for some days after the accident. No blood had ever escaped from the ear. A fit of shivering occurred on the night following the injury, but never returned. He soon recovered completely.

I subjoin a case of an opposite description. A coachman was knocked down, late on a Saturday night, and fell with his head on the corner of a stone on which masons had been recently working. After being carried to his lodgings, he recovered from the stupor produced by the combined causes of liquor and blows; and next morning he went to have his head dressed by an apothecary, who with difficulty extracted a fragment of the stone from the wound of the head. The patient then drove a party to church, and probably drank some more whiskey during the day. He afterwards felt indisposed, and was seized with sickness and shivering in the afternoon. On Monday he was in a violent fever, and I saw him in the evening. He had been delirious, but was now lying in a state of stupor. There was a hole in the right parietal bone, capable of admitting the point of the little finger, and many loose fragments of bone were felt lying on the dura mater; a trephine was applied, and numerous spicula were removed. Afterwards, the circulation became much excited, he was bled copiously, and antimony was exhibited in nauseating doses; but he died early on Wednesday morning. On dissection, there were found marks of violent inflammatory action on the surface of the hemispheres. The vessels were unusually numerous and highly engorged, and lymph and pus were effused in considerable quantity, the arachnoid was opaque, and the cerebral substance was somewhat softened. Had the operation been performed at an earlier period, there is every probability that the inflammation, which proved fatal, would have been averted, as in the following instance:—A quarryman received a blow from a sharp stone of considerable size, which rolled down a precipitous bank, and struck him on the vertex. He lay insensible for half an hour, but recovered, and followed his occupation during the rest of the day. In the evening he came for advice. There was a small wound in the scalp, and the subjacent bone was fractured exactly in the same manner as in the former instance, but he felt no uneasy symptoms whatever. The consequences likely to result from such an injury, and the necessity for trephining, were represented to him; he agreed, and the operation was performed on the spot. Many sharp fragments of the inner table were extracted; he proceeded home, never had a bad symptom afterwards, and consequently required no treatment save dressing of the wound.

The operation, if undertaken early, will, in all probability succeed in averting future evil, more especially if the dura mater be not wounded. As a proof of the unfavourable nature of this latter circumstance, I give the following case:—A young man, aged 18, received a kick on the forehead from a horse, September 9th. He remained perfectly sensible, and did not fall to the ground. Shortly after, he was seized with vomiting, which recurred at intervals; his pulse was regular, but feeble; pupils dilated. On the centre of the forehead, there was an irregular wound, which extended to the root of the nose; and on introducing the finger, the os frontis was found fractured, and a small portion of it comminuted and depressed. The trephine was applied, and several detached portions were removed, with some difficulty, from beneath the undepressed portion of the bone. A spiculum had lacerated the dura mater, and penetrated the substance of the brain, to the depth of half an inch; on removing it, a small portion of cerebral matter escaped. The fracture extended apparently in the direction of the right orbit. In the afternoon, the pulse was sixty-four, of good strength, and the pain in the wound had slightly increased. He was bled to fourteen ounces, and ordered an antimonial solution. Afterwards, the pain of the head increased, the pulse rose, the scalp around the wound became the seat of puffy swelling, and several small abscesses formed: the antiphlogistic regimen was rigorously followed, and the abscesses were freely opened as soon as they began to form. On the 21st, a portion of the brain had sloughed, and there was some appearance of fungus cerebri; an incision was made into a swelling over the right temporal muscle, and ℥viii. of blood allowed to flow. On the 22d, several portions of brain were discharged, the pulse was 100, and intermitting. Next day, he was delirious, and a hernia cerebri protruded, of sloughy appearance, and considerable size; pulse 142. Soon afterwards he became comatose; and died early in the morning of the 23d. On dissection, the integuments and pericranium surrounding the aperture, in the frontal bone, were found much thickened, and infiltrated with pus and serum. The dura mater at the wound had a sloughy appearance. There was great effusion of purulent matter, under the dura mater, investing the right hemisphere of the brain; the corresponding tunica arachnoidea was thickened and opaque; and between it and the pia mater there was considerable deposition of lymph and pus. The fungus was collapsed, of a dark colour, soft consistence, and connected with the anterior lobes; the surrounding cerebral matter was much softened, and mixed with pus. The fracture extended through the orbitar plate of the right os frontis, over which lay two small spicula of bone; and a similar fragment was situated over the right optic nerve.

Many cases illustrating the danger of punctured fracture might be related, but are unnecessary, inasmuch as they would lead to the mere repetition of such facts as have been already stated.

Fracture of the external table alone must be rare, but we occasionally see in museums specimens exhibiting a small portion of the outer table driven into the subjacent cancelli, without any fracture of the inner table. This kind of injury belongs entirely to that period of life in which the diploe is of considerable thickness. The treatment would of course be simply that adapted to contusion or concussion.

It is also possible for a blow on the head to produce fracture of the brittle inner table, the outer table remaining entire. However uncommon such a form of injury may be, as its effects may possibly be very serious, it is right to bear it in mind. A splinter of the inner table thus driven into the dura mater might cause violent symptoms and even death.

_Wounds of the Brain._—Laceration of this organ to a slight extent, with more or less extravasation of blood, often takes place, without external wound, and when the patient has symptoms of concussion only. In such cases, the blood may be absorbed, and the læsion repaired, without permanent impairment of the sensorial functions. Wounds of it, along with fracture of the skull, are often very extensive; and portions of its substance may be either severely injured, or entirely separated. Loss of substance, even to a considerable extent, in the upper part of the hemispheres, may occur, without bad symptoms or consequences ensuing. The exposed surface of the brain granulates, and is healed as other parts of soft structure. Generally, however, untoward symptoms result sooner or later in such cases. Hemorrhage occurs from the injured part, and a clot protrudes from the external wound. Or the cerebral substance in the neighbourhood of the wound softens, and becomes converted into a semifluid mass, often mixed with pus; and a fungous growth, connected with the disorganised matter, gradually protrudes through the aperture in the cranium, and is repressed with difficulty. If removed by knife or ligature, it is rapidly reproduced. Pressure is the only means left by which to attempt its retardation; and this, too, is generally ineffectual; for if not very moderate, the effects of compression extend from the fungus to the whole of the brain, and an impairment of the sensorial functions in a greater or less degree necessarily results. The formation of such a growth is generally attended with shivering, sickness, and fever, by a weak, rapid, and irregular pulse; the strength declines, convulsions and delirium supervene, and coma terminates the symptoms.[26]

_Perforation of the Cranium_ is not often resorted to since the treatment of injuries of the head has become better understood. In former times, the operation of trepan was performed frequently, and many seemed to rate the dexterity and science of a surgeon by the number of holes which he was able to bore in the skull of an unfortunate patient. It ought never to be performed, unless the necessity for, and the propriety of, the proceeding be clearly indicated. It used to be practised in a most unlimited manner for fissure: cracks were sought for with the greatest care, rules were propounded to enable the surgeon to distinguish fissures from the cranial sutures, and from furrow made in the bone by periosteal vessels; and the trepan was frequently applied over each part of the fissure, however extensive it might be, the only apparent end of the operation being to widen very materially the solution of continuity in the cranium. It was also resorted to in cases of compression without fracture, with the view of discovering the effused fluid, and removing it; but, as was already stated, it is unwarrantable in such cases; and much more so in concussion, for which latter accident, however, it has been occasionally performed. I met with a case some years since, in which the patient was certainly not much benefited by such active practice. The operation is of itself attended with danger, and likely, under many circumstances, to aggravate the patient’s symptoms, and diminish his chance of recovery.

The cranium must be perforated, however, when the existence and site of abscess under the bone is distinctly marked: and in such cases the practitioner is much to blame if he does not give his patient a chance of recovery by the operation: many are lost by its not being performed, and the following case is a striking example of such negligent practice. A young female fell from a great height amongst some rubbish, and sustained a severe blow on the left side of the os frontis, a considerable portion of which was thereby denuded. She seemed to be doing well for some time; but about the eighth day after the accident, pain in the head, with vertigo, rigors, and sickness, febrile excitement, and a white and dry state of the bare portion of the bone, supervened. She was depleted copiously, but notwithstanding all the symptoms indicating formation of matter under the exposed bone were present, the operation of trephine was deemed inadvisable. Severe rigors continued; she became affected with spasmodic twitchings of the muscles of the face, and stiffness of the jaw, neck, back, and breast, and was, in short, allowed to die. On the dissection, the dura mater below the diseased bone was found separated to a very considerable extent, and the cavity was filled with thin purulent matter; the abscess extended along the superior longitudinal sinus, and communicated with this vessel through an ulcerated aperture; the canal was filled with pus, as far as its junction with the transverse sinus, near which point its cavity was obstructed, and the abscess limited by a firm plug of lymph. A small abscess had formed between the bone and pericranium, above the extensive collection within; the internal table of the diseased bone was fractured and slightly depressed, and its fractured edge was rough, sharp, and projecting.

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

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

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

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

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

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

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

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

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

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

When the pains are fixed and violent, we are sometimes obliged to give small doses of the bichloridum hydrargyri at first, even though there is reason to think that mercurial medicines, perhaps imprudently or carelessly administered, have brought the constitution into its present morbid condition. The good effects of this medicine are well marked and speedy. The patient is freed from the nocturnal pain, gains flesh, and the swellings subside. It ought not to be resorted to, however, unless in severe cases, when the disease cannot otherwise be successfully combated; and when used, it should not be continued longer than is necessary for the removal of the more urgent symptoms: when the pains begin to yield, it is time to discontinue the medicine. Great care is necessary on the part of the patient; he must industriously avoid exposure to moist atmosphere, and ought to be well and warmly clothed, wearing flannel, chamois leather, or both, on the trunk and extremities. A patient treated with the corrosive sublimate of mercury is perhaps more subject to recurrence of the affection, after imprudent exposure, for a considerable time afterwards, than if simple and less powerful means had been employed. A cure can often be effected by the exhibition of the compound decoction of the woods, with or without antimony. Moderate diet and strict abstinence from wine and other internal stimulants should be enjoined; the patient, soon experiencing the good effects of temperance, is exceedingly willing to restrict himself to a somewhat antiphlogistic regimen.

In cases of violent fixed pains, with swelling and threatening of matter forming, incision may be sometimes practised with relief to the patient, but is not to be had recourse to unless there is a risk of the bone suffering. Local abstraction of blood is advantageous, and may, if necessary, be followed by counter-irritation, as the application of blisters or sinapisms. Friction with stimulating substances, or with opiate liniments, is often useful when the disease begins to yield, the pain and puffiness of the parts being thereby dispelled. The hair should be kept short during the cure, and ought not to be allowed to grow till the scalp is firm and sound.

The disease is often so far advanced that, in spite of the most active treatment, abscess forms in one or more points; and, on the matter being evacuated, the bone is found denuded. Exfoliation is then very likely to take place.

Exfoliation generally follows denudation of the bone by accident, but not uniformly. When the periosteum is stripped off by violent injury, the bone in some cases does not lose its natural colour; granulations arise from the exposed part, and it again becomes covered without any part of its substance having been destroyed. Again, careful removal of the periosteal covering, as in excising a tumour or ulcer by the knife, may be followed by death of the outer table of the skull; small portions only separating in some cases, whilst in others a large part of the bone, and of considerable thickness, perishes. The cranial bones may in part become dead throughout their entire thickness, and separate, either after a severe bruise, or in consequence of inflammatory action following injury or arising from disease. The process of separation is either speedy or tedious, according to the vigour of the constitution. The deficiency is repaired, in a great measure, from the subjacent bone, when its whole thickness is not thrown off. But when the breach is complete, the surrounding parts assume the reparative action; the granulations from the dura mater and integuments coalesce, and a dense membrane fills up the space.

The denuded bone should be kept covered and moist, and for this purpose lint frequently wetted with tepid water is the best dressing: spirituous or greasy applications can do no good. A free discharge for the matter should be afforded, and the wound kept clean. If the exfoliation goes on slowly, perforation in the dead bone may be made at different points down to the living parts, with the view of expediting the process. Exfoliations are sometimes retained by surrounding granulations overlapping their edges and confining them in their situation; or are fixed by atmospheric pressure, after separation has taken place from the parts underneath by the action of the absorbents, in the same way as a boy’s leathern sucker becomes firmly fastened to the stone to which it is applied. In such circumstances a small screw may be fixed into a perforation carefully made in the bone, and thus the dead part may be lifted out without pain or difficulty, when otherwise it might have lain for many weeks, keeping up the discharge. In this way the large sequestrum, represented at p. 240, was extracted from its bed. The powdered red precipitate of mercury may be occasionally sprinkled on the parts surrounding the dead portion, in order that the granulations embracing it may be destroyed, and the part more completely detached. The general health must be all along carefully attended to. Sarsaparilla with guaiac, sassafras, mezereon, &c., is often useful, more especially if pains in other parts continue to annoy the patient. Under such medicines he in general improves very rapidly in appetite, flesh, and strength.

The scalp is sometimes, though rarely, the seat of malignant ulcer. In the early stage the ulceration is not of great extent, and affects only the soft parts; perhaps it is confined at first to the common integument, but is extremely apt to extend to the deeper layers which invest the cranium, and even to the bone itself. It is by no means uncommon to find the cranium very extensively diseased, though the affection originated in the superimposed soft parts. Such ulceration of the bone is of a peculiarly destructive nature; it is a disease of the osseous tissue, corresponding to the most malignant ulceration of the soft parts. The bone around the ulcerated cavity is spongy and soft, its margin is irregular, and bristles with numerous spiculæ; the centre is composed of soft morbid deposit, entangling small portions of bone which have become detached, and flabby, almost lifeless granulations shoot from the distempered mass. Such disease, when the patient does not soon succumb to its virulence, advances to a frightful extent, affecting a large surface, destroying the whole thickness of the bone, and even exposing the internal parts. In a case of this description, which occurred in the Royal Infirmary under my care, the anterior half of the cranium was totally destroyed, the left orbit contained a putrid mass, consisting of the disorganised eye mixed with pus and bloody fluid; the dura mater was exposed, and sloughed at several points, and the unhealthy discharge from the parts lodged on the surface of the brain. In malignant diseases of scalp, as of other parts, the lymphatics become secondarily affected: the absorbents feel hard and thickened, the glands in the neighbourhood enlarge and ulcerate, and the sore thereby formed soon assumes the characters of decided malignancy,—hard everted edges, an angry surface, and fetid thin discharge.

Before the disease has become very extensive in the scalp, and when it is still limited to the superficial parts, it may be removed by the knife; the incisions being made at a considerable distance from the margins of the ulcer, so that those parts which may be supposed to have assumed a disposition to malignant action, may be taken away along with the ulcer. In more advanced cases, it may be necessary that the incisions should extend in depth to the bone; and it may be prudent to insist on a portion of the bone exfoliating, the periosteum being removed, and some potential cautery applied to the exposed surface,—as the alumen ustum, oxydum hydrargyri rubrum, &c. The actual cautery cannot be applied with safety to the cranium. Even where the integuments only are removed, and that to a small extent, and in a proper form, it is vain to think of approximating the parts and procuring union by adhesion; the wound must granulate. There is no difficulty in suppressing hemorrhage; either ligature or temporary pressure may be employed according to circumstances. Mild dressings are to be applied, and proper support afforded. The parts should be kept clean, and for that purpose the surrounding scalp must be shaved repeatedly.

_Tumours of the Scalp._—Tumours of a sarcomatous nature are seldom met with in this situation, but the adipose are not so unfrequent. The latter are easily removed, being seldom of large size, and their attachments being loose, unless when they have been irritated by accident or maltreatment. When sarcomatous growths do occur, they are to be excised, with those precautions which were formerly mentioned when treating of tumours generally.

Vascular growths not unfrequently form in the scalp, and attain considerable size; in general they are either congenital, or the degenerations of nævi materni. They may be so extensive as to forbid surgical interference; or they may be so indolent, may partake so much of the nature of simple varix, as not to warrant it. If small, they can be readily removed by the knife, the incisions being made rapidly, and wide of the diseased structure. If the tumour be prominent, extensive, and at all active, the employment of ligature is a more safe and equally effectual practice. One or two ligatures may suffice to encircle the swelling, or, as in other parts of the body, it maybe necessary to pass a great many double ones beneath the part, to separate their extremities, and to tie them to each other around the base of the tumour, the last being drawn so as to tighten all the others. Little benefit can be expected from tying, either at once or at different periods, the larger arterial trunks whose ramifications supply the diseased structure, the inosculation amongst the vessels around the tumour being so extremely free. But, in cases where the disease cannot be otherwise combated with any hope of success, ligature of the common carotid, on the affected side, may be tried as a last resource. The practice has proved successful in some cases of this disease, involving parts of the head and face to such an extent, or in such a situation, as to forbid any attempt at removal of the growth.

Encysted tumours frequently form in the scalp, and, if undisturbed, become large; they seldom occur singly. The disease appears in many cases to be hereditary, and it frequently happens that several members of one family are at the same time afflicted with it. The contents of the tumours vary as to consistence, but are generally atheromatous. The cyst is thick, and loosely connected with the surrounding cellular tissue; but as the tumour increases, the adhesions often become firm and intimate, more especially towards the skin. When the tumour is of small size, it is unnecessary to adopt any preparatory measures for its removal, not even to shave the scalp: the surface may be cleared a little with scissors. The swelling is transfixed, in the direction of the fibres of the occipito frontalis, by means of a curved sharp-pointed bistoury, and its internal structure is exposed by the knife being carried outwards. The soft contents are evacuated, and the sac is easily extracted by means of common dissecting forceps. The integuments are then laid down and retained in apposition, no sutures being necessary, and in many cases the wound heals by adhesion; sometimes a small coagulum forms between the edges of the wound, and is detached some days afterwards; then slight suppuration ensues. In larger tumours, however, a straight and narrow knife is perhaps the most convenient instrument for accomplishing removal. The part is transfixed, and in most cases it is necessary to take away an elliptical portion of the integuments, a part of the cyst corresponding to which is of course simultaneously removed; the remainder of the sac is pulled out by the forceps. If the adhesions at certain points are firm, they may be touched with the extremity of the knife, so as to expedite the extraction; and if after the operation there is reason to believe that the whole of the secreting surface has not been taken away, a pointed piece of caustic potass may be applied to the suspected parts. If the tumour is very large, the cyst can often be removed without difficulty unopened, sufficient integument being left to cover the exposed surface. In consequence of such operations on the scalp, erysipelas often supervenes, and precautions ought therefore to be adopted to prevent its occurrence, by a little preparation beforehand, by keeping the patient’s bowels freely open, confining him to moderate and mild diet, and avoiding exposure to moist atmosphere and easterly winds.

Osseous tumours of the cranium seldom attain any great size, and are in general neither troublesome nor dangerous. Small ivory exostoses are the tumours most frequently met with in this situation, and require no treatment whatever.

Tumours of malignant character occur, though rarely; commencing either in the diploe of the skull or on the surface of the dura mater, soon enlarging, and involving the parts around. Two or more sometimes form in one patient; they are attended with excruciating pain, and rapid destruction of the bone, and are followed by extinction of life either at an early or remote period. They are entirely beyond the reach of surgery; as are also those tumours, occasionally met with in children, which project through the cranial sutures and contain fluid; such are analogous to the disease named spina bifida, hereafter to be spoken of.

I may here remark, that puncture of the brain, with the view of abstracting fluid in chronic hydrocephalus, is an operation not often likely to be followed by success, and it may even accelerate the fatal issue. Some cases are recorded in which benefit is said to have arisen from the practice. Pressure was applied and kept up after the evacuation of the fluid.

DISEASES OF THE EYE AND ITS APPENDAGES.

_Of Inflammation and Abscess of the Lachrymal Passages._—In former times, all affections of the lachrymal passages, and of the parts in the neighbourhood, were denominated fistula lachrymalis, and were all treated nearly in the same manner, by opening the sac, and inserting probes, knives, terebræ, scalpra, caustics, and red-hot irons; the anatomy of the various parts being then ill understood, and the opinions as to the origin and nature of the diseases being founded on erroneous theories regarding the defluxion of acrid humours, formation of imposthumes, fungous growths, &c. The term, however, which was indiscriminately applied to all diseases in the inner corner of the eye, accompanied with derangement of the lachrymal secretion, is now confined to a distinct form of disease, as will afterwards be mentioned.

Inflammation sometimes occurs in the loose cellular tissue covering the lachrymal sac,—whilst that cavity remains free of all disease,—and is attended with some obstructions to the passage of the tears in their natural course, on account of the eyelids becoming swollen, from an extension of the inflammation. The morbid action resembles erysipelas in its nature, and usually terminates in unhealthy suppurations; thin purulent matter lodges in the opened out cellular membrane, a soft boggy tumour is formed, and the superimposed integuments become of a bluish colour, as in the case of other scrofulous collections.

Though the affection is at first unconnected with the lachrymal sac, this organ may ultimately be involved. It may become the seat of a like unhealthy inflammation, and matter may consequently form within its cavity; or, on account of the pressure of interstitial deposit around, the parietes of the sac may ulcerate before the abscess of the cellular tissue in front has discharged externally. Thus, the cavities of the lachrymal sac, and of the external abscess, will communicate with each other. If, after an external aperture has been made either by nature or by art, any doubt exist as to whether the sac is involved or not, such doubt will soon be removed by dexterous use of the probe.

In the treatment of this affection, it will be necessary, at the commencement, as in all other local inflammatory diseases, to attempt the accomplishment of resolution, by attention to the general health, local abstraction of blood, and warm fomentations. When matter has formed, it ought to be evacuated as soon as possible by a small incision, as there will then be less risk of the deeper parts becoming secondarily affected; or if the integuments have sloughed, and the matter has been discharged spontaneously, the natural opening may be enlarged either with the knife, or with the caustic potass. If it be discovered that the lachrymal sac is opened into, the same treatment is necessary as if it remained entire; the matter is to be allowed free exit, and granulation encouraged; in most cases, the aperture in the sac is soon repaired, and the parts heal as quickly and soundly as if the disease had been confined to the external cellular tissue. Light dressing during the cure, preferable in all cases, is more especially necessary in this situation.

_Of Inflammation of the Lachrymal Sac._—When the lachrymal sac becomes inflamed, it enlarges considerably; the swelling is small, hard, circumscribed, deeply seated, and extremely painful, more especially on pressure. At first the integuments are of their natural appearance, the increased action being confined to the sac, but they are soon involved, and often to a considerable extent; they become red and swollen, and as the surrounding parts are affected, the swelling increases. In some cases, the eyelids, the caruncle, and the conjunctival covering of the eye, participate in the inflammatory action. The inflammation is in most instances caused, or at least preceded, by some obstruction in the nasal duct, in consequence of which, the tears are interrupted in their natural course downwards, and either accumulate in, and distend the sac, or flow over on the cheek, the puncta lachrymalia remaining open. After increased vascular action has been produced, the lachrymal secretion is increased to a greater or less degree, and much inconvenience is caused to the patient by the profuse discharge following an unnatural course. When inflammation is intense, lymph is effused into the passages, producing obstruction sometimes complete. The mucous lining of the nasal duct becomes swollen, from the vascular excitement, either throughout its whole extent, or at one point only; and in either case the flow of the tears must be interrupted, either partially or wholly, according to the degree of swelling. The vitiated secretion of the part may also contribute towards narrowing the canal, by lodging and concreting there. But a more complete and permanent obstruction is formed by effusion of lymph, under or on the mucous lining, as happens in other canals of similar construction: and in this case also, the stricture may be partial or complete, according to the quantity of effused matter, and the extent of surface affected.