inch square. There was certainly no fracture. The scalp wound refused to heal, and it soon became quite clear that death of a portion of the skull was inevitable. About live or six weeks atter admission the exposed bone assumed a dark brownish appearance. The hospital assistant informed me that, if I pressed upon this portion, pus would well up from a minute crack in the most discolored part. Close" examination detected the fissure, and truly enough upon pressing the denuded bone, pus here made its appearance," and instantly retreated when pressure was removed,?a clear proof that a portion of skull was loose. I regarded the case as one of approaching exfoliation of the outer table with limited inflammation and suppuration of the diploe. The fissure rapidly increased. At this period there was some giddiness, slight confusion of sight and very trifling " weakness", of right arm and leg. Up to this date, the wound had been dressed with carbolic acid and oil, but henceforth water-dressing only was used. One morning, (about a week subsequently), I got the point of a forceps into the fissure and upon using it as a lever, to my amazement, I found no difficulty in elevating a piece, involving the entire thickness of the skull, and as large superficially as a two-anna piece. The only bold it had was shewn by a small spicula of the inner table, which remained at the opposite side to that of original fissure. The dura mater was of a dull slightly congested color, free from granulations, pus or lymph, and the pulsations of the brain were plainly seen. The few veryslight symptoms mentioned above now rapidly disappeared, and the wound healed quickly. Patient was two and a half months in hospital. The blow, given as it was with the back of a small axe, must, of course, have been light, or it would have produced Dr. Hastings, Deputy Inspectormore serious immediate results. General of Hospitals, and Assistant Surgeon A. Deane, saw this case several times, and are aware of the facts. Remarks.?So far as I can learn from the books at my disposal, including Holmes' System, Erichseu, Fergusson, Guthrie's Commentaries and Taylor's Jurisprudence, this case would almost appear to be unique. Dr. Chevers informs me that he has recorded a case in his jurisprudence in which nature, very nearly, succeeded in trephining (the patient died before completion of the process), but I believe, there are few points of resemblance in the modus operandi of the processes established by nature in these two Gases. Truly, it must be admitted that nature, in the present case, performed the operation in the most perfect manner. In Vol. II. of Holmes' System, Mr. Prescott Hewitt alludes to the point in these words:?"Again, the diseased action thus set up," (by a simple blow on the head), " may lead to caries or necrosis of the calvaria," and this " may be limited to the original seat or spread far and wide,'affecting either one or both tables of the bone." Here, certainly, is a complete definition or description of my case, but Mr. Hewitt only gives " references to cases of extensive disease" thus caused, and he does " limited" to the not mention, or give any reference to, cases seat of injury. Erichsen, in his 5th edition, disposes of original " contusion of bone'-' in 14 or 15 lines, stating generally that the vitality of a layer or the whole substance may be destroyed, and at page 368 he devotes only 11 lines to contusion of cranial bones without fracture, recognising three results ; 1, necrosis of outer table or whole ; 2, suppuration under the skull; and, 3 pyasmia from suppuration of diploe. Case II.?Moosafir, aged 15, a cook boy in the Royal Artillery barracks, a healthy, well nourished lad, was sent me for examination by the Cantonment Magistrate of Barrackpore on January 13th, 1872. On January 3rd, this boy was struck on the head, (with a knife it was stated), by a Gunner of the Royal Artillery. "When I first saw bim (on the 13th),.he complained of being weak and seemed dull; otherwise there were no symptoms. There was a scalp wound about 1| inch long, and of this shape at the upper part and loft side of head, in a state of suppuration. The probe detected a piece of denuded bone. Further examination discovered a depressed fracture of the skull; the fracture could be traced to a length of about half an inch, anu the amount of depression, could with accuracy be ascertained to be as nearly as possible one-sixth of an inch. "VVound was drawn together with sticking plaster, and water dressing applied. Patient purged, and kept on low diet.. J : 14th to 2,2>rd January.?Literally without symptoms of any the under above kind. The mental dulness rapidly simple treatment. Wound nearly all healed, only a small, which shews flabby granulations and exudes a small an
TWO REMARKABLE CASES OF INJURY OF HEAD. By Assistant
Surgeon
E. A.
Birch,
F.R.C.S.
CASE I.?CONTUSED WOUND! OF SCALP, AND CONTUSION OP SKULL. NATURE TREPHINED. RECOVERY.
CASE II.?COMPOUND DEPRESSED FRACTURE OP SKULL, ABSENCE OP SYMPTOMS FOR 23 DAYS, ABSCESS OF BRAIN. OPERATION OP TREPHINING. RECOVERY. Case I.?On November 8th, 1870, Sawal eeay a fokeer by built and badl)r nourished, aged about 3o or 40, was sent to me by-the Cantonment Magistrate of Meean Meer for report upon certain injuries, viz., one incised and two contused wounds of the scalp, and a contusion of back. It was subsequently proved in Court, that the contusions were caused by blows from the back of a small axe, and the incision by a slight blow from its edge. Two of the scalp wounds healed readily ; the back remained painful for some time, and the reniaining injury, which afterwards proved of so much interest, was a contused and lacerated wound of the scalp, on the top and a little to the left side of the head. Shortly after admission, this sloughed and some hajmorrhage took place from it; swelling and pain in the heqd followed. Bone became exposed, and denuded of periostium to the extent of about a quarter of
profession, small, badly
_
disappeared'
portion
July 1,
A' MIEBOR OF HOSPITAL PEACTICE.
1872:]
quantity of thin, unhealthy discharge, appears unruly. Probe here detects a piece of rough boue. No treatment further than Attention to the bowels and diet, quiet, and detention in hospital. 24th January.?No symptoms when I visited him. 25th.?Found the boy, at 5 p.m., sitting upon the steps of the hospital door, looking well enough, could only give a grunt in reply to questions, but understood perfectly well what was said, for -he obeyed directions accurately. Hearing very slightly, if at all, affected. Upon attempting to^ stand, he staggered and had to be supported. No power of articulation further than the grunt above noted; having been placed in bed, discovered partial paralysis of right side. There was complete inability to lift right arm, leg was capable of very sluggish movements; cannot feel the prick of a pin below the knee or in arm. Pupils sluggish, and dilated somewhat, but equal; slight fever present. These symptoms were ushered in with slight shiverings; freely purged. "Wound opened up with probe as far as possible ; low diet, confined to bed. Expecting increase of symptoms, I prepared to trephine but,? 26th.?Upon meeting Drs. Daly andCorbett at hospital, found all the symptoms mitigated in severity. No change in power of articulation. Leg more sensitive, and he can, when told, slowly -lift his arm; operation deferred. Jalap and calomel purge. Vespere.?Condition
same
;
pulse
88.
Temperatures 100'2;
tongue is protruded to right side, and left
corner
of mouth is
drawn up.
27th.?Pulse, 64 ; temperature, right side, 97'8?left side, 98-4; unchanged. Takes food well; enema cathartic ; Cal.
condition et jalap.
Vespere.?Stated to have had a little fever during the day. 28th.?Pulse, 64 ; temperature as yesterday. Articulation, tongue and limbs same. Pupils not much dilated, but very sluggish. Granulations on wound looking healthy; at 2*30 tp.fti-.,-I received a report that the boy wus altogether insensible. Found him apparently dying? stiert'crous breathing, complete insensibility, full and laboured pulse, dilated pupils?in fact, all the symptoms of a case of a apoplexy : proceeded at once ?to trephine, assisted by Assistant Surgeon Corbett, P.A. Following the directions of the two parts of the original wound, I made two cross incision down to the bone, back each five inches long, turned the flaps and inches discovered a fracture, two long, of a horseshoe shape, at A the bone was F depressed to the extent of onesixth of an inch, the imaginary chord joining the extremities of the fracture being simply bent, and the depression as it appreached either end of the fracture JT becoming more and more shallow: applied pin of trephine at P., removing segment, marked by the dotted line, from the inner table of which a portion was missing. Probe discovered a spicula in bottom of wound ; seized this with and extracted it?instantly tiie contents ot an abscess squirted to a height of about three feet into the air. Spicula had penetrated ?which was of this and
forceps
size, shape .the dura mater, and was fixed very ?angles in the substance of the quired a surprising amount of force to
nearly brain,
at
right
and reContents remove it. of abcess?thin, unhealthy looking curdy pus; guessed to be /ibotit two ounces in quantity. The point F. was now made the fulcrum, and the elevator applied \mder A, but the edge broke away in small fragments, which were dry, porous and light. Proceeding cautiously in this way, fragment after fragment, was removed along the whole length of the fracture till firm healthy bone was reached. The result being an aperture of this size and shape (the dark line represents the seat of fracture.) The angular piece B was now elevated, (e.ibent) a little above its natural level and when released it was found to be in its proper position. Flaps replaced. The only immediate result of the operation was, that the breathing became relieved from the moment the contents of the abscess were evacuated. When the segmeut was removed with the
157
to be of a dark purple livid bulge into the opening. At 10 p.m., (28th).?Pulse, 84; left pupil dilated, and insensible to light, lligkt less so, but still dilated, and very slightly influenced by strong light. Moves left leg a little when his name is called, he grants and partlyopens his eyes._ Bladder empty and bed wet; temperature, left side, 98"6, right side, 98 ; no motion. 29th January.?One liquid motion, passes urine,'opens his eyes, and looks about. Hears when gently spoken to, felt acutely when being dressed. Moves left limbs only, pupil very much dilated; left most so, both almost completely insensible to light. Took 6oz, of sago and milk during the night, pulse, 88 ; left side, 99 6; right side, 99 ; respiration, 23, and quiet; thick healthy pus on dressing. Kept the apertures of the flesh flaps separated to permit of free exit of pus. 30th.?Decidedly better; pulse, 100 and rather weak; skin cool; pupils naturally contracted, and respond (slowly) to light. Moves right leg and arm a little, and very sluggishly, the former when pricked with a pin, the latter when told so to do. Still only grunts when spoken to, and tongue still strongly protruded to the right side. Vcspere.?Chicken broth; temperature, 98'4 on left side; pulse, 84. 31s?.?Mouth not nearly so crooked. Thick healthy pus exceeding from depth of wound at one point Pupils almost natural. Moves all limbs, but those of right side sluggishly. Quite understand every thing said to him. Temperature, right side, 98; left side, 98-4. Gives notice when about to pass urine. 2nd February.?Tries forcibly to sit up; appetite excellent. Apex of bone (B.) always bathed in pus, and is now denuded of periosteum ; it, however, looks florid. Speaks to-day for first time, slowly, and with difficulty. Copious discharge from wound, says he has pain in head further back than wound; tongue nearly straight. Very little remains of paralysis. 4th.?Walks about a little, but requires support. Says his sight is dim ; native doctor states that the boy is voiding an unusually large quantity of urine, but this I have not been able to verify. Appetite ravenous. 8th.?States that his eye-sight is all right now; walks about
trephine,
the dura mater
color, without pulsation,
was
nor
seen
did it
well. 23rd.?From centre of the granulation (about
so
large now),
half a drachm or so of pus issues daily. Bone cannot be felt anywhere. Probe passes through the minute aperture, quite unopposed, that is, by its own gravity, one inch and three-eighths straight into cranium, and then there is resistance. Sleeps and eats well; bowels act daily. 15th March.?"Wound healed, with the exception of one little point, which still admits the probe. Boy quite well, not a symptom remaining. 5th April.?Boy gave evidence in the High Court with great clearness to-day, against the prisoner, Burke, who assaulted him, and who, I may mention, was sentenced to ten years penal servitude. Though not proved, it seems propable that the instrument used was the handle of a large pocket knife. 28th.?The boy has been at his work since the day of the trial. I sent for and examined him to-day. He is fat, and looking in excellent health, as, indeed, he says he is. The little aperture still exists, but the probe now only enters to the extent of half an inch. There is a marked depression of scalp, and the edges of the bone can be easily traced by the finger through the skin. Remarks.?In cases of compound depressed fracture of the skull without symptoms, there seems to be no very fixed rule as to the course .the surgeon should adopt. Sir A. Cooper, Abernethy and Dupuytren advise non-interference; cases recorded by Ballingall and Guthrie,.render it apparent that the older military surgeons viewed with favor the expectant treatment, and Mi'. Longmore, (Holmes' System, vol. II, p. 179) says, "in European military practice, the experience of inrecent years cases which would cause the "trephine to be employed only Mr. Holmes CoOte too (Holmes' were otherwise hopeless." System, vol. V. p. 1075) talks of the operation as a "last resource ^.Enchsen makes an attempt to compromise in extreme cases." the matter by laying down certain conditions of the fracture, be very difficult to be ascertained), and (which, by the way, may or not the operation; but no one scalp wound, as justifyingwith either of the two typical sets case is likely to coincide enumerated and and to symptoms the of conditions, by him, ^
* Sir \V. Fergusson says, " elevate the piece of bone be done without causing additiooal injury," otherwise
symptoms.
provided that can he would wait for
THE INDIAN MEDICAL GAZETTE.
158
young surgeon at all events, his remarks are likely to bring confusion instead of light at a critical moment of anxiety. Here, Mr. Prescott Hewitt comes to our relief, for he in compound depressplainly says, (Holmes' vol. II, p. 271) that " we are to operate, and ed cranial fractures without symptoms, at once." His reason being that intra-cranial suppuration is an almost certain result, but he makes three exceptions? ls?, slight depression of thicker parts of skull; 2ndly, in driving over frontal sinus; and 3rdly, "should a compound fracture with depression chance not to fall under the notice of the surgeon until some days after the accident, he ought, if there are no signs of inflammation, to abstain from operating." Under this last
exception
our
present
case
comes.
.All the text-books convey the old principle that as little bone as possible should be removed by the operation. It is, of course, appai'ent that more bone than necessary should not be removed, but I think too much stress (1 M'rite as a junior for juniors), has been placcd upon this rule. Surely, it is better to remove too much than too little. How would it have been in the pi'esent case to have left behind from timidity, hurry, the fear of making too large an aperature, &c , some of the spongy comminuted fragments, as might easily have occurred, at the ends of the fracture, where there was hardly any depression ? The flaps can, without difficulty, except at their apices, be kept sufficiently close together to prevent bulging of the dura mater or brain substance, so that the loss or otherwise of a little additional bone support cannot make much difference. The object is to cure the patient, and not to speculate as to the amount of skull which will be left to him. It is for a moment worth considering what might have been the result, had this patient been trephined, immediately after the accident. We now know that the dura mater had been penetrated,?would not a hernia have been a very likely result, had the trephine been applied on January 3rd. If this question is to be answered affirmatively, we must doubt the wisdom of the universal application of Sir. Hewitt's rule to "operate, and at once." We all know, Colles' precept not to remove a penetrating fragment, when there are not urgent symptoms, for a few days till the brain substance has had time to consolidate. In this case, presuming the dura mater to have been penetrated in any case, I cannot but think the penetrating fragment proved, so to speak, of great use, though not by producing consolidation; but its result, viz., the abscess, prevented apparently the possibility of hernia?a fact, if fact it be, accidental, and, of course, in no way bearing out Colics' theory ; the opening into the dura mater going directly into the cavity of the abscess, had no pressure to support from inside as soon as the abscess was emptied; and that this cavity filled up slowly, and not from any sudden bulging of the brain substance into it, is apparent from the probe examinations noted. Probably connective tissue lias filled up the gap. We can hardly doubt, too, that this abscess possessed a cyst of considerable thickness. All these circumstances were, it would seem, the cause of the absence of hernia cerebri. The obscurity of the symtoms of approaching abscess of the brain is too well illustrated by this case. The case appears to me to convey lessons of importance, Isi, that it is advisable in all cases where it is necessary to adopt such a proceeding, to make as minute on opening as possible in the dura mater; and 2ndly, that it is important in the after treatment of such cases to permit a perfectly free exit to the pus. by keeping the scalp flaps separated at the point of orifice of the abscess. Baurackpoke
:
April 30th, 1872.
[JULT 1, 1872.
TWO REMARKABLE CASES OF INJURY OF HEAD. By Assistant
Surgeon
E. A.
Birch,
F.R.C.S.
CASE I.?CONTUSED WOUND! OF SCALP, AND CONTUSION OP SKULL. NATURE TREPHINED. RECOVERY.
CASE II.?COMPOUND DEPRESSED FRACTURE OP SKULL, ABSENCE OP SYMPTOMS FOR 23 DAYS, ABSCESS OF BRAIN. OPERATION OP TREPHINING. RECOVERY. Case I.?On November 8th, 1870, Sawal eeay a fokeer by built and badl)r nourished, aged about 3o or 40, was sent to me by-the Cantonment Magistrate of Meean Meer for report upon certain injuries, viz., one incised and two contused wounds of the scalp, and a contusion of back. It was subsequently proved in Court, that the contusions were caused by blows from the back of a small axe, and the incision by a slight blow from its edge. Two of the scalp wounds healed readily ; the back remained painful for some time, and the reniaining injury, which afterwards proved of so much interest, was a contused and lacerated wound of the scalp, on the top and a little to the left side of the head. Shortly after admission, this sloughed and some hajmorrhage took place from it; swelling and pain in the heqd followed. Bone became exposed, and denuded of periostium to the extent of about a quarter of
profession, small, badly
_
disappeared'
portion
July 1,
A' MIEBOR OF HOSPITAL PEACTICE.
1872:]
quantity of thin, unhealthy discharge, appears unruly. Probe here detects a piece of rough boue. No treatment further than Attention to the bowels and diet, quiet, and detention in hospital. 24th January.?No symptoms when I visited him. 25th.?Found the boy, at 5 p.m., sitting upon the steps of the hospital door, looking well enough, could only give a grunt in reply to questions, but understood perfectly well what was said, for -he obeyed directions accurately. Hearing very slightly, if at all, affected. Upon attempting to^ stand, he staggered and had to be supported. No power of articulation further than the grunt above noted; having been placed in bed, discovered partial paralysis of right side. There was complete inability to lift right arm, leg was capable of very sluggish movements; cannot feel the prick of a pin below the knee or in arm. Pupils sluggish, and dilated somewhat, but equal; slight fever present. These symptoms were ushered in with slight shiverings; freely purged. "Wound opened up with probe as far as possible ; low diet, confined to bed. Expecting increase of symptoms, I prepared to trephine but,? 26th.?Upon meeting Drs. Daly andCorbett at hospital, found all the symptoms mitigated in severity. No change in power of articulation. Leg more sensitive, and he can, when told, slowly -lift his arm; operation deferred. Jalap and calomel purge. Vespere.?Condition
same
;
pulse
88.
Temperatures 100'2;
tongue is protruded to right side, and left
corner
of mouth is
drawn up.
27th.?Pulse, 64 ; temperature, right side, 97'8?left side, 98-4; unchanged. Takes food well; enema cathartic ; Cal.
condition et jalap.
Vespere.?Stated to have had a little fever during the day. 28th.?Pulse, 64 ; temperature as yesterday. Articulation, tongue and limbs same. Pupils not much dilated, but very sluggish. Granulations on wound looking healthy; at 2*30 tp.fti-.,-I received a report that the boy wus altogether insensible. Found him apparently dying? stiert'crous breathing, complete insensibility, full and laboured pulse, dilated pupils?in fact, all the symptoms of a case of a apoplexy : proceeded at once ?to trephine, assisted by Assistant Surgeon Corbett, P.A. Following the directions of the two parts of the original wound, I made two cross incision down to the bone, back each five inches long, turned the flaps and inches discovered a fracture, two long, of a horseshoe shape, at A the bone was F depressed to the extent of onesixth of an inch, the imaginary chord joining the extremities of the fracture being simply bent, and the depression as it appreached either end of the fracture JT becoming more and more shallow: applied pin of trephine at P., removing segment, marked by the dotted line, from the inner table of which a portion was missing. Probe discovered a spicula in bottom of wound ; seized this with and extracted it?instantly tiie contents ot an abscess squirted to a height of about three feet into the air. Spicula had penetrated ?which was of this and
forceps
size, shape .the dura mater, and was fixed very ?angles in the substance of the quired a surprising amount of force to
nearly brain,
at
right
and reContents remove it. of abcess?thin, unhealthy looking curdy pus; guessed to be /ibotit two ounces in quantity. The point F. was now made the fulcrum, and the elevator applied \mder A, but the edge broke away in small fragments, which were dry, porous and light. Proceeding cautiously in this way, fragment after fragment, was removed along the whole length of the fracture till firm healthy bone was reached. The result being an aperture of this size and shape (the dark line represents the seat of fracture.) The angular piece B was now elevated, (e.ibent) a little above its natural level and when released it was found to be in its proper position. Flaps replaced. The only immediate result of the operation was, that the breathing became relieved from the moment the contents of the abscess were evacuated. When the segmeut was removed with the
157
to be of a dark purple livid bulge into the opening. At 10 p.m., (28th).?Pulse, 84; left pupil dilated, and insensible to light, lligkt less so, but still dilated, and very slightly influenced by strong light. Moves left leg a little when his name is called, he grants and partlyopens his eyes._ Bladder empty and bed wet; temperature, left side, 98"6, right side, 98 ; no motion. 29th January.?One liquid motion, passes urine,'opens his eyes, and looks about. Hears when gently spoken to, felt acutely when being dressed. Moves left limbs only, pupil very much dilated; left most so, both almost completely insensible to light. Took 6oz, of sago and milk during the night, pulse, 88 ; left side, 99 6; right side, 99 ; respiration, 23, and quiet; thick healthy pus on dressing. Kept the apertures of the flesh flaps separated to permit of free exit of pus. 30th.?Decidedly better; pulse, 100 and rather weak; skin cool; pupils naturally contracted, and respond (slowly) to light. Moves right leg and arm a little, and very sluggishly, the former when pricked with a pin, the latter when told so to do. Still only grunts when spoken to, and tongue still strongly protruded to the right side. Vcspere.?Chicken broth; temperature, 98'4 on left side; pulse, 84. 31s?.?Mouth not nearly so crooked. Thick healthy pus exceeding from depth of wound at one point Pupils almost natural. Moves all limbs, but those of right side sluggishly. Quite understand every thing said to him. Temperature, right side, 98; left side, 98-4. Gives notice when about to pass urine. 2nd February.?Tries forcibly to sit up; appetite excellent. Apex of bone (B.) always bathed in pus, and is now denuded of periosteum ; it, however, looks florid. Speaks to-day for first time, slowly, and with difficulty. Copious discharge from wound, says he has pain in head further back than wound; tongue nearly straight. Very little remains of paralysis. 4th.?Walks about a little, but requires support. Says his sight is dim ; native doctor states that the boy is voiding an unusually large quantity of urine, but this I have not been able to verify. Appetite ravenous. 8th.?States that his eye-sight is all right now; walks about
trephine,
the dura mater
color, without pulsation,
was
nor
seen
did it
well. 23rd.?From centre of the granulation (about
so
large now),
half a drachm or so of pus issues daily. Bone cannot be felt anywhere. Probe passes through the minute aperture, quite unopposed, that is, by its own gravity, one inch and three-eighths straight into cranium, and then there is resistance. Sleeps and eats well; bowels act daily. 15th March.?"Wound healed, with the exception of one little point, which still admits the probe. Boy quite well, not a symptom remaining. 5th April.?Boy gave evidence in the High Court with great clearness to-day, against the prisoner, Burke, who assaulted him, and who, I may mention, was sentenced to ten years penal servitude. Though not proved, it seems propable that the instrument used was the handle of a large pocket knife. 28th.?The boy has been at his work since the day of the trial. I sent for and examined him to-day. He is fat, and looking in excellent health, as, indeed, he says he is. The little aperture still exists, but the probe now only enters to the extent of half an inch. There is a marked depression of scalp, and the edges of the bone can be easily traced by the finger through the skin. Remarks.?In cases of compound depressed fracture of the skull without symptoms, there seems to be no very fixed rule as to the course .the surgeon should adopt. Sir A. Cooper, Abernethy and Dupuytren advise non-interference; cases recorded by Ballingall and Guthrie,.render it apparent that the older military surgeons viewed with favor the expectant treatment, and Mi'. Longmore, (Holmes' System, vol. II, p. 179) says, "in European military practice, the experience of inrecent years cases which would cause the "trephine to be employed only Mr. Holmes CoOte too (Holmes' were otherwise hopeless." System, vol. V. p. 1075) talks of the operation as a "last resource ^.Enchsen makes an attempt to compromise in extreme cases." the matter by laying down certain conditions of the fracture, be very difficult to be ascertained), and (which, by the way, may or not the operation; but no one scalp wound, as justifyingwith either of the two typical sets case is likely to coincide enumerated and and to symptoms the of conditions, by him, ^
* Sir \V. Fergusson says, " elevate the piece of bone be done without causing additiooal injury," otherwise
symptoms.
provided that can he would wait for
THE INDIAN MEDICAL GAZETTE.
158
young surgeon at all events, his remarks are likely to bring confusion instead of light at a critical moment of anxiety. Here, Mr. Prescott Hewitt comes to our relief, for he in compound depressplainly says, (Holmes' vol. II, p. 271) that " we are to operate, and ed cranial fractures without symptoms, at once." His reason being that intra-cranial suppuration is an almost certain result, but he makes three exceptions? ls?, slight depression of thicker parts of skull; 2ndly, in driving over frontal sinus; and 3rdly, "should a compound fracture with depression chance not to fall under the notice of the surgeon until some days after the accident, he ought, if there are no signs of inflammation, to abstain from operating." Under this last
exception
our
present
case
comes.
.All the text-books convey the old principle that as little bone as possible should be removed by the operation. It is, of course, appai'ent that more bone than necessary should not be removed, but I think too much stress (1 M'rite as a junior for juniors), has been placcd upon this rule. Surely, it is better to remove too much than too little. How would it have been in the pi'esent case to have left behind from timidity, hurry, the fear of making too large an aperature, &c , some of the spongy comminuted fragments, as might easily have occurred, at the ends of the fracture, where there was hardly any depression ? The flaps can, without difficulty, except at their apices, be kept sufficiently close together to prevent bulging of the dura mater or brain substance, so that the loss or otherwise of a little additional bone support cannot make much difference. The object is to cure the patient, and not to speculate as to the amount of skull which will be left to him. It is for a moment worth considering what might have been the result, had this patient been trephined, immediately after the accident. We now know that the dura mater had been penetrated,?would not a hernia have been a very likely result, had the trephine been applied on January 3rd. If this question is to be answered affirmatively, we must doubt the wisdom of the universal application of Sir. Hewitt's rule to "operate, and at once." We all know, Colles' precept not to remove a penetrating fragment, when there are not urgent symptoms, for a few days till the brain substance has had time to consolidate. In this case, presuming the dura mater to have been penetrated in any case, I cannot but think the penetrating fragment proved, so to speak, of great use, though not by producing consolidation; but its result, viz., the abscess, prevented apparently the possibility of hernia?a fact, if fact it be, accidental, and, of course, in no way bearing out Colics' theory ; the opening into the dura mater going directly into the cavity of the abscess, had no pressure to support from inside as soon as the abscess was emptied; and that this cavity filled up slowly, and not from any sudden bulging of the brain substance into it, is apparent from the probe examinations noted. Probably connective tissue lias filled up the gap. We can hardly doubt, too, that this abscess possessed a cyst of considerable thickness. All these circumstances were, it would seem, the cause of the absence of hernia cerebri. The obscurity of the symtoms of approaching abscess of the brain is too well illustrated by this case. The case appears to me to convey lessons of importance, Isi, that it is advisable in all cases where it is necessary to adopt such a proceeding, to make as minute on opening as possible in the dura mater; and 2ndly, that it is important in the after treatment of such cases to permit a perfectly free exit to the pus. by keeping the scalp flaps separated at the point of orifice of the abscess. Baurackpoke
:
April 30th, 1872.
[JULT 1, 1872.
