CHAPTER VII DIAGNOSIS OF INJURIES OF THE HEAD (Part 1)

CHAPTER VII DIAGNOSIS OF INJURIES OF THE HEAD Few cases are of more interest or importance from a diagnostic point of view than those of injur}^ to the head. With the exception of the scalp, the con- dition of which can be thoroughly explored, it may in some cases be quite impossible to determine whether serious injury has or has not been inflicted upon various parts of the head. The skull may be extensively fractured or bruised without any ob- vious signs by which the injury may be recognized, and serious lesions of the cerebral membranes, or of the brain itself, may exist without symptoms enabling the surgeon to diagnose them. From this it follows that the utmost care must be expended upon every case of head injury, as those apparently trivial may be really most grave. Diagnosis being beset with so much difficidty, it becomes especially important that the examination of the patient should be systematic and thorough. The mode of procedure which is at the same time the simplest and the best is to search first for signs of injury to the scalp and pericmnium, then for those of fracture of the hone, and finally for those indicating lesion of the contents of the cranium. The affections of each of these three groups of tissues are— (1) primary, those produced more or less directly by the injury, and pre.^ent immediately, or within a" few hours; and (2) secondary, those which result 72 INJURIES OF SCALP 73 indirectly from tie injury, and come on after an interval of days or even months. I. Injuries of the Scalp Primary effects. — The scalp way he wounded or bruised. Notice the depth of the wound, whether its edges gape and the pericranium or the bare bone is exposed, and if either of its edges is separated as a flap. Observe the amount of hfemorrhage, the position of bleeding-points, signs of bruising of the tissue, the presence of hair, dirt, etc., in the wound. A splinter of bone or soft grey brain -matter in the wound must not be overlooked. If the edges gape, the wound is certainly through the occipito-frontalis, and extends at least into the " dangerous area " be- neath it; if the womid does not gape, it may or may not be a wound through the whole thickness of the scalp, and this fact therefore must not be considered as excluding injury to the cranium {see below). The effects of contusion are not so apparent in the scalp as elsewhere, and, owing to the smooth convexity of the skidJ, blows with a blunt weapon usually cause mcised wounds. In some cases large portions or even the whole of the scalp may be completely torn away. _ A swelhng that forms over the vault of the skull within a few hours after a blow or squeeze is due to either blood {cephalhcemaloma) or cerebro-spinal fluid (traumatic menirujocele) under the scalp. To distinguish between these two conditions, look for discoloration of the skin, test for fluctuation in all parts of the swelhng, carefully feel for any harden- ing of its edge, see if the swelling is translucent, and if it pulsat(!s or becomes more tense during crying or coughing. If it fluctuates in part only or indistinctly or if there is a firm edge to the swelling, caused by 71 SURGICAL DIAGNOSIS [cuAr. coagulation of some of the blood, or if the scalp is discoloured or the swelling opaque and imaffected by crpng and straining efforts, it is a hcBinaloma. ' A cephalhEematoma may be in the scalp, or beneath the aponeurosis, or under the periosteum. To dis- tinguish these varieties, notice whether the out- line of the swelling corresponds to that of a bone, or to the attachments of the aponeurosis, and also whether the swelling can be moved with or under the scalp. , 1. If the swelling is firm, more or less tlat, and moves with the scalp over the subjacent bone, it is a hcemaioma in the scalp. _ ... 2 If the swelUng is soft or fluctuatmg, givmg m places a soft crackling sensation to the fingers, and is not distinctly movable over the bone, it is a cir- cumscrihed suhaponeurotic hcBinatoma. 3 If the swelling is soft and fluctuatmg, and easily movable over^he bone and mider the scalp being capable, perhaps, of passing from the occipital protuberance to the supra-orbital arch and from zvgoma to zygoma, the whole scalp, mdeed bemg detached from the pericranium, it is a diffused subaponeurotic hematoma. , -i . 4 If the swelUng is fixed to the bone, while the scalp is movable over it. and if it corresponds m outlmc to one of the cranial bones, it is a sub pen - cranial hwmalorna. This form is most often met with over the parietal bone m cluldren at bi th, being caused by the pressure of the mother s pelvis or the forceps.' When the margin of the swd ing is Rrm^eii her from coagulation o the blood o rom effusion and more or less complete orgamza ion of lymph-while the centre remams soft, it may be mi.- tikin for a depressed fracture. The distmction can however be made by noticing that the tirm edge o| vir] INJURIES OF SCALP 75 the swelling is compressible, aud when indented by pressure the bone may be felt passing in an unbroken curve from beyond it into the centre of the swelling, and also by feeling that the firm edge is raised above the bone outside it. In a case of depressed fracture the hard edge is not raised above the bone beyond it, nor is it compressible, while the bone within is felt to be distinctly below the proper level. A good skiagram will show the presence or absence of a fracture. 5. If the swelling pulsates, and the pulsation is lost when the superficial temporal, occipital, or supra- orbital artery is compressed, or when all these vessels together are compressed, while coughing and strain- ing do not make the swelling more tense, the tumour IS a pulsating hcematoina or diffuse traumatic aneurysm due to the communication of a large artery with the effusion of blood. This diagnosis is confirmed if the swelling can be moved over the bone. CephalhEematomata usually undergo absorption, but the blood may remain fluid for a long time^ leaving a fluctuating swelling, which will then be distmguished from similar swellings by the history of Its formation. Occasionally they become in- flamed and suppurate ; and if a swelling which by Its history and characters is recognized as a hema- toma becomes more tense, hot and painful very tender, with a3dema around it, and the temperature IS raised, it may be diagnosed as a suppurating _ _ In the diagnosis of the late consequences of injuries to the head, the recognition of a scar in the ■scalp may be of great importance, both as corrobor- ating a history of a particular injury, and still more as localizmg it with precision. The development of 3. soft puffy swelling in the scalp was referred to b}' 76 SURGICAL DIAGNOSIS [chap. Pott as a valuable sign of subcranial abscess ; it is also seen where necrosis follows contusion of the bone. The secondary complicalious oi" wounds of the scalp are — 1. Suppuration. 2. Sloughing. 3. Delayed union. 4. Cutaneous erysipelas. 5. Cellulitis. Examine the wound and notice whether the edges are uniting and the deep surfaces of flaps adhering to the cranium ; observe also the presence of swelling, its extent and consistence, the colour of the skin, the state of the adjacent lymph-glands, and the presence or absence of fever and constitu- tional disturbance. 1. Pus may be found dotting the edges of the wound ; where a flap of scalp has been separated, if suppuration occurs, the pus is liable to bag under the flap ; • this is shown by the free escape of pus on pressure. Occasionally the pus collects in a circumscribed fluctuating swelling — an abscess. 2. As the result of ver)^ severe contusion tlie whole thickness of the scalp may slough : limited sloughing results from inflammation, eFpecially in contused or lacerated tissues. 3. Where suppuration has occurred, the edges of the wound may separate and become inverted and callous, and great delay in healing result. 4. If the skin of the scalp is found slightly swollen and tender, and tlie swelling extends some distance from the woimd, and has a well-defined edge, the disease i.s erysipelas. The cliaracteristic red blush is not seen in the scalp, but it appears if the disease spreads to the forehead or neck beyond the margin vii] INJURIES OP VAULT OF SKULL 77 of the scalp proj^er, and in the former case there will be cedema of the eyelids. The neighbouring lymphatic glands, i.e. the preauricular, mastoid, or occipital, will be enlarged and tender. There ai'e well-marked constitutional symptoms — fever, head- ache, nausea or vomiting — and these may have set in abruptly with a shiver or rigor. 5. If the scalp is greatly swollen and boggy, pale in colour or blotchy, there is cellulitis. There is usually oedema of ears, eyelids, and the upper part of the neck, and the lymphatic glands are enlarged and tender. The constitutional symptoms are severe in degree — high fever, a weak rapid pulse, headache or delirium. The secretion of the wound should be examined liacteriologically : a streptococcus, with or without iiher bacteria, will be found in cases of erysipelas or cellulitis. II. Injuries of the Vault of the Skull Severe injury may be inflicted on the bone of the skull without producing any symptoms by which it can be certainly recognized. A fracture of the vault can be shown in a skiagram, and its details are best demonstrated by X-rays ; its other signs are deformity and escape of cranial contents. Pass the fingers gently over the vault and note any irregularity of the surface, particularly any depression or sharp edge of bone, and any swelling. If a swelling is noticed, it should be examined for fluctuation, trans- lucency, and pulsation. If there is a wound in the scalp, it should be examined for splinters of bone and for portions of brain matter, and then the cleansed finger, or probe, should be pa.ssed in and the bone explored. If any depression is felt, its extent and depth, as well as the direction of fi.ssures running 78 SURfllCAL DIAGNOSIS [chap. from ifc, aud the presence of detached fi-agmcnts, should be noticed. On holding back the edges of the wound a fracture can be seen, the broken edjie of bone having a dark-red colour and an uneven surface. The primary effects of injuries of the bones of the skull are — Contusion. Infi-action. Fracture. 1. There are no positive signs whereby a con- tusion of bone can be recognized ; it is only known or suspected to have occurred when certain inflam- malory sequelce or necrosis occur. It may be inferred in all cases of severe injury to the skull, especially when not attended with fracture. 2. If in an infant at birth, or a young child in vyhom the skull is still soft, a shallow smooth depres- sion in the bone, with rounded edge, is felt, it may be diagnosed as a depression or dent in the bone, or infraction ; such a depression without fracture is only possible in quite early life. The surgeon must not mistake for an infraction the yielding of an unclosed fontanelle, or of a softened spot of bone in craniotabes ; in these there is no permanent depression, only a yielding of the bone under the pressure of the finger. 3. Fracture. — i. If an abrupt depression of the vault of the skull, with a sharp, perhaps irregular, edge and uneven sui'face, can be felt through the scalp, the sharp edge not being raised above the bone outside it, and being quite incompressible, it is a simple depressed fracture of the vault of the skull. ii. If on passing the fingers over the skull a sharp, irregular edge of bone can be felt, it indicates a simple fissured fracture of the vault of the skull; ii ^ii] INJURIES OF VAULT OF SKULL 79 I the fissure takes the line of one of the sutures, it is a separation of a suture. In some of these cases mobility and crepitus may be detected along the line of fracture. Effusion of blood in or under the scalp may partially or completely obscure these simple fractures. The surgeon must not mistake for fractures the normal sutures, which may be felt as slightly raised ridges on the bone, and which are always smooth and somewhat rounded ; nor sUglit smooth irregularities of the surface, which may be natural irregularities of the bone ; nor the bossy elevations met with in congenital syphilis. The dis- i tinguishing features of all these are their elevation . above the surface, not depression, and their smooth I rounded outline. It is impossible to diagnose a : simple fissure of the vault if there is no displace- I ment of the bones, unless it can be demonstrated ! in a skiagram, and stereoscopic pictures afford the I best means of detecting them. i iii. If, after an injury to the vault of the skull, I a translucent fluctuating swelling forms over the I part struck, it is a collection of cerebrospinal fluid beneath the scalp, and is proof of the existence of a 1 fracture of the vault with wound of the brain extend- ing into a lateral ventricle. The swelling may begin to form at once after the injury, or not be noticed for several days ; it may remain stationary, or gradu- ally increase in size ; there are no signs of inflam- ; mation in the scalp, nor of induration around the I margin of the swelling ; it can generally be noticed to pulsate, and to become tenser when the child cries. It lias been called traumatic meningocele. iv. Where there is a wound in the scalp leading down to the bone, it is easier to determine with certainty the existence of a fracture. If at the bottom of a wound an irregular red line is seen, 80 SURGICAL DIAGNOSIS [chap. from which, if the pericranium is torn, blood issues or may be squeezed, and especially if by pressure slight movement along this line can be detected, or if the finger-nail or the probe can be inserted into the line and detects a sharp edge of bone, there is a compound fissured fracture of the vault. This fissure must not be confounded with a su'ure exposed in the wo'und, which is not a bleeding line ; nor is the edge of the torn pericranium or temporal fascia to be mistaken by the finger for an edge of bone. The edge of the dense fibrous membrane can in either case be recognized by its slight yielding to pressure, by its smoothness, and by its not grating under the finger-nail. The mistake, however, has been made. If such a fissure is placed exactly in the line of a cranial suture, it may be distinguished as a separation of a suture. V. The finger in the wound will distinguish those varieties of fracture known as cotnpound depressed, comminuted, punctured, elevated, p'ond and gutter frac- tures. If the bone is fissured, and there is slight depression, it may be a fracture of the outer table of the bone only ; and similarly there may be an entire outer table and a fracture of the inner table alone : these conditions can only be diagnosed \vith certainty by a good skiagram. Where, however, from an injury inflicted on the outer surface of the bone, there is depression and splintering ot the outer table, it may be inferred that there is still greater injury of the inner table, and the more nearly any fracture approaches to the form of a punctured fracture the greater l>ecomes this probability. If a probe can bo passed into a fissure and under the bone laterally, and firm bone is still felt beneath it, a separaiion of the two tables of the bone, with depression of the inner plate, is indicated. VII] FRACTUEE OF BASE OP SKULL 81 The secondary eiltects upon the bone of injuries inflicted upon the vault are — Necrosis. Osteo- myelitis. Osteo-phlebitis. 1. If a scalp wound does not heal, but on the contrary the soft parts retract from the bone, and this is seen to be dry, bare, and of a dull-white colour, there is necrosis. It will not be possible to tell to what depth the necrosis extends until the sequestrum separates or is removed ; but so long as there are no signs of intracranial inflammation there is no indication that the inner table of the bone is involved. Necrosis of the bone may occur from contusion without a wound in the scalp. It will then be indicated by a puf!y swelling of the scalp, which when cut into exposes bare, dry, dull-white bone. 2. There are no positive signs whereb}^ osteo- myelitis and osteo-phlebitis may be recognized with certainty before they have led on to their more serious consequences, necrosis, pyfemia, and throm- bosis of the sinuses. But if, two or three weeks after an injury to the head, there is pain in the head, with fever, and tenderness of the skull when pressed upon through the scalp, or there is a slight deep swelling of the scalp, osteo-myelitiR may be suspected. III. F±1ACTURE OF THE BaSE OF THE SkULL The signs of fracture of tiie base of the skull are liiemorrhage, escape nf cranial, contents, and injury to cranial nerves. The Iiseraorrliage varies in amount according to the size of the vessel or sinus injured. Its special fcatui-es are its appearance at a distance from the