THE INTERNATIONAL ENCYCLOPAEDIA OF STJEGEEY. VOL. V. THE INTERNATIONAL ENCYCLOPEDIA OF SURGERY A SYSTEMATIC TREATISE ON THE THEORY AND PRACTICE OF SURGERY BY AUTHORS-OF VARIOUS NATIONS EDITED BY JOHN ASHHURST, Jr., M.D. PROFESSOR OF CLINICAL SURGERY IN THE UNIVERSITY OF PENNSYLVANIA, SURGEON TO THE PENNSYLVANIA HOSPITAL, ETC. ILLUSTRATED WITH CHROMO-LITHOGRAPHS AND WOOD-CUTS IX SIX VOLUMES YOL Y. REVISED EDITION NEW YORK WILLIAM WOOD & COMPANY 1888 Copyright : WILLIAM WOOD & COMPANY, 1 8 87. Publishers' Printing Company, 157 and 159 William Street New York. THE INTERNATIONAL ENCYCLOPEDIA OF SURGERY. ARTICLES CONTAINED IN THE FIFTH VOLUME. Injuries of the Head. By Charles B. Hancrede, M.D., Professor of Gen- eral and. Orthopaedic Surgery in the Philadelphia Polyclinic ; Surgeon to the Episcopal Hospital, and to St. Christopher’s Hospital. Page 1. Malformations and Diseases of the Head. By Frederick Treves, F.R.C.S., Assistant Surgeon to, and Lecturer on Anatomy at, the London Hospital. Page 111. Injuries and Diseases of the Heck. By Sir George H. B. Macleod, M.D., F.R.C.S. and F.R.S. Edin., Senior Surgeon to, and Lecturer on Clinical Surgery at, the Western Infirmary; Regius Professor of Surgery in the University of Glasgow; Surgeon in Ordinary to H. M. the Queen, in Scotland. Page 169. Injuries and Diseases of the Air-passages. By J. Solis-Coiien, M.D., Professor of Diseases of the Throat and Chest in the Philadelphia Poly- clinic, Honorary Professor of Laryngology in the Jefferson Medical Col- lege, Physician to the German Hospital, etc. Page 221. Injuries of the Chest. By Edward II. Bennett, M.D., F.R.C.S.I., Presi- dent of the Royal College of Surgeons in Ireland ; Professor of Surgery in Trinity College, Dublin ; Surgeon to Sir Patrick Dun’s Hospital, etc. Page 391. Diseases of the Breast. By Thomas Annandale, F.R.C.S.E., Regius Professor of Clinical Surgery in the University of Edinburgh, and Senior Surgeon to the Edinburgh Royal Infirmary. Page 423. VI THE INTERNATIONAL ENCYCLOPAEDIA OF SURGERY. Injuries and Diseases of the Abdomen. By Henry Morris, M.A. and M.B., Lond., F.R.C.S. Eng., Surgeon to, and Lecturer on Surgery at, the Middlesex Hospital, London. Page 451. Urinary Calculus. By E. L. Keyes, A.M., M.D., Professor of Genito- urinary Surgery in the Bellevue Hospital Medical College of New York; Consulting Surgeon to the Charity Hospital; Surgeon to Bellevue Hospital, to the Skin and Cancer Hospital, and to St. Elizabeth Hos- pital. Page 713. Lithotrity. By ¥m. H. Kingston, M.D., D.C.L., L.R.C.S.E., etc., Profes- sor of Clinical Surgery in the Montreal School of Medicine, Surgeon to the Hotel-Dieu Hospital, Montreal. Page 869. ALPHABETICAL LIST OF AUTHORS. (VOL. V.) THOMAS ANN AND ALE, EDWARD H. BENNETT, J. SOLIS-COHEN, WILLIAM H. KINGSTON, EDWARD L. KEYES, GEORGE H. B. MACLEOD, HENRY MORRIS, CHARLES B. NANCREDE, FREDERICK TREVES. (vii) CONTENTS. PAGE List of Articles in Vol. V. ...... v Alphabetical List of Authors in Vol. V. vii List of Illustrations ....... xxi INJURIES OF THE HEAD. By CHARLES B. NANCREDE, M.D., PROFESSOR OF GENERAL AND ORTHOPAEDIC SURGERY IN THE PHILADELPHIA POLYCLINIC j SURGEON TO THE EPISCOPAL HOSPITAL AND TO ST. CHRISTOPHER’S HOSPITAL. Injuries of the scalp ........ 1 Contusions of the scalp ....... 2 Effusions of blood ........ 3 Cephalhgematomata . . . . . . • . 3 Wounds of the scalp ....... 4 Complications of scalp wounds .... . . 6 Erysipelas of the scalp ...... C Injuries of the skull ........ 8 Contusions of bones of skull ...... 8 Osteomyelitis and pyaemia from skull-injury .... 8 Fractures of the skull . . . . . . .14 Fractures of the vault of the skull . . . . .15 Fractures of the base of the skull . , . . .27 Watery discharges from the skull ...... 38 Traumatic cephalhydrocele ...... 41 Separation of sutures of skull ...... 43 Injuries of the meninges and brain ...... 44 Intracranial extravasations of blood . . . . .44 Wounds and sutures of the great venous sinuses . . . .52 Concussion, contusion, compression, and laceration of the brain . . 53 Concussion of the brain ...... 53 Contusion of the brain ... . . . .59 Compression of the brain ...... 64 Laceration and protrusion of brain substance . . . .66 Hernia cerebri . . . . . . .67 CONTENTS. PAGE Injuries of the meninges and brain— Wounds of the brain and meninges .... .69 Foreign bodies in the brain ...... 72 Pachymeningitis, arachnitis, and cerebritis . . . .74 Cerebral abscess . ...... Chronic cerebral abscess ...... 87 Cerebral localization ........ Nature and forms of the palsies and convulsions observed in wounds of the head ........ 88 Trephining ......... 92 Method of performing the operation . . . . .95 Trephining in epilepsy . . • • • • .100 Injuries of the cranial nerves . . ♦ • • • .102 Secondary affections of the brain . . . . . .108 Bursting theory of fracture of skull by indirect violence . . . .110 MALFORMATIONS AND DISEASES OF THE HEAD. By FREDERICK TREVES, F.R.C.S., ASSISTANT SURGEON TO, AND LECTURER ON ANATOMY AT, THE LONDON HOSPITAL. Diseases of the scalp . . . . . . . .111 Erysipelas of the scalp . . . . . .111 Cellulitis of the scalp; diffuse phlegmon . t . .113 Abscess and ulcers of the scalp . . . . . . 11 f> Anthrax of the scalp . . . . . . .116 Gangrene of the scalp . . . . . . .117 Tumors of the scalp . . . . . . .117 Pneumatocele . . . . . . . .119 Haematoma . . . . . . .121 Cephalhaunatoma ..... 122 Internal cephalhsematoma . . . . . .123 Blood-tumors of the scalp in communication with the intracranial venous circulation . . . . . . . .124 Cysts of the scalp . . . . . . .125 Common sebaceous or follicular cyst . . .125 Follicular or fungating ulcer . . . . .127 Horns . . . . . . . .127 Congenital dermoid cysts . . . . . .128 Serous cysts . . . . . . . .129 Vascular tumors of the scalp . . . . . .129 Cirsoid aneurism . . . . . . . .131 Aneurism of the arteries of the scalp . . . . .132 Arterio-venous aneurism of the scalp . . . . .132 CONTENTS. XI PAGE Malformations of the skull . . . . . . .133 Meningocele, encephalocele, and hydreneephalocele . . . .133 Diseases of the skull, etc. . . . . . . .138 Pericranitis and cranitis . . . . . . .138 Caries of the skull . . . . . . » .141 Necrosis of the skull . . . . . . .144 Hypertrophy of the skull . . . . . . .146 Atrophy of the skull . . . . . . .148 Craniotabes and changes in the skull m hereditary syphilis . . .149 Tumors of the skull . . . . . . . .151 Fungus of the dura mater . . . . . . .156 Intracranial aneurism . . . . . . . .160 Chronic hydrocephalus . . . . . . . .163 Paracentesis capitis . . . . . . . .165 General scheme of tumors of vault of skull arranged for diagnostic purposes . 167 INJURIES AND DISEASES OF THE NECK. By SIR GEORGE H. B. MACLEOD, M.D., F.R.C.S. and F.R.S. Edin., SENIOR SURGEON TO, AND LECTURER ON CLINICAL SURGERY AT, THE WESTERN INFIRMARY ; REGIUS PROFESSOR OF SURGERY IN THE UNIVERSITY OF GLASGOW ; SURGEON IN ORDINARY TO H. M. THE QUEEN, IN SCOTLAND. Surgical anatomy of the neck . . . . . . .169 Contusions of the neck . . . . . . . .173 Burns and scalds of the neck . . . . . .174 Wounds of the neck . . . . . . . .175 Abscesses of the neck . . . . , . . .182 Fistulas in the neck .... _ 184 Gunshot wounds of the neck . . . . . . .186 Sprains of the neck . . . . . . . .187 Boils and carbuncles of the neck . . . . . , .187 Cicatrices of the neck . . . . . . . .187 Tumors of the neck . . . . . . . .189 Adenitis and adenoma . . . . . . .190 Lymphoma . . . . . . . . .192 Papillary growths, rnevi, and lipomata . . . . .194 Fibroma, enchondroma, osteoma, neuroma, and syphilitic gumma . .195 Myosclerosis : congenital induration or tumor of the sterno-mastoid . . 196 Lymphangeioma . . . . . . . .196 Treatment of cervical tumors . . . . .196 Cysts of the neck .... 199 Congenital serous cysts, hydrocele of the neck, etc. . . .199 CONTENTS. TAGE Cysts of the neck— Cysts containing teeth, hair, cartilage, etc. . . .199 Compound congenital cysts ...... *200 Non-congenital cysts ....... 200 Surgical affections of the thyroid gland . . . . . 203 Hypertrophy of the thyroid, or goitre ..... 203 Exophthalmic goitre . . . . . . 208 Tumors of the thyroid ....... 209 Surgical affections of the parotid gland ...... 210 Parotitis or mumps . . . . . . .211 Suppurative parotitis or parotid bubo . . . . .212 Parotid fistula . . . . . . . .213 Tumors of the parotid . . . . . . .214 Affections of the submaxillary gland . . . . . .218 INJURIES AND DISEASES OF THE AIIUPASSAGES. By J. SOLIS-COIIEN, M.D., PROFESSOR OF DISEASES OF THE THROAT AND CHEST IN THE PHILADELPHIA POLYCLINIC, HONORARY PROFESSOR OF LARYNGOLOGY IN THE JEFFERSON MEDICAL COLLEGE, PHYSICIAN TO THE GERMAN HOSPITAL, ETC. Laryngoscopy .- . . . . . ... .221 Wounds and scalds of the larynx and trachea ..... 224 Wounds of the larynx and trachea ...... 224 Wounds of external origin ...... 224 Wounds of internal origin ...... 231 Burns and scalds of the larynx and trachea .... 240 (Edema of the larynx ........ 243 Acute oedema of the larynx ...... 244 Chronic oedema of the larynx ...... 244 Subglottic oedema of the larynx . . . . . .244 Fractures of the larynx and trachea . . . . . .251 Fractures of the larynx ....... 251 Fractures of the trachea ....... 255 Tracheocele ........ 256 Luxation of the cartilages of the larynx 258 Foreign bodies in the air-passages .... . 260 Foreign bodies introduced by the natural orifice .... 260 Foreign bodies introduced by way of the walls of the air-tube . . 261 Fistula of the larynx and trachea 273 Congenital fistula .... ... 274 Pathological fistula . . . . . . 275 Stricture of the larynx and trachea ...... 277 CONTESTS. PAGTB Laryngitis ......... 286 Acute laryngitis ........ 287 Simple or catarrhal laryngitis 287 Other forms of laryngitis ...... 289 Acute infantile laryngitis ...... 289 Chronic laryngitis ........ 290 Chronic catarrhal laryngitis ...... 290 Chronic glandular laryngitis 290 Chorditis tuberosa ....... *291 Chronic hypertrophic laryngitis . . . . .291 Chronic tuberculous laryngitis ..... 291 Syphilitic chronic laryngitis ...... 292 Abscess of the larynx ........ 297 Perichondritis and chondritis ....... 298 Croup and diphtheria ........ 300 After-treatment in cases of tracheotomy for croup or diphtheria . . 304 Bronchotomy : laryngotomy, tracheotomy, etc. ..... 308 Bronchotomy ........ 308 Tracheotomy . . ‘ . . . . . . 309 Crico-thyroid laryngotomy . . . . . .314 Thyroid laryngotomy . . . . . . .315 Laryngo-tracheotomy . . . . . . .315 The tracheal canula . . . . . . .316 After-treatment of tracheotomy, etc. . . . . .319 Morbid growths of the larynx ....... 320 Benign growths ........ 320 Treatment by intra-laryngeal methods .... 325 Treatment by direct access ...... 330 Malign tumors ........ 332 Sarcoma ........ 332 Carcinoma ........ 334 Record of deaths after complete laryngectomy for carcinoma . 338 Morbid growths of the trachea ....... 339 Benign growths ........ 339 Table of cases of intra-tracheal benign tumor .... 340 Granulomatous formations ...... 346 Malign tumors: sarcoma and carcinoma . . . . . 346 Table of cases of intra-tracheal sarcoma . . . .347 Table of cases of primary intra-tracheal carcinoma . . .347 Laryngectomy . . . . . . . . .351 Table of complete laryngectomies ...... 353 Table of unilateral laryngectomies ...... 364 Indications for the operation ...... 366 Operative procedure . • • * • * .367 Unilateral laryngectomy .... .371 After-treatment of laryngectomy . • • • • .371 Artificial larynx and artificial phonatory apparatus . . .373 XIV CONTENTS. PAGE Motor disturbances of the intrinsic laryngeal muscles . . . .374 Spasm ......... 375 Paralysis ......... 377 Immobility of the vocal bands from mechanical restraint . . . 384 Apnoea .......... 384 Intubation of the larynx as a substitute for tracheotomy .... 388 INJURIES OF THE CHEST. By EDWARD H. BENNETT, M.D., F.R.C.S.I., PRESIDENT OF THE ROYAL COLLEGE OF SURGEONS IN IRELAND ; PROFESSOR OF SURGERY IN TRINITY COLLEGE, DUBLIN ; SURGEON TO SIR PATRICK DUN’S HOSPITAL, ETC. Contusions of the chest . . . . . . . .391 Contusions involving the thoracic viscera ..... 392 Rupture of the viscera without fracture .... 395 Ruptures of the heart and pericardium .... 399 Ruptures of the diaphragm ...... 401 Wounds of the chest ........ 402 Penetrating wounds of the chest ...... 403 Treatment of pleural effusions . ...... 413 Paracentesis of the pericardium ...... 419 Mediastinal abscess ........ 420 Wounds of the oesophagus . . . . . . .421 DISEASES OF THE BREAST. By THOMAS ANNANDALE, F.R.C.S.E., REGIUS PROFESSOR OF CLINICAL SURGERY IN THE UNIVERSITY OF EDINBURGH, AND SENIOR SURGEON TO THE EDINBURGH ROYAL INFIRMARY. Anatomy of the mammae ....... 423 Congenital peculiarities ....... 425 Supernumerary nipples and mammae ..... 425 Congenital absence of mammae ...... 426 Functional and sympathetic conditions of the mammae .... 426 Atrophy and hypertrophy of the breasts ... . . . 428 Inflammatory affections of the breast ...... 429 Mammitis and mammary abscess ...... 429 Milk fistulae . . . . . . . .431 CONTENTS. XV PAGE Inflammatory affections of the breast— Chronic inflammation anu abscess . . . . . .431 Lymphatic inflammation ....... 432 Irritable mamma, or irritable tumor of the mamma .... 432 Tubercular and syphilitic affections of the breast .... 433 Parasites affecting the mamma ....... 434 Affections of the nipple . . . . . . . .434 Inflammation of the nipples . . . . . .434 Retracted nipples ........ 435 Tumors of the breast ........ 435 Simple tumors . . . . . . . . 436 Fatty, vascular, nervous, and cartilaginous tumors 436 Cystic tumors . . . . . . .436 Adenomata and fibromata . j 438 Malignant tumors ........ 439 Sarcomata . . . . . . . - 439 Carcinomata ........ 441 Scirrhous cancer ...... 444 Medullary cancer ...... 447 Affections of the male breast ....... 450 INJURIES AND DISEASES OF THE ABDOMEN. By HENRY MORRIS, M.A. and M.B. Bond., F.R.C.S. Eng., SURGEON TO, AND LECTURER ON SURGERY AT, THE MIDDLESEX HOSPITAL, LONDON. Contusions of the abdominal parietes . . . . . .451 Simple contusion or bruise ...... 451 Contusion complicated by extravasation of blood .... 453 Contusion complicated by rupture of abdominal muscles . . . 454 Contusion with pulpefaction of injured parts .... 454 . Inflammation of parietes following contusion .... 454 Suppuration and abscess of abdominal parietes .... 455 Burns and scalds of abdominal parietes ..... 459 Cutaneous eruptions, carbuncle, furuncle, and ulceration of the abdominal parietes 460 Erysipelas of abdomen ........ 462 Affections of the umbilicus ....... 462 Epithelioma and sarcoma of the umbilicus ..... 462 Fleshy polypi of the umbilicus ...... 462 Hemorrhage from the umbilicus ...... 463 Sub-parietal contusion and rupture of viscera ..... 463 Contusion and rupture of abdominal bloodvessels .... 464 Contusion and rupture of stomach and intestines .... 466 Ruptures of omentum and mesentery . . . . .471 Contusion and rupture of hernia . . . . .472 XVI CONTENTS. PAGE Sub-parietal contusion and rupture of viscera— Rupture of solid viscera ....... 473 Rupture of the liver . . . . . . .474 Rupture of the spleen ....... 475 Rupture of the kidney . . . . . .476 Rupture of the ureter . . , . . .479 Rupture of the pancreas ...... 480 Rupture of the gall-bladder and biliary ducts . . . .481 Rupture of the peritoneum ....... 485 Traumatic peritonitis ........ 485 Wounds of the abdomen ....... 489 Non-penetrating wounds of the abdomen ..... 400 Incised wounds ....... 490 Punctured wounds ....... 402 Lacerated wounds ....... 403 Contused wounds ....... 404 Gunshot wounds ....... 495 Penetrating wounds of the abdomen ..... 407 Simple penetrating wounds ...... 407 Penetrating wounds with protrusion of uninjured viscera . . 409 Penetrating wounds with protrusion of injured organs . . 504 Penetrating wounds with injury to, but without protrusion of, the viscera ....... 507 Penetrating wounds of the stomach . . . .511 Penetrating wounds of the intestines . . . .513 Penetrating wounds of the liver ..... 518 Penetrating wounds of the gall-bladder and duct . . . 519 Penetrating wounds of the spleen . . . .521 Penetrating wounds of the pancreas and thoracic duct . . 522 Penetrating wounds of the kidney .... 523 Wounds of the ureter ...... 527 NVounds of the supra-renal capsule .... 528 Penetrating wounds involving the lymphatics and bloodvessels . 528 Wounds of the abdomen made by the surgeon . . . .531 Suture of the intestines ........ 535 Retro-peritoneal extravasation and suppuration . . . . .544 Retro-peritoneal associated with intra-peritoneal abscess . . . 552 Fatty tumors of the abdominal cavity ...... 553 Gastric fistulas . . . . . . . . .554 Biliary fistulae . . . . . . . . .556 External or cutaneo-biliary fistulae ...... 556 Internal biliary fistulae ....... 558 Urinary fistulae ......... 559 Fistulae which communicate with the kidney and pelvis of the kidney . 559 Fistulae which communicate with the ureter .... 560 Fistulae which communicate with the urinary bladder . . . .561 Urethral fistulae opening externally through the walls of the abdomen . 563 Urachal abscess and fistula ....... 564 CONTENTS. XVII PAGE Fecal fistulae ......... 569’ False anus, commonly called artificial anus . . . . .574 Entero-vaginal fistulae ........ 584 Foreign bodies in the stomach and intestines ..... 584 Foreign bodies in the stomach ...... 585 Gastrotomy ........ 587 Foreign bodies in the intestines ...... 589 Enterotomy ...... . . 592 Loose and foreign bodies in the peritoneum ..... 593 Abdominal abscesses ........ 593 Peritoneal abscesses ....... 593 Visceral abscesses ........ 599 Hepatic abscess . . . . . . .599 Biliary abscess ....... 605 Abscess of the spleen ....... 608 Abscess of the pancreas ...... 609 Abscess in the omentum and mesentery . . . .610 Perinephric abscess . . . . . . .611 Fecal abscess . . . . . . . .615 Ilio-pelvic abscess ....... 622 Ovarian abscess . . . . . . . 627 Haemato-salpinx, hydro-salpinx, and pyo-salpinx: abscess of the Fal- lopian tube ....... 631 Suppurating ovarian cysts . . . . . . 636 Hydatids ......... 639 Hydatid cyst of the liver ....... 640 Hydatids of the gall-bladder, spleen, kidney, mesentery, and omentum . 654 Hydatids of the abdominal parietes ..... 655 Hydatids between the bladder and rectum . . . . . 655 Cysts of the abdominal viscera . . . . . .656 Simple, watery, or serous cysts of the liver .... 656 Simple, or serous cysts of the kidney ..... 657 Cysts of the spleen . . . . . . . .660 Cysts of the pancreas . . . . . . .661 Cysts of the mesentery, omentum, and peritoneum . . .663 Cysts of the urachus ....... 665 Distension of the gall-bladder ....... 666 Distension of the gall-bladder with bile ..... 666 Distension of the gall-bladder with fluid secreted by the mucous glands and epithelium of the sac ....... 667 Distension of the gall-bladder with pus and with calculi . . . 668 Enlargement of the gall-bladder from cancerous deposit . . . 669 Cholecystotomy . . . . . . . - .670 Cholecystectomy . . . . . . - .673 Surgical diseases of the kidneys . . . . - .673 Renal calculus . . . . . . . .673 Tuberculous and scrofulous kidney . . . . .676 Syphilitic kidney . . . . • • • .678 VOL. V.—B CONTENTS. PAGE Surgical diseases of the kidneys— Amyloid kidney . . . . . « . .679 Tumors of the kidney . • . . . . . . 680 Hydronephrosis . . . . . . . .681 Pyonephrosis ........ 683 Solid tumors of the kidney . . . . . . 684 Carcinoma of the kidney ...... 684 Sarcoma and rhabdomyoma of the kidney .... 685 Tumors of the suprarenal capsule .... 685 Surgical kidney ........ 686 Operations on the kidneys ....... 688 Puncturing the kidney ....... 689 Nephrotomy ........ 690 Nephrolithotomy ... . . . . . . 691 Nephrorraphy . . . . . . . .694 Nephrectomy ........ 695 Splenotomy and splenectomy . . . . . . . 700 Pylorectomy or partial gastrectomy . . . . . .704 Other operations on the stomach . . . . . .709 Gastro-enterostomy . . . . . . . .709 Digital dilatation of the pylorus . . . . . .710 Dilatation of the cardiac orifice of the stomach . . . .711 Operations on the pancreas and liver . . . . . .711 Hepatic phlebotomy, etc. . . . . . .712 URINARY CALCULUS. By E. L. KEYES, A.M., M.D., PROFESSOR OF GENITO-URINARY SURGERY IN THE BELLEVUE HOSPITAL MEDICAL COL- LEGE OF NEW YORK; CONSULTING SURGEON TO. THE CHARITY HOSPITAL; SUR- GEON TO BELLEVUE HOSPITAL, TO THE SKIN AND CANCER HOSPITAL, AND TO ST. ELIZABETH HOSPITAL. Urinary calculus. . . . . . . . .713 Geographical distribution of stone . . . . . .715 Causes of stone formation . . . . . . .717 Influence of colloids. . . . . . . .717 Richness of urine in solid ingredients . . . . .719 Effect of age . . . . . . . .720 Water as influencing stone formation . . . . .721 Sex, race, and climate ....... 722 Social condition, habits, and occupation ..... 722 Exercise and fresh air, drink and food ..... 723 Constitution, acute maladies, heredity . . . . .723 Chronic disease of urinary passages . . . . . .724 CONTENTS. XIX PAGE Causes of stone formation— Foreign bodies ........ 724 Classification of urinary calculi ....... 725 Structure of stones and nature of nuclei ..... 727 Rate of growth of urinary calculi . . . . . .729 Gross characters of urinary calculi ...... 729 Spontaneous fracture of calculi . . . . , . . 731 Materials which enter into composition of urinary calculi . 732 Description of various types of urinary calculus .... 733 Uric-acid calculus ........ 733 Oxalate-of-lime or mulberry calculus ..... 734 Mixed phosphatic or fusible calculus ..... 734 Urate-of-ammonium calculus ...... 735 Ammonio-magnesian phosphate . . . . . .735 Phosphate of lime . . . . . . . 735 Carbonate-of-lime calculus ...... 735 Cystine or cystic-oxide calculus ...... 736 Xanthine, xanthic-oxide, or uric-oxide calculus . . . .737 Fibrinous and blood calculus ...... 737 Urostealith ; fatty or saponaceous calculus . . * . .737 Indigo calculus . . . . . . . .738 Chemical analysis of stone ....... 738 Organic constituents . . . . . * .739 Inorganic constituents . . . . . . .739 Pathological results of urinary calculus . . . . .740 Stone in the kidney . . . . . . . .742 Stone in the ureter . . . . . . . .742 Prostatic stone . . . . . . , .744 Urethral calculus . . . . . . . .745 Preputial calculi . . . . . . . .748 Umbilical calculi . . . . . . . .749 Urinary calculi outside of the urinary tract ..... 749 Stone in the bladdef . . . . . . .751 Position of stone in the bladder ...... 751 Symptoms of urinary calculus in the bladder . . . .752 Diagnosis of stone . . . . . . .756 Sounding for stone ....... 757 Preventive treatment of stone . . . . . . .760 Electrolytric treatment of stone . . . . . .765 Solvent treatment of stone . . ... . . . 765 Palliative treatment of stone ....... 770 Selection of method of radical treatment ..... 770 Lithotomy statistics . . - . . .. .771 Lithotrity statistics ....... 775 Relapse after radical treatment ...... 778 Choice of operation ........ 779 Peculiarities of patient . * . . . . 779 Peculiarities of stone . . . . . . .781 XX CONTENTS. PAGE Causes of death after lithotomy and lithotrity . 783 Preparation of patient for radical treatment of stone . . . 784 Lithotrity . . . . . . 4 . 786 Mode of performing lithotrity ...... 793 Complications of lithotrity ...... 796 Search for last fragment ....... 800 Litholapaxy .... .... 800 Mode of performing litholapaxy . . . . . .812 Search for last fragment . . . . . . .813 After-treatment of litholapaxy ...... 814 Time consumed by operation . . . . . .814 Relapse after litholapaxy . . . . . . .815 Complications during operation . . . . . • . 815 Complications after operation . . . . . .818 Applicability of litholapaxy to women and children and for removal of sub- stances other than urinary deposits . . . . .819 Lithotomy ......... 819 General considerations concerning lithotomy .... 825 Selection of a method in lithotomy ..... 825 Operations through the perineum ...... 829 Lateral lithotomy . . . . . . . .831 Obstacles encountered before operation . . . . 843 Complications during perineal lithotomy . . . 843 Complications after perineal lithotomy .... 848 Possible after-effects of perineal lithotomy . . . 851 Bilateral and median lithotomy ...... 853 Supra-pubic lithotomy ....... 855 Extra-vesical lithotomy ....... 861 Urinary calculus in the female . . . . . . .861 Treatment of stone in the female ...... 864 Explanation of plate illustrating appearance of some forms of urinary calculus . 868 LITHOTRITY. By WM. H. HIXGSTOY, M.D., D.C.L., L.R.C.S.E., Etc., PROFESSOR OF CLINICAL SURGERY IN THE MONTREAL SCHOOL OF MEDICINE, SURGEON TO THE HOTEL-DIEU HOSPITAL, MONTREAL. Introductory remarks ........ 869 Instruments for exploration ..... .870 Exploration of the bladder . . . . . . ,871 Dangers and advantages of lithotrity . . . . . .876 Preliminaries to lithotrity ...... 880 Method of operating ........ 882 Rapid lithotrity ...••■ 886 Lithotrity in women and children ...... 890 LIST OF ILLUSTRATIONS. CHROMO-LITHOGRAPHS. PLATE PAGE XXXII. Carcinoma of both breasts ...... 444 XXXIII. V arious forms of urinary calculus . . . . .737 WOOD-CUTS. FIG. 1075. Indentation and Assuring of outer table of skull . . . .15 1076. Fracture of inner table of skull . . . . .15 1077. 1078. Diagrams illustrating mechanism of fracture of inner table of skull. (After Teevan.) .... 16 1079. Diagram illustrating mechanism of fractures of skull . . .16 1080. Fracture of inner table of skull . . . . . .18 1081. Fracture of occipital bone by hatchet-wound . . . 18 1082. Disk, of bone removed by trephining, showing punctured fracture of skull . 19 1083. The same, showing fracture of inner table. . . . .19 1084. Depressed fracture of outer table of skull . . . . .20 1085. Fracture of inner table of skull ...... 20 1086. 1087. Fracture of skull, with shattering of internal table . . .24 1088. Punctured fracture of skull by piece of glass, with wound of middle menin- geal artery. (Conner.) ...... 45 1089. Pistol-shot wound of lateral sinus . . . . . .52 1090. Diagram showing localization of cerebral nerve-centres and determination of line of Rolando. (Modified from Lucas-Championniere.) . . 89 1091. Flexible square of Broca. (After Lucas-Championniere.). . . 92 1092. Flexible square applied. (After Lueas-Championiere.) . . .92 1093. Ready mode of determining position of bregma. (After Lucas-Champion- niere.) ......... 92 1094. Conical trephine ........ 95 1095. Ordinary trephine. ....... 95 1096. Trephine-brush . . . . . . . .96 1097. 1098. Two forms of Key’s saw . . . . . .96 1099. Lenticular ........ 96 1100. Application of the trephine ...... 97 1101,1102. Malignant tumors of the neck ..... 192 1103,1104. Lymphoma of the neck ...... 193 1105. Lymphoma of the neck ....... 194 1106. Large lipoma of the neck ....... 195 (xxi) XXII LIST OF ILLUSTRATIONS. FIG. PAGE 1107. Laryngoscopic mirror ....... 221 1108. Laryngoscopic mirror in position ..... 222 1109. Manner of'holding laryngoscopic mirror ..... 222 1110. Perforated reflector for laryngoscopy ..... 223 1111. Laryngoscopy by reflected artificial light. (After Tobold.) . . 223 1112. Laryngoscopic picture in contusion of larynx. (After Packard.) . 232 1113. Trendelenburg’s rubber-tampon canula; Gerster’s modification . . 237 1114. CEdema of epiglottis . . . . . . ' . 248 1115. (Edema of aryteno-epiglottic folds ..... 248 1116. Subglottic oedema of the larynx ...... 249 1117. Fracture of thyroid cartilage. (After Roe.) . . . .252 1118. Fracture of larynx. (After Roe.) ..... 252 1119. Brass ring straddling the larynx. (After Leflferts.) . . . 264 1120. Obstruction of larynx by piece of boiled beef. (After Poulet.) . . 264 1121. Obstruction of trachea by pan-cake. (After Poulet.) . . . 264 1122. Bifurcation of trachea. (After Durham.) .... 264 1123. Bone imprisoned in ventricle of larynx. (After Mackenzie.) . . 265 1124. Coin impacted in ventricles of larynx. (After Grazzi.) . , . 270 1125. Coin in grasp of*forceps. (After Grazzi.) .... 270 1126. Cusco’s lever-bladed laryngeal forceps ..... 270 1127. Trousseau’s dilator . . f . . . .*271 1128. Laborde’s dilator . . . . . . .271 1129. Golding-Bird’s retractor ...... 272 1130. Gross’s tracheal forceps ....... 272 1131. Cohen’s tracheal forceps . . . . . . -272 1132. Compression and deflection of trachea by cervical tumor. (After Janney.) 277 1133. Same case; canula in position three months after operation. (After Janney.) ........ 277 1134. Involution of trachea by aneurism of arch of aorta . . . 280 1135. Concentric constriction of trachea. (After Mackenzie.) . . 280 1136. Syphilitic cicatricial narrowing of trachea. (After Thornton.) . . 281 1137. Appliances used by Schroetter in dilating stenosis of larynx . . 283 1138. Schroetter’s method of dilating stenosis of larynx. (After Labus.) . 284 1139. Mackenzie’s laryngeal dilator . . . . . . 285 1140. McSherry’s modification of Stoerk’s dilator .... 286 1141. Pyriform swellings of tuberculous laryngitis .... 291 1142. Gumma in inter-arytenoid fold ...... 292 1143. Multiple gummata. (After Mandl.) ..... 292 1144. Hypertrophy of vocal bands. (After Tuerck.) . . . . 294 1145. The same after tracheotomy. (After Tuerck.) . . .. . 294 1146. Tuberculous laryngitis in ulcerative stage .... 294 1147. Multiple ulcerations in laryngeal tuberculosis. (After Mackenzie.) . 294 1148. Abscess from perichondritis of arytenoid cartilage . . . 297 1149. Primary perichondritis of cricoid cartilage. (After Tuerck.) . 299 1150. Perichondritis of cricoid cartilage with loss of arytenoid in enteric fever. (After Tuerck.) ....... 299 1151. Lines of incision in Bose’s method of tracheotomy. (After Mackenzie.) 314 1152. Trousseau’s double tracheotomy tube . . . .316 LIST OF ILLUSTRATIONS. FIG. PAGE 1*153. Cohen’s tracheotomy tube with hollow conductor .... 316 1154,1155. Durham’s tracheotomy tube and inner canula . . . 317 1156. Durham’s piloting trocar ...... 318 1157. Semon’s tampon-canula. (After Mackenzie.) .... 319 1158. Luer’s pea-valve tracheotomy tube ..... 320 1159. Multiple papillomata of the larynx ..... 323 1160. Larynx after their removal ...... 323 1161. Laryngeal fibroma ....... 323 1162. Angeioma on vocal band . . . ... 324 1163. Cystoma ........ 324 1164. Prolapsus of laryngeal sac ...... 324 1165. Flexible sponge-holder with bayonet-catch .... 325 1166. Cohen’s rigid sponge-holder with lateral slide-catch . . . 325 1167. Growths on both vocal bands ...... 326 1168. Appearance of bands after destruction of growths by chromic acid . 326 1169. Cohen’s laryngeal electric cautery r . . . . . 326 1170. Cautery terminals. (After Bruns.) ..... 327 1171. Laryngeal knives. (After Tobold.) ..... 327 1172. Perpendicularly cutting scissors. (After Tobold.) . . . 328 1173. Stoerk’s universal handle with two forms of guillotine . . . 328 1174. Mackenzie’s laryngeal forceps ...... 329 1175. 1176. Small-celled sarcoma on left ventricular band. (After Jurist.) . 332 1177. Sarcoma growing from posterior surface of cricoid cartilage. (After Mackenzie.) ........ 334 1178. Large spheroidal-celled carcinoma at an early stage . . .336 1179. Tracheal tumor seen by laryngoscopy. (After Labus.) . . . 350 1180. Same case after evulsion of tumor. (After Labus.) . . . 350 1181. Sarcoma of trachea. (After Schroetter.) .... 350 1182. Appearance of parts after laryngectomy. (After Lange.) . . 372 1183. Irvine’s modification of Gussenbauer’s artificial phonatory apparatus. (After Foulis and Mackenzie.) . . . . .373 1184. Artificial larynx with oesophageal obturator. (After Lange.) . .374 1185. 1186. Unilateral paralysis of abductor during respiration and during attempted phonation ‘. . . . . . . 373 1187, 1188, 1189. Paralysis of left vocal band during forced inspiration, during expiration, and during attempted phonation .... 379 1190, 1191. Bilateral paralysis of posterior crico-arytenoid muscle during inspi- ration and during expiration ...... 380 1192. Bilateral paralysis of thyro-arytenoids. (After Ziemssen.) . .381 1193. Paralysis of right thyro-arytenoid. (After Ziemssen.) . . . 381 1194. Bilateral paralysis of thyro-arytenoids with paralysis of arytenoid muscle. (After Ziemssen.) . . . . . . .381 1195. Paralysis of arytenoid. (After Ziemssen.) .... 382 1196. Bilateral paralysis of recurrent nerve. (After Ziemssen.) . . 382 1197. Position of vocal bands in cadaver. (After Ziemssen.) . . . 382 1198. Crossing of arytenoid cartilages. (After Ziemssen.) . . . 382 1199. Mackenzie’s laryngeal electrode and electrode for neck . . . 383 1200. O’Dwyer’s instruments for intubation of the larynx . . . 389 1201. Irreducible ilio-inguinal hernia following ilio-psoas abscess in a woman . 457 XXIV LIST OP ILLUSTRATIONS FIG. PAGE 1202. Ring-calculus extracted through a urachal fistula. (After T. Paget.) . 568 1203. Diagram of relations of false anus resulting from sloughing of knuckle of ileum. (After Scarpa and Otis.) . . . . .575 1204,1205. Intestinal fistulas from Dupuytren’s collection. (After Teale.) . 576 1206. Dupuytren’s enterotome . . . . . . .581 1207. Blasius’s enterotome ....... 581 1208. Reybard’s enterotome ....... 582 1209. Gross’s enterotome ....... 582 1210. Cannon-shaped pencil passed by the rectum .... 585 1211. Lembert’s suture ........ 587 1212. Jobert’s suture . . . . . . . ' . 587 1213. Fecal abscess originating in disease of colon and communicating with ileum at two places. (After Bristowe.) . . . . .615 1214. Extraction of urethral calculus with Thompson’s divulsor . .747 1215. Thompson’s searcher for vesical calculus .... 757 1216. Civiale’s litholabe ....... 787 1217. 1218. Jacobson’s lithotrite .... . 788 1219. Heurteloup’s percuteur ....... 788 1220, 1221. Thompson’s fenestrated lithotrites .... 789 1222, 1223. Thompson’s non-fenestrated lithotrites .... 790 1224. Thompson’s lithotrite, male blade ..... 790 1225. Thompson’s lithotrite, female blade ..... 790 1226. Handle of Thompson’s lithotrite ..... 790 1227. 1228. Jaws of Bigelow’s lithotrite ..... 791 1229. Handle of Bigelow’s lithotrite ...... 791 1230. Jaws of Keyes’s lithotrite . . . . . .792 1231. Keyes’s lithotrite ....... 792 1232. Urethral forceps ........ 798 1233. 1234. Alligator forceps, straight and curved . . . .798 1235. Leroy d’Etiolles’s scoop . . . . . . .798 1236. Urethral lithotrite ....... 799 1237. Mathieu’s instrument for perforating urethral calculi . . . 799 1238‘ Sir Philip Crampton’s evacuating bottle .... 802 1239. Cornay’s litheretie ....... 803 1240. Mercier’s washing bottle ..... . 803 1241. Clover’s first evacuator ....... 803 1242. Clover’s improved evacuator ...... 804 1243. Nelaton’s evacuating apparatus . . . . . 804 1244. Bigelow’s first evacuator ...... 805 1245. Stand for evacuator ....... 805 1246. Bigelow’s second evacuator ...... 805 1247. Bigelow’s third evacuator ...... 806 1248. Bigelow’s latest evacuator ...... 80G 1249. Thompson’s first evacuator ...... 807 1250. Thompson’s second evacuator ...... 807 1251. Thompson’s third evacuator ...... 807 1252. Thompson’s fourth and latest evacuator ..... 808 1253. Reservoir of Thompson’s evacuator ..... 808 LIST OF ILLUSTRATIONS. XXV FIG. PAGK 1254. Otis’s evacuator ........ 809 1255. Guyon’s evacuator ....... 809 1256. 1257. Evacuating tubes, curved and straight .... 809 1258. Keyes’s evacuating tube, straight . . , . .810 1259. Keyes’s evacuating tube, curved . . . . ,811 1260. Bar for separating limbs in lithotomy ..... 830 1261. Anklet and wristlet for lithotomy ..... 830 1262. Staff for lithotomy ....... 832 1263. Rectangular staff for lithotomy ...... 832 1264. Lithotomy scalpel ....... 832 1265. 1266. Blizard’s probe-pointed lithotomy knife .... 833 1267. N. R. Smith’s staff and knife for lithotomy .... 834 1268, 1269. Lithotomy forceps, straight ..... 834 1270. Lithotomy forceps, curved ...... 834 1271. Crested scoop ........ 835 1272. Blunt gorget ........ 835 1273. Crusher, or brise-pierre ....... 835 1274. Maisonneuve’s eclateur ....... 835 1275. 1276. Tubes for washing out bladder after lithotomy ... 836 1277. Horner’s awl ........ 836 1278. Thompson’s tenaculum with detachable handle .... 837 1279. Forcipressure forceps ....... 837 1280. Gross’s artery compressor ...... 837 1281. Shirted canula for plugging wound after lithotomy . . . 838 1282. Air-tampon for hemorrhage after lithotomy . - 838 1283. Dupuytren’s double lithotome cache ..... 853 1284. Wood’s bisector ........ 854 1285. 1286. Staff for median lithotomy ..... 854 1287. Little’s lithotomy director ...... 855 1288. Dolbeau’s dilator for perineal lithotrity ..... 855 1289. Rectal colpeurynter ....... 859 1290. Sound for exploring bladder ...... 870 1291. Large oxalate-of-lime calculus with external phosphatic layer , . 879 1292. Rack-and-pinion lithotrite ...... 884 1293. Lever-lithotrite ........ 884 1294. Civiale’s lithotrite ....... 884 1295. Gouley’s lithotrite ....... 886 THE INTERNATIONAL ENCYCLOPAEDIA OF SURGERY. INJURIES OF THE HEAD. BY ' CHARLES B. NANCREDE, M.I)., PROFESSOR OF GENERAL AND ORTHOPEDIC SURGERY IN THE PHILADELPHIA POLYCLINIC, SURGEON TO THE EPISCOPAL HOSPITAL AND TO ST. CHRISTOPHER’S HOSPITAL. Injuries of the Scalp. Contusions and wounds of the scalp are among the most common injuries of civil life. A preliminary consideration of the anatomy of the scalp will explain certain pathological peculiarities of injuries of that structure. The coverings of the skull, from without inward, are the skin, superficial fascia, aponeurosis and muscular bellies of the occipito-frontalis muscle, sub- aponeurotic cellular tissue, and pericranium. The integument is firmly bound to the subjacent muscle and aponeurosis by the so-called fascia, which con- sists of firm, interlacing bundles of fibrous tissue, in the interspaces of which are little pellet-like masses of granular fat, forming an exceedingly inelastic structure. In this ramify the numerous vessels and nerves of the scalp. A consideration of these anatomical points explains several well-known clini- cal facts, viz., that the inelastic, subcutaneous cellular tissue can actually be indented by a blow ; that scalp wounds which do not penetrate the aponeu- rosis seldom gape to any extent; and that when a scalp-flap is formed, it neces- sarily carries its entire blood-supply with it, owing to the physical characters of the subaponeurotic cellular tissue which I shall presently consider. The origin and attachments of the aponeurosis and muscular bellies of the occi- pito-frontalis should be carefully borne in mind, as a knowledge of them ren- ders easy the differential diagnosis between subaponeurotic collections of pus and erysipelas. The posterior bellies of the muscle arise from the outer two- thirds of the superior curved lines of the occipital bone, and from the mastoid process of the temporal. The space between them is occupied by the aponeu- rosis, which is attached to the occipital protuberance and to the inner thirds of the superior curved lines. The anterior muscular bellies are blended with the pyramidalis nasi, corruo-ator supercilii, and orbicularis palpebrarum on each 2 INJURIES OF THE HEAD. side. The aponeurosis covers the whole vault of the skull, and is continued laterally by a laminated layer of areolar tissue to the zygoma. Hence it will be seen that subaponeurotic fluid collections cannot pass lower, posteriorly, than thepointsof attachmentof the trapezii muscles; that anteriorly, fluid will gravi- tate into the eyelids and form a pouch over the root of the nose ; and that later- ally, the zygomatic arch is the lowest point attainable for a purulent collection. The cellular tissue which forms the bond of connection between the aponeu- rosis and the pericranium is exceedingly lax, permitting the former with its firmly adherent integument to glide readily over the calvaria. It will be at once seen that a wound penetrating the aponeurosis, on account of this laxity of the cellular tissue, will gape, and if raised in the form of flap may be extensively displaced. The vascular and nervous supplies of the scalp must not be forgotten with reference to the arrest of hemorrhage, and the neuralgias that occasion- ally follow injuries. The arteries of the scalp are derived from the temporal, occipital, auricular, supra-orbital, and frontal. Vessels arising from these trunks penetrate the deeper structures to ramify in the periosteum. The veins of the pericranium and of the scalp, the diploic veins, and those of the dura mater, or even the cerebral sinuses, intercommunicate, thus present- ing in their cellular coats a continuous tract of connective tissue, along which external inflammation may travel to the diploe, and even to the brain. The nerves of the scalp are the occipitalis major and occipitalis minor, the auric- ulo-temporal, the posterior auricular, the supra-orbital, and the facial. Contusions of the Scalp.—Owing to the anatomical structure of the scalp, certain peculiarities of form are presented by contusions, which sometimes give rise to difficulties in diagnosis. The swelling from a blow upon the scalp occurs within a few seconds, and is due to the rapid effusion of blood and serum. It is sharply defined, and does not insensibly blend with the surrounding parts. If examined within a few hours, a soft, central depression is felt, surrounded by a hard, elevated margin, giving the impression of a depressed fracture ; and this is all the more deceptive if, as in some instances, a ruptured artery communicates with the effusion, when the sensation com- municated to the hand closely simulates that of cerebral pulsation.1 The central depression with the surrounding hard margin, receives its explana- tion from the character of the dense, inelastic, cellulo-adipose, superficial fascia, which is indented at the point of impact, while the displaced fat, with the surrounding parts infiltrated with blood and serum, forms the hard margin. The diagnosis between this condition and a depressed fracture, can be made by pressing firmly with the finger at the bottom of the depression ; if there be no fracture, the surface can be still further indented, when the bone will usually be detected smooth and undepressed. The indurated margin itself can also be indented by pressure with the finger nail, which would not be the case in fracture. There are, besides, no symptoms of cerebral compression. It must be confessed, however, that, in certain instances, expe- rienced surgeons have cut down expecting to find a depressed fracture where none has existed, and again, that, after the effusion has been absorbed, a depression has been found where none had been supposed to exist. Attention to the diagnostic points just detailed should render such mistakes of rare occurrence. The degree of the contusing force may be so slight that the con- sequences pass away within a few hours, or so severe as to actually pulpify the scalp, although gangrene is of rare occurrence. 1 J. L. Petit gives an account of two such cases. (Euvres completes, p. 334. Paris, 1844. INJURIES OF THE SCALP. 3 Complications and Sequelae.—Contusion of bone, cerebral concussion, rup- ture of a scalp-artery, intra-cranial hemorrhage, and erysipelas may com- plicate contusions of the scalp. Abscess, neuralgia, cephalhematoma, traumatic aneurism, and pyemia—the latter usually the result of bone- contusion—are occasional sequele. Numerous other after-effects of scalp contusions have been described, but they are really the results of injuries of the scalp-nerves, of an undetected cranial fracture, or of secondary brain lesions.1 D'eatment.—Quiet, for cerebral complications may arise; cold, evaporating lotions, such as spirit and water, or muriate of ammonium in solution—or even a bladder of pounded ice, if the effusion tend to spread, or pulsate—and attention to the state of the bowels, amply suffice for the majority of cases. If suppuration occur, the treatment should be that of an abscess elsewhere. If a traumatic aneurism form, compression or acupressure of the vessel should be resorted to. Erysipelas, cerebral concussion, contusion of bone, and pyaemia, will be considered in connection with wounds of the scalp.2 Neu- ralgias must be treated upon general principles, or by excision of the scar, if they prove obstinate. Effusions of Blood.—These may occur, 1, in the dense subcutaneous tissue, where the blood forms a hard, unyielding lump; 2, in the subaponeurotic cellular tissue, either (a) circumscribed, or (b) diffused, when it sometimes forms a swelling of considerable extent, giving a crackling sensation when pressed by the finger; and 3, beneath the pericranium. In the last two situations, these collections have been called cephalhcematomata. The nature of the contents varies with the time after the accident at which they are examined. The blood may “ be arterial or venous, in a more or less fluid state ; or a thick, viscid fluid of a dark, bistre color; or bloody serum with clots; or serum alone.”3 The wall of the cavity, originally formed by con- densation of the environing tissues, eventually becomes lined with a serous- like, secreting membrane. Sometimes the sac is lined with layers of “fibrine” (lymph?) presenting the appearances found in a consolidating aneurism, or in a solidified bursal tumor.4 Cephalhcematomata.—Certain examples of the so-called caput succedaneum of the newly-born, the result of tedious or instrumental labor, are entirely or chiefly filled with blood, although from their rapid disappearance the major- ity certainly seem to be due merely to serous effusion. A caput succedaneum is usually described as being subaponeurotic, but Agnew considers this to be an error, and believes that the majority are simply subcutaneous. When these swellings, due to effused blood, are diffused at the outset, they must certainly be of the subaponeurotic form; but when circumscribed from the first, they may be either subcutaneous or subpericranial. Subaponeurotic cephalhcematomata occur in the form of soft, fluctuating tu- mors, usually situated over one parietal eminence.5 The margins of the swell- ing are somewhat indurated. Although considered almost peculiar to the newly-born, they are, according to Gant, of frequent occurrence in older children as the result of falls or blows.6 I have myself seen a very large one upon the head of a boy about thirteen years of age. Subpericranial cephalhcematomata are of very rare occurrence, according to 1 Gross, System of Surgery, 6th ed., vol. ii. p. 21. 2 See page 4. 3 Hewett, Holmes’s System of Surgery, 3d ed., vol. i. p. 574. 4 See Hewett, ibid.; and Vol. III., page 140, of this Encyclopaedia. 5 Bryant records a large one over the occipital bone. Manual for the Practice of Surgery, 2d Am. ed., p. 154. 6 Science and Practice of Surgery, vol. ii. p. 147. 4 INJURIES OF THE HEAD. Vogel, not being found oftener than once or twice in a thousand births. They are more common after first labors, and, according to Bouchard, more common in boys than in girls, in the proportion of 34 to 9.1 Commonly situated over one or other parietal bone, they are not infrequently multiple. They are usually small, being seldom larger than a walnut. A distinguishing peculiarity is the fact that, owing to the firmer adhesions of the periosteum at the sutures than elsewhere, these tumors are always confined to one bone, never passing a suture. Universally believed to be confined to the newlv-born, as indicated by the terms Cepliallnematoma neonatorum and Thrombus neonatorum, Gant reports the case of a child five years old, in whom a blood-tumor formed as the result of a blow over the right frontal eminence, and presented all the characteristics of a subperieranial effusion. The characteristic symptoms of the lesion are apt to be obscured by the oedematous swelling of the superjacent scalp, for the first few days after birth, but from the fourth to the sixth day, a soft, circumscribed, fluctuating swelling confined to one bone—usually the right parietal—can be readily detected, while the overlying scalp is not discolored. The centre is soft, while the circum- ference is hard, and has very much the feel of a margin of bone surrounding a depressed fracture. There are, however, no brain symptoms when firm pressure is made at the bottom of the depression, and by the same manoeuvre the finger can often detect the sound, undepressed bone. Valleix has shown, from his studies of the pathology of this affection, that the hard, crater-like margin is due to the formation of plastic and osseous matter between the pericranium and the bone, and that, upon the side of the cavity, it has abrupt, almost perpendicular, walls, while the outer margin of the ring insensibly slopes down to the level of the surrounding bone. The peri- cranium is elevated by the blood-effusion from the subjacent bone, both struc- tures being covered with plastic matter, but otherwise healthy. Sir James Simpson has observed that at times the plastic effusion upon the under sur- face of the pericranium becomes ossified, when pressure upon the resultant thin plate of bone communicates a crackling sensation to the finger. The diagnosis of cephalhsematomata, both general and differential, has been sufficiently indicated in the foregoing descriptions, except as to the necessity which may arise of distinguishing between pus and blood. In the former case, the collection would appear at a later period than a blood-effusion, and only after precedent symptoms of inflammation. Treatment.—This should in no wise differ from that advised for contusions of the scalp. If, as occasionally is the case, the swelling persists, or even increases, aspiration, or a valvular puncture, may become necessary, after which firm compression should be kept up over the site of the swelling for a considerable time. The sac will sometimes refill, again and again, requiring repeated tappings. Should the fluid be or become serous after several tap- pings, and tend to re-form, an injection of iodine may be tried. If pus form, either spontaneously or as the result of attempts to get rid of the effusion, free incisions, followed by the use of antiseptic injections and dressings, should not be delayed. Wounds of the Scalp.—These may be incised, punctured, contused, or lacerated. Incised wounds differ in no respect from those of other regions. Punctured wounds are more apt to be followed by trouble, because the vul- nerating body punctures the various planes of tissues forming the scalp at points which do not correspond, owing to the freedom of movement enjoyed by the occipito-frontal aponeurosis, and, in consequence, the resultant effusions 1 Erichsen, Science and Art of Surgery, Am. ed., vol. i. p. 529. INJURIES OF THE SCALP. 5 cannot get vent, but become widely diffused, setting up the most violent inflammation in those of intemperate habits, or with constitutions broken down from any cause. Even those in apparently robust health do not always escape. Contused and, lacerated wounds are usually the result of heavy blows, such as falls, blows from bludgeons, etc. Because a wound appears clean-cut, as if incised, it cannot always be inferred that the vulnerating body was sharp, as, owing to the flrmness of the subjacent bone, a fall on a plane surface will oftentimes give rise to wounds which closely resemble those made by cutting instruments. I merely mention this fact on account of its medico-legal bearings. These wounds when extending through the aponeurosis, gape markedly, and most extensive flaps may be formed, the scalp falling down over the face, upon the back of the neck, etc. Even the ears are sometimes torn off with lateral flaps. Usually a large portion of these wounds unites by flrst intention, and where this fails, healing by granulation completes the cure. As these flaps carry their entire vascular supply with them, sloughing is very limited, and the most mangled, bruised-looking scalp-tissue may recover its vitality. It is a golden rule to let nature, not the surgeon’s knife or scissors, determine what portion of an injured scalp shall be removed. Portions of the pericranium may also be torn off with the flap, or destroyed, by the body producing the injury. But even extensive denudation of the bone does not necessarily involve exfoliation of the external table of the skull, for in most instances the separated flap adheres. If primary union fails, either granulations cover in the bone from the surrounding tissues, or the outer table becomes vascularized from the diploe, so that sometimes merely small scales are thrown off, while at other times no osseous tissue can be detected in the discharges.1 Prognosis.—Scalp wounds are chiefly dangerous from their complications, which will be presently considered. Even complete scalping, with removal of the pericranium, may be recovered from.2 Treatment.—If the wound be of any size, the scalp must be shaved in its vicinity. Careful search having been made for any foreign bodies, or for a possible fracture, the wound should be thoroughly cleansed with some anti- septic solution, the best being mercuric bichloride, one part to two thousand. I have not mentioned the arrest of hemorrhage, which is usually free, because if it have not ceased from exposure to the air and washing with the bichlo- ride solution, the subsequent dressing with compresses and bandage will usually be all that is necessary. If this do not suffice, both ends of the divided vessels can usually be readily either twisted or tied. Sometimes the ends retract into the dense fibro-cellular tissue, where they can be best secured by passing a needle armed with a ligature around the vessel, including some of the surrounding tissues. Ligatures are rarely necessary except when the patients are drunk and unruly, when I have known them to pull off the dress- ings and start the hemorrhage afresh. A wound involving the lower part of the temporal fossa may, however, give rise to hemorrhage which may prove difficult to arrest. “ Should the bleeding recur and become dangerous, not- withstanding all our local means, the question of applying a ligature to the external or to the common carotid artery may arise.”3 Various measures have been recommended for coaptating scalp wounds. If of moderate size, and not gaping much, small locks of hair on opposite sides of the wound may be passed, through perforated shot, which can then be clamped, as Agnew suggests. I have achieved the same result by tying together locks 1 See page 8 for treatment of denuded external table by drilling into diploe. 2 Agnew, Principles and Practice of Surgery, vol. i. p. 257. 9 Hewett, Holmes’s System of Surgery, 3d ed., vol. i. p. 570. 6 INJURIES OF THE HEAD. of hair, and fixing them with collodion. Owing to the rapid growth of hair, it is difficult to make adhesive plaster hold for any length of time, while the flowing blood interferes with its proper application at the primary dressing. I prefer, therefore, where sutures are deemed unadvisable, to fix one end of a strip of fine gauze or mosquito-netting with collodion on one side of the cut, when the wound can be accurately coaptated, and held so by painting the other end of the gauze-strip with more collodion, the drying and consequent fixation of the dressing being hastened by blowing with the breath. In this way the most extensive wounds can be as accurately approximated as by means of sutures, and almost as rapidly. With such a dressing at our disposal, sutures are rarely demanded.. I am not opposed to their use when deemed necessary—at points of great traction, or in drunken or unruly patients—but anything like an attempt to closely sew up a lacerated scalp wound is to be deprecated, owing to the great ease with which the sub- aponeurotic fascia permits the diffusion of inflammatory products. Although as a rule I believe sutures to be unnecessary, with the above restrictions I should advise their use, provided that the anatomical peculiarities of the parts be borne in mind, and the sutures cut on the first symptoms of inflammatory swelling. Whatever the means used in closing the wound, care should be exercised lest the edges become inverted, as the hairs in their growth will in- terfere with healing. Contact of the flap with the deeper parts being secured by proper compresses, which also tend to prevent any collection of inflamma- tory products, a few folds of lint wet with a bichloride-of-mercury solution, and covered with waxed paper or oiled silk, should be laid over the line of the wound, and the whole firmly bandaged in place.1 Where any special dressing is not available, I have seen the best results from coaptating the wound by bandaging with dry compresses. Whatever the dressing, I would advise inspection of the wound at the end of forty-eight hours, when it can be either redressed, or left undisturbed, according to circumstances. Quiet, and attention to the state of the bowels, should be enjoined in view of possible cerebral complications. When suppuration takes place, the pus, if situated in the superficial fascia, forms circumscribed collections, which heal kindly after evacuation but when the abscess is subaponeurotic, it will be diffused, and must then be freely opened at the most dependent points to insure free drainage. Should this condition escape early recognition, the scalp may slough,or,more probably, the aponeurosis with its subjacent tissue, when the pericranium is almost certain to be more or less destroyed, imperilling the vitality of the outer table of the skull. Incisions, when made, should run parallel to the course of the occipito-frontal fibres. Complications of Scalp Wounds.—Erysipelas.—This affection has been already treated of in so exhaustive a manner, in Vol. I. of this work, as to render superfluous anything further than the indication of those peculiarities, due to the tissues in which it arises, which the disease presents, and the modi- fications in treatment which the concomitant injuries demand. It certainly is most apt to occur in drinkers, or in those with broken-down constitutions. The most common form is the cutaneous, which is rarely grave, and which may be ushered in by symptoms that are somewhat puzzling. Thus, I have lately had a case of trephining, in which violent headache, coated tongue, vomit- ing, steadily rising temperature, and the presence of a few enlarged and tender lymphatic glands, preceded, by more than forty-eight hours, a marked 1 The bichloride gauze, when at hand, may he substituted ; or carbolized gauze, or carbolized solution. INJURIES OF THE SCALP. 7 attack of erysipelas, which was chiefly facial, ancl which, when I saw it, did not seem to affect the neighborhood of the wound. This precedence of the general over the local symptoms, and the implication of the lymphatic glands, should be borne in mind in head injuries, when otherwise unaccount- able, feverish symptoms arise. In the treatment of this affection, attention to the bowels, nutritious food, stimulants, in those accustomed to their use and when not contra-indicated by the cerebral conditions, and iron and quinia, are all that need be resorted to. At times the patient experiences relief from the burning, tingling, cuta- neous pain by the application of cloths wet with lead-water and laudanum, or with simple mucilage of sassafras pith. Phlegmonous erysipelas, a much more serious affection, is apt to be ushered in by marked constitutional symptoms.1 It shows itself at first by slight pufliness near the wound, without redness of the skin. From plastic effusion, the scalp soon becomes greatly thickened and indurated, and, if unrelieved, the disease may lead to extensive sloughing of the cellular tissue, the aponeu- rosis, the pericranium, or even the scalp itself. In consequence, the bone may be extensively denuded, and in certain cases more or less necrosis follows, although this is no more a necessary result than it is where wounds denude the bone. Diagnosis.—From simple accumulation of pus or inflammatory products beneath the occipito-frontalis, erysipelas can be usually distinguished by remembering the points of attachment of the aponeurosis. Subaponeurotic pus may be accompanied by reddening of the skin somewhat beyond the attach- ments of the aponeurosis, but unless really complicated with erysipelas, the blush does not attack the ears, cheeks, etc. The pus can gravitate no lower than the zygoma, the upper eyelids, the attachments of the pyrimadales nasi, and the superior curved lines of the occipital bone behind, pouches being formed above the root of the nose, the zygoma, and the superior curved lines of the occipital. This condition, with the superficial blush which sometimes extends more over the face than I have described, has been often mistaken for erysipelas and attributed to the use of sutures, but it is in reality simply a dermatitis, due to retention of inflammatory products, which commonly declines when the imprisoned fluids have been drained away.2 As regards the treatment of phlegmonous erysipelas of the scalp, at the first onset of the local symptoms all stitches must be removed, the edges of the wound separated at a sufficient number of points to insure a free exit for the effused fluids, and poultices or water-dressings, covered with oiled silk or waxed paper, applied. The bowels should, if necessary, be opened by an enema or a mild saline purge, and the treatment just advised for the cutaneous variety of erysipelas, at once instituted. Despite these measures, should the plastic effusion extend, multiple punctures of the scalp, or, at most, numerous small incisions, will prove of advantage, and are not so likely to lead to free bleeding as the long incisions sometimes advised. Anything like free oozing, even from the punctures, must be checked as soon as possible, since these patients cannot afford to lose blood. In persons of previous good health, the relief of tension effected by these incisions usually suffices to prevent exten- sive sloughing, yet at times great destruction of cellular tissue, aponeurosis, and pericranium takes place, although from the peculiarities of the blood-supply of the scalp, already adverted to, this structure is rarely destroyed, at least to any considerable extent. A rare accident is the laying open of a large 1 Local symptoms may precede the constitutional. 2 Tetanus is an occasional complication. The reader is referred, for details, and a thorough consideration of all the varieties of erysipelas, to the article on that subject in Vol. I. 8 injuries of the head. arterial trunk by ulceration, giving rise to hemorrhage, the source of which is often difficult to ascertain, owing to the accumulation of blood beneath the scalp. Pressure upon the main trunks of the scalp arteries should be tried in turn, until the right vessel is detected, when it may be compressed, acu- pressed, or tied.1 A generous diet, iron and other tonics, carbonate of ammonium, and large quantities of stimulants, are, from the outset, often necessary to tide bad cases over the worst; but treated in the way described, it is astonishing how well they eventually do, the extensively separated scalp becoming adherent to the deeper structures, and the denuded bone being covered in by granulations. When the efforts of nature seem unequal to the task of vascularizing the denuded external table of the skull, left bare by the sloughing of the pericranium, the surgeon may drill with an awl a number of small holes close together into the diploe, and through these, as I have seen in a case of Agnew’s, granulations may sprout.2 The use of disinfectant injections beneath the separated scalp, counter-openings for the escape of pus and sloughs, and the application of compresses to prevent bagging of matter, are too manifest therapeutic indications to need more than this mention. Injuries of the Skull. Contusions of Bone.—Those complications which render injuries of the scalp most formidable, originate, for the most part, in contusions of the skull. Caused, as they not unfrequently are, by slight blows, falls, injuries from spent balls “removing perhaps only the hair,"3 etc., the resultant symptoms, delayed and insidious, often escape detection until hopeless complications have supervened. Bone-contusion may result in one or all of these conditions: 1, rupture of the bloodvessels may occur between the pericranium and the bone, resulting in an effusion of blood, and secondarily of inflammatory effusions, which strip the membrane from the skull to a varying extent; 2, the same accidents may happen to the vessels running between the dura mater and the inner surface of the skull; and 3, the sinus-like veins of the diploe may be either bruised or ruptured, or the cancellous tissue itself may be broken down, the more elastic compact tables of the cranium escaping manifest inj ury. In the first two instances, the contiguous bone, deprived of one of its chief sources of blood, is apt to become necrosed with consequent suppuration. In the third case, an osteo-myelitis results which probably goes on to necrosis, suppura- tion, implication of the dura, and even of the brain and its membranes. In most instances, more than one of the conditions co-exist, usually the first and third. The osteo-myelitis4 set up by contusion may be observed under three conditions:— 1. It may occur as an acute disease, limited to the site of injury; 2. It may also be seen as a chronic affection, lasting for years, and resulting in either limited or general, irregular thickening of the inner or outer tables of the skull, or of both, causing perhaps, when the inner table is affected, epilepsy or maniacal seizures, provoked, most probably, by some temporary 1 Agnew (op. cit., vol. i. p. 257) ascribes this advice to Hewett. 2 This operation originated with a French frontier surgeon, and was said to have been so exten- sively practised in cases of scalping, and with such uniformly good results, that soon after its introduction every frontier post had persons who performed it. (Eve, Remarkable Cases in Sur- gery, p. 35. Philadelphia, 1857.) 3 Gant, op. cit., vol. ii. p. 148. 4 I prefer the term osteo-myelitis rather than osteitis, as the diploe sooner or later becomes affected. INJURIES OF THE SKULL. 9 increase of the chronic irritation; or necrosis of the outer or inner table may result, and even the whole calvaria may ultimately separate.1 3. Osteo-myelitis, caused by a severe blow upon the skull, may also result in an atrophic condition.2 Symptoms of the Acute Form.—After a head injury involving a contusion of bone, the patient may at first complain of nothing, or at most of a persist- ent, dull headache. The next symptoms noted are, that not earlier than the sixth day, and usually not later than three weeks3 after the receipt of the injury, the patient begins to complain of malaise, headache, slight vertigo, abnormal acuity of the special senses, muscular feebleness or rigidity of the cervical muscles, fever, slight chilliness, and nausea or vomiting. The pupils are usually contracted. If there is a wound, the edges become everted, the previously healthy discharge becomes thin, ichorous, and gleety, the granu- lations lose their florid aspect, and become pale, and the periosteum secedes from the bone, leaving it dry, white, and discolored. If there is no wound, the site of injury becomes tender, and the scalp infiltrated with serum, pro- ducing a circumscribed, flattened, elevated swelling, the so-called “ putty tumor” of Pott, which indicates a subjacent suppurative periostitis, denuded bone, and in many instances subcranial suppuration with separation of the dura mater. The exceptions to this rule are not infrequent, and will receive future consideration. With these local conditions the constitutional keep pace, as indicated by increasing fever. Headache, delirium, drowsiness, and stupor steadily increase; one pupil is perhaps dilated while the other is con- tracted ; and paralysis and convulsions may supervene, coma and death closing the scene. In addition to the above, irregular chills, followed by high temperature; profuse sweatings; a rapid, feeble pulse; pain in the chest, with dyspnoea and cough; slight jaundice ; and swollen, painful joints, may, one or all, be super- added to the local and general symptoms first described. If the disease do not pass beyond a certain point, recovery may ensue, although the patient is liable to sutler, according to Gant, from chronic cerebral irritation, epi- lepsy, imbecility, impaired vision or hearing, aphasia, and various palsies. Let us inquire to what pathological changes these symptoms correspond. At first, there is a simple osteo-myelitis, with separation of the pericranium and slight constitutional reaction. The inflammation next spreads to the dura mater, which may have been separated by an effusion of blood caused by the original injury. Lymph and pus soon form. The inflammation, if unchecked, next attacks the arachnoid, when at once the process, up to this point circumscribed, extends over the free surface of that membrane. The visceral layer of the arachnoid soon becomes involved, and then the pia mater, and even the corresponding portion of the brain itself, become inflamed. Here we have a local inflammatory process, first producing bone suppuration and necrosis, then meningitis, and finally localized brain compression by intrameningeal or cerebral suppuration and abscess. When the second class 1 “ Dr. Abercrombie mentions a case in which the inner table alone of the calvaria was thus extensively destroyed.” (Holmes’s System of Surgery, vol. i. p. 571.) In Norris’s case, the dis- ease attacked both tables of the whole of the calvaria, and extended even as far as the foramen magnum. (Transactions of’the Medical Society of London, vol. i. p. 168.) But of all cases of this kind, Saviard’s is the most extraordinary. In this case, two years after a blow upon the head, the whole skullcap came bodily away. (Nouveau Recueil d’observations p. 386. Paris, 1702. See also (Euvres de Sabatier, tome ii. p. 400. 1796 ; Agnew’s Surgery, vol. i. p. 260.) The assumption that constitutional syphilis has anything to do with these extensive ex- foliations of bone, Agnew considers entirely gratuitous. 2 Agnew, ibid. 3 On the average, about the thirteenth day. Dease thought that between the eighth and six- teenth days was the period most to be dreaded. (Observations on Wounds of the Head, etc. Dublin, 1760.) 10 INJURIES OF THE HEAD. of symptoms are superadded, such as rigors, dyspnoea, etc.-, or when they have existed coincidently with those tirst given, the veins of the scalp or diploe near the injury will be found filled with pus. Ilewett also says that “ the veins on the surface of the hemispheres are sometimes loaded with pus, and so too, and much more commonly, is the superior longitudinal sinus.” In other words, we have the symptoms of pyaemia superadded to those of local osteo-myelitis of the cranium, intracranial suppuration, meningitis, and cere- bral abscess. Pyaemia may arise from a simple scalp wound, but bone con- tusion from a slight head injury is the most common cause. I have described the symptoms of intracranial suppuration, meningitis, etc., with those of pyaemia, since although the brain and its membranes may remain perfectly healthy, the association of the two morbid conditions is much more common. The diagnosis between them, especially in their earlier stages, when no signs of pyaemia exist in other parts of the body, is exceedingly difficult. Diagnosis.—In intracranial suppuration the earliest symptoms are apt to be those of meningeal and cerebral irritation, such as slight vertigo, head- ache, abnormal sensibility to light and sound, rigidity of the cervical muscles, broken and restless sleep, and a hard pulse of increased frequency. Sub- sequently, when symptoms of cerebral compression and paralysis occur, the diagnosis is usually clear enough. Upon the other hand, when pyaemia arises from suppurative osteomyelitis, it is so commonly preceded or attended by intracranial suppuration, that I think that many cases have been correctly regarded at first as non-pyaemic, which afterwards have become septic, so that we are left in doubt to which disease any one symptom or set of symp- toms belongs, and are thus deprived of reliable data for a differential diag- nosis. Pyaemia, although attended by malaise, slight headache, fever, etc., is not usually preceded by signs of cerebral irritation, but is succeeded by them. I must candidly confess that the distinctions which I have emphasized can be rarely drawn in practice as sharply as I have indicated them, but I am convinced that when a differential diagnosis is possible in the early stages of these affections, it can only be made by following out the line of thought and investigation just suggested. As to the value of the “ puffy tumor” of Pott, I would say that it is simply indicative of a suppurative periostitis, or osteo- myelitis, and that upon its appearance alone, or the spontaneous secession of the periosteum in an open wound, we cannot predicate separation of the dura mater and subcranial suppuration; but if such appearances coincide with paralytic, irritative, or convulsive symptoms on the opposite side of the body, supposing that the injury is in the anterior parietal region, the proba- bilities amount nearly to certainty that trephining will reveal subcranial or subdural suppuration, either immediately beneath, or near the diseased bone. Upon the other hand, should, in a case of bone contusion, the local signs of what the older authors thought subcranial suppuration, occur over the occiput, with hemiplegia or other paralysis, or convulsive movements on the side of injury, trephining would do no good, and the bone changes would really only be indicative of local periostitis, with injury or disease of some distant part of the encephalon.1 A reference to the section on cerebral localization will indicate the facts upon which I found these con- clusions.2 Treatment.—This should be mainly preventive. In any head injury involv- ing a chance of bone contusion, the case should be closely watched, for, as has been well said, no injury of the head is so slight as to be despised, nor so 1 Liston, Lectures on the Operations of Surgery, etc., edited by Mutter, p. 76. Philadelphia, 1846. 2 See also sections on traumatic meningitis, cerebritis, etc. INJURIES OF THE SKULL. 11 great as to be despaired of. The simplest diet and quietude should be en- forced, a watch being kept for those slight signs of meningeal irritation which have been mentioned. The bowels should be kept freely opened. Should persistent headache with slight fever be detected, I should advise in the robust—and I would not draw the line too strictly—a rigid anti-phlogistic regimen and wet-cupping, or even venesection from a large orifice, the patient sitting upright. In cases where these measures seem contra-indicated, a full dose of calomel, followed by purgatives, low diet, and arterial sedatives, should be resorted to. Calomel in small doses should be exhibited sufficiently often to touch the gums in either class of cases. Cold to the head, and large doses of the bromides, are indicated, if the cephalalgia be marked. The plan of treatment suggested is opposed by some surgeons, upon the plea that many cases really prove to be pysemic, and that in that event it would be prejudicial. I would ask how many cases of pyaemia from head injury recover under any plan of treatment ? Doubtless some cases where the advice here given is followed, will be treated with unnecessary activity, but I maintain that no permanent harm will result, while some lives may be saved. I am not one of those who think that the loss of a few ounces of blood is a serious matter, having demonstrated, experimentally and clinically, its power of cutting short traumatic inflam- mation in its early stages. Once again, I only recommend these measures in the incipient stages of meningitis following bone contusion. Hewett con- siders that the cases which do well under this treatment, are really instances of meningitis “ beginning not in the dura mater, but in the visceral layers of the brain, and dependent upon . . . concussion.” He may be right, but I think that ftie mere recovery of such cases is no valid argument against the correctness of the diagnosis. As the earliest symptoms indicative of commencing suppuration between the dura mater and bone, are those of incipient meningeal irritation, they should be so treated, especially as death results in such instances by extension of the inflammation to the meninges and the brain itself. I cannot help believing that in some instances the for- mation of pus between the dura mater and the bone is prevented. Suppose that the case is not seen until intracranial suppuration has taken place, what shall the surgeon do? If, as mentioned under the head of diagnosis, there is a reasonable probability of the presence of a subcranial or subdural ab- scess, he should trephine at once, and with a large instrument. Pott’s success was due to early, bold operation, and is explicable by the fact that in Iiis cases the diseased process was circumscribed, that is, was incipient.1 There is no reason why similarly favorable cases should not be met with nowadays, with equally prompt operative interference. Knowing as we now do that Pott’s local symptoms are merely the signs of a periostitis or osteo- myelitis, and that cerebral localization can at least inform us that no localized subcranial suppuration at the site of injury can possibly account for the symp- toms in certain instances, the trephine will be withheld in many cases that were uselessly operated upon in the past, and in some rare instances I believe that in the future the instrument will be used to evacuate pus from beneath an externally healthy bone, far distant from the injury and from the local signs of bone contusion. What if no pus between the dura mater and the bone be found ? If the membrane pulsate normally, nothing beyond abandonment of the operation remains, unless the symptoms are such as would warrant puncture of the brain-substance. If the dura mater bulge up into the tre- phine-hole—perhaps even to the level of tbp external bone—and be without pulsation, it should be cautiously incised to give vent to subjacent pus. Some- 1 Pott, Injuries of the Head, pp. 63-107. 1768. 12 INJURIES OF THE HEAD. times this procedure, by the removal of pressure over the abscess, permits the pus of a true cerebral abscess to make its way to the surface. Schmucker1 narrates the case of a grenadier who fell and struck his head against the corner of a stone, whereby a compound depressed fracture of the frontal bone was pro- duced. On the following day trephining, with removal of the splinters and elevation of the bone, restored consciousness. The patient was in the best of spirits until the fifth day, when feverish symptoms set in, followed in twenty-four hours by bulging of the dry and brown dura mater into the trephine-hole. Puncture evacuated upwards of a tablespoonful of laudable pus from a superficial abscess of the brain. The symptoms disappeared, particles of the brain-tissue were cast off, and the patient was well in two months.2 (Gross.) A child of nine years, suffering from a compound depressed fracture of the frontal bone, uras trephined by Petit.3 Fever with headache set in on the night of the fifth day, and on the following day the discolored and distended dura mater bulged into the opening. On being laid open, a tablespoonful of brown, fetid fluid escaped, but the symptoms increased until the night of the eleventh day, when the rapid improvement disclosed that a large abscess had burst, and bad saturated the dressings with offensive matter. In two months the cure was complete. (Gross.) In certain rare instances, where the surgeon has had good reason to believe in the existence of cerebral abscess, incisions into the brain-substance itself have been successfully made.4 The previous use of the exploring needle— or, better yet, the aspirating needle—would be proper in such cases. I shall now give the details of some cases of intracranial abscess treated by incision of the dura mater, which will indicate what seems to me the proper plan to be pursued under similar circumstances:— An officer wras struck on the occipital protuberance by a musket-ball. Symptoms of irritation of the brain having set in, Giersch applied the trephine, under the suppo- sition that there was a fracture of the internal table, but the bone was found to be sound, and there w'as slight purulent effusion beneath it. On removing the dressings a few hours subsequently, the prominent dura mater was punctured, and a considerable amount of bloody matter evacuated. Rapid and complete recovery ensued.5 (Gross.) A man struck his head against the corner of a writing-desk, and suffered from severe headache for several months. Mursinna removed three circles of the occipital bone and opened the dura mater, with the effect of giving vent to a very offensive yel- lowish fluid, which he regarded as a collection of disorganized blood.6 (Gross.) De La Peyronie trephined the parietal bone of a lad for symptoms wdiich made their appearance on the twenty-fifth day after a blow' from a stone. On incising the inflamed dura mater, three and a half ounces of pus, which extended by the side of the falx down to the corpus callosum, escaped.7 Death occurred in a fewr days. (Gross.) Mr. Dumville, of Manchester, removed a circle of the denuded frontal bone, for supposed abscess of the dura mater, three w'eeks after a scalp-wound. The membrane was inflamed and perforated at one point, from which, after the insertion and with- drawal of a probe, stinking matter spurted out.8 The patient recovered. (Gross.) A man, aged 37 years, was struck over the supraorbital ridge, and marked symp- toms of compression set in at the end of three weeks. Prof. Hughes applied the tre- phine at the injured spot, and found fragments of the inner table of the frontal bone depressed on the dura mater, w ithout involvement of the outer table. Upon incising the dura mater and evacuating a quantity of pus, there was an immediate return to consciousness.9 (Gross.) 1 Vermisclite chirurgische Schriften, Bd. i. S. 283. 2 This, as well as the following cases, is quoted from a paper on Compression of the Brain, by Prof. S. W. Gross. (Am. Jour. Med. Sciences, new series, vol. lxvi. p. 40-74.) 3 Traite des maladies chirurgicales, t. i. p. 91. 1790. 4 See page 82, infra. 5 Rust’s Magazin fur die gesammte Heilkunde, Bd. ii. S. 127. 6 Bruns, tlandbucli der practisclien Chirurgie, Abth. i. S. 937. 7 Hist, de Roy. des Sciences, p. 212. 1744. 8 British Med. Journ., vol. ii. p. 743. 1858. 9 Iowa Med. Journ., 1868, p. 34. INJURIES OF THE SKULL. 13 What, then, are the indications for or against the use of the trephine, when the diagnosis of intracranial suppuration from bone contusion has been arrived at ? In the present state of our knowledge, I think that all we are warranted in saying is that the operation is both justifiable and, when performed early,, likely to prove a valuable resource in several conditions:— 1. If, with a wound over the parietal bone, particularly when involving its anterior half, there are the local symptoms,1 with hemiplegia, hemispasm, etc., of the opposite side, especially if only the upper or lower extremity is involved, trephining is clearly indicated. 2. If, with wounds over other portions of the skull, symptoms of intra- cranial suppuration supervene, with neither distinct paralysis nor muscular spasms restricted to one-half of the body, but with general convulsions, or convulsions upon one side and paralysis upon the other, the local symptoms being well marked, trephining may be tried, and in some instances, when done early and freely, may save life.2 3. When there are symptoms clearly referable to the neighborhood of the fissure of Rolando, whether there be local signs of bone trouble or not, I think that, in otherwise desperate cases, we may properly trephine at the points which will be indicated when treating of cerebral localization, with a fair prospect of finding pus, either between the dura mater aud bone, or subdural, or cerebral. The prospects of success are in direct proportion to the limitation of the motor disturbances. I consider that the operation, at the point of injury, is positively contra- indicated in the two following conditions:— 1. When the so-called local symptoms of intracranial suppuration, or the wound, is situated either over the frontal or the occipital region, with hemi- plegia, hemispasm, or partial paralysis or spasm of the limbs, upon either the side of injury or the opp6site half of the body. 2. When, with a wound over the parietal region, either with or without the local symptoms, the motor disturbances are on the side of the injury. In either of these cases it is useless to trephine at the site of the wound. If pus wells up from the diploe while trephining, the prognosis is bad, as the case will probably prove pysemic. If trephining were a dangerous operation per se, I should be more chary in recommending it; but I hope to show hereafter that in itself, when skil- fully performed, it adds little to the danger of the case. When dealing with cases which are almost inevitably fatal if unrelieved, I feel that even temerity is justifiable; much more a comparatively safe operation, which, even if it do no good, can result in no great harm. In a general way, the following points may prove useful in forming an opinion:— As a rule, the symptoms produced by the formation of pus between the dura mater and skull do not begin to appear before the sixth day, nor later than the beginning of the third week; those of suppurative meningitis usu- ally appear about the eighth day, and are rarely delayed beyond the twenty- first ; while those of cerebral abscess, except in rare instances, are not noted before the end of two weeks, and most commonly set in about the twenty- fifth day. If purulent infection supervene upon bone contusion, nothing more can be done surgically than to evacuate pus wherever it is accessible, whether in the joints, the cellular tissue, the serous sacs, or the skull. Medically, a vigorous, 1 “Puffy tumor or secession of the periosteum, if there is a wound. a Chirurgical Works of Percival Pott, F.R.S., ed. by Sir Jas. Earle, F.R.S., vol. i. p. 82. Phila., 1819. 14 INJURIES OF THE HEAD. supporting treatment, with opiates to secure rest, should be resorted to. Mineral acids with bitter tonics are useful to check the diarrhoea sometimes present in blood-poisoning. Although pyeemic cases are usually fatal, occa- sionally one ends favorably, so that no efforts should be spared to prolong life.1 Hewett thinks that kidney disease may be at the bottom of the pyaemia, as well as of the erysipelas, of head injuries. With renal complications, he thinks that the serous sacs are more apt to be attacked. 2. Symptoms of the Chronic Form of Osteomyelitis.—Beyond the bony en- largement, nothing but local tenderness with slight hyperplasia of the scalp can be detected, although from thickening of the inner table of the skull, epilepsy, mania, etc., may result. Treatment.—The administration of iodide of potassium, either alone or combined with mercury, incisions, leeching, the local application of iodine, and repeated blisterings, may be tried. When a localized exostosis forms, after the delay of a few months to see whether its growth will not cease—as so frequently happens—it may be removed with the saw or bone-forceps. If necrosis result, the case should be here, as elsewhere, left to nature until the bone separates, when the sequestrum may be removed by appropriate incisions. The question of trephining for epilepsy will receive future consideration. Fractures of the Skull.—Fractures of the skull are naturally divided by anatomical peculiarities and pathological results into two classes, viz., those of the vault, and those of the base. A fracture of the vault, however, very often coexists with one of the base, and in fact some writers take the extreme view that this is always the case. That this is an error, I hope to demon- strate. Fractures of either class may be fissured, incised, punctured, commi- nuted, or depressed.2 Those of the vault may involve the external table alone, with crushing of the diploe; or the internal table may be comminuted and depressed, without any apparent injury of the external table; or the frag- ments may be elevated above the level of the sound bone. Finally, fractures of either class may be simple, that is, without any wound of the soft parts communicating with the fracture, or they may be compound, that is, with a lesion of the soft parts leading down to the injured bone. One important difference between compound and simple fractures must be here adverted to. In the former, the force being almost of necessity applied to a small portion of the skull, the fracture is more frequently strictly limited to the point struck than in simple fractures, where the force is so diffused as not to be sufficient at any one point to divide the integuments. Thus in eight cases of compound fracture out of twenty examined, the fracture corresponded to the point struck, while this was found to be the case in only one instance out of fifty-six examples of simple fracture. The anatomy of the scalp has already been sufficiently dilated upon to explain certain appearances presented by head injuries. A little reflection will indicate what an important part it plays in protecting the skull from fracture, its mobility converting many a direct into a glancing blow, thus avoiding fracture, or modifying its extent. The frangibility of skulls varies exceedingly. Other things being equal, the thinner the'skull the more brittle, usually from the almost complete absence of diploe. Some skulls are trans- lucent throughout nearly their entire extent, and are mere shells of compact tissue. Other skulls may average half an inch in thickness. Comparatively thick crania, however, may be quite brittle, but a thin one is always so for the reason just given, that is, the deficiency of diploe. 1 I have found digitalis invaluable in cases of exhausting surgical disease, with frequent feeble pulse and high temperature. It is specially useful when the secretion of the kidneys is deficient, or likely to become so. 2 Holmes’s System of Surgery, vol. i. p. 582. injuries of the skull. 15 At the outset, I wish to emphasize the fact that a fracture of the skull has no inherent danger, over and above similar injuries of other bones; indeed, not nearly as much if we except the peculiar arrangement of its diploic venous channels, which predisposes to purulent infection. I repeat again, a fracture of the skull per se is not a dangerous injury, and I thus reiterate the statement in order to point out the error, too often made, of concentrating attention upon the fracture instead of upon the concomitant cerebral injuries, and because so much has been written concerning the risk of converting a simple into a compound fracture by incising the integu- ments, when the former presents symptoms of cerebral compression, forget- ting that, though making a fracture of the thigh compound, directly imperils the patient’s life, the course of the injury, as far as life is concerned, differs little in compound and simple fractures of the skull, provided that intra- cranial inflammation can be avoided.1 I do not deny that intracranial com- plications may be aggravated by a reckless admission of air to a previously simple cranial fracture, but I deny that with modern antiseptic precautions the danger of the operation is to be compared to the risks of intracranial inflammation from the irritation of depressed fragments of bone, and that any comparison can be justly drawn between a compound fracture of a long- bone and one of the skull. I. Fractures of the Vault of the Skull.—These are usually the result of the direct application of force to a limited area of the skull, the bone yielding at the point struck. The resultant injury may be (1) a simple fissure, which is usually not limited to the site of injury, but may extend through several bones and even reach the basis cranii, and (2) a comminution of the bones, which varies in extent, but which, resulting, as it most often does, from vio- lent, concentrated force, is usually pretty much limited to the point of impact. Although comminution commonly results from the application of concern Fig. 1075. Fig. 1076. Indentation and Assuring of outer table of skull. Fracture of inner table of skull. From the same specimen as fig. 816. trated force, occasionally diffuse force will produce the same result. Thus, I have examined the skull of a negro which reminded me of the appearance of an egg dropped from a height. The comminution was the most extensive that I have ever seen, and was the result of blows from the head of another 1 Pyaemia more commonly follows contusion of bone than it does fracture. 16 INJURIES OF THE HEAD. negro, who had seized the victim by the lapel of his coat while he butted him. The skull would have been thin for that of a white man, and was singularly so for that of a colored one. Fissures of the surrounding, compara- tively uninjured bones, not uncommonly coexist with comminuted fractures. Indentation or Assuring of the outer table only, is occasionally met with, but, as a rule, even these slight injuries are accompanied by much more extensive splintering and depression of the inner table of the skull, as shown in Figs. 1075, 1076, from a specimen in the Mutter Museum. This result, which is observed in all fractures of the skull from direct force, is mainly due to the fact, pointed out by Teevan, that the bone yields first on the side of extension.1 Thus let e f, in Fig. 1077, represents a segment Fig. 1077. Fig. 1078. Diagrams illustrating mechanism of fracture of the inner table of the skull. (After Teevan.) of the calvaria, and the space g, included between the parallel lines, repre- sent the portion of bone struck. The portion of bone g yields to the blow, to a much greater extent than the portions of bone e and f, which in con- sequence may be considered as practically unmoved. The result is that the osseous tissue of the upper, convex portion of g is much compressed, while the lower, concave surface tends to be straightened out, or extended, with a consequent rupture of the bony fibres, and, the force continuing to act through the medium of the compressed outer table and diploe, the fragments of the inner table are depressed, the points c and d being widely separated. (Fig. 1078.) Unquestionably, as stated, the bone thus yields first and most markedly upon the side of extension ; and the want of support afforded by the soft cere- bral mass, with the resiliency of the whole skull, causing its over-recoil, explains the relatively extensive depression of the inner table produced by comparatively slight blows. A glance at Fig. 1079 will explain this, as well as the mechanism of fractures of the internal table alone. The double lines represent the secondary positions assumed by the skull just after the force has ceased to act, the dotted lines the primary effects of the blow, and the single black lines the condition in which the parts finally remain. Hence it will be seen, that the fracture commencing upon the side of extension, the fragments of the inner table remain almost undisturbed in the position in which they were left by the blow, while the outer table regains its normal level, owing to the mutual compres- sion of its component parts, and to the fact that Fig. 1079. Diagram illustrating mechanism of fractures of skull. 1 British and Foreign Medieo-Chirurgical Review, vol. xxvi. Teevan’s paper deals with frac- lures.of the internal table alone, hut the mechanism is the same for complete fractures, and. with the modifications here suggested, his explanations will serve to elucidate certain points which otherwise would be obscure, and which have very commonly been erroneously interpreted. INJURIES OF THE SKULL. the comparatively undisturbed surrounding bone serves as immovable abut- ments to the straightened arch. If there is a depression without actual fracture of the outer table as well as of the inner, the force has been such as, by partially crushing them, to overcome the resiliency of the bony fibres of the outer table and the diploe, and thus prevent restoration of the arch form. The truth of Teevan’s views as to the bone yielding first on the side of extension, is proved by the fact that blows inflicted upon the inner table of the skull, will cause more extensive shattering of the outer table than of it.1 A fissure of the outer table may be so slight as to escape close scrutiny, while the inner table has been extensively comminuted. After careful search in one instance, the Assuring would have been overlooked had it not been that a minute tuft of hair was imprisoned by the fissure when the impacting force made it gape widely. In a case reported by Dr. P. II. Watson, a tuft of hair was found in a portion of skull bared by what had been supposed to he only a scalp-injury, the fissure having been originally wide enough to allow the passage of a thin flake of lead from a passing ball, which was found, after trephining, lying upon the dura mater.2 Fissured fractures are the only variety of such injuries which occur by contrecoup, or counter-stroke; they may be very extensive, separating the upper from the lower part of the skull, or its anterior from its posterior segment, by extending through the base.3 There is one portion of the vault where extensive splintering and depression may occur without any involvement of the inner table, and that is in the region of the frontal sinuses. As these cavities do not exist until at or after pu- berty, and do not attain oftentimes any great size until after twenty-five years of age, fractures of this region must be most carefully examined. Even in advanced adult age, the frontal sinus may exist only on one side, or there may be a large sinus on one side of the median line and only a minute one on the other. Again, the frontal sinuses may be large enough to lodge a musket-ball without injury to the inner table of the skull. Race has some- thing to do with the development of these cells, which are peculiarly large in the full-blooded African.4 Fracture of the inner table of the skull is a very uncommon injury, and more often results from blows of glancing bullets5 than from the accidents incident to civil life. Still it may occur from blows by stones, sticks, or cricket balls, and the possibility should not be lost sight of, as the danger to life of these injuries is very great. In one case reported by Mr. Edwards,6 fatal intracranial hemorrhage occurred as the result of laceration of the mid- dle meningeal artery by a scale of the inner table. The external table of the skull was intact. The mechanism by which these fractures are produced has been already explained. Fig. 1080, from a specimen kindly placed at my dis- posal by Dr. J. F. Holt, of Philadelphia, exhibits the appearances seen in such cases. Although the broken fragments may remain at the same level with that of the healthy bone, they are generally upon a deeper plane, that is, are depressed. Still more rarely in civil life, the fragments may be above the level of the sound bone, as in a case reported by Hewett, where a chisel fell 1 Loc. cit. 2 Edinb. Med. Journal, July, 1870. 8 Sir A. Cooper, Lectures, ed. by Tyrrell, Am. ed., p. 131. 1839. 4 Hilton, Lectures on the Cranium. 6 Twenty such cases are reported in the Med. and Surg. History of the War of the Rebellion. See also Guthrie’s Commentaries on the Surgery of War, 6th ed. p. 322, etc. 1862. Pott, Dease, Deane, S. Cooper, Weeds, and others, report cases. There is a well-marked specimen of this form of fracture in the Mutter Museum. Similar cases are also to be found in the works of Par6 and other writers. 6 Edinb. Med. Journ., vol. viii. p. 191. 18 INJURIES OF THE HEAD. from a height, cutting and bending outwards a trapdoor fragment, including the whole thickness of the skull. In the Mutter Museum of the College of Physicians of Philadelphia, there is one specimen from a case in which a circular-saw accident elevated a large fragment, and another from one in Fig. 1080 Fig. 1081. Fracture of inner table of skull. Fracture of occipital bone by hatchet-wound. which a blow from a hatchet did the same, but appears to have completely separated the fragment, which, sliding down, has become co-ossified there, leaving a permanent opening through the occipital bone. (Fig. 1081.) Sabre- cuts not uncommonly produce similar elevations of the broken bone.1 “ In the Museum of the Royal College of Surgeons there are ten skulls which have suffered from very severe slicing cuts The portions of bone thus sliced, and they are large pieces, were once detached, and after- wards reunited a little out of their proper places."2 Incised fractures, the result of cutting instruments, are, however, rare in civil practice, although cuts with hatchets, knives, and circular saws occa- sionally produce such injuries. Sword guts, especially when the weapon is very sharp, may shave off a slice of bone involving only the,outer table, as in a specimen in the Army Medical Museum, or they may penetrate no far- ther than the diploe, as in a case observed by Dr. F. 11. Gross, of Philadelphia, where a shoemaker’s knife stopped just short of the inner table. This fact should be borne in mind, as there may be no necessity for cutting through the whole thickness of the skull to remove imbedded fragments. When both tables of the skull are involved, especially in hatchet and axe wounds, the inner table is apt to be extensively comminuted and depressed in a linear manner. The only specimen with which I am familiar, showing an exception to this rule, is that of which I have already spoken, where the sword was evi- dently exceedingly sharp, and made a number of almost clean cuts, without any appreciable splintering of the inner table. A probe introduced sideways beneath the fragments will sometimes demonstrate this separation of the inner table by detecting its presence at a lower level. Punctured fractures present two broad varieties, viz., those inflicted by sharp, and those inflicted by dull instruments. It will be seen that the distinction is not a superfluous one, when I explain that when the wound-is made by a narrow, smooth, sharp instrument, such as a penknife-blade, there may not be the slightest splintering or depression of the inner table, if the instrument 1 Cooper, op. cit., p. 132. 2 Guthrie, op. eit., p. 362. INJURIES OF THE SKULL. 19 be driven in at right angles to the planes of both tables, while if it enter obliquely, there is apt to be merely a curling down, as it were, or at most a splitting off, of a small scale of the inner table; but that when the vulnerating Fig. 1088. Fig. 1082. Disk of bone removed by trephining, showing punc- tured fracture of skull. (From a specimen in the mu- seum of the New York Hospital.) The same as Fig. 108:2 showing fracture of inner table. body is dull, such as a piece of stick, a cane-ferule, the corner of a brick, or a blunt-pointed nail, the fragments of the outer table and diploe are carried in, wedging apart and extensively comminuting the inner table. There is then a difference in the conditions of these two varieties of punc- tured wound, which explains the different course pursued by them in many instances. Penetrations of the skull, especially of the vault, by penknife- blades, fragments of glass, etc., may divide large branches of the menin- geal artery and cause fatal hemorrhage.1 It must not be thought that only pointed instruments can produce punctured fractures. The essentials, both mechanical and clinical, of a punctured fracture, consist in circumscribed injury of the outer portion of the skull, with extensive shattering of its inner table. Thus I have been compelled to trephine a young man who had broken his skull by a fall against the corner of a square iron nut. The injury to the outer table was most insignificant, while the inner table was broken up for a considerable extent into minute fragments, the number of which would never have been suspected by the uninitiated, from an inspec- tion of the injury to the outer table. Sabre and hatchet cuts thus present all the essential peculiarities of punctured fractures. Depressed fractures, involving both tables, present certain varieties of form which I shall now point out. One of the most common is that seen in the accompanying cuts from a specimen in the Mutter Museum. (Figs. 1084, 1085.) Here an ovoidal piece of bone, split into halves, has been driven down upon the brain. Owing to the longitudinal Assuring and firm impaction of the fragments in their slanting relation to one another, there must have been very marked pressure exerted upon the membranes and the brain ; much more indeed than would appear at first sight possible, and more than occurs in other varieties of impacted fracture. This is commonly the result of the application of great force by a heavy body presenting a convex, rather sharp edge, such as a horse-shoe, the edge of a beer mug, a dull hatchet, etc. Sometimes a form of fracture is met with, consisting of a long, single fissure, with marked overriding of one margin of the fractured bone. The most common variety of depressed fracture, however, is that in which a more or less ovoidal portion of bone is broken into a number of triangular fragments, with their apices directed inwards towards the deepest portion of thexpres- sion. When most of the fragments are driven down to about the same level, 1 See Fig. 1088, infra, for an illustration showing a wound of the meningeal artery by a frag- ment of glass. 20 INJURIES OF THE HEAD. firm impaction generally exists ; and even where they occupy different planes, it is oftentimes a matter of surprise to observe how firmly they resist eleva- tion, although further depression may be effected. Fig. 1084. Fig. 1085, Depressed fracture of outer table of skull. Fracture of inner table of skull. From same specimen as Fig. 1084. In all depressed, comminuted fractures, the inner table is, as a rule, much more extensively shattered than the outer. Bending of Bone without Fracture.—I do not believe that traumatic depres- sion of the skull can occur in the adult without fracture. In the child, such an accident has been frequently reported, but as I have been unable to find any account of a post-mortem examination of such a case, I can neither affirm nor deny the fact that none of the bony fibres give way. I am inclined to think, however, that in the young child, before co-ossification of the different cranial bones has taken place, such an accident might occur, with simple rupture of a few of the fibres on the side of extension, but no fissuring of the bone.1 The most curious distortions of the skull result from these bendings of the calvaria, which are apt to involve a large extent of such bones as the parietal, frontal, or occipital. Xo fracture can be detected, and the depression is smooth, and commonly ovoidal, although the late Professor Gross reported several cases where some of the normally convex portions of the skull were simply flattened, with exaggerated pro- jection of the other segments. I have seen a long, linear depression, which resulted from a fall against the edge of a marble step. Sooner or later, generally within a few days, these depressions resume their normal level. Intra- Uterine Fractures of the Skull.—Some authors teach that a blow upon the abdomen of a pregnant female may produce a cranial fracture, but do not bring forward any cases in support of this view. I am exceedingly skeptical of the accuracy of any such observations. Undoubtedly, in tedious labors, with a disproportion between the foetal head and the maternal bones— however caused—such accidents have been reported. Sometimes the arm has been interposed between the foetal head and the cranium, while at other times no assignable cause has been manifest. Occasionally the labor is neither tedious nor severe, and the pelvis may be of normal size. The parietals are the bones usually involved, or the parietal and frontal. Sometimes the occi- 1 The result of examination of fractures occurring during unassisted labor would seem, how- ever, to negative this view. See p. 21. INJURIES OF THE SKULL. 21 pital is broken, and most rarely of all the temporal. Depression is uncom- mon, the fracture consisting of one or more fissures, from half an inch to one and a half inches in length. Rarely there is marked depression, and cases have been reported where a spiculum of bone could be readily detected through the integument. This must, however, be an exceptional occurrence, as it is probable that a cephalhsematoma invariably accompanies such injuries. When not still-born, infants thus injured may recover, when any depression which exists will probably disappear in the course of time. Diagnosis of Fractures of the Cranial Vault.—There are no certain signs by which we can determine the existence of a fissured vault, when no wound leads down to the bone ; and in many cases a post-mortem examination first reveals an unsuspected fissure of the skull. Effusions of blood into the super- jacent tissues have induced experienced surgeons to cut down upon supposed fractures, and no fracture has been declared to exist when the skull has really been broken. When lying beneath the temporal muscle, an extensively •comminuted fracture may escape the closest examination. Gross relates a case where he was nearly led into error by a congenital malformation of the skull. I have myself been struck, in examining certain heads or skulls, to notice how readily a careless observer might mistake a depressed fontanelle, nr one closed by a Wormian bone, for a depressed fracture. Bearing in mind these possibilities, a few inquiries as to the patient’s previous history, and a proper examination of the anatomical relation of the parts, will secure against mistake. Absorption of the diploe, and consequent thinning of the skull, may likewise lead to errors of diagnosis. Compound fractures of the vault are usually readily detected, but this is not always so, as in Dr. P. II. Watson’s case, already referred to, where a few hairs, caught in the minute fissure, alone led to its recognition. I cannot agree with Sir Prescott Hewett, when he says that sutures and vascular grooves may be mistaken for fissured fractures even after careful examination, for there is one infallible test, viz., that the line of coagulated blood lying in an uninjured suture, or groove, can always be wiped away, while no amount of rubbing with the sponge will remove the line of blood effused between a fractured bone or separated suture. I have on more than one occasion satis- fied myself of the truth of this very ancient observation.1 Sometimes a line of coagulated blood beneath the edge of the adherent periosteum may appear like a fissure, but as this membrane can be pushed away, the absence of fissure at the site of the blood-line can be readily determined. Gross suggests that the cup-like depression of the outer table should be filled with water, when it cannot be determined whether or not the inner table is fractured as well as the outer. If only the latter be fissured, the water will remain, while if the inner table be also broken, the water will filter away between the fragments. I have never tried this expedient; and although the disappearance of the water would undoubtedly prove an injury of the inner table, its remaining might not disprove comminution of the vitreous layer of the skull. A foreign body—as a piece of bone—having been driven through the tem- poral fascia beneath which it remains, may give rise to the erroneous diagno- sis of a comminuted, depressed fracture, the margins of the firm fascia feeling like an opening through the bone. The error was in one case only corrected by observing that the supposed skull-fragment presented upon removal a 1 Hippocrates recommends the application of a solution of the “jet hlack” ointment to detect Assuring of the skull. . Celsus translates this “ atramentum scriptorum," and the note to the Sydenham translation of Hippocrates’s Works explains that this ink was made of the soot of pines and gum. It is this ancient suggestion, evidently, that has led to the significance of the line of coagulated blood in fissure of the bone being discerned. 22 INJURIES OF T1IE HEAD. white macerated appearance, and evidently was not a recently detached piece of human bone.1 Depressed fractures in the region of the frontal sinuses may only involve the outer table. The error has been made of mistaking an exudation of inspissated mucus through a break of the anterior wall of the sinus, for an extrusion-of cerebral matter. In these fractures the skin covering the frag- ments may become emphysematous, especially if the patient blow his nose violently. When emphysema is detected, it plainly indicates the presence of a fracture which at least involves the anterior wall of the frontal sinus. Prognosis.—This being almost entirely dependent upon the concomitant cerebral lesions and their sequelae, is uncertain. Linear fractures, with neither depression nor symptoms of compression, usually do well, especially when they are simple. Sometimes, however, such cases are followed by suppuration between the bone and dura mater, though compound fissured fractures of the skull are more apt to be thus complicated. In any event such an occurrence is rare. The course pursued by the case is then similar to that of one of contusion of the skull, under which heading the reader will find the subject fully treated of.2 The region of the vault affected also affords grounds for prognosis. Thus injuries of the anterior half of the parietal bone are apt to be followed by serious motor disturbances. Depressed fractures, simple or compound, are grave in proportion to the accompanying cerebral symptoms, and when these are absent throughout the course of the case, to the form of the injury. When the depression is slight, smooth, and uniform, the much dreaded secondary results, such as epilepsy and so forth, are far less liable to occur-than when the displaced bone is broken into many irreg- ular fragments, which press deeply into, or even penetrate, the brain. These remarks are equally applicable in regard to the chances of encephalitis, although of course no absolute rule can here be laid down, since there may be severe contusion or laceration of the brain with but little primary indi- cation of such an accident, and since with but slight injury to the outer table, the inner table may be much comminuted. Punctured fractures are exceedingly dangerous, and in most cases, when unrelieved by operation, prove rapidly fatal. In this class I would include all fractures which consist of a limited injury of the outer table with extensive shattering of the inner, such as those produced by the corner of a brick, a sword-cut, blows with hammers, pokers, or hatchets. Although a compound fracture presents some features of gravity that a simple one does not, yet the free drainage, preventing accumulation of in- flammatory exudates, and the more probable circumscription both of bone and of brain injury, in many cases do away with much of the apparent difference, and with modern antiseptic precautions the prognosis is materially improved. One of the chief additional risks, putting aside pyaemia, is from hernia cerebri following primary laceration or sloughing of the dura mater. The increased chances of encephalitis from the admission of air, are much lessened by antiseptic precautions, yet they undoubtedly exist. Finally, let me again reiterate that the one great danger to be apprehended is encepha- litis, and that, were it not for this, patients with fractures of the cranial vault would convalesce almost as certainly as those with fractures elsewhere. But a clear distinction must be drawn between the encephalitis necessarily resulting from the primary injury, which is unavoidable, and the encephalitis resulting from the pressure upon, and irritation of, the intracranial contents by fragments of bone, which the normal, pulsatory movements of the brain render remarkably efficient as constant sources of irritation. 1 Hewett, op. cit., vol. i. p. 582. 2 See page 8, supra. IMJURIES OF THE SKULL. 23 Treatment.—From tlie preceding remarks, it is clear that the surgeon’s main attention should be directed not to the broken skull, but to the injured brain. Encephalitis results, first, from injury done to the brain and membranes by the fracturing force and the bony fragments. Granted a certain amount of intra- cranial injury,and inflammation must ensue; but in many cases this unavoid- able result can be conducted to a favorable termination by antiphlogistic regi- men, and treatment such as was advised for concussion and laceration of the brain. I am desirous of emphasizing the fact that there is a form of encepha- litis after fracture of the skull, similar to that met with after head injuries where no bone lesion has resulted, which is inevitable, despite any treatment ad- dressed to the fracture, and which can be combated by general measures alone. At the other extreme, there are cases where the intracranial injury is so slight as to result, of itself, in little further trouble, but such cases prove fatal from the constant “ fretting” of the brain and its membranes by displaced frag- ments of bone. The only proper treatment for these cases manifestly is to remove the source of irritation, and with it almost the only cause of inflam- matory mischief. In the first class of cases, as elevation of fragments cannot remove precedent injury of the brain, such a procedure only proves useful by preventing secondary inflammation due to the irritation of bony spicula. To this class belong most of the fatal cases of primary trephining, where the operation is wrongly tabulated in statistical tables as fatal; the fact being that the operation, being incapable of restoring a lacerated, ruined brain, merely fails to do any good. But there is an intermediate variety, where the meningeal and cerebral injuries are not necessarily fatal in themselves, but are rendered so by the sloughing and inflammation—perhaps avoidable— which are rendered certain by leaving depressed, lacerating fragments of bone, goading the tissues; patients thus hurt may recover under the effect of rest, with removal of every source of irritation. Here extraction or eleva- tion of the depressed fragments of bone, with appropriate general treatment, is clearly indicated.1 , ' Hon-penetrating incised wounds must be treated as cases of contusion of bone, after careful removal of any foreign substances, such as, for instance, the point of a knife-blade. When a portion of the calvaria has been sliced off, carrying with it a broad-based Scalp-flap, according to most authorities it may be safely turned back, and will probably adhere, provided that free drainage be secured.2 When the fragment does not seem firmly connected with the scalp, or when the flap-pedicle is narrow, the bone had better be dissected out, and the case then treated as one of compound fracture with loss of bone. Fissures of the skull, simple or compound, do not call for surgical inter- ference unless symptoms of compression from extravasated blood, or at a later period from intra-cranial suppuration, call for operation. In compound depressed fractures, unless the fragments are very slightly de- pressed, the bone should be elevated. Such cases, when left to nature, must be watched with the utmost care, for even when the outer table seems merely bent down in the centre, with capillary Assuring of the margins of the depres- sion, extensive shattering of the inner table may exist. (Figs. 1086, 1087.) In compound, comminuted, depressed fractures, the surgeon should, in my judgment, always operate at once, to prevent intracranial .inflammation: in other words, “ preventive trephining” should be resorted to. To wait until symptoms of trouble arise, is to wait until operation can rarely be of any 1 See sections on Concussion and Contusion of tlxe Brain, and on Encephalitis. 2 Larrey reports a case where, after replacement of the bone, serious cerebral symptoms arose which compelled him to dissect out the fragment, when recovery took place. In another case he was not so fortunate, death following. 24 INJURIES OF THE HEAD. service. Such practice is illogical and opposed to the results of experience. When such cases prove fatal from trephining, they do so from concomitant lesions, not from the operation, if properly performed. Fig. 1086. Fig. 1087. Fracture of skull with shattering of internal table. (From a specimen in the Mutter Museum.) I shall not enter upon the vexed question, whether or not depressed bone produces cerebral compression, as I do not found my advice upon the exist- ence of such symptoms. Besides, experience shows that in many a case in which the patient has been thought to he suffering from compression by de- pressed bone, the symptoms have really been due to effused blood, which has been successfully removed. Any theoretical views which tend, therefore, to cast doubt upon the possibility of compression resulting from displaced bone (an occurrence which, however rare, has unquestionably been met with),1 are mischievous, as apt to restrain the elevation of depressed portions of the skull beneath which effused blood or pus may lie. There is one important occa- sional exception to this rule. When a depressed fracture takes place in the adult over the region of the frontal sinuses, there may oftentimes be an ex- tensive indriving of bone, with no injury to the brain. If, after careful examination, there are good grounds for believing that the inner table of the skull is uninjured, it is advisable to wait, remembering that upon the first symptoms of meningeal irritation an exploratory operation must be performed, and the fragments elevated should any be found depressed. The surgeon should not await compression-symptoms as an indication for operation in fractures of the vault, as then it often will be too late. Un- doubtedly many patients recover in whom the bone is not elevated,2 but in too many epilepsy, insanity, chronic cerebral irritation, etc., render life a burden, and operations are then required which often prove useless. Modern investigation and experience show most clearly the danger of leaving de- pressed fragments of the skull in situ. Operations for epilepsy show at times that, in the effort to bridge across the irregular fragments, and from the constant irritation due to the cerebral pulsation, driving the dura mater 1 See Sir Astley Cooper’s account of Mr. Cline’s famous case. (Op. cit., p. 138.) Other cases, quite as conclusive but not as striking, could be cited. 2 Hennen relates a case “where the man survived thirteen years, with no other inconvenience than occasional determination of blood to the head on hard drinking,” and yet there was “a funnel-like depression,” one and a half inches deep, “in the vertex.” (Op. cit., under Case XXXIX.) INJURIES OF THE SKULL. 25 against the bony fragments, nature throws out osteophytic growths which eventually—perhaps after years—set up serious trouble.1 For manifest reasons, punctured fractures of every variety should at once be operated upon, every fragment being carefully elevated or removed. In certain cases of extensive hatchet-wound, where the use of the trephine would result in the removal of too much of the calvaria, and where conse- quently the case would otherwise have to be left chiefly to nature, Iley’s saw may be used to remove a strip of bone upon either side of the wound.2 Fractures of the inner table, being unrecognizable by any definite symptom, are not usually detected except after death. The possibility of such an injury being caused by concentrated, violent force, such as a blow from a glancing bullet, from a pebble, etc., will in otherwise obscure cases, when secondary symptoms of compression arise, warrant the application of the trephine at the point of impact3—a mode of practice which lias occasionally proved suc- cessful.4 And now what shall be done for depressed, simple fractures ? This is the most difficult to decide of all the questions relating to head surgery. In giving the advice I do, I fully feel the serious responsibility that I am assuming. Still, I think that it is both theoretically correct, and, still better, warranted by experience. In simple depressed fracture, the chief removable primary danger is encepha- litis from the irritation of depressed fragments. In such cases if our medical measures fail, the patient can only die, but if he lives without elevation of the depressed portion of bone, a miserable life is too often before him, with chronic cerebral irritation, epilepsy, fatuity, insanity, or even murderous impulses. What shall be done in these doubtful cases ? If the untoward results just described were very unusual, or if the fear expressed of converting a simple into a compound fracture, which after all is the only valid ground of objection against elevation of the bone, were well founded, there could be no question as to the advisability of non-inter- ference. But I contend that the dangers of a simple, depressed, comminuted fracture are greater than those which follow its conversion into a compound fracture. With the knowledge which we now possess of the great proba- bility that sooner or later nearly every case of depressed skull-fracture will result in epilepsy, or in some form of secondary brain-disease, and since reliable statistics show that trephining itself is not a more dangerous opera- tion than those commonly resorted to in other affections, in order to avert possible dangers less grave than those entailed by depressed fragments of bone, I cannot but think that, with the restrictions which I shall presently point out, it is our duty to advise elevation of a simple, depressed, commi- nuted fracture of the skull. I think that the opinion which I have expressed is steadily gaining favor among surgeons, and I feel emboldened to express my views by the published opinions of such distinguished and experienced operators as the late Prof. S. I). Gross, and Prof. Moses Gunn, of Chicago. This return to the practice of our ancestors is more an apparent than real departure from that of the present day. Most surgeons would, I presume, agree with Hewett, when he says that, where the symptoms “ are urgent—if they indicate a decided pressure upon the brain—then operative interference becomes necessary.” I would simply go one step further and say that to 1 Dudley reports a case of epilepsy supervening nine years after the fracture. Operation in this case proved curative. Sir A. Cooper (op. cit., p. 137) also relates an instructive case. 2 Hey, Practical Observations in Surgery, page 19. Philadelphia, 1805. 3 Teevan shows that fracture of the inner table always occurs opposite to the point struck. (Loc. cit.) 4 See page 12, supra, for a recovery occurring after trephining, in the practice of Prof. Hughes. 26 INJURIES OF THE HEAD. prevent secondary inflammation and late brain-disease, I would operate at once in badly depressed, comminuted, simple fractures, even though they presented no decided symptoms of compression. When, however, the fracture is not extensive, only slightly depressed, and but little comminuted, a primary ope- ration should not be thought of, unless marked symptoms of compression are present. In these cases a little delay may prove that apparent compression is due to slight concussion, etc. General treatment must be relied on, and the strictest watch must he kept for symptoms which are indicative of sub- cranial suppuration, upon the supervention of which, according to the prin- ciples enunciated in a former portion of this article, trephining should at once be performed. If, however, the bone be much depressed and extensively comminuted, so as to press upon and injure the membranes and brain, the margins of the cranial opening being irregular and jagged, an incision should he made, and the case treated as one primarily compound. I consider this to be the best practice, even when no symptoms of compression are present; and of course an operation is still more imperatively demanded when pro- nounced compression of the brain exists. In all these cases, it is presupposed that the surgeon has arrived at the conclusion that the apparent pressure- symptoms are most probably due either to the depressed bone or to intra- cranial hemorrhage, and not to diffused injury of the brain. With careful antiseptic dressings, the minimum of risk results from thus converting simple into compound fractures. With children, especially very young ones, a different course must be pursued. In many cases there is mere bending, or at least insignificant fracture of the bone. There being no diploe, or at least very little, if the outer table be not comminuted, the inner cannot be much shattered. At what age the skull of a child approaches that of an adult in its behavior when subjected to a fracturing force, I cannot sa}T, but I am convinced that in children under two, and often up to three years of age, the observations just made hold good. In simple, depressed fractures in children, the bone will either sponta- neously resume its level, if recovery ensue, or it may be raised by pneumatic suction if the bones are yielding, as in two cases mentioned by Prof. Gross.1 Dr. W. L. Moultrie, of Charleston, S. C., in 1849, had a patient aged five months, with a, depression of one parietal bone large enough to contain the bowl of a tablespoon. A cupping-glass having been adjusted and exhausted of air, traction was made upon it with the effect of rapid and complete restoration of the entire surface to its natural level. A case of a similar nature, in a child two years of age, has been reported by Dr. Nicolls.2 The depression, a deep narrow one about three inches in length, was promptly raised by a cupping-glass placed upon an embankment of common glazier’s putty, in order to afford it a proper purchase. Complications and Sequelae.—Encephalitis from brain injury, and intra- cranial hemorrhage in all its forms, are the chief complications. Pyaemia is rare after fractures of the vault, although it may occur. The great sinuses may be wounded, and the formation of a thrombus, and purulent infection, may follow. Brain-abscess is a not uncommon sequel. The cicatrix formed where there is loss of bone-substance, may in very rare instances be ruptured, hernia cerebri and death ensuing, as in a case reported by Jamieson, where the accident resulted from the violent paroxysms of coughing incident to an attack of whooping-cough.3 The rent, however, may close, and recovery take place.4 1 Op. cit., vol. ii. p. 64. 2 Dublin Med. Press, Sept. 1853. 8 Med. Essays and Observations (Edinburgh), vol. ii. p. 217. 4 See Holmes’s System of Surgery, vol. i. p. 585. INJURIES OF THE SKULL. 27 Where there has been a loss of bone, the gap is usually bridged across only by a dense membrane, into which, however, ossification may sometimes extend for some little distance.1 II. Fractures of the Base of the Skull.—Basal fractures may result from either direct or indirect force. Among forms of direct violence may be enumerated (1) thrust wounds, by walking-canes, sticks, swords, bayonets, etc., which penetrate the skull through the roof of the orbit or of the nose ; (2) a blow upon the chin, which may actually drive one condyle of the jaw through the glenoid fossa; (3) a blow upon the nose, which, fracturing the bones of that part, may likewise shatter the cribriform plate of the ethmoid, as is shown in two specimens in the Mlitter Museum. Thrust wounds most commonly implicate the thin walls of the orbit, the cribriform plate of the ethmoid, the fragile, shell-like body of the sphenoid, and more rarely the occipital bone. Such accidents can readily occur in the roof of the orbit, through which the brain may receive fatal and unsuspected injury, since the vulnerating body may have passed through the retro-tarsal fold of the conjunctiva,2 producing merely an ecchymotic patch on that membrane; or there may be so small a skin wound that, seeing the vulne- rating body to be large, the surgeon may think that not even a penetrating wound of the skin has taken place.3 In such cases there are probably no brain symptoms for several days, after which they develop sometimes quite suddenly, death resulting, perhaps, in a few hours; or the case may run a longer course.4 M urderous wounds, which leave no trace that can be detected except after most careful examination, may also be readily effected by passing a small pointed instrument through the retro-tarsal conjunctival fold, and then pene- trating the delicate orbital roof and superjacent brain. This is especially easy in the case of children, but presents no great difficulty even in the adult. The medico-legal bearing of this fact is plain. Prognosis of Based Fractures from Direct Violence.—Death is the usual result of these fractures, the autopsy tirst revealing the nature and full extent of the injury. More rarely recovery has ensued, as in one case where the severe brain symptoms left no doubt of the nature of the injury, and in another5 where brain protrusion occurred.6 Treatment.—The prospects are very bad should any foreign body be left within the skull. An exceedingly instructive case related by Ilulke71 shall here quote, as it indicates a somewhat important point in practice. A girl, aged six years, received a punctured wound of the orbit from falling upon a slate pencil which she was holding in her hand. All portions, as was supposed, of the slate pencil were removed by the house surgeon, and the child passed a comfortable night. The next afternoon, when Mr. Hulke first saw her, he detected with the probe a portion of the pencil deep in the wound, enlarging which he exposed the fragment 1 There is a specimen illustrating this in the New York Hospital Museum. (No. 24.) 2 A case of this nature has been reported by Sir A. Cooper, where a pair of scissors penetrated the retro-tarsal fold, with no brain-symptoms resulting for over four days. (Lectures, edited by Tyrrell, Am. ed., p. 131. 1839.) See cases by Sir P. Crampton and J. Paynter, Dublin Quar- terly Journal of Medical Science. 1851. 3 Morgagni, De sed. et caus. morborum, Epist. li. Sect. 58. 4 Paynter’s case, already cited. J. H. Jackson, in the Lancet for Feb. 2, 1884, reports a case of punctured wound of the orbit from a blunt piece of stick, which wounded the lateral ven- tricle. The stick passed between the inner canthus and the eyeball, leaving only a slight ecchymosis. There were no cerebral symptoms until the fourth day, when they were suddenly developed, death taking place in a few hours. 5 Morgagni, op. cit., Epist. li. 6 Lancet, vol. ii. p. 16. 1837-38. 1 Holmes’s System of Surgery, vol. i. p. 586. 28 INJURIES OF THE HEAD. wedged in an opening in the skull. Sufficient of the latter was cut away with the gouge to admit of the removal by the forceps of what was again supposed to be the whole of the foreign body, which proved to be shattered. Encephalitis set in, with high temperature and rapid pulse, until the ninth day, when, after a quiet night, the temperature fell to 97.5° F., and continued subnormal until the sixteenth day, when it suddenly rose to 104° F. Restlessness, delirium, flushed face, screaming, vomiting, convulsions, and coma accompanied this high temperature. Death took place in twenty- four hours, and the post-mortem examination revealed a large abscess of the right frontal lobe, which had recently burst into the anterior horn of the lateral ventricle. In the abscess lay a piece of pencil one incli long. Mr. Ilulke goes on to say, that, “ Cutting away the bone by the gouge effected such a loosening of the splinters of the pencil as to result in a fragment being left behind and he expresses regret that a trephine had not been used instead of the gouge. To this latter point of treatment I would call particular attention, viz., the use of the trephine to remove foreign bodies imbedded in the skull, since by it the end in view can be most easily attained, the whole extent of the injury revealed, and removal of all shattered bone, foreign bodies, etc., readily secured. In other respects, the treatment is the same as that for other severe, penetrating head-injuries, which has already been described. The same misleading appearances of the external wound may be present in thrust wounds of the nose. Thus Dr. George Anderson1 reports a case where, while fencing with walking canes, a man was struck a blow upon the left ala of the nose, which produced a small puncture not larger than a leech- bite. Dying a few days afterwards with evident, acute brain disease, post- mortem examination revealed the brass ferule of a cane, lying close to the left side of the sella turcica, having reached this position By penetrating the body of the sphenoid bone. Although examined by a surgeon shortly after the accident, the nature of the injury was unsuspected. Fractures of the glenoid fossa from blows upon the chin have been reported. Sir Prescott Hewett gives a drawing of one such case from a specimen. Dr. Lefevre (de Rochfort) reports the case of a man, aged 22 years, in whom the right maxillary condyle was driven through the glenoid fossa into the skull, by a fall from a great height upon the chin. The patient lived over five months, presenting no other symptoms than pains in the head, and some mental peculiarities which were thought to be simulated until an autopsy revealed the nature of the injury. Then a cerebral abscess, due to the pres- sure of the maxillary condyle, was found situated at the under surface of the right middle lobe of the brain.2 Besides such instances of direct violence, there are others in which, as long since pointed out by David3 for other parts of the body, it is in reality the fracturing force. Suppose that a man falls from a great height upon his feet or buttocks ; what results? Why, practically the condyles of his occipi- tal bone are struck violently through the medium of the spinal column— struck just as directly for mechanical purposes as if with a sledge-hammer. Again, a man falls from a height and strikes full upon the vault in some ■comparatively yielding substance, such as soft earth. The weight of the body again strikes, through the medium of the spine, a violent blow upon the occipital condyles, thus fracturing them. The fact that such injuries are due to direct force may appear clearer when I say that a blow is merely 1 Dublin Quarterly Journal of Medical Science. 1851. 2 Gazette Hebdomadaire. Septembre, 1884. 3 In his well-known Prize Essay, published in the name of his pupil, Bazille (Prix de l’Acad- 6mie Roya'e de Chirurgie, tome iv. p. 420. Paris, 1819). See, also, the same translated in Jus- lamond’s Surgical Tracts, edited by Houlston, page 239. London, 1789.. INJURIES OF THE SKULL. 29 the exciter of vibrations, and that we must consider the point whence they start as in reality the point of impact. Aran has pointed out that the curved and elastic spine, by its recoil, in- creases the violence of the shock in such falls as I have just described. General crushes, where the head is caught between two opposing forces, fracturing the base as well as other portions of the skull, are also clearly fractures by direct force. Sometimes, where the head is thus compressed, the central bones of the base may be the only ones broken. Fractures of the base may result from extension of tissures of the vault into the base, the “ fracture by irradiation” of Fano. Finally, basal fractures may result from conduction and amplification of vibrations, or by counter-stroke (contre-coup), as it is commonly called. This form of fracture very rarely occurs alone, but is an efficient factor in certain instances of the preceding class. If by a fracture by counter-stroke, one directly opposite to the point struck is meant, this probably never occurs except when the centre of the vertex is the point of impact. For instance, a violent blow upon the right parietal boss will not produce a fracture at the left parietal eminence, but at the base of the cranium, through one or both petrous bones. The statement commonly made that the vibrations which are excited in the vault travel by the shortest route to the base, is incorrect. The majority reach the base by the “ shortest anatomical route,” indeed, but that is very different from the shortest route. Again, the opinion expressed by a recent writer, that when the petrous bones are broken from a fall upon the occiput, this is because the “ basilar process rests against the apices of the petrous bones” is both an anatomical and mechanical error. These mistakes arise from failing to remember that the various portions of the skull are of varying thickness, and are so constructed for specific ends. If the vault were of even thickness and density, as well as all of the base except its central portions, and if the skull were also a true sphere, then true fracture by counter-stroke might occur; for the vibrations would travel in all directions until—being probably of unequal velocity—when they met at the weak, central, basal portion, it would be disrupted. But the skull is of unequal thickness in different parts; it is not a true sphere; and certain portions of its base, although frequently broken, are in reality the densest and strongest. It is unquestionably true, that the portion of the skull struck, determines which of the fossse of the cranial base the fracture will probably traverse, when the fracture is not a severe one.1 This I hope to explain by certain anatomical peculiarities of skull structure. The theory that vibrations of the brain produce fractures of the orbital plates, is too manifestly untenable to demand refutation. I need hardly say that the force of the vibrations is directly propor- tioned to the amount of tissue set in motion. Let any one attempt to hold a heavy iron bar by one end, while the other, lying on an anvil, is struck a powerful blow with a sledge hammer: I think that in most cases the vibrations would force the unprepared hand open, and the bar would fall. Yet, if instead of the large bar a fine wire were substituted, and struck with precisely the same force, probably no vibration would be felt, although vibra- tory waves would undoubtedly be set in motion in the wire. In like manner, where the skull is thin,the vibrations are almost imperceptible; where thick they are marked. When the vibrations, starting in the thinner portions, reach 1 In 25 cases analyzed by Hewett, the fracture was limited to one fossa, as follows : the ante- rior fossa in 5 cases, the middle in 14 cases, and the posterior in 6 instances : of 29 cases in which two of the fossae were implicated, in-14 the middle and anterior fossae were fractured, and in 15 the middle and posterior. In 10 out of 64 cases all three fossae were involved. The middle fossa was fractured in fifty-three of the sixty-four cases examined. 30 INJURIES OF THE HEAD. the thicker, the latter, besides being better conductors of vibration, are actually amplifiers of the same. The base must be massive, at least in parts, in order to support the super- incumbent weight of the skull and brain, and to afford a firm basis for the movements of the lower jaw, and of the head on the spine, as well as to protect the important nervous structures in relation with it. While this arrangement is advantageous in health, there are compensating disadvantages when man is subjected to violence; indeed, in his ordinary movements this massiveness of portions of his cranial base would be disadvantageous, were it not for certain wise provisions to be presently mentioned. The pericranium Without, and the dura mater within, act precisely as a wet wash-leather covering and lining would to a bell, damping vibrations. To the ovoid form of the skull, a large part of the security of the brain is attributed, and to a considerable extent this is true; but one important point is almost universally ignored by writers upon this subject. Endless demonstrations exist, going to prove that any segment of the brain-case is a section of a spheroid, and to this fact the immunity from fracture enjoyed by the skull is attributed. If fractures were produced only by crushing forces, the proposition would be incontrovertible. If however a large part of the damage is done by setting up vibrations in the bones themselves, then the form of the skull only conduces in a slight degree to its immunity from fracture. An arch that will sustain hundreds of tons of pressure, if vibra- tions are set up in it may readily be fissured, although its form may remain unchanged.1 The arched form of the skull then merely resists the tendency of the bones to be pressed inward when a blow is struck, and, the vault not breaking, the force expends itself in producing vibrations which cause a basal fracture. Any brittle body will thus be injured whenever the vibrations become violent enough to overcome the cohesion between the particles com- posing that body. Examining the anatomy of a child’s skull will give some useful hints. Probably no young child’s skull has ever been fractured by a diffused blow upon the vertex, nor has more than’ one bone of the vault been broken, unless the force has been actually applied to it. Why is this? In an infant’s skull every bone is isolated from every other by membrane, than which there is no better arrester of vibrations. An attentive examination of a parietal or frontal bone,2 will show that the most projecting portions (those most liable to first strike the ground in falling) are the thickest, while extend- ing from these centres are radii of bone becoming more and more delicate. Each of the fine terminal points of these radii is enveloped by membrane. The vibrations initiated by a blow upon the thicker, central part of the bone are conducted on, or rather have to be propagated, by a gradually thinning structure, that is, one less and less capable of vibrating strongly, until they finally reach the terminal radii of bone which are completely enveloped in membrane, when they are totally arrested. Hence it is that the lines of fracture of an infant’s skull never pass beyond the one bone struck. Certain well-known clinical facts are thus explained by the anatomy of the child’s skull. As the bones come to be more and more in bony contact, with ad- vancing years, this immunity from radiation of lines of fracture from the point struck is gradually lost. In the adult skull, the parietal bones and the frontal eminences, instead of being the thickest, are often the thinnest portions of the vault, and the eight component bones of the brain-case are more or less co-ossified, or at 1 Basal fractures are practically always fissured, the form of the base remaining unaltered. 2 The arrangement mentioned can best be seen in a foetal bone, but exists, although not so easily detected, long after birth. INJURIES OF THE SKULL. least are practically in bony contact. The brain, which fitted fairly well the comparatively smooth base of the child’s skull, has now apparently to lie upon a number of irregular and often sharp bony projections, which, to any one examining a fresh brain and a dry skull, would appear to render the brain liable to serious laceration from the slightest jar of the body, while a jump from the height of a few feet would seem to render disorganization of the base of the brain inevitable. The mechanical effect of the diploe must now be examined. This is normally absent in certain parts, such as the cerebellar fossae, the greater part of the squamous portions of the temporal bones, the orbital plates of the frontal, and the floors of the lateral sinuses as they approach the base of the brain. It may also be exceptionally absent in any portion of the vault. A blow upon the vault will set up vibrations of the outer table, which are transmitted to the inner, with much decrease in force by the damping effect of the diploe. The inner table is both a better conductor of vibra- tions, and also an amplifier of them. Wherever the diploe is present, the vibrations of the two tables pass along to certain denser portions of the skull, which externally are covered with muscle, internally by dura mater and cerebro-spinal fluid, where the waves of motion cease. But when, provided that they are of sufficient violence, they reach a portion of skull where the diploe is absent—-just as where the insulating medium is removed between portions of an electric circuit, the spark leaps across, and a “shock” results —so the vibratory waves of differing intensity meet where the two tables become continuous, and a fracture takes place. But all know that, upon the whole, the brain is the best protected portion of the body. Ignoring many intrinsic provisions for safety, we shall find that, in the fresh skull, the numerous projecting points of the base, instead of endan- gering the brain, actually protect it. In truth, these projections no longer exist —being covered by dura mater, and rounded off or overlaid by the great venous sinuses and bloodvessels of the part, especially where the greatest dissimi- larity would seem to exist between the brain and its case, viz., at the central portion of the base. In addition, at these points the brain is lifted off from the skull by a “ water-bed” of cerebro-spinal fluid. Did space permit, I could demonstrate that, where peculiarly dense portions of tlffi skull are in contact with the brain or other bones, cartilage, sinuses, or arteries—that is, membranous tubes filled with fluid, the best possible arresters of vibrations— are interposed. Suffice it to say, that wherever needed such arrangements exist, so that those vibrations, excited in walking, etc., which do not neutralize one another, are safely conducted off to be “ damped” by membrane and fluid. Holding the base of a skull up to the light, the more massive portions will be seen to converge, in general terms, towards the petrous portions of the temporal bones, the anterior and posterior clinoid processes, and the crista galli of the ethmoid. The anterior and posterior clinoid processes, and the crista galli, are thickly enveloped in membrane and immersed in cerebro- spinal fluid. The apex of the petrous bones, and a portion of their inner margins, seem, the former in contact with the sphenoidal body, the latter with the basilar process of the occipital bone. In reality, the apex of the petrous bone is separated from the body of the sphenoid by the plate of car- tilaginous tissue which fills the foramen lacerum medium, and by the carotid artery, while the inferior petrosal sinus lies in a groove formed partly by the petrous bone, partly by the basilar process of the occipital bone. Any well- informed anatomist can readily fill in this outline sketch of cranial anatomy. How set in vibration the skull walls, and what results? The vibrations, indeed, reach the base, but only by the anatomical routes, the nearest pref- erably, but by all if the blow be sufficiently violent. 32 INJURIES OF THE HEAD. I think, then, that a little reflection will convince every reader, that the apparently useless and dangerous projections seen in the dried skull, do not exist in the normal state, but, being specially arranged, serve as the discharge- points for the vibrations which, by mechanical laws, must pass along the best conductors, that is, the densest portions of the bones, while these same conductors are also amplifiers of the vibrations. Physiological vibrations actually serve useful purposes, which I cannot here detail.1 The foregoing facts would indicate that Aran and others are wrong in stat- ing that fracture of the base is always accompanied by fissuring of the vault, which is the starting-point of the fracture. If, this were true, the greatest force being applied to the weakest portion, the fissures should be widest apart at that point, becoming finer and less widely separated as they reach the stronger portions of the base, but the reverse obtains, and, whether starting in the vault—which I admit is very often the case—or not, the amplification of the vibrations increases the shattering of the base. In slighter basal frac- tures the vault is not fissured, and even Hewett and Aran confess that the posterior clinoid processes may be broken off, or the roofs of the orbits fis- sured, without any line of fracture directly reaching them. If, therefore, slight fractures of the base do occur without fissuring of the vault, severer ones, where the vault is injured, may be similarly produced. The separation of the basal sutures shown in a case which I have elsewhere reported, and two specimens in the Mutter Museum, show that it would be impossible to produce the appearances presented if the fracture started in the vault; for then the upper continuation of the sutures would have been most widely separated. The suture could only have been separated as it was, had the fracture started in the vault, by some of the dentations being broken so as to drive one bone below the level of the other. Nothing of this sort was de- tected ; but vibrations acting most forcibly on the base, would force apart the masto-occipital suture as if from within, and would cause precisely the appearances actually seen. Examining basal contusions of the brain, we shall find that they demon- strate this conduction of vibrations to certain points of the base of the skull. The middle lobes of the cerebrum are most often bruised, next come the anterior, and finally the posterior, “which,” says Hewett, “owe their im- munity to lying upon the tentorium, while the others are injured by the sharp, irregular projections of the cranial base, which, although rounded oil* to a certain extent, and smoothed down by the dura mater, are still both sharp and numerous.” Now as contusions are frequently found in various portions of the brain without fracture, and as even in basal fractures the bones are very rarely displaced, the only explanation, especially in contusions of the middle lobes, is to consider them as resulting from the conduction to that point of powerful vibrations. No one who remembers‘what is really seen in post-mortem examinations of the brain-case, will accept the statement of “ sharp, bony projections;” especially when it is borne in mind that the sinuses and bloodvessels are tensely filled with fluid blood during life. As the occipital condyles often present two separate facets, if the head be extended when a blow is inflicted upon it, or during a fall upon the feet, the force will affect chiefly the posterior facets, while, if the head be flexed, the anterior ones bear the brunt.2 This goes far to explain, always subject to the 1 For details, see Hilton’s Lectures upon the Cranium, Huy’s Hospital Reports, 2d series, vol. viii., p. 351; also a paper by the author, Phila. Med. Times, Oct. 23, 1880. 2 H. Allen has laid special stress upon the position of the head as determining the portion of the base broken. INJURIES OF THE SKULL. 33 laws governing vibrations, why in one case a fall upon the feet, knees, or buttocks, produces a fracture of the anterior, and in another a Assuring of the posterior fossae. Such cases as a fracture of only the cribriform plate of the ethmoid by a fall upon the feet, are thus explicable by the conduction and amplification of vibrations, the motion-waves being directed almost solely forwards, owing to the peculiar position of the occipital condyles as just described.1 In the same way, fractures of the apex of the petrous bone and both posterior clinoid processes,2 and fractures of the petrous bone and side of the sella turcica,3 with no injury in any instance of the occipital bone through which the force is transmitted, demonstrate beyond doubt the theory of conduction and amplification of vibrations.4 [See page 110.] The following case, in which the injury was so trivial that it produced no symptoms of any moment, in which the contusion of brain-substance, if any, was at a minimum, and in which no inflammatory symptoms were present, suggests conclusions which I think go far to explain the fatality of basal fractures. Dr. Charles Wirgman requested me to see with him a young lad who had fallen upon his head when playing leapfrog, but who had walked home with his comrade’s assistance, immediately after the injury. When Dr. Wirgman first saw7 him, slight symptoms of concussion were noted. Next day he seemed better, only complain- ing of some pain in the head. Upon the third day the improvement wras very marked, nothing remaining but a little headache. He begged to be allowed to sit at the window, and, notwithstanding the doctor’s injunctions, walked about the apartment, and went to the yard to evacuate his bowels. A few hours after Dr. Wirgman’s last visit, he was hastily summoned, and on his w7ay called for me. Upon our arrival we w7ere informed that the patient had suddenly been attacked with vomiting, and that eclampsia and death had almost at once ensued. Post-mortem examination revealed an insignificant ecchymosis over the right mastoid region, the result of infiltration of blood from the line of fracture. On opening the skull, a fissure was found traversing the right petrous bone, and extending forwards from the occipito-mastoid suture, which was separated. A minute blood-clot, a few lines in extent, lay near the fracture, within the arachnoid sac, but otherwise the membranes and brain appeared singularly healthy. Hilton reports similar cases in his admirable Lectures on the Cranium. As long as such patients remain quiet, as long as no physiological vibra- tions are excited by efforts at locomotion, just so long does the brain-sub- stance contiguous to the lines of fracture remain uninjured. The primary jarring and slight brain-contusion are recovered from ; and, should quiet be sufficiently long maintained, recovery ensues. Let, however, the patient, tempted by his apparent recovery, leave his bed, and immediately the normal vibrations, which must mechanically arise, are excited. Safely conducted away in health, to points where they were annihilated, the course of the vibrations is now interrupted by the fissures, and the superposed brain-sub- stance is jarred and probably slightly lacerated. From such constantly recur- ring injuries, slight though they be, in the adult, encephalitis results; in the child, perhaps fatal eclampsia. Symptoms of Basal Fracture from Indirect Force.—Except in cases of direct hurt from thrust-wound, access cannot be had to the site of injury, and in many cases, if this were possible, little could be learned by the touch un- aided by sight, as the fragments of basal fractures are rarely displaced, and 1 Marmy, Bull, de la Soc. Anat. de Paris, p. 258. 1848. * L’Experience, Novembre, 1843. (Hewett.) 3 Marmy, loc. cit., p. 193. 4 In the Wood Museum (Bellevue Hospital, New York) is an uncatalogued specimen, pre- sented by Prof. F. S. Dennis, showing marked Assuring of the left petrous bone from a pistol- shot wound of the right ear. It forms a typical example of fracture by transmitted vibrations. 34 INJURIES OF THE HEAD. basal fissures are seldom widely separated. The only symptoms,1 therefore, upon which we can rely, are the escape of blood, watery fluid, or brain-sub- stance, by some one of the natural passages, and the detection of injury done to the cranial nerves as they emerge from the skull. Blood may escape by the nose, from the ears, or from the pharynx. When coming from the nose or pharynx, portions are swallowed, which are often ejected by vomiting. I have seen blood, however, welling up into the pharynx, whence it issued by the mouth and nose, in a steady though small stream. The blood may also escape into the cellular tissue of the orbit and eyelids, into that of the mastoid region, or into that of the back of the head. Orbital Eccliymosis.—Coming from the back of the orbit, the blood usually first shows itself beneath the ocular conjunctiva, where it may accumulate until it forms a brownish-red, much-elevated margin around the apparently deeply-sunken cornea.2 According to Ilewett, the eccliymosis subsequently spreads to the lids. Velpeau thought that the eccliymosis of the lower lid alone was a sign of basal fracture; but this symptom is of no special value without extensive subconjunctival and orbital effusion, although the lower lid usually becomes discolored before the upper. Upon the other hand, frac- ture of the anterior portion of the base may exist without ocular eccliymosis, or the lids alone may become discolored. Marked subconjunctival hemorrhage, coexisting with orbital and palpebral effusion, is then a fairly reliable symptom of fracture of the anterior basal region, if we except those rare cases which have been reported by Ilolmes, where fractures of the malar or of the superior maxillary bones, produced both ocular and palpebral ecchymosis.3 But the total absence of these symptoms cannot exclude a basal fracture. Thus, of twenty-three cases of fracture of the orbital plates of the frontal bone, in eight cases there were no traces of extravasated blood, in either the eyelids or beneath the ocular conjunctiva, while in five cases the lids were alone dis- colored. In the ten remaining cases, blood was extravasated both beneath the ocular conjunctiva and into the lids.4 It will be thus seen that when these symptoms are present they are valuable aids to diagnosis, but that their absence is not conclusive in the other direction. Injuries to the arteries at the back of the orbit have resulted in traumatic aneurisms, which often ultimately demand surgical interference.5 Hemorrhage from the Nose and Pharynx.—Epistaxis, from the vascular nature of the Schneiderian membrane, is a common symptom in head injuries, and can only be of any diagnostic value when persistent, and when accom- panying symptoms of grave cerebral concussion. In fourteen cases out of thirty-two, where central basal fractures occurred, bleeding from the mouth or nose, or subsequent vomiting of blood, occurred. Out of the fourteen cases in which this symptom was noted, in four the ethmoid alone was involved; in three, the body of the sphenoid; and in one, the ethmoid, sphenoid, and basilar process of the occipital bone were all implicated. (Ilewett.) 1 Le Grros Clark reports a case of basal fracture, with marked cerebral laceration, in which the temperature was depressed, being 87.4° F. one and a’half hours after the injury, and only reaching 90° F. nine hours subsequently. (Gant’s Science and Practice of Surgery, vol. ii. p. 162.) Mr. Hulke has reported, in the Lancet for 1877, a series of cases in which, the patients living for some days, an excessively high temperature was developed, without any coarse post- mortem evidence of inflammation being found. In all, however, there was extensive shattering and bruising of bone. 2 Maslieuret Lagemard first called attention to this subconjunctival ecchymosis. 3 British Medical Journal, 1855. 4 Hewett, op. cit., vol. i. p. 589, 6 Morton, Am. Journ. Med. Sc., vol. lx. 1870, pp. 43 and 45 ; Harlan, ibid., p. 47. INJURIES OF THE SKULL. 35 Hemorrhage from the pharynx is often from the vessels of the mucous membrane; but in one case, mentioned by Aran, the internal jugular was torn, producing almost instant death. Pharyngeal hemorrhage, or vomiting of blood—this liuid, when retained in the stomach for any time, presenting, when ejected, the appearance of coffee-grounds—is of much less value than either orbital or aural hemorrhage. When profuse, persistent, and the result of violent, diffused force, with accompanying cerebral symptoms, it may prove useful in determining the nature of a doubtful case. Bleeding from the phar- ynx, or vomiting of blood, may proceed not from fracture of the vault of the pharynx or roof of the nose, but from a fracture of the petrous bone without rupture of the membrana tympani,so that blood entering the tympanic cavity escapes into the pharynx by the Eustachian tube. Dolbeau has pointed out a rarely-observed symptom of fractured base, viz., ecchymosis extending over the posterior pharyngeal wall from the occipital bone to the upper cer- vical vertebrae. It is most difficult of detection, being generally concealed by the palate. Bleeding from the ears is the most valuable of the symptoms of fractured base, provided that it be profuse and prolonged, and that a recent rupture of the membrana tympani can be detected. With such conditions after a severe heiid injury, accompanied by cerebral symptoms, a diagnosis of basal fracture can be safely made ; for copious and prolonged hemorrhage indicates a fracture traversing the petrous bone, which has opened one of the larger vascular trunks, as bleeding from those of the mucous membrane would soon spontaneously ■cease.1 In one case, already mentioned, from fifty to sixty ounces escaped by the ear in the course of a few hours.2 Aran refers to two cases where post-mortem examination demonstrated a tear of the lateral sinus, and other such cases are on record. The flow of blood may continue from two to three or more days. Ilewett reports dissections of thirty-two cases of fracture involving the middle fossa, in fifteen of which there had been a free, steady hemorrhage from the ear. In these the tympanum was traversed by the fracture, and the membrana tympani ruptured. In twelve cases, however, the fracture did not involve the tympanum, and in the remaining five the tympanum was fractured, but the membrana tympani was unruptured. If, therefore, in a suspected case the membrana tympani be found upon examination, to be sound and non-bulging, and to present none of the appearances of blood being effused into the tympanic cavity—that is, change of color of the drumhead by the blood showing through—the fracture, if any exists, can be said not to have involved that portion of the petrous bone in which lie the internal and middle ear, and must involve the apex alone. Where a fracture of the petrous bone opens one of the large venous sinuses and into the tympanum, as before said, hemorrhage may take place from the nose or mouth, or blood may be vomited. Indeed, this sometimes may occur even with a ruptured membrana tympani. The possibility of this double hemorrhage arising from a fracture of the petrous bone alone, and not from one of the bones forming the roof of the nose or pharynx, must not be for- gotten in making the diagnosis, lest greater cranial injury be supposed to exist than in reality has occurred. Filtration of blood into the cellular tissue of the occipital region, or into the subcutaneous tissue of the lateral parts of the neck, may take place in basal fracture, producing an appearance as if bruising had there occurred. If 1 The very exceptional case mentioned by Erichsen, where a blow upon the jaw broke the ■external auditory meatus, and produced a free flow of blood from the ear, is so unlikely to occur again as not to invalidate the statements which I have made. 2 Lockwood, Am. Jour. Med. Sc., April, 1859, p. 354. INJURIES OF THE HEAD. it can be proved that the portion of the head struck was far distant from the discoloration, this is a valuable diagnostic sign in conjunction with distinct cerebral symptoms, either precedent or then existing. If no reliable infor- mation can be gained as to that part of the head upon which the blow was received, ecchymosis of the regions mentioned can be of no diagnostic value, except—according to llewett—when a puffiness occurs in the occipital region, with discoloration of the skin a few hours after a severe injury upon this part of the head. lie states that this is the result of injury to some of the great venous sinuses and of filtration of the blood between the fragments. I cannot but consider this an eminently uncertain symptom when the occipital region itself has been injured. The escape of brain-substance1 by the ears or nose, of course definitely settles the fact of basal fracture, but is of rare occurrence. The diagnostic value of watery discharges from the ear and nose will be considered hereafter. Paralysis of the nerves emerging through the various foramina at the base of the skull, especially paralysis of the facial and auditory, has been from time immemorial considered a sign of fractured base. The second, eighth, and ninth pairs are but rarely affected, while the first is not uncommonly injured. Involvement of many nerves, or of those of both sides, is not of much value as evidence of basal fracture, since the symptoms are then probably due to intracranial blood-extravasation.2 Paralysis of the facial often does not appear immediately after the injury ; in fact, in eight out of ten cases reported by Mr. Pick, it only appeared from the second to the sixth day. Owing to the connection of the facial with the spheno-palatine ganglion, it depends on the part of the portio dura injured, whether the uvula and soft palate will be paralyzed as well as the facial muscles, or not. In the former event, the liiie of fracture must traverse the internal auditory meatus, so as to injure or com- press the nerve before it gives off the greater petrosal nerve—that is, between the brain and the geniculate ganglion, which is situated in the first part of the aquteductus Fallopii. If the uvula and palate be unaffected, the line of fracture must traverse the petrous bone so as to injure the facial nerve as it passes in the Fallopian canal across the internal wall of the tympanum. Diagnosis of Basal Fractures.—The most important diagnostic points have been referred to in considering the symptomatology of basal fractures, but there are some general principles which the surgeon will do well to keep in mind when dealing with a supposed injury of this kind. Experience has shown that, as a rule, basal fractures result from the appli- cation of powerful, diffused force. Thus, in violent blows or falls upon the temporo-parietal region, with marked symptoms of cerebral concussion, we have, according to Aran,2 from the mere nature of the force, presumptive evi- dence of a fracture of the middle fossa. While I do not go as far as this author, such a combination of events certainly should suggest the strong pos- sibility of a basal fracture to the surgeon’s mind. In direct fractures, free hemorrhage, or hemorrhage followed by a watery flow, with perhaps symptoms of cerebral compression from intracranial effusion of blood, is apt to occur, and paralysis of one or many of the basal nerves from injury by the vulnerating body. Then, too, an open way having been made to the site of fracture, the Anger or the probe will give valuable information. 1 Guillemeau, Journ. de Med. 1779 ; De Gislain, Annales de Chirurgie, t. viii., p. 229. 1843; Aran, Archives Gen. de Med., 4e s6r., t. vi. p. 329 ; Lockwood, loc. cit. 1 Loc. cit. INJURIES OF THE SKULL. 37 In fractures by irradiation, that is, those spreading from a fractured vault, there are always marked symptoms of cerebral concussion; usually nasal, aural, pharyngeal, or orbital hemorrhages, according to the region injured ; and, if one of the middle fossse be broken, probably a watery discharge from the ear, either from the outset or following copious and prolonged hemorrhage. Pa- ralysis of one or more cranial nerves—such as the first, if the anterior fossa be involved, or the seventh, if the middle fossa be broken—are also probable symptoms. All these conditions are usually complicated with decided cerebral contusion, which is followed by encephalitis, and the case not unusually terminates in hemiplegia and death by respiratory failure. (1) Fractures of the Anterior Fossae.—There is usually either a wound or a contusion of the facial or frontal region, with fracture of the frontal bone; prolonged, copious epistaxis,ecchymosisof the eyelids—especially, and first, the lower—with effusion of blood beneath the ocular conjunctiva. Either the olfactory, optic, or third pair of nerves may be paralyzed. Watery nasal discharge may occur. In very exceptional cases cerebral substance may escape by the nares. (2) Fractures of the Middle Fossae.—There is apt to be a contusion or wound of the middle zone of the cranium, usually in the temporo-parietal region; or a blow across the face or neck may be the cause of fracture. Aural hemorrhage, free and prolonged, usually takes place, followed by watery dis- charge, and very rarely by an escape of cerebral substance. Paralysis of the facial or auditory, or loss of the function of both of these nerves, probably occurs either primarily, or more commonly within a few days of the injury. (3) Fractures of the Posterior Fossae.—These fractures ordinarily result from falls upon the occiput, and are often complicated with fractures of the apex of the petrous bone. The symptoms are apt, therefore, to be combined with those of fracture of the middle fossae. In occipital fractures, severe pha- ryngeal hemorrhage is more apt to occur than in injuries of other portions of the base, from tearing of the greater vessels which are so closely related to the roof of the pharynx. Occasionally, as a sequence of fracture of the petrous bone laying open the tympanum, a painless, smooth, circumscribed, elastic, non-fluctuating, resonant tumor forms in the temporal or mastoid region; this is a pneuma- tocele. The air may sometimes be made to escape with a hissing sound. Pressure will cause the total or partial disappearance of the tumor, which at once reappears when the pressure is removed. Usually confined beneath the pericranium, this membrane may give way, when the air becomes more or less diffused throughout the environing connective tissue. Firm pressure is the only appropriate treatment, after a preliminary puncture with a fine trocar. Incision, excision of the sac, and the introduction of a seton, have been followed by serious, if not fatal, symptoms. Prognosis.—Do basal fractures unite, and what are the chances of recovery? If the patient live long enough, union may undoubtedly occur. There is an admirable specimen of this in the Pennsylvania Hospital Museum,1 and Mr. Henry Lee gives an account and drawing of another example in the Medical Times and Gazette for 1852. Even months or years after a fracture of the base, no attempt at union may be found, while in other cases the union may be merely by fibrous tissue, or partly a thin plate of bone, partly mem- brane. In some cases exuberant callus forms, consisting chiefly of porous 1 There is also a well-marked specimen ol a very extensive fracture of the vault and base, in the Wood Museum, Bellevue Hospital, New York. Decided union has taken place, the patient dying long after the injury, from some other aifection. 38 INJURIES OF THE HEAD. hone, and when the line of fracture has traversed a sinus, this callus may be so excessive as to block up the channel. I have myself seen cases where there was no good reason to doubt that patients had recovered from basal fractures, yet such a result is rare. As I have endeavored to point out, and as Aran has positively stated, since basal fractures are simple linear fissures, with neither displacement nor depression, they, in themselves, add little, if anything, to the danger of the head-injury, if the brain have escaped primary harm. If perfect quiet be not maintained, as in the case of Dr. Wirgman’s patient, or as in Mr. Hilton’s cases, meningeal irritation and encephalitis will result, but these can often be avoided by rest and appropriate treatment. As an instance of the danger of movement, I may refer to a case of Sir Charles Bell’s, in which sudden displacement of a fragment of the occipital bone at the foramen magnum, caused instant death by compression of the spinal cord. And as most basal fractures are complicated with serious intracranial injuries, it has been estimated that 80 per cent, of fatal skull-fractures belong to this variety. Even when apparent recovery has taken place, death often results many months afterwards, from secondary brain-disease. Treatment.—As these fractures are almost never amenable to operative treat- ment—and as they depend for their gravity upon the concomitant intracranial injuries—even when their diagnosis is clearly made out, nothing beyond treatment appropriate for expected or present encephalitis should in most instances be resorted to. In some rare cases of injury to the more accessible portions of the base, such as the roof of the orbit or the occipital bone, opera- tive interference has been successfully employed. Occasionally the fragments are depressed, and when this is the case, and they are accessible, they should be elevated. Thus, Hewett lias seen a fragment, composing the greater part of the orbit, removed. The trephine has been successfully applied close to the foramen magnum, for a depressed fracture of that region, in a boy aged fourteen years. In this case an incision over an occipital contusion revealed a fissure which, when followed down, led to finding a depressed fragment of bone so firmly impacted as to require the trephine for its removal. Punc- ture of the membranes was secondarily resorted to for a serous effusion, and recovery took place.1 Watery Discharges from the Skull.—A discharge of thin, limpid, watery fluid from the ears, nose, or other portions of the skull, is a not unfrequent accompaniment of severe head-injuries, especially of basal fractures. The source of these discharges has been so much discussed, and their importance m the diagnosis of head-injuries has been so variously estimated, that I shall here consider the subject in some detail. Observed as early as 1727,2 it was reserved for Laugier, in 1839, to demonstrate by dissection that many cases of watery discharge from the ear coexisted with a fracture of the petrous bone and rupture of the membrana tympani. Opinions as to the source of the dis- charge may be divided, as pointed out by Hewett, into two classes: accord- ing to one, the fluid is thought to be nothing but the serum of the blood ; according to the other, it is a secretion from some membrane. Laugier first broached the view that the fluid was merely blood-serum from a clot lying in direct contact with the fracture. Afterwards, he taught that the “lace- rated vessels lying along the broken bone,” with those of the neighboring soft parts, “ contributed to the discharge by serous exudation.’'3 Chassaignac 1 Med.-Chirurg. Trans., vol. ii. p. 105. 2 Vander Wiel (Hewett, op. cit., vol. i. page 592). 8 Archives Generates de MSdecine, 4e ser., t. viii. p. 413. Laugier (ibid., p. 386,) declares that he had carefully noted the occurrence of watery aural discharge as far back as 1835. INJURIES OF THE SKULL. 39 maintained the untenable view, that, both from the ear and nose, these watery discharges resulted from a filtration of the serum of the blood through the frayed walls of some of the venous sinuses in relation with the fractured bone. The membrane of the internal ear, by an increased secretion of the liquor Cotunnii,1 has been also considered as the source of the discharge, as well as the arachnoid cavity and the subarachnoid spaces. Examining these views in detail, I would say, in the first place, that the analysis by Chatin2 proves that the fluid contains only a trace of albumen, and a large quantity of sodium chloride, a fact which I have myself observed. This explodes the blood-serum theory. When the lines of fracture of the petrous bone do not involve the internal auditory meatus, but the fissure traverses the middle and internal ear, rupturing the membrana tympani and the membranous labyrinth, we certainly cannot affirm that some of the fluid is not liquor Cotunnii, though its large quan- tity would tend to negative that view.3 Besides, more than one specimen has been dissected by competent anatomists, where neither fracture existed nor any abnormal communication between the two cavities, and where yet a free aqueous flow took place from the ear. Thus, as one instance:— A man fell about twenty feet, and striking his head produced a scalp wound, not denuding the bone, at the upper back part of the head. Upon admission to St. George’s Hospital there was a discharge of bloody fluid from the ear, which the next morning was roseate, gradually became clear, and was so profuse that two ounces were collected in an hour’s time. On the third day it decreased and became purulent. It had been very profuse, soaking the pillow-case so as to require towels to be placed beneath the head. The patient dying upon the seventh day, Sir P. Hewett4 and Mr. H. Gray repeatedly examined the specimen, but detected neither fracture nor abnormal communication between the middle and internal ear; but the membrane lining the tympanum and mastoid cells was “ intensely vascular and covered with muco-purulent secretion, while the membrana tympani was freely ruptured at its anterior inferior part.” “ The membrane lining the cavities of the internal ear was natural in every respect.” That certain of these free watery discharges really proceed from the sub- arachnoid spaces—that is, consist of cerebro-spinal fluid—is incontestably proved, by both analysis, dissection, and experiments upon the living patient* and upon the cadaver. M. Robert was the first, as far as I am aware, to thoroughly investigate the subject and place it on a firm basis. To allow the escape of cerebro-spinal fluid through the ear, the fracture must traverse the internal auditory meatus, open into the tympanum, and at the same time tear through the meningeal sheath6 which incloses the seventh nerve in the auditory meatus, and also rupture the membrana tympani. There is at least one specimen, dissected by Hewett, which proves that the tubular sheath of the arachnoid surrounding the nerves may be torn, coin- 1 Marjolin, Diet, de M6d., 2e edit., tome xxix. p. 570. 2 Ibid. Claude Bernard has also shown that both the cerebro-spinal fluid and that poured out in basal fractures often contain a trace of sugar. So little albumen is present that it may not fairly coagulate with heat or nitric acid, but only some cloudiness or opacity be thus pro- duced. 3 Robert (Archives Generales de 4e ser., tome ix.) relates a case where 1000 grammes of fluid were lost by the ear in sixty-six hours. 4 Op. cit., vol. i. p. 593. 5 Congestion of the intracranial circulation, effected by pressing upon the jugular veins and closing the mouth and nose with the hand so as to prevent respiration, in the case of a boy with fractured base, produced a marked increase in the flow of watery fluid from the ear (Hilton). 6 Robert (loc. cit.) says that even a tear of the dura mater lining the internal auditory meatus, at the point where the arachnoid is reflected upon the nerves, will allow the exudation of cerebro- spinal fluid. 40 INJURIES OF THE HEAD. cidently with a line of fracture pursuing the course which I have just described.1 We thus see that free watery discharge from the ear may coincide with such a fracture as I have described, when it is certainly cerebro-spinal fluid ; and that an equally free flow may take place with neither fracture nor injury to the internal ear. Of what value then in diagnosis are these watery ear dis- charges? Although cases do occur where free watery discharge takes place with neither basal fracture nor injury to the internal ear, yet this symptom is unquestionably of great diagnostic value under certain circumstances. When the flow is copious from the very outset, having commenced imme- diately after the accident, and not having been preceded by any hemorrhage from the ear, or by hemorrhage in only very small amount, there is no doubt that it is an outpouring of cerebro-spinal fluid, escaping through a fracture of the petrous bone, traversing the internal auditory meatus, and tearing the infundibular process of the meninges. Free and prolonged hemorrhage from the ear, succeeded by a watery dis- charge, is indicative of fracture of the petrous bone; but it does not necessa- rily follow that the fissure has traversed the internal auditory meatus. And it must be remembered, that, as Sir Prescott Hewett has well said, “ it is not to the watery discharge that we can trust for our diagnosis, but to the copious and prolonged bleeding.”2 When, however, there is at first only a moderate flow of blood, which persists for a short time and is followed by a watery discharge, variable as to time of appearance and amount, the value of the symptom is questionable. The watery flow may appear within a few hours of the injury, and may then rapidly become profuse. As the flow of blood is not enough in itself to be diagnostic, and as some of the facts which I have mentioned go to show that a profuse watery flow may proceed from the ear within a few hours of a head injury without any fracture, we are not warranted in cases of this third class in diagnosing basal fracture merely from the aqueous flow. The statement that free watery discharges after head-injuries belong to childhood and youth, is unquestionably an error. Prognosis.—Although often considered to be a fatal symptom, a number of recoveries have been reported; and I have had one case under my own care, of undoubted basal fracture with watery discharge from the ear, where recovery took place. Nevertheless it is a very grave symptom. Watery discharges from the nose sometimes occur after head-injuries, but rarely as compared to similar flows from the ear. Blandin first reported a case of this kind in the year 1840* but the source of the flux was not satisfactorily made out. An examination of a case which occurred five years later in the practice of M. Robert, revealed a tear of the dura mater about one inch in length over a fracture of the sella turcica. The visceral arachnoid covering the anterior lobes was also torn. As a proof of the source of the discharge, water dropt into the sella turcica soon filtered through into the nasal cavity, chiefly emerging through the right nostril.3 Analysis of the fluid composing these nasal discharges proves it to be identical in composition with the cerebro-spinal fluid, and a moment’s reflection will show how readily large quantities of this might be poured 1 Robert (loc. cit.) records a second case of careful dissection of a fracture of the petrous bone— watery fluid having been discharged by the ear during life—where a tear of the infundibular pro- cess of the arachnoid at the bottom of the internal auditory meatus was detected. 2 Erichsen reports a fracture of the external auditory meatus from a blow on the condyle of the jaw, where many ounces of blood flowed from the ear. This is however very unusual. * Loc. cit., p. 417. M. L. Brown reports in the Boston Med. and Surg. Journal, Dec. 29, 1881, p. 610, an example of watery nasal discharge in a case where, after death, a fracture implicating the cribriform plate of the ethmoid bone was detected. INJURIES OF THE SKULL. 41 out from the great sub-arachnoid spaces upon which rest large portions of the base of the brain. Hewett points out that, in addition to this source, another exists in the intra-ventricular fluid, free vent to which would be afforded by a tear of the infundibulum, that is, a part of the floor of the third ventricle. The pituitary gland connected with the infundibulum lies in the sella turcica,1 which frequently gives way in basal fractures. Strange as at first sight the statement may appear, watery nasal discharges sometimes accompany fractures of the petrous bone, the fluid escaping by the Eustachian tube into the nose from the tympanum, to which the cerebro- spinal fluid has gained access by a fracture implicating the internal auditory meatus. But what is the diagnostic value of this symptom as indicative of a fractured base ? Very little, I think, unless it occur immediately after the injury. Even then there is no certainty about it. If with the small extent of mucous surface of the tympanum and mastoid cells, fluid may be secreted at the rate of two ounces in an hour without any fracture, surely the same is much more likely to occur from the nose. Accordingly, we find that certain individuals are liable to periodical attacks of free discharge of a limpid fluid from the nostrils, which may last for hours.2 This fact must be borne in mind, lest a clear watery flow from the nose after a head-injury be considered of too great diagnostic value. In certain cases of compound fracture of the vault, where the membranes have been lacerated, a free discharge of the cerebro-spinal fluid takes place.3 Although in most instances the fluid comes from the sub-arachnoid space, this is not always so. In three cases, one of which has been already quoted in this article,4 the fluid came from the lateral ventricles. In these cases the flow was very free, and in two of them it came on suddenly at a late period.6 All proved fatal. Prognosis of Cases complicated by occurrence of Watery Discharges.—What is the prognostic import of these losses of cerebro-spinal fluid ? In themselves, they seem to exert no appreciable effect upon the course of the case, but as they prove an opening into the sub-arachnoid space or into the ventricles, they indicate the existence of visceral lesions which always add to the dangers of any skull-fracture. Where the ventricle is not opened, recovery seems to be the rule. Thus out of eleven cases cited by Hewett, eight ended in recovery, the three fatal cases being those in which the lateral ventricle was laid open. 'Treatment.—This must consist in the adoption of appropriate measures, as indicated by the general symptoms. In other words, the case must be treated upon an expectant plan, with no special reference to the escape of fluid. Traumatic Cephalhydrocele.—Prof. P. S. Conner,6 of Cincinnati, lias col- lected 19 cases of this rare affection, the list including two reported by himself. A traumatic cephalhydrocele consists in a subfascial accumulation of fluid, in most instances the result of a simple fracture of the cranial vault. In two cases of gunshot injury, where there had been a communicating wound 1 In Blandin’s case, before mentioned, this accident probably occurred. (Reported by Demar- quay, Gaz. des Hopitaux, p. 205. 1840.) 2 See Hewett, op. cit., vol. i. p. 596. 3 Dudley, after trephining for epilepsy, found a bony spicule which pressed on the dura mater ; the next day fluid commenced to flow and continued to do so for eight days, recovery ensuing. (Am. Jour. Med. Sciences, 1828.) O’Halloran (Dub. Med. Press, vol. xiii. p. 81), and Hey, of Leeds (Practical Observations in Surgery, p. 21), also report instances of watery flow from the vault after fracture. 4 Bouchacourt, Bull, de la Soc. Anat. de Paris, tome xiii. p. 13. 6 Erichsen, op. cit. ; also Hewett, op. cit.., vol. i. p. 597. 6 Proceedings of American Surgical Association, 1884. 42 INJURIES OF THE HEAD. of the scalp which had closed, and in one case of compound fracture where the external trephine-wound had cicatrized, a similar collection of fluid sub- sequently occurred. These cases are additional to the 19 already mentioned. There can be no question as to the nature of the fluid, which is most clearly cerebro-spinal; and in three cases a communication with the lateral ventricle has been detected.1 Where the original injury is not compound, traumatic cephalhydrocele occurs only in the young, 18 cases having been in patients under three years of age, while in one case only (Conner) was the patient 12J years old. This is explicable, according to Dr. Conner, in part at least, by the yielding character of the skull-bones in the very young, admitting of great depression and Assuring of the vault, without associated wound of the scalp. Symptoms.—Traumatic cephalhydrocele may appear at once after the injury, or not until the expiration of four months, and a positive diagnosis is often impossible without a withdrawal and examination of the contents of the swelling. A typical case presents a soft, compressible tumor, covered by normally colored, distended integuments, so thin, perhaps, as to be translu- cent. In more than one-half of the cases, pulsation was apparently not observed. When this symptom is present, with those already described; when pres- sure diminishes the bulk, with or without evidences of cerebral irritation ; when the tension of the swelling is increased by crying or holding the breath; and when the condition noted has followed a simple fracture of the vault, the diagnosis is clear. When, however, there is neither pulsation, translu- cency, nor evidence of fracture, if appearing early, the condition will proba- bly be mistaken for a hsematoma, or, when coming on long after the injury, for a deep-seated abscess. Under such circumstances an examination of the fluid can alone determine the nature of the swelling, and an exploratory aspi- ration is therefore indicated in doubtful cases. Prognosis.—The mortality of traumatic cephalhydrocele depending upon simple fracture, Dr. Conner shows to have been 50 per cent., death in fatal cases having resulted from encephalitis; while when the disease has followed compound fracture, one-third of the patients have died, from “cerebral ab- scess. Recovery, when it does ensue, is followed, in many cases, by a morbid mental state, irritability of temper, etc. Though complete consoli- dation of the fracture, with consequent abolition of the communication between the intracranial and extracranial cavities, may occur, it is, according to Dr. Conner, very unlikely to take place in any case in which the opening has been large and the subaponeurotic accumulation great. Treatment.—Nothing beyond aspiration or tapping with a fine trocar is admissible, and this only when symptoms of intracranial pressure, such as squinting, pain, or “ decided symptoms of distension of the nasal or orbital lymph spaces,” are noted. The sac should not be completely emptied, lest cerebral irritation result, as actually occurred in one of Dr. Conner’s cases, when pain in the forehead and side of the head compelled him to discontinue the operation. Moderate—but only moderate—pressure may, perhaps, lessen the rapidity and extent of the distension. The following conclusions are drawn by Dr. Conner, as the result of his researches and experience. 1. Simple fracture of the vault of the skull may give rise to a collection under the scalp of the cerebro-spinal fluid ; coming, it may be, only from an opened ventricular cavity. 2. Such traumatic cephalhydrocele may be developed quickly, or only after the lapse of a number of days or even weeks. i Guy’s Hosp. Reports, 3d series, vol. xxv. p. 91. Archiv f. klin. Chir., Bd. iii. S. 398 ; Jahr- buch f.* Kinderheilkunde, Bd. xviii. S. 367. (Conner.) INJURIES OF THE SKULL. 43 3. The condition is one that has thus far been noticed only in young subjects. - 4. The accident is quite likely to prove fatal from lepto-meningitis or meningo- encephalitis. 5. Operative interference should be restricted to the removal by aspiration of a limited amount of fluid ; and such aspiration should be made only when severe pressure- symptoms have manifested themselves. 6. A similar fluid accumulation may occur after closure of the external wound of a compound vault-fracture or of a trephining. Separation of Sutures.—When occurring in the cranial vault, these acci- dents are, as a rule, restricted to the young, in whom the skull-bones have not as yet become co-ossitied.1 In later life, force applied at the site of an obliter- ated suture may cause a fracture which accurately follows the old sutural line, as in a case recorded by Prof. Agnew.2 In the Wood Museum, New York, is a specimen (uncatalogued) where the line of fracture has passed exactly through the obliterated interfrontal suture. The injury resulted from dif- fused force, that is, a blow from a sand-bag. A musket-ball may, according to Guthrie, produce separation of a suture of the cranial vault, by impinging directly upon it with a moderate degree of force, although “ in general it takes place when the ball happens to lodge, as it were, between the bones concerned in the formation of the suture.” Guthrie3 reports one case where separation of the sagittal suture was caused by a fall upon the vertex, the patient dropping from his saddle with a bullet-wound of the thorax. In basal frac- tures of the skull, the sutures of other parts are not uncommonly separated. In fourteen cases of fracture accompanied by separation of sutures, examined by Hewett, the coronal suture was separated in seven cases, the lambdoid in six, the sagittal in four, the petro-occipital in one, the temporo-parietal in one, and the spheno-parietal in one. Referring to the great rarity of such acci- dents, he remarks that he has never seen but one example uncomplicated with fracture. In this case the temporal bone was slightly separated and driven upwards at the back part of the squamoso-temporal suture, closely simulating a fracture with depression.4 I have lately seen a case where the squamoso- parietal suture was slightly separated by a blow upon the parietal, which must have been slightly depressed, as the squamous plate was at one point about a line above the parietal bone. The sagittal (twelve times) and the inasto-occipital suture (seven times) have been those most commonly separated in the twenty-one specimens of fracture with sutural separation which I have examined. Where a number of sutures have been loosened, a whole bone, as for instance the frontal, may become almost detached from those around it. Prognosis.—Separation of sutures is most frequently effected by the appli- cation of great force, such as firm compression of the head between two hard, resisting bodies, falls from a great height, or the impact of a spent cannon ball. In consequence, the prognosis is very bad,5 for the bone-injury is fre- quently complicated by extensive pericranial laceration, or by separation of the dura mater, while at times both these membranes are freely torn, with lacer- ation and extrusion of the brain-substance, which, under such circumstances, may be found just beneath the integuments. This, however, is not always the case: in an extensive cranial fracture reported by Hewett, the parietals were widely separated, and at a different level along the whole extent of the 1 Morgagni, however, reports a case in a man sixty years old. 2 Principles and Practice of Surgery, vol. i. p. 274. 3 Commentaries on the Surgery of War, 6th ed., p. 349. 4 Hewett, op. cit., vol. i. p. 591. 5 Larrey (op. cit., p. 317) reports a case of recovery after separation of the coronal suture, death taking place from independent disease, six months afterwards. 44 INJURIES OF THE HEAD. sagittal suture, the depression of the right bone being fully two lines below the cranial surface; yet the brain itself was totally uninjured.1 Separation of the sagittal suture has, in several recorded instances, resulted in extensive intracranial extravasation of blood, requiring the use of the trephine upon one or both sides of the median line. In one instance this condition was indicated by the presence of coma, with “ a longitudinal elevation extending the whole length of the sagittal suture;”2 when incised, this gave vent to liquid blood and revealed a sutural separation. Subsequently the trephine was applied upon either side of the median line, evacuating much blood, and resulting in the cure of the patient. Treatment.—This is essentially that of fracture of the skull, except when the injury causes intracranial hemorrhage, when the treatment is that which has just been indicated in relating M. Mouton’s case. All compound fractures of the skull, whether operated upon or not, should be thoroughly irrigated with the corrosive sublimate, carbolic acid, or some other antiseptic solution, and then carefully dressed with sublimate gauze, a full Listerian dressing, or, in default of these, with any other antiseptic dressing that the circumstances may admit of. Injuries of the Meninges and Brain. Intracranial Extravasations of Blood. — Blood may be effused (1) between the dura mater and the skull ; (2) in the cavity of the arachnoid; (3) on the surface of the brain—that is, in the meshes of the pia mater; (4) in the cerebral substance ; and (5) in the ventricles of the brain. Although these collections may occur without fracture, they are much more commonly con- comitants of such an injury. (1) Extravasation between the Dura Mater ami the Skull.—The sources of the hemorrhage are threefold, viz : (1) the small vessels passing from the mem- brane to the bone; (2) the middle meningeal artery; and (3) the venous sinuses of the brain. Extravasations from the first source are usually verj limited, and have been mentioned in connection with bone contusion ; the effusions which come from ruptures of the meningeal artery or its branche: are by far the most common, for “out of thirty-one cases of fracture of the skull, accompanied by extravasation,” .... the hemorrhage proceeded “ from the middle meningeal artery in twenty-seven cases.”3 Extravasation due to rupture of one of the sinuses is the least common variety, but when it does occur may be very extensive, as in a case reported by Hewett, in which the lateral sinus was torn, “just as it turns under the petrous portion of the temporal bone.”4 The anterior branch of the middle meningeal artery is usually said to have been ruptured at the anterior inferior angle of the parietal bone. A moment’s consideration of the course pursued by the artery, after its entrance through the foramen spinosum, will show that in the most common variety of basal fracture of the skull, viz., that which involves the middle fossa, the vessel may be torn at any point from its entrance into the skull up to the anterior inferior parietal angle. The artery, in addition, frequently divides into two branches of nearly equal size, soon after its entrance into the skull. 1 Hewett, op. cit., vol. i. p. 592. 2 Mouton (Quesnay, Memoirs of the Royal Academy of Surgery, translated by Ottley, p. 8). * Holmes’s System of Surgery, 3d ed.. vol. i. p 575. . 4 It has been demonstrated by experiment, that a clot between the dura mater and bone, equalling one-twelfth the capacity of the cranium, will produce coma and death within a few hours. INJURIES OF THE BRAIN AND MENINGES. 45 The anterior division proceeds to the anterior inferior angle of the parietal bone,1 while the other branch, passing much more posteriorly, ramifies over the whole of the parietal, and also sends branches to the contiguous portions of the frontal and occipital bones. From these anatomical considerations, it will be seen that extensive extravasations of blood may arise from rupture of the middle meningeal artery, from lines of fracture which do not involve the anterior inferior angle of the parietal, but which run across some of the large branches just mentioned. From whatever source proceeding, the hemorrhage is large in amount from the extensive, coexistent separation of the dura mater.2 The clot forms a “ hard, granular mass, breaking down with great difficulty, even under heavy pressure, and adhering most firmly to the parts between which it is lying.”* The subjacent brain itself, in a large extravasation, is de- pressed in a cup-like manner, and the convolutions of the brain are apparently flattened. The statement that hemorrhage from laceration of the great menin- geal artery may cease from compression by the resultant clot, after a small effusion of blood, is probably purely theoretical.3 If the patient survives, the clot becomes decolorized and absorbed, to judge from the appearances presented by one case reported.4 Punctured wounds, as from a penknife blade or fragment of glass, have been reported, where death resulted from ex- tensive effusion due to a division of one of the large meningeal branches.5 Symptoms.—These are very variable, being dependent upon the greater or less rapidity of the sanguineous effusion, and are, in brief, those of compression. With marked collapse and consequent feeble circulation—perhaps from the small size of the effusion—the ordinary phenomena may be delayed for hours, even days. The symptoms differ from those conse quent. upon depression of bone, or the pressure of a foreign body, in not being immediate. Thus, after a blow upon the head, the ordinary phenomena of concus- sion are observed. With the feeble cir- culation the effusion is very slight, but, as reaction takes place, the blood rapidly collects between the dura mater and the bone. The patient usually regains complete consciousness, but the symptoms of concussion may, in some instances, become so merged with those of compression, that a differential diagnosis between compression from depressed bone, subcranial hemorrhage, and contusion of the brain, is impossible. (In such cases, the elevation of depressed fragments often gives vent to extravasated blood, which is then seen to have been the cause of the symptoms of compression, rather than the displaced bone.) Soon, generally within half an hour—although, when the flow is gradual, the brain accommodates itself to the pressure, so that many Fig. 1088. Punctured fracture of skull by a piece of glass, with wound of middle meningeal artery. (From a specimen belonging to Prof. Conner, of Cincinnati.) 1 The groove in which the vessel lies is often converted into a bony canal, thus rendering rupture of the artery almost certain when this portion of the bone is broken. 2 Although the primary separation effected by the blood is the chief factor in this condition, yet a collection of fluid blood, once formed between the dura mater and the bone, and communi- cating with an open artery, must, upon well-known hydrostatic principles, tend to extend, and to dissect off the membrane still further until clotting occurs. * S. W. Gross reports two cases, in private practice, with large clots, where the blood flowed freely from the trephine holes, despite the clots. 4 Hewett, op. cit. 5 Conner, Cincinnati Lancet and Clinic, Jan. 5, 1884. 46 INJURIES OF THE HEAD. hours or days may elapse—the patient becomes unconscious ; the respiration, at first laborious, usually becomes stertorous, while, at times, there is a peculiar whiff at the corners of the mouth; the pupils are either contracted or dilated—generally the latter—or one is dilated and the other contracted, but in any event insensible, or nearly so, to light; the pulse is full and slow; and there is paralysis, more or less complete, of the side opposite to the effu- sion, with diminution of its temperature. In addition, there may be retention of urine and involuntary discharge of feces. An epileptiform convulsion, after the interval of consciousness, may usher in the symptoms of compression. Prof. S. W. Gross reports the following instructive case:— A young soldier was struck senseless by a piece of shell, but soon recovered, vomited, and, although obliged to rest frequently, walked to the rear, a distance of nearly three miles. He appeared drowsy and unwilling to move, after each stoppage. He was per- fectly rational, was restless during the early part of the night, moaning so as to disturb his companion, but at the latter’s request keeping quiet, and in the morning seemed in a profound sleep. His comrade failing to rouse him, Dr. Gross was called, and found him in a state of profound coma, with a slow, stertorous, puffing respiration. The pulse was eighty-four, small and feeble; the “pupils dilated—the left nearly to its utmost extent—and completely insensible to light.” Slight left hemiplegia was noted, with contraction of the flexors of both arms. “ The left leg was firmly extended, power- less, and not so sensible to external impressions as the right, which was in the same condition, but to a less degree.” There was a lacerated scalp-wound, just below the right parietal eminence, without fracture. Death ensued after five hours, and, upon opening the skull, an enormous clot was found between the left parietal bone and the dura mater, completely filling the middle fossa of the skull, and thus compressing the left third nerve at the sphenoidal fissure. A linear fracture passed through the left spheno-parietal suture, dividing the bony canal inclosing the middle meningeal artery, which was torn. Corresponding to the site of the contused but unbroken bone, the brain was ecchymotie, and contained a small clot, “ the size of a hazel-nut.”1 This case teaches two important lessons, viz., that the effusion of blood may take place upon the side opposite2 to that of injury; and that rupture of the meningeal artery is apt to be complicated with contusion of the brain.3 An explanation is also afforded of the condition of the pupils. When the third nerve upon one side only is compressed, the pupil of that side will be dilated, while if the nerves of both sides are pressed upon, both pupils will be dilated. It is probable that where one pupil is dilated and the other really contracted—not merely in its normal condition—the nerve upon the side of dilatation is so compressed as to have its function abolished, while upon the side of contraction the effusion has simply irritated the nerve and exalted its func- tion. I dwell upon these minuter points because of the marked obscurity in the diagnosis of the injuries now under consideration. If the corpora quadri- gemina be either compressed or much lacerated, dilatation of the pupil occurs; a fact which must not be lost sight of, lest a severe contusion or laceration of the brain be overlooked. In exceptional cases there may be no loss of con- sciousness, and this condition may persist until shortly before death. The hemiplegia may also be imperfect, or may even be transient, with so large an effusion as three ounces poured out in the sphenoidal fossa.4 With large effu- sions there maybe no stertor; the pupils may be normal or nearly so; the pulse ma}’ he soft, compressible, frequent, or irregular; and paralysis may be absent or incomplete. 1 Loc. cit., p. 45. 2 Erichsen reports a similar case. (Op. cit., vol. i. p. 555.) * In twenty-five cases of large extravasations of blood between the bone and dura mater, observed at St. George’s Hospital, the brain was more or less extensively lacerated in every one. Hewett, op. cit., vol. i. p. 576. 4 Hutchinson, London Hospital Reports, vol. iv. p. 44. INJURIES OF THE BRAIN AND MENINGES. 47 Diagnosis.—It is important to note, first, that Duret has shown that, owing to the dura mater being freely supplied with sensory nerves mainly spring- ing from the fifth pair, certain symptoms are occasionally present when this membrane is irritated, which are also those of lesions of the brain-substance. As a guide in the differential diagnosis, I would, after Stimson and Duret, give the following points:— A slight injury of the brain-cortex will probably evidence itself, primarily, by exaggerated functional activity of the part, viz., muscular twitching, while from a destructive lesion, paralysis will result, and in both cases the abnormal symptoms will be on the side opposite to that of injury. Lesions of the dura mater are more apt to produce spasms and contractures of the voluntary muscles on the side of injury; “ they tend to become more or less general- ized, and involve the neighboring muscular groups; and never have the localization and voluntary appearance of contractions induced by lesions of the cortexfinally, paralysis never occurs. From the frequent coexistence of contusion and laceration of the brain,1 which, as we shall see, present symptoms closely simulating those of large suberanial effusions, a positive diagnosis is often impossible, especially in the exceptional cases just described. When, however, a patient receives a blow upon the head which stuns him, recovers consciousness for a variable but distinct interval, then becomes gradually comatose, and has opposite hemi- plegia, with dilated pupil and diminished temperature of the paralyzed side, the diagnosis is easy. Sir Prescott Hewett relates the following typical case:— A man came to St. George’s Hospital a few minutes after having been struck with a spade just over the anterior inferior angle of the parietal. A compound fracture with depression of a small piece of the skull was detected, with an entire absence of cerebral symptoms. In a short time, however, “ the patient became heavy and stupid, and coma was gradually supervening, when Mr. Keate arrived and at once proceeded to remove the depressed bone; whereupon a jet of blood spirted from a large branch of the middle meningeal artery, all the symptoms of compression were immediately relieved, and the patient recovered.”2 In every case of this kind, however obscure, if a distinct history of an interval of immunity from cerebral symptoms is obtained after a head injury, the presumption is that at least suberanial hemorrhage is present. If with this, one pupil is dilated, and we have a bruise, or even the history of a blow upon that side of the skull, the presumption almost amounts to a certainty. If now there are symptoms indicating involvement of the whole or a part of the motor area of the side of injury, with dilated pupil,3 we are warranted in affirming that there is an intracranial effusion of blood whose site we can define with reasonable accuracy, provided that there is an entire absence of the symp- toms of brain contusion, such as tonic spasm of the muscles, extreme restless- ness, etc.4 The symptoms of concussion are immediate and transient, and therefore cannot be confounded with those of effusion of blood. Compression symptoms after a depressed fracture will be immediate, if due to the dis- placed bone ; if of later development, they are probably due to effused blood. When the compression symptoms come on very soon after the injury, there is either extensive detachment of the dura mater, or some of the large men- ingeal branches have given way, or both conditions coexist. When a menin- 1 Erichsen (op. cit., vol. i. p. 555) reports two cases Where ruptures of the meningeal artery- resulted from most trivial injuries. 4 Hewett, op. cit., vol. i. p. 576. 4 See section on cerebral localization. 4 I am aware that many cases of brain contusion fail to give any such immediate or remote symptoms, but certainly when these symptoms are present, post-mortem examination will reveal contusion of the brain. When such symptoms are present, the accuracy of any diag- nosis of intracranial extravasation of blood is more than questionable. 48 INJURIES OF THE HEAD. geal branch is the source of the effusion, the clot is likely to be located at the side and base of the brain. Unless the shock and collapse are exception- ally prolonged, when the force of the circulation will not suffice to dislodge the clots in the torn vessels and overcome the resistance of the inverted vascular tunics, the delay of hours or days in the appearance of compression symptoms indicates a limited separation of the dura mater, and shows that the source of the hemorrhage is rather from the dural vessels than from the meningeal artery. Alcoholism may be differentiated by the thermometer, the temperature being markedly subnormal,1 and by the flushed, turgid face, instead of the pallor which attends severe injury. Drunken men with head injuries should be carefully watched until sufficient time has elapsed for recovery from intoxication, as there may be concomitant cerebral injury which otherwise might escape detection. Apoplexy, causing a fall, with a consequent scalp wound or cranial fracture, is a condition which would be impossible of recognition without the testimony of some eye-witness as to the fall having been produced by some precedent head trouble. In opium poison- ing, the pupils are both contracted to the size of a pin-point instead of being widely dilated, or one being dilated and the other only moderately contracted. Treatment.—To be of any avail, this must effect the removal of the blood already effused, and the prevention of further hemorrhage. The aid of the facts of cerebral localization must be invoked, together with a knowledge of the anatomical course of the two main divisions of the great meningeal artery. If the symptoms rapidly supervene, an opening at either the anterior inferior or the posterior inferior angle of the parietal bone, will probably reveal the source of hemorrhage, unless cerebral topography indicates some other point for the application of the trephine. When found, the injured vessel may be secured by plugging its bony canal with the point of a sharpened match, with a pellet of wax, or with a red-hot knitting needle. Early operation is indicated, since it affords the best prospect of success, as shown by results. Thus out of forty cases which I have collected in which operations have been performed under these circumstances, twenty-four have ended in recovery and sixteen in death.* Twenty-two were primary operations, of which number eight were fatal; two operations which were successful, were probably early, but I cannot ascertain the details; while of sixteen secondary cases, only one-half recovered. Several of the successful cases occurred within the past twenty years, thus refuting Mr. Hutchinson’s statement that no modern instances of success are on record. The cause of death is usually suppurative encephali- tis. If the dura mater does not rise up to the cranial level, the prognosis is bad, the dural depression probably indicating extensive injury of the sub- jacent brain substance. The trephine should be of large size, and should fluid blood issue from the first opening, and the source of hemorrhage not be detectable, one or more openings should be made along the course of the meningeal artery until the bleeding point can be reached. According to a statement in Dr. Keen’s edition of Mr. Holden’s “ Landmarks,” the vessel will be uncovered by a trephine applied with its centre-pin about an inch and a half behind the external angular process of the frontal bone, and the same distance above the zygoma. A number of the cases above referred to, were instances of depressed gunshot fracture from non-penetrating projec- 1 Agnew (op. cit., vol. i. p. 285) quotes Dr. B. W. Richardson to this effect. * S. W. Gross, fourteen cases (Am. Journal of the Med. Sciences, New Series, vol. lxvi. p. 45) ; Mouton, Dru, and Pineau (Quesnay, Memoirs of the Royal Academy of Surgery, Trans, by Ottley, pp. 8,12, 14) ; Physick (Gross, System of Surgery. 6th ed., vol. ii. p. 55) ; Conner (Cin- cinnati Lancet and Clinic, Jan. 5, 1884) ; Hennen (Military Surgery, Case XLIX.) ; Guthrie (Commentaries on the Surgery of War, 6th ed., p. 349); Keate (Holmes’s System of Surgery, 3d ed., vol. i. p. 576) ; Tatem (ibid.) ; S. D. Gross (op. cit., vol. ii. p. 55) ; Erielisen (op. cit., vol. i. 556) ; Larrey (Mil. Surg., vol. i. p. 306) ; Guthrie (Commentaries, pp. 315, 316), etc. INJURIES OF THE BRAIN AND MENINGES. 49 tiles; they are particularly instructive as giving the results of treatment of ruptured intracranial vessels, as nearly uncomplicated with cerebral injury as it is possible to conceive. Where an operation appears contraindicated, perfect quietude, cold to the head, purgatives, perhaps blood-letting, certainly an antiphlogistic diet, and the constitutional effect of mercury, should be tried. At a later stage of the case, iodide of potassium is indicated. I fear, however, that only a mistaken diagnosis will ever give time for such treat- ment, and that when cases of supposed marked extravasation between the dura mater and skull end in recovery, some other condition will have really existed. (2) Hemorrhage into the Cavity of the Arachnoid. —This is the most common site for traumatic extravasations of blood, which is found in the arachnoid cavity not only in the majority of severe head injuries, but “ also in cases where the injury has been a trifling one, and that without any apparent lesion either about the brain or its membranes.”1 The sources of the hemor- rhage are the vessels of the pia mater, with tearing of the visceral arachnoid ; the superficial cerebral veins; and the great sinuses ; and this form of extra- vasation may even coexist with effusion of blood from vessels between the dura mater and skull, the blood finding its way into the arachnoid cavity by a rent of the former membrane. In most instances the situation of the blood corresponds to the cerebrum, sometimes to the cerebellum, and very rarely to the medulla oblongata. Blood thus effused undergoes certain important changes, to which I would here call attention.2 At first after coagulation, the blood forms a membrane-like expansion which is accurately moulded by the parts between which it lies. When in large quantity it may cap both cerebral hemispheres. In time the coloring matter of the blood more or less disappears, when the decolorized clots present the appearance of membranes of varying hues, such as are found in the arachnoid cavity after head injuries, and were formerly erroneously considered to be of inflam- matory origin. “ In slight extravasations” only a mere film is found after the lapse of a few days, “ so delicate and so slightly tinged as easily to escape notice.” In most cases these false membranes are firmly attached to the parietal arachnoid, present a smooth, polished, serous-like surface, and are throughout supplied with numerous vessels, which are often detectable by the naked eye. Even as early as the twenty-third day, these characteristic appearances may be well marked. At first “ soft and pulpy,” these membranes may subsequently become “ leathery, fibrous, or even cartilaginous.”3 -Owing to the serous-like covering that these effusions early become coated with, there is a most deceptive appearance of the hemorrhage having been between the parietal arachnoid and the dura mater, thus stripping oft' the former. It has been only of late years that the French pathologists have pointed out the true nature of these appearances. Doubtless the organization of these clots is effected after the manner of those found after the ligation of arteries, so ably investigated by Rindfleisch and by E. 0. Shakespeare. When the effusion is large, instead of false membranes we may have true cysts formed, either single or multilocular, containing anything from the variously decolorized remains of the original clot, up to what appears to be pure serum. Recent clots may also be found, 1 Hewett, op. cit., vol. i. p. 576. 2 To Sir Prescott Hewett’s article On the Extravasation of Blood into the Cavity of the Arach- noid (Med.-Chirurgical Trans., vol. xxviii.), and to the same author’s article on Injuries of the Head, in Mr. Holmes’s System of Surgery, I am largely indebted, and would here once for all acknowledge the fact. 3 This refers merely to their physical, not to their histological appearances. 50 INJURIES OF THE HEAD. due to rupture of the newly formed vessels of the cyst. These cysts may con- tract more or less perfect adhesions to both layers of the arachnoid, but usually are firmly attached to the parietal arachnoid alone. They are more rarely found either attached to the parietal layer by a few filaments, or perfectly free in the arachnoid sac. They may be of large size, as one reported by Dr. Quain, which was seven and a half inches long and one and a half inches wide at its broadest part. The cyst had formed a corresponding depression upon the upper surface of the cerebral hemisphere.1 Xot confined to any age, these cysts when large compress and flatten the subjacent convolutions, and contract the area of the corresponding ventricle. If formed in early childhood, they have been known to produce bulging outward of the cranial bones.2 Yircliow has pointed out that some intra-arachnoid blood-cysts have their origin in ruptures of bloodvessels in newly-organized inflammatory false membranes. Symptoms.—These are not characteristic when the effusion is small, and even when large it may produce no very decided evidences of compression. The signs are apt to be masked by those of cerebral laceration, a common accompaniment of intra-arachnoid extravasation. Da Costa gives the symp- toms as “ ordinarily pain in the head, somnolency, and profound coma with paralysis, and without anaesthesia or slow pulse, but with relaxation of the muscles, and sometimes . . . convulsions.” When circumscribed or limited to one hemisphere, the symptoms are identical with those presented by effu- sions between the bone and dura mater. In most cases there is an interval of consciousness after the shock has been recovered from. When this is not so, there is probably extensive laceration of the brain, and the pulse is more apt to be rapid, small, and feeble, rather than slow, full, and labored. The respirations are, according to S. W. Gross, rather labored than stertorous. Marked inequality of the pupils is rare, and the hemiplegia is not as decided as in subcranial effusion. Diagnosis.—A differential diagnosis can, under the most favorable circum- stances, be only probable, and in most instances it is impossible. According to S. D. Gross, infants, “ before the completion of the ossific process,” suffer from intra-arachnoid effusion of blood, the results of blows upon the head. The “little patient lies in a state of insensibility, and is usually affected with convulsions, or spasmodic twitches, and perhaps some degree of stertor.” The scalp is commonly severely contused, but owing to the yielding nature of the bones, no fracture exists. The fontanelle appears to be elevated somewhat above its proper level, while pressure detects increased tension, and may increase all the symptoms, especially the tendency to convulsions. The prognosis is bad,3 for, even should recovery ensue, constant headache, irritability of temper, epilepsy, or insanity, may result.4 Treatment.—In most cases this must be that of other severe injuries of the head—the use of local cold, blood-letting, mercurials, and the iodide and bromide of potassium, as may seem indicated. In a few rare instances, where, owing to circumscription of the effusion, the symptoms resemble those of effusion between the dura mater and the bone, trephining may be resorted to, and the operation lias been successful in a few such cases. After the disk of bone has been removed, the dura mater bulges into the opening, is of a bluish 1 Trans. Path. Soc. Lond., vol. vi. p. 8. 2 Lancet, vol. i. p. 416. 1846. 3 An effusion equal in bulk to one-sixth or even one-fifth of the cranial capacity seems neces- sary, of itself, to produce death. 4 Diet, de Med. et de Chir. prat., t. xi. p. 407 ; Blandin, Anat. topographique, 2me ed., p. 36. 1834; Holmes’s System of Surgery, 3d ed., vol. i. p. 579. INJURIES OF THE BRAIN AND MENINGES. 51 appearance, and is devoid of pulsation. The membrane should then be incised to give free vent to the effused blood.1 In at least two reported cases, this bulging of the dura mater did not take place for hours—in one case thirty- six2—after the trephining. In the cases which occur during infancy, the elder Gross recommends leeching and cold to the head, stimulating enemata, and brisk purgatives when the child regains the power of swallowing. Fail- ing by these means to afford relief, he advises making a crucial incision over the fontanelle, and puncturing the “ distended, and perhaps purple-looking membrane,” making as small an aperture as will suffice to effect the purpose in view, after which a careful application of adhesive strips, compresses, and roller bandages must be made. In conclusion, as to operative measures, re- cognizing as I do the extreme difficulties presented by the diagnosis, and the small percentage of success attendant upon operative procedures in intracra- nial extravasations of blood, I think that three facts cannot be denied, viz., that in a certain proportion of cases life has been saved by trephining; that post-mortem records show that a number of patients have perished from intracranial extravasation of blood, who could probably have been saved by timely operation; and that trephining in such cases, though it fail to afford relief, cannot be said to measurably reduce the chance of recovery. I cannot but feel that too many cases are allowed to pass without operation, some few of which might be rescued if the surgeon were not deterred—as is too often the case—rather by considerations of what will be said if an unnecessary operation be performed, than by sound surgical contra-indications. Practi- cally, every case which recovers after the removal of extensive intracranial blood-effusion, may be considered as one which otherwise would have died, as clinical records show that such cases almost never terminate favorably. (3) Hemorrhage into the Pia Mater.—These extravasations occur much more rarely than those of the preceding variety, and are usually accompanied by some degree of cerebral laceration. Confined beneath the arachnoid, they spread far from their original source, until even the whole cerebellum and spinal marrow may thus be covered with blood proceeding from a laceration of the cerebrum only. Effusions of blood into the pia mater never become encysted, as far as I can ascertain. Symptoms.—This condition presents no symptoms, at present known, which can be relied upon. In most cases of hemorrhage upon the surface of the brain, the patients are said to have been comatose, and to have given no evidence of partial paralysis. Treatment.—As operative interference is out of the question, from the im- possibility of removing the blood already poured out, or, even if that could he done, of preventing further effusion, such remedies as are appropriate for other severe head injuries should be resorted to. (4) and (5) Hemorrhage into the Brain and Ventricles.—Large effusions into the structure of the brain may result from severe head injuries, as well as hemorrhage into the cerebral ventricles. Caution must be exercised lest cases of apoplexy from diseased vessels, either producing the fall which ap- pears to be the cause of the head symptoms, or rendering possible a large effusion from a slight injury, should be confounded with traumatic hemor- rhage in either of the situations just mentioned. Should the patient survive long enough, an unusual event from the severity of the concomitant intra- cranial lesions, the effused blood undergoes the well-known changes of a simple apoplectic effusion. 1 Successful cases are reported by Morand (Opuscules de Chir., tome i. p. 171. Paris, 1768), Ogle (Brodie, Med.-Chir. Trans., vol. xiv. p. 391), and others. Three cases are given in Bruns’s Handbuch der praktischen Chirurgie, Abth. i. S. 931. (Gross.) 2 Agnew, op. cit., vol. i. p. 286. 52 INJURIES of the head. Symptoms.—These are essentially those of apoplexy, such as marked coma, etc., with perhaps convulsions in a few cases. Treatment.—This, as in apoplexy, must be purely medical, and need hardly be further enlarged upon. Wounds and Ruptures of the Great Venous Sinuses.—Those most com- monly injured are the superior longitudinal and lateral sinuses. The mere shock of a violent blow upon the cranium may lacerate these vessels, but they are more frequently ruptured by separation of sutures. Penetration by the fragment of a depressed, comminuted fracture is the usual cause of wounds of the great sinuses, but penetrating wounds of the skull by pointed instru- ments or bullets may also injure these venous channels. I am led to thus specially treat of these injuries, on account of the general impression that the hemorrhage following them is usually fatal. So far is this from being true, that Pott actually bled successfully from the longitudinal sinus. Warner, Pott, and Lister, report cases where wound of this sinus was readily recovered from. In all such cases, either the application of the trephine or the elevation of fragments has given free access to the wounded vessel. Where the opposite conditions obtain, a fatal hemorrhage does at times occur. I am cognizant of one case where a prominent surgeon, while operating for a comminuted depressed fracture of the occipital bone, withdrew a pointed fragment which had been driven some distance beneath the sound skull, thus plugging a distant wound of the lateral sinus. Death resulted in a few minutes from the uncontrollable hemorrhage. I have examined the speci- mens from a fracture of the vertex, where the patient similarly perished upon the withdrawal of a depressed fragment. In basal fractures the hemorrhage from rupture of the sinuses may be very profuse. Thus in one case reported, it was estimated that between thirty and forty ounces were lost from the ear in the course of a few hours. Treatment.—Where this injury is suspected in a case of compound fracture, from the propinquity of the lesion to the course of a great sinus, I would suggest that the trephine-cut, or removal of bone necessary to elevate the fragments, be so planned as to give free access to the sinus should it be found wounded. This can usually be safely done, for the injury will have probably separated and depressed the dura mater so as to keep it clear from the teeth of the in- strument. In nearly all the cases where the wound has been accessible, the application of a little dry lint, with the pres- sure of the finger, has at once arrested the flow. Lister filled an opening in the longitudinal sinus with a bunch of catgut ligature, and J. H. Brin ton seized the lips of a wound of the lateral sinus with forceps, and tied it with fine silk. The only wound of a sinus which has occurred in my own prac- tice, was that of the right late- ral sinus, from a small pistol- ball. I suspected it from the history of a free flow of blood, Fig. 1089. B, opening made by ball in bony and membranous wall of late- ral sinus ; DD, portions of dura mater and sinus walls ; L, lateral sinus with portion of its membranous wall removed; P, portio dura and portio mollis of seventh nerve. INJURIES OF THE BRAIN AND MENINGES. 53 and from the course pursued by the ball through the mastoid process. No further hemorrhage took place, the ball was supposed to have penetrated the brain deeply, and the patient died of pyaemia. Post-mortem examination revealed that the missile had just penetrated the sinus, and had plugged the opening, which finally became so enlarged by ulceration as to permit the ball to tall into the lumen of the sinus, out of which it rolled when the vessel was opened. Although not recommending such a procedure when it is avoid- able, the ease with which hemorrhage from these venous channels can be arrested, proves that, as far as bleeding goes, trephining can be safely per- formed over the course of either the longitudinal or the lateral sinus. Concussion, Contusion, Compression, and Laceration of the Brain.— Certain preliminary anatomical facts must be considered, and a brief glance taken at the result of Buret’s experiments,1 before a clear idea can be ob- tained of the pathology or phenomena of concussion, cerebral contusion, and laceration. Buret’s observations on injuries of the dura mater have already been adverted to. The skull forms an exceedingly elastic case; in proof of which fact, an expe- riment of Felizet2 need alone be adduced. He tilled a skull with melted paraf- fine, which was allowed to cool. The skull was then dropped from the height of tyvo and a half feet, and examined. Opposite the point of impact, the paraf- fine was depressed for an area of more than an inch, the centre of the depres- sion being one-third of an inch in depth, or, in cubic measure, 0.13 of a cubic inch, which was a very considerable amount for such a moderate blow. The cerebro-spinal fluid is, roughly speaking, divided into two parts, viz., the ventricular and peripheral, communicating with each other by the narrow foramen of Magendie at the lower end of the fourth ventricle. The major part of the ventricular fluid is collected in the lateral and third ventricles, communicating with the smaller quantity in the fourth ventricle through the contracted iter e tertio ad quartum ventriculum. The relative bulks of these two portions must be kept clearly in mind. The peripheral portion begins in, or is continuous with, the lymph-sheaths of the fine cerebral arterioles, a fact never to be lost sight of, as it explains disseminated con- tusion of the brain. The spaces between the convolutions communicate on the one hand with the minute arterial lymph-sheaths, and on the other with larger sacs, the chief of which are located at the base of the Sylvian fissure, a central one at the base of the brain, an inferior cerebellar behind and below the cerebellum, and a terminal sac at the inferior extremity of the spinal cord. The inferior “ cerebellar lake”3 communicates with the fluid of the ventricles through the foramen of Magendie. The subarachnoid space in which is con- tained the cerebro-spinal fluid, really consists of a delicate meshwork sup- porting the thin-walled bloodvessels. I. Concussion of the Brain.—Concussion is the term used by Buret to indi- cate the symptoms of a sudden arrest, or suspension, of the cerebral functions, by force transmitted through the cerebro-spinal fluid to more or less distant portions of the brain, mainly, he thinks, to the fourth ventricle. The import- ance of Buret’s experiments must not be pressed too far, but they certainly indicate the manner and points at which much less severe lesions may, and, as will be seen, do, occur in man. The elastic skull, yielding to the blow, com- presses the cerebral hemispheres and the peripheral cerebro-spinal fluid. The 1 Etudes experimentales et cliniques sur les traumatismes cerSbranx, tome i., 1878. 2 Recherches anatomiques et experimentales sur les fractures du crane. Paris, 1873 8 This is Duret’s term. 54 INJURIES OF THE HEAD. compression of the hemispheres drives the larger fluid contents through the communicating passage into the fourth ventricle, which is of small capacity, the result being, as Duret found, a rupture of the median line of its floor, and a dilatation of the Sylvian aqueduct and the central canal of the cord. This could not occur, according to hydrostatic laws, if the peripheral fluid was as free to move as the intra-ventricular. What does clinical and post-mortem experience show ? That such appearances, much less marked to be sure, are occasionally seen after death, and that similar, but slighter, evanescent lesions would explain in a perfectly satisfactory manner some of the clinical symptoms of concussion. What, however, do we more commonly see in autopsies of con- cussion cases ? Intra-arachnoidean extravasations and effusions of blood into the meshes of the pia mater, with contusions of the brain-substance. Duret shows that these are due to the waves communicated to the subarachnoid fluid, which distends the meshes supporting the bloodvessels, thus resulting in the latter’s rupture. This satisfactorily explains the causation of many of these extravasations, but some of these injuries are due to direct transmission of vibrations through the cranial walls. From the wide distribution of the cere- bro-spinal fluid, it is clear how force acting upon and through it, produces disseminated lesions. Recalling the fact that the small cerebral arterioles are surrounded by minute prolongations of the subarachnoid space, that is, lymph- sheaths, a ready, and indeed the only, satisfactory explanation of the dissemi- nated form of minute cerebral extravasations is at once found. The impulse of the blow causes distension of the perivascular sheaths, whereby the arterioles are directly compressed, and the capillaries indirectly through the brain-sub- stance ; when the pressure is rapidly removed, as when the force ceases to act, “ the vessels burst from the unopposed tension of their contents.” An equally beautiful explanation of most of the symptoms of concussion is afforded by Duret’s observations. From contraction of the arteries, resulting from spasm of their muscular coats, the venous tension at once falls,' producing an in- tense cerebral anaemia which causes the primary loss of consciousness. The spasmodic arterial contraction1 is followed by a paretic dilatation which may prolong the loss of consciousness. If this be followed by a generalized inflammation, the unconsciousness may be prolonged until death. Viewed in the light of these experiments, further explanation of the phe- nomena of cerebral concussion will be unnecessary, and I shall define concussion of the brain as “ An assemblage of symptoms by which we recognize that a sudden arrest or suspension of the cerebral functions has taken place, the result of a commotion of the cranial contents, which may be produced, directly, by force applied to the head, or, indirectly, by an impulse transmitted through the spinal column, as by a fall from a height upon the feet, knees, or but- tocks.” Many authors teach that slight cerebral concussion, as evidenced by a momentary loss of consciousness and muscular power, followed by an apparent immediate return to the normal state, is produced by “cerebral vibration without visible lesion,” and is due to “a simple molecular disturbance of the 1 Huguenin, following Fischer, teaches that concussion is due to a reflex paralysis of the intracranial vessels, the result of a powerful peripheral irritation. Ansemia of the arteries and hypersemia of the veins, he says, are the only constant post-mortem appearances found in con- cussion. (See Ziemssen, op. cit., vol. xii.) Duret maintains that there is an intense spasm of all the muscles in concussion, which is so transient as generally to be overlooked, but the vas- cular spasm, from contraction of the muscular coat of the arteries, is more persistent; obstruction is offered to the blood-current: the tension in the veins is enormously decreased ; and most marked anaemia of the brain, with the primary symptoms of concussion, results. The congestion is secondary, the result of paretic or inflammatory dilatation from the irritation of the numerous hemorrhagic lesions. It will be thus seen that the latest experimenters have practically arrived at the same results. INJURIES OF THE BRAIN AND MENINGES. 55 cells.” This view is the outcome of the histories of several imperfectly recorded cases, where there was no proof that the cause of death was not situated far distant from the head. These were cases of instantaneous death without per- ceptible lesion of the brain or its membranes; wherefore, argue the vibratory theorists, this absence of all lesion must be still more true for the cases where recovery ensues. Unfortunately for the theorists, neither the spine nor the heart was examined in the cases referred to. Littre’s case is eminently sug- gestive of death from a broken or dislocated spine.1 Hewett gives two illus- trative cases, showing how careless post-mortem examinations tend to perpet- uate false theories of disease. One or more of the conditions found in these cases probably existed in those in which instantaneous death was supposed to have resulted from pure cerebral concussion, without any post-mortem evidence of injury to the brain or its envelopes. A man was admitted into the Hopital St. Antoine, having fallen from a great height upon the pavement. He was collapsed and insensible, but presented neither paralysis nor muscular spasm. After some hours he died. Upon post-mortem examination of the head alone, not a trace of injury was detected in any of the cranial contents, and the case was considered one of death from cerebral concussion. Fortunately, Dr. Deville, hearing of the absence of all lesions, proceeded to lay open the spinal canal, which he found filled by an extensive extravasation of blood, extending even beyond the point where the spinal cord had been divided when removing the brain.2 Hewett also relates the case of a boy suffering from concussion of the brain, whose intracranial contents showed comparatively trivial lesions, while an examination of his chest, which outwardly bore no evidence of traumatism, showed a rupture of the muscular tissue of the septum of the cardiac ventricles, extending up to but not through the serous covering. But what does actual post-mortem examination show to be the condition in slight cases of concussion, where death has ensued within a short time from other injuries? In two cases reported by Hewett, where “symptoms of concussion of the slightest nature had altogether passed off within a very short time,” the brain-substance itself was actually injured. In the first, where there had been mere “giddiness” from a blow upon the head,followed by complete recovery, patches of contusion were found at the base of the brain, in two or three places, of the size of a shilling; these patches consisted of minute specks of blood closely grouped together, extending about a line in depth into the brain-substance. The second case was one where, after a fall upon the back of the head, the concussion-symptoms soon disappeared, and death resulted from another disease eight days subsequently. Thin layers of coagulated blood were found firmly adherent to the parietal layer of the arachnoid, while the larger veins upon the cerebral surface were congested, as well as the brain-substance itself, which was rendered much darker from this cause. In the “centrum ovale, close to the right side of the corpus callosum, and extending partly into it, was an extravasation of blood of the size of a nut.”3 The experiments of Fano upon dogs killed within a few minutes of their recovering consciousness after a stunning blow, show that in the absence of any other lesions most extensive congestion results. Buret’s experiments, already quoted, are still more conclusive. Finally, in a case closely resem- bling that of Littre, already quoted, widespread congestion was discovered. Arrested, and failing in his efforts to ge.t away, the man dashed himself head-foremost against a wall, his hands being tied behind his back. He was picked up immediately afterwards, perfectly insensible, and died three-quarters of an hour after the injury 1 (Euvres de Sabatier, tome ii. p. 400. 2 Mem. de la Soc. de Chirurg. de Paris, t. iii. p. 180. (Hewett.) 3 Hewett, op. cit., vol. i. p. 601. 56 INJURIES OF THE HEAD. As far as the brain itself was concerned, there was not even a speck of extravasation either on its surface or in its substance, the consistence of which was perfectly natural. But the intense congestion of the vessels of the brain gave rise to a manifest alteration in the color of its structures, its cut surfaces being thickly studded with the minutest blood-points, from whence specks of fluid blood oozed upon gentle pressure.1 What, then, are we to conclude from such evidence as this ? Surely, that there is probably no such thing as “cerebral vibration without visible lesion.” Certainly my own clinical experience of cerebral concussion has led me to believe that there is some brain-lesion in every case of concussion, however slight it may be. Where no actual extravasation of blood takes place, the paresis of the vascular walls, which, as Duret has shown, follows the primary spasm, produces a congestion which may be evanescent—perhaps of only a few hours’ duration—but which, I think, always exists. Careful scrutiny of the histories and post-mortem records of an extended series of cases, has convinced me that in all cases of so-called concussion of the brain, we have in reality either a disseminated congestion of the organ, or contusion of some portions of its structure. Even in the slightest cases, we may have, as just shown, intra-arachnoid extravasation and ecchymosis of the brain-substance. It is time that the surgical mind should disembarrass itself from the old magisterial views so long taught; since from erroneous views of pathology, bad practice is sure to ensue. The later symptoms of concussion usually detailed, are in reality those of either congestion, contusion, or laceration of the brain-substance—perhaps of all three. In accordance with the parts chiefly injured, so will be, in all probability, the symptoms, although no finely drawn diagnosis can commonly be made, owing to the probably extended nature of the lesions, and the interdependence of the various portions of the brain, both anatomically and physiologically. From these remarks, it must be clear that no table of distinctive symptoms can be given, whereby concussion and compression may be differentiated ; since the so-called symptoms of concussion are really those of widely differ- ing lesions of the intracranial contents, varying from a transient paretic congestion to cerebral ecchymosis and laceration. The exceeding variety, in fact the absolute want of constancy, presented by the symptoms of concussion, as to the pupils, the sensorium, etc., clearly indicates that we are dealing with different structural conditions, which the post-mortem room has demon- strated over and over again; yet a recent writer describes as a case of fatal concussion, one in which blood extravasation was discovered in the medulla oblongata. * Symptoms of Concussion.—Should the lesions be entirely or chiefly confined to mere temporary circulatory changes, the patient will probably be either unconscious, or only giddy, for a few moments after a head injury ; will get up spontaneously, or with slight assistance ; will experience bewilderment of mind; will be unable to collect his thoughts; will have a pale face; and will experience facial sweating, nausea, and perhaps vomiting. In a short time these symptoms will disappear, and the patient will be able to walk, with perhaps slight tremulousness of the limbs; and in a few hours he will be well. This is the rule; but the reader will recall a case just cited, where, with much less evidence of cerebral injury, marked contusion of the brain- tissue existed. In severe cases, however, we have a much more serious condition. The patient is utterly insensible—pulseless, perhaps—with pallor of countenance, the only evidence of life being a hardly perceptible respiratory effort. Tho surface is cold, the limbs relaxed, the pupils normal or dilated, or one dilated 1 Denonvilliers, Compendium de Chirurgie, tome ii. p. 606. (Hewett.) INJURIES OF THE BRAIN AND MENINGES. 57 and the other contracted, and, in any event, responding slowly, if at all, to light. Hemorrhage from the nose is said by Gross not to be an uncommon symptom, and even bleeding from the ears may occur in rare cases, without fracture. If recovery is to ensue, the respiration becomes re-established, at first feeble and intermittent, interrupted by sighing, and then, perhaps—accord- ing to the cerebral lesions—noisy or labored. The circulation is feeble and irregular. The urine is usually retained, although there may be inconti- nence both of urine and feces. The skin is bedewed with a clammy sweat, and the temperature is subnormal, from 94° to 97° F. The special senses are obtuse, the patient usually lying with wholly or partially closed lids, or, when the eyes are opened, apparently not noting visual impressions. By loud shouting and shaking, the patient may be aroused enough to open his eyes and answer in a few short words. This condition, usually described as that of shock or collapse, may last only a few minutes, or hours, or even days. Indeed, the patient may only partially react, to finally die of collapse, apparently, although post-mortem examination will usually reveal extensive brain lesions. If reaction takes place, vomiting is apt to occur, the pulse regains its tone and is less frequent and irregular, the skin becomes warmer and drier, the pallor of the face disappears—giving place perhaps to a flushed countenance—while the mental hebetude is succeeded by the normal condi- tion, or by vertigo, headache, or delirium—in rare instances so violent as to require restraint.1 Reaction may be succeeded by convulsions in children, and. even in adults, or either a partial or general muscular tremor is observed.2 The moment that reaction transcends a mere return to the normal state, the symptoms cease to be those of concussion—that is, the immediate effects of vibration of the intracranial contents—and at once become the expression of some damage inflicted upon the encephalon by the vibratory waves. I might proceed to describe a variety of time-honored symptoms said by authors to be due to cerebral concussion, but the reader will see that I have already detailed symptoms which are indicative of extravasation of blood, either into the substance of the brain, or upon its surface. In conclu- sion, there is no symptom, or set of symptoms, invariably present in concus- sion of the brain. The pulse may be normal, slow, or frequent, and the respirations may be feeble, noisy, or stertorous, although the general account which I have given will apply to the majority of cases. The explanation of these variable phenomena lies in the fact that the cerebral centres of respira- tion, or of the heart, may be compressed, irritated, or partially destroyed.3 I believe with Sir P. Hewett, that many of the cases of concussion which have a prolonged convalescence, are in truth cases of extravasation within the arachnoid sac.4 I must again insist, at the risk of tediousuess, that tran- sient or persistent partial paralysis, loss of memory, etc., are not due to con- cussion—that is, to vibration of the brain-substance—but are the expression of some physical lesion ot the cerebrum produced by that vibration. The surgeon should be aware that, after reaction from concussion, con- vulsions and various brain maladies may set in, which, although appa- rently due to the injury, are, in many cases, merely a rekindling of old disease. Thus Callender relates a number of cases where old epilepsies 1 Callender, St. Bartholomew’s Hospital Reports, vol. iii. pp. 416—418. 2 In one case of Callender’s, what were supposed to be convulsive movements of the right arm were observed. One of the man’s companions explained that he was only “ steering his boat such facts must be kept in mind as explaining certain peculia- ities of the delirium of concussion. 3 See Agnew, op. cit., vol. i. p. 278 ; also Callender, Anatomy of Brain Shocks (St. Bartholo- mew’s Hospital Reports, vol. iii. p. 415. 1867) ; and Remarks on the Principal Injuries of the Head, etc., in the Hull General Infirmary (ibid. p. 234). 4 See Hewett, op. cit., vol. i. p. 602, for two conclusive cases. 58 INJURIES OF THE HEAD. returned temporarily with unparalleled violence, to again subside. Inquiry should always be made of friends or relatives as to the previous history of patients with head injuries. I lately assisted Dr. C. K. Mills and Dr. Healy in making a post-mortem examination of the brain of a young man, aged 19, who had been stunned by a horse-kick in the face, three weeks prior to his death. Upon opening the head, recent meningitis with serous effusion was found, and two small syphilitic tumors of the brain-substance. Here the concussion set up such a degree of congestion and irritation as to render fatal a disease of long duration, which had been quiescent and utterly unsus- pected. The head symptoms were first noticed by the patient just about a week after the injury, that is, at the time that intracranial inflammation usually declares itself to the patient, although the physician may perhaps detect its onset at an earlier date. Prognosis of Cerebral Concussion.—This should always be guarded. Rapid reaction, vomiting, restored intelligence, normal special senses, absence of severe or constant headache—especially if these negative symptoms persist for some days after the sixth, the usual time of advent of intracranial inflam- mation—are all encouraging symptoms. Prolonged collapse, relaxed sphinc- ters, a weak, rapid circulation, progressive stupor, and heavy, labored respi- ration—that is, symptoms indicative of serious cerebral lesion—are almost certain harbingers of death. A relapse into stupor after regaining conscious- ness, repeated convulsions, and subnormal temperature, are bad signs. “ Marked restlessness, screaming, and a rapid pulse,” Agnew thinks, are “infallible evidences of approaching death.” Excessive reaction, a full, rapid pulse, violent headache, delirium, and intolerance of light and sound, are— as indicative of impending, if not of actually present, intracranial inflamma- tion—symptoms of the utmost gravity. Treatment.—In the stage of collapse, warmth along the spine and to the feet, with sinapisms to the epigastrium, usually suffices. As we never can be sure whether we are not dealing with a case of intracranial extravasation of blood, or a contused cerebrum, stimulants must be resorted to as little as possible, since under such circumstances “ a period of depression would be the safeguard of the patient.” (Hewett.) If, however, death seems impend- ing, they must be cautiously resorted to.1 I prefer hot coffee, which is a good cardiac stimulant, then carbonate of ammonium, and lastly alcoholic preparations, which, on account of their being more readily obtainable, are those upon which we most commonly have to fall back.2 Prof. Gross re- commends the use of stimulating enemata, such as those containing oil of turpentine, etc., but I have had no personal experience of their use in cerebral concussion. Whiskey or ether may be injected subcutaneously if the patient cannot swallow. After marked depression, marked reaction is apt to result, although they are not always proportionate. Reaction within moderate limits should not be actively interfered with. Perfect quietude of mind and body should be enjoined. Ice, or evaporating lotions, should be kept constantly applied to the head, which, if the case be a serious one, should he shaved. The head and shoulders should be kept slightly elevated. A mercurial, followed by a saline purge, should 1 As the senses are so obtuse, great care must be exercised in the administration of fluids by the mouth, lest they gain access to the air-passages, thus producing suffocation. The same may be said concerning strong smelling-salts, aqua ammonife, etc., which it is often advised should be held beneath the patient’s nose. Laryngeal spasm and subsequent irritation of the air-passages may result from their careless use. 2 Stimulants, if given even in small quantities at too short intervals, may be unabsorbed in the stomach during collapse, to be absorbed as one large dose when reaction sets in, producing, possibly, a dangerous degree of cardiac action. INJURIES OF THE BRAIN AND MENINGES. 59 also be at once administered, and repeated when necessary. If there have been no serious loss of blood, water alone should be given for the first forty- eight hours, or, at most, milk with lime-water. As has already been pointed out, even with no other lesion there is intense cerebral congestion, rendering the affected parts of the brain of an obviously darker hue in those cases where death from other causes permits post-mortem examination. This clearly indicates what is the chief danger of these cases—viz., a distinct predisposition to inflammation, and against this probable result all our efforts must be directed. My invariable rule has been to treat the slightest cases of cerebral concussion as serious, and though much complaint on the part of the patients has resulted, I have never seen cause to regret the course pursued. Bleeding is never indicated in the stage of depression, and I have never had occasion to resort to it even in that of reaction. At a later period, if there are marked delirium, fever, and flushed face, in a robust patient, bleeding from the arm or wet-cupping will prove beneficial. Some surgeons advise small doses of mercurials to affect the system. I see no objection to their use. Bromide of potassium or the deodorized tincture of opium, in repeated small doses, is useful for excessive restlessness or wake- fulness. With the subsidence of the acute symptoms, or if exhaustion super- vene, a more generous diet must be prescribed, with a cautious resort to stimulants. During convalescence, tonics are sometimes useful. The recum- bent posture, gradually changed for the upright by pillows or a bed-rest, should be enforced for at least ten days or two weeks after apparent convalescence has set in. II. Contusion op the Brain.—Bruising of the brain may be either circum- scribed—the more common variety—or disseminated. In the slighter forms of circumscribed contusion, the injured part is seen to be of a dark-purplish color, this coloration being dependent upon numerous, closely-set, minute specks of extravasated blood no larger than pin-points. As the periphery of the ecchymosis is approached, the depth of coloration decreases, owing to the increasing dissemination of the minute extravasations. The cineri- tious portion of the brain is alone atfected in this variety. The consistence of the brain seems but little, if at all, altered, as a gentle stream of water affects neither its color nor firmness. These remarks apply to an examina- tion made within a short time of the injury. The more severe cases have the central portions of the ecchymosis infil- trated with blood, so that they present a uniform, dark-purple color. Both the white and cineritious portions of the brain are involved. Instead of the pin-point extravasations, in the central portions, small clots of blood of varying size are found, while the periphery presents a series of smaller ex- travasations more and more widely separated. The cerebral structure is torn and disorganized, as shown by the effects of the impact of even a gentle stream of water, which loosens and washes away the clots, “ leaving little pits with irregular and shaggy margins, and thickly studded throughout wffth pin-point extravasations.” (Hewett.) Examined a few days after the injmy, the bruised part will be found to present an irregularly depressed surface, with sharp, ragged borders. The surrounding brain-surface will be probably tinged yellow, with subordinate yellow circles surrounding the lesser extravasations. Either of these two forms of brain-contusion may be found alone, but they much more commonly coexist in the same brain. In the slighter cases, the meshes of the pia mater contain more or less extravasated blood in the form of small clots. The visceral arachnoid, with the pia mater, are usually torn in the more severe cases, in which event the cavity of the arachnoid contains extravasated 60 INJURIES OF THE HEAD. blood in varying quantity, besides that poured out into the meshes of the pia mater. Sir P. Hewett reports that in sixty-nine autopsies of more or less severe brain contusions, “ independent of compound fractures,” intra- araclmoid blood-extravasations were found in fifty-two, thirty-one of these being very extensive. In eleven cases, blood was found infiltrating the pia mater for some distance beyond the actual brain lesion, and in six instances u the extravasation was widespread.” In the remaining six cases only, was the extravasation in the pia mater insignificant in amount, and limited solely to the site of the brain-injury. The whole cerebral mass is not equally liable to contusion, some portions being almost constantly bruised in severe head-injuries, while others are so rarely affected as to be almost exempt. This statement is true as autop- sies are usually conducted, but it is of importance to note that those por- tions of the encephalon said to be most rarely injured, such as the pons, crura, and medulla oblongata, may present at the autopsy no external evidences of injury, while careful sections will demonstrate well-marked spots of extra- vasation. From this fact I am inclined to think that many extravasations are overlooked, especially as Duret has experimentally shown that the floor of the fourth ventricle is peculiarly apt to be injured when severe blows are inflicted upon the head.1 The medulla oblongata and the crura of the cere- bellum and cerebrum are but rarely the seat of extravasations, and when so injured, intra-arachnoid extravasations are apt to coexist. The pons Varolii is an occasional but rare site of bruising. The cerebellum is quite commonly contused, its under-surface being that portion which is usually injured. The ecchymotic spots are usually small, superficial, and confined to one lobe, although larger extravasations into the deeper parts have been observed, as in a case mentioned by Ilewett, or as in one of Blandin’s, where multiple minute spots were found scattered through- out the organ. These injuries are apt to accompany lacerations and contu- sions of other portions of the brain, although they may be occasioned by slight injuries, such as a drunkard's fall in the street. The cerebrum is more commonly bruised upon its under surface than elsewhere. The extent of injury varies from a few patches of contusion to an extensive bruising of the entire surface of one, or even of two lobes at the same time.2 Both the cortical and medullary structures may be extensively involved, to such an extent as even to lay open one of the lateral ventricles. The extent of injury done to the cerebral substance is not always commen- surate with the degree of force applied. Thus, a case is reported, where, after a fall from a height of only about eight feet, extensive bruising and laceration of the anterior lobes of both hemispheres occurred, and produced a tear into the right lateral ventricle large enough to readily admit the finger. In addition, the deeper portions of the cerebrum may be bruised; and this, too, in some instances, without any injury to the exterior of the organ, or at least without injury corresponding in position to that of the deeper parts. Any portion of the brain is liable to injury, which may be so limited in extent as to escape anything but the closest scrutiny. The septum lucidum was in one case found bruised and torn for nearly its whole length, with spots 1 A case is reported in the Lancet for Nov. 30. 1878 (page 769), from the practice of Verneuil, in which sudden death followed a severe head-injury, and in which the autopsy revealed sub- arachnoid hemorrhage at the “bulb and protuberance.” On opening the fourth ventricle, a small central focus of hemorrhage was found in its floor, with two others, one on either side of the median line. These appearances are precisely those observed in Duret’s experiments on concussion. 2 The term lobe here is iised in the sense of the older anatomists, where each hemisphere is divided into an anterior, middle, and posterior lobe. INJURIES OE THE BRAIN AND MENINGES. 61 of extravasation in the remainder of the septum, and in the back part of the fornix. Ko other brain laceration was found, although blood was poured out in small quantity into the arachnoid sac and pia mater at several points. I am thus particular in quoting cases—to which I shall presently add others— because they demonstrate how readily serious injury to the brain may be over- looked, unless the most minute and skilful sectio cadaveris be performed, and how the error of “ concussion without cerebral injury” may be thus perpetu- ated. The only injuries in the cerebral mass which could be detected in an- other case, were a minute extravasation of blood in the edge of the fornix, a second upon its under surface, and “ several specks” upon the surface of the thalamus. In addition, there were extravasations into the pia mater, over the posterior lobes of the cerebrum and the back part of the cerebellum. In still another case, an extravasation of the size of a nut was detected in the right centrum ovale, close to the corpus callosum. This coexisted with several thin layers of extravasated blood in the arachnoid sac. Finally, I would call attention to the post-mortem appearances presented in a fourth case, as illustrative of how serious the results of an apparently trivial lesion may be. Sir Prescott Hewett states that there is, in the museum of St. George’s Hospital, a specimen in which the ventricle was filled with blood from the laceration of a large vein, produced by a slight rent in the septum lucidum, which also involved the floor of the left lateral ventricle. In the disseminated form of cerebral contusion, the foci of extravasated blood, instead of being grouped together, are widely diffused throughout the brain, involving not only the surface but the deeper portions of the organ. In rare instances, the deeper parts may be alone involved. The diffused form of contusion of the brain is a very rare affection, and one not easy of detection, being doubtless often passed by for want of a careful scrutiny of the parts. Diffused contusion of the brain presents itself in the form of minute foci of extravasated blood scattered through the cerebral substance. The size of the extravasations varies from that of the smallest pin-point to that of a split-pea. When of the latter size, the condition will hardly be overlooked, but with the minute variety, the spots are apt to be mistaken for the orifices of cerebral vessels. The two conditions can be readily differentiated by remembering that if the appearances are due to the gaping orifices of divided vessels, the specks can be readily wiped away, the spots reappearing if gentle pressure be made upon the brain. Miliary extravasations cannot be wiped away, and when picked out with the knife-point leave little depressions in the brain- substance. If examined within a short time after the injury, the brain-sub- stance is normal in appearance around the extravasations, but when viewed some days after the accident, little greenish-yellow haloes will be seen around each spot; in other words, the appearances are those presented by a bruise of any other tissue. Although there are usually numerous miliary extravasations, in some instances there may be so few that only a speck here and there can be detected after most careful search. In one recorded case, three very small extravasa- tions were found in the left anterior lobe, a fourth small one in the fornix, and a fifth in the right lobe of the cerebellum. There were a few minute extravasations into the arachnoid and pia mater, but no fracture of the skull existed.1 I hope that I have made it sufficiently clear that, whether circum- scribed or disseminated, these extravasations are not the lesions of concussion, but of contusion of the brain. When diffused, they are the result of the sudden removal of pressure from the previously distended perivascular lymph-sheaths, tensely filled by the impulse impressed on the cerebro-spinal 1 Hewett, op. eit., vol. i. p. 607. 62 INJURIES OF THE HEAD. fluid by the compressing force, which, as demonstrated by Duret, the blow exerts upon the elastic skull.1 Oftentimes there is direct contusion beneath the part of the skull struck, but it rarely exists alone, being accompanied by ecchymoses in other parts of the brain, except when it is a direct result of the depression of fragments. In many cases the extra vasation is directly opposite to the point struck, seemingly the result of counter-stroke. Direct contusion and that by counter-stroke are apt to coexist in severe head injuries. The upper portions of the brain rarely suffer from contusion, for of thirty- six cases of fracture which started in the vault, but extended into the base, in only five was bruising of the upper surface of the hemispheres detected. (Ilewett.) All portions of the base of the brain are not equally liable to be bruised. The middle lobes are those most frequently contused, the anterior ones less often, while the posterior are still more seldom injured. Of the thirty-five cases referred to by Ilewett, the middle lobes were bruised in twenty-live, the anterior in eighteen, and the posterior in only four. In twelve of these cases, where the injury was exceptionally severe, both the anterior and middle lobes were contused. As to the reasons for this pre- ponderance of injury in one part more than in others, I cannot accept Sir P. Hewett’s and Sir B. Brodie’s explanations, as they seem to me not sustained by anatomical considerations. In the macerated skull there are, indeed, a number of “ irregular and angular projections,” but in the fresh skull, I deny that they exist. In the section on fractures of the cranial base, I have tried to render these points clear, and to explain why the middle and anterior lobes are so commonly contused. Symptoms and Diagnosis of Cerebral Contusion.—These are so uncertain as to render it exceedingly doubtful whether these lesions have any character- istic symptoms of their own. In the absence of fracture—probable or ascer- tained—after the first symptoms of shock have passed off, if there be pro- nounced unconsciousness, or marked somnolency, with the absence of stertor, or if there be extreme agitation and restlessness, it is exceedingly probable that contusion is present. If there be rigid contraction of one or more of the limbs, or of isolated groups of muscles, especially those of the fingers, the probability amounts almost to certainty. Now, if to these we have added marked isolated palsies, I think that we are justified in assuming the exist- ence of contusion, provided that irritating lesions of the dura mater can be excluded. These, as I have already said, are more apt to occur on the side of injury—supposing this to have been produced by a circumscribed applica- tion of force—and never produce paralysis. Slight effusions of blood into the arachnoid sac are usually attended by no symptoms. Even when blood is effused in larger quantities, the symptoms are commonly those of compression of the brain-substance, not of irritation, and where both sets of symptoms coexist, I consider those of irritation to be due to concomitant brain-contusion. In mild cases of contusion, partial contraction of one pupil, partial paralysis of an eyelid, impaired vision, thick speech, slight spasmodic twitching of the facial muscles, one or all, have been noted. Unless there is evidence to the contrary, if after the application of severe diffused force to the skull, marked brain-symptoms—other than hemiplegia—persist after the shock has passed off, cerebral contusion and laceration will in most instances be found after death. I hesitate to thus differ from such a distinguished authority as Sir Prescott Ilewett, recognizing, as I do, the fact that severe brain-bruising may exist without presenting any symptoms until several days after the injury, or indeed that they may be altogether wanting. But if, because the diag- nosis is difficult, and because mistakes must sometimes occur when a positive 1 See Duret’s experiments, p. 53, supra. INJURIES OF THE BRAIN AND MENINGES. 63 opinion is ventured upon, the surgeon should be discouraged from making the attempt, he must abandon all hope of any further advance in the diagno- sis of head injuries. There is one variety of brain-bruising which I am confident that I have met with on a number of occasions, and which I shall now proceed to describe. To this condition Mr. Erichsen has applied the term “cerebral irritation.” I have over and over again recognized the accuracy of his description. The pro- babilities are that in these cases the cortical matter of the brain is diffusely contused, and intensely congested—possibly the latter alone. The patient assumes a peculiar and most characteristic attitude, lying upon his side “curled up in a general state of flexion.” The head is bent upon the chest, the trunk is bent forwards, the knees are drawn up on the abdomen, the legs are bent, and the arms flexed with the hands drawn in. The patient “ does not lie motionless, but is restless, and often when irritated tosses himself about.” “ However restless he may be, he never stretches himself out or assumes the supine position, but invariably reverts to the attitude of flexion.” He violently resists every effort to open the firmly closed eyelids, but, if this be done, the pupils will be found contracted. The skin is pale, cool, or cold ; there is no heat of head; the pulse is slow—seldom above 70—small and feeble. The sphincters are usually unaffected, the patient emptying the bladder when it requires it, although retention of urine sometimes occurs. “ Irritability of the mind is the prevailing characteristic.” Unconscious, and paying no attention to what passes, when loudly called to, the patient “ shows irritability of temper, frowns, turns away hastily, mutters indistinctly, and grinds his teeth.” There is no stertor during sleep. After the lapse of from one to three weeks, the pulse improves in quality, the surface temperature increases, and the tendency to flexion subsides, the patient lying stretched out. Irritability of temper “ gives way to fatuity,” and the mind is evidently weak. Recovery is apt to be slow, but may eventually be perfect. Secondary com- plications may of course ensue at a later period. Erichsen says that “ cerebral irritation” usually follows blows upon the forehead or temples, but the most marked instances which I have seen have been from injuries to other regions of the head. Prognosis.—Contusion of the brain is a most dangerous injury, yet some cases end favorably. When recovery takes place, the contusion is repaired in the same manner as are apoplectic hemorrhages into the brain. In the slighter cases all traces may have disappeared, or a more or less dense cicatrix, with possibly some central coloring matter, may be detected, when death occurs independently of, and some time after, the injury. As an instance of the methods of repair in the more severe cases, Sir P. Ilewett1 thus describes the appearances seen in a case of extensive brain-contusion and laceration, twenty years after the accident:— The convolutions of the anterior parts of both hemispheres of the brain were exten- sively excavated, and here the arachnoid and pia mater were carried evenly over both depressions, so that a* space was inclosed beneath them, which was filled by loose areolar tissue and serum. In the right hemisphere, the mouth of the excavation was nearly circular, about an inch and a half in diameter, and so placed that the inferior margin lay close to the base of the brain, whilst the inner one was close to the median fissure. The depth of the excavation was about an inch, and the convolutions about its edge were natural. The cavity commenced, for the most part, abruptly, but one or two convolutions could be traced in a stunted condition down the walls, which had an even surface, and were loosely coated with areolar tissue. In the corresponding part of the left hemisphere, there was also an excavation similar in all respects save that it was only about half the size of that in the right hemisphere. 1 Op. cit., vol. i. p. 609. 64 INJURIES OF THE HEAD. The cerebral tissue, in the neighborhood of these cavities, and forming their walls, had a perfectly healthy appearance. There were no remains of blood extravasated in the cavity of the arachnoid ; the other parts of the brain were perfectly healthy, and so, too, was the brain-case ; no traces of fracture; no sign of injury to the bones. The patient died of aneurism of the subclavian artery, at the age of forty-eight, but twenty years before his death, when I was house-surgeon, he had been admitted into St. George’s Hospital with several other men, all of whom had fallen a great height in con- sequence of the giving way of some scaffolding. At the time of his admission he was suffering from several severe injuries ; and especially of the head, marked by the symp- toms of so-called concussion of the brain, but there was no sign of fracture of any part of the skull. For several days he struggled between life and death, in a state of per- fect unconsciousness, followed by violent delirium, which ultimately, however, subsided, and in a few weeks he was so far well that he was able to leave the hospital. After a while he resumed his occupation, that of a house decorator, and for years he worked for one of the best firms in London, and was known as one of their ablest workmen. His intellect was as clear as it had ever been, and when I accidentally met him, from time to time, he always said that he did not suffer more from headaches than other people. Treatment.—The chief danger is that of encephalitis, against which all our efforts are to be directed. As inflammation of the brain and its mem- branes, after such injuries, is apt to pursue an insidious course, every head injury which presents indications that the intracranial contents have suffered even in a minor degree, should be most assiduously watched, as traumatic intracranial inflammation often suddenly declares itself, after a number of days of deceptive calm. Usually the incipient indications show themselves not later than the fifth day, but their advent is sometimes much longer de- layed.1 The therapeutic measures to be adopted are those recommended for warding off encephalitis, and when these efforts fail, those advised for intra- cranial inflammation should be instituted. III. Compression of the Brain.—Any diminution in the capacity of the cranium must, from the presence of the cerebro-spinal fluid, exert an effect at all points occupied by that fluid. This increased tension compresses the vessels, and, by the consequent anaemia, causes disturbances of the functions of the encephalon. Theoretically, when this tension equals that of the blood in the vessels, death results. This point, probably, can never be reached except m experiments, as Buret has shown that the vascular spasm produced by irritation of the sensory nerves, or their centres, at once enormously increases the intra-vascular tension. He has shown that a clot amounting to one-twelfth of the cranial capacity, between the dura mater and the bone, will produce coma and death in a few hours. In the arachnoid cavity, how- ever, a clot of one-sixth or even one-fifth the bulk of the cranial cavity is requisite for a lethal effect. These results are only true when no lesion of the nerve-centres coexists. Although not by any means scientifically accurate, “ compression of the brain” is a term so commonly used as to need no apology. Its causes are exceedingly various. Thus a foreign body, such as a bullet lodged in the brain, depressed bone, extravasation upon the surface or into the substance of the brain, and frequently all the last three, coexisting, may produce symp- toms of compression which are then usually primary. Inflammatory pro- ducts, viz., serum, lymph, and pus, are causes of secondary compression. Symptoms.—Due as these are to such varied and often combined conditions, there are only a few symptoms which are always present. Before insensi- bility comes on, pain in the head is complained of, doubtless the result of pres- 1 See section on Pachymengitis, Arachnitis, etc., p. 74, infra. INJURIES OF THE BRAIN AND MENINGES. 65 sure and tension on the sensitive dura mater. The patient lies on his back in a more or less comatose condition, is unconscious, and breathes with a slow, stertorous respiration, often accompanied by a peculiar whiff at the corners of his mouth, as if he was smoking. The last-mentioned symptom appears to be due to paralysis of the cheek muscles, and is a sign of bad prognostic import. The pulse is full, and usually slow ; the skin is cool, or it may be, as in one case which I recall, very hot and dry ; or again, it may be hot and moist. The pupils are at first sluggish, and then fixed and immovable, being moderate in size, widely dilated, or one dilated and the other normal or contracted. This condition varies, as we have seen, with the part of the brain affected,1 or with the presence or absence of intracranial extravasation of blood. There are retention of urine and fecal incontinence. There is paralysis of motion, usually affecting one side, but there may be right hemiplegia with spasmo- dic contractions of the left side, or only certain groups of muscles may he affected, according to the particular form of brain injury. General tremors or convulsions may occur. The most constant symptoms are coma, stertor, and paralysis. When death ensues, respiratory paralysis is the cause, whence the plain indication to resort to artificial respiration. The fundus oculi pre- sents certain changes in well-marked cases of compression, such as venous stasis with relatively small arteries, and slight reddening of the papilla. Apoplexies of varying extent can sometimes be detected. Commencing neuro-retinitis descendens, with turbid redness of the papilla and. indistinctness of its outline, may be noted, or—a very common form—stasis and oedema of the papilla, in addition to the neuro-retinitis* that is, “ choked disk.”2 These sjmiptoms can only be detected in compression which lasts for some time, and usually result from the secondary compression exerted by pus—abscess of the brain, or diffuse suppurative cerebritis. When compression is due to a foreign body, or to depressed bone, the symptoms will be immediate, the patient being probably unconscious from the moment of injury. If the com- pression results from intracranial hemorrhage, it will come on gradually, in most cases after a distinct interval of consciousness, when the symptoms of concussion have partially or completely passed off. If due to cerebral con- tusion and parenchymatous hemorrhage, consciousness will not return after the injury, but the concussion-symptoms will steadily merge into those of com- pression. If resulting from the pressure of serum, lymph, or pus, the symp- toms of compression will set in at a later period of the case, and commonly after distinct indications of intracranial inflammation. Diagnosis of Cerebral Compression.—From what has been said concerning concussion and compression, it will be seen that in most severe cases the distinction cannot be made, since the symptoms are oftentimes produced by similar injuries, the two conditions presenting differences only of degree. Concussion in its first stage has no definite symptoms beyond those of shock and syncope—which may be also present at the incipiency of compression — while if extravasation or cerebral contusion exist to any marked degree, symp- toms resembling those of compression will probably present themselves almost from the outset. Slight causes of compression, such as a limited depression of bone, or small extravasations of blood, may produce only evanescent symp- toms, the brain soon accommodating itself by virtue of its displaceable cerebro- spinal fluid. Thus in many cases no positive diagnosis is possible, since, as investigation has shown and over again, no one diagnostic symptom can be implicitly relied upon Of course, when a patient suffers from profound 1 See Concussion of the Brain, supra; also Leyden’s experiments, Ziemssen, op. cit., vol. xii. p. 666. * See section on Cerebral Abscess, p. 80, infra. 66 injuries of the head. coma, with hemiplegia, dilatation of one pupil, stertorous respiration, etc.; or when he recovers consciousness after stunning, to again relapse into coma, with hemiplegia, etc., we can confidently pronounce the cause of the trouble to.be compression. Those who see many severe head-injuries, and the results of post-mortem examination, will concur with me, I am sure, in expressing the opinion that it is eminently misleading to the younger practitioner to authoritatively tabulate the diagnostic symptoms of compression and concus- sion. It is a relic of ancient magistral surgery which it is time should be dispensed with. Prognosis.—This depends upon the cause. If slight, the patient regains consciousness and recovers. In other instances the cause may be a removable one, when, if the concomitant cerebral injuries are not in themselves mortal, recovery often ensues. The later forms of compression of the brain by lymph and pus, are peculiarly grave, and unless remediable by the surgeon’s giving them free vent—and too often then—they sooner or later destroy the patient. Treatment.—This has been so fully dwelt upon under various other heads, that I need only refer the reader to the sections on intracranial hemorrhage, intracranial abscess, foreign bodies in the brain, fractures of the skull, etc. I would however call attention to the possibility of resuscitating a patient even apparently dead from respiratory failure, after the cause of compression has been removed, by means of artificial respiration, the hypodermic use of atropia, and electrical stimulation of the diaphragm. This sudden respira- tory failure is more common than is ordinarily supposed.1 IV. Laceration and Protrusion of Brain-substance ; Hernia Cerebri.— Bruised and lacerated fragments of brain-tissue may be driven through a fracture situated in any part of the skull, but such injuries are usually the result of compound fractures of the vault, the force producing which at the same time ruptures the meninges. Very rarely the brain-substance is ex- truded through a basal fracture of the skull, in direct communication with the ear, nose, or pharynx. Brain protrusion would occur more commonly with fractures of the base, were it not that they usually consist of mere fissures of the bone, without any laceration of the dura mater. When such an accident does occur, it must necessarily be, with rare exceptions, fatal, from the violence of the force producing it, and from the consequent intra- cranial damage. Hewett reports a case seen at St. George’s Hospital, London, where a pro- fuse hemorrhagic flowT from the left ear, containing fragments of brain- substance, resulted from a fall upon the vertex, from a great height.2 Two other similar cases are referred to by him, the original histories3 of which I have carefully perused, and which I find closely resembled that above men- tioned. I am acquainted with only three recorded cases where brain- matter has been forced through the nostrils, and in one of these recovery followed.4 I append brief notes of two cases of recovery after protrusion of brain-substance. A man, aged forty years, fell from a scaffold, a height of twenty feet, striking with his head some iron bars; he was stunned, but upon admission to the hospital, half an hour later, he had recovered consciousness. There was a small wound over the right eyebrow, sticking in which was seen a fragment of brain-substance. There was slight 1 See Cerebral Abscess, p. 80, infra. 2 Op. cit., vol. i. p. 610. 3 Journ. de Med. et de Chirurg., tome iii. p. 454. 1779; and Annales de Chir., tome Yiii. p. 229. 1843. 4 Compend. de Chirurg., tome ii. p. 595 ; Bull, de la Soc. Anat. de Paris, p. 228. 1837; Am. Jour. Med. Sciences, April, 1859, p. 354. INJURIES OF THE BRAIN AND MENINGES. 67 hemorrhage from the right nostril, while the pulse and respiration were undisturbed, and only some pain in the head was complained of. The next day a fragment of the brain, of the size of a hazel-nut, together with some blood-clot, escaped from the right nostril. The inner wall of the frontal sinus had been broken, which afforded a means of exit for the lacerated brain.1 A seaman, on board the United States ship Constellation, fell from the mast-head through a hatchway, landing full upon the vertex. Copious bleeding from the ear, estimated at from 50 to 60 fiuidounces, occurred within a few hours, and mingled with the blood were small fragments of brain-tissue. This was followed the next day by a free watery discharge from the auditory meatus, in which were found several small pieces of true brain-substance. In five weeks the man had returned to duty, only com- plaining of giddiness and a “ stuffed-up ” head.2 After an extensive search through the literature of the subject, I can find no record of brain-substance having been forced into the pharynx; but Ilewett says that he has seen the contents of the pharynx within the skull, to which they had gained access between the widely separated fragments of a fracture of the cranial base. Prognosis.—As just said, nearly all cases in which cerebral protrusion occurs at the base of the skull, terminate fatally; but when the vault is involved, although the injury is a most dangerous one, it is not necessarily mortal, since the records of surgery contain a large number of instances where recovery has ensued after losses of considerable portions of brain-tissue—recoveries, too, in many instances, without any apparent sequelae, either mental or physical. I have been present myself at an operation, performed by another surgeon, where several teaspoonfuls of brain-substance were lost, and where yet the patient made a good recovery. Two high authorities are diametrically opposed to each other as to which is the most dangerous region for these injuries, Brodie3 saying that he could discover no record of recovery where the posterior lobes of the cerebrum were involved, while Guthrie thought that an injury of the forehead was far more dangerous than one of the back of the head, and that injuries of the side or middle of the cranium occupied a mean place as to their mortality.4 I am unable to throw any light upon this vexed question, but am inclined to think that each case must be considered by itself, and that all generalizations must be fallacious where the lesions are so exceedingly varied. Treatment.—This must be that of other severe head-injuries, with special reference to the probability of the formation of secondary protrusion of the brain-substance, or hernia cerebri. Hernia Cerebri.—In the great majority of cases, this protrusion consists largely of true brain-substance. This has been proved macroscopically—in one case of Mr. Stanley’s the cortical and medullary substance were readily distinguished by the naked eye—and microscopically, as in Mr. Hewett’s case, where “many nerve-tubules were detected in every portion thus sub- mitted to the glass.” In some cases the mass has been described as consisting chiefly of blood etfused beneath the pia mater, while in others the tumor has been found to consist of a mass of hyperplastic granulation-tissue. Although almost always the result of a fracture with consequent rent of the dura mater, or when that membrane has been purposely or accidentally opened during an operation, hernia cerebri may result from syphilitic caries, as in two recorded 1 Medical Gazette, new series, vol. iii. p. 77. 1846. 2 Amer. Jour. Med. Sciences, April, 1859, p. 354. 3 Med.-Cliirg. Trans., vol. xiv. p. 421. 4 Guthrie, Injuries of the Head. Commentaries on the Surgery of War, 6th edit., p. 284. 68 INJURIES OF THE HEAD. cases.1' The opening through the dura mater may be primary, or may occur at a later date from sloughing of that membrane. The presence of splinters of bone, piercing and irritating the dura mater, seems peculiarly apt to give rise to hernia cerebri. The time of its appearance is most various. It may be quite voluminous, as I have seen it, within twenty-four hours, or it may not ap- pear until the sixty-eighth day ;2 but in most instances it has been first noticed from the fifth to the seventeenth day, that is, when inflammation has set in and is well under way. Large portions of the cerebral substance may be destroyed, as in a case of M. Bouchacourt,3 where the lateral ventricle was laid open—as shown before death by the large quantities of limpid fluid which came from the wound, and after death by direct examination. There is often a great apparent loss of brain-tissue before death, when at the autopsy but little cere- bral substance is found to have been destroyed ; which shows that much of the protruded mass, in certain cases, must have consisted of granulation-tissue, extravasated blood, infiltrated serum, etc. The swelling is usually painless on pressure or incision, although in a few cases evanescent pain has been com- plained of when the mass has been cut away. The subjacent brain-substance is soft, swollen, and cedematous, and the whole brain is often infiltrated with serum, and contains abscesses, or the ventricles may be filled with large quantities of fluid ; all these conditions may coexist. Extensive intra arachnoid and sub-arachnoid effusions of pus and lymph are commonly found. Although, in a general way, the truth of Guthrie’s statement is borne out by experience, that protrusion of the brain-substance is more apt to take place when there has been a limited removal of bone, yet M. Bouchacourt’s4 case, and two others mentioned by Hewett, prove that the contrary may be true. As in the case of primary brain-protrusion, from the rarity of gaping of basal fractures and consequent rupture of the dura mater, hernia cerebri rarely occurs except in the vault of the skull. With the necessary pre-requisites, however, that is, removal of pressure by destruction of the bone and dura mater, secondary brain-protrusion may occur at the base. Thus, a boy under the care of Mr. Cresar Hawkins received a pistol-ball wound through the right malar bone, with lodgment of the missile in the head. There were no marked cerebral symptoms for seven days, when he became restless and delirious. That afternoon a soft fungus showed itself in the wound, and he died thirty hours later. Post-mortem inspection revealed a large gap in the sphenoid and temporal bones, through which quite a large mass of brain- substance projected. The substance of the brain around the protrusion was vascular, and of the yellow color usually found in such cases.5 The tumor, pressing its way externally, when it reaches the level of the cranial walls, tends to spread mushroom-like over the contiguous scalp. Its surface is irregularly indented, soft and discolored with blood, or gray and firm. The protrusion may be only moderately vascular, or may be most abundantly supplied with blood, and may pulsate synchronously with the brain. Portions are apt to slough away from time to time, so that in some cases the whole tumor may drop away piecemeal, cicatrization of the wound, and cure, following; or again, pari passu with the sloughing away of portions of the growth, new protrusion may take place, until the patient finally dies exhausted. In one case reported by Quesnay, the patient tore the whole mass away, a cure resulting. Finally, without sloughing, the hernia may gradually shrink, and totally disappear.6 1 Med.-Cliirurg. Trans., vol. viii. p. 45. Gross, op. cit., vol. ii. p. 78. 2 Laurie, Lond. and Ed. Monthly, June, 1844, p. 478. 8 Bull, de la Soc. Anat. de Paris, tome xiii. p. 13. 4 Loc. cit. 5 Hewett, op. cit., vol. i. p. 612. 6 Laurie, loc. cit.; Crawford, Edinb. Med. and Surg. Journ., vol. xii. p. 22. INJURIES OF THE BRAIN AND MENINGES. 69 Pathology.—The removal of pressure, in conjunction with softening of the cerebral tissue, renders a very slight increase of intracranial tension effi- cient as a cause of protrusion of a portion of the brain-substance. This is shown by cases where it has followed cranial necrosis. In all other parts, a hyperplastic induration of the connective tissue commonly takes place, whereby pus, if it forms, is limited. In the brain-tissue, the delicate neuroglia readily allows of infiltration with inflammatory products, and its acute hyper- plasia, instead of strengthening, seems to weaken the tissue, so that the brain readily yields to the least pressure. Now intracranial inflammation with cerebral softening is usually present at the time when hernia cerebri makes its appearance, and at a stage, too, when free effusion into the ventricles, arachnoid sac, and substance of the brain, is prone to occur. In those rarer cases which occur within the first forty-eight hours, I would suggest that the condition is probably due to the paretic dilatation of the vessels observed in concussion, which is, as pointed out by Prof. Agnew,1 commonly followed by free exudation of bloody serum. Symptoms.—They are those of inflammation of the brain and its mem- branes, and therefore need not be dilated upon. It is interesting to note that there may be almost a complete absence of all symptoms beyond slight rambling of speech, occasional twitching of the facial muscles, broken sleep, and a full pulse. Not unfrequently the patient dies of pyaemia. Diagnosis.—This can hardly be confounded with any other affection except the “ tumeur hematique” of Velpeau, which arises from a mere effusion of blood upon the outer surface of the dura mater. I do not know of any spe- cial diagnostic points, but as such tumors are among the great rarities of surgical practice, they can but rarely give rise to mistakes. D'ognosis.— Although a very fatal complication, recovery does occasionally ensue. Thus, of 80 cases which I have collected, 25 ended favorably, and 55 in death. Of the patients who recover, the majority suffer from vertigo, headache, etc. I do not presume to say that such a small number of cases settles the percentage of mortality, but merely give the figures for what they are worth, as a lethal issue is commonly quite as much the result of concom- itant injuries, inflammation, etc., as of the hernial protrusion. Treatment.—In general, the less done the better. As the cause is primarily loss Of support, gentle pressure at the outset, with the use of some antiseptic absorbent dressing, may be advantageously tried. The parts should be fre- quently cleansed with some antiseptic astringent wash. Removal by the knife, tearing, or ligature, must in general be avoided, especially where granulations are springing upon or around the protrusion, as we should thus still further remove pressure and encourage the growth. The removal of protruding brain-masses is rarely, if ever, effectual, and experience shows that they at times disappear spontaneously. As the intracranial inflammation, in most instances, stands in a causative relation to hernia cerebri, appropriate treat- ment for that condition is indicated. Great care should be exercised to remove, when possible, all fragments of bone which may irritate and injure the dura mater and brain. Mallet, Hewett, and other surgeons report a number of apposite cases where bony fragments, by causing sloughing of the dura mater and irritation of the brain, have apparently favored the formation of hernia cerebri. Special attention should be paid to the state of the cir- culation, which, if over-excited, must be controlled by appropriate remedies. This is, however, as pointed out by Laurie, rarely the case. Wounds of the Brain and Meninges.—According to the nature of the vulnerating body, these may be incised, punctured, lacerated, contused, or 1 Op. cit., vol. i. p. 277. 70 INJURIES OF THE HEAD. gunshot wounds. The contused and lacerated varieties may be produced without fracture of the skull, but this accident almost necessarily precedes the more severe forms.1 Punctured wounds may be caused by spicules of bone driven down into the substance of the organ, but most frequently result from thrusts with penknives, forks, dirks, pointed pieces of wood, nails, ferules of umbrellas or walking canes, etc. Those portions of the skull most often perforated are the orbital plates of the frontal bone and the cribriform plate of the ethmoid, although in young children any portion of the skull may be thus injured. Gross states that a bad punctured fracture sometimes results in children from a blow by the spur of an enraged cock.2 The brain has been traversed from one extremity to the other by balls, swords, bayonets, ram- rods, etc. In one case reported by Larrey, a ramrod passed through a soldier’s head without wounding any important structure:— A metal ramrod entered the head of a soldier in the middle of the frontal bone, making its exit upon the left side of the neck, and was so firmly imbedded as to defy all efforts at removal. After death, the missile was found to have passed between the cerebral hemispheres without wounding them, but tearing the falx ; after which it pierced the body of the sphenoid bone, and finally emerged through the occipital bone near the foramen magnum. This patient lived two days.3 Incised and punctured wounds of the brain, when small and clean-cut, may, according to Rokitansky, sometimes heal by adhesion. In minor degrees of contusion, repair is effected as in ordinary apoplexies. A superficial mortification of the contused parts may occur, the extent of the process depending upon the degree of the contusion. If slight, the pro- cesses peculiar to red softening occur at the points of injury and in the sur- rounding tissue. When the bruising is more severe, a dark-brown, pulpy mass is apt to be found in the centre of the injured spot, around which is seen a broad zone of intense congestion, with numerous capillary apoplexies. Out- side of the belt of congestion, one of inflammatory oedema will be detected. In other instances, acute, diffused, superficial suppuration occurs, which is in- variably accompanied by meningitis. The suppuration is not limited to the surface contusions, but a number of small abscesses are grouped around the superficial one. A contusion of the brain-substance which results in encephalitis, may not end in suppuration but in yellow softening. This is especially true in regard to contusion of the punctiform variety. Here the initial necrotic changes are more pronounced than those of inflammation ; hence the appearance of yellow softening. In many cases further changes take place. The softening may extend until large portions of the brain are involved. This is rendered pos- sible by the border zone of cedematous brain-tissue, wherein the nerve-elements already have their nutrition seriously impaired. Even with compound frac- ture of the skull, neither inflammation nor yellow softening invariably occurs, when the contusion consists simply of capillary apoplexies. After death, these injuries, when the patient survives some time, are evidenced by a slight thickening around a small collection of fat granules, granule-cells, and lisema- toidin crystals. Finally, slight contusions may—in very rare instances where the skull is not opened—result in circumscribed yellow softening, without any trace of inflammation. These spots of softening may give rise to no trouble for prolonged periods, and then unfortunately, under entirely unknown con- 1 See sections on Contusion of Brain and Fracture of Base of Skull. 2 Op. cit., vol. ii. p. 76. 3 Larrey’s Mem. Mil. Surg., vol. ii. p. 313. Am. ed. 1814. I need hardly do more than refer to the famous case recorded by Harlow and Bigelow, in which a tamping iron, weighing over 13 pounds, was blown through a patient’s head, and yet recovery ensued. INJURIES OF THE BRAIN AND MENINGES. 71 ditions, a rapid extension may set in and terminate fatally. The clinical history of these cases of consecutive softening is not clear, and closely resem- bles that of brain-abscesses. Wounds producing loss of substance heal by granulations, which fill up the cavity, adhesion taking place between the resulting granulation-tissue and the cicatrix which closes in the opening through the bone and meninges. Rokitansky shows that, under these circumstances, the lateral ventricle on the side of injury enlarges, to partially supply the place left by the loss of cerebral tissue. At a later period, the brain tends to sink inward, and by this process of stretching of the cicatrix, a loose connective tissue, with its interstices filled with a serous fluid, comes to lie between the brain and the superficial scar, where the two structures were formerly firmly bound together. Prognosis.—This is dependent upon the portion of the encephalon wounded, and upon the concomitant injuries. With a limited lesion, and one not com- promising the integrity of the involved brain-tissue, recovery is possible, and indeed under judicious treatment has often taken place readily. Recovery is also compatible with destruction by bruising and tearing of large portions of the brain-substance, although the danger is usually proportionate to the extent of tissue involved. Large portions of brain may be lost, and yet, pro- vided that neither the motor area nor that of speech be involved, no appa- rent loss of intellectual power nor disorder of motility may be detected. The preceding remarks are chiefly applicable to injuries of the superior and lateral surfaces of the hemispheres, for if wounds involve the base of the brain, or the medulla oblongata, the respiratory centre may be involved, when instant death from cessation of breathing will occur. Even when those cen- tres which are immediately necessary to life are not at first involved, they generally become affected sooner or later, either by contiguity of structure or from pressure of inflammatory products, when death follows. Should recovery take place after basal injuries, it usually does so with marked impairment of the mind, and varied palsies of motility and sensa- tion. The special senses also are apt to be lost or impaired. Nothing like certainty in prognosis is possible, as the most frightful injuries may be recovered from, while the most trivial may result in death. In the words of Percival Pott, however, “ no injury is too great to be despaired of.” The chief dangers to be apprehended are encephalitis and hernia cerebri. Symptoms.—These are so dependent upon the portions of brain involved, that it would be useless to attempt to detail them. Wounds of the meninges are always grave, indeed often as fatal as wounds of the brain itself. Suppuration and sloughing of the dura mater generally follow contused wounds, with a consequent, diffused, intracranial inflamma- tion, and in very many cases hernia cerebri results. These evil consequences are peculiarly apt to follow from the irritation caused by depressed splinters of the inner table, whence arises the practical precept to remove these by ope- ration, when such untoward results may oftentimes be avoided.1 A portion of dura mater which might have recovered its vitality if the pressure and irrita- tion of bony fragments had been removed, is too often “ left to nature” as it is said, and with fatal consequences. Extensive incised wounds of the meninges, removing considerable portions, as in sabre wounds where large segments of the cranium have been sliced off, not infrequently end in recovery, as in cases reported by Hennen,2 Larrey,3 and others. 1 See section on Hernia Cerebri for the influence exerted by bony spicules in causing this affection. 2 Hennen, op. cit., p. 231. 8 Larrey, op. cit., vol. ii. p. 281. 72 INJURIES OF THE HEAD. Tre.atment of Wounds of the Brain and Meninges.—This should embody the prophylactic and curative measures appropriate for encephalitis, to the section upon which subject the reader is referred. Foreign Bodies in the Brain.—Foreign bodies may become encysted, either actually imbedded in the cerebral tissue, or merely lying in con- tact with the exterior of the brain. Their usual tendency is sooner or later to induce fatal inflammation, even after years of immunity from all trouble. Foreign bodies like bullets, may remain lodged in the brain for years, when a drinking bout, or some extraordinary mental excitement, may bring about sudden death. (Quesnay, Henhen, Wharton.) “In a case observed by Dr. John E. Gibson, of Nashville, the ball remained in a quiescent state in the anterior lobe of the brain for six years, when it excited fatal inflammation.”1 In an admirable paper by Dr. II. R. Wharton, of Philadelphia,2 published in 1879, that surgeon gives an analysis of 316 cases where a foreign body was lodged in the brain. Of this number, one hundred and sixty ended in recovery, while one hundred and fifty-six proved fatal. The influence upon recovery of the removal or retention of the foreign body was most marked. The foreign body was removed in one hundred and six cases, seventy-two patients recovering, while only thirty-four died. In the remaining two hundred and ten cases, no attempt at removal was made, and recovery took place in only eighty-eight cases, while one hundred and twenty-two patients died. A further analysis shows that among those classed as recoveries, death ultimately took place in ten cases at periods varying from three to fifteen years, and that many of the patients suffered from such after-effects as ver- tigo, incapacity for physical exertion, loss of sight or hearing, epilepsy, and deterioration of the mental powers. Still further, of those cases in which the patients recovered without mani- festing any of these sequelae, numbering in all one hundred and eleven, the foreign body was removed in fifty-six cases, and allowed to remain in forty-five. The evil results of allowing a foreign body to remain in the brain are usually manifested sooner or later—even as long as thirteen years after the injury. Inflammation, slow or rapid, sometimes involving large portions of the brain tissue, or yellow softening, is apt to be set up around the foreign substance, either spontaneously, so to say, or from the most trivial exciting causes.3 The usual termination is cerebral abscess, this condition having been found in fifty-three of Wharton’s cases, in which a post-mortem examination was obtained. Apoplexy is an occasional cause of death, as is pressure of the foreign body on the venous trunks, inducing ventricular effusion and con- sequent compression of the cranial nerves. Convulsions, coma, etc., have also been thought to have originated from venous pressure. The probable explanation of those cases in which no symptoms have been present for long periods, but in which death has rapidly followed upon the sudden develop- ment of brain-symptoms, is that quoted by Wharton from Flourens. The latter observer introduced bullets into different portions of the upper parts of the hemispheres, and upon the cerebellar lobes of dogs and rabbits. By their own weight the balls gradually penetrated the brain-substance, ulti- mately reaching the basis cranii, the bullet tracks healing after them. In man, something analogous probably takes place, thus accounting for the late supervention of rapidly fatal symptoms. As to the fatality of wounds of the different portions of the brain, fifty- 1 Gross, op. cit., vol. ii. p. 73. 2 Pliila. Med. Times, 1879. 3 Drinking, mental excitement, or slight injury caused seven deaths among the fatal cases in Dr. Wharton’s table. INJURIES OF THE BRAIN AND MENINGES. 73 eight deaths took place out of one hundred and thirty-two cases where the foreign body entered through the frontal bone. Fifty-eight wounds of the parietal showed twenty-seven deaths and thirty-one recoveries. The occipital bone was penetrated twenty-three times, with sixteen deaths and seven recoveries. The temporal bones were penetrated in thirty-one cases, with twelve deaths and nineteen recoveries. Orbital wounds were very fatal, only one recovery taking place out of eighteen cases. Four deaths took place out of live cases of penetration of the sphenoid bone. I admit that a penetrating wound of any special cranial bone does not exclude injury of portions of the encephalon far distant from that immediately subjacent to the perforation of the skull, yet, as in many cases the foreign body was removed, only the brain contiguous to the point of penetration must have been compromised, and I therefore consider Dr. Wharton’s analysis of considerable value in determining the relative mortality of wounds of different parts of the brain. Indeed, it is only in accord with what the physiology of the different portions of the encephalon would indicate. Treatment.—From what has been said as to the increased chances of recovery, and as to its completeness, after removal of foreign bodies lodged in the brain, when contrasted with the results of non-interference, it must be clear that whenever an extraneous substance can be removed without too much destruction of tissue, it should be done. The difficulty of locating a foreign body in the brain is very great, owing to the ease with which the probe gets out of the track of the vulnerating body by penetrating the healthy cerebral substance. Great care should therefore be exercised in the use of the ordinary probe. A soft—not flexible—catheter may be used with compara- tive safety; by resorting to this instrument, Larrey successfully detected and removed bullets in the two following cases. A soldier received a musket-ball wound in the middle of the frontal bone near the sinus, which passed between the cranium and the dura mater, and along the longitudinal sinus to the occipital suture. It produced all the symptoms of compression. Larrey, inferring the location of the ball from the patient’s complaints of pain at a point dia- metrically opposite to the wound, introduced a gum-elastic sound until he touched the bullet. By measurement, the portion of the cranium beneath which the ball lay was exposed, a large trephine was applied, pus was evacuated, the ball was removed from between the dui-a mater and brain, and recovery ensued.1 A ball penetrated the left parietal eminence of a soldier, passed obliquely along its inner surface, and was ai*rested about one centimeti-e fx-om the occipital suture. The presence of a slight ecchymosis near this spot, the symptoms, and the employment of a small soft sound, induced Larrey to lay bare the bone, when he found a small fissure, applied a large trephine, and removed a piece of the bullet. The “patient did well for five days, and then died of a fever.2 How of course I do not advise the surgeon in every case of lodgment of £l foreign body in the brain, to imitate Larrey, but I simply relate the cases to show what skill, boldness, and good fortune will sometimes effect, and to prove that apparently perforating wounds of the brain itself may be only so in seeming, so that a careful examination in suspected cases may reveal a more favorable condition admitting of operative interference, which may turn the scale towards the side of recovery. As already remarked, a silver probe should be used, if at all, with the utmost care; it is better to resort to a small, soft rubber, or French, sound or catheter, and even with such an instrument, to examine with judgment, and not make persistent efforts to locate the foreign body, since patients may recover with permanent lodgment 1 Op. cit., vol. i. p. 307. 2 Ibid., vol. ii. p. 170. 74 INJURIES OF THE HEAD. of extraneous substances. For the methods of extracting such objects, I would refer the reader to the section on trephining. Pachymeningitis, Arachnitis, and Cerebritis.—Any injury of the head may give rise to intracranial inflammation, but some are more apt to produce such an untoward result than others. Thus, lesions of the brain-substance are more frequently followed by inflammation than scalp-wounds and injuries of the bones. When intracranial inflammation arises from a scalp-wound, where the vulnerating body has injured none of the cranial contents, it is always due to a complicating erysipelas or diffuse cellulitis. Under these circum- stances, cerebral symptoms not uncommonly manifest themselves. The post- mortem examination of cases fatal from such complications, usually reveals nothing beyond an increased vascularity of the pia mater, with effusion of opaque fluid in the subarachnoid tissue over the upper surfaces of the hemi- spheres, and marked congestion of the cerebral substance itself. When the disease starts in the bone or its coverings, the inflammation spreads inwards, first involving the dura mater, then the parietal arachnoid, the visceral arachnoid, next the pia mater, and finally the cortex of the brain. Examining the different tissues involved, it will usually be found that, in the acute forms, especially in those arising from osteo-myelitis after bone injury, the dura mater becomes infiltrated, and its outer surface smeared with lymph or pus; it may even slough. Although the inflammation, as far as the dura mater is concerned, is almost invariably confined to that portion of the membrane which lies immediately beneath the diseased bone, yet this is not always the case, as it tends in exceptional instances to spread along the cellular coat of the meningeal arteries until the disease reaches even the base of the skull. When inflammation of the dura mater results from chronic mischief set up by traumatic osteitis, caries, or necrosis, the membrane is apt to be thickened, more vascular, and closely adherent to the bone. Rokitansky states that under these circumstances either bony plates may be developed, which become fused with the cranial bones, or osseous concretions may be formed in the dura mater itself, which often in time co-ossify with the adja- cent part of the skull.1 As the parietal arachnoid is, histologically, really a part of the dura mater, in the acuter cases the inflammation soon involves the former tissue, when the disease usually becomes rapidly widespread. This is the rule, but Hewett relates one case where the effusion of pus and lymph upon the arachnoid was exactly limited to the diseased area of the dura mater. Traumatic arachnitis, as it usually appears, involves the upper and lateral surfaces of both hemispheres, although only the surface of that which corresponds to the bone injury may be affected. Sometimes the surfaces of both hemispheres may be involved without any effusion at the base of the skull. In the majority of cases the arachnoid cavity contains a large amount of a yellowish, or greenish-yellow, fibrinous, or purulent exudation. In rare instances adhesions take place between the opposite lymph-coated surfaces, and the purulent matter becomes circumscribed, forming an appar- ent cerebral abscess. Thus De la Peyronie,2 Soulier,3 and others have reported cases where the pus extended alongside the falx as low down as the corpus callosum. S. W. Gross has collected a number of cases where circumscrip- 1 Rokitansky, Manual of Pathological Anatomy (Sydenham Society’s edition), vol. iii. pp. 324-326. 2 (Euvres de Sabatier, tome ii. p. 452. 1796. 3 M6m. de l’Acad. Roy. de Chir., tome i. pp. 210. Paris, 1743. INJURIES OF THE BRAIN AND MENINGES. 75 tion of the arachnoid effusion has taken place.1 Hewett says that he has seen at an autopsy one case where the pus was thus circumscribed, the fluid running down between the falx and left hemisphere as far as the corpus callosum. The next tissue attacked is the pia mater, which is usually extensively infiltrated with the same greenish-yellow, puriform or plastic exudation that I have described as occupying the arachnoid sac. In one very severe case, the pia mater had become so thickened that it could be removed “ whole from the brain, and with its prolongations, which dipped down between the convolutions,” looked “ as if it had been cast in wax.”2 The inflammation is usually limited to the pia mater of the convexity of the hemispheres, although this is not an invariable rule. The subjacent cortical brain-tissue is frequently dark and discolored, and so softened as oftentimes to permit adherent fragments of brain-substance to come away with the pia mater, even when the latter is removed with the utmost care.3 The whole thick- ness of the cortical portion of the brain may be involved, or only a thin stratum of its periphery, while the white substance is entirely unaffected except by simple congestion, as evidenced by the larger size and greater number of its vascular puncta. As exceptional conditions found after death from meningitis resulting from injury of the skull or its coverings, I may mention that, with pus between the bone and dura mater, the arachnoid sac upon the side of injury has been seen to contain purulent lymph, covering the posterior third of the upper and lateral surface of the hemisphere, with entire absence of sub- arachnoid effusion.4 This is a very uncommon condition. In another case, with the dura mater covered with adherent lymph, and “ matter running from thence along the branches of the middle meningeal artery down to the base of the skull, no effusion was found in the arachnoid cavity,” while sero- purulent fluid was found in large quantities in the subarachnoid tissues covering the whole of the corresponding hemisphere.5 I would here call attention to the interesting fact that, while it is the rule to find inflammatory effusions in the arachnoid sac when the disease is due to traumatism of the bone, meningitis from brain injury resembles the idio- pathic form of inflammation, in that the arachnoid cavity is in the majority of cases free from effusion. If the morbid appearances of the membranes after contusion6 of the brain be examined, the exudation will be found chiefly if not entirely in the pia mater, which, it infiltrates to a varying extent. In those cases alone in which the inflammatory process is of an exceptionally high grade, does the effusion take place into the arachnoid cavity. When purulent, the effusion into the pia mater is not infrequently of a decidedly green color. There are then two kinds of traumatic inflammation of the meninges, in which the primary source of the disease affects first the membranes nearest to it. Thus, when the bone is the starting point, the dura mater becomes affected, and, as a consequence almost without exception, the free surface of the arachnoid. Originating in the cerebral substance, the inflammation attacks the pia mater, to which it is confined, except when the morbid process is very severe.7 Owing to the visceral arachnoid in many parts 1 Am. Jour, of Med. Sci., vol. lxvi. p. 63. 1873. 2 There will be found in Holmes’s System of Surgery, 3d ed., vol. i. p. 620, a cut which shows the appearances described. See also Rokitansky, op. cit. 3 Rokitansky, op. cit., vol. iii. p. 342. 4 Hewett, op. cit., vol. i. p. 620 ; Watson, Practice of Physic, 4th ed., vol. i. pp. 377, 378. 6 Hewett, op. cit., vol. i. p. 621. 6 Many such cases would be called concussion by the majority of surgeons. i The intense cerebral congestion mentioned as having been found soon after concussion, readily explains the readiness with which the pia mater becomes inflamed after such accidents. INJURIES OF THE HEAD. having a covering of endothelial cells upon the surface next to the brain, the relations of this membrane to its subjacent connective tissue differ from those of any other serous membrane, a difference which probably accounts for the peculiarities of limitation of inflammation just described. Accumulations of perfectly clear, or slightly turbid serum, sometimes take place in the ventricles after head injuries. They generally coexist with inflam- mation of the membranes. Again, these effusions may take place slowly, when the head symptoms will be long delayed, and will probably concern the physician rather than the surgeon. When, however, the effusion takes place rapidly, with a scalp wound and bare bone, as in a case reported by Hewett, an error in diagnosis is very liable to occur, and the trephine may be resorted to with the expectation of evacuating pus between the dura mater and bone. A middle-aged man received a scalp-wound by a fall in the street, which did not denude the bone. After prolonged collapse he reacted, and had most furious delirium, requiring restraint. The day before he had had, for the first time in his life, some kind of convulsive fit, but unattended with frothing at the mouth. The day following he com- plained of violent pain in the head, which persisted despite of treatment until the sixth day, when the scalp-wound became oedematous, and the bone denuded. Early in the morning of the seventh day the man suddenly began to hiccough, and became com- pletely comatose, with normally acting pupils, a feeble, running pulse, and no stertor in respiration. A trephine was applied, after consultation, over the exposed bone, with the hope of evacuating matter from between the skull and dura mater ; none was found, both the membrane and bone being healthy. The patient died unrelieved the same evening. Some serous effusion was found in the subarachnoid tissue, especially at the base of the brain, but the membranes were normal, and the pia mater was not congested. The ventricles were dilated, being filled with a large amount of serum, and the cerebral tissue was oedematous and softened. A small tubercular deposit was found in one of the cerebral convolutions of the base, but elsewhere none others were discovered, while all the organs of the trunk were normal.1 This case bears out the advice which I have given with regard to trephin- ing for intracranial suppuration; there were no pressure signs to warrant the belief that operation could afford relief. Cerebritis.—As we have just seen, the cortical substance may be affected in inflammations which have reached the pia mater from whatever source. This form of cerebritis, however, is probably secondary to meningitis. In some cases of concussion, without laceration of the brain or eccbymosis into its substance, I have said that intense, general congestion may result. In such cases a cortical cerebritis supervenes, which we occasionally have an oppor- tunity to investigate. I say occasionally, since simple concussion rarely pro- duces a fatal inflammation. In the early stages of this form of cerebritis, the gray matter is swollen, soft, and of a dark-red color, and covered by a mark- edly congested pia mater, which, when stripped off, is apt to bring away soft- ened portions of brain-tissue. At a later period, exudation takes place into the pia mater, and the dark cortical substance is so softened that it readily washes away under a gentle stream of water, leaving the white matter bare, much congested, but not softened. The extent of implication of the brain- cortex is variable, but it may even occupy a whole hemisphere, except the base, which in most cases is unaffected. Brain-contusion and brain-laceration are the most common causes of trau- matic cerebritis, and this can be detected should the patient survive for only a few hours. The first change noticed is a congestion of the brain, which impli- 1 Hewett, op. cit., vol. i. p. 623. INJURIES OF THE BRAIN AND MENINGES. 77 cates its whole structure, but is most marked about the injured spot or spots. Next the cerebral tissue around the contusions assumes a darker hue, and becomes oedematous, swollen, and softened. Soon inflammatory effusions take place, which reduce the brain-substance to a variously tinted, soft, pulpy, or diffluent mass, readily washing away under a gentle stream of water. The portions of brain around the softened area are altered to a less extent, appear- ing disintegrated and shreddy. Although these changes are commonly limited to the neighborhood of the original injury, the greater part of an entire hemi- sphere sometimes becomes involved, when the white substance is apt to be of a “peculiar saffron-color” (Iiewett) at the centre of intensity of the morbid process, the tissue being soft and diffluent.1 A few drops or a gentle stream of water should be allowed to fall upon all suspected spots, as at times the marked disintegration undergone by the brain substance is not at first plainly perceptible. The yellow color is due to the large number of pus corpuscles and cells in a state of fatty degeneration, and possibly also to the remains of blood effused from the original injury, or more recently from the rupture of small vessels. When the inflammation is limited, an abscess may result, proliferation of the surrounding neuroglia forming in some cases a thickened fibrous wall; under which circumstances the malady may remain quiescent for a long time. A recent abscess consists of a rounded, irregularly-shaped cavity in the brain-substance, with walls formed of suppurating cerebral tissue, shreds of which, soaked in pus, hang into the cavity. The surrounding brain is in a state of inflammatory red softening, contiguous to which the cerebral sub- stance is oedematous, while in many cases around the area of red inflammation is a zone of yellow softening. The contained pus is thick and greenish, and sometimes has an extremely offensive odor.2 Cerebral abscess most commonly results from contusion and laceration of the brain-substance, but may arise from so-called simple concussion. Like collections of pus in other organs, it has a tendency to extend at its periphery, although it may burrow sinus-like in various directions. When it ruptures into one of the ventricles, death rapidly ensues. Various cases have been reported in which the pus from cerebral abscesses has found its way, by ulceration through the bones, into the nasal fossse or ear, recovery having ensued. The amount of pus and the suddenness of its discharge have been the arguments chiefly relied upon to prove the cerebral origin of these abscesses, when recovery lias taken place. I have no doubt myself that some of these have been really cases of circumscribed intra- meningeal accumulation, although in a few, post-mortem examination has demonstrated their cerebral origin. Symptoms of Intra-cranial Inflammation.—The symptoms of intracranial inflammation will be first considered as a whole, and then an endeavor will be made to point out those special symptoms which may be of use in deter- mining which of the various intracranial structures is chiefly diseased. My reason for treating the subject in this manner, is that I do not believe it to be possible to determine positively whether in one case the membranes alone are inflamed, or whether in another the brain is solely involved. The first symptom commonly noticed is headache, which may be either slight or severe, may be confined to the seat of the blow, or may extend from that point over the whole head. Dizziness, vertigo, tinnitus aurium, flushed face and suffused eyes, coated tongue, and anorexia are commonly observed. The pupils are contracted and abnormally sensitive to light, and there is in- 1 This is the yellow softening already referred to on page 70. 2 Rokitansky, op. cit., p. 413. 78 INJURIES OF THE HEAD. tolerance of sound. Fever, with hot, dry skin, and a rapid, hard pulse, accom- pany these cerebral symptoms. All the symptoms increase in severity with the advance of the intracranial inflammation, and soon nausea, vomiting* obstinate constipation, restlessness, constant jactitation, delirium, and con- vulsions—one or all—mark the progress of the case. Then, as the inflammatory effusions are poured out, symptoms hf irritation or pressure begin to manifest themselves. Drowsiness, dilatation of one or both pupils, oscillation of the eyeballs, irregular twitchings or even spasms of the muscles, steadily increas- ing coma, stertorous, puffing respiration, a slow, full pulse, incontinence of feces and urine—the result of paresis of the sphincters—paralysis, and death, too commonly succeed one another. Where the pressure-symptoms are due to the formation of pus, more or less marked chilliness, or rigors, are apt to precede the signs of compression. If cerebral abscess forms, the temperature will he usually subnormal, either at the outset only, or continuously until the pus is evacuated, when it will probably suddenly rise. While typical cases present most, if not all, of the symptoms detailed, and commonly in the order given, in many instances they vary markedly. So dissimilar from the standard given in text-books are many cases met with in practice, that the diagnosis of intracranial inflammation is oftentimes a most puzzling affair to the tyro, and may sometimes even baffle the expert. Al- though it may be impossible positively to assert, in any case of head-injury, that the symptoms proceed from an inflammation of the brain-substance and the visceral layers of the meninges, the result of concussion—or that they are due to contusion and subsequent inflammation of the bone and the subjacent dura mater, with the parietal arachnoid—yet attentive study of the time of onset of cerebral symptoms often enables the surgeon to determine where the inflammation has started, and therefore the structures which are most likely to be chiefly involved. A post-mortem examination will, indeed, often dis- prove the opinion thus formed, but in many cases it will verify the accuracy of the inferences founded upon the time of onset of the symptoms. From the intense congestion of the cerebral mass, with its investing pia mater, which results from concussion, we should expect the early onset of signs of inflammatory mischief; and accordingly we find that in many cases the symptoms begin within a few hours. Four or five days usually elapse before symptoms of cerebritis declare themselves after contusion or laceration of the brain-substance, and until this time a most deceptive calm, with an apparent entire absence of any mischief resulting from the injury, is apt to prevail. Inflammation consequent upon contusion of bone may appear early, as in a number of Pott’s cases, but it is far more apt to “ smoulder,” as has been said, for two or three weeks, and then to suddenly burst forth. The symptoms of cerebral abscess are not usually pronounced until about the twenty-fifth day upon the average, although I have seen them within two weeks of the injury. Convulsions are a most uncertain symptom, especially in the young. When occurring immediately after the injury, they are certainly not due to inflammation. Again, they may appear just about the time when intracra- nial inflammation is to be expected, leading to the supposition that encepha- litis has commenced, when nothing of the sort exists. Being simply indica- tive of irritation of the cerebrum, of its membranes, or of all these structures, convulsions are produced by too many varied causes to be of any particular value as a means of diagnosis in intracranial inflammations. Treatment.—I place in the first rank as to importance, prophylaxis. As has been, I trust, made clear, there is a variety of meningitis arising directly from the intense congestion of the brain and its membranes which results INJURIES OF THE BRAIN AND MENINGES. 79 from concussion, even without any cerebral contusion, and this inflammation sets in very early, sometimes even within a few hours. I am, therefore, in the habit, in cases of concussion, unless the patient has lost much blood, or is from any cause peculiarly feeble, of directing that the strictest antiphlogistic regimen shall be pursued for the first forty-eight hours, that is to say, that nothing but water shall be allowed. Dry cold should be applied to the head, which should be shaved if the case be a bad one. The room must be darkened and the head kept slightly elevated. A calomel purge, followed by a saline, should be at once administered. After the first forty-eight hours, or from the outset if the patient be feeble or have lost much blood, a milk diet must be substituted for the starvation plan, lest suppuration should be favored by de- pression of the bodily powers. I prefer, however, that the smallest quantity of milk compatible with supporting the patient’s strength should be indulged in until after the fifth or sixth day, that is, until after the usual time of onset of intracranial inflammation. I know that with many this system of treat- ment is out of vogue, but when judiciously resorted to, I am satisfied that it is the safest course to pursue, and on this plan I have treated a number of severe head-injuries without anything indicating that I had better have resorted to other measures. Upon the other hand, an increase of diet has been followed over and over again by vertigo, increased headache, and fever, all of which symptoms have spontaneously subsided upon returning to a more meagre allowance. At the first onset of pronounced cerebral inflammation, in very vigorous patients, venesection may be resorted to in just sufficient quantity to sensibly affect the pulse. I prefer, however, to rely upon wet-cupping or leeching, without venesection, and, should the latter have been resorted to at first, wet cups to the nape of the neck should be used if occasion arise for the further abstraction of blood. I am persuaded that free cupping cannot fail to be of decided benefit in many of the cases which are received into our large hos- pitals. The system should be as rapidly as possible gotten under the influence of mercury, and to this end one-fourth of a grain of the mild chloride, combined with an equal amount of opium,1 should be exhibited every two hours. Should the system prove rebellious, mercurial inunctions may be used as adjuvants. When the abstraction of blood is thought inadmissible at the outset, or wThen no longer considered advisable, free and frequent purgings are indicated, always remembering that the patient under treatment is to be considered, not as a supposititious “ case’* of encephalitis for which such and such remedies have been recommended, hut as a person whose condition varies from day to day, nay, from hour to hour. Intermittent compression of the carotids has been recommended by ISTeu- dorfer, Vanzetti, and others, and where practicable it might be tried, as it should theoretically prove beneficial. Sleeplessness, or the furious delirium which occasionally supervenes within the first few days after a head-injury, must be relieved by the cautious use of opium. I cannot enter into theoretical reasons why opium is not harmful in head-injuries, as is so often contended. I only know that I do not hesitate to use it when it appears indicated, and that so far, in common with the most experienced surgeons, I have seen nothing but good result from its employ- ment. By quieting the heart’s action, less blood is sent to the brain, the mind is set at rest during sleep, and nervous fret and worry are relieved. Opium in some way unquestionably causes contraction of the peripheral capil- laries; why should it not then similarly affect those of the brain ? When the 1 If this amount of opium should produce too much drowsiness, or stupor, especially in the case of children, it must, of course, be diminished. 80 INJURIES OF THE HEAD. heart’s action is strong and frequent, aconite and veratrum viride may be found useful, either with or without the opium. Chloral and the bromides, as sup- plementary to opium, or to replace it, will prove useful in cases of excessive wakefulness, and where there is a marked tendency to convulsions. The condition of the kidneys as to prior renal disease should be investi- gated, as otherwise we may confound cerebral symptoms of renal origin with those due to traumatism. What testimony does experience give as to the results of antiphlogistic treatment? In our late war, where it was not considered essential, Otis states that four-fifths of the cases of injury to the skull and its contents proved fatal, while the British surgeons in the Crimean War, and the German sur- geons in 1849-50, saved more than one-half. To be sure, the more universal adoption of rifled weapons may make this difference in reality less than it seems, but it cannot account for the entire discrepancy. Should blisters or other forms of counter-irritation be used? I think not, and certainly only late in the disease. Suppose that the case does well, when must the antiphlogistic measures be exchanged for a more ordinary diet and treatment? This must be left to the surgeon’s judgment in each special case. I know nothing much harder to decide than, at the bedside of a patient with serious head-injury, to correctly indicate when a resort to a more liberal diet should be initiated. Of course, when the patient is manifestly becoming rapidly exhausted, the question is simple enough. It is in those cases which are doing well, with apparently not much amiss with them, that errors arise, iso sudden change should be allowed, but a more generous dietary may be tentatively instituted. Stimu- lants even are required in some cases, but here I prefer digitalis, to improve the power of the heart, or ammonia in some form, rather than alcohol. Having gotten the system under the mercurial influence, the calomel must be omitted, or given at longer intervals. In the later stages, iodide of potas- sium and ergot have proved serviceable in my hands. In the later and more insidious forms of traumatic encephalitis, to which the terms subacute or chronic may be applied, where the patient, after some slight injury, persists in attending to work and business, until slight head- ache, mental irritability, constipation, broken sleep, vertigo, and fever set in, to be followed by delirium, etc., the treatment does not materially differ from that already indicated, except that depletion is less well borne, and that mercurial purgatives and a more generous diet seem rather indicated than a strict antiphlogistic regimen. After any attack of intracranial inflammation, the patient must regard himself as an invalid for a long period, entirely abstaining from work or only gradually returning to it, and at once relinquishing it upon the slightest sign of cerebral irritability. Cerebral Abscess.—So grave does any operation for intracranial abscess appear to the public, that many surgeons allow themselves to be influenced by the fear of blame should death result, and are too apt to confound the great fatality inherent in the disease itself, with that of the operation destined for its relief. A calm consideration of the natural history of the affection in question, will, I believe, show that, when accessible, these depots of pus should be treated upon the same principles that govern us in dealing with circumscribed suppurations elsewhere. Are such collections of pus, even in the arachnoid cavity, ever absorbed ? There is no such case on record. What do autopsies teach us with regard to abscesses of the cerebral substance? That in the vast majority of cases they enlarge, by involving more and more INJURIES OF THE BRAIN AND MENINGES. 81 of the brain at their periphery,1 until they either by pressure2 induce fatal trouble, or by bursting into the ventricles rapidly destroy life.3 In some few cases the surrounding proliferating neuroglia is finally organized into a firm sac-wall, and the disease remains stationary for a time, but only station- ary—not cured.4 In a few of these cases, post-mortem appearances would seem to indicate that caseation of the contents of a former brain-abscess had taken place, and that recovery by partial or complete absorption was therefore possible. Such an occurrence must be exceedingly rare, and I doubt if it ever takes place in traumatic cases, where the surrounding cere- bral substance, instead of being condensed, is more apt to be softened. Sooner or later, such quiescent abscesses will terminate life, and that, too, very suddenly in most cases. A still further study of the natural history of cerebral abscess will give us, I think, some valuable therapeutic hints. Among the greatest of surgical rarities is the spontaneous evacuation of a cerebral abscess, either through the nares, orbit, or external auditory meatus.5 This can only take place when the suppurating cavity lies near such portions of the skull as the cribriform plate of the ethmoid, the roof of the orbit, or the tegmen tympani. Such was the case in a patient who was under the care of Mr. C. Hawkins, and an abstract of whose history I here subjoin:— A man twenty-eight years of age, three weeks before his admission into hospital, struck his head violently against the edge of a door, producing a small wound on the right side of the forehead, with much ecchymosis, with but little external hemorrhage. There was intense pain at the seat of the blow. A week afterwards, headache and deli- rium came on. A discharge from the left ear of many years’ duration, which had before stopped running from time to time, when marked deafness was always noticed, now ceased. The pulse was frequent and weak, but there was no more pain upon the left side of the head than upon the right side. Two days subsequently the pulse was “ laboring” (I presume slow and full). The patient became comatose, and died the next day. After death, an abscess with softened, ragged walls was found in the left anterior and middle lobes of the cerebrum, containing about three ounces of pus. The dura mater was adhe- rent to the roof of the tympanum, and through the necrosed bone a small probe could be passed into the middle ear, which showed evidences of chronic otitis with destruction of the membrana tympani.6 This abscess was clearly secondary to the old otitis, and the blow probably set up active disease in the adherent and diseased dura mater overlying the chronically inflamed middle ear. Other similar cases, where recovery has ensued, might be quoted if it were necessary, to demonstrate that nature can and does successfully evacuate cerebral abscesses.7 The next link in my chain of argument is, that after an unsuccessful attempt had been made to discover pus in certain cases, and when the trephine had revealed a healthy, non-bulg- ing, pulsatile condition of the dura mater, this membrane was nevertheless 1 By a rapidly progressing yellow softening in many instances. 2 Acute oedema of the brain is frequently the immediate cause of death. Chronic internal hydrocephalus is common in cerebellar abscess, whenever it tends to lessen the cavity of the fourth ventricle, or to compress the aqueduct of Sylvius. (See Ziemssen’s Cyclopaedia of Practical Medicine, vol. xii.) 3 Abscesses situated in the middle of the parietal and frontal lobes open usually into the ven- tricles. Those of the middle lobe may open at the base of the brain, giving rise to a most fatal form of meningitis. 4 Meyer (Ziemssen’s Cyclopaedia of Practical Medicine, vol. xii.) has shown that, although as reported by Lallemand, a capsuled brain-abscess may be met with as early as the thirteenth day, a distinct abscess-wall is upon the average not seen before seven weeks. 6 Perforation through the orbit, the temporal bone, and other portions of the skull-bones, after agglutination of the membranes, has been reported. If adhesions do not form, a widespread fatal meningitis is apt to occur when nature strives to spontaneously evacuate these abscesses. 6 London Medical Gazette, First series, vol. xvii. p. 156. i Tassi, Proceedings of the Royal Academy of Medicine of Romo, quoted in the Lancet, April 26, 1884; Hawkins, loc. cit., p. 162. INJURIES OF TIIE HEAD. incised, and in a few hours or days nature ruptured the superjacent brain- substance, and, the pus having escaped externally, recovery ensued. Here, as elsewhere, a brief account of a few selected cases will convey my idea better than a mere general description:— A child nine years old, suffering from a compound depressed fracture of the frontal bone, was trephined by Petit. Headache and fever set in on the night of the fifth day, and on the following day the dura mater, distended and discolored, bulged into the opening. A tablespoonful of brown, fetid fluid was evacuated by incision of the dura mater, but the symptoms steadily increased up to the night of the eleventh day, when rapid improvement occurred, and it was found that a large abscess had burst and satu- rated the dressings with offensive matter. Complete recovery ensued in two months.1 Dr. Joseph Pancoast trephined in a case where the altered dura mater puffed up through the trephine-opening. Incising this, allowed the softened brain-substance to pout through the wound. Urgent symptoms being absent, although a sensation of distinct fluctuation was felt, nothing further was done. The abscess opened spontaneously next day, and the patient improved for two weeks, more or less pus being constantly dis- charged. On the sixteenth day, owing to obstruction to the flow of pus—as was proved by an autopsy—death resulted. The abscess communicated with the posterior horn of the opposite ventricle.2 Acquaintance with these facts logically leads us a step further, and, an abscess of the brain-substance having been diagnosticated, an incision would seem indicated to evacuate the matter, just as it would be in a case of subcu- taneous phlegmon. Examination of the records of our art shows that this practice has been repeatedly adopted. Thus among others I find the follow- ing apposite cases:— An officer was struck by a pistol-ball, which grooved the outer table of the left frontal bone. Marked symptoms of encephalitis set in on the tenth day, but subsided under treatment. In consequence of excesses of diet, intense headache, rigors, etc., de- clared themselves upon the twenty-third day, followed in seventy-two hours by con- vulsions, aphasia, right hemiplegia, and coma. Upon the twenty-ninth day after injury, Surgeon J. F. Weeds trephined over the left frontal eminence, and found a small scale of the inner table lying loose upon the slightly lacerated dura mater. An incision was made into the substance of the brain, evacuating half an ounce of green, offensive pus, when the symptoms of compression disappeared in ten hours, and recovery ensued.3 Dupuytren had a patient who had been wounded by a knife-blade on the top of the head. The weapon broke off short in the bone, and the fragment was overlooked by the surgeon who first dressed the wound. This healed, and no trouble, save occa- sional pains about the scar, followed for over two years, when the man suddenly became unconscious, and in that condition was admitted into the Hotel-Dieu. Examination of the old scar and subsequent incision revealed the point of the knife imbedded in the bone. He was trephined without relief, and opposite hemiplegia made its appear- ance. Incision of the dura mater revealing nothing, Dupuytren plunged his knife deeply into the brain, whereby a large quantity of pus was evacuated; the symptoms disappeared, and the patient ultimately recovered.4 Upon the other hand, an equally favorable opportunity for surgical interference pre- sented itself to De la Peyronie, but was lost; and with it the patient’s life, by the declination of further operative interference after the dura mater had been incised without discovering pus. In this case, the autopsy revealed an abscess immediately below the trephine-opening, only three or four lines beneath the surface.5 1 J. L. Petit, op. cit., p. 354. 2 Treatise on Operative Surgery, 2d ed., p. 106. 8 Nashville Journal of Medicine and Surgery, April, 1872. 4 Lemons Orales, 2e ed., tome vi. p. 146. 5 Memoires de l’Academie Royale de Chirurgie, tome i. p. 319. Paris, 1743. INJURIES OF THE BRAIN AND MENINGES. 83 Finally, let me illustrate by my own practice and that of others, what I believe to be the proper treatment in cerebral abscess:— On the morning of March 6, 1884, J. Y., aged nineteen years, walked into the Epis- copal Hospital, complaining of a sore on the top of his head. He said that it was the result of a blow which he had received two months previously at Chicago. On ex- amining the wound, an ulcer was found located about the position of the left middle parietal lobe. In the centre of this ulcer was the broken edge of a knife-blade. Upon being told of this, he seemed thoroughly surprised that such was the case. But little could be made out by closely questioning him as regarded the incidents of the attack, except that a man had struck him on the top of the head so forcibly, that he had fallen on his hands and knees, but had recovered himself almost immediately. He said that he did not at that time, nor afterwards, lose consciousness, nor had he had even a headache. All symptoms of brain-injury were absent. He did not complain of any pain or uncomfortable sensation when the knife-blade was removed by the gentleman who first saw him; but in the afternoon of the same day he had slight pain in the head. His appetite was good, and his bowels constipated. March 7, patient had rested well through the night; did not complain of headache. Temp. 100° F.; pulse 80. An examination of the eyes was made by Dr. Heyl, five hours after the withdrawal of the knife-blade, with the following result:— Pupils reacted normally to incident light. Media and optic papilla normal. Re- tinal arteries of full size in the left eye, probably also in the right eye. It was difficult to pronounce positively on this point, owing to the peculiar distribution of the vessels. Veins in both retinae enlarged and of a black color. Arteries and veins in each eye tortuous. Very many fine, thread-like reflections of light, doubtless from very fine vessels. Diagnosis was retinal hyperaemia, arising from intracranial circulatory disturbance. March 8, temp. 100° F.; pulse 80. This afternoon, at one P. M., after the wound had been examined, he was seized with an epileptiform convulsion which lasted about two minutes; no particular movements were made which could lead to the localization of the source of irritation. At four P. M. he had another attack, but not as severe as the first, being conscious during the paroxysm. At ten P. M. a very violent convulsion occurred, the patient remaining unconscious five minutes. The attack began with a twitching of the right arm, but soon became general. Having been sent for, I tre- phined the skull over the seat of injury, removing a button of bone which showed a slight depression of the inner table. The position which the blade had occupied could be seen in the dura mater, there being an opening surrounded with dense cicatricial tissue. The dura mater did not seem to be congested, and there was evidently no pus or fluid beneath it. The wound was washed out with a solution of corrosive subli- mate, one part to two thousand, and then dressed with sublimated gauze. March 9, temp. 100° F. ; pulse 83. The patient seemed easy this morning, except for slight pain about the wound. At 11 A. M. he was seized with a muscular tremor of the lower extremities. He was conscious during the attack, but could not control the movements, which lasted about three minutes. March 10, temp. 100° F. ; pulse 80. Doing well this morning, no headache. March 14, temp. 98° F.; pulse 62. The wound is looking well; moderate, healthy suppuration. Patient’s general condition is worse. Marked hebetude and slow pulse. He sleeps the greater part of the time. Brain-abscess suspected. March 17, temp. 102° F.; pulse 67. This morning an erysipelatous blush is noticed over the forehead, but not about the wound. The attack lasted until the 21st, being limited to the face and yielding easily to treatment. March 22, temp. F.; pulse 76. Patient’s condition is still worse. The tongue is coated, dry, and fissured. Pulse slower, and memory failing. March 25, morning and evening temp. 98° F. ; pulse 60. March 26, temp. F.; pulse 53. March 27, morning temp. F.; evening temp. F.; pulse 70. March 29, the patient’s condition is about the same ; incontinence of urine ; hebetude more marked. Pulse 52 ; morning temperature 99° F. March 30, temperature 99° F.; pulse 70. This morning I found the patient uncon- scious, and with right-sided hemiplegia; he was rapidly sinking. 84 INJURIES OF THE HEAD. The symptoms of brain-pressure being so marked, immediately upon my arrival I reflected the flap covering the trephine-hole, and found it filled by the tensely stretched dura mater, which, however, pulsated strongly at every portion. A feeling as of fluctuation was conveyed to the tinger. While examining the wound, a minute drop of pus, not larger than a small pin-head, oozed up through the dura mater. Supposing that the cause of the trouble was reached, I made a small incision through that membrane, but, to my disappiontment, nothing was evacuated. Further manipulation brought about half a minim of pus, which was thought to come, perhaps, from a diffused layer of pus in the arachnoid cavity. The coma rapidly deepening, an aspirator-needle connected with a vacuum was passed in at least three, if not four different spots, to the depth of two-thirds of an inch, but with no result. Feeling convinced that pus was present, and that from the symptoms it was compressing the ascending frontal and parietal convolutions, I pro- ceeded to set a large crowned-trephine in front of, and below the first opening, which was slightly behind the fissure of Rolando, according to my calculations. Before I had more than half divided the skull, both pulse and respiration ceased, and the patient was thought to be dead, by both my colleague Dr. Morris J. Lewis, the three resident physicians, and myself. After laying the instruments aside for a moment, I determined to complete the operation. Rapidly dividing the bone, I found an apparently normal dura mater, which I incised, but found nothing. While Dr. Lewis and I were examining the exposed membrane, a large drop of pus oozed up through one of the aspirator-punctures. I at once plunged a knife into the brain-substance, and evacu- ated from one to two fluidounces of greenish pus. The patient appeared to be quite dead, but placing my hand over his heart I thought, but was not sure, that I felt a feeble cardiac pulsation. Dr. Lewis immediately seized the patient’s arms and began to practise artificial respiration. In about half a minute his skilful efforts were re- warded by a gasp, and then the diaphragm feebly contracted. I then sent for the battery, which was effectively used by Dr. J. K. Mitchell; one-hundredth of a grain of atropia was subcutaneously injected; sinapisms were applied over the heart; a turpen- tine enema was administered; warmth was applied to the feet, etc. After some twenty minutes’ vigorous treatment, the intercostal muscles commenced to act slightly, but, on the cessation of efforts at artificial respiration, in a few moments the patient ceased to breathe. Renewed efforts resuscitated him. In two hours’ time he wras semi-con- scious, and could feebly move his right arm. All pulse and respiration had ceased, at the lowest computation, for fully three minutes. March 31, temp. F. ; pulse 120. Patient much better, and conscious. An ophthalmoscopic examination was made to-day by Dr. Heyl. Left pupil a little sluggish in its reaction to light. Right pupil normal. Margin of each papilla absent. Retinal veins of large calibre, tortuous, and filled with very black blood. Arteries, if of abnormal calibre, are slightly diminished in size on the retina, but of normal calibre on the disks. The optic disks do not look swollen, as is commonly the case in papillitis, but as if they possessed the same level as adjoining parts of the retina. The refraction of the papilla and surrounding parts of the retina were not obtained. It is also noted that at the time of examination the patient’s face is dusky, but that his mind seems clear. The diagnosis is double papillitis in the stage of retrogression. A hernia cerebri the size of a wralnut is extruding from the wTound in the dura. The abscess discharges freely. The patient does not complain of headache. April 1, temp. 102° F. ; pulse 110. Erysipelas again on forehead, extending over face. The hernia cerebri is now7 about the size of an egg. Patient is losing strength. April 2, temp. 103° F.; pulse 112. Condition worse, hernia breaking down and coming away with poultices. April 4. The patient died this morning at 6.30 A. M. He remained conscious until three hours before his death. Autopsy About the position of injury, the dura mater was bound down to the brain by inflammatox-y adhesions. The left parietal lobe w7as an enormous abscess-cavity. The abscess was superficial, destroying the greater portion of the upper part of the left hemisphere. The right hemisphere moist; the dura congested. Old pleuritic adhe- sions were found in the chest; the lungs were affected with hypostatic congestion, but otherwise normal. INJURIES OF THE BRAIN AND MENINGES. 85 Mr. Hulke reports the following cases:— A boy aged 13, whose forehead had been grazed by a push against an iron fence, was trephined by me seven weeks after the accident, incomplete hemiplegia having supervened. The graze had festered, healed slowly, and left a tender scar. From the time of the injury there had been more or less severe headache ; and latterly nausea and retching. The pulse was unnaturally slow and the temperature subnormal. The trephine was put on at the site of the injury on the right of the middle line of the fore- head. The outer table was found slightly starred, but the cracks did not reach the inner surface of the bone. The dura mater, which appeared to be healthy, bulged up tensely into the bone-hole An aspirator-trocar, connected with an exhausted syringe, was pushed through it, and when this had reached the depth of about one inch, greenish pus was drawn up. The abscess was then freely opened with a narrow scalpel, and a quantity of pus, estimated at from three to four fluidounces, escaped. The hemiplegia soon disappeared ; the other symptoms less quickly. Optic neuritis supervened and ended in blindness. Several months afterwards, whilst in the blind school, the patient had epileptiform fits. He was kept in view during several years, and, when last seen, was a very intelligent, well grown youth.1 A laborer, aged about 60 years, was recently admitted into the Middlesex Hospital, under my care, a fortnight after being struck a glancing blow on the right temple by a falling ladder, which stunned him for a few minutes and caused a considerable bruise. He continued, nevertheless, to work as usual until the middle of the third day, when the headache which he had had from the time of the accident became very severe—so severe that his wife feared he would go out of his mind. When taken into hospital he described the pain as darting from the seat of the blow (marked by a slight discoloration) through his head. The pulse was 56, and the tempera ture slightly below the normal average. His mind was unclouded. About one week afterwards, he became insensible in the night, and in the morning the right upper and lower limbs were found absolutely palsied as regarded motion, and nearly so as regarded sensation. When the right arm or thigh was severely pinched, he gave scarcely any sign of consciousness of it, but shrank slightly when the left arm or leg was pinched similarly. Two days subsequently, spastic rigidity of the left arm supervened. His wife, who had till now obstinately refused any surgical interference, permitted trephining. A small disk of bone beneath the bruised spot in the right temple was cut out. It appeared uninjured and healthy. The dura mater bulged up so tensely into the bone-hole that pulsation could neither be seen nor felt. The exposed surface of the membrane appeared healthy. An aspirator-needle, connected with an exhausting syringe, was pushed through it to a depth of about one and a quarter inches. A brownish, turbid fluid rose up into the receiver, and continued to flow through the prick-hole after the needle was withdrawn. The minute opening was enlarged with the scalpel, and a considerable quantity of fluid escaped. The flaps which had been reflected were replaced, and the wound was very lightly dressed with a little boric charpie. An hour afterwards he asked for food. Next morning the spastic rigidity of the left arm had gone. On the second day slight return of power was noticed in the right limbs, and before the end of a week their palsy had disappeared. For a very few days after the operation, the charpie was wetted and discolored by the fluid which continued to ooze ; but this oozing soon ceased, the wound soon healed, and two months from the date of the operation the patient appeared quite well.2 In some cases, even less operative interference may be necessary, owing to the sloughy condition of the dura mater and of the superjacent brain-sub- stance. Thus Mr. Hulke gives the following account of a case under his charge:— A middle-aged woman, having fallen down in a fit in a neighboring street, Was brought to the Middlesex Hospital. She was unconscious, and her left arm and leg were rigidly flexed. On the right temple was a small festering wound, leading to 1 Medico-Chirurg. Trans., vol. lxii. p. 367. 2 Holmes’s System of Surgery, 3d ed., vol i. p. 628. 86 INJURIES OF *THE HEAD. necrosed bone. On perforating this with a trephine, several drachms of pus were forcibly ejected through a sloughy hole in the dura mater. The spastic rigidity of the left arm and leg immediately disappeared, but the patient soon died. At the exami- nation of her body the empty cavity of a large abscess was found in the anterior lobe of the right cerebral hemisphere.1 Diagnosis of Cerebral Abscess.—As to diagnosis, I can only refer to the histories of the last cases which I have given. Mental hebetude, slow pulse, headache, perhaps rigors, subnormal temperature, constipation, and at the end sudden development of the symptoms of compression, as evidenced by profound coma, hemiplegia, respiratory failure, and death, seem to have, in all cases, marked the course of the brain-abscess. I believe that an abscess involving the cerebral tissue alone, will be accom- panied in most cases by a subnormal, or at least not an elevated temperature.2 Where a high temperature is observed, either the pus-collection is simply a localized suppurative arachnitis, limited by adhesions, or there is a menin- gitis in addition to the abscess. If originating from bone-caries, middle-ear disease, etc., where the abscess is secondary, there is almost of necessity an elevated temperature, although even here, during the height of the symp- toms, as in the last six days of life in a case reported by Huguenin,3 the temperature may be normal. If these observations are confirmed by others, a valuable diagnostic point will be afforded. Can cerebral localization aid us in our diagnosis? I think that- in cases where, after head injury, the patient presents the train of symptoms just detailed, with distinct implication of one or all portions of the motor area of one side, when death is imminent, even without external wound trephining and the use of the aspirator are at least warranted, if not demanded, in view of the success which has been obtained by their employment. If the motor area is not involved, or has not been primarily affected or injured, nothing beyond the purest chance could lead to a successful operation, with no bone- injury as a guide.4 Prognosis.—I do not presume to say that great success will attend opera- tions for brain-abscess, but experience warrants the statement that every recorded recovery has been due to operation. As in the great majority of cases, it is impossible at the time of operation to determine whether the abscess is located solely in the cerebral tissue, whether there is simply a localized collection of pus in the arachnoid sac, or whether the abscess-cavity consists partly of cerebral tissue and partly of the membranes, I shall quote the results of thirty cases, which will give an approximate idea of the chances of recovery in these affections. These cases have been reported byDela Peyronie, Dupuytren, Guthrie, Dumville, ISToyes, Detmold, Ashhurst, Clark, Weeds, Holden, Ilulke, Maunder, Tillaux, Lloyd, Chinault, Courvoisier, Stimson, Morehouse, Bontecou, Peck, Jalland, Elcan, Broca, Polaillon, Kilgarriff, Edmunds, Milford, W. E>. Roberts, and myself. Of this number just one-half proved fatal. Of course I do not mean to say that fifty per cent, represents the actual mortality, but, as far as this series of cases goes, the results are encouraging. 1 Holmes’s System of Surgery, 3d ed., vol. i. p. 626. 2 See p. 27 of this article for a third case by Mr. Hulke, where the temperature was sub- normal, making, with the following, five cases which I have noted as presenting this symptom. M. L. Brown reports a case of brain-abscess after fracture of the ethmoid bone, where the tempe- rature was subnormal—97° F.—for eleven days. (Bost. Med. and Surg. Journ., Dec. 29, 1881, p. 610.) 8 Ziemssen’s Cyclopaedia of Practical Medicine, vol. xii., page 735. 4 See a case on p. 76 of this article, which I consider was eminently unfitted for operation, as perusal of its history will make clear. INJURIES OF TIIE BRAIN AND MENINGES. 87 Chronic Cerebral Abscess.—Although death after acute encephalitis may take place in the period of red softening and suppuration, consequent upon traumatisms of the brain, nearly all the cerebral symptoms may disappear, even while a chronic abscess is forming. During this latent period (which usually varies from one to two months, although it may be of only a few days’ duration), when portions of the brain possessing definite functions are affected, symptoms of localized disease may be noticed, such as aphasia, paresis, or hemiplegia, and even convulsions, which are commonly general, but are more rarely limited to certain groups of muscles. Strabismus is very rare. Signs of constant, slight pressure upon the brain may sometimes be detected, such as more or less continuous headache, accompanied during the exacerbations by occasional slight fever, dizziness, and nausea. Violent headache probably means tension of the abscess, and congestion around it. The more frequent these attacks of severe cephalalgia, the more probable is it that acute red-inflammatory softening, yellow softening, and extensive cere- bral oedema, are imminent; in other words, that death may take place at any moment. Occasionally dulness of the senses, slowness and want of motor energy, and gradual imbecility, accompany the chronic headache. Sleepless- ness, optical delusions, and intermittent attacks of extreme terror have also been recorded. Again, after a rapidly developed, severe headache, the patient may become comatose and feverish, these symptoms lasting only for a few hours. Chills have been very rarely noted, but have been sometimes so marked as to give rise to the erroneous diagnosis of intermittent fever. Epileptiform convulsions often occur during the latent stage of chronic brain- abscess, but are in no way peculiar or diagnostic. The terminal processes of chronic cerebral abscess are, perforation outwards, with meningitis of the con- vexity of the brain; perforation at the base, with basal meningitis; rupture into the ventricles, extensive cerebral oedema, pressure upon the medulla oblongata by a cerebellar abscess, and remarkable anaemia of the brain. The symptoms attendant upon the last stages of brain-abscess are often those of mental irritation, restlessness, illusions, and violent delirium, with elevated temperature; but they are of such brief duration as to be frequently over- looked, and are followed by sopor, severe headache, slow pulse, dilated and feebly-acting pupils, depressed temperature, passive retinal congestion, occa- sional vomiting, complete coma, and involuntary evacuations. Hemiplegia— or more rarely other forms of paralysis—respiratory failure, and death usually result. Convulsions sometimes occur. Muscular contractures are at times noted. When perforation induces meningitis, a corresponding change and confusion of symptoms result, which I need not here attempt to describe. Cerebral localization may aid us in locating these abscesses, provided that they occupy certain positions. They—even more than acute abscesses—give rise to errors because of secondary involvement or irritation of contiguous or closely associated portions of the encephalon, wrhence errors can so readily arise that the greatest caution must be exercised in making up our final opinion. I would refer the reader to Huguenin’s excellent article on this subject in Ziemssen’s Cyclopaedia of Practical Medicine, for the differential diagnosis of chronic cerebral abscess, as my limits do not admit of my saying more than that intraocular ophthalmoscopic appearances and eye-symptoms are here unreliable, and that hrain-tumor is the disease with which this affection is most apt to be confounded. 88 INJURIES OF THE HEAD. Cerebral Localization. Whatever may be urged by the opponents of cerebral localization, I think that there will be few who will deny that the situation of the cortical motor area of the brain is now definitely known, and that by the aid of certain measurements we can locate, with sufficient accuracy for operative purposes, the fissure of Rolando, and, in consequence, the ascending parietal, frontal, and other convolutions. The latest authoritative expression of opinion is to the effect that, “ there does not yet exist a single accurate observation of a destructive lesion outside the motor area, having produced permanent paralysis, nor does there exist a single accurate observation of a destructive lesion of any extent of the ascending convolutions, which has not given rise to permanent paralysis of the opposite side of the body.5'1 Owing to the commissural connections of the various portions of the brain, to the surround- ing areas of softening, or to the oedema which accompanies inflammatory lesions, secondary phenomena attendant upon brain-injuries apparently con- tradict these statements, but primary circumscribed lesions produce symptoms which are neither uncertain nor misleading. For surgical purposes, it must never he lost sight of, that in proportion as the symptoms indicate circum- scription of the lesion, so is their value; and that evident implication of many centres, and inconstant symptoms, should make the surgeon review his diagnosis, so that no unnecessary or useless operation may be performed. There are already on record at least five cases in which success, as regards the discovery of the lesions, has attended an operation guided by cerebral localization, and in three of these cases the patients have recovered or been relieved. Let no one think that I am contending that cerebral localization can be frequently available for surgical purposes as indicating an operation. This must be comparatively rare, although I believe that confidence resulting from more extended experience will in the future lead to more frequent interference. The chief advantage to be gained at present from our improved knowledge of cerebral topography, is that it will direct in many cases when to with- hold operative interference, as has been pointed out under the head of intra- cranial extravasations of blood. For surgical purposes, we may consider that the various cerebral centres are located as taught by Lucas-Championniere:— Lower extremity, summit of the ascending parietal convolution. Upper and lower extremity, summit of the ascending frontal and parietal convolutions. Upper extremity, middle portion of the ascending frontal convolution. Upper extremity and aphasia, inferior third of the ascending frontal, and foot of the third convolution. Facial paralysis, inferior third of the ascending frontal, and foot of the second frontal. Aphasia, foot of the third frontal. These differ slightly from Ferrier’s points, but less so than would appear at first sight, and I am disposed to agree with Lucas-Champion- niere, that, surgically, they are more practically useful. Mature and Forms of the Palsies and Convulsions observed in Wounds of the Head.—These palsies result from superficial lesions of those portions of the brain which lie almost without exception beneath the anterior half of the parietal bone (see Fig. 1090), and they correspond closely to those experi- mentally produced upon animals. As traumatic cerebral lesions are almost never limited to a point, but com- 1 Charcot, Revue de MMecine ; Med. Times and Gazette, 1883, vol. i. p. 616, and vol. ii. p. 491; Ibid., 1884, vol. i. p. 270. CEREBRAL LOCALIZATION. 89 prehend a certain extent of brain-tissue, neighboring centres to those chiefly injured will give rise to symptoms confusing the diagnosis. The paralysis is opposite to the side of lesion. The following combinations are those usually met with: Paralysis of face and aphasia. Aphasia and palsy of the Fig. 1090. Diagram showing localization of cerebral nerve-centres and determination of line of Rolando (Modified from Lucas-Championnifere.) , arm. Paralysis of the arm and face. Paralysis of the upper and lower ex- tremities. The palsies are more apt to be limited than those of pathological origin. Thus oftentimes the upper extremity is alone affected. Again, in- complete motor paralysis may alone be detected. They often vary in their intensity, according to the greater or less degree of inflammatory compli- cation, or the amount of compression. Spontaneous cures of traumatic paralysis are very rare, although it may improve up to a certain point. More often it increases, and merges its phenomena with those of secondary paralysis. Secondary hemorrhage into inflamed or softened brain-tissue, probably accounts for certain cases of paralysis of intermediary origin. After operation, the paralysis may either suddenly or gradually disappear, but the inflammatory phenomena pass away only gradually. In some rare instances the paralysis disappears or diminishes after operation, only to return at a later period, and to be followed by atrophy. Here the cerebritis has gone on to secondary atrophy instead of to repair. Thus it is clear that irritation and compression of a centre not only suppress its function, but may lead to secondary degeneration, whence the advisability of active interference whenever the functions of a centre are distinctly involved. Traumatic palsies are usually complete at the outset. They are often pre- ceded, followed by, or alternated with convulsions. The convulsions are not often general at first. They usually commence in one limb. When they become more extended, there is commonly an aggravation of the general con- dition. Sometimes the paralyzed member is alone affected; at other times it is uninvolved. Generalized convulsions closely resemble those of epilepsy, and 90 INJURIES OF THE HEAD. are met with in fractures outside of the motor zone. Too little is known of their nature, significance, etc., to warrant any definite statements. As a result of traumatism, true epilepsy, hysteria, or even the convulsions due to apoplexy, may occur. Convulsions are of diagnostic value in direct propor- tion to their limitation. Total hemiplegia cannot have a cortical origin, and therefore contra-indi- cates operation,1 unless it has been incomplete at the outset, is irregular, and coincides with a very extended depression of the bone covering the motor region of the opposite side. Then a trephine-crown may he applied upon the middle of the line of Rolando, when, if the appearance of the dura mater warrant it, still more bone may be removed. Monoplegia, or spasms limited to one member, or to a portion of a member, indicates limited lesions. If the lower limb be affected, the upper portion of the Ascending parietal convolution, with perhaps also the corresponding part of the ascending frontal, is involved. A trephine-crown must then be applied about the upper part of the Rolandic line. With paralysis of the arm and leg, the lesion probably involves the upper two-thirds of the ascending convolutions or the paracentral lobule. The trephine should then be placed at the upper part of the line, a little lower than in the preceding case. It may perhaps be necessary to enlarge the open- ing by cutting out another circle lower down.2 Paralysis of the upper extremity alone, probably indicates injury to the middle third of the ascending frontal convolution, and the trephine should be applied a little in front of the middle third of the line of Rolando. Paralysis of the lower part of the face points to lesion of the inferior third of the ascending convolutions, or of the foot of the second frontal. Here the trephine should be placed a little in front of the inferior third of the Rolandic line. In all the above instances, one portion of the periphery of the cut should cover the line of Rolando. Immediate aphasia after injury of the left side of the head, is probably the result of the pressure of a bony fragment or a clot of blood. Should aphasia occur within a few days or weeks, it is probably due to abscess, and although the operation may prove of doubtful value, it may be attempted. The surgeon must never forget, however, that this symptom may result from a lesion extending from the primary injury, seated perhaps at some distance from the speech centre. In simple aphasia, the trephine-crown should be placed lower down still, in front of and below the inferior extremity of the line (see Fig. 1090). Fortunately, in most cases many centres are attacked, and consequently the surface to be exposed is much larger. Thus :— With paralysis of both lower extremities, the summit of the line, and the contiguous superior portion of the cranium, must be removed; with paralysis of one upper and one lower extremity (hemiplegia), the operation must be performed at the middle and upper portion of the line ; in paralysis of the arm with facial palsy, the trephine is to be applied at the inferior third of the line, and a little in front; in palsy of the upper extremity with aphasia, the open- ing should be made below and in front of the line; with facial paralysis and aphasia, the bone should be removed well in front of the line, and below its inferior extremity (see Fig. 1090). The above, following Lucas-Champion- niere, give all the possible combinations, and the proper positions at which 1 Brain-abscess excepted, when operation is indicated. 2 MacEwen (Glasgow Medical Journal, Feb. 1884) reports a successful trephining over the middle third of the ascending frontal and parietal convolutions, for hemiplegia the result of syphilitic disease. CEREBRAL LOCALIZATION. 91 to apply the trephine according to the present state of science. These state- ments are subject to revision with advancing knowledge. Let the surgeon never forget that it is often necessary to remove large portions of bone to free the injured centres, and to obviate secondary inflammation. Following Gross and Seguin, I shall now proceed to give certain general indications and contra-indications. Indications.— When hemiplegia occurs after a blow upon the head, or hemiplegia with hemispasm, however slight be the injury—provided that it is in the temporo-parietal region, even although it be not directly over the motor area—the surgeon is justified in exploring that area. In the coma resulting from intracranial hemorrhage—from the middle meningeal artery for instance, as already pointed out—cerebral localization should guide the surgeon’s hand unless in those instances where the effusion is so large as to present no limited compression-symptoms, when the operation should be conducted upon the principles laid down when considering intra- cranial extravasations of blood.1 In those cases where the paralysis is on the side of injury, that is, the result of hemorrhage or fracture by counter- stroke, provided that laceration of the brain seem improbable, an operation over the motor area of the side opposite to that of injury would seem indicated. This must be a rare condition, and is too often complicated with cerebral laceration at or near the site of the external injury itself.2 Contra-indications.—Lesions of the base of the brain, as indicated by paralysis of one or more cranial nerves, neuro-retinitis, or Cheyne-Stokes respiration, I consider, with Gross and Seguin, to be positive contra-indications in otherwise favorable cases. Hemiplegia accompanied by marked anaesthesia contra-indicates operation, as the latter symptom indicates lesions which implicate other portions of the encephalon than the motor area, and which are too deeply seated to be acces- sible to operative interference. How is the line which corresponds to the fissure of Rolando to be mapped out in the living head ? There are several methods, the least complex of which I shall now describe. The head should be shaved, and then placed so that the alveolo-conclyloid plane shall be horizontal. With a little care this can be readily done, even with the patient lying down. The next and most important point is to find the bregma. This can oftentimes be felt, but there are two devices which render its detection certain. The most accurate is the “flexible square” of Broca. (Rig- 1091.) A little behind the point of junction of the arms Is a smooth, conical plug, which is to be introduced into the external auditory meatus. The horizontal branch of the square is then placed beneath the column of the nose (as in Fig. 1092), when the posterior border of the vertical arm will indicate the bregma. According to Broca, the bregma is at the front border of this line, but Lucas-Championniere has ascertained that this point is too far forwards. A ready method of finding the bregma, suggested by the latter author, is indicated in Fig. 1093. A piece of pasteboard is cut out so as to fit the shaved head, astride of which it is placed, passing across both auditory meatuses. A pencil is passed through it at right angles, at the level of the eyes, so as to ascertain whether the head is in a horizontal posi- tion ; the middle of the pasteboard, marked B, will then indicate the bregma. Having determined this all-essential point, measure backwards 5.5 centi- 1 See page 44, supra. I must here express my indebtedness to the monograph of M. Lucas- Championniere, and to the summary of the subject by Dr. Seguin in the last edition of Prof. Gross’s System of Surgery, vol. ii. p. 41 et seq. 8 See Prof. S. W. Gross’s case, page 46, supra. 92 INJURIES OF THE HEAD. metres in man, or 5 centimetres in women (BR), which will give the upper extremity of the Rolandic fissure.1 Next, measure backwards a horizontal line, 7 centimetres in length, from the external angular process of the frontal bone where it begins to curve upwards to form the temporal ridge (Fig. 1090). Fig. 1091. Fig. 1092. Fig. 1093. Flexible square of Broca. P. wooden plug to be introduced into auditory- meatus. (After Lucas-Championni&re.) Flexible square applied. H. bregma. (After Lucas-Championniere.) Ready mode of determining position of bregma. (After Lucas-Championni&re.) Upon this elevate a perpendicular line A B/, 3 centimetres long, which will give the lower point of the fissure of Rolando; connecting these two points by the line R' R, we have the whole fissure defined with sufficient accuracy. The line should be distinctly marked upon the shaven scalp with an aniline pencil, or with strong tincture of iodine. Even when there is marked oedema, steady pressure with the finger will readily make out the bony point required. As a large-crowned trephine should be used for all operations where we seek to expose individual nerve-centres by the rules of cerebral topography, any little inaccuracy in measurement, which may be unavoidable, proves of no great moment. In conclusion, I would remark that the whole subject of cerebral localiza- tion is yet in its infancy; that what has been said must be considered as provisional; but that by the light already gained, a few surgeons have suc- ceeded in operations, solely guided by cerebral topography, while more have been partially guided, as I have been in two instances; and that in the past operations have been refrained from, and still more will be in the future, which a knowledge of cerebral localization may show to be useless. Trephining. It is of the first moment to ascertain the danger inherent to the operation itself. For this purpose it is useless to refer, as is commonly done, to such statistics as those of Fritze, 53.98 per cent.; of Pirogoff, from 60 to 70 per cent.; of Le Fort, 56.22 per cent.; of Otis, 56 per cent.; of Bluhm, 51.25 per cent.; and of Bermann, 46 per cent, of mortality. My reasons for making this sweeping statement are, that, as shown by W. J. Walsham in his admir- able paper on the dangers of trephining, investigation proves that in many 1 Broca, Seguin, and most authors say only 5 centimetres, but Lucas-Championniere insists that this is not enough. TREPHINING. 93 instances death has been due to injuries other than those of the head, such as rupture of the renal vein, of the liver, etc. In many others, the post-mortem examination has shown that death has resulted, not from the operation, but from the injuries for which the trephining was done. In some cases, which have been quoted at second or third hand, trephining was not performed, but mere elevation of fragments with no removal of sound bone, while in a few no operation at all has been done. To obtain, with anything like an approach to accuracy, the actual death- rate, we must resort to a series of cases where the operat ion has been performed upon persons in good health, without concomitant cerebral traumatism. The nearest approach to this is where the operation has been done for epilepsy, persistent pain in the head, etc., where the patients have been otherwise in good health. When death results in this class of cases, the operation must certainly be chargeable with it. An examination of the extended statistics of Mr. Walsham, combined with the results of other cases which I have added, show that the immediate mortality only amounts to 10.69 per cent., for out of 159 cases but 17 have proved fatal.1 That statistics are easily manipulated I am aware; but, as far as I know, these cases have been taken just as they have come. I could add others which might make the exhibit more or less favorable, but the figures quoted are the most extended, and at the same time the most trust- worthy, that I am acquainted with. I have added 37 cases of operation for epi- lepsy and insanity to the 122 of Walsham. Through the kindness of Prof. W. T. Briggs, of Nashville, I am in possession of the details of 33 operations for epilepsy or insanity performed by him, and the details of the remaining 4 cases are also known to me. These figures are therefore more valuable for determining the mortality of the operation, per se, than those of Billings’s or Eccheverria’s tables of operations for epilepsy, in which details are, for the most part, wanting. The latter writer, too, includes cases of recent head injury, to which the term traumatic epilepsy is not strictly applicable. These were doubtless cases of epileptiform convulsion from contusion of the brain, etc., and of course increase the apparent mortality of the operation. For similar reasons, the statement of the mortality of operations for traumatic epilepsy, which will be given hereafter, is not derived from either Billings’s or Eccheverria’s tables, but from a series of cases with the details of which I am familiar. A further examination of those cases of which the details are sufficiently accurate, show that in 85 cases where there was no wound or fistulous tract, 72 ended in recovery and 13 in death, a mortality of 15.29 per cent. In 40 addi- tional cases, where a fistula communicated with the dead bone, or an intracranial abscess existed at the time of operation, 39 patients recovered and only one died, a death-rate of 2.5 per cent. In the aggregate of statistics above given, of 159 cases, the mortality of 10.69 percent, probably fairly represents the risk of the operation per se, as it is done for fractures and acute head-injuries, some of which are compound, some of which are made so—as in trephining for simple frac- ture—and m some of which more or less ancient suppuration exists. I think likewise that the death-rate ot 15.29 per cent, may be taken as a guide as to the risks of trephining in simple depressed fracture, that is to say, that it expresses the risk of the operation per se, exclusive of that which attends the concomitant intracranial injuries. The correct appreciation ot the share which trephining has in conducing to a fatal result in cases of acute traumatism, such as compound fracture, is 1 Briggs, Trans. Am. Med. Association, vol. xxxi. 1880, and personal communication from author ; Walsham, St. Barth. Hosp. Reports, vol. xviii. p. 220; Byrd, Proceedings of the Am. Surgical Association, 1884. 94 INJURIES OF THE HEAD. in any given case a more difficult matter. The following propositions, which, of course, are only approximately true, may aid in the solution of this difficulty. 1. When death occurs from intracranial inflammation, the disease must, if due to the operation, have first started in the bone and dura mater, whence it has spread to the arachnoid, pia mater, and cortical substance of the brain, but very rarely to the white matter. 2. If the intracranial inflammation has its starting point in the brain, both the cortical and medullary portions will probably be involved, and thence the diseased process will extend outwards to the pia mater, arachnoid, etc. In addition, when of traumatic origin, the cerebral substance will probably pre- sent either signs of recent contusion or laceration, or traces of such injuries if the case be of some standing. 3. If then, in a given case, laceration or contusion of the brain, and inflam- matory involvement of both the medullary and cortical portions of the cere- brum—the inflammation not involving more than the arachnoid membrane— coexist with a healthy condition of the dura mater around the trephine-hole, death certainly has not been hastened by the operation. 4. When intracranial inflammation has existed prior to operation, the opera- tion cannot be justly charged with the fatal result. 5. When the time of onset of intracranial inflammation has been doubtful— that is, when it is uncertain whether it preceded or followed the operation— any opinion as to the effect of the latter upon the result of the case must be purely conjectural. General surgical principles, however, would suggest that inflammation would be more apt to result from contusion of the diploe, with a ragged, shattered state of the bone—which condition necessarily in- volves defective drainage—than from a clean trephine-cut, with its facilities for ready escape of the wound-fluids. 6. Great caution should be exercised in drawing conclusions in these cases, since the most severe injuries are sometimes recovered from without compli- cations, while the slightest in appearance have at times proved fatal. From want of knowledge of the actual death-rate of uncomplicated tre- phining, together with failure to recognize the facts embodied in some of the propositions just stated, and from the unreliable character of the statistics which have been published, as shown by Mr. Walsham, prominent surgeons differ as to the advisability of trephining. Those who are impressed with statistics gathered from any and every source, and unaccompanied by details to show whether operation or concomitant injury has been the cause of death, reprobate the operation; while those who have carefully investigated the matter are gradually reviving the procedure, so that there is reason to hope that it will soon be established on a surer foundation than ever before. I would premise, before giving the results of Mr. Walsham’s and my own carefully compiled statistics, that many of the operations included were performed at a time when all operations exhibited a higher rate of mortality than at present. Thus, out of 748 cases there died 276, a percentage of 36.9 per cent.1 My own experience has taught me that trephining 'per se is not a dangerous operation, and that more patients commonly die from complications which might have been prevented by a timely operation, than from the removal of a disk of healthy bone. When should the trephine be used ? As early as possible, in order to an- ticipate the secondary inflammatory affections which result from the irritation caused by fragments of bone, and from the impossibility of irritating fluids • Amidon’s statistics and estimate of the dangers of trephining (Med. Record, June 14, 1884), are, I am convinced, too low, the result of omitting unfavorable cases which legitimately should have been included. TREPHINING. 95 draining easily away. When is it too late to trephine? Never—since a sufficient number of cases have recovered after trephining for cerebral abscess, than which nothing can be more dangerous; indeed, I myself saved, for the time, one patient who had ceased to breathe for some minutes, and who was only resuscitated by artificial respiration, the use of the battery, etc.1 The grounds of my belief are found in the following statistics: Of 150 cases of preventive trephining, collected by Walsham, Briggs, and myself, only 33, or 22 per cent., proved fatal, while, on the other hand, 66 deaths, or a mortality of 52.8 per cent, followed 125 operations performed after the super- vention of symptoms indicative of brain-disease produced by the skull-injury. I freely admit that the average of cases of preventive trephining may possibly have been less severe than that of the secondary cases, but I think this highly improbable, since, in the severer ones, the patients would hardly have sur- vived until a later date. With the details of the greater number of these cases I am familiar, and they go rather to prove the severity of those in which the operation was preventive. It is in accord with sound surgical prin- ciples to expect that preventive trephining should succeed, since by remov- ing sources of irritation we may prevent intracranial mischief which, once initiated, the trephine is usually powerless to relieve, simply because it rarely can do more than remove one source of irritation, while others, and the more dangerous, that is, inflammation and its products, cannot be thus favorably influenced in the majority of instances. A cerebral abscess may be success- fully evacuated, but much more commonly the operation fails; and the form of intracranial suppuration usually met with is diffused, not circumscribed. Therefore, I repeat, trephine early when possible, but here, as in other cases, use judgment. The indications for trephining for intracranial extravasation of blood, intracranial abscess, and depressed fracture, will all be found under their appropriate headings. Method of Performing the Operation.—I shall include, under the term trephining, all operations which involve removal of more or less sound bone, Fig. 1094. Fig. 1095. Conical trephine. Ordinary trephine whether by the trephine, bone-forceps, or Hey’s saw.2 The special instruments required are an elevator,3 a knife with raspatory attached,4 trephines of various sizes (Figs. 1094,1095), a pair of stout forceps, a trephine-brush (Fig. 1096), a 1 He died six and a half days subsequently from exhaustion, the result of his second attack of erysipelas within three weeks. (See page 84, supra.) 2 Scultetus’s saw, in reality. 3 See Vol. III., p. 566, Fig. 644. 4 See Vol. III., p. 564, Fig. 633. 96 INJURIES OF THE HEAD. pair of Key’s saws (Figs. 1097, 1098), and gouge-forceps1 (rongeur, as it is sometimes called), or a pair of small, cutting bone-forceps.Some surgeons prefer to use the lenticular (Fig. 1099), to elevate the bone and smooth Fig. 1096. Fig. 1097. Fig. 1098. Fig. 1099 Trephine-brush. Two forms of Hey’s saw. Lenticular. edges of the trephine-cut; but I have never seen any necessity for its use, as an elevator in careful hands is perfectly safe, and its rough, serrated edges serve admirably to tile away, as it were, an}7 inequalities left by fragments of the brittle inner table, which may have been left at the periphery of the aper- ture. The rongeur is an admirable instrument, and, where it can be used, serves a better purpose than the trephine or Iley’s saw, in removing an over- hanging shelf of bone, while it is a more rapid and safer instrument. Of the two forms of trephine, the conical, commonly called Galt’s, is the safer, since from its form it is almost impossible for it to injure the brain, if, as the last portions of the inner table are divided, undue pressure should be made; while under these circumstances the old form of instrument has occasionally been accidentally plunged into the brain-substance. There is a theoretical objec- tion to the conical instrument—viz., that from the uneven division of the outer and inner portions of the skull, necrosis is more apt to occur—but I am unaware of any facts to support the assertion that such is the case. The instruments should be placed in a solution of carbolic acid, one part to twenty of water, and the scalp cleansed by a solution of turpentine two parts, alcohol fourteen parts. The sponges should be kept in corrosive sublimate, one part to two thousand, with which solution the wound also should be kept more or less constantly irrigated. In most cases of compound fracture, flaps formed by incisions, regulated somewhat by the original wound, will readily expose the bone; indeed, in 1 See Vol. III., p. 566, Fig. 641. 2 A few American surgeons are enthusiastic in their advocacy of the dental engine instead of the trephine in removing portions of the skull. Having had no personal acquaintance with this method of operating, I can neither commend nor condemn it. TREPHINING. 97 some cases none are needed. Where there is no wound, crucial, Y-shaped, or, which I greatly prefer, a horseshoe-shaped incision, should be made. Any bleeding which does not spontaneously cease in a few moments, should be arrested with serre-lines, or by the application of a piece of dry antiseptic lint, which will, by the pressure of an assistant’s fingers, stanch the blood. Ligatures may be used if preferred, but are usually unnecessary. The peri- osteum should next be incised, carefully separated by the raspatory or knife- handle, and kept out of harm’s way, so as to avoid, as much as possible, the risk of future necrosis. The trephine, with its centre-pin protruded about one-sixteenth of an inch, and firmly screwed in this position, should be now applied to the portion of bone which it is intended to remove. The instru- ment should be worked with a light, sharp, quick movement from left to Fig. 1100. right, and from right to left, care being taken not to press unevenly, and the pressure being chiefly exerted as the hand is carried from left to right. As soon as a sufficient groove has been cut to steady the trephine, the centre-pin should he withdrawn, and fixed so as to avoid injury to the dura mater. When the outer table of the skull is cut through, the bone-dust, which up to this time has been dry, becomes soft and bloody, as the instrument penetrates into the diploe. Both the sound and feel are also different. Where the use of the centre-pin is undesirable, Dr. P. H. Watson, of Edinburgh, has sug- gested that the instrument should be steadied by applying it through a per- forated piece of pasteboard, firmly held against the bone. The trephine should be removed from time to time, and cleansed in the carbolized water, either by the brush or a sponge. The detritus lying in the bony groove should be removed by a tooth-pick or the flat end of a probe, advantage being taken at the same time to measure the depth of the cut at various portions of the circumference, to ascertain whether the bone is being evenly divided. If one segment of the groove be deeper than another, the trephine must be inclined towards the shallow side, and pressure made at that point alone until the groove is of equal depth throughout. The surgeon must remember that the bone is frequently of unequal thickness at various parts of the circum- ference of a trephine-cut, so that while the osseous disk may be firmly held fast at some point by portions of the inner table, the teeth of the instrument may at other points be tearing the dura mater, the chief thing to be avoided. When the instrument reaches the inner table, both the sound to the ear and the sensation conveyed to the hand usually give warning. Great care Application of the trephine. 98 INJURIES OF THE HEAD. should now be exercised, and each turn must be made cautiously and with very light pressure. By a slight rocking movement of the trephine, the looseness of the piece can be ascertained; but it is better to lay the instru- ment aside, and seizing the edge of the disk in the grasp of a pair of stout forceps, gently move it from side to side. If loosened at one edge, the trephine teeth must be made to cut upon the opposite, attached part, for a turn or two, when the forceps should again test the stability of the disk. When loosened, the bone may come away in the crown of the trephine, but I think it safer to remove it by tilting the piece out with the forceps, using a rocking move- ment, and always drawing it out towards that side where any portion of the inner table remains unsawn, as then the dura mater escapes the slightest injury from the other thoroughly sawn and perhaps splintered edge of bone. Any portions of the inner table that are left behind, can be removed with the forceps, elevator, or lenticular. If the case be one of punctured fracture, a trephine large enough to include the starring of the outer table should be used, when most of the fragments will come away at once. Great care must be exercised in removing splinters of the inner table, lest the dura mater or venous sinuses be wounded. In the case of an ordinary depressed fracture, the trephine should be applied so that only about two-thirds of the circumference of the cut will be located upon the sound bone. A trephine of only sufficient size to enable an easy introduction of the elevator should be used. If after the removal of a disk of bone sufficient room have not been obtained, free use of the gouge-forceps or Iley’s saw will usually suffice to enlarge the opening; otherwise, a new segment of bone must be removed with the trephine. If the fracture is near a sinus which we sus- pect may have been wounded by the depressed fragments, the trephine-cut should be so planned as to give free access, if necessary, to any bleeding point. When operating for blood or pus within the cranium, a trephine with a large crown is preferable. Abernethy suggested, that at the very outset of suppu- rative osteomyelitis a disk of the outer table only of the skull should be re- moved with the trephine, so as to give free vent to the unhealthy pus. The advice is theoretically good, and has been approved b}7 Liclell, but I am not aware that it has ever been put in practice. Performed for whatever purpose, all loose fragments of bone should be removed, depressed pieces elevated, but allowed to remain in situ, unless evi- dently so much denuded of pericranium and dura mater as to be likely to become necrosed, and the edges of the opening in the skull smoothed as far as practicable, with the gouge-forceps, or file-surface of the elevator, so as to lessen the risk of ulceration of the dura mater. If the sinus-like veins of the diploe bleed, a pellet of softened wax will readily arrest the flow, if the point be accessible. I was once compelled, on account of the very free hemorrhage, to pass a pledget of lint beneath the margins of an irregular opening of the frontal bone, when the inner table and diploe were broken for a considerable distance beyond the outer table, and to leave it there between the dura mater and bone for twenty-four hours. The bleeding in this case was so free that I had not time to remove the bony edge to reach the source of hemorrhage, which burst out as soon as I had elevated a large fragment. The patient recovered. In another instance, where I successfully removed nearly the whole of the left temporal fossa, for a terrible crush of this part, after taking up and tying with fine catgut one or more branches of the middle meningeal artery, which lay in the dura mater, I was finally compelled to fill the whole wound with corrosive-sublimate cotton, and lay down the flaps to arrest the free oozing; this case also ended in recovery. After arresting hemorrhage, the wound should be freely and repeatedly TREPHINING. 99 washed out with the mercuric-bichloride solution, and the flaps laid in place and kept in position by straps or sutures. Means for free drainage must be provided, either by the arrangement of the flaps or by a small drainage tube. Over all, several layers of mercuric or carbolic gauze, or layers of lint soaked in the mercuric or carbolic solution should be placed and retained by the gentle pressure of a well-applied bandage. The dressings should be frequently changed, lest pent-up pus beneath the flaps should prove a cause of cerebral oppression. The after-treatment should be strictly antiseptic as far as the wound is concerned, and should be that of a bad cranial fracture as regards the head symptoms. Eceheverria recommends the administration of eonium and ergot after trephining for epilepsy, with the constant application of the ice-cap to the head for a number of days, after which frequent cold affusions may be substituted. A head-cap, formed of a continuous coil of block-tin pipe, through which iced water is kept constantly flowing, is the most satis- factory way of applying dry cold.1 It is unadvisable to apply the trephine over the course of sutures, if it can be avoided, simply because the dura mater usually adheres at these points with exceptional tenacity, rendering tearing of that membrane a probable acci- dent, and, also, because of the great difference in the thickness of the bone; thus, along the sagittal suture, which is grooved for the longitudinal sinus, at one portion of the periphery of the trephine-cut the teeth would almost certainly touch the dura mater, while at other portions the bone would be only half sawn through. In cases where it seems imperative to apply the trephine over a suture, especially one beneath which lies a sinus, there is, fortu- nately, very frequently a separation of the dura mater produced by the injury, which removes it out of harm’s way. Notwithstanding, when possi- ble, sutures should be avoided. In like manner, trephining over the anterior inferior parietal angle is undesirable, lest the middle meningeal artery should be wounded. If this happen, plugging the bony canal with a sharpened match, or a pellet of wax, will usually arrest the bleeding. If not, a knitting- needle or iron wire at a dull red heat may be made to effectually seal the vessel. The course of the lateral sinus, which, in a general way, may be said to correspond to a line drawn from the externa] occipital protuberance to the external auditory meatus, should also be avoided. Trephining over the frontal sinus, it is said, must never be done except under compulsion, lest an aerial fistula result. This presupposes that the cavity is always present and in the same position. Mr. Hilton2 has shown that the sinus does not begin to make its appearance before fifteen or six- teen years of age, and that in many cases it may not begin to be developed until a still later period. Examining different adult crania, he found these cavities sometimes altogether absent. Oftentimes but one small cell was found on one side of the median line, while in other cases there was a small cell on either side. In other specimens there were fair sized cavities, at times symmetrical, but usually differing much in outline and dimensions. Sometimes the sinus may extend upwards nearly the whole distance of the forehead, and backwards an inch or more along the orbital plates of the frontal bone. An aerial fistula does not always result ;3 still, when possible, the supposed site of the frontal sinuses should be avoided. When it is not possible, a large-crowned instrument must be used to perforate the outer wall of the sinus, and a smaller one for the inner. Finally, when there are imperative reasons for so doing, the surgeon may trephine at any point of the skull, bearing in mind the special dangers to be 1 See, also, Petitgand’s apparatus, Yol. II. p. 175, Fig. 287. 8 Guy’s Hosp. Reports, 2d series, vol. viii. pp. 362 et seq. 3 See Larrey, op. cit. 100 INJURIES OF THE HEAD. avoided in certain localities, and remembering that there is no such thing as an invariable rule in surgery. Sometimes Key’s saw or the gouge-forceps can be with advantage substituted for the trephine. With these instruments, a projecting angle of bone may be removed, or a strip of bone sawn from an overhanging edge, so as to permit the introduction of the elevator and the restoration of depressed fragments to their normal level, or to allow their successful removal. The skullcap varies in thickness from one-fifth of an inch, upon the average, to as much as three-fourths of an inch at the occipital protuberance. In the young child, the diploe may be absent, whence great caution must be exer- cised in those rare cases in which the operation is required in the very young.1 In the old, the bone is often much thinned by absorption. The advice of Holden is admirable: “ Think that you are operating on the thinnest skull ever seen, and thinner in one portion of the circle than the other.” The trephine-hole is usually closed by fibrous tissue, sometimes by fibro-cartilage, and, very rarely, by a more or less complete, thin plate of bone. Sometimes the bony margins thicken, forming a raised ring, while at other times they become thinner, and blend with an imperfect ring of osseous tissue which extends into the fibrous membrane, thus closing the opening to a varying extent. As an exceedingly rare secondary complication of trephining, I would mention hemorrhage from the middle meningeal artery. Thus, Mr. Jackson reports a secondary and uncontrollable bleeding from this vessel, which required, six weeks after trephining, ligature of the carotid artery. The patient recovered.2 Trephining in Epilepsy.—Each case of this disease must be judged by itself. All that I shall attempt, therefore, will be to give the mortality and probability of success attendant upon operative interference, with the indi- cations which have induced surgeons to trephine, in this condition. Causes: Lesions found in the Bone and Dura Mater.—The cause of the lesions inducing epilepsy has been in the majority of instances the application of great violence to the skull, but many times the reverse has been noted. When the result of great violence, the disease has usually been due to de- pressed bone-fragments. When the exciting cause has been a slight injury, the lesions usually observed have been chronic inflammation and thickening of the bone, leading perhaps to the formation of an exostosis. Finally, merely inflammation and thickening of the dura mater or pericranium have been the sole lesions detected in a number of cases. Sometimes the convulsions have been the result of a slight injury which has detached a small fragment of the inner table. “ Where mania, idiocy, or other form of mental deterioration occurred, the lesion may be said generally, to have existed in the anterior half-segment, of the cranium ; where paralysis was present, the parietal, with exception of two cases, was the part injured, the lesion, however, in both of these exceptional cases being so far back as to be practically in the parietal region.”3 The onset of the disease has been, in a few cases, immediately after the injury, but in the majority a variable period has elapsed, in a few cases as much even as thirteen years. In proportion to the duration of the disease is usually the impairment of the intellect, from which the important precept may be drawn, to trephine early, since, although some of the cases of longest duration and of gravest character have been entirely relieved by operation, 1 A child, twelve months old, has been successfully trephined for a punctured fracture of the skull, produced by a large nail. (Gross, op. qit., vol. ii. p. 88.) 2 Brit. Med. Journal, November 1, 1876. 3 Walsham, St. Bartholomew’s Hospital Reports, vol. xix. p. 139. TREPHINING. 101 most patients, according to Walsham’s statistics, are only improved, are unre- lieved, or die. Symptoms Indicating Operation.—Pain in the head, mostly located at or about the injured spot, has been present in most instances. Out of a total of 82 cases collected by Mr. Walsham, in 3 there were no local indications, while in 44 a depressed cicatrix or a depressed spot, painful or tender on pressure, existed. In some, the cicatrix or depressed spot was merely sensitive, in others the seat of constant pain. Pressure at these points produced in 2 cases vertigo, in 1 convulsions, and in 1 rigidity; in 1—a point worthy of future investigation—the temperature was 3° F. higher at the tender spot than elsewhere upon the cranium. In 8 cases there was neither cicatrix nor depression, but a tender, painful, or sensi- tive spot, pressure upon which caused pain, vertigo, or convulsions. In 8 cases there was a fistulous tract leading down to dead bone. In 3 patients a fissure was felt in the bone. In 2 there was a bony elevation. In 2 there was a tumor or swelling of the bone. Eleven operations were said to have been performed at the site of a former wound or injury. In one instance there was no scar or any other local indication, but from the symptoms tre- phining seemed indicated over the fissure of Rolando, and was there success- fully applied.1 In the majority of cases, depressed bone was discovered at the operation, or the osseous tissue was found variously altered and diseased. Where carious or necrosed, a sinus generally led down to the bone. The dura mater was usually found healthy, but in other cases was thickened, congested, vascular, or adherent. A strange fact is, that in 16 cases nothing to account for the epilepsy could be detected, and yet in 10 such cases, in which recovery took place, 7 patients were cured, 2 were relieved, and only 1 was unrelieved. In one of the cases in which the patient died unrelieved, an undetected bone- fragment was found after death to have caused the failure of the operation. Results ; Prognosis.—In 48 of the 82 cases under review a cure was effected, the patients being restored to good health ; 13 patients were relieved, some of whom may ultimately have been really cured, as they were steadily improv- ing when last heard from.2 In a certain proportion the fits persisted at first, and gradually disappeared. Four patients were not improved, and 17 died. In certain of these deaths the fatal termination occurred so long afterwards as hardly to be fairly attributable to the operation. Taking the whole number of cases collected by Walsham, and 37 added by myself, making in all 167, 32 ended fatally, a mortality of 19.16 per cent. As to the prognosis, with regard to recovery from the epilepsy, etc., the cases above referred to, where the details are given, furnish the only thoroughly trustworthy data which are available. If there is a distinct history of injury, a well-marked cicatrix, or a sinus lead- ing down to dead bone, and if the epilepsy has undoubtedly been initiated by the injury, there can be no doubt of the propriety of operating after the failure of medical treatment. So simple an operation as mere removal of the cicatrix and pericranium, will in certain cases permanently relieve epilepsy, as in a patient of Dr. J. Ewing Mears, of Philadelphia. Portal cured one case of epilepsy by excising a cicatrix upon the thumb, and another by a similar operation upon a scar of the scalp. The amputation of injured toes, lithotomy, and evacuating the contents of a wounded eye have also cured epileptics. In most of these cases a so-called aura has been present, starting in the point 1 Walsham, loc. cit., p. 133. 2 One of the cured patients in this list was reported at first as only unimproved, yet a later report showed that he had had no fits for years. 102 INJURIES OF THE HEAD. operated upon. Wherever similar expedients seem indicated they should therefore be tried, if depressed bone be not manifestly the exciting cause. With Mr. Walsham, I would add, as to doubtful cases where the indications are not clear, that with the fact before us that, in many cases where the history of an injury has been obscure, or where no history whatever has been obtained, or where the only local indication has been a sensitive, painful, or even a tender spot without any evidence of depression or inequality of bone, patients have been rescued from a miserable existence and restored to one of health and comfort, “ I think we may go further, and say that even with such slight indications the trephine ought to be used ; and holding as I do that the operation is one in itself not attended, when the membranes are not wounded, with much danger, I would give the patient the beneflt of the doubt, and would myself press the operation.”1 What if at the operation nothing be found ? Wait for some months, and then, if no improvement take place, the operation may be repeated near the site of the first, remembering that in one case mentioned, an undetected fragment of the inner table was found, after death, to be the cause of the disease. As to the operation itself, Prof. Briggs, whose experience is greater than that of any other operator in this country, points out that, to be successful, all the thickened and diseased bone should be removed. In one of his cases he successfully cut out six large buttons of bone with the intervening osseous tissue. Prof. Briggs also calls attention to the very im- portant fact that after removal of the bone, we should still watch the case, lest some other source of peripheral irritation should arise, such as a painful cica- trix, which would then require excision. One of the sources of failure in operations for epilepsy, is the neglect of after-treatment, medical as well as surgical. The operation indeed removes the most important cause of the epilepsy, but only one cause. The disturbed circulation in the nervous centres, arid the excessive mobility of the nervous system, can only disappear with time; and if all other sources of peripheral irritation are not most carefully guarded against, the patient may be slightly if at all benefited, whereas judicious after-treatment will sometimes relieve an apparent operative failure. Injuries of the Cranial Nerves. As a consequence of head injury, one or more of the cranial nerves may have its functions suppressed, either temporarily or permanently. This may result from various causes: (1) the nerve may he divided by the vulnerating body, as in thrust-wounds of the orbit or nose, or in penetrating bullet-wounds of the head ; (2) by laceration of the brain-tissue, the nerve may be torn from its centre ; (3) it may be torn across by the fissure of a basal fracture, travers- ing the foramen through which it passes out of the cranium, or the bony canal in which it lies; (4) it may be compressed by displaced fragments of bone ; (5) it may be compressed by blood, either effused into its sheath, or along its course through the skull; (6) the deep origin of the nerve may be destroyed or compressed by effusion, either hemorrhagic or inflammatory. The olfactory, optic, and orbital nerves, are those most frequently lacerated by thrust-wounds, etc. Injuries from such a cause are rare. Owing to the frequency with which the petrous portion of the temporal bone is involved in fractures, injuries of the facial and auditory nerves are of common occur- rence. Palsies of these nerves in undoubted fractures of the petrous bone do not always appear at first., nor are they persistent, which shows that they are by no means certain signs of a basal fracture. When loss of function is 1 Walsham, loc. cit., p. 143. INJURIES of the cranial nerves. 103 produced by hemorrhagic pressure, or by that of inflammatory products, gradual recovery not uncommonly ensues. I shall now briefly allude to the injuries of each special nerve, and the consequent lesions—if any—produced in distant organs. First Pair, or Olfactory Serves.—A fracture involving the cribriform plate of the ethmoid must almost of necessity injure the olfactory nerves. Owing to the excessive softness and delicacy of these nerves, and to their being firmly held against the under surface of the anterior cerebral lobes by the arachnoid, injuries which tend to drive the anterior portions of the brain against the bony floor of the anterior cranial fossae, may readily injure the olfactory bulbs. According to Hr. Ogle, blows upon the occiput—as in two cases reported by him—may rupture the nerve-filaments as they pass from the bulb through the foramina in the cribriform plate of the ethmoid bone. Hemorrhage into the neighboring portions of the anterior lobes, or surround- ing and compressing the nerve between the bone and brain—to judge from results—is a much more common cause of loss of smell than basal fracture. I have seen one case of anosmia, in private practice, the result of a probable fracture of the base of the skull. Four years after the accident, when I first saw this gentleman, all sense of smell was absolutely lost, and this had been so since the date of the injury. Brodie reports two cases of anosmia after head-injury. In one, there commenced some time after the injury a gradual restoration of the sense of smell, which steadily went on until a perfect cure resulted; in the other, examined many years after, complete loss of smell persisted. In an excellent paper, Mr. Henry Lee1 relates a case showing how caution must be exercised in determining the presence or absence of anosmia. A patient in St. George’s Hospital appeared for several weeks to have lost the sense of smell upon the left side, after a traumatism of the head which had resulted in facial paralysis. Finally, a more careful examination showed that, owing to the combined effect of a deviated nasal septum and paral- ysis of the dilator naris, etc., the left nostril had practically become imper- vious to air; when, however, the left nostril was held open, the man per- ceived odors with equal facility upon each side of the nose. Anosmia is sometimes said to coexist with loss of taste, but this is a mistake. True sapors —that is, excitors of the sense of taste, such as salt, acids, or bitters, which are non-volatile—can be readily tasted after complete destruction of the first pair of nerves. Those substances which depend chiefly upon volatile odors for their so-called taste—and to odor most articles of food owe their palatableness— can no longer be distinguished from tasteless or even disagreeable substances. This was the case with the patient that was under my care. From the pro- pinquity of the centres of speech and smell, anosmia and aphasia not uncom- monly coexist. Second Pair, or Optic Serves.—The optic nerve may be torn through by a fracture traversing the orbit; may be compressed by hemorrhage within the neurilemma; may be crushed by a displaced fragment of bone; or may be divided by a penetrating wound. Of the first method of causation, a case reported by M. Pigne is a good illustration. Here, from the application of a powerful compressing force, that is, the passage of a carriage-wheel over the head, the orbital roof was extensively comminuted, resulting in a complete tearing across of the optic nerve and of all the recti muscles.2 As an instance of a displaced fragment of bone suppressing the function of the optic nerves, 1 Medical Times and Gazette, new series, vol. iv, p. 2S8 et seq. 1852. 2 Bull, de la Soc. Anat. de Paris, p. 228. 1837. 104 INJURIES OF THE HEAD. Brodie relates the case of an old man, run over by a cart, who with a depressed fracture of one parietal bone complained of total blindness. After death, fragments of the sphenoid bone were found compressing both optic nerves, just behind the orbits.1 Hewett says that there are, in St. George’s Hospital Museum, two optic nerves derived from the same patient, where the neurilemma was distended with blood, thus producing compression. He says that he has found this con- dition in several instances after severe injuries of the head, and especially after those near the orbits. The nerve-sheath was in these cases distended with blood, which had escaped from the veins contained within the neuri- lemma. This observation of Sir P. Hewett serves to explain the gradual recovery of sight which takes place after certain head-injuries, where prima- rily vision lias been lost.2 M. Duponchel reports a case where the optic nerve was divided by a penetrating wound of the orbit:— A dragoon was wounded in a duel by a sabre-thrust. After death it wras found that the weapon had passed beneath the globe of the eye, and had completely divided the optic nerve.3 Third Pair ; Oculo-Motor Nerves.— Although from their relations, this pair of nerves is less liable to be torn by osseous fragments than those just mentioned, it is quite often compressed by extravasated blood. While all the parts supplied by this nerve may be paralyzed, it is much more frequent for the levator palpebne to be alone affected, resulting in complete ptosis. Still more strange is it to learn, that one branch of the upper division of the nerve, with another branch of its lower division, may be alone affected. In a case which I have already related to illustrate another point, the third nerve upon the left side was compressed by an enormous clot of blood proceeding from a ruptured middle meningeal artery, and during life the left pupil was widely dilated.4 Brodie5 relates an interesting case in which recovery ensued, and as, though the paretic condition of the pupil per- sisted so long, complete restoration eventually took place, it may not be amiss to give here an abstract. A gentleman received a severe contusion of the head by a fall from his horse, which rendered him insensible; and the fact that the loss of consciousness persisted for several days, showed that the cause was some form of compression. When consciousness began to return, ptosis of the right upper eyelid wras observed, with a completely dilated pupil, which did not contract with the stimulus of light. It was only after the lapse of nearly a year that the right pupil returned to its normal condition. Those cases where vision is said to have been affected in injuries of the third nerve, are probably not due to any accompanying lesion of the optic nerve, but to the state of the pupil. If such be the case, a stenopaic slit, or pinhole through a card, will render a differential diagnosis easy, provided that no original difference from refractive anomaly existed in the eyes pre- vious to the accident. An ophthalmoscopic examination would, in these latter circumstances, be necessary to determine whether the impairment of vision, after the use of a stenopaic apparatus, was due to injury, or to congeni- tal or acquired defect of refraction. 1 Med.-Chir. Trans., vol. xiv. p. 348. 2 Gaz. des Hopit., p. 446. 1854. 3 Bull, de la Soc. d’Emulation, 1822; quoted by Aran. 4 See, also, Aran, Archives GAn. de M6d., 4e serie, tome vi. p. 338; Pick (Left third nerve compressed in sella turcica by blood clotj, Brit. Med. Journ., May 27, 1865. 5 Brodie, loc. cit., p. 354. INJURIES OF THE CRANIAL NERVES. 105 Fourth Pair ; Pathetic Nerves.—Owing to the protected position en- joyed by these nerves, they seem never to be injured ; at least I have not been able to find a record of any such accident. Fifth Pair ; Trifacial Nerves.—These nerves not uncommonly suffer in head-injuries, and usually in conjunction with lesions of some other cranial nerve.1 All the branches of the nerve are rarely involved, but more than one are usually affected. A man was rendered completely insensible by a severe blowr upon the left side of the head, inflicted by a heavy piece of timber. Much blood was lost from the ears, nose, and mouth. Regaining consciousness upon the following day, right hemiplegia and ptosis of the left eyelid wrere noted. Seven weeks afterwards, upon admission to St. George’s Hospital, he complained of severe pain upon the left side of the head; the ptosis persisted, and there was a purulent discharge from the left ear. The hemiplegia had almost entirely disappeared. There was total loss of sensibility in all parts supplied by the left fifth nerve; he could neither taste nor feel upon the left side of the tongue, except at its root; a probe wras not felt in the nostril of that side ; and cutaneous sensi- bility was absent over the whole left side of the face, upper part of the head, etc. Gradual improvement ensued, but the cornea became opaque, owing, perhaps, to the eye remaining partly open and without sensation, thus allowing foreign bodies to lodge within the lids and there remain a constant source of irritation. He could close the eye when directed to do so.2 Another interesting case is on record, where, after a severe injury, both sensation and motion of the right side of the face were seriously impaired. In about two weeks, the conjunctiva of the right eye became chemosed; the cornea had lost all sensibility; it was cloudy, and presented, at its lower part, appearances of an interlamellar abscess. Soon slight ulceration commenced over the site of the abscess, extending until, between two and three months after the injury, the cornea gave way with a loss of only the aqueous humor. The cornea finally cicatrized, and the patient could see through its upper segment. Ultimately, both sensation and motion of the right side of the face were restored.3 Where recovery ensues, the paralysis has probably been due to hemor- rhagic or inflammatory deposit; where the loss of function is permanent, tearing of the nerve, or permanent pressure by displaced bone, is probably the cause. Why in some cases corneal ulceration takes place, while in others it does not, is a much vexed question which it is beside our present purpose to attempt to elucidate.4 Sixth Pair ; Abducent Nerves.—This nerve being small, and lodged in a groove upon the upper portion of the petrous part of the temporal bone, is liable to be torn across in fractures implicating this part of the base of the skull. Paralysis of this nerve is apt to coexist with a similar condition of some of the other cerebral nerves. Recovery has ensued in several such cases, where not only the abducent nerve has been affected, but where other cere- bral nerves were at the same time paralyzed. Aran reported a case where, after a violent blow upon the head, the right abducent nerve was completely paralyzed. He considered that the lesion 1 Thus Hulke (Lancet, Nov. 30, 1878, p. 769) reports a case in which, after death, the right portio dura and the fifth and second nerves were found to have been torn. 2 Lee, Med. Times and Gazette, new series, vol. iv. p. 240. 1852. 3 Richard, Gaz. des Hopitaux, 1844. I quote this case on the authority of Hewett (op. cit., vol. i. p. 616), having failed to gain access to the original report. 4 See Dixon, Med.-Chirurg. Trans., vol. xxviii. p. 373 et seq. 106 injuries of the head. was produced by a fracture of the cranial base.1 Still more striking as an illustration is the following:— A man, aged forty years, fell from a height of twelve metres upon his feet. He experienced only some slight symptoms of concussion. Omitting unnecessary details, among his other symptoms he had internal squint of the right eye. Dying about four months subsequently, an extensive fracture was found, implicating the clinoid processes and the right petrous bone, a considerable fragment of which was entirely detached from the rest of the skull. The sixth nerve was torn by the edge of the broken bone.2 Seventh Pair; Facial and Auditory Nerves.—(1) Portio Dura or Facial Nerve.—The long, bony canal in which the greater part of the intracranial segment of the facial nerve is lodged, occupying as it does the petrous por- tion of the temporal bone, renders its tearing or compression an almost necessary consequence of fractures of the middle fossae of the skull. Indeed, paralysis of this nerve has been .from time out of mind considered to be a valuable sign of fracture of the base of the skull. Loss of function of this nerve is, however, not conclusive proof that a fissure has traversed its bony canal, for it may be due, as in a case observed by Hewett, to the pressure of a small clot of blood in the common sheath between the facial and auditory nerves. Again, in undoubted fracture this nerve may not be affected at first, showing that its paralysis in basal fracture may be due to mere irrita- tion by the broken fragments and subsequent inflammatory pressure, rather than to tearing, thus explaining—remembering that absorbable blood-clot may also compress the facial nerve—the gradual recovery of function that may ensue after the most strongly-marked paralysis. Pick reports that of ten cases of facial paralysis after basal fracture, in only two was it present at the time of the patient’s admission into the hospital, while in the remaining eight cases the nerve-affection appeared from the second to the sixth day.3 (2) Portio Mollis or Auditory Nerve.—For similar anatomical reasons to those given for the facial, the auditory nerve is not uncommonly injured in fractures of the cranial base. Recovery from such injuries being rare, it is not often that deafness from fractured skull is observed. The following case, reported by Aran,4 illustrates how the portio mollis may be torn while the portio dura of the seventh pair remains intact, although included in the same bony canal for a part of its course. The reverse is also equally true, but is explicable by the longer and more tortuous course pur- sued by the facial nerve through the temporal bone. A young man fell from a height of twenty feet, and lost consciousness. On the fifth day, a fracture of the temporal bone was diagnosed from symptoms which I need not detail. Death took place on the sixth day, and at the autopsy, among other injuries, a fissure was found traversing the petrous bone so as to tear the auditory nerve. Eighth and Ninth Pairs ; Glossopharyngeal, Pneumogastric, Spinal Accessory, and Hypoglossal Nerves.—Intracranial injuries of these nerves are of rare occurrence, owing to their passage through short, bony foramina, the first three in conjunction with the large, soft, compressible jugular vein. These are also protected in their intracranial course by one of the largest of the subarachnoidean spaces, which is filled with a fluid that readily becomes displaced when blood is extravasated. After persisting for a time, symptoms due to traumatic affections of these nerves may disappear. Owing to the emergence of the three first mentioned nerves through the same foramen, their affections must be considered more or less together. 1 Arch. Gen de M6d., 4e s6r., tome vi. p. 338. 3 British Med. Journ., vol. i. p. 530. 1865. 2 Ibid., p. 191. 4 Aran, loc. cit. INJURIES OF THE CRANIAL NERVES. 107 Mr. Hilton, in his lectures upon fractures of the cranium, relates one case where, with lesions of other cerebral nerves, the result of a severe injury to the head, the patient exhibited great difficulty of deglutition; the “ tongue was thrust over to the other side; articulation was slow, and enunciation very imperfect.” Pain in the neck, upon the affected side, extending as far as the clavicle, was complained of. Recovery, leaving only slight traces of paralysis, took place after the lapse of a few months. Aphonia, dysphagia, dyspnoea, with contraction of the muscles accessory to respiration, and more or less paralysis of the pharynx, oesophagus, and stomach, were the main symptoms presented by a patient who recovered from a brain- wound, in which the glosso-pharyngeal, pneumogastric, hypoglossal, spinal accessory and suboccipital nerves were divided by the thrust of a lance. Finally, I shall give an abstract of the voluminous notes of Mr. Hilton on a case of basal fracture in which the fragments became secondarily displaced, causing compression of the eighth pair of nerves. A man with basal fracture of the skull was admitted into Guy’s Hospital, and did well until the tenth day, when, after getting out of bed and walking across the ward, he had rigors, followed by vomiting, and gradually lapsed into semicoma. Later in the day, dysphagia, with a gasping respiration, was noticed. The difficulty of deglutition rapidly increased, until before morning “ everything was rejected as soon as it reached the pharynx.” Death resulted within forty-eight hours from coma and asphyxia. Post- mortem examination revealed a healthy state of the brain and its membranes; there were signs neither of inflammation nor of injury of the brain-tissue. The line of frac- ture passed through the right jugular foramen, whence it ran across the base of the skull, dividing the posterior part of the cranium into two portions, which freely moved upon one another. The fragments were displaced in such a manner that the right cerebellar fossa was lower than the left.1 Doubtless some motion made by this patient in walking across the ward caused the bony displacement which resulted in. his death. This resulted from asphyxia, as was the case in a patient of Agnew’s. In Hilton’s case it is a matter for regret that no examination of the lungs was made, to deter- mine whether there were actually pulmonary lesions as in Dr. Agnew’s patient, and as in one of Yerneuil’s.2 In Agnew’s case, irregular, labored, noisy respiration, with great dulness upon per- cussion over the back of the chest, w'as noticed during life, and after death a blood- extravasation into the medulla oblongata, that is, into the pneumogastric centre, was discovered, with intense engorgement of both lungs.3 Erichsen says that he has seen “ repeated vomitings with palpitations, and a sense of suffocation continuing for months after an apparent injury to the origin of the pneumogastric. In other cases, from lesion of the spinal acces- sory, spasm of the trapezius and sterno-mastoid muscles, simulating tetanus, may set in.”4 Treatment.—Any special therapeutic measures seem uncalled for, since, if the lesions are due to blood-extravasations or inflammatory products, nature will suffice to cause their absorption. Mercury, blisterings, etc., are com- monly recommended, but I question their efficacy. Iodide of potassium in the later stages may prove beneficial. Electricity, if resorted to at all after 1 Two cases are given by Sir C. Bell (Lectures on the Nervous System, Am. ed., p. 202. Cases LXII. and LXV. 1833), where sudden death resulted from secondary displacement of frag- ments of the occipital bone at the foramen magnum, causing pressure upon the medulla oblon- gata. These are cited as somewhat analogous cases, since they demonstrate the possibility of secondary displacement of bone being a cause of nerve-compression. * Lancet, Nov. 30, 1878, p. 769. 3 Aguew, op. cit., vol. i. p. 278. 4 Eriehsen, op. cit., vol. i. p. 551. 108 INJURIES OF THE HEAD. head-injuries, must be most cautiously used, and not until a late period if we would not renew the previous cerebral disturbance. Secondary Affections of the Brain. These result quite as often from slight as from severe injuries. They come on at variable periods after the occurrence of the primary lesion. The same may be said with reference to the time of appearance of the symptoms indicative of cerebral complication. Defects of memory are among the most common after-effects of head-injuries, and these may be the sole evidences of cerebral disease, or the amnesia may be associated with other affections. In most in- stances the patient forgets only recent events, but at times the whole history of his past life is a blank. All power of speaking a well-known language may be lost, the patient using that of his childhood. He may forget his own name, or his residence. Again, the patient may give the most circumstantial and minute account of the way in which he was injured, upon one day, only to contradict it upon the next; and can sometimes be led to say in good faith almost anything that his interrogator pleases, as in a case related by Erichsen. This is of great importance as a medico-legal fact. The patient’s disposition may be completely altered, a gentle, quiet demeanor being exchanged for a captious, morose, or quarrelsome temper. Sleep may be broken by frightful dreams. The mind may become generally weakened, so as to be incapable of the slightest exertion. Cephalalgia, vertigo, and tinnitus aurium may also be complained of. Aphasia is a not uncommon occurrence, especially if the anterior cerebral lobes be affected. There may be also agraphia, and loss of the power of articulation. Occasionally the patient loses both memory and speech. All these troubles may be evanescent, but loss of speech and memory is only too apt to be permanent. Insanity, apt to be permanent, is a not infrequent sequel of so-called con- cussion. I have seen one case where, after as long a period as three months of mental alienation, at times so marked as to require bodily restraint, the mind ultimately seemed completely restored. Some few of these cases can be relieved by operation, as in the famous instance recorded by Cline, where, after a depressed fracture of the superior portion of the left parietal bone, trephining, eleven months subsequent to the injury, restored consciousness and voluntary motion. Impairment, disorder, or loss of the special senses is quite common, but special sensation may be at times exalted. Instances have been reported, such as those quoted by Prof. Gross, where deafness of long standing has disappeared after severe concussion of the brain. Unnatural slowness of the pulse, probably due to lesions of the medulla oblongata, the crura cerebri, or the pons Varolii, is an occasional result of concussion of the brain. This cardiac slowing may last for months, the con- dition coexisting with a peculiar irritability of the heart, so that under excitement the pulse becomes very rapid—again resuming its subnormal rate of frequency upon cessation of mental or other irritation. Changes Affecting the Digestive Organs.—An icteroid hue of the skin is a rare sequel. Nausea and vomiting, or obstinate constipation, have been sometimes noticed to persist for a considerable time after a head-injury. Gross thinks that when obstinate and prolonged gastric distress is present, there has SECONDARY AFFECTIONS OF THE BRAIN. 109 probably been direct involvement of the pneumogastric nerves or their centres. Although the appetite remains good, emaciation and loss of strength, due to defective assimilation, mark the after-course of certain head-injuries. Urinary Changes.—Cases are met with in which abnormalities of the renal secretion are more or less marked. Thus irritability of the bladder, retention or incontinence of urine, with a marked increase of the amount secreted—that is, traumatic diabetes—may all be noticed. The diabetes men- tioned is usually of the saccharine variety, comes on soon after the accident, and persists only for about eight or ten days in most instances. This is not invariably the rule, irritable bladder, etc., with marked diabetes insipidus, sometimes persisting for months. As a result of severe injuries of the skull and brain, albumen, with or without a diminution of urea, may be present in the urine.1 The amount of saccharine matter in traumatic diabetes is usually small, and its presence has been variously ascribed to an injury of the floor of the fourth ventricle, to defective oxygenation of the blood, etc. Genital Changes.—An occasional, early effect of blows upon the head, especially of its posterior portion, has been violent sexual excitement with incessant erections. It appears most probable, according to the latest investi- cations, that this, as well as impotence, is due to injury of the medulla oblongata, rather than of the cerebellum or cerebrum.2 Atrophy of the testes may or may not accompany impotence. Paralysis of some of the facial or ocular muscles is not uncommon. Want of co-ordination of certain muscles, muscular twitchings, and paralysis of a single linger, of the hand, or of a limb, may also occur. As one of the causes of these various symptoms, Gross calls attention to a calcification and necrosis of the nerve-cells of the brain, described by Virchow, in which the cell-processes and even the fine nerve-fibres of the brain-cortex may sometimes be also calcified, as a result of so-called concussion. In the vast majority of cases, however, the symptoms are due to local congestions or inflammations of various parts of the encephalon, the result of injury to the brain or its envelopes, to intracranial hemorrhages, or to the effusion of inflammatory products, and secondary changes, such as sclerosis. The paralysis may also be due to compression or lesion of the cranial nerves, and not to any cerebral injury proper. Treatment of Secondary Brain-Affections.—This is involved in that of the injuries which give rise to the secondary results. Over and above this, atten- tion to the state of the bowels, careful regulation of the diet, change of air, and, at a later stage, tonics, hot or cold douches—or alternations of these—with perhaps sea-bathing and electricity, may prove useful. Quietude of mind and body should be enforced. A prolonged course of iodide of potassium, with or without mercury, may be tried. AYhen local congestions seem to be the cause of the symptoms, ergot should be exhibited, and dry or even wet cupping should be resorted to. Prolonged counter-irritation, by setons and issues, has been recommended upon high authority. In conditions of the pathology of which we know so little, such remedies seem to me of doubtful propriety, and having no personal experience of their use I do not recommend, but merely mention them, as said to have proved remedial in the hands of others. 1 Albumen, according to Huguenin, is more commonly found in the urine than sugar. A case of Yerneuil’s, already quoted, presented distinct evidences of both sugar and albumen in the urine. 2 Harkin, Practitioner, Feb. 1884, p. 98. 110 injuries of the head. [Additional Remarks on the Mechanism of Fractures of the Skull by Indirect Violence : the “ Bursting Theory.” A few words must be given to a theory in regard to the mechanism of fractures of the skull, which appears to have originated about the middle of the last century with Sabouraut, Chopart, and other French surgeons, and which has been more recently revived by Felizet, in France, by Messerer, Wahl, and Greder, in Germany, and by Dulles, in this country. This theory, which has been called the “ bursting theory,” is based upon a well-known law of physics, that if an elastic sphere is compressed in one diameter, it is necessarily widened in those diameters which are at right angles to that which is shortened. The effect of violence applied therefore to any part of an elastic case like the skull, is to approximate the point of impact with that diametrically opposite to it—this being drawn in, as it were, to meet the point struck—and to separate all parts which are equatorially related to the diameter thus shortened. As a fracture always begins in the line of exten- sion, the bones of the skull commonly give way in some meridional line, the particular locality depending upon the strength of the different parts, and the mechanical conditions as to position, etc., under which the violence is applied. An exception, which is apparent only, is met with in certain rare cases in which the skull is broken only at a point more or less directly oppo- site the point of impact, the explanation here being that the meridional parts are more resisting than that which sustains the fracture, and that this has occurred inwards, the line of extension being, under these circumstances, on the inner surface of the skull. This theory appears to me to be reasonable, and to be founded on accepted physical laws, and I have myself taught it to my classes for many years; nor do I think it inconsistent, as it is often maintained to be, with a proper ap- plication of the “ vibratory theory,’" as adopted by Dr. Nancrede in the body of this article. The force applied to the skull is undoubtedly transmitted to all other parts by vibrations originating at the point of impact, and whether the skull shall give way where struck, or at an opposite or at a meridional point, depends upon so many factors varying with the individual injured and the particular circumstances under which the violence is inflicted, that no rules can be laid down which can be applied with mathematical certainty in all cases.] MALFORMATIONS AND DISEASES OF THE HEAD BY FREDERICK TREVES, F.R.C.S., ASSISTANT SURGEON TO, AND LECTURER ON ANATOMY AT, THE LONDON HOSPITAL. Diseases of the Scalp. Erysipelas.—The head is very frequently the seat of erysipelas. In 692 cases of erysipelas, collected by Zuelzer,1 the disease was met with on the head in 246 instances. On the scalp it usually assumes the simple cutaneous form, the morbid changes extending no deeper than the aponeurosis of the occipito- frontalis muscle ; on the face, however, the subcutaneous structures are almost invariably involved, and great swelling of the parts is produced. Erysipelas of the scalp may also be “cellular” (cellulitis) or “ cellulo-cutaneous.” Scalp erysipelas usually extends to the face, and face erysipelas to the scalp. Ery- sipelas of the head may (1) be either idiopathic, oi\(2) have for a starting- point some wound, ulcer, or chronic skin-disease involving breach of surface. The great bulk of the cases of so-called idiopathic erysipelas occur in this situation, and commence usually on the face, extending subsequently to the scalp. Trousseau2 and others very rightly question the spontaneous character of this form of erysipelas, and urge that in all but a few cases some slight lesion can be detected—a scratch, or a trifling sore upon the skin, a breach of surface on the nasal mucous membrane, or within the mouth, or the auditory meatus, or even in the lachrymal canal. And with regard to these latter sources of erysipelas, it is to be noted that the reputed idiopathic disease most commonly commences about the orifice of some mucous cavity. Scalp wounds are more commonly followed by erysipelas than are wounds elsewnere. As in other parts, it is most frequent after recent wounds, and more common after small wounds than large. This latter fact is explained by the probable neglect of treatment in smaller wounds. Symptoms.—These are the same as those of erysipelas elsewhere, with some few modifications.3 The constitutional disturbance is often considerable, and nausea and vomiting, as concomitant symptoms, appear to be unduly frequent in erysipelas in this situation (Zuelzer4). Certain cerebral symptoms also com- monly appear. Headache, often of severe character, drowsiness, or, on the other hand, undue excitement, may be among the earliest constitu- tional evidences of the disease. As the malady advances, more serious symp- toms may supervene, the more usual being sleeplessness, mental confusion, extreme restlessness, or delirium, often of a furious character. These symp- toms are usually dependent upon some hypersemia of the pia mater, and may appear in any form of head erysipelas, independent of cause -or extent 1 Ziemssen’s Cyclopaedia of the Practice of Medicine, vol. ii. p. 457. 1875. 8 Lectures on Clinical Medicine, 3d ed., vol. ii. p. 253. 1869. 3 See Vol. I. pp. 177, 184. 4 Loc. cit», p. 460. 112 MALFORMATIONS AND DISEASES OF THE HEAD. In many fatal cases of head erysipelas with brain symptoms, this hyperaemia has been the only cerebral change noticed at the autopsy. In some cases thrombosis of the cerebral sinuses may occur, producing distinctive symptoms. Hothnagel1 states that such thrombosis is due to extension from some phle- bitis of the surface (scalp or skull). Meningitis is rare in erysipelas, and when it does occur is usually suppurative, and due either to metastasis, or more com- monly to direct extension of suppurative inflammation from the bones or soft parts. Huguenin has only observed it in cases where suppuration existed. When it occurs it is associated with the usual symptoms—the patient dying with convulsions, paralysis, coma, etc Certain ocular symptoms may occur in erysipelas of the head, especially when it involves the orbital region. The most common are conjunctivitis and photophobia, the latter often due to cerebral hyperaemia; in some cases the cornea has ulcerated, and has led to perforation and subsequent wasting of the globe (Wagner). Cases also are recorded of complete suppuration of the globe. In many instances a distur- bance of vision exists, which, as a rule, perfectly disappears during conval- escence, and is ascribed by Heineke2 to an oedema of the orbital connective tissue. Amblyopia, neuro-retinitis, and optic atrophy, are reported as occa- sional sequelae, the last named being the most frequent. The local symptoms have these peculiarities: The inflammation extends with unusual rapidity; yet, although the entire head and face may be in- volved, there is little tendency for the erysipelas to extend to the neck or trunk. The manner of extension is very irregular on the scalp, although Pfleger and Zuelzer3 have endeavored to establish some rules for its extension. If beginning from a wound, it commonly spreads centrifugally, but irregularly so ; or, starting from the forehead, it may run transversely around the head to the point of commencement. Over the face it is usually very evenly dis- tributed, the chin, however, remaining nearly always free. The redness is but very little marked on the scalp, owing to the tenseness of that structure and its hairy covering; the swelling also is inconsiderable, and is best noticed at the spreading edge of the erysipelas, where the redness also is best seen. On the face, however, the redness is most conspicuous, and the swelling, especially of the eyelids, often very considerable. Bullse very rarely occur in scalp erysipelas, but are met with in face erysipelas, especially on the forehead, cheeks, ears, and over the mastoid process. Abscess is a rare sequela, especially on the scalp, and gangrene or sloughing are still more uncommon. In the eyelid, however, both these conditions are sometimes met with in cases that have been severe. The- lymphatic glands behind the ear and below the occiput, are vert' constantly enlarged during the eruption. After the eruption has subsided, the hair usually falls off to a varying extent, but is in time per- fectly renewed. Like erysijielas elsewhere, that of the head is liable to relapse and to recur. Prognosis.—The prognosis is a little more grave than that of erysipelas elsewhere, owing to the probability of cerebral complications, and to the fact that the so-called idiopathic form is apt to occur in unhealthy or debilitated subjects, whose very ill condition has indeed predisposed them to the disease. In the great majority of cases, however, perfect recovery follows. Erich sen's4 statement that erysipelas of the head, “ when arising from wound, is very commonly fatal; when it is idiopathic, it is very seldom indeed followed by death,” is certainly not supported by other observers. The duration of head 1 Ziemssen’s Cyclopaedia, vol. xii. p. 212. 2 Pitha und Billroth, Handb. der Chirurgie, Band iii. 1873. Chirurgische Krankheiten des Kopfes (W. Heineke), S. 2. 3 For full account see Zuelzer, loc. cit., p. 451 et seq. 4 Science and Art of Surgery, 7th ed., vol. i. p. 701. London, 1877- DISEASES OF THE SCALP. 113 erysipelas is, according to Zuelzer (who speaks from a large collection of ob- servations), on the average, 10, 12, or 14 days; less often, 6 days, and still more rarely does it become a matter of weeks. Diagnosis.—The diagnosis of facial erysipelas presents no special difficulties, but when on the scalp its recognition is sometimes dubious, owing to the often scarcely noticeable amount of swelling and redness. The constitutional dis- turbance should arouse suspicion of erysipelas, and an existing injury of the scalp should direct attention to that part, when at the spreading edge the features of the disease would be obvious. Treatment.—The treatment of head erysipelas presents little that is special.1 The scalp should be shaved, all wounds kept scrupulously clean, and, as a local application, I should advise the constant use of lead and spirit lotion. The practice of multiple punctures is to be condemned. If any symptoms of cerebral hypersemia appear, an ice-bag should be applied to the head, bro- mide of potassium administered, and the case treated on general principles. The eyelids, if they remain swollen, should be carefully examined for abscess, and immediate exit given to the pus, if present. Cellulitis.—Diffuse Phlegmon.—This term refers to a diffuse inflamma- tion, very commonly erysipelatous, involving the loose layer of connective tissue lying between the aponeurosis of the occipito-frontal is muscle and the pericranium. It is usually due to a wound opening up that layer of loose tissue, but may depend also upon any deep ulceration, upon injuries without breach of surface, that lead to suppuration—for instance, fracture, extravasa- tion of blood, etc.—upon various forms of bone disease inducing suppuration, and, lastly, upon the extension of erysipelas to the deeper parts. It is very doubtful if it is ever spontaneous, although Chassaignac2 states that it may occur idiopatliically during convalescence from cholera. Symptoms.—About the affected spot a deep-seated swelling of the scalp appears, which extends somewhat rapidly, and is due to effusion in the sub- aponeurotic tissue. This swelling is at first hard, hot, tender, and painful. As it increases it becomes more brawny, and the parts more evidently oede- inatous. The extent of the swelling varies, but, as a rule, before it has attained any great size it becomes softer and boggy in spots; the skin, which has up to this time been of normal color (unless erysipelas* exists), now becomes reddened; fluctuation, perhaps, is evident; and, at last, pus is dis- charged. With the evacuation of the pus much of the oedema subsides, and the local symptoms, which are often very severe, become less distressing. These local changes are ushered in and accompanied by symptoms of general disturbance, by rigors which are often repeated, by fever which may run very high, by sickness, headache, and general malaise. Cerebral symptoms, such as occur in erysipelas, may also be present, but, as a rule, all the con- stitutional symptoms subside considerably when the pus has found an exit. The extent of the local mischief varies. In some cases the whole of the scalp may be lifted up, and appear to rest upon a boggy stratum beneath. Sup- puration occurs very early, often in two or three days, and resolution is extremely uncommon. The pus, as a rule, soon finds an outlet, and mostly this is situate in the temporal region or behind the ear, about the inferior limits of the aponeurosis. There are commonly several openings. Sloughs of the connective tissue are discharged or may be removed. Often the apo- neurosis itself sloughs in larger or smaller portions, and in some cases the pericranium dies in part, leaving the bone bare, and the condition may be followed by very extensive necrosis. It is remarkable that sloughing of 1 See Yol. I. p. 191. VOL. V.—8 2 Traits Pratique de la Suppuration, tome ii. p. 7. 1859. 114 MALFORMATIONS AND DISEASES OF THE HEAD. the scalp itself is excessively rare in these cases, no matter how extensive may be its separation from the deeper parts. Facial oedema may exist, but will subside when the pus has had vent. The prognosis is often grave, and open to much conjecture. Death fre- quently occurs, and in the earlier stages is usually due either to purulent infection or to an extension of suppurative inflammation to the meninges of the brain. Death has also occurred from hemorrhage due to the opening of an artery by ulceration.1 If the disease is, on the other hand, protracted, the prolonged suppuration may cause a fatal issue. The duration and graveness of the case will depend much upon the original cause, the health of the patient, the extent of the suppuration, and the amount of sloughing; but, perhaps, the two most serious local conditions are imperfect discharge for the pus and extensive stripping of the pericranium. The latter condition is noted in a great majority of the fatal cases. The diagnosis can be inferred from the above account. From simple ery- sipelas, cellulitis is distinguished by the absence of redness, the absence usually of gland enlargement, the greater degree of the local swelling, and the more severe symptoms. Its diagnosis from acute pericranitis, which it may closely resemble, is detailed below. Treatment.—In addition to the general treatment of diffuse cellular inflam- mation2 the head should be shaved, and free incisions made the moment sup- puration is suspected, or before that occurrence if the swelling be consider- able or very tense. These incisions should be made at the most dependent spots possible, and as near to the attachment of the aponeurosis as the swell- ing extends. They should be so arranged as to avoid the scalp arteries, and to meet this end some advise radial incisions. Drainage with drainage-tubes should then be carefully and fully carried out, and a poultice applied to the entire scalp. All sloughs should be removed as soon as loose, and when they have all separated the poultice may be discarded for lead and spirit lotion. Throughout the entire case the various sinuses should be well irri- gated with a weak carbolic solution at least twice a day, and any new col- lection of pus at once evacuated. When there is any tendency to bagging, pressure with a Martin’s elastic bandage often answers well, but its use requires careful watching, as if applied too tightly it may add to the slough- ing action. The drainage-tubes should be removed one by one as soon as the granulating cavity contracts around them, and then gentle pressure with a common bandage may be maintained for some time longer. Often these cases are very tedious, especially when any bone mischief exists ; and some- times (though rarely) the sinuses refuse to heal in spite of the treatment just indicated, and in the absence of any special complication. In one such case that came under my notice, suppuration had continued eighteen months when the accidental discovery of a piece of imbedded drainage-tube, that was supposed to have been removed more than a year before, led to its almost immediate cessation, and to perfect cure. In another case, under my care at the London Hospital, healing was prevented by the formation beneath the aponeurosis of a vast amount of gelatinous, ill-formed connective tissue. On enlarging the sinuses and scraping out this jelly-like matter, a rapid healing ensued. Many cases of protracted suppuration are due to the natural and constant movement of the scalp muscle, which prevents perfect coaptation of the surfaces, as pointed out by Mr. Hilton.3 He readily cured several chronic cases of this character by simply keeping the muscle at rest by strap- ping the scalp. 1 Follin et Duplay, Traite Element, de Path. Ext., tome iii. p. 549. 1869. 2 See Vol. III., p. 119. 3 For interesting accounts of these cases, see Mr. Hilton’s “ Rest and Pain,” 3d ed., p. 139. 1880. DISEASES OF THE SCALP. 115 Abscess.—Abscesses of the scalp may be met with in three situations: 1. In the scalp proper, above the aponeurosis ; 2. In the lax tissue beneath the aponeurosis ; and 3. Beneath the pericranium. Abscesses in the first and second situations are circumscribed, but suppuration beneath the aponeurosis is generally diffuse. Scalp abscesses may be due to many causes, principal among which are contusions, extravasation of blood in the various situations named, retrogressive changes in certain wounds, especially those that have rapidly healed at the surface, the breaking down of syphilitic nodes and of so-called scrofulous deposits, suppurating cysts, and bone affections. . Owing to the tension of the parts, scalp abscesses are apt to be associated with severe local symptoms when acute, and with much constitutional disturbance. These acute suppurations are readily diagnosed. A chronic abscess in the scalp may be mistaken for a sebaceous cyst, from which, however, it may be distinguished by its more rapid growth, its pain, its tenderness, its more distinct fluctuation possibly, and by the fact that it would feel to the touch more dense at the periphery than at the centre. A grooved needle, more- over, would clear up all difficulty. There is a form of superficial abscess, com- mon in young scrofulous children, that usually appears as a sequela of chronic eczema. These abscesses are small, often multiple, well circumscribed, and covered by very thin and purple integument. They are, as a rule, painless, and associated with little or no constitutional disturbance. They should be opened early ; either by simple puncture, or, better still, by the actual cautery. They sometimes lead to troublesome scrofulous ulcers. Suppuration in the tissue beneath the aponeurosis is apt to assume the character described under cellulitis, although not necessarily of so acute and rapid a course. It is seldom, however, distinctly chronic. Abscesses beneath the pericranium are difficult to diagnose early, and are generally associated with symptoms of bone mischief—necrosis or caries. They will be referred to hereafter. Mr. Thomas Smith1 gives an account of a remarkable abscess in a child aged 4 years, that happened to form over a congenital hole in the skull, in the upper occipital region. It assumed the form of a small, rounded, fluctuating tumor, that pulsated but was not reducible. At its Jbase the deficiency in the skull could be felt. Other congenital holes could also be felt in the parietal bones. The abscess was let alone, and ultimately more or less disappeared. This case will be again alluded to in speaking of “ Malformations of the skull.” Eollin and Duplay2 allude to the great difficulty of diagnosing abscesses situated deeply in the temporal fossa and beneath the temporal muscles. The symptoms of such abscesses are most insidious, vague, and often misleading; fluctuation, even if observable when the muscle is relaxed, is at once lost when the jaws are clenched. It is important that all abscesses of the scalp should be opened early and as soon as detected, and this remark applies very especially to those beneath the pericranium, inasmuch as the longer they are left unopened the more extensively will the pericranium become separated. U lcers.—Many various forms of ulcer are met with on the scalp. Some follow upon injuries of various kinds, or upon simple eruptions, such as that of eczema. These require no special notice. The more important ulcers of the scalp are of spontaneous origin, and may be classed as (1) Syphilitic ulcer; (2) Strumous ulcer; (3) Lupus; (4) Rodent ulcer; (5) Epithelioma. Detailed descriptions of these ulcers will be found elsewhere, but the follow- ing points that affect their differential diagnosis may be here briefly stated. (1) Syphilitic ulcers are usually limited to the tertiary stage of syphilis, and are most often met with on the forehead. They proceed either from some pre- 1 Transactions of the Path. Soc. of London, vol. xvi. p. 224. 2 Op. cit., tome. iii. p. 550, 116 MALFORMATIONS AND DISEASES OF THE HEAD. existing eruption, commonly rapid, or from the breaking down of a gumma. The general features of these ulcers are that they are of rounded outline, or are annular in figure, or serpiginous; their edges are sharply cut, their bases usually level, and the skin around them of a dusky color that has been well compared to.the color of raw ham. Those due to a previous eruption are often multi- ple, and usually superficial. Those due to gummata are preceded by a hard, irregular, somewhat painful lump, covered by adherent, purplish skin, that in time softens and forms an ulcer, the base of which presents the well- known “ wash-leather” or cellular-membranous slough. These ulcers are apt to extend, and often expose the bone, and may then be associated with necrosis. They are all benefited by anti-syphilitic treatment. (2) Strumous ulcers are met with in scrofulous ehildren; and may be on any part of the scalp. There are, as a rule, more than one. They are pre- ceded by a small, hard deposit in the scalp, covered with reddened skin. In time this mass indolently breaks down. The ulcer, when fully formed, is oval or roundish, with thin, undermined, purple edges, and a foul base often covered by exuberant granulations that readily bleed. (3) Lupus non-exedens never occurs primarily on the scalp (Ileineke1), but may spread thereto from the face, ears, or mastoid region. (4) Rodent ulcer usually appears on the forehead. It is uncommon before 45. The ulcer formed spreads deliberately and very slowly—so slowly that it takes years to effect an amount of destruction that would be accomplished by epithelioma in a less number of months.2 Its edges are elevated, hard, sinuous, clean, with little adjacent induration, and none of the warty growth of epithelioma. The glands are scarcely ever affected. The bone may be exposed, and so extensively destroyed as to lay bare the dura mater.3 (5) Epithelioma of the scalp is rare, and most commonly appears on the skin of the forehead or frontal region. The ulcer formed grows rapidly, has indurated, everted, and most irregular, warty edges, and often an equally irregular base. Unlike rodent ulcer, it invades the glands, and, unlike the syphilitic ulcer, it is single. With regard to the general prognosis of scalp ulcers, it must be remem- bered that any extensive or deep ulceration may cause death from cerebral complication, usually by inducing a thrombosis of the cerebral sinuses, or a meningitis of the convexity. The treatment of these ulcers calls for no special mention in this place. Birkett records a case4 of successful removal of a large epitheliomatous ulcer over the right temple. Holmes relates a case® in which he removed from the fronto-parietal region of a man aged 64, an epitheliomatous ulcer three and a quarter inches in diameter. The pericranium was exposed. The man died shortly after the operation with cerebral symptoms. Anthrax.—This is extremely rare in the scalp. When it does occur, it is usually met with in the inferior occipital region, and is due to extension from the neck. The next most usual situation is the forehead. Anthrax of the scalp is especially dangerous by its tendency to induce cerebral compli- cations. This is usually effected by a thrombosis of the sinus, produced by an extension of phlebitis from without, This thrombosis is then apt to end in purulent “ phlebitis sinuum.” Xotlmagel6 gives an excellent account ot 1 Heiiieke, loc. cit., S. 8. 2 Hutchinson, Illustrations of Clinical Society, vol. i. p. 14. 3 Erichsen (Science and Art of Surgery, 7th edit. vol. i.) gives a cut showing very extensive exposure of the dura mater in a man who had been afflicted with the disease for thirty years. 4 Trans, of Path. Soc. of London, vol. xix. p. 389. 5 Ibid., vo}. xxiii. p. 277. 6 Ziemssen’s Cyclopaedia of the Practice of Medicine, vol. xii. 221. DISEASES OF THE SCALP. 117 such cases. Purulent meningitis of the convexity may also, according to IIu guenin,1 be induced in a like manner. Sir Astley Cooper2 “never saw a patient who recovered from any considerable carbuncle on the head.” Since that statement was made, cases of recovery have, however, been recorded. I saw two years ago an extensive anthrax, involving the greater part of the forehead, that in time healed perfectly, with but trifling constitutional dis- turbance. (f axgrexe.—More or less extensive gangrene of the scalp may follow severe injuries, especially in the cachectic. I have seen extensive gangrene of the scalp over the frontal and occipital regions follow upon the application of a tight bandage. This had been applied to arrest bleeding from a frontal scalp wound, the patient being an intemperate, ill-conditioned woman, past middle life. Gangrene of the scalp may also follow upon diffuse cellular inflammation of the scalp, especially if the treatment by prompt incision be neglected. Sir Prescott Iiewett,3 however, mentions a case of very consider- able gangrene following cellulitis where early incision had been made. The patient was a woman of middle age, and the case ended fatally. Ileineke4 states that in feeble, unhealthy children a very, trivial cause may induce a partial scalp gangrene. It has occurred after slight injuries, after otitis ex- terna, after eczema behind the ear, and after erysipelas. Mr. Thomas Smith5 has described an unique case in a little girl, aged nine. After an attack of erysipelas, a large piece of the left parietal bone came away by spontaneous necrosis, bringing with it a corresponding portion of the hairy scalp. The case did well. The treatment of gangrene in this situation requires no espe- cial notice. Tumors of the Scalp.—In addition to those tumors described below under the special headings “Pneumatocele,” “ Ilsematoma,” “Cysts,” “Horns,” “ Vascular Tumors,” and “ Aneurism,” the following growths are met with in the soft parts that cover in the cranium. Fatty Tumors.—These are very rare. They may occur on any part of the scalp, and, although as a rule small, may attain a considerable size, and may even become pedunculated.6 In some cases they are congenital, or are at least noticed very early in life.7 Their origin—in most cases at least—appears to be from the loose connective tissue beneath the scalp aponeurosis, and they are frequently found to be adherent to the pericranium. As a rule, their growth is very slow, although in one case7 the tumor reached the size of half an orange in eighteen months. When of large size the diagnosis is very simple; but when small and beneath the aponeurosis the diagnosis is diffi- cult, the mass often feeling very hard and adherent. In Mr. Sydney Jones’s case the mass appeared to become tighter and more prominent when the child cried. These tumors give no trouble other than by their bulk, although some time ago I removed a small fatty tumor from beneath the frontalis muscle in a woman, aged thirty-one, that had been associated with intense neuralgia of the supraorbital nerve. The tumor was directly over the nerve. If these growths give any inconvenience they should be excised at once. Fibrous tumors are also very rare unless they appear as the tumors of mol- 1 Ibid., p. 603. 2 Lectures on Surgery, vol. i. p. 243. 3 Lectures on Injuries and Diseases of the Head. Medical Times and Gazette, vol. ii. p, 200. 1855. 4 Loc. cit., S. 8. 5 Trans, of Clin. Soc. of London, vol. iii. p. 163. 1870. 5 Bruns, Handb. der prakt. Chirurgie, Bd. i. S. 96. 1854. 7 Case recorded by Mr. Sydney Jones. The tumor was first noticed when the child was two months old. Lancet, Oct. 1880, p. 587. 118 MALFORMATIONS AND DISEASES OF THE HEAD. luscum fibrosum, which are, however, as a rule, more of a fibro-cellular structure, and are not infrequent on the scalp. Sir Prescott Hewett1 and Professor Gross2 both describe cases of large fibrous tumors of the scalp, in each instance about the size of an orange. In Ilewett’s case, the mass was behind the ear, and hung down by a thick pedicle. In the other case the tumor was on the vertex. In both instances the fundus of the mass had ulcerated. Such tumors as these are readily removed if they occasion any trouble. Pachydermatocele ; Elephantiasis of the Scalp ; Hypertrophy of the Scalp.— A remarkable condition of the scalp has been described by different authors under one or other of these titles.3 There is now no doubt, however, that these terms have all been applied to one and the same disease. The dis- ease consists in a remarkable overgrowth of the scalp tissues at some one spot. The mass thus formed hangs down as a huge, pendulous, bag-like tumor, often lobulated and thrown into transverse folds or creases, doughy and flabby to the feel, quite painless, and covered by normal skin. Dr. Mott, who gives an excellent account of these tumors, says that they are always con- genita1 and begin in a mole. Subsequent authors have, however, not con- firmed this statement.4 These masses have occurred most frequently about the age of puberty and in young adults. In females they are more common about the occiput ;5 in males about the temporal or parietal region. They grow slowly, and are innocent, causing trouble only by their bulk, which may be considerable. When they hang down from the temple, the}7 close in the eye and drag down the mouth. In a case recorded by Sir E. Home, the tumor was larger than the patient’s head.6 With regard to treatment, Thi- rion7 obtained a cure by the use of continued pressure and iodine applica- tions ; but no doubt the bulk of such cases must be treated by removal, if treated at all. One case so operated on was fatal from hemorrhage,8 and in one of Dr. Mott’s cases9 the mass recurred twice, a circumstance explained by its imperfect removal in the first instance. Each operation must be planned to meet the particular case. If great bleeding be anticipated, the common carotid may be tied as a preliminary measure. Osteoma.—Virchow10 records two cases of osteoma of the scalp, in patients respectively forty-eight and sixty-seven years of age. They had existed for a long time. These cases, however, were only examined clinically, and may be fairly open to question as to their real nature. Papillomata of the scalp are extremely rare. They are probably always congenital, and commence from a minute wart or mole. They are most common about the frontal region, and present precisely the ordinary aspect of papillomata elsewhere. In a woman aged thirty-five, under my care at the London Hospital, there was a papilloma, measuring 3| inches by 3 inches, over the coronal suture just to the right of the middle line. It had grown from a minute mole. It was very prominent, slightly pedunculated, and gave issue to a thin discharge, having the peculiarly offensive odor of 1 Medical Times and Gazette, vol. i. p. 315. 1862. 2 System of Surgery, 5th ed., vol. ii. p. 115. 3 For some collected cases, see Bruns, Handb. der prakt. Chirurgie, Bd. i. S. 91 ; also a paper by Dr. Valentine Mott (Med.-Chir. Trans., vol. xxxvii. p. 154), including excellent drawings of the disease, and records of five cases—two being situate on the scalp. An excellent case will also be found in the Clinical Society’s Transactions, Nov. 1876, reported by Mr. Walsham. 4 See, however, Gross, op. cit. 5 Follin et Duplay, Traite de Path. Ext., tome iii. p. 569. 1869. 6 See drawing in Med. Times and Gazette, vol. i. p. 315. 1862. 7 Revue Med.-Chir., tome ii. p. 100. 1852. 8 Case quoted by Ericlisen. Science and Art of Surgery, vol. ii. p. 384. 1872. 9 Loc. cit., p. 156. 10 Die krankliaften Geschwulste, Bd. ii. S. 65. 1864. DISEASES OF THE SCALP. 119 papillomata elsewhere. It was absolutely devoid of hair, and had the usual cauliflower aspect. As the hair had always been combed over the mass, its surface was flatter than is usual in these growths. The treatment should be the same as that for papillomata in other situations. Sarcoma of the scalp is occasionally met with, although more usually the disease commences in the bone or in the dura mater (“ fungus”). It appears to be usually of the spindle-celled variety, and to present the usual signs that distinguish sarcomatous growths elsewhere. Neither the diagnosis nor the treatment calls for any especial notice in this place. Carcinoma usually assumes the form of epithelioma.1 MM. Follin and Duplay2 state that a malignant growth may appear in the deeper parts of the scalp having all the characters of scirrlius. Solid Congenital Tumors.—In addition to the congenital dermoid cysts, cer- tain solid congenital tumors are sometimes met with in the scalp. They are, as a rule, deeply seated, and adherent to the pericranium. In a case of Mr. Thomas Smith’s, quoted by Holmes,3 the tumor was 2 inches by 1 inch in size, and was lobulated, hard, and purely fibrous in structure. Some of the less superficial tumors contain cysts, while those nearer the surface are quite solid. These growths appear to have the same general structure as have like congenital tumors elsewhere. Pneumatocele.—This term is applied to tumors formed by a collection of air beneath the pericranium, and due to a spontaneous perforation of the mastoid cells, or of the frontal sinus. To appreciate its exact nature, it is necessary to exclude from consideration all emphysematous tumors of the scalp. Emphysema of the scalp may occur in connection with a more general em- physema of the cellular tissue of the body, or may. be due to the decomposi- tion of retained inflammatory products. Localized emphysematous tumors may also be due to fractures of the frontal, nasal, or ethmoid bones, and, also, according to Leduard,4 to a fracture of the temporal bone-—in any such case a cavity containing air being opened up. Such tumors may also be due to necrosis of the frontal bone (Warren,5 Duverney6), or to like disease in the mastoid process (Prescott Hewett7). These tumors must not be confused with pneumatocele. Only ten cases of pneumatocele have been put on record ;8 of this number, nine occurred in the mastoid region, and are stated to have been due to opening up of the mastoid cells, and only one has been met with in the frontal region.9 Nine of the ten cases occurred in males. The average age of the patients was about thirty, the youngest being eighteen,10 the oldest forty-seven.11 Symptoms.—When in the mastoid region, the tumor is situated behind the ear, although in Balassa’s case it first appeared in the temporal region. Jar- javay’s case was situated at the outer border of the orbit. Pneumatocele begins as a small, hard, rounded tumor, of regular outline, and covered by I See page 116 supra. 2 Op. cit., tome iii. p. 570. 3 Surgical Treatment of Children’s Diseases, p. 28. 1868. 4 Quoted by Heineke, op. cit., S. 10. 5 J. M. Warren, Surgical Observations, chapter xiii. Boston, 1867. 6 Quoted by Heineke, loc. cit., S. 15. 7 Lectures on Diseases and Injuries of the Head. Med. Times and Gaz.,vol. ii. p. 106. 1855. 8 An excellent abstract of all these cases will be found in Heineke’s monograph, S. 11 u. folg. See, also, Costes, Moniteur des Hopitaux, tome vii. Nos. 21-24. 1859 ; Louis Thomas, Du Pneu- matocele du Crane. These de Paris, 1865 ; and M. Gayraud, Art. Crane, Diet. Encyc. des Sci. Med. 1879. 9 Jarjavay’s Case, Compendium de Chir. pratique, t. iii. p. 100. 10 Balassa, Tumeur Emph. du Crane. Revue Med.-Chir., 1854. II Voison, Du Pneumatocele du Crane. These de Paris, 1860. 120 MALFORMATIONS AND DISEASES OF THE HEAD. normal skin. Its distinguishing feature is that it is resonant on percussion. By pressure, the tumor, when not too large, can be entirely emptied, this reduction being often accompanied by a hissing sound in the ear. In Chavance’s case the membrana tympani had been ruptured, and on applying pressure to the tumor air issued from the ear with a whistling noise. In the frontal pneumatocele, a like hissing sound could be heard on auscultation when attempts were made to reduce the mass. Forcible expiratory efforts often increase the size of the tumor. Pneumatocele is painless and causes no inconvenience, although in a few cases it has been associated with pain in the part, some deafness, vertigo, and sickness. These symptoms are increased or induced by pressure on the tumor. In one case (Lloyd’s) there was para- lysis of the arm, and in the frontal tumor the sense of smell had been lost. The progress of pneumatocele is very slow, being usually a matter of years. The tumor steadily increases in size, although in one case (Lloyd’s) it trebled its dimensions in two days. It often attains large size, occupying one-half of the vault of the skull. Such large tumors are scarcely, if at all, affected by pressure. Pneumatocele shows no tendency to spontaneous cure, and at the same time a fatal issue has never occurred directly from this affection. The prognosis, therefore, is favorable. Anatomy.—The air in these cases is always beneath the pericranium, and is derived from the mastoid cells or frontal sinus by spontaneous perforation of the bone covering those cavities. Chemical analysis shows this air to be somewhat modified in composition, its oxygen being diminished, its nitrogen and carbonic acid increased. These changes are similar to those noted in analyses of the gaseous matter obtained from cases of ordinary surgical em- physema. It is unnecessary to observe that the mastoid cells communicate with the middle ear, and the frontal sinus with the nasal cavity. The pericra- nium in these cases is of normal aspect, and the extent of the tumor is always found to be limited by the attachments of this membrane. The bone which underlies these tumors, and which is exposed when they are opened up, pre- sents always a remarkable alteration. It is found to be extremely rough, and to present many irregular elevations and depressions; and so large are these bosses or elevations in some cases, that they can be felt through the integu- ments when the contents of the tumor have been removed by pressure. The cause of this remarkable change is unknown. It is coextensive with the separation of the pericranium; and it is stated that the bony irregularities disappear when the pericranium again becomes adherent to the skull, a con- dition that obtains in cases of cure. Apertures are observed in the exposed bone, and although there is no doubt that some at least of these communicate with the sinuses of the affected part, yet this communication has not been actually demonstrated in the only two cases which have been examined after death.1 The evidence of this communication depends upon clinical obser- vation, and is, I imagine, indisputable. The causes of pneumatoceles are still most obscure. It is acknowledged that they are due to a spontaneous perforation of the bone covering an air- containing cell or sinus, but how that perforation is brought about is still unknown. Injury appears to be no factor in its production. In only one of the ten cases known to surgeons can a traumatism be fairly considered to have had any real concern in the etiology. It is probable, therefore, that the perforation is brought about either by a localized and progressive atrophy of the bone, or by the destructive action of caries sicca.2 The atrophic 1 Lecat, Recueil des Actes de la Soc. de Saute de Lyon, tome i. p. 31. 1798; and Fleury, Observat. de pneumat., Bull, de la. Soc. de Chir., 2e serie, tome viii. p. 520. Paris, 1867. s Heineke, loc. cit., S. 14. DISEASES OF THE SCALP. 121 theory is supported by a comparison between this affection and the changes that occur sometimes in the skulls of old people whereby perforations in the vault are produced.1 Hyrtl,2 moreover, has shown that the air cavities of the skull may undergo great enlargement by the gradual atrophy of their walls; but as to the cause of that atrophy nothing is known. Many facts support the theory that the perforation is due to caries sicca. The pain and other symptoms often associated with the disease would bear upon this point, as would also the condition of the bone itself. It is maintained,3 however, that, the irregularities on the surface of the bone are subsequent to the separation of the pericranium, hut I would urge that this relation has not yet been satis- factorily demonstrated. The treatment of pneumatocele should, in most cases, be merely palliative, and may consist of gentle and constant pressure upon the mass, maintained by a suitable pad and an elastic bandage, or, if on account of troublesome symptoms, or for other reasons, more active measures are called for, the tumor may be reduced, or if irreducible, emptied by a fine trocar, and then firm pressure kept up over the site of the tumor for a number of weeks. In Denonvillier’s case, the mass was very much reduced in size in fifty days. Many of the recorded cases were treated by incision, a treatment that must be strongly condemned. For in each case so treated, severe suppuration fol- lowed, and in two cases led to a fatal issue—by pyaemia in Lecat’s case, and by extension of the inflammation to the brain in that of Fleury’s patient. ILematoma.—As far as the external soft parts of the head are concerned, collections of blood may be formed in three situations: 1. Above the aponeurosis, in the substance of the true scalp. (Hsematomata in this situa- tion are generally small and circumscribed.) 2. Below the aponeurosis, in the loose connective tissue that separates it from pericranium, (These blood collections are generally extensive and diffuse.) 3. Beneath the pericranium. It is to blood tumors only in this last situation that the term cephalhcematoma is applied. Under the generic term of hsematoma may also conveniently be considered certain remarkable blood tumors that communicate with the in- tracranial venous circulation. Simple Heematomata of the Scalp.—Simple collections of blood situated either in the true scalp or in the connective tissue beneath its aponeurosis, require no especial mention in this place. They are the results of injury, and an ac- count of the general history and treatment of such collections will be found elsewhere. One word, however, may be said with regard to extensive blood collec- tions beneath the aponeurosis in children. These may involve nearly the whole vault, being limited solely by the attachments of the aponeurosis, and may attain an immense size. So extensive may these blood tumors be, that they may simulate hydrocephalus ;4 from which affection, however, they may readily be distinguished by their history, by the absence of the characteristic shape of the forehead, and by the fact that the normal skull may be felt beneath the collection of fluid. Such large extravasations are most frequent in cachectic children, and often follow upon apparently very trifling injuries.5 1 Vide infra, Atrophy of Skull. 2 Hyrtl, De la dehiscence spontanee de la route du tympan et des cellules mastoidiennes. Comptes rendus de l’Acad. des Sciences, tome xxx, No. 10. 1858. 3 (tayraud, Art. “Crane.” Diet. Encycl. des Sc. M6d., p. 538. 1879. 4 Holmes, Art. Regional Surgery. System of Surgery, 2d ed., vol. v. p. 963. 5 See a remarkable case in a boy of eight years, reported by Dr. James Finlayson ; the tumor was so large as to simulate hydrocephalus, and there was no direct history of injury. The case proved fatal. Glasgow Med. Journal, 1880, p. 190. 122 MALFORMATIONS AND DISEASES OF THE IIEAI). Cephalhematoma.—This term is limited to blood tumors formed between the pericranium and the bone, and occurring in newly-born children. These tumors are very rare. In observations made at the Hospice de la Charite de Marseille, Seux1 met with only 19 cases of cephalhsematoma in 5674 newly- born children—a proportion of about 1 in 298. Bouehacourt,2 from the col- lected statistics of other observers, gives the proportion as 1 in 250 newly- born children. Cephalhematoma is much more common in male than in female children, and is said to be somewhat more frequent in the children of primiparae than in others. Seat.—The great majority of these tumors are situated on the parietal bones, and more often on the right side than on the left. They generally occupy the posterior superior angle of the bone. Elsewhere they are very rare. A few have been met with over the occipital bone, still fewer over the frontal, and none on the temporal bone. There may be one, or even more than one, on each parietal. Anatomy.—The pericranium inclosing the extravasated blood is quite unal- tered, except under certain circumstances, to be hereafter mentioned. The subjacent bone usually presents a normal aspect, although in cases of long standing it may become rough by a deposit of new bone upon its surface.3 In some rare cases it may be thinned, and, still more rarely, perforated.4 The contained blood may be fluid, and coagulate on removal; but more usu- ally it is found more or less coagulated, and of jelly-like consistence. Some- times it appears to be inclosed in a kind of pseudo-membrane. Before it has existed long, and generally within a week, certain changes take place at the extreme periphery of the tumor, which finally result in the mass being encircled in an osseous ring or “ bourrelet.” This osseous circle is typical of cephalhsematoma. It occupies precisely the angle formed at the spot where the pericranium actually leaves the bone, and as that surface of the long ring which looks towards the blood collection is perpendicular to the plane of the skull, it will be seen that this bourrelet will in transverse section present a tri- angular outline.6 The bony matter of the ring is easily separated from the subjacent bone, which then appears normal. Similar formations of bone are observed in rabbits subjected to experimental elevation of the pericranium.6 As the cephalhematoma subsides, the osseous circle disappears, and in time leaves not the least trace of its existence. In certain cases, more especially in those of old standing, a thin layer of bone forms beneath the separated peri- cranium, and a tumor so modified often crackles under the finger like tinsel.7 Causes.—Valleix,8 and also Paul Dubois,9 have shown that, in the newly- born, the external table of the skull is porous, vascular, incomplete, and par- tially absent. The diploic vessels, therefore, are almost exposed; and it is easy to understand that even a trifling pressure applied to the yielding head of an infant, during delivery, may cause the pericranium to glide upon the subjacent bone, and, by a slight injury to vascular connections, produce a hemorrhage. Bouchacourt’s10 researches show that at the base of the com- mon swellings of the head in the newly-born, a slight subpericranial liemor- 1 Seux, Recherches sur les Maladies des Enfants Nouveaux-nfis. Paris, 1863. 2 A. Bouehacourt, Nouveau Diet, de Mfid. et de Chir. Prat., Art. Cephalematome. 1873. 3 West, Diseases of Infancy and Childhood, 6th ed., p. 59. 1874. 4 Follin et Duplay, Traits de Path. Ext., totne iii. p. 556. 1869. 5 A good drawing to show this osseous ring is figured by Follin and Duplay, op. cit., p. 558. B Bouehacourt, loo. cit., p. 5. 2 This change is well described in South’s edition of Chelius’s “ Surgery,” vol. ii. p. 449. 8 Valleix, Clinique des Malades des Enfants Nouveaux lies, p. 494. Paris, 1839. 9 Diet, de Medecine, etc., 2e fid. (Diet, en 30), Art. Cfiphalfimatome. ,3 Bouehacourt, loc. cit., p. 6. DISEASES OF THE SCALP. 123 rhage is almost invariably to be found. A little pressure of the head upon the pelvis of the mother, or, as some would urge, the contractions of the uterus itself upon the head, may provide all the force required to produce a cephalhsematoma. It is well known that this blood tumor occurs in children delivered by the very easiest form of labor, and that it has been observed also in cases of breech or foot presentation. Some, therefore, insist on a spon- taneous or even an intra-uterine cause for this affection. I think, however, that it may be safely ascribed to injury—however trilling—inflicted during birth. Symptoms—Cephalhsematoma is little noticed at birth, but usually appears within forty-eight hours. When first observed it is generally about the size of a hazelnut; it gradually increases, and in a few days may be the size of a chestnut. Some ceplialhrematomata have been as large as hens’ eggs, and Chelius says that they may involve the whole parietal bone. The tumor is circumscribed, soft, elastic, slightly fluctuating, and painless. The skin over it is normal, or a trifle discolored, if some days have elapsed ; or tense, if the tumor has grown quickly. The tumors are always precisely limited by the pericranium, and, therefore, never extend beyond a suture, a feature of value in diagnosis. In a few days a tolerably hard ring can be felt around the soft tumor. This is probably due to partial.coagulation, and is soon replaced by a quite hard ring, which, as above stated, is actually osseous. Sometimes too the crackling on pressure,due to subpericranial ossification, can be appreciated. Having attained certain dimensions, the tumor begins to subside. As it be- comes more flaccid, the bony circle becomes more distinct, and is the last component of the tumor to disappear. These tumors do not pulsate, except in those very rare cases in which a neighboring artery gives some feeble impulse to the mass, or in which a communicating internal ceplialhsematoma exists. In the diagnosis of cephalhsematoma, the chief points are its time of ap- pearing, its tendency to increase, its elastic character, its osseous ring, and the precision with which the tumor is limited to one bone. The prognosis is most favorable. In the great majority of cases, spontane- ous cure follows in from fifteen days to two months from the date of appear- ance of the tumor. In a few cases suppuration has followed, and in still less frequent instances, caries or necrosis of the subjacent bone is recorded. The treatment of cephalheematoma simply consists in letting the tumor alone. Interference of any kind is useless, if not harmful. If, however, it should at any time become painful, or if it should persist for more than two months, and still appear soft, the mass may be aspirated, and firm pressure applied. Discutients, pressure, the seton, cautery, and incision, are simply mentioned to be condemned. Internal Cephalblematoma.—This term has been applied to hemorrhages between the dura mater and the bone observed in the newly born. It is im- possible to diagnose this condition during life, and it presents no practical interest. Sometimes, however, a hemorrhage in this situation may coincide with an external cephalhsematoma, and not infrequently the two blood tumors have communicated through a fissure in the bone, whereby pulsation has been given to the superficial mass. Such tumors are, however, very rare, and, as a rule, soon end fatally. They may be mistaken for meningoceles, from which tumors they may be distinguished by the fact that they are small, flat, without pedicle, and quite opaque, and that they are usually situ- ated on the parietal bone where meningoceles do not occur. The “ cephalematome des femmes” of French authors refers to a tumor said 124 malformations and diseases of the head. to occur in the scalp of women and young girls, and to be associated with retarded menstruation. Blood-Tumors of the Scalp in Communication with the Intracranial Venous Circulation.1—These tumors are very rare, and consist essentially of a collection of venous blood beneath the pericranium, communicating by an aperture in the bone with the superior longitudinal sinus. Communications with no other intracranial veins have been actually made out, although Du- pont has endeavored to prove that in some cases the communication is with the diploic veins. The communication with the sinus may be either effected by an injury or spontaneous. Pott2 gives an excellent example of the former mode of causation. A splinter of bone having been driven into the superior longitudinal sinus without laceration of the skin, a typical blood-tumor was the result. As to how the spontaneous perforation of the bone is effected, nothing certain is known. Many theories have been advanced, some urging that the perforation is the result of atrophy in a Pacchionian depression, others that it is due to bone-disease, and others that it is brought about by means of a varicose emissary vein. The blood is, in the first instance at least, beneath the pericranium; but in some cases it may come through that membrane and appear beneath the skin. If the case be due to injury, one crack or fissure in the bone will be found to maintain the abnormal com- munication ; but in cases of spontaneous perforation many holes are gen- erally found, some of them very minute. Apart from these apertures the bone as a rule presents a normal aspect. In some cases a slight peripheral ring of bone exists like that found in cephalhematoma. Symptoms.—Most of the cases are met with in the frontal region, a few in the parietal, and very few, indeed, in the occipital region.3 In all instances they are about the line of the sinus. So little trouble do these tumors occa- sion, that they are generally discovered by accident. They are never large, being, as a rule, about the size of a chestnut; are round and soft; possess dis- tinctly fluid contents; and are covered either by normal skin or by a thinned and purple integument. They are reducible by pressure, either wholly or in part, and, when reduced, the perforation in the skull may sometimes be detected, and a return of the mass prevented for a time by applying the finger to the bone. They can be increased in size by coughing, by stooping the head, and by compressing the internal jugular veins in the neck. In certain rare cases “a dull kind of pulsation” (as Pott expresses it) can be felt. A bruit is never These blood tumors show little tendency to in- crease, and less to undergo spontaneous cure. In a few instances they cause some pain and vertigo (increased by pressure), but as a rule they give no trouble. The prognosis, therefore, is perfectly favorable as long as these tumors escape injury. Diagnosis.—To diagnose these tumors from varices of the superficial veins, a ring of ivory or lead is made use of. This is placed on the head so as to encircle the tumor, and is pressed firmly down against the scalp. A simple varicose vein cannot be reduced in size while the ring is on, whereas its 1 An excellent account is given of these tumors by Dupont (These de Paris, 1858, No. 78), and also by Hermann Demme (Virchow’s Archiv, Band xxii. H. 1, 2. 1861.) ; the latter author at- tempts to divide these tumors into tluee distinct categories. See also article “Cnine” by Dr. Gayraud, in the Diet. Encyclop. des Sc. MM., p. 544. 1879. Dufour (Comptes Rend, de la Soc. de Biologie, le s6rie, tome iii. p. 155. Paris, 1851), and Hutin (Memoires de MM. de Cliir. et. de Pliar. Militaires, 2e sSrie, tome xiv. Paris, 1854), record post-mortem examinations. 2 The Cliirurgical Works of Percival Pott, vol. i. p. 156. London, 1808. 3 See, however, cases by Flint (New England Journ. of Med., vol. ix. p. 112), and by J. W Ogle (British and Foreign Med.-Chir. Review, vol. xxxvi. p. 212. 1865). DISEASES OF THE SCALP. 125 presence will not at all influence the reduction of the blood tumor. These collections may be distinguished from collections of pus, which, being situated both within and without the cranium, communicate through a hole in the bone, by the absence of any previous inflammation or evidence of bone- disease. Xo treatment is needed. All that is required is that the tumor shall be protected by a well-fitting plate of gutta-percha or metal. Perhaps pressure may be tried. Any operative procedure would be almost unjustifiable, con- sidering the immediate connection of the tumor with the interior of the cranium. Cysts of the Scalp.—The true cysts of the scalp include common seba- ceous cysts, congenital or dermoid cysts, and serous cysts. With the common sebaceous cysts will also be considered, for convenience sake, follicular ulcers of the scalp, and horns. I. The Common Sebaceous or Follicular Cyst.—Anatomy.—These cysts form the very commonest tumors of the scalp, and are popularly known as “ wens.” As regards their nature they may be classed as retention-cysts, being due, for the most part at least, to an accumulation of secretion in the seba- ceous follicles of the skin. A large number of them show on their surface a black spot which represents the still patent orifice of the greatly distended follicle. Some, however, show no such orifice, and these have been considered to be derived from abortive follicles—from follicles imperfectly developed, and that probably have never contained a hair, and have never opened upon the skin. The cyst wall is generally distinct and well formed ; at first thin and pliant, it may become in time thicker and more firm. It has a distinct lining of squamous epithelium, and it is important to note that between this lining epithelium and the epithelial contents there is no line of distinct de- marcation.1 The contents of the cysts vary. In what may be regarded as their most typical state, they consist of layers of soft, white, epidermic scales, that show evidence of softening about the centre of the mass. Such is the appearance in young cysts, but in long-standing tumors the nature of the contents varies considerably. They may be wholly pultaceous, or the centre may be pultaceous while the epidermic matter at the periphery has from pressure become so hard as to appear like a distinct, laminated, horny layer. In this way are formed what are incorrectly known as “ thick-walled cysts the thickness of the wall is due to no changes in the thin wall or capsule, but simply to lamination of the contents. Portions of the horny matter which form the so-called “walls” of these cysts may be detached and lie loose among the softer contents, and such hard masses may sometimes be distinctly felt through the integument.2 At other times the contents may be almost or quite fluid, and may even, according to Sir Prescott Hewett, become trans- parent. Or they may be discolored by admixture with blood, or may contain much cholesterin (cholesteatoma). Lastly, the contents may become firm and putty-like, or cretaceous, and according to Ileineke3 a peculiar ossifica- tion of the whole mass may be met with. This last observer says that calcification is not uncommon in the smaller cysts. These tumors are situated primarily in the subdermic tissues between the skin and the aponeurosis of the scalp muscle, and have at first but a loose 1 Cornil et Ranvier, Manuel d’Histologie Pathologique, 2e ed., tome i. p. 350. 1881. 2 Hewett, Sebaceous Tumors of the Cranial Region. St. George’s Hosp. Reports, vol. iv. p. 96. 1869. * Loc. cit., S. 37. He believes the ossification to take place through a connective-tissue forma- tion that appears among the epithelium. 126 MALFORMATIONS AND DISEASES OF THE HEAD. connection with adjacent parts, so that they may be almost made to roll under the skin. They soon become more adherent, especially if inflamed at any time. The skin covering them, although at first normal, becomes thinned, pinkish, and more or less bald. And, on the other hand, progressing deeply, the cyst, if large, often comes in contact with the skull. It is now generally allowed that this form of sebaceous cyst does not affect the subjacent bone, and never causes perforation.1 The very utmost change which it may pro- duce is to form a trifling depression on the surface of the skull, and this even is denied by some. Of the etiology of these cysts, little is known. They are often distinctly hereditary, are more common in women than in men, and usually appear first in youth and early adult life. They are much more frequent upon the hairy scalp than upon the forehead and temples, and often appear to be produced by injuries or by erysipelas of the scalp. When on the scalp they are often multiple. Prof. Gross alludes to the case of a man who had some two hun- dred of these tumors on his scalp.2 Progress and Termination.—The rate of growth is usually very slow, and generally a matter of years. It varies, however, considerably. At any period the cyst may remain stationary for an indefinite time. As a rule, these tumors do not attain a great size. The largest, however, are met with on the scalp, and usually at the posterior part of the scalp, and here they may attain enormous dimensions. On the brow they seldom, if ever, attain a large size. The skin may rupture spontaneously and give exit to the cyst, although this is more usually the result of injury. At any time the cyst may suppurate. Such suppuration is usually most tedious, a sinus result- ing that for an indefinite time discharges a thin pus mixed with the fetid contents of the cyst. Extensive ulceration may follow, and a so-called u fungating or follicular ulcer” be produced.8 From a peculiar growth of epithelium from its exposed lining membrane, “horns” may be formed.4 Cases of entire absorption or disappearance of sebaceous cysts have been recorded. I had under my care recently a woman in whom this had occurred. The cyst was the size of a large marble. The diagnosis is easy, and may be gathered from the preceding remarks. “ The chief points to be looked to, in addition to those that are common to all cysts, are their immediately subcutaneous situation; their regular, smooth, round, or oval form, which may in some instances be made to change by pressure when the contents are of a soft substance that may be moulded into various shapes ; the easy mobility; the dark central point; the heredi- tary origin ; the slow growth ; the healthiness of the immediately surround- ing parts; the absence of change in them from the pulse or respiration, and of head symptoms when they are pressed."5 Treatment.—The oidy treatment is that by excision. As a rule the cysts on the scalp shell out very readily. Sometimes, if small, the cyst can be re- moved entire with very little dissecting. If any difficulty be experienced, the tumor may be transfixed, and the cyst then forcibly pulled out with forceps. It is essential that every portion of the cyst-wall should be removed. On no account should an attempt be made to remove a sebaceous cyst while in a state of acute inflammation. If it be inflamed, a simple puncture should be made into the cyst, a poultice applied, and further operation left until, the 1 See an intesting discussion before the Surgical Society of Ireland, April 6, 1866, opened by Dr. B. Wills Richardson. 2 System of Surgery, 5th ed., vol. ii. p. 114. Philadelphia, 1877. 3 See page 127. 4 See page 127. 5 Holmes’s System of Surgery, 2d ed., vol. i. p. 517. Art. “ Tumors,” by Sir James Paget and Mr. C. H. Moore. DISEASES OF THE SCALP. 127 more urgent inflammatory symptoms have subsided. If the cyst be very large, it may he necessary to remove some of the redundant skin. If, for any reason, a portion of the cyst-wall should be left behind after attempted ex- cision, the epithelial surface should he well rubbed with solid nitrate of silver to destroy the secreting elements, and the wound should be dressed for a while from the bottom. Considering the frequency of the operation of exci- sion, and the little after-attention which the wound generally receives, it is a proceeding no more frequently followed by ill consequences than the inflic- tion of any other simple wound. Follicular or Fungating Ulcer.—This term is given to an ulcer sometimes formed by the breaking down of one of these sebaceous cysts. The skin over the cyst usually gives way in several places, so that many discharging holes are formed, and the destructive process proceeds until a large ulcer is formed with these characters: its edge is raised, everted, rugged, prominent, and very irregular; its base is occupied by a foul, fungating mass; it is of consid- erable depth ; and it spreads by advancement of the ulcerative action. The fungous mass represents the remains of the sebaceous contents mixed with a crowd of very exuberant granulations that spring from the lining membrane of the cyst, now irritated by the presence of too much effete matter. The sebaceous matter does not itself actually become vascularized, as some less recent authors have urged, but the persistent irritation produced by the morbid changes in the exposed cyst-wall perpetuates the ulcerative process, and leads to a spreading of the sore. Cock gives some excellent drawings of this condition.1 This peculiar ulcerative process appears to be most apt to affect cysts of some standing, and especially those occurring in old persons, the disease being rarely met with before fifty. Considering the usual age of the patients, and the general features of the ulcer, it will be seen that this might readily be taken for epithelioma,2 Any difficulties on this point may, however, be cleared up by noticing in the non-malignant ulcer the history of the case, the presence possibly of unaltered sebaceous matter, the absence of a hard infiltration of the periphery, as in epithelioma, the fact that the disease progresses with little bleeding and less pain, while the health remains good, and"the glands are unaffected. It must be remembered, however, that "such ulcers as these may take on a genuine epitheliomatous action.3 Some of the reported cases are cases rather of .fungating sarcoma of the scalp.4 In regard to treatment, the surface of the ulcer having been well cleaned by a poul- tice, the remaining portion of the cyst may be excised. The operation is, however, often tedious and bloody, and a better plan, therefore, is to apply the actual cautery lightly, but thoroughly, to the whole remaining surface of the cyst, when a slough separates, and the ulcer generally heals kindly. Horns.—These strange excrescences are developed from the interior of a sebaceous cyst that has been opened up, either by rupture, or, more usually, by inflammation. They have the appearance, and almost the density, of actual horn, and are formed of heaped-up sebaceous matter that has become dry and indurated. Fresh matter is constantly being formed at the base of the excrescence, and so it increases in length and bulk. Sir Erasmus Wilson has given a full account of these growths.5 Out of 90 collected cases, 44 were in females and 39 in males, the sex of the remainder being unknown; in 1 A few Remarks on a Peculiar Follicular Disease. Guy’s Hosp. Reports, 2d s. vol. viii. p. 51. 1853. 2 See a celebrated case of M. Chassaignac’s, in Bull, de la Soc. de Chir., tomes i. et ii. 3 See case reported by Dr. Pean, Lemons de Clinique Chirurg., p. 532. 1876. 4 Goodliart, Follicular Disease of the Scalp. Guy’s Hosp. Reports, 3d s. vol. xviii. p. 221. 1873. 6 Transactions of the Royal Medical and Chirurgieal Society, vol. xxvii. 1843. 128 MALFORMATIONS AND DISEASES OF THE HEAD. no less than 48 out of the 90 cases the horn grew from the head, and 38 of these scalp cases occurred in patients past middle life. The horn is generally single, somewhat pointed, and curved. In the Xew York Medical Reposi- tory, for 1820, is recorded the case of a man from whose forehead grew a horn that had three branches and was fourteen inches in circumference. In many of the recorded cases the horns have been four, five, six, and eight inches in length. If accidentally torn off they are apt to be re-formed. Their growth is slow, and they are only troublesome mechanically, and from an aesthetic point of view. As regards treatment, the mass should be removed, and every trace of the cyst or secreting surface at its base most scrupulously excised. II. Congenital Dermoid Cysts.—These, as regards their anatomy, closely resemble the common cyst. They have thinner and more perfect walls, as a rule, and are lined by a perfect epidermis, with, very often, small growing hairs. The contents are commonly spermaceti-like, or more oily or turbid, or even serous and clear, and generally present some line loose hairs. Bryant reports a case in which the cyst contained “a complete ball of hair."1 The contents are seldom offensive. These tumors have a tendency to indent or even perforate the subjacent bone. Many such cases are recorded.2 As a rule, a round depression has been found on the bone, at the bottom of which has been a small hole leading to the cranial cavity. The precise cause and significance of this perforation are unknown. Site.—The congenital cyst is usually found about the outer angle of the orbit, next in frequency on the front of the frontal bone, and very rarely, over the other bones of the vault. Cases are recorded of cysts imbedded deeply in or beneath the temporal muscle. These growths are (primarily at least) beneath the scalp muscle, and are, as a rule, closely adherent to the peri- cranium. Progress.—These tumors grow very slowly, seldom exceeding the general rate of growth of the body. They rarely attain a greater diameter than two- thirds of an inch.3 As to the diagnosis of these round, tense, and typically cystic bodies, no- thing need be said. They are compared with other congenital growths else- where. Two remarkable cases are reported of dermoid cysts mistaken for meningocele. Both cases occurred in female children, respectively three and eight months old. In each case the tumor was small, translucent, without pulse, and irreducible, and located close to the anterior fontanelle. In one case,4 tapping gave exit to a clear fluid ; in the other,5 the cyst was situated over a congenital hole in the skull, and had pulsated in earlier infancy. Both tumors proved to be dermoid cysts, and to have no communication with the cranial cavity. The treatment involves questions of difficulty. These cysts are often diffi- cult to excise, especially when about the orbit. They appear superficial, and yet are found to extend often to a dangerous depth, and if any cyst wall be left behind an intractable suppuration follows. In other parts their removal may not be difficult. If a cyst about the orbit therefore is small, not increas- ing, and a source of no inconvenience, it may be well to let it alone. If excision is demanded for any reason, it must be performed with the utmost care and patience. It would, in most cases, be unwise to operate on those 1 Manual for the Practice of Surgery, 2d ed., vol. i. p. 104. 2 Athol Johnson, Lectures on the Surgery of Childhood, p. 15. London, 1860. 3 Sir James Paget and Mr. C. H. Moore, loc. cit., p. 514. 4 Giraldes, Comptes rendus de la Soc. de Biologie, 4e s§rie, tome iii. p. 77. 1866. 6 Henry Arnott, Trans, of Path. Soc. of London, vol. xxv. p. 228. 1874. diseases of the scalp. 129 cysts that have certainly perforated the skull. Mr. Athol Johnson1 reports a fatal case of this kind. Sir Prescott Hewett,2 on the other hand, reports a case in which a dermoid cyst, after causing no trouble for twenty years, grew, perforated the orbital roof, and caused death. An unusual case of this kind, however, should hardly lead us to advocate an early removal in all instances III. Serous cysts are extremely rare. They are either (1) congenital, or (2) formed from extravasated blood, or (3) formed from a meningocele whose connection with the cranial cavity has been cut off. Those that are con- genital are, as a rule, small, multi-cystic, situate in the occipital region, and located either above or beneath the aponeurosis.3 They contain clear serum, too rich in albumen to be mistaken for cerebro-spinal fluid. Billroth gives an example of a serous cyst over the occiput as large almost as the patient’s head. The subjacent bone was quite sound. The history of the case would, in each of the three forms, greatly assist the diagnosis. The treatment of such tumors requires no special notice. Vascular Tumors of the Scalp.4—Ncevus; Telangeiectasis; Simple or Plexi- form Angeioma ; Cavernous Angeioma ; Erectile Tumor. The various forms or varieties of vascular growth included under these different terms are all met with on the scalp, and may be conveniently considered under the common and generic term Ncevus. Xievi occur more frequently on the head than on any other part of the body, and, according to Ileineke, arterial angeiomata may be said to belong exclusively to the head.5 Vsevi may occur anywhere on the scalp, but are most common about the anterior fontanelle, the orbit, and the temple. They are much less common about the occiput. As Vir- chow has pointed out, angeiomata are often located on the sites of the bran- chial clefts—the “ tumeurs erectiles fissurales” of French authors. The undue frequency of mevi about the head may perhaps be due to the dependent pos- ture of the head in foetal life, and to injury inflicted during birth. The superficial or capillary mevus is more commonly met with on the head than is the deeper or venous nsevus, or cavernous tumor, the latter being generally limited to the hairy £art of the scalp, while the former may occur anywhere. All these growths are, for the most part, congenital, and appear at or soon after birth. The superficial nsevus is not met with at an earlier period than are the deeper growths—the subcutaneous or venous mevus, or cavernous angeioma. There is little limit in the size of these tumors; some may be enor- mous, and may occupy wide tracts of the head. As Chelius6 observes, some of the largest and most rapid growths have been met with about the ear. Mr. Barwell7 remarks that naevus over the mastoid process may “ by growth in size and complexity become a cirsoid aneurism.” A growing naevus under the hairy scalp causes baldness, the hairs falling out as the atrophy of the skin progresses. These tumors may extend in depth and involve the galea, the pericranium, and even the bone, which in such cases becomes porous from the number of its vessels.8 They may, on the other hand, undergo sponta- neous cure, especially after an inflammation of the soft parts. Such a cure usually occurs in the superficial, cutaneous mevi, and is much less frequent in the more deeply seated tumors, or in the cavernous angeiomata. Diagnosis.—These blood-tumors may be conveniently divided into 1, the cu- 1 Loc. cit., p. 15. 2 Loc. cit., St. George’s Hosp. Reports, p. 93. s Ward, Trans, of Patli. Soc. of London, vol. xi. p. 268. 1860. « See Vol. II., p. 803. 5 Loc. cit., S. 22. 6 Chelius’s Surgery, translated by South, vol. ii. p. 381. 7 Lancet, vol. i. p. 642. 1875. 8 Dr. Robert Lee (Med.-Chir. Trans., vol. xxii. p. 300. 1829) gives the case of a monster with extensive nsevoid growth of the scalp that involved also the dura mater, the intervening hone being absent. He gives references to cases of somewhat like character. 130 MALFORMATIONS AND DISEASES OF THE HEAD. taneous ; 2, the subcutaneous; 3, the mixed. 1. The cutaneous angeiomata are composed of capillary vessels arranged in an intricate plexus, and considerably altered in structure. These form the simplest kind of plexiform angeiomata, and appear as bright-red or claret spots upon the skin, their surface being com- monly a little raised and granular. 2. These tumors are situated in the sub- cutaneous tissues, although they may extend beyond them. They are venous in structure, as a rule, the vessels being arranged in a plexus (plexiform an- geioma), or after the manner of erectile tissue (cavernous angeioma, erectile tumor); they form distinct tumors, covered with purplish and thinned integu- ment, are smooth, somewhat lobulated, doughy, and elastic, and are capable of being more or less emptied on pressure. They often increase also on violent respiratory efforts. If the tissue has much of the arterial element, the mass may feebly pulsate, but such a growth would more aptly be considered with cirsoid aneurism. 3. The mixed form is a complication of the two preceding forms, the skin being more or less involved. The tumors may ulcerate and give rise to severe hemorrhage. Treatment.—If the tumor be quite stationary and small, and cause no gross disfigurement, the advisability of operation may be questioned. With regard to the many different modes of treating nsevus I will say nothing, but will refer merely to those measures that appear most applicable in the scalp. Pressure with a disk of lead or a small coin, secured by an elastic band, has answered well in some small naevi that involved the tissues to no great depth.1 It may at least be tried. With regard to operative measures, I would urge that most naevi of the scalp can be well treated either by the actual cautery or the simple ligature, with in a few cases a recourse to excision. Naevi up to the size of a shilling can, as a rule, be well treated by a light application of the tliermo-cautery, if quite cutaneous, and by a more prolonged application when they extend beyond the skin. This treatment is at the time more painful than that by nitric acid (which, however, is only applicable to superficial growths), but the pain passes off much sooner, and the result is much more certain, one application being in the great majority of cases all that is required. I have used the thermo-cautery in a very large number of cases, and without a single bad result. If one has to deal with a very ex- tensive superficial naevus, involving only the skin, the same method may be adopted, and it is then better to treat portions only of the diseased area at a time, commencing at the periphery. Large venous naevi and cavernous tumors of the width of a shilling and larger can be well treated by the simple ligature. This method is especially suited to prominent tumors covered with thin and diseased integument. I have found the following mode of using the ligature most efficacious. The mass is ligated in the usual way in two segments, a harelip pin having been passed through its base, and the threads at right angles to the pin. It is important to lightly incise the skin at the base of the growth, in the line that will be followed by the ligature. This lessens the amount of pain and the duration of the strangulating process, and in young children much diminishes the liability to convulsions. The pin is not removed. In four days the whole of the ligatured mass should be sliced off level with the surrounding skin, by passing the knife beneath the harelip pin; some bleeding follows, which is immediately checked by light pressure with cotton-wool. The advantages of this subsequent excision are these: The duration of the treatment is very greatly diminished, the risks of ill effects much lessened, and a much cleaner and finer scar is produced. If the skin over the mass be sound, ligation will hardly be so applicable, owing 1 See Lancet, vol. ii., 1867, article on Naevi, by Mr. Thomas Smith; and Surgical Diseases of Children, by Mr. Cooper Forster, p. 223. London, 1860. DISEASES OF THE SCALP. 131 to the tension of the scalp; excision may then be practised, bleeding during the operation being checked by a ring of lead, or by strips of the same metal, pressed firmly against the scalp. The subcutaneous ligature appears to be peculiarly unsuited to the scalp. ISTsevi larger than can be treated by ligature may be excised, if all other means have failed, or treated with puncture by the actual cautery. By the latter method a fine thermo-cautery point is thrust in various directions into the substance of the nsevus through the same skin puncture. Little reaction, as a rule, follows, but the mass begins to shrink. The treatment may require to be repeated five or six times in a large mass. I have found it most successful in very large nsevi. Much has been said as to the treatment of nsevi over the anterior fontanelle. All operative measures applied to such mevi, while the fontanelle is still open, are attended with much risk, and should never be undertaken, unless under urgent rea- sons, until the opening has closed.1 The nsevus, especially if deeply seated, will often much diminish in size when such closure has taken place. Michaud2 records a case of nsevus of the scalp that communicated by small veins with the superior longitudinal sinus. A communication of a like character probably occurs more frequently than is at present supposed, and may account for some of the rapid deaths with brain symptoms that have followed in a few instances the treatment of even the most simple nsevi in this situation. Cirsoid Aneurism. — Aneurism by Anastomosis; Racemose Aneurism. ; Arterial Varix.—These terms are applied to tumors made up of the dilated and varicose arteries of a given area, and their smaller branches. When the disease atfects the larger arterial trunks, the name cirsoid aneurism is used, and when it extends into the capillary networks, it is known as racemose or anastomotic aneurism; the term arterial varix has been limited by some authors to the affection as it involves single large arteries. This disease is almost limited to the head, being very rare elsewhere. It occurs usually in connection with the temporal, posterior auricular, and occipital arteries. As it increases, it may extend either towards the capil- laries or towards the main trunk, and, in the latter case, may involve even the common carotid. It may extend beyond the middle line, and involve the other side of the head. The skin over the mass is usually thin and wrinkled, but may be thickened. The subjacent bone is often grooved by the dilated vessels, and Verneuil3 gives a case in which the bone was actually perforated. These tumors are sometimes due to injury, but more commonly arise from the dilatation of the* afferent arteries of a simple angeioma, which latter growth can often be detected in the centre of the arterial swelling. They occur most usually in young adults. Progress.—These growths are apt to increase to some extent, and may attain enormous size. They may, however, at any time become stationary, or even undergo spontaneous cure, an event that has in most cases been sub- sequent to a fever. The mass may ulcerate, or the skin become so thinned that rupture occurs, followed by fatal hemorrhage. The symptoms of these tumors have been fully described elsewhere,4 and it is here only needful to allude to their leading features: an irregular, varicose mass with visibly dilated arteries about its periphery, pulsation, a blowing bruit, a fine thrill felt by the fingers, reducibility of the mass on pressure, and an altered state of the integument, which is usually found thinned and discolored. 1 Mr. Erichsen expresses an opposite opinion ; Science and Art of Surgery, vol. i. p. 717. 1872. 2 L’Union Medicate, p. 254. 1859. 3 Varices artSrielles du Cuir chevelu. These. 4 See Vol. II., pages 804 et seq. 132 malformations and diseases of the head. Treatment.—These vascular tumors are most difficult to cure, and are very intractable to any treatment. Should the cirsoid aneurism show no tendency to increase, give no great inconvenience to the patient, and threaten no imme- diate danger, it had better be let alone, being merely protected by a suitable cap or disk. With regard to operative measures, the following may be placed among those that have been tried and discarded as of little or no value: compression, ligature of the separate vessels entering the mass, and ligature of the external carotid of the same side. Ligature of the common carotid has had but indifferent success. Heineke1 states that only three cases of cure have resulted in thirty-two instances in which this operation has been performed. [Dr. Wyeth’s statistics, though not quite so unfavorable, also show that this operation should be reserved for exceptional cases.2] The treatment to be advised in these cases is mainly directed against the mass itself. If the cirsoid aneurism be quite small, it may be ligatured en masse. This has been successful, but ligature of larger tumors, and the practice of partial ligature, or ligature of successive portions, is not to be advised. Galvano-puncture also may be tried, and has beeii successful. It can at least do little harm. If these measures fail or he inadmissible, the best results are obtained from excision of the whole mass. This operation, to be successful, should be preceded by ligature of the common carotid artery, or by the adoption of some local means to arrest hemorrhage. This object is best attained by applying acupressure to the entire periphery of the tumor by a number of needles. After the mass has been excised, the needles should be withdrawn one by one and the separate vessels ligatured as exposed. Of all operations for the relief of cirsoid aneurism of the scalp, that of exci- sion has certainly met with the greatest amount of success. Aneurism of the Arteries of the Scalp.—Aneurism is very rarely met with on the scalp, and in all the recorded cases appears to have been of trau- matic origin. The tumor is most commonly situated on the temporal artery, though cases are also recorded of aneurism of the posterior auricular and occi- pital arteries. These aneurisms seldom attain a great size, few being larger than a hazel-nut, and they give, as a rule, little or no trouble. They are apt to hollow out the bone, and the skin over them may become so thinned as to lead to rupture of the sac. The tumor being very superficial, the symptoms are most characteristic. As a rule, they are readily cured. In some cases compression has effected this end,3 and this simple treatment may at least be tried in any instance. If this fail, the artery should be ligatured on either side of the aneurism, or the “ old operation” performed. Arterio-venous aneurisms are very rare on the scalp. Heineke could only find records of five cases. Of these, four concerned the temporal artery and vein, and one the posterior auricular vessels. In every instance there had been tin injury. These tumors do not tend to attain great size, and they give but little trouble. If small, not increasing, and attended by no real incon- venience, they may be let alone. If for any reason an operation is demanded, the most successful consists in excising the entire mass, and ligaturing all the vessels concerned. In one case, Clielius4 thought fit to tie the common caro- tid for an arterio-venous aneurism of the temple. Benefit followed, but it was only temporary. 1 Loc. cit., S. 30. 2 [ See Dr. Wyeth’s table of 73 cases (82 operations) in Vol. II., pp. 808 et scg.] 8 See case by M. Mirault, Gazette des Hopitaux, No. 147. 1860. 4 Op. cit., vol. ii. p. 271. malformations of the skull. 133 • Malformations of the Skull. These malformations are numerous, varied, and for the most part congeni- tal. The majority of them are of no interest to the practical surgeon, and many, as, for instance, auencephaly, exencephaly, etc., are incompatible with existence. Cephalocele will be treated of hereafter. Among the acquired deformities, it is only necessary to allude to those purposely produced by cer- tain nations1 (such as the Caribs) by pressure upon the skull in infancy; to the “ diamond-shaped head”2 produced by compression at birth ; and to the “ obliquite du crane par propulsion unilaterale”3 induced by allowing very young infants to lie always upon the same side of the body. These are at least of some slight interest in being not quite unpreventable. Of much more interest, however, are certain congenital holes and fissures in the skull that appear to be of no infrequent occurrence, and to persist often throughout the life of the individual. They are all due to imperfect developments.4 The occipital bone may present persistent fissures, the remains of those that occur in the developing bone; or a larger or smaller part of the superior angle may exist as a separate bone, the “ os epactale,” whose line of union with the main bone may be mistaken for a fracture. The parietal bone is frequently the seat of certain holes that may persist during life. These parietal holes are generally two in number, and are symmetrically disposed, one on either bone, at or about its most prominent point. Their usual diameter is from one- third to one millimetre. They may, however, be much larger,5 and in the Musee du Yal-de-grace, there is a skull with parietal holes that measure three centimetres. These holes may be mistaken for fractures, and are apt to seriously complicate diagnosis when a superficial growth happens to be located over one of them. Mr. Thomas Smith6 records a case in a child aged four years, in whose skull were found the following congenital holes: one on the right side of the occipital bone, three inches by two inches, and one on either parietal, measuring respectively two inches by two inches, and two inches by one inch. Over one of these holes an abscess had formed, which pulsated synchronously with the pulse. Meningocele ; Encephalocele ; IIydrencephalocele.—These terms are applied to certain tumors that consist essentially of a protrusion of some part of the cranial contents through an aperture in the skull. They are congen- ital, and are observed either at or soon after birth. Reference will he made hereafter to certain rare tumors known as acquired cephaloceles. These must be kept distinct from those now under consideration. The contents of these tumors vary, and it is according to the nature of these contents that they are classified and named. When the tumor contains a protrusion of the meninges only, the term meningocele is used; when a protrusion of brain, the term encephalocele ; and when the mass is formed by a portion of brain, greatly distended with fluid from a dropsical ventricle, it receives the name of hydrencephalocele. 1 For an account of such like deformities, see M. Topinard’s “Anthropology.” 2 Dr. Ogier Ward, Path. Trans. London, vol. iii. p. 225. 3 M. Gu6niot, Bull, de la Soc. de Cliir., tome x. p. 383. 1866. 4 An excellent account of these mal-developments is given by M. S. Pozzi, Art. Crane (Deve- loppement), Diet. Encyl. des tic. Med., p. 467. 1879. 5 tiee Depressions in the Parietal Bones, by Professor Humphry, Journ. Anat. and Phys., vol. vii. p. 136. 1874. 6 Path. Soc. Trans. London, vol. xvi. p. 224. For account of Aplasia Cranii (imperfect ossifi- cation of skull), see, also, Heineke, loc. cit., S. 43. 134 MALFORMATIONS AND DISEASES OF THE HEAD. Anatomyd—These various tumors are of a round or pyriform outline, and present as a rule a uniform surface. Sometimes, however, sharp fissures or depressions appear upon the surface, giving the mass a lobed appearance, sug- gestive of its division into two or more parts. In size they vary greatly: the smallest may be the size of a little nut, and the largest may exceed the dimensions of the patient’s head. They usually present a distinct neck, and are often actually pedunculated. As a rule, they are covered by normal scalp, more or less deficient in hair, according to the size and tenseness of the tumor; but in other cases the integuments may be much atrophied, or red and vascular, or raw like a granulating surface, or represented solely by a scar-like tissue. The sac is composed of dura mater lined by the arachnoid, and in some cases presents irregular sacculi and partitions, although in the majority of instances its interior is perfectly smooth. The hole in the skull through which the mass protrudes, varies greatly in size and shape, and usually presents a clean and even edge. If much brain has escaped from the cranium, microcephaly will exist, although it may be somewhat modified in its conspicuousness by the hydrocephalus that is very often present in these cases. Scoliosis or unequal development of the skull is also common in severe instances; and other congenital deformities, such as spina bifida, hare- lip, cleft palate, talipes, and umbilical ruptures, not infrequently coexist. Of these tumors, meningocele is the rarest. Indeed, some authors question its existence.2 It simply consists of a protrusion of the dura mater and arachnoid, and may be regarded as a limited hydrops of the arachnoid sac. Heineke regards it as the remains of an encephalocele, the protruded portion of brain having returned into the skull. Others, however, consider menin- gocele as the commencement of a brain protrusion. There is no doubt that this tumor is extremely rare, and that the bulk of the cases reported as meningoceles are really hydrencephaloceles. Encephalocele is not so uncom- mon, and consists of a hernia of a portion of the brain, that is usually con- nected with the cerebral mass by a narrower portion or pedicle. There may be no fluid in the sac, but if any is present, it is entirely external to the brain substance. Hyd,r encephalocele, by far the gravest of these tumors, is, unfortu- nately, the variety most usually met with. The piece of brain protruded in these cases is found to be distended by fiuid from a ventricle. Indeed, the con- dition is that of an extreme but limited ventricular hydrocephalus. The cavity in the protrusion is connected with the affected ventricle by a contracted channel that may be very narrow, the hernial portion being as it were a diverticulum from the ventricle. The protruded portion of brain may be so distended as to be represented by a mere film of cerebral matter, and in many cases all traces of it are lost except about the neck of the tumor. The cor- responding ventricle is always distended, such distension being, however, as a rule, infinitely less in degree than that found in the protruded part. This is generally so distended that all trace of convolution on the surface is lost. In addition to the internal collection, some fiuid may also be found in the sac, quite external to the brain. Situation.—By far the most common site for these tumors is the occipital region, and next the fronto-nasal region. From the base of the skull, and from the parietal and temporal regions, these protrusions are rare. In 93 collected cases, 68 were about the occiput, 16 in the fronto-nasal region, and 9 about the base.3 1 For a full account of the anatomy of these affections, see an article by Sir Prescott Hewett, in St. George’s Hospital Reports, vol. vi. p. 117. 1873. Also monograph by M. Spring, M6m. de l’AcadSm. de Belgique, tome iii. Brussels, 1853. 2 L.-A. de Saint-Germain, Art. Enc6phalocele, Nouveau Diet, de Med. et de Chirg. Pratique, p. 195. 1870. 3 Houel, Arch. G6n. de Med., 5e serie, tome xiv. pp. 409, 569. 1859. MALFORMATIONS OF THE SKULL. 135 (1) Occipital Region.—The hole in the occipital bone through which the mass protrudes, is in or near the middle line, and may be above or below the protuberance. If above, it may blend with the front fontanelle, and if below, with the foramen magnum, or in addition with the cleft for a spina bifida. The tumors in this situation are apt to be large and pendulous, of pyriform shape, and pedunculated. Chauvier records a case, occurring in this locality, in which the mass hung from the back of the head to the loins.1 In some cases the whole or the greater part of the occipital bone may be absent; or, if present, it may show a complete median cleft. Occipital eneephaloceles may contain portions of the posterior cerebral lobes or of the cerebellum. A hydrencephalocele in the upper part of the bone would probably contain part of the posterior lobe or lobes of the cerebrum, and the distended posterior cornu of the lateral ventricle; in the lower part of the bone, the whole or part of the cerebellum with a dropsical fourth ventricle. In large masses, both the cerebrum and cerebellum may be concerned. (2) Frontal Region.—The tumors usually appear at or about the root of the nose, the protrusion leaving the skull between the cribriform plate and the frontal bone, and appearing externally between the frontal and nasal bones. In a few cases the protrusion has been between the halves of the frontal bone,2 and in still fewer in the lateral parts of the bone.3 The anterior lobes are the parts of the brain involved, with, in cases of hydrencephalocele, the anterior cornua of the lateral ventricles. Tumors in this site are usually smaller than those on the occiput, and present few, if any, of those surface divisions so commop in the tumors of the latter situation. The skin covering them is also very trequently red and vascular, so that these frontal tumors have often been mistaken for vascular growths. Enormous tumors have, however, been met with in this locality,4 but they are rare when compared with the frequent occurrence of such large growths over the occiput. Sides and Base of the Skuil.—Congenital protrusions have occurred at various parts of the sides of the skull, chiefly about the lateral fontanelles or in the lines of sutures. Mr. Hutchinson5 quotes a case occurring at the an- terior fontanelle, and Dr. Steavenson6 a median protrusion through a cleft extending from the posterior fontanelle to the alveolar process of the jaw. At the base of the skull, the hole has been found between the ethmoid and sphenoid bones, or between the sphenoid and its greater wing, or through the sphenoid itself. Tumors issuing from such apertures have appeared in the pharynx or in the mouth, have even projected beyond the mouth, have occupied the orbit and displaced the globe, or have escaped by the spheno- maxillary fissure. Hydrencephaloceles about the base have been composed of the temporo-sphenoidal lobes distended by the inferior cornua or the base of the third ventricle, or by the infundibulum and pituitary body pushed down by fluid distension occurring in the last-named ventricle. Into the etiology of these affections, the limits of this article will not allow me to enter. A vast number of theories have been advanced, the most gene- rally received being one that explains the protrusion by the existence of an intra-uterine hydrocephalus. The whole matter is well discussed by ITeineke.7 1 Quoted by Sir Prescott Hewett, loc. cit., p. 119. 2 See a case, for instance, reported by Mr. Christopher Heath. Trans, of Path. Soc. London, vol. xvi. p. 10. 1865. 3 Case by Robt. Adams, Dublin Journ. of Med. and Chein. Science, vol. ii. 1833. Other cases are quoted. 4 See a case reported by Niemeyer (De Hernia Cerebri Congenita. Halse, 1833.), in which the tumor reached the clavicle. 6 Illustrations of Clinical Surgery, vol. ii. Plate 46. 6 Trans. Clinical Soc. Lond., April, 1881. 7 Pitha und Billroth’s Handbuch, Band iii. Chirurgische Krankheiten des Kopfes. 136 MALFORMATIONS AND DISEASES OF THE HEAD. Symptoms and Diagnosis.—All these tumors have to a greater or less ex- tent the following general characteristics. They are congenital, are most common over the occiput or root of the nose, and are fixed at their bases. They form roundish, elastic tumors, with, as a rule, some evidence of fluid contents; have often a pulsation synchronous with the beat of the heart are increased in size by forced expiratory efforts ; and are more or less reduci- ble, such reduction being often followed by brain symptoms (sense of pain or restlessness, vomiting, convulsions, or stupor, with, in some cases, stra- bismus and temporary loss of muscular power). If pendulous, the very weight of the tumor may cause such symptoms, all trouble passing off when the mass is elevated. In some cases the hole in the skull may be felt, and often the head is microeephalic, or shows unequal development. The separate symp- toms of each special form of tumor, and the points in which they differ from one another, and which constitute the elements of their differential diagnosis, may be best exhibited in the form of a table. Size and surface. Cover- ings. Pedicle. Fluctua- tion. Trans- lucency. Pulsa- tion. Effects of forced expira- tions. Reduci- bility. Pressure effects. Condition of skull, etc. ■ r Small, es- As a As a rule Most dis- Perfectly Rarely Render Always Symp- As a rule peciallv rule peduncu- tinct. translu- present the reducible, toms normal. Meningo- j at first. normal; lated. cent tumor as a rule produced CELE. — may he through- more com- only on Surface thinn’d. out. tense. pletely. strong L smooth. pressure. f As a rule As a Has a Absent Opaaue, Distinct Pro- Reduci- Symp- As a rule small, sel- rule wide (mass soft unless pulsa- duce ble, but toms normal. dom ex- normal; base ; is and yield- there be tion. distinct not al- readily ceeds size may be rarely ing) un- fluid in enlarge wavs com- induced. Encephalo-J of small unduly peduncu- loss there sac, when ment. pletelv. CELE. orange. vascu- lated. be fluid in mass may — lar. sac. be trans- Surface lucent at L smooth. apex. r Generally Often As a rule Distinct. Often Very Pro- As a rule Symp- Microce- large, thin,ex- distinctly translu- seldom duce are but toms phalic, or often of coriated peduncu- cent, but pulsate only a little af- seldom scoliosis. great size, or lated. only at very fected in induced. May be and pen- wrin- the most slight size by paralvsis Htdrence- dulous. kled. prominent effect. pressure, of limbs PHALOCELE. — and de- and are or talipes. Surface pendent irreduci- often irre- parts. ble. gularly divided or lobed. These tumors have been mistaken for sebaceous cysts,2 for abscesses,3 for vascular growths,4 for ceplialluematomata,5 for serous cysts,6 and for nasal polypi.7 In the last instance (Dr. Lichtenberg’s case), a large bluish tumor projected some way out of the mouth. Its pedicle was traced through a cleft palate up to the roof of the nose. It was ligatured. Death ensued in 1 Sir Prescott Hewett says that pulsation is absent in the majority of cases. Loc. cit., p. 134. 2 Holmes’s Surgical Treatment of Children’s Diseases, page 67. 1868. See also Prescott Hewett, loc. cit., pp. 134. 3 Athol Johnson, Lectures on the Surgery of Childhood, p. 11. 1860. 4 Th. Zdzienski, Encephaloceles Congenitse Casus rarior. Dorpati, 1857. Paul Dubois, quoted by Sir P. Hewett, loc. cit. M. Guersant, Bull, de la Soc. de Chir. de Paris, tome i. p. 66. Jon. Hutchinson, Ulus, of Clin. Surgery, vol. i. page 1. 5 Observations on Surgical Diseases of Head and Neck. (Ferrand.) Sydenham Soc., p. 125. 1848. 6 Case of M. Chassaignac’s, quoted by M. L.-A. de St. Germain. Nouveau Diet., loc. cit.; also Holmes, op. cit., p. 66. 7 Lichtenberg, Trans. Path. Soc. Lond., vol. xviii. page 250. MALFORMATIONS OF THE SKULL. 137 four days. It was then found to be a cerebral protrusion that had issued through a hole in front of the sella turcica. Progress and Prognosis.—The majority of infants who are born alive with these deformities do not long survive their birth, but die during the tirst. few days or sometimes weeks of life. The prognosis is worse in hydren- cephalocele than in the other tumors. In hydrencephalocele, indeed, the prog- nosis is absolutely bad; in many cases the condition of the brain is incom- patible with any but the briefest existence, and in other instances the mass rapidly enlarges, and in time bursts, death occurring from collapse or con- vulsions, or acute meningitis. Very few indeed live even a few weeks. Sir Prescott Hewett1 and Laurence2 give cases in which patients survived some months, but these instances must be regarded as quite exceptional. In meningocele the prognosis is a little better. As a rule, however, the tumor increases rapidly, bursts and causes death, and this event usually occurs soon after birth. Some increase much more slowly, and months may elapse before a rupture takes place. Others, having attained a certain size, remain stationary for an indefinite period, while in still more fortunate instances the cavity of the tumor becomes cut off from the cranial cavity, and the tumor becomes harmless.3 Many eases therefore of cure of meningocele have been recorded. It is in enceplialocele that the prognosis is the most favorable. Although a great number die soon afterbirth, yet the early mortality is not as great as in the other forms of tumor. In some cases there may be fluid in the sac, and this, by increasing, may cause rupture, and death from meningitis, etc. But commonly the tumors attain no great size, and very commonly remain stationary. Some patients thus affected may therefore reach puberty, but they often are idiotic, or suffer from paralysis or some other gross nerve lesion. Patients with encephalocele have, however, survived many years and eujoyed perfect health. Such cases have been met with in patients aged 15,4 20,5 and 336 years, and between these ages no small number of cases have been re- corded. As regards the situation of these congenital tumors (regarded gene- rally), the prognosis is most unfavorable for those about the occiput, not so grave for those in the frontal region, and least serious for those upon the vertex. Treatment.—Operation in these cases is only justifiable under one condition, and that is when rupture of the tumor is threatening. Otherwise the mass should be simply protected, and as firm pressure applied as the patient can bear without inconvenience. (1) Meningocele.—If rupture be threatening, the sac may be emptied by the trocar, and pressure applied. If it refill, it should be tapped again, and the repeated tapping may result in cure.7 If, however, the sac refill in a shorter time after each tapping, and the fluid become dull, injections of iodine may be used. It must be owned, however, that this latter treatment has met with no success, although in two cases8 the tumor remained stationary after the injection. Mr. Holmes uses a solution of one part of tincture of iodine to two parts of water; he injects two drachms of this solution, and allows it to 1 Loc. cit., p. 132. 2 Med.-Chir. Trans., vol. xxxix. p. 307. 1856. 3 See cases by Mr. Solly, Med.-Chir. Trans., vol. xl. p. 19, and Mr. Hutchinson’s Illust. of Clin. Surg., vol. ii. p. 25. Dr. Carrington has recorded a case of so-called meningocele that became apparently quite harmless. Lancet, vol. ii. p. 894. 1880. 4 Prescott Hewett, loc. cit., p. 138. 5 Robert Adams, loc. cit. 6 Guyenot, M6moires de l’Academie de Cliirurgie, tome i. p. 863. See other cases in J. Z. Laurence’s paper. 7 Case recorded by Mr. James West; Lancet, vol. vii. p. 552. 1875. 8 Cases recorded by Sir James Paget, Path. Trans., vol. xvi. p. 12, and by Mr. Holmes, St. George’s Hosp. Reports, vol. i. p. 35. 1866. 138 MALFORMATIONS AND DISEASES OF THE HEAD. remain. In a case where the coverings of the sac were sloughing, Mr. An- nandale1 ligatured the mass; a cure followed. (2) Encephalocele.—If there be liuid in the sac, by the increase of which perforation is threatened, the case may be treated as one of meningocele, as far only as repeated tappings are concerned. If the case be one of simple encephalocele, gentle pressure should be tried in reducible cases, and pro- tection adopted in those that are irreducible. In one case, at least, pressure has induced cure.2 (3) Hydrencephalocele.— These tumors can only be treated by protecting them from injury or undue pressure. All operations, save puncture to pre- vent a threatened rupture, would be impracticable. Several cases are recorded where meningoceles, and even encephaloceles, have been cut into by mistake, and a cure of the tumor resulted. Such cases should, however, be regarded rather as warnings than as examples for practice. Diseases of the Skull, etc. Pericranitis and Cranitis. (Osteo-periostitis.)—The term pericranitis is applied to inflammations of the pericranium, the term cranitis to an inflam- mation of the bones of the skull. From a pathological and a clinical point of view, however, it is both difficult and inadvisable to consider these two affections apart from one another. In the great majority of instances of peri- cranitis, the subjacent bone is already inflamed, and the mischief in the mem- brane is secondary to the mischief in the bone. Primary pericranitis is an affection by no means of common occurrence, and inasmuch as inflammations of the bone and of the membrane on its outer surface are so intimately asso- ciated, it is more convenient to consider them together under the title of osteo-periostitis. It must be remembered that the pericranium does not hold those important relations to the bone it covers that exist between the periosteum and the bones of other parts of the body. The principal blood-supply of the skull bones is derived from the vessels supported by the dura mater. These bones are, therefore, to a great extent, independent of the support afforded by the pericranium, a fact illustrated by those cases in which little or no bone mischief has followed upon extensive separation of this outer membrane. Osteo-periostitis of the skull may be acute or chronic. I. Acute Osteo-periostitis.—Etiology.—The commonest cause of this form is injury, especially a lesion that directly injures or exposes the bone, or that is associated with impacted foreign substances of any kind. It not infrequently follows from wounds, the discharges of which have become retained or offensive. It may be due to the spreading of a like mis- chief from neighboring parts, from the bones of the face, orbit, or ear. In some rare cases, acute osteo-periostitis has been set up by the invasion of the bone or periosteum by a spreading ulcer of the scalp. It has been asserted that this affection may be of purely spontaneous origin, and may be due to exposure to cold, to rheumatism, to gout, and to syphilis; but the facts brought forward in support of these assertions are, it must be confessed, somewhat meagre. Pathology.—The pericranium becomes congested, softened, and thickened, and dissected from the subjacent bone by a varying amount of inflam- 1 Edinburgh Medical Journal, April, 1867. 2 Case recorded by M. Ferrand, loc. cit., p. 125. DISEASES OF THE SKULL, ETC. 139 matory material that has been poured out between them. The ipflam- matory products are apt to soon become purulent, and an acute periosteal abscess to be thus formed. The diploic tissue is congested and invaded with an inflammatory exudation that is also very apt to become purulent. At an early stage phlebitis of the diploic veins is prone to occur, and these vessels will be found blocked with thrombi, that in severe cases are breaking down in suppuration. As not infrequent complications may be noted inflammation of the dura mater or of the other membranes of the brain, collections of pus between the dura mater and the bone, thrombosis of the cerebral sinuses, and in rare instances abscess of the brain. The inflammatory action may extend towards the surface and result in a suppurative inflammation of the sub-aponeurotic connective tissue, or of the scalp itself. If a fatal termination does not ensue at an early date, necrosis of the affected bone is a common result of this malady.1 The symptoms of this disease are somewhat obscure, and are apt to be masked by those more serious complications with which it is so often at- tended. The patient complains at first of a fixed pain at some part of the skull, which pain persists, is frequently intense, and usually much worse at night. Rigors occur, associated with fever, headache, vomiting, and in some cases delirium. A painful, tense, and deep-seated tumor appears at the affected spot, if the skin be intact, and in the centre of this mass fluctuation in time becomes evident. There is often some oedema of the scalp, especially in the later stages. If the tumor be incised, pus escapes, and the subjacent bone is found to be bare. Cerebral symptoms are apt to supervene, or, if the case assume a more favorable aspect, necrosis of the affected bone may be diagnosed. From diffuse inflammation of the scalp this malady may be distinguished by the early appearance of oedema in the former affection, the somewhat less intense character of the pain and general symptoms, and the fact that the swelling is diffuse and apt to spread widely, whereas in osteo- periostitis it remains limited to the bone involved, and does not extend be- yond the lines of the sutures. The prognosis is unfavorable. Death occurs in the majority of cases, being caused usually either by cerebral complications or by pyaemia. The early and marked implication of the veins of the part especially favors this latter termination. In rare instances resolution may occur. In other cases a necrosis of the inflamed bone is brought about. This necrosis may be of a slight and superficial character, but more usually it involves the entire thick- ness of the affected bone. Treatment.—Cases of acute osteo-periostitis of the skull must be treated on the general principles advocated in the treatment of like conditions elsewhere. An early incision is imperative, and a free exit must be given to all purulent collections. An ice bag should be kept constantly applied to the head. If the affection can be recognized early, and its nature clearly demonstrated, it may be advisable to trephine the external table and open up the diploe. The early occurrence, however, of diploic phlebitis would negative to some extent the usefulness of this measure. II. Chronic osteo-periostitis may in rare instances follow upon the acute form of the disease, but in the great majority of cases is due to syphilis. The pathology of this affection (considering only the more common form) is treated of in other portions of the work. In this place it is only necessary to allude to the few points that follow: The inflammatory process involved 1 A good account of this affection, illustrated by excellent plates, will be found in Mr. Jona- than Hutchinson's Illustrations of Clinical Surgery, vol. i. London, 1878. 140 MALFORMATIONS AND DISEASES OF THE HEAD. iii the usual form of chronic osteo-periostitis is that known as the gumma- tous ; and, indeed, the disease is described by some authors under the title “osteitis gummosa cranii.” The gummatous change may commence either in the hone itself, in the deeper layers of the pericranium, or in the dura mater. Most usually it commences as a gummatous pericranitis. The frontal and parietal bones are those most commonly attacked, but the disease may involve many bones, and is in some cases very extensive. If the affection commence on the surface of the bone, the pericranium becomes lifted off by the material of the gumma, and an external tumor is perceptible that is known as a syphilitic node. If the bone be affected, it is found to be penetrated by gummatous matter, and the parts involved often become converted into a soft lardaceous mass. This soft material may be absorbed, and in this way a loss of substance in the bone becomes obvious; and if the whole thickness of the bone has been in- volved, a perforation results. These defects and perforations are not filled up by new bone, but are covered in by a fibrous cicatrix derived from the fib- rous investments of the bone at the affected part. Many parts of the bone may be attacked at once, and so many little pits and perforations may be formed in a comparatively small area. To this form of the malady Virchow has given the name of dry syphilitic caries. About these bone defects, osteo- phytic plates are apt to form upon the surface of the skull, and are derived from ossification of the inflammatory or gummatous material. Speaking generally, the syphilitic deposit (as it is often called) may (1) be •absorbed, (2) may ossify, or (3) may break down into suppuration. An ex- ample of absorption is afforded in dry syphilitic caries, and in the entire disappearance of large subpericranial nodes. Ossification is not uncommon. By its agency, the affected bone is rendered denser, thicker, and more com- pact. If the pericranial deposits ossify, hard, irregular elevations of bone, of variable size, may be formed, constituting one form of exostosis. In the same way, from ossification of material thrown out between the dura mater and the bone, exostoses or growths from the inner surface of the skull may be produced. The rarest mode of ending for the syphilitic material is by suppuration. Necrosis may follow from this disease, of which sequence more will be said presently. The symptoms are often somewhat indefinite, and the nature of the disease can be more often suspected than positively diagnosed, especially when the morbid process is deeply seated in the bone. The patient, the subject of ter- tiary syphilis, complains of slight but fixed pain in some part of the head. This pain is worse at night, and is influenced not a little by the state of the weather. There will generally be some tenderness on pressure. If the peri- cranium be involved, a deep-seated, hard swelling very slowly forms—a syphilitic node. This swelling holds a very chronic course, and may in time disappear, or become bony, or break down into pus. If there be no surface node, the diagnosis is more difficult, and no cases are more hard to interpret than are those in which the irritation of a projecting syphilitic mass from the interior of the skull has caused brain symptoms. The amenability of the disorder to antisyphilitic treatment is of much value in the diagnosis. The treatment of syphilitic osteo-periostitis of the skull does not materially differ from the treatment adopted in like bone disease elsewhere. Iodide of potassium should be freely and diligently given, and every measure adopted that may improve the patient’s general health. In the majority of cases, the administration of mercury at the same time will be found of considerable advantage, unless there be something in the patient’s condition to contra- indicate the drug. The inflamed part should be protected, and no appli- cation is needed beyond that used for this protection. If there be certain DISEASES OF THE SKULL, ETC. 141 evidence of suppuration, an early incision down to the bone will be called for. The prognosis in these cases is on the whole favorable. Caries of the Skull.—Caries is frequently met with in the skull bones, although the structure of these bones predisposes them rather to necrosis. Etiology.—The commonest cause of caries in this locality is undoubtedly tertiary syphilis, the disease following upon a chronic syphilitic osteo-perios- titis. Many cases are due to scrofula, and in a few rare instances, the cause is injury. Caries from injury is extremely rare in the healthy, the usual degenerative change, if any, being necrosis. If caries should follow upon traumatism, it will then be usually quite limited and restricted to the exter- nal table. Some conspicuous exceptions have, however, been recorded. Sir Prescott Hewett1 cites a case of caries of the frontal and both parietal bones, and of part of the occipital bone, that followed from a simple blow on the head. Abercrombie2 records a remarkable case where very extensive caries of the internal table occurred after a by no means severe fall upon the head, and a few other exceptional cases of a like nature have been reported. Caries may also extend from the upper cervical vertebrae to the adjacent bones of the base of the skull, and Sir P. Hewett asserts that caries in this lat- ter situation may likewise be due to extension of inflammation from extensive syphilitic ulcers of the pharynx. Caries of certain parts of the temporal bone is usually subsequent to suppurative catarrh of the tympanum. Pathology.—Caries may attack any part of the skull, although it has a special predilection for certain localities. It is most often met with on the frontal bone, particularly at its anterior part, or about its union with the parietals. Next in order of frequency may be placed the mastoid process, and then, perhaps, the occipital bone. Although the disease is usually limited, it may be, on the other hand, very extensive, and may involve, in- deed, almost the entire skull. The external table is more frequently impli- cated than is the internal table; or, if they are both involved, then still will the change be usually more extensive in the outer plate. Mr. Gray3 has recorded a curious case of caries, fatal through brain complications, where the disease was limited to a small carious spot on the sella turcica. Caries may commence in either the external or internal table, or in the diploe; or it may appear simultaneously in more than one of those parts. Into an account of the minute changes in caries of the skull, it is unnecessary here to enter. Such changes are identical with those observed in caries elsewhere, and have already been fully dealt with in a previous article. Some few special points, however, require notice. Caries of the skull in the dried specimen presents the familiar aspect of caries in other parts. The diseased surface is eroded and worm-eaten, and the limits of the affected district very irregular. The depth to which the destructive action may penetrate from the surface varies greatly. It may extend only through the outer table, or may involve more or less of the diploe, or may perforate to the internal skull-plate. The carious action is usually more destructive in the diploic tissue than in either the ex- ternal or internal table; the result being that some undermining of those tables about a carious hole is very common. If the disease has spread from without inwards, and caused perforation of the inner plate, the perforations are apt to be small and numerous, rather than solitary and extensive. Excep- tions, however, are by no means uncommon. 1 Lectures on Injuries and Diseases of the Head. Med. Times and Gazette, vol. i. p. 230. 1855. 2 Pathological and Practical Researches on Diseases of the Brain and Spinal Cord, p. 188. Edinburgh, 1845. 8 Trans. Path. Soc. London, vol. ii. p. 19. MALFORMATIONS AND DISEASES OF THE HEAD. Caries due to syphilis may assume one of two aspects—dry caries (so called) and ulcerating caries. The former variety has already been alluded to in speaking of osteo-periostitis. A skull, the subject of this affection, usually exhibits over a more or less extensive surface a number of holes in the outer plate. These holes are clean cut and irregular, and vary in size from that of a mere pin’s-point to that of a three-penny piece, or larger. The edges of these holes are, as a rule, very thin, and much undermined by a more extensive loss of tissue in the diploe. The internal table may be thinned and perforated in a few places. In some rare cases there is a slight formation of coarse, new bone about the carious spots, and in other instances the edges of a large hole in the external table will be found rounded off, and the diploe beneath con- verted into dense compact bone, that may fairly be spoken of as an osseous cicatrix. In the recent specimen, the depressions, holes, and cavities in the bone are filled in with gummatous material. In the ulcerating form of caries, suppuration has taken place, and the disease presents the aspect of ordinary caries, except for the fact that very often the mischief so spreads as to form an annular or semi-annular outline. This tendency of the edge to become rounded is identical with a like tendency in tertiary syphilitic ulcers of the skin. This form of caries usually begins with the formation of a sub- pericranial gumma; and in cases where the internal table is first attacked, with a gummatous deposit between the dura mater and the bone. As com- pared with other varieties of caries, that due to syphilis is more apt to be extensive. In scrofulous or tuberculous caries, we have to deal with a true tubercular process in the bone. The affection commonly commences by changes in the deeper layers of the pericranium, and probably at the same time in the outer surface of the bone. The pericranium, thickened and congested, is lifted off by a collection of inflammatory material beneath it. Thus an external tumor is formed that is sometimes known as a scrofulous node, or gumma. In process of time, if this tumor be incised, a quantity of curdy, ill-conditioned pus will escape, and the subjacent bone be found carious. In like manner the mischief may commence on the inner aspect of the cranium. In some instances the dis- ease would appear to commence in the diploe, and when so commencing it may lead to the most typical forms of what is known as perforating tuberculosis of the skull. In this disease, the affected bone is found converted into a more or less cheesy material, and more or less extensively destroyed. The inner and outer tables are both perforated. At the seat of these perforations, the dura mater and pericranium will be found more or less separated from the sub- jacent bone by inflammatory or purulent matters. In time an external tumor forms. This, on being incised, allows of an escape of pus that has been pent up beneath the pericranium, and the nature of the affection becomes obvious.1 Scrofulous caries is usually of limited extent, but some few cases are re- corded in which it has involved large portions of the skull. Mr. Csesar Haw- kins, for example, describes a case where the right parietal bone, the right half of the occipital, the squamous and mastoid portions of the right temporal, the great wing of the sphenoid, and a large part of the frontal, were affected with scrofulous caries on both surfaces.2 The disease in this case was rapid and soon fatal. Symptoms.—The course of caries is usually slow and deliberate. In caries of the outer table, a part of the skull becomes a little tender, and the seat 1 For a full account of Perforating Tuberculosis, see a paper by R. Volkmann, Centralblatt fiir Cliirurgie, 1880, No. 1. 2 Med.-Chir. Trans., vol. xxxix. page 285. 1856. DISEASES OF THE SKULL, ETC. 143 perhaps of a fixed pain that is worse at night. In time, a small, hard, deeply seated tumor appears at this spot. This enlarges and softens. On being incised, pus escapes, and carious bone can be felt with the probe. Caries of the inner table may give rise to the most misleading symptoms. Its certain recognition is almost impossible. There will probably be fixed headache, perhaps some tenderness of the skull over the painful part, and then possibly head symptoms of various kinds—vertigo, convulsions, partial paralysis, delirium, etc. Indeed, the symptoms of caries in this situation are rather those of the brain mischief induced by the disease. If the dura mater be much separated from the bone by pus, there will probably be symptoms of compression. In perforating caries the evidences are a little more pre- cise. After a period marked by some local pain and tenderness, and possibly by some vague cerebral symptoms, a tumor forms externally, which increases, and in time fluctuates. It will then be found that this tumor may be more or less reduced by pressure, and such reduction may cause temporary brain symptoms. The size of the mass also may be affected by respiration. On incision, much pus escapes, the discharge of which is rendered more free on forced expiration. The bone being now bared, a perforation of both tables may be observed. The diagnosis of syphilitic caries depends to a great extent upon the history of the case, the evidences of tertiary syphilis, and the beneficial effects of antisyphilitic remedies. Dry syphilitic caries may be marked by almost a total absence of symptoms. A skull showing extensive disease of this nature was exhibited by Dr. Norman Moore at the Pathological Society of London. The whole vault of the skull was affected, but during life the patient had exhibited no symptoms of bone disease of any kind; the only fact noted about the head being that at one part of the scalp there was a little “ eczema.”1 In most cases, however, there is pain in the cranial bones that increases at night, tenderness of the skull, some oedema possibly of the scalp, and in some instances slight evidences of brain disturbance. Of the other varieties of caries no especial notice is required. Prognosis.—The progress of the disease is slow, and may last months and often years, especially when it depends upon some constitutional defect. Death may occur from simple exhaustion, in cases of extensive caries, but, as a rule, the fatal issue depends upon some intra-cranial mischief, and less frequently upon pyaemia. The depth to which the caries extends, and the de- gree to which it involves the inner table, are therefore matters of more gravity as regards prognosis than is the simple extension of the disease upon the sur- face. The usual intra-cranial lesions are thrombosis of the sinuses of the dura mater (especially apt'to occur when the diploe is involved), meningitis of the convexity, and abscess of the brain. In some cases, fatal compression may be caused by a collection of pus between the dura mater and the bone, and in several instances epilepsy lias followed upon the bone disease. In caries of the mastoid and petrous bones, fatal hemorrhage has occurred from the internal carotid artery, from the internal jugular vein, and from one of the adjacent sinuses, these vessels having been opened up by an ulcerative process. Treatment.—When the disease depends upon syphilis or struma, the appro- priate constitutional remedies are required. In any case the health should be supported, and freedom, if possible, from all mental excitement advised. Collections of pus should be immediately evacuated, and free exit given to all discharges. In most cases, and in those especially in which the exter- 1 See Lancet, Feb. 5, 1881. 144 MALFORMATIONS AND DISEASES OF THE HEAD. nal plate only is involved, no operative treatment is required, it being only needful to aid repair by general measures. If the caries extend deeply into the bone, and be still spreading, a cautious use of the gouge may be advised ; but in no case should either the actual cautery or liquid caustics of any kind be used. In certain cases, where pus is pent up either in the substance of the bone itself, or between the bone and the dura mater, the use of the trephine is to be recommended. In caries of the mastoid process, for example, an early application of the trephine will often relieve the most distressing symptoms and arrest the progress of the disease (for a while, at least), by the evacuation of pus situated deeply in the bone. In cases of so-called perforating tuber- culosis, also, where pus is retained between the dura mater and the bone, or in the substance of the diploe, great benefit may attend the application of the trephine to the diseased area.1 The ancient treatment of recklessly applying the trephine at many points around a carious spot is strongly to be condemned. Mr. Bryant2 has recorded a case in which he trephined out a piece of carious bone in a patient who had become epileptic after the appear- ance of the disease, and who was suffering from hemiplegia. Considerable improvement followed upon the operation, but it was only temporary. Necrosis of the Skull.—Etiology.—Necrosis may follow upon injuries of all kinds, especially upon fractures, where pieces of bone have been more or less entirely separated from the skull, and thus deprived of their blood supply. It may follow also upon simple contusions of the head, and in such cases it is probably due to some lesion of the bloodvessels nourishing the bone. There has been perhaps an extravasation of blood in the diploe, with some damage to the diploic tissue, or an extravasation has separated the dura mater from the bone, or a like separation has occurred in the pericranium. As the blood supply of the cranial bones is mainly derived from the dura mater, damage to that membrane is more effective in producing necrosis than is a corres- ponding lesion of the pericranium. Necrosis may also follow upon burns, or upon injuries of the parts from corrosive substances. Necrosis may terminate acute or chronic osteo-periostitis. It may be due to scrofula, and, in individuals with this diathesis, it is especially apt to occur after the eruptive fevers. But if one that slight form of superficial necrosis (exfoliation) which is common after certain injuries, then certainly it is to syphilis that one must look for the most common cause of skull necrosis. According to some authors, nine-tenths of all cases of necrosis of the cranium can be ascribed to the tertiary form of this disease. Heineke* quotes a remarkable case of necrosis of the contiguous parts of the frontal and parietal bones and great wing of the sphenoid, that occurred in a patient aged nineteen, after typhus fever. At the autopsy, it was found that the middle meningeal artery was blocked by a thrombus. Pathology.—The seat of necrosis varies considerably. When due to injury, it may of course be in any bone, but the idiopathic forms are especially apt to attack the frontal and parietal bones, and are rarely met with in the occipital. Great variety is also seen in the extent of the disease. The necrotic action may involve the entire thickness of the bone, or may implicate only the external or the internal table. Its most frequent seat is in the external table, whereas necrosis of the inner plate only is extremely rare. When the whole thickness of the skull bone is necrosed, the outer table will usually be found to be more extensively involved than the inner table; or, in many 1 R, Volkmaitn (loc. cit.') has performed this operation in four cases of perforating tuberculosis with good results. 2 Medical Times and Gazette, vol. ii. page 158, 1860. 3 Loc. cit., S. 65. DISEASES OF THE SKULL, ETC. 145 instances, the destruction will be found equal on the two surfaces. Cases oc- casionally occur in which the whole thickness of the skull is lost at one place, and one table only at another. The necrosis is usually limited in extent. When the outer table alone is involved, the disease usually takes the form of exfoliation of bone, and sometimes the pieces of bone thus separated are so small as to be almost imperceptible. This is common after scalp wounds associated with a considerable surface of bared bone. Many cases are, how- ever, recorded of very extensive necrosis. One of the most frequently quoted cases of extensive disease is the case given by Saviard, where the whole vault of the skull became necrosed subsequent to an injury to the head. As this case is one of great importance and interest, I quote in full Saviard’s account of the patient “ Une pauvre mallieureuse sortit de l’Hotel Dieu au mois d’Oct. 1688, apres avoir ete malade pendant plus de deux ans, en suite d’une playe a la tete qu’elle s’etaitfaite en tombant, pour avoir bu du vin avec exces. La partie superieure de l’os coronal, les deux parietaux entiers et une grande portion de l’os occipital s’etant decouvert dans la suite du traitement, s’exfolierent dans toute leur epaisseur et se separerent en meme temps : de sorte que cette exfoliation resemblait au dessus d’une tete que l’on aurait sciee et separee du reste du crane. L’on vo'ioit, a l’endroit d’ou ces os etaient sortes, le battement de la dure-mere qui n’etait couvert que d’une pellicule fort amince.”1 Norris2 gives a case in which considerable portions of the parietal and tem- poral bone3 were lost, together with a great part of the frontal and occipital bones. The disease followed upon a fall on the head. A somewhat similar case is recorded by Drummond,3 where an equally extensive necrosis followed upon a scalp wound. South4 describes the case of a woman, who, in nine years, lost the greater part of both parietals, and some parts of the temporal, parietal, and occipital bones, from a necrosis that was supposed to be of syphilitic origin. The mode of separation of the sequestrum is the same as that observed in necrosis elsewhere, and indeed the only pathological feature special to skull necrosis is the absence of any new bone formation. There is no invagination of the dead piece of bone, and no fresh osseous production formed to till up the deficiency caused by its removal. If the external table alone separates, granu- lations spring up from the exposed, subjacent bone; these form a fibrous tissue which—with assistance from the pericranium—fills up the defect on the surface. If the whole thickness of a skull bone be involved in the seques- trum, granulations spring up from the adjacent bone, from the pericranium, and from the dura mater, and together form a mass of fibrous tissue that more or less perfectly fills up the void. The rough edges about the gap become rounded otf and shelving, but beyond this show no reparative changes. In some cases of syphilitic disease, however, a slight amount of new bone may be formed around the sequestrum, so as to retain it as a watch- glass is retained, or, in the absence of such a definite formation, feeble growths of porous bone may be sometimes observed on the outer table in the vicinity of the necrosis, and such deposits often assume an annular outline.5 It is important to note that necrosis is not limited by sutures, and, indeed, often involves the contiguous parts of two or more bones at the same time. In the matter of symptoms and diagnosis, nothing need be added to the 1 Reoueil d’Observ. Chirurg., p. 836. 1762. 2 Trans. Med. Soc. Lond., vol. i. p. 168. 1810. Skull in Museum of Royal College of Surgeons. 3 Med.-Chir. Trans., vol. xxxiv. p. 103. 1851. A wax model of the patient’s head is pre- served at the Hadlar Hospital, at Portsmouth. 4 Clielius’s Surgery, ed. by South, vol. i. p. 699. 1847. 6 Cornil et Ranvier, Manuel d’Histologie Pathologique, p. 405. 1881. 146 MALFORMATIONS AND DISEASES OF THE HEAD. information given elsewhere. As may be supposed, special symptoms may arise, due to implication of neighboring nerve-structures. Sir James Paget, for example, has recorded a remarkable case of great atrophy of the right half of the tongue consequent upon necrosis of the occiput after injury. The mischief had evidently implicated the hypoglossal nerve in its passage through the diseased bone. On the removal of the sequestrum, the tongue rapidly regained its normal condition.1 Prognosis.—In slight necrosis involving only the external table, a cure, as a rule, results after no very protracted period. When the disease, however, is more extensive, and when the whole thickness of the bone is involved, the course may be very chronic, and often extends over months and years. Some of the most severe cases have ended in cure without a bad symptom, but as long as the sequestrum remains unseparated there is considerable risk to the patient. Heath may occur from exhaustion, as in Norris’s case quoted above, but more usually it is due to meningitis, or to suppurative thrombosis of some of the cranial sinuses, or to compression of the brain by pus between the dura mater and the bone, or to pysemic infection. The probability of cere- bral mischief in any case is difficult to estimate. It is most common after necrosis in the mastoid process, and least common after like mischief in the frontal region. It has occurred in cases of most insignificant bone-disease on the one hand, and has been absent in cases where the dura mater has been freely exposed to a considerable extent. Speaking without the guidance of any actual statistics, cerebral troubles would appear to be more frequent after syphilitic necrosis than after the traumatic form of the disease. Treatment.—Collections of pus should he immediately evacuated, and free exit given to all discharges. Superficial necrosis of the outer table may be practically left to itself, or the process of exfoliation may be aided by a cautious application of sulphuric acid. Loose sequestra should be removed as soon as possible, and, if the necrosed piece be too large for convenient removal through reasonable incisions, it may be so trephined as to allow of its being extracted in segments. Trephining also may be resorted to in those rare cases in which compression of the brain is being caused by a collection of pus between the dura mater and the bone. After the removal of the sequestrum, every pre- caution should be taken to protect the part from injury, while, at the same time, the wound is kept scrupulously clean. The knowledge that the dura mater is exposed in any case, would appear to me an argument in favor of early removal of the sequestrum, rather than an excuse for leaving it in situ for a while, as some have vaguely advised. Hypertrophy of the Skull.—Under the simple term “ hypertrophy,” or the vaguer title “ hyperostosis cranii,” several distinct and different forms of morbid change in the cranial bones have been described. It is no matter of sur- prise, therefore, that this subject has been involved in considerable confusion. Under the above title, we may, I think, recognize at least four different forms of bone change. I do not maintain that these various forms represent of necessity different pathological processes: That may or may not be the case. I would only point out that a casual collection of so-called “ hypertrophied skulls” would (if numerically large enough) present such distinct and con- stant varieties as to enable us to classify them under the four following heads: 1. Simple hypertrophy, general or local. 2. General “ concentric hyperostosis.” 3. “ Osteo-porosis” in its various forms, the “ diffuse excen- tric hyperostosis” of some authors. 4. “ Leontiasis ossium,” or “ limited ex- centric hyperostosis.” This medley of terms is the natural result of grouping 1 Trans, of Clinical Soc., vol. ii. p. 238. DISEASES OF THE SKULL, ETC. 147 different morbid appearances under a common bead. I will now deal with these four aspects of disease in detail. 1. Under this heading are classed simple hypertrophies, using that term in its purest sense. Of general, true hypertrophy of the skull, I know only one example. It is in the Museum of the Royal College of Surgeons. This skull is hypertrophied in every part. In structure the bones appear quite normal; the hypertrophy is uniform and accurately symmetrical, every bone and every point of a bone being in all parts evenly increased in size; the base is as much affected as the vault; all parts, therefore, of the cranium, bear to one another their normal relations, and, indeed, the only feature is pathologi- cal exaggeration. Of the cause of this condition nothing is known. It is a true hypertrophy of normal bone. Examples of local, true hypertrophy are common enough. The enlargement of certain parts of the skull, especially of the frontal bones, consequent upon atrophy of the brain, may be placed under this head.1 In some of these cases, the increase in thickness of the bone appears to be mainly effected by the inner table. In other instances—which can hardly be called true hypertrophies—there is a deposit of new bone upon the internal plate, thus causing much thickening. The instances of thickening of the skull bones after the subsidence of hydrocephalus are also, as a rule, instances of this last-mentioned condition. 2. In so-called general concentric hyperostosis there is no alteration in the form of the skull, and no increase in the thickness of the component bones. There is, however, a great condensation of bone tissue, so that the diploe becomes as compact as the tables that inclose it, and the skull on section pre- sents an uniform, ivory-like aspect. The sutures are generally obliterated. Thus are formed those compact, heavy skulls, of which specimens exist in most pathological museums. The change is usually limited to the vault, but is then evenly distributed over its entire area. It is most common in advanced life. Of its cause, nothing is known, and its recognition is impos- sible during life. This condition of the bone is often ascribed to a blow, or to syphilis, but I am aware of no evidence to support such suggestions. Chronic cranitis often causes a limited condensation of the diploe, but in such cases the adjacent bone-tissue shows evidence of inflammation, and it is hardly possible to conceive a cranitis that would evenly and precisely involve every part of the vault, and yet cause no symptoms, and be asso- ciated with no changes on the surface of either of the skull-plates. 3. The term osteo-porosis has been applied to the condition found in certain large, thick skulls with obliterated sutures, the bones of which on section appear uniform, and finely porous, and, to use a comparison of Sir James Paget’s, very like white brick. The general shape of the skull is, as a rule, not altered, but the thickness of the component bones may be extreme, and represent four or five times the normal width on section. In the Musee Dupuytren is a skull, for example, four centimetres in thickness. Both the surfaces of the bones are generally smooth, but the vascular channels on the inner table are greatly increased in depth. The change is, more or less, entirely limited to the vault, although, in some cases, the base may be impli- cated. This condition of skull, known by some as diffuse excentric hyper- ostosis, is the outcome of several different diseases, among which may be placed, with some certainty, (1) osteitis deformans ; (2) osteomalacia; and (3) a peculiar form of rickets (?), occurring in animals. 1 See cases in Med.-Chir. Trans., vol. xix. p. 367. 1833; also in article “Cerveau,” by M. Potain, Diet. Encyclop., p. 294. Paris, 1873. In November, 1881, Mr. Pearce Gould exhibited at the Path. Soc. of London, the occipital bone from a patient with congenital absence of one lobe of the cerebellum. The bone showed a true hypertrophy at the part corresponding to the absent lobe. 148 MALFORMATIONS AND DISEASES OF THE HEAD. (1) One of the most conspicuous features in osteitis deformans is this change in the skull, and there is no doubt that several specimens in museums ascribed to syphilis, to the effects of blows, and to compensatory hypertrophy after wasting of the brain, are examples really of this remarkable disease.1 (2) lii cases of cranio-malacia the skull-bones become greatly and evenly thickened, the sutures are obliterated, and the texture of the bone is light, spongy, and very brittle.2 (8) In the museum of the Royal College of Surgeons are several skulls of young lions and monkeys, that have died in confinement of a disease resem- bling rickets in man, and that without doubt depended upon improper diet. In these skulls, the entire vault is evenly and greatly thickened, the sutures are obliterated, and the base is not involved. The bone is very uniform on section, and is very finely porous. What is the exact nature of the affection it is impossible to say; and, indeed, the whole pathology of so-called osteo- porosis of the skull is in a condition of extreme obscurity. 4. In the condition known as limited eccentric hyperostosis, the skull is thickened and deformed by the growth of irregular bossy masses of rough and porous bone. These masses appear to be deposited upon the outer, or sometimes upon the inner, table of the skull, but an examination of the bone in section shows that its whole structure is involved in the disease. The disease spreads; the bones of the face and lower jaw are involved. The malar bones are especially apt to be affected, and may be converted into bossy masses as large as oranges. As regards the skull, the frontal and parietal bones are those most severely involved, while the occipital bone is, as a rule, but slightly affected, and may remain absolutely exempt from the disease. The deformity produced by the disease is extreme and horrible; the cavities of the skull, nose, orbit, and mouth are encroached upon. The cranial foramina are nar- rowed, and may even become closed. Paralysis of the nerves at the base of the skull is therefore not uncommon, and the patient usually dies, simply worn out by the effects of the disease. The morbid change is usually very symmetrical. The bone is very vascular, and is rendered porous by the entrance of many bloodvessels. Virchow considered this disease to be akin to elephan- tiasis of the soft parts, and gave to it the name of leontiasis ossium. It occurs most usually in the young, appearing at or before puberty, and lasts for years. In a very fully reported case, recorded by I)r. Murchison, the disease had ex- isted for twenty years.3 It is commonly attended by more or less continuous headache, by neuralgia, spasms, or limited palsies. Like the other forms of skull hypertrophy, it is unaffected by any treatment. Atrophy of the Skull.—Atrophy of the skull, or analosis cranii, appears under various forms. Considered generally, it is an affection of old age, being quite rare before the age of 50. It would appear to be most common in the female sex, for out of 28 cases mentioned by M. Gayraud,4 the patients in 22 instances were women. This subject has been very fully investigated by M. Sauvage,5 who asserts that he met with twenty-eight cases of atrophy in examining two thousand adult skulls. This proportion, however, is probably too high. The condition and extent of the atrophied parts vary considerably. In 1 See Sir James Paget’s paper, Med.-Chir. Trans., vol. xlii. p. 37. 1877 ; also case reported by- author in Trans. Path. Soc., 1881. 2 A good specimen will be found in the Museum of the Royal College of Surgeons (Mr. Solly’s case). 3 Trans. Path. Soc., vol. xvii. p. 243. 1866. 4 Diet. Encyclop. des Sciences Med., Art. Crane. Paris, 1879. 6 Recherches sur l’fitat s6nile du Crane. Paris, 1869. diseases of the skull, etc. 149 some cases, the bone loses its volume by progressive wasting of the diploe and approximation of the two cranial tables. These tables at last meet in one compact layer, and, by becoming themselves still further thinned, may, in time, exhibit actual perforations in parts. This condition may be gene- ral, or it may involve parts only. Parts of the skull, naturally thin, show this change most conspicuously, as for example, the lower part of the occiput, the squamous portion of the temporal bone, and the orbital roof. In other cases the absorption appears rather to take place centrifugally from one or more points, and may then commence in either of the two tables, or in the diploe. Most usually it commences in the outer plate. The entire skull may be thus involved, and a severe example of one phase of this condition is afforded in osteo-malacia. One of the most peculiar forms of the present affection is a limited atrophy of a part of both parietal bones, whereby very distinctive depressions are pro- duced on the outer aspects of the bones. These “ parietal depressions” are met with in the skulls of the aged, and are symmetrical, although they are usually more marked on the right side. The depression is oval, is situate over the parietal eminence, and has its long axis placed obliquely, so that it is directed from the posterior and upper part of the bone, forwards, and a little outwards or downwards. The depression may occupy the greater part of the antero- posterior diameter of the bone. The depression is at the expense of the outer table and the diploe. The inner table will be found unaltered in position, and the cranial cavity, therefore, is no way encroached upon.1 In some cases, however, the disease may go on to perforation.2 The causes of this remark- able affection are unknown.3 There is on record a case of symmetrical atrophy of the frontal bone on either side of the middle line, and several cases of like atrophy of the occipital bone. Atrophy of the skull is attended by no special symptoms, cannot be diagnosed, and, even if recognized during life, would probably be unaffected by any treatment. Craniotabes and the Changes in the Skull in Hereditary Syphilis.— The term craniotabes is applied to two morbid conditions met with in the crania of young infants, that differ, however, only in degree. They are (1) a limited thinning of the skull bones, and (2) perforations in those bones due to extreme degrees of that thinness. Elsaesser,4 who first described the affection, considered it to be due to rickets, but at the present time, owing mainly to the researches of M. Parrot, Hr. Barlow, and Dr. Lees, the condi- tion is considered to be a manifestation of hereditary syphilis. The conclu- sions of the two last-named observers upon this point are thus expressed: “ We have found craniotabes (1) not common in pure rickets, (2) not at all special to rickets, (3) very common in congenital syphilis.”5 The changes in the skull in syphilitic infants present themselves under three aspects: 1. Oelatiniform atrophy (Parrot6); 2. Craniotabes* 3. Osteophytic formations. These changes occur in varying degrees and at somewhat varying periods, and it is important also to observe that these changes do not occur in the crania of all syphilitic infants. 1 An excellent description of these depressions is given by Professor Humphry. Journ. Anat. and Phys., vol. vii. p. 136. 1874. 2 Larrey, Bull, de la Soc. de Chirurg., tome vii. p. 30. 1867. 3 The subject of causation is well discussed by M. Pozzi. Diet. Encyc. des Sc. Med., Art. Crane (Developpement), p. 497. 4 Der weiche Hinterkopf. Ein Beitrag zur Physiol, und Pathol, der ersten Kindheit. Stuttgart und Tubingen, 1843. 5 Trans. Path. Soc. Lond., vol. xxx. p. 333. 1879. 3 Ibid., p. 339. 150 MALFORMATIONS AND DISEASES OF THE HEAD. 1. Gelatiniform atrophy is very rare, and is met with only in very young' infants, so that M. Parrot suggests that it may commence during intra-uterine life. The bones affected waste and assume a somewhat gelatinous aspect, being soft and watery; the surface of the affected portions looks eroded when the specimen is fresh. The change always commences at the surface, beneath the periosteum, and is very seldom of any depth, although M. Parrot men- tions a case in which it produced perforation. It may be circumscribed or diffuse, and may involve any or all of the cranial bones. 2. Craniotabes appears mainly about the lambdoid suture, affecting the upper part of the occipital bone and the posterior border of the parietal hones. It consists of a great thinning of the bone, which thinning is mainly at the expense of the inner surface, so that when holes are formed, they cannot well be felt in the fresh specimen by passing the huger very lightly over the external surface of the bone. The thinned bone yields to the huger like parchment, and this parchment condition has been observed in the lower part of the occipital bone, and also in the squamous bone. The holes are gene- rally small, about the size of a bean, and are tilled in by a thin membrane. These changes occur mainly from the third to the sixth month, and occupy a period somewhat antecedent to that of the osteophytes. 3. The osteophytic formations consist of certain local thickenings of the skull. These appear as lens-shaped elevations on the exterior of the hone, and may increase considerably in size. Their most constant position is about the anterior fontanelle. Here bosses form on the four hones that form the fontanelle, and give rise to a remarkable elevation, traversed by depressions arranged in a crucial manner, and marking the situations of the coronal, sagittal, find interfrontal sutures at the point where these sutures meet. The anterior fontanelle, therefore, appears to be at the bottom of a hollow formed by the heaping up of the adjacent hones. Sometimes only two bosses exist instead of four. These changes appear first on the frontal hones, and then on the parietals; the occipital bone may also be affected, but not primarily. The elevations are composed of a very porous bone formation, and are of a red, violet, or maroon color; they involve the exterior of the skull only, the cor- responding part of the inner table being unaltered. The thickening tends to extend from the fontanelle along the sutures first, and ultimately over the general surface of the bones. The centres of ossification are the points last attacked, so that the frontal and parietal eminences are very seldom the seat of these bone thickenings. By an extension of the enlargement, the whole skull may become much thickened, the sutures obliterated, and the develop- ment of the brain considerably hampered. These osteophytes appear to be formed from the deeper layer of the periosteum, and present the structure of very imperfect bone. Dr. Barlow considers them to be due to a hyperos- tosis depending upon altered nutrition, and not to be of the nature of periostitis. They appear in older children than those affected with atrophy, so that the two conditions never coexist. Craniotabes and osteophytic growth are, however, often met with on the same skull, but on quite opposite parts, the osteophytes being on that part of the skull which is most elevated in dorsal decubitus, the craniotabes on those parts which are the most dependent. It is usual, therefore, to ascribe the latter condition to pressure. Taken as a whole, all these changes appear early, certainly within the first two years of life, and usually well within the first year. Diagnosis.—The condition of gelatiniform atrophy cannot be diagnosed during life. (Parrot.) Craniotabes is easily recognized by the parchment-like reaction of the bone under pressure, and by the presence of the holes. The latter are, however, much less easily recognized than is the former condition. The osteophytic condition can be recognized during life, if the enlargement TUMORS OF THE SKULL. 151 is in any way pronounced, and so peculiar often is the general outline of the deformity about the anterior fontanelle, that M. Parrot speaks of it as the “natiform” deformity. The general condition of the infants who are the subjects of these skull changes needs no mention in this place, nor does the treatment of the constitutional malady. The only local treatment to be advised is to keep the back of the head free from pressure, and this is easily effected by the use of a ring of cotton-wool, or some such simple contrivance. Tumors of the Skull. Cysts of the Skull.—Some few cases have been recorded of cysts developed within the substance of the cranial bones. It is probable that in every instance these were hydatid cysts. Four examples of cyst have been cited by Bruns; of these, three were located on the vault, and one on the base of the skull. One ot the best recorded cases of this affection is that detailed by Robert Keate.1 A female, aged 18, presented a large tumor on the frontal bone, that occupied nearly the whole of the left half of the bone, and extended some way across the right half. It had been growing slowly for six years. The patient complained of headache, vertigo, sickness, and noises in the ears. On attempting to remove the tumor, which was of bony hardness, it was found to be composed of a cyst in the substance of the bone, lined by a membrane. A clear fluid escaped from it. The c}rst had evidently developed in the di- ploe and had separated the two tables, the inner plate being depressed towards the cranial cavity. The contents having been evacuated, the wound was allowed to heal. The cyst re-formed, and, on being re-opened, many small cysts were found embedded in the wall of the original cyst. Attempts were made to destroy the growth with caustics, and ultimately, after an applica- tion of the saw and much exfoliation of bone, the wound healed, and a com- plete cure resulted, microscopic examination was made of the cyst-con- tents, but there can be little doubt that the growth was due to the hydatid parasite. In a case recorded by Holscher,2 a hydatid cyst appears to have developed from the dura mater beneath the parietal bone, and to have perfo- rated that bone and so formed an external tumor. This tumor was soft and fluctuating, with a distinct rim of bone at its base. It suppurated, and on incision a number of hydatids were evacuated. The patient, a lad aged 14, did remarkably well. Clemenceau gives a case of spontaneous cure of a hyda- tid cyst of the brain, brought about by its opening externally. Sarcoma op t.he Skull.—Sarcomatous growths from the cranial bones are not very uncommon, and probably most of the cases of cancer of the skull, described by older authors, were of this nature. The tumors may grow either from the surface of the skull (pericranial sarcoma) or may commence in the diploe (diploic sarcoma). In the pericranial form, a tumor rapidly develops beneath the pericranium, and separates it more or less extensively from the subjacent bone. The sar- comatous growth soon penetrates into the osseous tissue at its base, diving in at many points so that the bone becomes riddled with the new material. Fine bony trabecuhe form early on the substance of these tumors. The tra- beculae radiate from the base of the growth, and serve to support the softer parts. The amount and density of tins trabecular tissue vary greatly. As the mass extends externally, it forms a large, rounded, orlobulated mass, very distinctly outlined. The growth at the same time spreads more deeply into 1 Med.-Chir. Trans., vol. x. p. 279. 1819. 2 Heineke, loc. cit., p. 78. 152 MALFORMATIONS AND DISEASES OF THE HEAD. the substance of the bone; ultimately, perhaps, penetrates the inner cranial plate; and extends then between the bone and the dura mater. The sarcoma generally spreads evenly over the dura mater, forming a flattened rather than a rounded elevation of that membrane towards the cranial cavity. In time, also, the dura mater itself may become invaded by the growth. In the diploic form, a very similar course is observed. The mass commences in the diploe, and slowly separates and expands the cranial plates. The growth naturally tends towards the external surface as the direction of least resistance. The outer table becomes expanded and thinned, until it forms a mere cap of bone over the now fair-sized swelling. In time this bony cap gives way, and the growth appears immediately beneath the soft tissues of the pericranium and scalp. Some displacement and expansion of the inner skull-plate may be observed, but it is not common in any but a trifling degree. Sarcomata of the cranium may be primary or secondary. Most often they are secondary to like tumors elsewhere. They are usually multiple, seldom affect the corresponding glands, and, when primary, are very apt to lead to metastases in various parts. They are most common in youth and middle life. Some few cases are recorded in quite young children,1 and Mr. Birkett2 has described a case of myeloid sarcoma of the frontal bone in an infant aged two months. The patient lived nine months after the appearance of the growth. Mr. Butlin3 observes that these sarcomata in young children are usu- ally of the round-celled variety, that they are nearly always multiple, and that, they kill by metastatic formations. Microscopically, these tumors are usually of the spindle-celled variety, espe- cially such as grow beneath the pericranium. The more rapidly growing tumors are, as a rule, examples of round-celled sarcoma, and in any variety a certain proportion of myeloid cells is usually to be found. Symptoms, etc.—These growths first appear as small, flat, rounded masses, which are deeply placed and very fixed. Their appearance may be preceded by headache and local pain, and these symptoms are more apt to occur in con- nection with tumors growing from the diploe. These growths are at first of bony hardness, and may well be mistaken for exostoses. In the case of the diploic tumor, the covering of the growth is actually of bone ; in the case of the more superficial growths, there is a covering of tense pericranium. The mass enlarges rapidly, and becomes softer; if it has expanded the bone, egg- shell crackling will be detected at some period. At last, a roundish, tuberous tumor is developed, that feels soft, and perhaps in places almost fluctuating. The skin becomes gradually thinned over the mass, the hair falls off, and in time the sarcomatous material protrudes through the integuments. Often around the edge of the tumor, at its base, a raised rim of bone can be detected, and perhaps portions of the long trabeculae may be felt in the substance of the mass. The growths, as already observed, are apt to be multiple, and to be associated with metastatic deposits. They may attain great size, especially if they occur in parts where facilities are offered for extension. Mr. Toynbee4 records the case of a female, aged nineteen, from whose occipital bone grew a mass that in three years’ time occupied the greater part of the neck on one side. It would appear from the accounts given to have been a spindle-celled sarcoma. Mr. Stanley5 also records a case in which an enormous tumor de- veloped from the vertex in a lad, aged fifteen. It looked like “ an additional cranium growing from the vault of the skull.” The patient died with brain symptoms three years from the first appearance of the disease. At the autopsy, 1 See case occurring in a child aged four. Path. Soc. Trans. 1879. 2 Path. Soc. Trans., vol. ii. p. 232. 1859. 3 Report of Proceedings of Path. Soc., Lancet, Nov. 1879. 4 Path. Soc. Trans., vol. ii. p. 243. 5 Ibid., vol. iii. p. 415. TUMORS OF THE SKULL. the mass was found to have penetrated the bone, and to have spread out over the inner surface of the skull. There is little doubt, from the account given of the microscopic appearances, that this was also a spindle-celled sarcoma. In cases where the growth has invaded the interior of the cranium, various brain symptoms may be produced, such as vertigo, vomiting, severe head- ache, convulsions, paralysis, etc. The prognosis is bad in all cases. Death may occur from exhaustion, or may be consequent upon the suppuration and breaking down of the growth; or from this condition pyemia may ensue, associated probably with thrombosis of the sinuses. In most cases, however, death is due either to brain complica- tions or to the development of metastatic masses in distant parts. The patient may survive for many years. Dr. Ogle1 records a case of what was no doubt sarcoma of the skull that had perforated both tables, where the patient lived for sixteen years after the first appearance of the tumor, lie died of gan- grene of the lung, but during a greater part of the sixteen years had been troubled with epileptic attacks and other evidences of brain disturbance. In the matter of treatment, little or nothing can be done. It is needless to observe that the practice adopted some years ago of recklessly trephining out portions of the morbid tissue, is worse than useless. Heineke2 advises that in quite recent cases, when the tumor is small, and especially when it is of periosteal origin, an attempt should be made to remove the mass by cutting away successive portions of the skull with a chisel. In this way he suggests that the morbid tissue may be quite removed, together with some of the adjacent healthy bone. But, in actual fact, the nature of these tumors is seldom recognized until they have reached a fair size, and have involved an extent of the skullcap not anticipated by Heineke’s operation. Moreover, they are very often multiple. It thus happens that in the majority of cases no operation is to be advised. Carcinoma of the Skull.—Carcinoma of the cranial bonefe is always second- ary. (Heineke.) It is very certain that the majority of the cases of skull cancer recorded by the older authors, were cases of rapidly growing sarcomata. The form of carcinoma that would involve these bones is the encephaloid, and it would appear that the growth seldom attains such dimensions as to form a manifest tumor. Should it form a distinct tumor, the course and symptoms would resemble those already detailed as pertaining to the sarcomata. The progress of the disease, however, would be more rapid, and it would prove fatal at an earlier period. Angeioma of the Skull.—Angeiomata of the scalp may, by a process of extension, involve the subjacent cranial bones. Apart from this mode of origin, however, angeiomata may arise independently from these bones, and constitute distinct affections. They may have their origin from the surface of the bone, but more often would appear to be developed in the substance of the diploe. The affected bone becomes invaded with the vascular growth, and when that growth has origin in the diploe, the cranial plates may become more or less expanded, and replaced by the morbid tissue. The bones most often affected are the frontal and parietal. At the seat of disease, the osseous tissue is seen to be occupied by irregular, cavernous spaces, supplied by a vast number of dilated vessels.3 The mischief is seldom of great extent, although Virchow records the case of an old woman, one of whose parietal bones was almost entirely transformed into a cavernous erectile tumor. If the mass is 1 British and Foreign Med.-Chir. Rev., vol. xxxv. p. 498. 1865. 2 Loc. cit., S. 83. 3 See Fig. 535, Vol. II., page 819, taken from Erichsen, to show an aneurism by anastomosis of one of the parietal bones. 154 MALFORMATIONS AND DISEASES OF THE HEAD. very large, pulsation of a feeble character may be evident. It would appear that these angeiomata, as a rule, cause no trouble, and therefore require no active treatment. It will be obvious that any operative procedures directed against a vascular growth, large enough to cause trouble, would be associated with insurmountable difficulties and dangers if directed against the part itself. On the other hand, it is doubtful if carotid ligature would affect the progress of the growth with any great certainty. Exostoses.—Bony tumors of the skull may be divided into three classes, according to their situation or point of origin. Those that grow from the outer table are termed exostoses, those from the inner enostoses, and those that spring from the diploe of the bone receive the name of parenchymatous exos- toses. Considered with reference to their structure, these growths may again be divided into ivory tumors, compact tumors, and cancellous or spongy tumors. The ivory tumor is by far the most common of these, being, indeed, almost limited to the bones of the head and face; and, on the other hand, if one regards the situation of the mass, the most common growth will be that classed with the exostoses. The causes of these tumors are but little known; some appear to be real new growths, others to be but partial hypertrophies of existing bone-tissue, and very many to be of inflammatory origin. Often, therefore, no cause can be ascribed to explain the production of these tumors. The symmetry which they at times exhibit, and the great number of growths that one skull may present, would suggest some very general cause in some instances. Follin and Duplay1 quote from Hauff, the case of a woman in whom each succeeding preg- nancy increased the size of a bony growth; and the same authors also mention prolonged exanthems of the scalp as a cause of at least one form of this malady. The osteomata of inflammatory origin are, however, easily explained. The great bulk of them are due-to tertiary syphilis—to 411 osteo-periostitis occurring in that affection—while others can he traced to an injury, a blow or a fracture, followed by some inflammatory change in the part. The structure of these masses is simple. The ivory osteoma is, as a rule, made up of concentric bone lamellae arranged parallel to the surface of the tumor, while among the lamellae bone-corpuscles are found, whose canaliculi radiate towards the periphery, as they do in tooth cement. The growth is non-vascular. It has to the naked eye the appearance of ivory, and its white or yellowish-white color readily distinguishes it from the adjacent bone, so that, by these means, an ivory exostosis the size of a pin’s head can be easily detected.2 The spongy tumors have a structure like that of the cancellous tissue or medulla of bone, and are provided with a thin covering of compact tissue. The compact osteoma is intermediate between these two varieties. Its tissue is like that of the compact tissue of long bones. On section it appears porous, and its lamellae are, as a rule, concentrically arranged around vas- cular canals. Its color is so like that of the adjacent bone, that it forms tumors much less conspicuous to the eye, when small, than are the ivory osteomata. O11 microscopic section, these hone tumors are readily distinguished from the ancient bone, owing to the fact that the Haversian canals in the growths are nearly always arranged perpendicularly or obliquely to those of the original tissue.3 In every instance, the adjacent pericranium is continued over the surface of the exostosis. 1 Traite de Path. Ext., tome iii. p. 577. 2 Hewett, Exostoses of Skull. St. George’s Hosp. Reports, vol. iv. p. 3. 1869. * Cornil et Ranvier, Man. d’Histologie Path., tome i. p. 267. 1881. TUMORS OF THE SKULL. 155 Connection.—The parenchymatous growth may assume the form of a dis- tinct or an ill-defined conversion of the diploe into a compact or ivory mass. Usually, however, a tumor is formed which may project externally, inter- nally, or in both directions. Sometimes the connections of exostoses, especially of the larger masses, to the skull, appear to be very slender, a slight degree of force separating the tumor, and separation, indeed, in rare instances, occurring spontaneously.1 As a rule, the inner or outer table, as the case may be, of the affected spot, is lost in the tumor, but in the Musee Dupuy- tren is a skull with a cancellous enostosis, beneath which the inner table is to be traced, distinct and unaltered, between the tumor and the rest of the skull. Sir Prescott Ilewett states that he has seen similar cases.2 Some cranial osteomata may grow from the sinuses of the skull, mostly from those in the frontal bone, but also from the ethmoidal and sphenoidal sinuses. Much has been written as to the origin of bony growths in these parts, but still nothing certain is known as to their anatomical parentage. Certain it is that they form some of the very densest, largest, and most irregular exostoses of the skull; that they may cause terrible deformity ; and that, at the same time, they often possess a singularly frail connection with the main bone. The bone in the vicinity of cranial osteomata may be normal, but it is often unduly porous, and is sometimes thickened. If an exostosis involves a suture, it usually solders the two connected bones together at the spot affected ; but Ilewett3 records a case in which a suture was continuous through the middle of an ivory exostosis, so that when the skull was disarticulated the mass appeared in halves. Seat.—Most exostoses grow from the vault, and most commonly from the frontal bone ; next in frequency must be mentioned the mastoid process, and lastly, the occipital bone. As before observed, the tumors are often symme- trical. A few osteomata have been met with on the base of the skull, and allusion has already been made to those which spring from the sinuses. Number, Shape, and Size.—The number of growths in any given case varies. If very large, the mass is usually single, and this remark especially applies to those tumors which grow from the sinuses. They are very often multiple and irregularly distributed. A skull in St. George’s Hospital Museum shows no less than nineteen exostoses. The shape of these tumors varies greatly. Some are rounded elevations, others assume a conical shape, others are pointed and spine-like, and others most irregular and bossy. Occasionally they have a pedicle, and this may give them a very peculiar outline on section.4 The majority, however, possess a broad base. Their size is equally variable. Some ivory exostoses may be met with as small as little peas; and they commonly do not exceed the size of a hazel-nut. The cancellous tumors are often larger, and may indeed attain a considerable size. The largest bone masses, how- ever, belong to those tumors that spring from the sinuses. Symptoms.—As a rule, these growths, when external, cause absolutely no symptoms, although those of inflammatory origin may be at first associated with vague pains, worse at night and increased by pressure. Their rate of growth is slow, and is measured by years, and they may at any time become stationary. The enostoses may also cause no trouble,* but in some cases they induce brain disturbances, shown by such symptoms as severe headache, con- vulsions, epilepsy, amaurosis, deafness, and partial paralysis. In one case at least (Lecat’s) the patient died of compression, and M. Gayraud speaks of a patient dying with symptoms of meningitis.5 Those near the orbit may 1 See instances quoted by Sir P. Hewett, loc. eit., p. 3. 2 Loc. cit., p. 4. 3 Loc. cit., p. 6. 4 Quain, Trans. Path. Soc. Lond., vol. iii. p. 149. 6 Diet. Encycl. des Sc. Med., Art. Crane, p. 528. 1879. 156 malformations and diseases of the head. grow into that cavity, and cause protrusion or destruction of the globe; or in like manner they may invade, to some extent, the cavity of the nose or pharynx. The exostoses are readily recognized by their bony hardness, harmless character, extremely slow growth, and absolute fixity. The exist- ence of enostoses can merely be suspected, and then only in cases where brain symptoms have been produced. In confirming such a suspicion, the points of most value would be a history of syphilis or of previous injury, the discovery of exostoses on the surface, and a knowledge of the doctrines of cerebral localization. Treatment.—As exostoses are innocent, and seldom cause even mechanical inconvenience, they should be let alone. If any external tumor is large enough to cause mechanical trouble, it will also be too large to remove. If with an exostosis one has reason, from localized brain mischief, to suspect a corresponding enostosis, the part may be trephined if the mass be small; or, in any case—especially cases with a history of distinct previous injury—where the cerebral disturbance is thoroughly well localized, the skull may he tre- phined for suspected enostosis. Many external tumors, some of great size, have been removed from the skull in past times; but such operations must be regarded rather as relics of the barbarian age of surgery. The accounts of some of these proceedings with hammer, chisel, and saw, are fearful to read.1 In all cases with a history of syphilis, appropriate treatment should be adopted. Fungus of the Dura Mater. This term is applied to certain tumors which, springing from the dura mater, in time perforate the skull and appear externally beneath the scalp. Pathology.—Many tumors of various kinds may have their origin in the dura mater, but it is only a very small segment of them that ever make their way through the cranial bones. There are, for example, fibrous, fatty, and osseous tumors of the dura mater.2 These never perforate the skull. On the other hand, growths arising from other parts within the cranial cavity, besides the dura mater, may under certain circumstances penetrate the bone and appear superficially. Thus, sarcomatous growths from the arachnoid may perforate the skull, and Lancereaux3 cites a case of “ lipoma” of the pia mater, in which the intracranial tumor was continuous through a deficiency in the skull with a like tumor beneath the scalp. It is probable that this particular growth was congenital. Carcinoma of the brain also may project externally after having made a hole in the bones that cover it.4 The same may possibly be said of some sarcomata of the brain, and of malignant and sarcomatous growthsfrom the pia mater. All these examples, however, of perforating tumor are ex- tremely rare. It is indeed quite the exception for growths from the brain or softer meninges to penetrate the bone, and thus it happens that in nearly all instances of such perforation the tumor has its origin from the dura mater. Fungus of the dura mater may occur either as a primary, or as a secondary tumor. In the latter instance it is due to metastasis in connection with a like growth or growths elsewhere. In some few instances the growth may 1 In some of these cases the dura mater was freely exposed ; in other instances the surgeon hammered at the patient’s skull for three or four hours at a sitting, and applied the trephine some six or eight times. 2 See for examples, Path. Soc. Trans., vol. vii. p. 1 ; vol. viii. p. 13 ; vol. x. p. 10. Lancet, vol. i. 1872, p. 147 ; vol. ii. 1873, pp. 660, 837, etc. 3 Traite d’Anatomie Patliologique, tome ii. premiere partie, p. 448/ Paris, 1879. 4 Ball et Krishaber, Diet. Encyl. des Sc. Med., Art. Cerveau (Pathologie), p. 439. 1879; Malespine, Thfese de Paris, No. 14, 1846. FUNGUS OF THE DURA MATER. 157 spread to the dura mater from neighboring parts, as for example, from the orbit. The primary tumors are nearly always single, the secondary tumors are not infrequently multiple. Moreover, the growth of the secondary masses is usually more rapid than is that of the primary forms of the disease. Structure.—As regards structure, these growths from the dura mater are sarcomatous. With reference to the primary tumors, I think that this state- ment may be accepted absolutely, but there is some slight and doubtful evi- dence in support of the assertion made by some that certain of the secondary forms of the malady may be carcinomatous. Less recent observers almost in- variably speak of these tumors as cancerous, hut there can be little doubt, from the descriptions which they give, that they dealt with sarcomatous new growths. These tumors indeed have in a marked degree the clinical and physical features that distinguish the sarcomata from the carcinomata. They are, as a rule, well encapsuled; they displace rather than invade the parts around (frequent reference is made to the ease with which they shell out on post- mortem examination); they usually attain a large size before they break down; their rate of growth is usually less rapid than that observed in most carcino- mata ; they seldom induce glandular enlargements; and, lastly, they are often attended by metastasis. All these features are appropriate to sarcoma and not to carcinoma. Lancereaux1 and other observers assert that metastatic carci- noma never occurs in the dura mater, and in, I think, all of the more recent accounts given of the microscopic aspect of these fungous growths, it lias been shown that they were sarcomatous. The following may be taken as examples of the cases that appear to support the view of the possibility of metastatic carcinoma of the dura mater. Dr. Williams2 records the case of a female, aged fifty-six, who had presented a scirrhus of the breast for ten years. For five years she had had “ cancer of the abdomen.” Scirrhous tubercles afterwards appeared on the skin of the chest and abdomen. After certain head symptoms she died. The dura mater presented many round and firm nodules of “ cancer.” In this case the report is hardly full enough, and the long duration of the breast tumor is somewhat opposed to the diagnosis of scirrhus. Dr. Habershon3 reports the case of a female, aged twenty-nine, who had had a scirrhus of the breast that had recurred after removal. She developed fungus of the dura mater. At the autopsy, many nodules were found on the dura mater, and there was besides “ cancer” of the clavicle, ribs, humerus, bronchial glands, liver, and pleura. A drawing is ’given of the microscopic structure of the fungus, showing irregular cells in al veoli. Here the age of the patient is strongly against the notion of scirrhus, and much in favor of the diagnosis of sarcoma of the breast. The extensive metastases also are extremely sug- gestive of sarcoma, and it is striking that there is no mention of any glandular implication in the axilla. Many cases,4 akin to these, have been put on record, and it must be confessed that they do not satisfactorily demonstrate the existence of metastatic carcinoma of the dura mater. It would appear that in a majority of instances this sarcomatous fungus is of the spindle-celled variety. In several cases it has been a round-celled sarcoma (and these are probably the growths mistaken for soft carcinoma); in other examples it has been described as a myxo-sarcoma, a glio-sarcoma, etc. It must not be supposed that even the majority of the sarcomata of the dura mater perforate the skull. The majority do not perforate, but rather 1 Op. cit., tome ii. p. 393. 2 Path. Soc. Trans., vol. ii. p. 163. 3 Path. Soc. Trans., vol. vi. p. 321. * For an account of many such cases, see an Article by Dr. J. W. Ogle, On Morbid Growths of Brain and Cord, etc., in British and Foreign Med.-Chir. Rev., vol. xxxv. p. 486 et seq. 1865. 158 MALFORMATIONS AND DISEASES OF THE HEAD. grow towards the brain and spread out between the dura mater and the bone. Some may grow deeply into the brain. It is obvious, moreover, that such of these tumors as grow from the base of the skull cannot well perforate unless located in certain situations. The course of the perforating tumor is as fol- lows: It commences as a small, round nodule on, as a rule, the outer surface of the dura mater. As it increases, the bone adjacent to it undergoes slow absorption, and in time a bole is made which allows the morbid growth to escape. The boles thus formed are generally roundish, they present sharp and irregular edges, and show usually a greater destruction of the inner than of the outer table. Many older writers speak, therefore, of the bone being carious. In all cases the bone appears to be absorbed, and not to be infil- trated and thereby destroyed by the morbid growth. The tumor itself is well encapsuled, and, as a rule, easily separated, not only from the adjacent parts, but also from the dura mater itself. When the growth has reached the surface, it spreads rapidly over the skull, stretches the scalp, and ulti- mately—if the patient survives—breaks through the skin as a necrosing, sup- purating mass. As a rule, the sarcoma spreads at the same time some way between the dura mater and the hone, and it may in any instance grow exten- sively in the direction of the brain. As regards seat, the true fungus is met with on the vault, and the bones most frequently involved are the parietal, then the frontal, then the occipital or temporal together, perhaps with the great wing of the sphenoid. It may project into the orbit, nose, or pharynx, or may escape through the pterygo- maxillary fossa.1 No cause can in most instances be ascribed for these growths, although very often they have appeared to follow upon an injury.2 In some cases the tumor would seem to have been congenital. Fungus of the dura mater is equally common in the two sexes, and the most frequent period of life for it is between twenty and forty. It has been met with in young children; Louis, for example, records a case in a child, aged two years. Symptoms and Diagnosis.—In most cases no symptoms precede the appear- ance of the tumor, the external tumor itself being the first tiling noticed. In other instances, certain cerebral symptoms are observed as preliminary to the appearance of the growth, and these symptoms may be somewhat severe. They take the form of severe headache, or of violent neuralgic pains about the skull, of nausea or vomiting, of vertigo, of some confusion of ideas. In the severer instances there may be convulsions, partial or complete loss of sight or hearing, and slight muscular paralysis. Before the fungus actually appears above the surface, a soft spot of thinned bone may perhaps be felt, that crackles on pressure. Louis3 records a case in which the discovery of the tumor was made by a barber while shaving the patient’s head. He noticed a faint sensation like the crackling of parchment when his razor passed over a certain spot. In a few days a tumor appeared at that spot. The external growth is at first small, flat, and firm. It exhibits pulsations transmitted to it from the brain, and can usually be reduced on pressure. This reduction makes evident a sharp-edged aperture in the skull, and the act itself may cause sudden pain to the patient, and induce vertigo, stupor, or even complete insensibility. As the mass increases it becomes rounded or bossy, and pre- sents a distinctly constricted base. It becomes also softer and more elastic, and may appear to fluctuate at places. It is no longer reducible, and exhibits no pulsation, although in some instances it may present a feeble pulse due to 1 Sir Wm, Lawrence, Lancet, August, 1853. 2 For instances, see Louis’s well-known monograph rn “Fungous Tumors of the Dura Mater.” Memoirs of the Academy of Surgery. Sydenham Society’s Translation, p. 83. 1&48. * Loc. cit., p. 85 FUNGUS OF THE DURA MATER. 159 its contained bloodvessels, and not to impulses transmitted from the brain. The scalp becomes stretched over the prominent, growing mass; becomes hair- less, thinned, and purplish; and in time perhaps gives way over a soft, fluc- tuating spot. So extensively may the tumor break down, that the linger introduced through the gap in the scalp, may feel the aperture in the skull. From this giving way of the scalp, severe hemorrhage may ensue. The tumor may attain a large size before the skin yields. Louis1 records a case in which the growth was thirteen inches in circumference and seven inches in height, and on removal weighed four pounds and six ounces. Tumors of almost equal size have been noted by others. Sometimes the growth is attended by much pain. Louis imagines this to be due to the pressure of the mass against the sharp edges of the hole in the bone, and cites a case in which the patient found relief from severe pain and grave brain symptoms by lying in the position that caused the tumor to be the least prominent. During the progress of the case there may be cerebral symptoms—such as headache, impairment of sight and hearing, vertigo, stupor, spasms, etc.—but more these symptoms are absent. Louis reports a case in which the tumor was twelve inches in circumference, but in which the patient presented no symptoms of this kind. In the matter of diagnosis, the general features of the case will be such as usually point out a sarcomatous growth. As long as the tumor is small, is reducible, and presents pulsations, little difficulty can occur in the diagnosis. It may in this stage be mistaken for eneephalocele, from which, however, it should be early distinguished by the fact that the hernial tumor is congenital, is restricted as to its site, is softer to the touch, and does not present the com- paratively rapid and deliberate growth of the so-called fungus. Vascular growths from the dura mater are preceded by some injury or disease of the bone (Ileineke), and present, in addition to a strong pulsation in all their parts, a distinct bruit. When the tumor has attained some size and become tixed, and has lost all pulsation, the diagnosis may be more difficult. It can, however, scarcely be confounded with any growth other than a sar- coma of the cranial bones, and the points of difference between these two forms of sarcoma are, I think, well marked. The sarcomata from the bone are harder than those from the dura mater, and are, indeed, often covered with a cap of bone; they show less constriction at their base, and present in that situation very commonly a distinct osseous rim ; moreover, they present in their interior bony trabeculae that can be detected with a tine needle. An incision made, as Ileineke suggests, at the base of the fungus, would show that the edge of the bony gap had no connection with the substance of the growth, as it has in the case of sarcoma arising from the cranium. When the fungus appears in unwonted situations, errors in diagnosis are very prone to occur; and as an example of such I may cite a case reported by Dr. McKenzie,2 of Glasgow, in which the fungus pierced the great wing of the sphenoid bone, and, appearing externally, was mistaken for an enlarged gland. The prognosis in these cases is bad, the malady, left, to itself, being invari- ably fatal. Death is due usually to increasing exhaustion and marasmus, or to implication of the softer meninges and brain. The duration of the disease is very variable ; it may last for years,3 and on the whole does certainly ex- hibit a less rapid growth than do the majority of sarcomata. Some cases are, however, recorded, in which there has been a very rapidly fatal termination. As regards treatment little is to be said. The external tumor should be 1 Loc. cit., p. 112. 2 London Medical Gazette. 1838. * Louis gives a case that existed for seven years, and another in which the tumor remained quiescent for twelve years, and then took on rapid growth. (Loc. cit., p. 112.) 160 MALFORMATIONS AND DISEASES OF THE HEAD. protected from pressure and injury, and sucli general and local symptoms as arise should be met by the usual modes of treatment. If the mass ulcerate, it may be well to destroy the more prominent parts with the actual cautery. This procedure would greatly lessen for a while the suppurative action, and would add to the comfort of the patient. Operations for the entire removal of the mass are not to be advised, for such operations would fall short of their pur- pose, unless with the tumor was excised a considerable portion of the Jura mater. Whether antiseptic surgery can render sucli procedures less fatal than they are at present, remains to be seen. These tumors have been subjected to a vast number of operations of various kinds at the hands of one surgeon and another, and certain of these so-called “modes of treatment” have been of the most horrible and reckless character. Many times have these sarcomata been incised, with in some instances a fatal hemorrhage; many times have they been ligatured, and in a still greater number of cases subjected to the action of some caustic. Of more elaborate operations, the performance of Berard1 may well be taken as a conspicuous example. This surgeon, in an attempt to excise a fungus of the dura mater, made no less than sixteen trephine holes in a patient’s skull. The unfortunate individual lived twenty-four hours. In only three instances have operations for the removal of tumors from the dura mater proved other than rapidly fatal. The patients in these instances were operated upon respectively by Grosmann,2 Peechioli,3 and Orioli ;4 and in each case a cure of the disease is said to have resulted. Intracranial Aneurism. Intracranial aneurisms are not uncommon. They are mostly situated at the base of the skull, about the circle of Willis, and more often affect the carotid than the vertebral segment of that anastomosis. According to Quincke,5 the artery of the fossa Sylvii is the one most frequently affected, being involved in forty per cent, of all cases. The aneurism is apt to be found at the bifurcation of any given vessel. In size these tumors are as a rule small—some are very small; the average dimensions would be from those of a pea to those of a hazel-nut. Tumors of large size, however, have been met with; thus a case of multilocular aneurism of the left posterior cerebral artery, the size of a small apple, has been reported by E. W. Smith.6 Aneu- risms in this situation differ from aneurisms elsewhere in certain respects. In the first place, they do not observe the same restrictions with regard to age, but occur in the young with almost as much frequency as in those more advanced in life. Then again aneurisms elsewhere are—taken as a whole— of much more common occurrence in men than in women, whereas in these intracranial aneurisms, that disproportion is very much less marked. Lastly, intracranial aneurisms appear to be often independent of preceding local changes in the vessels, and are probably due in a majority of cases to embo- lism. They are indeed often found associated with endocarditis and embolic lesions of various parts, especially in the young. In anatomical structure, moreover, they present certain peculiarities, which it is not necessary to discuss in this place. In growing they are apt to press rather upon the brain than upon the unyielding bone, although cases are recorded of absorptive destruction of some of the bony parts of the base of the skull. Their progress is most uncertain, and as a rule very slow. In three-fourths of all cases, a 1 Gazette Medicate, tome i. p. 735. 1833. 2 Stolz, Theses de Haller, tome i. p. 1(19. 3 Gaz. Med. 1838. * Bull, delle Scienze Mediclie, Maggio, 1834. 6 Ziemssen’s Cyclopedia of the Practice of Medicine, vol. vi. page 440. 1876. 6 Dublin Journal of Medical Science, vol. xxv. INTRACRANIAL ANEURISM. 161 rupture of the aneurism is the mode of termination.1 Several cases of spon- taneous cure are recorded. Such are some of the chief facts in connection with intracranial aneurism. It must be owned, however, that (in the present state of our knowledge, at least) these tumors have little concern with practical surgery. This conces- sion must he made with some reservation, and must not include at least two intracranial aneurisms, viz., aneurism of the internal carotid artery, and aneurism of the middle meningeal. These aneurisms will receive separate consideration presently. With regard to the rest—the bulk of intracranial aneurisms—it may be said that they are at present excluded from the pro- vince of practical surgery for a twofold reason. The first of these deals with diagnosis. The majority of these aneurisms have not been recognized until the patient has reached the post-mortem room. In very many cases the tumor has produced absolutely no symptoms, and it has been only when death has occurred from other causes that the unsuspected aneurism has been dis- covered. In other cases, the only symptoms have been those that have im- mediately preceded death, and that have been due to the rupture of an aneu- rism of whose previous existence no evidence had been given. In the most favorable cases, the diagnosis can be little more than con- jectural, and would certainly not be clear enough to justify an operation, even presuming any operation to be proposed*. The existence of a cere- bral tumor may be recognized, but when the nature of the tumor is dis- cussed, and the direct question asked—Is it aneurismal ?—a chaotic district in medical knowledge is exposed, and a positive answer is seldom to be obtained. Immense progress has of late been made in this department of medicine, and no doubt in time this void will be filled up, but at present no basis is afforded for active surgical practice. In the second place, supposing the diagnosis to have been made, can sur- gery do anything to cure or relieve the patient ? At present the answer must certainly be in the negative—bearing in mind that we are quite ex- cluding from these remarks the two special aneurisms already alluded to. Four large vessels enter into the circle of Willis; and so large are their con- tributions, and so free their anastomoses, that ligature of one, or even of two of the supplying trunks, would have but very doubtful prospects of success. Presuming that both carotids were tied, the circulation through the vertebrals would still be too vigorous to allow of much hope of good result. Indeed, I think it may safely be said that these particular intracranial aneurisms are at present beyond the reach of any surgical treatment. It would be foreign to the purpose of this work to discuss the symptoms that might be associated with these aneurisms; such an inquiry would open up a subject of immense interest and great complexity—the diagnosis and localization of cerebral tumors—a subject that is however at present more the concern of the physician than of the surgeon. Aneurism of the Internal Carotid Artery at the Cavernous Sinus.— The symptoms of this aneurism vary somewhat, but, taken as a whole, are fairly characteristic. The symptoms often appear suddenly after an injury of some kind, or, on the other hand, may develop spontaneously, and assume a very leisurely and chronic course. There is usually frontal headache, that is often severe and associated with exacerbations, and that is sometimes located by the patient at the back part of one orbit. In addition, a rasping or sawing noise in the ears—or more particularly in the ear of the affected side—is complained of. With this there is not unfrequently vertigo, and an 1 Ball et Krishaber, Diet. Encyclop. des Sciences Med., Art. Cerveau, p. 448. 1879. __ 1 i 162 MALFORMATIONS AND DISEASES OF THE HEAD. inability to stoop, or to hang down the head. If the patient sleep with the head low, he is apt to be troubled with fearful dreams, and to wake up terri- fied. On the whole, however, symptoms due to brain pressure are not observed with this aneurism, or only to some slight degree—the growth of the tumor, and its injurious contact with the brain, being opposed by the dura mater. Vomiting may occur, but is much less common than it is in other cerebral aneurisms, and epileptic attacks, muscular spasms, gross palsies, and in- tellectual troubles, are all either entirely absent or at least quite exceptional. The special symptoms depend upon lesion of the nerves in the cavernous sinus, the nerves most usually affected being the third and fifth, and then the fourth or sixth. The optic nerve appears to be seldom pressed upon. The special symptoms, therefore, will probably commence with ptosis, dilated pupil, and external strabismus, or with severe neuralgia of the first division of the fifth nerve, associated with photophobia, and sometimes with tempo- rary congestion of the conjunctiva.1 In time, paralysis of the fourth and sixth nerves usually follows, and the eye becomes motionless, but the loss of func- tion in either of these nerves may not occur for a considerable time, as, for example, in Mr. Hutchinson’s case, where the paralysis of the superior ob- lique muscle did not appear until ten years after the commencement of the symptoms.2 As a rule, the neuralgia gives way to numbness of the forehead and some part of the face. The troubles of vision consist usually of loss of accommodation and diplopia. But there may be optic neuritis, and absolute blindness in the eye of the affected side.3 It is unnecessary perhaps to observe that all these pressure symptoms are strictly limited to one side. In addi- tion to these evidences, a very distinct blowing bruit can be heard on auscul- tation over the affected side of the head, more especially about the anterior temporal region; and in those cases in which the cavernous sinus is much compressed, there may be vascular engorgement of the globe with undue pro- minence of the eyeball. This aneurism may undergo spontaneous cure, as oc- curred in the celebrated case reported by Mr. Hutchinson, and just referred to. With regard to treatment, the only operative measure to be advised is liga- ture of the common carotid artery. This operation should not be performed until the diagnosis has been clearly established, and other means have failed to effect improvement. One must also assume that no obstacle to the ope- ration is offered either by the patient’s general health, or by the condition of the main artery in the neck. One such operation has been recorded. It occurred in the practice of Mr. Coe, of Bristol.4 The patient was a woman aged fifty-five, and the operation resulted in a complete cure. Aneurism of the Middle Meningeal Artery.—Aneurisms of this vessel are extremely uncommon, and are usually, if not always, due to injury of some kind. They have a tendency to perforate the skull, and to appear externally beneath the scalp. Before such perforation occurs, the nature of the tumor may be a matter of much uncertainty. The symptoms before per- foration are those due to pressure upon the brain. The patient complains of severe and often well-localized headache, of vertigo, of a constant buzzing in the ears, and of a tendency to faintness, and perhaps to vomiting. There may be moreover spasms in some particular set of muscles on the opposite side, or paralysis of those muscles, or even hemiplegia of the opposite side.6 In 1 See a case recorded by Dr. Humble. Lancet, vol. ii. page 489. 1875. 2 Trans. Clinical Soc. Lond. 1875. 3 J. W. Ogle, Brit, and For. Med.-Chir. Review, vol xxxvi. page 493. 1865. 4 Association Journal, page 1067. 1855. 5 Follin et Duplay, Traite de Patli. Ext., tome iii. p. 584. 1869. chronic hydrocephalus. 163 addition, the patient will probably complain of a pulsation in the affected district, and on auscultation the aneurismal bruit may be heard. When the tumor perforates the skull, the diagnosis becomes much more evident. A tumor appears over the site of some main division of the middle menin- geal artery, it pulsates distinctly, and, if large enough, may give to the fingers a sense of lateral expansion. It feels soft and fluctuating, and has possibly a slight thrill noticeable to the touch. On pressure being applied, the tumor will be found to be reducible, and, after such reduction, the hole in the bone may possibly be detected. This reduction moreover is not apt to be associated with cerebral symptoms. Pressure on the common carotid of the affected side causes diminution, or temporary disappearance, of the tumor, whereas pressure upon the opposite carotid increases the size of the mass. On auscultation, a distinct aneurismal bruit is to be heard over and around the site of the tumor. The diagnosis would also be aided by the history of the case, and by a knowledge of the symptoms experienced by the patient. In one case,1 where a tumor had formed from perforation of the skull, the mass was mistaken for a cyst, and an operation was performed for its removal. Severe hemorrhage occurred from the incision. It could not be checked, and soon led to a fatal result. The only operative treatment appli- cable to these aneurisms is ligature of the common carotid of the affected side. Ivremnitz2 records a case in which this operation was performed for a menin- geal aneurism that had perforated the skull, and had formed a large external tumor. It resulted in a complete cure, the hole in the skull being protected by the application of a silver plate. Chronic Hydrocephalus. This term is applied to a disease characterized by certain accumulations of fluid within the cranial cavity. This fluid may be within the ventricles (internal hydrocephalus), or in the arachnoid sac (external hydrocephalus). Internal hydrocephalus is the usual form of the disease. The accumula- tion of fluid in the arachnoid sac is rare, and, according to some authorities, is merely an accidental complication of the commoner form. Others maintain the independent existence of external hydrocephalus. The disease (considered generally) is as a rule congenital, or appears within the first six months after birth. It may however occur at any time before the sutures unite, or even after that event. Internal Hydrocephalus.—The fluid, as just observed, usually occupies the ventricular cavities, and as a rule all those cavities (viz., the lateral, the third, and the fourth ventricles). The dilatation is not always uniform, and not unfrequently involves one lateral ventricle or one part of such ventricle more considerably than the rest of the general cavity. The affected ventricles become immensely distended, and assume a rounded outline. The ganglia appear flattened out, and the various commissures stretched, or even removed. Owing to the ventricular enlargement, the convolutions of the brain become as it were unfolded, and more or less obliterated, arid the cerebral mass be- tween the ventricles and the surface becomes greatly thinned by the increas- ing distension. In certain severe cases, this brain matter may be reduced to a layer no thicker than one-half or one-quarter of an inch, and instances are recorded in which a mere film of brain tissue has in places bounded the mass 1 Krimer, Journ. des Progres des Sciences Med., tome x. p. 237. 2 Kremnitz, Deutsche Zeitschr. fur Chirurgie, Bd. iv. S. 473. 1874. 164 MALFORMATIONS AND DISEASES OF THE HEAD. of fluid in the ventricular cavities. It is possible for this thin layer to give way, and for the contained fluid to find its way into the arachnoid sac.1 The quantity of dropsical fluid varies from a few ounces to quarts. In appear- ance it is clear, limpid, or slightly yellow, is of somewhat higher specific gravity than cerebro-spinal fluid, and contains but very little solid matter, in the form mainly of albumen and salts of sodium. The cause usually ascribed for this disease is chronic inflammation of the lining membrane of the ventricles, while among less frequent causes are classed excess or deficiency of blood supply to the brain, with the various organic effects that follow such conditions, and certain malformations of the brain and its membranes. Effects on the Skull.—The head enlarges mainly at the expense of its upper and lateral portions. The fontanelles become more open, and the sutures wider, while the bones of the vertex gradually recede from one an- other. The frontal bone is pressed forwards, the parietals backwards and out- wards, and the occipital so much downwards that its vertical part may be- come almost horizontal. The enlargement is seldom quite symmetrical, and the head as a rule becomes conspicuously flattened at the top. The orbital plates of the frontal bone become depressed and oblique in direction, so that the orbits may be reduced to mere chinks. This change in the base of the skull is diagnostic of ventricular dropsy, as it never occurs in cases of external hydro- cephalus. At the same time, it must be remembered that the orbital plate would not be affected in those rare cases in which ventricular dropsy had occurred after consolidation of the bones at the base of the skull.2 At the sides of the cranium, the great wing of the sphenoid and the squamous bones are driven out, the temporal and zygomatic fossse are tilled up, and, if the deformity be severe, an appearance is given to the face as if the cheeks were greatly blown out. The scalp looks thin and tense, is covered with scanty hair, and presents on its surface many prominent veins. Fluctuation may generally be felt in the course of the open sutures, and these parts may sometimes he seen to sink and rise with respiration. With the greatly enlarged head the small and often ema- ciated face is in striking contrast. Owing to the frontal enlargement, the face has a somewhat triangular outline with the apex at the chin. If the orbital plate be much depressed the eyes are unduly prominent, and have an incli- nation downwards, so that often a good deal of the pupil may be concealed by the lower lid. Symptoms.—Enlargement of the head is by no means of necessity the first symptom. Very often—especially in congenital cases—this enlargement is preceded by cerebral symptoms, such as convulsions, rolling of the eyes, squint- ing, paroxysms of screaming, restlessness, etc. The child wastes and be- comes puny and ill-nourished. It cannot well support its head, and prefers to lie down rather than to sit. If it lives until it is old enough to walk, its gait is usually slow and cautious, like that of a decrepit old man; it is fre- quently idiotic, and is apt to be fretful and to exhibit paroxysms of passion. Children thus affected are liable to the brain disturbances already mentioned, and, in addition to these, may become the subjects of spasmodic croup, of muscular spasms in various parts of the body, and of muscular rigidity in one or more limbs. Prognosis.—Death is the usual termination of these cases, and, unless it occurs at or soon after birth, commonly supervenes during the first or second years of life. The immediate cause of the fatal result may be exhaustion simply, 1 Bright’s Reports, vol. i. part i. page 433. 2 Hewett, The Deviations of the Base of the Skull in Chronic Hydrocephalus ; St. George’s Hosp. Reports, vol. i. page 27. 1866. CHRONIC HYDROCEPHALUS. 165 or coma, or convulsions, or even acute cerebral mischief. Some children survive a few years, and some may even attain adult age, but such cases are very rare. In these instances the skull becomes in time solidified by the growth of new centres of ossification in the membranous parts, and by the increase also of the existing bones of the vault. The fluid ceases to increase, but it is doubtful if is ever reabsorbed except under most unusual circum- stances. External Hydrocephalus.—This condition is referred to three causes :4 (1) to escape of fluid from ventricular dropsy ; (2) to congenital atrophy of the brain ; (3) to hemorrhage into the arachnoid sac. Apart from the absence of alteration in the base of the skull, it is doubtful if there are any absolute signs whereby an independent, external hydrocephalus may be diagnosed from the more common form of the disease. All the remarks, moreover, made upon this latter affection may be considered as also applicable to the form now under notice. Legendre2 distinguishes the form due to hemorrhage by the facts that it is never congenital, that the head does not attain the size com- monly seen in internal hydrocephalus, and that it is always preceded by con- vulsions, or other evidences of cerebral disturbance. Treatment of Hydrocephalus.—With the general treatment of hydroceph- alus the present article has no concern. The local treatment that has been proposed in certain cases consists (1) in the application of pressure, and (2) in paracentesis. Pressure to the skull is maintained by means of strapping, or by an elas- tic bandage, the latter being the most suitable appliance. This treatment is applicable to nearly all those cases that are not absolutely hopeless, and that do not show evidence of a rapidly fatal termination. It can be regarded merely as a palliative measure, and may no doubt restrain the increase of the dropsy, at least for a while. The results of the treatment have been unsatisfactory, and for the most part negative. If it has done no good, it has at least done no harm, if exception be made of a few cases in which too vigorous pressure has induced symptoms of compression of the brain, and, in a case of Trousseau’s, even death. The best mode of applying compression by means of plaster, is that advised by Trousseau, who gives the following directions. The plaster should be in strips one-third of an inch broad, and should be applied “ 1st, from each mastoid process to the outer part of the orbit of the opposite side; 2d, from the hair at the back of the neck, along the longitudinal suture, to the root of the nose; 3d, across the whole head, in such a manner that the differ- ent strips shall cross each other at the vertex; 4th, a strip is cut long enough to go thrice around the head. Its first turn passes over the eyebrows, along the ears, and a little below the occipital protuberance, so that the ends of all the other strips shall project about one-quarter inch below the circular strip. These ends are next to be doubled up on the circular strip, and its remaining two turns are then to be passed over them just in the same direction as the first turn.”3 Paracentesis.—Much difference of opinion exists as to the value of this operation for the relief of chronic hydrocephalus, and it must be confessed that the results of paracentesis have so far not been very satisfactory. West4 collected fifty-six cases in which tapping had been performed, and out of this number he considered that cure had followed in only four instances. It 1 West, Diseases of Infancy and Childhood, 8th ed., page 130. 1874. 2 Legendre, Recherches Anat. Path., p. 135. Quoted by West. 3 West, op. cit., page 133. 4 Medical Gazette, April, 1842. 166 MALFORMATIONS AND DISEASES OF THE HEAD. must, in the first place, be allowed that the operation is not in itself danger- ous, and that it is applied to a disease the prognosis of which is extremely grave. This point therefore can he urged in favor of the operation, that it is not likely to do much harm even if it effects little good. There is no doubt, however, that in many cases it has been followed by temporary relief, even if cure has not ultimately followed. The following appear to be the cases most suitable for paracentesis. As a general rule it may be practised in cases of great enlargement, with steady increase. In cases of external hy- drocephalus, it is more likely to be followed by a good result than in cases of ventricular dropsy. It would be inapplicable to cases due to cerebral mal-de- velopment, and it is unfortunate that such cases cannot always be diagnosed, inasmuch as the functional disturbances that accompany the disease bear no constant relation to the amount of organic defect. Paracentesis is likely to fail in congenital cases, in cases associated with preceding acute cerebral dis- ease, and in cases marked by extreme mal-nutrition. Indeed, in such instances, its employment is rather to be condemned. JVlalgaigne1 advises the operation: 1st, in patients under four months old, in whom the disease appears stationary ; 2d, in children beyond that age, but who have not yet reached the period of complete cranial ossification, in whom the disease is increasing and threaten- ing life. The operation should be performed with a very fine trocar, which should be entered in the coronal suture, about one inch from the anterior fontanelle. The instrument should be thrust downwards, and a little backwards. Only a few ounces of fluid should be drawn off at a time, and the operation should be repeated at intervals of from a few days to a few weeks, according to the condition of the patient, and the rate at which the dropsy is increasing. Com- pression of the skull should be maintained, both during and after each opera- tion. Dr. Thompson,2 of Newcastle, reports a case in which two tappings ended in cure. In some instances iodine injections have been associated with paracentesis, but so far with unsatisfactory results. Sir James Paget3 treated a case in this manner, throwing in about three ounces of a solution composed of ten grains of iodine and twenty grains of iodide of potassium to one ounce of water. The child died of convulsions three days after the second injection had been employed. 1 Malgaigne, De la Ponction du Crane dans chronique. Bull, de Therap., tome xix. p. 226. 1840. 4 Med.-Cliir. Trans., vol. xlvii. page 289. 1864. 8 Medical Times and Gazette, vol. ii. page 613. 1860. GENERAL SCHEME OF THE TUMORS OF THE VAULT OF THE SKULL. 167 GENERAL SCHEME OF THE TUMORS OF THE VAULT OF THE SKULL, ARRANGED FOR DIAGNOSTIC PURPOSES. I.—Tumors that Communicate with the Cranial Cavity. [Common features: Reducibility. Pulsation. Increase on expiration. Hole in bone often to be felt. May be cerebral disturbance on pressure or attempted reduction.] A. Congenital. 1. Encephalocele. 2. Meningocele. 3. Hy dr encephalocele. 4. External cephalhcematoma, communicating with an internal cephal- luematoma through a perforation in the bone. B. Not congenital. 5. Fungus of dura mater. 6. Aneurism of middle meningeal artery that has perforated the bone. 7. External venous tumor communicating with the superior longitudinal sinus. 8. External collection of pus communicating with an internal collection through a perforation in the bone. II.—Tumors that do not Communicate with the Cranial Cavity. A. Tumors that pulsate. 1. Aneurism. 2. Arterial erectile tumor. 3. Certain sarcomata of the cranial bones. B. Gaseous tumors. 4. Pneumatocele, the only tumor tympanitic on percussion. C. Tumors with fluid contents. 5. Simple hcematoma, either (a) in substance of scalp; (b)*beneath aponeurosis; or (c) beneath pericranium ; blood may be coagulated. 6. Cephalhcematoma, in infants only ; mostly over parietal bone. 7. Abscess, either (a) in substance of scalp; (b) beneath aponeurosis; or (c) beneath pericranium. 8. Serous cyst, very rare. Hydatid cyst of bone. 9. Certain sebaceous and dermoid cysts, whose contents have softened, may appear to contain fluid. D. Solid tumors. 10. Exostosis, 11. Sarcoma and carcinoma of bone, 12. Dermoid cyst, contents often fluid, 13. Papilloma, deeply seated. 14. Common sebaceous cyst, contents often more or less fluid, 15. Sarcoma of scalp, 16. Solid congenital tumor of scalp, in substance of scalp. 17. Lipoma. 18. Fibroma. 19. Osteoma of scalp (?). 20. Gumma. It must be noted that certain of the tumors in Class I., viz., fungus of the dura mater and meningocele, may cease to present any evidence of communication with the cranial cavity, and that certain tumors in Class II., viz., certain sarcomata of the hone, that have perforated, and some dermoid cysts, may acquire some of the signs that are con- sidered to indicate origin from within the cranial cavity. INJURIES AND DISEASES OF THE NECK. BY SIR G. H. B. MACLEOD, M.D., F.R.C.S. and E.R.S. Eras., SENIOR SURGEON TO, AND LECTURER ON CLINICAL SURGERY AT, THE WESTERN INFIRMARY J REGIUS PROFESSOR OF SURGERY IN THE UNIVERSITY OF GLASGOW ; SURGEON IN ORDINARY TO H. M. THE QUEEN, IN SCOTLAND. Surgical Anatomy of the Heck. The many important structures which exist in the neck give great surgical interest to its affections. It is true that there are few organs which exclusively belong to this region. The most important structures merely pass through it from the head to the trunk. From the vertebral column with the spinal cord behind, to the windpipe in front, there are a vast number of different tissues packed into the small compass which is included under the term “neck.” It is this combination of important bloodvessels and nerves,air and food passages, muscles, lymphatic and other glands, cellular tissue and fascia, which gives special interest to the surgical maladies of this region. The spinal cord, behind, is well protected by its bony case, but in front and on the sides of the neck, lie structures of the greatest importance and delicacy, which are liable to injury by accident or design. The neck varies considerably in different persons, in both shape and length. This is mostly due to original conformation and development, but its appear- ance alters in no small degree, in the same person, with age, state of health, and obesity. Fat tills the hollows in females and in children more than in most adult males, so that the landmarks which define the relations of parts are in them more obscured. Among males, again, the cartilages and muscles have more prominence in some than in others. Persons with high shoulders appear to have unnaturally short necks; and the surgeon may by position so stretch the anterior and lateral surfaces as not only to render them more tense, and thus better prepared for an operation, but also to elongate the part to a considerable degree. The great mobility and rapid movements of the head, and the quickness with which the shoulder is raised on a menace of danger, so conceal the neck as to prove a powerful protection to its structures. It is unnecessary here to dwell in any detail on the different divisions or regions of the neck which are recognized by anatomists. Suffice it to say that its boundaries are, superiorly, the line of the lower jaw, the mastoid pro- cess, and the superior occipital line to the external occipital protuberance. Interiorly, a line from the centre of the sternum, passing along the clavicle by the acromion, to the spinous process of the seventh cervical vertebra behind. Anteriorly, the middle line of the neck, and posteriorly, the centre line from the occipital protuberance to the spinous process of the seventh cervical vertebra, complete the definition of either side. A lateral view, when the parts are put on the stretch by turning the head to the opposite side, is somewhat quadrilateral, and, being divided diagonally by the sterno-mastoid, 170 INJURIES AND DISEASES OF THE NECK. is usually described as forming two triangles. The sterno-mastoid muscle being easily found, and having a close relationship to some of the most im- portant structures, is always a leading guide to the surgeon. There are a few points connected with the anatomy of the neck which it is desirable to epitomize as shortly as possible. Their direct bearing on many surgical affections renders a clear comprehension of them essential. The fascia? of the neck are among the most important of its structures. They inclose, fix, divide, and yet bind together, the various tissues and organs. The most superficial layer is continuous with that of the chest and head, and incloses in its folds various muscles, bloodvessels, and nerves. Attached at various points to bone (jaw, cranium, vertebrae, sternum, clavicle, and ribs), the cervical fascia gives firm support to the structures it incloses. Impor- tant septa pass inwards from the deep layer to be attached to the transverse processes of the cervical vertebrae, from the second to the seventh, and to the two first ribs. These, besides inclosing the roots of the cervical and brachial nerves, divide the deep portion of the sides of the neck into an an- terior (larger) and a posterior region. In each of these compartments, again, each muscle has its sheath, while the great vessels, together with the trachea and oesophagus, are effectively inclosed. From this arrangement both good and harm may arise. Fluid collections, diffuse inflammation, and even new growths, make their way more readily downwards, towards the chest, than either upwards or to the side, and thus a source of much difficulty and anxiety is occasioned to the surgeon, seeing that there may be much obscurity as to the origin and relations of such affections. Growths, etc., lying above the deep fascia are readily dealt with, while those placed below it are often beyond interference. The movability of tumors, though capable of occasion- ing deception as to their connections, is, as a rule, a most valuable guide regarding their relation to this deep fascia. This character, together with the possibility or not of raising them, so as, as it were, to insert the fingers below them, always commands the surgeon’s attention when considering the possibility of an operation for their removal. A triangular portion of the middle layer of the cervical fascia, to which Richet has given the name of “ omo-clavicular aponeurosis,” has been credited by that author with the important office of keeping the great veins 'of the neck open, and so facilitating the return of blood from the head. This struc- ture has its base below, and its apex at the hyoid bone. It lies on either side of the middle line, and to its outer sides the omo-liyoid muscles are attached. These muscles render the fascia tense, and in ‘this way produce the effect above mentioned. The infra-hyoid muscles, the thyroid plexus of veins, together with the lower portion of the jugulars and the other great venous trunks at the root of the neck, being attached to offsets from it, are all power- fully influenced by its degree of tension. The risk of air gaining admission into these vessels when wounded in this dangerous region, is, however, much enhanced by the same mechanism. Fluid forming underneath the fascia, will, of course, be directed with facility into the axillae or mediastina. With the middle line of the neck the surgeon is often occupied, and with its anatomy he should be well acquainted. Below the symphysis we have the supra-hyoid space, which, if opened, will give access to the cavity of the mouth and to the tongue. A longitudinal incision in the middle line will, however, wound no structures of any consequence external to the mouth. Through such an incision Chassaignac passed the chain of the ecraseur, in order to divide the tongue; and Regnoli, making a semicircular incision extending along the border of the jaw, drew the tongue down through the opening, and was thus able to excise its anterior half. Close below the jaw lies a lymphatic gland, which occasionally inflames and suppurates, and if SURGICAL ANATOMY OF THE NECK. 171 not opened may leave an ugly mark. Sebaceous cysts are also met with in this region, and may attain so considerable a size as to project in the floor of the mouth, as well as below the jaw. Hydatid cysts have also occasionally been seen here. Ranula, when large, may cause considerable bulging in the supra-hyoid region. It is not always easy to recognize small fluid collections in this part of the neck, from the softness and pliancy of the structures. By pressing the Anger into the floor of the mouth, close behind the symphysis, the parts will be steadied and the presence of the fluid more easily distin- guished. The hyoid bone, though buried in the tissues, is easily recognized by its resistance and horse-shoe shape. From its floating so much it is displaced with facility. The cornua, passing outwards and backwards, serve as important guides to the surgeon in seeking for the lingual arteries. The submaxillary and sublingual glands, with the surrounding lymphatic glands, the lingual, sublingual, facial, and submental bloodvessels, together with the lingual, hypoglossal, and other nerves, lie in the supra-hyoid region. The hyo-thyroid membrane, with the small superior laryngeal artery (a branch of the superior thyroid, of the external carotid) and nerve upon it, comes next. A wound in this region might implicate the epiglottis. The upper part of the larynx may be reached by an operation, suggested by Vidal and Malgaigne, for gaining access to abscesses in the glosso-epiglottidean folds, or to polypi or foreign bodies not otherwise accessible. A bursa, lies on the anterior surface of the thyro-hyoid membrane, and passes under the hyoid bone. If this bursa enlarges, it will give rise to a small, tense, fluctuating and chronic tumor, which may finally end in a fistula. The upomum Adami,” below this, with its notch at the point of union of its wings, is a well-known landmark on the front of the neck. The projection of this cartilage varies in different persons, and is more pro- nounced in males than in females. By keeping the notch in line with the chin and the supra-sternal hollow, the middle line of the neck is easily re- tained. The thyroid cartilage ossifies comparatively early in some persons. It can be divided with safety in the middle line, for the removal of foreign bodies, growths, etc., but of course any deviation from the central line will cause risk to the vocal cords. A small, serous, subcutaneous bursa lies in front of the thyroid cartilage. Below the thyroid cartilage comes the crico-thyroid membrane. It is slightly depressed, and has a minute artery distributed to it. In this mem- brane the operation of laryngotomy is performed. Next comes the ring-like cricoid cartilage, which is readily distinguished by its greater firmness and resistance. It corresponds in level to the sixth cervical vertebra, and is of great interest to the surgeon in connection with tracheotomy, laryngo-trache- otomy, ligature of the common carotid, cesophagotomy, operations on the thyroid body, etc. At the level of this cartilage also, the pharynx becomes oesophagus, and is at the point of junction so narrow as to be liable to arrest the passage of foreign bodies and instruments. The carotid tubercle on the transverse process of the sixth cervical vertebra, against which the carotid artery can be compressed, is found to the side of and below the cricoid carti- lage. After the cricoid, comes the trachea, wfith the isthmus of the thyroid gland, covering the second, third, and fourth of its rings. The breadth of this connecting bridge varies very much in different cases, being usually broader and more developed in females. In thin persons, the upper rings of the trachea can be traced when the finger is pressed over them. The thyroid lobes, lying upon either side, are not easily distinguished unless enlarged. They rise and fall with the windpipe, and, when increased in size, the superior thyroid arteries can be felt pulsating on their upper and anterior surfaces. 172 INJURIES AND DISEASES OF THE NECK. When there is great hypertrophy or other enlargement of the thyroid bodies, the isthmus may cover the whole of the front of the windpipe, and form a pyramidal body, ascending even to the hyoid bone. Compression of the windpipe, and impeded flow of blood, both in the veins and arteries of the neck, may be produced by the mechanical pressure of the thyroid lobes and isthmus, and so disturbance within the cranium may follow. When enlarged, the bloodvessels in the isthmus may become formidable and dangerous to wound. The trachea gets deeper and deeper as it descends to the chest, and in fat persons may, as it passes behind the sternum, be an inch and a half distant from the surface. The thymus may present itself in young children as a considerable tumor in the supra-sternal notch. In exceptional cases it has been known to rise high up in front of the neck.1 Lymphatic glands, the first of the bronchial chain, also lie above the notch. They occasionally enlarge and suppurate profusely, in young, delicate persons, and as a pulsation is communicated to the abscess by the great vessels which lie close to it, such a swelling has been mistaken for aneurism of the arch of the aorta. A deep and unsightly scar is often left after the healing of such suppurations. If these glands become much enlarged, they may by their pressure produce “ false croup.” The distance between the top of the sternum and the vertebral column, is on an average two inches ; that between the cricoid and the sternum, when the neck is in its usual position, is about an inch and a half; but in paroxysms of dyspnoea, these two points may be closely approximated. In front of the trachea, arranged chiefly in a longitudinal direction, lie the thyroid veins, and, it may be, an anterior jugular vein. Numerous lymphatic glands also exist close to the windpipe. Behind the thyroid veins lies,, in those unusual cases in which it exists, the middle thyroid artery, first described by Neubauer. Originating from the aorta, it passes straight up in front of the trachea to the isthmus, and would of course cause a compli- cation in tracheotomy. The oesophagus, at first placed behind the larynx, comes to be deflected to the left side so that it can be opened clear of the windpipe. Deep in the groove between the trachea and oesophagus, on either side, lie the recurrent laryngeal nerves. They are not disturbed when the oesophagus is reached by Nelaton’s method of keeping close to the trachea in order to avoid the carotids. It may be here noted that neither the shape, consistence, color, nor movements during deglutition, form reliable guides to the oesophagus when it is to be opened on the living subject. It is only by feeling for the foreign body (if one be present), or better still, by passing down a sound from the mouth, that confidence and safety in opening the gullet can be insured. Both the superficial and deep layers of the cervical fascia meet in the mid- dle line of the neck, hut the platysmas (which are inclosed in the fascia) only do so at the upper part. The pre-tracheal muscles lie on either side of the middle line, and are united by the aponeurosis which crosses over it. The windpipe and oesophagus are very movable, both laterally and vertically, in consequence of the loose bed of cellular tissue in which they lie. This freedom of motion is essential to their function, but it increases the difficulty of the operator in dealing with them. The sheath of fascia which incloses the trachea and oesophagus, accompanies them into the chest, so that pus getting access to its interior may pass into the mediastinum. The writer has known a post-pharyngeal abscess to cause death by bursting into the chest. 1 Allan Burns, Observations on the Surgical Anatomy ot the Head and Neck, 2d ed. Glasgow, 1824. CONTUSIONS OF THE NECK. This sheath is connected on either side with that of the great bloodvessels, and in front with the omo-clavicular aponeurosis before alluded to. From all that has been said, it is apparent that tracheotoipy may become one of the most difficult and anxious operations, especially in young children with short fat necks, who have had sinapisms and poultices applied, and in whom the veins are distended from impeded respiration, especially if the thymus be also enlarged. From the tenor of what has been said, it may be inferred that the middle line of the neck, from the chin to the sternum, is the safest place for incisions to be made. The structures become more and more dangerous to interfere with, as we diverge on either side. In all cases in which it is possible, deep ab- scesses lying near the middle line are best got at by an incision in the centre, followed by the use of dressing forceps inserted along the groove of a director, as recommended by Mr. Hilton. Other positions in which incisions can be made with safety, are along the line of the lower jaw and behind the ster- no-mastoid, where, too, the director and forceps should be employed for com- pleting the deeper parts of the incision. Finally, the space which intervenes between the posterior edge of the sterno-mastoid and the anterior limit of the trapezius, is of much interest to the surgeon. It varies considerably in extent according to the development of these muscles. The posterior belly of the omo-hyoid can, in thin persons, be seen like a cord running athwart the neck, nearly parallel to the clavicle. The pulsations of the subclavian artery can also be detected close to the external edge of the sterno-mastoid, which edge again closely corresponds to the outer border of the scalenus, the first guide to the ligature of the subclavian in the third part of its course. The artery can be here com- pressed by the thumb (the surgeon standing behind the patient), or by a padded key-handle or roller-bandage pressed downwards and somewhat inwards, so as to bear directly on the tubercle of Lisfranc. Lastly, the exter- nal jugular vein is visible in many people between the sterno-mastoid and trapezius. As was before remarked, the neck escapes injury in a remarkable manner through the great protection afforded it by the head and shoulder. Yet contu- sions and wounds (homicidal and suicidal), burns, and morbid growths of various kinds, have to be dealt with. In the following remarks, injuries of the spine are not considered, nor are affections of the larynx, trachea, and oesophagus; nor yet the affections and operations connected with the great vessels of the neck, these subjects being all discussed in other articles. Contusions of the Heck. Contusions of the neck, if violent, may cause insensibility, and even death, from shock or spasm. The hyoid bone, or the laryngeal cartilages, may be broken or crushed. It is well known that these structures may be seriously injured by the grasp of a garroter, or by the rope in hanging, or by the passage of a wheel, or by a fall on a pointed body. A violent blow with the fist alone may very seriously injure the larynx,and be followed by dangerous symptoms.1 Fractures of the hyoid may implicate the body or the wings. The frag- ments may be displaced, or not. This accident is said to have been caused by muscular action alone. (Ollivier.) The fragments may project so as to cause a visible deformity. The cartilages may be driven inwards or to one 1 Lalesque, Jour. Hebdomad., Mars, 1833 ; Auberge, Revue Mgdicale, Juillet, 1835 ; Orfila, Medecine Legale. 174 INJURIES AND DISEASES OF THE NECK. side. They have been driven through the mucous membrane, and have occa- sioned severe bleeding. Much bruising, swelling, and pain accompany these accidents, and all movements of the parts or of the tongue, as in articu- lation or deglutition, become both difficult and painful. The trachea has been ruptured and yet no wound has existed externally. (Bryant.) An attempt by manipulation may be made, under chloroform, to restore any displaced fragments, but such measures are difficult and seldom succeed. If replaced, they may be secured by adhesive plaster, or by fixing the head on a pillow, with the neck straight or bent according as the parts are found most relaxed. Easily swallowed food should alone be given, and it may be necessary to use the stomach-pump for alimentation. If there be much laceration, it will be almost impossible to retain the fragments in place. Tracheotomy may be required if there is a threatening of asphyxia, and artificial respiration may be needed to overcome the immediate danger. If an accumulation of air or blood in the cellular tissue cause injurious pressure, an incision in the middle line may be necessary. It has been alleged that the hyoid bone may be dislocated,J but this obser- vation is far from being confirmed. Fracture of the cricoid is a very dangerous accident. It implies much vio- lence, gives rise to shock, convulsive cough, and spasm, and is apt to be fol- lowed such severe inflammation and swelling as to render it generally fatal. Mr. Durham gives a summary of recorded cases from Ilenoque and others. He mentions sixty-two cases in all, of fracture of the bones and cartilages of the larynx, with only twelve recoveries.2 Necrosis may attack the cartilages of the larynx as a result of injury, but more usually it is due to syphilis. Much local and constitutional disturb- ance is thereby occasioned. Though this disease is usually chronic in its course, yet acute symptoms may arise at any time and induce the utmost danger. The portions of dead cartilage may be discharged with the profuse and offensive expectoration, or may cause abscesses which, after dissecting their way far and near, may allow the debris to escape externally. Fistulse may thus be established, and a cachexia which is severe and difficult to deal with. All such pus-collections should be opened as early as possible, their drainage secured, and any dead and detached pieces of cartilage removed. Bronchotomy may be required at any time to relieve spasm and oedema, and this measure may be rendered desirable even to secure rest to the dis- eased parts, and to give time for the employment of constitutional remedies, or local applications, such as medicated air, etc. The sterno-mastoid muscle may become the seat of swelling and effusion, from being strained at birth {congenital tumor or induration3), and one form of wryneck may be due to this cause. Violent twists of the head, falls, and even rapid and strong contraction of the fibres of this muscle, have been known to cause partial rupture in the adult, followed by sudden and dis- tressing pain, together with considerable effusion, necessitating rest, fixa- tion, and fomentations, with subsequent friction, for its removal.4 Burns and Sc alds of the Neck. Scalds and burns are not uncommon in the neck, and, if severe, are attended with serious shock. They occasion much anxiety subsequently from the 1 Gibb, The Hyoid Bone. London, 1862. * See Holmes’s System of Surgery, 2d ed., vol. ii. p. 462. 3 See Myo-sclerosis, page 196, infra. 4 Revue des Sciences Medicates, tome ii. p. 741. 1873. WOUNDS OF THE NECK. 175 inflammation and effusion which are apt to occur within the larynx, together with the contraction and deformity which may follow (See Volume I., pages 715, 723, 739.) Wounds of the IVeck. Wounds of all kinds have to be treated in the neck, and though in their general features they do not differ from similar injuries in other parts, yet from the mode of their infliction—being for the most part homicidal or sui- cidal—from the structures usually involved, as well as from the severe and dangerous complications which may follow, they are especially important and interesting. Many of these lesions are fully dealt with in other portions of this work. In the present article they can be considered but generally and concisely. Suicide by cutting the throat is more commonly attempted in Great Britain than elsewhere, in proportion to other modes of self-destruction. Homicidal wounds of the neck are also not infrequent. All sorts of weapons have been used, and every degree of injury and very various complications have had to be dealt with. That wounds of the neck are frequently seen in military practice, is shown in the official reports of the recent European and Ameri- can wars. Foreign bodies, too, may be buried and lost in the tissues of the neck. Wounds of the neck may be superficial, and uncomplicated by the lesion of any important structure ; or deep (that is, penetrating the fascia), and then they usually involve bloodvessels and nerves of importance. There may be a very extensive division of the soft parts, and yet the windpipe and great vessels may escape; while with a small, external wound, there may be serious, deep injury, the exact nature of which may be difficult to ascertain. It is by con- sidering the nature of the weapon which has inflicted the wound ; the direction and depth of its penetration ; the clothing of the parts at the time ; the nature of what escapes (air, arterial or venous blood, food, or mucus); the effects on the function of the larynx, lungs, oesophagus, and nerves; the occurrence or not of emphysema; and also, in case of an assault, by taking into account the relative position of the assailant to the sufferer, that a judgment is to be formed. In gunshot-wounds, it is seldom that the modern bullet is deflected from its course as the old round ball used to be, but even the conical ball, if much spent and travelling at a low rate of speed, may take a devious and unexpected course in the neck. Large, open wounds are of course easily judged of, as they admit of being examined by the eye and finger. The external jugular vein, from its superficial position, may be injured in comparatively shallow wounds. Pressure will often arrest the bleeding. If not, the vessel should be tied on both sides of the wound. The entrance of air might, of course, prove a serious danger. Wounds of the thyroid body may prove very dangerous from bleeding. The lips of transverse wounds of the neck gape much, but those of longi- tudinal wounds, such as are made by the surgeon, seldom do so. The elastic- ity of the skin and the action of the platysma usually cause the lips of trans- verse wounds to curl inwards, and it is in order to secure their more accurate apposition that sutures have been advised in their treatment. The risk of the drainage proving insufficient, and so causing diffuse inflammation and the bur- rowing of pus, is, in the experience of many, a stronger argument against their use. In most cases, however, the surgeon will be enabled to employ sutures without inducing harm. The most ample provision for drainage is essential, and to secure this it may be requisite to make a longitudinal incision at the 176 INJURIES AND DISEASES OF THE NECK. centre or other appropriate part of a transverse wound, and not to close the more dependent part under any circumstances as long as there is any discharge. If sutures are used, they should he placed close to the edge of the wound ; and adhesive plaster, with careful position, should be employed to support the stitches and keep the platysma at rest. The sutures may be of catgut, horse- hair, or wire, as is thought most appropriate, and antiseptic dressings can be perfectly adapted to superficial wounds, though primary union is not usually got throughout, however desirable it may be to obtain it. The appearance of swelling or erythema, or -any evidence of pressure, will make it necessary to remove the sutures partially or completely. Wounds of the neck which involve the air-passages, great vessels, and nerves, are of course extremely dangerous, and often rapidly fatal. The air-passages alone are not uncommonly involved. The suicide, as has been often remarked, frequently fails in his purpose by cutting high and throwing his head too far backwards. In this position the windpipe is advanced, and the carotids are covered by the sterno-mastoids, which become tense. When, on the other hand, the wound is inflicted lower down, the resistance of the laryngeal and tracheal cartilages, the spasmodic contraction of the sterno-mastoid muscles, and the greater depth at which the carotids lie, frequently save those vessels from being wounded. Mr. Hilton suggests that when the air-passages are opened below the glottis, and air escapes from the lungs, the muscles con- necting the chest and arms are so weakened as to diminish their power of action. The carotid arteries have been laid bare by the suicide, and yet not opened, and well-authenticated cases have been recorded in which both the trachea and oesophagus have been wholly divided, and yet both the caro- tids and jugulars have escaped. Very free bleeding may attend wounds of the forepart of the neck, and prove highly dangerous to weak patients, even although the great bloodvessels be not wounded. There are also many irregularities and abnormalities in the size and distribution of the blood- vessels in this region, which may render wounds especially dangerous. If the carotids are wounded, rapid death will probably ensue, unless faint- ing occur and give time for surgical aid, or the irregularity and narrowness of the wound prevent the rapid escape of blood. No doubt, if skilled help were at hand, death might in some cases be warded off by pressure, followed by ligature of both ends of the artery, or by ligaturing the lower end and compressing the upper, as may be seen in cases related by Larrey and Hodgson. The former lias recorded instances in which the liga- ture of the main vessel on the proximal side alone, succeeded in arresting hemorrhage, but this must always prove a most unsafe proceeding, and that it fails in practice is shown by the cases related by Breschet in liis notes to Hodgson. Compression can with some success be applied to the common carotid, but as there is no firm point of support behind the external and in- ternal carotids, there is little use in attempting it in wounds of these vessels. Wounds of the great veins of the neck are particularly dangerous, not only from hemorrhage but from the risk of admission of air." The free anastomosis between these vessels greatly favors bleeding. The occlusion of one of the jugulars is not without danger from inflammation occurring within it, and also from the disturbance which follows in the circulation within the head. It is in the later stages of the operation of excising growths that the jugulars are most apt to be wounded, when the tumor is drawn forwards in order to divide its posterior connections, and any adherent veins are in this way put upon the stretch. A part of the vein may be thus excised, and air may rush in with an audible sound, rapidly occasioning the utmost danger. I have twice witnessed this accident, but the danger in each case was overcome by rapidly applying pressure, followed by ligature of WOUNDS OF THE NECK. the wounded vessel. The hissing, sucking, or whistling sound, as it has been variously described, is quite peculiar and distinctive, while the sudden blanching of the face and tumultuous action of the heart which follow, but too surely indicate what has occurred. Such an occurrence may follow wounds of any of the great veins in the “ dangerous region” at the root of the neck, but it has been most often seen in the jugular, subclavian, and axillary veins. A large opening is not necessary. Eriehsen1 relates a case in which 'entrance of air took place, and was followed by death, during the passage of a seton into the forepart of the neck, and Le Gros Clark has shown that the air may be so slowly drawn in by the orifice of a half-divided, small vein, as not to evidence itself at the wound by the usual signs.2 In narrow wounds, where the opening in the vein and that in the soft parts have lost their par- allelism, the neck may be extensively intiltrated. Pressure should in all such accidents be at once applied, till the vein is tied above and below the wound. It is better to tie the vessel completely, even though its calibre be but partially divided, rather than pick up the orifice alone in the hope of not obstructing the vessel, as was at one time recom- mended. In an elaborate study of the subject, Professor S. W. Gross has with his usual ability dealt with these lesions of the great veins.3 When the thyroid body is wounded the bleeding may be very profuse, and difficult to arrest from the very free anastomosis which exists between its vessels. Both arteries and veins bleed violently, the veins especially, if the respiration is embarrassed. To tie these vessels is very difficult, and pressure cannot be borne. In some cases it might be possible to pass a needle under the bleeding point and apply the twisted suture. The various nerves of the neck, especially those connected with the arm, may be involved in wounds. Bullets have frequently injured the cervical nerves, and paralysis with wasting has followed. The pneumogastric and phrenic nerves may also be cut, when the carotids are divided, and bullets have occasionally injured both these nerves as well as the sympathetic, though few such cases have been described in detail. The most common position for suicidal and homicidal wounds has been made the subject of statistical inquiry. They have been most commonly seen at or about the thyro-hyoid membrane, or a little below it.4 In assaults, the chin being depressed has protected the upper part of the throat. Gunshot wounds may, however, occur anywhere, and portions of the throat may be in them even torn away. Wounds in the supra-hyoid region may open the cavity of the mouth, wound the root of the tongue, and partially or even wholly detach the epiglottis. Suffocation may be caused by the entrance of blood or other matters into the air-passage, or by the epiglottis or the tongue occluding its orifice. Swelling and oedema, which usually follow, may also occasion danger. The facial and lingual arteries with the hypoglossal and other nerves, may be injured in such high wounds, and fatal bleeding may follow if efficient surgical aid cannot be obtained. These vessels can, however, be readily ligatured. In wounds lower down, besides the windpipe, the ary- tenoid cartilages and vocal cords, and the aryteno-epiglottidean folds, may be involved, with the lingual and superior thyroid arteries, the superior laryn- geal nerves, and even the carotids. 1 Science and Art of Surgery, 5th ed., vol. i. p. 418. 2 Lectures on the Principles of Surgical Diagnosis, etc., p. 225. London, 1870. 3 American Journal of the Medical Sciences, 1867. 4 Durham, in Holmes’s System of Surgery, gives a summary of 158 unselected cases, from which it would appear that 45 of the wounds were through the thyro-hyoid membrane, 35 through the thyroid cartilage, 26 through the crico-thyroid membrane or cricoid cartilage, 41 into the trachea, and only 11 above the hyoid bone. Horteloup and Sarazin have also published statistics upon this point, but the teaching from these figures is of little moment. 178 INJURIES AND DISEASES OF THE NECK. When the epiglottis is divided, besides the danger of suffocation, the speech, respiration, and deglutition, will be affected, and the latter perhaps rendered impossible by spasmodic cough. A wound in this region gapes more or less, and the food (especially liquids) will probably escape. If the thyroid vessels, jugular veins, and thyroid body are involved, the hemorrhage will be very profuse and probably fatal. The recurrent laryngeal nerves may also be implicated. Thirst is a frequent, though not universal, complaint in these wounds, and there is great risk of serious complications such as diffuse cellulitis, producing great swelling and oedema, and attended with great constitutional disturbance. The edges of incised wounds are often very irregular, from the skin not having been stretched at the time it was cut. Suicidal wounds are especially apt to be attended by serious complications, on account of the state of health of the patients who are their subjects. Such wounds are frequently indicted during a period of temporary insanity caused by intemperance, when the whole system is out of order. The air-passages have been wounded in every possible way, and with wounds of the most diverse descriptions. Every species of wound has been met with, and foreign bodies of many sorts have been driven in from without. The records of surgery supply a curious collection of such accidents. The surgeon makes his incisions in the axis of the windpipe, but homicidal and suicidal wounds are usually more or less transverse. Suicides sometimes so hack and cut the throat that portions of the carti- lages may be wholly detached and removed, as occurred in an extreme degree in a case under my own care. These wounds may be very irregular, and attended with much laceration of the soft parts. If the larynx or trachea are only partially divided, the wound will not gape much, but if the division be complete (which is not common), the separation of the lips may be very considerable. The oesophagus may be severed as well as the air-tube, by one stroke of the knife. I saw this lesion in the case of an intemperate surgeon who com- mitted suicide, and who, from notes found among his papers, had evidently studied the subject carefully. The whole of the tissues on both sides of the neck, including the great bloodvessels, were divided, and even the spinal column was marked by the blade of a long, sharp amputating knife which he had used. When the wound is sufficiently deep to implicate the air-pas- sages, the complications which may occur early or late are gaping, bleeding (which will vary with the direction and extent of the wound), and the escape of air and mucus, and possibly of alimentary matters, if the wound be high in the neck. Aphonia and various alterations of the voice, together with difficulty of breathing and emphysema, may also be present. The latter condition will appear when the orifice is so narrow as to allow the air more readily to penetrate the cellular tissue than to escape externally, arid in that case it may possibly extend far and wide, especially downwards along the trachea and oesophagus into the mediastinum, and, according to Horteloup, it may even reach the scrotum. Death will be rapid if the great bloodvessels are largely opened, but when the wound is small, life may be saved by fainting. Second- ary hemorrhage, days or weeks afterwards, may end life. Effusion into the glottis and cellular tissue is one of the menacing dangers, especially in narrow wounds. The whole interior of the air-passages, from the glottis to the minute divisions of the bronchial tubes, may become involved, as well as the substance of the lung itself. This may be due to the mere extension of the inflammation, or to the admission of cold air, or of foreign bodies. Suppuration too may eventually arise at the wound, and pus may dissect its way far and near in the cellular tissue of the neck. If recovery from these conditions follows, permanent contraction of the air-passages, with WOUNDS OF THE NECK. 179 aphonia and fistulous orifices, is likely to remain. There are a few instances in surgical literature of the entire obliteration of the upper part of the larynx, and that too without the entire loss of the voice. In these rare cases, the air has gained admission to the vocal cords by the external wound. Suffocation may, however, threaten, from the contraction of the passage and the adhe- sion to surrounding parts preventing movement. Fistuhe (which under ordinary circumstances are not common) are, for the most part, due ter loss of substance, or to such gaping of the lips of the wound as treatment fails to counteract. They are very difficult to repair. It may he here said that spontaneous rupture of the trachea during violent fits of coughing has been said to occur, but the fact is somewhat doubtful, and is of too little practical interest to be dwelt upon. Bullets, poniards, etc., may reach the pharynx or oesophagus, either through the mouth or by the side of the neck. Jugglers have fatally wounded them- selves in passing swords down their throats. Mr. White relates a remark- able case in which a navvy fell backwards upon a small, sharp pick, which penetrated his neck, and, passing between the carotid vessels, pierced the pharynx immediately behind the posterior pillar of the fauces. The man made a rapid recovery.1 Insane persons have inflicted serious wounds on these parts through the mouth ; and bougies, forceps, etc., used by surgeons, have caused laceration and rupture. Even violent vomiting is said to have ruptured what appeared to have been a sound oesophagus. Punctured wounds in which both the air-passages and oesophagus have been penetrated, are uncommon, yet in deep transverse or oblique wounds they may both be in- volved. Wounds of the pharynx and oesophagus are said to occasion pain, spasm, hiccup, dysphagia, thirst, and a feeling of constriction amounting almost to suffocation. The escape of alimentary matters is not constant, and its occur- rence does not necessarily show that the food-passage has been opened. If the glottis, as the result of swelling or diminution of its nerve supply, loses its sensibility, as it occasionally does in the later stages of wounds of the air-passage, it may no longer act as a barrier to the passage of foreign bodies, and thus food may gain admission into the windpipe and appear at the wound ; but although the escape of alimentary matters is thus not diagnostic of a wound of the pharynx or oesophagus, yet it is in any case a serious symp- tom, as it implies a grave lesion. Wounds of the back of the neck may either involve the soft parts alone, or penetrate into the spinal cord. In the latter case they are quickly fatal, but in the former they may be very extensive, and yet not cause death.2 The difficulty in dealing with deep and extensive flesh-wounds in the back of the neck, is to keep the head fixed in a good position and to provide effective drainage. The well-known observations of Larrey, as to atrophy of the testicle and paralysis of the lower limbs following such wounds even when the brain and cord have apparently escaped, have not been verified by more recent experience. In France, it is said that infanticide is occasionally accomplished by insert- ing a needle between the axis and atlas, a mode of murder very difficult to detect. The prognosis of such wounds of the neck as are not rapidly fatal, is not always easy. The part wounded and the depth of the lesion are often more important than its extent; but the opinion formed of the result will in all 1 British Medical Journal, vol. ii. p. 146. 1876. 2 See Legouest, Traite de Chirurgie d’Armee ; Surgical History of the War of the Rebellion ; and the author’s Notes on the Surgery of the War in the Crimea. 180 INJURIES AND DISEASES OF THE NECK. probability chiefly turn on the complications which may exist. All wounds in this region are of course liable to the same accidents as similar injuries else- where, but they have, besides, special dangers of their own, and even slight wounds may become the source of the utmost anxiety. Inflammation followed by extensive and rapid effusion may arise at any time and occasion the utmost danger. The great risk is interference with the breathing, and it has been shown how many conditions may cause this either early or late. Small wounds of the air-passages are sometimes more dangerous than large ones, from imperfect drainage. The weak and irritable condition so often present in suicides, insane per- sons, and the old, renders their wounds more liable to complications. Per- sons suffering from delirium tremens, as is well known, are peculiarly apt to suffer from low inflammation and rapid exhaustion. That, however, there is always hope of recovery even in the most desperate cases, is amply shown by the records of surgery. Many instances exist of recovery following the most extensive, and, at first sight, hopeless-looking wounds, and this some- times in most unpromising patients. When the bleeding can be stayed and the breathing kept free, we need never despair. As to the treatment of wounds of the neck, it is manifest that the leading indications are to command the bleeding, secure free respiration, and overcome shock. To accomplish these ends, the same measures are employed here as in other wounds, and do not call for detailed remark. If, in order to fulfil these purposes, it be requisite to enlarge th.e original wound, the surgeon must not hesitate. To secure all the wounded bloodvessels may not be easy, and requires much precious time. A ligature should be applied to both ends of divided vessels, and upon either side of punctured wounds. In narrow, deep wounds, the difficulty of carrying this out is very great. Pressure is almost impossible to apply effectively, even in superficial wounds. Pressure-forceps, if quickly applied, will, however, be of much service by giving time for the application of ligatures. The entrance of blood into the windpipe must be carefully prevented, and if necessary a large tracheal tube must be inserted, and the space round it closed by plugging. The trickling of blood into the air-passages will, in a weak or fainting patient, readily occasion slow and insidious suffocation. Hemorrhage from small veins is best arrested by keeping the respiration free. Other sources of embarrassed respiration, such as the semi-detached tongue, or epi- glottis, or cartilage, must be attended to. If dangerous emphysema arise, it may be necessary to enlarge small and narrow wounds ; but otherwise, unless there be bleeding or deficient drainage, they are best left alone. The use of sutures in wounds of the throat, has given rise to much contro- versy. Their careless employment has occasioned so much harm as to have led to their general condemnation. Modern surgery, however, does not so rigidly exclude their use in all cases as was done some years ago. It is true, and cannot be too strongly insisted on, that if the breathing, or drainage, be in any way obstructed, or emphysema caused, by their presence, then noth- ing but harm and danger can come from their use. Good and not evil will, however, follow by approximating the lips at the ends of long wounds by a few stitches, so as to counteract the great gaping, and this will be the more necessary if the trachea be entirely divided, and if it retract much, as it is apt to do. It is seldom that the larynx or trachea themselves require to be stitched, and when that has been attempted, good results have rarely followed. It is the centre of the external wound which it is of most consequence to leave open, and if at any time indications of deficient drainage or imprisoned air appear, any stitches which have been introduced should be removed. The WOUNDS OF THE NECK. 181 head should be fixed in such a position as may promote the approximation of the lips of the wound, and relieve tension, wliile not interfering with the escape of discharges. There are various methods of accomplishing this. Put- ting a night-cap on the head, and attaching it to a body band by tapes, while the head and shoulders are raised, serves the purpose in most cases. All speak- ing and movement, as in swallowing, should as much as possible be avoided, and watchful nursing is essential, especially in suicidal cases. Sutures may be used to unite wounds of the oesophagus, if position fail to approximate the divided parts. Drainage must of course, in all cases, be carefully secured. In the early stages of treatment, deglutition should be avoided as much as possible, and for this purpose we must resort to the use of carefully prepared enemata. A tube may be passed into the stomach either by the wound or by the mouth, but as soon as cicatrization has begun the former method must be avoided. In any case it is bad practice to leave the tube in place, and if its passage cause much inconvenience, enemata must alone be relied on. Legouest suggests a method of passing the oesophageal tube by first introducing a small urethral bougie by the wound into the lower end of the oesophagus, and attaching to its upper extremity, by means of a small sound passed from the buccal cavity downwards to the wound, a long thread which is brought out by the mouth, and then using the thread and bougie as a conductor for the oesophageal tube. During cicatrization, the calibre of the canal must be retained by a careful and judicious use of bougies. Thirst is a serious annoyance in such cases. Small bits of ice put on the tongue relieve it, but have the disadvantage of causing frequent acts of swallowing. As soon as healing has well advanced, unirritating fluid food may be allowed. If there be much exhaustion, milk, broths, and other forms of concentrated nourishment must be administered. The air respired should be moderately warm and moist, without being exhausting. A temperature of between 70° and 80° Fahr. suits best. The entrance of foreign bodies must be prevented by covering the wound with moistened muslin. If dyspnoea occur, its exact cause must be sought for and remedied. The base of the lungs should be frequently and minutely examined. By temporarily closing the wound, the patient will be enabled to eject fluid which he cannot otherwise get rid of. Inflammation in any part of the air-passages, lungs, or pleurae, must be constantly watched for and promptly treated. It may come on very insidiously and spread rapidly. (Edema of the glottis is a most serious complication. It may be dealt with by the usual remedies, or by introducing one of the tubes described by Dr. McEwen. The healing of the wound must be supervised, and exuberant granulations, if they occasion obstruction, repressed by appropriate* means. Restlessness and excitement may require to be combated by the subcutaneous use of morphia. Tracheotomy low down in the tube may be reasonably considered when the wound is more than usually difficult to manage, especially if signs of obstruction follow its closure. The rest thus gained will promote the healing of the wound, and the dilatation of a contraction following the cicatrization will be better managed from below than by passing instruments from the mouth. In some cases the laryngoscope may prove serviceable in dealing with such contractions. Abscesses, if they form, must be effectually drained. Schrotter proposes to render the larynx insensible by the application of a saturated solution of acetate of morphia, after having first increased the capability of absorption of the membrane by touching it repeatedly with pure chloroform. This is done the night before an operation is to be per- formed. An hour should elapse between the applications of the chloroform and the morphia. 182 INJURIES AND DISEASES OF THE NECK. Abscesses of the Neck. Abscesses of the neck of various kinds (acute and chronic, circumscribed and diffuse, superficial and deep) are common from the large amount of cellular tissue present in its structure.1 Abscesses may be due to many causes, such as injuries and diseases in the soft parts, or bones, or glands ; affections of the sockets of the teeth (especially the last molars), of the pharynx, oesophagus, air-passages, and thyroid body ; irritation any where over the scalp, in the ear or the cavities of the face, "in the tongue, etc. The most serious abscesses are perhaps those which occur in the course of low fevers. They are not infrequent during scarlet fever, measles, and smallpox. The scrofulous diathesis is always a powerful, predis- posing cause. Purulent collections in the neck make themselves known by signs similar to those which appear in affections of a like kind in other parts, but they are remarkable from the great swelling, oedema, and tension, together with the embarrassment of function which they occasion. The effects produced will vary with the position of the pus as regards the cervical aponeurosis. If it be superficial to the fascia, it will usually be circumscribed, and come quickly to the surface; but it may fill the whole side of the neck, extend to the clavicle, and even descend in front of the chest. When deep, the pressure-effects may be very serious. Abscesses rarely form in the nape of the neck, though occasionally they arise there in connection with the glands. From being firmly bound down they occasion great pain, and take long to come to the surface. Fluctuation is not easily recognized. They should be opened early. Inflammation of the gland below the chin may cause great swelling, in- vading the floor of the mouth. Mastication and deglutition are embarrassed by the pain. By pressing down the floor of the mouth with one finger, so as to steady and render tense the swelling, fluctuation can be more easily made out. The pus generall}7 points under the chin, but it may pass backwards towards the pharynx, or downwards along the windpipe or great vessels even into the chest. Alterations of voice, and inflammation within the air- passages, may result from pus formations in front of the larynx. The sheath of the sterno-mastoid may be filled with pus so as to render its movements both painful and difficult, and one species of wryneck may arise from the contraction caused by inflammation of this muscle. The great sources, how- ever, of cervical abscess, are the lymphatic glands so numerous in this region, and so liable to irritation. Though occasionally no explanation, unless it be a state of depressed health or cold, can be found for these glandular affections, yet as a rule, if carefully sought for, evidence will be found of irritation, somewhere in the wide circuit of the lymphatic vessels leading to these glands. The worst form of cervical abscess arises when the cellular tissue becomes involved after injury or after scarlatina. The whole side of the neck may become one hard mass, which slowly suppurates and causes extensive destruction. Violent and fatal bleeding may follow in these cases, even days after the abscess has been opened, and constitutes one of their most serious complications. Persons of enfeebled health are most liable to these formidable affections, and their lives may be placed in great jeopardy by the pain, fever, pressure-effects, and prostration. Serious complications too may follow. Beside the pressure on the bloodvessels, nerves, air-passages, and oesophagus, there may be sloughing and ulceration, with serious and 1 See Yol. IV., page 524 et seq., for those connected with the vertebrae. ABSCESSES OF THE NECK. 183 even fatal hemorrhage ; diffuse inflammation, passing far and wide even to the chest and axilke ; thrombi in the great vessels, with embarrassment of the circu- lation in the brain and lungs; and, above all, blood-poisoning.1 Cervical abscesses, if placed near the great vessels, may receive a trans- mitted pulsation which will cause the surgeon to hesitate as to their diagno- sis from aneurism, especially as they cannot always be raised up or pushed aside so as to be freed from the influence of the vessel. The distinction is to be made by observing the difference in clinical history of the two cases, and the ages at which they occur; the pulsation is not expansive, nor as distinct as in aneurism, and the swelling is less defined in its outline, and more superficial and diffused. In abscess, too, there will be signs of previous inflammation, probably involvement of several glands, and of the skin, and the existence of fluctuation. If an aneurism have burst into an abscess, then the difficulty of recognizing the true condition of affairs will be greatly increased. Post-pharyngeal abscess will demand consideration in the article on affec- tions of the throat. Suppuration rarely occurs in the thyroid body, but, when it does, it mani- fests itself by the usual signs of local inflammation, accompanied by much constitutional disturbance. It is attended by much swelling and oedema of the neck, and the pressure-effects are considerable. The thyroid may even undergo sphacelation and be destroyed, and that without necessarily pro- ducing fatal results, nor even much inconvenience from its loss. Pus placed deeply in the neck may be very difficult to distinguish clearly. Fluctuation may not be recognizable, from the slight resistance of the sur- rounding parts, and from the firm way in which the pus is bound down. Elasticity alone may be present, but the cedema, diffuse redness, and pain, form important guides to diagnosis, unless the abscess he of small size and very deeply placed, when neither redness of the surface nor swelling may be marked. Chronic abscesses of the neck are almost always of constitutional origin, or the result of degeneration of the glands, or of disease of some of the bones or cartilages. Sometimes these pus-collections are “ residual,” or the result of former inflammatory action which has left its products behind to remain quiescent for a time, and to recover their activity when the general health has from any cause become deteriorated. These abscesses are of very slow progress, and are important chiefly from the evidence which their appear- ance gives of weak, local and general conditions. They are often attended by very little disturbance. They may burst by several small openings which become either troublesome sinuses, or the starting points of ulceration which spreads and is difficult to repair. From the absence of much pain, and from the slow formation and advance of these pus-collections, they might be mistaken for cysts or other tumors; but a regard to the diathesis of the patient, the clinical history of the affection, and the probability of other abscesses of a similar nature having existed, together with a careful examination of the local condition, will indicate their character. Unhealthy children who have been exposed to bad hygienic surroundings are the most common subjects of these abscesses. Treatment.—It will of course be most important to prevent the formation of pus, by removing, if possible, the irritation or cause, local or constitutional, upon which it depends, and by the use of such local antiphlogistics as may be required. In some cases counter-irritants, in the form of embrocations con- taining iodine, or even of blisters used for short periods, as recommended by 1 Gross, Amer. Jour. Med. Sci. 1871. 184 INJUKIES AND DISEASES OF THE NECK. Velpeau,1 may be of use, but tjiese are in the majority of eases more than doubtful remedies, unless it be in the later stages, to remove the chronic hardness which may remain. When pus has formed, the sooner it is evacu- ated the better. Its presence can only do harm, and it is best got rid of by such a free incision as may, if possible, obviate the need of repeating the operation or of using drainage tubes, or of any squeezing or handling after- wards. The abscess should be opened antiseptically, and its drainage care- fully attended to. Capillary punctures can only be of use in the case of very limited collections. Their supposed advantage is the avoidance of a scar, but this is frequently illusory, and as a rule they are very unsatisfactory, and give much more annoyance by the necessity for their repetition than by any good which they can produce. The use of the aspirator, hypo- dermic syringe, trocar, or grooved needle, vaccination, and the introduction of setons of linen, metal, catgut, or other threads, capillary tubes, etc., are all ineffective, and are apt to cause greater subsequent evils than a free, clean cut. Deep abscesses require careful management. The plan of opening them recommended by Mr. Hilton is a great improvement on the ordinary method. After incising the superficial and less important parts, a blunt director is carefully pushed down through the tissues, separating without cutting them ; when the pus is seen to well up along the groove, a pair of dressing forceps is pushed in with the blades closed, and when within the cavity these are expanded, so as to enlarge the opening to the necessary extent. In incising the structures, if the knife be used, they should be carefully and slowdy divided layer by layer, so as to allow of their being recognized as we pro- ceed. Advantage should be taken of all natural shadings in the skin so as to reduce subsequent scarring to the last degree. Of course these abscesses should be opened at their most dependent part, and sufficiently freely to pro- vide for drainage. Ghassaignac2 and more recently Professor Marshall have shown how easily and safely deep abscesses at the side of the neck, below the deep fascia, may be evacuated by an incision in the middle line in front of the trachea, and how far back we can seek for the pus by keeping close to the windpipe. Incisions may also be made behind the sterno-mastoid, as well as along the base of the lower jaw-bone. The cavity of large abscesses may have to be washed out with a weak solution of carbolic acid or iodine, but great care must be taken not to force any of the fluid so used into the cellular tissue of the neck. Sinuses too may require to be split up in order to pro- mote their closure, and indurations may need to be got rid of by blisters, colorless iodine, or mercurial embrocations, while constitutional treatment will also in most cases be required to strengthen the system and improve the nutrient qualities of the blood. Fistula: in the Neck. Cervical fistulse may be either congenital or acquired. 1. Congenital fistulas, called “ branchial” by Heusinger, were errone- ously called tracheal fistulse by Dzondi, who first drew attention to them in 1829. Ascherson3 first ascribed the affection to its true cause, viz., an arrest of development in the closure of the pharyngeal fissure or cleft. The closure of the branchial arches, which terminates about the end of the second month of foetal life, will, as is well known, if arrested, give rise to various con- 1 Graz. M§d., Arril, 1871. 2 Graz, des Hopit. 1843. 3 De fistulis Colli. 1832. FISTULA? IN THE NECK. 185 genital deficiencies, of which cleft palate, hare-lip, and deformities in the ear, form a part with these fistulous orifices.1 These fistula usually com- municate with the pharynx, though in rare cases they are found to open into the trachea or larynx. Though usually present at birth, they have been in some cases apparently overlooked, or at least not brought under medical observation till the patient has attained adult life. They have been found in several cases to be hereditary, occurring in several generations, and, in one case, affecting five children out of eight. They have been usually seen on the right side of the neck, behind or in front of the sterno-mastoid muscle, some- where* between the thyroid cartilage and the sterno-clavicular articulation. In rare cases they have been seen as high as the angle of the jaw. More rarely they have been met with in the middle line, or on both sides, in corres- ponding positions. They may be complete, that is, communicating wfith the external surface and the pharynx, or incomplete in so far that no internal opening can be found. Authors have also spoken of such fistulse having an internal and no external orifice, though there does not appear to be good reason for such a statement. Generally they are very small, admitting a probe with difficulty, but they have been seen large enough to permit the intro- duction of the point of the little finger. The external orifice is occasion- ally found upon a small projecting mass of granulations, or it may be con- cealed under a fold of the skin. A thin, viscid fluid containing epithelial cells distils from the orifice, or can be expressed from it. This discharge is occasionally purif'orm, and may concrete so as to close the orifice and prevent the escape of the fluid. The narrow tract is lined with membrane which occasionally is highly sensitive, and a cord-like thickening may be traced backwards along its course. The discharge from these fistulse is augmented by deglutition, especially of warm fluids, and even by mental excitement; and it is said that menstruation in some cases causes an increased flow of the fluids as well as irritation in the orifice of the fistula. Alimentary matters are not found to escape by the orifices. The direction of the fistula may be straight, or tortuous, and generally runs toward the great cornu of the hyoid bone. When incomplete the passage may be of various lengths, and occasionally portions of cartilage or even of bone may be found attached to it, being vestiges of the branchial arches. The direction of the fistula may in many cases be shown by the passage of a probe or small sound, but from the nar- rowness and irregularity of the passage, and the violent cough excited, this exploration may be impossible. The injection of colored or pungent fluid may occasionally succeed in proving the communication with the pharynx, while the laryngoscope may in some cases assist the investigation. The true nature of these fistulous openings is thus shown by their not having been preceded by any local inflammation; by their position, size, and direction ; by the appearance of the external orifices, and the hard cords run- ning upwards therefrom towards the hyoid bone, as well as by the fluid which distils from them. These fistuke very rarely heal spontaneously. They seldom embarrass either deglutition or respiration to any serious degree, and, as a rule, they neither demand nor admit of treatment. Injections of tincture of iodine or of solutions of nitrate of silver, and the galvanic wire, have been tried, but there is risk of bringing about closure of the external orifice only, and so doing harm by inducing an accumulation of the secretion within. Incisions are useless unless the lining membrane of the track be entirely removed, and to attempt anything of this kind in such a situation, and for so trifling an affection, would be altogether unjustifiable. 1 See Virchow’s Archiv, 1864 und 1865 ; also Pitha und Billroth’s Handbuch, 1871 ; and Arch. Gr6n. de Med., Janv. 1875. 186 INJURIES AND DISEASES OF THE NECK. 2. Accidental or acquired fistula of the neck may he due to wounds, inflammatory action, the presence of dead bone or cartilage, etc. They may occupy any position, and involve any of the structures or organs of the neck. Pus, mucus, air, or alimentary matters, may escape from their orifices. In chronic disease of the larynx, when attended by necrosis of cartilage or bone, very troublesome fistuhe may form. Reference has, however, been already made in a previous part of this article to such affections. Suppurations of any kind in the neck, especially those connected with glands, bursae, etc., may occasion the formation of fistuhe. The suppuration of a small serous bursal sac lying between the hyoid bone and thyroid cartilage, or of some of the small glands at the base of the tongue, may be the origin of a small but very troublesome fistula seated in front of the larynx. Injections of various kinds have been employed with but little effect, but when, which is seldom the case from the depth or direction of the fistula, it is possible to excise it along with its deep terminal extremity, its closure may be secured. As a result of venereal ulcers, or of wounds made by the surgeon, or by accident, a small orifice may lead into the larynx or trachea. I had lately under my observation a patient in whom an opening large enough to admit the point of the little finger remained after a determined attempt at suicide, which removed a considerable portion of the cartilage. 'When such large fistula* exist below the glottis, there is great risk of the upper part of the air- passage being in a great measure obliterated by contraction, and of the voice being lost. These fistula, unless very small, are difficult or impossible to close, and in cases where contraction has taken place above, it may not be safe to oblite- rate them, for fear of undue interference with respiration. Cauterization and plastic operations usually fail when the orifices are large. Many methods, however, have been tried. Helaton employed two flaps adjusted in the same way as in his well-known operation for urethral fistuhe. Roux and Despres have introduced other plans. Jamieson’s suggestion has also been put into practice. This consists in rolling up and inserting into the pared orifice a narrow strip of tissue dissected from the neighborhood, and retaining its connection at one end. It is fixed by a needle or sutures. Erichsen1 describes a simple and useful method of operating: “ The edges of the fistulous opening having been freely pared, and the knife passed under them for some distance so as to detach them from the subjacent parts, a ver- tical incision is made through the lower lip of the opening so as to split it downwards. Two points of suture are then inserted into each side of the horizontal incisions bringing their edges into contact, but the vertical cut is left free for discharges and mucus to drain through, and for the expired air to escape, lest emphysema occur. Unless this outlet is afforded, these fluids will burst through the sutures and destroy union of the edges.” (Esophageal fistulre are very rare, and need not be considered. Gunshot Wounds of the Xeck. Gunshot wounds of the neck are not very uncommon in war. The vari- ous campaigns which, in Europe, America, and India, have afforded exten- sive fields for observation within the last quarter of a century, have abundantly illustrated the pathology of these wounds, but have not added much to our knowledge regarding their management. In the records of these wars, now accessible to all, the facts are clearly set forth, but there is nothing which in this place specially calls for comment. Doubtless many of those who are 1 Op. cit., vol. i. p. 422. CICATRICES OF THE NECK. 187 wounded in the neck die of hemorrhage on the field, but many escape in a marvellous manner, and recover from injuries which at first appear hopeless. Any of the important structures may be hurt, the windpipe and oesophagus may be perforated or carried away, in part or to a wide extent, and one or more of the great nerves, which are here so numerous and important, may be destroyed or so bruised as to fail in their function. It is in the nerves of the upper extremity that this failure is most frequently seen after gunshot wounds, but it would be altogether beyond the scope of this article to do more than refer to these lesions. Sprains of the Keck. Sprains of the neck causing pain on movement, especially when the head is drawn backwards, are not uncommon. It is perhaps in railway accidents that these injuries are most apt to occur. A passenger, sitting reading when a collision takes place, is thrown forward, against his opposite neighbor or on the side of the carriage, striking the crown of his head. The pain is in such cases not confined to the muscles and ligaments of the neck, but shoots into the arms, and may for a time occasion derangement or deficiency of sen- sation, and feebleness in motion. I have lately seen two such cases, within a few days of each other. One patient was hurt, as described, on a railway; the other was thrown on his head when hunting, his neck being bent. What was somewhat remarkable, was that the pain mostly complained of in each case was strictly confined to the distribution of the musculo-cutaneous nerve, and that it could always be aroused by bending the head on the chest, or pressing on the upper part of the neck. It did not disappear in either case for several weeks. Sprains of the neck are to be treated by rest and fixation (sand-bags may be required), with fomentations, and afterwards anodyne embrocations. Cup- ping and blisters may be necessary to remove the after-effects. Boils and Carbuncles. The back of the neck is one of the common positions where boils and car- buncles appear. Occasionally they also occur on the sides and front. The pain which such affections cause when they invade the indistensible structures of the nape, is very great, and may, with the loss of sleep and want of appetite, produce dangerous weakness. Fatal results occasionally arise from blood poisoning, as the pus which forms gains ready access to the veins and sinuses of the brain; and the vertebral canal may be laid open by the destructive erosion of a carbuncle. Enormous phlegmonous masses are at times seen on the back of the neck, extending from ear to ear, and as they generally occur in persons who from habits or employment are in a depraved and depressed state of health (intemperate persons with hepatic and renal affections, especially), the danger to life is often very imminent. They demand early and decisive care, but their remedies are in all respects those used for similar affections in other regions, and which have been elsewhere described. Cicatrices of the Keck. Cicatrices may follow burns, wounds, abscesses, or ulcers of the neck, and require careful treatment on account of the unsightly appearance which they 188 INJURIES AND DISEASES OF THE NECK. cause. It is not, however, the uncomely look of these contractions alone which calls for the surgeon’s attention, but the displacement ofpartsand theembarrass- ment of function depending thereon demand to be remedied. It is chiefly after deep burns that these deformities are met with, and in such cases the most extensive displacement may take place, the chin being drawn towards the chest, or the head twisted or held firmly in some inconvenient or ungainly position. The power and long endurance of such contractions are well known. When the lower jaw is drawn down and fixed, and the lower lip everted, the gums exposed, and the tissues swelled and livid, a most distressing appear- ance is produced, and if it is established early in life, and not corrected, the development of the face is so interfered with that recovery becomes impossible. Excoriations arise from the irritation of the dribbling saliva, mastication and deglutition are impaired, and even plionation and respiration are seriously hindered. These cicatrices vary much in extent and depth, as also in color and arrange- ment. They may be extensively adherent, or may be attached at their ends only. They may vary in color, from white to red, or brown. Bands or cords of great firmness and tenacity, projecting more or less from the surface, and having deep hollows between, run in different directions and produce a very repulsive effect. If ulceration takes place, it is difficult or impossible to heal it. The treatment of these cicatrices is always difficult, and often most unsatis- factory. Mechanical appliances, together with a careful attention to position, will achieve much during the consolidation of the cicatrization, but they are apt to be discontinued, or only carelessly applied, before that process is complete and the contractile force exhausted. By successive grafts of new skin, the healing area may be much diminished and the suppleness of the tissues increased. The healing is thus not only expedited, but the repairing tissue is rendered much more flexible and abundant, and so more capable of being stretched—a capability which should be taken full advantage of as long as the due closure of the wound is not arrested. No operation need be at- tempted while the contraction is active, and it is far from easy to decide when best to interfere, as each case presents special features which require consideration. When old, modular tissue does not readily allow of meddling; it is apt to have firm and insoluble connections established, and the deformity is often great and incapable of rectification. To allow of stretching the tissue, incisions of various kinds are employed, while to diminish its thickness and resistance, compression, and agents which are supposed to promote absorption, have been used. To get altogether rid of the objectionable material, its removal has been effected by caustics or by excision, followed by simple re-union of the bordering healthy tissues, or by replacing by a plastic operation what has been taken away. The treatment by incision is seldom adequate to the requirements of these cases, and it is not easily applied in an effective way in the neck. Though carried out with ingenuity and skill, it has often failed. Sometimes open incisions have been made; sometimes subcutaneous; occasionally the bands have been merely divided, and at other times they have been dissected up from the parts below. Multiple, small incisions, and extensive and deep ones, have all been tried. They have been made across the bands, or in zigzag, and all that mechanical skill could suggest in the way of apparatus, to keep up exten- sion afterwards, has been used, but in nine cases out of ten they have only led to disappointment by their inadequacy to counteract the contraction, or by the irritation, inflammation, and ulceration which the subsequent exten- sion has induced. When the cicatrix is limited in extent, lies in the line of the superficial muscles, and is set in supple tissue, perhaps the most satisfactory way is to TUMORS OF THE NECK. remove it entirely and unite the wound carefully by suture, taking every advantage of plaits of skin, shadows of surface, etc. A straight, linear cica- trix may thus be substituted for a raised, rough, and deformed band. In other cases the replacement of the objectionable tissue by a plastic operation is the happiest resource. In removing the old tissue, such a line of incision should be employed as will best fit the adaptation of the proposed new flap. The bed in which the flap is to lie must be very carefully prepared, and all hard tissue removed from its surface and sides. The “ method by sliding” (erroneously called “ the French”) is that most commonly employed. Flaps must be secured from one side or both, and that in varying proportions and shapes to suit the state of the parts and the ease of adjustment; and in the fashioning, fitting, and subsequent treatment of such parts, the well under- stood and widely practised principles of plastic surgery must be carefully applied. Flaps have been taken to replace cicatrices on the neck, from any and all the surrounding surfaces. Thus the face, front of chest, top of shoulder, and neck itself, have all been put under contribution. Carden and Teale in England, Mutter in America, Hichet and Pean in France, have all published leading cases.1 The “ Indian method,” by replacement, can of course be combined with that by sliding, while incisions and skin-grafting may also help in securing the desired result. In cases of extensive deformity, part only of the surface involved should be dealt with at a time, so as not to run too much risk. Esmarch’s operation for establishing a joint in the body of the bone may be called for, when the lower jaw is drawn down and fixed, and cannot be freed. As to the use of compression, and of caustic applications, little need be said. Plates of lead, or special apparatus, have been used, in order to cause the ab- sorption of the unduly prominent tissue, but to little purpose. Caustics and iodine cannot be used effectually without running great risk of setting up ulcerative action, and when that begins in cicatricial tissue, it is impossible to say where it will cease. I have secured very good results, in cases of slight or medium severity, by the prolonged use of colorless iodine, begun in small quantities, painted on once or twice a day with a camel’s-hair brush, and desisted from on the appearance of any undue irritation. The strength and frequency of the application must be regulated by its effects, and it may have to be continued for months. I have seen no benefit in the way of im- proving the color, from the use of chlorine or other remedies. Tumors of the I^eck. These may be of many diverse kinds, and may present some most formida- ble features. Innocent or malignant in character; connected with or lying in contact with the important structures of this region ; congenital or not in their origin ; merely giving rise to discomfort or deformity, or rapidly menac- ing the life of the patient, they cannot fail to secure the attention and anxious care of the surgeon. Their superficial or deep position, and their relation to the deep cervical aponeurosis, are points of the utmost importance. Abscesses have been already spoken of. Adenoma, cystoma, angeioma, lipoma, sarcoma, fibroma, myxoma, enchondroma, osteoma, papilloma, lym- phoma, neuroma, epithelioma, and carcinoma, in short almost all the fluid and solid growths we are acquainted with, may be met with in some of their forms in the region of the neck. Some of these are fortunately rare, and the 1 See Med. Times and Gazette, 1857 ; Brit, and For. Med.-Chir. Review, vol. xiv., and Union Medicate, 1868. 190 INJURIES AND DISEASES OF THE NECK. consideration of them need not detain us, but others are common enough, and demand detailed description. The various glandular structures here present are frequent starting points of tumors, and especially of the more formidable sorts which in this position occasionally attain a very great size. Pneumatocele and emphysema of the cellular tissue may be passed lightly by. A pneumatocele is capable of being emptied by pressure, but reappears on forced expiration. It forms a circumscribed tumor, increasing and diminish- ing with the respiration. It is resonant on percussion, and soft on palpa- tion. The lung may also be projected into the lower part of the neck so as to form a hernia. This is a very rare condition, and is irremediable. In examining a growth of the neck, it is most desirable to determine its relationship to the deep fascia. The information thus secured will help mate- rially to distinguish the nature of the tumor, its future effects, and the hope of removing it When placed below that strong and firmly bound down mem- brane, it will as it grows induce symptoms which are very manifest and import- ant. The consistence of such deeply placed tumors is augmented, their outline is less clear, the fingers cannot be passed under them, nor can they be raised up and isolated. The pressure which they occasion will early begin to tell, and the pressure-effects will he out of proportion to their apparent size. The in- fluence too of the fascia will be observed in the fixed character of the growths. Any or all the organs in the neck may suffer from the pressure of a deep growth. The air-passages, the pharynx and oesophagus, the great bloodvessels, and the nerves—including the sympathetic, the recurrent, and the pneumo- gastric—may be thus affected. The well-known effects on the temperature and cutaneous sensibility of the face and ear, and the changes in the conjunc- tiva and pupil, which indicate compression of the sympathetic,1 may be ob- served. The circulation through the brain too may suffer, and, in short, most serious and wide-spread effects may follow from the pressure exercised on important organs. The observation of Vidal, that the violence of the pressure in deep tumors may subside as the growth progresses, has not been verified in my own experience, though the fact that it is only in the later stages of superficial tumors—that is, when they have reached considerable dimen- sions—that the evidence of pressure may appear, is in keeping with what would naturally be expected. Aneurism, spina bifida, and ranula do not lie within the range of this article, but adenitis, lymphoma, cystoma, lipoma, fibroma, enchondroma, and carcinoma will be considered, while various growths of less frequency or importance will be very shortly alluded to. Adenitis and Adenoma.—Acute inflammation of the glands has been already described. The chronic form is both common and difficult to deal with, and that chiefly from the circumstance that it may he dependent on either a local or a constitutional cause, or on both, acting in varying degrees. The subacute form of the affection is also frequently met, with after depress- ing ailments. Irritation in some part of that enormous surface whose lym- phatic vessels end in the cervical glands, is the usual, if not (as some believe) the sole cause of that enlargement which characterizes chronic adenitis. Upon the violence or acuteness of that irritation will of course greatly depend what the effect on the gland will be, whether it shall be excited to acute action, or shall slowly and painlessly increase by hypertrophy. The surfaces of the head, outside and within its various cavities, are frequently the seat of such lesions as would create the irritation required, but behind this, and giving it emphasis and force, we too often have a constitutional or general 1 Porteau, Des lesions de la portion oervicale du grand sympathetique. Paris, 1869. TUMORS OF THE NECK. 191 predisposition, or diathesis, which promotes and augments the pernicious effects. It is in the young and those of feeble constitution that glandular enlargements are most common, and it is not infrequent to find them present in various members of the same family. A temporary derangement of the health, due to unaccustomed strain on mind or body, may -cause this malady to appear very quickly, and the best barrier which can be raised to its progress is to recognize and remove the depressing cause. In constitutional syphilis, we frequently meet with small, hard, rolling and painless glands in the back of the neck, and sometimes along the edge of the trapezius; but in neither position are they as constant or as was at one time supposed. -v_ In size, shape, consistence, and number of glands involved, there is much variety in adenitis of the neck. Its dimensions range from that of a pea, to that of a mass as big as the fist, and it may be round, oval, or irregular in shape, from the fusing or matting together of several glands. Its consistence varies from that of flesh to that of bone, and as regards number, while occa- sionally, but rarely, single glands are inflamed, they are more commonly met with in groups or chains, sometimes filling the whole side of the neck. If chronic, they are painless, and are slow to suppurate or break down, while long periods ma\7 pass with but little perceptible change in their size or connections. If from any cause more violent action arises in them, not only may the gland be destroyed, but the surrounding cellular tissue and overlying skin may par- take in the inflammation, and, if pus works its way to the surface, sinuses may remain to mark the point of its passage. If the whole of the diseased tissue is expelled, these openings may close, and leave deep and indelible marks. If large and hard, and placed near compressible structures, these glandular en- largements may exert injurious pressure. Bloodvessels and nerves may thus suffer, as we see when the axilla is filled by glandular masses causing the violent pains and oedema in the arm which produce so much distress in car- cinoma. Caseous degeneration is a not uncommon affection of unhealthy youth, and is generally wide-spread in its ravages, attacking many glands contempo- raneously or in succession. These glands are liable to suppurate, but not always in a distinct and satisfactory manner. Part of the gland may break down, while the stool or basis remains behind to feed the suppuration and delay the recovery. Early and efficient opening with antiseptic precautions, with, it may be, the free use of the spoon to remove the debris of the gland, is the most essential point in the local treatment. It is far from easy to avoid leaving disagreeable marks after such proceedings, but the surgeon’s interference, if judicious and well directed, will produce less destruction, and leave less objectionable traces, than spontaneous evacuation of the pus. When the glands of the neck become enlarged from malignant disease, they grow quickly, and produce early and disastrous pressure-effects, causing shooting pains along the nerves, interference with the blood supply, displace- ment of the soft structures, and implication of the skin leading to ulceration. The general health becomes involved, and thus from a combination of symp- toms the true nature of the growth is recognized. It is secondarily to other cancerous deposits existing on the line of the lymphatic vessels converging to the glands in the mouth, throat, larynx, etc., that the disease appears. Primary cancer is extremely rare in these glands. When it occurs, many glands will be affected in succession, and soon such a condition will be estab- lished as to be beyond surgical aid. It is by the hardness and fixation of these masses, the pain in the nerves compressed, the early matting together of the growth and its close adhesion to the parts around it, the implication of the overlying skin and rapid deterioration of the health, that true cancer 192 INJURIES AND DISEASES OF THE NECK. in these glands is distinguished from lympho-sarcoma and other tumors. The photograph here copied (Fig. 1101) was taken from a cast made from a case ol malignant disease after death. It shows the terrible destruction which such Fig. 1101. Fig. 1102, Malignant tumor of neck. Malignant tumor of neck. an affection may occasion before death relieves the sufferer. The other (Fig. 1102) was taken shortly before death from a patient under my care, in whom the nature of the affection was recognized when the growth was a small, hard, deep-set tumor, only four months before it attained the size represented. Lymphoma has attracted much attention of late years. It is not uncommon in the neck, and is difficult or impossible to distinguish, in its early stages, from mere hypertrophy of glands. In minute structure this tumor resembles lymphatic-gland tissue, but its constituents vary considerably in different examples, the cells and the containing basis-fibre bearing different propor- tions to one another, and so causing the consistency of these tumors to differ. When the cell-elements greatly predominate, the growth is not only less coherent and softer, but it becomes very malignant, infecting neighboring structures, and many and distant parts, contaminating the whole system, causing a general and characteristic anaemia, and killing miserably. This general form, this “ lymphoid cancer” as it has been termed, is chiefly known in England as “ Hodgkin’s Disease,”1 and abroad as lymplio-sarcoma (Virchow) and lymphadenoma (Cornil and Ranvier). The simple or local form may involve one gland or many, and may be con- fined to the neck. It may attain a great size, and occasion considerable pres- sure. It is firm, fleshy, movable, indolent, and loosely set in the part, and the skin over it is unchanged. This growth may begin on one side of the neck, most frequently at the"angle of the jaw, or by the edge of the sterno-mastoid. It may progress very slowly, and may even remain stationary for a time. 1 See Medico-Chir. Trans., vol. xvii. 1832. TUMORS OF THE NECK. 193 Many masses may be adherent to one another, but they are readily shelled out when the overlying parts are divided. In the general form of the affection, there will appear in other regions, as the armpit, groins, etc., similar growths to that present in the neck, while the spleen, liver, and other organs, may also present tumors of like structure. When the blood has become so altered in composition as to present a great excess of white corpuscles, then we have that “leucocy- thsemia” established which makes its presence so evident in the complexion. It is beyond our present art to differentiate the two forms of lymphoma where the growths are small and undeveloped, and even to distinguish them from chronic adenitis, can at times be but a happy guess. When the rapid growth, soft consistence, multiplicity, bossy contour, freedom from pain, and absence of all scrofulous taint, become apparent, then the idea of mere adenitis drops out of view, and, as the affection quickly progresses and shows itself in various parts, either internally or externally, and the general system begins to suffer, then the diagnosis of the special form of lymphoma present can no longer be doubted. In “ white-blood” disease, an examination of the blood will of course demonstrate its condition. It is on the clinical history that our chief reliance must be placed, for though various instruments have been invented for securing a minute portion of the tumor for microscopic examination, such an examination could not furnish confidence in forming a • © judgment. The photograph here copied (Fig. 1103) was taken from a cast in my possession, and is historically interesting, as it is one of those which were Fig. 1103. Fig. 1104. Lymphoma of the neck. (From a cast by Allan Burns.) Lymphoma ot the neck. Dissection of the parts seen in Fig. 1016. made by Mr. Allan Burns, when studying the subject of the anatomy of the head and neck, for his well-known work; and the next (Fig.1104) appears to have been taken from a dissection of the same. Fig. 1105 represents like 194 INJURIES AND DISEASES OF THE NECK. them a case of lymphoma which was under my care, and in which the tumor occupied the clavicu- lar region. Papillary growths are met with in the neck in both the simple and epithelial forms of warts, but they do not demand detailed notice. Kavi are not unusual in the neck, and may be either arterial, venous, or mixed, cutaneous or subcutaneous, etc., as in other parts, but there is nothing in their nature, progress, or man- agement, special or peculiar, derived from the region in which they occur. 1 have twice had occasion to excise deep arterial naevi lying on and implicating the sterno-mastoid muscle. In the first case, the growth, before being cut upon, had all the physical characters of a glandular tumor, and, as it was enlarging and causing deformity, the patient (a female) wished it removed. There was no pulsation observed till the soft parts were divided, and it was prominent and firm. It bled very freely indeed when touched with the knife, and it had to have needles placed under it, and a twisted suture applied, before the bleeding could be arrested. When the true nature of the tumor was recognized, it was removed along with an inch and a quarter of the muscle which was involved. This patient died of septicaemia in ten days. In the second case the tumor had been cut into in the country, and the patient was sent to me in Glasgow, with many pins and ligatures in position, which had been applied to command the serious bleeding that had taken place. In this case the tumor was successfully excised along with all the affected muscle. In both cases the nsevoid nature of the tumor was recognized after removal. It is always to be remembered that venous and mixed nsevi usually disap- pear spontaneously after teething is over, and that injections should never be used in dealing with these affections on the head or neck, from the danger, which is very real and imminent, of causing thrombosis. Excision is by far the best mode of dealing with nsevi here and elsewhere, when it can be em- ployed, but the ligature, cauterization, electrolysis, etc., may in some cases be preferred. Fig. 1105. Lymphoma of the neck. Lipoma is sometimes met with in the neck, and may attain a very great size, growing slowly and painlessly, and only occasioning harm by its me- chanical effects. Such a growth may affect even a young child, and may appear for the first time soon after birth. iSTo part of the neck is exempt from these tumors, but it is on the posterior aspect that they have been most usually seen. Liston refers to several examples of large fatty growth in the neck, and medical literature is rich in such cases; in many instances very large tumors of this kind have been successfully removed.1 Their physical characters are all well known. They may be sessile or pedunculated, doughy to the hand, and occasionally so soft as to appear fluctuating. They may be in rare cases symmetrical, and they may, it is said, occasionally cause the skin to ulcerate 1 See Trans. Pathol. Soc. of London (especially for 1860) ; also Indian Med. Graz. 1874. TUMORS of the neck. 195 over them. They are movable, grow slowly, are painless, and have the su- perficial veins sometimes enlarged and prominent. Long prolongations may pass deeply from these tumors among the muscles, and even around the bloodvessels, giving but slight indication of their ex- istence as the movability of the growth is thereby little affected; but, as a general rule, lipomata do not dip beyond the subcutaneous •cellular tissue. When the skin over them is rendered tense, the line of attachment of the inter- lobular partitions will be seen, and this is distinctive. The hard- ening effects of ether, which has been used to differentiate fatty growths from others, is quite un- reliable as a diagnostic test. Fig. 1106. Fibroma, enciiondroma, and os- teoma are unusual tumors in the neck, but in connection with the ligamentum nuchse, or the verte- bral periosteum, we may have the two former, while enchondroma may also be met with in the parotid and submaxillary glands, and exostoses occasionally grow from the transverse processes of the vertebrae. Fibrous and cartilaginous tumors, as a rule, grow slowly, are smooth or lobed, and in consistence vary from being elastic to being stony hard. They may attain a great size, are often quite movable and free from pain, and are covered by unchanged skin; they may too, as may more especially the exostoses, give rise to much suffering by their pressure on nerves, and may interfere greatly with the circulation in both arteries and veins.1 Large lipoma of neck. Neuromata, both single and multiple, have been recognized in connection with the fifth, sixth, and seventh cervical nerves. They have been observed most usually on the pneumogastrie, but the sympathetic and phrenic also have both been found so affected.2 Syphilitic gummata may appear in the glands and subcutaneous tissue of the neck, and also in the sterno-mastoid muscle. They may soften, suppurate, and discharge, leaving fistulse. The sterno-mastoid is also occasionally the seat of chronic inflammation of a syphilitic nature, and of a curious hardening which goes by the name of “ myo-sclerosis.” When affected with chronic inflammation (in the secondary or tertiary stage of the disease), there are ten- derness, stiffness, and irregular swelling in the muscle, and the pain is increased by motion of the part.3 The external and internal use of iodine is the best remedy for this condition. 1 Trelat, Gazette des Hopitaux. 1868. 2 Accounts will be found of such growths in the well-known monograph of Professor R. W. Smith, of Dublin ; in Langenbeck’s Archiv, Bd. iii.; in Mem. de la Soc. de Chir., tome iii.; in Pathol. Trans., vol. viii. ; and in Comptes Rendus de l’Acad. des Sciences, 1845. 3 Bouisson, Gaz. Med. de Paris. Juillet, 1856. 196 INJURIES AND DISEASES OF THE NECK. Myo-Sclerosis. (Congenital Induration or Tumor of the Sterno-Mastoid.)— As to myo-sclerosis, it appears a few days, or at most weeks, after birth, and appears to be due to inflammatory exudation. Part only of the muscle may be involved, or the whole of its extent may become hard like, bone, and swelled so as to present a very noticeable condition. It is always unilateral, and has its seat in the sheath of the muscle. The skin is not involved, and pain may be occasioned when the muscle is compressed or put in action. In the last case which fell under my observation, all movement of the head appeared to produce much uneasiness. No explanation quite adequate to account for this curious affection has yet been found. Strains during de- li very, or the pressure of the forceps, may in some instances account for it; but it has also been observed in cases in which the child has been born without any difficulty whatever. No hereditary or constitutional state has been so commonly associated with this affection as to establish the existence of any connection with it. The spontaneous disappearance of this condition after some months—from two to six on an average—and the restoration of the muscle to its normal state, may be expected with confidence; if any interfer- ence were thought of, it would probably take the form of friction, or possibly gentle counter-irritation—but these measures are really unnecessary. Lymph-angeioma is a name given to a rare tumor formed of capillary lym- phatic vessels, which has been said to occur in the neck and to attain a con- siderable size. Nothing is known of its etiology or clinical characters that is reliable or worthy of remark. Solid growths of the neck, especially glandular tumors, occasionally derive a more or less distinct pulsation from contact with, or adhesion to, the carotid artery. If the tumor surround the artery, as it has been found to do, then the deception is complete, as the pulsation appears excentric and expansive. It will be chiefly by careful inquiry into the clinical history of the case, by noting its progress, the consistency and outline of the tumor, the possibility or not of pushing it aside and so arresting the pulsation, and at the same time of defining the outline of the growth and the position of the artery below, and finally by observing the probable existence of other similar tumors when, the disease is glandular, that the diagnosis is arrived at. As to the treatment of these various tumors, it will be best given in the order in which they have been spoken of. Treatment of Cervical Tumors.—Chronic adenitis will demand, in the first place, the correction of the cause, constitutional or local, on which it depends, if that can be found, and is capable of being dealt with. In many cases the digestion is deranged and the system lowered. The assimilating organs will require careful attention, and their vigor must be maintained or improved •, then iron, iodine, phosphorus, and cod-liver oil may be given in some of the many combinations which have of late years so much simplified the adminis- tration and increased the usefulness of these remedies. The hygienic surround- ings of the patient—his dress and exercise, his food and air suppty, the action of his skin, etc.—will profitably engage the surgeon’s attention and super- vision. Sea-air has a well-established reputation in these cases, especially when the scrofulous diathesis is present. If there is any suspicion of syphilis, that will supply an important hint to guide the treatment. If inflammation should arise in the glands, fomentations, and it may be one or two leeches applied close to the affected part, will be serviceable, but cold is not to be commended. Counter-irritation by colorless iodine, or by a lotion containing iodine with iodide of potassium and a little spirit, or by the various ointments 197 TUMORS OF THE NECK. into whose composition iodine enters, is, if properly regulated, most useful in the subacute and chronic stages of simple adenitis, but it is very liable to abuse and overuse, and must be supervised. The employment of more powerful local applications, such as cantharides, tartar emetic, croton oil, or mercury, is hazardous, because of the risk of inducing too violent action. Belladonna, too, to relieve pain, is rarely required, and in young persons may occasion annoying symptoms. If suppuration occur, the pus cannot be too early evacuated, and this should be done by a clean cut with antiseptic precautions. That is better than the use of the aspirator, seton, etc., which rarely fulfil the end in view, and may irritate and do barm. Such puerilities as applying the iodine, not to the gland, but to the part (mouth, nose, etc.) from which its lymphatic vessels are derived, need hardly be mentioned. Shampooing, compression, crushing, acupuncture, and gal vanism, either in the form of galvano-puncture or of the continuous current, have all their advocates in dealing with hypertrophy of cervical glands. Shampooing is very liable to be overdone, and so set up inflammation. Pressure cannot well be applied in the neck, except, perhaps, in the parotid and mastoid regions, where there is bone behind ; but special forms of apparatus have been invented for its employment. Compresses of metal, wood, bone, agaric, cliarpie, etc., have been applied, and expensive and elaborate instruments have been con- structed, but their success has been small, and occasionally the harm caused has been considerable. Crushing alone, or combined with subcutaneous division by a cataract-needle, has too often been attended with diffuse inflam- mation and suppuration. Mere manipulation has been used as a step pre- paratory to excision, “in order to render the gland more movable.” “Igni- puncture,” or the introduction of a pointed, red-hot iron into the middle of the mass, or the placing there some of Maisonneuve’s chloride-of-zinc pencils (“fleches”), have both been fairly tried, but with very indifferent success. Such applications are very painful, very violent, and attended with marked danger in deep and large, tumors, and they leave serious scars. Electrolysis is slow, troublesome, and generally* unsatisfactory, but there are cases on record in which considerable masses of scrofulous glands have been dissipated by perseverance in its use.1 Interstitial injections of many kinds have been tried. Various solutions of iodine, nitrate of silver, chloride of zinc, salts of sodium, alcohol, perchloride of iron, and carbolic acid, and Fow- ler’s solution of arsenic, have heen employed. In most cases the aim has been to set up suppuration, and so to break down the mass; but iodine, when so introduced, in the simple, chronic form of adenitis in healthy persons, is un- doubtedly a valuable remedy. It causes absorption, with but little disturb- ance, if used in small and repeated quantities, passed by means of a small hypodermic syringe deeply into the tumor, after the surface has been rendered insensible by the ether-spray. In scrofulous subjects, it is apt to be followed by suppuration and local disaster. Injections of solutions of chloride of zinc have, however, even in scrofulous cases, occasionally answered well. The excision of hypertrophied glands has been often practised. In simple chronic adenitis, and in scrofulous enlargements, it is quite justifiable when other mea- sures of less violence have failed, unless in children and young persons, for whom time and improved hygienic conditions may be expected to do much. It is, perhaps, in healthy females—in whom local and general remedies have failed, and who suffer from superficial, distinct, chronic, and movable growths, which occasion deformity and annoying pressure—that excision is most justi- fiable. The position, size, connections, etc., of the tumor, must guide the 1 Golding-Bird, Lancet, 1877. 198 INJURIES AND DISEASES OF THE NECK. surgeon in determining his conduct,together with the clear conviction that less severe measures have been exhausted, and that the case is such as to demand such a step being carried out. No doubt the use of antiseptics has greatly diminished the risk of such operations, and the mark left may, by a careful planning of the line to be followed, together with the rapid union which anti- septic surgery insures, be very insignificant. The propriety of getting rid of scrofulous collections is now well understood, and contrasts with the old fear of such interference causing outbreaks elsewhere. The treatment of carcinoma in the neck is, as might be expected, most unsatisfactory. Generally it is quite beyond the surgeon’s aid. It cannot, as a rule, be completely excised from the connections which it has formed by the time its true nature is recognized, and as the tumors are usually secondary to other, like growths elsewhere—which are often still more inaccessible— it would be of little use to remove them. Interstitial injections are highly dangerous in such growths, and chloride-of-zinc arrows are of very limited application i n this region of the body. Lymphoma.—The treatment of this disease in any form is confessedly very difficult and unsatisfactory. All irritating applications tend to make these tumors increase with enhanced speed, and electricity has proved quite useless. When the growths are part of a general affection (lymphosarcoma), no remedy is of any value, and interference is to be declined, though arsenic and phos- phorus, when injected into the tumor or given internally, so as to develop their poisonous effects, have been said, on reliable authority, occasionally to arrest the progress of the disease. These favorable results, however, have too rarely been secured to make the risk of their employment quite justifi- able. Arsenic in particular, when used by interstitial injection, occasions most violent effects, difficult, or impossible, to regulate or command; and there seems good reason to suppose that any influence which the drugs named have in retarding the growth of the tumor, is only due to the general de- pression which they bring about in the nutrient functions—an effect equally seen after attacks of acute rheumatism and erysipelas. From the loose con- nection of lymphoma, it is easy to shell it out before it has attained a great size; but if the constitution be involved, a rapid recurrence will take place. If the larynx or trachea be seriously compressed, it may be necessary to open the windpipe. An observation of Duplay is worthy of record, though its clinical use has not been found great. It is this, that if a tumor of the nature now under consideration increases in the direction of the lymphatic vessels, that is, downwards towards the chest, the worst opinion may be formed of its nature; but if, on the contrary, it grows in the contrary direction, that is, against the flow of the lymph, a more favorable prognosis may be formed. When similar growths occur in other regions of the body, all interference is of course plainly unjustifiable. Fatty, fibrous, and cartilaginous tumors can only be excised, if they are inter- fered with at all. If they are increasing, the sooner such a step is taken the better. A deep dissection will, in all likelihood, be required to effect the removal of fibroma and enchondroma, and no small difficulty may attend the separation of their deep connections. So great has been the intricacy of their relations in not a few recorded cases, that it has been found necessary to remove them piece by piece. The risk of wounding the veins is especially great. The treatment of venous or mixed ncevi of the neck differs in no way from their management elsewhere, except that coagulant injections are here very dangerous, from the risk of clots being carried into the blood stream. Arte- rial naevi are best excised or strangulated by passing needles under them and CYSTS OF THE NECK. 199 applying the twisted suture. Electrolysis, cauterization, and the ligature have all been applied to nsevi of the neck. Syphilitic tumors are to be dealt with through the general system, according to the stage of the disease in which they arise. Iodide of potassium and iron in large doses are, as a rule, the most efficacious treatment, with possibly the careful administration of the green iodide of mercury in the event of the other remedies failing, or being slow to act. Iodine may also be applied locally.1 Cysts of the Heck. There are many forms of cystoma met with in this region. Some of these tumors lie above and some below the cervical aponeurosis. Some are soli- tary, and others are found in groups forming large and formidable tumors.2 Congenital serous cysts (hydrocele of the neck; hygroma) have their seat in the subcutaneous cellular tissue, and are chiefly seen on the left side of the neck in its antero-lateral region. They are usually unilocular, but are at times divided into various compartments by imperfect partitions. They are, for the most part, round, smooth, elastic swellings, having but a loose connection to the parts above and below them. If very tense, they may communicate to the hand the firmness of a solid growth. It is seldom that they are sufficiently prominent to enable translucency to be made out, but a certain bluish or opaline color can be sometimes distinguished. They cause no pain, but as they may attain an enormous size, so as even to fill the whole side of the neck, their bulk and the deformity which they occasion may cause much inconvenience. The contents may vary much in color and con- sistence, being at times like water, and at other times thick, and of a yellow, green, or dark-brown color, from mixture with blood. More rarely there are solid contents. The fluid is saline and albuminous, and if there are several cysts combined, each may have a different colored fluid within it. The cyst wall is usually very thin*and delicate, so as to be difficult to recognize and remove ; but in consequence of inflammatory deposition it may become thick and resistant. These cysts are not vascular, and the skin covering them may be healthy and unchanged. They do not, as a rule, cause functional distur- bance ; but in young children, when they attain a large size and are deeply placed, they may occasion a dangerous amount of pressure. If injured and consequently inflamed, or if bleeding take place into them, a serous cyst may become a source of danger. The least dangerous position for serous cysts (though they may cause much deformity when placed there) is the back of the neck, where they may reach a large size. When a number of cysts are combined in a congeries, the grouping may vary considerably, as secondary growths may be attached to the main mass and give it a very irregular shape. Congenital cysts occasionally undergo spontaneous cure. They may burst inwards into the pharynx, or outwards by the skin. They may become consolidated after inflammation, and may then disappear by absorption. Cysts containing teeth, hair, cartilage, etc., have in rare instances been seen as congenital growths in the neck. They are soft, round, smooth and 1 Bouisson, Gaz. M6d. de Paris. Juillet, 1856. 2 On this subject see Yoillemier, Dee kystes du cou. Paris, 1851 ; Boucher, Etude sur les kystes congenitaux du cou. Paris, 1868 ; Maunoir, Memoire. Paris, 1825 ; Hawkins, Med.- Chir. Trans. 1839 ; Bryant, Med. Times and Gazette. April, 1876 ; Anger, Bull, de la Soc. de Chirurgie. D6c. 1875 ; Vernher, Die angebornen Kystenhygrom; also many papers in Langenbeck’s Arch, fiir klin. Chir., in the English Med. Journals, in the Gazette des Hopitaux, Arch. Gen. de Medecine, etc. 200 INJURIES AND DISEASES OF THE NECK. indolent, and often deeply placed and firmly connected. If they are opened or burst, they give rise to very troublesome fistulous openings. Compound Congenital Cysts.—The compound congenital cyst, from the deep position which it may occupy among the muscles (going even behind the pharynx and oesophagus), and from its close relation to important structures, is often a very formidable affair. It may be made up of many separate masses, or the growth may appear to be lobed, from being bound across by muscular or cellular bands, or by the partial or complete division of the cyst by partitions within. These cysts occur on the back of the neck, and not unfrequently in front, to the inner side of the sterno-mastoid. These growths have been seen at birth of a size to impede delivery. They have not only covered the whole side of the neck, but have hung down in front of the chest, and by their pressure on the floor of the mouth have occasioned serious difficulty in both breathing and swallowing. Various vices of conformation may be found to accompany them—conditions not connected with simple congenital cysts. Their contents are very much varied (glandular, sarcomatous, cartilaginous, colloid, and sanguineous elements), and their walls are not unusually hard and thick from calcareous, cartilaginous, or bony deposit, or from having undergone sarco- matous or other change. From the nature of their contents and the altera- tions in their walls, these cysts are firmer and more irregular in outline than simple cysts. Their consistence may vary greatly in different parts of their surface, being soft and fluctuating at one part, and hard as bone at others. There is little or no pain, and no pulsation, but the veins on their surface may be enlarged. They may burst and disappear, but at other times this occurrence has led to the breaking up of the patient’s health. Non-congenital cysts are sufficiently common. The sebaceous cyst occurs here as elsewhere, and presents its usual, well- known characters. When deeply placed, as it occasionally is, it is difficult to be certain of its true nature before puncturing it. The sanguineous cyst occurs mostly in young children, and appears to be due to bleeding into a serous cyst. The blood may be at rest within the cavity, or there may be a direct connection with a vein which allows of its circulation through the interior of the cyst. Hydatid cysts are very rare, and their real nature may not be known till they are punctured. They may lie superficially, or they may be placed deeply among the muscles, especially on the back of the neck. Symptoms of Non-congenital Cysts of the Neck.—Non-con genital cysts in adults grow slowly as a rule, and remain long stationary, and often attract little attention till they have attained a considerable size. If they are affected by inflammation, their rate of progress may be greatly accele- rated, and they may become what otherwise they are not, painful. These cysts, however, occasionally make a rapid start in growth without any apparent cause. If small, they may appear to be solid from their tense- ness, but if large, their soft consistence is commonly evident. No help is got in their examination from transparence. The skin covering them is not involved, and they are as a rule movable, smooth, and without pulsation or bruit, unless it be merely a heaving when they are in contact with the carotid. It is said that Mr. Syme on one occasion ligatured the common carotid for a supposed aneurism, when in reality it was a thick-walled cyst adherent to the vessel’s side. The kind of movement, and the effects on the tumor of arresting the current of blood by pressure applied at the root of the neck, will, with the history, best aid the surgeon to avoid a like error. The noil-congenital cysts of the neck occur most frequently in connection CYSTS OF THE NECK. 201 with the glands of that region, though they may grow in the cellular tissue without any relation to the glandular structures. When situated in front of the neck, such a cyst may be confounded with goitre, wrhich it may closely resemble in physical characters ; but if a clear clinical history is obtainable, the distinction can be made, seeing that the goitre springs from a different part of the neck, and that it is only in their later stages that they come to coincide in position, and that, as a rule, the goitre is firmer, and has a move- ment with deglutition, and often, also, an effect on respiration* which is not observed in the case of a cyst unconnected with the thyroid body. Diagnosis.—From spina-bifida and encephalocele, a cyst of the neck is differentiated (in those cases in which its position might cause the question to arise) by being more superficial, by having no connection with or influ- ence upon the spinal cord or the brain, even when compressed, by exhibiting no movement on expiration and no pulsation, by not being reducible or pedunculated, and by there being no aperture in the parts below, such as may be frequently detected in hernia of the membranes of the cord or brain. In many instances it is impossible to distinguish a cyst composed of a single cell, from one having many compartments. If the wave of fluid caused by percussion is found to be circumscribed, and if various distinct centres of movement are made out in a tumor, then its multilocular character cannot be doubted; but it is by no means the case that this is usually recognized in a satisfactory manner, and that because of the varying thickness of the cyst-walls and contents. In small cysts, even fluctuation may, from such causes, be very obscure and difficult to define. An exploratory puncture may be necessary to discover what is contained in such a cyst, but a conside- ration of the age of the patient, and the shape and history of the tumor, will supply important aids to diagnosis. As to prognosis, it will, of course, turn on the nature, position, size, and connections of the cyst, and on the age of the patient. When large and deeply placed, in young children, the cysts will manifestly prove very dan- gerous. The multilocular cysts are worse than the unilocular, as they attain a greater size and are more difficult to deal with. The etiology of cysts of the neck is very obscure, and as yet little under- stood. They have been ascribed to many causes, some of them not a little fanciful—injury received during pregnancy, undue uterine contractions, pressure from the umbilical cord, etc. That sanguineous cysts may arise from contusions or strains during delivery, has more probability to com- mend it. The various cysts have been traced by different observers to the bloodvessels, glands, and cellular tissue, and have been ascribed to imperfect development of structure, and to the uncertain realm of “new formations;” but notwithstanding the ample discussion which this point has undergone, little reliable light has yet been thrown upon it, and consequently it would be fruitless to dwell upon it further.1 Xo hereditary history can, as a rule, be traced regarding the occurrence of these cysts, and nothing important or reliable is known with reference to the influence of sex, age, etc., in their production. Treatment.—In very young children it is well to delay, if possible, all inter- ference till the strength of body diminishes the danger. Repeated punctures, aided, if possible, by compression, may retard the progress of these cysts. The plans which may be pursued in the treatment of cysts of the neck are numerous and diversified, in order to meet the requirements of the various 1 Reference can be made to Liicke, Traite des Tumeurs ; Pitha und Billroth’s Handbuch der Cliirurgie ; Richard, Bulletin de la Soc. de Chir. 1851 ; Lawrence, Medical Times. 1850; Voille- mier, Des kystes du cou. 1851; Comptes Rendus de la Societe de Biologie. 1853, 1854; Gi- raides, Bull, de la Soc. de Chir. 1859 ; Verneuil, Tumeur congenitale du cou. 1875. 202 INJURIES AND DISEASES OF THE NECK. conditions and forms of the affection. If the contents could be got rid of by absorption, it is manifest that much would be gained. If this cannot be accomplished, then the evacuation of the fluid, followed by the obliteration of the sac, would present itself as the least objectionable device, while its destruction by caustic, its incision, or its entire removal by excision, might be in certain conditions the most feasible or most promising mode of management. Compression is difficult or impossible to apply in the neck, so as to be effective and endurable. Even elastic collodion, which seems well adapted to exercise a certain useful pressure, proves objectionable in young and tender children from the irritation which it causes. Counter-irritation by iodine or cantharides, and the use of mercury or muriate of ammonium in solution or ointment, cause too much irritation in the child, and so are productive of harm. It is seldom that any appreciable or abiding influence is thus exercised in inducing absorption. To puncture the cyst without attempting to oblite- rate the sac, can only be a temporary expedient, as the fluid is quickly re-formed. In sanguineous cysts, serious and even fatal bleeding has in a few cases followed simple puncture. A fine aspirator needle is the best instru- ment to employ, if puncture is to be tried. To excite adhesive inflammation in the sac, after it has been emptied, has been attempted by the use of electric- ity, injections, the seton, etc. From the first of these agents little good has been got, though it has been frequently tried, and in many ways. Of the various injections, iodine has commended itself most. If thrown into a bloodvessel, or employed in too concentrated a form, it will unquestionably be followed by mischief; but these errors are not likely to occur when their possibility is present to the surgeon’s mind. The quantity used is generally equal to half the bulk of the fluid which has been in the first instance withdrawn. It is thrown in slowly, through a small canula, which has been carried a short way under the skin before entering the cyst, so as to diminish the risk of air being introduced. A previous puncture of the skin with a knife, allows the canula to be passed with less force and with more precision. Xo washing-out of the cyst, preparatory to the injection of the iodine, is requisite,but that fluid should be allowed to escape (without squeezing) after it has remained in the sac for a short time. This, at least, is a safe precaution to enforce on the first occasion, as we cannot be certain what degree of action will be set up, and it is not wished that it should be too great. It is also well to wait the full effects of each injection, before another is used, and to be guided thereb}'. If pressure could be afterwards applied, it would materially aid the injection. Heated wine, alcohol, perchloride of iron, chloride of zinc, etc., have also been used by injection, and occasionally most disastrous results have followed from ex- cessive inflammation. Some practitioners desire to occasion so considerable an amount of inflammation as to produce suppuration, but it is difficult to restrain or guide such a complication. A seton is obnoxious from the undue irritation which it is apt to cause, and, in its usual form, from its obstructing rather than aiding drainage; but a small vulcanite tube, or carbolized catgut (which is capable of being absorbed), or horse-hair, might, when injection failed, be thought of. The interior of the sac may be washed out, through a drainage-tube, with Condy’s fluid, or with one of the unirritating antiseptic agents now in use. It is difficult to apply injections to the interior of multi- locular growths. Jules Roux’s suggestion, first to break down the partitions between the cysts, is more specious than practical. To destroy a cyst of the neck by the application to its external surface of caustic in any form, can hardly be advocated, as such a method is not only slow, violent, painful, and uncertain, but leaves a most objectionable scar behind. A mark must also result from incision, but it need not be great, and if antiseptic precautions are taken there will not be that risk of inflammation and suppu- SURGICAL AFFECTIONS OF THE THYROID GLAND. 203 ration in the cyst which constituted the chief objection in former times to this procedure. The drainage must, however, be carefully attended to, as other- wise annoyance or danger will arise. Laying the sac open and applying caustic to the lining, so as to cause its destruction, is a practice now seldom followed. Excision has its chief use in dermoid cysts, and in multilocular cysts which threaten asphyxia, when no less serious or difficult plan of treating them is available. Experience does not, however, encourage these operations, and they have proved, in the case of large cysts, very difficult and sometimes very disastrous. The deep relations of these growths are frequently such that extirpation is impossible. The ligature is not adapted for the removal of cysts of the neck, though in cases of attempted excision, the deeper portions may sometimes be thus dealt with. Surgical Affections of the Thyroid Gland. This very vascular gland, lying on either side of the upper part of the trachea, in near proximity to the great bloodvessels, is a ductless, encapsuled body, largely supplied with lymphatics, and consisting of a cellular structure of firm texture, pervaded by a glairy, gummy, yellowish fluid, which coagulates when heated. The two lateral portions of the thyroid, which lie on either side of the windpipe, are connected by a bridge or isthmus which covers the three upper rings of the trachea, where also an intermediate lobe or pyramid may exist.1 The thyroid varies considerably in size in different persons, and may atrophy and almost disappear in the old. It is liable to temporary enlarge- ment during menstruation and pregnancy, afterwards resuming its normal size, or nearly so, and no change of structure being caused by such increase. Permanent enlargement occasions that condition which is called “bronchocele,” or u goitre,” or, in England, “ Derbyshire neck.” There is great variety in the degree of this abiding enlargement. It may cause only a certain broaden- ing of the neck, which attracts little observation, or it may produce a great pendulous mass covering the whole front of the neck, and in extreme cases extending: down in front of the abdomen.2 Hypertrophy of the thyroid, or goitre, may be simple and without much structural change. It appears to be more common on the right side than on the left, and may be confined to one side and the isthmus, or at least these parts may be developed out of all proportion to the rest of the gland. Goitres have been variously classified according to their structure. The terms solid and liquid goitres, cystic and parenchymatous, etc., have been proposed as dis- tinguishing the leading forms. The cysts of which these growths may be chiefly composed, vary widely in size, shape, contents, etc. The contents may be a clear and albuminous fluid, or a gummy, gluey, or jelly like material, or may consist of blood, or may be made up even of calcareous matter. The interior of the cyst may also present much diversity as to shape and construc- tion. The cavity may be divided by septa more or less complete. The walls, sometimes thin and pliant, are at other times hard and rigid, with calcareous and osseous deposits. These walls are firmly attached to the gland, but only 1 See Boechafc, Recherches sur la Structure du Corps Thyro'ide. Paris, 1873; and Burns, op. cit. 2 See Berger, Archives Generates de MSdecine, 1874 ; also Virchow, Krankhaften Geschwiilste. 204 INJURIES AND DISEASES OF THE NECK. loosely connected with the surrounding structures. When the walls are thus hard and dense,the disease has been termed “cartilaginous” or “osseous” goitre. A considerable amount of the growth may consist of dilated bloodvessels, and if these burst so as to allow of bleeding into the substance of the tumor (into the cyst, or into the parenchyma), a species of apoplexy is produced. If it he the arteries which are chiefly enlarged and convoluted, the goitre has been designated “ aneurismal,” while if it be the veins which are mainly involved, it is termed “ varicose” goitre. Both sets of vessels, however, but in varying degrees, are commonly affected.1 Expansile pulsation, vibratory thrill, and “ bruit de souffle” have been occasionally observed in aneurismal bronchocele. The worst forms of goitre are met with in the narrow valleys running into the great mountain ranges of Asia, Europe, and America. In many of these localities it is endemic. It is met with in France, Savoy, and Switzerland; in the chalky parts of England and Central Scotland; in the valleys of the Himalayas, and in Thibet and Oude; in the Atlas range of Forth Africa; in the Cordilleras of South America, and in Chili and Peru ; in Mexico and in Virginia, and in other mountainous i*egions of North America. I have repeatedly seen it in patients from the high-lying districts in the centre of Scotland, where it is little known to exist. A condition similar to that seen in man is occasionally found in dogs, horses, cows, and cats. Etiology of Goitre.—The hereditary character of goitre has not been clearly established, though it is often asserted. When both parents suffer from the disease, the children are usually similarly affected, and are not unfrequently cretins and idiots. Whether, however, this result is not more correctly to be ascribed to the identity of exciting causes acting on both children and parents, rather than to any inborn influence, is at least a fair contention. The true cause of goitre lias probably yet to be found. It has been diligently sought after and abundantly discussed. Coarse food ; impure water, from mix- ture with snow or calcareous matter (sulphate or carbonate of lime) ; vitiated air; want of sunlight; a constant residence in low-lying and damp, or in ele- vated, cold, and exposed habitations; a “peculiar state” of the atmosphere; physical conformation of the country; extremes of temperature; intermar- riage within a narrow circle; repeated congestions of the neck from violent efforts which force the blood into the vessels of the head and oppose its return—have all been described as its cause ; but none of these are constant concomitants, and at best are only entitled to be considered as predisposing causes. Symg)toms.—Goitre is usually chronic in its progress, and may long remain stationary. Perhaps the most remarkable instances of acute bronchocele are those recorded in 1861 by Collin,2 as having occurred at the year before. Women, especially those of a sanguineo-lymphatic constitution, are most subject to it. It seldom becomes developed till after a child has reached ten years of age, though it has been seen in rare cases to appear shortly after birth. A goitrous tumor rises and falls in deglutition, and is, as a rule, painless, and covered by unchanged skin, whose veins are unusually evident. It may be smooth or lobed, and of various shapes. It may exert severe and even dan- gerous pressure on the windpipe (“goitre suffocant ”), and may cause alteration or loss of voice, and dysphagia. It has been seen to surround the trachea, and penetrate between it and the oesophagus, so as to compress both passages. The trachea may be thus flattened or pushed to one side. The great vessels 1 See Heidenreich, Der Kropf. 1845. 2 Recueil de M§moires de Med. de Chir. et de Pliar. Militaires. 1861. SURGICAL AFFECTIONS OF THE THYROID GLAND. 205 and nerves, too, may be constricted by its wedging itself behind the sternum, and this has followed from goitres of even small dimensions when so placed. Diagnosis.—Goitre is distinguished from glandular tumors by its point of origin, and by its consisting of one or two slowly-growing masses, and not of multiple swellings, at first distinct and finally coalescing, and occurring in dif- ferent positions from that of the thyroid bodies. Hydroceles of the neck, abscesses, and hydatids, have all a different clinical history, and, for the most part, a different position, and their physical characters and progress are differ- ent. An aneurism of the carotid is altogether distinct in position, character, and effects. Tubercular disease is rare in the thyroid, is indolent in its progress, occurs in persons of a special diathesis, and is commonly combined with similar disease elsewhere. Disseminated abscesses and fistulous open- ings, too, are usual in tubercular affections. Scirrhus is known by its hardness, mode of growth, fixation, bossy and irregular outline, absence of fluctuation and pulsation, great pain and rapidly- established pressure-effects, and by its influence on the general health. Treatment.—Internal remedies are of little use when bronchocele has attained a great size. When recent, and of small or moderate dimensions, such remedies may prove serviceable in the measure with which they improve the general health and vigor, and correct those conditions on which the disease may depend. The removal of the patient from the district in which the disease has been contracted to a healthier one, careful attention to the sanitary surroundings of his dwelling, and also to his food and water supply, are measures which at once suggest themselves. If any of those supposed causes which have been already alluded to be in action, they must be removed or counteracted. Iodine, given internally, has long enjoyed a large measure of confidence in the treatment of bronchocele. Sponge, first used by the Arabians, was administered as an electuary, or in the form of pastilles, tablets, etc. It was also burned and applied externally, as well as given internally. Coindet, of Geneva (whose name is intimately connected with this subject), used the hydri- odate [iodide] of potassium, which is, perhaps, still the best preparation of iodine to use in this affection. It should be given freely, and is well com- bined with quinine and iron. “Lugol’s solution” (that is, iodine, 20 grains ; iodide of potassium, 30 grains ; water, 1 ounce; dose, six to twenty minims) is also a very favorite prescription with many. Iodine, however, is used in a great variety of ways in the treatment of goitre, and in doses of all degrees of concentration. It has been exhibited in natural and artificial mineral waters, in food, in wine and milk, and even in cigars and snuff, but few now-a-days have the same faith in it as formerly, or believe it to possess any “ specific ” action in bronchocele. When combined with iron and accompanied by other measures tending to improve the general health, it is no doubt very useful. Every kind of local treatment of goitre has had its advocates. Leeches, purging, counter-irritation, and electricity have all been tried and found of no avail, unless to relieve congestion or the slighter forms of hypertrophy. Iodine is the most commonly employed external application. In the form of tincture, or as an ointment variously combined with camphor, lead, mer- cury, etc., it has long been used in both the cystic and solid forms of goitre. In the East Indies, the biniodide of mercury (5iij to the pound of lard) lias a high repute. According to Mouat1 it is best rubbed in, in the early morning, for about ten minutes, a fresh portion being then applied, and left to be absorbed, while the tumor is exposed to the heat of the sun. When, the skin 1 Indian Annals of Medical Sciences, 1857. 206 INJURIES AND DISEASES OF THE NECK. becomes irritated, the application should be desisted from till the part is again free from pain. I have, in Scotland, occasionally seen much good result from this treatment, tire-heat being substituted for the sun’s rays. The action of the remedy is apt to be too violent unless watched. The compound iodine ointment of the British Pharmacopoeia, the iodide of ammonium (“ colorless iodine”), equal parts of camphorated mercurial ointment and iodine, are other forms of the application which are sometimes used. Cysts may be simply tapped, or may be injected as well as emptied. Mere tapping can only afford, as a rule, temporary relief, and, however carefully managed, has not always proved free from danger.1 Rarely has it led to a cure, as it did in a case related by Gosselin. Consecutive hemorrhage and profuse suppuration have occasionally followed mere tapping. Iodine is the favorite substance chosen for injection, but alcohol, ergot, and perchloride ot iron are also used. The tincture of iodine, mixed with water in the proportion of one to four, or stronger, or combined with camphor or alcohol, has been frequently employed. Dr. Morel] Mackenzie2 prefers a drachm of the tincture of the perchloride of iron in half an ounce of water, injected after drawing off the fluid by a dependent, central puncture, with a trocar and canula. The canula is left in place and plugged after the injection is made, so that the iron solution may be re-introduced at intervals of a few days, till suppuration is set up, after which the tube is withdrawn and poultices are applied, and the affection treated as a chronic abscess. Iodine, iod ide of potassium, cam} thorated spirit of wine and rose-water, are recommended by Bouchacourt.3 Maunoir used wine, but it is wholly inefficient. In old, hard goitres, interstitial injections are powerless. Nothing short of removal is of much service in such cases. Tt is in the cystic and glandular forms that injections of iodine are of most value ; and though it is not unusual for the immediate effects to be violent, and even alarming, yet in a few days the beneficial results will show themselves. The surgeon must proceed with caution, and be guided as to the strength of the injection and its repetition, by the effects of the last operation. In vascular goitres, solutions of the per- chloride of iron are to be preferred. Incision followed by plugging has also been employed in the treatment of cysts of the thyroid. Portions of the cyst may at the same time be removed. Violent and irrepressible bleeding has, however, thus been occasioned, and has ended most disastrously. Billroth’s experience of this method has been very unfavorable. Caustics and the actual cautery have also been used to open the cavity of the cyst, so as to diminish the risk of bleeding; and pieces of caustic have been suspended within the cyst, in the delusive hope of dimin- ishing the dangers of using the knife. The wire or thread seton is also another method of treatment which has been practised; but here, too, violent bleeding and inflammation have arisen, and have ended fatally. Pressure has been well spoken of by an American surgeon, Dr. Dwight.4 He applied it by means of adhesive plaster. In the vascular form of goitre it has been proposed to tie the main vessels leading to the tumor. This operation is difficult and dangerous, and has been attended with little benefit, as the collateral circulation is very easily established. In the solid forms of goitre, various methods of treatment have been attempted. Electricity, crushing, breaking up with a trocar, interstitial > See Graz, des Hopitaux, 1857. 2 Lancet, 1872; and Transactions of Clinical Society of London, 1874. 3 Bulletin de ThSrapeutique, 1849. i Transactions of the American Medical Association, vol. iv., 1851. SURGICAL AFFECTIONS OF THE THYROID GLAND. 207 injection, the seton, etc., have all been tried with the object of bringing about absorption. The biniodide ointment, used as already described, has also been employed for this form of the affection. When other means fail, excision may be thought of in favorable cases, but is a proceeding so formidable that few surgeons have had the courage to attempt it. In the words of Dr. Greene, “ accurate anatomical knowledge and a perfect self- control under the most trying ordeals through which a surgeon can pass, are indispensable to its performance.” Yet it has been done, and that success- fully, in very formidable cases. The ligature was used by Moreau, Desault, Mayor, and others, but with very indifferent success. The knife has been preferred by some, and while in not a few cases the bleeding has been very great—so profuse as to cause the arrest of the operation—it has been success- fully commanded in others without much difficulty. Some patients, how- ever, have died of hemorrhage, either at the time of the operation or shortly afterwards; and that excision is not an operation to be undertaken by surgeons without experience in perilous undertakings, or in other than exceptional circumstances, must be admitted. It appears to have been first performed by Desault, and since then has frequently been executed both in Europe and America, and the successful cases have been about two-thirds of those operated on.1 Greene, in 1871, described the method which, as subsequently improved by Dr. TIeron Watson, of Edinburgh,2 Prof. Billroth, and others, is that now generally followed. An incision is made in the middle line down to the capsule of the gland. This incision must be free, and may extend from the chin to the sternum. In this there is little bleeding. The tumor is then enucleated without opening the capsule. This is done rapidly with the finger. The lateral and anterior connections having been broken up, and the sterno-mastoid muscles held aside, the superior and inferior thyroid arteries are secured by double ligatures, where they enter the tumor at its upper and lower angles. The various veins are also tied as they are encountered round the circumference of the growth, till the whole vascular circle has been made secure. The vessels are then divided between the ligatures by which they have been tied, and the mass removed. Greene did not stop to secure the lesser vessels, but sought rapidly for the pedicle and tied it. Where the pedicle is large, or when some part of the growth cannot be isolated, the ecraseur may be employed. The galvano-cautery has also been suggested, but the careful and systematic deligation of each vessel is the most reliable plan to follow. Primary and secondary hemorrhage are beyond doubt the most serious dangers, and these have occasioned the most appalling catastrophes when the capsule has been opened and when the vessels have not been systematically and completely secured. Shock,' septicsemia, and diffuse cellulitis have also proved fatal after this operation. Ligature of the thyroid arteries, and also of the carotid, has been employed in the treatment of goitre, when highly vascular, without the tumor being otherwise interfered with ; but, as has been already said, these operations are not only difficult, but have not been attended with such success as to encourage their repetition. When suffocation threatens a patient suffering from goitre, we have to consider whether it is due to temporary congestion which can be relieved by local depletion and the application of ice, etc., or whether, as is more usual, it arises from the permanent pressure of the growth. If there be a distended cyst, then tapping may give rapid relief; but if the tumor be solid, no aid can be thus got. Tracheotomy may be impossible from the position and size of the growth, from the displacement of the windpipe (which is so apt to occur), 1 Koclier. Convspondenzblatt: Welch, Trans. Am. Med. Assoc., 1878 2 Edin. Med. Journal, Kept. 1873. 208 INJURIES AND DISEASES OF THE NECK. or from the presence of large bloodvessels, and even if it can be managed it may prove abortive from the low point at which the compression acts, and from the narrowing which the windpipe has undergone, or, perhaps, from the tumor having passed behind the trachea. The longitudinal division of the tissues lying over the windpipe in the middle line, or the subcutaneous severance of the aponeurosis and muscles “ at the seat of greatest constriction,” have been suggested, but these measures are open to very obvious objections when we consider the disposition, situation, and structure of the growth which is the cause of the pressure. Exophthalmic Goitre.—In that form of goitre described by Basedow and Graves, and commonly known as exophthalmic goitre, or the goitre of spa- nsemia, the protrusion of the eyeball is a marked and characteristic feature. The patients most liable to it are females whose health has been depressed by loss of blood, feeble digestion, leucorrhcea, prolonged mental anxiety, or overwork. The heart is usually irritable, and it may have its cavities dilated and its sounds altered. The pulse is weak and rapid. There is excessive action of the great arteries in the neck, and the patient complains of throb- bing in the head, tinnitus aurium, palpitation, and great nervous depression. The cause of the protrusion of the eyeballs has been much discussed. The distension of the bloodvessels within the orbit, and possibly hyperplasia of the cellular tissue and fat there, have been credited with producing this effect, while changes in the cervical ganglia of the sympathetic have also been said to account for it. No single condition, however, has been found so constantly as to properly be considered the true and invariable cause, though there seems good reason to suppose that the chief phenomena which mark the affection are referable to morbid changes in the middle and lower gan- glia of the sympathetic nerve. It is, however, as bearing on the thyroid body that this curious disease comes to be spoken of here. The thyroid becomes enlarged, though rarely to any great degree. It becomes very vas- cular, and is often covered by large, prominent veins. It may be markedly moved by the pulsations of the neighboring great arteries, and may undergo increase with any excitement in the circulation. One lobe may be specially enlarged. It is usually soft at first, but when of long standing may become very hard and resistant. It seldom suppurates, but may inflame or break down; and if the surface gives way, a very malignant-looking sore may be the consequence. The etiology and pathology of this disease are as yet very unsatisfactorily determined, notwithstanding all the labor which has been expended on it, and the treatment is mainly based on an endeavor to improve the general health and recruit the blood, and so diminish the nervous exhaus- tion which is so marked a condition. Attention to the digestion, the diet, and the hygienic surroundings of the patient, the avoidance of mental strain, the arrest of all wasting discharges, and the administration of iron, digitalis, and strychnia, either separately or combined, or quinine and belladonna, have been found most useful. Iodine has also been employed, but it is in iron, digitalis, and strychnia that confidence is most placed. Ice has, in the early stages, been much used for this enlargement of the thyroid, and iodine, with compression, in the later conditions of the gland. The state of the thyroid will, however, depend mainly on the condition of the general health, so that it is to its amendment that attention should be chiefly directed.1 1 See Graves, Clinical Medicine; Dublin Hospital Gaz., June, 1860; Stokes, Diseases of the Heart; Virchow, Die cellular Pathologie ; Laycock, Brit, and For. Med.-Chir. Review, 1864, and Medical Times and Gaz. vol. ii. 1864; Trousseau, Clinique Medicale; Greene, Medical Record, 1871; Buffalo Med. Journal, 1851 ; Begbie, Practitioner ; Charcot, Gaz. Med. de Paris, 1856 ; and Trousseau, Ibid., 1862. surgical affections of the thyroid gland. 209 Tumors of the Thyroid.—Adenoid growths occasionally occur in the thyroid, and lie imbedded in its substance. They form outgrowths, and are more or less detached, and so capable of being enucleated. Carcinoma occasionally attacks the thyroid, and that usually subsequent to its appearance in the neighborhood or elsewhere. It is very rarely seen as a primary affection, though cases of reputed cancer have been not very uncom- monly reported. All forms ot carcinoma have been met with in this organ, but the soft or brain-like cancer is perhaps the most common. The rapidity of growth, the great pain, the marked pressure-effects, the invasion of the skin and the parts around (especially the windpipe and pharynx), and the propa- gation of the disease to glands, lungs, etc., together with the disastrous influ- ence it has on the general health, proclaim the nature of the affection. There may be sanguineous cysts formed in the carcinomatous mass; and, if the skin gives way, a malignant ulcer may be established. The great bloodvessels may be opened, and the inevitable death hastened by bleeding. The clinical history, physical features, and progress of malignant growths of the thyroid, differentiate them from all those of a simple character, which are for the most part smooth and of rounded outline, of soft consistence (fluc- tuant, perhaps), of slow growth, painless for the most part, causing pressure- effects only when they have attained a great size, and not involving the over- lying or surrounding parts, or the constitution. In dealing with tumors of the thyroid, it is, of course, essential to obtain a distinct knowledge of their nature, as otherwise neither their progress nor treatment can be determined. Not only the clinical history of the growth— its origin and progress—but its exact anatomical position and its connections, together with the state of the surrounding parts and the effects it occasions, must be carefully studied and considered. Whether it occupies the whole gland or part only ; in what portion of the gland it has begun, and whether it has penetrated deeply or not into the tissues; what has been its rate of pro- gress, and whether its growth has been regular or the reverse; whether its increase has been expedited by any temporary cause, such as pregnancy, menstruation, etc.; what is its consistence at all parts of its surface; its mobility on the underlying and in the surrounding parts, and the state of the skin and bloodvessels over it; its weight, if it can be poised on the lingers; its movement with deglutition ; the presence of pulsation or fremitus; the effects of forced expiratory efforts on it; its pressure-effects on windpipe, oesophagus, bloodvessels, and nerves; the presence of pain locally or at a dis- tance, as caused by it, and the state of the general health—these, with an inquiry into any inherited tendency, or any connection by residence with specially unhealthy localities, will supply materials for a sound opinion. The surgeon will probably determine first whether the tumor is simple or malignant, and, if simple, then what species of innocent growth it is. Cysts and solid tumors are usually easily distinguished; yet there are many cysts which, from their tenseness, the thickness or hardness of their walls, and the nature of their contents, are easily mistaken for solid growths. The shape, weight, resistance, and pressure-effects are generally characteristic, in solid tumors, and the speed with which they grow will vary according as they consist of fibrous, cartilaginous, or bony elements. By the aspirator the contents of cysts can be determined, but it is unde- sirable to have recourse to puncture if not really necessary. Much irritation may thus be occasioned, and violent bleeding has sometimes given much trouble. Cysts of the thyroid are to be distinguished from congenital, uni- lateral, simple cysts of the neck, by their position and history, and the fact that they are firmer and not transparent, and are accompanied by an altera- tion in the whole thyroid body. The congenital simple cysts and the com- 210 INJURIES AND DISEASES OF THE NECK. pound cysts of the neck do not, as a rule, occasion the pressure-effects which result from those cysts which form in connection with the thyroid, and their movement with the trachea is not so marked. Cysts of the thyroid, too, do not show below the tongue, as congenital cysts are apt to do. Remarkable errors have been made between highly vascular goitres and aneurismal tumors. This has been due to the presence of expansile pulsation, souffle, etc., in both. A careful inquiry into the mode and exact place of origin, the extent, shape, and consistence of the tumor, together with an ob- servation of the effects of pressure applied in turn to each carotid at the root of the neck ; the movements of the tumor with deglutition ; the absence of any decided reducibility, or of effects detectable in the arteries beyond the growth ; also, the state of the superficial veins, and, possibly, even the influ- ence of internal treatment by iodine and tonics, will clear up the diagnosis. The rapid enlargement which the thyroid occasionally undergoes as the result of inflammation and congestion, is easily recognized. It is seen at times as the result of injury to a pre-existing, though perhaps little observed, goitre. The violent pain increased on pressure and movement; the local signs of inflammation (heat, redness, and swelling), and the serious fever which it occasions, together with the quickly-established pressure-effects, and the in- fluence of antiphlogistic treatment, will conjoin to distinguish it. The chronic glandular hypertrophy and lymphoma of the neck, have had their characters fully described. In the former, the enlargements are almost always multiple and in chains, in the well-known position of the lymphatic glands. Firm or hard, painless as a rule, slow of growth, with unaltered skin, and, possibly, with concomitant evidence of a strumous diathesis, the nature of these tumors will usually be apparent. They have not the same position as that occupied by thyroid growths, do not occasion the same local effects, and do not follow the movements of the windpipe in deglutition. Surgical Affections of the Parotid Gland. The parotid is the largest of the salivary glands, and lies on the ramus of the lower jaw, passing also deeply behind it and between it and the mastoid process, being thus in close relation with most important structures. The external carotid artery with its great terminal branches, together with the veins which accompany them, the facial nerve and its important divisions, with branches from the cervical plexus, are imbedded in it, while the internal carotid and internal jugular, the spinal accessory, glosso-pharyngeal and vagus nerves lie close to its deep surface. It is inclosed, except its pharyngeal sur- face, in a strong fibrous sheath, and its duct, which is a resistant, fibrous tube lined by mucous membrane,opens within the cheek opposite the second molar tooth of the upper jaw. Cellular tissue and muscle lie over or superficial to the parotid, so that it is firmly hound down and covered on its outer aspect, hut the deficiency of its capsule on the deep or pharyngeal surface has an important bearing on the direction taken by pus when formed deeply within the gland, and by cancerous growths in their extension. The parotid varies considerably in size, within the limits of health, and it is occasionally the seat of inflammation and of various growths. Many absorbent glands exist over, within, and below the parotid, and as they derive lymphatic vessels from the velum and gums, they are liable to many sources of irritation. Some authors have described a curious sweating or distillation of salivary fluid, from minute points in the skin over the parotid, during eating, and in one case1 in which this was observed, it was found after death that the paro- 1 Baillanger, Bull, de l’Acad. de Medecine. Paris, 1847. SURGICAL AFFECTIONS OF THE PAROTID GLAND. 211 tid ducts were obliterated; yet Brown-Sequard1 and others have tried to disprove the nature of the transudation, and to show that it is mere perspir- ation escaping in excessive quantity. Parotitis, or mumps, is a common affection which attacks one gland, or occasionally both, and that simultaneously or in succession, in young males chiefly, and which at times assumes an epidemic character. It is most common before puberty, but has been observed not only in adults but even beyond middle life. In schools and public institutions it has now and then affected large numbers, especially in spring and autumn, when cold and damp have been thought to originate it. Its exact pathology has been much dis- cussed.2 It has been ascribed to rheumatism, has been classed with the erup- tive fevers, and, as it is commonly preceded or accompanied by inflammation of the fauces, has been thought by many, in all cases, to proceed by continuity of tissue along the duct. It reaches its acme in two or three days, and in eight or ten days it disappears. Parotitis causes considerable local swelling, which, however, may so spread as to involve the whole side of the neck, especially if the other salivary glands become affected, as they sometimes do. There is no heat or redness, but the pain is considerable, especially during mastication and deglutition. This pain is little if at all aggravated by pressure, as long as no suppuration follows. The attack may be ushered in by chills, sickness, headache, and elevated temperature, and by so much constitutional disturbance as to deceive the practitioner regarding the nature of the ailment, and lead him to expect some serious eruptive fever; but this only occurs in exceptional cases, as in general there is little or no fever present from first to last. The transference of the inflammation from the parotid to the testicle or mamma, which occasionally (in 2 or 3 per cent, of the cases) occurs about the fifth or sixth day of the attack, is a curious and unaccountable complication of this ailment. It is not as often seen to involve the mammary gland as the tes- ticle, but it does so occasionally, and may implicate the uterus and ovaries as well. The parotitis more rarely follows the orchitis.3 The testicle on the same side as the affected parotid is that usually involved, but this is not always the case. The transference is most often observed in patients who are of somewhat advanced age. Of late years attempts have been made to throw doubt on this “ metastasis,” as it has been called, to the testicle, and to allege that when orchitis has appeared there has always been a latent gonorrhoea. I have had most conclusive evidence of the untenableness of this view, but am inclined to think that masturbation during the attack of mumps, had, at least in one case, some influence in attracting the inflammation to the testes. Various other complications in the ear, eye, tonsils, and brain, have been recorded as following parotitis.4 Mumps as a rule subsides spontaneously, and leaves no harm behind, unless a little thickening which disappears in a short time if not interfered with. A blister may occasionally, however, be thought desirable, to hasten the dis- persion of the condensation. As to the treatment of the ordinary simple parotitis, little need be said, as rest of the part (using soft food), fomentations, simple or medicated with chamomile flowers, and the use of a saline, are all the remedies which it usually demands. Liniments containing belladonna, camphor, or iodine, are fre- quently employed after the acute stage. The soap and opium liniment, alone 1 Journal de Physiol., tome ii. 2 Trousseau, Clinique Medicale ; Pitha und Bilroth, Handbuch, Bd. iii. S. 373; Grosselin, Clinique; and Vidal, “ Des Oreillons.” 3 Billoir, Graz, des Hopitaux, 1850. 4 Trousseau, Archives Grenerales de 1854. 212 INJURIES AND DISEASES OF THE NECK. or combined with chloroform liniment, twice as much of the former as of the latter, does very well to remove the stiffness which remains. Leeches and cold are not used, and blisters are seldom required. If the inflammation in a lymphatic gland, however, were very acute, of course local depletion might be useful. Many prefer to cover a simple swelled parotid with cotton wad- ding, and to abstain from all active local treatment. As a rule, I have myself found this quite sufficient. The orchitis which occasionally arises during the course of parotitis is easily managed. Rest, fomentations, and elevation of the part, will soon subdue it. Leeches, if used, assist the induction of that atrophy which occasionally follows, and therefore should not be applied. Leeches too are very troublesome when applied to the scrotum or cord. Blisters and caustics are even more objectionable. It is useless to try and attract the inflamma- tion again to the parotid, by blisters applied to it, if the testis be already involved. Time and rest will do more than active treatment to secure an effectual and safe recovery. The administration of mercury and iodide of potassium, as recommended by some, is unnecessary. Suppurative Parotitis (Parotid Bubo).—In weakly subjects, and. in de- pressed conditions, as after child-birth, erysipelas, typhoid fever, diphtheria, and smallpox, or in the course of septicaemia, from a too prolonged course of mercury, or from closure of Steno’s duct, suppuration may occur in the parotid after an attack of acute “ phlegmonous” inflammation within the gland, and it is not so very unusual for it to implicate the cellular tissue which lies over it. The pus, when formed within the strong capsule of the gland, lias great difficulty in coming to the surface, and may work havoc in various direc- tions. It may pass downwards even into the chest, upwards along the sheath of the vessel into the skull, backwards behind the pharynx, or into the ear and the articulation of the lower jaw. It is therefore necessary to give early vent to an abscess situated in the parotid. If the pus lies external to the gland, the incision made should correspond in direction to the course of the facial nerve, but if the gland has to be cut into, the knife should be carried parallel to the external carotid, one or more of whose branches may possibly be wounded notwithstanding every care. A director and dressing forceps should be employed to reach the pus if it be deep, and antiseptic dressings should be used, as violent and dangerous bleeding, thrombosis, and blood- poisoning have followed deep wounds in the parotid. Sloughing, and even what has been designated as mortification, have been seen after violent in- flammation, and this will be the more readily produced if, when an abscess forms, early and effectual drainage be not secured. It is not in the parotid gland that inflammation leading to troublesome suppuration is so commonly seen, as in the lymphatic glands which lie in and especially below the parotid. Such inflammation causes the usual local signs of its presence. The redness is occasionally erysipelatous, while there is heat, with acute pain increased on pressure and movement. There is also marked constitutional disturbance. The swelling is often great, and the cavity of the mouth inflamed, while the pressure caused by the swelling may not only occasion great pain and tension, but may interfere with the return of blood from the brain, and so bring on delirium and other troublesome symptoms. The pus has a horrid fetor from being mixed with air, and it may collect in one large or several small ab- scesses. Recovery is often protracted, and relapses are not unfrequent. Dis- agreeable marking, parotid fistula, and facial paralysis may eventuate from extensive suppuration in this region. If the inflammation is acute, it will require to be promptly and actively treated by leeches and repeated blisters, and if pus forms, by an early incision. 213 SURGICAL AFFECTIONS OF THE PAROTID GLAND. Parotid Fistula.—Steno’s duct may become occluded either by adhesions following acute inflammation—as in violent salivation, or during the healing of wounds—or by calculi (phosphatic) which sometimes form within it. A more or less complete arrest of the flow of saliva will result, and an oval fluc- tuating tumor will form in the line of the duct. The size of this cyst-like tumor will probably be seen to increase during mastication, and, if it burst externally, a salivary flstula may be established. Fistulse may either be con- nected with the parotid itself, and be placed over some part of its surface, or in its neighborhood though beyond its limits ; or they may open into Steno’s duct.1 The oriflce of the fistula may be so small as to be difficult of detection unless it be elevated, as it sometimes is, on a small papilla, or sunk into a little pit, or unless it be red and irritated by the discharge, so as to mark its presence. The flow of the saliva may be readily increased by the patient chewing some pungent substance, or placing a bit of lemon on the tongue, and then the distillation of the saliva by the orifice may be seen, and the nature of the secretion exactly determined by chemical tests. If the external oriflce is large enough to allow of a colored injection (milk, or a solution of iodine) being thrown along the duct into the mouth, or in the reverse way, or of a probe being passed through it, then all doubt will be removed. Small listulse connected with the gland are usually cured easily, if seen early. In truth, thOy not unfrequently close spontaneously, if any obstruction which was present is removed, but*fistulous orifices connected with Steno’s duct, especially if long open, are very difficult to rectify. The application of various caustics, especially a pointed piece of lunar caustic, is a favorite and simple remedy which in slight cases may succeed, especially if combined with well-adjusted pressure and rest to the part. The galvanic cautery at a low heat, or a hot needle, is however more reliable. All sorts of injections have also been used—wine, alcohol, caustic solutions, iron, iodine, etc.—but little advantage follows their employment. In fistula of the duct an infinite number of remedies have been suggested. Some aim at re-establishing the duct, if partially or wholly closed; some aim at forming a new orifice for the duct within the mouth; some try to arrest the secretion of the saliva by destroy- ing the parotid gland ; and others employ various methods for merely closing the opening on the cheek by plastic or other operations. If the duct is obstructed between the fistulous opening and the mouth, a fine leaden probe, or a firm piece of catgut, may possibly be passed from the mouth along the duct and beyond the fistula, so as to act as a conductor for the saliva, and thus allow the abnormal aperture to close or be dealt with by the surgeon. Setons of wire, silk, etc., have been used in the same way. A new orifice within the cheek has been secured in various ways. A seton of wire, catgut, cotton, lead, or other material; a trocar and canula (the latter being left in place); the bistoury, followed by a tent, have all been used for this purpose. Feguise’s plan has secured considerable favor. He passed a small trocar from the fistulous orifice inwards and backwards, and passed the end of a leaden wire. The trocar was then passed a second time from the original point of introduction, but this time it was carried in the direc- tion of the duct, and the other end of the wire was passed into the mouth. The two free ends of the leaden wire, which now projected into the mouth, were then twisted together within the cheek, thus constricting some of its substance. The external orifice was next closed by the ordinary twisted suture, and its edges became adherent in a few days as the saliva escaped into the mouth along the wires, which were finally removed as the 1 Duparcque, Revue Mfidicale, 1842; and Mem. de la Soc. de Cliir., tome ii.; Jarjavay, Ibid., tome iii. 214 INJURIES AND DISEASES OF THE NECK. apertures along which they had passed became permanently established as internal openings. Threads of gold, silver, silk, and catgut, have been substi- tuted for the lead, and additional means have been used to constrict and divide the piece of soft tissue inclosed in the loop, without improving De- guise’s method. Langenbeck and Van Buren dissected out the extremity of the duct where it opened on the cheek, with a margin of the surrounding tissue, and carried the whole through the cheek into the mouth, fixing it there for some weeks by fine wire sutures, while the outer wound was closed. Professor Horner attained the same end by placing a broad wooden spatula in the mouth, to protect the tongue, and then removing entirely the fistulous orifice with a large sharp punch, so as to drive a hole right through the cheek. The outer wound was then united by the twisted suture. Maisonneuve tried to cut oft'the flow of saliva from the parotid, by apply- ing pressure between it and the fistulous opening, and it has been asserted that pressure applied to the parotid itself has brought about its atrophy, and thus arrested the stream of salivary fluid which escaped. These latter reme- dies, however, need hardly be discussed. Finally, autoplastic operations may be resorted to if an internal orifice have been secured, and if the exter- nal opening cannot be otherwise closed. If a calculus is impacted in the duct, its presence can easily be recognized by the swelling and discomfort which it occasions, and by an examination made with one finger within the mouth, and another outside the cheek. These calculi are of an elongated shape, and lie in the axis of the duct. They should be at once removed by a free incision on the buccal surface, while pressure is kept up by the finger outside. They may, if left, occasion the formation of a fistula, by setting up ulceration. Tumors of the Parotid.—The parotid is occasionally the seat of various tumors of a simple or malignant kind. They may consist of one element, but they are more usually mixed. The simple growths are either mere hy- pertrophy, which is very rare indeed, or consist of fibrous, cartilaginous, adenoid, fatty, and myxomatous elements. Of malignant tumors, carcinoma is not very rare, while sarcoma is occasionally seen, and the recurrent fibrous [spindle-celled sarcoma] is also met with. Cysts have their seat at times in this region, and these different neoplasms may be variously combined. The lymphatic glands lying over and in the parotid, may become the seat of enlargement, or may be altered in structure; and in this way the surgeon has at times no easy task to distinguish with accuracy the nature of the tumor which he is called upon to treat. It is by a consideration of the clinical history and physical characters of the tumor, and of its effects on neighboring structures, as well as by observing the age and condition of health of the patient, that a surgeon is chiefly guided in his opinion. The slow, painless growth in an outward direction ; the absence of close adhesion to the parts below, above, and around, so that the fingers can, as it were, be inserted below the tumor, and separate it from its surroundings ; the healthy condition of the distended skin ; the non-existence of facial paralysis and lymphatic gland-irritation as well as of other pressure- effects, and the non-involvement of the general health, would point to the tumor being innocent. The cancers again contrast in all respects with such growths, but in varying degrees according to their special forms. The hard, ill-defined tumors which appear under the ear in persons at or after middle life, early fixed (especially laterally), with pain flashing up to the temple and down the side of the neck, markedly compressing surrounding structures and so interfering with their function, growing rapidly, involving the SURGICAL AFFECTIONS OF THE PAROTID GLAND. 215 skin and making it coarse and dark-colored before it gives way, and estab- lishing in time the broad-spreading, deep, characteristic, bleeding ulcer, with hardened chain of glands and dilated veins, with facial paralysis and early embarrassment of deglutition and mastication, very plainly point to the hard and condensed form of carcinoma. Between these two extremes there will be found many diversities and combinations. Carcinomata of the soft form, myxomata, cysts, and cartilaginous tumors, occur mostly in young persons; tibrous and sarcomatous growths before middle life; and hard cancers and epitheliomata in old age. Soft cancers, lymphomata, and sarcomata grow most cpiickly, and fatty, fibrous, and cartilaginous tumors most slowly. The shape, outline, and- consistence of the tumor, the presence or absence of lobulation, its rapidity and regularity of increase, its size, the state of the overlying skin, the interference of the tumor with function, together with the age and health of the patient, and possibly the family history, will chiefly aid the surgeon in distinguishing the species of growth with which he has to deal. Simple hypertrophy of the parotid is very rare. The case related by Berard,1 and verified after the death of the young patient, and one or two others whose exact nature was not determined, make up the sum of such cases.2 The “ glandular parotid tumor” is perhaps that with which the surgeon is best acquainted. Its pathology has been much debated. At one time it was thought to spring from a lymphatic gland lying in contact with the parotid, at another to be always due to a growth of the parotid gland itself, or of its fibrous envelope.3 The common parotid tumor is fibrous or glan- dular for the most part, but has mixed with it cartilaginous masses and often cysts. It compresses the parotid more or less, and may occasion its atrophy and almost total absorption, so that when it is removed a deceptive appear- ance is produced of the parotid having been excised. These tumors often attain a great size, and are yet movable and but loosely connected. Their surface is irregular, tuberous, lobed, or round, firm and hard at most points, but elastic at others. The skin, though marked by enlarged veins, is not involved or adherent. They lie below, in front of, and behind the ear, and grow slowly and perhaps capriciously, or remain stationary for years. They have no effect on the general health, and cause little pressure as a rule, though facial paralysis, impediment to the venous return from the head, and embar- rassment of swallowing and chewing, have in rare cases been observed. Parotid tumors rarely consist of pure cartilage, but the great bulk of them may be formed of that structure, and when soft and quick-growing, as they are in exceptional cases, they may recur after excision. They may be wholly buried in the gland, or be merely pressed into it and covered by the fascia, and the facial nerve may pass through them, be spread over them, or be firmly adherent to their under surface. They usually appear about middle life, and are generally innocent. The only effectual remedy for these growths is removal, and if they are growing, the sooner this is effected the better, as with increased size comes augmented difficulty. The method of excising them will be hereafter described. Lipomata are occasionally met with, over, Avithin, and below the parotid, and are recognized by their well-known characters. Ncevi also occur over the gland, and cysts (serous, sanguineous, sebaceous, and compound) form here as elsewhere, but do not demand special description.4 1 These de Concours, 1841. 2 Vidal, Traite de Pathologie Externe, tome iii. p. 669-70. s Berard, These ; Bauchet, Mem. de la Soc. de Chir., Juin, 1856 ; Dolbeau, Memoire sur les enchondromes de la parotide, Gaz. Hebdom., 1858. 4 See Paget, Lectures on Surgical Pathology, 3d edit. 1870. 216 INJURIES AND DISEASES OF THE NECK. Carcinoma is not as common an affection of the parotid as was at one time supposed, when no distinction was drawn between it and sarcoma, enchon- droma, fibro-plastic and other tumors. All forms of carcinoma have been met with here. The clinical characters of such growths have already been referred to. Sarcoma is more common than carcinoma, and cannot in many cases be distinguished from it by its history, or physical and vital effects; but as a rule it does not exert as much pressure, does not involve and destroy the skin in the same way, and does not poison the blood. But sarcoma may show marked local malignancy and return after excision, though as to this we cannot express an opinion till the histological elements of the tumor have been examined. The excision of malignant growths of the parotid is beyond our art, and should not be attempted. They insinuate themselves in and around the important structures in their neighborhood, and backwards toward the pharynx, in a way hardly to be recognized before the parts are opened up. Even after death, it has been found impossible to effect a sepa- ration of their prolongations without great destruction of surrounding parts. It has been found impracticable to discover even whether the internal carotid artery, and hypoglossal and other nerves, were not involved, and portions of the growth have been found after death to penetrate the internal jugular vein, without any sign of such a complication having been visible during life. Notwithstanding these considerations, it must yet be allowed that cases are recorded in which the excision of a cancerous parotid is said to have been successfully performed. This point, however, will be again alluded to. Pure myxomas are very rare in the parotid. No distinction, which is of much clinical value, can be drawn between them and sarcomatous growths. They are usually softer and more diffuse, that is, less circumscribed, and more apparently fluctuating. The lymphatic glands lying in contact with the parotid may enlarge and suppurate, or may assume the characters of lympliadenoma and lympho-sar- coma. In the latter case it is only by the clinical history and progress of the tumor, and by an examination of its histological elements, that its true nature can be recognized. Tumors lying over the parotid will, till they attain a considerable size and anchor themselves more firmly, be much more movable than those found in the gland itself—that is, below the strong sheath which incloses the gland—and it is chiefly by observing this mobility, and their greater diffuseness and less limitation to the area of the parotid, that the true seat of the growth is determined. As to the excision of tumors lying over, or in, the parotid gland—fibrous, cartilaginous, glandular, etc.—it may be said that in many cases the operation is easy enough, though from the size and appearance of the tumor before- hand it may appear very formidable. If, however, there are deep and irregular prolongations of the growth, as when it grows within the capsule of the parotid, and if these have formed close connections with the bloodvessels and nerves behind and below the angle of the jaw, then no operation can be more difficult or dangerous. Mere size is no contra-indication to an opera- tion. Tumors in this region have been removed successfully, which have masked the whole side of the neck. In many cases the bulk is due to the increase of the tumor being solely in an outward direction. The mobility and circumscription of the growth ; the possibility of inserting the fingers below it, and, as it were, raising it up; the freedom from pressure-effects on bloodvessels and nerves; the healthy state of the skin and the lymphatic glands; the rate and direction of the tumor’s increase, together with the age and state of health of the patient, and the possibility of removing the whole mass, will chiefly influence the judgment in determining for or against an operation. SURGICAL AFFECTIONS OF THE PAROTID GLAND. 217 In excising simple growths, the overlying parts should be freely divided down to the tumor itself. If it is encapsuled, the growth should then be enucleated with as little dissection as possible—the linger and handle of the knife being chiefly employed. An incision passing down the posterior sur- face of the tumor, and another leaving the first at either its centre or lower end, and running forwards, generally best meet, the requirements of these cases. If deep dissection be required, the parts to be divided should be scraped through only after careful inspection, and the securing of each doubt- ful portion by two ligatures before division. Drainage must be very care- fully provided for, and no skin should be removed unless it be diseased. If important bloodvessels running through the tumor are divided, they can be secured without much difficulty, and it is well to dissect from below upwards (as all operators have stated), and from behind forwards, so as to tie at once the main bloodvessels which are necessarily cut, and not have to ligature them again and again in the course of the operation. It has been shown that if the main trunk of the facial nerve be divided, and its cut ends placed together, the function of the nerve will be restored. It would be well in such a case to unite the extremities of the nerve by suture. The common carotid is not now tied as formerly, preparatory to the excision of tumors of the parotid, and the use of the ecraseur and galvano-cautery is seldom thought of, though the latter instrument might, in complicated cases, be found of much use. It is right to add that the possibility of excising the parotid has been the subject of much controversy. That in its unchanged condition it is impos- sible to define accurately its limits so as to take it all away without injury to surrounding structures, has been asserted since Allan Burns and others studied the question ; but that it can be removed when so altered by disease as to become more defined, prominent, and prehensible, must be admitted.1 Xelaton, Malgaigne, and many others have taken a prominent part in this discussion, but the terms of the question debated have not always been iden- tical. To excise a sound, unchanged parotid, and one affected with cancer, are very different things; and these again differ widely from dealing with a parotid, the seat of affections which have not the tendency to burst the cap- sule of the gland, and spread far and wide, working themselves into the sur- rounding parts as malignant tumors do. It is from not observing this difference in the problem, that much of the diversity of opinion which is so copiously expressed in the writings of several authors has arisen.2 It is not necessary here to enter on this question. In America, excision of the diseased parotid has been, perhaps, more frequently reported than elsewhere. Warren of Boston, in 1798, led the way, and McClellan, of Philadelphia, several times repeated the operation. Many cases (over one hundred) are on record in which it is said to have been performed, but there is strong reason to sup- pose that in a certain proportion of these it was not the gland itself, but a tumor deeply imbedded in it, which was removed. Malgaigne, in his report to the Academy, even went the length of asserting that the diseased parotid could be excised without injuring either the external carotid or the facial nerve. Paralysis of the portio dura may, however, be always looked for when the parotid is seriously dealt with, and the bleeding cannot fail to be very severe, so that it is in any case an operation which demands experience and mature knowledge in the surgeon who undertakes it. The incision em- ployed is usually a straight one, but it may assume other directions to suit the 1 See Berard, Des operations que reclament les tumeurs developpees dans la region parotidienne. 1841. 2 Bulletin de l’Academie de Octobre, 1858. 218 INJURIES AND DISEASES OF THE NECK. casein hand. A -psliapedor J-shaped wound is often preferred. It should freely expose the mass, and should make ample provision for drainage. The tumor is best detached from below and behind, upwards and forwards, though Malgaigne and others dissected it from above. It is in dealing with the back of the growth that difficulties chiefly arise. The surgeon must keep close to the tumor, and examine well every fibre before dividing it, scratching and tearing, rather than cutting. The digastric muscle may have to be severed, and each vessel opened must be at once secured. It has been found com- paratively easy to compress and tie the external carotid as it enters the tumor. It should be tied with a double ligature. Malgaigne shows how opening the mouth freely, enlarges the space behind the angle of the jaw, and so facilitates the separation of the deeper portions of the growth. If too much traction be made, the internal carotid and jugular may be so displaced as to come within the field of operation. This should be carefully avoided. The large termi- nal branches of the external carotid will be cut as the upper end of the tumor is detached. The facial nerve cannot escape, unless the growth be so friable that it can be teased out. Ligature of the carotid, in order to induce atrophy of the parotid gland, has not been found to succeed, from the great freedom of anastomosis; and removal of the gland by ligature and caustic has signally failed. Affections of the Submaxillary Gland. The submaxillary gland resembles the parotid in respect to the growths to which it is liable. It is inclosed in a very perfect fibrous capsule, derived from the cervical fascia. Its duct (“Wharton’s”) may be obstructed by cal- culi of the same chemical composition as those found in Steno’s duct; and in consequence of inflammatory adhesions, the escape of saliva may be so im- peded, that a soft, fluctuating swelling forms in the floor of the mouth, due to its accumulation. This is not ranula, but was long confused with it. If from any cause the secretion from the submaxillary duct does not get free vent, engorgement, and (if prolonged) permanent enlargement, of the gland may be caused. The presence of a concretion is best made out by placing one finger in the floor of the mouth and one below the jaw, so as to compress the duct between the fingers, and then rolling one finger on the other. Much swelling and uneasiness may arise from the presence of such a foreign body. In mumps, the submaxillary gland may participate, and may become swelled and painful. Inflammation of the submaxillary gland may follow the irritation induced by a piece of dead bone in its neighborhood, or by a carious tooth or violent stomatitis. It is, however, the lymphatic glands which abound in the neighborhood of the submaxillary, which are most usually affected by such causes, and which simulate an affection of the submaxillary itself; and there is every reason to think that in not a few cases in which growths have been supposed to be seated in the submaxillary gland, calling for its excision, it has been the lymphatic glands which have been really involved, and which have been removed. Cysts, adenoma, enchondroma, fibroma, sarcoma, lymphoma, and sarco- lymphoma have been occasionally met with in the submaxillarv gland. Paget declares that enchondroma is not as common in the submaxillary as in the parotid, and in this he certainly expresses the opinion of most, if not of all, surgeons. Submaxillary growths may attain a considerable size, pressing upwards into the floor of the mouth, and so causing embarrassment of func- tion by their bulk; and even, in rare cases, compressing the pneumogastric AFFECTIONS OF THE SUBMAXILLARY GLAND. 219 and sympathetic nerves, and so causing, with other signs, dilatation of the pupil. The windpipe and oesophagus have also been pressed upon by these tumors. Carcinoma is rare as a primary affection in the submaxillary gland, but it may extend from neighboring parts to this with other structures. It is, however, in the surrounding absorbent glands that this disease is most usu- ally met with. Cancer causes much pain, and occasions a hard, fixed, irregular mass, which soon involves the skin and mucous membrane, and ends in foul ulceration. If it grows to any size, it produces pressure, and may at an early date arrest the flow of saliva from the affected gland. The absorbent glands quickly participate, and the whole of the parts are matted together in one mass. To remove a submaxillary gland so affected is no easy matter, and by the time the true nature of the disease is fully recognized and an operation determined on, it is usually hopeless as regards the saving of life. Jobert (de Lamballe1) and others, are said to have removed small cancerous tumors of the submaxillary through the mouth, without any ex- ternal excision, but they must have been of trifling size, little adherent, and of a simplicity seldom encountered. The drainage would necessarily be bad, the difficulties great if the tumor were of any considerable bulk, and the advantage over the usual operation, below the jaw, difficult to discover. Unless the t umor has attained a large size, it is not a formidable operation to remove it by an external incision. The facial artery, which lies on or in the substance of the gland, is the only vessel which is likely to give trouble. It is best tied before the growth is moved from its bed. The hypoglossal and lingual nerves can be easily avoided, and the branch of the lingual artery which is cut can be readily secured. 1 Gaz. des Hopitaux, 1849. INJURIES AND DISEASES OF THE AIR-PASSAGES. BY J. SOLIS-COHEN, M.D., PROFESSOR OF DISEASES OF THE THROAT AND CHEST IN THE PHILADELPHIA POLYCLINIC, HONORARY PROFESSOR OF LARYNGOLOGY IN THE JEFFERSON MEDICAL COLLEGE, PHYSICIAN TO THE GERMAN HOSPITAL, ETC. Laryngoscopy. Laryngoscopy—inspection of the interior of the larynx—is effected by means of a small mirror so mounted as to be readily passed into the mouth and placed in a position which will reflect the image of the larynx. The same principle has long been employed by the dentist to obtain images of such portions of a tooth as are out of the line of direct inspection. It is to the experiments of Manuel Garcia, of London, a teacher of singing, that modern surgery is indebted for a knowledge of the laryngoscope it is to Prof. Czermak, of Pesth, that is due its reception into the medico-chirurgical armamentarium ;2 and it is to Prof. Tuerck, of Vienna, that medicine is chiefly indebted for copious clinical representations of its great usefulness in diagnosis and treatment.3 All that is needed to examine the larynx and adjoining structures, in the presence of a good light, is a good glass mirror, mounted on a rod firm enough to resist being bent by the muscular action of the soft palate. A circular mirror one inch in diameter (Fig. 1107) will suffice lor most purposes in the adult. Smaller mirrors are sometimes needed with adults, and almost always with children. Fig. 1107. Laryngoscopic mirror, The position of the mirror in the mouth, and the general features of the image of the normal larynx as seen in it, are fairly represented in Fig. 1108. The manipulation of the laryngoscopic mirror may be briefly described as follows: The mouth of the patient being well illuminated by natural or 1 Physiological Observations on the Human Voice. Proc. Royal Soc., vol. vii. No. 13, p. 399. London, 1855. 2 Wien med. Woch., No. 13, Marz, 1858 ; Der Kehlkopfspiegel und seine Verwerthung fur Phy- siologie und Medizin. Leipzig, 1860. 3 Klinik der Krankheiten des Kehlkopfes und der LuftrOhre. Wien, 1866. 222 INJURIES AND DISEASES OF THE AIR-PASSAGES. artificial light, direct or reflected as may be most convenient at the moment, the patient is directed to open his mouth, to put out his tongue as far as possible, and to prevent his tongue from slipping back by holding it in a fold of a handkerchief or napkin (Fig. 1108). The surgeon, with his mirror in hand much as he would hold a pencil (Fig. 1109), warms the glass over Fig. 1108. Fig. 1109. Manner of holding a laryngoscopic mirror. Laryngoscopic mirror in position. The tongue extended, and held with a napkin. the flame of an alcohol lamp or gas jet, to prevent condensation of the breath on its surface, and then passes the mirror into the mouth, reflecting surface downward, and rests it against the soft palate, which he lifts slightly with the uvula on the back of the mirror. The reflecting surface now pre- sents itself obliquely forward and downward, and shows an image of the parts in front of it and below. By moving the mirror gently, the image is changed from point to point until the inspection has been completed. With a steady hand and a little practice, the larynx can be thus examined at once in the great majority of instances. Repeated attempts are necessary, at intervals of a few moments of rest, with nervous subjects, and in cases of hypersensitiveness of the parts from disease. For the minute details of manipulation the reader must be referred to manuals of laryngoscopy and of diseases of the throat. When examinations are made with daylight, the parts appear in their true colors, which are much paler than the colors produced by artificial light. When direct daylight cannot be used, the diffuse daylight may be concen- LARYNGOSCOPY. trated upon the interior of the mouth and throat by means of a concave reflector similar to those used in ophthalmoscopy (Fig. 1110), which may be held in the hand, or may be attached to the head. The same kind of reflector is used with artificial light, a combined illumination practised more frequently than any other, and then the reflector may be conveniently attached to either a lamp (Fig. 1111) or a gas-bracket. Various lanterns, or light-concentrators, are used for illuminating purposes, but a good naked gaslight answers admirably, and a coal-oil light is still more satisfactory. The lanterns, whether for coal- oil, gas, oxy-hydrogen, or electric lights, are not needed .for ordinary purposes. The brightest light available is sunlight, direct, or reflected from the surface of a plane mirror. Fig. 1110. Fig. 1111. Perforated reflector for laryngoscopy, with hand for attachment to head. Laryngoscopy by reflected artificial light. Method of Tobold. (Tobold.) The image of the structures thus to be inspected by laryngoscopy requires some little preliminary study on the normal subject, or on the exsected larynx, to be fully comprehended; for it appears in a position nearly verti- cal, while the natural plane is much more horizontal. Then, too, there is an apparent antero-posterior reversement of position, with maintenance of the actual lateral relations of left and right. The structures which can be inspected laryngoscopically are, from before backward and downward: The posterior portion of the base of the tongue; the posterior surfaces of the anterior palatine folds, and their attachment to the sides of the base of the tongue; the lateral ligaments connecting the tongue with the hyoid bone; the ligaments connecting the tongue with the epiglottis, together with the lingual sinuses on either side of the middle glosso-epiglottic ligament; the tonsils; the posterior palatine folds; the ligaments connecting the epiglottis with the hyoid bone; the epiglottis, on both lingual and laryngeal surfaces; the aryteno-epiglottic folds forming the lateral borders of the entrance into the respiratory portion of the larynx; the arytenoid and supra-arytenoid (Santorini) cartilages; the poste- rior or arytenoidal vocal processes, extending into the structure of the vocal bands; the base and sometimes more of the cuneiform (Wrisberg) cartilages; the laryngo-pharyngeal sinuses between the wings of the thyroid cartilage and the soft lateral walls of the laryngeal tube; the posterior wall of the 224 INJURIES AND DISEASES OF THE AIR-PASSAGES. pharynx down to its transition into the oesophagus; the posterior wall of the larynx down to where the pharynx merges into the oesophagus; the supra-glottic portion of the interior of the larynx; the vocal bands (true vocal cords), the laryngeal ventricles (Morgagni) above them, and the ven- tricular bands (false vocal cords) above the ventricles; the infra-glottic por- tion of the cavity of the larynx to a variable extent, and the internal face of the anterior portion of the thyroid cartilage, crico-tliyroid membrane and cricoid cartilage; the anterior portion of the trachea in variable extent, clear down to its bifurcation under favorable anatomical relations; a portion of the interior of the right bronchus under exceptional normal conditions; and more or less of the posterior wall of the trachea. Wounds and Scalds of the Larynx and Trachea. Wounds of the larynx and trachea occur as results both of external and in- ternal injuries. Wounds from external injuries usually, but not invariably, implicate the integument by solution of its continuity. They are usually attended by extensive hemorrhagic extravasations into the abundant loose connective tissue. They are frequently complicated by fractures of the car- tilages. They are occasionally complicated by wounds of the great cervical bloodvessels and nerves. Wounds from internal injury almost always impli- cate the mucous membrane in the first instance; in rare instances they may penetrate the cartilage ; even a wound of the carotid artery has been known to occur in this manner. Wounds of external origin present themselves in the usual varieties of con- tused, punctured, incised, lacerated, and gunshot wounds. Wounds of internal origin present themselves mostly as lacerated, but occasionally as punctured wounds. They are usually the result of injury by a foreign body in the air- passage. Scalds or burns may be caused by hot or caustic fluids swallowed acci- dentally or designedly, or by flame or hot air inhaled from burning buildings or ships. I. Wounds of the Larynx and Trachea. Wounds of External Origin.—Contused wounds of the larynx are usually produced by intentional blows upon tlie tbroat with the fist or a weapon, by kicks from men or beasts, by accidental blows from hard objects, or falls upon them, or by attempts at strangulation, whether with hands, with cloth, or with rope. They are liable to cause considerable extravasations of blood into the submucous and intermuscular connective tissue. In some instances the injury is sustained by the soft parts only. Some cases are complicated with fracture of the cartilage—simple, or even comminuted—occasionally the cricoid, but more frequently the thyroid. These fractures may be anterior or lateral, and are usually vertical, or nearly so.1 Other complications comprise rupture of the ligaments and connecting membranes of the different com- ponents of the laryngeal skeleton; rupture or laceration of the vocal bands, mucous membrane, and other soft tissues ; fracture of the cornua of the hyoid bone ; dislocation of an arytenoid cartilage; and contusion, rupture, or other injury to the trachea. Contused wounds of the trachea occur from the same class of causes as similar 1 See Fractures. WOUNDS OF THE LARYNX AND TRACHEA. 225 wounds of the larynx. They are usually associated with rupture of one or more intercartilaginous ligaments, or with rupture of the trachea from the cricoid cartilage. Sometimes they are associated with longitudinal fractures of one or more rings; and sometimes with comminuted fractures, as when the result of crushing violence.1 Sometimes they are associated with lacera- tion or rupture of the membranous wall, either with or without perforation into the oesophagus. Hemorrhagic extravasations may be very extensive. In most, instances these wounds are associated with wounds of the larynx, similar or still more severe. Punctured wounds of the rlarynx are usually accidental, as from falls upon pointed objects. Legouest2 has reported one in which the tine of a pitchfork perforated the larynx from right to left. Sometimes they are the result of homicidal attacks with sharp or pointed weapons; occasionally they are suicidal. Modern military records seem to furnish few examples of bayonet wound of the air-passage. Only nine bayonet or sabre-wounds of the neck are recorded in the History of the War of the Rebellion, and in none of these had the air-passage been implicated. Durham, however,3 relates the case of a patient under his care in G-uy’s Hospital, London, whose larynx had been wounded by a bayonet during this war. According to the same author, punc- tured wounds through the thyroid cartilage occasionally penetrate between the vocal bands, or injure one or both of them ; oedema of the glottis(?) ensuing almost invariably, and producing death by suffocation. A case is quoted from Sir Charles Bell in which suffocation from exuberant granulations ensued some months after a wound in this situation, inflicted with a penknife. The wound in the integument may be trifling. Emphysema is a frequent complication, and may produce severe dyspnoea. Punctured wounds of the trachea are due to the same class of causes as are punctured wounds of the larynx. Beach4 has reported a case of perforation of the trachea by the tine of a pitchfork. Such an injury from a sword has been recorded by Pare,5 and one from the point of a closed pair of scissors, by W. F. Atlee.6 Three instances of penetration of the trachea in injecting bronchocele have been mentioned by Mackenzie,7 in one of which persistent haemoptysis ensued. Emphysema of the neck is quite a common result in punctured wounds of the trachea, and general emphysema may reach alarm- ing proportions within a few hours.8 Pncised wounds of the larynx are more frequent than those of all other varie- ties together. Surgical wounds for operative purposes will not be discussed in this connection. Incised wounds may involve not only the integument and the structures of the air-passages, but also the muscles, bloodvessels, nerves, submaxillary glands, and tongue. Occasionally accidental, as in falling upon a sharp object, such as a fragment of glass or crockery, and sometimes due to homicidal attacks, most wounds of this class are suicidal. In some wars they are produced by sabre-cuts. (Pare, Legouest.)9 It has been estimated statis- tically that of 4595 suicides in Prance, 125 had cut their throats ;10 and that of 6696 cases of suicide in England, between 1863 and 1867, 1235 were cases of cut-throat.11 Quite a large proportion of suicidal wounds are seen in insane subjects and 1 See Fractures. 2 Horteloup, Plaies du larynx, de la tracliee et de l’oesophage, p. 51. Paris, 1869. 3 Holmes’s System of Surgery, vol. i. p. 689. Am. ed., 1882. 4 New York Med. Jour., March, 1877, p. 302. 6 (Euvres completes, ed. par Malgaigne, t. iv., liv. 8, chap. xxx. ; Mackenzie, Diseases of the Throat and Nose, vol. i. p. 540. London, 1880. 6 Am. Jour. Med. Sciences, April, 1878, p. 439. 7 Op. cit.,p. 540, note. 8 Beach, loc. cit. * Horteloup, op. cit., pp. 53-55. 10 Brierre de Boismont, Du Suicide. Paris, 1856. 14 Durham, op. cit., vol. i. p. 684. 226 INJURIES AND DISEASES OF THE AIR-PASSAGES. in incarcerated criminals. The sane and unconfined suicide usually uses a razor or a knife; but the insane suicide and the prisoner, from whom cutting implements are withheld, often construct weapons out of spoons or forks, frag- ments of glass, or other available objects. The individual who determines to commit suicide by cutting his throat, has usually become impressed with the erroneous popular belief in the ne- cessary fatality of an extensive wound into the windpipe ; while, the source of immediate danger to life really resides in division of the cervical blood- vessels, the elasticity and mobility of which often protect them from direct injury. As a rule, too, the head is bent backward, to render the wind- pipe more prominent as the stroke is made. Hence, the sterno-mastoid muscles are advanced, and the large bloodvessels are pushed behind the ordinary range of the knife, especially if the cut be made high up ; and thus the main portion of the deep wound is in the air-passage. When, however, the suicide, like Lord Castlereagh, who thrust a penknife through his carotid artery, is familiar with the anatomy of his neck, or when in his excitement he makes a sweeping cut, the great cervical blood-vessels are severed in the incision, and death takes place by hemorrhage and not by reason of any opening that has been made into the air-passage. Sometimes, however, hem- orrhage into the air-passage produces speedy death by suffocation. The infrequency of wounds of the great vessels is furthermore attributed to the resistance of the cartilages, which prevents deep incision at the level of the lar}Tnx; and to spasmodic contraction of the sterno-cleido-mastoid muscles when the cut is at a lower level (Durham); while when the trachea is severed, the sudden escape of air from the lungs is supposed to deprive the arm of the full support of the thoracic muscles, so that the arm falls before the stroke has been completed. (Hinton, cited by Durham.) The wound of the integu- ment is usually from left to right, and more obliquely downward than trans- verse, the. greater portion of the cut being upon the left side when the right hand has been used, as is the rule. The size of the external wound varies from little more than a puncture to a length of several inches, even reaching from one sterno-cleido-mastoid muscle to the other. As a rule it is much larger than the wound in the air- passage, but sometimes it is much smaller, as in a case reported by Fine,1 in which but a small external wound was made with the point of a penknife, while the thyroid cartilage was divided into eight portions. Incised wounds of the neck, above the hyoid bone, do not implicate the larynx, although they may penetrate the air-tract by opening into the pharynx or into the mouth. Nevertheless, death by suffocation may ensue from occlu- sion of the larynx by the posterior portion of the divided tongue.2 The hyo-thyroid membrane is the most frequent seat of lesion. Wounds of this membrane, although, anatomically, wounds opening into the pharynx, must be discussed in connection with wounds of the larynx, because the epiglottis is frequently severed in the incision, sometimes in its free portion and sometimes at its attached portion. If not severed it is often wounded. In some instances the epiglottis escapes the cut, and the upper portion of the larynx is exposed to view uninjured. In a case of this kind, in an aged subject but recently (April, 1884) under observation in consultation with my colleague Dr. James Collins, at the German Hospital, Philadelphia, the section had divided the tongue, the sterno-cleido-mastoid muscles, both submaxillary glands, and the pharynx to within an inch of its entire circumference. In 1 Jour, de Med., Chir., Pharm., etc., 1790; quoted by Fischer (Pitha und Billroth’s Handbuch, Bd. iii. 1 Abth. 3 Lief. S. 101). 2 See Durham’s case, Holmes’s System of Surgery, vol. i. p. 687. WOUNDS OF THE LARYNX AND TRACHEA. 227 some instances the hyoid bone and the tongue are severed from the larynx ; and the upper fragment of a still attached epiglottis may be seen in the upper segment of the wound, and its intra-thyroidal portion in the lower. The gap- ing in these wounds is very great. The extent to which the pharynx is severed may comprise its entire circumference, the knife penetrating a verte- bra.1 In a case seen by myself in the hospital practice of Dr. R. J. Levis, of Philadelphia, less than half an inch of the posterior pharyngeal wall had escaped division. Cuts through the thyroid cartilage may wound the vocal bands. They seldom penetrate the entire cartilage. Sometimes they fail to reach the mucous membrane, so that the air-passage is not opened at all. Cuts through the crico-thyroid membrane may sever the larynx completely.2 Cricoid car- tilage3 and pharynx may be injured likewise. Sometimes one or both supra- arytenoid cartilages, or even the arytenoid cartilages, are severed or wounded. The crico-traclieal membrane is very rarely the seat of the wound. The resistance being slight, wounds here generally sever the trachea from the larynx. That the larynx is wounded more frequently than the trachea, seems to be the individual opinion of surgeons as drawn from personal observations. Nevertheless, a systematic compilation by Sabatier4 gives the trachea as the seat of injury in 22 instances out of 45, or practically in one-half the cases, the crico-thyroid membrane having been severed in 13 and the thyroid car- tilage in 10. Durham5 gives the trachea as the seat in 41 out of 158 unse- lected cases of penetration of the air-passages, the situation of the wound hav- ing been above the hyoid bone in 11 cases, through the hyo-thyroid membrane in 45, through the thyroid cartilage in 35, and through the crico-thyroid membrane in the remaining 26. According to Malgaigne,6 the larynx is severed in young subjects only, and for the reason that they can throw their heads further back than old persons, in whom the suicidal injury is consequently more frequent in the trachea. If this be the rule, it is not without many exceptions ; for wounds through the thyro-hyoid membrane at least are not uncommon in aged subjects. • When the epiglottis, or a portion of the arytenoid or supra-arytenoid •cartilage, has been severed, there is liability to impaction of the fragment between the vocal bands or above them; an accident that may take place within a brief interval,7 or not until after some hours or a few days. Suffo- cation may ensue in such instances.8 Hence any movable fragment which might induce such an accident should be promptly excised, for it can rarely be safely secured for any length of time by stitching. If the suicide has made several cuts in his neck, as shown by a jagged wound of the integument, portions of the cartilages may have been hacked into a number of pieces, some of which may hang loosely. Under such circum- stances it becomes still more imperative to remove all fragments. The immediate danger of death by suffocation from hemorrhage into the air- passage, or from occlusion by blood-clots, is much greater in multiple wounds of this sort, than in wounds by a single stroke. The like danger is greater in wounds of the trachea than in wounds of the larynx, because of simul- taneous severance of thyroidal vessels or of the thyroid body. 1 Fischer, Pitha und Billroth’s Handhuch, Bd. iii. 1 Ahth. 3 Lief. S. 101. 2 Hennen, Principles of Military Surgery, 3d ed. p. 368. London, 1829; Gross’s System of Surgery, 6tli ed. vol. ii. pp. 315 and 316. Philadelphia, 1883. 3 Stokes, quoted by Gross (op. cit., vol. ii. p. 315). * Horteloup, op. cit., p. 16. 5 Holmes, op. cit., vol. i. p. 687. 6 Horteloup, op. cit., p. 17. 7 Houston, Dublin Hospital Reports, vol. v. page 315 ; cited by Ryland, Durham, and others. s See cases narrated by Sir Chas. Bell (Surgical Observations, vol. i. p. 44). Dr. Wm. Stokes, .and Prof. S. D. Gross (op. cit., vol. ii. p. 315). 228 INJURIES AND DISEASES OF THE AIR-PASSAGES. (Edema of the larynx sometimes follows incised wounds, especially those in which the upper portion of the larynx has been uncovered by division of the hyo-thyroid membrane. The action of the atmospheric pressure in rolling the cedematous aryteno-epiglottic folds inward and downward at each inspiration, is beautifully demonstrated in these instances, confirming Sestier’s antelaryngoscopic theory of the mechanism in some cases of suffocation in oedema of the larynx. Emphysema occurs in some cases of incised wound, especially when the wound in the integument does not open directly upon the wound in the air- passage. This emphysema may spread not only over the neck, face, and thorax, as is not infrequent, but likewise over the entire abdomen, down into the scrotum, or even into the mediastina or into the interior of the larynx.1 It is most likely to occur in cases where the surgeon has been too assiduous in approximating the edges of the external wound. Incised wounds of the trachea are due to causes similar to those of incised wounds of the larynx. They usually occupy the upper portion of the tube. They are often associated with wounds of the thyroid gland. They are liable to serious complication by suction in of the soft parts, so as to occlude the air-passage and threaten suffocation. Durham2 refers to a fatal case of this kind related by Casper, and to a case narrated by Richet, in which the oeso- phagus projected forward and became interposed between the cut ends of the divided trachea. The wound usually implicates the anterior or cartilaginous portion of the trachea only, and occupies one or more rings, passing obliquely from left to right. Sometimes the tube is divided in its entire extent, exposing the intact or wounded oesophagus, as may be ; and then the lower end may become greatly retracted—so much so, if the wound be low down, as to become almost hidden at each inspiration. Durham3 cites a case from Richet,4 in which the trachea had been divided obliquely through four or five of its rings, the separation between the two portions measuring more than two inches, with an increase of about half an inch additional during inspiration, and the lower part plunging down almost into the mediastinum. The oesophagus is very liable to suffer injury in case of complete division of the trachea. Hemorrhage is often quite copious from incised wounds of the trachea, especially if the thyroid veins or the thyroid gland have been wounded. The danger from entrance of the blood into the air-passage is greater than in similar wounds of the larynx. The laryngeal nerves are sometimes wounded (Larrey), but as a rule neither nerves nor great bloodvessels are injured, even though the sterno-mastoid be severed and the carotid artery exposed. Emphysema occurs as in incised wounds of the larynx, and much more frequently because of the small size of the wound and the corresponding difficulty in the escape of the air. Lacerated wound,sof the larynx, other than gunshot, are very infrequent. They result from falls, kicks, blows from falling objects, and crushing violence by machinery and otherwise. They are almost always accidental. They are sometimes associated with wounds of the pharynx, as in the case of a fall on broken crockery, which recovered under the care of Mr. Bryant.5 Sometimes they are associated with comminuted fracture. They may be accompanied by laceration of the trachea, as in an injury from the kick of a horse, where a rupture extended through the thyroid and cricoid cartilages, and continu- ously through the first tracheal ring.6 1 Horteloup, op. cit., pp. 53, 71 ; Durham, op. cit., vol. i. p. 688. 2 Op. cit. 3 Op. cit. 4 Gaz. des Hop. 1855, p. 35. 5 Brit. Med. Jour.. .Tan. 26, 1884, p. 164. 6 O’Brien, Edinb. Med. and Surg. Journ., vol. xviii. ; quoted by Ryland and others. WOUNDS OF THE LARYNX AND TRACHEA. 229 Lacerated wounds are sometimes wholly internal, although caused by ex- ternal violence. Lacerated wounds of the trachea are more common than lacerated wounds of the larynx. They occur most frequently in the form of rupture between cartilage and ligament. Like lacerated wounds of the larynx, they are most frequently the result of various local injuries, such as falls, blows, kicks, and crushes. Counter-pressure may be an occasional cause, as in a case reported by Godlee,1 in which the trachea of a child was split, front and back, immediately above the bifurcation, in consequence of the passage of a cart-wheel over the chest—the third, fourth, and fifth ribs sustaining fracture on the right side at their point of greatest convexity. Causes of non-surgical origin occasionally produce rupture or laceration ol the trachea, such as cough in croup2 and bronchitis,3 chiefly in children; violent inspiratory efforts in dyspnoea from obstruction or compression ;4 and violent expiratory efforts in parturition, or even in defecation. Rupture of the softened trachea may result from the pressure of an abscess, an aneu- rism, or a morbid growth. In cases more strictly surgical in origin and character, the laceration or rupture may be associated with fracture of the cartilages. It often occurs independently. The rupture occurs most frequently between two of the upper rings, or between the upper ring and the cricoid cartilage. In the latter case, the trachea may recede quite a distance from the larynx. An instance is recorded by Mr. Long,5 in which the trachea had become separated from the larynx for a distance of about two inches, as demonstrated during a tracheotomy which saved the life of the patient. The violence had been very great in this instance, the neck having been caught by the coupling-irons of two rail- way coaches. A case of complete rupture of the trachea from the larynx, the result of a kick from a horse, is recorded by Robertson.6 Gunshot wounds are most frequent in military practice. Nevertheless, their small proportion seems sometimes remarkable, the records of several exten- sive wars of the present generation not presenting a single example. The resiliency and mobility of the larynx and trachea doubtless deflect many balls, so that the air-tube, though struck, is not penetrated.7 The texture of the beard, and the position of the lower jaw, especially in the position of firing a gun, are regarded as additional factors in protection. The French contingent in the Crimean war8 reported but one wound of the larynx, and that a gunshot wound, out of a total of 28,401 wounds, of which 460 impli- cated the neck. The English contingent9 reported eight wounds of the larynx, pharynx, and oesophagus, out of 147 neck-wounds. Five of these cases, and an additional one, are related by Mr. Longmore in Holmes’s System of Sur- gery. In Demme’s Record of the Italian War of Independence, in 1859, there is no mention of wounds of the larynx, although there were 170 neck-wounds in the Austrian army, and 187 in the forces of the allies. Loffler’s report of the Schleswig-Holstein war, in 1864, is said to be equally silent as regards 1 Med. Times and Gaz., December 12, 1874, p. 675. 2 Latour, Manuel sur le Croup. Orleans, 1808; Voss, New York Med. Jour., Jan. 1860, p. 37. 3 Bredschneider, Casper’s Wochenschrift, S. 261. 1842; Lefferts, Medical Record, Nov. 25, 1882, p. 599. 4 Marshall, cited by Gross (op. cit., vol. ii. p. 317). 5 Brit. Med. .Tourn., July 26, 1856. 6 Lancet, September 6, 1856. 7 See case of Hooper, mentioned by Gross (System of Surgery, 6th ed. vol. ii. p. 315) ; and cases in the Medical and Surgical History of the War of the Rebellion, Part First, Surgical Volume, p. 406. s Chenu, cited by Witte (Arch. f. klin. Chir., Bd. xxi. S. 184. 1877). 9 Medical and Surgical History of the British Army, 1854-6, Witte, loc. cit. 230 INJURIES AND DISEASES OF THE AIR-PASSAGES. the larynx, the number of neck-wounds being 48 out of 2855 among the Prussians, and 26 out of 1203 among the Panes. In the Austro-Prussian war of 1866, Biefel reports two wounds of the larynx and trachea out of 382 cases, and Maas reports one out of 212. As regards the last Franco- Prussian war, neither Bussenius nor MacCormac reports a single wound of the air-passage, but Beck reports nine cases out of 83 neck-wounds. Fischer reports three cases out of 15 neck-wounds, and Kirchner reports one out of 32. Witte, from whom the above references have been culled, mentions other wars, the statistics from which are valueless in the present connection. 27one of the statistics yet cited approach in completeness those given in Surgeon Otis’s encyclopaedic records of the War of the liebellion.1 Gunshot wounds of the larynx and trachea comprised 2.2 per cent, of the gunshot wounds of the neck that came under treatment during that war. In a few, the larynx and trachea were both involved; in others, the air- passages together with the pharynx or oesophagus. The trachea was less frequently injured by small projectiles than the larynx, and was most fre- quently wounded in its posterior, membranous portion. Ample evidence was afforded that missiles are diverted from their course on impact with the trachea. Out of 4895 cases of gunshot wound of the neck, without known injury to the cervical vertebrae, 41 involved the trachea, with 21 deaths, the result in one case being unknown; 30 involved the larynx, with 10 deaths, and 10 results unknown; 4 involved both trachea and larynx, with no death; 2 the trachea and pharynx, with no death ; 2 the trachea and oeso- phagus, both fatal; 1 the larynx and oesophagus, the patient recovering; 2 the pharynx and larynx, both fatal.2 Only four specimen-preparations are preserved in the U. S. Army Medical Museum—Fos. 648, 697,1440, and 2021. Gunshot wounds are mostly caused by bullets; some, by fragments of shell. They are usually complicated with contusion and laceration of the soft parts, and with comminuted fracture of the cartilages. Contusion, effusion, and suppuration of the interior may take place, although the ball does not penetrate the larynx.3 Fractures from gunshot wound have been recorded, without destructive wound of the integument.4 Whether the bullet shall pass through the larynx, as it does in some instances, or whether it shall remain impacted, as occasionally happens, depends upon the distance travelled by the missile, the tissues traversed before it impinges upon the larynx at all, the part struck, and the position of the individual and the part at the moment of injury; but Preparation 1440, U. S. Army Medical Museum, shows an imitation of the battered conoidal ball which lodged in the upper portion of the right wing of the thyroid cartilage, after having shattered the inferior maxilla to the right of the symphysis. The missile may lodge elsewhere in the tissues, after traversing the larynx. In a ease reported6 by Dr. Daly, of Pittsburg, at the meeting of the American Laryngological Association in 1884, the bullet was removed from within the sheath of the sub- clavian artery on the side of exit. Large portions of the anterior portion of the larynx or trachea are occasionally destroyed in this manner. Dr. Chisolm* mentions that several instances occurred among the Confederate forces, in the late war in the United States, where the larynx had been carried away. Sometimes the destruction is confined to the perforation made by the ball. 1 Med. and Surg. History, etc., Part First, Surgical Volume, p. 406. 2 Op. cit., Part Third, Surgical Volume, p. 688. 8 See cases recorded in Med. and Surg. History of the War of the Rebellion, Part First, Surgical Volume, p. 404. 4 Medical and Surgical History of the British Army, 1854-56, cited by Witte (loc. cit., S. 484); Wales, Am. Journ. Med. Sci., Jan. 1867, p. 269. 6 New York Med. Jour., July 12, 1884, p. 29. 8 Cited by Otis, Med. and Surg. History, etc. WOUNDS OF THE LARYNX AND TRACHEA. 231 Sometimes the epiglottis is carried away; sometimes it is split or simply wounded. The missile sometimes wounds the larynx after having passed through the face, the chest, or the upper extremity ; and thus fractures of the jaw, clavicle, or humerus, and lacerations of the face, neck, and chest, become associated with gunshot wounds of the air-passages.1 The hemorrhage in these cases is usually much less than in those of incised wound, but the syncope therefrom perhaps more frequent and more protracted. The comparative infrequency with which the great cervical bloodvessels and nerves sustain injury, is attributed to their great mobility and elasticity. Xo mention of injury to the great bloodvessels or nerves is made in the description of any of the four specimens of gunshot wound of the larynx in the U. S. Army Medical Museum,2 while the absence of such injury is alluded to in the description of two. (Specimens 648 and 1440.) Wounds of internal origin may be lacerated, contused, or punctured. They are usually produced by foreign bodies with hard, sharp, and jagged edges, such as coins, fish-hooks, needles, nails, splinters, fish and meat bones, and pieces of glass. These wound the epiglottis, or penetrate or tear the larynx or the trachea.3 They may excite inflammatory tumefaction with resultant oedema, or may irritate the nerve-tracts and excite spasm of the glottis, and may thus necessitate tracheotomy in either case. Witte4 narrates a case, reported by Surgeon Cotting, in which a dart was inhaled into the larynx, point upward. The continuous efforts of the injured lad to cough the foreign body out, gradually drove the point of the nail through the thyroid cartilage into the sheath of the great bloodvessels, and death followed in consequence of a wound of the carotid artery. Awkward and incautious attempts at intra-laryngeal surgery are respon- sible for a certain number of contused, lacerated, and even incised wounds. Hemorrhagic oedema may be instantaneous after contusions and lacerations. The wounds resulting from a proper use of the knife, forceps, or galvano- cautery, are to be discussed in connection with the affections requiring such treatment. Ziemssen5 relates a fatal case of oedema from spearing of the walls of the laryngeal ventricle by the rib of a tobacco leaf, and another sudden death from the same cause, after a wound produced by a pointed piece of bone. Cases of wound from foreign bodies are sometimes promptly fatal by suffo- cation. In occasional instances, the inj ury has occurred by emesis during drunken- ness, or in the course of cerebral disease, the soup or gruel vomited having contaiued hard substances which thus entered the air-passage.6 Beigel7 reports the case of a twenty-four year old female, with rupture of both vocal bands from their intersections at the arytenoid cartilages, and transverse rup- ture of the left band in addition, from continuous crying when a baby. Inflammation follows the injury. (Edema may ensue, threatening suffo- cation, or spasm of the glottis with similar manifestations. Symptoms of Laryngeal and Tracheal Wounds.—The symptoms of a wound of the larynx or trachea are usually sufficiently evident, save in some instances of contused wounds, in which the special manifestations do not promptly follow the receipt of the injury. 1 For cases illustrating these points, see Catalogue U. S. Army Medical Museum, Surgical Sec- tion, p. 477. Washington, 1866. (Specimens 697, 1440, and 2021.) 2 Op. cit. 3 See Foreign Bodies. 4 Arch. f. klin. Chir., S. 193. Berlin, 1877. 6 Cyclopaedia of Practical Medicine, vol. xii. p. 80. 6 Witte, loc. cit. " Berlin, klin. Woch., 1868, S. 394 ; cited by Witte. INJURIES AND DISEASES OF THE AIR-PASSAGES. Contused Wounds give rise to one or more of the following group of symp- toms : Bruise or other external evidence of injury ; severe pain or tenderness on motion of the parts and on deglutition ; dysphonia or aphonia; cough, with bloody expectoration; spasm of the glottis ; spasmodic, opisthotonic retraction of the cervical muscles;1 tumefaction of the integument. Dys- pnoea is but slight, unless there has been tumefaction, effusion, or laceration and hemorrhage internally—cir- cumstances under which apncea may ensue. Insensibility from shock is noticed as a prominent symptom in some cases. Laryngoscopically, the evidence of congestion and of hemorrhagic effusion may be quite marked, as in a case reported by Dr. Packard,2 of Philadelphia. (Fig. 1112.) Punctured wounds give rise to threatening apnoea from accumulation of blood in the air-passages. Punctured wounds of the trachea may give rise to hemorrhage internally, as shown by haemoptysis, even though there be no hemorrhage externally. Emphysema of the neck is quite a pro- minent symptom, and may occasion serious dyspnoea. Sometimes it extends to a great distance from the seat of the external wound. In the efforts at expectorating, blood-clots may become lodged in the air-passage so as to oc- clude it. Such a clot has-been known to become impacted in a ventricle,and to form there a valve preventing ingress of inspiratory currents of air. In either event, symptoms of suffocation will ensue. Pain or tenderness, cough, dyspnoea, and dysphonia or aphonia, exist in some instances as in wounds of the air-passages in general. Incised wounds occasion various combinations of symptoms according to the extent of the wound, its location, the injury to the surrounding tissues, and the age and physical and mental condition of the individual. The main objec- tive symptoms are : first, the gaping external wound, exposing the muscular and vascular tissues of the neck, the air-passage, and the pharynx or oesophagus, as may be; and, secondly, hemorrhage, and the escape of mucus, blood, and saliva, through the wound as well as from the mouth. Fluids swallowed will escape likewise in some instances, unless the parts are supported exter- nally during deglutition. In a case of suicidal wound seen by myself, this was the first symptom to attract attention, hemorrhage having ceased, and the divided parts being concealed by a beard. Emphysema is usually a later manifestation than those detailed. The edges of the wound gape little or much, according to its location and the depth of the section. They are but slightly separated when the incision into the larynx or trachea lias been shallow or incomplete, while they may be separated to a distance of several inches, even the breadth of a hand, when the section has been a deep or com- plete one. In wounds through the thyro-hyoid membrane, or the superior portion of the thyroid cartilage, the upper segment may recede to the very jaw. In wounds through the trachea, the lower segment may recede behind the sternum. Fig. 1112. Laryngoscopic picture in contusion of the larynx. (Packard.) The hemorrhage is usually copious, even though the great cervical blood- vessels be uninjured. Dyspnoea or apncea sometimes results at once, from entrance of blood into the air-passages; both much more frequently with small wounds than with large ones. The hemorrhage often ceases by syncope. Secondary hemorrhage, however, is to be expected on reaction, and this, again, may suffocate the patient, especially if the edges of the external wound have been stitched meanwhile in close apposition. 1 Stromeyer, Handbuch der Chirurgie, Bd. ii. S. 309. Freiburg, 1865. 2 Archives of Laryngology, vol. i. p. 57. 1881. WOUNDS OF THE LARYNX AND TRACHEA. Suffocation is not imminent from hemorrhage alone ; hut other causes may produce it, varying according to the location and character of the wound. Thus it may be due to occlusion of the larynx by the base of a divided tongue, or by a divided or detached epiglottis; or to occlusion of some part of the air-tube by impacted fragments of severed or partially severed carti- lage or other structure. Even the ball itself, in cases of gunshot wound, has been known to produce this symptom by its arrest in the air-passage. In case of threatening apncea from loose fragments of cartilage, distinct Happing of the fragment may be recognized, as in the case under the care of Sir Charles Bell which has already been alluded to. The subjective symptoms of incised wounds are paiii, cough, spasm, dys- phagia or aphagia, dyspnoea or threatening apnoea, dysphonia or aphonia. Debility of voice sometimes results from direct injury to the vocal bands in wounds through the thyroid cartilage. In wounds above the vocal bands, the voice will be lost while the edges of the external wound are allowed to gape, and will be restored when they are approximated by bending the head, or when the external orifice is occluded with the hand or with a compress. Dysphagia and aphagia are usually due to section of the pharynx or oeso- phagus, food and drink escaping by the external wound, or passing into the air-passage. Cough is due to direct access of air, and access of mucus, blood, and saliva. Expectoration is usually difficult, and apnoea may result from this cause. Intense thirst is an occasional symptom, and may be very promi- nent, as in a suicidal case mentioned in the Medical and Surgical History of the Rebellion,1 which required the use in a peculiar way of twenty gallons of water daily, to assuage it. Some water was sucked through a tube attached to a reservoir, and apparently swallowed; and then a quantity was allowed to pass through the pharynx and escape by the wound. Lacerated wounds present much the same symptoms as incised wounds. The hemorrhage is much less as a rule; the danger from suffocation by blood or blood-clots, greater. Gunshot wounds, complicated as they often are by serious contusion, may present the symptoms of contused wounds in addition to pain, emphysema, escape of fluids from the wound, aphonia or cough, expectoration, etc., as detailed in connection with the symptoms of incised wounds. The impact of the ball sometimes produces a local numbness, or a numbness extending into the arm, indicative of implication of the spinal accessory nerve. Torticollis is mentioned in military records as quite frequent. Con- tusion or laceration of the pneumogastric nerve or of its laryngeal twigs, may produce paralysis or spasm of the laryngeal muscles, entailing aphonia on the one hand or stridor on the other, from that cause, independently of any mechanical result of the direct lesion in the tissues. Stridor may be due, likewise, to paralysis of the dilating muscles of the glottis. Internal injury of the laryngeal structures is quite frequent, and aphonia may result from such direct injury to the vocal bands. Mr. Erichsen has called attention to a special loss of sensitiveness of the glottis, permitting the passage of food and drink into the air-passage, a condition recognized by S. D. Gross,2 McGuire,3 and other writers, as a characteristic symptom of gunshot wounds of the larynx. The primary hemorrhage is much less than in incised wounds ; but the secondary hemorrhage may be more profuse, and may suffocate the patient by inundating the air-passage or by occluding it with clots. Such accidents are particularly to be feared after too great assiduity in closing the external 1 Op. cit., Part First, Surgical Volume, p. 409. 3 Op. cit. 3 Holmes’s System of Surgery, Am. Ed. vol. iii. p. 484. INJURIES AND DISEASES OF THE AIR-PASSAGES. wound. They are most to be apprehended after wounds of the trachea, in which injuries may have been sustained by the thyroidal vessels and the thyroid body. The inflammatory swelling of the tissues during the process of repair may compress the air-passage externally, or encroach upon it internally, producing dyspnoea in either event. Internal wounds of the larynx present no objective symptoms to direct inspection. Laryngoscopic exploration reveals the rent or other lesion in some instances, and fails to do so in others. The subjective symptoms are pain, cough, bloody expectoration, dyspnoea or threatening apncea, dysphonia or aphonia, and dysphagia or aphagia. Inflammation takes place in all wounds of the larynx or trachea. Some- times restrained within beneficial limits, it may be excessive in debilitated, starved, or drunken subjects, and may readily become gangrenous. Diagnosis.—The special diagnostic signs indicating the penetration of an external wound into the air-passages, are the presence of frothy blood at the seat of external injury, escape of air at the same point, or emphysema of the neck from escape of air into the cervical connective tissue, and escape of fluids through the wound on attempts to swallow them. To these may be added aphonia or dysplionia, aphagia or dysphagia, and dyspnoea or threaten- ing apncea. Blood which has inundated the air-passage is expectorated in part by the mouth, and in part by the wound. Syncope is the usual result of severe hemorrhage, and in many cases the patients are found in that condition when seen immediately after the injury. Prognosis.—Although recovery ensues in a large percentage of cases of wounds of the larynx and trachea, the prognosis is almost always to be regarded as doubtful. Wounds apparently insignificant terminate fatally in some instances ; and recovery sometimes ensues in very severe cases, even when complicated by multiple section of cartilage, and by extensive injury to the pharynx, (esophagus, and other structures. Horteloup1 records 67 recoveries out of 88 cases of large wound, and 10 recoveries out of 21 cases of small wound. Recovery is usually more protracted after punctured, lace- rated, and gunshot wounds, than after contused and incised wounds. Contusions of the larynx from blows may, according to Durham, prove suddenly fatal by shock, or by spasm of the glottis. Insensibility is said by the same writer to be a common effect, and one utilized by garroters to rob their victims. Hemorrhagic effusion into the connective tissue may produce suffocation. Incised wounds of the trachea present a graver prognosis than those of the larynx. In either instance advanced age, insanity, and delirium tremens are additionally bad prognostics. Suicidal wounds, if not fatal within a few hours, may prove slowly fatal by exhaustion or otherwise, in from one to two weeks. Recovery from severe wounds rarely ensues earlier than in four or five weeks, and sometimes occupies a much longer period. The prognosis is gravest as a rule in gunshot wounds, on account of the complicated nature of the injury in the first instance, which entails inflam- matory tumefaction of the superjacent soft tissues, and on account of the greater danger from secondary hemorrhage. Contrariwise to what has been noticed of incised wounds, gunshot wounds of the larynx are much more fatal than those of the trachea. When both of these structures are involved, a fatal 1 Op. cit.. p. 86. WOUNDS OF THE LARYNX AND TRACHEA. 235 result would seem theoretically much more imminent, yet recovery ensued in the four such instances noted in the Medical and Surgical History of the War of the Rebellion. Simultaneous involvement of the pharynx and oeso- phagus does not seem to add much gravity to the case. Contusions or lacerations of the pneumogastric nerve or of its divisions render the prog- nosis more unfavorable, on account of the resultant paralysis of the dilator muscles of the glottis, or spasm of its constrictors, with consequent dyspnoea or even apnoea. At a later date, tumefaction of the integument and of the mucous membrane, and extravasations of blood beneath the mucous mem- brane or in the loose connective tissue, may again threaten death by apnoea. In both incised and gunshot wounds, hemorrhage, venous or arterial, may be quickly fatal either by inducing exhaustion or by suffocation. As a rule, however, the bleeding soon ceases with syncope. A small amount of clotted blood in the trachea is sufficient to produce suffocation, if the patient is unable to eject it. Death, immediate or gradual, may ensue, too, from entrance of air into a vein,1 an instance of which in a case of suicidal incised wound is alluded to by Stromeyer.2 After the immediate dangers have subsided, the result of suppuration may derange a favorable prognosis. Escape of mucus, pus, necrosed cartilage, food, or drink, into the air-passages, often occasions septic infection, usually manifested at first in broncho-pneumonia, and in rare instances proceeding to pulmonary gangrene. In this manner a cheerful prospect is often changed into a gloomy one. Circumscribed abscesses may form about the suppurating edges of the wounds, or diffuse ones may dissect the planes of connective tissue down into the mediastina, and thus excite pleuritis, or compression of the bloodvessels and phlebitis. In some instances, too, more especially in gunshot injuries, perichondritis and necrosis of the cartilage takes place, and renders the prognosis still more dubious. Recovery takes place usually only after protracted treatment, in which weeks upon weeks may be occupied. Gaps in the cartilage become repaired with fibro-cellular tissue, the irregular and exposed edges having meanwhile become necrosed and exfoliated, and the uninjured portions ossified, as is usual in inflammatory affections generally. The tissue filling the gap gradu- ally becomes fibro-eartilaginous, or actually cartilaginous. (Witte, Fischer.) In some instances a permanent fistula of the air-passage remains, often small, but sometimes quite large—after extensive injuries or great loss of substance— huge gaps exposing the epiglottis, the pharynx, and even the pharyngo-pala- tine folds. Albers, cited by Fischer,3 describes and illustrates one an inch broad and two inches long. In some instances, either fungous or cicatricial stenosis of the larynx or trachea takes place during recovery, or after it. In the one case, the excessive granulations, or the exuberant tissue, may be destroyed by cauterization, excision, or evulsion. In the other, the perma- nent use of the tracheotomy-tube is usually required. Attempts to excise or otherwise destroy the obstructive cicatricial tissue are rarely of service: while systematic dilatation is hardly more promising. Recontraction usually takes place on the suspension of the manipulations. A cicatricial membranous web sometimes forms across the larynx at the seat of the wound, a variety of stenosis said to be quite common.4 Similar stenosis of the trachea is a very rare sequel. (Witte.) Permanent thickening of the cartilages is likewise a frequent result. The dysphonia, or even the aphonia, which accompanies these injuries, is sometimes permanent. Diplophonia, or sudden change of 1 Durham, op. cit., vol. i. p. 687. 3 Op. cit., Bd. iii. 1 Abth. 3 Lief. S. 96. 4 Mackenzie, op. cit., p. 409. 2 Op. cit., Bd. ii. S. 310. 236 INJURIES AND DISEASES OF THE AIR-PASSAGES. voice from shrill to deep, has been noted by Gibb,1 after cicatrization of an incised wound of a vocal band. Treatment.—The first indication is to avert impending suffocation; the next, to restrain hemorrhage. Threatening apnoea, as intimated, may be due to nerve-lesions on the one hand—paralysis of the dilators of the glottis or spasm of its constrictors ; or on the other hand to mechanical lesions—hemorrhagic or other effusion, oedema, or occlusion by detached portions of tissue. In either instance immediate tracheotomy is demanded, to be followed by the institution of artificial respi- ration if requisite. This preliminary tracheotomy is much more likely to be necessary in punctured, lacerated, and gunshot wounds, than in simple incised and contused wounds. Treatment of Contused Wounds.—If respiration be impeded, laryngotomy should be promptly performed through the crico-thyroid membrane, and artificial respiration should be instituted through the opening. Respiration progressing satisfactorily, the next thing is to attend to any symptoms of collapse. This indication is best met by the injection of hot alcoholic fluids into the rectum, and subsequently into the stomach. It may be necessary to resort to hypodermic injections of stimulants, or even to intravenous injec- tions of ammonia. Treatment of Punctured, Incised, and Gunshot Wounds.—Impeded respira- tion having been relieved by withdrawal of blood and other liquids from the air-passages—by suction through a catheter, or by tracheotomy—and by removal of clots or detached tissues from occluding positions; hemorrhage having been restrained by ligature or compression ; and collapse having been removed by stimulating injections into the rectum, or by hypodermic or intravenous injections, as may be—the next indication is to closely scrutinize the locality of the wound so as to recognize its entire bearings, as far as prac- ticable, before tumefaction renders this impossible. If the wound penetrate into the mouth, careful search should be made for clots in order to remove them. The tongue should be carefully examined to see whether it be intact. Should it have been severed, the posterior portion should be carefully secured by ligature, so that it may not fall back upon the orifice of the larynx. Any other wounds of the tongue, or any wounds of the palatine folds, should be secured with sutures. If the wound pass through the hyo-thy roid membrane, or the upper por- tion of the thyroid cartilage, the condition of the epiglottis should be deter- mined. Any detached pieces should be removed. Attempts at saving semi-severed portions by suture rarely succeed, and almost always entail inflammatory oedema of the epiglottis. If prophylactic tracheotomy have been performed below the injury, attempts to save semi-detached portions of the epiglottis by suture are justifiable; but under other conditions they may be imprudent. In all wounds, whether situated in this region of the air-pas- sage or in any other, search must be made in the wound for any missing por- tions of cartilage or other tissue, that they may be promptly withdrawn. If the trachea have been divided, a tracheotomy-tube should be adjusted to the lower segment. If merely punctured, or but slightly severed, the wound should be enlarged, and a tracheotomy tube inserted, unless the opening be so insignificant as to cause neither serious hemorrhage nor emphysema. Inflammatory or infiltratory tumefaction, or any other sequel which pro- duces sufficient encroachment on the calibre of the air-passage, will demand 1 Fischer, op. cit., Bd. iii. 1 Abth. 3 Lief. S. 99. WOUNDS OF THE LARYNX AND TRACHEA. 237 tracheotomy at any stage of the treatment; a fact recognized and utilized in wounds both of the larynx and of the trachea by llabicot, as early as 1594.1 Severe injuries to the larynx or trachea—whether fracture, laceration, or contusion—and the presence of foreign bodies in the air-tube, demand precau- tionary tracheotomy to insure the safety of the patient from the dangers of suffocation—dangers which cannot be ignored. The point at which tra- cheotomy is to be performed will have to be selected with reference to the individual case. This may be just below the cricoid cartilage, further down, or through the crico-thyroid membrane. The tampon-canula (Fig. 1113) is Fig. 1113, Trendelenburg’s rubber-tampon canula; Gerster’s modification. The dotted lines indicate the distension of the soft-rubber jacket when filled with air. preferable in these cases to the naked instrument, as it occludes the entire calibre of the air-passage. In fact, it is questionable whether all wounds opening into the larynx through the thyro-hyoid membrane, or through the thyroid cartilage, should not be regarded as demanding precautionary trache- otomy. Although it is well known that extensive incised wounds do get well when left almost without surgical interference, it is equally well known that sudden suffocation sometimes takes place, despite every precaution save that of tracheotomy. This subject has been admirably discussed by Witte2 in an article on wounds of the larynx and their treatment, especially in refer- ence to the value of a prophylactic tracheotomy, the importance of which he has ably demonstrated. The precautionary tracheotomy does not add to the immediate risk in the slightest degree, and suppresses the risk in approxi- mating the edges of the external wound, which is always run under other plans of treatment. Yon Langenbeck3 counsels the performance of trache- otomy in all cases in which either phonation or respiration is seriously impeded. The arrest of primary hemorrhage by syncope is apt to mislead the uncau- tioned practitioner, and tempt him to close the wound by suture—a procedure which prevents the escape of the blood at the second hemorrhage, which is almost certain to occur when reaction takes place. If the external wound be closed, this blood will run down the air-passage, and may drown the patient, or, clotting, may suffocate him. Cases made fatal by too assiduous attention of this kind are on record, and others are known by tradition and by obser- vation. Liston was one of the most strenuous teachers of the impropriety of 1 Sur la Bronchotomie. Questions Chirurgicales, chap. xv. pp. 77-83. Paris, 1620. 2 Arch. f. klin. Chir., Bd. xxi. H. 1, 2, 3. s Militairartzliche Zeitschrift, Bd. i. S. 60; cited by Witte, loc. cit., S. 395. 238 INJURIES AND DISEASES OF THE AIR-PASSAGES. such measures, and yet his own house-surgeon would have lost a patient in this way, had his master not instantly cut the sutures and removed a clot which impeded respiration.1 It is important, therefore, in treating incised wounds that the parts should not be united by suture until there remains no further risk from reactionary hemorrhage. Arterial hemorrhage must be restrained by ligatures above and below the wound in the vessel, whenever practicable. But even ligature of the bleeding vessel does not secure immunity from the later hemorrhage, for this may be parenchymatous, or may proceed from vessels whose bleeding is not controlled by the ligatures. Should the hemorrhage be profuse, and beyond restraint by compression and by ligature of such vessels as are within reach, the indication would be to tie the carotid artery, a measure successfully employed under these circumstances by Le Gros Clark. When the external wound is very large, it is allowable to unite its outer portions ; but the central part should be left open. Should bagging of the horizontal wound take place, the pockets should be divided vertically, as recom- mended by Stromeyer,2 so as to prevent the burrowing of pus, which is otherwise almost certain, since union cannot take place by first intention, and extensive suppuration is to be expected. When all danger from hemor- rhage has ceased, the tissues on either side of the opening into the air-passage may be brought together with adhesive strips, and a few sutures may be taken into the soft parts, ample room being left for drainage; but no suture should be taken through the cartilage or its perichondrium. Sutures are so illy-borne in these situations, and so pulled on in coughing, that they either cut out and are useless, or excite such an amount of local irritation as to necessitate their withdrawal. Although Prof. Gross and other surgeons express themselves free from fear of this kind, a careful perusal of published records shows that those cases have done best in which these sutures have not been used ; and that in most instances in which they have been employed, they have torn their way out, or have had to be removed, even in cases where the wound was not extensive. Sutures are rarely necessary even in the soft parts. They will tear out from the pharynx ; while extensive wounds, com- prising almost the entire circumference, will, when let alone, sometimes heal up with a very small cicatrix. Should the external wound be drawn together too much, emphysema may take place by interference with the full escape of the expiratory currents of the breath. The parts having been placed in apposition as far as may be judicious, and the patient placed in the semi-recumbent position, the head is to be flexed and to be retained in position by a cap or handkerchief-bandage (Mayor’s occipito- sternal cravat) attached to a chest bandage beneath the arms, or to the waist- band of a pair of drawers, or to the foot of the bed—the object being to main- tain the horizontal edges of the wounds in juxtaposition, and thus to favor cicatrization, which may be expected in from two to three weeks. The head should not be drawn so far forward as to make the edges of the wound over- lap. Prof. Stromeyer attaches a small tuft of hair sidewise over the brow to a bandage fastened to a girdle or jacket, to act as a reminder to the patient to avoid incautious movements. He mentions the case of a man in whom the sterno-mastoid muscle had been cut through ; and although the head stood straight when no movement was made, it flapped toward the opposite side on the slightest movement, as quickly as the snap-to of the blade of a pocket knife; an action which ceased as soon as the head was bound by a tuft of hair to the opposite side. The dressing should be completed by covering the wound lightly with a 1 Practical Surgery, 2d ed., p. 364. London, 1838. s Op. cit., S. 32. WOUNDS OF THE LARYNX AND TRACHEA. 239 piece of gauze, or a woven scarf, to raise the temperature of the inspired air and prevent the access of hies. This dressing may be carbolized. The apartment should be kept at a warm temperature, and the atmosphere moist, just as after ordinary tracheotomy. Insane patients and determined suicides require close watching, to see that the dressings remain undisturbed. The inflammatory action following the injury is to be treated on ordinary antiphlogistic principles, locally and constitutionally ; by rest, cold, anodyne fomentations, and leeches, if necessary, and by febrifuge and anodyne mix- tures. If oedema of the larynx or other obstruction to respiration occur at the seat of injury, the trachea should be opened at a lower point, and a tube introduced. A precautionary, prophylactic tracheotomy will have anticipated this contingency. Emphysema of the neck may require punctures or incisions through the integument; but if the edges of the wound be not yet adherent, the air can often be expelled by systematic manipulation towards the orifice. Should this be unsuccessful, the external wound should be enlarged, and the process repeated. Low tracheotomy is sometimes required under similar conditions to prevent suffocation; and quite a long tube, or a section of rubber tubing, may be necessary for a few days to insure access of air into the trachea. Exuberant granulations should be cauterized with solid nitrate of silver. Cough is to be repressed by anodynes. Nourishment can be given by the mouth if there be no wound of the pha- rynx or oesophagus, and can usually be well taken even though the epiglottis have been severed. If those structures have been wounded, it is best to insert a soft rubber catheter through the larger nasal passage into the oesophagus, where it may be maintained undisturbed for several days. Most surgeons prefer that the tube should be inserted through the mouth. Liquid nourish- ment can be passed through the catheter at stated periods by means of a syphon- tube or funnel, the external orifice being, in the intervals, secured by a ligature. Food may likewise be administered by enema; and medicine, if necessary, by either method, or by hypodermic injection. Antiseptic sprays allowed to play upon the wound at stated intervals tend to keep the granulations clean and healthy. The secretions escaping from the wound should be caught upon a disinfected sponge or mop as fast as they are expelled, to prevent them from being sucked back by the inspiratory current. The administration of opium is indicated to restrain hypersecretion and to repress cough, but caution is requisite to avoid obtunding sensibility to such an extent as to favor the passage of fluids into the air-tuba Should the wound fail to unite in its entire extent, the fistulous opening which remains can sometimes be closed by systematic cauterization, nitric acid and nitrate of mercury being the most efficient agents. In case of failure by this plan, a plastic operation may succeed. Transplantation of cartilage from the ear of the rabbit might be tried under these circumstances. A pad, secured by a bandage, is sometimes worn over the opening, so that voice and articulation can be rendered effective. Stenotic constrictions can sometimes be overcome by systematic dilatation. Successes have been reported by Liston and others. In many instances, per- haps in most, a tracheotomy tube becomes a permanent necessity. It is sometimes practicable to overcome the stenosis by dilatation years after immediate treatment has been discontinued. In a case placed under my care by Prof. Joseph Pancoast, of Philadelphia, in 1866, this was satisfacto- rily accomplished by the frequent passage of large, perforated, hard catheters 240 INJURIES AND DISEASES OF THE AIR-PASSAGES. through the wound, which was just below the vocal hands, up into the mouth, and by see-sawing them forcibly for a few moments at a time. In a case of extensive adhesion of the vocal bands in a case of cut-throat, Dr. Eysell, of Halle, succeeded in effecting the division with a narrow tenotome passed through the cicatrix.1 Treatment of Wounds of Internal Origin.—If respiration be very much impeded, prophylactic tracheotomy is indicated in this class of wounds, as in those of external origin, and for like reasons. Foreign bodies must be removed ; whether by the aid of laryngoscopic manipulation, or by gaining direct access externally, will depend upon conditions which will be discussed hereafter. If there be great tendency to hemorrhage, the tampon-canula instead of the naked instrument, should be inserted into the tracheotomy wound. Locally, cold externally, ice-pellets in the mouth, and sedative inha- lations in spray, are indicated to repress inflammation and allay pain. To- pical applications of solutions of morphia or of aconite are useful when the pain is severe. II. Burns and Scalds of the Larynx and Trachea. Burns and scalds of the larynx and trachea are usually associated with similar injuries to the mouth, tongue, palate, nasal passages, pharynx, or oesophagus. Hums are most frequently produced by the inhalation of flame, hot steam, or the heated air and smoke of burning houses or ships. They are often associated with burns of the head, neck, arms, and chest, and sometimes with burns over large portions of the body. Scalds are usually due to the voluntary or involuntary deglutition of hot and caustic fluids. Some scalds from caustic substances in adults are suicidal. Scalds were formerly quite prevalent in England among the children of the poor, who, having been accustomed to drink cold water from the spout of a tea-kettle, endeavored to quench their thirst while the vessel contained boiling water.2 When flame or hot air is inhaled, and when hot or caustic fluid is swal- lowed unknowingly, the larynx is much more likely to be involved than when the drink is taken designedly. In the latter case, the epiglottis pro- tects the larynx as usual from ingress of fluid, and the injury is sustained chiefly in the mouth, pharynx, and oesophagus—sometimes even in the sto- mach—the act of deglutition having been completed despite any pain or spasm. In unwitting deglutition, however, the epiglottis is surprised, as it were, and fails to occlude the larynx efficiently, so that that organ sustains the brunt of the injury. It is contended, too, that an involuntary inspiration draws the caustic fluid into the larynx. Spasm of the glottis takes place, as a rule, protecting the subglottic portion of the larynx; for the portion below the vocal bands is often found normal in post-mortem examination after these accidents,3 the injury having been confined to the upper part. Swallowing is rarely completed under the circumstances just indicated, and regurgitation takes place in part through the nasal passages, thus injuring the mucous membrane of that region and of the adjoining retro-nasal portion of the pharynx. In support of the statement that hot and caustic fluids taken accidentally are rarely swallowed, it may be mentioned that, on consulting the records of 1 Med. Times and Gaz., October 17, 1874; Am. Journ. Med. Sci., January, 1875, p. 275. 2 Marshall Hall, Med.-Chir. Trans., vol. xii. London, 1822 ; and others. 3 For recent examples, see Davies-Colley, Med. Times and Gaz., February 18, 1882. BURNS AND SCALDS OF THE LARYNX AND TRACHEA. 241 numbers of cases in which boiling water has been taken into the mouth, and in which death has ensued from the resulting laryngitis, no evidence has been found of the fluid having reached the stomach in any instance, and in but few cases had it reached even the upper portion of the oesophagus. I have seen no record of deglutition of boiling water for suicidal purposes; but it is fair to infer that a case of the kind would furnish evidence that the fluid had reached the stomach, just as acid and caustic solutions do in suici- dal cases. Acute laryngitis, laryngitis combustionis, rapidly supervenes upon burns and scalds of the larynx, often immediately. It is often intense, and is generally attended with extensive oedema. It is not limited to the mucous membrane, but engages the submucous tissues likewise. The inflammatory process is usually confined to the supra-glottic portion of the larynx; but in some instances it extends to the trachea and the bronchi, and even to the lungs. Pneumonia and broncho-pneumonia may supervene without direct implica- tion of the trachea and the larger bronchi. In some instances the inflamma- tion does not overstep the pharyngeal surface of the larynx. In others a plastic, exudatory slough, similar to the plastic exudation of croup—showing arrested circulation from the violence of the inflammation, and consequent necrosis of the mucous membrane, coagulation necrosis (Weigert)—is produced along the entire tract of injury and beyond it. It has been found after death in the larynx, trachea, and bronchi. Symptoms.—The immediate symptoms are pain, dyspnoea, dysphagia, dys- phonia or aphonia, shock, accelerated pulse and respiration; and, at a later period, inspiratory stridor, spasm, threatening suffocative apnoea, and col- lapse. In cases of burns from the heated air and smoke of burning buildings, the sputa may contain black, carbonaceous material.1 (Edema of the epiglot- tis or of the aryteno-epiglottic folds may be almost immediate, or may be developed during the course of a few hours. In cases associated with burns of the trunk and limbs, rather than of the head and neck, it may not occur within a week. The symptoms do not ahvays appear at once. Thus, Porter2 says that he knew a girl, after swallowing a dose of sulphuric acid, to sit quietly and drink tea with some companions, who were afterwards suspected of having poisoned her, although the dose had been so powerful that she died in a few hours. He likewise knew of a man who took a second drink of the sul- phuric acid, because he thought that the first dose was not sufficiently quick in dispatching him. Diagnosis.— Except when the nature of the accident is purposely concealed by a determined suicide, the diagnosis is easy, especially in adults. Severe pain in the part, dyspnoea, dysphagia or aphagia, acceleration of the pulse and respiration, and the history of the case, are usually sufficient to establish the fact of a burn or scald. The interior of the mouth, the posterior portion of the tongue, the palate and pharynx, if seen early, are inflamed, swollen, and vesicated or blistered, or are covered with white patches, as though cau- terized—often from detachment of a slough of epithelium—while the mucous membrane is seen to have undergone destruction in spots. In some in- stances, the oedematous epiglottis can be seen erect on ordinary inspection.3 There are few records of laryngoscopic examination of the parts injured. Tuerck4 has depicted the laryngoscopic appearance of a circumscribed, sym- metrical cauterization of the outer, inferior surfaces of the arytenoid car- 1 Cohen, Inhalation : its Therapeutics and Practice, p. 294. Philadelphia, 1869. 2 On the Larynx and Trachea, p. 178. London, 1837. 8 Mackenzie, op. cit., p. 281. 4 Klinik der Krankheiten des Kehlkopfes und der Luftrohre, S. 182. Wien, 1866. 242 INJURIES AND DISEASES OF THE AIR-PASSAGES. tilages, from deglutition of dilute nitric acid. In a case examined by myself, there was oedema of the aryteno-epiglottic folds, in a case of burn of the larynx, the result of inhalation of flame in a burning building. Prognosis.—The prognosis is always grave when the injury has been ex- tensive, recovery being rare in severe cases. In slight cases the patients may recover thoroughly in a few days, but in severe cases they may perish at once, or within from twenty-four to forty-eight hours. The suppuration is profuse and exhausting. Sloughing of the arytenoid cartilages has been observed. (Ryland.) When recovery does ensue, it is often with perma- nent stenosis of the larynx, cicatricial and infiltratory, requiring the use of the canula for respiration through an artificial opening. Death may take place by shock or by suffocative apncea, or at a remoter period by laryngitis, bronchitis, or pneumonia. Even though immediate death by threatening suffocation be averted by tracheotomy,2 statistics show that more than half of the patients operated upon perish. Treatment.—It is very rarely that a patient is seen soon enough after swal lowing an acid or caustic alkali, to expect advantage from administering neu- tralizing agents, whether by deglutition or by the stomach tube. In severe cases of burn or scald of the larynx, precautionary tracheotomy seems to be demanded, as the laryngitis excited is apt to be attended with oedema of the larynx, which may prove fatal by suffocation before surgical relief can be given. Most surgeons, however, prefer to await the onset of the threaten- ing symptoms, this delay, perhaps, accounting in part for the slight amount of success which follows tracheotomy in these cases. Durham3 reports that of 28 cases of tracheotomy in scald of the larynx, of which he had notes, 23 terminated fatally. If tracheotomy be deemed unnecessary, puncture or scari- fication of the cedematous mucous membrane may be employed with great advantage, and in some instances may obviate the necessity for the graver operation. As the inflammatory process rarely extends below the glottis, owing to spasmodic closure of the vocal bands at the time of the injury, the larynx may be opened through the crico thyroid membrane in these cases ; especially in the adult, in whom the opening will be large enough to admit a sufficiently capacious tube. The operation is much less successful in children than in adults; the hemorrhage being more profuse, and the debility greater from the loss of blood. Slight cases may be treated efficiently by rest in the recumbent position, cold compresses or ice externally, and anodyne inhalations in vapor or in spray. Mucilaginous drinks are soothing to the parts, and contribute some- what to nourishment. Anodynes may be combined with them. Sprays of acetate of lead and of carbonate of sodium sometimes afford great relief. Severe cases require active antiphlogistic treatment, locally and constitution- ally. Collapse having been counteracted in the first instance by stimulant enemata, blood may be drawn by leeches from the upper portion of the ster- num, and the same part may then be covered with warm, sedative fomentations, while ice-bags, iced-water tubes, or cold compresses may be applied over the larynx as in milder cases. If the patient can swallow, an emetic should be given by the mouth; if not, emesis may be excited by apomorphia hypo- dermically. Mild chloride of mercury in doses of one, two, or three grains, every half hour, hour, or two hours, until free bilious evacuations ensue, has 1 Inhalation, its Therapeutics and Practice, p. 294. Philadelphia, 1867. 2 Kuehn, Die kiinstliche Eroffnung der Luftwege, S. 278. 1864 ; Unrlt, Arch. f. klin. Chir., Bd. i., S. 172, 194 ; Bryant, Surgical Diseases of Children, p. 67. London, 1863; Durham, op. cit., vol. i. p. 701. 3 Op. cit., vol. i. p. 701. (EDEMA OF THE LARYNX. 243 been highly recommended.1 Mercurial inunction may be substituted, if swallowing be impracticable, and may hasten the specific action of the drug when calomel is given internally. Durham2 reports the best results in burns from the administration of preparations of antimony and aconite, in small doses frecpiently repeated ; the intervals being but fifteen minutes for the first hour or so, and being then lengthened according to the effects pro- duced. Anodynes may be given by the mouth or hypodermically, as indi- cated. Pellets of ice in the mouth, ad libitum, add much to the comfort of the patient, and tend to repress inflammation. Milk may be given as nourishment in most instances. If dysphagia prevent deglutition, the rectum must be depended on for the introduction of nourishment. (Edema of the Larynx. (Edema of the larynx, long incorrectly called oedema of the glottis, for the rima glottidis is rarely involved, is an infiltration of fluid or semi-fluid pro- ducts into the submucous connective tissue of the upper or of the inner sur- face of the larynx, or of either surface of the epiglottis. It is rarely an oedema in the strict sense of the word—a hydrops, that is to say, or a passive accumulation of serum—but it is rather an cedematous infiltration accompany- ing an inflammatory process by which it has been occasioned, whatever may have been the origin of the inflammation. Thus, the infiltration may be serous, lymphous, sero-sanguinolent, sanguinolent, sero-purulent, or purulent. The serous effusion occurs in cases marked by great rapidity of morbid action, and the purulent in cases of slower and less violent inflammation. Hemor- rhagic effusions are sometimes instantaneous, as in contused and other wounds. Lymphous effusions are usually gradual. The oedema may be acute or may be chronic. Sometimes the process is idiopathic, sometimes traumatic, and often deuteropathie. However occasioned, the effusion diminishes the space for breathing, so that the process of respiration becomes first impeded and then obstructed ; and if subsidence of the effusion does not take place spontaneously, or by prompt surgical interference, rapid apncea by suffoca- tion may ensue, or slow apncea by congestion of the brain or lungs, death taking place within a few hours or a few days, as may be. The pathology of acute oedema of the larynx was not understood before the present century; and many cases, among them, most probably, the fatal cases of General Washington and of the Empress Josephine, were looked upon as cases of croup, the subjective symptoms of which are closely similar. But in 1808, a remarkable paper by Bayle3 was presented to the Society of the Parisian School of Medicine, fully discriminating the malady from all others, and this led the way to its thorough recognition, and to its prompt and intelli- gent treatment. Impediment to free circulation in the venules of the laryn- geal mucous membrane, whether from inflammatory process, mechanical obstruction, or paralysis of vessels, is the immediate physical cause of the effusion as in the case of many other serous accumulations—the remoter cause being idiopathic or deuteropathic inflammation, or mechanical or sur- gical injury. Mechanical impediment to respiration by the tumefaction of the tissues hardly represents the entire pathology of the dyspnoea in laryngeal oedema. 1 Wallace, Lancet, 1833, vol. i. p. 657 ; Bevan, Dub. Quart. Journ. of Med. Science, Feb. 1860 ; Sloane, Brit. Med. Journ., Jan. 14, 1866 ; Croly, ibid., June 16, 1866 ; and others. 2 Op. cit., vol. i. p. 700. * Memoire sur l’oed&me de la glotte ou angine laryngee cedemateuse. 244 INJURIES AND DISEASES OF THE AIR-PASSAGES. Spasm of the muscles closing the glottis (lateral crico-arytenoids and central arytenoid), or paralysis of the muscles opening it (posterior crico-arytenoids), probably exists in many instances. Otherwise it is impossible to account for the fatal issue, even allowing that the oedema subsides after death. As elsewhere mentioned,1 the encroachment upon the breathing space has been seen laryngoscopically to be much less in some instances than would be cred- ited without inspection, although the swollen tissues cast such shadows upon the glottis as to render it impossible to pronounce as to its patency. These views have received additional support from recent observations2 of actual obstruction of the glottis by paralysis or spasm. Acute cedema of the larynx from acute laryngitis usually occupies the two aryteno-epiglottic folds, although instances occur in which but one is involved. The epiglottis may be involved likewise, or it may be the sole location of the effusion. The ventricular bands, the inter-arytenoid folds and the inner aspect of the arytenoid cartilage, are much less frequent seats of the process; and the vocal bands, with their intrinsic thyro-arytenoid muscles, are the least frequent seat. Occasionally the process is wholly subglottic. (Edema of the tracheal submucous tissue occasionally occurs, six instances of this condition having been collated by Sestier3 out of a total of one hundred and thirty two of cedema of the larynx. Infiltration into the base of the tongue and into the pharynx is a more frequent complication. Chronic (edema of the larynx occurs as an epiphenomenon in tlie chronic laryngitis of tuberculosis and syphilis, both ulcerative and non-ulcerative; in laryngeal perichondritis and chondritis of whatever origin; in the irrita- tive laryngitis due to morbid growths ; in carcinoma of the larynx or pharynx ; in glossitis; in the pharyngitis consecutive to tonsillitis and to malignant disease of the tongue, palate, pharynx, and oesophagus, whether implicating the larynx directly or not; in glandular and other cervical and mediastinal tumors; in thoracic and abdominal aortic aneurisms; and in fractures, wounds, and other injuries of the larynx, adjacent soft tissues, or great cervical bloodvessels. Under these circumstances the affection becomes for the time more important than the disease which has occasioned it. It comes on gradually, rarely without prodromic manifestations, and may continue for weeks and months before it excites a suffocative paroxysm, even though it present great occlusion of the orifice of the larynx. This occlu- sion occurs so gradually that the system becomes accustomed to it; for the same amount of oedema in an acute case would be almost certain to produce intense dyspnoea, suffocative paroxysms, and passive pulmonary congestion. Chronic oedema is more frequently unilateral than acute oedema, the dis- eases of the larynx which produce it being themselves often unilateral. Subglottic (edema of the larynx is not frequent. The closeness with which the mucous membrane hugs the perichondrium below the vocal bands does not favor accumulations of fluid in that region. Still, there is some loose connective tissue in the lateral regions of the cricoid cartilage, where such accumulations can take place. The effusion is usually fibrinous; rarely serous. It is usually independent of any effusion in the upper portions of the larynx; but the two conditions have been known to coexist.4 1 Diseases of the Throat, etc., 2d ed., p. 443. New York, 1879. 2 Gougenheim: Annales des Maladies du Larynx, etc., Juillet, 1883, p. 125. 3 Traite de l’angine laryngSe oedemateuse. Paris, 1852. 4 See Specimen in St. George’s Hospital Museum, London, described by Gibb (op. cit., p. 218). (EDEMA OF THE LARYNX. 245 Etiology.—Very rarely, indeed, is acute oedema of the larynx a primary, idiopathic affection. Sestier1 noted 36 cases out of 190. It has been known, however, to follow so closely upon exposure to cold and rain, deglutition of very cold drinks,2 and prolonged vocal effort, as to seem primary ; but acute or subacute inflammatory laryngitis may have preceded. It may follow trau- matism quite as promptly, for Ziemssen3 has reported a case, in a man who was smoking, of death within a few minutes after penetration of the wall of the laryngeal ventricle by a piece of rib of tobacco-leaf. It often occurs in the trau- matic laryngitis from deglutition of hot and caustic solutions, from burns, or from the presence of foreign bodies. It is quite frequent in wounds of the larynx. It may occur in gunshot wounds of the neck, even when the larynx is not implicated. Thus, fatal oedema is reported on the fourth da}’ after such a wound from a 1| inch grape-shot, which entered near the right horn of the hyoid bone, passed obliquely across the neck, and lodged in the subscapular fossa, whence it was removed by incision.4 It sometimes occurs in sore throat. Roger5 relates an instance of sudden death in a slight case of sore throat in a hospital servant. Trousseau mentions a case saved by tracheotomy, in which it occurred from sleeping in the open air after an evening’s debauch ;6 and Laverau, a case fatal within fifteen minutes, in a soldier, a day after suspen- sion of treatment for sore throat.7 Simple inflammation was regarded as the cause in more than six per cent, of Sestier’s cases. In such instances, Mackenzie8 believes the oedema to be nearly always due to blood-poisoning. (Edema of the larynx has been noted in aneurism,9 obstruction of the hepatic duct,10 erysipelas,11 ecthyma,12 scarlatina,13 measles,14 smallpox, facial erysipelas (by myself), typhus and enteric fever,15 glanders, nephritis,16 whoop- ing cough,17 capillary bronchitis, pneumonia, croup, diphtheria, and maras- mus.18 It is chiefly in the waning stages of these affections, or during con- valescence therefrom, that the oedema takes place, probably in consequence of lack of protection from drafts of air. It is a rare accompaniment of general anasarca, probably because there is no sore throat or laryngitis to start it.19 It occurs occasionally in acute iodism20 and in mercurialization. It is therefore prudent to supervise patients with laryngeal disease to whom, for the first time, mercury and iodine are being administered in decided doses. Phleg- monous glossitis, and diffuse inflammation of the connective tissue of the neck, sometimes give rise to oedema of the larynx, by contiguity. Mackenzie21 attributes oedema of the larynx largely to septicaemia, having met with the affection in hospital physicians, medical students, and nurses. 1 Op. cit. 2 Albers, cited in my work already quoted (Diseases of the Throat, etc., p. 477). 3 Cyclopaedia of Practical Medicine, vol. vii. p. 794. 4 Med. and Surg. History of the Rebellion, Part First, Surgical Volume, p. 404. 5 Diet, de M6d., t. xxii. p. 575. 6 ciin. M6d., t. i. p. 651. Paris, 1877. 7 Graz, des Hop., 20 Juin, 1876, p. 565. 8 Op. cit., p. 274. 9 Moore, Dub. Quar. Jour. Med. Science, August, 1869, p. 13. 10 Farre, Lancet, April 21, 1860, p. 393. 11 Gibb, Diseases of the Throat, p. 218. London, 1864. •2 Boeckel, Annales des maladies de l’oreille, dir larynx, etc., tome i. p. 387. 13 Barry, Central Zeitung fur Kinderlieilkunde, No. 19. 1879. 14 Ryland, op. cit., Case IV. ; Pilcher, An Epidemic of Measles, p. 5. 1876. 15 Emmet, Amer. Jour. Med. Sciences, July, 1856 ; Merklein, La France Med., No. 69, 1883. 16 Fauvel, Aphonie Albuminurique. Rouen, 1863. (He has shown it to be sometimes the first symptom.) ; Thompson, St. George’s Hosp. Rep., vol. iii. p. 302. 1868 ; Hayden, Brit. Med. Jour., April 11, 1874, p. 489 ; myself, and others. 17 Barthez, Graz, des Hop., No. 32, 18 Mars, 1869, p. 121. 18 Billard, Traite des maladies des enfans nouveau-nes & la mamelle, p. 491. Paris, 1828. 19 Sestier, Mackenzie. 20 N61aton, Abeille Med., t. x. p. 217 ; Laurie, cited by Stille (Therapeutics, 3d ed., vol. ii. p. 763) ; Fenwick, Lancet, Nov. 13, 1875, p. 698 ; Cohen, Diseases of the Throat, etc., p. 446, note. 21 Op. cit., p. 274. 246 INJURIES AND DISEASES OF THE AIR-PASSAGES. and in cases where defective drainage seemed to be its cause. lie adds that in every case that has come under his notice, ample opportunity of acquiring septicaemia has been present. Exposure to cold and moisture appears to be the usual exciting cause, in idiopathic and deuteropathic oedema, whatever the predisposing cause. Acute oedema from disease is exceedingly infrequent in childhood. Out of a total of 245 cases, Sestier1 reports five under five years of age, one being in a new-born infant, and twelve cases between five and fifteen years. It is much more frequent in men than in women; simply, probably, because of their greater exposure to atmospheric changes. Of 187 cases in adults, in Sestier’s lists, but 56 occurred in women. It is more frequent in intemperate individuals than in the temperate. Predis- position seems to exist in some individuals, for cases of recurrence have been recorded.2 (Edema occurs traumatically from severe intra-laryngeal or perilaryngeal cauterization, and from attempts at removing morbid growths—the epiglottis and aryteno-epiglottic fold, or a supra-arytenoid cartilage, being seized and contused between the blades of forceps. Symptoms.—Acute oedema of the larynx occurs so suddenly at times that the subject perishes without any premonitory symptoms whatever. Van Swieten3 mentions a death with sudden change of voice, while dining. Morgagni4 mentions a similar case, in a physician, who suddenly became hoarse, and died at once. Porter5 knew of two young men found dead from oedema in the morning, without any complaint having been made by them the night previous. Ruehle6 mentions a young man with swollen tonsils and overheated by dancing, found dead in the morning from oedema which had suffocated him without awakening him ; and likewise the case of a servant girl, slightly hoarse, who went out lightly clad in the morning, and was suf- focated while going up stairs on her return. Sometimes the manifestations are so sudden and intractable that even in a hospital the patient perishes before aid can reach him. Roger,7 while an interne at IIotel-Dieu, was summoned to an attendant in an adjoining ward, who died of sudden suffocation before he could be reached; and yet there had been no complaint save of a sore throat, so slight as not to interrupt the man’s work in the hospital. These instances of sudden death certainly seem to indicate a sudden occlusion of the glottis from spasm of its constrictors, or from paralysis of its dilators, rather than a mechanical death from serous effusion. It is quite probable that the oedematous condition may have existed for some hours or days undetected and unsuspected, and that some sudden inspiration of dust, or of saliva, has produced an immediately fatal spasm. Deuteropathic oedema of the larynx may be preceded by pyrexia. In some instances discomfort in the larynx, and a disposition to cough, may exist for two or three days. Much more frequently the symptoms are sudden, marked, and rapidly progressive in severity. They are local tenderness—sometimes amounting to intense pain in acute cases—with hot and dry throat, and a sense of constriction or obstruction within it. Inspiratory stridor now en- sues, sometimes sonorous or sibilant, and this rapidly increases until suffoca- tive apncea seems impending. Cough occurs in the form of voluntary efforts 1 Op. cit. 2 See particularly case of Roberts* infra. 3 Cited by Rnehle, Die Kelilkopf-Kranklieiten, S. 158. Berlin, 1861. 4 De Sed. et Caus. Morborum, Epist. xxii. ; cited by Bayle. 5 Surgical Pathology of Larynx and Trachea, p. 82. London, 1837. 6 Cited in my work already quoted, p. 447. 1 Diet, de M6d., t. xvii. p. 575. (EDEMA OF THE LARYNX. 247 to rid the throat of the obstruction within; and saliva and mucus are some- times expectorated. The voice gets feeble, then indistinct, and finally extinct in some instances. Dysphagia exists in consequence of the swollen epiglottis or margin of the larynx, and sometimes amounts to aphagia. Forced deglutition has sometimes proved immediately fatal. ' Restlessness soon ensues. Sleep may be impossible from fear of suffocation, or occasional slumbers are soon broken by suffocative paroxysms. These often subside quickly at first, leaving intervals of absolutely unimpeded respiration—fur- ther evidence in favor of the nervous origin of the dyspnoea and the stridor. The obstruction to breathing is at first confined to the inspiratory phase of the act, and is generally attributed to occlusion of the entrance of the larynx, by contact of the tumid folds of tissue approximated by the force of the atmospheric current upon them. This turning in of the upper portion of a pair of oedematous aryteno-epiglottic folds can be recognized laryngoscopic- ally, and occasionally directly, in cases of incised wound through the hyo- thyroid membrane, even though the inferior portions of the swollen tissues are drawn apart by the separation of the arytenoid cartilages in the inspira- tory act. After a while breathing becomes obstructed in the expiratory phase of the process also. The usual physical phenomena of suffocation are recognized: general agitation; anxious countenance; face flushed at first, and then livid; lips and tongue blue; eyeballs projecting ; respiration shallow, hurried, and perhaps spasmodic or gasping ; pulse small, quick, and frequent. Death may ensue in the first paroxysm, or in any subsequent one. In acute oedema the paroxysms are usually abrupt, violent, and irregularly recurrent at intervals of a few hours. Slight agitation or emotion may bring them on. In chronic oedema they usually follow steadily increasing dyspnoea, culmi- nating in a paroxysm which is followed by relief to the difficulty of breath- ing, and does not recur for a few days, or even for a few weeks. The inter- vals gradually diminish, until finally several paroxysms a day may occur, those at night being the most severe. The subjective symptoms of subglottic oedema of the larynx are similar to those of acute laryngitis, with the addition of mild symptoms of ordinary oedema of the larynx ; but the stridulent dyspnoea is present in both phases of respiration, and is attended with a noisier hoarseness. There is more cough, and more expectoration of mucus, rings of fibrinous sputa being sometimes ejected. Dysphagia does not occur unless there be oedema of the upper aperture of the larynx also. Diagnosis.—The tongue, palate, uvula, tonsils, and even the pharynx, sometimes show evidence of infiltration—usually when the oedema is the result of acute inflammation ; but in many instances there is no manifesta- tion of disease in these structures. In some cases the oedematous epiglottis is visible without depression of the tongue; in others it is brought into view by that manipulation. If the tongue be so far depressed as to induce retching, the swollen aryteno-epiglottic folds will sometimes come into view. The marked inspiratory dyspnoea, with comparative freedom in the expi- ratory phase of breathing, is to be regarded as a characteristic symptom, though by no means pathognomonic. According to Billard,1 oedema of the larynx in the new-born is indicated by a peculiar, bleating cry, veiled and incomplete. Digital exploration will readily detect oedema of the epiglottis or of the aryteno-epiglottic folds ; but the manipulation has been known to produce serious suffocative phenomena.2 Forward and upward manipulation ' Op. cit., p. 489. * Trousseau, Clin. Med., New Syd. Society’s transl., vol. iii. p. 98. 248 INJURIES AND DISEASES OE THE AIR-PASSAGES. of the larynx, externally, affords no relief to the dyspnoea as it does in retro- pharyngeal abscess, and serves therefore as a method of discrimination. Accuracy in diagnosis is assured at once by laryngoscopic inspection. The oedematous epiglottis presents itself as a gelatinoid, quivering tumor, varying in size from that of a peanut to that of a walnut. Its configuration varies. Occasionally it is constricted by the glosso-epiglottic ligament, so as to re- semble two bladder-like projections instead of one. Sometimes it looks like a large, limpid sac overhanging the upper aperture of the larynx. The laryn- geal surface does not favor accumulations of fluid ; hence the oedema is usually confined to the lingual surface and the crest. Fig. 1114. Fig. 1115. (Edema of epiglottis. (Edema of aryteno-epiglottic folds. (Edema of the aryteno-epiglottic fold, usually bilateral, appears, in the laryngoscopic image, as a pale pink or yellow, translucent or semi-translueenr, pyramidal tumor, resembling in color an oedematous prepuce or an (edematous eyelid. As a rule, the ventricular band (false vocal cord) becomes obliterated into a mass continuous with the aryteno-epiglottic fold. When bilateral, the oedema is usually unequal. Sometimes these tumors are livid. They may attain the size of a pigeon’s egg. The swollen folds of tissue project towards each other, and occlude the calibre of the upper portion of the larynx—the glottis of the ancients—hence, probably the term (Edema glottidis. The space between them becomes diminished to a mere slit; and in pronounced cases, this slit becomes smaller during inspiration, from the pressure of the inspi- ratory current, which slightly forces its surfaces into contact. Sometimes, indeed, they stick together for a moment. During the expiratory phase of respiration they separate, at times sufficiently to disclose the vocal bands be- neath them. Gougenheim1 denies this downward and inward movement by atmospheric pressure, and asserts that the oedematous folds separate in inspi- ration, following the movements of the vocal bands. He attributes the dys- pnoea to spasm. That he is correct as far as concerns the cases observed by himself, there is no reason to doubt; but I have noticed the action above described, not only laryngoscopically, but likewise directly, in the oedema consecutive to suicidal wounds of the neck which exposed the larynx to direct view. In a case of acute inflammatory oedema of the vocal bands recorded by Semon, “ the upper surfaces of these structures were quite rounded, so that they looked semi-cylindrical,” and “ their color was changed into a bright, semi-transparent red.” 1 Annales des Maladies de l’Oreille et du Larynx, etc., p. 125, Juillet, 1883. (EDEMA OF THE LARYNX. 249 In subglottic oedema of the larynx, laryngoscopic in- spection reveals projecting tumors beneath the vocal bands. (Fig. 1116.) The affections from which oedema of the larynx is to be discriminated are thymic asthma, stridulous laryngitis, croup, the presence of a foreign body in the air-passage, that of a tumor in the larynx, and compres- sion of the air-passage by an aneurism of the aorta or of the innominate artery. The history of the attack, and inspection with the laryngoscope, will usually suffice for diagnosis. In antelaryngoscopic days, the symp- toms due to compression from aneurism were sometimes attributed to oedema of the larynx (Cruveilhier), and tracheotomy even was performed in consequence. (Lawrence, Cheyne.) Fig. 1116. Subglottic oedema of the larynx. Prognosis.—The danger of suffocation, which may come on with little warning, or with none at all, renders the prognosis grave whenever the oedema is extensive or bilateral, or attended with spasm of the- glottis. Suffocation has been known to occur at the apparent onset of the oedema, before it has been possible to know what was the matter. Left to itself, a serious case of oedema will be apt to terminate fatally in from three to five days, sometimes by suffocative apnoea, sometimes by slow apncea, sometimes by supercar- bonization of the blood, even after the respiration has become comparatively tranquil. Idiopathic, serous oedema, in robust subjects, affords a favorable prognosis, provided that prompt measures are taken for relief. Sero-purulent and puru- lent oedema offer a far less favorable prognosis. That of the oedema attending aneurisms, malignant tumors, and tuberculosis, is always unfavorable. The prognosis is doubtful in the deuteropathic oedema of acute constitutional disorders, such as enteric fever, smallpox, scarlatina, and erysipelas. Both immediate and ultimate prognosis are less favorable in subglottic than in supraglottic oedema. The prognosis of chronic oedema of the larynx is not so immediately serious as that of acute oedema, but the hope of ultimate recovery is much slighter; and tracheotomy may be indicated for the permanent establish- ment of an artificial opening for respiration. Treatment.—The best treatment for oedema of the larynx is to make a few punctures or incisions into the tumid mass, with a well-curved knife protected to within a line or two of its point, so as to give vent to the fluid. Special knives have been constructed for the purpose, which are easier to manipulate, but in an emergency a gum-lancet will be found quite efficient. If practica- ble, the little operation should be performed under guidance of laryngoscopy; otherwise the forefinger of the disengaged hand may be relied upon as the guide for the knife. It is not necessary to make an intra-laryngeal cut for oedema of the aryteno-epiglottic fold. An incision in the exterior wall will do just as well, and will avoid the entrance of blood into the air-passage. A little spasm follows the cut, and seems to help force the serum out. The hemorrhage is insignificant in most instances, amounting usually to less than a drachm, and rarely to more than two or three; but occasionally the bleeding may be profuse, and may require persistent coughing to expel it.1 Bleeding is more apt to be profuse from scarification of the epiglottis than from scari- fication of the aryteno-epiglottic fold. When the hemorrhage is slight, it may 1 Cohen, op. cit., p. 451. 250 INJURIES AND DISEASES OF THE AIR-PASSAGES. be encouraged by warm-water gargling, or by inhalations of steam. If the first scarification be effective, a second is rarely required in acute oedema. In chronic oedema, repetitions may be called for from time to time. When the effused products are semi-solid, they cannot be evacuated by scarification. Should the hemorrhage from the operation fail to give relief under such conditions, tracheotomy is indicated. Its postponement sur- renders the patient to the risk of suffocation.1 Too long a delay in trache- otomy may favor death by congestion of the lungs or brain, even though free respiration be re-established2 for a few hours or a few days. Tracheotomy is preferable to laryngotomy, inasmuch as this sort of laryngeal oedema may extend down to the point of election for laryngotomy, and that operation may, therefore, fail to afford relief. Respiration having been secured by the tracheotomy, ample time will be afforded for deliberate scarification of the cedematous tissues—a proceeding which will be required should deglutition be impeded by the swelling. It is sometimes practicable, as suggested by Stro- meyer, to rupture the swollen mucous membrane by strong pressure with the finger at the moment of digital exploration. In one instance of oedema of the epiglottis, I was enabled to perform this little operation with success. Pressure and scarification failing to afford relief, tracheotomy is indicated at once, lest suffocation ensue before absorption can be induced by constitu- tional measures. Cases recover sometimes under antiphlogistic treatment,3 and spontaneous subsidence occurs occasionally, too, within a few hours without treatment; but it is better by far, as regards the safety of the entire number of patients, to perform tracheotomy than to run any risk. Indeed, tracheotomy once indicated in a case not under continuous professional super- vision, had better be performed as a precautionary measure even though the urgent symptoms have subsided. Otherwise death may ensue in a fresh suffocative attack.4 Frequent compression of the parts to promote absorption (Thuillier), seems hardly worthy of commendation. Catheterization of the larynx usually fails to afford any relief, though Chiari claims good results from this procedure in the acute oedema attending nephritis and inflammation in the vicinity of the larynx.6 In cases of moderate severity, unattended with laryngeal spasm, iced appli- cations externally, and ice in the mouth, will sometimes favor absorption of the effused serum, and obviate any necessity for resort to the knife. In hemorrhagic oedema, puncture or incision of the mucous membrane is indicated to give vent to the effused blood. Pellets of ice in the mouth, and the administration internally of turpentine or ergot, or the hypodermic admin- istration of the latter, are likewise indicated. Should suffocative apnoea be threatened, tracheotomy becomes indicated for the reasons already alluded to. In sub-glottic oedema, scarification is the theoretic remedy; but the loca- tion of the lesion renders it impracticable to follow the indication. In mild cases, the constitutional influence of mercurials may be tried in the first instance. Tracheotomy once indicated, should not be long deferred, lest, as in an unfortunate instance in my early practice, it may fail to save the patient from the lethal effects of prolonged supercarbonization of the blood. In some cases of this kind it becomes impossible to dispense with the 1 For a recent case in point, see Jour, de Med. de Bordeaux, 24 Juin, 1883. 2 Pitman and Page, Lancet, April 21, 1800, p. 392. 3 Wilson, Med. Chir. Trans., vol. v. p. 156; Arnold, ibid., vol. ix. p. 31 ; Anderson, Edinb. Med. and Surg. Jour., vol. x. p. 284; Roberts, Med.-Chir. Trans., vol. vi. p. 135. Roberts’s pa- tient died in a subsequent attack fourteen years afterward. 4 Jour, de Med. de Bordeaux, 24 Juin, 1883 ; Med. and Surg. Reporter, Sept. 8, 1883 p. 270. 6 Monatsschrift fur Ohrenheilkunde, Juni, 1881 ; Rev. mens, de Lar., etc., Janv. 1882, p. 25. fractures of the larynx and trachea. 251 tracheotomy tube, the effused matters failing utterly to undergo absorption under any treatment. In chronic oedema, tracheotomy can do little more, in many cases, than put the larynx at rest for a time. In many instances it but adds additional irritation to the evils already in existence. It does not facilitate the cure of the affection. In case of threatening suffocation, it is demanded as in similar conditions under other circumstances. Scarification, followed by topical applications of strong astringents, such as solutions of nitrate of silver, chloride of gold, chloride of zinc, and sulphate of copper, sometimes reduces the tumefaction for a time. Sedative inhalations relieve the local distress. Blisters and other counter-irritants are rarely efficacious, and are sometimes injurious. These cases, as a rule, are hopeless. Fractures of the Larynx and Trachea. Fracture of the Larynx.—Fractures of the larynx are not frequent. They are commonly the result of great violence. They are usually associated with a wound of the integument, but the reverse occasionally occurs.1 Sometimes they are associated with fractures of the hyoid bone, and occasi- onally with fractures of the lower jaw and of the extremities.2 There may be a single fracture, or several fractures. Multiple fracture of the cricoid cartilage is rare.3 Ossification of the cartilages is assigned as the chief cause of multiple fracture. The fracture may be complete or incomplete. It may be simple, compound, complicated, or comminuted. But little was known of fracture of the larynx before the eighteenth century. The earliest record is usually attributed to Morgagni,4 and among the earlier cases may be mentioned those of Valsalva (1703), Weiss (1745), Colombo, and Plink (1775)5 The subject has been particularly studied or discussed by Malgaigne,® by Cavasse,7 by Gurlt,8 by Hunt,9 by Fredet,10 by Ilenoque11—who sums up the conclusions of the writers referred to, and others with them—and by Caterinopoulos.12 Usually the fracture is limited to the thyroid and cricoid cartilages. I know of no positive record of fracture of an arytenoid cartilage, save an undefined “ articular fracture” of the right arytenoid in a case cited by Cavasse. The arytenoid cartilages, moving so freely on the cricoid, are much more apt to suffer luxation. In extensive injuries, indeed, such a lux- ation is not infrequent, and is often a serious element of danger. Li many cases both the thyroid and the cricoid cartilages are fractured. The thyroid suffers much more frequently than the cricoid when but one cartilage is broken. In 52 cases collected by Ilenoque, the thyroid alone was fractured in 23, the cricoid alone in 7, and both cartilages in 7. Durham13 adds seven- teen cases, four of which are personal, to the fifty-two collected by Ilenoque, I Macler, Union Med., 1864, p. 142. 2 Bell, Lancet, Oct. 21, 1871, p. 571. 3 Treulich’s case, infra. * Op. cit., epist. xxix. 6 Masucci, Arch. Ital. di Lar., Anno i., 1881-2, p. 110. 6 Traits des fractures et des luxations, tome i. Paris, 1847. 7 Essai sur les fractures traumatiques des cartilages du larynx. Th&se de Paris, 1850. 8 Handbuch der Lehre von den Knochenbriichen, Theil. II; Lief. i. Hamm, 1864. 9 Am. Jour. Med. Sciences, April, 1866, p. 378. 10 Gaz. des Hop., 1868, Nos. 90, 91 ; Quelques considerations sur les fractures traumatiques du larynx. Paris, 1868. II Gaz. Hebdomadaire, 25 Sept., 2 Oct., 1868. 12 Etude sur les fractures des cartilages du larynx, et leur traitement par la tbyrotomie imme- diate. These de Paris, 1879. 13 Op. cit., 3d edit., vol. i. p. 749. 252 INJURIES AND DISEASES OF THE AIR-PASSAGES. with the following summary: indefinite “fractures of larynx” 7; thyroid only 30 ; cricoid only 11; thyroid and cricoid 9 ; thyroid, cricoid, and trachea 2 ; cricoid and trachea 3 ; thyroid and hyoid bone 4; thyroid, cricoid, and hyoid bone 2 ; cricoid, trachea, and hyoid bone, 1. Ossification of the cartilages is hardly the important element in the injury that it was formerly supposed to be, for of 4b cases of fracture of the larynx and trachea collected by Gurlt,1 16 occurred in individuals between nine and thirty years of age, 12 in males and 4 in females. The thyroid car- tilage alone was injured in 6 of these 16 cases, the cricoid alone in 1, the trachea alone in 1, the “larynx” in 2. Of the 27 cases collected by Hunt, 5 had occurred in children. Fractures are sometimes associated with contused, incised, lacerated, and gunshot wounds of the integument and of the larynx itself. The causes of fracture of the larynx are attempts at choking with the hand, whether premeditatedly or during a struggle ; blows with the fist, foot, or a hard weapon, such as a billet of wood ; falls upon hard objects; awkward hanging ;2 and crushing violence. Mackenzie3 records one from an acrobatic jump upon the patient’s neck. Treulich records a multiple fracture in a patient whom a horse seized by the throat and lifted from the ground. Fig. 1117 Fig. 1118. -Fracture of thyroid cartilage. CO, Line of fracture, (Roe.4) Fracture of larynx A, Rupture of mucous membrane where hemorrhage took place; B, Upper cornu turned inward. (Roe.5) Fracture of the thyroid may be single or multiple, complete or incomplete. The single fracture is usually vertical. Its most frequent seat is anteriorly, 1 Op. cit. 2 For a recent example, see Porter, Archives of Laryngology, vol. i. p. 142 (illustrated). s Op. cit., p. 402. 4 Archives of Laryngology, April, 1881, p. 129. 6 Ibid., p. 130. FRACTURES OF THE LARYNX AND TRACHEA. at the middle line or a little to one side, the intermediate cartilage usually adhering to the larger fragment (Fig. 1117). Multiple fractures may occur in one wing only or may involve both. Stellate fractures are sometimes pro- duced by gunshot injuries. Fractures of the cricoid cartilage are usually vertical or slightly oblique in direction. They may occupy the posterior, the lateral, or the anterior portion of the cartilage. They are usually single, but may be multiple. A case is recorded in which the cartilage was broken into three fragments.1 Fractures may be complicated by disrupture of the larynx from the trachea ;2 by oedema of the larynx or epiglottis ;3 by laceration or rupture of the mucous membrane (Fig. 1118); by displacement of fragments so as to occlude the calibre of the respiratory passage ; by clotting of blood within it; in fact by nearly all the complications detailed in connection with contused, lace- rated, and gun-shot wounds of the larynx. A case has been recorded4 in which blood was effused in the neighboring parts to such an extent as to push the larynx over to one side. Symptoms of Fractured Larynx.—The symptoms vary with the cause of the injury and with the extent of the lesions. Unconsciousness is some- times an immediate result, not only in cases of fracture from manual com- pression,5 but in those from blows and falls upon hard objects,6 and in those from fire-arms. The ordinary subjective symptoms are pain, dyspnoea, and cough. The cough is usually spasmodic or paroxysmal, and serves to eject both frothy and coagulated blood, and bloody mucus. The dyspnoea is usually severe, and is attended with lividity of the countenance. It progresses in some instances to threatening suffocative apncea, with all the usual accompaniments of that condition. Coarse mucous rales may be heard in the larynx. Dysphonia usually exists to some extent, in some cases amounting to aphonia. Diffi- culty of articulation occurs in some instances, and occasionally absolute in- ability to speak. Pain is usually excited by swallowing or by handling the part. Sometimes it is constant. The dysphagia, as in Mackenzie’s case,7 which was examined laryngoscopi- cally, may be found due to an inflamed and cedematous epiglottis. In exceptional cases there may be but slight hoarseness, slight dysphagia, and slight pain or mere tenderness, with total absence of dyspnoea. Should a laceration in the mucous membrane communicate with the site of fracture, emphysema of the throat and neck will be likely to occur. Such emphysema has been known to spread over the face, thorax, and back, down into the mediastinum, and even over the entire body. It is said to be more likely to involve the intermuscular connective tissue than that which is sub- cutaneous. The suffocative symptoms may arise from serous oedema of the larynx, from hemorrhagic effusion, from accumulation of fluid or of clotted blood, or from occlusion by displaced fragments of broken cartilage and lacerated soft tissues. In some instances there has been but little dyspnoea at first, or none at all, and yet severe dyspnoea has suddenly ensued within a few hours, or as late as after several days of comparatively quiescent respiration. These 1 Treulich, Viei-teljahrschrift f. d. prakt. Heilkunde, Bd. v. S. 129. 1876; Centralbl. f. Chir. 1876, No. 14. 2 Wagner, Centralbl. f. Chir. 1883, No. 23. 3 Mackenzie, op. cit., p. 402. 4 Stokes, Dub. Jour. Med. Sei., May, 1869; cited by Durham. 5 Wagner, Centralbl. f. Chir., 1883, No. 23; London Med. Record, October 15, 1883. 6 Roe, loc. cit. ; Sajous, Archives of Laryngology, July, 1882. * Op. cit., p. 402. 254 INJURIES AND DISEASES OF THE AIR-PASSAGES. manifestations have been attributed to oedema in some instances, and to dis- placement of fragments in others. The symptoms of incomplete fracture appear to be very slight in com- parison to those of complete fracture. Although there is no absolute displacement of fragments, crepitus is said to have been elicited in some instances, when the parts were pressed upon for the purpose. Diagnosis.—The history of wound or other injury, and the manifestations described as the symptoms, will indicate the character of the lesion. If the injury be the result of a direct blow or a fall, the neck may be flattened anteriorly; if the result of choking or other form of strangulation, it may be flattened laterally. Some evidence of bruise, contusion, or external wound is usually observed. Ecchymosis is commonly present, with tumefaction externally. Early swelling is attributed to extravasated blood ; late swell- ing to inflammation. Abnormal mobility of the cartilages can usually be detected on manipulation. In severe lesions there may be deformity from overriding of the fragments. In others, there may be no displacement at all. (Gibb.) Crepitation may be produced by manipulation of the fragments in some instances; but care must be taken not to be deceived by the crepitation normally produced by lateral movements of the larynx, or by slight pressure against the vertebral column. The horn of the right cartilage may be anomalously inclosed in the lateral thyro-hyoid ligament,1 or may be entirely absent.2 Prognosis.—The prognosis is always grave, especially so when the cricoid cartilage has suffered fracture. But two instances of recovery after fracture of the cricoid seem to be on record.3 In the entire 28 instances of fracture of this cartilage tabulated by Durham,4 not one patient recovered. Wagner’s cases5 furnish additional examples. The fatal result is probably attributable to the great contusion and laceration sustained by the bloodvessels, nerves, and other soft parts, in an injury sufficiently severe to fracture this very strong cartilage. Fractures of the thyroid cartilage are usually fatal, only 10 patients having recovered in Durham’s list of 30 cases of fracture of that cartilage only, and 2 in 4 cases of fracture of the thyroid complicated with fracture of the hyoid bone. Guanck’s case6 also terminated fatally. A patient referred to my clinic from the surgical out-door department of Jefferson College Hospital, and placed under care of the clinical chief, recovered with a weak voice—crepitation being reported to have been as distinct four months after the injury as it had been on its receipt.7 Harrison8 likewise reports a case which terminated favorably. In Treulich’s case of recovery,* there had been fracture of the thyroid and double fracture of the cricoid, with rupture of the trachea. It is presumable that the repair is by fibro- cartilage as in other wounds of the same parts. Severe cases often terminate fatally at once, or within a few hours ; usually by suffocative apnoea from extravasation of blood beneath the intra-laryngeal mucous membrane—-hemorrhagic oedema—or from displacement of fragments occluding the calibre of the respiratory tract, or from accumulation of blood within it. Extensive injuries to the superjacent soft parts, or to other por- tions of the body, help to exhaust the forces of the patient, and render the prognosis still more gloomy. 1 Luschka, Virchow’s Archiv, 19 Marz, 1868, S. 478. 2 Cohen (Miitter Lectures), Phila. Med. Times, April 12, 1873, p. 435 ; op. cit., p. 609. 3 Treulicli, loc. cit., cited by Ashhurst (Principles and Practice of Surgery, 3d ed. 1882, p. 351) : The cricoid was fractured in two places, isolating the anterior median segment; Masucci, Arch. Ital. di Lar., Anno I., 1881-2, p. 108. 4 Op. cit., 3d edit., vol. i. p. 749. 5 Loc. cit. 6 Wien. med. Wocli., 1 Sept. 1883. 7 Sajous, Archives of Laryngology, July, 1882. 8 Lancet, June 1, 1882. 9 Loc. cit. FRACTURES OF THE LARYNX AND TRACHEA. 255 Unless forestalled by precautionary tracheotomy and insertion of a tube, suffocative phenomena may intervene at any time from oedema, displacement of fragments, or occlusion of the calibre of the air-tube with blood-clots. Recovery occupies a number of weeks. In complicated cases, three months or more may be consumed in the process. Suppuration ensues during repair; and this may entail cicatricial stenosis. The injured cartilages may undergo necrosis in part, and the dead portions may be expectorated, or may be discharged externally. Suppurative inflammation of the connective tissue sometimes follows the emphysema. Death has taken place in this way by mediastinal emphysema and secondary pericarditis ;J by pleurisy from contiguity to the burrowing abscess; and by pneumonia (Wagner’s case) and broncho-pneumonia.2 Permanent hoarseness, or even aphonia may remain after recovery. Treatment.—Recovery is so rare unless tracheotomy has been performed at some stage of the treatment, and the danger of sudden suffocative apnoea is so great under almost any other method of management, that prudence seems to suggest the propriety of a prophylactic tracheotomy in every instance, as a precautionary measure, for reasons mentioned in discussing the treatment of incised and gunshot wounds of the larynx (p.237). Of the entire sixteen cases of recovery out of the sixty-nine tabulated by Durham, in nine the patients were saved by timely opening of the air-passage, and a tenth was restored by long-continued artificial respiration after tracheotomy, although he succumbed to broncho-pneumonia a fortnight later.3 To this list of recoveries after tracheotomy, may be added the exceptional case of Treu- lich, already referred to. Better far that an unnecessary tracheotomy should be occasionally performed without detriment to the patient, than that a number of cases should be allowed to terminate fatally for want of it.4 The safety of the patient from suffocation being apparent, or having been secured by the operation recommended, the displaced fragments should be care- fully adjusted, the crico-thyroid membrane being incised, if necessary, to facili- tate their reposition by means of catheters, probes, or the little finger passed through the artificial opening—a procedure which practically adds nothing to the peril of the patient. STo attempts should be made to retain the frag- ments in position by sutures, for reasons previously mentioned (p. 238). Any wound in the soft parts may be closed by sutures and adhesive strips; an open- ing being left for drainage, and kept patulous by a strip of lint or a drainage- tube. The treatment of emphysema and other complications, and the after- treatment altogether, should be conducted on the same principles as that of wounds of the larynx generally. If the fragments of the thyroid cartilage fail to unite, or if stenosis cannot be prevented, extirpation of the partially detached portion, and even removal of half of the larynx has been suggested ;5 and in a case reported by Billroth, this partial operation was performed, and a good voice retained. Fractures of the Trachea,.—Fractures of the cartilages of the trachea occur under similar conditions to those under which fractures of the larynx are met with. In some instances the injury is confined to the trachea ; in most it is associated with fracture of the larynx, of the hyoid bone, or of both. Gurlt.6 records nine cases of fracture of the trachea, in four of which 1 Steiner, Wien. med. Woch., Bd. xviii. S. 15. 1867, 2 Couper, Med. Times and Gaz., Dec. 18, 1880, p. 695. 8 Op. cit., 3d edit., vol. i. p. 750. 4 See especially Fredet, op. cit., p. 5. 5 Wagner, loc. cit. 6 Op. cit., S. 316. 256 INJURIES AND DISEASES OF THE AIR-PASSAGES. that structure alone was involved. Dr. Corley1 records a case following a squeeze of the throat in a domestic quarrel, in which three of the upper rings of the trachea had suffered fracture. A comminuted fracture is reported by Drummond,2 in which the cartilaginous rings were crushed by a fall upon the exposed spindle of a chair from which the upper rung was missing. >Symptoms.—These are similar to those of fracture of the larynx; severe dyspnoea and rapidly extending emphysema. There is no elevation of dislo- cated fragments, no abnormal mobility, and no crepitation. False crepitus may be due to emphysema or to extravasated blood. Diagnosis.—The character of the accident occasioning the dyspnoea and emphysema, and the evidence of external injury, will commonly indicate the nature of the case; but the absence of the physical signs of crepitus and deformity may render the diagnosis difficult. Prognosis.—This is unfavorable, especially if the trachea be not freely opened for re-establishment of the respiration. Fracture of the trachea seems more promptly fatal than fracture of the larynx. Of seven cases collated by Gurlt, death followed in five of them from an hour and a half to a day after the accident. In one only was life saved, and then by tracheotomy after apparent death, the accumulated masses of blood and mucus being removed, and artificial respiration instituted. Recovery ensued in the case of commi- nuted fracture recorded by Drummond. Treatment.—This is similar to the treatment of fracture of the larynx. The trachea should be laid freely open, either at the injured part or below it, and a tube inserted, through which respiration may be carried on with safety. The subsequent treatment should be like that adopted for similar wounds of the trachea. Tracheocele. Tracheocele is the term applied to a sacciform diverticulum of the mucous membrane of the trachea3—a hernial protrusion externally, between two of the cartilaginous rings or through a congenital fistula. A tumor is thus formed on the external wall of the air-tube, the contents being air, and the cyst-wall mucous membrane. Its position may be anterior or lateral. The lesion is quite rare. The tumors vary in size from the bulk of peas (Gross) to that of hens’ eggs. The tumor is usually single; occasionally it is bi-lobed. Faucon4 relates one instance of ten years’ standing, in which the tumor was divided into an upper and a lower lobe. Devalz6 narrates a case in which the tumor ■was composed of two principal lobes; one passing under the muscles of the neck to the right, and the other under the clavicle to the left. Eldridge6 likewise records a bilateral case. In a thoughtful article he presents a table of nine cases, two of which, however, were not really tracheoceles, and were not so recorded by their observer.* Detis8 reports a case of median tracheo- cele in the practice of Godefroy, and reproduces eight cases published by other writers. Tracheocele has been observed much the more frequently in males, and usually in the adult. Leriche9 has recorded a case of double tracheocele in 1 Dub. Jour. Med. Sci., October, 1877, p. 346. 2 Brit. Med. Jour., Dec. 28, 1872; Boston Med. and Surg. Jour., Jan. 16, 1873, p. 72. 3 Rokitansky, Manual of Pathological Anatomy, vol. iii. p. 48. Philadelphia, 1855. 4 Gaz. des Hop., 1874, p. 77. 6 Gaz. Hebd., 24 Juin, 1873, and Gaz. Med., 15 Nov. 1873, p. 612. 6 Am. Jour. Med. Sci., July, 1879, p. 70. 7 Cohen, Diseases of the Throat, etc., p. 395. 1872. 8 Contribution a du tracheocele. These de Paris, 1882. 8 Comptes-rendus de la Soc. des Sciences Med. de Lyon, 1868 ; reproduced by Detis, loc. cit. TRACHEOCELE. 257 an infant eight months of age. Faucon1 has recorded an instance in a child eighteen months old, in which the tumor was seen, during a plastic operation, to have been the result of a defect in the lining membrane of the trachea—the only instance of any anatomical examination of tracheocele with which I am acquainted. Imperfect descriptions of congenital examples have been recorded by Gold2 and by Fischer.3 Gohl’s case was associated with bron- choeele. Under the title of aerial or vesicular goitre, Larrey4 has mentioned some cases of what appears to have been circumscribed emphysema of the neck, occurring in the blind Muslimim who chant verses of the Koran every hour from the tops of their minarets—the pouches being compared to the submaxillary pouches of monkeys. He also mentions two cases in drill-sergeants. A number of similar cases, with aerial tumors more or less evanescent, are recorded by various observers as having followed straining of the voice, violent cough, violent vomiting, and violent physical effort while holding the breath, two instances of this kind being mentioned in my work, already quoted.5 But these are not cases of tracheocele, since there is no evidence of the existence in them of a sac formed at the expense of the mucous membrane of the trachea, which seems necessary to constitute that affection. Pathogenetically, tracheocele seems due in most instances to a congenital defect in the closure of a branchial cleft. Through the fistula thus left, the tracheal mucous membrane is forced by the expulsive power of the expira- tory current of air in violent coughing, or in straining with closed glottis. The sac produced in this way gradually enlarges, and is presumed to undergo thickening by inflammatory processes. Laceration of the air-tube in violent efforts with closed glottis, as during defecation and parturition, has been regarded as a cause of this affection, but it is not improbable that a congeni- tal defect may have existed even in those instances in which such laceration has occurred. Symptoms.—The subjective symptoms are dyspnoea, occasionally noisy and sometimes threatening in character; a hoarse, low, muffled voice ; and aphonia and even dysphagia in some instances. In Devalz’s case the pronunciation of each syllable was accompanied by a peculiar cooing, said to be faithfully imitable by pronouncing oavouvou in a very deep tone. The objective symptoms are connected with the presence of a compressible, gaseous tumor, sometimes resembling a cystic goitre, just above the sternum or not higher than the cricoid cartilage, whether anterior, lateral, or bilateral. This tumor enlarges somewhat during the expiratory phase of the respira- tory act, and conversely diminishes in size during inspiration. Marked enlargement can be produced on forced expiration with closed mouth and nose, but this enlargement is much less than that observed to take place during a paroxysm of intense dyspnoea. In some instances the tumefaction is paroxysmal for some months before it becomes constant.6 Laryngoscopi- cally, the action of the laryngeal muscles has been seen to be sluggish (Eld- ridge), and this condition may partly account for the enfeeblement of voice In other instances (Devalz), laryngoscopy has shed no light on the case. Diagnosis.—The history of the sudden appearance of the tumor, its gradual enlargement, its increase under the force of the expiratory current of the breath, the control of some of this enlargement by exercising deep pres- 1 Loc. cit. 2 Ammon, Die angebornenen chirurgischen Krankheiten des Menschen. Berlin, 1842 ; cited by Eldridge (loc. cit.). 3 Pitlia nnd Billroth, Handbuch der Chirurgie., Bd. III. Lief. i. S. 3. 4 Clinique Chirurgicale, tome ii. p. 81. Paris, 1829. B Diseases of the Throat, etc. 6 Eldridge’s case, loc. cit. VOL. V.—17 258 INJURIES AND DISEASES OF THE AIR-PASSAGES. sure at some point of the base of the tumor, the emphysematous sensa- tion of crepitus on pressure of the mass, and its diminution or disappearance under equable compression, all point to the nature of the lesion. Palpation gives the sensation of a sac containing air.1 Auscultation may reveal the normal tracheal murmur. (Devalz.) Tympanic resonance may be elicited on percussion in some cases., (Faucon, Lize, Detis.2) Tracheocele may be mis- taken for goitre. The distinction could be made by an exploratory puncture, for in Eldridge’s case the needle gave exit to a stream of air forcible enough to extinguish a lighted match. Discrimination from circumscribed emphysema would depend chiefly on the discovery of a sac by palpation, but the distinc- tion from emphysema resulting from rupture at the summit of the lung, as in Lize’s case, might prove difficult. Prognosis.—This is said to be favorable by Detis, who reports a case cured after six weeks’ compression. Other records seem to indicate the hopeless- ness of doing much more than preventing increase of size. FTo danger to life, however, is to be apprehended. The supposed cures have occurred in cases of emphysema rather than of tracheocele. Treatment.—The treatment should consist in manipulation of the tumor, so as to drive as much air as possible out of it into the trachea, followed by the application of continuous pressure at the seat of control of the expansion of the tumor, so as to excite obliterative inflammation in the neck of the sac at the tracheal orifice. Dyspnoea may require special treatment by ano- dynes. Godefroy cured his patient within six weeks by permanent compres- sion with a sort of hernia-bandage, and Leriche3, too, promptly cured his patient by compression. Others have simply advised the use of an appara- tus, to hide the deformity and prevent any further distension of the sac. Luxation of the Cartilages of the Larynx. Luxation of the cartilages of the larynx is rare. The cause may be trau- matic, and proceed from without, or may be pathological, and proceed from within. From without, it is the result of direct violence; in most instances, perhaps, associated with fracture of the larynx. Disarticulation of an arytenoid car- tilage from the cricoid is the most usual form of the lesion. Disarticulation of the lower horn of the thyroid cartilage, in connection with other lesions, has been recorded by Holden4 and mentioned by Mackenzie,5 the cause in the former instance having been a severe blow or kick during a drunken brawl, and in the latter instance an accidental blow with the side of the hand. From within, the cause is usually cicatricial contraction of the overlying or adjacent soft parts. In two instances, reported by Stoerk,6 of luxation of the left arytenoid cartilage transversely inwards, the lesion was observed in adult males with falsetto voices, and in both the dislocated arytenoid was seen laryngoscopically to be immensely tumefied, the opposite cartilage being pushed out of position. The vocal bands were seen to be permanently in the position occupied in paralysis of the posterior crico-arytenoid mus- cles. One case was attributed to cicatricial contraction after diphtheria; but no. assignable cause could be detected for the other. A case supposed during life to have been one of paralysis of the muscles mentioned, was dis- covered after death to be one of dislocation of both arytenoids on the interior 1 Faucon, Eldridge (loc. cit.). 2 Op. cit. 3 D6tis, op. cit. 4 Am. Jour. Med. Sci., Jan. 1873, p. 129. 5 Op. cit., p. 541. 6 Wien. med. Wocli., No. 50, 1873 ; London Med. Record, May 15, 1879. LUXATION OF THE CARTILAGES OF THE LARYNX. 259 surface of the plate of the cricoid cartilage, their bodies lying horizontally, and being closely united by cicatricial tissue.1 In this instance, likewise, the lesion was attributed to contraction of a syphilitic cicatrix in the posterior wall of the larynx. As far as these meagre records are available, they seem to indicate that cicatricial contraction of an ulcer may be regarded as a cause of the dislocation. Judging from the laryngoscopic image alone, unsupported by post-mortem evidence, or by the published observations of other writers, it has seemed to me that luxation or subluxation of a supra-arytenoid cartilage is an accident of occasional occurrence. In several subjects, principally singers who have become hoarse after unusual vocal exertion, I have noticed the supra-arytenoid cartilage of one side to incline decidedly forward and inward, in marked con- trast to the erect position of the cartilage of the other side. The lesion does not seem to be of any special significance. Symptoms.—The symptoms of dislocation of an arytenoid cartilage are not characteristic. They comprise difficulty in respiration and in phonation, with other manifestations due to the concurrent injury or disease which has occasioned the lesion. The symptoms described in Holden’s case of disloca- tion of the inferior cornu of the thyroid cartilage—namely, acute pain, sense of suffocation, hemorrhage, dyspnoea, dysphagia, and aphonia—are indicative of concurrent contusion of the larynx. Diagnosis.—As reported in the three instances cited, the laryngoscopic image in dislocation of the arytenoid cartilages presents a close resemblance to that of paralysis of the dilating muscles of the larynx; a circumstance which might be regarded as liable to induce a mistake in diagnosis, were it not for the recognition of the displacement of the cartilage. The diagnosis must rest chiefly on laryngoscopic inspection, in cases of internal origin, and on direct inspection and palpation in cases of external origin. In Holden’s