Indications for Operation in Head Injuries

WILLIAM N. BULLARD
1902 Boston Medical and Surgical Journal  
Previous to the introduction of antiseptic surgery, and indeed until within the last twenty years, the only conditions which were generally believed to call for operative interference in head injuries were compound depressed or compound comminuted fractures of the cranium. With the general use of antisepsis and, later, asepsis, the comparative safety of operations was immensely increased, and it became natural to inquire whether operations could not be undertaken with benefit in other forms of
more » ... in other forms of head injury. Tho general interest taken in the later eighties and early nineties in brain surgery, and the greater frequency of operations on the brain, drew attention to the fact, which was contrary to the preconceived views of the time, that under aseptic conditions the meninges and the brain could be incised, punctured and manipulated with comparative impunity. I shall never forget how, in one of the earliest cerebral operations in which I was professionally interested, I saw one of our best-known surgeons plunge a bistoury into the optic thalamus, and the mental relief when no symptoms whatever followed. The comparative safety of simple incisions of the brain being proved, there was still much discussion in regard to the dangers of interference with the meninges, and many physicians and surgeons were convinced of the serious results likely to follow upon an incision or a laceration of the meninges. In consequence of this opinion many operations were only partially performed, the meninges being left intact after the trephining, and the results being thus impaired. The question of tho safety of incision of the meninges, and 1 Read before The Massachusetts Medical Society June 10 and 11,1902. whether such procedure increases the severity of the operation and endangers the recovery of the patient, has now in my opinion been definitely settled. Aseptic incision of the meninges is not in itself dangerous or even very serious. It is imperative in many cases of brain injury if the full benefit of the operation is to be obtained. What are, in the present state of our knowledge, the indications for operation in head injuries? Opinions differ somewhat in this matter. Some surgeons go so far as to advocate operation in all cases of fracture of the cranium, and in many cases of prolonged unconsciousness following injury to the head. Others are more conservative, and would advise operation only in those cases where it is obviously and imperatively de-manded. In answer to this question I shall consider the more common signs and symptoms of head injury in detail, and discuss the value of each by itself and in combination with others. FRACTURE OF THE CRANIUM. I. How far is fracture of the cranium in itself an indication for operation ? This depends on the character of the fracture, on its position and on the age of the patient. I will speak only of fractures of the adult cranium. Compound depressed and compound comminuted fractures should be operated upon in practically all cases. (This, of course, presupposes, as we do throughout this paper, the presence of suitable conditions for operating and asepsis.) All punctured or perforating fractures come under this class. I believe that in all bullet wounds of the skull from the outside, that is, not through the mouth, nose or ears, or through the base of the skull, where there would be excessive difficulty in reaching the opening, the bone around the bullet wound should be trephined, not for the sake of finding the bullet, but simply for the purpose of cleansing the wound, as far as may be, and allowing no secretions to collect about the meninges or between them and the bone. In compound fractures of the cranium where there is no depression and where only a single fissure is found it is safer to operate (trephine) even though there be no other symptoms. /Simple fractures.-What shall we do in cases of simple fracture without symptoms '( This is the class of cases about which opinions differ most strongly. I believe that on the whole it is wiser and better in these cases to be conservative and not to operate, but the patient should be kept under careful observation and operation be undertaken at once if any indication presents itself.
doi:10.1056/nejm190207311470503 fatcat:xk7e4l4i7jguxnrac4te2s6e34