Violence of no great intensity, when applied to a limited area of the skull, may cause a fracture with only a mo mentary displacement, with a rupture of a meningeal artery, or a rupture of an artery without fracture. A local izin
Amer. Med. Assoc., Sept. 7, 1901).
—The treatment of con tusion of the scalp is very simple. The use of some evaporating lotion or lead water and laudanum with slight press ure is usually sufficient. Under no cir cumstance should the swelling be punct ured or the blood let out in any other way. Erichsen has found contusion of the scalp in girls and young women in some cases to be followed by severe neuralgic pains in the part struck. In such cases incisions down to the bone have been followed by improvement.
Severe contusions may cause concus sion or laceration of the brain.
Technique of Intracranial Surgery.— The consideration of the technique of cerebral operations as here presented is that advocated by L. McLane Tiffany, of Baltimore. It is important to notice that these operations may be rendered necessary by traumatic or pathological lesions. The two should be considered quite separately, since comparison be tween them is almost impossible. In traumatic cases operation is undertaken as a matter of necessity, suddenly, per haps with instruments not entirely suit able, but certainly without delay, the condition of the patient not permitting it. No previous preparation of the pa tient or preparatory treatment has been possible. His general condition is un known. Septic elements are often—in deed, generally—present, not only upon the surfaces, but have, perhaps, been in troduced deeply into the tissues by the traumatism for which the operation is undertaken, and infection may have al ready occurred within the head. The condition of the kidneys may be un known to the surgeon; for, even though the urine be examined immediately after the injury and before the operation is undertaken,—and this should always be done,—yet, if the patient has been trans ported a certain distance in cold weather, or the surface of the body has been largely uncovered, as is not unusual after an injury, albumin may generally be found, and possibly also casts. The details in operative work, also, are often obscure, and landmarks obliterated, both within and without the skull. The head is opened, in traumatic cases, as circum stances permit or seem to indicate. The head may have already been opened be fore the case is seen by the surgeon, who is forced to do patch-work.
In operations for pathological condi tions the reverse of what has been said exists. The proper time is chosen; all things are prepared beforehand; the proper light is provided; asepsis is se cured; there is a due regard for both local and general cleanliness; the con dition of the internal organs has been learned, and they have been made to functionate properly; a well and care fully considered operative procedure is carried through after due study and consideration, and all necessary things are at hand. The operation then is undertaken in the best way for the pa tient's welfare.
An aseptic field of operation is pre eminently essential to success. In cere bral surgery it is best that the whole head should be prepared and cleaned in all cases, unless of a very minor char acter.
In traumatic cases the head is to be shaved and the skin cleaned with green soap, hot water, nail-brush, and care fully scrubbed. The ears should be cleaned out and filled with sterile cotton. The eyes should be closed with pads of sterile cotton. The scrubbing should be done, not only upon the surface, but, if a wound exist, it should be scrubbed , likewise, and an effort made to get out any dirt which has been forced beneath the skin; punctured wounds should he laid open; tracks beneath the skin should be opened and scrubbed; the edges of irregularly-bruised tissue may be trimmed away and a clean surface ob tained. When coal-dust or grease has been forced beneath the surface, scrub bing with a nail-brush and soap and washing with ether and alcohol will often be sufficient to obtain a clean sur face. Dirt ground into the surface or edges of broken bone can be scraped away, or nibbled away with forceps, so as to be gotten rid of. After cleansing the head for traumatic operations a towel wrung out in corrosive-sublimate solution (1-2000), or sterile water, per haps, can be used as a cover for the pre pared region until the instruments and other things are ready. In preparing a patient for an operation undertaken for some pathological condition (not trau matic, of course) the patient is prepared a clay before the operation, and then again just prior to the operation. An alkaline (sodium bicarbonate) solution may be found useful to remove dandruff from the scalp, but Tiffany advises the use of green soap. Shaving and scrub bing with green soap, or a poultice of green soap applied over the surface after shaving and left on for a couple of hours and then scrubbing afterward, is effica cious. The green soap should be re moved with alcohol, then ether, and the clean scalp tied up in a moist corrosive sublimate dressing until the following day; a repetition of the cleansing as al ready described gives a clean surface upon which to operate.