Consideration of some of the indications for operation in head injuries

Consideration of Some of the Indications for
Operation in Head Injnries.

UY

WILLIAM N. BULLARD, M. D.,

Physician to the Department of Diseases of the Nervous System,
Boston City Hospital.

Reprinted from the Bosto?t Medical and Surgical Journal
of January 24, i8gj.

BOSTON:

DAMRELL & UPHAM, PUBLISHERS,

283 Washington Street.

1895.

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S. J. PARKHILL A CO., PRINTERS
BOSTON

A CONSIDERATION OF SOME OF THE INDI¬
CATIONS FOR OPERATION IN HEAD IN¬
JURIES.*

BY WILLIAM N. BULLARD, M.D.,

Physician to Department of the Diseases of the Nervous System, Bos¬
ton City Hospital.

The subject of the indications and contra-indica¬
tions for operations in bead injuries is so large that it
will be possible to cover only a small portion of the
ground this evening, and I shall therefore confine my¬
self to presenting to you certain points which seem to
me to have not yet been appreciated at their full
value by the profession. For the purposes of this
paper it will be necessary to limit ourselves to the con¬
sideration of some of the indications for immediate
operation in cases of head injuries in adults. By im¬
mediate operations we understand such as are per¬
formed within at least twelve hours of the time of the
injury. As a rule, the operations under consideration
are to be performed within as short a time after the
injury as possible. ,

The indications for later operations, that is, more
than twelve hours after the injury, differ very consid¬
erably from those for immediate operations, and are,
on the whole, much easier of determination. These
we will not consider to-night.

The symptoms on which we rely in order to decide
on the advisability of immediate operation in cases of
severe head injury may be roughly divided into four
groups : (1) extracranial or cranial local symptoms,
(2) intracranial local symptoms, (3) extracranial gen¬
eral symptoms, (4) intracranial general symptoms.

1 Read before the Surgical Section of the Suffolk District Medical
Society, December 6, 18M.

2

(1) The direct local symptoms, those which are
immediately due to the injury and are perceptible to
the surgeon. Such are wounds, ecchymoses, evident
fractures of the cranium and all other local and evi¬
dent conditions due to direct injury in any part of the
body, which have any bearing on the diagnosis or
prognosis. These are local extracranial or cranial
symptoms.

(2) The intracranial or indirect local symptoms. In
this group 1 would include all localized symptoms
which are to be referred to intracranial conditions.
Such are the various forms of paralysis, partial or
total, of local spasms and certain conditions of the
pupils. Symptoms of this group point more or less
distinctly to affections of special portions of the intra¬
cranial organs, and so far as they do so are local¬
izing.

(3) The third group is a somewhat indefinite one.
It includes sucli general symptoms and conditions as
may exist after any injury without special relation to
intracranial conditions. Under this heading I should
place the general strength or weakness of the patient
and the condition of the pulse. I have called the
symptoms of this group the extracranial general
symptoms.

(4) The intracranial general symptoms. This in¬
cludes all general conditions presumably due to intra¬
cranial conditions. Such are the states of cerebral
activity or of cerebral repose ; consciousness, semi¬
consciousness, unconsciousness, coma and delirium.
These may be reasonably referred to intracranial con¬
ditions caused by the injury and may be fairly consid¬
ered as the index of these conditions.

The direct external symptoms are too well known
to every surgeon to render their discussion valuable.
The localizing symptoms, though often of great value

8

in combination with other symptoms, in themselves
rather determine where we shall operate than when we
shall operate.

I propose this evening to pass over the symptoms
which I have placed in the first three groups, and de¬
vote myself principally to the consideration of those
general symptoms indicative of intracranial conditions
which we have mentioned in the last group.

It is largely from the general mental condition of
the patient, meaning by this term those states or con¬
ditions which we have before enumerated, conscious¬
ness or unconsciousness, delirium, quiet or irritation,
that the indications or counter-indications for imme¬
diate operation in head injuries are in many cases to be
drawn. We will now, therefore, consider the indica¬
tions for and against immediate operation in cases of
severe head injury in adults where the external signs
and the localizing symptoms do not exist or do not af¬
ford sufficient indication.

The primary indication for immediate operation in
severe head injuries is increased intracranial pressure.
The question of operation in these cases depends on
the degree of this pressure.

Whenever it has reached a certain point operation
is imperative, unless otherwise contra-indicated. This
point is the condition of deep stupor where the patient
cannot be roused by supraorbital pressure. When,
however, the unconsciousness is deep, but the patient
can still be roused by passive movements or in other
ways, the indication is less definite. Yet in all such
cases, and they form a large proportion of those enter¬
ing the large hospitals, we must be largely guided in
our action by the depth of this unconsciousness.

Cases of this kind, as a rule, grow more unconscious
during the first few hours, so that if we wait we may
often be obliged to act rapidly later. On the other

4

hand, the lighter cases of unconsciousness, which do
not tend to become more unconscious, should not be
operated upon at once. In any doubtful case the
most careful watch should be kept for any increase in
the degree of unconsciousness, and as soon as this has
been thoroughly determined operation should be per¬
formed.

In all cases, whether only lightly or deeply uncon¬
scious, where there has been a rapid increase in the
depth of unconsciousness, or where there is a distinct in¬
crease of paralysis of the extremities within the course
of a few minutes or hours after the injury, operation
should be performed. Gradual increase of paralysis
and gradual increase of unconsciousness becoming ap¬
parent shortly after a head injury, suggest intracranial
hemorrhage, usually middle meningeal, and demand im¬
mediate surgical interference in all persons under forty
years of age. In persons much above this age, in cases
where the external injury is slight or doubtful, the
question of the presence of slow hemorrhage from
some of the deep vessels of the cerebrum (ingraves¬
cent apoplexy) must be considered.

When together with unconsciousness there exists
cerebral activity or irritation, as evidenced by delirium,
it has usually seemed to me more advisable to wait and
not operate at once, although some of these cases have
fatal terminations. On the whole, I consider delirium
as rather a sign for delay than for immediate action.
Where delirium without unconsciousness exists, it con¬
tra-indicates operation or indicates that we should not
operate at once.

Localized cerebral irritation, as evidenced by clonic
convulsions, either general or local, is not a common
sign of head injury (surgical). In cases where there
is no history, convulsions render it probable that the
case is non-traumatic, or that some ordinarily non-

5

traumatic condition has been set up by the trauma.
These are the results of clinical experience.

It would seem scarcely needful to state that in each
individual case we must consider the special symptoms
and indications. In those cases in which there is no evi¬
dence of paralysis, and no pupillary symptoms exist,
we rely on the general condition of the patient. The
important signs are two: (1) the depth of uncon¬
sciousness, (2) the increase of unconsciousness.

(1) It is hard to define exactly the degree of uncon¬
sciousness at which — there being no special contra¬
indication— operation is absolutely demanded. In
most of the more doubtful cases we have some sec¬
ondary symptoms (fracture, paralysis, pupillary con¬
ditions) to guide us. Where these do not exist, we
must rely to a certain extent on the general appear¬
ance of the patient, his pulse, apparent strength and
respiration. Jf his strength is failing but he can still
bear operation, operate at once. As a rule, we should
advise operation in any case where the patient (adult)
could not be roused by supraorbital pressure and where
the pupils did not react to light.

(2) When the unconsciousness, light at first, rap¬
idly becomes deeper, especially if this be accompanied
by any commencement or increase of paralysis, we
should at once suspect intracranial hemorrhage, usu¬
ally middle meningeal.

Where an unconsciousness, deep from the begin¬
ning, becomes slowly and very gradually deeper, with¬
out an increase of paralysis of the face or limbs, we
can only diagnosticate an increase of intracranial
pressure, and cannot determine whether such increase
be due to hemorrhage or not.

What now are the pathological conditions existing in
these cases ? I believe that wherever the conditions of
lasting unconsciousness, stupor and coma exist, we

6

have to deal with an increase of intracranial pressure.
This conclusion is based on the results of many opera¬
tions and observations.

The cause of this increase of intracranial pressure
is not altogether plain. It is not by any means, as is
sometimes supposed, always a pressure from intracra¬
nial hemorrhage. In fact, I am inclined to believe
that pressure from this cause is much less frequent
than is supposed. It takes a considerable quantity of
blood to produce from outside the brain substance an
active pressure on the brain, even when the pressure is
produced rapidly.

In many cases, moreover, on operation we have no
evidence suggestive of any severe hemorrhage, and
yet the increased pressure is apparent. Again, this
increased pressure in all probability occurs in the
cases of so-called concussion, and in other mild cases
where unconsciousness exists but where there can be
no question of any profuse hemorrhage. What seems
to occur is this: The brain in some way acts as
a sponge, and swells and pushes so hard against the
dura as to inhibit or diminish pulsation. If in these
cases the dura is incised, the cerebral pulsation a^ain
becomes visible, and the relief to the patient is in¬
stantaneous and extraordinary.

And here let me state that after a tolerably large
experience in these operations I have never seen a
case in which the incision of the dura has caused the
slightest injury to the patient, or has apparently caused
any untoward symptoms whatever. The cause of this
brain swelling I will not discuss to-night, because it is
a difficult subject, not well understood, and, moreover,
has immensely broad bearings in various directions.
It occurs undoubtedly in certain cases of apoplexy
and, in a chronic form, in many intracranial diseases.
This or something analogous, the so-called acute

7

edema of the brain, is the immediate cause of death
in cases of acute alcoholism, of sunstroke and per¬
haps (in its chronic form) in uremia.

Let us now pass to certain surgical considerations
in operations such as we are discussing. It is evident
that unless the operation be of a suitable and efficient
character, its value is likely to be much impaired and
the result not conformable to our expectations. It is
as important to know how to operate as it is when to
operate or where to operate. It may seem a little
presumptuous for one who is not a practical surgeon
to attempt to speak on this subject, but I have for
years followed these operations with care, and feel jus¬
tified in laying down certain rules. These are :

(1) Be sure that the opening in the cranium is suf¬
ficiently large. In the early days of these operations,
and to a certain degree even to the present time, there
has been a tendency on the part of the surgeon in ex¬
ploratory trephining or opening of the cranium to
make his aperture too small.

This is a serious matter, both because it prevents
the surgeon from seeing and from working inside the
cranium at his ease, and still more because it prevents
him from opening the dura sufficiently, and efficiently
relieving the intradural pressure. I believe that in
the ordinary' case nothing smaller than a one-inch tre¬
phine should be used, and then the opening enlarged,
with bone forceps, if possible. An opening, as a rule,
to be efficient should be at least two inches by one.
Of course it makes no difference how this opening is
made providing that it is made as quickly as possible,
with as little jar as may be to tlie patient and without
laceration of the dura.

(2) The second point to be emphasized in these
operations is always to open the dura where there is
evidence of intradural pressure. There is no more

8

danger in opening the dura under proper antiseptic or
aseptic precautions than there is in opening any other
serous cavity. The superstition that the dura was a
structure which it was exceedingly dangerous to med¬
dle with dies hard, and still lingers consciously or un¬
consciously in the minds of many surgeons and physi¬
cians. I can only repeat that having closely observed
for a number of years a very considerable number of
patients in whom the dura has been opened, either in¬
tentionally or otherwise, I cannot recall a single case
in an adult where any essential harm was produced.
In a very large proportion of cases there is neither
any perceptible shock at the time, nor are any future
harmful effects (of no matter how slight a character)
perceptible.

(3) Remember that in these operations time is an
important factor. Do what has to be done as rapidly
as possible. In children many deaths are caused in
these operations by loss of time. In adults the con¬
sequences are not, as a rule, so serious, nevertheless
next to asepsis time is probably the most important
factor in the success of an exploratory cranial opera¬
tion.

(4) In an exploratory operation, where it is not
certain that a large extradural clot exists, look out for
the middle meningeal artery. Remember that it runs
in a deep groove on the inner surface of the cranium,
and that in trephining directly over it, unless the dura
be separated in some way from the cranium, the ar¬
tery is likely to be cut by the trephine before the bone
has been completely sawn through. Again, remem¬
ber how closely the dura is or may be attached to the
inner surface of the cranium, and that in cutting with
bone forceps in the course of the artery or its branches,
great care must be taken not to tear or cut the blood¬
vessel.

9

(5) It 18 perhaps scarcely necessary to mention that
all cases of intracranial hemorrhage with which the
surgeon has to deal (that is, all cases from superficial
vessels, from sinuses, etc.) can be stopped by pressure.
Ligating the vessel when possible is preferable, but
sometimes it is not possible.

(6) The last point I wish to speak of is a some¬
what doubtful one in my mind, and I only desire to
call your attention to it. This is the length of time
during which packing should be left in the intracra¬
nial cavity. I am inclined to think that the present
tendency is to remove it too early.

Gentlemen: I thank you for your attention, and I
hope that you will pardon my presumption in speaking
on surgical subjects before a surgical society.

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