hemorrhages, where an operation may be expected to give relief, the symptoms are indefinite and may be entirely wanting.

In distinctly operable cases, which include about 40% of all deaths associated with fracture of the skull, we usually find at autopsy a fissure beginning in the vault and running into or through the middle fossa, death being due to pressure from extradural or subdural clot. These cases may or may not be associated with varying degrees of cerebral laceration. A careful study of the symptoms in such cases will show that there probably was good reason to suspect some form of intracranial disturbance, but little, if any, definite proof.

Of the fracture itself we may have some definite sign, either of depression or that a crack exists from which a deep hemorrhage appears. If such a hemorrhage exists, either in the ear, nose, under the scalp or in the post-orbital space, it is safe to assume that a fracture will be found in that region. In a very large number of cases we simply find indefinite signs of cerebral disturbance without any localizing symptoms, either of fracture or injury to the brain. In these cases it is my habit to do an exploratory trephining, and a very large proportion of them are found to be those which most definitely require operation.

In the dim light afforded by these facts I lay down the following rules: Given positive signs of intracranial disturbance following an accident which might well cause such a condition, but without definite signs of fracture, I should explore. Given a case in which there is probable evidence. of fracture, and a probability of interference with the brain, I should operate.

I have never seen fatal or serious results follow trephining by skilful hands, even when two or three openings in the skull were made, and I have seen many lives saved by exploratory operations in this very large class of doubtful head injuries.

ARTICLE XVII.

INDICATIONS FOR OPERATION ON

HEAD INJURIES.

BY WILLIAM N. BULLARD, M.D.

OF BOSTON.

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 head injury.

The 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 the safety of incision of the meninges, and 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 demanded.

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.

on

What shall we do in cases of sim

ple fracture without symptoms? This is the class of cases about which opinions differ most strongly. I believe that 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. Investigations on the results of simple fracture of the cranium show that only in rare cases are they serious, or such as could have been relieved by operation. I wish here to emphasize certain facts. Intracranial complications may arise with any severe head injury. Deep cerebral hemorrhages, single or multiple, may exist. We may have single hemorrhages situated in the basal ganglia or in other inaccessible parts or we may have numerous minute or microscopic hemorrhages scattered throughout the brain substance. Neither of these conditions are operable, and their symptoms and results are not to be confused with those of simple fracture. Again, in all cases of severe blow upon the head, and probably in practically all cases of fracture of the skull, there is more or less contusion of the brain. This is apt to be on the opposite side from the direct blow. It is prob

of the brain,