Scalp wound

“ In the first instance, careful search should be made for any sign of injury, especially on the head. The discovery of a severe scalp wound or of a fracture of the skull, in association with the symptoms of concussion or compression, will in most cases raise the presumption that the unconsciousness is due to some traumatic intra-cranial lesion. ”

“ The wound in the skull is behind and above the left ear, is roughly circular, and measures one inch and seven-sixteenths at most, and a ragged scalp-wound runs from it towards the left eye. On the right cheek is a linear contused wound three and a quarter inches long. There are no other injuries. ”

“ They have no rational mode of treating the scalp wound. A squaw who had been scalped, covered the part, after its edges had healed, with a peruke made of bison hair, until the hair on the other parts of her head became of sufficient length to conceal the deformity. ”

“ Fractures of the vault of the skull may occur without the bone being driven in to compress the brain, and in such cases their existence may be revealed only after death. But if there is also a severe scalp wound the line of fracture may be traced in the bare bone as a thin red crack. ”

“ When the outer table alone has been divided, the wound in the scalp should be treated as a simple incised one, and united as quickly as possible, a practice of which I have seen several successful instances. When the instrument even penetrates to the diploe, the same course should be pursued; for although the external wound may not unite by the adhesive process, and some small exfoliations may occur, it is not common for serious consequences to ensue under that strictly antiphlogistic plan of treatment to which all persons with such injuries should be subjected. ”

“ Wounds of certain parts of the body heal more quickly than others: those of the scalp, face, and neck, for example, heal more quickly than those over the buttock or sacrum, probably because of their greater vascularity.
The extent of the wound influences the rate of healing; it is only natural that a long and deep wound should take longer to heal than a short and superficial one, because there is so much more work to be done in the conversion of blood-clot into granulation tissue, and this again into scar tissue that will be strong enough to stand the strain on the edges of the wound. ”

“ The bleeding from scalp wounds is often profuse and difficult to control, because the vessels, fixed as they are in the dense subcutaneous tissue, cannot retract and contract so as to bring about the natural arrest of hæmorrhage, and it is difficult to apply forceps or ligatures to their cut ends, suture ligatures are more efficient. ”

“ The temperature is high and rigors are frequent. The pulse is small and rapid, the respiration increased in frequency, irregular, and often partaking of the Cheyne-Stokes type. The face is livid, the skin hot and burning. Vaso-motor disturbance is evidenced by profuse sweating and well-marked tache cérébrale.
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Prognosis and treatment. The prognosis is almost hopeless unless radical measures are adopted in the early stages. The scalp-wound should be enlarged and comminuted fragments of bone removed, or the skull trephined over the region of the suspected abscess. ”

“ The granular structure of the hairy scalp is opposed to the occurrence of the slit forms of exit, hence the openings were usually irregularly rounded. Any increase of size in the exit wound in the soft parts due to the passage of bone fragments with the bullet, was equalised in that of entry by the fact that the latter, as supported by a hard substratum, was usually larger than those met with in situations where the skin covers soft parts alone. ”

“ When associated with a punctured wound implicating the skull, an extra-dural abscess may develop within a few days of the injury, or not till after the lapse of several weeks, and it may spread over a wide area and come to encroach on the cranial cavity sufficiently to raise the intra-cranial tension and cause symptoms of compression, or even to press upon cortical centres and produce localised paralyses. As discharge can escape from the wound in the scalp, the puffy tumour does not necessarily form. ”

“ Separation of the dura mater from the cranium, with more or less extravasation of blood between, sometimes takes place as a consequence of blows on the head, even though not severe. The blood may be absorbed, or an unhealthy abscess may form between the bone and membrane, attended with violent, dangerous, and, if neglected, fatal results. The internal mischief is not without external marks of its occurrence. If the scalp is undivided, a puffy tumour forms; and, when it has been injured, the wound degenerates, its surface is pale, and the discharge gleety ”

“ They warn about the possibility of fracture of the skull even when there is no penetrating wound of the scalp, and they even suggest the advisability of exploratory incision when there is some good reason for suspicion of, though no evident sign of, fracture. In “Old-Time Makers of Medicine,” I quoted some of the details of this teaching as to head [Pg 92] surgery that may serve to illustrate what these surgeons taught on this important subject. ”

“ As the result of septic infection by an accidental wound, abscess is likely to form beneath the scalp, and if it is left to increase in size unchecked it may detach a large area of the scalp. As soon, therefore, as it is thought that matter is forming beneath the scalp, an incision should be made down to the bone, and provision taken for insuring free drainage. ”

“ For instance, if a man is hit by a metal instrument shaped like the clapper of a bell or by a heavy key, or by a rounded instrument made of lead—this would remind one very much of the lead pipe of the modern time, so fruitful of mistakes of diagnosis in head injuries—special care must be taken to look for symptoms in spite of the lack of an external [Pg 240] penetrating wound. Where there is good reason to suspect a fracture because of the severity of the injury, the scalp should be incised and a fracture of the cranium looked for carefully. ”

“ When the evidence points to implication of the middle fossa, the scalp incision is prolonged upwards for about 1 inch and the soft parts retracted. The supra-tegmental extra-dural space can be exposed either by chiselling away the osseous roof of antrum and middle ear, or by means of a separate opening above the level of the supramastoid crest. In the event of the discovery of an extra-dural collection of pus, the purulent material is gently wiped away, free drainage supplied, and the wound closed. ”

“ When the operation is conducted in the temporal region the towels, unless fastened to the skin by means of a few sutures or safety-pins, tend to become displaced, and by so doing add to the risk of wound infection.
THE CONTROL OF HÆMORRHAGE Hæmorrhage from vessels of the scalp. All surgeons must have appreciated the difficulty attendant on the application of forceps to, and the ligature of, divided scalp-vessels. The patient may lose a considerable quantity of blood, and much valuable time will be wasted before the more essential part of the operation is commenced. ”

“ In injuries of the scalp, if the wound has penetrated the tendon of the occipito frontalis, we expect extensive suppuration, not from the injury to the tendon, quoad tendon, but from the laceration or other injury done to the cellular membrane between the tendon and pericranium. In like manner wounds of fasciæ, whether of the hand, foot, or other parts of the extremities, are dangerous in their consequences, not from the injury done to the tendinous fibres, but from the exquisitely acute inflammatory action set up in the subjacent cellular tissue. ”

“ The greatest danger of compound fractures of the cranium does not arise from the admission of air. It is not the wound of the scalp, but the mechanical irritation of the brain and its membranes that proves dangerous. Injuries of the cranium inflicted by sharp bodies, such as divide the scalp and cause compound fractures, are generally attended with splintering of the internal table, and require the trephine. ”

“ It may possibly be asked whether or no a man, who has simply lost his scalp, can recover. In reply we can safely say that without any other wound, and under favorable circumstances, with good care the sufferer stands a chance of being restored to health. There was a man who formerly was living and working at his trade as a blacksmith in Santa Fé, who, in a fight with the Camanches while crossing the plains, was wounded by a lance and then scalped. ”

“ To send a patient to the operating room while in a state of shock is to court disaster. Abdominal and head injuries need to be wisely appraised. Many head injuries seem slight on casual examination; yet these, if not recognized and properly treated, will result in fatal complications.
All scalp wounds are serious, and sometimes it is a question for the surgeon to decide whether the metallic foreign body should be removed or not. Actually, there is a fifty-fifty chance that the man who has a bullet in his brain will develop epilepsy. ”

“ Sits up thirty minutes twice in twenty-four hours. Is very childish; wishes to go home to Lebanon, N.H. The wound in the scalp is healing rapidly.
Nov. 8th.—Improving in every particular, and sits up most of the time during the day. Appetite good, though he is still kept upon a low diet. Pulse 65. Sleeps well, and says he has no pain in the head. Food digests easily, bowels regular, and nutrition is going on well. The sinus under the frontalis muscle has nearly healed. ”

“ S01.00 Unspecified open wound of scalp S01.01 Laceration without foreign body of scalp S01.02 Laceration with foreign body of scalp S01.03 Puncture wound without foreign body of scalp S01.04 Puncture wound with foreign body of scalp S01.05 Open bite of scalp Bite of scalp NOS Excludes1: superficial bite of scalp (S00.06, S00.07-) S01.1 Open wound of eyelid and periocular area Open wound of eyelid and periocular area with or without involvement of lacrimal passages S01.10 Unspecified open wound of eyelid and periocular area S01.101 Unspecified open wound of right eyelid and periocular area S01. ”

“ From infection of such wounds of the scalp abscess or diffuse cellulitis of the scalp may develop as well as erysipelas. The constitutional symptoms in such a case may be marked or even severe, but the prognosis is favorable. In very rare cases necrosis of the skull may result or the inflammation may even extend to the brain. These incised and lacerated wounds of the scalp are usually accidental or inflicted by another; they are rarely self-inflicted. Contusions and contused wounds are the most common forms of injury to the head. ”

“ No injury of the head, in fact, is too slight to be despised, or too severe to be despaired of.
Punctured and lacerated wounds, more especially those penetrating all the layers of covering, are frequently followed by violent and extensive inflammation of all the tissues, with severe constitutional disturbance, and with delirium and other symptoms denoting functional derangement of the brain. The swelling is often extensive, involving the whole scalp, together with the integuments of the face, and completely shutting the eyelids. ”

“ In many unpromising cases of lacerated scalp, when a great part of the cranium has been exposed, and partially deprived of its periosteum, a rapid cure has taken place without the formation of much matter. The detached scalp, though much torn and bruised, ought not at first to be removed, it being more prudent to leave nature to determine how much must be destroyed. After the sloughs, if any, have separated, and granulation has commenced, the loss of substance is rapidly repaired in this region, more especially when the patient is young and healthy. ”

“ A short time after painting the hairs of the head black, a fashion now more common in France than at the period in which they powdered them, there is often experienced pains in the head and a swelling of the hairy scalp, though the skin has been in no way concerned, has not been pulled, and the hair only has been affected. ”

“ They never examined into that, and yet it is highly probable that from the condition that body was in, from its position, with the head being down and the feet up, and from the evidence of the men who told you that when they attempted to pull the body up it slipped back, it is physically possible that those very wounds on the scalp might have been made while pulling the body out. ”

“ On account of the free arterial anastomosis in the deeper layers of the integument, large flaps of scalp will survive when replaced, even if badly bruised and torn, and it is never advisable to cut away any un-infected portion of the scalp, however badly it may be lacerated or however narrow may be the pedicle which unites it to the head. ”

“ The local treatment of the first form essentially depends on puncturing the red and inflamed skin all over with the point of a lancet, assisting the flow of blood by warm fomentations. The punctures should be repeated, if necessary. The second form is to be treated by incisions, perhaps the greatest improvement of the surgery of the Peninsular war.
The scalp in such cases is in a state of general puffiness, causing the head to look considerably larger than usual, but without redness; it retains the impression of the finger. ”

“ Vascular changes in the scalp due to the same cause, the exaggeration of impulses during their transit of the gray matter of the hind-brain, making believe that the scalp is injured and needs more blood, react upon the nerve-endings increasing the illusion of injury. The pain is no illusion. It is impossible to decide whether vascular changes are the first effect of vagal agitation and therefore the immediate cause of pain or whether they are merely subsidiary results of the exaggeration of sensory impulses from the scalp. ”