of _bruise_ of the scalp.—Blood is effused, and the surrounding parts
are thereby separated to a greater or less extent; and thus a tumour
is formed, either rapidly or slowly, according to the size of the
injured vessel. The swelling is in general large, soft in the centre,
and hard towards its circumference; the blood in the latter situation
being coagulated, and firmly impacted in the condensed cellular
tissue; whilst in the centre it is fluid, or at least partially so,
and occupies a free cavity. These characters of the tumour are apt
to mislead a careless or inexperienced examiner, the feel being in
some degree similar to that attending fracture with depression, but
still easily distinguishable from it by attentive and experienced
manipulation. By pressing the finger or thumb firmly on the centre
of the tumour, the blood is displaced, and the bone felt distinctly.
In slight cases of this affection, no treatment is required, as the
tumour is of no importance, and soon disappears, by the effused blood
being absorbed. When, however, the swelling is accompanied with
unpleasant symptoms, cold applications are to be made to the part,
and low diet, with occasional purgatives, enjoined. If inflammatory
symptoms occur, local abstraction of blood may be necessary, followed
by hot fomentations to the part. When the pain has ceased, and the
swelling is not speedily removed, absorption is promoted by stimulating
applications, such as fomentation with a solution of the muriate of
ammonia in a decoction of the anthemis nobilis, in the proportions
of ℥ss. to ℔ii.; a spirit lotion containing the tincture of
arnica montana, in the proportion of one part to fifteen or twenty of
water, will be found a good application in many such cases.
Such tumours may ultimately require to be laid open, in consequence
of the blood putrefying and becoming mixed with purulent secretion.
Under no other circumstances is incision warrantable, as unhealthy,
troublesome, and tedious suppurations are sure to follow.
_Of Concussion._—Concussion, in a greater or less degree, attends
most injuries of the head. The functions of the brain are either
disturbed or suspended; there is loss of sensibility, of volition,
and frequently of the power of motion. The confusion of intellect
or stunning may disappear in a short time, or may continue, though
diminished in intensity, for many days, and even for weeks; it is
seldom, however, that the functional disorder exceeds in duration two
or three days, and in general it disappears before that length of time
has elapsed. The stupor is seldom complete; the patient can perhaps
be roused, though with difficulty, so as to answer questions by a
hurried monosyllable, or make signs in regard to the seat of pain, or
for such things as he may suppose himself to be in need of. At first
the circulation is weak; the pulse is fluttering, often intermitting,
and scarcely to be felt in the extremities; the countenance is pale,
and the surface cold; there is occasional vomiting, a symptom which
seldom occurs when compression of the brain exists, and the breathing
is difficult, though scarcely ever stertorous. The pupils are generally
contracted, but not uniformly so; one pupil may be contracted and the
other dilated; at first, they are insensible to light, neither dilating
when in darkness, nor contracting further when the light is suddenly
increased; not unfrequently a considerable degree of squinting exists.
The muscles are neither much relaxed, nor spasmodically contracted.
After a time, the circulation is restored, and the heat of the surface
returns, with more or less of regained sensibility. The pulse either
becomes altogether natural, or else more slow or more rapid than in
health. The circulation is then easily excited; by even raising the
patient in bed, the pulsations of the carotids are increased, in some
cases, by fifteen or twenty beats. Sensibility returns, always very
gradually, and in some cases more slowly than in others; frequently the
patient becomes quite collected after the lapse of some hours or a few
days, but in other instances a degree of mental confusion remains for
many weeks; occasionally the intellect continues weak for a lengthened
period, and sometimes even for the remainder of life.
When the insensibility has begun to diminish, the patient can be roused
with less difficulty; if pinched, he complains of it by uttering some
inarticulate sounds, or by attempting to move himself further from the
quarter whence he supposes the injury to come; he answers, though with
unwillingness, loud questions regarding the pain which he suffers, and
points to the part where it is chiefly felt. As the stupor goes off,
symptoms of inflammatory action, or a threatening of it in a greater
or less degree, manifest themselves. The pulse becomes more rapid and
sharp, the skin is hot and dry, the face is flushed, the conjunctiva
is redder than usual, and the pupils are often much contracted: the
patient is restless, and tosses about in bed; mutters confusedly to
himself; often attempts to enact a part in some fanciful scene which he
supposes to be passing around him, or talks rapidly and incoherently
concerning circumstances which have formerly occurred. His flitting
ideas are often of an alarming nature; he endeavours to get out of bed,
and struggles violently if opposed. He frequently puts his hand towards
his head, and gives other indications of suffering acute pain in that
region, much increased by any movement of the part.
Such symptoms are often followed by vomiting and rigors, and too
frequently by convulsions, more furious delirium, and coma. On
examination after death, an increased vascularity of the cerebral
membranes is observed; there is an effusion of gelatinous-looking
matter on the surface of the membranes, and in the cellular tissue
beneath the arachnoid. In more advanced cases, thin patches of lymph,
or more extensive strata of it, cover the arachnoid and the inner
surface of the dura mater; a puriform fluid is found effused between
these membranes, and sometimes blood and matter are deposited in
some part of the cerebral substance; bloody serum is effused into
the cavities, and at the base of the brain. The above symptoms and
appearances sometimes follow injuries not at first thought severe, but
are most frequently the result of such as are attended with læsion of
the bone, or of the internal parts.
It is not at all improbable that concussion is produced after a manner
somewhat resembling the following. The brain has a natural tendency to
remain at rest, but is liable to be brought into a state of commotion
by impulses on the cranium being communicated to it. When a slight
blow is inflicted on the skull, only a slight commotion of the brain
is induced, the cranial contents are, as it were, slightly jumbled,
and a temporary and trifling confusion of its functions follows. When,
however, the stroke is more severe, the brain is separated from its
cranial attachments, both at the point struck and at the part directly
opposite,—it is thrown upon itself towards its centre; its substance
is thereby condensed, its diameter in the direction of the impulse is
diminished, and a separation between the brain and cranium is formed at
each extremity of that diameter. By post mortem examinations, it has
been ascertained that condensation of the substance of the brain does
exist in cases of severe concussion. Such commotion may be sufficient
to cause instant extinction of life, or the brain may gradually resume
its former condition, or with only such slight incited action as may
be required to reunite the dura mater with the inner table of the
skull. Extravasation of blood or serum is extremely liable to occur
in such cases, the vessels being either compressed, stretched, or
otherwise thrown out of their natural relations along with the other
cranial contents, reparation can only take place by absorption of the
extravasated fluid, and gradual deposition of plastic matter. When
extravasation takes place to a greater extent, compression is the
consequence, as will be more fully explained further on. Perhaps the
brain does not recover itself gradually, but suddenly; the impulse,
which was at first directed from the circumference towards the centre,
now acting from the centre towards the circumference; and then the
propulsions and recoilings may be repeated, though gradually lessening
in their intensity, until the effect of the original impulse is lost,
and all vibration consequently ceases. But concussion may be caused by
an impulse received not immediately on the cranium, but on some other
part of the body, as when a person falls from a considerable height and
alights on the feet or buttocks; and in such a case also its effects
may be indirectly communicated to it through the brain, and may produce
equally violent effects, without there ever being any appreciable
lesion of the cerebral matter.
The circulation may be merely disturbed, or laceration of the brain may
occur with extravasation of blood into its substance. It may present
the appearance of having been bruised, or the tear of its substance may
be extensive. A multitude of minute vessels may be torn without the
substance of the brain being much broken, in which case bloody specks
will be observed over a large surface of the interior of the organ.
In many fatal cases no change in the state, either of the vessels or
of the cerebral substance, is perceptible on minute examinations. The
organ in these cases has been merely disturbed and shaken, without
visible rupture or hurt having occurred. Again, many patients are
supposed to labour under concussion only, in whom fracture of the base
of the cranium, or extravasation of blood on the surface, or into
the substance of the brain, are discovered after death. It is always
difficult to distinguish between the effects of mere concussion and
those of compression of the brain by extravasated fluid; for, in the
greater number of cases, the symptoms of both affections are blended
together. In both there is insensibility from the first; but if an
interval of sensibility occur, diagnosis is rendered more easy and
certain, it being a fact well verified by experience, that the state
of stupor which precedes the return of correct intellectual function
is the effect of concussion, and that there is every reason to believe
that the insensibility into which the patient subsequently sinks, is
caused by compression of the brain; if compression existed from the
first, the stupor might not be of longer duration than if it were
the effect of concussion, but its stillness would not be interrupted
by any restoration of mental exercise, however short. Remarkable
effects sometimes result from commotion of the brain; the patient may
suffer loss of vision or of hearing, either partial or complete; or
partial paralysis may occur; of the muscles, for instance, supplied
by the portio dura. In many cases such affections may be supposed
to arise from compression of nerves, or other læsion subsequent to
and caused by the effects of concussion, and probably connected with
fracture of the base of the cranium. Again, it occasionally happens
that the senses are rendered more acute than previously, and of this
I shall mention an example which came under my own observation. An
old nurse sustained fracture of the vertex, with slight depression of
the broken part, in consequence of some rubbish having fallen on her
from a considerable height. Stupor, along with the other symptoms of
concussion, was the immediate effect of the injury, but disappeared in
two or three days. Her hearing, which previously to the accident had
been long so obtuse as to render it necessary for her to discontinue
her employment, became so intensely acute, that the most trifling
noise became a source of pain. She gave immediate orders for the clock
to be stopped, the ticking of which annoyed her greatly. Her hearing
gradually became of the natural intensity, and continued perfect. In
this case there can be little doubt that restoration of a sense which
had long remained dormant arose entirely from cerebral commotion, for
no discharge of blood or other fluid occurred from the ears, by which
cerumen accumulated in these organs might have been displaced. People
sometimes forget languages from hurts of the brain, whilst they retain
memory in other respects; or, rather, the memory on certain things
becomes injured, but remains quite perfect on others.
_Treatment._—Whilst the circulation remains depressed after injuries
of the head, or of other parts of the body, it is a common practice to
abstract blood; but it is one which cannot be too much reprobated, for
it is attended with great risk, and can be productive of no benefit;
the feeble remains of vital power, whilst struggling as it were against
the depressing cause, may by depletion be quickly annihilated, when
the vigour which they still retained might have been sufficient, if
encouraged and supported, to overcome those effects of external injury
which had so far reduced them.
When a patient is seen insensible, it is highly proper and necessary
to examine carefully the trunk, head, and limbs, in order to ascertain
whether either fractures or displacements have occurred; for it is by
no means creditable to the care or science of a surgeon to be made
aware of such accidents when the patient regains his senses, after the
lapse perhaps of weeks, and when they can be remedied, if at all, with
much difficulty.
In the first stage of concussion, as was already observed, the
circulation is much weakened, and it is therefore necessary to adopt
means for sustaining and strengthening it; and with this view, warmth
is to be applied to the surface, more especially to the extremities and
epigastrium.
When the powers of life appear to be failing, stimulants must be
administered internally. Perhaps the most convenient stimulus is ardent
spirit, the only objection to its use being, that when imprudently
given in large quantities, its effects, though at first stimulant,
become sedative; it ought to be given in small quantities, and at short
intervals. Other stimuli, as preparations of ammonia, may be given
by the mouth; and much advantage will often be found to follow the
employment of a turpentine enema, free motion of the bowels, as well as
excitement of the system, being thereby procured.
Stimuli, however, should always be used with much caution and prudence,
and never unless fully warranted by the train of symptoms under which
the patient is labouring at the time; when the circulation is restored
in the limbs, and is becoming throughout steady and more natural, all
sources of excitement must be abandoned and carefully avoided, as there
is considerable risk of reaction proceeding to too great a height.
The patient is to be kept quiet in a darkened room, cold applications
made to the head, previously shaved, and free motion of the bowels
procured by neutral salts with antimony, or by other purgatives not of
an irritating nature, and not given in such doses as to prove violently
cathartic. Enemata are in some cases preferable, and are always a
valuable adjunct, to the employment of purgatives by the mouth; they
procure evacuation from the larger intestines, in which feculent matter
chiefly accumulates; they ought to contain asafœtida and turpentine;
with these additions more salutary effects are produced than from mere
evacuants. The latter ingredient would seem, by its local stimulus, to
impart energy to the bowels sufficient for the correct performances of
their functions, while the former tends to allay spasm and irritation,
both locally and generally.
If the circulation becomes unduly excited, abstraction of blood
from the system, in sufficient quantities and at proper intervals,
is absolutely necessary; and the depletion must be regulated by the
symptoms and circumstances of each case. The action will in general
be more speedily and effectually moderated by one copious bleeding
at the commencement, than by repeated bleedings to a less extent. An
easy and open state of the bowels is of much importance in the excited
stage. Mercurial preparations are sometimes useful, as they are known
to possess the power of causing the absorption of coagulated lymph and
serum, and probably of preventing their effusion.
In cases where insensibility continues after the arterial excitement
has been subdued, counter-irritation on the head or the back of the
neck is often useful, as the application of blisters, or the rubbing in
of antimonial ointment. These are supposed to act by causing an unusual
influx of blood to the surface, producing a change in that fluid by the
copious purulent, serous, and lymphatic secretions from the irritated
part, and thereby diminishing the distended and engorged state of the
internal vessels, which might produce considerable compression of the
brain.
If, at a late period in the case, the powers of life begin to flag,
stimulants must be again had recourse to, and may now be pushed pretty
freely, there being less risk of inordinate action ensuing, and much
reason to fear that life can be prolonged only by the continued use of
powerful means for the excitement of the system. Nor ought the surgeon
to cease stimulating though the vital powers continue to diminish in
spite of the treatment, and though the circumstances of the case may
be so hopeless as to lead him to suppose that death cannot be further
delayed; for many patients, who would otherwise have necessarily
perished, have, by the continued use of stimuli, recovered under my
care their sensibility, and been ultimately restored to health.
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; the exposed bone appears white and dry. It is
also preceded by general disorder of the system, by restlessness and
fever; there is sickness, occasional vomiting, shivering, pain of the
forehead and back of the neck; in some cases, delirium and convulsions,
and perhaps partial paralysis, and ultimately coma. All these symptoms,
however, may exist without indicating precisely either the existence or
the site of abscess, as I experienced in the following cases.
A middle-aged man was brought intoxicated into the Royal Infirmary with
a lacerated wound of the scalp, over the upper part of the occipital
bone, on the _right_ side of the mesial line. For thirteen days after
the accident he did well, walking about the wards in good health, with
the wound healing kindly; but on the fourteenth he became affected with
hot skin, restlessness, slight incoherency, severe pain in the head,
and intolerance of light, with a full but not quick pulse. A vein was
opened, but after three ounces of blood had flowed, he was seized with
rigors, vomiting, and violent convulsions; and these symptoms again
occurred after the application of leeches to the head. Rigors returned
at various intervals; stupor supervened and gradually increased. He
became delirious on the eighteenth. A considerable part of the bone
was exposed and dead, and there was a puffy swelling of the scalp
around the wound. On the nineteenth he lay insensible. A portion of the
dead bone was removed by the trephine, and the dura mater was found
covered with lymph, but no appearance of effused blood or pus could
be perceived. He seemed to suffer nothing from the operation, but
continued insensible, passing his urine and feces in bed, with dilated
pupils, quick breathing, and subsultus tendinum; his pulse, which had
previously never been above 80, now rose to 100. He died on the morning
after the operation. On dissection, the right hemisphere of the brain
was found of the healthy appearance; but four ounces of pus lay over
the _left_ hemisphere, between the dura mater and arachnoid, which
latter membrane was of a granular appearance; there was also a small
sloughy spot of the dura mater over the left anterior lobe.—A woman,
aged 40, fell down and sustained a wound of the scalp on the upper part
of the occipital bone on the left side; she suffered but little from
the accident, and continued to live freely and irregularly. Seven days
after the injury she was seized with shivering: and on the ninth day
she lay comatose, voiding her feces and urine involuntarily. The wound
was pale and gleety, and the surrounding scalp puffy; the bone was bare
and white; pupils dilated; pulse slow. The trephine was applied, and
fluctuation felt beneath the exposed dura mater, which was otherwise
unchanged in appearance; the membrane was divided by a trifling crucial
incision, but only a small quantity of bloody serum escaped. Shortly
after the operation she became quite sensible, but again sunk into a
state of stupor, with slightly stertorous breathing and contracted
pupils. However, all traces of coma disappeared next day, and she
recovered soon and perfectly, apparently without having received either
benefit or injury from the operation of trephine.
Purulent collections under the cranium, between the bone and dura
mater, are not of very frequent occurrence, when symptoms are well
watched and treatment properly conducted. But these collections
certainly may and do occur, and usually at a considerable period after
the accident: many such cases are related by the older authors. Their
attendant symptoms are materially different from those of extravasated
blood; in the latter case, all the symptoms of compression ensue
immediately after the effusion has occurred, and that is generally
very shortly after the injury. But matter is not formed till after a
considerable period has elapsed; it is not attended with symptoms of
compression suddenly supervening, but is preceded by restlessness
or febrile excitement; and in the later stages only of the affection
do the symptoms of cerebral compression manifest themselves. By the
external injury, those bloodvessels by which the dura mater is attached
to the skull, and by which it communicates with the pericranium and
more external parts, are lacerated, or otherwise materially injured,
inflammatory action is excited in the connecting medium, unhealthy
suppuration ensues, and by the accumulation of matter, the membrane
is completely separated from the cranium, and generally participates
in the morbid action. It may ultimately slough and give way, and the
matter will then be effused internally. A similar process goes on in
regard to the bone and its pericranium, a tumour forms externally, and
the bone, being deprived of its supply of blood, necessarily dies,
either in part, or throughout its whole thickness. When an external
wound exists, the altered appearance of the bone, with the sloughy
state of the detached pericranium, gives evident warning of the
mischief which is proceeding internally.
The general symptoms of suppuration are the same, whether the
collection forms in the substance of the brain, or on its surface.
Perhaps the symptoms are not so severe, nor the collection so speedily
fatal, when in the substance of the brain, as when situated immediately
under the bone, or at the base of the cranium. The external marks
already mentioned, are generally indicative of the site of such
internal collection, but not uniformly.
Formation of matter in the diploe of the skull, in consequence of
external injury, is of rare occurrence; and when it does occur,
somewhat similar symptoms and appearances ultimately ensue as when the
suppuration commences between the bone and dura mater.