Part 30

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.

Sometimes the abscess under the bone is of a chronic nature, as in the following case:—The patient, a boy, æt. 11, received a blow on the vertex, after which a puffy tumour formed in the injured scalp, and was freely incised. He afterwards became subject to epileptic fits, which were relieved by copious evacuation of matter from the wound. Exfoliation of the cranium occurred; one small sequestrum was separated, which involved the whole thickness of the bone, and a collection of matter between the dura mater and skull-cap was thereby exposed. The contained matter was evacuated, and the wound was carefully dressed, with the view of procuring adhesion between the membrane and bone, but without effect. The dura mater was ascertained to be extensively detached around the opening; it was found necessary to remove a large portion of bone by means of the trephine and cutting pliers, and then the dura mater soon became united with the integuments of the head. Many months afterwards, the patient complained of severe pain in the back of the neck; an abscess formed in that situation, and, pointing under the right scapula, was opened. Weakness of the right arm and of the inferior extremity suddenly supervened, and the patient gradually sunk. On examination after death, the cervical portion of the spinal chord was found much softened, with infiltration of purulent matter into its substance. The deficiency in the cranium was supplied by a ligamentous expansion, to which the dura mater and scalp adhered intimately.

_Of Compression of the Brain._—Compression is produced by extravasation within the cranium of blood or other fluid, by the lodgement of a foreign body on the surface of the brain, or in its substance, or by displacement inwards of portions of the cranial bones; and these causes are usually the effects of external injury. It may either follow the injury instantaneously, or supervene some time thereafter. Many examples have occurred of a patient, at first insensible, with symptoms of concussion, having had the functions of the brain restored almost entirely, and again having relapsed very quickly into a comatose state, in consequence of extravasation of blood. The whole circulation is at first lowered by the shock of the commotion, and the blood scarcely flows in the cerebral vessels; but on its restoration, blood is poured out from the lacerated vessels, or from those which have been so injured in their coats as to be unable to withstand the increasing impulse of their contents. As was already observed, the symptoms of compression are often mixed up with those of commotion, but, when an interval of sensibility has occurred, mistake in diagnosis can scarcely occur. Compression is attended with slow, stertorous breathing; a distinct slow pulse; a relaxed state of the limbs, features, and sphincters; and dilated pupil. Total insensibility to external impressions attends compression of the brain, whatever the cause of it may be. These symptoms may, and do sometimes, gradually disappear after a time. But they may continue unabated, and the patient may gradually sink under them. Or, again, his dissolution may be preceded by excited circulation and furious delirium, the vital powers recovering from their first depression, only to become roused into violent and destructive action, again to sink to a still lower ebb, and be ultimately annihilated. Extravasation is most commonly met with on the lateral parts of the brain in the situation here indicated; the coagulum is perhaps extensive, reaching to the base of the skull, in consequence of rupture of the middle meningeal artery, with or without fracture of the parietal bone.

Little or nothing can be done in cases of compressed brain from extravasation. We possess no means of preventing the effusion, and though we did, the mischief has generally taken place before the patient can receive assistance. Again, the site of the extravasation can seldom be ascertained; and, should that objection to the propriety of surgical interference not exist, still the coagulated blood cannot be evacuated even after extensive removal of the bone. If the coagulum is small, it may be gradually and wholly absorbed, or the brain may become accustomed to the pressure of what remains. It is the surgeon’s duty to take means for averting inflammatory action, and to subdue or moderate it when it has been excited. The symptoms arising from displaced bone may be relieved by surgical operation; but we must premise some observations on fracture, before speaking of the treatment necessary in such cases.

FRACTURES OF THE CRANIAL BONES.

At an early period of life the bones are soft and elastic; they yield readily under external violence, and it requires a great and direct force to produce fracture of them. Late in life, when the diploe disappears, the external and internal tables come in contact; the bone is brittle, and solution of continuity in it is easily effected. And it is wisely so arranged, for thus in the recklessness of childhood and youth, severe blows on the cranium, which are then of so frequent occurrence, are seldom attended or followed with danger; whilst the aged are taught by experience to avoid the unfortunate consequences so apt to result from even a slight blow on the then brittle cranium, by cautiously preserving themselves from exposure to violence.

Solutions of continuity in the cranium, caused by external force, are either attended with depression or not. Fissures, mere capillary rents in the bone, may take place at the part of the cranium which is struck, or on the side opposite to that to which the force is applied. They will be found either short and limited by sutures, or extending in different directions through several sutures, as from the vertex to the base of the skull, and terminating perhaps in the foramen magnum. Fissures in the upper part of the cranium are of themselves attended with comparatively little danger; they produce of themselves no claim to attention, and really require none. But the force which gave rise to the injury of the bone may have disturbed the internal parts; and though the patient may have recovered from the first shock and the immediate effects of the violence, severe and dangerous consequences often result, and at a late period from the infliction of the injury.

Fractures of the base of the skull are the result of great force applied to the lateral parts of the head, to the vertex, or to the base itself through the spinal column. A blow inflicted by an obtuse body on the top of the head, whilst it is at rest and fixed—by producing expansion of the lateral parietes, and forcing the base down upon the upper part of the spinal column—may have the effect of breaking up the connections of the bones at the base, which is the weakest part of the cranium, and splintering them to a greater or less extent. Again, if a person falls from a height, he perhaps alights on some part of his trunk, as the buttocks, and this coming to a state of rest, whilst the head is still in projectile motion, the spinal column is driven towards the cavity of the cranium, and the same effects are thereby produced as in the preceding instance. Or the patient alights on his head, and the base of the cranium is then impinged upon by the weight of the whole trunk, as well as by the force of the projecting power, and in this case also the base is frequently broken up. In the sketch here given, showing extensive fracture of the occipital and sphenoid bones into the foramen magnum, the patient, a brick-layer, fell from a ladder on the vertex. He lay comatose for some days before death: there was found extensive extravasation over the middle lobes and cerebellum. Concussion has resulted from falls when the person has alighted on his nates or feet; but the symptoms attendant on fracture of the base are more generally those of compression of the brain. In this accident the bones are seldom displaced to any great extent; the dura mater is generally lacerated, its bloodvessels, and frequently its sinuses, are wounded, and blood is consequently effused at the base of the brain, where injury is most fatal. The upper part of the brain may bear pressure to a considerable degree without bad consequences ensuing, but compression at the origins of the nerves is always highly dangerous and generally fatal. Bleeding from the nose, mouth, and ears, when attended with other circumstances and symptoms evincing a violent injury and consequent cerebral disturbance, has been considered as decisive of fracture at the base having occurred. But we find that such bleeding happens in slight injuries unattended with any circumstances or consequences to induce a belief that so serious an injury has taken place: and again, in cases where dissection has shown most extensive fracture in the temporal, sphenoid, and æthmoid bones, no blood had issued from their external openings. Fracture of the base of the skull generally proves fatal, but many cases are met with in which there is reason to believe that it had taken place, and yet the patients have recovered with perhaps partial paralysis. Of this I lately met with a good example in the case of a girl seven years of age, whose head had been squeezed between a wall and the back of a cart, and thereby considerably flattened. She lay insensible for several days, with all the symptoms of compression, and with blood flowing in small quantity from the nose, mouth, and right ear. An extensive abscess formed over the right temporal bone. She ultimately recovered, but remained affected with paralysis of the right side of the face and amaurosis of the left eye; sensation in the paralysed parts being quite perfect.

Fractures of the upper part of the cranium are generally attended with displacement to a greater or less extent, and with wound of the cranial coverings. The size of the depressed portion, the depth to which it is displaced, and the extent of wound, will depend upon the nature and intensity of the force applied. When both tables are broken, the fracture of the inner is almost always more extensive than that of the outer one, as fissures will extend furthest in the most brittle part. A broken fragment, comprehending the entire thickness of the skull, presents generally a much larger portion of the inner than of the outer table, so much so that the piece would sometimes not admit of removal, though perfectly detached, without enlarging the opening in the outer table. Fractures, with depression of a considerable portion of one of the flat bones, are sometimes unattended with any alarming symptoms. The effects of the injury soon disappear, and even in cases where the depression has been very considerable, and where, from the escape of brain, it was evident that both this organ and its membranes had been seriously injured, no bad symptoms have occurred to retard the patient’s recovery. Symptoms of compressed brain, however, may generally be expected to attend depression of any considerable portion of bone below its natural level. Still the brain may become accustomed to the pressure, and the symptoms may gradually subside without surgical interference. And if the indications of compression are not very alarming, the coma not very profound, a little delay is allowable, means being taken to avert inflammatory action: for danger is not imminent, the cure may not be expedited by operative aid, and there is chance of injury resulting from rash interference.

But it is in general necessary to remove the cause of the symptoms, to elevate the depressed bone, and take away those portions which may be detached.