Part 32

_Inflammation of the Scalp_ occurs either spontaneously, or in consequence of external injury, though slight; and is generally met with in those who have lived freely and irregularly, and are of a bad habit of body. It is more dangerous than inflammation of any other part of the surface, on account of the sympathy and connection which exists between the parts affected and those situated internally: frequently, at an early stage of the affection, delirium occurs, with violent fever. In slight cases, in which the external surface merely is affected, there is little swelling, and but little pain or fever. But when all the pericranial coverings are involved, the symptoms are uniformly severe. The swelling is elevated and puffy, and extends to the eyelids, to the face, and, in some cases, even to the neck: the constitutional symptoms run high, and there is considerable risk of the patient dying comatose. If he recover, and if the disease is little interfered with, but allowed to take its own course, much sero-purulent fluid is infiltrated into the cellular tissue, which generally perishes, along with a greater or less portion of the tendinous expansion lost by sloughing. Often, in neglected cases, a large abscess forms, separating perhaps one-half of the scalp, and bulging over the ear.

The constitutional treatment must vary according to the nature of the symptoms which present themselves; in some cases they show great vascular excitement, and in others they bear unequivocal evidence of general debility from the first. In slight cases of the local affection, it is sufficient to relieve the tension, and abstract blood and effused serum by means of a few punctures, and afterwards to use warm fomentation. More violent cases require free incision in the direction of the fibres of the occipito-frontalis muscle, and thus only can destruction of the parts be averted; the incision must necessarily be deep, for the scalp is often swollen to the thickness of one or more inches. When a depôt of matter has formed, it must be evacuated early, otherwise there is a risk of the bone becoming extensively denuded and exfoliation ensuing.

_Chronic thickening of the Scalp_ is a consequence, by no means unfrequent, of slight injuries in those of strumous habit, but may also occur without any assignable cause. In delicate subjects it is often attended with chronic periostitis of other bones besides those of the cranium. The patient perhaps complains of pains about the shoulders, in the tibiæ, femora, the tuberosities of the ischia, the sternum, the cervical vertebræ, or in the clavicles and ribs. He cannot bear pressure on some points without suffering the most excruciating agony. The pain is also much increased by motion of the parts, as by coughing when the ribs are affected. Such painful affections of parts external to cavities are often mistaken for diseases of the internal organs, and are treated as such by violent bleedings, purgings, and starvation, to the still farther impairment of the patient’s constitution. The symptoms are frequently and correctly attributed to exposure to cold and moisture, sleeping in a damp bed, sitting with wet clothes or on the cold ground; but such affections are very apt to occur in those whose constitution has degenerated into that peculiar cachectic state formerly mentioned, after mercurial courses, whether short or severe; or in those who for some real or fancied derangement of the digestive organs have persevered in swallowing, for months or even years, the universal panacea of some practitioners, Plummer’s or blue pill. The bones and their coverings, of even the best constituted, can scarcely resist a perseverance in such a course.

The swelling of the scalp is often general, and is slightly œdematous; some points are more elevated than others, feel soft, and are the seat of extreme pain when pressed upon. But such affections frequently flit from one part to another; what was most unsound, at one time, recovering itself, and painful swellings attacking that which was comparatively free of disease. The same holds true in regard to the other bones at the commencement of the affection; but when much change of structure takes place, then the pain and swelling become fixed. The pains are most severe during the night, being then so violent as to deprive the patient of rest, and even prevent him from placing his head on the pillow: they abate towards morning, and remain tolerable during the day. They are always aggravated by change in the atmosphere from dryness to moisture, and the prevalence of easterly winds is peculiarly distressing to patients afflicted with such diseases. The swelling is composed of thickened and vascular periosteum with œdematous integuments. The bone too is often increased in size, and condensed, from continuance of increased vascular action; and its surface is roughened in consequence of its texture being opened out, and new bone having been deposited. Death of portions of the bone often follows, either spontaneously, or after slight bruises received during the continuance of the disease. A few accidental blows on the head, and a perseverance in the use of mercurial alteratives for a series of years, gave rise to the state of matters represented in the accompanying illustrations. The large dead portion represented was removed some months before death. Here the deficiency in the cranial bones is partly owing to ulceration, partly to death of portions of them. The patient’s health becomes undermined by want of sleep and continual suffering; and he may at the same time have relaxation of the mucous surfaces, with increased discharge from them, produced by the same cause as occasioned the affection of the coverings of the bones. He may be subject to a relaxed or ulcerated state of the throat, increased or caused by the slightest exposure; and may have hemorrhage from the nostrils, copious expectoration, mucous stools, &c. The periosteal affection alone is a troublesome and serious complaint.

When the pains are fixed and violent, we are sometimes obliged to give small doses of the bichloridum hydrargyri at first, even though there is reason to think that mercurial medicines, perhaps imprudently or carelessly administered, have brought the constitution into its present morbid condition. The good effects of this medicine are well marked and speedy. The patient is freed from the nocturnal pain, gains flesh, and the swellings subside. It ought not to be resorted to, however, unless in severe cases, when the disease cannot otherwise be successfully combated; and when used, it should not be continued longer than is necessary for the removal of the more urgent symptoms: when the pains begin to yield, it is time to discontinue the medicine. Great care is necessary on the part of the patient; he must industriously avoid exposure to moist atmosphere, and ought to be well and warmly clothed, wearing flannel, chamois leather, or both, on the trunk and extremities. A patient treated with the corrosive sublimate of mercury is perhaps more subject to recurrence of the affection, after imprudent exposure, for a considerable time afterwards, than if simple and less powerful means had been employed. A cure can often be effected by the exhibition of the compound decoction of the woods, with or without antimony. Moderate diet and strict abstinence from wine and other internal stimulants should be enjoined; the patient, soon experiencing the good effects of temperance, is exceedingly willing to restrict himself to a somewhat antiphlogistic regimen.

In cases of violent fixed pains, with swelling and threatening of matter forming, incision may be sometimes practised with relief to the patient, but is not to be had recourse to unless there is a risk of the bone suffering. Local abstraction of blood is advantageous, and may, if necessary, be followed by counter-irritation, as the application of blisters or sinapisms. Friction with stimulating substances, or with opiate liniments, is often useful when the disease begins to yield, the pain and puffiness of the parts being thereby dispelled. The hair should be kept short during the cure, and ought not to be allowed to grow till the scalp is firm and sound.

The disease is often so far advanced that, in spite of the most active treatment, abscess forms in one or more points; and, on the matter being evacuated, the bone is found denuded. Exfoliation is then very likely to take place.

Exfoliation generally follows denudation of the bone by accident, but not uniformly. When the periosteum is stripped off by violent injury, the bone in some cases does not lose its natural colour; granulations arise from the exposed part, and it again becomes covered without any part of its substance having been destroyed. Again, careful removal of the periosteal covering, as in excising a tumour or ulcer by the knife, may be followed by death of the outer table of the skull; small portions only separating in some cases, whilst in others a large part of the bone, and of considerable thickness, perishes. The cranial bones may in part become dead throughout their entire thickness, and separate, either after a severe bruise, or in consequence of inflammatory action following injury or arising from disease. The process of separation is either speedy or tedious, according to the vigour of the constitution. The deficiency is repaired, in a great measure, from the subjacent bone, when its whole thickness is not thrown off. But when the breach is complete, the surrounding parts assume the reparative action; the granulations from the dura mater and integuments coalesce, and a dense membrane fills up the space.

The denuded bone should be kept covered and moist, and for this purpose lint frequently wetted with tepid water is the best dressing: spirituous or greasy applications can do no good. A free discharge for the matter should be afforded, and the wound kept clean. If the exfoliation goes on slowly, perforation in the dead bone may be made at different points down to the living parts, with the view of expediting the process. Exfoliations are sometimes retained by surrounding granulations overlapping their edges and confining them in their situation; or are fixed by atmospheric pressure, after separation has taken place from the parts underneath by the action of the absorbents, in the same way as a boy’s leathern sucker becomes firmly fastened to the stone to which it is applied. In such circumstances a small screw may be fixed into a perforation carefully made in the bone, and thus the dead part may be lifted out without pain or difficulty, when otherwise it might have lain for many weeks, keeping up the discharge. In this way the large sequestrum, represented at p. 240, was extracted from its bed. The powdered red precipitate of mercury may be occasionally sprinkled on the parts surrounding the dead portion, in order that the granulations embracing it may be destroyed, and the part more completely detached. The general health must be all along carefully attended to. Sarsaparilla with guaiac, sassafras, mezereon, &c., is often useful, more especially if pains in other parts continue to annoy the patient. Under such medicines he in general improves very rapidly in appetite, flesh, and strength.

The scalp is sometimes, though rarely, the seat of malignant ulcer. In the early stage the ulceration is not of great extent, and affects only the soft parts; perhaps it is confined at first to the common integument, but is extremely apt to extend to the deeper layers which invest the cranium, and even to the bone itself. It is by no means uncommon to find the cranium very extensively diseased, though the affection originated in the superimposed soft parts. Such ulceration of the bone is of a peculiarly destructive nature; it is a disease of the osseous tissue, corresponding to the most malignant ulceration of the soft parts. The bone around the ulcerated cavity is spongy and soft, its margin is irregular, and bristles with numerous spiculæ; the centre is composed of soft morbid deposit, entangling small portions of bone which have become detached, and flabby, almost lifeless granulations shoot from the distempered mass. Such disease, when the patient does not soon succumb to its virulence, advances to a frightful extent, affecting a large surface, destroying the whole thickness of the bone, and even exposing the internal parts. In a case of this description, which occurred in the Royal Infirmary under my care, the anterior half of the cranium was totally destroyed, the left orbit contained a putrid mass, consisting of the disorganised eye mixed with pus and bloody fluid; the dura mater was exposed, and sloughed at several points, and the unhealthy discharge from the parts lodged on the surface of the brain. In malignant diseases of scalp, as of other parts, the lymphatics become secondarily affected: the absorbents feel hard and thickened, the glands in the neighbourhood enlarge and ulcerate, and the sore thereby formed soon assumes the characters of decided malignancy,—hard everted edges, an angry surface, and fetid thin discharge.

Before the disease has become very extensive in the scalp, and when it is still limited to the superficial parts, it may be removed by the knife; the incisions being made at a considerable distance from the margins of the ulcer, so that those parts which may be supposed to have assumed a disposition to malignant action, may be taken away along with the ulcer. In more advanced cases, it may be necessary that the incisions should extend in depth to the bone; and it may be prudent to insist on a portion of the bone exfoliating, the periosteum being removed, and some potential cautery applied to the exposed surface,—as the alumen ustum, oxydum hydrargyri rubrum, &c. The actual cautery cannot be applied with safety to the cranium. Even where the integuments only are removed, and that to a small extent, and in a proper form, it is vain to think of approximating the parts and procuring union by adhesion; the wound must granulate. There is no difficulty in suppressing hemorrhage; either ligature or temporary pressure may be employed according to circumstances. Mild dressings are to be applied, and proper support afforded. The parts should be kept clean, and for that purpose the surrounding scalp must be shaved repeatedly.

_Tumours of the Scalp._—Tumours of a sarcomatous nature are seldom met with in this situation, but the adipose are not so unfrequent. The latter are easily removed, being seldom of large size, and their attachments being loose, unless when they have been irritated by accident or maltreatment. When sarcomatous growths do occur, they are to be excised, with those precautions which were formerly mentioned when treating of tumours generally.

Vascular growths not unfrequently form in the scalp, and attain considerable size; in general they are either congenital, or the degenerations of nævi materni. They may be so extensive as to forbid surgical interference; or they may be so indolent, may partake so much of the nature of simple varix, as not to warrant it. If small, they can be readily removed by the knife, the incisions being made rapidly, and wide of the diseased structure. If the tumour be prominent, extensive, and at all active, the employment of ligature is a more safe and equally effectual practice. One or two ligatures may suffice to encircle the swelling, or, as in other parts of the body, it maybe necessary to pass a great many double ones beneath the part, to separate their extremities, and to tie them to each other around the base of the tumour, the last being drawn so as to tighten all the others. Little benefit can be expected from tying, either at once or at different periods, the larger arterial trunks whose ramifications supply the diseased structure, the inosculation amongst the vessels around the tumour being so extremely free. But, in cases where the disease cannot be otherwise combated with any hope of success, ligature of the common carotid, on the affected side, may be tried as a last resource. The practice has proved successful in some cases of this disease, involving parts of the head and face to such an extent, or in such a situation, as to forbid any attempt at removal of the growth.

Encysted tumours frequently form in the scalp, and, if undisturbed, become large; they seldom occur singly. The disease appears in many cases to be hereditary, and it frequently happens that several members of one family are at the same time afflicted with it. The contents of the tumours vary as to consistence, but are generally atheromatous. The cyst is thick, and loosely connected with the surrounding cellular tissue; but as the tumour increases, the adhesions often become firm and intimate, more especially towards the skin. When the tumour is of small size, it is unnecessary to adopt any preparatory measures for its removal, not even to shave the scalp: the surface may be cleared a little with scissors. The swelling is transfixed, in the direction of the fibres of the occipito frontalis, by means of a curved sharp-pointed bistoury, and its internal structure is exposed by the knife being carried outwards. The soft contents are evacuated, and the sac is easily extracted by means of common dissecting forceps. The integuments are then laid down and retained in apposition, no sutures being necessary, and in many cases the wound heals by adhesion; sometimes a small coagulum forms between the edges of the wound, and is detached some days afterwards; then slight suppuration ensues. In larger tumours, however, a straight and narrow knife is perhaps the most convenient instrument for accomplishing removal. The part is transfixed, and in most cases it is necessary to take away an elliptical portion of the integuments, a part of the cyst corresponding to which is of course simultaneously removed; the remainder of the sac is pulled out by the forceps. If the adhesions at certain points are firm, they may be touched with the extremity of the knife, so as to expedite the extraction; and if after the operation there is reason to believe that the whole of the secreting surface has not been taken away, a pointed piece of caustic potass may be applied to the suspected parts. If the tumour is very large, the cyst can often be removed without difficulty unopened, sufficient integument being left to cover the exposed surface. In consequence of such operations on the scalp, erysipelas often supervenes, and precautions ought therefore to be adopted to prevent its occurrence, by a little preparation beforehand, by keeping the patient’s bowels freely open, confining him to moderate and mild diet, and avoiding exposure to moist atmosphere and easterly winds.

Osseous tumours of the cranium seldom attain any great size, and are in general neither troublesome nor dangerous. Small ivory exostoses are the tumours most frequently met with in this situation, and require no treatment whatever.

Tumours of malignant character occur, though rarely; commencing either in the diploe of the skull or on the surface of the dura mater, soon enlarging, and involving the parts around. Two or more sometimes form in one patient; they are attended with excruciating pain, and rapid destruction of the bone, and are followed by extinction of life either at an early or remote period. They are entirely beyond the reach of surgery; as are also those tumours, occasionally met with in children, which project through the cranial sutures and contain fluid; such are analogous to the disease named spina bifida, hereafter to be spoken of.

I may here remark, that puncture of the brain, with the view of abstracting fluid in chronic hydrocephalus, is an operation not often likely to be followed by success, and it may even accelerate the fatal issue. Some cases are recorded in which benefit is said to have arisen from the practice. Pressure was applied and kept up after the evacuation of the fluid.

DISEASES OF THE EYE AND ITS APPENDAGES.

_Of Inflammation and Abscess of the Lachrymal Passages._—In former times, all affections of the lachrymal passages, and of the parts in the neighbourhood, were denominated fistula lachrymalis, and were all treated nearly in the same manner, by opening the sac, and inserting probes, knives, terebræ, scalpra, caustics, and red-hot irons; the anatomy of the various parts being then ill understood, and the opinions as to the origin and nature of the diseases being founded on erroneous theories regarding the defluxion of acrid humours, formation of imposthumes, fungous growths, &c. The term, however, which was indiscriminately applied to all diseases in the inner corner of the eye, accompanied with derangement of the lachrymal secretion, is now confined to a distinct form of disease, as will afterwards be mentioned.

Inflammation sometimes occurs in the loose cellular tissue covering the lachrymal sac,—whilst that cavity remains free of all disease,—and is attended with some obstructions to the passage of the tears in their natural course, on account of the eyelids becoming swollen, from an extension of the inflammation. The morbid action resembles erysipelas in its nature, and usually terminates in unhealthy suppurations; thin purulent matter lodges in the opened out cellular membrane, a soft boggy tumour is formed, and the superimposed integuments become of a bluish colour, as in the case of other scrofulous collections.

Though the affection is at first unconnected with the lachrymal sac, this organ may ultimately be involved. It may become the seat of a like unhealthy inflammation, and matter may consequently form within its cavity; or, on account of the pressure of interstitial deposit around, the parietes of the sac may ulcerate before the abscess of the cellular tissue in front has discharged externally. Thus, the cavities of the lachrymal sac, and of the external abscess, will communicate with each other. If, after an external aperture has been made either by nature or by art, any doubt exist as to whether the sac is involved or not, such doubt will soon be removed by dexterous use of the probe.

In the treatment of this affection, it will be necessary, at the commencement, as in all other local inflammatory diseases, to attempt the accomplishment of resolution, by attention to the general health, local abstraction of blood, and warm fomentations. When matter has formed, it ought to be evacuated as soon as possible by a small incision, as there will then be less risk of the deeper parts becoming secondarily affected; or if the integuments have sloughed, and the matter has been discharged spontaneously, the natural opening may be enlarged either with the knife, or with the caustic potass. If it be discovered that the lachrymal sac is opened into, the same treatment is necessary as if it remained entire; the matter is to be allowed free exit, and granulation encouraged; in most cases, the aperture in the sac is soon repaired, and the parts heal as quickly and soundly as if the disease had been confined to the external cellular tissue. Light dressing during the cure, preferable in all cases, is more especially necessary in this situation.