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
