The integuments of the cranium are frequently so bruised by a blow, that the blood is injected chiefly into the cellular tissue, between the cutis and occi pito-frontalis muscle, communicating to the fingers of the surgeon the feeling as if a portion of the bone was depressed ; whereas it is mere ecchymosis, or, suggillation, according to J. Bell. There is a tu rnout. commonly the size of a crown-piece, hard in its circumference, from the cellular tissue injected with extravasated blood, which gradually declines towards the centre, where the bone is distinctly felt through the blood, which here remains fluid. In such cases, all that should be done, is either to leave this blood to be absorbed by the vessels, or to apply warm discuticnts. If a considerable quantity of blood is effused, it is liable to destroy the connec tion of the pericranium with the bone, and even the bone itself; therefore, all such cases should be care fully watched, and if the effused fluid does not di minish in a few days, but continues to increase, or begins to excite headach, &c. a puncture should be made to evacuate it, and the condition of the bone examined. See cases detailed by Hill and J. Bell.
When a blow is inflicted on the head so as to stun the individual for a time, it frequently lays the foundation for irreparable evil. In a short while, he recovers his faculties and pursues his ordinary occupations for a week or two, when he begins to complain of headach, listlessness, thirst, loathing of food and nausea, passes restless nights, feels his face flushed, his eyes tender, swollen and watery, with contracted pupils, and which feel pained on looking at the light of a candle or a fire. He is at tacked with rigors, cannot articulate distinctly, his tongue quivers and will not obey the voluntary powers. A small turnour appears where the blow was inflicted, feels tender on pressure, which, if se vere, produces a convulsive action. Ile now be comes despondent, peevish, fretful, oppressed and sick during the day, muttering to himself in a lethargic state, and when roused, appears stupid, immediately relapsing into the same comatose con dition. The pulse Is quick, feeble and hard, the tongue foul, the skin dry with flushed countenance, and red gummy swollen watery eyes, the urine scanty and high-coloured, the hands and the tongue tremble, the bowels are constipated, and during the night he is delirious. He then becomes comatose, has a dilated pupil, occasionally stertorous breath ing, delirium, and sometimes convulsions, when death closes the scene. On dissection, the puffy tumour contains a sanious fluid, the pericranium is separated from the bone, the latter of which is of a white colour, and has a dry appearance, no blood vessels being present. Underneath the bone, mat ter is also deposited, and the dura mater separated from the bone is ulcerated, presenting a dirty yel lowish green colour, while the brain itself is soft and also ulcerated. These fatal effects arc all at tributable to the bone in the first instance having been so contused, that its circulation is destroyed, the pericranittm and dura mater separated from it, a slow degree of inflammation is excited, which terminates in suppuration. The death of the bone sometimes follows lacerated, contused, and punctured wounds of the scalp, as proved in J. Bell's Principles of Surgery. It is only when the bone is contused that such fatal events occur, for other wise it is very tenacious of life, being highly vascu lar, and having three sources of nourishment, the vessels of the pericranium, those of the diploe, and those of the dura mater; and when cut and replaced, readily unites. The dura mater is a sero-fibrous membrane possessing little or no sensibility, for acids and cauteries have been applied without producing pain, and like bone enters slowly into inflammatory action, but then that action is with greater difficulty checked. These insidious symptoms are by no
means regular in the period of their occurrence after an injury, varying from weeks to months; but whenever any of them do present themselves, we should instantly take alarm and apprehend the most dismal consequences, for too often the patient is be yond the reach of help. The most diagnostic symp tom is the rigors, which are occasionally very slight; we are therefore immediately to confine our patient to bed, and pursue the most active antiphlogistic treatment. And if the insidious inflammatory symptoms are not subdued by such means, but on the contrary becomes comatose with rigors, with or without a puffy tumour, the operation of trephining should be performed, in or der to give exit to the matter; for a puffy tumour is not always present to guide us. See Abernethy's Surgical vol. ii. p. 27.
The patient ought to be laid on a low firm table, with the head on a thin pillow; a tripod or crucial incision is then to be made through the integuments forming this puffy tumour, the contents of which are foul and sanious, and the bone dry and of a yel lowish white tinge; the crown of the trephine re presented in Fig. 17 of Plate DXV. is then applied to this dead bone, with the central pin elongated, and cautiously and lightly worked with semicircular turns, first standing on the one side of the table and then on the other, until the teeth of the saw have made a distinct circular groove. The central pin is then to be retired and fixed, and the crown of the trephine cautiously turned in the same manner, ex amining very frequently the depth to which the in strument has sawn, with a quill cut like a pen, and brushing away the dry and bloodless dust from the teeth of the instrument and the groove in the bone. If the groove be attentively examined, the inequality of the bone may be observed, and whenever one point appears sawn through the outer table, diploe, and the least of the inner table, the elevator delin eated in Fig. 13 of Plate DXV, should be tried. The operator must then saw those points of bone which remain entire with short turns, and use the elevator from time to time. If the circular disc remains, it is to be removed with the forceps. if any spiculx of bone remain so as to injure the dura mater, they are to be removed with the elevator, but the surgeon should not be too fastidious about these spiculx. Some use a perforator before applying the crown of the trephine, but this is seldom neces sary. As this operation is generally done on pa tients in an insensible state, and as it is attended with the greatest danger, there is no cause for ex pedition. It is one of the operations in surgery whose success depends more on cautious delay than celerity. After the removal of the circular disc, the dura mater will be found coated with mat ter green and ulcerated, and if the matter does not exude out at the trepan hole, it ought to be gently syringed with warm water; and if no relief what ever has been obtained, but the symptoms still con tinue, this membrane should be freely incised across with a bistoury; and even then, if the symptoms are not sensibly alleviated, an incision ought to be made into the brain itself. " Melius esse experir reme dium anceps quam nullum;" or " can the surgeon he said to destroy by his operation, a patient who is declared past all hope?" For confirmation of this practice, the reader is referred to Hill's Cases in Surgery, and to the Lancet, No. 117; also to Wise man's and J. Bell's works.