HEAD, IN.U'fUF.S OF THK. 



HKAKT, DISEASES OF THE. 



. hen the blood U immediately Iwnoath the upper parts of the 

 kull. 



iMtead of blood, purulent nutter may collect between the dura 

 mater and skull, and produce equally fatal results. ThU is indicated 

 by the patient (usually com* considerable time after the accident) 

 coni| Jaining of headache, rrirtlnannnn. and extreme languor ; he has 

 frequent irregular shivering*, his pulse is quick nnil ban), nnd In 

 cannut aleep : if unreliered by treatment, all these symptom* increase, 

 and are shortly followed by delirium, convulsions, insensibility, <>r 

 paralysis, which are no distant precursors of death. Early after their 

 tint appearance, a puffy, soft, but not very hot nor painful tumour 

 forma over the part struck. If thin be opened, the pericranium will 

 be found detached for some extent from the skull, which when exposed 

 1* seen to be dead, of a dull yellow colour, and covered by purulent 

 fluid. In this case it may be expected that the dura mater is separated 

 from the interior of the skull to the same extent that the pericranium 

 is from its exterior, and the only hope of relieving the patient is to 

 perforate the dead portion of bone with the trephine, and let out the 

 matter collected between it and the dura mater, and which compressed 

 the brain. 



The brain itself may suffer injury either from blood effused in it l.y 

 rupture of its vessels, from compression by fractured portions of bone 

 being forced down upon it, from wounds, from concussion, or from 

 inflammation, and its various effects following any of these injuries. 

 The first need not here be particularly treated of ; it does not differ in 

 its symptoms from the cases of common apoplexy with effusion of 

 blood [APOPLEXY], and admits of no mechanical treatment. The 

 second class comprehends the most important injuries of the head ; 

 those of "fracture with depression," as they are called, and those 

 which occasionally happen in children, in which the skull is indented 

 without being broken. The symptoms of such an injury are insen- 

 sibility, generally in direct proportion to the degree of pressure ; the 

 breathing is slow, laboured, and snoring, and at every expiration the 

 cheeks are puffed out and elevated ; the pulse is slow and irregular ; 

 the pupil widely dilated and insensible to light ; the patient neither 

 feels nor moves, and lies as if in a fatal state of apoplexy. The part 

 struck may of course present most varied characters : it may be starred 

 from the centre of the blow, so as to have a shallow conical depression ; 

 it may be fissured, and one edge have passed under the other ; or it 

 and the scalp may be broken up confusedly, and the brain be pro- 

 truding through the openings in them. It is worth remembering that 

 the inner part of the skull may, in consequence of its brittle-net*, be 

 much more widely fractured than the external, so that the degree of 

 pressure on the brain is not always indicated by the depth of the 

 indentation felt in the scalp. If unrelieved by treatment, the patient 

 from the time of the accident grows more and more insensible ; his 

 pulse becomes more irregular, and he rapidly dies. The evident and 

 indeed the only mode of affording relief is to remove the pressure from 

 the brain, by exposing the fractured part of the skull by enlarging the 

 wound in the scalp, or making a fresh one, and taking away or 

 elevating all the portions of bone that are depressed. The mode of 

 doing this will be determined in each case by the form of the fracture 

 and other circumstances ; in some it may be sufficient to remove the 

 loose pieces with forceps; in others, to saw off portions with a I ley's 

 saw, or to apply the trephine and raise the other depressed parts to 

 their proper level with an elevator. These proceedings however must 

 of course be limited to the cases in which the fracture is in a part 

 within view ; when it extends across the base of the skull no mecha- 

 nical means are applicable, and recovery is therefore extremely rare. 

 Such cases, and all others in which compression cannot be mechanically 

 relieved, can only \>e treated like common apoplexy, by bleeding the 

 patient, by cold sedulously applied. and by rigorous reducing measures. 

 The after-treatment of cases in which the trephine or analogous means 

 have been used is nearly the same as in wounds of the skull and soft 

 I*rU ; the edges should be brought gently together, and slight pressure 

 eni]>l..yi:<l tn Mi|>port the dura mater where it is exposed by the 

 aperture in the skull : and the other usual precautionary and curative 

 measures, as cold, local bleeding, 4c., resorted to. 



The immediate consequences of wounds of the brain vary greatly, 

 and indeed unaccountably : in som cases a very slight injury is 

 rapidly fatal, as in those (of which many are now recorded) in which a 

 pointed instrument has passed in through the orbit, and produced 

 almost instant death ; whilst in others severe and extensive injuries, 

 as from gun-shots, have been followed by serious symptoms at only :\ 

 late period from their reception. In most of the cases where tin- .1m. i 

 mater is perforated, whether by wound or by ulceration, the wounded 

 or exposed brain protrudes through the aperture in the form of a 

 darkish dirty-looking fungous maw, called " Hernia Cerebri." Its 

 surface discharges purulent matter abundantly, and often bleeds 

 slightly: prrwure on it, as on the brain itself. produces immediate 

 insensibility ; but the whole mass may be cut off without producing 

 any pain or ill consequences. This is indeed the best treatment of it. 

 If after having protruded to some distance it shows no disposition to 

 decrease or to slough, it should be cut down to the level of the skull, 

 and gentle pressure by compresses covered with the mildest ointment 

 applied, so as to compensate, if possible, for the deficiency in the dura 

 m:iU-r. Should the mass again sprout forth, the same treatment may 

 be repeated. In a few cases the growth is check. brain 



c healthy granulations, which unite to the surrounding parts 

 and skin over ; in others the fungous mam sloughs and the remaining 

 parts heal ; but in the Urge majority the exposure of the brain and iU 

 irritation by surrounding parts produce such continued inflammation 

 of it as proves fatal. 



The hut injury of the brain that needs particular notice is that 

 called concussion or commotion. The exact nature of It is totally 

 unknown; the name indicates only that which has been supposed, 

 namely, a sliaking or general disturbance of the mlottt* Mrts of the 

 brain. In it* slightest degree it is merely a stunning, from which 

 perfect recovery takes place in a few minutes ; in its most severe, it is 

 rapidly fatal; but even in these, a post-mortem examination .h 

 no alteration whatever in the structure of the brain. One of th. 

 interesting points in surgery in the diagnosis of concussion from com- 

 pression of the brain. As the latter seldom occurs without the i 

 (for of course a blow whi. h would fracture or indent the skull 

 violently shake the brain), compression has the symptoms of con- 

 cussion, with the addition of some of the most severe which we have 

 already mentioned. In concussion the patient is insensible only to 

 slight impressions, for if he be loudly called (>. he will wake up, 

 a word or two, perhaps even rationally, and then relapse into 

 the same state. If he be severely pinched or otherwise irritated he 

 will withdraw the part so injured: be occasionally moves his limbo; 

 he appears, in short, as if in a sound heavy sleep, like that of a drunken 

 man. The breathing is not stertorous, but generally quite natural ; 

 the pupil is contracted and irritable ; the pulse is sometimes unaffected, 

 but in severe cases small and weak ; there is nausea or vomiting, and 

 the extremities feel cold. If the case is about to terminate fat-illy, the, 

 whole body grows rapidly cold, the pulse becomes irregular and weaker, 

 the breathing short and interrupted, and the insen.-il'ility increases. 

 In treating cases of concussion much caution is needed : it has not 

 appeared that bleeding, which is the remedy popularly expected for all 

 such accidents, has at all diminished its primary symptoms, nor has 

 the contrary treatment by stimulants been more successful. The 

 patient, while suffering from the immediate stunning consequences of 

 the blow, should merely be kept quite warm in bed, and carefully 

 watched ; if the pulse grow weaker, the extremities colder, and the 

 other symptoms of sinking seem increasing, stimulants are first called 

 for, and should be given till he is completely roused to his former 

 state; but if, instead of being depressed, he remain stationary, no 

 active means of any kind should lie employed. Cases are not rare in 

 which, after remaining in a nearly insensible state, as if in a sound 

 sleep, for four, six, or eight weeks, with only very slight temporary 

 ons, the patient wakes, complaining of but little mcoavatiiance, 

 and rapidly recovers. If instead of waking nearly well, he is observed 

 to grow restless, to seem suffering from headache, or should he be 

 di -liiimis or convulsed if his pulse becomes quick ami hard, and his 

 eyes are hurt by strong light he has in all probability ii, 

 '. lip- brain, which is the most frequent consequence of concussion, 

 and must be at once met by the active depleting and reducing 

 measures necessary for its cure, from whatever cause it may arise. In 

 some cases the symptoms of concussion gradually change into those 

 of compression, which may then be suspected to arise from effusion of 

 blood into or on the brain, as in the cases already mentioned. 



The account here given is only a sketch of the most prominent and 

 constant symptoms, progress, and treatment of the effects of injuries 

 of the head. There are other symptoms that occur occasionally, and 

 as it were accidentally, which it is necessary briefly to advert to. 

 Furious delirium, lasting for some days and requiring active depletion, 

 sometimes immediately follows concussion ; violent convulsions also 

 ensue, either on slight compression or on concussion ; paralysis or 

 hemiplegia is not (infrequently produced directly by compression, and 

 they still more commonly occur as its sequels. Loss of memory, 

 sometimes most singularly limited to particular classes of events or 

 things; impairment of individual sensations, and various fori, 

 insanity, are all the occasional consequences of these injuries, or of the 

 inflammation and disorganisation of the brain which follow them 

 to the prevention or cure of which the chief attention i, in the 

 majority of cases, to be directed. 



IIKADBOROUOH. [CONSTABLE.] 



Ill :\I,TH. (Pi-nuc HEALTH.] 



REARING TRUMPET. [EAR-TRUMPET ; SPEAKHH. 



HKAKSAY. lEvim-M 



HKAKT. I'ISKASKS or Till:. The heart, like the ..(her viscera, 

 is concealed from the eye, hence little knowledge of it* healthy i 

 diseased conditions can.be obtained l.y mere inspection. Kven tin- 

 touch fails to ascertain much, on account of the )>ny c.isc in whi. h it 

 is enclosed. Its impulse may, however, be detected by grasping the 

 chest with the hand. The arterial pulse may be also felt l.y the finger, 

 but these means of examination give but little information of the 

 nature of diseases of the heart, compared with the use of the ear. 

 Disease of the heart can be detected both by the aid of ausculi 

 and percussion. 



\Vlieii the ear is applied to the left side of the chest, either .i 

 or with the aid of the stethoscope, two sounds are heard, called the 

 first and second sounds of the heart. [HEART, in NAT. HIST. Drv.J 

 The two sounds differ from each other, and the period of silence 

 >ctween the t The first sound is longer than the 



