along the base to the medulla, from which it had slowly penetrated into
the f lurth ventricle, in wiiich was found a fresh clot, which was un-
doubtedly -the cause of speedy death. No fracture of the skull nor
injury of the brain was found. Sudden death is not the usual termina-
tion in these cases, but they lead usually to mild pressure-symptoms,
mental uncertainty, sleepiness, and slowing of the pulse. There may lie
certain automatic motions or jxisturc-symptoms — as continuous holding
of both hands up to the face, the drawing up of one limb, etc. — though
' Gui/f Hosp. Reports, 1876, p. 131.
652 DISEA/^ES AXD IXJUEIES OF THE HEAT).
tliese arc not coininoii. At othor times tlic usually conscious ])ationt is
very restless, ditticult of restraint, and perhaps noisy and disturl)ant.
This milder type of brain-pressure, which is apjiarently due for the
most part to cortical irritation, may contiruie over several weeks. The
first imjiulse in these cases ]K'rliai)s is to endeavor to revive the patient
to consciousness, but oxperient'c has siiowu that this is an unwise course
to follow. While these jiatients live they are caj)able of resorbing
even extensive clots, and the best treatment, so long as there is no dis-
tinctly surgical indications to folh^w, is that which may best supj)ort and
sustain strength and circulation. They, as a rule, gradually recover
from the long sleep, and even more suddenly regain tlieir mental powers.
Perhaps the most obstinate remaining signs or symptoms are headache
and difficulty in mentality, loss of meniory being one of the most com-
mon results.
In these cases one has naturally to distinguish between persistent
coma and the numerous minute hemorrhages sometimes known as "dis-
seminated capillary a])<)j)lexics." These minute ecchymoses constitute,
of course, minute focal lesions; throughout a large part of the cortex
they produce no distinct symptoms ; only at certain points may they
lead to disturbance of single functions — namely, in the so-called motor
region, and possibly in the medulla. In most instances long duration
of unconsciousness bespeaks a congestive disturbance ; ])atients quickly
relax into somnolence after being roused or they show sudden signs of
irritability, sucii as jumping out of bed, crying out, grinding the teeth,
or some paroxysmal muscular action. These attacks gradually subside
in frequency and violence. The more active manifestations are to be
ascribed to congestive influences ; the more comatose the patient, the
more positive and permanent the hemorrhagic lesion. Inasmuch as
limited subdural hemorrhages produce no specific nor patliognomonic
symptoms, no positive line of action can be laid down ; in fact, they
are often scarcely to be distinguished from those of contusion of the
brain, and call, in fiict, only for the same general treatment. These are
cases which perfectly justify an aseptic exploration, in spite of the
sneer with which Bergmann records the case already reported, as above
mentioned, liy Parker. This, which appears to Bergmann only an
instance of sheer luck, will strike surgeons of to-day as an instance of
remarkably clear judgment.
Finally, it may be added that it has been suggested to tie the common
carotid, or ])erhaps its internal branch, in certain cases of ingravescent
cerebral hemorrhages (apoplexies). For this course there would seem
in selected cases sufficient ground, and the writer urges a trial of the
same.'
' The followino; cases of this char.ncter mav better illustrate this. They were reported
by Dercum and Keen tJmirn. nf Arcc. iiihI Meiit. Dix., Sept., 1894) :
Case I. — Patient of fifty, with apoplexy of progressive character and left hemiplegia.
Eememl)ering that Horsley in experimenting could control hemorrhage from the basal
ganglia ami corpuscles by ligating the common carotid, and that in consequence lie had
suggested ligation of this vessel as the treatment for cerebral hemorrhage in man, it was
here proposed and accepted, and performed. The progressive course of the paralysis
was evidently arrested thereby, and was continuously improved so long as it was kept
under observation.
Case II. — Middle-aged man, also with symptoms of ingravescent liemorrhage, in
whom, while the preparations were making for similar ligation, the paralysis so rapidly
lyjUETES OF IXTRACEAyiAL VESSELS AXD SINUSES. 653
HKMORRHAGE IXTO THE LATERAL VENTRICLE.
This might lie (li.stingiiished as one variety of subdural hemorrhage,
and the distinction would bo of more importam-e could it be made clin-
ically. In such instances, however, the individuality of symptoms is
lost in the general comatose condition of the jnitient, and these eases are
of interest ijatliologioally rather than in any other way. In one or two
instances, however, tiie presence of such clots has been suspected, and
deliberate incision has been made into the ventricle for the ])urpose of
their evacuation. The first such case on record was l)y Dennis, who
diagnosed the presence of intraventricular clot in a ca.se of traumatic
hemorrhage with monoplegia, and who deliberately incised into it, with
the result of ])erniitting the escape of a clot which was pressed out to a
considerable distance.'
A case similar to this 1 liavc re])orted in the Medical Newn for Dec. 3,
1892, and will briefly epitomize as follows : A man of fortv fell from a
height not exceeding five feet. Upon the morning following the injurv
he was walking about the house, but not talking. During the third
night following the injury he became hemiplegic upon the right side,
and next morning was comatose. Operation was undertaken as a last
resort to see if brain-pressure could be relieved. A large 5 cm. trephine
was applied low down over the left motor area, although the only exter-
nal evidence of injury w'as a slight linear ecchymosis behind the opposite
right ear. Even after exposing tiie bone no sign of fracture was re-
vealed. Upon removal of the bone the dura aji]>eared darker than
natural. After ojiening it some laceration of the brain-cortex was dis-
covered. The most striking feature was marked increase of intracranial
pressure. After further exj)l<)ratiou without discovery of satisfactory
cause I passed the needle of an ex|)loring sn-inge in the direction of the
lateral ventricle. At the depth of 6 cm. I removed 12 or 15 c.c. of
fluid blood with the syringe. I then passed a director down alongside
the needle and removed 30 c.c. more of semifluid blood. After the ope-
ration the [iressure was so reduced that the cortex subsided to its proper
level and the man began to use his right arm. Tiie ventricle was then
drained. The patient lived only a few hours. On autopsy complete
diastasis of the longitudinal suture was found, extending far down pos-
teriorly and anteriorly, so that the halves of the skull were almost ready
to fiiU apart. There was also a small fracture on the right side. Nu-
merous other small clots were found, and in the left lateral ventricle,
which had been already tapped, was found remaining a small. Arm clot."
deepened that unconscioiisiiess li.id supervened before it could be performed. Artery tied
at 10 l>. M. withnnt an ana'sthetic. Patient, however, failed to rally, and survived but a
few hours.
' Case reported by Keen, "Surgery of Lateral Ventricles," Trniis. nf Internat. Med.
Congress for 1S90, vol. iii. p. 109.
^ In the I'hilml. .V«?. JVcic.s, .June 5, 188ti, Forniad terminated a medical-legal study
of intracranial hemorrhage with conclusions, some of which may be of interest here:
Hemorrhage on the outside of the brain is always due to traumatism, provided that a
cerebral source for hemorrhage is excluded and that the vessels and membranes are not
diseased.
Hemorrhage in the floor of the fourth ventricle is always traumatic, provided there
are no blood-clots in the lateral ventricles or in any parts of tlie congested cerebral sub-
stance. In the ana'mic brain-substance a slight ventricular ecchymosis may indicate that
death ensued from epileptiform convulsions.
654 BTSEASES AND INJURIES OF THE HEAD.
Lacerations and Injuries of the Brain.
These may lie divided into two groups — one in wiiicii the cranial
bones themselves have been broken, and the (jther in which only the
cerebral tissue itself is involved, or at least in which the bone does not
]iartieipate save by some triflino; fracture of the inner table. A recog-
nitiiin of the importance and character of these lesions was tirst made by
I)Mpuvtren. Since his time suriicons have striven to portray an accurate
clinical picture of brain-contusion an<l to separate it from compression
and concussion. Du])uytren himself tauglit that this was only possible
after a few days ; others, like Sanson, and Boinet his student, sought to
constitute a new symptom-groii]i wliich should be recognized at once.
These views were acceiHed nmch earlier in F" ranee than in Germany or
England. Up to the time when (iriesiiiger divided these l)rain-lesions
into the diffuse and the local or focal it was held that contusions of the
brain in general produced clinical symptoms which followed a pretty
typical course. It was this division which did much to clear up the
subject. Later, it was shown clearly that bj-ain-injurics of this kind
produce lacerations, extravasations, disturbances of circulation, and later
inflammatory lesions, and that it was difficult to include the results of
all of these in any single clinical picture.
The api>earance of the injured brain-substance will ilejiend upon the
degree and extent of the lesi<in : we may have minute local disturbances
or lesions involving an entire liemisphere. The milder forms show at
the point of tissue-injury a sprinkling of numerous dark hemorrhagic
points, most numerous in the centre of the injured area, while the brain-
tissue itself takes on a more or less diffuse red tint, fading out toward
the peri])herv. The points are due to minute hemorrhages, the redness
to the imbibition of bloody coloring-matter by the substance of the brain.
In more extensive injuries we may find clots as large as peas imbedded
in the sul)stance of the brain, with an area of imbibition-redness around
each of them. These clots may often be washed out with an irrigating
stream, leaving well-defined cavities behind them. When blunt foreign
bodies or fragments of bone have been driven into the brain, the tissue
takes on a brownish-red color, while a mixture of tissue-fragments and
blood-clots, containing perhaps hairs or fragments from the coverings of
Hemorrhage exclusively below the pia in the brain-substance or into the ventricles,
except the fourth, is always iiliopathic.
The blood-clot in concussion (contusion) of the normal brain is not found at the point
of application of violence, but usually somewhere on the opposite side, and always be-
tween the pia and the dura. In rapidly-fatal cases of fracture there is usually a second
intradural clot in some otlier i>art of the brain, due to contrecoup.
Blood-clot within the cranial vault is more favorable if due to fractured skull than if
due to mere concussion (contusion).
Only clotted blood and infiltration of blood-corpnseles into the tissues indicate an
ante-mortem hemorrhage. Exudation of coaKula!)le blood indicates a post-mortem
hemorrhage. Post-mortem oozing only stains, hut does not infiltrate, tissues. In cases
of instantaneous death the blood may remain liquid. Where rapid asphyxiation or
certain poisons co-operate with the injury in causing speedy death the blood may also
remain liquid and clots may fail to form.
Severe bruises and cuts may be seen in cases of idiopathic apoplexy where a sudden
cerebral hemorrhage causes a person to fall.
The bulk of intracranial hemorrhage stands usually in direct proportion to the dura-
tion of time elapsed from the moment of injury to death ; but it stands in inverse propor-
tion to the bulk of external scalp hemorrhage.
LACERATIONS AND INJURIES OF THE BRAIN. 655
the l)rain, and otlier foreign material, will he met with. Tlie transi-
tiiin from tlie involved to tiie iininvolved tissue in these cases is alwavs
at first (|uite ahrupt. Finally, in certain instances of great violence we
may iiave ahsolnte rupture of hrain-tissue, tlie fissure extending from the
cortex even perhaps into the ventricle. The more severe forms of brain-
injury accompany compound fractures with depression and penetration
of bone-fragments or of foreign bodies ; the milder forms, especiallv the
minute jiunctate hemorrhages, iielong to the milder type of contusion.
The more the elastic skull is compressed, the more significant are these
apjiearances in the injured area. They are perhaps found most typically
in those cases where the skull has been run over or oompressed in some
such way. It is undeniable and positive that contusions of this kind
may occur without evident lesion of the bone. Astley Cooper and his
followers long since settled this beyond question.
So far as the location of the injury is concerned, it will depend upon
the nature of the lesion and the object which inflicts it. A\'licn the bodv
which injures the skull is small — at least, when the ajiplied surface is
small — the contusion will usually be found in that part of the brain just
under the site of the injury, or perhaps also exactly opposite to it; but in
many other cases, especially when the surface involved is extensive, the
principal tissue-disturbances will Ije found ujioii the other side of the
brain. Thus, in severe injuries to the occipital region we may find the
frontal or temjioral lobes contused and lacerated ; as, for instance, in
injuries produced by falls from a height or by blows Avith a cluli or kicks
from a horse the brain will show most injury at the point opposite to
that where the bone is broken and depressed.
^A'e have again here to allude to the importance of the cerebro-spinal
fluid as a means by which many of the minute lesimis fV)und in these
cases are produced. \\'lien, for instance, the direction of the violence
is from before and above in a backward and downward direction, the
fluid contents of the lateral ventricles are powerfully forced out, and
immediately seek to escape through the Sylvian aqueduct. Inasmuch,
however, as this fluid must find insufficient room in the fourth ventricle
and the central canal of the cord — the lateral ventricles containing five
or six times more than these cavities — their walls are materially distended,
and must give way at one or more points, while from the injured vessels
blood may escape into the nerve-substance. In consequence, one finds
the brain-tissue around these cavities dotted with niinnte extravasations.
A cross-section through the a(|ueduct, the fourth ventricle, and the U])per
part of the central canal will show these lesions very plainlv (Plates VII.
and YIII.).
Duret has even found perimedullary extravasations in the lumbar
portions of the cord under these circumstances. It is often quite possible
to iiurst the fourth ventricle by force ujion the head, as Duret's experi-
ments have shown, in one case the medulla being separated into halves
as the result of excessive action thus produced. M'heii we appreciate
these facts, it is quite easy to understand how the evidences of violence,
even when this is applied to the outside of the skull, may be very con-
spicuous in the neighborhood of tlie fourth ventricle and the medulla.
This also will explain many of the phenomena which follow such in-
juries.
656 DISEASES AND INJUIilKS OF THE HEAD.
Laccratwl wouikIs of tlio hraiii-inatcrial lie, almost without exception,
in and about tiic convexity of the iieniisplieres, tiie exceptions being
])roiluce(l by forei<ju bodies penetrating from witliont. Lacerations in a
narrower sense, liowever, are found for the most part in the deptlis of
the brain or at its base, especially when the applied surface of the im-
pinging object is large. In 3() fissures extending from the convexity of
the skull to its base, along with lacerations of the brain, studied by
Hewett, the brain-lesions themselves were found only 5 times in the
upper part, and -'A times in the neighborhood of the base of the brain.
Evidences of contusion are much less often found in the pons. In the
post-mortem I'ccovds of St. George's Hospital for sixteen years they
were met with only four times. Boinet only records one case, and Falk
in one case of de])rcssc(l fVacture of the convexity found a small hemor-
rhage in tiie middle of the pons. Contusions in the cerebellum are more
frecpient, and are met witii almost entirely in its lower ]iortion. Thus
Hewett found here an extravasation the size of a hazelnut, and Blandin
has found the entire cerebellum dotted with numerous capillary hemor-
rhages. So, too, in eleven cases rejjortcd by Hewett the cerebellum was
that part of the brain most partiindarly involved. In the cerebellum
Hewett lias found tiic majority of these lesions in tiie neighborhood of
the septum j)elluci(lum, in the fornix, and in the thalanuis.
The fi'equent occurrence of contusions of the brain-tissue along with
intrameningcal hemorrhages is so conspicuous that it finds a place even
in legal medicine. Very often the question has arisen whether it be
|)rol)al)le that one in a drunken state falling to the ground have suffered
from apoplexy or from the result of violence. Should a single fresh
lesion in the interior of tlic brain present, the prol)al)ility is that it is
apoplectic, especially should there be evidences of degeneration in the
cerebral arteries or in the heart. On the other hand, should the picture
be rather one of contusion, it is much more likely to be of a truly trau-
matic character. Spontaneous caj>illary apoplexies are usually scattered
over the brain, ])articularly in the cortical region. When there are several
extensive hemorrhages in tlie lirain there are almost always minute capil-
lary hemorrhages between them. Of particular significance are minute
ecchymoses in the medulla ; even before Duret had announced his views
upon cerebro-spinal shock Beck had remarked their frecpiency in his
experiments concerning concussion. They seem, therefore, to be evidences
of violence, and much less often of non-traumatic lesions.'
COURSE OF BRAIN-CONTUSIONS.
During the course of these injuries, as well as of lacerations of the
brain, it obviously makes an immense difference whether sup])tn'atlve
processes complicate them or not. With reference to these, the first and
most important factor by wliicii infection may lie excluded is that the
integrity of the soft parts outside of the cranium should be preserved.
Next to this, perhaps, come into play disturbances of the circulation,
both inside and outside the cranium. It is well known that traumatic
swellings under some circumstances assume very great dimensions, which
' Zeller, " Ein Fall von schwerer Hirncontusion ohne SchiidelverletzuDg," Deutches
Zeilaclijt. /. Chir., xxxvii. 540.
LACERATIONS ASD INJURIES OF THE BRAIN. 657
are only limited by their enviruniiieiit. Slowing of tiie circulation, which
is more or less marked in cases of contusion and laceration, is not such
a very important factor, except as it may produce oedema of the brain in
an indirect way. It will be remembered that lacerations of the l)rain
are very frequently combined with intrameningeal hemorrhages. These,
of course, will predispose to swelling of the injuri'd region by pres-
sure upon the veins. Extensive lacerations and hemorrhages may in
this way produce swelling in dangerous degree, not merely in that they
encroach upon and disturb neighboring regions of the brain, but that the
quantity of cerebro-spinal fluid may be increased by extensive transuda-
tion, by which also the intracranial pressure is increased, perhaps even
to a fatal extent.
Supposing this danger to be successfully passed, the next question is
with regard to repair. It is well established that brain-lacerations may
heal by cicatricial repair, the remains of the same corresponding very
much to those of old apoplectic foci in the cortex. The most frequent
result is a simple depression finnly united by the pia and dura, sometimes
even with the bone, especially wiien the latter has been fractured. If
this be examined, it will be found that we have a jiicture of sclerosis of
nerve-tissue rather than of a fibrous cicatrix. In rare instances there
will be found a spongy tissue beneath the membranes, more or less
porous, in whose cavities is contained a yellowish fluid. This tissue will
be surrounded with more or less sclerotic and cicatricial new formation.
These correspond to the apoj)lectiform cysts which are found in the
interior of tiie brain, only these are ]ieculiar to the surface. A com-
pletely-formed cyst with brownish-red or chocolate contents is the result,
usually, of deep and considerable hemorrhages into the cerebral tissue.
A possible third result may be met with in the shape of yellow softening,
due to disturbance of circulation in the cortex in the innnediate neighbor-
hood. The injured area conducts itself very much as would a conglome-
ration of punctate hemorrhages, which are known to terminate in red
and yellow softening. The flnal result is a defect or loss of substance
taking place beneath the pia, which is often indicated by a yellowish
fatty emulsion ; the borders of this area are tinted brownish-red. In
some cases these changes show a tendency to jirogress toward the interior,
which is usually favored by fatty degeneration of the vessels.
During the latter part of the present century considerable pains have
been taken to ascertain experimentally the exact ct)ndition of repair
inside of the brain and the methods by which it is carried out. Gliige
began experimenting with needle punctures in the brain ; since his day
numerous investigators have varied the methods, but have arrived at pretty
uniform results. It has been found that there is a striking analogy
between repair of cerebral tissue and that of liver-tissue, as Bergmann has
pointed out.' Other things have also been made plain ; among them
this — that even when cicatrization is proceeding there may occur a radi-
ating degeneration of connective tissue through the brain, which may
develop an interstitial encephalitis or a progressive yellow softening
or gray degeneration of the same tissues. Kraft-Ebing has described
changes of tiiis kind occurring throughout the brain of an executed
criminal who in his fourteenth year sustained a severe injury to the skull,
' i. c, p. 423.
Vol. II.— 12
658 DISEASES Axn /.v./r'/?//?.s' of ttte head.
with ailhesioiis Ix'twccn tlio (•(irtcx Mild the hone ; tlic midcrlyini;' liemi-
spiiere was pfrmoated by cicatricial fibres, and its actual cerebral tissue
reduced in volume by at least a third. Changes analogous to these have
been described by Tillmanns, the same being in effect a traumatic cirrho-
sis. Progressive yellow softening is nmcli more frequent than the changes
just noted.
Another group of sequehe of these injuries is constituted by cases
which present evidence of secondary degeneration of nerve-fibres, as a
result, apjiarently, of their laceration. These have been j)articularly well
descril)ed l)y Charcot and Vulpian, who found them most often after
cortical lesions, es|iecially of the central convolutions.
Not less interest centres in the ijuestion of tiie possibility of regen-
eration of these same tissues. It is well known that in the nerves of the
extremities a remarkable and functionally almost perfect regeneration of
divided nerves may occur, the experiments and clinical experiments of
Gluck being especially instructive in this direction. It is largely through
his experiments that the now weli-establishetl procedure of nerve-suture
has been placed on a firm basis. Unfortunately, that whicli obtains in
the peripheral nerves cannot be depended ujion within tlii' Itrain. Demrae'
is perhaps the only writer who claims to have seen a real regeneration
of primary nerve-fibi"es in the brain. Our present position in this matter,
based upon general experience, must be to the effect that a defect in the
human brain is, to an almost complete extent, irreparable.
Another (piestion of great interest is with reference to the encapsula-
tion or iniiealing of foreign 1 todies. Some years ay;o Ih'uns came to the
conclusion that a j)ermanent healing of a patient who had a bullet in the
brain was a rare exception, and that scarcely a single patient remained
Mcll who had suffered this injury. Of 73 cases of perforating gunshot