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A Beginner’s Guide
to Internet of Things
Security
 A Beginner’s Guide
to Internet of Things
Security
Attacks, Applications,
Authentication, and Fundamentals

B. B. Gupta
Aakanksha Tewari
CRC Press
Taylor & Francis Group
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Boca Raton, FL 33487-2742

© 2020 by Taylor & Francis Group, LLC

CRC Press is an imprint of Taylor & Francis Group, an Informa business

No claim to original U.S. Government works

Printed on acid-free paper

International Standard Book Number-13: 978-0-367-43069-6 (Hardback)

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Dedicated to my parents and family for their constant support during
the course of this book.

-B. B. Gupta

Dedicated to my mentor, my parents, and my friends for their constant

encouragement and belief during the course of this book.

-Aakanksha Tewari
Contents

Preface xi
Acknowledgments xiii
Authors xv

1 Evolution of Internet of Things (IoT): History, Forecasts,

and Security 1
1.1 Evolution of IoT 2
1.2 Statistics and Forecasts 4
1.3 Fundamentals of IoT Security 8
1.3.1 Security at Different Layers 8
1.3.2 System Requirements of the IoT System 8
1.4 Conclusion 9

2 IoT Design, Standards, and Protocols 11

2.1 Layered IoT Architecture 12
2.2 Security and Privacy Issues with IoT Architecture 13
2.2.1 Perception-Layer Security Problems 13
2.2.2 Network-Layer Security Problems 14
2.2.3 Application-Layer Security Problems 14
2.3 IoT Protocol Design 15
2.3.1 Protocol Stack for IoT 15
2.3.2 Security
 Requirements 16
2.4 IETF and IEEE Design Standards 17
2.5 Taxonomy of Threats to IoT Networks 17
2.6 Conclusion 19

3 IoT’s Integration with Other Technologies 21

3.1 IoT Experimentation Setups 21
3.2 Platforms and Software Tools for IoT Simulation 22
3.3 Integration of IoT with Various Domains 23
3.3.1 Data Storage 23
3.3.2 Cloud Computing 25
3.3.3 Big
 Data 26
3.3.4 Fog
 Computing 27
3.4 IoT and Radio Frequency Identification (RFID) 28

vii
viii Contents

4 Industrial Internet of Things (IIoT) 31

4.1 M2M to IoT 32
4.2 IoT and Secure Automation 34
4.3 IIoT Applications 35
4.4 IIoT and Cybersecurity 38
4.5 Conclusion 39

41
5.1 Privacy in IoT 41
5.2 Threat to Data Privacy in IoT 43
5.3 Enforcing Trust in IoT 44
5.4 Trust Management 46
5.5 Conclusion 47

6 Authentication Mechanisms for IoT Networks 49

6.1 Data Security in IoT 50
6.2 IoT Limitations 51
6.3 Need for Authentication and Access Control in IoT 51
6.4 System Requirements for Authentication Mechanisms 52
6.5 Taxonomy of IoT Authentication Protocols 53
6.5.1 Hash-Based
 Protocols 53
6.5.2 ECC-Based
 Protocols 56
6.5.3 PUF-Based
 Protocols 56
6.5.4 HB
 Protocols 57
6.5.5 Ultra-Lightweight
 Protocols 58
6.6 Conclusion 59

7 Provable Security Models and Existing Protocols 61

7.1 Provable Security Models 62
7.1.1 Vaudeney’s Model 62
7.1.2 Canard et al.’s Model 64
7.1.3 Universal Composability Framework 66
7.1.4 Juels–Weis Challenge–Response Model 67
7.2 Issues with Security Models 70

8 An Internet of Things (IoT)-Based Security Approach

Ensuring Robust Location Privacy for the Healthcare
Environment 73
8.1 Problem Definition 74
8.2 Abstract Overview 74
8.3 Detailed Protocol Description 75
 Contents ix

8.3.1 Location Privacy-Based Mutual Authentication

Protocol75
8.3.2 Authentication of IoT Devices 76
8.4 IoT Authentication Scheme Ensuring Location Privacy 76
8.4.1 Concept of a Basic Location Privacy-Based
Authentication Scheme78
8.5 Security Analysis 78
8.5.1 Game-Based Security Model 78
8.5.2 Strong Location Privacy 80
8.6 Performance Analysis 81
8.7 Conclusion 81

References 83
Index 91
Preface

The potential capabilities of Internet of Things (IoT) can reduce a lot of time
and expenditure of various organizations. These devices are excellent data
collectors and sensors; therefore, they can help in efficient decision-making
in a wide range of applications. However, security remains the biggest issue in
the IoT domain. A lot of research is being carried out in this area to provide
strong security and privacy mechanisms in IoT networks. The development
of standards and protocol sets is necessary to build the IoT network properly.
Only time will ultimately tell how far IoT will reach and how it will reshape
the world. However, by the planned integration of existing technologies, we
can make IoT networks secure and more efficient. We address various issues in
securing IoT networks, which enabled us to develop various mutual authentica-
tion protocols that strengthen the security and privacy of IoT devices and pre-
vent confidential data from theft. The present scenario of IoT research is mainly
focused on the development of technologies for its implementation. By exam-
ining the recent statistics and literature, it also uncovers various challenges
that have the potential to prevent IoT from growing to its full potential.
Specifically, the chapters contained in this book are summarized as
follows:

Chapter 1: Evolution of Internet of Things (IoT): History, Forecasts,

and Security. This chapter introduces the origin and concept of IoT along with
its system requirements. It also explores the significance of security in the IoT
domain by providing an in-depth statistical analysis of past events and future
predictions.
Chapter 2: IoT Design, Standards, and Protocols. This chapter provides
an overview of design and system requirements of IoT networks and security
and privacy issues linked to the architecture. It also elaborates the configura-
tion and underlying standards and protocols necessary for the development
of IoT. This chapter also highlights the security requirements for platform
development.
Chapter 3: IoT’s Integration with Other Technologies. This chapter
discusses various domains and the support they need from IoT for their
growth. It also illuminates the security aspects of the integration of IoT with
other domains such as cloud computing and big data.

xi
xii Preface

Chapter 4: Industrial Internet of Things (IIoT). This chapter discusses

the applications of IoT in industries. It explores various technologies such as
edge computing, mobile technologies, and 3D printing, which have helped in
realizing IIoT. We also discuss cybersecurity and the modular architecture of
IIoT and how security comes into play with each module.
Chapter 5: Trust and Privacy in IoT. This chapter facilitates the
significance of trust and privacy in IoT and how the lack of any one of these
can diminish users’ faith, which may result in the failure of any technology.
It elaborates on the types of attacks and the degree of damage they can do to
the networks. This chapter also gives an overview of methodologies through
which trust can be ensured within a network.
Chapter 6: Authentication Mechanisms for IoT Networks. This
chapter discusses how authentication mechanisms can secure IoT networks.
It illuminates the workflow of authentication schemes customized for IoT and
their feasibility and cost analysis.
Chapter 7: Provable Security Models and Existing Protocols. Further
exploring the authentication-based security schemes, this chapter discusses
some provable security models and existing protocols that have used these
schemes, as they are crucial in ensuring that a protocol is secure.
Chapter 8: An Internet of Things (IoT)-Based Security Approach
Ensuring Robust Location Privacy for the Healthcare Environment. This
chapter discusses a simple low-cost authentication protocol, which ensures
strong location privacy by giving proof of indistinguishability and forward
secrecy. Further, it elaborates on the security strength of the protocol by a
game-based model.
Acknowledgments

Writing a book is a huge task and more rewarding than one could fathom. This
book entitled A Beginner’s Guide to Internet of Things Security is the result of
great contributions and encouragement from many people. None of this would
have been possible without their ideas and support, which has helped greatly
in enhancing the quality of this book. The authors would like to acknowledge
the incredible CRC Press/Taylor & Francis Group staff, particularly Randi
Cohen and her team, for their continuous assistance and motivation. This book
would not have been possible without their technical support. The authors are
eternally grateful to their families for their love and unconditional support at
all times. In the end, the authors are most thankful towards the Almighty who
is always helping us to overcome every obstacle not only for this work but also
throughout our lives.
September 2019
B. B. Gupta
Aakanksha Tewari

xiii
Authors

B. B. Gupta received a Ph.D. degree from the Indian Institute of Technology

Roorkee, India, in the area of information and cybersecurity. He has published
more than 200 research papers in international journals and conferences
of high repute, including IEEE, Elsevier, ACM, Springer, Wiley, Taylor &
Francis, Inderscience, etc. He has visited several countries, that is, Canada,
Japan, Malaysia, Australia, China, Hong-Kong, Italy, and Spain, to present his
research work. His biography was selected and published in the 30th edition
of Marquis Who’s Who in the World, 2012. Dr. Gupta also received the Young
Faculty Research Fellowship Award from the Ministry of Electronics and
Information Technology, Government of India, in 2018. He is also working as
a principal investigator of various R&D projects. He is serving as an associate
editor of IEEE Access and IEEE TII, and an executive editor of IJITCA and
Inderscience, respectively. At present, Dr. Gupta is working as an assistant
professor in the Department of Computer Engineering, National Institute of
Technology, Kurukshetra, India. His research interests include information
security, cybersecurity, mobile security, cloud computing, web security, intru-
sion detection, and phishing.

Aakanksha Tewari is a Ph.D. scholar in the Department of Computer

Engineering at the National Institute of Technology (NIT), Kurukshetra, India.
Her research interests include computer networks, information security, cloud
computing, phishing detection, Internet of Things, radio frequency identifi-
cation (RFID) authentication, and number theory and cryptography. She has
done her M. Tech. (Computer Engineering) from the Department of Computer
Engineering at the National Institute of Technology (NIT), Kurukshetra,
India. She has participated and won in various national workshops and poster
presentations. Currently, her research work is based on security and privacy in
IoT networks and mutual authentication of RFID tags.

xv
Evolution of
Internet of
Things (IoT)
1
History, Forecasts,
and Security
The Internet of Things (IoT) is a new paradigm which is transforming
everything from the consumer market, that is, household devices to industrial
applications at large scales. The Internet was always intended to bring pieces
of software, services, and people together on one platform at a global level [1].
Nowadays with the evolution of IoT, day-to-day objects have also become
a part of the Internet sending and receiving updates continuously from one
place to another. Therefore, we can define IoT as a network of interconnected
devices, which provide services and share data-connecting and performing
tasks in various applications [2].
The highly distributed and dynamic nature of IoT enables it to receive and
store data continuously in huge amounts. For example, in the field of health-
care, it has led to remote health monitoring, emergency notifications, etc. The
consumer electronics markets are also exploding with wearable gadgets [3].
Various domains such as wireless sensor networks (WSN), embedded systems,
and radio frequency identification (RFID) are found to be huge contributors
towards the growth of IoT.
As IoT is an evolving domain, it requires a lot of attention from the
researchers and the industry as well. Various standardization organizations
such as IEEE and IETF are also working towards developing standards and
protocols for IoT architecture. The sensors and actuators that are consumed in

1
2 A Beginner’s Guide to Internet of Things Security

the consumer electronics market are very low cost and small sized and have
high computational capabilities, which are the reasons for the growth of IoT as
automation is made so easy. Industries are also deploying IoT at large scales
such as in retail management and transportation [3,4].
The understructure for IoT is the Internet providing connectivity, which
also adds to the vulnerabilities in these networks. IoT networks face the same
security threats as the Internet; in addition, due to their limited capabilities and
simpler architecture, they are easier to compromise. At the physical layer, most
of the IoT devices use RFID, therefore ensuring that RFID tags can secure our
data from any threat to security and privacy [5].
Our aim is to perform an in-depth analysis of the recent advancements in
the field of security and privacy in IoT networks. Research needs to be done
in order to facilitate the integration of IoT with other technologies in a secure
environment. This can be accomplished by designing standard communi-
cation methodologies and standard protocols. It is a primary requirement
to make IoT power efficient and reliable. The use of proper authentication
mechanisms is one way to ensure security against various attacks and main-
tain the availability and integrity of data and services at all times for autho-
rized users.

1.1 EVOLUTION OF IoT

In order to grasp the concept of IoT, it is important that we dig a little deeper
towards the history of IoT and how it became what it is today. During 1982, a
group of programmers at Carnegie Mellon University were successful in con-
necting a soda-dispensing machine to the Internet, which was able to check
whether the machine has any cold soda cans left before going to purchase.
In 1990, John Romkey connected a toaster to the Internet through which he
was able to turn it on and off. These are the few earliest examples of automa-
tion before IoT. The year 1999 brought a big reform to consumer electronics
when the term “IoT” was coined by Kevin Ashton, director of Massachusetts
Institute of Technology s auto-ID center [6,7].
The first Internet-connected refrigerator was introduced in 2000. In
2004, the term “IoT” was used by magazines such as The Guardian. During
the same period, the RFID technology was also being deployed on a large
scale in various industries such as Walmart. During 2005, UN’s (United
Nations) international telecom union (ITU) stated that IoT is a new dimen-
sion of Information and Communication Technology (ICT), which will
 1 • Evolution of Internet of Things (IoT) 3

multiply the connections leading to a new dynamic network [8]. In 2007,

the first iPhone was out in the market, which changed the whole scenario of
communication between users. In 2010, the Chinese government declared
IoT to be a key technology and a major part of China’s long-term develop-
ment [9].
In 2011, Nest developed a Wi-Fi-enabled thermostat, which was capa-
ble of modifying the atmosphere by monitoring users’ habits. Platforms like
Arduino were made more advanced so that they simplify IoT-based simulation
for experimentation purposes [10]. In 2014, Amazon released Echo into the
smart home domain. The research firm Gartner added IoT to their hype cycle,
which is their graph that compares popular technologies. In 2016, Apple show-
cased HomeKit, which is a proprietary platform for supporting smart home
appliance software. During the same year, the first IoT-related malware called
Mirai was discovered, which collected default credentials through which it
attacked devices using them. In 2017, governments started taking IoT security
seriously as a result of several violations [11]. Various countries proposed a ban
for hard-coded passwords.
In the past few years, IoT devices and related technologies have gotten
a little cheaper and broadly accepted globally. In the long term, IoT is going
to be the new normal. However, Gartner reports claim that IoT is going to
hit a plateau in the coming years. Figure 1.1 shows a brief timeline for IoT
development.

FIGURE 1.1 Brief history of IoT and RFID technology.

4 A Beginner’s Guide to Internet of Things Security

1.2 STATISTICS AND FORECASTS

To secure IoT devices, we need to incorporate security between the network
connections and the software applications that run on those devices. It is
anticipated that in the next ten years, a shift will happen from consumer-based
IoT to industrial IoT. However, it is not sure whether the users and industry
are fully aware of the impact that IoT is going to have in the next few years.
According to Gartner’s report, by 2020, 95% of consumer electronics will
be enabled by IoT. As IoT networks are evolving into huge ecosystems, the
government needs to devise some cybersecurity plans that can recognize
threats and prevent them. Some of the recent trends that show the significance
of IoT are as follows [10]:

• The number of Internet-connected devices surpassed the number

of people on the planet in 2008, and it is estimated that by 2020,
a number of Internet-connected devices will be around 50 billion.
• IoT is having a huge economic impact on the consumer electronics
market; it is estimated that IoT technology will make about 19
trillion dollars of profit in the coming decade.
• It is estimated that by the end of 2019, about 2 billion home appli-
ances will be shipped and will make homes a part of the Internet
as well.
• Healthcare domain has adopted IoT at a large scale, and it is
estimated that by 2025, the total worth of IoT in the markets will be
around $6.2 trillion.
• In the past few years, it was estimated that about 10% of the total
number of cars are connected to the Internet, and by 2020, it will
reach 90%.
• A report by McKinsey & Company estimated that the total revenue
generated by IoT will range from $4 to $11 trillion by 2025.

The aforementioned trends show that the rapid growth IoT has been in the past
few years as well as its potential growth in the coming years. It is estimated that
the economy of IoT security will be around $28.90 billion in 2020. However,
in 2015, it was $6.89 billion. The growth in IoT requires a significant amount
of investment in its security as well. We need security mechanisms that can
protect the IoT network architecture as a whole [12,13].
The current rate of development in IoT technology will help us predict
its future. Currently, the number of connected IoT devices is around
5 billion, most of which are personal devices. Most of the devices are
 1 • Evolution of Internet of Things (IoT) 5

consumer based, and the largest increase in number is shown by automotive.

IoT has provided various business opportunities, such as smart homes and
automobiles with better decision-making skills. However, we also need to
address and resolve any security issues, which might prove to be a big threat
to IoT networks in the future. Hewlett-Packard (HP) reported that about
70% of connected IoT devices these days are vulnerable to various threats
due to their default settings. In a report by Harvard Business Review, it was
estimated that nearly 45% of IoT networks have to deal with data privacy-
related issues [14]. Figure 1.2 shows the rate of growth of IoT applications
in the next ten years.
Every IoT device needs a unique identification technique so that there is
no ambiguity in communication. The most popular identification technique
these days is RFID, which has several advantages over the barcode. The
RFID system consists of RFID tags, a reader, and a database or distributed
databases, which keep records of the objects or devices within the network.
RFID technology uses radio frequency mechanism for unique identification
of objects. Every RFID tag contains a chip that has some storage, space, and
sensing capability. In the last couple of years, significant growth in the use of
RFID technology with various applications has given rise to various security
threats such as a denial of service, man-in-the-middle, and desynchronization
attacks.
To promote IoT and make larger networks, we must consider their security
issues that affect the development of IoT networks and devices. Nowadays,
attackers are always one step ahead of existing security mechanisms; they can

FIGURE 1.2 Percentage growth of IoT applications in the next ten years.
(Source: DBS Bank.)
6 A Beginner’s Guide to Internet of Things Security

carry out attacks, which can disrupt services or transfer control to attackers at
remote locations. IoT devices are vulnerable to various attacks such as replay,
forgery, phishing, and denial of service.
In January 2015, Proofpoint revealed a spamming incident where the traf-
fic was routed through several devices across various countries. This global
attack had more than 750,000 malicious emails transferred from various
locations, which were sent from consumer devices such as home routers,
televisions, media and centers. Later on, it was discovered that at least one
refrigerator was also involved in this attack. It was observed that the incident
started from December 23, 2014, and continued till January 6, 2014, where
the malicious email traffic was sent thrice a day with a burst size of 100,000
emails each. The targets were both enterprises and individuals. The primary
cause of these attacks was a lack of caution and awareness. The attackers
exploited misconfigurations and the continued use of default passwords, which
made the devices vulnerable and easy to control [13–15].
Another wave of IoT attacks occurred in 2016, which mainly involved
devices such as IP cameras and routers. The compromised devices were turned
into botnets. These botnets were used collectively to launch attacks on a large
scale. The cybercriminals are becoming more and more advanced. In an attack
in 2018, a device that controlled around 15 CCTV cameras was attacked.
However, in due time, the security operator detected the malicious activity and
issued a warning that this might infect many more CCTV models. Another
cause of these flaws is a lack of complete patching of IoT devices [16].
The IoT-based companies sometimes ignore security, or they are not expe-
rienced enough to realize the gravity of the situation (Figures 1.3 and 1.4).
Lack of consumer awareness is also a very big cause behind these successful
attacks. Consumers are often excited about the features and functions these
devices provide so that they do not pay attention to security updates and setting
strong passwords.

FIGURE 1.3 Growth in IoT consumer devices. (Source: Gartner, Inc.)

 1 • Evolution of Internet of Things (IoT) 7

FIGURE 1.4 Top five IoT-based industries from 2017 to 2022.

The attacks are proof of the lack of security schemes in IoT networks,
which need to be taken very seriously. In the current scenario, IoT gadgets are
vulnerable to various attacks that may disrupt their services and transfer the
control to some remote attacker. The attacker can impersonate a server and
make the devices decrease their message-sending rates or increase the rate of
their resource consumption and bandwidth. The attacker might also imper-
sonate any tag and send multiple fake requests to engage servers’ resources
eventually leading to DoS.
IoT devices are also needed to be protected from a wide range of threats,
which include malware infections, disruption of services, and information
theft. The attacker could easily gain in controlling the devices that are a
part of smart home, automobiles, or personal fitness and disease-monitoring
gadgets. An attacker can simply hack the software in a person’s smart watch
or an insulin pump to track their location, or they might gain access to
the information systems present in the automobiles and use them to carry
malicious activities.
The most serious threat IoT devices face is malware such as Trojans,
viruses, and worms that can disable IoT systems. Besides, this work also needs
to be done to ensure that updates received by IoT devices are secure along with
secure default settings. There is still a huge room for improvement when it
comes to securing the IoT architecture.
8 A Beginner’s Guide to Internet of Things Security

1.3 FUNDAMENTALS OF IoT SECURITY

To implement IoT in real time, we need to integrate it with other existing
technologies. However, due to the lack of standards, IoT does not have a
fixed architecture yet. Various groups are working on developing protocols
and standard modular or layered IoT architecture. The existing idea of IoT
architecture has three layers (which in some cases are further subdivided):
perception layer, network layer, and application layer. Each layer has its own
security issues that need to be resolved to facilitate its growth. We need
security mechanisms at every layer of IoT to prevent any security and privacy
threats. In this section, we briefly discuss the security and system requirements
of IoT networks.

1.3.1 Security at Different Layers

Each layer of IoT architecture has some security- and privacy-related issues,
which we are required to be addressed in order to secure IoT applications. In
fact, all such issues should be taken into account and remedied at the very
initial stage of system design. The existing IoT architecture raises the require-
ment of proper security checks during the beginning and at regular intervals
for an IoT network as a whole. At the network layer, threats to confidentiality,
integrity, and availability should be dealt with. Attacks such as eavesdropping,
man-in-the-middle, DoS/DDoS, and network intrusion are common threats at
this layer. The application layer needs different security standards as per the
application requirements, which makes the task of securing the application
hard and complicated.

1.3.2 System Requirements of the IoT System

In order to ensure the security of an IoT system, we can ensure the basic
security requirements at the RFID level. These are considered to be basic
criteria that must be fulfilled by the protocol to protect security attacks on a
system [17].

• Mutual authentication: It is an essential requirement that the

server should authenticate the tag to be legitimate and tag should
also authenticate the server before they exchange any important
information.
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been exceeded and bone cohesion overcome. Children particularly
suffer from depression without fracture, which formerly was never
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the Bones, Chapter XXXII), and among the insane may be found so
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probably yield more or less before a fracture results. Much may be
learned from such experiments as those of Félizet, who filled skulls
with paraffin and dropped them from varying heights, and then
divided the bone, to note in numerous instances that, although the
bone had not been fractured, it had yielded at the point of impact to a
degree producing a marked depression in the paraffin beneath. After
various injuries, especially to the top of the head, the shape of the
skull may be altered and its diameters affected. Many fractures,
then, are the result of a bursting force, which may be shown by the
fact that hair has been found included within apparently closed
fissures, and even on the dura. Moreover, particles of bullets have
been found within the skull without any visible opening through which
they could have entered, showing that the bone has yielded under
impact for a fraction of a second. In certain injuries to the head, as
when a man is struck to the ground, there is injury at two points
nearly opposite.
Fractures of the skull, especially of the vertex, possess surgical
interest mainly as they are accompanied by more or less evidence of
intracranial complications. So long as there is no evidence of
hemorrhage or laceration within they are ordinarily regarded as a
feature of the external wound with which they are usually found, and
unless there be comminution, depression, or some other good
reason for operating they are covered over as the wound is closed
and are left to the natural process of repair by formation of minute
callus or by the ossification of granulation tissue.
It is unfair to contrast the results of the surgery of today with those
of the pre-antiseptic era. Rules then enforced are now abrogated.
One respect in which we violate precedent is in our disregard of the
periosteum or pericranium. This is sacrificed without hesitation when
found to be infected or torn or lacerated beyond repair. A flap of
scalp will adhere as readily to denuded bone as to periosteum, and
skin grafts can be applied and will adhere to this same bone—if not
upon the first day, a little later when granulations have appeared. In
the various plastic operations necessitated about the head we may
also transplant flaps upon otherwise uncovered bone without the
slightest hesitation. Fractures should be treated mainly in
accordance with intracranial complications, or through what can be
seen either through the wound or through an opening intentionally
made under antiseptic precautions for purposes of exploration. It is
conceded to be better policy to remove fragments of bone whose
vitality is uncertain and to sacrifice tissue injured or lacerated to such
an extent that sloughing would probably follow or be so exposed as
to have become infected.
Diagnosis of Fractures of the Vertex.—In the absence of an
open wound, and unless
incision be made, diagnosis of fractures of the vertex is necessarily
conjectural. In the presence of a wound diagnosis is usually easy. In
case of a small puncture it will be better to enlarge it sufficiently to
permit the introduction at least of the finger. With the finger and the
eye we seek to detect differences in level, depressions, fissures, etc.
Mistakes arise from the formation of an exudate or a clot, by which a
depression of the soft parts may be regarded as depression of the
bone. Error occasionally arises from the existence of previous
atrophy of the bone or any congenital defects in ossification of the
skull; also in the skulls of syphilitic patients where disappearance of
a gumma is often followed by absorption of the underlying bone. In
case of doubt exploratory incisions should be made under aseptic
precautions. These should not be made, however, unless the
attendant is ready—i. e., has the facilities immediately at hand—for
carrying out any further operative procedure that may be necessary,
as elevation of fragments, removal of foreign bodies, etc. Error also
may arise from mistaking for fracture a deceptive circular effusion of
blood which frequently occurs beneath the scalp after injury. Areas of
bloody infiltration often have abrupt margins which are calculated to
easily deceive. In children, more especially, we often have a
circumscribed bloody tumor which may contain cerebrospinal fluid
rather than pure blood. In some of these cases after exploration
there will be found material resembling brain matter, which, however,
is not always such, although real brain substance may escape,
caused by rupture of the overlying membranes. Should it be noted
that the fluid used for irrigating and cleansing such a wound begins
to pulsate, it will imply connection with the cranial cavity, and,
obviously, fracture. A suture should not be mistaken for a line of
fracture. This mistake is more easy when Wormian bones are
present. Blood may be wiped away from a suture line, but not from
that indicating fracture. It is not often possible to diagnosticate an
isolated fracture of the inner table. It happened, however, once to
Stromeyer to notice that so soon as an injured patient assumed the
horizontal position he began to vomit, and that nausea subsided
when he was placed in the upright position. On autopsy it was found
that there had occurred a depressed splintering of the inner table
with perforation of the dura—less irritation was produced in the
upright position than when the patient was lying down, which
accounted for his vomiting when in the horizontal posture. When a
comminution has been produced it is always of prognostic value if an
unbroken dura be found. Prolapse of brain substance is a serious
complication. Escape of cerebrospinal fluid is relatively rare. Rising
temperature after these injuries is always a sign of danger.
Treatment.—Treatment comprises attention to the local injury and
the suitable dealing with the condition of the brain
within when injured. The treatment of simple fractures is expectant.
In the absence of indication for operation it should be simple, and
should consist of physiological rest, aseptic dressings, ice
applications to the head, the administration of such laxatives,
diuretics, antacids, etc., as may be necessary to favor free excretion
and to guard against autointoxication. Whenever there is reason to
suspect a depression, exploratory incision should be made. Actual
depression, whether the fracture be compound or not, requires
operation. This course is justified by the numerous instances in
which later consequences have been noted, such as traumatic
epilepsy, insanity, etc.
 Compound injuries should always be operated upon in some
manner, which includes the removal of loosened splinters, the
elevation of depressed bone, the removal of foreign matter, the
checking of hemorrhage, the excision of bruised and lacerated
tissue, and the proper closure of the wound, with or without
drainage.
In serious and lacerated cases it is inadvisable to close the wound
with the view of attempting primary union. It should be packed with
gauze and temporarily closed with secondary sutures. These
measures should be seconded by physiological rest (quietude of the
head, which may even be enforced by the posterior plaster-of-Paris
splint to the head and neck), attention to the primæ viæ, the
avoidance of transportation, the prevention of auto-intoxication, etc.
The surgeon should use discrimination as to the amount of bone to
be removed, the wisdom of opening the dura when not lacerated, of
examination of the brain with the exploring needle, the matter of
drainage, and the time during which it shall remain. With reference to
all these matters exact rules cannot be given. When drainage is
made in recent cases it is usually sufficient to drain the scalp wound.
Only in cases where there is probability of meningeal infection is it
advisable to attempt to drain the dural cavity. This is better
accomplished with gauze, catgut, or folded rubber tissue than with
drainage tubes.
Skull fractures where the injury is limited to a small area are
treated according to a bolder method than was in vogue a number of
years ago. There should be careful and judicious operating in every
case where distinct depression can be made out, as well as in every
case where indications point to injury of parts within the bone. The
statistics of trephining in the pre-antiseptic era are valueless as
arguments in this consideration. If done according to aseptic
precautions, and if good surgical judgment be used in every respect,
the operation is per se almost devoid of mortality and should not be
regarded as a last resort, but rather in such cases as a first one. I
have seen so many instances of later untoward consequences
resulting from delay, which corroborate the experience of others, that
I would not be misunderstood in this matter. My advice might
perhaps be summed up in the following words: Where there are no
brain symptoms and no skull symptoms, in fractures of the vertex, let
the case alone; when either of these are present, especially the
former, it will always be advisable to operate.

Fractures of the Base of the Skull.

In the majority of these fractures the violence is applied at some
more or less distant point, and, by transmission through the arch-like
structure of the skull, expends itself in fissuring or comminuting the
base. The most frequent location of the indirect injury is upon the
convexity. The mechanism of these fractures has been a problem for
many centuries, but has been cleared up mainly within the past three
decades. Félizet has shown, for instance, how the handle of a
hammer may be forced into its head by striking it in either one of two
different ways, and has compared the mechanism of basal fractures
to this fact. The secret of these fractures probably resides in the
elasticity of the skull, which varies within wide limits in different
individuals, and which breaks, as do the ribs and the pelvis, at points
more or less distant from that at which the injury occurred. Were the
skull everywhere equally thick and elastic, there would be much less
variation in these fractures, but lacerations frequently extend
between the most resistant parts; and when violence is applied upon
the forehead we find that the resulting fissure extends between the
crista and the wings of the sphenoid, upon the same side, in its
course toward the base; that when the lateral region of the skull is
injured the fissure extends between the sphenoidal wings and the
occipital bone; and that when the occipital region receives the first
injury the fracture lies between the pyramid and the occipital crests.
The analogy between fractures of the skull and cracks made in
nutshells (cocoanuts, etc.) when struck with a hammer is too self-
evident to be disregarded. Many years since the French introduced
the term fracture by contre-coup (counter-stroke)—a practical
admission of the occurrence of fracture at a point more or less
opposite to that struck.
 Fig. 375 Fig. 376

Fracture of base of skull. (Bruns.) Fracture of base by fall on vertex. Both

condyles broken off and driven in. Vertex
was fissured.

There is, however, no certainty about these fractures. Extensive

fissures of the vertex are almost always extended to the base of the
skull, while the reverse is seldom true. There are doubtless also
many cases in which a bursting force compromises the bone rather
than mere radiation of unexpended violence; but so long as skulls
conform to no fixed mathematical figures nor proportions, and are
composed of bones varying in shape, density, and strength, it will be
impossible to formulate any laws which are sufficiently
comprehensive to be satisfactory. Fractures in the posterior fossa
occur most often through violence applied posteriorly and from
below. There is a ring form of basal fracture produced mainly by the
impact of the vertebral column, as when an individual falls upon his
head the weight of the body forcing the cranial base in upon the
brain.
PLATE XLII
 Fractures of the Base of the Skull. Illustrative lines
of fissure or fracture are printed in red.

Fractures of the anterior fossa may involve the roof of the orbit;
even facial bones may participate in the injury. These considerations
are not without importance, for if a patient presents symptoms of
injury of the petrous bone, and if these be accompanied by injury to
the lateral region of the skull, we are in a position to make a
diagnosis of fracture of the middle fossa. (See Plate XLII, and Figs.
375 and 376.)
By all means the majority of basal fractures are mere fissures
which open and close instantly upon their production—close so
quickly, in fact, as scarcely even to include blood between the
broken bony surfaces.
Prognosis.—The majority of basal fractures are fatal, either
because of injuries to the brain, or of hemorrhage or
violence along the nerve trunks, or from infection extending along
the newly opened paths. Other things being equal, the longer the
fissure the greater the danger, particularly so when it takes its origin
in the vertex, and because of greater ease of infection. Air infection
may occur in any basal fracture by fissures extending into the
various air-containing cavities—nose, ears, sinuses, etc. They are
then practically compound, though invisibly so. The general
prognosis will depend, first, upon the injury to the cranial contents;
second, upon the possibility of infection. Statistics are absolutely
unreliable, although always possessing interest. Numerous museum
specimens show the perfection with which bony repair may occur
and the admirable way in which compensation is afforded for
defects. Suppuration after basal fractures is mainly that due to
purulent basal meningitis, in which case the brain symptoms
dominate in the clinical picture, while the appearance of a single
drop of pus in the ear or upon the surface is of the greatest
significance. The conversion of a serous outflow (e. g., from the ear)
into purulent fluid is also pathognomonic. Various paralyses,
principally of the cranial nerves, may follow this injury and prove
temporary or permanent. Diagnosis is often made by a study of
these special nerve lesions.
Diagnosis.—The most significant diagnostic features are:
1. Spread of blood from the point of fracture until it
appears as an ecchymosis at certain points beneath the skin: This
will occur early in some cases and late in others. It may appear
beneath the skin or beneath the conjunctiva or other mucous
membranes, even in the pharynx. Occurring about the mastoid, it
implies fracture of the middle or posterior fossa; about the eyelids, of
the anterior fossa. Beneath the bulbar conjunctiva it means
extravasation along the optic sheath, probably from within the dura.
In fractures of the posterior fossa it will come to the surface of the
neck, but only after two or three days. The ecchymoses about the
lids or orbits occurring after two or three days mean more than those
occurring within these days, for the latter may be caused by external
bruising. The globe of the eye may be pushed forward by blood
accumulating within the orbit. Exophthalmos thus produced is
therefore most significant, though not common.
 2. Escape of serous fluid, blood, or brain substance from the
cavities of the skull: Hemorrhages from this cause occur most often
from the ear, the petrous bone being tunnelled with various canals
through which blood may thus escape. The surgeon should,
however, assure himself in every instance that the blood is escaping
from the ear and not from some trifling wound of the external soft
parts, the soft walls of the meatus, or the tympanum. Profuse
hemorrhage can probably only come from a basal fracture. Escape
of serous fluid is usually noted as a sequel to hemorrhage, although
it may begin almost immediately after an injury. Rarely more than
twenty-four hours elapse before it begins to flow. The quantity of fluid
discharged is sometimes considerable. It may occur in frequent
drops or during expulsive efforts, like coughing, or may ooze in such
a way as to be insensibly collected by the absorbent dressings. In
average cases the amount in twenty-four hours is from 100 Cc. to
200 Cc.; 800 Cc. have been noted in occasional instances, and in a
very few still more. Occasionally violent expiration will increase the
flow.
In some cases the fluid may escape through the Eustachian tube
into the pharynx, whence it may escape by the nostrils or be
swallowed.
The escape of brain substance is rarely noted, but obviously
implies such serious injury as to make the prognosis of the worst.
3. Disturbance of function along particular cranial nerves, paralysis
of which is often produced by fractures of the base, especially those
involving the foramen of exit of the nerve involved: The nerve may
be lacerated or injured in such case by the fragment of bone.
In addition to these distinctive features there will be in the majority
of instances brain symptoms, either of contusion or compression,
varying in severity within all possible limits, but adding their weight to
the value of the testimony.
Other and unusual signs of basal fracture may occur, such as
communication between the cavities of the petrous bone and the
mastoid cells, leading to the formation of pneumatocele (see page
545), or emphysema of the overlying soft parts, observed mostly
about the orbits, when the nasal cavity is involved.
Treatment.
—The treatment of basal fractures is mainly symptomatic. The first
effort should be to make antiseptic all those parts of the skull
involved, which means to shave the scalp; to thoroughly cleanse and
irrigate the external ear and the auditory meatus, using a head mirror
and ear speculum for this purpose; to tampon the meatus with
antiseptic cotton; to provide a copious absorbent dressing for such
fluid as may escape and to change this frequently; to cleanse the
nasal cavity as well as the conjunctival sac, for all of which the
peroxide of hydrogen is serviceable. All of this should be done
promptly, while at the same time studying the patient for evidence of
brain injury or of involvement of special nerves. By the time these
measures are thoroughly performed a decision as to the necessity
for immediate operation should have been reached. Evidence of
brain compression wanting, and in the absence of external or
compound injury the patient may be left at rest, with cold applications
to the head and active purgation. In many of these instances benefit
follows the application of a number of leeches to the mastoid region
and to the occiput. Operation is necessary later only when brain
symptoms supervene, these consisting of evidences of compression,
either from blood or from pus, as compression from other causes
should have been acting at the time of the first examination, and
should have been recognized at that time. When direct fractures are
evident the possibility of the entrance of foreign bodies should be
also remembered. Thus penetrating fractures of the base have
occurred through the orbit as the result of accident or assault, and
such weapons or implements as foils, ramrods, drumsticks, canes,
umbrella points, etc., have been known not only to penetrate into the
brain, but perhaps to leave some portion of their substance—e. g., a
foil tip or an umbrella tip—within the cranium after their withdrawal.
Separation of sutures, known also as diastasis of the same, is the
occasional result of injury instead of, or complicated with, fissures or
other fractures. It is the result of violence, and is virtually a specific
form of fracture, from which it differs in no essential particular.
Diastasis can only take place along lines of previous suture, but it is
possible that Wormian bones may be thus loosened. Sutures thus
separated ordinarily heal by fibrous repair rather than osseous union.
Diagnosis is possible only as they are exposed to view, although
displacement in the middle line or along known suture lines may be
regarded as diastasis. The treatment differs in no respect from that
of other fractures.
Injuries to the frontal sinuses occasionally complicate fractures of
the skull. These sinuses vary in different individuals, are rarely truly
symmetrical, and are not found in the young. They connect with the
nose in such a way that emphysema of the frontal region is quite
possible, while air may be blown beneath the periosteum or may
communicate with the interior of the cranium. In wounds of the
frontal region the sinuses are occasionally opened—a fact of
importance, for infection of the Schneiderian membrane may occur
and endanger life, mainly because of the retention of infectious
products within its cavities. Moreover, by such wounds the ethmoid
may also be injured. Pus which escapes from these sinuses and
from the ethmoidal cells is usually thin and bad-smelling. Long
continuation of suppuration after such injuries probably means
necrosis and formation of sequestra.

INJURIES TO THE BRAIN AND ITS ADNEXA.

By better acquaintance with certain portions of the brain whose
function is now generally recognized and described, as well as with
the more exact knowledge regarding the entire encephalon, the
outcome of many recent studies, the teaching of the past in regard to
the nature of various brain lesions has been essentially modified.
Especially is this true in regard to the distinction formerly
emphasized as between concussion and compression. In discussing
brain injuries we should, first of all, distinguish between traumatic
disturbances of the entire endocranium and localized injuries to the
brain or particular vessels and nerves entering into its composition.
In regard to the first, it is possible that the entire blood or lymphatic
circulation within the cranium may be affected in such a way as to
influence its nutrition and function, by which means activity and
function are mildly or seriously perverted. The immediate effect of
severe injury to any part of the body is reflex vasomotor spasm,
which constitutes the essential feature of the condition known
everywhere as shock. It is this condition, with its marked local
expressions, which was formerly known as concussion of the brain.
When studied upon its merits it is found to be indistinguishable from
shock produced by injuries to other parts. The condition for so many
years taught and recognized as concussion is but shock following
injury to the head. This makes no further demands upon the question
of pathology than those prompted by any traumatic disturbance.
Through the mechanism of the cerebrospinal fluid rapid alterations
of pressure and of the volume of the brain are produced. There is an
easy path between the inelastic cranial cavity and the exceedingly
elastic and accommodating spinal canal, which latter serves as a
reservoir for the fluid which may be pressed out of the cranium when
brain pressure is increased. While the subdural and subarachnoid
spaces are each of them absolutely closed sacs and do not
communicate one with the other, there is ample accommodation
within each to permit a constant equilibrium of pressure under
ordinary circumstances, as between the spinal canal and the cranial
cavity. The brain expands in volume with every systole of the heart,
while with every diastole it contracts. Its size is, moreover, modified
by the motions of respiration. Under these extremely accommodating
conditions it is scarcely credible that external injuries which leave no
internal evidences of violence should do anything more than disturb
the equilibrium of fluid distribution.

“CONCUSSION” OF THE BRAIN.

We inherit this term concussion from the earlier masters of our art,
by whom, however, it was used in a much broader sense than of
late. Its modern significance was given to it by Boirel, who made it
apply to a group of cerebral symptoms the result of injuries not
accompanied by fracture or perceptible laceration of vessels,
symptoms varying in intensity and duration.
Our present position is practically this: The possibility of pure
concussion of the brain—i. e., disturbance of brain function without
gross mechanical lesions—is admitted, but its general frequency is
denied. When present it should either pass away quickly, the
condition being equivalent to that called “stunning,” or, if it assume
distinct form, its signs and symptoms are indistinguishable from
those of shock, consisting essentially of rapid and feeble pulse, quick
and shallow respiration, pallor of the skin, copious perspiration,
complete or partial unconsciousness, muscle incoördination, with
lack of sphincter control, occasional vomiting, the pupils usually
reacting in light.
Treatment.—The treatment for this condition is essentially that for
shock, and whatever may be called for in the way of
attention to injuries about the head—e. g., sewing up a scalp wound,
etc. (See Chapter XVIII, on Blood Pressure.)

CONTUSION OF THE BRAIN.

The condition of shock (cerebral concussion), when of pure type,
passes away with reasonable promptness, especially when aided by
surgical treatment. Anything which persists in the way of muscle
paralysis, disturbance of function of nerves of special sense, or other
sign of importance, indicates something more than mere vibratory
disturbance: it implies mechanical lesion which could be perceived
by the eye were the parts exposed, and constitutes the condition
known as contusion. This implies the existence of trifling exudates,
or hemorrhages, which lead not only to absorption but even
cicatrization. Contusion pure and simple differs from ordinary
laceration as a contusion elsewhere may differ from a wound. It
cannot be separated, however, from conditions in which there are
minute separations of continuity and actual lacerations. It may be
divided into three postmortem forms—general hyperemia, with or
without edema; punctate or miliary hemorrhages; and thrombosis of
minute vessels, which may occur separately or together. Moreover,
there may exist similar lesions in the meninges, constituting
meningeal contusion. Ordinarily minute vessels of the pia are
ruptured and blood is effused in small and thin patches over various
parts of the brain. The so-called compression apoplexies of certain
authors are inseparable from the conditions above described. Such
minute blood clots are only to be distinguished upon very careful
sectioning of the brain, and are found most often in the region of the
medulla and along the floor of the fourth ventricle. They are probably
caused by the forcing into the fourth from the lateral ventricles of the
fluid contained in the latter.
Symptoms.—When the ordinary symptoms of shock, which follow
all severe injuries to the head, especially when the
deep lesions are not too severe, fail to disappear in a short time
under proper treatment, and when new and irregular symptoms are
superadded to those of shock alone, it is reasonable to suppose that
the intracranial condition is one of contusion rather than of shock.
When mental agitation changes into delirium, when the rapid, feeble
pulse becomes stronger and slower, the respiration deeper, the limbs
move in incoördinate ways, the speech disturbed from muscle
incoördination, the patient selects wrong words, or when the mental
condition becomes more serious and stupor or coma take place of
the delirium, while external irritants have less and less effect, and
when the pupils gradually enlarge while failing to respond to light, it
may be said that the condition of contusion is making itself apparent.
If along with muscle uncertainty there is also muscle spasm or
rigidity, with fixation of the fingers in the athetoid position, the
evidence to this effect is increasing. If with all this the thermometer
fails to show that an active inflammatory condition—i. e., meningitis
—is prevailing the diagnosis may be regarded as certain. Error may
possibly arise when there are evidences of alcoholism. Coma
following head injury ought not to be ascribed to the alcoholic
condition except by the strictest process of exclusion. Temperature
alone will be of the greatest service in this direction, since in
alcoholism it is usually subnormal. In apoplexy and non-traumatic
hemorrhages it is also usually subnormal at the commencement of
the attack, rising to normal, and remaining there if the patient
recover, but continuing to rise in cases where the prognosis is bad.
Treatment.—The treatment of brain contusion should be managed
largely in response to special symptoms. Physiological
rest, attention to scalp wounds, fractures, etc., shaving of the scalp,
application of ice to the head, with such stimulation to the heart as
may be necessary in extreme cases by subcutaneous administration
of adrenalin, atropine, etc., by local fomentations over the
epigastrium, or by immersion in a hot bath when surroundings permit
it—these in a general way constitute most of the methods of
treatment in contusion. When only symptoms of diffuse and minute
lacerations can be recognized the use of the trephine is
impracticable except when indicated by some external marking—
i. e., compound fracture or the like. When localizing symptoms are
present the trephine is, of course, indicated. When the skull injury is
recognized as a basal fracture, venesection or the application of
leeches behind the ears will be most serviceable. In every such case
there is the greatest necessity for regulating the excretions and
preventing auto-intoxication. For this purpose diuretics and laxatives
should be used, often in conjunction with intestinal antiseptics. The
catheter should be employed whenever indicated by the condition of
the bladder, which should be carefully watched. As the days go by,
and patients lie more or less helpless and inert, the greatest care
should be exercised for the prevention of bed-sores. When mental
inertness, muscle rigidity, etc., fail to disappear, potassium iodide
should be used internally.

BRAIN PRESSURE OR COMPRESSION.

That the cranial contents—brain, blood, lymph, and cerebrospinal
fluid—completely fill the cranial cavity has been already amply
shown, as well as that there is no room for anything in the shape of a
foreign body without seriously affecting the equilibrium between the
brain and the contents of the spinal canal. When, however, any
foreign substance exerts pressure upon the brain the results are
invariably the same, be this substance what it may, and compression
signs are always the same, no matter what the compressing cause.
Reduction in capacity of the cranial cavity (i. e., compression) may
be produced—
PLATE XLIII
FIG. 1.

FIG. 2.
 Fig. 1. Compound Fracture of Cranium, with
Depression; Fracture of Bones of Face; Extradural
Clot from Rupture of Middle Meningeal Artery.
Fig. 2. Horizontal Section of same, showing
Depressed Fracture of Bone. (Anger.)
C, extradural clot; D, laceration of brain substance, with extensive intracerebral
clot; F, same condition produced by contrecoup. Punctate hemorrhages and
minute lacerations at numerous points, characteristic of contusion of the brain.

1. By reducing the dimensions of its enclosing walls (e. g.,

depressed fractures or by direct pressure);
2. By increase in the quantity of cerebrospinal fluid or of the
volume of the brain, which latter may be produced by edema, by
serous exudate, or by actual hypertrophy;
3. By foreign bodies, which may enter the skull from without;
4. By pathological conditions—collections of blood or pus, tumors,
etc., which may be produced either from the brain substance, its
containing bone or membranes, or its vessels.
In every one of these conditions the size and tension of the brain
are affected. The cerebrospinal fluid is mainly involved in acute not
in chronic conditions. A slow reduction of the diameters of the skull
produces such slow alterations of pressure as to cause a minimum
of disturbance. So far as compression from traumatic influences is
concerned we distinguish mainly between compression—
1. By extravasation of blood (see Plate XLIII);
2. By fractures of the skull with depression, or by foreign bodies
penetrating from without;
3. By products of acute infectious inflammation due to septic
infection from without.
The result common to all of these is increase of intracranial
tension, and its consequence is a less rapid flow of blood and an
altered blood supply to the brain and its membranes.
Experiment has established that in compression of the brain
cerebrospinal fluid is forced by pressure into the spinal canal, whose
membranes are more elastic, and which thus help to accommodate
it; it has been also established that compression of the brain by one-
sixth of its volume, by any material, is fatal, and that much less is at
least serious. That fractures with depression produce sometimes
serious, at other times trifling, symptoms is due to the varying
accommodation of the spinal canal. Both experiment and
observation seem to confirm the view that consciousness pertains to
the cortex as a whole, and that unconsciousness is an inhibitory or
paralytic condition which is produced in compression.
Temperature is a matter of great importance in studying
compression and foretelling its consequences. Elevation of
temperature is an early, continuous, and constant symptom in these
cases. If temperature be subnormal and subsequently rise,
prognosis is bad. Variations of temperature are more reliable guides
than conditions of consciousness. As Phelps has remarked, in no
condition except sunstroke is temperature so uniformly high as in
cases of serious encephalic lesions.
Symptoms.—As indicated above, the symptoms and signs of
compression are practically identical, no matter what
the compressing cause. When this cause acts instantly there is no
time afforded for differentiation, but when it occurs slowly we note
the following symptoms, and about in the order here presented:
Irritability or restlessness; visceral disturbances; pain; intense
cephalalgia; congestion of the face; narrow pupils; augmented pulse,
often seen in the carotids. If compression occur more rapidly, torpor
quickly succeeds erethism, after which patients vomit, have
convulsions or at least convulsive motions, speech is disturbed, and
stupor comes on, from which they neither awake nor can be
awakened until the compression is relieved. All of these indications
refer to involvement of the cortex, which is generally regarded as the
seat of consciousness as well as of projection and imagination.
During the night, of the senses produced by pressure upon the
cortex only the automatic basal apparatus and that of the spinal cord
continue in more or less disturbed operation. Of all the general
functions consciousness vanishes first and returns among the last.
When intracranial pressure has reached a certain point, epileptiform
convulsions result, varying in intensity, affecting all the limbs, and
terminating perhaps with rigidity. These form an expression of high
pressure. Similar convulsions occur in various head wounds,
explanation for which is the result of pressure, which, though not
extensive, may produce alteration in the circulation, with its
disastrous consequences. The later and constant evidences of
compression, and those which in aggravated cases supervene at
once, are reduction of pulse rate, due to the action of the
pneumogastric, which suffers first an irritation and later a paralysis.
The pulse becomes not only slackened but full; the respiration rate is
correspondingly reduced, so that breathing during coma is deep,
slow, and often stertorous. This feature of stertor is an expression of
paralysis of the palatal and pharyngeal muscles, which flap, as it
were, in the air current. Vomiting, which may occur before brain
tension has risen high, does not occur in the most serious cases.
Coma is absolute.