242. Injuries of the head affecting the brain are difficult of
distinction, doubtful in their character, treacherous in their course,
and for the most part fatal in their results. The symptoms which
appear especially to indicate one kind of accident are frequently met
with in another. It may even be said that there is no one symptom
which is presumed to demonstrate a particular lesion of the brain,
which has not been shown to have taken place in another of a different
kind. Examination after death has often proved the presence of a most
serious injury the existence of which had not even been suspected;
and death has often ensued immediately, or shortly after the most
marked and alarming symptoms, without any adequate cause for the event
being discovered on dissection. One man shall lose a considerable
portion of his brain without its being productive at the moment of
the slightest apparent functional inconvenience; while another shall
fall, and shortly die without an effort at recovery, in spite of any
treatment which may be bestowed upon him, after a very much slighter
injury inflicted apparently on the same part. During the war with the
United States, in 1814, a soldier in Canada was struck by a ball which
lodged in the posterior part of the side of the head; the wound healed,
and the man returned to his duty. Twelve months afterward, having got
drunk, he fell in the streets of Montreal, and died. The ball was found
lying on the corpus callosum, where it had made a small hole or sac for
itself. After the battle of Waterloo, I recommended, in the case of a
soldier similarly wounded, that nothing should be done unless symptoms
arose demanding the use of the trephine; as none occurred, and the
wound healed, the man was sent home to Colchester, where he got drunk,
and fell dead in the marketplace. The ball was lodged deeply in a cyst
in the posterior lobe of the brain. Persons rarely live with a foreign
body lodged in the anterior lobe of the brain, although many recover
with the loss of a portion of the brain at that part. An injury of
apparently equal extent is more dangerous on the forehead than on the
side or middle of the head, and much less so on the back part than on
the side. A fracture of the vertex is of infinitely less importance
than one at the base of the cranium, which, although not necessarily
fatal, is always attended with the utmost danger. The treatment of
these several injuries (although they may be at first sight apparently
similar) cannot, and must not be alike in all--a fact which should
always be borne in mind in their management. In civil life, both in
hospitals and among private persons, injuries of the base of the
cranium are most frequently met with, because they are generally the
consequence of falls; while in military life injuries of the base of
the skull are rare, and those of other parts are common. The practice
of the military surgeon, with respect to injuries of the cranium and
its contents, is therefore more successful, all things considered,
than that of the surgeon in civil life, and particularly in a great
metropolis; this may perhaps account for some of the discrepancies in
opinion which have existed between them.
243. Many physiologists have thought they could indicate the part of
the brain injured from the symptoms which followed, and there are
some which do not admit of dispute as to their cause; but there are
very many which at present do not admit of being distinctly traced
to their source. Birds, small quadrupeds, fishes, and reptiles will
live for some weeks after nearly all the contents of the skull have
been removed. Sensation, volition, memory, judgment, sight, hearing,
and all other sensations are lost by the removal of the cerebral
hemispheres. The mobility of the iris is destroyed, not by the removal
of the hemispheres, but of the corpora quadrigemina. If the cerebellum
be cut away, a bird can no longer jump, walk, or retain its natural
position, but it can move and live. When the medulla oblongata, or
medulla spinalis, or the nerves of these parts, have been divided,
muscular contraction ceases, and all power of movement is lost. Life
is destroyed because respiration ceases when the medulla oblongata
is divided at or immediately below the origin of the eighth pair of
nerves. The removal of any one of these nervous parts in the lower
animals only weakens the powers of those which remain. In man it
destroys them, and life is extinguished.
244. Respiration consists of four movements--1, the opening of the
mouth and dilatation of the nostrils; 2, the opening of the glottis;
3, the elevation of the ribs; 4, the contraction of the diaphragm. The
division of the dorsal spinal marrow, below the origin of the phrenic
nerve, paralyzes the movement of the ribs; above the phrenic nerves it
paralyzes the diaphragm, and respiration ceases; the yawning or opening
of the mouth and glottis alone remain. On dividing the point of origin
of the par vagum, the movements of the glottis cease. On slicing the
upper part of the medulla oblongata instead of the lower, from before
backward, the opening or yawning of the mouth ceases; another slice,
and the dilatations of the nose are arrested, and the inspiratory
movements of the trunk alone remain.
While the power of motion in each part seems thus to be dependent on
isolated points of the medulla oblongata and the medulla spinalis, an
indirect or connecting influence is admitted to take place between them
and the remaining parts of the brain; and whatever may be its nature
or extent in animals, there can be no doubt of its being so infinitely
greater in man as to be essentially different; for none of these
experiments can be made either artificially or accidentally on any one
of these parts in him, without being productive of the ultimate if not
almost immediate death of the whole.
Dr. Marshall Hall, in the comprehensive and luminous view he has taken
of the nervous system, supposes that each sentient and motor nerve
of the spinal marrow is further endowed with an excito-motor power
for reflex action. He calls these generally excito-motor nerves, and
considers them to be connected with a part of the medulla spinalis,
distinct from that portion which is strictly an appendage to the brain.
_Incident_ nerves arise from the skin and certain mucous membranes,
and convey impressions from them to the spinal marrow. _Reflex_ nerves
convey back the nervous influence excited through the medium of the
incident nerves, to the voluntary muscles in which they terminate;
and Dr. Marshall Hall further considers that these nerves, and the
part he calls the true spinal cord, constitute the true spinal system
which presides over ingestion and exclusion, retention and egestion;
and consequently that its influence is exerted upon the muscles which
belong to the entrances and outlets of the animal frame; or, in other
words, upon the sphincters, and the muscles of deglutition and of
respiration; and that the true spinal system maintains the tone of the
whole muscular system. Stimulating an incident or excitor nerve of the
extremities, by tickling or pricking the sole of the foot or the palm
of the hand after sensation is apparently destroyed, causes a special
muscular contraction or motion in the limb, if the excito-motor system
be uninjured. Irritating the eyelashes induces contraction of the
eyelids; and the irritation of one will sometimes cause contraction
of both. Tickling the verge of the anus induces contraction of the
sphincter muscle. Irritating the fauces and the root of the tongue,
by pressing it down with the handle of a spoon, induces an action of
deglutition. Respiration is excited by irritating or exciting the
trifacial or fifth pair of nerves, by throwing cold water on the face,
and stimulating the nostrils; by influencing the spinal nerves by a
similar use of cold water to the body and chest, and by tickling or
stimulating the sides, soles of the feet, and verge of the anus.
The great object or value of these and other facts and physiological
experiments is to enable us to conclude, as far as possible, what part,
what great division of the brain or spinal marrow is most seriously
injured, more particularly with respect to the prognosis than to the
treatment. Great severity and persistence of the symptoms lead to the
belief that the part of the brain or spinal marrow on which they depend
is directly injured rather than indirectly affected, and that the
result is more likely to be fatal. Permanent insensibility and loss of
motion may depend on cerebral mischief only. The loss of the mobility
of the iris implies an affection of the tubercula quadrigemina.
Convulsions, vomiting, a drawing up of the limb not affected by
paralysis, stertor, a difficulty in swallowing, strabismus, and relaxed
sphincters, show derangement of the spinal functions; which is well
marked when tickling the eyelashes does not cause closing of the lid,
of the verge of the anus no contraction of the sphincter, of the sole
of the foot no motion of the toes.
245. In order to simplify the investigation of Injuries of the Head,
they have been divided into two great classes: one denominated Injuries
from Concussion; the other, Injuries from Compression or Irritation of
the Brain. By the term Concussion of the Brain, a certain indefinable
something, or cause of evil which cannot be demonstrated, is understood
to have taken place; the effect of which is often clearly proved by
the almost instantaneous death of the individual, or by a succession
of symptoms which quickly lead to his destruction. The term concussion
is very aptly and forcibly illustrated by the homely but striking
expression in use in the sister country, when a man has been suddenly
killed by a fall on the head, “that the life has been shook out of
him.” On a dissection of the brain in a pure case of this kind, no
trace of injury or even of derangement of any part of it can be
perceived. Life is extinct, but the brain is intact. The immaterial
has been separated from the material part, by an injury apparently
inflicted on the very seat of life, with as little apparent derangement
of its structure as if death had occurred in a secondary manner from
the abstraction of blood by a rupture of the heart.
Modern surgery has in fact added nothing to our information on the
subject, perhaps from the peculiar difficulties of the case, which may
not admit of removal in the present state of our knowledge; although
all writers seem to coincide in opinion that a sudden stoppage of the
circulation of the blood is the more immediate cause of death. That the
positive shock communicated to the brain from one side to the other,
and the repercussion which follows from its resiliency, are capable of
giving rise to a direct and visible injury, is indisputable. It usually
forms on what may be termed the edges of the hemispheres, which appear
to be discolored, bruised, and sometimes torn, so as to have caused
the term laceration to be given to this kind of injury. This mischief,
however, is most commonly found in the examination of those persons
who have survived the accident for some days, and is therefore only a
predisposing cause of death.
246. When an injury is not immediately fatal, and life, although for
a time in imminent danger, is not destroyed, yet fluctuates on the
verge of destruction, gradually to be restored, again to fail, and at
the end of several days to be eventually extinguished, the changes
which take place in the functions of the brain during this period are
accompanied by alterations which are observable in its appearance. The
assemblage of phenomena which have taken place constitute inflammation;
and it is only by that vigorous treatment which subdues inflammatory
action that a person in whom they have occurred can be preserved. The
immaterial part of man is so intimately connected with his material
part that they cannot be suddenly separated without the material part
receiving an irrecoverable though often an imperceptible detriment;
the bonds which unite them cannot be temporarily loosened without a
derangement taking place, which appears to require for its recovery
the aid of some of those processes of nature which are known to occur
in the restoration to health of other parts of the body. A moderate
shock is often immediately followed by sickness, faintness, weakness,
and in a few hours by a slight headache, from which the person quickly
recovers without further inconvenience; or the headache may remain
for several days the sole symptom or sign of an injury having been
sustained; the slightest possible approach to that action which we
call inflammation having sufficed to effect a cure. One step further,
the headache continues, the stomach sympathizes, there is little or
no desire for food, the whole person feels more or less deranged, and
the pulse quickens. A smart purgative will perhaps relieve all these
manifestations of approaching evil, but the loss of a little blood will
be more certainly efficacious.
A child ten years of age fell over the banisters into the passage, and
struck its forehead. It was taken up apparently lifeless, but it soon
appeared that it was only stunned; it breathed deeply, looked about
vacantly, and could not speak; it then vomited, and gradually recovered
its speech and senses. A brisk purgative was all that was required to
remove the slight headache which followed on the subsequent day.
In more dangerous cases which ultimately prove fatal, the laceration
of the brain alluded to complicates the mischief as well as the
symptoms, and is perhaps the actual cause of death. It has, however,
been demonstrated that a slighter injury of the kind, giving rise
to long-continued symptoms, need not necessarily be fatal; in which
case it is supposed that the cure is effected by adhesion, and not by
granulation accompanied by the secretion of purulent matter.
247. When a concussion of the brain has rendered the sufferer
insensible and motionless, the countenance is deadly pale, (the
reverse of what takes place in sanguineous apoplexy;) the pulse is
not discoverable: the man does not appear to breathe. It is useless
to open his veins, for they cannot bleed until he begins to recover;
and then the loss of blood would probably kill him. It is as improper
to put strong drinks into his mouth, for he cannot swallow; and if he
should be so far recovered as to make the attempt, they might possibly
enter the larynx and destroy him. If he should appear to breathe, and
be made to inhale very strong stimulating salts, it will probably
give rise to inflammation of the inside of his nose and throat, to
his subsequent great distress. Mild stimulants and disagreeably
smelling substances held to the nose, together with partial as well
as general friction with the warm hands, are the best means to be
adopted, and should be continued until it be ascertained that life is
extinct. If the patient should recover, some signs of breathing will
be discoverable, followed by a distinct inspiration, repeated at so
distant an interval as to render its recurrence uncertain. At last
respiration is satisfactorily established, and the pulse, which was
doubtful at the commencement of the restoration to existence, becomes
perceptible, although often irregular, and sometimes continues so until
reaction has taken place. With this partial recovery of the natural
functions of the body, vomiting is apt to supervene, and is one of
the earliest and most satisfactory symptoms of returning sensibility.
It was formerly supposed to be peculiar to cases of concussion, but
it is often present in cases evidently of compression or irritation
from external violence. The breathing becomes in general quite free;
and although it is occasionally labored, it is rarely stertorous, a
symptom which may be considered, when permanent, as a more distinct
sign of continued irritation, or of compression and of extravasation,
than of concussion. The sensibility of the surface, however, is not
fully re-established, the patient is not cognizant of any injury
committed upon him, and if he should recover, has no recollection of
what has passed. This first stage does not last long, and with the
partial re-establishment of the functions of the lungs and of the
heart, and of the circulation of the blood through the brain, although
irregularly or insufficiently performed, the second stage may be
supposed to begin. The patient is still in a state of stupefaction,
although now perhaps sensible to personal maltreatment; and in this
condition he may remain for many days; he draws away or moves the part
aggrieved; he may be able to answer in a monosyllable correctly or
otherwise to questions loudly put, as if to rouse him from slumber;
but if the answer should be longer, it will generally be incoherent.
The pupils are for the most part in a medium or in a contracted state,
but rarely dilated. Stimulants were formerly given at and up to this
point, with a view of reviving and restoring the patient to greater
activity, and to prevent a relapse into his former state. Dissection
has, however, proved that it is a state in which congestion is about
to be followed by inflammation of the brain or of its membranes; that
the stage succeeding to this is one of active inflammation, even if the
patient should eventually recover; and if he relapse into that state of
stupefactive insensibility which precedes death, sufficient evidence to
account for his decease may be found in the laceration of the substance
of the brain, in small extravasations in various parts, or in other
mischief which may not perhaps be expected. Previously to this stage
of fatal termination, the muscles are not relaxed, and do not lose
their tone, as in a similarly fatal case of compression of the brain;
the urine does not flow involuntarily until after the spinal marrow
has been some time seriously implicated, and death is at hand. This
renders it necessary, in all cases of injury of the head, to attend to
the state of the bladder, which may become distended, and render the
use of the catheter necessary. The urine will be acid as long as the
catheter is required, and will become alkaline as soon as it dribbles
away involuntarily. The bowels will at an early period be confined,
and more powerful doses of aperient medicines will be required than
are needed under more ordinary circumstances, although the sphincter
ani may be relaxed, and the power of retention be lost from the
first, provided the injury has been very severe. When the feces pass
involuntarily, it is presumed that the cerebro-spinal axis is seriously
affected, and that the excito-motory system is greatly impaired, if
not wholly destroyed. When a person is insensible, it is not always
easy or convenient to ascertain whether the feces pass involuntarily
from loss of power of the sphincter ani, or are discharged from the
ordinary action of the bowels, of which the patient cannot give
notice. It may be inferred when the urine flows in a stream, although
apparently in an involuntary manner, that the power of the detrusor
muscle of the bladder is only impaired. In general, certain efforts are
made to evacuate the bowels, although the person may be upon the whole
unconscious of the act, showing that the defect is not essentially in
the sphincter ani, but in the want of consciousness in the brain.
Vomiting should not be solicited, as it may do harm when in excess,
but when slight, it has appeared to be beneficial. The more simple
the treatment during this the period of commencing reaction, the
more likely is it to be ultimately successful. The period at which
insensibility ceases, and the re-establishment of the natural functions
of respiration and of the circulation begins, must always be uncertain.
248. The termination of the first and the commencement of the second
or really inflammatory stage, or that tending to recovery, is marked
on dissection by the vessels of the brain and of its membranes being
full of blood, and showing those appearances which are indicative
of inflammation. If the patient is to recover, the stupefaction, or
_assoupissement_, continues, although a greater degree of sensibility
prevails; the pulse becomes regular, if it were not so before; the
skin is hotter than natural; the patient can often be induced to show
his tongue, which is white, and to answer shortly, and tell where he
feels pain, although he often answers incorrectly; he can sometimes
put out his hand and help himself, and occasionally even get out of
bed. He usually turns to avoid the light, and the pupils are for the
most part contracted; but no reliance can be placed on the state of the
pupils at this period of the complaint; both are sometimes dilated,
or one is dilated and the other contracted--sometimes dilating on
the admission of light, sometimes contracting; or they may not be in
the least changed until shortly before death. An alteration from the
ordinary state of the pupils does not prove the absence or presence
of any serious general injury, but only that a particular part of the
brain has been more or less affected. The breathing at this period is
free, and not in the least noisy or stertorous, unless the concussion
be complicated with irritation occurring from lesion of the brain or
its membranes, or of the medulla oblongata. The patient may remain in
this state without any sensible alteration for several days, or he may,
as is more commonly the case when restoration to health is to follow,
recover his speech as well as his general sensibility; nevertheless he
frequently speaks more or less incoherently, mutters to himself as if
thinking of something, and wanders at night, becoming even delirious,
and requiring restraint to keep him in bed. Inflammation of the brain
is now fully established and must be subdued. It is at or about this
period that other symptoms occur, which are frequently enumerated as
those indicative of concussion--it should be added, of concussion in
its latter stage. The pulse becomes quicker, perhaps full or hard,
varying from 84 to 90, and even to 100. In such cases, an augmented
pulsation of the carotids may often be observed, and is considered by
some to be confirmative of the fact of concussion, although it is by
no means a sign to be entirely depended upon. Such a person will not
be comatose, but watchful, sleeps little or none, talks incoherently,
or is often really delirious, refuses food if offered, drinks with
avidity, has a hot skin, and a white tongue. If other symptoms occur,
such as spasms or convulsions, the absolute loss of any sense, or
paralysis of any or the whole of a part, the case is complicated by
laceration of the brain, compression, or other causes of mischief,
from the effects of which, if he cannot be relieved by blood-letting,
he gradually sinks into a state of coma, and dies.
The deviations which take place from the usual and ordinary modes
of breathing are supposed to offer distinctive signs of the nature
of the injury which has taken place, but they are uncertain; they
mark the degree of injury, and perhaps the part injured, rather than
anything else. Stertorous breathing has always been considered a
sign of extravasation causing compression of the brain. Many cases,
however, have occurred of slight extravasation with partial loss of
power of one-half the body, accompanied by great numbness, without any
stertor in breathing; but a well-marked case of large extravasation has
rarely or never been observed without it, or another peculiarity of
breathing which is less thought of, although an equally characteristic
and dangerous sign of such mischief having taken place when it is
permanent; this is a peculiar whiff or puff from the corner of the
mouth, as if the patient were smoking. This, when observed among other
urgent symptoms, is usually followed by death. Stertorous breathing and
the whiff or puff at the corner of the mouth are presumed to indicate
an injury to the cerebro-spinal axis as well as to the cerebrum; but
whether the injury be direct or indirect is uncertain, although it
is frequently accompanied by extravasation or laceration. When the
breathing is only oppressed or labored or heavy, neither extravasation
nor lesion to any extent can in general be discovered after death.
The surgeon will then practically be right in considering the stertor
or whiff in breathing to be accompanied by, if not directly dependent
on, extravasation or lesion; and the heavy or labored breathing to
be dependent generally on a derangement of function, which is not
perceptible on examination. If there be truth in experimental anatomy,
stertorous breathing ought to be dependent on a direct affection of the
medulla oblongata; nevertheless there can be no doubt that a temporary
stertor or a puff at the corner of the mouth may exist without it, as a
consequence of too great an abstraction of blood.
An officer, exercising his regiment under a hot sun in Portugal,
suddenly fell back on his horse, and was carried home insensible and
breathing stertorously; from this state he soon recovered, feeling weak
in his lower limbs and incapable of influencing the sphincter ani,
which was soon followed by incontinence of urine. His intellectual
faculties were never affected after the first insensibility; and on
the third day he rode on a mule, with care, twenty miles to Lisbon.
Many months elapsed before he recovered the necessary command over the
sphincter ani. Years have elapsed, and he cannot now always retain
his urine. In this case the spinal marrow would seem to have been
principally affected.
It is important to recollect that the stupefaction or insensibility
of concussion is coeval with the injury, and that as few cases of
compression of the brain occur without some degree of concussion, the
insensibility may in many instances depend on it. The stupefaction
peculiar to compression, demanding relief by blood-letting or by
operation, is that which comes on some two or more hours after the
accident, and is caused by congestion or by extravasation; it must
also be distinguished from that which appears after several days, and
is the consequence of inflammatory action and effusion. The pulse has
been supposed to offer a diagnostic sign of the nature of the mischief
which has taken place in the brain; pressure or extravasation, it is
said, being attended by a slow and labored action of the heart. This
may be admitted as a general, but by no means as a certain rule, for
many of the largest extravasations, and many of the most diffused,
have been accompanied throughout by a very quick pulse. When the
physiological doctrines of the circulation are duly considered, as
well as the experiments on which they are founded, it will be evident
that the action of the heart may be influenced by other causes than
those occurring from the part of the brain apparently injured. Pressure
made purposely on the brain or dura mater in man during life is always
followed, when carried to too great an extent, by a diminution in the
frequency of the pulse, and even by syncope.
When the stage of depression is slowly passing into that of excitement,
and inflammation is about to be set up, bleeding may be had recourse
to; but what quantity of blood, if any, should be taken away, is often
doubtful. The loss of six, eight, or even of ten ounces can do no
harm, if it do no good, and it may enable the surgeon to form a more
accurate judgment of the state or degree of the complaint than he could
otherwise have done.
A laboring man, thirty years of age, fell from a height of fifteen
feet, on the back of his head, a small puffy tumor being perceivable
near the junction of the right parietal with the occipital bone. He was
insensible and motionless; countenance deadly pale; circulation weak
in the arms, but more marked in the carotids; respiration heavy and
slow; pupils much dilated and fixed; no relaxation of the sphincters.
Hot-water bottles were applied to the feet, and friction to the body
generally. In the afternoon he became warmer; some reaction seemed
to be taking place, accompanied by slight twitchings of the face,
and shiverings. At four o’clock he was bled to sixteen ounces, in
consequence of the pulse having become fuller, although soft and 96 in
the minute. The surface was warm and moist, and he was so far sensible
as to complain, on being pressed for an answer, of pain at the part
of the head injured. The bleeding was discontinued, in consequence of
its bringing on _convulsive_ movements ending in syncope; the pupils
contracted, the countenance became deadly white, and he breathed on
the right side of his mouth for a few minutes, with the whiff or puff
so peculiar in cases of compression of the brain. On recovering from
his swoon, the pulse became regular and 85 in number, the skin warm
and moist, and the pupils more sensible to their proper stimulus. The
bladder, which had been a little distended, acted voluntarily. The next
day he was perfectly collected, and complained only of a little pain
in the head. Pulse 84; was quiet and slept during a part of the night.
The bowels acted under the influence of the calomel and colocynth given
the evening before, and of a senna draught in the morning. He quickly
recovered, without any further bad symptoms.
The effects of a large abstraction of blood at too early a period are
well shown in this case, especially by the convulsions and by the
peculiar kind of breathing.
249. When the period of excitement or of inflammation has begun,
and the patient, although disposed to coma, is still irrational and
impatient when roused, he is not to be left to await the effects of a
blistering plaster or of a dose of physic, as has been recommended in
such cases, but ought to be bled sitting up in bed to whatever extent
may be necessary to relieve the symptoms, or at least to cause a near
approach to fainting, for nothing less can relieve such a person
effectually, and give him a fair chance for life. The bleeding must
be steadily repeated as the symptoms recur until relief has been
obtained, or until it becomes evident that the powers of the patient
cannot resist the inroads of the disease and of the efforts made for
its cure. The quantity of blood that may be lost in two or three days
by powerful, healthy men is sometimes enormous, amounting to 100, 150,
and even 200 ounces, with the happiest effect. The following case,
which was one of inflammation tending to effusion, will show the extent
to which it ought to be carried in an elderly person of a different
habit of body:--
A gentleman, sixty-seven years of age, had suffered for three weeks
from occasional attacks of gout in his right foot, which he had himself
treated by simple means, taking the pulvis ipecacuanhæ compositus at
night to relieve pain. Once or twice his family had observed that his
head was, for a short time, not so clear as usual; but no suspicion
of further evil was entertained until he awoke one morning, evidently
talking incoherently. As the gout had nearly disappeared from his feet,
sinapisms were applied to both; purgatives and diaphoretics were freely
administered, and he appeared to be relieved. On the third morning he
became more loquacious and forgetful, was occasionally incoherent, and
complained of a certain loss of power, and of numbness in the right
side. Pulse 84, full and regular; tongue white; some confusion of ideas
was evident, with slight headache. He was cupped at ten in the morning
to ten ounces, without advantage; as all the symptoms appeared to be
increasing, at four in the afternoon sixteen ounces of blood were taken
from the arm, which produced a marked effect for some time. At ten at
night, the symptoms having returned, and the blood drawn being very
much cupped and buffed, twelve ounces more were taken from the arm,
when the pulse quickened and began to intermit; he appeared to be about
to faint, and the object seemed to be attained. Calomel and opium were
then given every four hours, until the mouth became affected; but the
essential symptoms were already subdued, and the patient recovered,
with a slight sensation of numbness and loss of power of the right side
of the body and head.
The necessary effect was in this case produced by the loss of forty
ounces of blood. In a younger and more vigorous man it might have
required three or four times as much to have been taken away by
repeated bleedings, before the object could have been attained; of
this the following case is a good instance:--
Mr. B., having jumped out of a carriage, the horses of which were
running away at full gallop, fell on his face, and was found insensible
and motionless. Some cold water having been poured upon him, he
gradually recovered, and afterward ate a hearty dinner, drank a
bottle of port wine, and walked home, a distance of three miles. He
thought himself quite well the next morning, and went to bathe; but on
returning about noon he felt uneasy, lay down on a sofa, began to talk
incoherently, and was soon quite delirious. At one o’clock he was bled,
but the symptoms of inflammation were not completely subdued until he
had lost eighty-four ounces of blood, the last quantity being taken
away at eleven at night. The vigorous treatment adopted in this case
during the first ten hours in all probability saved the life of the
patient.
250. It sometimes happens that congestion precedes inflammation to such
an extent as to give rise to stupefaction and symptoms of compression.
A Portuguese soldier of General Harvey’s brigade of the fourth division
of infantry was struck by a musket-ball at the first siege of Badajos,
on the top and toward the back part of the head; it divided the soft
parts, and grazed the bone without fracturing it. He walked from the
trenches to the rear, and said he was not much hurt. About five or
six hours afterward, he was found apparently asleep, and could not be
awakened, on which I was asked to see him. Finding the pulse at 60,
regular and full, although compressible, I directed him to be raised
and blooded until he fainted. When he had lost some twenty ounces of
blood, he opened his eyes, recovered his senses, and knew those about
him. The next day he went to the rear, free from all symptoms, and
rejoined some time afterward, in apparent good health, although he
complained more than was usual to him of the heat of the sun.
In some less important cases of injury, one bleeding will answer the
purpose; cupping and leeches may also be resorted to with advantage;
but in all very severe ones general blood-letting is the only
trustworthy source of relief. It should always be done with effect,
the finger examining the opposite pulse, and regulating the amount to
be taken away. At an early period of concussion, the quantity drawn
should not be large; it should increase with the urgency for its
abstraction, and diminish with the frequency of the repetition, being
always, however, carefully regulated by the effect. The inability of
blood-letting to overcome the disease will be shown by the increase
in frequency of the pulse, its diminution in power under slight
compression, its greater softness, together with the persistence of the
other symptoms.
It is in these cases that repeated small bleedings, to the amount of
six or eight ounces, ought to be resorted to, when it is doubtful
whether the loss of blood can or cannot be borne; they may then be
considered not as curative, but as explorative measures, although they
sometimes prove very effective; and when not properly regulated, the
reverse.
In all these, and in other more desperate cases, the effect of mercury,
provided it has been early and rapidly administered, may yet be
decisive. Calomel, combined with another and not less important remedy,
opium, ought to be given every two or three hours until the effects of
both are fairly induced.
Blisters should never be applied to the head until after the leading
symptoms of inflammation have been overcome; they will do more good
at a later period, applied between the shoulders or on the nape of
the neck. They should be dressed with mercurial and savine, or other
stimulating ointment.
The hair should be cut close in ordinary cases, or shaved off in the
more serious ones. The head should be raised in bed, and kept wet with
a cold evaporating lotion, or one composed of two ounces of the nitrate
of potash, one of the muriate of ammonia, one pint of vinegar, and
five of water, made in small quantities at a time, as may be required;
or with a small quantity of pounded ice and water in a large bladder.
Perfect quietude, cold drinks, at pleasure, and nearly absolute
starvation should be enforced.
The different points of practice which have been noticed are well
illustrated by the following case, in which the symptoms of concussion
were complicated by those which are commonly observed in compression of
the brain:--
An old man, when cleaning windows, fell from some steps on his
forehead, which he slightly cut and bruised, the left temporal
artery being divided by another small cut: it bled profusely until
the hemorrhage was arrested by a surgeon. He remained in a state of
insensibility for nearly two hours, when he rallied, and answered
questions, although imperfectly. Pulse quicker than natural,
and intermittent. He shortly afterward relapsed into a state of
insensibility, with convulsions, stertorous breathing, puffing at the
corner of the mouth, and complete loss of voluntary motion: the pulse
could scarcely be felt. This convulsive fit lasted about ten minutes,
when his respiration became natural, and his pulse was restored. The
insensibility continued for an hour, when it was attempted to bleed
him, but the pulse fell immediately, and it was not persisted in.
He soon, however, became quite sensible, sat up in bed, and vomited
some blood. In the afternoon he had another and slighter fit, from
which he quickly recovered. On the third day he was free from all
bad symptoms, and said, when asked, that he had only a very slight
headache. The pulse occasionally intermitted. On the fourth he declared
he was starved, became snappish and irritable, complained of pain in
the head, and had a quick and irregular pulse. On the fifth he got up
and dressed himself, had another slight convulsive fit, and fell into
a state of stupefaction, for which bleeding gave little relief; and
in the evening he died. From the first period of his improving until
his death, sensation and motion remained. On examination, a starred
fracture without depression was found corresponding to the wound on
the forehead, continuing to the base of the frontal bone, across
the ethmoid, over the body of the sphenoid bone, breaking off the
posterior clinoid processes, and extending to the basilar process of
the occipital bone, but not quite to the foramen magnum. The anterior
lobe of the right hemisphere of the cerebrum was lacerated to the
extent of an inch; that part was surrounded by the usual appearances
of inflammation. Some blood was extravasated on the tentorium, beneath
the posterior lobe of the brain, and lymph was effused over the whole
of its surface, between the arachnoid membrane and the pia mater. The
trephine, if resorted to, would have only added to the mischief.
Inebriation from spirituous liquors may complicate a case at its
earliest period, from the stupefaction it occasions; but the odor of
the spirits is usually demonstrative of the fact, and the stomach-pump
in such cases is an admirable remedy.
251. Mania sometimes supervenes on concussion, as the inflammatory
symptoms subside. It is best treated by the different preparations of
opium.
George Grey, aged forty-five, a stout man, fell from an omnibus,
Nov. 1, 1839, and received a blow on the right parietal bone, a
little behind the coronal suture. He lies on his back in a state of
stupefaction, although sensible when pinched, but is restless, and
suffers from convulsive motions of the mouth and limbs; pupils fixed,
the right being more dilated than the left; pulse 120; heat of skin
natural; respiration deep and rapid, without stertor; the sphincters
not relaxed. A turpentine enema was given, and a calomel pill was
swallowed with great difficulty. The head was shaved, and a cold lotion
applied; he soon afterward became violent, and required the restraint
of a tight jacket. The pulse fell in the afternoon to 84.
Nov. 2d.--Passed a restless night without sleep, and has a wild
appearance: pulse 96, and regular. At twelve o’clock became sensible,
and gave a confused account of the accident. Was freely purged, and
a quarter of a grain of the acetate of morphia was given every four
hours: the first at seven, the second at eleven, and the third at three
in the morning.
3d.--Has passed a quiet night, but with little sleep; the morphia has
had a soothing effect; talks rationally, although a little confusedly,
and recognized his mother, who says he received a violent blow on the
head three years ago, which has rendered him mad ever since whenever he
drinks too much. Pulse 72; bowels open, and is free from restraint. At
seven in the evening, he suddenly started up in bed, saying some one
was going to murder him. Half a grain of the acetate of morphia quieted
him; it was repeated at half-past twelve and at half-past four, and
kept him quiet, although he did not sleep.
4th.--He was collected, quiet, and free from restraint; pulse 96,
rather full; secretions natural. The morphia was continued in adequate
doses for a few days, and he gradually recovered.
252. Concussion induces affections of the brain and of its membranes
of an equally serious nature, at a more distant period of time, when
the stage of stupefaction and insensibility is wanting; it is to guard
against such an occurrence that persons who suffer from falls or severe
blows on the head usually lose blood. A gentleman was thrown from
his gig near Hounslow, and received a very severe shock and several
bruises, without feeling much hurt, or being aware that his head had
actually touched the ground. He came up to town, went to bed, and got
up next morning suffering only from a slight headache, and stiff from
his bruises, of which, however, he thought nothing. On the second
day I saw him in consequence of headache, throbbing in the temples,
sickness, and general malaise or discomfort. Being a stout young man,
thirty ounces of blood were taken from the arm in a sitting posture,
until he nearly fainted, after which he was relieved. In the evening,
the symptoms having all returned, pulse 88, and full, he was bled in
the erect position until he fainted, forty ounces being taken away. The
blood of the morning was buffed and cupped, and the bowels had acted
freely. On the morning of the third day the pulse, which had become
fuller, yielded to the loss of twenty-four ounces of blood, and in
the afternoon, on its rising again, to sixteen more; after which the
symptoms gradually subsided, and he appeared to be restored to health,
with one interruption from irregularity in diet, requiring the further
loss of blood by cupping behind the ears, and some sharp purgation.
His cure was not, however, permanent; for having dined out a month
afterward, he became delirious during the night, and required to lose
sixteen ounces of blood in the morning, which relieved, but did not
cure him. Some pain remained in his head, the pulse continued at 90,
the tongue was white, with thirst, loss of appetite, and watchfulness.
Calomel and opium were now administered until the mouth became
affected, when he quickly got well; although a slight relapse or two
afterward convinced him that he could not drink nor lead an irregular
life with impunity.
There are no cases of convalescence after disease or injury which
require more care than those which follow injuries of the head.
Relapses, from apparently trifling causes, are extremely frequent,
and gradually but certainly undermine the health; they are, in fact,
connected with chronic derangement of the brain, or of its membranes;
and unless successfully met, generally end, after the lapse of a few
weeks or months, in irritative fever and death. In many instances,
particularly among poor people subject to privations and of irregular
habits, in whom an injury of the head has not originally been of any
apparent importance, such a state of irritation, if it occur, combined
with debility, is very difficult to manage; it requires a combination
of local as well as of general means for its cure. A few leeches and
blisters may be applied alternately over the part affected, with great
advantage; and a mild, nourishing diet, with gentle alteratives and
tonics, will expedite the cure, especially when aided by perfect repose
and a fresher atmosphere. An issue in the arm, which establishes a
gentle but permanent drain, will often be found an efficacious remedy.