Part 30
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.